Telemedicine in Neurology: A Scoping Review of Key Outcomes in Movement Disorders.

Introduction: Telemedicine for neurological care has been researched and practiced in various ways over the past three decades, but the recent COVID-19 pandemic has rapidly expanded its use and highlighted the need for a synthesis of the existing literature. We aimed to review the methodology and outcomes of previous studies that have evaluated the use of telemedicine in movement disorders. Methods: This scoping review was performed by searching PubMed, Ovid MEDLINE, and CINAHL databases from 1946 to November 2020. Studies that assessed the application of telemedicine for delivering care to patients with a movement disorder were included. We reported the aims and employed methodologies and categorized the outcomes from each study. Results: The search retrieved 228 articles, and 41 studies met the criteria for inclusion in the review. The majority of telemedicine studies were case series or randomized controlled pilot trials, investigating feasibility and acceptability in Parkinson's disease. Even with heterogeneity among outcome measures, they can be categorized into themes, such as feasibility, satisfaction, and efficacy. Conclusions: Telemedicine use has grown rapidly, due to the demands of providing care during a global pandemic. This application of telemedicine has been considered a promising way to expand care in Neurology, although research evaluating the dissemination of its use is dilatory. This review highlights the number of studies that have found telemedicine to be an acceptable and feasible way to deliver care for movement disorders. Further research is needed to expand on harmonization of outcomes, reach, adoption, and long-term use of telemedicine.

An Update on Telepsychiatry and How It Can Leverage Collaborative, Stepped, and Integrated Services to Primary Care.

INTRODUCTION: In this era of patient-centered care, telepsychiatry (TP; video or synchronous) provides quality care with outcomes as good as in-person care, facilitates access to care, and leverages a wide range of treatments at a distance. METHOD: This conceptual review article explores TP as applied to newer models of care (e.g., collaborative, stepped, and integrated care). RESULTS: The field of psychosomatic medicine (PSM) has developed clinical care models, educates interdisciplinary team members, and provides leadership to clinical teams. PSM is uniquely positioned to steer TP and implement other telebehavioral health care options (e.g., e-mail/telephone, psych/mental health apps) in the future in primary care. Together, PSM and TP provide versatility to health systems by enabling more patient points-of-entry, matching patient needs with provider skills, and helping providers work at the top of their licenses. TP and other technologies make collaborative, stepped, and integrated care less costly and more accessible. CONCLUSION: Effective health care delivery matches the intensity of the services to the needs of a patient population or clinic, standardizes interventions, and evaluates both process and clinical outcomes. More research is indicated on the application of TP and other technologies to these service delivery models.

Approved and Off-Label Use of Prescribed Psychotropic Medications among Federal Canadian Inmates.

OBJECTIVE: To examine psychotropic medication prescription practices in federal Canadian penitentiaries. METHOD: 468 files were drawn from a purposive sample of thirteen Canadian federal institutions representing the five regions, different security levels, and male and female designated facilities. Information on the names of all psychotropic medications prescribed, indications for use, dosage, frequency, and route of administration was retrieved. Designation of approved or off-label use of medications was determined by consulting: (1) the Health Canada (2016) Drug Product Database, (2) the Canadian Compendium of Pharmaceuticals and Specialties 2016, and (3) the American Hospital Formulary Service Drug Information 2016. Prescription rates were examined by gender, Indigenous ancestry, drug class, institutional infractions, and current offence. RESULTS: 36.2% of prescriptions for psychotropic medication were coded as 'off-label'. Anxiolytic/hypnotics drugs were the psychotropic drugs most commonly used for off-label purposes. There were no differences in the prevalence of approved versus off-label prescriptions based on Indigenous ancestry or gender, and no pattern of elevated off-label prescription practices for offenders involved in institutional misconducts or those sentenced for the most serious crimes. CONCLUSIONS: The rates of prescribing 'off-label' psychotropic medication are not elevated relative to other correctional settings or to rates cited in Canadian surveys conducted in the community.

Predictors of Electroconvulsive Therapy Use in a Large Inpatient Psychiatry Population.

