Consultation and liaisonConsultation and liaisonConsultation and liaison Consultation and liaison psychiatry psychiatry

Gábor Gazdag MD, PhDGábor Gazdag MD, PhD

Szent István and Szent László Hospitals,Szent István and Szent László Hospitals,ConsultationConsultation--Liaison Psychiatric ServiceLiaison Psychiatric Service

DefinitionDefinitionDefinitionDefinition

ConsultationConsultation--Liaison Psychiatry is a subLiaison Psychiatry is a sub--specialty of psychiatry that incorporatesspecialty of psychiatry that incorporatesspecialty of psychiatry that incorporates specialty of psychiatry that incorporates clinical service, teaching, and research at clinical service, teaching, and research at the borderland of psychiatry and medicinethe borderland of psychiatry and medicinethe borderland of psychiatry and medicine.the borderland of psychiatry and medicine.(Lipowski, 1983)(Lipowski, 1983)

Where did the name (CWhere did the name (C--L) come from?L) come from?

What is consultationWhat is consultation--liaison liaison psychiatry?psychiatry?

Liaison psychiatryLiaison psychiatry, also known as , also known as consultative consultative psychiatrypsychiatry or or consultationconsultation--liaison psychiatryliaison psychiatry (also, (also, psychosomatic medicinepsychosomatic medicine) is the branch of) is the branch of psychiatrypsychiatrypsychosomatic medicinepsychosomatic medicine) is the branch of ) is the branch of psychiatrypsychiatrythat that specialises in the interface between other specialises in the interface between other medical specialties and psychiatrymedical specialties and psychiatry, usually taking , usually taking place in aplace in a hospital or medical settinghospital or medical setting "Consults" are"Consults" areplace in a place in a hospital or medical settinghospital or medical setting. Consults are . Consults are called when the primary care team has questions about called when the primary care team has questions about a patient's mental health, or how that a patient's mental health, or how that patient's mental patient's mental health is affecting his or her care and treatmenthealth is affecting his or her care and treatment TheThehealth is affecting his or her care and treatmenthealth is affecting his or her care and treatment. The . The psychiatric team works as a "liaison" between the psychiatric team works as a "liaison" between the medical team and the patient. medical team and the patient. Issues that ariseIssues that arise include include capacity to consentcapacity to consent to treatmentto treatment conflictsconflicts with thewith thecapacity to consentcapacity to consent to treatment, to treatment, conflictsconflicts with the with the primary care team, and the primary care team, and the intersection of problemsintersection of problems in in both physical and mental health, as well as patients who both physical and mental health, as well as patients who may report physical symptoms as a result of amay report physical symptoms as a result of a mentalmentalmay report physical symptoms as a result of a may report physical symptoms as a result of a mental mental disorderdisorder[1][1]. (Wikipedia). (Wikipedia)

What is consultationWhat is consultation--liaison liaison psychiatry’s present position?psychiatry’s present position?

The American Board of Psychiatry and The American Board of Psychiatry and Neurology: recommended subspecialty forNeurology: recommended subspecialty forNeurology: recommended subspecialty for Neurology: recommended subspecialty for ConsultationConsultation--Liaison Psychiatry renaming it Liaison Psychiatry renaming it Psychosomatic MedicinePsychosomatic MedicineJune 2001: American Psychiatric Association June 2001: American Psychiatric Association Board of Trustees supported applicationBoard of Trustees supported application2003: American Board of Medical Specialties 2003: American Board of Medical Specialties approved the recommendationapproved the recommendation

Psychosomatic Medicine became the 7thPsychosomatic Medicine became the 7thPsychosomatic Medicine became the 7th Psychosomatic Medicine became the 7th subspecialty in Psychiatrysubspecialty in Psychiatry

History of Consultation History of Consultation –– Liaison Liaison yyPsychiatryPsychiatry

Its early origins reflect the emergence of General Its early origins reflect the emergence of General Hospital Psychiatry. Hospital Psychiatry. In the 1920s psychiatry became closer to medicine In the 1920s psychiatry became closer to medicine as hospitals started to establish psychiatric units . as hospitals started to establish psychiatric units . Th t f h ti l ti hi dTh t f h ti l ti hi dThe concept of psychosomatic relationships and The concept of psychosomatic relationships and the role of emotions and psychological states in the role of emotions and psychological states in the genesis and maintenance of organic diseasesthe genesis and maintenance of organic diseasesthe genesis and maintenance of organic diseases the genesis and maintenance of organic diseases emerged.emerged.Thus, Consultation Thus, Consultation –– Liaison Psychiatry became Liaison Psychiatry became ,, y yy yan applied form of psychosomatic medicine. an applied form of psychosomatic medicine.

Characteristics of pCharacteristics of psychosomatic sychosomatic pp yymedicinemedicine

1) Studies the correlations of 1) Studies the correlations of psychological and social phenomena psychological and social phenomena with physiological functionswith physiological functions

2) Focuses on the interplay of biological 2) Focuses on the interplay of biological and psychosocial factors in theand psychosocial factors in theand psychosocial factors in the and psychosocial factors in the development, course and outcome of development, course and outcome of all diseasesall diseasesall diseases. all diseases.

3) Advocates the biopsychosocial 3) Advocates the biopsychosocial approach to patient careapproach to patient careapproach to patient care. approach to patient care.

Consultation styleConsultation styleConsultation styleConsultation style

Characteristics of effective psychiatric Characteristics of effective psychiatric consultant (Goldman, Lee, Rudd, 1983):consultant (Goldman, Lee, Rudd, 1983):consultant (Goldman, Lee, Rudd, 1983):consultant (Goldman, Lee, Rudd, 1983):

1.1. Talks with the referring physician, nursing Talks with the referring physician, nursing and other staff before and after and other staff before and after consultation. Clarifying the reason for the consultation. Clarifying the reason for the consultation is the initial goalconsultation is the initial goalconsultation is the initial goal.consultation is the initial goal.

