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The number of people over the age of 65 attending Emergency Departments (ED) in the United Kingdom (UK) is increasing. Those who attend with a mental health related problem may be referred to liaison psychiatry for assessment. Improving responsiveness and integration of liaison psychiatry in general hospital settings is a national priority. To do this psychiatry teams must be adequately resourced and organised. However, it is unknown how trends in the number of referrals of older people to liaison psychiatry teams by EDs are changing, making this difficult.
Method
We performed a national multi-centre retrospective service evaluation, analysing existing psychiatry referral data from EDs of people over 65. Sites were selected from a convenience sample of older peoples liaison psychiatry departments. Departments from all regions of the UK were invited to participate via the RCPsych liaison and older peoples faculty email distribution lists. From departments who returned data, we combined the date and described trends in the number and rate of referrals over a 7 year period.
Result
Referral data from up to 28 EDs across England and Scotland over a 7 year period were analysed (n = 18828 referrals). There is a general trend towards increasing numbers of older people referred to liaison psychiatry year on year. Rates rose year on year from 1.4 referrals per 1000 ED attenders (>65 years) in 2011 to 4.5 in 2019 . There is inter and intra site variability in referral numbers per 1000 ED attendances between different departments, ranging from 0.1 - 24.3.
Conclusion
To plan an effective healthcare system we need to understand the population it serves, and have appropriate structures and processes within it. The overarching message of this study is clear; older peoples mental health emergencies presenting in ED are common and appear to be increasingly so. Without appropriate investment either in EDs or community mental health services, this is unlikely to improve.
The data also suggest very variable inter-departmental referral rates. It is not possible to establish why rates from one department to another are so different, or whether outcomes for the population they serve are better or worse. The data does however highlight the importance of asking further questions about why the departments are different, and what impact that has on the patients they serve.
Early assessment, diagnosis and management for people living with dementia is essential, both for the patient and their carers. We recognised delays in established local pathways when patients had unplanned acute hospital admissions preventing them from attending memory diagnostic appointments. The Psychiatric Liaison Team (PLT) Memory Pathway was introduced as we had the skills and expertise to resume the process and to find new undetected patients.
Our aim was to determine how well the newly implemented PLT Memory Pathway follows the standards outlined in the National Institute of Health & Care Excellence (NICE) Clinical Guideline 97 (CG97): Assessment, management and support for people living with dementia and their carers.
Method
A retrospective analysis of all PLT referrals from July 2018 to February 2020 (20 months) was performed to identify patients on the community memory pathway and those with possible undetected cognitive impairment. Data were collected from electronic patient records which included demographics, primary and collateral history, cognitive testing and imaging, dementia type among others. Results were analysed using Microsoft Excel.
Result
41 patients were included (59% female). 80% of patients were referred for memory problems or confusion. 63% had previous referrals to a memory service and was on the community memory pathway at the time of the referral. 34% were on anticholinergic medication but in only 14% were this documented as reviewed. 100 % were offered and had head imaging. A finding worthy of note was the absence of any from the ethnic minority background. 63% of patients were given a memory diagnosis and 34% had anti-dementia medication started. Patients’ families were made aware of the diagnosis in 83% of cases, due to the absence of next of kin details in the patient record. Primary Care was made aware in 100% of cases; post-diagnostic support was 100%.
Conclusion
The PLT is well placed to bridge the service gap between the acute care trust and established community memory services when dealing with patients with dementia. A dedicated Memory Pathway has helped to close this gap and adherence to NICE CG97 standards was good, but there is room for improvement. A particular focus will be on improving documentation of anticholinergic medication review and exploration for the absence of ethnic minority patients. Aiming to achieve 100% family involvement is also recommended.
This study has been submitted to the Royal College of Psychiatrists' Faculty of Old Age Annual Conference 2021.
Courts are centers of power, whether religious or political, which create cultural forms that represent these centers to themselves and to those outside them. The continuity of great courts contrasted with the peripatetic courts of India and Western Europe. In virtually every court, cultural production, both by and for members of the court, developed forms that sought to separate court culture from the rest of society. Western courts, like those of Japan, were but one center of cultural production, the other being major monastic foundations. Chinese and Japanese courts followed prescribed cycles of annual events through various rites, festivals, banquets, and ceremonies. The Chinese court formed the model for Eastern courts such as the Japanese, while the Byzantine, which had absorbed aspects of Persian courts before the Islamic conquest as had those of India, provided a model for Western Christian and Islamic courts, which in turn influenced each other.
This chapter introduces the researchers to randomized and non-randomized designs that permit relatively strong causal inferences, particularly in field settings. It discusses the perspectives on the generalization of causal effects. The chapter considers some basic issues in inferring causality, initially drawing on work by Rubin and his associates in statistics and later drawing on work by Campbell and his associates in psychology. It also considers three classes of quasi-experimental designs, the regression discontinuity design, the interrupted time series design, and the nonequivalent control group design. The emphasis on designs for field research in the chapter contrasts sharply with standard practice in basic social psychology. Randomized experiments are typically considered to be the gold standard for causal inference. Some basic research in social psychology and personality now focuses on areas such as the influence of culture, major life stressors, religion, intimate relationships, and evolution of social behavior.
