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Background: Older adults are interested and able to complete video visits, but often require coaching and practice to succeed. Data show a widening digital divide between older and younger adults using video visits. We conducted a qualitative feasibility study to investigate these gaps via ethnographic methods, including a team member in older participants' homes. Methods: This ethnographic feasibility study included a virtual medication reconciliation visit with a clinical pharmacist for Veterans aged 65 and older taking 5 or more medications. An in‐home study team member joined the participant and recorded observations in structured fieldnotes derived from the Updated Consolidated Framework for Implementation Research and Age‐Friendly Health Systems. Fieldnotes included behind‐the‐scenes facilitators, barriers, and solutions to challenges before and during the visits. We conducted a thematic analysis of these observations and matched themes to implementation solutions from the Expert Recommendations for Implementing Change. Results: Twenty participants completed a video visit. Participants were 74 years old (range 68–80) taking 12 daily medications (range 7–24). Challenges occurred in half of the visits and took the in‐home team member and/or pharmacist an average of 10 minutes to troubleshoot. Challenges included notable new findings, such as that half of the participants required technology assistance for challenges that would not have been able to be solved by the pharmacist virtually. Furthermore, although many participants had a device or had used video visits before, some did not have a single device with video, audio, Internet, and access to their email username and password. Conclusions: Clinicians may apply these evidence‐based implementation solutions to their approach to video visits with older adults, including having a team member join the visit before the clinician, involving tech‐savvy family members, ensuring the device works with the visit platform ahead of time, and creating a troubleshooting guide from our common challenges. See related article by Allison et al. in this issue. [ABSTRACT FROM AUTHOR]

Background: Half of the 4.7 M veterans who reside in rural communities and rely on U.S. Department of Veterans Affairs (VA) health care are older (≥65). Their rurality presents unique challenges, including a shortage of clinicians skilled in geriatric medicine. Community‐based outpatient clinics (CBOCs) help extend VA's geographic reach but are typically located in under‐resourced settings. Telemedicine may increase access to care, but little is known about CBOCs' capacity to leverage telemedicine to meet older patients' needs. We identified organizational barriers and facilitators to the use of geriatric telemedicine specialty care from the perspective of rural clinicians and staff. Methods: From February–April 2020, we interviewed CBOC clinicians and staff (N = 50) from 13 rural CBOCs affiliated with four VA Geriatric Research Education and Clinical Centers. Semi‐structured interviews addressed patient population characteristics; CBOC location, staffing, and in‐house resources; use of VA specialty care services; and telemedicine use. We developed a codebook using an iterative process and Gale's Framework Method thematically organize and analyze data. Results: Respondents perceived that their CBOCs serve a predominantly older patient population. Four characteristics enabled CBOCs to offer geriatric telemedicine specialty care: partnerships with larger VA Medical Center teams; social worker/telehealth clinical technician knowledge of geriatrics and telehealth resources; periodic outreach/education from geriatric specialists; and routine use of other telehealth services. Barriers included: constraints on clinic space and unstable internet for telemedicine visits; staffing challenges leading to limited familiarity with telemedicine resources; and clinician and staff perceptions of older veterans' preference for in‐person visits. Conclusions: Telemedicine is an important modality to enhance access to care for an increasingly older and medically complex patient population. Although rural CBOCs provide a large portion of care to VA's growing geriatric population, staff are insufficiently trained in geriatrics, work in resource‐poor settings, and are largely unaware of VA telemedicine programs designed to support them. [ABSTRACT FROM AUTHOR]

Home and community-based services (HCBSs) such as home care and adult day centers are vital to supporting adults with dementia in community settings. We investigated whether HCBS use (use of both home care and adult day, use of one service, and use of neither service) varied between adults receiving care from three types of health-care teams with case management from social workers and nurses, and by comorbidity level, using 2019 data of 143,281 patients with dementia in the Veterans Health Administration. We compared HCBS use by patients' type of case-managed team (Home-Based Primary Care, geriatrics-based primary care, and dementia-focused specialty care) to patients in none of these teams, stratified by patients' non-dementia comorbidities (<4 or ≥4). Each type of health-care team was associated with both home care and adult day services, at each level of comorbidity. Home-Based Primary Care was most consistently associated with other forms of HCBS use, followed by Dementia Clinics and geriatrics-based primary care, for patients with ≥4 non-dementia comorbidities. Our findings suggest that case management in primary and specialty care settings is a contributor to the use of critical community supports by patients with the most complex needs. [ABSTRACT FROM AUTHOR]

