Mohammed T. Abou-Saleh

710 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYtherapeutic benefits may be derived from semi-private rooms forpatients who are withdrawn, or for cases in which a higherfunctioningroommate can provide aid to another with respect toorientation and structure. All patient room entrances andbathroom facilities should be wheelchair-accessible. An emergencycord should be available in the bathroom and should bereachable from the floor by patients who may have fallen. Thesame architectural suicide prevention considerations found ongeneral psychiatric units should be built into the medicalpsychiatry inpatient unit. Other needs include shower andpatient-lifting devices, a bedside weight scale, suitable chairs,supply facilities/cart and, more controversially, mechanical (soft)restraints and effective methods of observation.The unit ideally will include built-in handrails along the walls,television facilities for bedridden patients, and industrial-gradecarpet to soften falls in the hallways and/or common or publicareas but with vinyl to facilitate cleaning in patient rooms. Patientrooms are designed to maximize observation and minimize noisethat may distract the staff. Finally, consideration must be given towhether a medical psychiatry unit will be locked, closed orcontrolled, and whether involuntary patients will be admitted.With adequate numbers of trained staff, it should not be necessaryto have barriers to free movement. Where sufficient trained staffcannot be provided, some units have double-handed doors. Thecontrolled unit, utilizing electronic beep or entry computer codes,ensures that wandering by cognitively impaired patients can bethoughtfully controlled. The locked or controlled-access unitprovides both safety and containment. Separate areas aredesigned for activities and occupational or physical therapy.The flow of staff and consultants tends to be great on a medicalpsychiatry unit; thus, workspace is an important consideration.Nursing units may be better divided into modular work stationswith built-in cabinetry and shelving. The record and medicationroom can be separated by a locked door and the entire nursingstation designed as an enclosed area with an observation/reception window made of safety glass. Sufficient storage spacefor medical equipment and supplies should also be considered.The care of complex, medical–psychiatric patients often requiresfrequent, small conferences among professionals of differentdisciplines and specialties in order to coordinate care. On-siteprofessional offices for the medical director, social worker, headnurse and trainees afford privacy and a quiet environment forconferences and interviews. Preferably, physical therapy shouldbe provided on-site if at all possible; a physical therapistpermanently assigned to a medical psychiatric unit may incorporatepsychiatric skills into the therapy treatments and maybecome an integral part of the treatment team. In addition tocommon areas for group dining, activities, educational programs,family meetings, group therapy and occupational therapy,additional space is necessary for staff meetings and conferences.An adequate staff lounge not only improves morale but alsofacilitates communication between the healthcare professionalsand multidisciplinary personnel.OPERATIONAL FEATURES OF THE GERIATRICMEDICAL PSYCHIATRY INPATIENT UNITA multidisciplinary treatment team is generally assembled in orderto address the complex needs of geriatric patients with combineddisease. Each member contributes to the administration andoperation of the unit, and each discipline contributes uniquely. Anurse clinical specialist with both medical and psychiatricexperience may act as a milieu coordinator/supervisor for thenursing staff. Complex social work interventions require greatexpertise in family consultation, assessing hospital and communityservices and providing assistance in disposition. Consultingpsychologists with experience in neuropsychology, personalityassessment and behaviour therapy are invaluable team members.The nursing staff should consist primarily of registered nursescombining medical–surgical and psychiatric skills. Practicalnurses and nurses’ aides can participate in the delivery of careand may also become adept in the clinical care of combinedmedical–psychiatric problems. Senior nurses with extensivepsychiatric experience often contribute greatly to the managementof behaviourally difficult patients. Irrespective of experience andbackground, nurses who enthusiastically support the model ofcombined medical–psychiatric care are ideal. Above all, thenursing staff must possess flexibility and resourcefulness combinedwith a practical and optimistic approach, in view of the constantchanges in demands.The usual format for the medical psychiatry inpatient unit inNorth America employs a model in which a psychiatrist orinternist acts as an attending professional, experienced in directinga team and communicating with both mental health professionalsand medical–surgical professionals. The medical director isresponsible for gatekeeping, quality assurance, staff supervision,training, in-service education, trouble-shooting and the provisionof consultation (directly or indirectly) in difficult cases. Liaisonwith community agencies, public affairs and assistance with legaland ethical problems in patient care are also required of themedical director. Administrative interfaces with the affiliateddepartment, hospital, community mental health center andreferring resources are essential. These interactions will varyaccording to the individual orientation and characteristics of thefacility. Similarly, other third-party, legal and governmentalinteractions will vary accordingly.CLINICAL AND PATIENT CHARACTERISTICS OF AGERIATRIC MEDICAL PSYCHIATRY UNITA variety of patient subtypes may be considered appropriate foran inpatient medical psychiatry unit. Three patient subtypes havebeen identified by Stoudemire and Fogel 3 : (a) patients with severemedical illness requiring daily medical coverage in addition totreatment of psychiatric illness; (b) psychiatrically disorderedpatients who require frequent but not daily medical attentionfrom a surgeon or internist, e.g. diabetic or post-surgical cases;and (c) patients who merely require an initial consultation orperiodic access or review/adjustment of medications by a medicalconsultant. Depression in the medically ill, chronic schizophreniawith concurrent physical disease, i.e. stroke, epilepsy, Parkinson’sdisease, head trauma, delirium, complications of dementia, orparoxysmal behaviour disorders, and a variety of other generalmedical illnesses with complex family or psychosocial issues,characterize appropriate cases for admission and treatment.The average length of stay on a typical unit is generallyapproximately 7–21 days. Site-specific considerations pertainingto the selection of appropriate patients must be analyzed in orderto determine specific inclusion and exclusion criteria. A welldefinedpriority system can then be established in order todetermine which patients are admitted or provided with access tocare. Regarding admission, patients on affiliated medical/surgicalwards, and cases seen by the emergency or staff physicians, aretypically given special consideration. Above all, patient acuity,dispositional resources and the staffing will determine the answersto many gate-keeping decisions. Moreover, the primary mission ofthese units remains the provision of psychiatric care to individualswho also have significant medical/surgical illness. Again, thesepatients are often not welcome in either traditional psychiatry ormedical/surgical units. Finally, decisions regarding admission ortransfer of inpatients from medical/surgical units may depend onthe likelihood that the patient will receive true benefit, respond to