The problem of formulating knowledge bases containing action schema is a central concern in knowledge engineering for artificial intelligence (AI) planning. This paper describes Learning Object-Centred Models (LOCM), a system that carries out the automated generation of a planning domain model from example training plans. The novelty of LOCM is that it can induce action schema without being provided with any information about predicates or initial, goal or intermediate state descriptions for the example action sequences. Each plan is assumed to be a sound sequence of actions; each action in a plan is stated as a name and a list of objects that the action refers to. LOCM exploits assumptions about the kinds of domain model it has to generate, rather than handcrafted clues or planner-oriented knowledge. It assumes that actions change the state of objects, and require objects to be in a certain state before they can be executed. In this paper, we describe the implemented LOCM algorithm, the assumptions that it is based on, and an evaluation using plans generated through goal-directed solutions, through random walk, and through logging human-generated plans for the game of freecell. We analyze the performance of LOCM by its application to the induction of domain models from five domains.
During the late nineteenth century, contests over prohibition gripped hundreds of American towns and cities, nowhere with greater consequences than in the post-Reconstruction South. This article examines those effects in Greenville, South Carolina, a small marketing and manufacturing center in the white-majority upcountry. During the 1880s, prohibition split white Democrats who had “redeemed” Greenville's town government just a few years before and led to a surge in voter registration and participation among African Americans. The liquor question's repercussions for politics in the Gilded Age South have been largely neglected, both by social historians of prohibition and by political historians, who have failed to see it as one of the issues that roiled the region's politics between Reconstruction and the Populist rebellion. This article also emphasizes the overlooked importance of municipal elections and governance—even in so small a place as Greenville—as an arena for African Americans’ political activity. Greenville's black voters used their influence during the 1880s to achieve modest but tangible gains in education and municipal services and to erect at least a partial bulwark against the tide of white supremacy. These developments were part of a region-wide revival in African Americans’ municipal power, which Southern Democrats were careful to target in their disfranchising campaigns as the century drew to close.
China under the Mongols was a time of paradox: the Yuan had the shortest span of any major dynasty, yet the reach of its territory was the most extensive. It was diverse and multiethnic yet was a time in which many peoples were united in a single linguistic–cultural realm. It is also an era the scholarship of which owes much to an interest spawned outside of China by the Mongols– globalized reach. It witnessed the spread of literature in Chinese as far as Samarkand and Uzbekistan; its producers were Buddhists, Christians, Muslims, Chinese, Uighurs, Koreans, and Kazakhs. Whether one calculates the time span of Yuan literature 134 years backwards from its demise in 1368 to the time the Mongols snuffed out the Jin (1234), 107 years to the establishment of the Great Yuan dynasty by Khubilai Khan (1261), or 92 years to its destruction of the Southern Song (1276), it was short-lived. But such neat political divisions, datable to exact symbolic or real moments in the flow of time, obscure the tenacious knit of culture–s web, which loosens only through duration of change, reforming and reshaping culture–s pattern in small but important ways. While the Yuan–s political policies actually did create a significant break in literary continuity and an immediate and recognizable change in the whole cloth of Chinese literature, the dynasty was so short that many of these changes are visible only retrospectively as they unfold more elaborately in later times.
Determining appropriate topics and target audiences is essential to design effective educational outreach programs. Based on landowner responses to a mail survey, we determined both the importance and the availability of wildlife and forest management information topics to Mississippi landowners. Combining this information clearly identified the appropriate subject matter for outreach programs—topics important to landowners and for which information was relatively unavailable. The importance of wildlife and forest management information relative to its availability depended on the region, land use patterns, and landowner characteristics, thus demonstrating which segments of the population should be targeted to maximize program impact.
The purpose of the study was to examine the zero-order and unique
relations of effortful attentional and behavioral regulation, reactive
impulsivity, and anger/frustration to Chinese first and second
graders' internalizing and externalizing symptoms, as well as the
prediction of adjustment from the interaction of anger/frustration and
effortful control or impulsivity. A parent and teacher reported on
children's anger/frustration, effortful control, and impulsivity.
Parents reported on children's internalizing symptoms, and teachers
and peers reported on children's externalizing symptoms. Children
were classified as relatively high on externalizing (or comorbid),
internalizing, or nondisordered. High impulsivity and teacher-reported
anger/frustration, and low effortful control, were associated with
externalizing problems, whereas low effortful control and high
parent-reported anger were predictive of internalizing problems. Unique
prediction from effortful and reactive control was obtained and these
predictors (especially when reported by teachers) often interacted with
anger/frustration when predicting problem behavior classification.This research was supported by a grant from the
National Institutes of Mental Health (2 R01 MH60838) to Nancy Eisenberg
and an Earmarked Research Grant (CUHK4620/05H) of the Research Grants
Council, Hong Kong Special Administrative Region, China, to Lei
Chang.