Older Veterans' Treatment Preferences: Psychotherapy and Self-Management Treatment Modalities.

OBJECTIVES: Self-management may help older Veterans with mental health challenges and can overcome barriers to traditional psychotherapy. However, the reasons underlying older Veterans' treatment preferences remain unknown. The current study investigated older Veterans' perspectives on psychotherapy and self-management. METHODS: Seventy-four Veterans ≥ 60 years old were included in this mixed methods study. Participants provided rationale(s) after ranking their preferences for psychotherapy and four self-management modalities. Logistic regressions examined whether depressive and anxiety symptom severity contributes to preferences. Qualitative analyses were conducted to investigate reasoning for preferences. RESULTS: Most participants preferred psychotherapy (64.9%) over self-management (35.1%). Logistic regressions showed that depressive and anxiety symptom severity was not significantly associated with preferences. Qualitative analyses revealed that past experience and access-related barriers were underlying the preferences. Themes unique to psychotherapy included the availability of emotional support and the process of information sharing. In contrast, ease of access was associated with self-management. CONCLUSIONS: Older Veterans preferred psychotherapy to receive support and to develop trust in meeting their goals. CLINICAL IMPLICATIONS: Older Veterans' needs point to the importance of providers' consideration of a person-centered approach and treatment collaboration. Notably, Veterans' preference for psychotherapy highlights the importance and need for human support in addition to self-management tools.

Barriers to Telemedicine Video Visits for Older Adults in Independent Living Facilities: Mixed Methods Cross-sectional Needs Assessment.

BACKGROUND: Despite the increasing availability of telemedicine video visits during the COVID-19 pandemic, older adults have greater challenges in getting care through telemedicine. OBJECTIVE: We aim to better understand the barriers to telemedicine in community-dwelling older adults to improve the access to and experience of virtual visits. METHODS: We conducted a mixed methods needs assessment of older adults at two independent living facilities (sites A and B) in Northern California between September 2020 and March 2021. Voluntary surveys were distributed. Semistructured interviews were then conducted with participants who provided contact information. Surveys ascertained participants' preferred devices as well as comfort level, support, and top barriers regarding telephonic and video visits. Qualitative analysis of transcribed interviews identified key themes. RESULTS: Survey respondents' (N=249) average age was 84.6 (SD 6.6) years, and 76.7% (n=191) of the participants were female. At site A, 88.9% (111/125) had a bachelor's degree or beyond, and 99.2% (124/125) listed English as their preferred language. At site B, 42.9% (51/119) had a bachelor's degree or beyond, and 13.4% (16/119) preferred English, while 73.1% (87/119) preferred Mandarin. Regarding video visits, 36.5% (91/249) of all participants felt comfortable connecting with their health care team through video visits. Regarding top barriers, participants at site A reported not knowing how to connect to the platform (30/125, 24%), not being familiar with the technology (28/125, 22.4%), and having difficulty hearing (19/125, 15.2%), whereas for site B, the top barriers were not being able to speak English well (65/119, 54.6%), lack of familiarity with technology and the internet (44/119, 36.9%), and lack of interest in seeing providers outside of the clinic (42/119, 35.3%). Three key themes emerged from the follow-up interviews (n=15): (1) the perceived limitations of video visits, (2) the overwhelming process of learning the technology for telemedicine, and (3) the desire for in-person or on-demand help with telemedicine. CONCLUSIONS: Substantial barriers exist for older adults in connecting with their health care team through telemedicine, particularly through video visits. The largest barriers include difficulty with technology or using the video visit platform, hearing difficulty, language barriers, and lack of desire to see providers virtually. Efforts to improve telemedicine access for older adults should take into account patient perspectives.

Converting a Geriatrics Clinic to Virtual Visits during COVID-19: A Case Study.

