Psychiatric assessment and screening for the elderly in primary care: design, implementation, and preliminary results.

INTRODUCTION: We describe the design and implementation of a psychiatric collaborative care model in a University-based geriatric primary care practice. Initial results of screening for anxiety and depression are reported. METHODS AND MATERIALS: Screens for anxiety and depression were administered to practice patients. A mental health team, consisting of a psychiatrist, mental health nurse practitioner and social worker, identified patients who on review of screening and chart data warranted evaluation or treatment. Referrals for mental health interventions were directed to members of the mental health team, primary care physicians at the practice, or community providers. RESULTS: Subjects (N=1505) comprised 38.2% of the 3940 unique patients seen at the practice during the 4-year study period. 37.1% (N=555) screened positive for depression, 26.9 % (N=405) for anxiety, and 322 (21.4%) screened positive for both. Any positive score was associated with age (p<0.033), female gender (p<0.006), and a non-significant trend toward living alone (p<0.095). 8.87% had suicidal thoughts. CONCLUSIONS: Screening captured the most affectively symptomatic patients, including those with suicidal ideation, for intervention. The partnering of mental health professionals and primary care physicians offers a workable model for addressing the scarcity of expertise in geriatric psychiatry.

Piloting a Text Message-based Social Support Intervention for Patients With Chronic Pain: Establishing Feasibility and Preliminary Efficacy.

OBJECTIVES: To examine preliminarily the effectiveness of a short message service (SMS) text message-based social support intervention for reducing daily pain and pain interference levels, improving affect and perceptions of social support in patients with chronic noncancer pain, and exploring the feasibility of a novel mobile application to track perceptions of pain and pain interference. MATERIALS AND METHODS: Participants (17 men, 51 women) from 2 pain clinics in New York City downloaded a pain tracking application (App) on their Smartphone and used it to record twice-daily pain, pain interference, and affect scores over the 4-week study period. Participants were randomly assigned to receive standard care (control) or standard care along with receipt of twice-daily supportive SMS text messages delivered during the second and third week of the study (intervention). Demographic and clinical data were obtained at baseline, and social support measures were administered at baseline and at 4 weeks. Statistical analysis was carried out using general linear mixed models, taking into account variances associated with time of assessments and with patients. RESULTS: The social support intervention reduced perceptions of pain and pain interference and improved positive affect for chronic noncancer pain patients assigned to the intervention condition in comparison with controls. Participants completed approximately 80% of the daily measurements requested. DISCUSSION: These findings establish the feasibility of collecting daily pain data using a mobile tracking App and provide significant implications and insight into a nuanced approach to reducing the daily experience of pain through mobile technology, especially because of its accessibility.

Improving symptom management in hemodialysis patients: identifying barriers and future directions.

BACKGROUND: Hemodialysis (HD) patients experience significant symptom burden that is often undertreated. OBJECTIVE: This study identified (1) barriers to symptom management in the HD population, (2) potential targets for improving symptom burden, (3) provider attitudes toward palliative care for HD patients, and (4) perceptions of how transplant eligibility impacts care. DESIGN: Semistructured, one-on-one interviews were conducted, audiotaped, and transcribed. Data were analyzed qualitatively by two investigators to identify discrete themes. SETTING/SUBJECTS: Health care providers (HCPs) and caregivers were recruited (June to October 2012) from three outpatient HD units in New York City. MEASUREMENTS: Open-ended questions were used with follow-up probes. RESULTS: Interviews were completed with 34 HCPs (8 physicians, 2 nurse practitioners, 4 social workers, 13 registered nurses, 7 patient care technicians) and 20 caregivers (14 family members, 5 home health aides, 1 friend). Barriers to symptom control were identified in three areas: (1) provider unawareness of symptoms, (2) provider's uncertainty as to whose responsibility it is to treat symptoms, and (3) inherent difficulty in symptom management. Ideas for ameliorating symptoms included enhancing systems for patient/caregiver education, improving systems for HCP communication with other disciplines, and encouraging alternative methods of dialysis when appropriate. HCPs also expressed discomfort with the term "palliative care." CONCLUSIONS: Renal HCPs are often unaware of the magnitude of symptom burden in their HD patients. This study found that there is lack of ownership for assessing and treating these symptoms. Providers also feel certain symptoms are "untreatable." Research is needed to develop effective treatment strategies for HD populations.

