Telephone-based care management for older adults initiated on psychotropic medication

Navigating Through Innovation in Elderly's Health: A Scoping Review of Digital Health Interventions

Objectives

Comprehensively map and summarize digital health initiatives for the elderly and caregivers.

Methods

Scoping review between April and May 2022 based on Joanna Briggs methodology. Databases used included PubMed, Cochrane Library, CINAHL Plus, and Web of Science, along with grey literature and hand searches. Two reviewers independently conducted screening and eligibility phases, with a third resolving disagreements. Data were thematically analyzed.

Results

The review included 421 documents. Most documents were published between 2013 and 2022, with a recent increase. Most studies, originating from high-income countries, focused on home applications and were mainly in the testing and validation stages. Telephones and computers were the predominant devices. Health objectives included monitoring, prevention, and treatment, with interventions utilizing directed communication and personal health monitoring for individuals, and telemedicine and decision support for healthcare providers.

Conclusion

Increasing integration of technology in older adults' lives, along with their increasing proficiency, is driving a significant rise in digital health interventions. Despite this growth, further research in middle- and low-income countries, for caregivers and evaluating effectiveness and feasibility of these technological interventions is needed.

Progress toward a performance measure for mental health based on a generic patient- reported outcome measure: Findings from the Veterans Outcome Assessment survey

We report on studies conducted to develop outcome-based performance measures (PROM-PMs) based on generic patient-reported outcome measures (PROMs) that could support strategies for quality improvement applicable to all patients in a mental health system. Data were from the Veterans Outcome Assessment Survey at baseline and three months for the Mental Component Score (MCS-12), a widely used measure of mental health-related quality of life, for 15,540 outpatients beginning treatment in General Mental Health clinics in 140 Veterans Affairs (VA) facilities. Mental health diagnoses from medical records were coded using hierarchical categories. Mental health staffing levels and quality measures were from administrative data. Changes in MCS-12 scores were associated with demographics, baseline scores, and diagnostic categories; in fully adjusted models, differences between facilities accounted for only 0.5% of the total variance between patients. There were small but significant associations of both baseline and changes in MCS-12 scores with staffing levels and administrative measures of the quality of care that support the potential value of adjusted measures of changes in MCS-12 as a PROM-PM. Remaining issues include the low proportion of variability that can be attributed to differences between facilities and the associations of staffing and quality with possible case-mix adjustment variables.

Remote care management for older adult populations with elevated prevalence of depression or anxiety and comorbid chronic medical illness: A systematic review

BACKGROUND

Comorbidity of psychiatric and medical illnesses among older adult populations is highly prevalent and associated with adverse outcomes. Care management is a common form of outpatient support for both psychiatric and medical conditions in which assessment, care planning, and care coordination are provided. Although care management is often remote and delivered by telephone, the evidence supporting this model of care is uncertain.

OBJECTIVE

To perform a systematic review of the literature on remote care management programs for older adult populations with elevated prevalence of depression or anxiety and comorbid chronic medical illness.

METHODS

A systematic review was performed in accordance with PRISMA guidelines. A multi-database search was performed. Articles were included for review if they studied fully remote care management for older adult populations with elevated prevalence of depression or anxiety and chronic medical illness or poor physical health. A narrative synthesis was performed.

RESULTS

A total of 6 articles representing 6 unique studies met inclusion criteria. The 6 studies included 4 randomized controlled trials, 1 case-matched retrospective cohort study, and 1 pre-post analysis. Two studies focused on specific medical conditions. All interventions were entirely telephonic. Five of 6 studies involved an intervention that was 3 to 6 months in duration. Across the 6 studies, care management demonstrated mixed results in terms of impact on psychiatric outcomes and limited impact on medical outcomes. No studies demonstrated a statistically significant impact on health care utilization or cost.

CONCLUSION

Among older adult populations with elevated prevalence of depression or anxiety and comorbid chronic medical illness, remote care management may have favorable impact on psychiatric symptoms, but impact on physical health and health care utilization is uncertain. Future research should focus on identifying effective models and elements of remote care management for this population, with a particular focus on optimizing medical outcomes.

Randomized Controlled Trial of a Collaborative Care Intervention for Mood Disorders by a National Commercial Health Plan

OBJECTIVE

Few individuals with mood disorders have access to evidence-based collaborative chronic care models (CCMs) because most patients are seen in small-group practices (<20 providers) with limited capacity to deliver CCMs. In this single-blind randomized controlled trial, we determined whether a CCM delivered nationally in a U.S. health plan improved 12-month outcomes among enrollees with mood disorders compared with usual care.

METHODS

Aetna insurance enrollees (N=238), mostly females (66.1%) with a mean age of 41.1 years, who were recently hospitalized for unipolar major depression or bipolar disorder provided informed consent, completed baseline assessments, and were randomly assigned to usual care or CCM. The CCM included 10 sessions of the Life Goals self-management program and brief contacts by phone by a care manager to determine symptom status. Primary outcomes were changes over 12 months in depression symptoms (nine-item Patient Health Questionnaire [PHQ-9]) and mental health-related quality of life (Short Form-12).

RESULTS

Adjusted mean PHQ-9 scores were lower by 2.34 points (95% confidence level [CL]=-4.18 to -0.50, p=0.01), indicating improved symptoms, and adjusted mean SF-12 mental health scores were higher by 3.21 points (CL=-.97 to 7.38, p=0.10), indicating better quality of life, among participants receiving CCM versus usual care.

CONCLUSIONS

Individuals receiving CCM compared with usual care had improved clinical outcomes, although substantial attrition may limit the impact of health plan-level delivery of CCMs. Further research on the use of health plan-level interventions, such as CCMs, as alternatives to practice-based models is warranted.

