Behavioral Disorders

The Emergency Center for Psychogeriatrics
and Behavioral Disorders at Herzog Hospital 
The Emergency Center for Psychogeriatrics and Behavioral Disorders was established at Herzog Hospital, with the help from a grant from the Nash Foundation. The objective of the Center is to provide comprehensive diagnosis and care for behavioral crisis in people with dementia on an emergency and out-patient basis. Through emergency assessment, patients with behavioral problems resulting from cognitive decline or dementia (such as Alzheimer’s disease) are treated enabling them to return to the community as soon as possible.
 This specialized Center provides a long-needed multi-disciplinary service to deliver acute care to patients who have until recently, “fallen between the chairs” of medical services that did not have the facilities nor the expertise to deal with acute behavioral disorders in demented patients. Caregivers were helpless when trying to deal with sleepless nights with an agitated Alzheimer’s patient.

Previously, in the best-case scenario these patients would turn to the general hospital emergency rooms where they were not treated by a Behavioral Neurologist who has a special clinical expertise. They would be drugged with medications causing major side-effects and discharged on the same day without providing a long term comprehensive solution, much to the frustration and stress of the caregivers.

A critical element in treating these disorders is real-time early intervention and accurate diagnosis, which our Emergency Center now provides. Improving neurological evaluation and treatment, by combining diverse medical and paramedical fields (i.e., geriatrics, behavioral neurology, psychology, psychiatry, internal medicine, nursing and social work), reduces chances of further deterioration in health and future hospitalization. Diagnosis and treatment lasts 24-72 hours, with some patients requiring hospitalization for a longer period until stabilization.

With the first allocation from the Nash Foundation, Herzog Hospital began preparations to hire staff, allocated physical space, and purchased furniture and necessary equipment.  Dr. Yakir Kaufman, Director of Neurological Services at Herzog Hospital, was hired and appointed to organize and supervise the Emergency Center for Psychogeriatrics and Behavioral Disorders.

Beginning in February 2005, the first patients were treated at the Emergency Center. The Center was officially and publicly launched in July 2005 with a conference held at Herzog Hospital for health care professionals, social workers and caregivers dealing with the elderly from municipal, social and health care service agencies operating in the Jerusalem area.  The conference was held in cooperation with the municipality of Jerusalem Department of Social Services and attended by over 80 professionals.

The launching of the Emergency Center was received with great enthusiasm by health care professionals throughout the Jerusalem area. Doctors, nurses and social workers throughout the Jerusalem health care system, including Kupot Cholim (Health Care Funds), hospitals and the social services of the Jerusalem municipality are regularly referring patients to the new Emergency Center. These emergency services did not exist anywhere in Israel prior to the opening of the Center at Herzog Hospital.

We carried out considerable preparatory work, meeting and extensively lecturing to medical staff throughout Jerusalem’s hospitals including Hadassah Hospital, emergency rooms, psychiatric units and the Ministry of Health. We have printed and widely distributed flyers advertising our services through our mailing list and at lectures. We have held conferences for social workers in the community and those working for the Jerusalem municipality (with which we work with closely) explaining our new concept and services. We have encountered warm appreciation to this new concept and service, many remarking how obvious the need was and how surprised they were that such a key service had not been established sooner.

Since we started we have treated patients with dementia and cognitive impairments ranging from Alzheimer’s Disease through vascular dementia, fronto-temporal dementia, anoxic brain damage, cerebral hemorrhages, etc. Word has spread quickly amongst our colleagues, including physicians, nurses and social workers throughout Jerusalem and in other hospitals. They feel relieved since they know of our services as they now have an appropriate long-needed solution for so many patients that suffer from behavioral disorders. As our center is part of a monthly international Behavioral Neurology videoconference (in conjunction with Baycrest Hospital in Toronto), this has also become another venue through which we have presented this new concept and service.

The staff of the new Center has also been instrumental in educating the medical staff within Herzog Hospital in how to treat these patients, and to develop their expertise in this area in order to work in an integrative multi-disciplinary fashion.

Currently the project is running smoothly with very good results. We have two inpatient beds dedicated for this service. We have evaluated and treated over 200 patients in our pre-admission assessment program. Among these, we have hospitalized only the 20 patients with the most extreme behavioral disorders that could not have been managed on an ambulatory basis. This is due to the fact that we are aware of the ill-effects of shifting a demented patient from his natural environment at home to a hospital.

Behavioral disorders we treat include acute agitation, verbal and physical aggression and violence, disinhibition, anxiety, hypersexuality, psychoses, severe post-stroke depression, exit-seeking, paranoia, and shouting in demented patients.

Patients are referred to us through general hospitals, emergency rooms, treating physicians, community social workers or family members/caregivers who have heard of our services. If the admission is not urgent we invite families to visit our facility and meet our staff before patient admission. In these cases it is possible to assess patients prior to admission. At times we make house or hospital visits to see patients before admission. On admission patients go through a comprehensive multidisciplinary assessment which results in a working diagnosis and a plan for further investigation and a multidimensional treatment plan. As we practice integrative team medicine, we treat patients through pharmacological means as well as enhancement of occupational, social and functional well-being. We work with caregivers to educate them on how to create a more therapeutic environment and interactions to reduce patient agitation. We recommend adjustments in the home surroundings.

The average inpatient stay is 12 days. All our patients had a favorable outcome with a substantial improvement in behavioral parameters. Our intervention allowed patients to return to their home environment saving them unnecessary hospitalization and institutionalization, thus contributing to the patient and caregivers’ well-being.

The health reforms due to be implemented in Israel after Jan 1, 2007 will provide partial payment for these services on a per patient basis, in addition to the grant from the Nash Foundation.

By way of an example here is a brief case report.  AR, a 60 year-old Russian-born, former physician was found by the police wandering purposelessly on a major highway near Jerusalem, thus endangering herself and others’ safety. She could not express herself clearly and she was brought to a general hospital emergency room without a clear diagnosis or treatment. She had a profound behavioral disorder and cognitive dysfunction. From there she was transferred to the internal medicine department. All investigations including head neuroimaging were negative or unremarkable. She was assessed by internists, neurologists and psychiatrists again with no clear diagnosis and no improvement in terms of her behavioral-cognitive disorder after two weeks of hospitalization. The head physician in charge of geriatrics in the Ministry of Health called us urgently to help with this perplexing and complex patient. She was immediately transferred to our new Emergency Center for Psychogeriatrics and Behavioral Disorders. On admission she was extensively assessed and in a matter of a few hours a diagnosis was made (Fronto-temporal Dementia) and the appropriate therapy was initiated. In 3 days her severe behavioral disorder had resolved and she was discharged to the community in 6 days

This is just one of many patients who have been benefiting from the expertise of the Center.

The Emergency Center for Psychogeriatrics and Behavioral Disorders is filling a void in health care services in the Jerusalem area, providing effective, critically needed emergency services 24 hours a day, seven days a week. It has demonstrated the efficacy of correct diagnosis and treatment of those who did not respond to regular assessment and treatments through general hospitals, psychiatric services, emergency rooms and internal medicine departments. Health care professionals and caregivers now have a facility that can provide them with professional expertise and the environment for the more effective diagnosis and treatment of behavioral-neurological dysfunction/disorder on an emergency basis. With the growth of these services, we foresee reduced patient hospitalization, resulting in higher satisfaction of patients and caregivers, and lowering costs for the health system.

We are indebted to the Nash Family Foundation for making this project possible. Without the funding from the Foundation, Herzog Hospital would not have been able to launch this critically needed Emergency Center