Diagnostic accuracy of eHealth literacy measurement tools in older adults: a systematic review.

BACKGROUND: In Canada, virtual health care rapidly expanded during the COVID-19 pandemic. There is substantial variability between older adults in terms of digital literacy skills, which precludes equitable participation of some older adults in virtual care. Little is known about how to measure older adults' electronic health (eHealth) literacy, which could help healthcare providers to support older adults in accessing virtual care. Our study objective was to examine the diagnostic accuracy of eHealth literacy tools in older adults. METHODS: We completed a systematic review examining the validity of eHealth literacy tools compared to a reference standard or another tool. We searched MEDLINE, EMBASE, CENTRAL/CDSR, PsycINFO and grey literature for articles published from inception until January 13, 2021. We included studies where the mean population age was at least 60 years old. Two reviewers independently completed article screening, data abstraction, and risk of bias assessment using the Quality Assessment for Diagnostic Accuracy Studies-2 tool. We implemented the PROGRESS-Plus framework to describe the reporting of social determinants of health. RESULTS: We identified 14,940 citations and included two studies. Included studies described three methods for assessing eHealth literacy: computer simulation, eHealth Literacy Scale (eHEALS), and Transactional Model of eHealth Literacy (TMeHL). eHEALS correlated moderately with participants' computer simulation performance (r = 0.34) and TMeHL correlated moderately to highly with eHEALS (r = 0.47-0.66). Using the PROGRESS-Plus framework, we identified shortcomings in the reporting of study participants' social determinants of health, including social capital and time-dependent relationships. CONCLUSIONS: We found two tools to support clinicians in identifying older adults' eHealth literacy. However, given the shortcomings highlighted in the validation of eHealth literacy tools in older adults, future primary research describing the diagnostic accuracy of tools for measuring eHealth literacy in this population and how social determinants of health impact the assessment of eHealth literacy is needed to strengthen tool implementation in clinical practice. PROTOCOL REGISTRATION: We registered our systematic review of the literature a priori with PROSPERO (CRD42021238365).

Efficacy of virtual interventions for reducing symptoms of depression in community-dwelling older adults: a systematic review.

BACKGROUND: Older adults experience symptoms of depression, leading to suffering and increased morbidity and mortality. Although we have effective depression therapies, physical distancing and other public health measures have severely limited access to in-person interventions. OBJECTIVE: To describe the efficacy of virtual interventions for reducing symptoms of depression in community-dwelling older adults. DESIGN: Systematic review. SETTING: We searched MEDLINE, EMBASE, Cochrane Libraries, PsycINFO, and gray literature from inception to July 5, 2021. PARTICIPANTS AND INTERVENTIONS: We included randomized trials (RCTs) comparing the efficacy of virtual interventions to any other virtual intervention or usual care in community-dwelling adults ≥60 years old experiencing symptoms of depression or depression as an outcome. MEASUREMENTS: The primary outcome was change in symptoms of depression measured by any depression scale. RESULTS: We screened 12,290 abstracts and 830 full text papers. We included 15 RCTs (3100 participants). Five RCTs examined persons with depression symptoms at baseline and ten examined depression as an outcome only. Included studies demonstrated feasibility of interventions such as internet or telephone cognitive behavioral therapy with some papers showing statistically significant improvement in depressive symptoms. CONCLUSIONS: There is a paucity of studies examining virtual interventions in older adults with depression. Given difficulty in accessing in-person therapies in a pandemic and poor access for people living in rural and remote regions, there is an urgent need to explore efficacy, effectiveness, and implementation of virtual therapies.

Chemical and physical restraint use during acute care hospitalization of older adults: A retrospective cohort study and time series analysis.

BACKGROUND: Chemical and physical restraints are associated with harm in older adults, but our understanding of their use during acute care hospitalizations is limited. OBJECTIVES: To (1) describe restraint use during acute care hospitalizations of older adults at the onset of the COVID-19 pandemic compared to pre-pandemic levels and (2) describe between-hospital variability in restraint use. DESIGN: Retrospective cohort study with a time series analysis. PARTICIPANTS: Acute care hospital inpatients, aged 65 years or older, who were discharged from one of four Alberta hospitals or six Ontario hospitals in Canada, between November 1, 2019, and June 30, 2020. MAIN MEASURES: We used autoregressive linear models with restricted cubic splines to compare proportions of chemical restraint (that is, psychotropic medications, namely antipsychotics, benzodiazepines, and trazodone) and physical restraint (e.g., mittens) use immediately after the onset of the COVID-19 pandemic with pre-pandemic levels. We describe between-hospital variability in restraint use using intraclass correlation coefficients (ICC) and median odds ratios (OR). KEY RESULTS: We included 71,004 hospitalizations. Adjusted for the prevalence of dementia and psychotic disorders, chemical restraint use increased in Ontario hospitals from a pre-pandemic average of 27.1% to 30.8% (p<0.001) before returning to pre-pandemic levels within eight weeks. Physical restraint orders in Ontario increased from 5.9% to 8.3% (p = 0.012) and remained elevated at eight weeks. No significant changes in restraint use were observed in Alberta. There was moderate between-hospital variability in chemical restraint use (ICC 0.041 and median OR 1.43). Variability in physical restraint use was higher (ICC 0.11 and median OR 1.83). CONCLUSIONS: The COVID-19 pandemic impacted in-hospital use of chemical and physical restraints among older adults in Ontario but not Alberta. Substantial differences in chemical and physical restraint use by region and hospital suggests there are opportunities to improve best practices in geriatric care. Future research must support implementation of evidence-informed interventions that standardize appropriate restraint use.

