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Recent Advances – Innovations in Care in Geriatric Psychiatry

Large-scale care provision is one of the largest challenges associated with meeting the mental health needs of the burgeoning older adult population. In the last month, three manuscripts have been published describing innovative approaches to psychiatric care for the elderly:

Conn, D.K., Madan, R., Lam, J., Patterson, T., Skirten, S. Program evaluation of a telepsychiatry service for older adults connecting a university-affiliated geriatric center to a rural psychogeriatric outreach service in Northwest Ontario, Canada. International Psychogeriatrics November 2013; 25(11): 1795-1800.

Conn et al. from Baycrest Hospital and University of Toronto describe a retrospective analysis of 253 most recent patient assessments from referrals to a telemedicine program. Two psychiatrists have been providing care from their offices in a tertiary care center in Toronto, Canada, via secure internet-based videoconferencing to remote areas almost 2,000 km away, where psychiatric care is sparse. More than half of the consultations were for complex patients with multiple diagnoses. Only 3% of patients reported problems with technical aspects of the consultation, and the mean evaluation of all sub-items across the years ranged from 4.60 to 4.85 on a scale of 1 to 5 (with 5 being the best possible score). Focus groups with local care providers confirmed the positive perceptions of the patients, and identified an intriguing barrier – some physicians felt that providing telemedicine would be a disincentive for securing in-person geriatric psychiatry expertise in the local area. Team education was another well-rated aspect of the program.

McMurchie, W., Macleod, F., Power, K., Laidlaw, K., Prentice, N. Computerised cognitive behavioural therapy for depression and anxiety with older people: a pilot study to examine patient acceptability and treatment outcome. International Journal of Geriatric Psychiatry November 2013; 28(11): 1147-1156.

McMurchie et al. conducted a study in the United Kingdom in which 58 older adults who had significant depressive symptoms opted to receive either treatment as usual (TAU) or TAU in addition to 8-weekly hour long sessions of a computerized cognitive behavioral therapy that has previously been studied in younger adults: “Beat the Blues”. They compared both groups on change from baseline on three scales: Geriatric Depression Scale, Geriatric Anxiety Inventory and Clinical Outcomes in Routine Evaluation, immediately after treatment and one month later. They found that the “Beat the Blues” group had significant relative reduction in the GDS score, but not the other measures. Similarly, using a response definition of more than 2 SD below baseline score, 42% of the “Beat the Blues” group were deemed responders at endpoint compared with 10% of the treatment-as-usual-only group on the GDS, but the other measures were not significantly different between the groups. Their reported 57% “uptake” of the intervention accounted for those who did not complete the intervention after agreeing to start, but did not take into account the 19 participants who met criteria for the study but declined to participate. The authors took a conservative last observation carried forward approach to dealing with the drop-outs, and provided a useful discussion of addressing the technology gap and the need for further randomized study of this intervention incorporating delayed outcome measures.

Czaja, S.J., Loewenstein, D., Schulz, R., Nair, S.N., Perdomo, D. A videophone psychosocial intervention for dementia caregivers. American Journal of Geriatric Psychiatry November 2013; 21(11): 1071-1081.

Czaja et al. from Florida, United States, studied the effects of a videophone intervention based on a published multicomponent intervention aimed at reducing caregiver burden, caregiver depression and institutionalization. The intervention included six one-hour monthly sessions with brief video lectures, support group sessions and additional resources. Caregiving tips were provided, as well as “quick solutions” to crises. The authors randomized 110 African American or Hispanic community dwelling caregivers of patients with dementia to the videophone intervention, an attention control via videophone (focused on nutrition) or an information control without videophone use. They found moderate to large effect sizes for measures of “unconditional bother” (bother from any of the patient-related problems), positive aspects of caregiving, and satisfaction with social support at endpoint, but there were no differences for depression or “negative aspects of caregiving”. Using a dichotomous analysis they found that of those in the intervention group, 46% were found to have at least 0.5 SD improvement in “positive aspects of caregiving” compared to 16% in the control groups. The authors analyzed only completers, and lumped both control groups together in this analysis so it is impossible to know whether the active ingredients pertained to the use of the videophone or the specific aspects of the caregiver intervention. Only 16/138 refused to participate, and of those randomized, only 4 participants in the active intervention group either were lost to follow-up or quit, and as such, the authors demonstrated the feasibility of integrating a technology-enabled solution into an intervention aimed at meeting the complex needs of caregivers. 

Mark J. Rapoport, MD, FRCPC

Excerpted article as reprinted from IPA’s newsletter, the IPA Bulletin, Volume 30, Number 6


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