Objectives: This pilot project aimed to explore a new model of healthcare delivery to older adult medically complex Veterans by combining telehealth technology with an interdisciplinary medical team operating in real time. Methods: The Geriatric-Interdisciplinary Mobile Patient Access Team (G-IMPACT) was comprised of a field team including a nurse practitioner and technology assistant who visited enrolled patients in their homes using synchronous video to link to a suite of geriatric specialists in a video-enabled room at a Veterans Affairs hospital. Clinicians interacted with patients, caregivers, and each other to develop mutually agreed upon treatment plans that were then immediately implemented in the field. Results: 11 total visits were conducted with 9 Veteran patients aged 55–91 (mean = 75.3 years). Both patients and clinicians reported a high level of satisfaction across multiple metrics, including visit quality, and positive indirect indicators of effectiveness were apparent from qualitative data. Conclusions: Nurse practitioner facilitated video visits allowed geriatric patients to meet with multiple specialists simultaneously with both high patient satisfaction and increased real-time care coordination. Clinical Implications: This project identified challenges and opportunities afforded by this type of real-time telehealth care delivery and can inform the development of future interdisciplinary mobile medical teams. [ABSTRACT FROM AUTHOR]

Quality dementia care, which recognizes caregivers as vital care partners, is a scarce resource. Innovative solutions like video telehealth may increase the reach of extant clinicians; however, little is known about perceived barriers and facilitators to in-home video telehealth for dementia management from the perspectives of caregivers. Twenty-four caregivers of community-dwelling Veterans with dementia participated in semi-structured interviews. Questions gathered perceived facilitators and barriers to in-home video telehealth for dementia management through experience with related technology. Transcripts were analyzed using directed content analysis which was guided by factors previously identified as influencing older adults' adoption of technology. Caregiver experience with related technology was mostly facilitative to video telehealth, which was thought best suited for follow-up care. Increased access and decreased patient-caregiver stress were potential benefits. Barriers included perceived limitations of video and the belief that persons with dementia would have limited ability to manage technological aspects and to engage in video telehealth on their own. This study improves our understanding of the factors that caregivers perceive as barriers and facilitators to in-home video telehealth for dementia management. Strategies to optimize video telehealth include capitalizing on caregivers' social network and providing targeted training. [ABSTRACT FROM AUTHOR]

Date Presented 03/22/24 This paper presents three cases from interviews with caregivers who assisted older rural clients in OT video sessions, describing a range of family caregiver perspectives. Primary Author and Speaker: Megan E. Gately Additional Authors and Speakers: Dylan E. Waller, Matthew Maynard, Lauren R. Moo [ABSTRACT FROM AUTHOR]

Dementia is a syndrome characterized by cognitive changes which interfere with daily functioning. Neuropsychiatric symptoms (NPS) are also pervasive and may even occur prior to any noticeable cognitive decline. Still, NPS are less associated with the early stages of the disease course, despite mounting research evidence that NPS present early and often in several dementia syndromes, even in the absence of cognitive decline (i.e., mild behavioral impairment [MBI]). Primary care teams are at the forefront of dementia care, yet they frequently report insufficient training in dementia diagnosis and management. This poses a serious problem considering that timely diagnosis of dementia is critical for optimal outcomes and maximum efficacy of intervention. We provide a concise narrative review of four dementia syndromes (Alzheimer's disease, vascular dementia, dementia with Lewy bodies, and behavioral variant frontotemporal dementia) and their associated neuropsychiatric presentations, as well as at‐a‐glance clinical guides, to help primary care team members recognize possible prodromal neurodegenerative disease and to prompt further workup. We also review next steps in the management of dementia and symptoms of MBI for primary care team members. As evidenced by the NPS profiles of these dementia syndromes, subacute new onset of psychiatric symptoms in an older adult should prompt consideration of an emerging dementia process and possible further workup of such, even in the absence of cognitive decline. [ABSTRACT FROM AUTHOR]