BACKGROUND: To characterize the experience of converting a geriatrics clinic to telehealth visits in early stages of a pandemic. DESIGN: An organizational case study with mixed methods evaluation from the first 8 weeks of converting a geriatrics clinic from in-person visits to video and telephone visits. SETTING: Veteran's Health Administration in Northern California Participants Community-dwelling older Veterans receiving care at VA Palo Alto Geriatrics clinic. Veterans had a mean age of 85.7 (SD = 6.8) and 72.1% had cognitive impairment. INTERVENTION: Veterans with face-to-face appointments were converted to video or telephone visits to mitigate exposure to community spread of COVID-19. MEASUREMENTS: Thirty-two patient evaluations and 80 clinician feedback evaluations were completed. This provided information on satisfaction, care access during pandemic, and travel and time savings. RESULTS: Of the 62 scheduled appointments, 43 virtual visits (69.4%) were conducted. Twenty-six (60.5%) visits were conducted via video, 17 (39.5%) by telephone. Virtual visits saved patients an average of 118.6 minutes each. Patients and providers had similar, positive perceptions about telehealth to in-person visit comparison, limiting exposure, and visit satisfaction. After the telehealth appointment, patients indicated greater comfort with using virtual visits in the future. Thirty-one evaluations included comments for qualitative analysis. We identified 3 main themes of technology set-up and usability, satisfaction with visit, and clinical assessment and communication. CONCLUSION: During a pandemic that has limited the ability to safely conduct inperson services, virtual formats offer a feasible and acceptable alternative for clinically-complex older patients. Despite potential barriers and additional effort required for telehealth visits, patients expressed willingness to utilize this format. Patients and providers reported high satisfaction, particularly with the ability to access care similar to in-person while staying safe. Investing in telehealth services during a pandemic ensures that vulnerable older patients can access care while maintaining social distancing, an important safety measure.

Factors Associated with Supportive Care Service Use Among California Alzheimer's Disease Patients and Their Caregivers.

BACKGROUND: Existing literature on factors associated with supportive care service (SCS) use is limited. A better understanding of these factors could help tailor SCS to the needs of frequent users, as well as facilitate targeted outreach to populations that underutilize available services. OBJECTIVE: To investigate the prevalence of SCS use and to identify factors associated with, and barriers to, service use. METHODS: California Alzheimer's Disease Center patients with AD (n = 220) participated in the study from 2006-2009. Patients and their caregivers completed assessments to determine SCS use. Cognitive, functional, and behavioral status of the patients were also assessed. A two-part hurdle analysis identified 1) factors associated with any service use and 2) service use frequency among users. RESULTS: Forty percent of participants reported using at least one SCS. Patients with more impaired cognition and activities of daily living and more of the following: total number of medications, comorbid medical conditions, and years of education were more likely to use any SCS (p < 0.05). Factors associated with more frequent SCS use included younger age, more years of education, older age of AD onset, female gender, and having a spouse or relative for a caregiver (p < 0.05). Caregivers frequently indicated insufficient time as a reason for not receiving enough services. CONCLUSION: Factors associated with any SCS use mostly differed from those associated with SCS frequency, suggesting different characteristics between those who initiate versus those who continue SCS use. Our findings highlight the importance of targeted education on services and identifying barriers to long-term SCS use.

Implementation of a brief anxiety assessment and evaluation in a Department of Veterans Affairs geriatric primary care clinic.

Anxiety disorders are common and debilitating in older individuals, yet anxiety is often not formally assessed in primary care. We conducted a quality improvement project to examine the feasibility of implementing a brief anxiety assessment, the Geriatric Anxiety Inventory (GAI), in a Department of Veterans Affairs geriatric primary care clinic. We compared the GAI with a depression assessment, the 15-item Geriatric Depression Scale (GDS-15). Fifty older Veterans (mean = 78.5 +/- 7.4 yr) completed the GAI and GDS-15. Mean completion time and feedback to patients was brief (6.20 min; n = 10). Good internal consistency (alpha = 0.82) was found for GAI scores. Patients with psychiatric diagnoses obtained significantly higher GAI scores (mean = 4.73 +/- 1.15) compared with patients without psychiatric diagnoses (mean = 1.15 +/- 1.86, t(11.46) = -3.10, p = 0.01). Findings suggest that the GAI is acceptable to patients but may not be suitable for differentiating anxiety symptoms or disorders from depression. Interdisciplinary team members continued to implement the GAI after project completion to screen for and track anxiety symptoms in our geriatric primary care patients. Detecting anxiety with the GAI had the benefit of allowing providers to initiate conversations about available treatments and track symptoms as part of noting treatment progress.

A preliminary investigation of developmentally sensitive items for the assessment of social anxiety in late life.

The current study aimed to examine the salience of anxiety-provoking social situations for older adults. A list of potentially anxiety-provoking situations was developed from a review of existing measures of social anxiety. In addition to items derived from existing measures, the investigators generated items thought to be particularly relevant for older adults. One hundred and four older adults were asked, "Please check all situations where you might feel uncomfortable, nervous, scared, worried, embarrassed, or anxious." Participants were also prompted to record any additional situations in which they experienced anxiety. Older adults endorsed items not included on typical measures of social anxiety at high rates. Exploratory analyses of the effects of gender on item endorsement were examined and significant differences were found for several items. The authors discuss these findings and their implications for the assessment of late-life social anxiety.