2. Establishes the level of urgency.2. Establishes the level of urgency.

ASSESSMENTASSESSMENTASSESSMENTASSESSMENTThe consultant should establish the The consultant should establish the URGENCYURGENCY of of

the consultation (i.e., emergency or routinethe consultation (i.e., emergency or routine——within within 24 h )24 h )24 hours).24 hours).Commonly, requests for psychiatric consultation Commonly, requests for psychiatric consultation

fall into several general categories:fall into several general categories:1. Evaluation of a patient with 1. Evaluation of a patient with suspected psychiatricsuspected psychiatricdisorder, a psychiatric history, or use ofdisorder, a psychiatric history, or use ofppsychotropic medications.sychotropic medications.2. Evaluation of a patient who is 2. Evaluation of a patient who is acutely agitated.acutely agitated.

Requests for psychiatric consultationRequests for psychiatric consultation3. Evaluation of a patient who expresses 3. Evaluation of a patient who expresses

suicidal or homicidal ideation.suicidal or homicidal ideation.4. Evaluation of a patient who is at 4. Evaluation of a patient who is at high risk for high risk for

psychiatric problemspsychiatric problems by virtue of serious by virtue of serious p y pp y p yymedical illness.medical illness.

5. Evaluation of a patient who requests to see a5. Evaluation of a patient who requests to see a5. Evaluation of a patient who requests to see a 5. Evaluation of a patient who requests to see a psychiatrist.psychiatrist.

6 Evaluation of a patient with a medicolegal6 Evaluation of a patient with a medicolegal6. Evaluation of a patient with a medicolegal 6. Evaluation of a patient with a medicolegal situationsituation

7 E l ti f ti t ith k7 E l ti f ti t ith k7. Evaluation of a patient with known or 7. Evaluation of a patient with known or suspected suspected substance abusesubstance abuse..

Reasons for consultation (own data)Reasons for consultation (own data)( )( )3%

1% 3% 5%Not known

4%Psychiatric symptoms

19%8% No organic basis for the

symptoms

N liNoncompliance

Positíve psychiatric history,p y ytherapy revision request

Legal reason

57% follow up

More contemporal reasons

Common psychiatric symptoms as Common psychiatric symptoms as p y y pp y y preasons for consultationreasons for consultation

DepressionDepressionAgitationAgitationAgitationAgitationDisorientationDisorientationHallucinationsHallucinationsAnxietyAnxietyAnxietyAnxietySleep disorderSleep disorderS icide attempt or threatS icide attempt or threatSuicide attempt or threatSuicide attempt or threatBehavioural disturbanceBehavioural disturbance

No organic basis for symptoms (8%)No organic basis for symptoms (8%)No organic basis for symptoms (8%)No organic basis for symptoms (8%)

Conversion disorder: different neurologic Conversion disorder: different neurologic symptoms(anesthesia, paresthesia, seizures, symptoms(anesthesia, paresthesia, seizures, etc) with autonomic nervous system symptomsetc) with autonomic nervous system symptomsSomatization disorderSomatization disorder (Briquet sy): multiple (Briquet sy): multiple ( q y) p( q y) pbody complaintsbody complaintsFactitious disorder: wish to be hospitalized (wishFactitious disorder: wish to be hospitalized (wishFactitious disorder: wish to be hospitalized (wish Factitious disorder: wish to be hospitalized (wish for attention)for attention)--provoking physical symptoms (e.g. provoking physical symptoms (e.g. fever, hypoglycaemia)fever, hypoglycaemia)fever, hypoglycaemia)fever, hypoglycaemia)Malingering: obvious secondary gain Malingering: obvious secondary gain (compensation case)(compensation case)(compensation case)(compensation case)

PrevalencePrevalence of somatizationof somatizationPrevalencePrevalence of somatizationof somatizationM di ll l i dM di ll l i dMedically unexplained symptomsMedically unexplained symptoms–– Common in community samplesCommon in community samplesy py p

General practice / New outGeneral practice / New out--pt referralspt referrals–– Up to 40% have symptoms for which no organic Up to 40% have symptoms for which no organic

cause is identifiedcause is identified

‘Much less common’ in in‘Much less common’ in in--pt samplespt samples (8%)(8%)–– Majority of pMajority of patienatients reassuredts reassured

Minority persist or develop other symptomsMinority persist or develop other symptoms–– Strong association between number of somatic Strong association between number of somatic

symptoms reported and likelihood of underlying symptoms reported and likelihood of underlying mental illnessmental illnessmental illnessmental illness

Aetiological factorsAetiological factorsAetiological factorsAetiological factorsChildhood experienceChildhood experience–– IllnessIllness–– Lack of parental careLack of parental care

–– Physical illness triggers care and attention which otherwise Physical illness triggers care and attention which otherwise they would not receivethey would not receiveyy

Lack of social supportLack of social supportFamily reFamily re--inforcementinforcementFamily reFamily re inforcementinforcement–– OverOver--solicitous care or ‘helpful advice’solicitous care or ‘helpful advice’

Iatrogenic causesIatrogenic causesIatrogenic causesIatrogenic causes

Iatrogenic causesIatrogenic causesIatrogenic causesIatrogenic causesM di li i f ’M di li i f ’Medicalisation of pt’s symptomsMedicalisation of pt’s symptoms–– OverOver--investigationinvestigationgg–– Inappropriate treatmentInappropriate treatment

Especially by junior doctorsEspecially by junior doctorsEspecially by junior doctorsEspecially by junior doctors–– Failure to provide clear explanation for Failure to provide clear explanation for

symptomssymptomssymptomssymptomsIncreasing uncertainty and anxietyIncreasing uncertainty and anxiety

F il t i d t t ti lF il t i d t t ti l–– Failure to recognise and treat emotional Failure to recognise and treat emotional factorsfactors

