Dementia and Suicidality in the ED

[F0nzie]

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Anybody have any experience with what to do with dementia patients who have SI or suicide attempts who roll into the ED and their families ditch them? I tried to admit an elderly SI + demented patient that was turned down by Geripsych because "The pt is has dementia".

I was thinking several things:

1. If they are DTS/DTO because they have dementia, a petition probably won't hold. But I am not sure, one could argue that the patient has a past psychiatric history and is imminently a danger to self and others.

2. If they lack capacity they can't sign in to a psych unit voluntarily. Therefore you must get a surrogate decision maker according to state law. If the family abandons the pt, they will just sit in the ED. Call adult protective services?

4. Does SI or suicide attempts even count in dementia? What MMSE score is relevant? I mean if they can't even remember what they said 1 minute ago... But still you can't exactly send them home.

5. While the ED physician bitches at you to get the patient off their service... What do you do with this patient besides get a sitter and PRNs. What placement options are there if Geri-psych turns you down? Are there specific admission criteria for Geri-psych (do they only accept elderly pts with mood or psychotic disorders and require an MMSE of 30???) 😕

 

[nitemagi]

A lot of the answers to your questions are hospital, state, locality, and insurance specific.

Check with your supervisors, and whoever runs your consult/ED service should have an algorithm in place for these situations.

 

[atsai3]

These cases are really hard. They are GD, and the family has abandoned them, so you can't send them home. Psych hospitals will turn them down because they are frail and demented and require 1:1 (often useless because they often cannot be redirected) for which the nurse manager will say she does not have the requisite staffing ("try calling back in the morning"). Geri-psych wards will turn them down because they have dementia, not a bona fide mental illness (e.g., it will be as if you are trying to get someone admitted to a regular psych hospital for SI d/t acute cocaine withdrawal -- often psych just won't take them). Nobody, including the ED, likes them because they are demented and striking out at staff.

At our program we didn't have an algorithm (nor did we have a social worker on call overnight -- something I wish I had known to ask about while on the interview trail!). The only thing we could do was apply the hold, start making phone calls, and continually reassure the ED that we were doing everything we could do to dispo the patient.

 

[BobA]

What to do in these situations is going to be institution and situation specific.

In our institution, if the patient has severe behavior changes related to their dementia then they are best served on psych.

However, frequently these are patients who are transferred from a nursing home because they expressed SI at the home. These pts are usually upset at having to live in a nursing home -and may have bad feelings towards a particular staff member or another nursing home resident - and expressing SI is one way that they can assert control in their situation. This type of conditional suicidality might occur in someone without any prior substantial psych hx and who has limited family support. At our institution, these cases tend to be seen as dispo problems rather than psych programs, and dispo problems are usually taken by medicine because pts are easier to place from a medicine floor and they don't usually need psych involvement anyway.

Of course, patients can go to medicine if you deem them as not having the capacity to refuse placement.

 

[siked]

I don't understand why it is even your responsibility to find placement? I would assume you are in the Medical ED in the capacity of a psychiatric consult. Once you have assessed the patient and determined him/her to not be suitable for psych (due to, among other reasons, dementia and an inability to benefit/ partake in the therapeutic milieu and groups of a psych unit), you can leave some recommendations for PRNs/ meds, but that's it. As you have determined the patient to NOT be suitable for psych, your duties are over (unless, of course, the patient is admitted and the consult relationship continues). This patient sounds like a social dump, and would most likely be admitted to Medicine for placement. Tell that ED physician who is "bitching" at you to eat it.