OBJECTIVE: There is limited research on reliable and clinically useful predictors of electroconvulsive therapy (ECT) use. We aimed to examine factors that predict ECT use in an inpatient psychiatric population. DESIGN: Retrospective analysis of provincial database for inpatient psychiatry. METHODS: This study is a retrospective analysis of a provincial database for inpatient psychiatry. The study includes all psychiatric inpatients 18 years or older in Ontario, Canada, assessed with the Resident Assessment Instrument for Mental Health (RAI-MH) within the first 3 days of admission between 2009 and 2014 (n = 153,023). The RAI-MH is a validated assessment tool which includes a breadth of information on symptoms, self-harm, functioning, social support, comorbid medical diagnoses, and risk appraisal. Multivariable analyses were performed using SAS. RESULTS: One hundred forty-five thousand seven hundred (95.2%) of patients admitted had no history of ECT treatment and were not scheduled to receive ECT. A total of 7323 (or 4.8% of the patient population) had either a history of ECT use or were scheduled to receive ECT. Overall rate of ECT use was highest in patients with a provisional diagnosis of mood disorder (7.2%) compared with schizophrenia/other psychotic disorder (3.1%) or substance-related disorder (1.7%). Women were more likely to receive ECT compared with men (overall rates of ECT use 6.2% and 3.4%, respectively). Overall rate of ECT use increased significantly with increasing age. Number of prior hospitalizations was also a strong predictor of ECT use. Conversely, patients with elevated Risk of Harm to Others, schizophrenia, or a substance use disorder were all significantly less likely to receive ECT. All variables examined were statistically significant (P < 0.0001). Higher Severity of Self Harm Scores predicted past use, but not scheduled use of ECT. CONCLUSIONS: This is the largest study to date on predictors of ECT use. Utilization of RAI-MH is a novel and clinically useful method for evaluating predictors of ECT use. Predictors of ECT use within an inpatient population include: presence of a mood disorder, female sex, older age, low risk of harm to others, number of lifetime hospitalizations, lack of substance use disorder, and inability to care for self.

Pilot Study of a Telehealth-Delivered Medication-Augmented Exposure Therapy Protocol for PTSD.

Posttraumatic stress disorder (PTSD) is a serious condition, with certain occupations at increased risk due to greater trauma exposure. These same individuals face multiple barriers to care. This study aimed to investigate the feasibility of conducting a research trial with exposure therapy delivered via videoconferencing. Eleven adults working in occupations at risk with PTSD enrolled and seven completed 12 to 15 sessions. Individuals were randomized to receive the cognitive enhancer D-cycloserine or placebo, and participants provided saliva samples for genetic analysis. Treatment completers demonstrated decreases in PTSD and depressive symptomatology (measured by CAPS [p < 0.001, d = 2.79] and BDI-II [p = 0.004, d = 0.92]). Participants reported high therapeutic alliance, treatment satisfaction, and telehealth satisfaction. There were no significant technical, medication, or safety issues, and no clinical emergencies. The results suggest that it may be feasible to conduct clinical research using telehealth for PTSD and to use telehealth to increase access to care.

An Investigation of Patient Preferences for Music Played Before Electroconvulsive Therapy.

OBJECTIVE: Patients often feel anxious before electroconvulsive therapy (ECT), which can lead to avoidance of treatments. Music is a noninvasive safe option to reduce anxiety in the preoperative setting. Therefore, we examined patients' preferences of listening to music while receiving ECT by providing music-by way of headphones or speakers-to participants before treatment. METHODS: Patients receiving ECT were recruited for this study. Patients served as their own controls in 3 separate music intervention sessions: 1) randomization to music via headphones or speakers, 2) no music, 3) the remaining music intervention. Patients completed a questionnaire related to satisfaction and preferences of music being played before ECT. Patients received a final questionnaire at the end of the study asking which intervention they preferred. RESULTS: Thirty patients completed the study. Ninety percent enjoyed listening to music through speakers. Eighty percent liked listening to music through headphones. Seventeen percent preferred not having any music. The difference in preference between speakers and headphones was not significant (P = 0.563; McNemar-Bowker test). There was no association between preference at the end of the study and the initial assignment of speakers or headphones (P = 0.542 and P = 0.752, respectively; Pearson χ tests). No adverse events were reported. CONCLUSIONS: Music is a low-cost intervention with virtually no side effects that could be offered as an adjunctive therapy for patients receiving ECT. A significant proportion of patients liked hearing music before treatment.

