Video-conferencing; risks and safeguards for older adults

Video-conferencing with older people with mental health problems: reflections on risks and safeguards
 by Susan Mary Benbow, FRCPsych MB ChB MSc  and Dr. Sharmi Bhattacharyya
 Older Mind Matters Ltd & University of Chester; Chester, United Kingdom

The COVID-19 pandemic has resulted in a rapid and unprecedented change in how services are delivered in the United Kingdom (UK). One of the changes it has precipitated is a shift to remote working, with face-to-face encounters between patients and healthcare practitioners limited to essential and unavoidable circumstances. The General Medical Council published guidance and a flowchart to help medical practitioners decide when it is appropriate and safe to treat patients remotely.¹ There are issues of particular concern when working with older people and with those older people who have mental health problems and, as old age psychiatrists, we have had to try to connect with people differently over the past four months. Whilst video consultations have potential advantages in this pandemic period (and in future), they also pose significant ethical considerations for healthcare services, practitioners, patients and carers.

Our experiences

Between us, we have experience of systemic therapy and supervision online, carrying out second opinions under mental health legislation and remote video hearings as a Mental Health Tribunal doctor: but who would have imagined that memory clinics could be carried out remotely? Yet earlier this year one of us carried out her first remote primary care memory clinic, involving telephone and online video-conferencing consultations with follow up and new patients. It went surprisingly well.

Thus, the COVID pandemic has highlighted the importance of video consultations between clinicians in different settings, and also between clinicians and patients in their own homes, for routine reviews as well as new assessments. For routine reviews, video consultations have been relatively easy, as the patient may be well known to the clinician, but new assessments are more difficult, especially in cases where risks may be high and are only elicited after starting the video consultation: sometimes consultations have had to be aborted in favour of face-to-face assessment.

Balancing the pros and cons            

Reading about remote consultations, the literature supports some of our main concerns, including:

• Digital and language exclusion – are older adults less likely to be acquainted with the devices needed for video-conferencing and, even if assisted by family members, to find the experience of using them anxiety-provoking or daunting? Against this, we know that older adults are increasingly using devices for a variety of purposes, so this may be less of a problem than one might anticipate. And what about exclusion by virtue of language – how would we carry out a remote consultation with someone who speaks no English or requires an interpreter?
• Technical difficulties – we may need to plan ahead for poor connections and contingencies should the connection fail. Sometimes the connection can lag behind and audio or video is delayed or unsynchronized: how might this affect an older adult with sensory difficulties and/ or cognitive issues?
• Risk and safeguarding – how to assess risks online, recognising that risks in older adults may be different from those in younger people. On screen, how do we see whether there is food in the kitchen and detect signs of self-neglect? How do we identify people where there are safeguarding issues?
• Carer issues – Whilst acknowledging that the vast majority of carers have their relative’s best interests at heart, sometimes it may be difficult to know how someone is potentially being influenced by others when seeing them online and, if the other person is asked to leave, can we be sure they have left the room and are not continuing to influence the conversation?
• Capacity and consent – Does this person understand that this online contact, bizarre as it might seem, is, for example, a memory clinic and that the person talking to them is a doctor carrying out an assessment?
• New assessments – are there particular concerns about new assessments? With older adults there may be additional challenges in engaging and developing a therapeutic relationship remotely, particularly if someone has sensory impairments.
• Body language – we lose the information that comes from body language. This might be particularly tricky when someone’s first language is not English or perhaps when they have some form of speech difficulty. In addition, digital platforms may compress video, so that facial expressions are hard to interpret.² This might be very risky during mental health assessments and mental state examinations, as it is imperative to be able to assess the appearance and behaviours of the patient/ relatives.
• Sensory impairments – may complicate remote consultations. Hearing impairment may make communication online difficult, and visual impairment may make lip reading difficult although tech-savvy people might enlarge someone’s face onscreen to make lip-reading easier (and certainly easier than when talking with someone wearing a face-mask).
• Therapeutic relationship - Some issues may be better discussed face to face. Is the challenge implicit in sharing a diagnosis or working out an advance care plan exacerbated by difficulties in establishing a therapeutic relationship and demonstrating empathy in virtual consultations? However, against this, during the pandemic, these issues have had to be addressed remotely and sensitively.
• Power – does remote consultation privilege clinician power over the autonomy and power of patient and family? How might this influence shared decision-making?
• Costs - some evidence suggests that telepsychiatry would be expensive for healthcare organisations initially due to necessary investments in infrastructure etc., but over time money may be saved (e.g., in relation to travel and other overheads, and due to savings in clinicians’ time): yet what about the costs to patients and carers who will also need appropriate technologies and the confidence to use them?

Alongside this, remote consultations offer advantages to healthcare practitioners, patients, and family (and perhaps society):

• No time needed to travel for clinicians and families. Sometimes family members need to devote a lot of time and effort to getting their relatives out of the house and to the clinic. How much easier it is to be seen at home.
• In the midst of a pandemic, risks to all concerned are considerably less as contact with others is kept to a minimum or completely abolished.
• Care Homes, in particular, may appreciate remote consultations for the above reason, and patients, family, and practitioners may all connect simultaneously should that be appropriate and should all concerned consent to do so.
• Patients and family members may be more relaxed in their own environment: attending a clinic, even in primary care, may be a source of anxiety.

Conclusions

Tele-psychiatry is an option in some areas of mental health because the nature of the specialty involves gathering information from audiovisual assessments, and it is possible to provide diagnosis and treatment remotely. It raises a number of ethical issues, including in relation to the doctor-patient relationship, assessment of risk, the role of technology, and data confidentiality and security. In older adults, do the disadvantages outweigh the advantages? The balance will be different for different individuals and families, but we have been surprised how well remote consultations have gone, and how our concerns about video-conferencing with families have not been borne out in practice. Nevertheless, we believe that caution is still justified.

Prof. Susan Mary Benbow and Dr Sharmi Bhattacharyya are both old age psychiatrists located in the United Kingdom.

[1] https://www.gmc-uk.org/-/media/gmc-site-images/ethical-guidance/learning-materials/themes/remote-consultations-diagram-april-2020-(002).svg?la=en&hash=3BFAD4683392DABF0E512E931617952CDAC385C4
[2] Greenhalgh T, Vijayaraghavan S, Wherton J, et al. BMJ Open 6:e009388, 2016.