Consequences of somatisationConsequences of somatisationConsequences of somatisationConsequences of somatisation

–– Unnecessary use of healthcareUnnecessary use of healthcareInvestigationsInvestigationsAdmissions for treatment / operations Admissions for treatment / operations

–– Often making matters worseOften making matters worse

–– Prescribed drug misuse and dependencePrescribed drug misuse and dependence–– Disability and loss of earningsDisability and loss of earnings

Social disability paymentsSocial disability paymentsy p yy p y–– Poor quality of lifePoor quality of life

Impact on family / social networkImpact on family / social networkImpact on family / social networkImpact on family / social network

Functional somatic syndromesFunctional somatic syndromesFunctional somatic syndromesFunctional somatic syndromes

GastroenterologyGastroenterology Irritable Bowel SyndromeIrritable Bowel SyndromeFunctional dyspepsiaFunctional dyspepsiaCardiologyCardiology Atypical chest painAtypical chest painNeurologyNeurology Common HeadacheCommon HeadachegygyChronic fatigue syndromeChronic fatigue syndromeRheumatologyRheumatology FibromyalgiaFibromyalgiaComplex regional pain syndromesComplex regional pain syndromes(Reflex sympathetic dystrophy)(Reflex sympathetic dystrophy)GynaecologyGynaecology Chronic pelvic painChronic pelvic painOrthopaedicsOrthopaedics Chronic back painChronic back pain

Approach to managementApproach to managementApproach to managementApproach to management

Identify features of organic diseaseIdentify features of organic disease–– Overlaying psychological elementsOverlaying psychological elements

Establish degree of insightEstablish degree of insightg gg g–– Extent to which they recogniseExtent to which they recognise

psychological basis for their problemspsychological basis for their problemspsychological basis for their problemspsychological basis for their problems–– Extent to which they ‘want out’Extent to which they ‘want out’

Determine the appropriate programmeDetermine the appropriate programmeDetermine the appropriate programmeDetermine the appropriate programme–– Physical / psychological / bothPhysical / psychological / both

Characteristics of effective psychiatric Characteristics of effective psychiatric p yp yconsultant (Goldman, Lee, Rudd, 1983):consultant (Goldman, Lee, Rudd, 1983):3. Reviews the chart and the data thoroughly.3. Reviews the chart and the data thoroughly.4. Performs a complete mental status exam and4. Performs a complete mental status exam and4. Performs a complete mental status exam and 4. Performs a complete mental status exam and

relevant portions of a history and physical exam.relevant portions of a history and physical exam.5 Obtains medical history from family members or5 Obtains medical history from family members or5. Obtains medical history from family members or 5. Obtains medical history from family members or

friends as indicated.friends as indicated.6 M k t b i f i t6 M k t b i f i t6. Makes notes as brief as appropriate.6. Makes notes as brief as appropriate.7. Arrives at a tentative diagnosis.7. Arrives at a tentative diagnosis.8. Formulates a differential diagnosis.8. Formulates a differential diagnosis.9 Recommends diagnostic tests9 Recommends diagnostic tests9. Recommends diagnostic tests.9. Recommends diagnostic tests.

Characteristics of effective psychiatric Characteristics of effective psychiatric consultant (Goldman Lee Rudd 1983):consultant (Goldman Lee Rudd 1983):consultant (Goldman, Lee, Rudd, 1983):consultant (Goldman, Lee, Rudd, 1983):10 Has the knowledge to prescribe psychotropic10 Has the knowledge to prescribe psychotropic10. Has the knowledge to prescribe psychotropic 10. Has the knowledge to prescribe psychotropic

drugs and be aware of their interactions.drugs and be aware of their interactions.11 M k ifi d ti th t11 M k ifi d ti th t11. Makes specific recommendations that are 11. Makes specific recommendations that are

brief, goal oriented and free of psychiatric jargon brief, goal oriented and free of psychiatric jargon andand disc sses findingsdisc sses findings and recommendationand recommendationand and discusses findingsdiscusses findings and recommendation and recommendation with consultee with consultee –– In personIn person whenever possible.whenever possible.

12. Respects patient’s rights to know that the 12. Respects patient’s rights to know that the identified “customer” is the consulting physician. identified “customer” is the consulting physician. (m(maintaining absolute Doctoraintaining absolute Doctor--Patient Patient confidentiality is not possible for a psychiatric confidentiality is not possible for a psychiatric consultantconsultant))

Characteristics of effective psychiatric Characteristics of effective psychiatric p yp yconsultant (Goldman, Lee, Rudd, 1983):consultant (Goldman, Lee, Rudd, 1983):

13. 13. FFollowollowss--up patient until they are discharged from up patient until they are discharged from the hospital or clinic or until the goals of the the hospital or clinic or until the goals of the consultation are achieved.consultation are achieved. AArranges outrranges out--patient patient carecare--if necessary.if necessary.

14. Does not take over the aspects of the patient’s 14. Does not take over the aspects of the patient’s medical care unless asked to do so.medical care unless asked to do so.medical care unless asked to do so.medical care unless asked to do so.

15. Follows advances in the other medical fields and 15. Follows advances in the other medical fields and is not isolated from the rest of the medicalis not isolated from the rest of the medicalis not isolated from the rest of the medical is not isolated from the rest of the medical community.community.

The ”fThe ”formal”ormal” consultantconsultantThe fThe formalormal consultantconsultant

Works in a the traditional psychiatric setting, Works in a the traditional psychiatric setting, starts, and arrives back therestarts, and arrives back therestarts, and arrives back there starts, and arrives back there

The liaison psychiatrist

Works on the ”Terra incognita” field b t ti d hi t ibetween somatic and psychiatric care.

