Damian Sendler: Consultation-Liaison Psychiatry Services (CLPS) play an important role in delivering age-friendly hospital treatment because of the rising understanding of the health-related particular requirements of older patients. Patients with probable medical-psychiatric comorbidity are assessed by CLPS, and ward teams are supported in bio-psycho-social care management by CLPS. Analysis and discussion focused on the differences between older and younger people who were sent to a CLPS over the period of two decades. OV65 (patients above the age of 64) and NONOV65 (consultations for patients under the age of 64) were the two categories of consultations developed based on the patients’ ages in the 2000–2019 period at the Modena (North of Italy) University Hospital CLPS (all the rest of consultations). There were 375 consultations for OV65 every year, compared to 589 consultations for NOV65 per year. Over the last two decades, the number of patients over the age of 65 who were sent to other doctors has climbed dramatically. Both the overall sample and the OV65 and NOV65 subsamples showed substantial changes in the mean age and male/female ratio over time. Among NOV65, urgent referrals were more common, and the percentage of urgent/non-urgent referrals differed between the two categories. Future therapeutic, educational, and scientific efforts may be guided by the trends identified in this study.
Damian Jacob Sendler: Mental health professionals who specialize in the field of consultation-liaison medicine (CLP) are concerned with the complex interconnections of “multi-morbidity,” which includes its psychosocial origins and consequences. In the second half of the twentieth century, it has become the operationalized arm of psychosomatic medicine and the bio-psycho-social paradigm promoted by George Engel and other researchers and clinicians.
Dr. Sendler: When patients have medical-psychiatric issues such as adjustment disorders, anxiety, self-harming behavior, suicidality, delirium, medically unexplained symptoms of physical illness, eating disorders, alcohol and substance abuse disorders, and so on, CLPs in the GH perform diagnostic assessments and activate treatment plans. Another frequent aim of a CLP Service (CLPS) is the prevention of work-related stress and burnout syndrome among health professionals as individuals or in teams [3]. In order to achieve better integration and coordination of care, rationalization of health care resources, and reduction of excessive medical sectorialization, CLP emphasizes strong interaction with related health and social agencies (such as general practice or social services) within and outside the GH.
Damian Sendler
Health care outcome measures like as long-term medical prognosis, adherence to treatment plans, patient well-being and functional limitations, hospital length of stay and health-related direct and indirect expenditures have been shown in research to be beneficial when implemented by CLP clinical activities.
Most patients admitted to the GH are above the age of forty percent (40%) and over sixty percent (65%) in western nations [11,12]. Over the course of 30 years, the percentage of in-patients aged 65 and over who were referred to a CLPS climbed from 0.7 to 2.89 percent [13]. Up to 40% of elderly patients may have concurrent psychiatric symptoms because of the increased risk of numerous mental health diseases, such as depression and anxiety disorders and neurocognitive disorders, with aging [11,14]. Patients’ health outcomes are greatly impacted by the complex bio-psycho-social needs of their health care providers [16], but these needs are often overlooked because of delayed diagnosis, inadequate use of psychotropic medications and other therapeutic tools, stigmatizing beliefs about the elderly, and limited integration of care. It is less common for elderly persons to be referred for psychiatric consultation [15].
For their contribution to the World Health Organization’s “Global Age-Friendly Cities: A Guide,” elderly citizens from over 30 countries were asked to discuss the positive and negative aspects of their daily lives. When asked about health-related issues, disease prevention and health promotion were mentioned as the most relevant expectations, while lack of coordination among services was mentioned as a common problem [17]. Elderly patients’ needs need specialized attention and training, whether they’re in or out of the hospital. Multimorbidity is more common as patients become older, and efforts should be taken to ensure that patients get coordinated and integrated treatment. As a result, it has been shown to enhance health outcomes in terms of prognosis, quality of life, and cost-effectiveness. When it comes to CLP’s primary goals, it is interesting to note that these same themes are among the most significant ones. To make “the patient at the center” not only an empty metaphor but an actual endeavor toward patient autonomy and active engagement in their treatment action plans, CLP’s clinical, teaching, and research activities are based on the strong holistic tradition of psychosomatic medicine [21,22].
Over a 20-year period (2000–2019), this study aimed to describe the socio-demographic and clinical features of the population referred to a hospital-based CLPS. Data was analyzed for both the whole sample of seniors (those 65 and over—OV65) and the general population (those 18 and 64—NOV65) evaluated by the service.
Damian Jacob Markiewicz Sendler: Clinical activities at a northern Italian hospital-based CLPS were analyzed for 20 years to identify and discuss key aspects and changes connected to the population referred for psychiatric consultations, with particular focus paid to comparison of various variables associated to aging. In order to enhance the CLPS’s performance, such an analysis was deemed relevant and verified to be so. Organizational elements (such as specific care routes) or training activities (such as on psychogeriatric subjects) or more research projects might be suggested.
