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General Hospital Psychiatry 32 (2010) 99 – 101
Emergency Psychiatry in the General Hospital The emergency room is the interface between community and health care institution. Whether through outreach or in-hospital service, the psychiatrist in the general hospital must have specialized skill and knowledge to attend the increased numbers of mentally ill, substance abusers, homeless individuals, and those with greater acuity and comorbidity than previously known. This Special Section will address those overlapping aspects of psychiatric, medicine, neurology, psychopharmacology, and psychology of essential interest to the psychiatrist who provides emergency consultation and treatment to the general hospital population.
Substance misuse among older patients in psychiatric emergency service Benjamin K.P. Woo, M.D.a,b,⁎, Weilu Chena a
Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, CA 90095, USA b Olive View-UCLA Medical Center, Sylmar, CA 91342, USA Received 27 May 2009; accepted 3 August 2009
Abstract Objective: To determine the prevalence of substance misuse among older patients presented to a psychiatric emergency service (PES) on involuntary bases. Method: At the time of initial presentation to the PES, all patients received a comprehensive assessment that included a urine toxicology screening. The screening consisted of six substances: barbiturate, benzodiazepine, cocaine, opiate, phencyclidine and amphetamine. Charts of elderly patients (aged 65 and above) with positive urine toxicology were reviewed to ensure that the results were not due to (1) home medications and (2) medications given in the PES. Results: During the 2-year study period (2006–2007), there were 5914 patients under the age of 65 and 104 patients aged 65 and above. Our findings indicated that 471 (8.0%) and 14 (13.4%) urine toxicology screens were not collected during the PES visits in younger and older patients, respectively (P=.04). The positive urine toxicology rate was 31.5% (1716/5443) and 26.7% (24/90) for younger and older patients, respectively (P=.33). Conclusions: Substance misuse in the older population presenting with psychiatric emergency is prevalent in the PES. Urine toxicology screens, as well as patient or collateral report of substance usages, should be obtained from this group of patients to ensure quality of care delivered at the PES. Published by Elsevier Inc. Keywords: Psychiatric emergency service; Substance; Geriatric
1. Introduction The number of elderly persons with psychiatric disorders is expected to reach 15 million by the year 2030 [1]. While substance abuse among older adults is on the rise, little is known about the epidemiology of substance use practices in the elderly [2,3]. In particular, there is a paucity of information on substance use disorders of geriatric patients in the psychiatric emergency service (PES). The PES serves as the gateway for elderly patients to receive mental health services [4]. Reasons for PES visits by elderly patients include psychiatric emergencies in the form of aggression, confusion, depression, homicidality, suicid⁎ Corresponding author. Tel.: +1 818 364 1555. E-mail address:
[email protected] (B.K.P. Woo). 0163-8343/$ – see front matter. Published by Elsevier Inc. doi:10.1016/j.genhosppsych.2009.08.002
ality and substance abuse. The function of the PES is to conduct an evaluation, establish an initial diagnosis and provide emergency treatment and appropriate disposition [5]. Unrecognized substance use may lead to inaccurate psychiatric diagnoses in the PES [6]. Thus, screening for substance use in elderly patients may allow for appropriate treatment and prognosis. Estimates based on the 2007 National Survey on Drug Use and Health indicate that the past year and lifetime history of illicit drug use for the elderly were 1.0% and 10.7%, respectively [7]. Holroyd and Duryee [2] found the prevalence of substance use disorder in a specialized geriatric psychiatry outpatient clinic to be 20%. Schlaerth et al. [8] studied 3417 patients over 50 years of age that presented to an emergency room in California and found that 107 patients had positive urine toxicology screens.
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The current study was done to determine the prevalence of substance misuse in elderly patients presenting with psychiatric emergencies at the PES. Substance misuse was defined as a positive urine toxicology screen in patient without a valid prescription for the drugs. We hypothesized that illicit drug use among older adults (patients aged 65 and above) is not rare, but as prevalent as that among younger patients (under age 65) presented to the PES.