TheThe ”f”formal”ormal” The LiaisonThe The fformal ormal consultantconsultant

The Liaison psychiatrist

Set up the diagnoseSet up the diagnoseConsultationConsultation

ti t t dti t t dSet up the diagnoseSet up the diagnoseTreatTreat

–– patient centredpatient centredLiaisonLiaison

Act as a Act as a dispatcherdispatcher –– team team centredcentred

The The ”l”liberating iberating troop”troop” Member of the teamMember of the teamtrooptroop

Patterns of Patterns of liaisonliaisonss

P iPrimary care physician

Primary care physician

Patient Consultant ConsultantPatientT di i l i C l i d l

Primary care

Traditional setting Consultation model

physician

PatientPatient ConsultantConsultantConsultationConsultation Liaison modelLiaison modelConsultationConsultation--Liaison modelLiaison model

Psychiatric disorders in the Psychiatric disorders in the yymedical settingmedical setting

As many as 30% of patients have a psychiatric As many as 30% of patients have a psychiatric disorder.disorder.disorder.disorder.

2/3 of patients who are high users of medical 2/3 of patients who are high users of medical p gp gcare have a psychiatric disturbance.care have a psychiatric disturbance.

D li i i d t t d i 10% f ll di l iD li i i d t t d i 10% f ll di l iDelirium is detected in 10% of all medical inDelirium is detected in 10% of all medical in--patients & in over 30% in some high risk groups.patients & in over 30% in some high risk groups.

The presence of a psychiatric disturbance is The presence of a psychiatric disturbance is associated with increased hospital length of stay associated with increased hospital length of stay p g yp g yOR an increased medical readmission rate.OR an increased medical readmission rate.

Psychiatric disorders in the medical Psychiatric disorders in the medical yysettingsetting

Only a small subset of patients is currently Only a small subset of patients is currently being identified.being identified.being identified.being identified.

The percentage of patients receivingThe percentage of patients receivingThe percentage of patients receiving The percentage of patients receiving psychiatric consultation varies from 1% to psychiatric consultation varies from 1% to 10%.10%.10%.10%.

There is a great disparity between the amountThere is a great disparity between the amountThere is a great disparity between the amount There is a great disparity between the amount of psychiatric pathology that exists in the of psychiatric pathology that exists in the medical setting and that which is identified bymedical setting and that which is identified bymedical setting and that which is identified by medical setting and that which is identified by medical staff.medical staff.

Psychiatric diff diagnoses in medical Psychiatric diff diagnoses in medical ttittisettingssettings

Psychiatric presentations of medicalPsychiatric presentations of medicalconditions

Psychiatric complications of medicalPsychiatric complications of medicalconditions or treatments

P h l i l ti t di l ditiPsychological reactions to medical conditions or treatments

M di l i f hi iMedical presentations of psychiatricconditions

Medical complications of Psychiatricconditions or treatments

Comobid Medical and Psychiatric conditions

The Consultation note

Is best if brief and focused on the referring physician’s concerns with attention to all domains.

Avoid using jargons or other wording that is likely to be unfamiliar to other physicians.The note needs to be titled with mention “Psychiatry”

and “Consultation” . The history of present illness should include the y p

relevant data from the history that may have significanceThe consultant’s objective findings on mental status The formulation, diagnosis, recommendations shouldThe formulation, diagnosis, recommendations should

be written concisely.

DiagnosisDiagnosis

The consultant should organize the diagnosis ti di t th DSM IV’ lti i lsection according to the DSM-IV’s multiaxial

guideline.Axis I or II diagnosis cannot always be made at

the time of the initial consultation. Only the one or two central medical diagnoses should be included on Axis IIISignificant medical and psychological stressors can be noted and documented on Axis IV.can be noted and documented on Axis IV.Axes IV and V may be omitted if the consultant

feels they will not be useful or familiar to thefeels they will not be useful or familiar to the consultee.

DSMDSM IV axesIV axesDSMDSM--IV axesIV axes

Axis I: Clinical disorders, including major Axis I: Clinical disorders, including major mental disorders, and learning disorders mental disorders, and learning disorders ggAxis II: Personality disorders and mental Axis II: Personality disorders and mental retardationretardationretardation retardation Axis III: Acute medical conditions and Axis III: Acute medical conditions and physical disordersphysical disordersphysical disorders physical disorders Axis IV: Psychosocial and environmental Axis IV: Psychosocial and environmental factors contributing to the disorder factors contributing to the disorder Axis V: Global assessment of functioningAxis V: Global assessment of functioninggg

Diagnostic Testing and Consultationg g

Th C L lt t t b f ili ithThe C-L consultant must be familiar with diagnostic testing regarding:

The indications for anatomic brain imaging or g gneurophysiological screening by CT, MRI, EEG, etc.

The indications for the administration ofThe indications for the administration of neuropsychological testing

Follow-UppThe scope, frequency, and necessity of follow-

i it d d th t f th i iti lup visits depend on the nature of the initial diagnosis and recommendations.

Follow-up visits reinforce the consultant’s precommendations and allow the consultant toEvaluate results of recommendationsEvaluate results of recommendationsPrioritize relative importance of particular interventionsinterventionsPrevent breakdowns in communication between

lt t d ltconsultants and consultees.

Follow-UpFollow Up

At least daily follow-up should be considered for several types of patients:yp p

Those in restraints Constant observationConstant observationAgitated, potentially violent, or suicidalDeliriumPsychotic or psychiatrically unstable.y p y yAcutely ill patients started on psychoactive

medications should be seen daily untilmedications should be seen daily until they have been stabilized.

INTERVENTIONSINTERVENTIONS

Psychotherapy:Psychotherapy:

The modality introduced should be primarily selectedprimarily selectedin response to the patient’s needs.p p

No single psychotherapeutic modality will be effective with all patients, at allwill be effective with all patients, at all times, in the medical setting.

Pharmacotherapy andOther Somatic Therapies

35% f hi t i lt ti i l d35% of psychiatric consultations include recommendations for medications.

About 10%–15% of patients require reduction p qor discontinuation of psychotropic medications.

