The Telepsychiatry Advantage: Episode 13

How to make telepsychiatry work for Elderly Patients

Introduction & Demographics

Today, we’re going to address a problem that’s growing in this country. The gap between the supply of geriatric psychiatrists with the demand for geriatric psychiatry in a growing elderly population.

In 1960, only about 9% of the American population was aged 65 or older. Today, that’s 17%. So by my math, that’s almost double. And by the year 2030, about 1 in 5 people, about 20% of people in America are going to be aged 65 and older.

So what does that mean? Well, it means that we need more geriatric psychiatry. But we’re not going to get a higher proportion of people choosing geriatrics as their subspecialty.

Why Choose Geriatric Psychiatry?

I remember in residency there were these people in my residency class that chose actually, I think it was just one person who chose geriatrics as her subspecialty. And I was thinking, what is wrong with this person? What a weirdo. Why would you choose that when there are so many more exciting specialties like emergency medicine, psychiatry or child and adolescent psychiatry where you can change the course of somebody’s life?

Well, the joke’s on me because geriatric psychiatrists actually really enjoy their job, because you can make a huge difference in the lives of patients. You have a long term relationship with the family and with the patient that’s really fulfilling, and you get a lot of appreciation for the work that you do. So I do encourage you all to consider geriatrics as a subspecialty or area of focus, but at the very least, you should be competent to be able to see geriatric patients.

And what does that mean? Well, you have to have a good understanding of what are the common reasons why an elderly patient will need mental health care.

Key Conditions and Patient Settings

Basically, there are about three conditions that represent the majority of the conditions that geriatric patients face. It’s cognitive disorders, depression and anxiety. And so those three represent the vast majority of the conditions that are going to be presented to you. And when we’re talking about a telepsychiatry appointment, we’re going to focus a lot on the cognition part, because it’s going to be a different skill set to try to elicit the symptoms and signs of a cognitive deficit or impairment via telepsychiatry.

I want to quickly also say what the settings are going to be. So the majority of the patients that you’re going to see are going to be from assisted living, subacute nursing facilities and patients in their homes. So that’s the majority of where you’re going to see elderly patients.

Now you are going to see them in other areas as well, like in the emergency department and other places, so that’s why this episode is going to be important, not just for people who are geriatric psychiatrists, but for anybody who’s in any setting where you might encounter somebody age 65 and older.

How are you going to address this growing need? It’s going to be through telepsychiatry, just like every other problem. Guys, literally every problem is going to be addressed by telepsychiatry, child and adolescent psychiatry, shortages, emergency medicine, the Middle East peace process, and you know, all of that stuff. Everything, literally every condition and every problem that we face as a society will be addressed through telepsychiatry. And one of those will be geriatric telepsychiatry.

Overcoming Technology Barriers

It takes a skill set to see people that are 65 and older and do it in a way that is most optimal. So let’s first start with the misconception that telepsychiatry is not good for your patients because they’re not digital natives. Digital native, what I mean by that is anybody who grew up with technology, and obviously everyone grew up with some sort of technology like the wheel is a technology, but I’m talking more like the internet and more advanced technologies like smartphones and video conferencing. So we’re dealing with people who are not digital natives, and so they’re going to struggle a little bit with the technology, but that’s not going to be something that prevents us from seeing patients via video.

Well, the first thing you need to do is make sure that the technology on the patient’s side is dialed in. Make sure that they have some help. Understand are they working with a smartphone, a laptop, a tablet? Is the technology very simple and easy to use? So these are some of the things that are going to avoid some of the major problems. Make sure that the audio is good. The video is coming out clean. They have good internet, all of the things that we need to do anyway, but make sure that you do this 100% because an elderly patient is going to get frustrated easily with the technology, and so you want to make sure that you present as few problems as possible right up front.

You want the technology to be as simple as possible. You want them to have some assistance on their end, either the care giver, family, whoever it is that’s helping the patient on their end, make sure that they do a test call with you so that before the patient sees you, everything is ready to go. And really, what you want in an optimal situation is for the patient to just go and sit down right in front of you, not have to fiddle with anything and just talk to you just like they would in the office. So you want to make sure that you are creating an environment for the patient that sets them up for success and less frustration.