An average of around 40% of the CLPS’ clinical duties are devoted to serving the needs of the aging population. It also rose throughout the 20 years studied, and this variance in mean age was particularly pronounced among the elderly. As the general population and the hospital population both age [13,20,28], our results are in line with this overall trend and demonstrate the need of looking at these patterns of consumption. There are known differences between geriatric patients’ mental health needs [14,16,29] and those of younger patients, thus both consultees and consultants should understand these differences when making referrals and conducting assessments of their geriatric patients (i.e., the ability to perform a differential diagnosis between depression and hypoactive delirium, or a safe and appropriate management of psychotropic medications).
Over-65 patients were more likely to be diagnosed with depressive symptoms, which was the most prevalent cause for psychiatric referrals in the entire sample and in the two age groups.
As a result of factors such as multiple comorbidities, difficulties in interpreting somatic symptoms, and clinicians’ apprehension about using antidepressants for fear of side effects or interactions, depression in older patients is often overlooked and mismanaged [30,31]. However, a more implicit conceptual reason for this is the tendency to believe that depression is normal or inevitable as a person ages. A rise in the number of older patients being diagnosed and treated for depression may be a good indicator that doctors are increasingly aware of the need of addressing and treating depression in this population. In the two age groups, there was no statistically significant difference in the percentage of delirium diagnoses, which also confirms both the epidemiology and the high reliability of doctors in identifying the disease.
Damian Jacob Sendler
Damien Sendler: More individuals were referred for alcohol, drug, or medication misuse among younger patients, but there was also a wide range in the number of referrals for other diagnostic categories. Even though age is a significant factor that surgeons consider when selecting transplant candidates and pre-transplant assessments were more common among patients under 65 years old, the number of pre-transplant assessments in both age groups clearly increased in recent years, consistent with Modena’s growing importance as surgical hub for transplantation [33]. There has been a decrease in the number of generic referrals for psychomotor agitation since 2012. This may be due to improved diagnostic abilities among consultees, who are now able to apply more comprehensive diagnostic frameworks like delirium. Such shifts, made possible by the extended period of work under consideration, serve as an additional indication that the CLPS’s ongoing efforts to increase liaison and more formal training are both useful in the long term and contribute to more efficient utilization of resources [34]. Additionally, there has been a significant decrease in the number of individuals who have been referred for treatment owing to MUPS during the last 20 years, which may be a sign of a shift in the nomenclature of somatization and so-called functional disorders [35].
In both older and younger patients, female patients referred to the CLPS were more prevalent, although their share reduced with time in both groups. However, the older individuals in the study showed a more pronounced shift. According to this study, the number of patients referred for pre-OLTx, which is mostly male, has grown [36]. According to the prevalence of more severe forms of various diseases in male patients (e.g., depression), knowledge on the elevated risk of self-harm behaviors should be an essential priority in establishing and defining training activities for the CLPS and the CLPS staff.
The Modena CLPS has a back-referral waiting period of one and a half days on average. Much for elderly patients, who may be prioritized in the day’s activities by the experts, this amount of time is even more limited. As a probable evidence that consultees have learned to “trust” CLPS, urgent referrals declined significantly in both groups over the last 20 years, whereas younger patients were more often referred. On the subject of changing trends, it’s worth noting that wait times increased significantly in both demographics about 2008 before plummeting dramatically in 2013. Due to the Modena CLPS’s long history of frequent cooperation with the Liver Transplant Unit’s outpatient clinic, scheduling appointments became more complicated and time consuming for a period of time after 2008. When it comes to analyzing patterns and changes in both internal and external events, consistent record-keeping of therapeutic activity is essential [3].
The following are some research limitations that must be explained in order for the findings to be properly discussed: Over time, the experts who gathered the data changed. It is possible that some of the data entered by the professionals was incorrectly entered, despite the fact that they were given a brief training session. For the majority of hospital wards, psychiatric consultation requests were not specified by a protocol or criterion check-lists: medical practitioners chose in absolute autonomy when to seek consultation for their hospitalized patient. Using a spreadsheet did not enable to prevent mistakes in data input. Subjectivity may have influenced the allocation of requests in the various departments; for example, transplant surgery had a very strong relationship with the CLPS. Because of this strong synergy, the number of requests from those wards is likely to have been affected by it; (5) the database does not collect variables measuring the level of dependence; activities of daily living; social support; or even the degree of frailty, which we were therefore unable to document.
One of the primary objectives of CLPSs functioning in the GH is to cultivate a more health-oriented mindset. As a result of this study’s epidemiologic approach to clinical data and the long time period it covered (20 years), the CLPS may better address medical-psychiatric comorbidity in older patients by identifying and addressing organizational impediments, opportunities, and other requirements.
More over a third of all CLPS activities were spent on consultations with elderly patients, and this number was steadily rising. For the general population and older adults, depression was the most often diagnosed mental illness by CLPS. The mean lag time between referral and assessment, as well as the percentage of urgent/routine referrals, were found to have changed.
These results show that as the population ages, there is an increasing need for hospital-based CLPS to enhance their abilities in treating old-age specific psychopathology and modify their organizational, training, and research efforts appropriately. Identifying high-risk illness patterns and fostering specialized clinical practices, as shown in the current research, may help us better meet the requirements of the elderly (i.e., detection of mild cognitive impairment, coordination with primary care or social services, prevention of delirium).
