#446 Psychiatry Primer for the Hospitalist

July 1, 2024 | By Monee Amin

Audio

Video

Transcript available via YouTube

Anxious about psychiatry on the wards? Don’t be! Join us with guest Dr. Aaron Gluth (Emory University) as we learn about the role the hospitalist plays in managing co-morbid psychiatry conditions on the wards. 
Claim CME for this episode at curbsiders.vcuhealth.org!

Show Segments

• Intro
• Rapid fire questions/picks of the week
• Case
• Pertinent history
• Physical Exam including Mental Status Exam
• Role of the multidisciplinary team
• Work-up for reversible causes
• Agitation management
• Framework for capacity and challenging ethical scenarios
• Mortality gap
• Transitions of Care
• Outro

Psychiatry on the Wards Pearls

1. Patients with severe mental illness have a 10-20 year shorter life expectancy than the general population, attributable to physical life-limiting illness including cardiovascular disease and metabolic diseases. This is referred to as the mortality gap.
2. Due to the mortality gap, it is important to risk-stratify patients with psychiatric illness for cardiovascular disease by checking a hemoglobin A1c and lipid panel.
3. A cognitive assessment is important to diagnose delirium, which may mimic a psychiatric diagnosis. If short on time, focus on assessing areas of attention rather than orientation. 
4. In triaging the patient, remember that psychiatry units are designed as milieu units to encourage patients to be mobile and physically engage in care. If a patient is unable to participate due to ongoing medical illness, likely they are better served on the medical floor. 
5. For agitation requiring chemical restraints, individualize the therapy to the patient. Medical comorbidities may preclude use of certain medications. 
6. Always assess capacity, and remember that capacity is determined for a single specific decision.

Psychiatry Primer for the Wards

Mortality Gap of Patients Experiencing Comorbid Psych Conditions

The prevalence of psychiatric conditions in medical-surgical inpatients ranges from 15-50%, so hospitalists frequently encounter and treat patients with psychiatric disease (Schijndel, 2022). Patients with severe mental disorders (SMDs) die 10-20 years earlier than the general population, driven primarily by cardiovascular and metabolic disease, rather than suicide, homicide, or accidents (Fiorillo, 2019). Dr. Gluth suggests that the internist can have a profound impact on this population by addressing this disparity. 

History and Physical

History

First, Dr. Gluth explains that the clinician needs to establish how and why a patient came to the hospital. If psychiatric conditions preclude obtaining a clear history, seek collateral information from anyone the patient will allow. If there is a language barrier, use a medical interpreter. This will help differentiate organic disease from cultural phenomena.

Hospitalists should focus on obtaining a psychiatric and substance use history and compare the patient’s current presentation with their baseline. Useful questions to establish a patient’s baseline include questions about employment and which ADLs and IADLs they can perform. When assessing safety, Dr. Gluth emphasizes the more questions we ask, the more opportunities we will have to keep the patient safe. A complete safety assessment includes asking about suicidal ideation, homicidal ideation, prior attempts, current plans, access to means to complete a plan (e.g. firearms), and assessing the likelihood that patient would complete a plan (e.g. on a scale of 1-10 how likely are you to go through with this plan?). 

Mental Status Exam

Dr. Gluth explains that a good mental status exam can facilitate communication with psychiatry colleagues. The core components of a mental status exam are (adapted from Norris, 2016): 

• Appearance: how the patient is dressed and groomed (e.g. well-groomed, disheveled)
• Behavior: what the patient is doing (e.g. pacing, sitting calmly)
• Speech: what is their speech like (e.g. fluid, hyperverbal, pressured)
• Motor: a description of their movements (e.g. psychomotor agitation or slowing)
• Mood: the patient’s stated mood (e.g. happy, sad)
• Affect: what the patient’s expressed mood looks like (e.g. congruent with affect, bright, dysphoric)
• Thought Process: how is the patient thinking through problems (e.g. linear, logical, circumstantial, tangential, flight of ideas)
• Thought Content: what ideas do they have (e.g. suicidal ideation, homicidal ideation)
• Perceptions: are they perceiving reality accurately (e.g. hallucinations)
• Cognitive Exam: there several tests to choose from, examples include the Mini Mental Status Exam (MMSE) and the Montreal Cognitive Assessment (MoCA)

The cognitive exam is very important for inpatient clinicians as it can help identify delirium (expert opinion). Delirium increases mortality risk during and after hospitalization (Setters, 2017). If you are short on time, but you need to assess cognition, prioritize assessing attention (e.g. spelling “world” backwards, or serial 7s) rather than orientation (expert opinion). 

Physical Exam

The neurologic exam can help narrow the differential diagnosis. Assessing muscle tone and cogwheel rigidity provide insight into underlying parkinsonism or dystonia from psychiatric medications. Asterixis may suggest metabolic derangements or medication side effects. Finally, don’t forget to look for manifestations of the various toxidromes (e.g. anticholinergic, sympathomimetic, etc.). 

Multidisciplinary Team

Patients often need care from hospitalists and psychiatrists simultaneously. This dual need has led to the development of different management models ranging from the traditional consultant and primary services to combined med-psych units. Integrated models of care for medicine and psychiatry have been shown to improve psychiatric symptoms and functional outcomes, and reduce length of stay (Hussain, 2014). Regardless of the model used, clear communication between primary and consulting services is essential. 

