Providing rehabilitation services to major traumatic injury survivors in rural Australia: perspectives of rehabilitation practitioners and compensation claims managers.

PURPOSE: The delivery of healthcare services in rural locations can be challenging. From the perspectives of rural rehabilitation practitioners and compensation claims managers, this study explored the experience of providing and coordinating rehabilitation services for rural major traumatic injury survivors. MATERIALS AND METHODS: Semi-structured interviews with 14 rural rehabilitation practitioners and 10 compensation claims managers were transcribed, and reflexive thematic analysis was conducted. RESULTS: Six themes were identified (1) Challenges finding and connecting with rural services, (2) Factors relating to insurance claims management, (3) Managing the demand for services, (4) Good working relationships, (5) Limited training and support, and (6) Client resilience and community. System-related barriers included a lack of available search resources to find rural rehabilitation services, limited service/clinician availability and funding policies lacking the flexibility to meet rehabilitation needs in a rural context. Strong peer and interdisciplinary relationships were viewed as crucial facilitators, which rural practitioners were particularly adept at developing. CONCLUSIONS: Greater consideration of unique needs within rural contexts is required when developing service delivery models. Specifically, flexible and equitable funding policies; facilitating interdisciplinary connections, support and training for rehabilitation practitioners and compensation claims managers; and harnessing clients' resilience may improve the delivery of rural services.IMPLICATIONS FOR REHABILITATIONRural survivors of major traumatic injury often have ongoing health and rehabilitation needs and struggle to access required treatment services.Rehabilitation providers and compensation claims managers highlighted areas for improvement in rural areas, including resources for locating available services, funding the additional costs of rural service delivery, and greater service choice for clients.Building rural workforce capacity for treatment of major traumatic injury is needed, including improved clinician access to specialist training and support.Developing good working relationships between clients and clinicians, including interdisciplinary collaborations, and supporting client resilience and self-management should be promoted in future service delivery models.

Perspectives of major traumatic injury survivors on accessibility and quality of rehabilitation services in rural Australia.

PURPOSE: For the 30% of Australians who live in rural areas, access to rehabilitation services after sustaining a major traumatic injury can be challenging. This study aimed to explore the experience of rural major traumatic injury survivors accessing rehabilitation services. MATERIALS AND METHODS: Semi-structured interviews were conducted with 21 rural major traumatic injury survivors (Mage = 47.86; SD = 11.35; Range: 21-61) who were an average of seven years post-injury (SD = 3.10; Range: 3.25-13.01). Transcribed interviews were thematically analysed. RESULTS: Four themes were identified: (1) Managing the transition back to local services, (2) Independence and determination to get better, (3) Rehabilitation is an ongoing process, and (4) Limited service access and quality. While injury-related symptoms persisted for many participants, they expressed strong determination for independence and self-management of their recovery. Barriers to accessing rehabilitation services included poor knowledge of local services, travel burden, financial costs, and a lack of local practitioners experienced in major traumatic injury rehabilitation. Facilitating factors included financial, psychological, community, and informal supports. CONCLUSIONS: To support recovery, future rural service models should improve consideration of factors resulting from living at a distance to services and harness independence to self-manage.IMPLICATIONS FOR REHABILITATIONRural major traumatic injury survivors need support to navigate numerous barriers to accessing rehabilitation services.Rural participants expressed their preference for greater involvement in planning their transition back home following hospitalisation and help to link with available services in their local area.Specialist training and support for rural rehabilitation practitioners is needed, to effectively treat impairments related to major traumatic injury, particularly psychological and cognitive difficulties.Future service delivery models should incorporate methods to locate rural services; facilitate telehealth access and client self-management; and provide financial and mental health support to both rural survivors of major traumatic injury and their carers.

Comparing face-to-face and videoconference completion of the Montreal Cognitive Assessment (MoCA) in community-based survivors of stroke.

