Mohammed T. Abou-Saleh

724 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYgeropsychiatry unit, which together function as a regionalreferral center for the treatment of the elderly with complexand concurrent psychiatric and medical problems. ParthenonPavilion’s geriatrics program opened in 1985 and the originalmemory disorders unit was developed in 1987. This programprovides a structure for supporting continuity of care byorganizing clinical services and concentrating resources aroundthe diverse and specialized needs of patients with severepsychiatric disorders, often complicated by behavioral difficultiesand/or serious medical problems. The hospital also includesa geriatric partial hospitalization program which adds anotherdimension to the continuum of psychiatric care for senioradults.Clinical ProcessThe geriatrics program has developed a philosophy of treatmentand a clinical services model that places an emphasis oninterdisciplinary care, so as to provide psychiatric and medicalmanagement of treatable symptoms in order to reduce distress,disability and complications in the older patient. A second majortenet of the program’s treatment philosophy is that the family andprofessional caregiver systems are helped by providing:(a) accurate diagnosis and education around the nature of diseaseprocesses in the context of the unique manifestations of a diseasein a given individual; and (b) supportive assistance and practicalguidance tailored to the care and management issues of a givenpatient and caregiver system. This clinical services model alsoplaces a high priority on providing consultative and clinicalliaison services to families, agencies, nursing homes and residentialfacilities, to assure continuity of care and maintenance of theclinical goals established during hospitalization for patients afterthey are discharged from the program.The importance of family involvement in such a programcannot be overstated. Hardwig 9 challenges the ethically simplisticnotions of patient autonomy frequently espoused when he pointsout the integral role of the family in making medical decisions.This is especially relevant when working with older persons, dueto the prevalence of cognitive impairment found in this group.When a patient becomes demented, family members mustfrequently assume decision making in medical situations. Thismay violate family taboos as well as established patterns of familyinteraction, which may require renegotiation. Family conferences,as a means for mediating the moral process of medical decisionmakingand planning for ongoing care, are an integral aspect ofthe clinical services offered by the Geriatric Program, and result ina consistently high level of family satisfaction.Administrative and Team FunctionThe administrative structure of this program includes: the clinicaldirector, who is a psychiatrist specializing in geropsychiatry; aprogram director who is a Master’s-trained social worker; a nursemanager with experience in geriatric nursing; and access to aclinical nurse specialist with a Master’s degree in psychiatricnursing. The clinical director provides leadership in programplanning, program evaluation and quality assurance, while alsobeing available to provide consultation to other attendingpsychiatrists as needed. The program director coordinates theday-to-day operation of the program and works closely with theclinical director and nurse manager in implementing the abovedesignatedfunctions.Each patient has an attending psychiatrist, who directs thetreatment, meets with families in diagnostic feedback conferences,participates in clinical liaison activities with nursing homes andother placement facilities and develops an aftercare plan, alongwith other disciplines represented on the staff 10 . The program issupported by a number of psychiatrists with added qualificationsin geriatric psychiatry and considerable experience in thetreatment of such patients. Although many private psychiatricfacilities have limited professional staff with particular expertise ingeriatrics, such persons are increasingly available, due to anincreasing number of specialized training programs. The programis joined by a group of board-certified internists, who have specialinterest and expertise in evaluating and treating acute and chronicmedical problems in the elderly. Upon admission, the internistconducts a comprehensive review of systems and physicalexamination on each patient. Throughout the hospitalization,the internist provides follow-up of existing or developing medicalproblems and, when necessary, participates in family conferencesand team staffing. Medical subspecialists, such as neurologists andcardiologists, are consulted when clinically indicated and theiravailability is fostered by the fact that the hospital/program is partof a regional tertiary care medical center which also providesaccess to available technology, brain imaging, laboratory servicesand specialized neuropsychological testing as medically indicated.Nursing care is delivered through a primary nursing system.Nurses are recruited who have strong medical/surgical backgroundalong with geropsychiatric interests 11 . Meeting thesestaffing demands remains challenging, particularly in an erawhen most hospitals are experiencing professional nursingshortages. Supportive nursing administration within the programand the promotion of educational opportunities have fostered areduced staff turnover rate well below the 20% annual rateexperienced nationally 12 . The program director and the nursemanager are involved in pre-admission screening and clinicalliaison activities, along with providing inpatient clinical services tofamily and professional caregivers. The social workers coordinatedischarge planning and aftercare follow-up, which is a vitallinkage in maintaining continuity of care. Activity therapistsconduct functional assessments and design appropriate activitiesfor the units within the program, according to the level of functionof the patients. They can provide feedback to families andprofessional caregivers regarding functional abilities and deficits,making recommendations for modifications in the patient’senvironment and activities to support remaining abilities. Staffeducation is conducted through a variety of means, includingweekly teaching rounds conducted by the clinical director,monthly interdisciplinary staff education meetings, and specialteaching modules designed by the clinical nurse specialist.Physical and Environmental FeaturesThe physical design of the geriatric program provides for separateunits divided by a nursing station. Two are for patients withdementia and memory disorders; the other for the generalgeriatric population. Prior to the development of the specialtyunits, demented patients were integrated with non-dementedpatients and separate therapeutic activities and groups wereplanned for each population 13 . However, it ultimately wasdetermined that separating the program into specialty units,serving cognitively impaired patients with Alzheimers’s diseaseand related disorders and a general geropsychiatric unit providedthe optimal arrangement both clinically and administratively. Thememory disorders units are designed for security and have unitdoors that can be locked. Such a unit is specifically designed andadapted for the particular needs of sensory and cognitivelyimpaired persons. There is an emphasis on music, videotapes andappropriate sensory stimulation without overload. The generalgeropsychiatry unit and the memory disorders units are podshaped,with a day room outside the bedrooms, and have activity