Most psychiatry units are designed as so-called “milieu units,” meaning they incorporate patient social interaction and mobility. This can pose limitations for medically ill patients: 

• Some services common in other parts of the hospital (e.g. radiology, phlebotomy, physical therapy) may be limited or unavailable on psychiatry units. 
• Medical equipment like Hoyer lifts or tube feeding pumps may not be available, and may prevent patients from fully participating in the milieu. 
• Psychiatric nurses often excel at de-escalation and boundary-setting with patients, but may lack supplies or experience to deal with lines and tubes. 
• Isolation precautions may be a barrier to participation in the milieu. 

Reversible Causes 

Dr. Gluth reminds us that while some patients with new psychiatric decompensation have reversible non-psychiatric causes, the typical work-up is often too broad. He recommends prioritizing tests for the “can’t miss” diagnoses and tests to risk-stratify patients for cardiovascular disease. Below is a list of tests he recommends for everyone:

• Syphilis and HIV testing
• Vitamin B12
• TSH
• Urine drug screens
• A1c and lipids (an opportunity to modify cardiovascular risk factors while the patient is engaged in the system). 

Below is a list of tests to consider in specific scenarios: 

• Vitamin B1: treat empirically if suspicious, recalling that thiamine deficiency can occur with or without a history of alcohol use. 
• Vitamin D: has shown some benefit in depression, although effect size remains uncertain (Parker, 2017). Additionally, it should be checked in patients who are on anti-epileptic drugs as mood stabilizers, since these can have deleterious effects on bone health (Scinischalchi, 2020)
• Drug levels: if the patient is on a drug whose serum levels can be tested (e.g. Lithium, Valproic acid), drug levels may be useful. 
• Alcohol level: consider if concern for unreported alcohol use 
• Imaging: may be useful in patients with trauma, focal neurologic deficits, or neurologic symptoms. Also consider imaging in immunocompromised, geriatric, or anticoagulated populations (Chow, 2019).

He recommends against folate testing in the hospitalized patient (Breu, 2015) due to poor test characteristics and low prevalence of folate deficiency. 

Agitation

Regardless of the cause of the agitation, the first line therapy is verbal redirection. When a patient is agitated, try to determine the underlying cause. If agitation is due to an underlying psychiatric disorder, this can influence medication choices to control agitation. However, if delirium is from a metabolic cause, fix the underlying metabolic cause. Even in the setting of agitated delirium, there may be a point that safety becomes a concern and chemical restraints are the only option (Pahwa, 2019). 

Dr. Gluth suggests that in a young, healthy patient, consider using a combination of antipsychotic, benzodiazepine, and anticholinergic medications, such as haloperidol, lorazepam, and diphenhydramine. Oral medications should be offered as first-line to maintain patient autonomy and reduce side effects, but if this is not an option due to the degree of agitation, intramuscular administration may be required. However, in the elderly or patients at risk for delirium, avoid benzodiazepines and anticholinergics, and favor antipsychotics as monotherapy. Start with the lowest dose of antipsychotic and increase dose as needed based on response (Wolfe, 2023). 

Capacity

When complicated medical decisions arise, the clinician will need to assess the patient’s decision-making capacity. Dr. Gluth reminds us to take the benefits and risks of any proposed intervention into account in your conversation to assess capacity (Barstow, 2018). To help you assess risk and benefit, consider these questions:

• What alternatives could provide similar information? If a patient is paranoid about a CT scan, do not assume they will be paranoid about an MRI.
• How urgent is the intervention? Can it wait until medications have taken effect?
• What is the big-picture goal for the patient? 
• If a patient does not have capacity, are there interventions that can improve the likelihood of regaining capacity? For example, if the patient has neurosyphilis, can we wait until they have completed treatment and then reassess capacity? 
• Consider the benefits of the intervention, length of intervention, burden to the patient, and aftercare of the intervention.
• Consider the risks of the intervention and the risks associated with potentially forcing the patient into the intervention (physical restraints or regular use of chemical restraints). 

Links

1. Nicholas Cage
2. Vampire’s Kiss
3. Unbearable Weight of Massive Talent
4. Costa Rica 
5. San Diego Zoo

Goal

To equip healthcare clinicians to address the complex needs of patients with co-morbid psychiatric conditions in a hospital setting, with a focus on delivering comprehensive and patient-centered care.

Learning objectives

After listening to this episode listeners will…  

1. Describe the prevalence and impact of co-morbid psychiatric conditions in hospitalized patients, including their contribution to the mortality gap observed in individuals with severe mental disorders.
2. Identify reversible causes of psychiatric decompensation through appropriate diagnostic workup, including laboratory tests and imaging studies, and integrate findings into treatment plans.
3. Assess and address capacity to make informed medical decisions in patients with co-morbid psychiatric conditions, considering factors such as risk-benefit analysis, urgency of intervention, and potential interventions to improve or regain capacity.

Disclosures

Dr. Gluth reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

Trubitt, M, Amin, M, Coleman, C,  Gluth, A, Williams PN, Watto MF. “#446 Psychiatry Primer for the Hospitalist. The Curbsiders Internal Medicine Podcast”. thecurbsiders.com/category/curbsiders-podcast  July  1, 2024.