INTRODUCTION: Videoconferencing may help address barriers associated with poor access to post-stroke cognitive screening. However, the equivalence of videoconference and face-to-face administrations of appropriate cognitive screening tools needs to be established. We compared face-to-face and videoconference administrations of the Montreal Cognitive Assessment (MoCA) in community-based survivors of stroke. We also evaluated whether participant characteristics (e.g. age) influenced equivalence. METHODS: We used a randomised crossover design (two-week interval). Participants were recruited through community advertising and use of a stroke-specific database. Both sessions were conducted by the same researcher in the same location. Videoconference sessions were conducted using Zoom. A repeated-measures t-test, intraclass correlation coefficient (ICC), Bland-Altman plot and multivariate regression modelling were used to establish equivalence. RESULTS: Forty-eight participants (26 men, Mage = 64.6 years, standard deviation (SD) = 10.1; Mtime since stroke = 5.2 years, SD = 4.0) completed the MoCA face-to-face and via videoconference on average 15.8 (SD = 9.7) days apart. Participants did not perform systematically better in a particular condition, and no participant variable predicted difference in MoCA performance. However, the ICC was low (0.615), and the Bland-Altman plot indicated wide limits of agreement, indicating variability between sessions. DISCUSSION: Our findings provide preliminary evidence to support the use of videoconference to administer the MoCA following stroke. However, further research into the test-retest reliability of scores derived from the MoCA is needed in this population. Administering the MoCA via videoconference holds potential to ensure that all stroke survivors undergo cognitive screening, in line with recommended clinical practice.

Comparing Performance Across In-person and Videoconference-Based Administrations of Common Neuropsychological Measures in Community-Based Survivors of Stroke.

OBJECTIVE: Neuropsychological assessment via videoconference could assist in bridging service access gaps due to geographical, mobility, or infection control barriers. We aimed to compare performances on neuropsychological measures across in-person and videoconference-based administrations in community-based survivors of stroke. METHOD: Participants were recruited through a stroke-specific database and community advertising. Stroke survivors were eligible if they had no upcoming neuropsychological assessment, concurrent neurological and/or major psychiatric diagnoses, and/or sensory, motor, or language impairment that would preclude standardised assessment. Thirteen neuropsychological measures were administered in-person and via videoconference in a randomised crossover design (2-week interval). Videoconference calls were established between two laptop computers, facilitated by Zoom. Repeated-measures t tests, intraclass correlation coefficients (ICCs), and Bland-Altman plots were used to compare performance across conditions. RESULTS: Forty-eight participants (26 men; Mage = 64.6, SD = 10.1; Mtime since stroke = 5.2 years, SD = 4.0) completed both sessions on average 15.8 (SD = 9.7) days apart. For most measures, the participants did not perform systematically better in a particular condition, indicating agreement between administration methods. However, on the Hopkins Verbal Learning Test - Revised, participants performed poorer in the videoconference condition (Total Recall Mdifference = -2.11). ICC estimates ranged from .40 to .96 across measures. CONCLUSIONS: This study provides preliminary evidence that in-person and videoconference assessment result in comparable scores for most neuropsychological tests evaluated in mildly impaired community-based survivors of stroke. This preliminary evidence supports teleneuropsychological assessment to address service gaps in stroke rehabilitation; however, further research is needed in more diverse stroke samples.

Cognition in elderly patients receiving unilateral and bilateral electroconvulsive therapy: a prospective, naturalistic comparison.