Risk and protective factors associated with intentional self-harm among older community-residing home care clients in Ontario, Canada.

OBJECTIVE: We aim to concurrently examine risk and protective factors associated with intentional self-harm among community-residing older adults receiving home care services in Ontario, Canada. METHODS: Administrative health data from the home care sector were linked to hospital administrative data to carry out the analyses. Home care data are collected in Ontario using the Resident Assessment Instrument-Home Care (RAI-HC), an assessment tool that identifies strengths, preferences and needs of long-stay home care clients. The sample included Ontario home care clients aged 60 years or older assessed with the RAI-HC between 2007 and 2010 (N = 222,149). Multivariable analyses were performed using SAS. RESULTS: Hospital records of intentional self-harm (ISH) were present in 9.3 cases per 1000 home care clients. Risks of ISH included younger age (60-74 years; OR = 3.14, CI: 2.75-3.59), psychiatric diagnosis (OR = 2.29, CI: 2.06-2.54), alcohol use and dependence (OR = 1.69, CI: 1.34-2.14), psychotropic medication (OR = 1.94, CI: 1.75-2.15) and depressive symptoms (OR = 1.58, CI: 1.40-1.78). Protective effects were found for marital status and positive social relationships, yet these effects were more pronounced for men. Cognitive performance measures showed the odds of ISH 1.86 times higher for older adults with moderate to severe cognitive impairment. CONCLUSIONS: This study based on provincial data points to tangible areas for preventative assessment by frontline home care professionals. Of interest were the risk and protective factors that differed by sex. As demand for home care in Canada is expected to increase, these findings may inform home care professionals' appraisal and approach to suicide prevention among community-residing older adults.

A longitudinal examination of rural status and suicide risk.

There is limited research on suicide risk in Canadian home care. Older adults have the highest rates of death by suicide worldwide. This article examines characteristics of rural and urban home care recipients with a hospital or emergency department visit for suicide attempts in Ontario, Canada. Factors that increase or decrease risk for emergent care are identified. This research builds on a growing need for health leadership to ensure that home care providers have appropriate training and resources to assess and respond to potential risk of suicide among frail elders.

Development of mental health quality indicators (MHQIs) for inpatient psychiatry based on the interRAI mental health assessment.

BACKGROUND: Outcome quality indicators are rarely used to evaluate mental health services because most jurisdictions lack clinical data systems to construct indicators in a meaningful way across mental health providers. As a result, important information about the effectiveness of health services remains unknown. This study examined the feasibility of developing mental health quality indicators (MHQIs) using the Resident Assessment Instrument - Mental Health (RAI-MH), a clinical assessment system mandated for use in Ontario, Canada as well as many other jurisdictions internationally. METHODS: Retrospective analyses were performed on two datasets containing RAI-MH assessments for 1,056 patients from 7 facilities and 34,788 patients from 70 facilities in Ontario, Canada. The RAI-MH was completed by clinical staff of each facility at admission and follow-up, typically at discharge. The RAI-MH includes a breadth of information on symptoms, functioning, socio-demographics, and service utilization. Potential MHQIs were derived by examining the empirical patterns of improvement and incidence in depressive symptoms and cognitive performance across facilities in both sets of data. A prevalence indicator was also constructed to compare restraint use. Logistic regression was used to evaluate risk adjustment of MHQIs using patient case-mix index scores derived from the RAI-MH System for Classification of Inpatient Psychiatry. RESULTS: Subscales from the RAI-MH, the Depression Severity Index (DSI) and Cognitive Performance Scale (CPS), were found to have good reliability and strong convergent validity. Unadjusted rates of five MHQIs based on the DSI, CPS, and restraints showed substantial variation among facilities in both sets of data. For instance, there was a 29.3% difference between the first and third quartile facility rates of improvement in cognitive performance. The case-mix index score was significantly related to MHQIs for cognitive performance and restraints but had a relatively small impact on adjusted rates/prevalence. CONCLUSIONS: The RAI-MH is a feasible assessment system for deriving MHQIs. Given the breadth of clinical content on the RAI-MH there is an opportunity to expand the number of MHQIs beyond indicators of depression, cognitive performance, and restraints. Further research is needed to improve risk adjustment of the MHQIs for their use in mental health services report card and benchmarking activities.

