Mental Health Needs of Aging Veterans: Recent Evidence and Clinical Recommendations.

Objectives: Large numbers of older Americans have a history of military service, which may be positively or negatively associated with mental health in late life. We reviewed literature with the aim of better understanding the mental health needs of older Veterans.Methods: Articles included those published in 2009-2018 and focused on prevalence/risk for mental illness and suicide among older Veterans; utilization of mental health services; effectiveness of evidence-based behavioral treatments; and pertinent care delivery models.Results: Older Veterans are generally resilient. A significant minority experience mental health concerns that are associated with poor outcomes including a substantial number of suicides. Most published research is based on the approximately one third of Veterans who use the Veterans Health Administration (VHA) for care. Older Veterans with mental health diagnoses are less likely to utilize mental health services compared to younger Veterans, but as likely to benefit once engaged. Integrated care models in primary and geriatric care settings are promising.Conclusions: Aging Veterans are a large subset of Americans whose mental health needs are complex and deserve attention.Clinical Implications: Clinicians should ask about history of military service (i.e., Veteran status) and utilize available resources when providing care for older Veterans.

Efficacy of the Home-Based Mental Health Evaluation (HOME) Program for Engaging Patients in Care After Hospitalization.

OBJECTIVE: The risk of suicide is elevated in the days and weeks after discharge from a psychiatric hospitalization, and lack of treatment engagement posthospitalization is also associated with suicide. The authors sought to determine whether the Home-Based Mental Health Evaluation [HOME] Program is efficacious in helping patients engage in care after psychiatric hospitalization. METHODS: This study was a nonrandomized, controlled, two-arm (HOME Program versus enhanced care as usual [E-CARE]) trial that took place at four Department of Veterans Affairs medical centers. Participants (N=302) were patients admitted to a psychiatric inpatient unit. The HOME Program consists of phone- and home-based contacts that include suicide risk assessment, safety planning, and problem-solving around barriers to care. The primary outcome was treatment engagement, as documented in the electronic medical record. RESULTS: Veterans in the HOME Program group were 1.33 (95% confidence interval [CI]=1.29-1.37) times more likely to engage in treatment, compared with veterans in the E-CARE group (p<0.001). HOME Program participants were estimated to have attended 55% more individual appointments (95% CI=12%-113%, p=0.02), compared with those in the E-CARE group. The adjusted difference in median time to treatment engagement was 15 days (95% CI=3.5-27.0) such that HOME Program participants engaged in treatment more quickly than participants at the E-CARE sites. CONCLUSIONS: Findings suggest that participation in the HOME Program can help individuals at high risk of suicide engage in care after psychiatric hospitalization.

The Older Driver with Cognitive Impairment: Perceptions of Driving Ability and Results of a Behind the Wheel Test.

Older adult drivers with cognitive impairment pose a potential safety risk to themselves and others. Providers are often uncertain about when to request a formal evaluation of driving ability, leaving subjective reports of concerns by the patient or family as common initiators of objective driving evaluation referral. This observational study evaluated the correspondence of patient and caregiver report of driving concerns relative to objective behind-the-wheel (BTW) testing. Data were analyzed from occupational therapy driving evaluations of older adult U.S. Veterans referred from cognitive disorder specialty clinics between 2005 and 2015 (n = 151). Driving ability was evaluated with a pre-testing interview of the patient and a knowledgeable caregiver, followed by objective BTW testing. Patients referred had a mean age of 77.6 (SD = 8.1) years, were 97% male, and 98% white. Results demonstrated that most patients are evaluated for driving concerns far too late, with only 3% of the sample being evaluated as independent to drive without restrictions, and 38% recommended to retire from driving. Although both patients and caregivers denied specific driving concerns (obey signs and lights) relative to objective testing, caregiver concerns were greater than their respective patient's concerns (p < 0.001) and were associated with road test outcome (p = 0.001).

A pilot project to improve access to telepsychotherapy at rural clinics.

BACKGROUND: The U.S. Department of Veterans Affairs (VA) has pioneered telemental health (TMH) with over 500,000 TMH encounters over the past decade. VA community-based outpatient clinics were established to improve accessibility of mental healthcare for rural Veterans. Despite these clinics clinics and increased availability of TMH, many rural Veterans have difficulty receiving mental healthcare, particularly psychotherapy. MATERIALS AND METHODS: Twelve therapists participated in a pilot project using TMH technologies to improve mental healthcare service delivery to rural Veterans treated at six community clinics. Therapists completed online training, and study staff communicated with them monthly and clinical leaders every other month. Therapists completed two questionnaires: before training and 10 months later. This article describes barriers and facilitators to the implementation of the project, as well as therapists' knowledge, confidence, and motivation regarding TMH. RESULTS: Two clinicians were offering telepsychotherapy after 10 months. At all six sites, unanticipated organizational constraints and administrative barriers delayed implementation; establishing organizational practices and therapists' motivation helped facilitate the process. Adopters of the project reported more positive views of the modality and did not worry about staffing, a concern of nonadopters. CONCLUSIONS: Despite barriers to implementation, lessons learned from this pilot project have led to improvements and changes in TMH processes. Results from the pilot showed that therapists providing telepsychotherapy had increased confidence, knowledge, and motivation. As TMH continues to expand, formalized decision-making with clinical leaders regarding project goals, better matching of therapists with this modality, and assessment of medical center and clinic readiness are recommended.

