- Email: [email protected]
CHALLENGING BEHAVIORS ON INPATIENT MEDICAL UNITS: INTEGRATED, NON-PHARMACOLOGICAL APPROACH FOR PATIENTS WITH DEMENTIA
AAGP Annual Meeting 2019 third parties that may be communicating with patients. However, patients increasingly recognized that data from their digital lives can enhance the quality of care. Our initial feasibility study with a 77-year-old man illustrated the importance of incorporating patient feedback into study design and procedure. Our feasibility study also indicates that patients may be more willing to share private electronic media directly with physicians, rather than unrelated third parties. This research was funded by: This work is supported by the Once Upon a Time Foundation
Poster Number: LB - 11
MINDFULNESS-BASED ART PSYCHOTHERAPY GROUP FOR OLDER ADULTS USING DIGITAL TOOLS Elaine Hawkes1; Hannah Heintz1; Brent Forester1,2; Ipsit Vahia1,2 1
McLean Hospital Harvard Medical School
2
Introduction: Art therapy is effective for older adults by stimulating cognitive processes, helping to externalize and express emotions, and creating the potential for meaningful activity. Mindfulness has been shown to improve working memory and focus, and enhance integration of verbal and nonverbal processing. Phototherapy involves taking, viewing, manipulating, and interpreting photographs as a therapeutic process. Because of its relatively easy accessibility, spontaneity, and the ability to easily correct errors, phototherapy is an especially approachable form of art therapy compared to painting or drawing. The explosion of digital tools for phototherapy in the past 5 years offers the capability to maximize the potential of this modality by facilitating combination of both mindfulness and phototherapy for exponential treatment impact. In this study we report preliminary findings from a digital phototherapy-based mindfulness group in the SAGE program within the Division of Geriatric Psychiatry at McLean. The primary objective of this study was to assess the feasibility and qualitative effectiveness of a mindfulness-based phototherapy group for older adults experiencing anxiety and depression. Methods: This was an observational pilot study of a 13-week group of 4 older women. Each session was 60 minutes long, which was later expanded to 75 minutes to allow times for mindfulness exercises and group sharing. Each participant learned how to take pictures and use the MyMoments, Union, Fuse, & Collage apps on their iPhone and iPad. Effectiveness was evaluated both qualitatively and quantitatively, by collecting unstructured participant feedback at Week 13 and administering the Rosenburg Self-Esteem Scale (RSES) and the Day to Day Experiences Scale at baseline and Week 13. Results: We demonstrated that an approach combining digital phototherapy with mindfulness is feasible and possible to implement in a group of older adults. We also demonstrated the feasibility of teaching this cohort the use of apps for phototherapy in a group setting. While we did not conduct quantitative analysis of intervention efficacy, we noted 3 out of 4 patients scored higher on the Day to Day Experiences Scale at Week 13 compared to baseline; in addition, on the RSES at Week 13, participants endorsed statements indicative of higher self-esteem compared to baseline. Qualitative feedback indicated that participants felt a sense of mastery and continued interest in both mindfulness and phototherapy practices. Conclusions: Our preliminary study points to the vast potential of incorporating technologies to accelerate and expand the process of art therapies such as phototherapy. Our findings bear replication and quantitative validation but point to the possibility of improving self-esteem and mindfulness skills in older adults. They may also serve as a model of how to incorporate digital tools into the process of clinical care in group and individual settings. This research was funded by: This study was supported by the McLean Hospital Division of Geriatric Psychiatry.