Monitoring daily affective symptoms and memory function using interactive voice response in outpatients receiving electroconvulsive therapy.

OBJECTIVE: Recently, there has been a gradual shift from inpatient-only electroconvulsive therapy (ECT) toward outpatient administration. Potential advantages include convenience and reduced cost. But providers do not have the same opportunity to monitor treatment response and adverse effects as they do with inpatients. This can obviate some of the potential advantages of outpatient ECT, such as tailoring treatment intervals to clinical response. Scheduling is typically algorithmic rather than empirically based. Daily monitoring through an automated telephone, interactive voice response (IVR), is a potential solution to this quandary. METHODS: To test feasibility of clinical monitoring via IVR, we recruited 26 patients (69% female; mean age, 51 years) receiving outpatient ECT to make daily IVR reports of affective symptoms and subjective memory for 60 days. The IVR also administered a word recognition task daily to test objective memory. Every seventh day, a longer IVR weekly interview included questions about suicidal ideation. RESULTS: Overall daily call compliance was high (mean, 80%). Most participants (96%) did not consider the calls to be time-consuming. Longitudinal regression analysis using generalized estimating equations revealed that participant objective memory functioning significantly improved during the study (P < 0.05). Of 123 weekly IVR interviews, 41 reports (33%) in 14 patients endorsed suicidal ideation during the previous week. CONCLUSIONS: Interactive voice response monitoring of outpatient ECT can provide more detailed clinical information than standard outpatient ECT assessment. Interactive voice response data offer providers a comprehensive, longitudinal picture of patient treatment response and adverse effects as a basis for treatment scheduling and ongoing clinical management.

ATA practice guidelines for video-based online mental health services.

Table of Contents PREAMBLE SCOPE INTRODUCTION Internet-Based Telemental Health Models of Care Today CLINICAL GUIDELINES A. Professional and Patient Identity and Location 1. Provider and Patient Identity Verification 2. Provider and Patient Location Documentation 3. Contact Information Verification for Professional and Patient 4. Verification of Expectations Regarding Contact Between Sessions B. Patient Appropriateness for Videoconferencing-Based Telemental Health 1. Appropriateness of Videoconferencing in Settings Where Professional Staff Are Not Immediately Available C. Informed Consent D. Physical Environment E. Communication and Collaboration with the Patient's Treatment Team F. Emergency Management 1. Education and Training 2. Jurisdictional Mental Health Involuntary Hospitalization Laws 3. Patient Safety When Providing Services in a Setting with Immediately Available Professionals 4. Patient Safety When Providing Services in a Setting Without Immediately Available Professional Staff 5. Patient Support Person and Uncooperative Patients 6. Transportation 7. Local Emergency Personnel G. Medical Issues H. Referral Resources I .Community and Cultural Competency TECHNICAL GUIDELINES A. Videoconferencing Applications B. Device Characteristics C. Connectivity D. Privacy ADMINISTRATIVE GUIDELINES A. Qualification and Training of Professionals B. Documentation and Record Keeping C. Payment and Billing REFERENCES.

Urinary incontinence in inpatient psychiatry: prevalence, change and relationship to length of stay.