2. Methods The study was conducted at the Psychiatric Emergency Service of UCLA-Kern Medical Center. The PES is the only psychiatric emergency room in a county of 800,000 inhabitants. Under California law, a person may be held involuntarily for 72 h for psychiatric assessment if they are deemed a danger to self, danger to others or gravely disabled. During the 2-year study period (2006–2007), there were 6018 involuntary evaluations. There were 5914 patients under the age of 65 and 104 patients aged 65 and above. At the time of initial presentation to the PES, all patients received a comprehensive assessment that included a urine toxicology screening. Urine toxicology screening consisted of six substances: barbiturate (BAR), benzodiazepine (BNZ), cocaine (COC), opiate (OPI), phencyclidine (PCP) and amphetamine (AMP). Cut-off concentrations for a positive screen are as follows: BAR 200 ng/ml, BNZ 200 ng/ml, COC 300 ng/ml, OPI 300 ng/ml, PCP 25 ng/ml and AMP 1000 ng/ml. Charts of elderly patients (aged 65 and above) with positive urine toxicology were reviewed to ensure that the results were not due to (1) home medications (i.e., prescribed medications for the patient only) and (2) medications given in the PES. As blood/breath alcohol levels (BALs) were not part of the routine laboratory panel for patients in psychiatric emergency at our facility, the current study did not attempt to determine the prevalence of alcohol misuse among older patients in PES. Only three of the 104 older patients had BALs ordered, and all were negative. We first compared the baseline characteristics of urine toxicology screens in younger (under age 65) vs. older (age 65 and above) patients. Then, we provided descriptive data on baseline characteristics, demographics, diagnoses and prevalence of substance use among older patients. Chisquare tests for categorical variables and t tests for continuous variables were calculated using SPSS.
3. Results There were 5914 younger patients (under age 65) and 104 older patients (age 65 and above) during the 2-year study period. Data gathered from urine toxicology screens were compared between the younger and the older patients. Our findings indicated that 471 (8.0%) and 14 (13.4%) urine
toxicology screens were not collected during the PES visits in younger and older patients, respectively (χ2=4.168, df=1, P=.04). The positive urine toxicology rate was 31.5% (1716/ 5443) and 26.7% (24/90) for younger and older patients, respectively (χ2=0.970, df=1, P=.33). The older, involuntary patients (n=104) had the following demographic characteristics: mean age (S.D.)=72.4 (8.1) years, ethnicity=58.7% (n=61) Caucasian, gender=57.7% (n=60) female, committed involuntarily to inpatient setting=19.2% (n=20) and insurance=26.0% (n=27) with no insurance. While patients aged 65 and above should be eligible for Medicare, patients in the current study were likely not to be US citizens or permanent residents who have worked for a minimum of 10 years at a job that has paid into the Medicare system to qualify for Medicare as an insurance source. A total of 93.3% (n=97) had at least one chronic medical illness. The most common Axis I diagnoses were psychosis (n=28) and depression (n=27). There were 14 instances in which the secondary diagnosis was substancerelated disorder. A total of 26.7% (n=24) of the 90 older patients with urine toxicology screens had a positive result. There were no older patients with positive urine toxicology results excluded because of home medications or medications given in the PES. Table 1 summarized the prevalence of substance misuse in involuntary elderly patients presenting at PES. The group of older patients with positive urine toxicology result was compared with the group of older patients with negative urine toxicology result. The two groups did not differ on Axis I diagnoses (χ2=0.033, df=2, P=.98) or committed involuntarily to inpatient setting (χ2=0.014, df=1, P=.91).
4. Discussion Overall, our results indicated that a sizable portion (26.7%) of older patients in psychiatric emergencies presented to the PES were using illicit drugs. Although this is the first study to evaluate the prevalence of substance use and characteristics of older involuntary patients treated in PES, studies in other medical settings [2,7,8] have also highlighted the emergence of co-occurring psychiatric and substance use disorders in the older population. While a positive urine screen result does not determine the cause of Table 1 Prevalence of substance misuse in involuntary elderly patients (n=90) presenting at PES Substance
n
%
95% confidence interval
Amphetamine (AMP) Barbiturate (BAR) Benzodiazepine (BNZ) Cocaine (COC) Opiate (OPI) Phencyclidine (PCP)
8 1 6 6 3 0
8.9 1.1 6.7 6.7 3.3 0
4.4–16.8% 0–5.2% 2.8–14.1% 2.8–14.1% 0.7–9.8% 0–5.0%
B.K.P. Woo, W. Chen / General Hospital Psychiatry 32 (2010) 99–101