Poster Number: LB - 12
CHALLENGING BEHAVIORS ON INPATIENT MEDICAL UNITS: INTEGRATED, NON-PHARMACOLOGICAL APPROACH FOR PATIENTS WITH DEMENTIA Kurtis Kaminishi1; Elizabeth Sutherland2; Erica Youngblood2; Jessica Capistrano2; Linda Tseng2 1
San Francisco VA / UCSF San Francisco VA
2
Introduction: Inpatient medical care is a critical hospital function, but is costly and associated with risks to both patients and staff. Patients often demonstrate behavioral problems that interfere with care, prolong length of hospitalization, increase
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AAGP Annual Meeting 2019 utilization of resources, delay discharge, and even lead to staff injury. To address these challenges, the San Francisco VA Health Care System (SFVAHCS) developed the Behavioral Education and Support Team (BEST). This team is comprised of psychiatry, psychology, nursing, and occupational therapy staff. BEST provides support, education, and interventions to patients who are engaging in treatment interfering behaviors. Goals include reducing risk to patients and staff, improving treatment adherence, reducing utilization of resources, shortening length of stay, and facilitating discharge. BEST staff also collaborate with inpatient staff to develop and consistently implement behavioral treatment plans. Since implementation in October 2015 to March 2018, BEST has served 488 veteran patients. Data demonstrate that BEST is associated with a 40% reduction in staff injuries in acute medicine settings, a 42% reduction in emergency psychiatric codes, and a 25% reduction in formal inpatient setting complaints. In addition, it is estimated that BEST reduces inpatient costs due to improved time to discharge and reduced staffing turnover and work loss due to injury. This presentation will provide an overview of the BEST team function and outcomes. Given the critical nature and high costs of inpatient medical care, the SFVAHCS determined that investment in a dedicated team to address these problems would be justified by reducing utilization of resources, length of hospitalization, overall cost, and adverse patient and staff outcomes. Methods: The BEST team was initially implemented as a behavioral consultation team for inpatient medical patients in October, 2015, and was comprised of 5 members: A RN team coordinator A part-time psychiatrist (.2 FTE) A psychologist An RN team member An Occupational Therapist The data from the BEST consultations between October 2015 and March 2018 were reviewed, and analyzed. Analysis of data included identification of total number of consultations, average age of patients, marital status, discharge status, themes for admission, days in hospital, presence of psychiatric disorder, dementia, serious mental illness, staff injury frequency, frequency of emergent psychiatric code calls, frequency of formal inpatient complaints. Results: Since initiation in October, 2015, the BEST program has served 488 patients. Complex geriatric patient accounted for 78.7%. As of July, 2017, the majority of veterans served had a psychiatric disorder or need, including depression (50%), dementia (26%), delirium (21%), serious mental illness (18%), and suicidal ideation (10%). Adherence to treatment was a target problem in 56% of those referred. Specific Outcomes: 40% reduction in staff injuries among acute medicine staff 42% reduction in emergency psychiatric code calls 25% reduction in formal inpatient complaints. In addition, a conservative estimate suggests that improving compliance with treatment and reducing length of stay by 1 day per non-compliance referral, extrapolated to the current time point, would generate a savings of approximately $835,000. In addition, inpatient nursing staff report a subjective increase in morale and perception of competence for coping with behavioral disruptions. Consult Summary (October 2015 to March 2018) 488 Consults Average Age 69 (youngest 29 to oldest 101 466 Males and 22 Females Marital Status − 156 Never Married; 96 Married; 18 Separated; 181 Divorced; 33 Widowed; 4 Unknown Discharge Status − 11 Against Medical Advice; 10 Died; 4 Homeless; 87 Skilled Nursing Facilities; 219 Home/Board & Care/Shelters; 31 Mental Health Rehabilitation; 83 Long-Term Care; 35 Unknown; 8 Acute Hospital Themes for Admission − 55 Altered Mental Status; 43 Failure to Thrive; 28 Placement Issues; 15 Falls; 68 Pain; 39 Shortness of Breath Days in the Hospital: 13,827 Total days in the hospital 7,218 Days in the hospital awaiting placement after being cleared by medical team $28 Million − cost awaiting placement Conclusions: Since implementation of the BEST team at the SFVA Medical Center, data reveal overall reduction in utilization of resources, length of hospitalizations, overall costs, and adverse patient and staff outcomes. Specifically: 1. A dedicated behavioral team can significantly improve the experience of inpatient nursing staff, reducing injuries, improving morale, reducing staff turnover and burnout.