Meeting the continuing education needs of rural mental health providers.

BACKGROUND: Historically, mental health clinicians at Department of Veterans Affairs (VA) community-based outpatient clinics (CBOCs) have not had the same access to continuing education (CE) as providers at VA medical centers. Mental health clinicians at CBOCs desire an opportunity for VA-sponsored CE, especially on topics and issues pertinent to rural mental healthcare. MATERIALS AND METHODS: Since November 2011, VA CBOC mental health providers in 11 states have been offered a monthly live Web conferencing CE program. This article describes the program's development, implementation, and evaluation. RESULTS: Eleven CE programs have been offered to 397 unique participants. Participants have provided positive feedback about the topics and their impact on job performance. Most negative feedback has been related to technical and logistical problems with the Web conferencing platform. Although providers asked for reportable CE units for licensure, many did not complete the post-test, which is required to receive credit for completing the course. CONCLUSIONS: The Web conferencing format has been well received by participants. Despite technical issues, results show that the participants were satisfied with the content of the trainings and could apply the materials to their job. Although CE units were available, not all participants applied for credit. Efforts to improve technical support and the rate of post-test completion are discussed. Rural mental health providers often have limited access to training opportunities. The VA CBOC Mental Health Rounds, using an interactive Web conferencing platform, has been a successful modality for delivering CE to rural clinicians in the United States.

Improving detection of psychiatric disturbances in Parkinson's disease: the role of informants.

BACKGROUND: Under-recognition of psychiatric disturbances in patients with Parkinson's disease (PD) contributes to greater overall morbidity. Little is known about the value of collateral psychiatric history, obtained using standardized assessments with informants, for increasing recognition of PD-related psychiatric illness. OBJECTIVE: To examine the extent to which informants provide critical information that enabled psychiatrists to establish psychiatric diagnoses in patients with PD. METHODS: Individuals with PD (n = 223) and an informant were interviewed separately regarding the PD patient's psychiatric history and current status. A six-psychiatrist panel rated the extent to which informant data was required to establish the final consensus best-estimate current psychiatric diagnoses. Informants rated as "Crucial" or "Significantly Informative" comprised a "Critical Informant" (CI) subgroup; remaining informants were classified as the "Non-Critical Informant" (NCI) subgroup. RESULTS: Of the informants, 71 (31.4%) were "critical" for determining a psychiatric diagnosis. Without a CI, 81.3% of those with impulse control disorders and 43.8% of those with anxiety disorders would not have been diagnosed. Male PD patients and those with less severe motor deficits were also more likely to require a CI. CONCLUSIONS: Informants aid in the identification of psychiatric diagnoses, especially impulse control and anxiety disorders. This has implications for clinical practice and conduction of clinical trials.

Driving behaviors in early stage dementia: a study using in-vehicle technology.

According to the Alzheimer's Association (2011), (1) in 8 people age 65 and older, and about one-half of people age 85 and older, have Alzheimer's disease in the United States (US). There is evidence that drivers with Alzheimer's disease and related dementias are at an increased risk for unsafe driving. Recent advances in sensor, computer, and telecommunication technologies provide a method for automatically collecting detailed, objective information about the driving performance of drivers, including those with early stage dementia. The objective of this project was to use in-vehicle technology to describe a set of driving behaviors that may be common in individuals with early stage dementia (i.e., a diagnosis of memory loss) and compare these behaviors to a group of drivers without cognitive impairment. Seventeen drivers with a diagnosis of early stage dementia, who had completed a comprehensive driving assessment and were cleared to drive, participated in the study. Participants had their vehicles instrumented with a suite of sensors and a data acquisition system, and drove 1-2 months as they would under normal circumstances. Data from the in-vehicle instrumentation were reduced and analyzed, using a set of algorithms/heuristics developed by the research team. Data from the early stage dementia group were compared to similar data from an existing dataset of 26 older drivers without dementia. The early stage dementia group was found to have significantly restricted driving space relative to the comparison group. At the same time, the early stage dementia group (which had been previously cleared by an occupational therapist as safe to drive) drove as safely as the comparison group. Few safety-related behavioral errors were found for either group. Wayfinding problems were rare among both groups, but the early stage dementia group was significantly more likely to get lost.

