Q. I am a mental health professional. What I see is a problem placing and managing some of the psychiatric patients in the community - mainly due to chronic illness, behavioral problems and the patient's poor compliance. This often causes high re-admission rates and the results are oftentimes poor. What are some of the solutions for the following problems?

3. How do we take care of the geriatric patient with a psychiatric disorder who becomes combative/disruptive that he is not allowed to remain in secure environments due to the high risk of harm to other patients?

A. You are raising some of the most vexing and frustrating issues in all of psychiatry--so, please don't imagine I have any miracles up my sleeve! A rather flippant response to your question might begin by saying: "Since behavioral problems and poor compliance often lie behind the difficulty in placing the patient, first fix the behavioral problems and poor compliance!" It's flippant--but it's also probably correct.

Of course, I'm well aware that the neurobehavioral problems of geriatric patients (e.g., those with dementia, chronic schizophrenia, etc.) and other chronic psychiatric patients are devilishly hard to manage. Whole textbooks have been written on this topic, and I can't begin to cover it all here. However, I highly recommend the excellent review entitled, "Nonpharmacologic interventions for inappropriate behaviors in dementia," by Dr. Jiska Cohen-Mansfield (American Journal of Geriatric Psychiatry, Fall 2001).

For pharmacologic approaches to the demented patient, see chapter 8 in Handbook of Geriatric Psychopharmacology, edited by Dr. Sandra Jacobson, Dr. David Greenblatt, and myself (American Psychiatric Press, 2002). This book also has chapters on mood and psychotic disorders in the elderly, and a section on managing non-compliance.

Regarding actual placement issues, you may want to read the paper by Dayson et al, entitled, "The TAPS project. Difficult to place, long term psychiatric patients: risk factors for failure to resettle long stay patients in community facilities."(BMJ 1992 Oct 24;305(6860):993-5). This paper finds that risk factors associated with placement failure included a high level of psychosis; a diagnosis of paranoid psychosis; incontinence; and being male. But having a social network, especially a large one, seemed to aid successful placement in the community.

Thus, reducing these risk factors and maximizing social supports are part of the solution to the problem you are raising--but only a part. Financial resources, as you note, are also essential. I don't have any recommendations for you on that, except to refer you to some websites you may find helpful; e.g., the State Agencies on Aging (www.aoa.dhhs.gov/aoa/pages/state.html); The Bazelon Center for Mental Health Law (www.bazelon.org); Senior Site (www.seniors-site.com); and, of course, the National Alliance for the Mentally Ill (NAMI, www.nami.org). All these may provide advice and resources on how to secure funding, housing, supports, etc. for your most difficult patients.

As I said, there are no easy answers--but, keep in mind these consoling words from O'Sullivan & Brody (QRB Qual Rev Bull 1986 Feb;12(2):55-67): "Community placement philosophy dictates that, assuming some measure of psychiatric stability, any time spent in the community as opposed to the hospital is advantageous to the patient. Thus readmission rates are not accurate indicators of success or failure in community placement."

September 2002

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