Appropriate use of psychopharmacologyAppropriate use of psychopharmacology necessitates a careful consideration of the underlying medical illness drug interactionsunderlying medical illness, drug interactions, and contraindications.

Ph th f th di ll ill ftPharmacotherapy of the medically ill often involves modification in dosage because of liver, kid di di b fkidney, or cardiac disease, or because of potential for multiple drug–drug interactions.

Pregnancy presents another challenge, with g y p g ,concerns regarding potential teratogenicity.

The C-L psychiatrist must be knowledgeable about electroconvulsive therapy (ECT)about electroconvulsive therapy (ECT)

Important field of CImportant field of C L activity 1: NoncomplianceL activity 1: NoncomplianceImportant field of CImportant field of C--L activity 1: NoncomplianceL activity 1: Noncompliance

Negative transference between patient andNegative transference between patient andNegative transference between patient and Negative transference between patient and primary care doctorprimary care doctorFear of medication or procedureFear of medication or procedureImpaired cognitive capacityImpaired cognitive capacityImpaired cognitive capacityImpaired cognitive capacity

Noncompliance study Noncompliance study ( t ti h t i )( t ti h t i )(retrospective chart review)(retrospective chart review)

1020 consultations between 11/99 and 11/041020 consultations between 11/99 and 11/041020 consultations between 11/99 and 11/04.1020 consultations between 11/99 and 11/04.In 22 cases the reason of the consultation was: In 22 cases the reason of the consultation was:

noncompliance (2 2%)noncompliance (2 2%)noncompliance (2,2%)noncompliance (2,2%)

45%45%

55%

M lMale

Female

Psychiatric syndromes behind Psychiatric syndromes behind y yy ynoncompliancenoncompliance

1; 5%2; 9%

No psychiatric diagnosis

1; 5%4; 18%

2; 9%

Affective disorder

Org.psychosyndrome

D ti4; 18%

Dementia

Addiction9; 40%

4% Adjustment disorder

Schizofrenia

Basic Basic somatic disordersomatic disorderss25

percent20

percent

15Noncompliance

5

10all cases

0

5

0 cardiolog

pulmonol

nephrolo g

hepatolog

gastroent

neurolog y

ophtalmo

diabetolo

urology

rheumato

oncolog y

endocrino

dermatolo

hematoloy ogy

gy

gy erology

y logy

gy logy

y ology

ogy

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ConclusionsConclusionsConclusionsConclusions

In patients with chronic illnessIn patients with chronic illnessIllness behavior frequently negativeIllness behavior frequently negativeIllness behavior frequently negative Illness behavior frequently negative (ambivalence, psychosocial factors)(ambivalence, psychosocial factors)Noncompliance can result rapid somatic Noncompliance can result rapid somatic deterioration (DM) that can result hospitaldeterioration (DM) that can result hospitaldeterioration (DM) that can result hospital deterioration (DM) that can result hospital admissionadmissionN li b t fN li b t fNoncompliance can be a symptom of a Noncompliance can be a symptom of a hidden psychiatric disorderhidden psychiatric disorder

Important field of CImportant field of C--L activity 2: deliriumL activity 2: delirium

D li i i COMMOND li i i COMMONDelirium is COMMONDelirium is COMMONSymptoms areSymptoms are alarmingalarming1010--15% of patients on surgical ward and 1515% of patients on surgical ward and 15--25% 25% on general ward experience episode of delirium on general ward experience episode of delirium g p pg p pduring hospital stay.during hospital stay.3030--40% of hospitalized patients over age 6540% of hospitalized patients over age 653030 40% of hospitalized patients over age 65 40% of hospitalized patients over age 65 have had an episode of delirium.have had an episode of delirium.30%30% 90% patient in ICU experience delirium90% patient in ICU experience delirium30%30%--90% patient in ICU experience delirium.90% patient in ICU experience delirium.

Kaplan & Sadock’s Synopsis of Psychiatry. 8Kaplan & Sadock’s Synopsis of Psychiatry. 8thth Ed. Philadelphia, PA, 1998.Ed. Philadelphia, PA, 1998.Liatker, D., Locala, J., Franco, K, Bronson, DL, Tannous, Z. Preoperative risk factors for postoperative delirium. Gen Liatker, D., Locala, J., Franco, K, Bronson, DL, Tannous, Z. Preoperative risk factors for postoperative delirium. Gen

Hosp Psychiatry. 2001; 23:84Hosp Psychiatry. 2001; 23:84--89.89.

Definition of DeliriumDefinition of DeliriumDefinition of DeliriumDefinition of Delirium

A.A. Disturbance of consciousnessDisturbance of consciousnessBB Change in cognitionChange in cognitionB.B. Change in cognition Change in cognition C.C. Develops over a short period of time (usually hours to Develops over a short period of time (usually hours to

days) Tends to fluctuate during the course of the daydays) Tends to fluctuate during the course of the daydays). Tends to fluctuate during the course of the day.days). Tends to fluctuate during the course of the day.D.D. There is evidence from history, physical exam, or There is evidence from history, physical exam, or

laboratory findings that the disturbance is caused by thelaboratory findings that the disturbance is caused by thelaboratory findings that the disturbance is caused by the laboratory findings that the disturbance is caused by the direct physiological consequences of a general medical direct physiological consequences of a general medical condition, Substance Intoxication or Withdrawal, use of a condition, Substance Intoxication or Withdrawal, use of a medication, or toxin exposure, or a combination of these medication, or toxin exposure, or a combination of these factors.factors.

