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Older Adults & Psychiatric Inpatient Units

Interview with Dr. Lisa Frank (Part 3)

Episode #030


Dr Regina Koepp:    People can have a longstanding mental illness and then also have dementia on top of that. People can have a dementia that lowers cognitive reserve and sort of reveals some mental illness. Sometimes we'll see like they call it co-morbid- that's when a mental illness and a medical illness sort of exist at the same time. So around the earlier stages, I see some folks with sort of this co-morbid condition end up in the psych unit. So the person can have an early stage of dementia and then have some psychiatric symptoms on top of it. And that's really messy and really scary for families. Because also at the same time, the person's an older adult. And so now you have this 85 year old who has severe depression or a bipolar disorder or a psychotic disorder AND early stages of dementia. And now they're in the psych unit and the family's terrified and think: "my family member was able to cope all this time and now in this early stage of dementia, and we don't even know, is it dementia?... all of his symptoms are happening and we're terrified.

Dr Regina Koepp:    Hello there I am Dr Regina Koepp and this is The Caring for Aging Parents Show. I'm a Board Certified Clinical Psychologist and I specialize in older adults and families. I help you manage the most complicated situations with your aging parents so that you have peace of mind knowing that you are doing everything you can to help your parents live their best lives without giving up your own life in the process. So for the best tips on helping you to care for your aging parents, subscribe to my show and you'll get new tips every Wednesday.

Dr Regina Koepp:    As we get started. I wanted to share with you an important guide that I made called Dementia 101: A Beginner's Guide to Dementia Disorders. In this guide I talk about what dementia is and what it isn't. I describe the phases of dementia and what to do if you're worried that your aging parent may have dementia. I'll link to it in my show notes, so take a minute and download it. It answers some of the most frequently asked questions I get about dementia. This is the last of a three part interview with my best friend, Dr. Lisa Frank. Today, Dr. Frank and I will talk about older adults and older adults with dementia who are receiving care on a psychiatric inpatient unit. We're going to talk about how you as a family member can help while your loved one is on the psychiatric inpatient unit and then how you can help with discharge planning and what discharge planning might even look like. So as a family member, you have a really important role and this video is going to give you tips for helping your aging parent when they're on the psych unit and when they're discharging. So let's get started.


Who is on the psychiatric inpatient team?

Dr Lisa Frank:    Okay, so on a psych unit, the psych team includes a psychiatrist, typically, although some hospitals will have a nurse practitioner with a psychiatrist supervising, but typically a psychiatrist who is the prescriber on the team, a social worker who would be the person who gathers information from the family. And we call that collateral information. It's incredibly important for a person who's on an inpatient unit to have family members, friends, give that information to the treatment team because the treatment team is just meeting this person for the first time. They have no idea who this person is. So that's very important. So psychiatrist, social worker, nurse and the nurse changes from shift to shift there usually three shifts per day, per 24 hour period. And nurses tend to work maybe a few days in a row. And so your loved one may have the same nurse for the first two days of the stay and then it switches for the next three days of the stay. And the inpatient team or the psychiatrist and social worker will more than likely work Monday through Friday. And then there will be a different psychiatrist for the weekend. And so if your loved one is admitted on a Friday, say Friday night, they may have a different team over the weekend. And then Monday morning they have a brand new psychiatrist and Social Worker.

Dr Regina Koepp:    So the family has to start all over?

Dr Lisa Frank:    Well, hopefully the weekend team has gathered information from the family that they include in their notes and that gets conveyed to the Monday morning team. Um, but it's always good to err on the side of giving more information.

Dr Regina Koepp:    Okay. So the family could go on a Thursday, have one inpatient team of a psychiatrist, a nurse, a social worker, and then Saturday have a completely different team and Monday have a completely different team.

Dr Lisa Frank:    Well, Monday it would probably be the same team that admitted on Thursday.

Dr Regina Koepp:    Okay. Got it. Okay.


How to communicate with the psychiatric inpatient team when your aging parent is hospitalized

Dr Regina Koepp:    I hear this from families a lot: "My loved one was not living with me, admitted, or maybe was living with me, but admitted to the psych unit and I don't know who, how to get in touch with the psych unit. I want to help my loved one. I want to reach and see what's going on. It's scary." How does a person's family get in touch with the psych unit?

