Managing Psychiatric Symptoms in the Acute Med/Surg Setting

Where?

• ED• ICU• Med/Surg floors• OB/Gyn floor• Waiting areas, etc.• In short, EVERYWHERE!

Why?

• Sepsis• Substance Intoxication/Withdrawal• Electrolyte imbalance• Hepatic Dysfunction• CVA• Drug toxicity• Hyper or hypothyroidism

• Renal Dysfunction• Hypoxia• Head injury

How Do They Present?IN ED-

Overdose

AMS

Psychotic symptoms (not taking psychotropic meds)

Substance intoxication

Suicidal thoughts/ Suicide attempt

Self harming behaviors

Other floors- ANY Diagnosis and

Psychosis

Agitation/ Combativeness

Confusion

Delirium tremens/Drug withdrawal

Anxiety/Panic attacks

Depression

Pre-existing psychiatric illness

Diagnostic Tests

• CBC• Electrolytes• BUN, Creatinine• LFTs, Ammonia• Drug screen, therapeutic drug levels• Thyroid panel• CT Head

Case Studies

Betty is a 65 y/o white female who presents to ED with AMS- brought in from home by EMS. Betty denies any drug use and says she only drinks occasionally. She is a poor historian. CBC, Lytes, BUN, Creat are all WNL. CT of the head is normal. Betty is talking nonsense and having conversations with imaginary people in the room.

Case Studies

Joe is a 19 y/o white male who presents to ED with AMS- brought in by police because he was running naked down FM 1960 at 9AM. He is delusional- thinks aliens are after him. He sees the alien creatures out in the hall and hears them taunting him, saying they will kill him. Joe is afraid, he is screaming, and he wants to run away.

Case studies

Mary is a 58 y/o black female. She was admitted for DKA 4 days ago. She was in ICU for a few days on an insulin drip, but is now on the floor in more stable condition. You notice Mary is crying on and off throughout the day, and ask her what is wrong. She tells you that she lost her husband about a year ago.

Mary says she stays at home alone and cries all the time. She does not care about her diabetic diet and eats whatever is on hand. Friends and family bring her food so she doesn’t have to go to the store. Her blood sugar is always high (when she remembers to check it). She says she forgets to take her medications fairly often, and her B/P has been running high, too.

Case Studies

David is a 28 y/o Hispanic male who was admitted through ED for an infected wound on his left 5th toe. He is a type I diabetic (since age 8) and is now on an insulin pump. David seems like a nice fellow-pleasant and talkative. He tells you his medical history in detail. You notice his speech is rapid. He says he is disabled, but that he does many things.

When you ask him what kinds of things he has done, he replies, “What have I done? What haven’t I done?!” David proceeds to inform you that he is the number one, top record producer of Hip Hop artists in Houston, and in the nation, and that he has won numerous awards. He also owns a recording studio, a private jet, a yacht, and he is friends with Kanye West and the Kardashians.

David denies any history of mental illness or substance abuse. His toe has osteomyelitis, and is starting to look gangrenous. He refuses amputation of his toe, even though the consequences have been explained to him. A psychiatric consult is ordered. David says he knows better than the doctors.

His mother and aunt appear to be afraid of him, and will not contradict anything he says. The mother will shake her head “No” when he is saying things that are not true if she is sure he cannot see her. They do his bidding, as they have done all of his life.

Being One Step AheadAccurate Patient History is Critical• Current meds• Alcohol/Substance use• Previous psychiatric treatment• Suicide attempt/ Suicidal thoughts• Sleep pattern• Appetite issues

Problems Associated with Depression

• Chronic illness• Grief• Feelings of failure- fear of losing job,

relationship• Newly diagnosed illness• Terminal illness diagnosis• Feeling hopeless, overwhelmed

Depression Statistics• 6.7% of American adults experience MDD

each year.• Women are 70% more likely to experience

MDD than men in their lifetime.• Average age of onset is 32 years.• 3.3% of 13-18 year olds have experied a

debilitating depressive disorder.• Non-Hispanic blacks are 40% less likely

than Non-Hispanic whites to experience depression in their lifetime

DALYs- Disability Adjusted Life Years

The sum of years of potential life lost due to premature mortality and the years of productive life lost due to disability.

Ten leading causes of burden of disease, world, 2004 and 2030

People who have depression along with another medical illness-

• Tend to have more severe symptoms of both illnesses

• Have more difficulty adjusting to their medical condition

• Have more medical costs

(When compared to people without depression)

Treating the depression can improve the outcome of treating the co-occurring illness.

Problems Associated with Anxiety

• Worry about self, home, job, relationships• Confinement to hospital• Fear of illness effects, need for treatment

• Money worries• OCD• Panic disorders• PTSD

Anxiety Statistics

• Anxiety disorders affect 40 million American adults (18%) each year.

• Women are 60% more likely than men to experience an anxiety disorder in the lifetime.

• Non-Hispanic blacks are 20% less likely than Non-Hispanic whites to experience an anxiety disorder in their lifetime.

• About 8% of 13-18 year olds have an anxiety disorder.

• Only 18% of those 13-18 year olds receive mental health care.

• Symptoms commonly emerge around the age of 6.

Schizophrenia Statitics

• About 1% of Americans have this illness.• Men and women are affected equally.• Rates are similar in all ethnic groups around

the world.• Usual onset is at ages 16-30.• Men usually show symptoms earlier than

women.

• People usually don’t develop schizophrenia after age 45.

• Rarely seen in children, but childhood onset is increasing.

Psychotic Symptoms

Hallucinations, Delusional Thoughts, Bizarre Behaviors• Substance intoxication• Psychosis in Psychiatric illness• Dementia• Delirium• Substance withdrawal

Agitation

• Patient is yelling, cursing• Patient is combative• Patient is trying to leave the hospital• Patient is violent toward others

Management

• Keep patient and others safe• Treat associated cause• Keep environment calm and quiet• Provide reassurance• Monitor closely• Re-orient patient• Maintain a safe distance from patient when

they are agitated

Tools

• Medications-

Benzodiazepines

Antipsychotics• Sitters• Restraints• Use of protocols

MAT

• MAT assesses patients for transfer to inpatient psychiatric hospitals.

• MAT is made up of Social Workers• MAT cannot prescribe medication• MAT can tell you if a patient meets criteria

for transfer to an inpatient psychiatric hospital and assist with the paperwork.

• MAT can assist with the EDO process.

DSRIP (Delivery System Reform

Incentive Payment)• SW visits patients who are at high risk of

being readmitted in 30 days.• SW offers the patients to participate in our

program after discharge from the hospital.• Follow up phone calls for 30 days• Visit in the home by Nurse Aide with

Facetime visit from Psychiatric APRN.

• SW offers resources to patient in hospital prior to D/C whether or not they choose to participate in DSRIP program.

• SW and Psych APRN will see patients not on DSRIP list if asked to do so.

• All adult patients on MedSurg floors, in ICU, ED, Obs should have D2S2 screen done on admission and every 8 days.

Moving Forward

• Communicate• Educate• Disseminate• Represent

ANY QUESTIONS???

THANK YOU!!!