DSMDSM--IVIV--TR, 2000TR, 2000

Associated FeaturesAssociated FeaturesAssociated FeaturesAssociated Features

Psychomotor disturbancePsychomotor disturbanceAgitation Agitation (related to disorientation or (related to disorientation or gg ((

confusion)confusion)Apathy and WithdrawalApathy and Withdrawalp yp yEmotional disturbances and Emotional disturbances and instabilityinstabilitySleep ImpairmentSleep ImpairmentSleep ImpairmentSleep Impairment

Merck Manual of GeriatricsMerck Manual of Geriatrics

CourseCourseCourseCourse

Symptoms usually develop over hours or daysSymptoms usually develop over hours or daysIn some they begin abruptly (e.g. after head injury)In some they begin abruptly (e.g. after head injury)More typicallyMore typically prodromal syndromesprodromal syndromes such as restlessnesssuch as restlessnessMore typically, More typically, prodromal syndromesprodromal syndromes such as restlessness, such as restlessness, anxiety, irritability, disorientation, distractibility, sleep anxiety, irritability, disorientation, distractibility, sleep disturbance progress to fulldisturbance progress to full--blown delirium within a 1blown delirium within a 1--3 day 3 day periodperiodperiod.period.May resolved in few hours to days or may persist for weeks May resolved in few hours to days or may persist for weeks to months, part in elderly or people with preto months, part in elderly or people with pre--existing existing yy ggdementia.dementia.Duration largely controlled by course of underling condition Duration largely controlled by course of underling condition Symptoms of delirium typically become most severe atSymptoms of delirium typically become most severe atSymptoms of delirium typically become most severe at Symptoms of delirium typically become most severe at night.night.

DSMDSM--IVIV--TR, 2000TR, 2000Casey et al. Delirium: Quick recognition, careful evaluation, and appropriate treatment. Postgraduate Medicine, 1996, 100(1).Casey et al. Delirium: Quick recognition, careful evaluation, and appropriate treatment. Postgraduate Medicine, 1996, 100(1).

Risk FactorsRisk FactorsRisk FactorsRisk FactorsAdvanced ageAdvanced ageYoung age (children)Young age (children)Underlying brain disease such as dementia, stroke or Underlying brain disease such as dementia, stroke or Parkinson’sParkinson’sMultiple severe acute or unstable medical problemsMultiple severe acute or unstable medical problemsMultiple severe, acute or unstable medical problems Multiple severe, acute or unstable medical problems PolypharmacyPolypharmacyInfectionInfectionInfection Infection Alcohol dependenceAlcohol dependenceSensory impairmentSensory impairmentSensory impairmentSensory impairmentMalnutritionMalnutritionHistory of deliriumHistory of deliriumyyLow levels of social interaction Low levels of social interaction

Prognosis better ifPrognosis better ifPrognosis better if…Prognosis better if…

Underlying etiological factor is promptlyUnderlying etiological factor is promptlyUnderlying etiological factor is promptly Underlying etiological factor is promptly corrected.corrected.Patient has better prePatient has better pre--morbid cognitive and morbid cognitive and physical function.physical function.p yp yPatient has NOT had previous episode of Patient has NOT had previous episode of deliriumdeliriumdelirium.delirium.

Elderly PatientsElderly PatientsElderly PatientsElderly Patients

Persistent cognitive deficits common in Persistent cognitive deficits common in elderly suffering from delirium.elderly suffering from delirium.elderly suffering from delirium.elderly suffering from delirium.These deficits can be due to a preThese deficits can be due to a pre--existing existing d ti th t t f ll i t dd ti th t t f ll i t ddementia that was not fully appreciated.dementia that was not fully appreciated.Delirium may be the only indication of acute Delirium may be the only indication of acute y yy yillness in older patients suffering from illness in older patients suffering from dementiadementiadementia.dementia.

Differential diagnosisDifferential diagnosisDifferential diagnosisDifferential diagnosisObs.Obs. DeliriumDelirium Dementia Dementia DepressionDepression PsychosisPsychosis

OnsetOnset AcuteAcute IInsidiousnsidious VariableVariable VariableVariableOrientationOrientation ImpairedImpaired ImpairedImpaired IntactIntact IntactIntactSensoriumSensorium FluctuatingFluctuating VariableVariable IntactIntact IntactIntactAttentivenessAttentiveness ImpairedImpaired VariableVariable Usually intactUsually intact VariableVariableDelusionsDelusions CommonCommon SometimesSometimes RareRare CommonCommonHallucinationsHallucinations VisualVisual UncommonUncommon RareRare AuditoryAuditoryDurationDuration ShortShort ChronicChronic VariableVariable VariableVariable

Delirium: Quick Recognition, careful evaluation and appropriate treatment,Delirium: Quick Recognition, careful evaluation and appropriate treatment,Postgraduate Medicine, July 1996, 100 (1).Postgraduate Medicine, July 1996, 100 (1).

Diagnosis: DeliriumDiagnosis: DeliriumDiagnosis: DeliriumDiagnosis: Delirium

WHAT IS CAUSING IT?WHAT IS CAUSING IT?

I WATCH DEATHI WATCH DEATH (acronym)(acronym)I WATCH DEATHI WATCH DEATH (acronym)(acronym)

III I Infection (pneumonias, UTI, sepsis, Infection (pneumonias, UTI, sepsis, cellulitis, menigitis, encepalitis, syphilis)cellulitis, menigitis, encepalitis, syphilis)g y )g y )

W W ithdrawal (bezos, ETOH, sedativeithdrawal (bezos, ETOH, sedative--hypnotics)hypnotics)hypnotics)hypnotics)

A A cute metabolic (electrolytes, acidosis, cute metabolic (electrolytes, acidosis, l f il b l l i t ll f il b l l i t lrenal failure, abnormal glycemic control, renal failure, abnormal glycemic control,

pancreatitis, )pancreatitis, )T T rauma (head injury, pain, fracture, burns)rauma (head injury, pain, fracture, burns)

I WATCH DEATHI WATCH DEATHI WATCH DEATHI WATCH DEATH

C C NS pathology (tumor, AVM, encephalitis, abscess, normal NS pathology (tumor, AVM, encephalitis, abscess, normal pressure hydrocephalus, seizures, stroke)pressure hydrocephalus, seizures, stroke)

