Supporting Veterans, Caregivers, and Providers in Rural Regions With Tele-Geriatric Psychiatry Consultation: A Mixed Methods Pilot Study.

OBJECTIVES: Cross-facility tele-geriatric psychiatry consultation is a promising model for providing specialty services to regions lacking sufficient geriatric psychiatry expertise. This evaluation focused on assessing the feasibility and acceptability of a consultation program developed by a geriatric psychiatrist in a Veterans Health Administration regional telehealth hub. DESIGN: Concurrent, mixed methods program evaluation. SETTING: A region served by a VA health care system telehealth hub. PARTICIPANTS: Patients with at least 1 geriatric mental health encounter with a geriatric psychiatrist consultant during a 1 year-period; referring providers. INTERVENTION: Virtual psychiatric evaluation of Veterans with time-limited follow-up and e-consultation with providers. MEASUREMENTS: Interviews with consultant, medical record data, and referring provider surveys. RESULTS: Three hundred fifteen Veterans (M = 76.0 ± 9.64 years; 40% rural-dwelling) had 666 encounters (M = 2.11 ± 1.78) with most occurring via clinical video telehealth (n = 443; 67.6%), e-consultation (n = 99; 15.1%), or video to home (n = 95; 14.5%). Most encounters were related to neurocognitive disorders, depressive disorders, trauma-related disorders, or serious mental illness. Referring providers (N = 58) highly recommended the program, reported high satisfaction, followed through with recommendations, and believed that this program increased access to geriatric psychiatry. CONCLUSIONS: This single program was shown to be feasible, acceptable, and valued by the referring providers. The findings highlighted the complex presentations of Veterans referred, and the current unmet need of providers of such Veterans, providing impetus for wider implementation.

Delivering Virtual Care to Patients with Cognitive Impairment within the Veterans Health Administration: Multi-level Barriers and Solutions.

Older patients with cognitive impairment, including dementia, may benefit from virtual care that increases access to geriatric specialties. Here, we identify clinician-level strategies to address the numerous barriers that reduce utilization of virtual services. We describe two innovative programs in the Veterans Health Administration that deliver geriatric medicine and geriatric psychiatry services virtually. This commentary outlines concrete strategies addressing identified barriers, including technology access, digital literacy, and ambivalence and communication challenges during video visits. Two virtual care programs (tele-geriatric psychiatry consultation; tele-dementia care) that address complex medical and mental health issues in older adults with cognitive impairment are described. The Consolidated Framework for Implementation Research (CFIR) is used to categorize the clinician-level strategies and program elements as they relate to the implementation domains and constructs. Clinicians can use education strategies prior to and during virtual care visits to facilitate access to video, optimize the virtual experience, and promote information retention. These strategies rely on aspects of the inner setting, outer setting, and characteristics of individuals. The two virtual programs vary in their intervention characteristics and the inner setting, yet both programs share similar characteristics of individuals. Key elements contributing to adoption and sustainment of these virtual care programs for patients with cognitive impairment include the relative advantage of virtual care to leverage access to specialists over alternative solutions in each setting. Other factors to consider include the importance of communication, program champions, and the role of the Veterans Health Administration.

Distinctions between depression and anxiety with fear of being a burden in late life.

Objectives: The perception of being a burden is a well-known risk factor for dying by suicide. Research on factors that precede the state of perceived burdensomeness, such as fearing being a burden, is necessary. We investigated the extent to which health status, elevated depressive symptoms, and elevated anxiety symptoms are associated with fear of being a burden in late life.Method: Older adult participants (N = 155) completed the Geriatric Anxiety Scale (GAS), Patient Health Questionnaire (PHQ-8), and demographic and health questions. Fear of being a burden, assessed with a supplemental item on the GAS, was categorically grouped as 'no fear' or 'some fear'. Using logistic regression, we examined predictors of fear of being a burden.Results: In the first step, elevated depression was associated with fear of being a burden (OR = 2.30, 95% CI: 1.09, 4.89, p = .03), but health status was not significant. In the second step, elevated anxiety was significant (OR = 2.63, 95% CI: 1.15, 5.99, p = .02); depression was no longer significant.Conclusion: Contrary to expectations, anxiety more strongly predicted fear of being a burden than depression. Future research should further investigate the role of anxiety in fear of being a burden and ways of intervening.

Changes in Quality of Life and Loneliness Among Middle-Aged and Older Adults Participating in Therapist-Guided Digital Mental Health Intervention.

Background: This study aimed to examine the effects of a 12-week multicomponent mobile app-delivered intervention, the Meru Health Program (MHP), on mental health quality of life (QoL) and loneliness among the middle-aged and older adults with depression symptoms. Methods: The eligible participants (M age = 57.06, SD = 11.26 years) were enrolled in the MHP, a therapist-supported mobile intervention. Using a non-randomized pre-post design, change in mental health QoL [WHO QoL Brief (WHOQOL-BREF) psychological health] and loneliness (UCLA Loneliness Scale) from baseline to post-treatment were examined. Time of enrollment [pre- vs. post-coronavirus disease 2019 (COVID-19)] was included as a between-subjects factor in the repeated measures analyses. Results: Forty-two participants enrolled prior to the COVID-19 pandemic; eight enrolled after the pandemic began. Among the pre-COVID-19 enrollees, increase in mental health QoL, F(1, 38) = 12.61, p = 0.001, η2 = 0.25 and decreases in loneliness emerged, F(1, 38) = 5.42, p = 0.025, η2 = 0.13. The changes in mental health QoL, but not loneliness, held for the combined sample, such as post-COVID-19 enrollees, F(1, 44) = 6.02, p = 0.018, η2 = 0.12. The regression analyses showed that increases in mindfulness were associated with the increased mental health QoL and decreased loneliness. Conclusion: Therapist-supported digital mental health interventions, such as the MHP, have the potential to improve mental health QoL and decrease loneliness among the middle-aged and older adults. The findings for loneliness may not hold during the periods of mandated isolation. Instead, therapists supporting digital interventions may need to tailor their approach to target loneliness.