Scheduling and Environmental Pro Tips

You want to choose a time of day that’s optimal for the patient. This is a pro tip here. Sometimes you don’t have that luxury, but if you have the ability to choose a time, I would choose earlier in the day when the patient is fresher and you avoid the sun downing, that happens toward the evening where the patient is not going to be as mentally sharp, and it’s going to be a little bit harder communicating with the patient.

Try to keep the visits predictable on a regular schedule. See, elderly patients need routines and we all need routines, but especially elderly patients. And if you can get them into the habit and the routine of seeing you, then not only are you going to be able to have continuity of care, but the patient is going to be used to the appointment and you’re not going to get no show rates, and the patient is going to be able to settle in into the appointment without any problems, hopefully.

Communication Techniques

So one of the things that you want to do when you’re dealing with patients with cognitive impairment is you want to speak slower. About 20 to 30% slower than you would with a patient that’s not elderly. You want to include pauses. And we all have, I think we all do, but maybe not everybody, but we all have difficulty allowing other people to talk.

And you want the patient to talk. If you are continuously talking to an elderly patient and you’re not giving pauses and allowing them to speak without interrupting them, they’re just going to shut down. They’re not going to be listening to you, and you won’t know if they’re understanding you. So you want to pause, give the patient a time to finish their thought, and then you want to rephrase. You want to rephrase what the patient told you and feed it back to them to make sure that you understood them. And that’s also a great way to validate to the patient that you’re listening to them.

Make sure to look at the camera. Look directly at the camera so that the patient sees eye contact virtually. You want to keep the questions very simple okay? Because if you don’t then you’re not going to get anywhere. The patient is not going to understand you.

In general, simplicity is best in life. I’m a big fan of keeping everything simple, but it’s going to be even more important with elderly patients. Keep everything simple, the technology simple, your questions simple, the treatment you want to try to keep as simple as possible. Everything should try to be as simple as possible, because elderly people don’t deal with complexity very well.

Observing Nonverbal Cues

When you’re conducting a telepsychiatry appointment, it’s also important that you notice the nonverbal cues of your elderly patient. Their facial expressions are really important, so just take a moment and just observe them while they’re talking or at the beginning of the point, observe their facial features. Do they have a flat affect that could be due to a condition like Parkinson’s disease? Do they look irritable, anxious, depressed? What are some of the facial features that are standing out? Do they have drooping? That’s a sign, potentially a sign, that they had a stroke. Make sure to observe whether they have eye contact, because elderly patients, if they have a particular condition that causes them impairment in orientation or attention that may cause them to have poor eye contact, distract ability, that kind of thing.

One of the nonverbal cues that’s really important is psychomotor retardation. I think probably the more appropriate term is psychomotor slowing or psychomotor agitation. Psychomotor slowing can be due to conditions like depression, Parkinson’s disease, dementia, and medication side effects. There are several conditions that can cause an elderly patient to have psychomotor slowing. They could also have psychomotor agitation, restlessness, akathisia some of the conditions that can cause psychomotor agitation can be medication side effects. They could be anxious, they could be delirious. So psychomotor agitation or slowing either one can be a really important indicator during your telepsychiatry appointment.

And oftentimes the gait can be important too. In fact, I would say it’s always important when you’re dealing with elderly patients to observe their gait. So you want to be able to observe that as the patient’s coming in and sitting down. And pro tip here, psychiatrists often miss that part, like they’re busy looking at the electronic record for doing something else while the patient is walking into the office. And this is especially important in telepsychiatry, because you have limited windows of opportunity to observe how the patient is walking. And so one of the most important things I would say is just have your eyes fixed on the screen and see how the patient is walking, how they sit down. Do they have difficulty? And generally these nonverbal cues are really important.

Establishing Rapport and Reading the Background

Now when the geriatric telepsychiatry appointment starts, one of the most important things that you need to do is establish rapport. Relationships are so important to all of us, but they’re more important to elderly people than any other population. I mean, relationships are everything to elderly people. Because really, toward the end of life, what’s important other people, relationships, you know, we get distracted in our society as when we’re young to pursue all kinds of things, but the most important thing that we forget is relationships. But elderly patients typically know this. That’s the wisdom of getting older, you understand generally, what’s more important.