Correlates of Caregiver Participation in a Brief, Community-Based Dementia Care Management Program

Purpose of the Study

The evidence base for dementia care management interventions for informal caregivers (CGs) is strong, yet enrollment and sustained engagement in academic and community-based research trials is low. This study sought to examine rates and correlates of participation in a community-based, telephone-delivered dementia care management program designed to address logistic and practical barriers to participation in CG trials and services.

Design and Methods

Participants included 290 CGs of older, community-dwelling, low-income care recipients (CRs) who met criteria for enrollment in a collaborative dementia care management program that provides assessment, psychosocial support and education, and connection to community resources via telephone. Cross-sectional analyses examined the association between CG-related (e.g., financial status, relationship to CR, caregiving burden) and CR-related (e.g., functional limitations, symptom severity) factors and CG enrollment and engagement.

Results

The majority of CGs were non-Hispanic White, female, financially stable, and adult children of the CRs. Over half of CGs lived with the CR and provided 20 or more hours of care per week. Roughly half of CGs refused care management services. Adjusted logistic regression models revealed that perceived caregiving burden and financial status were related to initial enrollment and engagement in services once enrolled, respectively.

Implications

A significant proportion of CGs refuse free, convenient, evidence-based dementia care management services, underscoring the need for further examination of correlates of program acceptance. Nonetheless, community-based programs that address barriers may improve enrollment and engagement rates among CGs, including those who are especially vulnerable to negative CG and CR outcomes.

Telephone-based management of chronic pain in older adults in an integrated care program

OBJECTIVE

Few studies have explored behavioral strategies for managing chronic pain in older adults. Pain Care Management (PCM) is a telephone-based behavioral intervention for chronic pain. The present study examined chronic pain characteristics among older adults and tested the delivery of PCM as an adjunct to depression and anxiety care management.

METHODS

Participants were drawn from a state-sponsored program offering care management services to community members aged 65 and older who were prescribed a psychotropic medication by a primary care provider. Chronic pain information was collected for all participants in the state program (N = 250) and treatment outcome data were collected for a subset with significant chronic pain. Eighty participants with high chronic pain interference were offered PCM and compared to 80 participants with chronic pain who received monitoring only on depression, anxiety, and pain interference outcomes.

RESULTS

Chronic pain was identified in 14% of older adults newly prescribed a psychotropic medication. Compared to monitoring only, PCM participants had higher odds of seeing a reduction of 2 or more points in pain interference at 6 months. Pain care management participants' anxiety scores significantly decreased over the study period.

CONCLUSIONS

Older adults treated with psychotropic medications often also experience chronic pain that interferes with daily activities. A telephone-based care management intervention is acceptable and feasible with an older community-based population and can lead to improvements in anxiety symptoms and interference from chronic pain. Further research will help to refine interventions that may help improve symptoms and increase functioning with this population.

Older adults recently started on psychotropic medication: where are the symptoms?

OBJECTIVE

The objective of this study is to understand the characteristics of older adults on newly prescribed psychotropic medication with minimal psychiatric symptoms.

METHODS

Naturalistic cohort study of non-institutionalized older adults in Pennsylvania participating in the Pharmaceutical Assistance Contract for the Elderly. Persons newly prescribed antidepressant or anxiolytic monotherapy or combination therapy were contacted for clinical assessment by a telephone-based behavioral health service. The initial assessment included standardized mental health screening instruments and scales including the Blessed Orientation-Memory-Concentration test, Patient Health Questionnaire-9, Generalized Anxiety Disorder-7, and Medical Outcomes Survey (SF-12). In addition, patients were asked for their understanding of the prescription indication.

RESULTS

Of the 254 participants who met minimal symptom criteria (Patient Health Questionnaire-9 < 5 and Generalized Anxiety Disorder-7 < 5), women comprised slightly more of the anxiolytic compared with antidepressant monotherapy group (88.9% vs. 76.7%, p = 0.04). The most common self-reported reason for prescription of an antidepressant or anxiolytic was depression or anxiety, respectively, despite near-absence of these symptoms on clinical assessment. Comparing monotherapy to combination therapy groups, those with combination therapy were more likely to report a history of depression (12.6% vs. 1.8%, p < 0.001) and also report depression as the reason for the prescription (40.2% vs. 21.0%, p < 0.01).

CONCLUSIONS

In this sample of older adults on new psychotropic medication with minimal psychiatric symptoms, there are few patient characteristics that distinguish those on antidepressant versus anxiolytic monotherapy or those on monotherapy versus combination therapy. While quality of care in late-life mental health has focused on improving detection and treatment, there should be further attention to low-symptom patients potentially receiving inappropriate pharmacotherapy.

Safety assessment of essential medicines for elderly people: a bibliographic survey

Certain medicines are considered potentially inappropriate (PIM) for elderly people as they increase the risk of adverse drug events (ADE) and because safer alternative therapies are available on the market. In this context, in order to identify the instruments that assess the quality of medical prescriptions for elderly and to determine which drugs are considered PIM, a bibliographic survey was conducted in PUBMED, LILACS and PAHO databases, in February and March/2010. The search strategy included the use of health descriptors and a manual search in the references cited by selected papers. During the period of data collection, 15 instruments were identified. In 2012, with the publication of the update of Beers criteria, this instrument was included in the study. We identified 163 PIM of 25 therapeutic classes, of which 125 (76.7%) are marketed in Brazil. Of these, 31 (24.8%) are essential medicines (RENAME 2012), of which 13 have safer therapeutic equivalents and 19 (15.2%) are over-the-counter drugs. Data suggest the need for inclusion of safer alternatives for the elderly in the national list of essential medicines and the pharmaceutical care for early detection of ADE in this age group, in order to contribute to the safe use of medicines.