The wait for “geripsych”: Prolonged boarding of older adults awaiting inpatient psychiatry

Abstract

Prolonged boarding of older adults with neuropsychiatric illness has become a common, yet underrecognized, feature of contemporary mental health care delivery. I highlight the ways boarding functions as a de facto stage of care that impacts the system and hospitalists tasked with caring for these patients. Boarding reflects structural vulnerabilities around psychiatric capacity, long‑term care, and community services. Boarding time should be treated as a reportable safety metric, paired with unit‑level prevention and escalation pathways to guide hospital leaders, hospitalists, and regional planners.

A patient in her 90 s is admitted to the medical floor after severe behavioral dysregulation at home, marked by agitation, running into the street at night, and paranoia that her family is stealing from her. As a consultation‑liaison (C‑L) psychiatrist, this consult question is familiar: “90‑year‑old with agitation.” Yet when I walk into the room, I find a calm, pleasant nonagenarian. She has no idea she is in a hospital. She thinks she is at home and tells me she is fine, with no recollection of what day it is or where she is. She answers my questions patiently, denies hallucinations, sleep disturbance, and depression, and tells me stories about her family and work. She thanks me when I leave and seems carefree about what comes next.

Her family is far less carefree. They describe months of worsening paranoia, nocturnal wandering, and increasing fear that they can no longer keep her safe. She has had “dementia” for years. They want her to be further treated in the hospital and do not feel she is safe to be discharged, even though she has been calm and pleasant throughout her stay. The medical team agrees she has no active medical issues and is “cleared” for discharge.

Here is the dilemma I face often as a C‑L psychiatrist. Today she is stable, with no behavioral symptoms in more than 24 h. At home, her condition does a 180, with significant concern from her family. Do I go by what I see and tell the primary team there are no acute psychiatric reasons to keep her in the hospital? Or do I recommend geriatric psychiatry hospitalization, knowing this will likely mean days of boarding on the medical floor with a real risk that she will worsen?

This case illustrates a broader systems failure I now encounter routinely: older adults with neuropsychiatric illness boarding for days on medical units while they await scarce geriatric psychiatry beds. Prolonged boarding is no longer the exception; it is becoming a predictable stage in the care of many older adults in crisis. Recent work has documented how older adults boarding in emergency department (ED) hallways describe stress, disorientation, and powerlessness, and has framed hallway boarding as a critical geriatric safety issue. ¹ In this commentary, I suggest that prolonged boarding of older adults awaiting geriatric psychiatry admission can be a stage of care that amplifies delirium risk, functional decline, and system strain. It also reflects structural decisions about psychiatric capacity and long‐term care rather than individual “placement problems.”

When I wrestle with this choice, I'm not just thinking about her. I'm thinking about what happens the moment I say, “Yes, let's admit to geriatric psychiatry.” At first, nothing happens. She stays on the medical floor, occupying a bed that the hospital would very much like to turn over. Her chart gains a new label: “awaiting psych bed.” The team starts to round on her a little faster. Her name goes onto inpatient psychiatry waitlists that already feel endless.

In theory, boarding is temporary, a holding pattern. In practice, for older adults, it becomes its own stage of care. The longer she stays, the more likely it is that we will see what we are trying to prevent: sundowning, delirium, and falls. We try to “keep her safe” with constant checks, bed alarms, and sometimes a sitter, but the environment itself is disorienting. ²

Geriatrics has long reminded us that hospitalization can trigger functional decline in vulnerable older adults through a cascade of immobility, sensory deprivation, and iatrogenic complications. ³ Boarding adds another layer: recent data from a large cohort of adults boarding in the ED found that each additional hour of boarding was associated with higher odds of delirium during the hospital stay. ⁴ Many of the patients who ultimately land on geriatric psychiatry waitlists occupy the intersection of advanced age, major neurocognitive disorder, and medical comorbidity, and so boarding is not a neutral time. A single older adult boarding for psychiatry also blocks a medical bed, backing up the ED and leaving other patients, often other older adults, waiting on stretchers in hallways.

This is the paradox of prolonged boarding on medical units: by trying to protect an older adult while we wait for the “right” bed, we often create the very complications that make discharge harder. The boarding period becomes an iatrogenic fork in the road.