The driver with dementia: a survey of physician attitudes, knowledge, and practice.

BACKGROUND: One of the most difficult issues physicians must address when caring for persons with dementia is fitness to drive. The purpose of this project was to investigate the attitudes, knowledge, and practices of physicians toward drivers with dementia. METHODS: A questionnaire that obtained perspectives about and experiences with drivers' with dementia was mailed to physicians from North Carolina and South Carolina. RESULTS: The sample was comprised of 239 physicians who worked with persons with dementia. Respondents who were aware of the Physician's Guide to Assessing and Counseling Older Drivers, had a strong perceived role regarding driving, were older, and believed it was important to address driving were more likely to engage in driving discussions. CONCLUSIONS: Concerns associated with the driver with dementia have implications for not only patient care but also public safety. We recommend that all physicians be encouraged to address the issue and utilize existing educational materials.

Social workers' knowledge, beliefs, and practices regarding driving and dementia.

Drivers with dementia present a significant public safety concern. Failure to recognize and address declines in driving skills associated with dementia can have hazardous consequences for the driver and others. A random sample of social workers was surveyed to better understand their knowledge, beliefs, and practices toward drivers with dementia. Six-hundred five social workers completed the questionnaire. Results reported are based on the analyses of the 152 respondents (25.1% of the sample) who indicated that they worked with persons with dementia. Social workers were significantly more likely to address driving if they had seen more clients with dementia, were more knowledgeable about driving-related issues, and believed they should have a strong role in helping persons with dementia and their families deal with mobility concerns. Social workers who reported that driving situations were more difficult to address than other topics were significantly less likely to broach it in their practices. Implications of the findings are discussed.

Mandatory testing of drivers on the basis of age and degenerative diseases: stakeholder opinions.

Concerns about the driving competence of older drivers have led to policy discussions about mandatory aged-based and disorder-based assessments. This study explored the attitudes, beliefs, and preferences of older adults, law enforcement officers, and licensing authorities toward reexamination of driving skills for persons with Alzheimer's disease (AD) and Parkinson's disease (PD) and at varying ages. With few exceptions, participants across all groups supported retesting drivers with AD. Moderate support was given for further evaluation of 90-year-olds and those with PD. Least endorsement was given for reassessment of 70-year-old drivers. Findings have implications for legislative changes to address drivers with AD and PD and at older ages.

At-risk drivers with Alzheimer's disease: recognition, response, and referral.

OBJECTIVE: This manuscript addresses the following questions for licensing authorities: 1) Are drivers with Alzheimer's disease (AD) an issue that should concern licensing authorities? 2) What critical driving skills impacted by AD should authorities recognize? 3) What should their response be? 4) Do licensing authorities have a role in providing information about or referral to community agencies that offer alternative transportation options and other services? METHODS: To address issues important to licensing authorities the authors reviewed pertinent driving and dementia literature. RESULTS: Drivers with AD have unique impairments that should be recognized and responded to early on in the disease process, with sensitivity and respect for continued mobility. As the disease progresses and they must stop driving, former drivers and their families could benefit from resource referrals that provide information about transportation alternatives and support services in their communities. CONCLUSIONS: The authors believe that drivers with AD should be a concern for licensing authorities. Licensing decisions and policies to assess and regulate drivers are in the end made individually by each state. Policymakers will make their decisions based upon current research and concerns of their constituency and need to consider a seamless approach to addressing safe mobility. Licensing authorities are an important partner along with individuals, family members, health care professionals, social service providers, researchers, and policymakers in assuring public safety and individual mobility. All of the partners should confront the concern directly-none should "look the other way." The goal is to keep people driving safely for as long as possible. The responsibility is to recognize, respond, and refer when driving safely is no longer assured.

Transportation and aging: a research agenda for advancing safe mobility.

PURPOSE: We review what we currently know about older driver safety and mobility, and we highlight important research needs in a number of key areas that hold promise for achieving the safety and mobility goals for the aging baby boomers and future generations of older drivers. DESIGN AND METHODS: Through the use of a framework for transportation and safe mobility, we describe key areas of screening and assessment, remediation and rehabilitation, vehicle design and modification, technological advancements, roadway design, transitioning to nondriving, and alternative transportation to meet the goals of crash prevention and mobility maintenance for older adults. RESULTS: Four cross-cutting themes emerged from this review: safe transportation for older adults is important; older adults have a variety of needs, abilities, and resources; research to help meet the transportation needs of older adults may be of benefit to persons with disabilities; and transportation issues concerning older adults are multifaceted. IMPLICATIONS: Safe mobility is essential to continued engagement in civic, social, and community life, and to the human interactions necessary for health, well-being, and quality of life. When safe driving is no longer possible for older adults, safe and practicable alternative transportation must be available. Furthermore, older adults are individuals; they have specific needs, abilities, and resources. Not all older adults will have difficulty meeting their transportation needs and no single transportation solution will work for all people. Research and countermeasures intended to help meet the transportation needs of older adults will likely also benefit younger users of the transportation system, particularly those with disabilities. The issues surrounding the maintenance of safe transportation for older adults will require an interdisciplinary research approach if we are to make significant progress in the next decade as the baby boomers begin to reach age 70.