psychiatric emergency, it reveals some of the drugs a patient has recently used and provides useful information in determining treatment and disposition. Our study also found a small but not statistically significant difference between prevalence of substance misuse in younger vs. older patients. This confirms our hypothesis that substance misuse is not limited to the younger population. Untreated substance illnesses may lead to psychiatric emergencies. Steadman et al. [9] found a relationship between substance abuse and violence in a prospective study. As substance use disorders can solely or partially be responsible for behavioral disturbances, our study adds that clinicians should actively screen for substance use in both the younger and older patients presented to the PES. Another result worth discussing is the higher likelihood of disposition in older patients made without including the urine toxicology results. It is reasonable to assume that PES health care providers may neglect to thoroughly evaluate older patients with psychiatric emergencies because they underestimate the prevalence of substance misuse in this population. The general perception may be that illicit substance misuse may be less of a problem than the misuse of prescribed medications. As abuse of illicit drugs has no age limits, substance screening should be part of a comprehensive evaluation for older, involuntary patients presented to the PES. The current study methods did not examine whether toxicology screens would add value over patient self-report or collateral information regarding substance misuse. Vitale et al. [10] concluded that self-reported illicit drug use may be more preferable than biochemical markers in emergency room patients. Another study found 10.2% of psychiatric emergency patients with positive drug screens who denied drug use or from whom physicians did not expect drug use [11]. The study also determined that routine urine drug screening in PES would not affect disposition. Given that 27% of the older, involuntary patients had a positive urine screen result in the current study, a more thorough workup for substance misuse for the older patients would be necessary in the PES. The assessment could include patient self-report, collateral report or urine toxicology screen. This study assessed the frequency of substance misuse disorders associated with older adults presented to a PES with severe psychiatric emergencies. Our findings are methodologically limited because of their primary reliance on emergency records and included only involuntary patients. Because of the study design, our data consisted of tabulation of positive urine screens from only 90 of the 104 older, involuntary patients. As temporal association does not indicate causation, we could not prove that the substance misuses caused the psychiatric emergencies. Results from the National Survey on Drug Use indicate that among adults aged 50 or older, 1.1% used marijuana and 0.7% misused prescription-type drugs (e.g., pain relievers, tranquilizers, stimulants and sedatives) [12]. Misuse was defined as use
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without a prescription for the patient or simply for the experience the drugs may cause. However, our retrospective data set did not include marijuana, alcohol and prescriptiontype drugs. Thus, the prevalence of substance misuse may be slightly underestimated in this study population. Lastly, our findings are geographically restricted, as drug of choice may be different in other regions. Nevertheless, the PES in this study is the only psychiatric emergency room in a county of 800,000 inhabitants. In conclusion, our results indicate that substance misuse in the older population with behavioral disturbances presented to PES is frequent. Knowledge about the characteristics of older patients using PES is important to better understand their clinical needs and to improve service delivery in this setting. Future studies should investigate risk factors for predicting unrecognized substance misuse disorders among older patients presented to PES. As PES maybe the last resort for patients with behavioral disturbances, and substance misuse is associated with poor health outcomes, detecting substance-related disorders among older adults in PES may improve the quality of care. The mental health system will need to address the special needs of an older population of substance abusers presenting to the PES. References [1] Jeste DV, Alexopoulos GS, Bartels SJ, et al. Consensus statement on the upcoming crisis in geriatric mental health: research agenda for the next 2 decades. Arch Gen Psychiatry 1999;56(9):848–53. [2] Holroyd S, Duryee JJ. Substance use disorders in a geriatric psychiatry outpatient clinic: prevalence and epidemiologic characteristics. J Nerv Ment Dis 1997;185(10):627–32. [3] Oslin DW. Evidence-based treatment of geriatric substance abuse. Psychiatr Clin North Am 2005;28(4):897–911. [4] Woo BK. Utilization patterns of psychiatric emergency services by elderly patients. J Am Geriatr Soc 2009;57(1):182–3. [5] Woo BK, Chan VT, Ghobrial N, et al. Comparison of two models for delivery of services in psychiatric emergencies. Gen Hosp Psychiatry 2007;29(6):489–91. [6] Woo BK, Sevilla CC, Obrocea GV. Factors influencing the stability of psychiatric diagnoses in the emergency setting: review of 934 consecutively inpatient admissions. Gen Hosp Psychiatry 2006;28(5): 434–6. [7] National Survey on Drug Use and Health. http://www.oas.samhsa.gov/ NSDUH/2k7NSDUH/tabs/Sect1peTabs1to46.htm#Tab1.11B. [8] Schlaerth KR, Splawn RG, Ong J, et al. Change in the pattern of illegal drug use in an inner city population over 50: an observational study. J Addict Dis 2004;23(2):95–107. [9] Steadman HJ, Mulvey EP, Monahan J, et al. Violence by people discharged from acute psychiatric inpatient facilities and by others in the same neighborhoods. Arch Gen Psychiatry 1998;55(5):393–401. [10] Vitale SG, van de Mheen H, van de Wiel A, et al. Substance use among emergency room patients: Is self-report preferable to biochemical markers? Addict Behav 2006;31(9):1661–9. [11] Schiller MJ, Shumway M, Batki SL. Utility of routine drug screening in a psychiatric emergency setting. Psychiatr Serv 2000;51(4):474–8. [12] Substance Abuse and Mental Health Services Administration. Results from the 2003 National Survey on Drug Use and Health: National Findings. Rockville (MD): Office of Applied Studies; 2004 [NSDUH Series H-25, DHHS Publication No. SMA 04-3964].