Part of why this keeps happening is simple math. Over the past several decades, inpatient psychiatric capacity in the United States has steadily shrunk, especially in the public and safety‑net sectors. A recent national cross‑sectional analysis found that as of 2023, the United States had about 28.4 inpatient psychiatric beds per 100,000 people, roughly half of the ~60 beds per 100,000 that expert consensus considers an optimal benchmark, and that many counties have no inpatient psychiatric beds at all. ⁵ The result is a patchwork system in which access to inpatient psychiatry depends heavily on geography, financing, and hospital type. Geriatric psychiatry beds are an even thinner slice of this shrinking pie. In many states, the total number of licensed geriatric psychiatry beds can be counted in the hundreds for populations of well over a million older adults.

These beds are not just scarce; they are often occupied for long stretches by patients with nowhere else to go: individuals with severe major neurocognitive disorder, complex medical needs, or a history of behaviors that make long‑term care facilities reluctant to accept them. Each of these “un‑placeable” patients represents a person our long‑term care and community systems have failed to absorb, and a bed that won't turn over quickly.

By the time I meet a patient like this on the medical floor, several systems have already said “no” in quieter ways. Community mental health likely doesn't have the capacity for urgent home visits. Outpatient geriatric psychiatry clinics are often booking months out. Adult day programs may have discharged her because her behaviors were “too disruptive.” The nursing home that seemed promising on paper has declined the referral. What's left is the hospital, which was never designed to be the default holding place for chronic neuropsychiatric crises.

The consequences ripple outward. Prolonged boarding contributes to burnout among nurses and physicians on medical floors who feel ill‑equipped to manage complex behavioral symptoms day after day. It shapes how trainees learn to think about older adults with major neurocognitive disorder, that they are “difficult,” “placement problems,” “social admits”, rather than patients whose needs are predictable consequences of resource gaps. It reinforces a quiet ageism in the system: the idea that long waits, hallway beds, and weeks spent in limbo are somehow an acceptable norm for people in their seventies and eighties.

When I stand in that patient's doorway and decide whether to recommend a geriatric psychiatry admission, I'm not just making an individual risk–benefit calculation. I'm deciding whether to plug her into a pipeline that I know is clogged at every step. If I say no, her family may leave feeling abandoned, forced to shoulder behaviors they no longer feel safe managing. If I say yes, I may be signing her up for days of disorienting boarding and the real possibility that she will be more impaired, cognitively and functionally, by the time we finally find a bed.

Where do we go from here?

For mental health systems and psychiatric services, one starting point is measurement. What would it mean to treat prolonged boarding of older adults as a quality and safety problem rather than a background inevitability? At a minimum, hospitals and health systems could begin tracking age‑stratified boarding times for patients awaiting geriatric psychiatry, reporting these alongside more familiar throughput metrics. If we do not count how long older adults spend in this limbo, we will continue to underestimate its impact on patient outcomes and psychiatric service capacity.

On medical units, we can treat boarding as a high‑risk geriatric condition that warrants structured prevention efforts: consistent delirium screening, early mobilization, and ready access to geriatric and geriatric psychiatry expertise. At the system level, we need to include geriatric psychiatry capacity and alternatives to hospitalization in regional planning. The bed‑capacity literature now gives us a clearer sense of how far we are from even minimal psychiatric bed adequacy in many communities ⁵ ; that information should inform targeted investments in geriatric‑specific units, hospital–long‑term care partnerships for “un‑placeable” patients, and crisis and home‑based services that might avert some hospitalizations altogether.

The patient in front of me may be calm today, smiling as she talks about her past and insisting she is “fine.” But the choice I make about her disposition is inseparable from all of this: from the limited units that still exist to take her, from the long‑term care facilities that will not accept her, from the community programs that never had enough funding to reach her. Her boarding is not an accident; it is the predictable outcome of a system that has never fully decided where someone like her is supposed to belong.

CONFLICT OF INTEREST STATEMENT

The author declares no conflicts of interest.

ETHICS STATEMENT

The patient and her healthcare proxy provided verbal consent for the case to be mentioned in this commentary. This manuscript is not a case report; all potentially identifying clinical details have been de‑identified and anonymized to protect patient confidentiality.