The older driver with dementia: an updated literature review.

INTRODUCTION: At some point during their illness, drivers with dementia pose a public safety risk. METHOD: To address the issue of determining driving competence in drivers with dementia, the authors reviewed 11 studies. RESULTS: When comparing different driving assessments, the authors found that while road tests, simulators, and neuropsychological tests are important, each has limitations. CONCLUSION: Neuropsychological tests that highlighted visual spatial skills, attention, and reaction time provided the most meaningful correlations with driving performance. Furthermore, the authors recommend that patients with MMSE scores of 24 or less have a driving evaluation, and that driving evaluations be repeated at six month intervals or more frequently if a noticeable decline is observed. IMPACT: Because many older adults with dementia continue to drive, competence must be addressed.

Driving habits and patterns in older men with glaucoma.

Glaucoma, an eye disorder that gradually decreases peripheral vision, affects millions of older adults. Consequences of glaucoma can mean changes in the ability to perform familiar tasks, including driving an automobile. We surveyed older drivers with glaucoma and a control comparison group in order to learn more about their driving habits and expectations about driving cessation. Findings indicate that compared to the control group, drivers with glaucoma are significantly more likely to change their driving habits with regard to driving at night (p=0.003), on freeways (p=0.05), and in unfamiliar areas (p=0.01). Drivers with glaucoma were also significantly more likely to report family concern about their driving (p=0.01). However, the drivers with glaucoma did not anticipate that their disease would force them to discontinue driving. Social workers play a pivotal role in coordinating the complex care needs of visually impaired elders. When driving skills are affected, social workers must address transportation, housing as well as quality of life concerns.

Effects of repetitive work on maintaining function in Alzheimer's disease patients.

The effects of repetitive work on Alzheimer's disease (AD) patient functioning were examined when nine veterans were moved from a work program to a traditional adult day care program. Subjects were reassessed four months after the move with the Mini-Mental State Examination (MMSE), Cognitive Performance Test (CPT), and Geriatric Depression Scale (GDS). Individual slopes were calculated for seven subjects who had longitudinal scores, and expected scores were predicted based on the rate of decline. Observed scores at reassessment were significantly lower than expected scores. The MMSE was on average 4.9 points lower, and the CPT .64 points lower than expected. The GDS did not change. The spouses of all nine patients reported declines in daily living activities. Compared to traditional day care activities, work activities involve sequencing skills and practice may translate to self-care activities at home.

Driving cessation in older men with dementia.

The process of driving cessation was studied in a group of older men with dementia. During the initial phase of the project, 53 drivers with dementia provided information about their driving history, driving habits, and expectations about driving cessation. A collateral for each patient completed a similar questionnaire providing corroborating information about the patient's driving. Collaterals were contacted 25-39 months later to gather information about patients' current driving habits. Twenty patients (46.5%) continued to drive almost 5 days per week. Twenty-three subjects (53.5%) were no longer driving at follow-up. The decision to stop driving was frequently abrupt and often made in response to a physician recommendation. Using logistic regression analyses, lower Mini-Mental State Examination scores (p = 0.02) and increased age (p = 0.02) at baseline were shown to be significant predictors of driving cessation. Findings indicate that an unexpected number of men with dementia continue to drive for several years after disease onset.

The influence of age and gender on the driving patterns of older adults.

The purpose of this study was to investigate the influences of age and gender on the driving patterns of 300 older adults. Odds of driving less than every day increased significantly with age and female gender. However, no differences were found in the reduction of overall driving. Females were more likely than men to have stopped or reduced driving under certain adverse conditions and for elective purposes. The driving patterns of today's cohort of older females suggest that the gender gap may be narrowing. Social and cultural issues such as security, safety, and identity with driving may explain existing gender differences.

The Driver With Dementia: A Review of the Literature.

The authors review 10 studies of driving and dementia. They found poor agreement among the researchers with regard to the stage at which a patient with dementia should discontinue driving and the appropriate tools to be used for an assessment of driving skills. They make recommendations for a comprehensive driving assessment and for the clinical management of drivers with dementia. Because the impaired driver is a medical as well as a public safety concern, clinicians and policymakers must work together to address the many problems associated with this issue.