Complementary therapies for osteoarthritis: are they effective?

Increasing interest has focused on complementary management modalities, including tai chi, acupuncture, yoga, and massage therapy, as treatments for osteoarthritis (OA). This review article synthesizes evidence from randomized controlled trials (RCTs) and systematic reviews (SRs) that examined one or more of the above as treatments for OA. Medline, Pubmed, and Cinahl databases were searched to identify English-language articles using an RCT design or that conducted a SR of published studies and presented data on symptom or functional outcomes. Two authors independently abstracted relevant information (e.g., study sample, intervention characteristics, treatment effects, safety data). Retained articles (n = 29) included those that evaluated tai chi (8 RCTs, 2 SRs), acupuncture (11 RCTs, 4 SRs), yoga (2 RCTs), and massage therapy (2 RCTs). Available evidence indicates that tai chi, acupuncture, yoga, and massage therapy are safe for use by individuals with OA. Positive short-term (≤6 months) effects in the form of reduced pain and improved self-reported physical functioning were found for all 4 treatments. Limited information exists regarding the relative effectiveness of the therapies (e.g., yoga vs. tai chi vs. acupuncture), as well as treatment effects in persons with joint involvement besides the knee and in distinct patient subgroups (e.g., older vs. younger adults, persons with mild vs. moderate vs. advanced disease). Complementary therapies can reduce pain and improve function in adults with OA. Research is needed to evaluate long-term benefits of the treatments, as well as their relative effects among diverse patient subgroups.

Disparities in symptom burden and renal transplant eligibility: a pilot study.

BACKGROUND: Patients with end-stage renal disease (ESRD) on hemodialysis (HD) suffer from a high symptom burden. However, there is significant heterogeneity within the HD population; certain subgroups, such as the elderly, may experience disproportionate symptom burden. OBJECTIVES: The study's objective was to propose a category of HD patients at elevated risk for symptom burden (those patients who are not transplant candidates) and to compare symptomatology among transplant ineligible versus eligible HD patients. DESIGN: This was a cross-sectional study. SETTING/SUBJECTS: English-speaking, cognitively intact patients receiving HD and who were either transplant eligible (n=25) or ineligible (n=32) were recruited from two urban HD units serving patients in the greater New York City region. MEASUREMENTS: In-person interviews were conducted to ascertain participants' symptom burden using the Dialysis Symptom Index (DSI), perceived symptom bother and attribution (whether the symptom was perceived to be related to HD treatment), and quality of life using the SF-36. Participants' medical records were reviewed to collect demographic and clinical data. RESULTS: Transplant ineligible (versus eligible) patients reported an average of 13.9±4.6 symptoms versus 9.2±4.4 symptoms (p<0.01); these differences persisted after adjustment for multiple factors. A greater proportion of transplant ineligible (versus eligible) patients attributed their symptoms to HD and were more likely to report greater bother on account of the symptoms. Quality of life was also significantly lower in the transplant ineligible group. CONCLUSIONS: Among HD patients, transplant eligibility is associated with symptom burden. Our pilot data suggest that consideration be given to employing transplant status as a method of identifying HD patients at risk for greater symptom burden and targeting them for palliative interventions.

Pharmacologic management of osteoarthritis-related pain in older adults.