Dr Lisa Frank:    So all hospitals are a little bit different, but what I would suggest is calling the, um, the main hospital number and asking for the behavioral health unit number. You could also call the intake department and the intake department would be able to give contact information. When people are admitted to psychiatry units, they are able to write down people that they would like contact with. There are privacy issues on psychiatry units that require people to or would require staff to not be able to confirm or deny that someone is hospitalized.

Dr Regina Koepp:    And that's why families when they call in-

Dr Lisa Frank:    They get frustrated.

Dr Regina Koepp:    They're like: "But, I just want to help my family member"

Dr Lisa Frank:    Right.

Dr Regina Koepp:    So they'll call into the hospital and they'll say, my family member's admitted to the psych unit and the psych unit will say, we can't confirm or deny that your loved one is here.

Dr Lisa Frank:    Right. And so then you could say, okay, I believe that my loved one, John Smith was admitted last night. If he was, here's my number. I am his daughter. I would love a call back from the treatment team. I'm happy to provide information.


How to talk with the psychiatric inpatient team when your aging parent is refusing your involvement in their care

Dr Regina Koepp:    Say the loved one who's on the psych unit is refusing family involvement. What can the family do? Because the family is like, I have to get this information, I have to see my loved one and the loved one might say, I don't want you here.

Dr Lisa Frank:    Right.

Dr Regina Koepp:    And so the family member's stuck in the cold and scared and worried and frustrated. So what can they do?

Dr Lisa Frank:    So, families are able to give information. If the person who's admitted does not want the family involved and that person has capacity and the family is not the conservator and guardian, then they have a right to dictate what information gets conveyed to their family members. But the family members can always give information to the treatment team, which is again, super helpful.

Dr Regina Koepp:    Yeah. So the family can still reach out and give information. The treatment team can't share information with the family.

Dr Lisa Frank:    Correct.

Dr Regina Koepp:    So the treatment team can say "daughter Smith. Wife Smith, husband Smith. Thank you for calling and giving us information about John Smith who's been admitted. We really want to know what John Smith's history has been and we value your input. At this time, we can't share any information. So that's what the family might hear?

Dr Lisa Frank:    Correct. The treatment team is going to want the person to have family involvement because they need that. When someone is admitted to a psychiatric unit, the nature of psychiatric units is unfortunately that they are short stays. And so from the admission, the team is thinking about how do we figure out what's going on? How do we treat it? And where is this person going to go when we stabilize them because we only have a very short amount of time to help this person rapidly stabilize and then move them to their next level of care. And so we, need to have communication with the family.

Dr Regina Koepp:    Because you also need to know what the person's, John Smith's, resources are outside of the hospital. Like where does he live and who does he live with and will it be safe for him to return home? And what does that home environment look like?

Dr Lisa Frank:    Right. And so if a person who's admitted is not allowing family involvement, the team is going to be working every day on getting that person to a place where they allow family involvement.

Dr Regina Koepp:    Wonderful.


What does a day on a psychiatric inpatient unit look like?

Dr Regina Koepp:    What does a day look like for a person who's on a psych unit?

Dr Lisa Frank:    Okay. So first they're woken up a lot to get vital signs checked and that's just the, again, the nature of the inpatient unit.

Dr Regina Koepp:    Even on a psych unit?

Dr Lisa Frank:    They have to have their vitals checked routinely. They're likely woken up pretty early in the morning to get morning medications if they're taking morning medications. Psychiatric units are very different from medical units in that they have a structured program. So breakfast is at a certain time and we always encourage people to come out to the community area...

Dr Regina Koepp:    Out of their rooms.

Dr Lisa Frank:    Out of their room. And then there's typically a group, some kind of activity for older adults. It could be a movement like, um, a chair yoga group or they could have music therapy or on a geriatric psychiatry unit they may have a memory group and so that will be the morning and there may be one or two groups for the morning and then it's lunch time and lunch is typically early. And then there may be a break and then there's another group. So there are a lot of activities.

Dr Regina Koepp:    That's what you mean by programming.

Dr Lisa Frank:    Correct. So group activities, medication administration, meals. At some time the treatment team is going to come through and take the person into either their room or an interview room and talk with them. And then the person, typically for older adults, there's going to be a period of time where they can have an nap in the afternoon.