H H ypoxia from COPD exacerbation, anemia,ypoxia from COPD exacerbation, anemia,carbon monoxide poisoning, cardiac failurecarbon monoxide poisoning, cardiac failurep g,p g,

D D eficiencies Beficiencies B--12, folate, water12, folate, waterEE ndocrine thyroid cortisol cancer hyper or hypoglycemiandocrine thyroid cortisol cancer hyper or hypoglycemiaE E ndocrine thyroid, cortisol, cancer, hyper or hypoglycemiandocrine thyroid, cortisol, cancer, hyper or hypoglycemia

A cute vascular MI, stroke, intracerebral bleedA cute vascular MI, stroke, intracerebral bleedT oxins or drugs medications, pesticides, solventsT oxins or drugs medications, pesticides, solventsH eavy metalsH eavy metals lead, mercurylead, mercuryyy yy

Important field of CImportant field of C L activity 3: dementiaL activity 3: dementiaImportant field of CImportant field of C--L activity 3: dementiaL activity 3: dementia

Aim of a CAim of a C--L survey conducted in geriatric L survey conducted in geriatric inpatient population:inpatient population:inpatient population:inpatient population:To asses comorbide psychiatric syndroms in To asses comorbide psychiatric syndroms in

i t i ti t h d itt d ti t i ti t h d itt d tgeriatric patients who are admitted to geriatric patients who are admitted to internal medicine wardsinternal medicine wardsTo asses the impact of the psychiatric To asses the impact of the psychiatric disorders on the length of hospital staydisorders on the length of hospital staydisorders on the length of hospital staydisorders on the length of hospital stay

Results: dementia (own survey)Results: dementia (own survey)Results: dementia (own survey)Results: dementia (own survey)

Cognitive function (MMMS Cognitive function (MMMS points)points)

Number of patients (n=83)Number of patients (n=83) Mean length of hospital Mean length of hospital stay (LOS)stay (LOS)

Cognitive deterioration is Cognitive deterioration is possible (MMMS; ≥ 85 pont)possible (MMMS; ≥ 85 pont)

34 (41%) 34 (41%) 12,4 days12,4 days

Detectable cognitive Detectable cognitive deterioration (75deterioration (75--84 point)84 point)

14 (17%) 14 (17%) 14,7 days14,7 days

Moderate cognitive Moderate cognitive deterioration (60deterioration (60--74 point)74 point)

21 (25%) 21 (25%) 15,3 days15,3 days

Severe deterioration (59 pont Severe deterioration (59 pont ≥)≥)

14 (17%) 14 (17%) 19,8 days19,8 days

Characteristics of dCharacteristics of dementiaementiaCharacteristics of dCharacteristics of dementiaementia

Deterioration of memory and other cognition Deterioration of memory and other cognition functions in an alert person, impairing daily functions in an alert person, impairing daily activities activities Onset is usually insidiousOnset is usually insidiousOnset is usually insidious Onset is usually insidious Course is over months Course is over months -- years; little daytime years; little daytime fluctuationfluctuationfluctuation fluctuation Deficits persist even during a clear level of Deficits persist even during a clear level of consciousnessconsciousnessconsciousness consciousness There must be a social impairment and decline There must be a social impairment and decline from previous functioning from previous functioning

Differential diagnosisDifferential diagnosisDifferential diagnosisDifferential diagnosisObs.Obs. DeliriumDelirium Dementia Dementia DepressionDepression PsychosisPsychosis

OnsetOnset AcuteAcute InsidiousInsidious VariableVariable VariableVariableOrientationOrientation ImpairedImpaired ImpairedImpaired IntactIntact IntactIntactSensoriumSensorium Fluctuating Fluctuating VariableVariable IntactIntact IntactIntactAttentivenessAttentiveness ImpairedImpaired VariableVariable Usually intactUsually intact VariableVariableDelusionsDelusions CommonCommon SometimesSometimes RareRare CommonCommonHallucinationsHallucinations VisualVisual UncommonUncommon RareRare AuditoryAuditoryDurationDuration ShortShort ChronicChronic VariableVariable VariableVariable

Delirium: Quick Recognition, careful evaluation and appropriate treatment,Delirium: Quick Recognition, careful evaluation and appropriate treatment,Postgraduate Medicine, July 1996, 100 (1).Postgraduate Medicine, July 1996, 100 (1).

Clock DrawingClock Drawing TestTestClock DrawingClock Drawing TestTest

Study showed that cognitive impairment was a Study showed that cognitive impairment was a main factor in low Clock Drawing scores in elderlymain factor in low Clock Drawing scores in elderlymain factor in low Clock Drawing scores in elderly main factor in low Clock Drawing scores in elderly patients. patients.

Neither the presence or severity of delirium had Neither the presence or severity of delirium had additional significant effect on clock drawing.additional significant effect on clock drawing.additional significant effect on clock drawing.additional significant effect on clock drawing.

The performance of the Clock Drawing Test in elderly medical inpatients: does it have utility The performance of the Clock Drawing Test in elderly medical inpatients: does it have utility in the identification of delirium? J Geriatric Psychiatry Neurol. 2005 Sep; 18 (3): 129in the identification of delirium? J Geriatric Psychiatry Neurol. 2005 Sep; 18 (3): 129--3333

Clock DrawingClock Drawing TestTestgg

Important field of CImportant field of C--L activity 4: chronic illnesesL activity 4: chronic illneseschronic viral hepatitis treated with IFNchronic viral hepatitis treated with IFNchronic viral hepatitis treated with IFNchronic viral hepatitis treated with IFN

InterferonInterferon alfaalfa (IFN(IFN )) isis usedused forfor thethe therapytherapy ofof aa varietyvarietyInterferonInterferon--alfaalfa (IFN(IFN--αα)) isis usedused forfor thethe therapytherapy ofof aa varietyvarietyofof oncologicaloncological andand chronicchronic viralviral disordersdisorders..