And so for a patient relationships are important. And in elderly patients if you don’t establish rapport then the patient doesn’t think that there’s a relationship that’s going to develop and they’ll be less interested in listening to you. They won’t follow your instructions as well, and it’s just going to be a lot harder to connect with the patient. So start with some questions about the patient. Hey, how are you doing? I see, you know, note something maybe in the background, something that is of interest to them, ask them a little bit about themselves and just kind of keep it open ended because you really want to establish rapport.

Another thing that is helpful, just like all other telepsychiatry appointments where the patient is in their home, you want to look at the background. Is it organized, is it neat or is it very messy? Is there food on the floor? Are there signs that the patient is not functioning well? Now? This may be harder to do if the patient is in a clinic or in someone, someone else’s home, like a family. If they’re in another setting where it’s not actually their home environment, you’re not going to know this information. But if they’re in their home, that’s a valuable piece of information that you need to gather.

And by gathering, I mean just look at it, just look in the background. It’s so interesting how a lot of psychiatrists don’t even pay attention to the background. The background can not only give some information about the patient, but it can also show how the patient’s environment may be affecting them. Is it a very noisy environment? You do not want to have a noisy environment in a telepsychiatry appointment, especially with geriatric clientele, because that is going to very much negatively impact your ability to connect and gather information about the patient.

Managing Session Time & Caregivers

Another pro tip is don’t let the caregiver answer every question. That can happen because people are impatient. Doctors can be impatient, the caregiver can be impatient. And when the doctor is asking a question and the patient takes a bit more time to answer, the caregiver or somebody on the other end is going to be quick to jump in on answering that question. You do need their perspective, and that’s actually very important to gather their perspective and information from collateral sources. But you want the patient to be able to communicate their own concerns as well. And what does this mean? It means that sometimes the geriatric sessions are going to need to take longer than regular sessions. It might not be enough to do a one hour intake, although you also need to understand the patient’s energy levels.

So we were talking about time of day and energy. Like I said before, you want to choose the correct time of day, but you also don’t want to make the appointment so long that the patient is fatigued. So sometimes 60 minutes for an intake is too short and sometimes it’s too long. And that’s where the skill and experience of the provider is going to come into play. What you want to do is you want to gather as much information as you can from outside sources, so that when it comes time to speak with the patient, you take only as much time as you need, and sometimes that it may be a long time, longer than 60 minutes, but sometimes you can do it in a shorter period of time if you’re prepared.

So did I just confuse you? Did I say okay? Well, sometimes 60 minutes is too long and sometimes it’s too short? Well, I’m going to put it on you to make sure that you spend the correct amount of time with the patient. That’s the take home message here.

Performing Cognitive Examinations Remotely

Now, when you’re doing the assessment, the mental status examination, obviously with elderly patients, we want to spend a little more time understanding if they’re oriented, if they’re alert, if they’re memory is short term or long term memory, you know, the mini mental status examination is really important. And actually you can do it even though it’s telepsychiatry. So you can use the note taking function on your video connection to have to write notes for your patient to see, like the commands and the mini mental status examination, the command part of it, drawing the the shapes and writing out the sentences so that all can be done and the patient can hold up the piece of paper, or the character can hold it up, or you can use the note taking function on the computer.

And another pro tip is whenever you are struggling communicating with the patient, you can sometimes write down simple instructions that they can read, assuming if their eyesight is good, they’re able to read. It can be a helpful thing for you to use written language to communicate as well. So whether it’s verbal or written, keep everything simple, just like I said before, and you should be able to communicate with most geriatric patients if you keep it simple, keep it slow, and just make sure that you are doing things in a way that the patient can understand.

Safety, Capacity, & Wrap-Up

Something that I think is very important in elderly patients is to make sure that you focus on safety. So understand whether the patient has a fall risk. Look at polypharmacy. Make sure that the medications are not causing undue side effects that could be risks to their safety. Make sure that the patient has access to their medications, and also make sure that the patient is being supported by family or caregivers. That’s really important, especially in cases where the patient has cognitive deficits.