BACKGROUND: The cognitive side-effects of ECT are minimized by individualized, supra-threshold dosing with brief pulse electrical stimuli. Unilateral ECT is associated with fewer cognitive sequelae but bilateral ECT is possibly more effective. Little is known of the relative effectiveness and tolerability of the two placements in the treatment of elderly, severely depressed inpatients. METHODS: Patients of five public aged psychiatry services and a private psychiatric hospital who received right unilateral ECT (n=47) dosed on average at 3 times seizure threshold or bitemporal ECT (n=16) dosed at 1.5 times threshold completed an abbreviated Rey Auditory Verbal Learning Test, a visual memory test and a section of the Autobiographical Memory Inventory as close as possible to 24h after the first or second treatment and again after the fifth or sixth treatment. This design was intended to maximize recruitment of severely depressed patients with a limited ability to consent and cooperate with testing. RESULTS: Only 35% of eligible patients completed both assessments, mostly due to refusal or lack of capacity to consent. Moderate dose unilateral and bilateral ECT produced equivalent improvements in mood. There was a tendency for scores on most cognitive tests to decline more with bilateral than unilateral ECT but these differences were statistically significant only for immediate verbal memory and autobiographical memory. CONCLUSIONS: Our findings suggest that bilateral ECT is no more effective as an antidepressant than moderately dosed unilateral ECT, at least on a short-term basis, and confers a slightly greater risk of cognitive impairment. This supports the rationale of prescribing unilateral ECT in the first instance in this vulnerable clinical population. LIMITATIONS: It proved impossible to recruit most ECT recipients, limiting the capacity to generalize findings to all aged patients. Reports concerning ECT should list recruitment rates to help set findings in context.

Continuation-maintenance electroconvulsive therapy: quality standards in 3 Australian aged psychiatry services.

OBJECTIVE: To check if experienced psychiatrists in Victoria, Australia, observed the standards outlined by the American Psychiatric Association and the Royal College of Psychiatrists regarding the administration and monitoring of continuation-maintenance electroconvulsive therapy (ECT). METHODS: A retrospective chart review of 60 consecutive patients given continuation-maintenance ECT in 3 Victorian public aged psychiatry services. RESULTS: Practice guidelines were often not observed concerning documentation of treatment plans, mental state reviews and patients' and carers' viewpoints. CONCLUSIONS: Continuation-maintenance ECT proved highly effective in this clinical sample. Our audit identifies areas for improvement in clinical practice. It will be helpful to have a simple checklist of treatment plans, rating scale scores, and discussions with patients and carers that clinicians can complete at regular intervals.

The effectiveness of continuation-maintenance ECT in reducing depressed older patients' hospital re-admissions.

BACKGROUND: We report on the outcomes in aged patients with severe, treatment-resistant depression or psychosis who were given ongoing outpatient continuation-maintenance ECT of varying duration to prevent remission and relapse following a successful course of acute ECT. METHODS: A retrospective chart review of 58 consecutive patients of three Australian aged psychiatry services comparing the number and length of psychiatric admissions before and after the start of continuation-maintenance ECT. RESULTS: Four patients had only one treatment and two received over 50 (mean 14.7). Five were still enrolled in a maintenance program two years later. In the two years after continuation-maintenance ECT started, admissions fell by 53% in number and 79% in duration compared with the previous two years. Within the actual treatment period which varied from one patient to another, admissions fell by 90% in number and 97% in duration compared with the same period beforehand. CONCLUSION: A treatment effect cannot be proven but the severity and chronicity of patients' conditions make placebo effects and spontaneous remission unlikely. Randomised, controlled trials are almost impossible in this setting and so carefully conducted reviews and case-control studies are still of value. Our findings suggest that continuation-maintenance ECT is effective in carefully selected patients at high risk of relapse.

Psychosocial treatments of psychological symptoms in dementia: a systematic review of reports meeting quality standards.

BACKGROUND: This paper provides a systematic review of selected experimental studies of the effectiveness of psychosocial treatments in reducing psychological symptoms in dementia (e.g. anxiety, depression, irritability and social withdrawal). METHOD: English language reports published or in press by February 2008 were identified by means of database searches and checks of previous reviews. Reports were appraised with respect to study design, participants' characteristics and reporting details. Because people with dementia often respond positively to personal contact, studies were included only if control conditions entailed similar levels of social attention or if one treatment was compared with another. RESULTS: Only 12 of 48 relevant papers met every specification. Treatments proved more effective in reducing psychological symptoms than an attention control condition or another treatment in only six of the 12 selected studies. Interventions with moderate effect sizes included music and recreation therapy. CONCLUSIONS: Some psychosocial interventions appear to have specific therapeutic properties, over and above those due to the benefits of participating in a clinical trial. Their effects were generally modest with an unknown duration of action. This limited efficacy suggests that treatments will work best in specific, time-limited situations, tailored to individuals' requirements. There is no preferred method to rate psychological symptoms.