Dr Regina Koepp:    Oh. That's nice.

Dr Lisa Frank:    A little downtime.

Dr Regina Koepp:    I would like that in my day.

Dr Lisa Frank:    And then dinner time, which will again be early and then medication administration time again for evening meds and then it's time to go to bed.


Will my aging parent be safe on a psychiatric inpatient unit?

Dr Regina Koepp:    You know, they're all ages, they're all physical levels of physical ability on a psych unit. Some psych units. And I hear families often asking, how am I going to have peace of mind knowing that my loved one's going to be safe, my loved one is a frail 78 year old woman. And, with mental illness at this time and likely dementia process happening, how, how will she be protected? How will you guys protect her from people who are also in an acute mental illness state?

Dr Lisa Frank:    Sure, sure. Okay. So there are a couple of pieces to that question. So number one is safety. So, I'll address safety first. And that is our focus for all of psychiatry and especially on inpatient units. We are very concerned with patient safety and patient safety is going to differ depending on what each person is dealing with. And so in this case, Mrs. Jones gets admitted and she is frail and if there are other patients on the unit at the same time who are younger and maybe agitated, those patients will be managed appropriately with medication treatment plan staff. And so will Mrs. Jones, she will maybe have additional staff who keep her out of the way of younger, more agitated patients. She will likely be in a room that's closer to the nurses station so that they can observe her more closely. The other thing that we worry about with the older adults who are hospitalized is falls and um, and so typically those patients who have a higher falls risk will be placed closer to the nurses station. The other piece about reassuring family members that their loved one is safe, is communicating with the staff. And so family members can call once they find the number to the inpatient unit, they can call and ask for the nurse who's assigned to their patient for the day or the charge nurse to let them know how, "how is my mom doing today? Is she safe? Is she eating? Is she taking her meds? Did she sleep last night?" And the nurse may or may not be able to answer when you call. So you may have to request a call back or you may have to call again in an hour or so to try again, and what I would convey to families is that staff on an inpatient unit are very busy managing multiple patients, managing lots of people coming and going, getting x-rays on and off the unit, giving medications. So they may not, they may be brusk or short with you on the phone. Uh, it means that they're in the middle of managing another person, or maybe your loved one and they're just not able to be as friendly and communicative as they might be at other times.


How to help your aging parent prepare for discharge

Dr Regina Koepp:    Say there is an older adult with or without dementia on a psychiatric inpatient unit and he or she is going to be discharged. How can the family best help the person who's being discharged get back home, get back into the community, you know, what's their role, how can they be helpful?

Dr Lisa Frank:    So it is... Short answer is it's really the job of the inpatient team to make sure that those pieces are in place. So one important piece is follow-up appointments and if a person is admitted to a psychiatry unit, they have to have a follow-up appointment typically within seven days from discharge with an outpatient provider, either their existing one or a new one. And that's the role of the inpatient team. And that's typically something that the social worker on the inpatient team sets up. So if the family has been communicating with the social worker and they are aware of the patient's providers, outpatient providers, that information is important to convey. But at this point it's really the family receiving information from the inpatient team, about follow up about who the person needs to follow up with. If they had a primary care doctor before and not a psychiatrist, do they now need a psychiatrist? And the inpatient team can help the family find those providers in the community if they exist.


How to find geriatric psychiatrists near you

Dr Regina Koepp:    And sometimes you just hear horror stories. I could never get in touch with the social worker. Nobody would call me back. So if the family ends up having to do it on their own, how do they find a geriatric psychiatrist?

Dr Lisa Frank:    So if a family is looking for a geriatric psychiatrist, good places to start are just to Google, Google geriatric psychiatrist in your area.Some psychiatrist advertise on psychology today, which is, um, a good resource for psychologists, but also for psychiatrists.

See more resources here!


Wrapping Up!

Dr Regina Koepp:    In wrapping up our episode for today, I wanted to remind you to download that free guide that I created just for you called Dementia 101: A Beginner's Guide to Dementia Disorders. So if this video was helpful, be sure to subscribe and don't forget to share this video with your friends who are caring for their aging parents because nobody should have to do this caregiving-thing alone. Lots of love to you and your family. I'll see you next Wednesday.



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