Barriers and facilitators to virtual care in a geriatric medicine clinic: a semi-structured interview study of patient, caregiver and healthcare provider perspectives.

BACKGROUND: COVID-19-related physical distancing measures necessitated widespread adoption of virtual care (i.e. telephone or videoconference), but patients, caregivers and healthcare providers raised concerns about its implementation and sustainability given barriers faced by older adults. OBJECTIVE: To describe barriers and facilitators experienced by people accessing and providing virtual care in a geriatric medicine clinic. DESIGN: Qualitative semi-structured interview study. SETTING AND PARTICIPANTS: We recruited and interviewed 20 English-speaking patients, caregivers and healthcare providers who participated in virtual care at St. Michael's Hospital's geriatric medicine clinic, Toronto, Canada, between 22 October 2020 and 23 January 2021. METHODS: We analyzed data in two stages: framework analysis and deductive coding to the Theoretical Domains Framework. RESULTS: We included six healthcare providers, seven patients and seven caregivers. We identified eight themes: impact of the COVID-19 pandemic on virtual care uptake, complexity of virtually caring for older adults, uncertain accuracy of virtual assessments, inequity in access to virtual care, importance of caring for the patient-caregiver dyad, assimilating technology into the lives of older adults, impact of technology-related factors on virtual care uptake and impact of clinic processes on integration of virtual care into outpatient care. Further, we identified knowledge, skills, belief in capabilities, and environmental context and resources as key barriers and facilitators to uptake. CONCLUSIONS: Patients, caregivers and healthcare providers believe that there is a role for virtual care after COVID-19-related physical distancing measures relax, but we must tailor implementation of virtual care programs for older adults based on identified barriers and facilitators.

Diagnostic accuracy of virtual cognitive assessment and testing: Systematic review and meta-analysis.

BACKGROUND/OBJECTIVES: Virtual (i.e., telephone or videoconference) care was broadly implemented because of the COVID-19 pandemic. Our objectives were to compare the diagnostic accuracy of virtual to in-person cognitive assessments and tests and barriers to virtual cognitive assessment implementation. DESIGN: Systematic review and meta-analysis. SETTING: MEDLINE, EMBASE, CDSR, CENTRAL, PsycINFO, and gray literature (inception to April 1, 2020). PARTICIPANTS AND INTERVENTIONS: Studies describing the accuracy or reliability of virtual compared with in-person cognitive assessments (i.e., reference standard) for diagnosing dementia or mild cognitive impairment (MCI), identifying virtual cognitive test cutoffs suggestive of dementia or MCI, or describing correlations between virtual and in-person cognitive test scores in adults. MEASUREMENTS: Reviewer pairs independently conducted study screening, data abstraction, and risk of bias appraisal. RESULTS: Our systematic review included 121 studies (15,832 patients). Two studies demonstrated that virtual cognitive assessments could diagnose dementia with good reliability compared with in-person cognitive assessments: weighted kappa 0.51 (95% confidence interval [CI] 0.41-0.62) and 0.63 (95% CI 0.4-0.9), respectively. Videoconference-based cognitive assessments were 100% sensitive and specific for diagnosing dementia compared with in-person cognitive assessments in a third study. No studies compared telephone with in-person cognitive assessment accuracy. The Telephone Interview for Cognitive Status (TICS; maximum score 41) and modified TICS (maximum score 50) were the only virtual cognitive tests compared with in-person cognitive assessments in >2 studies with extractable data for meta-analysis. The optimal TICS cutoff suggestive of dementia ranged from 22 to 33, but it was 28 or 30 when testing was conducted in English (10 studies; 1673 patients). Optimal modified TICS cutoffs suggestive of MCI ranged from 28 to 31 (3 studies; 525 patients). Sensory impairment was the most often voiced condition affecting assessment. CONCLUSION: Although there is substantial evidence supporting virtual cognitive assessment and testing, we identified critical gaps in diagnostic certainty.

Factors associated with virtual care access in older adults: a cross-sectional study.

BACKGROUND: virtual care has been critical during the COVID-19 pandemic, but there may be inequities in accessing different virtual modalities (i.e. telephone or videoconference). OBJECTIVE: to describe patient-specific factors associated with receiving different virtual care modalities. DESIGN: cross-sectional study. SETTING AND SUBJECTS: we reviewed medical records of all patients assessed virtually in the geriatric medicine clinic at St. Michael's Hospital, Toronto, Canada, between 17 March and 13 July 2020. METHODS: we derived adjusted odds ratios (OR), risk differences (RDs) and marginal and predicted probabilities, with 95% confidence intervals, from a multivariable logistic regression model, which tested the association between having a videoconference assessment (vs. telephone) and patient age, sex, computer ability, education, frailty (Clinical Frailty Scale score), history of cognitive impairment and immigration history; language of assessment and caregiver involvement in assessment. RESULTS: our study included 330 patients (227 telephone and 103 videoconference assessments). The median population age was 83 (Q1-Q3, 76-88) and 45.2% were male. Frailty (adjusted OR 0.62, 0.45-0.85; adjusted RD -0.08, -0.09 to -0.06) and absence of a caregiver (adjusted OR 0.12, 0.06-0.24; adjusted RD -0.35, -0.43 to -0.26) were associated with lower odds of videoconference assessment. Only 32 of 98 (32.7%) patients who independently use a computer participated in videoconference assessments. CONCLUSIONS: older adults who are frail or lack a caregiver to attend assessments with them may not have equitable access to videoconference-based virtual care. Future research should evaluate interventions that support older adults in accessing videoconference assessments.