Am J Geriatr Psychiatry 27:3S, March 2019
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AAGP Annual Meeting 2019 2. A behavioral intervention team can significantly reduce psychiatric codes and patient complaints, while improving clinical outcomes and patient satisfaction. 3. Reductions in staff injuries and improvements in treatment adherence can recoup costs for team staffing. 4. Reducing risk factors for disruptive behaviors reduces overall costs to the system and overutilization of resources. This research was funded by: Funded through the San Francisco VA
Poster Number: LB - 13
THE APPLICATION OF VIRTUAL REALITY IN GERIATRIC MENTAL HEALTH: THE STATE OF THE EVIDENCE Liana Mathias1; Aniqa Rahman1; Miranda Skurla1; Ipsit Vahia1,2 1
McLean Hospital Harvard Medical School
2
Introduction: In recent years, there has been a rise in the prevalence of cognitive and affective disorders in the ageing population. This has led to an impetus on innovative, scalable and engaging interventions for these disorders, and technology has proved to be a promising frontier. In the past decade, virtual reality (VR) technology has seen a shift from two-dimensional non-immersive projections to three-dimensional fully immersive experiences, allowing for the development of more sophisticated simulations. There have been successful applications of VR in clinical settings with children and teens, including social cognition training for autism, sustained attention in attention-deficit hyperactivity disorder (ADHD), exposure-based therapies for anxiety disorders, and depression pathology. However, VR has been less studied in the geriatric population. The purpose of this study is to determine the existing levels of evidence for use of VR in clinical settings and identify areas where more evidence may guide translation of existing VR interventions for older adults. Methods: This study is a systematic review. We conducted a search on PubMed in December 2018 for peer-reviewed journal articles published in English within the last 10 years. We narrowed the search to VR technology and its applications in older adults, as well as studies of VR in normal aged adults for comparative value. We rejected articles if the title and abstract did not meet inclusion criteria and authors LM, AR and MS agreed by consensus on which articles were relevant. We also used the bibliographies of selected articles to find additional articles that we may have missed in the initial search. We then reviewed article content to classify the articles into appropriate domains of geriatric mental health (content domains) and research objectives (research domains). Results: Based on our review, a total number of 426 articles were found, and 49 met our inclusion criteria related to older adults. We conducted a yearly count for the number of search results to identify if there has been an increase in research in the field. The number of search results by year are positively correlated (see Figure 1). We also identified 5 additional articles which focused on younger adults which we opted to include in the review based on internal consensus amongst all authors that they reflected VR application in domains of mental health that are known to apply to older adults as well. We found that the articles fell across several content domains: Cognition, conditions along the mood spectrum, anxiety, post-traumatic stress disorder (PTSD), and caregiver burden. The research domain with the highest number of articles was VR validity testing (26), followed by cognitive training (18), indicating that these are the VR applications for which the best evidence exists currently. Conclusions: Currently, existing evidence offers clear support for the use of VR as a screening tool for cognitive impairment in older adults, and as a training tool to improve cognitive skills. VR-based tasks demonstrated validity comparable to some traditional paper-based assessments of cognition. Furthermore, there are indications that VR can play a role in delaying the onset of Alzheimer’s Disease (AD), mild cognitive impairment (MCI), and other forms of dementia. More work is needed to refine VR screening capabilities for more specific diagnoses, but the potential for innovation in VR environments and tasks makes VR a promising medium to achieve this specificity. Additionally, there were many different VR environments used across studies, which may show a need for standardization of environments before comparisons can be made between VR simulations. Given the robust evidence of VR as a treatment in affective disorders in younger adults, we see potential for the same intervention in older adult mood spectrum disorders and other psychiatric conditions. Finally, future studies should address key issues surrounding VR use in clinical settings, such as usability, data privacy, and confidentiality. This research was funded by: Anonymous philanthropic donation to McLean Hospital.