AIMS AND OBJECTIVES: To identify the prevalence of urinary incontinence in inpatient psychiatric settings and its relationship to length of stay. BACKGROUND: Urinary incontinence is a common and disabling condition. Previous work has shown that urinary incontinence is not always considered to be important in inpatient psychiatry. DESIGN: Retrospective analysis of provincial database for inpatient psychiatry. METHOD: The study included all psychiatric inpatients in Ontario assessed with the Resident Assessment Instrument Mental Health at both admission and discharge since 1 October 2005. We used sex-based analyses to examine the prevalence of urinary incontinence at admission and change over the inpatient stay. Logistic regression was used to determine the relationship between urinary incontinence and experiencing an above average length of stay in hospital. RESULTS: The prevalence of urinary incontinence at admission was 5·6%; rates were higher among women and the profiles of afflicted men and women differed. Approximately 35% of psychiatric patients were no longer incontinent at the time of discharge, and new cases of incontinence were reported for 1·2% of patients. Both the presence of urinary incontinence at admission and development of urinary incontinence over the inpatient stay were related to increased likelihood of having a longer than average length of stay. These odds were significant for both sexes, but higher for women for the role of urinary incontinence at admission and higher for men for the role of developing urinary incontinence. CONCLUSION: Urinary incontinence was present among a non-trivial proportion of psychiatric inpatients and persisted for most throughout the inpatient stay. Presence of urinary incontinence was related to increased hospital stay. RELEVANCE TO CLINICAL PRACTICE: Mental health service providers should identify urinary incontinence quickly and pay attention to it; incorporating treatment into the care plan early on in the inpatient stay may help to ensure a more rapid return to the community.

Content of Tele-Palliative Care Consultations with Patients Receiving Dialysis.

Background: Little is known about the content of communication in palliative care telehealth conversations in the dialysis population. Understanding the content and process of these conversations may lead to insights about how palliative care improves quality of life. Methods: We conducted a qualitative analysis of video recordings obtained during a pilot palliative teleconsultation program. We recruited patients receiving dialysis from five facilities affiliated with an academic medical center. Palliative care clinicians conducted teleconsultation using a wall-mounted screen with a camera mounted on a pole and positioned mid-screen in the line of sight to facilitate direct eye contact. Patients used an iPad that was attached to an IV pole positioned next to the dialysis chair. Conversations were coded using a preexisting framework of themes and content from the Serious Illness Conversation Guide (SICG) and revised Edmonton Symptom Assessment System-Renal. Results: We recruited 39 patients to undergo a telepalliative care consultation while receiving dialysis, 34 of whom completed the teleconsultation. Specialty palliative care clinicians (3 physicians and 1 nurse practitioner) conducted 35 visits with 34 patients. Median (interquartile range) duration of conversation was 42 (28-57) minutes. Most frequently discussed content included sources of strength (91%), critical abilities (88%), illness understanding (85%), fears and worries (85%), what family knows (85%), fatigue (77%), and pain (65%). Process features such as summarizing statements (85%) and making a recommendation (82%) were common, whereas connectional silence (56%), and emotion expression (21%) occurred less often. Conclusions: Unscripted palliative care conversations in outpatient dialysis units through telemedicine exhibited many domains recommended by the SICG, with less frequent discussion of symptoms. Emotion expression was uncommon for these conversations that occurred in an open setting.

Feasibility and impact of telemonitor-based depression care management for geriatric homecare patients.

OBJECTIVE: The objective of this study was to test the feasibility, acceptability, and preliminary clinical outcomes of a method to leverage existing home healthcare telemonitoring technology to deliver depression care management (DCM) to both Spanish- and English-speaking elderly homebound recipients of homecare services. MATERIALS AND METHODS: Three stand-alone, nonprofit community homecare agencies located in New York, Vermont, and Miami participated in this study. Evidence-based DCM was adapted to the telemonitor platform by programming questions and educational information on depression symptoms, antidepressant adherence, and side effects. Recruited patients participated for a minimum of 3 weeks. Telehealth nurses were trained on DCM and received biweekly supervision. On-site trained research assistants conducted in-home research interviews on depression diagnosis and severity and patient satisfaction with the protocol. RESULTS: An ethnically diverse sample of 48 English- and Spanish-only-speaking patients participated, along with seven telehealth nurses. Both patients and telehealth nurses reported high levels of protocol acceptance. Among 19 patients meeting diagnostic criteria for major depression, the mean depression severity was in the "markedly severe" range at baseline and in the "mild" range at follow-up. CONCLUSIONS: Results of this pilot support the feasibility of using homecare's existing telemonitoring technology to deliver DCM to their elderly homebound patients. This was true for both English- and Spanish-speaking patients. Preliminary clinical outcomes suggest improvement in depression severity, although these findings require testing in a randomized clinical trial. Implications for the science and service of telehealth-based depression care for elderly patients are discussed.