TheThe CNSCNS effectseffects ofof IFNIFN--αα areare basedbased onon thethe inductioninduction ofofthethe cytokinecytokine--cascadecascade andand thethe neuroendocrineneuroendocrine system,system, asaswellwell asas thethe modulationmodulation ofof thethe severalseveral neurotransmitterneurotransmitterwellwell asas thethe modulationmodulation ofof thethe severalseveral neurotransmitterneurotransmitterpathwayspathways..

MoodMood andand anxietyanxiety disordersdisorders areare commoncommon psychiatricpsychiatricsequalessequales ofof thatthat treatmenttreatment.. TheThe CNSCNS sideside--effectseffects callcall forforthethe droppingdropping outout ofof IFNIFN--αα treatmenttreatment oror forfor dosedose reductionreduction..pp gpp g

ItIt isis challengechallenge forfor thethe consultationconsultation psychiatristspsychiatrists toto findfind aatherapeutictherapeutic solutionsolution forfor patientspatients whowho suffersuffer fromfromtherapeutictherapeutic solutionsolution forfor patientspatients whowho suffersuffer fromfrompsychiatricpsychiatric sideside--effectseffects ofof thethe IFNIFN--αα..

Time Course of IFN Side EffectsTime Course of IFN Side Effects

SeveSeve FatigueFatigueFlulikeFlulike

symptomssymptomsrityrity

symptomssymptoms

Depressive/anxietyDepressive/anxietysymptomssymptoms

0 4 5 11 126 7 8 9 101 2 3

symptomssymptoms

0 4 5 11 12IFN Treatment IFN Treatment

(Weeks)(Weeks)

6 7 8 9 101 2 3

LateLate--Appearing Interferon Appearing Interferon pp gpp gSide EffectsSide Effects

Manifest as mood disturbance, anxiety, Manifest as mood disturbance, anxiety, and cognitive difficultiesand cognitive difficulties

Develop insidiously over weeks to monthsDevelop insidiously over weeks to months

Worsen with timeWorsen with timeWorsen with timeWorsen with time

Coupled with fatigue, represent the principal Coupled with fatigue, represent the principal reason for IFN discontinuationreason for IFN discontinuation

Major Depression With Major Depression With j pj pInterferon alfaInterferon alfa

Prevalence is 30%Prevalence is 30%––50%, depending on 50%, depending on diagnostic criteria and IFN dosagediagnostic criteria and IFN dosagediagnostic criteria and IFN dosagediagnostic criteria and IFN dosage

Recent large study of patients receivingRecent large study of patients receivingRecent large study of patients receiving Recent large study of patients receiving peginterferon for hepatitis C suggests rates peginterferon for hepatitis C suggests rates of full major depression may be lower thanof full major depression may be lower thanof full major depression may be lower than of full major depression may be lower than previously reportedpreviously reported

Musselman DL, et al. N Engl J Med. 2001;344:961. Raison CL, et al. In preparation.

Psychiatric side effects of IFN Psychiatric side effects of IFN yytreatment (own survey)treatment (own survey)

21 patients21 patientspp–– 18 depression18 depression

Mild:5Mild:5Mild:5Mild:5Moderate:8Moderate:8Severe:5Severe:5Severe:5Severe:5

–– 5 panic disorder (4 with co5 panic disorder (4 with co--morbide depression) morbide depression) 1 i di d ith h bi1 i di d ith h bi–– 1 panic disorder with agoraphobia1 panic disorder with agoraphobia

–– 1 delirium1 delirium

Treating IFNTreating IFN--Induced Induced ggDepressionDepression

Peginterferon may need to be stoppedPeginterferon may need to be stoppedPeginterferon may need to be stopped Peginterferon may need to be stopped until antidepressant begins to workuntil antidepressant begins to work

Pretreatment with antidepressant shown Pretreatment with antidepressant shown to significantly decrease development ofto significantly decrease development ofto significantly decrease development of to significantly decrease development of depression withdepression with highhigh--dose IFN alfadose IFN alfa

Paroxetine Paroxetine PretreatmentPretreatment Reduces the Reduces the Incidence of Major Depression During Incidence of Major Depression During

the First 12 Weeks of IFN alfathe First 12 Weeks of IFN alfathe First 12 Weeks of IFN alfathe First 12 Weeks of IFN alfa

Ma

Ma 100

FFajor D

eajor D

e

60

80

ree of ree of epressepress 40

60

Paroxetine

sion (%sion (% 20 PlaceboParoxetine

Weeks on IFN alfaWeeks on IFN alfa

%)

%)

0 2 4 6 8 10 120

Weeks on IFN alfaWeeks on IFN alfa

Musselman DL, et al. N Engl J Med. 2001;344:961.

Other important fields of COther important fields of C L activityL activityOther important fields of COther important fields of C--L activityL activity

Transplantation (Bone marrow, heart and Transplantation (Bone marrow, heart and p (p (lung, liver, kidney)lung, liver, kidney)OncologyOncologyOncologyOncologyLegal issues (competency)Legal issues (competency)HIV, AIDSHIV, AIDSAddictionsAddictionsAddictionsAddictions

CostCost Effectiveness of CLPEffectiveness of CLPCostCost--Effectiveness of CLPEffectiveness of CLPSt di h t dl d t t d th t C LStudies have repeatedly demonstrated that C-L

service can significantly lower health care cost and at the same time improve the quality of medical care ofthe same time improve the quality of medical care of medically ill patients with psychiatric symptoms.

There is a significant association between psychiatric There is a significant association between psychiatric or psychological AND medical comorbidity and or psychological AND medical comorbidity and i d l th f ti d l th f tincreased length of stay.increased length of stay.

E l d t ti d t t t i ifi tlEarly detection and treatment may significantly decrease LOS and the expenditure of medical resourcesresources

Thank you for your attention!Thank you for your attention!Thank you for your attention!Thank you for your attention!