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Poster Number: LB - 11
MINDFULNESS-BASED ART PSYCHOTHERAPY GROUP FOR OLDER ADULTS USING DIGITAL TOOLS Elaine Hawkes1; Hannah Heintz1; Brent Forester1,2; Ipsit Vahia1,2 1
McLean Hospital Harvard Medical School
2
Introduction: Art therapy is effective for older adults by stimulating cognitive processes, helping to externalize and express emotions, and creating the potential for meaningful activity. Mindfulness has been shown to improve working memory and focus, and enhance integration of verbal and nonverbal processing. Phototherapy involves taking, viewing, manipulating, and interpreting photographs as a therapeutic process. Because of its relatively easy accessibility, spontaneity, and the ability to easily correct errors, phototherapy is an especially approachable form of art therapy compared to painting or drawing. The explosion of digital tools for phototherapy in the past 5 years offers the capability to maximize the potential of this modality by facilitating combination of both mindfulness and phototherapy for exponential treatment impact. In this study we report preliminary findings from a digital phototherapy-based mindfulness group in the SAGE program within the Division of Geriatric Psychiatry at McLean. The primary objective of this study was to assess the feasibility and qualitative effectiveness of a mindfulness-based phototherapy group for older adults experiencing anxiety and depression. Methods: This was an observational pilot study of a 13-week group of 4 older women. Each session was 60 minutes long, which was later expanded to 75 minutes to allow times for mindfulness exercises and group sharing. Each participant learned how to take pictures and use the MyMoments, Union, Fuse, & Collage apps on their iPhone and iPad. Effectiveness was evaluated both qualitatively and quantitatively, by collecting unstructured participant feedback at Week 13 and administering the Rosenburg Self-Esteem Scale (RSES) and the Day to Day Experiences Scale at baseline and Week 13. Results: We demonstrated that an approach combining digital phototherapy with mindfulness is feasible and possible to implement in a group of older adults. We also demonstrated the feasibility of teaching this cohort the use of apps for phototherapy in a group setting. While we did not conduct quantitative analysis of intervention efficacy, we noted 3 out of 4 patients scored higher on the Day to Day Experiences Scale at Week 13 compared to baseline; in addition, on the RSES at Week 13, participants endorsed statements indicative of higher self-esteem compared to baseline. Qualitative feedback indicated that participants felt a sense of mastery and continued interest in both mindfulness and phototherapy practices. Conclusions: Our preliminary study points to the vast potential of incorporating technologies to accelerate and expand the process of art therapies such as phototherapy. Our findings bear replication and quantitative validation but point to the possibility of improving self-esteem and mindfulness skills in older adults. They may also serve as a model of how to incorporate digital tools into the process of clinical care in group and individual settings. This research was funded by: This study was supported by the McLean Hospital Division of Geriatric Psychiatry.
