Anxiety disorders are as common among the old as the young, yet often the elderly go undertreated. Telepsychiatry could offer an elegant solution for older adults – and their caregivers – who have trouble leaving the home. Here are six strategies to consider before getting started.
by Jodi Lyons
Anxiety disorders affect 40 million adults in the United States, and nearly half of those suffering from anxiety also suffer from depression. These statistics have been well publicized in medical journals and consumer publications alike. Less appreciated is the fact that, according to the Anxiety and Depression Association of America, older adults are just as likely to experience depression and anxiety. This is significant because mental health issues often go under recognized in elderly populations. Clinical anxiety is often missed because it gets expressed as another ailment, like fatigue, headaches, insomnia, irritability, or muscle pain. According to the BCAT Research Center, estimates of anxiety disorders among community-dwelling older adults range from 10%–20%; rates of depression range from 5%–15%; and rates of dementia range from 8%–14%.
And what about those who care for the elderly? Today, there are 15.7 million caregivers for the 5.3 million people with Alzheimer’s. Fifty-nine percent of family caregivers who provide care for those with Alzheimer’s or other dementias rate their stress levels as “high” or “very high.” Often, caregivers themselves become housebound in a practical—if not medical—sense, since they can’t leave the person with dementia alone while they go to their own medical appointments.
The high prevalence of mental illness in older adults, combined with the propensity for being under-treated in this population, means that they—and their caregivers—represent a significant opportunity for telemedicine, and specifically telepsychiatry. For homebound older adults, it doesn’t matter whether the setting is rural, suburban or urban, or whether the nearest medical care is five miles away or five hundred miles—getting out of the house is the challenge, and it’s a challenge easily overcome by telemedicine.
If your institution is ready to build a tele-psych program to serve older adults and their homebound caregivers, here are some tools and strategies to get you started.
1. Know your patient, and their environment.
Best practices still suggest that the initial assessment be conducted in-person. Either the patient goes to the practitioner or vice versa. The patient should be screened for depression, anxiety disorders, and dementia using tools that are sensitive, specific, scientifically validated, and can identify mild cognitive impairment (MCI) in addition to dementia. Since nearly half of people with dementia are incorrectly diagnosed, undiagnosed, or are unaware of their diagnosis, it seems obvious to include this screening along with the depression and anxiety screening. Since MCI is often missed, it is important that the screening be able to identify the disease as early as possible. As part of this assessment, one needs to evaluate the family’s ability to actually implement a telemedicine system on their end. Do they have a phone or computer with video conferencing capability? Do they know how to use it? If not, could a friend, family member, or home care agency help?
2. Make sure that the relationship between practitioner and patient is stable.
Practitioners would need to agree to treat via video conferencing for an extended and realistic period of time. Particularly in cases where medication management is necessary, there needs to be a safety net built in to mimic that of traditional treatment sites. This can’t be a few “visits” with no plan for follow-through.
3. Know who you’re talking to.
The practitioners need to verify that they are communicating with the actual patient—not with someone pretending to be the patient, speaking for the patient, etc. Fortunately, there are secure video conferencing services allowing for visual communication that e-mail, telephone, and texting don’t. This allows the practitioners to see and analyze visual cues, a vital tool in their diagnosis and treatment plans. Telephones alone aren’t enough.
4. Address privacy concerns.
When the originating site is a patient’s home, there will be privacy concerns. Yet, there is a balance between providing the service and ensuring privacy. In homebound patients, there often is no option other than asking the patient if they are comfortable speaking freely.
5. Know what’s happening in the home.
The practitioners might be the only professional eyes and ears “in” the home. Look for problems. Has the patient’s appearance or hygiene declined? Be sure to ask questions about eating habits, how the patients get their food/medicine, who prepares the meals, etc. Does the house look dirty or disorganized? Can the patient and caregiver handle the Instrumental Activities of Daily Living (IADLs) or Activities of Daily Living (ADLs)?
6. Develop an exit strategy.
Know when the patient isn’t safe at home anymore, or at least when to call in reinforcements.
Worsening of symptoms, cognitive decline, and inability to manage IADLs or ADLs should raise safety concerns that need to be addressed. Do you need to call in a care manager, a home care agency or Adult Protective Services?
There have been multiple studies showing that telepsychiatry in general offers effective treatment options, particularly in vulnerable populations. When combined with scientifically validated brain rehabilitation, working memory exercises, or meaningful engagement programs, telepsychiatry is a vital tool in maintaining the psychological well-being and brain health of homebound older adults, including those with dementia and their caregivers.
4. Randomized clinical trial of telepsychiatry through videoconference versus face-to-face conventional psychiatric treatment. De Las Cuevas C, Arredondo MT, Cabrera MF, Sulzenbacher H, Meise U. Telemedicine Journal and e-Health; June, 2006