OVERVIEW: Because pain is a common and debilitating symptom of osteoarthritis in older adults, the authors reviewed data on the efficacy and safety of commonly used oral, topical, and intraarticular drug therapies in this population. A search of several databases found that most studies have focused on knee osteoarthritis and reported only short-term outcomes. Also, treatment efficacy was found to vary by drug class; the smallest effect was observed with acetaminophen and the largest with opioids and viscosupplements. Acetaminophen and topical agents had the best safety profiles, whereas oral nonsteroidal antiinflammatory drugs and opioids had the worst. Little data were available on patients ages 75 years old and older and on patients from diverse racial and ethnic groups. Most drug therapies gave mild-to-moderate pain relief; their long-term safety and efficacy and their effects in diverse populations (particularly older adults) remain undetermined.

Pharmacologic management of osteoarthritis-related pain in older adults: a review shows that many drug therapies provide small-to-modest pain relief.

OVERVIEW: Because pain is a common and debilitating symptom of osteoarthritis in older adults, the authors reviewed data on the efficacy and safety of commonly used oral, topical, and intraarticular drug therapies in this population. A search of several databases found that most studies have focused on knee osteoarthritis and reported only short-term outcomes. Also, treatment efficacy was found to vary by drug class; the smallest effect was observed with acetaminophen and the largest with opioids and viscosupplements.Acetaminophen and topical agents had the best safety profiles, whereas oral nonsteroidal antiinflammatory drugs and opioids had the worst. Little data were available on patients ages 75 years old and older and on patients from diverse racial and ethnic groups. Most drug therapies gave mild-to-moderate pain relief; their long-term safety and efficacy and their effects in diverse populations (particularly older adults) remain undetermined.

Pharmacologic Management of Osteoarthritis-Related Pain in Older Adults: A Review Shows that Many Drug Therapies Provide Small-to-Modest Pain Relief.

Because pain is a common and debilitating symptom of osteoarthritis in older adults, the authors reviewed data on the efficacy and safety of commonly used oral, topical, and intraarticular drug therapies in this population. A search of several databases found that most studies have focused on knee osteoarthritis and reported only short-term outcomes. Also, treatment efficacy was found to vary by drug class; the smallest effect was observed with acetaminophen and the largest with opioids and viscosupplements. Acetaminophen and topical agents had the best safety profiles, whereas oral nonsteroidal antiinflammatory drugs and opioids had the worst. Little data were available on patients ages 75 years old and older and on patients from diverse racial and ethnic groups. Most drug therapies gave mild-to-moderate pain relief; their long-term safety and efficacy and their effects in diverse populations (particularly older adults) remain undetermined.

Directly observed patient-physician discussions in palliative and end-of-life care: a systematic review of the literature.

OBJECTIVES: To review studies that used direct observation (i.e., videotaping or audiotaping) methods in palliative/end-of-life care communication research. DESIGN: Descriptive thematic analysis. SETTING: Multinational studies were conducted in both the outpatient and inpatient setting. MEASUREMENTS: Extensive bibliographic searches (January 1, 1998 to July 31, 2009) of English-language literature involving physician-patient (or physician-family) interactions were conducted and augmented by reviews of reference listings. Three investigators independently abstracted key information from each article. RESULTS: Of the 20 retained articles, most enrolled young-old participants (mean age, 60 years) who were white and had a cancer diagnosis. Patient/family participation rates ranged from 68% to 89% demonstrating feasibility of this approach when studying palliative/end-of-life care communication issues. Four common themes were identified: (1) physicians focus on medical/technical and avoid emotional/quality of life issues; (2) sensitive topics are perceived by physicians to take longer to discuss and often do take longer to discuss; (3) physicians dominate discussions; and (4) patient/family satisfaction is associated with supportive physician behaviors. CONCLUSIONS: This study demonstrates that direct observation methods can be feasibly used when studying physician-patient/physician-family communication in palliative/end-of-life care, but few investigations have utilized this approach. This article highlights areas that need improvement, including physicians' ability to address patient/family emotional issues and provide what patients and families find most satisfying (participation and support). A particular focus on older patients and patients with end-stage or late-stage chronic (noncancer) illness, the adaptation/application of existing communication measurement tools to capture palliative care communication issues, and development of corresponding outcome measures to assess impact is now needed.