Feasibility and Acceptability of Telemedicine-Facilitated Palliative Care Consultations in Rural Dialysis Units.

Background: Patients receiving dialysis have unmet palliative care needs. Limited access to palliative care is a key barrier to its integration into routine dialysis care. Objective: To determine the feasibility and acceptability of telepalliative care in rural dialysis units. Methods: This was a single-arm pilot clinical trial. The target population was patients with kidney failure receiving outpatient dialysis in a rural U.S. state. Feasibility was measured by one-month completion rate. Acceptability was measured using an adapted telemedicine questionnaire. Results: We recruited 39 patients with mean age 71.2 years to undergo a telepalliative care consultation while receiving dialysis. Four specialty palliative care clinicians (three physicians and one nurse practitioner) conducted the visits. The recruitment rate was 40% (39/96), scheduling rate was 100% (39/39), and one-month completion rate was 77% (30/39). Thirty-six patient participants (14 women and 22 men) completed the baseline survey. Audiovisual aspects of the visit were rated highly. More than 80% reported the visit being at least as good as an in-person visit and 41% felt the teleconsult was better. Eighty-one percent of patients felt the appointment was relevant to them, 58% felt they learned new things about their condition, and 27% reported the appointment changed the way they think about dialysis. Discussion: Telepalliative care is acceptable to patients receiving dialysis and is a feasible approach to integrating palliative care in rural dialysis units. The study was registered with Clinicaltrials.gov (NCT03744117).

Report of the Academy of Consultation-Liaison Psychiatry Task Force on Lessons Learned From the COVID-19 Pandemic: Executive Summary.

BACKGROUND: The COVID-19 pandemic forced consultation-liaison psychiatrists to adapt to unprecedented circumstances. The Academy of Consultation-Liaison Psychiatry (ACLP) recognized the need and opportunity to assess its response and convened a task force in mid-2020 to review the lessons learned from the initial experience of the COVID-19 pandemic. OBJECTIVE: The aim of the study was to summarize experience and make recommendations to the ACLP Board of Directors about potential ACLP directions related to current and future pandemic response. METHODS: In August-November 2020, the task force reviewed local experiences, ACLP list-serv contributions, and the published literature and generated recommendations for ACLP actions. RESULTS: Recommendations addressed telepsychiatry, hospital staff wellness, support for consultation-liaison psychiatrists, the need for additional research on psychiatric and neuropsychiatric aspects of COVID-19, and the ACLP's role in advocacy and dissemination of information. The task force report was submitted to the ACLP Board of Directors in November 2020. CONCLUSIONS: As the preeminent organization of consultation-liaison psychiatrists, the ACLP can implement actions related to pandemic awareness and preparedness for the benefit of consultation-liaison psychiatrists, other health care workers, patients, and the general population.

Benefits of a telepsychiatry consultation service for rural nursing home residents.

Psychiatric care for nursing home residents is difficult to obtain, especially in rural areas, and this deficiency may lead to significant morbidity or death. Providing this service by videoconference may be a helpful, cost-effective, and acceptable alternative to face-to-face treatment. We analyzed data for 278 telepsychiatry encounters for 106 nursing home residents to estimate potential cost and time savings associated with this modality compared to in-person care. A total of 843.5 hours (105.4 8-hour work days) of travel time was saved compared to in-person consultation for each of the 278 encounters if they had occurred separately. If four resident visits were possible for each trip, the time saved would decrease to 26.4 workdays. Travel distance saved was 43,000 miles; 10,750 miles if four visits per trip occurred. More than $3,700 would be spent on gasoline for 278 separate encounters; decreased to $925 for four visits per roundtrip. Personnel cost savings estimates ranged from $33,739 to $67,477. Physician costs associated with additional travel time ranged from $84,347 to $253,040 for 278 encounters, or from $21,087 to $63,260 for four encounters per visit. The telepsychiatry approach was enthusiastically accepted by virtually all residents, family members, and nursing home personnel, and led to successful patient management. Providing psychiatric care to rural nursing home residents by videoconference is cost effective and appears to be a medically acceptable alternative to face-to-face care. In addition, this approach will allow many nursing homes to provide essential care that would not otherwise be available.