Psychosocial treatments of behavior symptoms in dementia: a systematic review of reports meeting quality standards.

OBJECTIVE: To provide a systematic review of selected experimental studies of psychosocial treatments of behavioral disturbances in dementia. Psychosocial treatments are defined here as strategies derived from one of three psychologically oriented paradigms (learning theory, unmet needs and altered stress thresholds). METHOD: English language reports published or in press by December 2006 were identified by means of database searches, checks of previous reviews and contact with recognized experts. Papers were appraised with respect to study design, participants' characteristics and reporting details. Because people with dementia often respond positively to personal contact, studies were included only if control conditions entailed similar levels of social attention or if one treatment was compared with another. RESULTS: Only 25 of 118 relevant studies met every specification. Treatment proved more effective than an attention control condition in reducing behavioral symptoms in only 11 of the 25 studies. Effect sizes were mostly small or moderate. Treatments with moderate or large effect sizes included aromatherapy, ability-focused carer education, bed baths, preferred music and muscle relaxation training. CONCLUSIONS: Some psychosocial interventions appear to have specific therapeutic properties, over and above those due to the benefits of participating in a clinical trial. Their effects were mostly small to moderate with a short duration of action. This limited action means that treatments will work best in specific, time-limited situations. In the few studies that addressed within-group differences, there were marked variations in response. Some participants benefited greatly from a treatment, while others did not. Interventions proved more effective when tailored to individuals' preferences.

A review of the cognitive effects of electroconvulsive therapy in older adults.

OBJECTIVE: To review studies that examined the impact of electroconvulsive therapy (ECT) on cognitive functioning in depressed older people. METHODS: Studies were systematically retrieved using PsychINFO and MEDLINE, with additional articles sourced from lists of references. Given our aged-care focus, study participants had a minimum mean age of 60 years, with no single participant younger than 50 years. RESULTS: Twenty-seven studies met our criteria. Apart from evidence of interictal slowing of information processing speed, there were mixed results with regard to the impact of ECT on other cognitive domains. Factors contributing to this variability in results include the lack of discrimination between unilateral, bilateral, or mixed electrode placement; the inclusion of patients with dementia; the small sample sizes; and the use of tests insensitive to subtle cognitive changes. CONCLUSIONS: The effect of ECT in elderly recipients' cognition remains unclear, and further research with more critically selected methods is required. In the meantime, we recommend that clinicians regularly administer brief focused cognitive tests before, during, and after treatment to monitor progress.

The impact of stimulants on a clinical measure of attention in children with ADHD.

The effect of stimulant medication on the attentional functioning of 23 children (8-12 yrs) with attention deficit/hyperactivity disorder (ADHD) was investigated. Significant main effects of medication and TEA-Ch subtests were found, however there was no significant interaction. Planned contrasts showed that stimulants improved performance on the sustained attention, but not the selective or divided attention, subtests. Similar to previous studies, the results indicate that stimulants improve sustained attention in children with ADHD. Significant effects of stimulants on selective and divided attention, however, were not as apparent. Therefore, care must be taken when using TEA-Ch subtests to assess performance change subsequent to stimulant administration.

Progressive age-related changes in the attentional blink paradigm.

Previous studies on aging and attention typically examine group differences between younger and older adults, rather than seeing aging as a continuous process. Using correlational analyses, this study examined progressive changes in the magnitude of the attentional blink (AB) associated with aging. Increased age was found to be significantly associated with the ability to detect the second target (T2), whereby older age was correlated with the production of a longer and more pronounced AB; this supports the proposition that aging is associated with reduced inhibitory processes and selective attention. It was also found that AB performance somewhat improves between ages 18-39 years, but tends to decline from 40 years of age onward, providing an interesting and novel finding that AB effects may become more sensitive at this point in time. The AB task may prove useful in the assessment of selective attention in normal healthy adults, as well as changes associated with pathological aging.