At the end of the appointment is also an important time to recognize that geriatric telepsychiatry may require a little extra TLC than regular telepsychiatry. When the visit is concluding, make sure that you explain to the patient what you think in terms that they can understand, and have the patient repeat back to their understanding of what happened during the visit as far as the diagnosis, the medication plan. Just make sure that they understand as much as they can, and that the follow up plan is very clear.

The patient’s ability to rephrase and retain the information is going to speak to their capacity, and that’s something that we haven’t discussed yet. The capacity for the patient to make medical decisions, the capacity for them to follow through with the things that you’ve asked them to do. And so that’s not only a matter of the patient’s ability to understand, but their ability to to follow up with the directions and complete the things that are required of them for their treatment. And they may need some help with that. But assessing capacity is also really important during a geriatric telepsychiatry appointment.

And the patient’s capacity you assess throughout the entire appointment, are they able to answer your questions in an organized way? Are they able to follow directions, especially with the mini mental status exam? Are they able to communicate their concerns or do they have preferences in terms of their treatment. And this is really important in terms of capacity for all patients. Are they able to communicate a sustained choice? So all of these things are just as important in telepsychiatry as in-person psychiatry. And you can use the telepsychiatry appointment to assess their capacity.

Documentation Best Practices

Another aspect of telepsychiatry that’s really important is that you document. You document the patient’s capacity, you document the treatment plan, their mental status examination, document everything.That is something that you’re going to hear from me. I’m going to scold you guys on this podcast from time to time about failure to document, because if you don’t document, people are going to say that it didn’t happen. So let’s not find ourselves in court trying to explain ourselves. Let’s make it easy for everyone and document.

So documentation is really important and in telepsychiatry you want to make sure that you document that the patient was there for their appointment, their location where they oriented. Did they follow instructions? What about their cognitive impairment, depression, anxiety, some of the more common symptoms and signs of mental illness in geriatric patients. You want to document all of that. You want to document the safety plan, whether they’re going to have help with the plan, not just the safety plan, but the overall plan. So make sure to document everything that is pertinent and important.

Why Telepsychiatry is Superior for Geriatrics & Outro

So let’s end this episode by telling you a secret of telepsychiatry. The secret is to wait for it. telepsychiatry is better than in-person care. You know, we can debate whether it’s better or not as good, but I’m going to say it’s better because let me give you some examples.

With a geriatric patient, oftentimes when you’re doing telepsychiatry, you automatically talk with their caregiver. The caregiver is there. And that may not be the case necessarily in an in-person appointment. You also have access, like I’ve said before, to the patient’s environment, especially if they’re at their home. And I know I sound like a broken record here, but I want to emphasize that one more time. You can have them show you their pill bottles, see if their pill bottle is full. Maybe that means they’re not taking the medication. Maybe they can’t find their pill bottle. That’s another sign that they might not be taking their medication. So there are some advantages of telepsychiatry with elderly patients. Maybe you’re going to see in their environment that there are these horrible stairs that the patient has that there’s no way that the patient can walk up the stairs. Or maybe if they do, they’re going to be in danger. So you can see some of the dangers in their environment.

One of the most important advantages, probably the most important advantage, is that you don’t need the patient to travel with telepsychiatry. And that’s so important because what is one of the most common things about seeing an elderly patient? They might not be able to walk, their mobility might be impaired, and therefore it might be much harder for them to leave their homes, much harder to go in traffic, either driving or being driven by somebody going into an office where they’re exposed to other people and, and their illnesses. You know, of course, elderly patients are going to get sick faster. So does it really make sense to have them travel long distances and sit in waiting rooms with other sick people, exposing them to disease? No, it doesn’t make sense. Telepsychiatry is better for that. And so I want to highly encourage you to use telepsychiatry for geriatric patients, but to develop your skill set and pay attention to some of the important things that happen during the patient’s appointment.

So I hope today’s episode was helpful. I believe that all of The Telepsychiatry Advantage podcasts are helpful, and if you agree, please put in a five star review. Don’t give me a four star review. If you’re going to do that, just don’t review me at all, please. But in order for me to bring more people the benefit of The Telepsychiatry advantage, do me a quick favor and do a quick review. Five star review, and if you have some time, maybe put in a nice comment. But until next time, thanks so much and keep raising the standard.