Background: The COVID‐19 pandemic and consequent protective measures, including quarantines reduced or eliminated access to supports for dementia CGs. Dementia CGs have also reported increases in behavioral problems and decreases in cognition for the person with dementia (PWD) during the pandemic. We collected data on the impact of COVID‐19 on dementia CGs. Method: CGs of PWD enrolled in a telehealth intervention were interviewed via video. At baseline, CGs completed The Caregiver COVID‐19 Limitations Scale. During interviews, CGs responses to questions about COVID‐19 related concerns and spontaneous discussion of concerns were recorded in field notes. Result: Most CGs had a low level of concern that they would contract COVID‐19, but a slightly higher level of concern about the PWD. Several CGs reported at least a moderate impact of COVID‐19 related limitations on getting respite care (37.5%), leaving the house (50%), having outside visitors (25%), and gaining access to healthcare (25%). A quarter of CGs noticed at least a moderate change in the PWDs behavior. CGs also noticed cognitive decline. CGs felt changes were due to isolation, boredom, and depressive‐like symptoms. Caregivers also noted the loss of pleasurable activities they could engage in both alone and together with the PWD. A quarter of CGs also reported a great deal of difficulty explaining COVID‐19 related restrictions to the PWD. Specifically, memory loss experienced by the PWD necessitated frequent reminders about COVID‐19 and related limitation Conclusion: Our results are consistent with literature demonstrating reduction in CG access to respite care and other supportive services during the pandemic. CGs noted declines in cognition and increases in neuropsychiatric symptoms in the PWD perceived to be due to isolation and lack of stimulation. CGs lacked access to previously enjoyable activities outside the home. CG noted the additional burden of lack of a shared pandemic experience due to memory loss that necessitated reminders about the pandemic and associated safety measures. In conclusion, dementia caregivers grapple with lost supports that increase burden, with simultaneously increases in perceived cognitive and behavioral problems in the PWD along with new pandemic‐specific burdens. Our findings underscore the necessity for increased dementia CG programming. [ABSTRACT FROM AUTHOR]

Telehealth and telemedicine have encountered explosive growth since the beginning of the COVID-19 pandemic, resulting in increased access to care for patients located far from medical centers and clinics. Subspecialty clinicians in behavioral neurology & neuropsychiatry (BNNP) have implemented the use of telemedicine platforms to perform cognitive examinations that were previously office based. In this perspective article, BNNP clinicians at Massachusetts General Hospital (MGH) describe their experience performing cognitive examinations via telemedicine. The article reviews the goals, prerequisites, advantages, and potential limitations of performing a video- or telephone-based telemedicine cognitive examination. The article shares the approaches used by MGH BNNP clinicians to examine cognitive and behavioral areas, such as orientation, attention and executive functions, language, verbal learning and memory, visual learning and memory, visuospatial function, praxis, and abstract abilities, as well as to survey for neuropsychiatric symptoms and assess activities of daily living. Limitations of telemedicine-based cognitive examinations include limited access to and familiarity with telecommunication technologies on the patient side, limitations of the technology itself on the clinician side, and the limited psychometric validation of virtual assessments. Therefore, an in-person examination with a BNNP clinician or a formal in-person neuropsychological examination with a neuropsychologist may be recommended. Overall, this article emphasizes the use of standardized cognitive and behavioral assessment instruments that are either in the public domain or, if copyrighted, are nonproprietary and do not require a fee to be used by the practicing BNNP clinician., Competing Interests: Dr. Camprodon has served on the scientific advisory boards for Hyka and Flow Neuroscience, and she has served as a consultant for Mifu Technologies and Neuroelectrics. Dr. Newhouse has served as a consultant for Musculo. Dr. Perez has received honoraria for continuing medical education lectures; he has received royalties from Springer Nature; he serves on the editorial boards of Brain and Behavior, Epilepsy & Behavior, and The Journal of Neuropsychiatry and Clinical Neurosciences; and he has received funding from NIH and the Sidney R. Baer Jr. Foundation. Dr. Razafsha is a shareholder with Masimo Corporation. Dr. Schmahmann is site principal investigator for Biohaven (NCT03701399, NCT02960893, and NCT03952806); he has received royalties from Elsevier, MacKeith Press, Oxford University Press, and Springer; and he holds a license with the General Hospital Corporation for the Brief Ataxia Rating Scale, the Cerebellar Cognitive Affective/Schmahmann syndrome scale, the Cerebellar Neuropsychiatry Rating Scale, and the Patient-Reported Outcome Measure of Ataxia. The other authors report no financial relationships with commercial interests.