Poster Number: LB - 12
CHALLENGING BEHAVIORS ON INPATIENT MEDICAL UNITS: INTEGRATED, NON-PHARMACOLOGICAL APPROACH FOR PATIENTS WITH DEMENTIA Kurtis Kaminishi1; Elizabeth Sutherland2; Erica Youngblood2; Jessica Capistrano2; Linda Tseng2 1
San Francisco VA / UCSF San Francisco VA
2
Introduction: Inpatient medical care is a critical hospital function, but is costly and associated with risks to both patients and staff. Patients often demonstrate behavioral problems that interfere with care, prolong length of hospitalization, increase
S172
Am J Geriatr Psychiatry 27:3S, March 2019
AAGP Annual Meeting 2019 utilization of resources, delay discharge, and even lead to staff injury. To address these challenges, the San Francisco VA Health Care System (SFVAHCS) developed the Behavioral Education and Support Team (BEST). This team is comprised of psychiatry, psychology, nursing, and occupational therapy staff. BEST provides support, education, and interventions to patients who are engaging in treatment interfering behaviors. Goals include reducing risk to patients and staff, improving treatment adherence, reducing utilization of resources, shortening length of stay, and facilitating discharge. BEST staff also collaborate with inpatient staff to develop and consistently implement behavioral treatment plans. Since implementation in October 2015 to March 2018, BEST has served 488 veteran patients. Data demonstrate that BEST is associated with a 40% reduction in staff injuries in acute medicine settings, a 42% reduction in emergency psychiatric codes, and a 25% reduction in formal inpatient setting complaints. In addition, it is estimated that BEST reduces inpatient costs due to improved time to discharge and reduced staffing turnover and work loss due to injury. This presentation will provide an overview of the BEST team function and outcomes. Given the critical nature and high costs of inpatient medical care, the SFVAHCS determined that investment in a dedicated team to address these problems would be justified by reducing utilization of resources, length of hospitalization, overall cost, and adverse patient and staff outcomes. Methods: The BEST team was initially implemented as a behavioral consultation team for inpatient medical patients in October, 2015, and was comprised of 5 members: A RN team coordinator A part-time psychiatrist (.2 FTE) A psychologist An RN team member An Occupational Therapist The data from the BEST consultations between October 2015 and March 2018 were reviewed, and analyzed. Analysis of data included identification of total number of consultations, average age of patients, marital status, discharge status, themes for admission, days in hospital, presence of psychiatric disorder, dementia, serious mental illness, staff injury frequency, frequency of emergent psychiatric code calls, frequency of formal inpatient complaints. Results: Since initiation in October, 2015, the BEST program has served 488 patients. Complex geriatric patient accounted for 78.7%. As of July, 2017, the majority of veterans served had a psychiatric disorder or need, including depression (50%), dementia (26%), delirium (21%), serious mental illness (18%), and suicidal ideation (10%). Adherence to treatment was a target problem in 56% of those referred. Specific Outcomes: 40% reduction in staff injuries among acute medicine staff 42% reduction in emergency psychiatric code calls 25% reduction in formal inpatient complaints. In addition, a conservative estimate suggests that improving compliance with treatment and reducing length of stay by 1 day per non-compliance referral, extrapolated to the current time point, would generate a savings of approximately $835,000. In addition, inpatient nursing staff report a subjective increase in morale and perception of competence for coping with behavioral disruptions. Consult Summary (October 2015 to March 2018) 488 Consults Average Age 69 (youngest 29 to oldest 101 466 Males and 22 Females Marital Status − 156 Never Married; 96 Married; 18 Separated; 181 Divorced; 33 Widowed; 4 Unknown Discharge Status − 11 Against Medical Advice; 10 Died; 4 Homeless; 87 Skilled Nursing Facilities; 219 Home/Board & Care/Shelters; 31 Mental Health Rehabilitation; 83 Long-Term Care; 35 Unknown; 8 Acute Hospital Themes for Admission − 55 Altered Mental Status; 43 Failure to Thrive; 28 Placement Issues; 15 Falls; 68 Pain; 39 Shortness of Breath Days in the Hospital: 13,827 Total days in the hospital 7,218 Days in the hospital awaiting placement after being cleared by medical team $28 Million − cost awaiting placement Conclusions: Since implementation of the BEST team at the SFVA Medical Center, data reveal overall reduction in utilization of resources, length of hospitalizations, overall costs, and adverse patient and staff outcomes. Specifically: 1. A dedicated behavioral team can significantly improve the experience of inpatient nursing staff, reducing injuries, improving morale, reducing staff turnover and burnout.
Am J Geriatr Psychiatry 27:3S, March 2019
S173
AAGP Annual Meeting 2019 2. A behavioral intervention team can significantly reduce psychiatric codes and patient complaints, while improving clinical outcomes and patient satisfaction. 3. Reductions in staff injuries and improvements in treatment adherence can recoup costs for team staffing. 4. Reducing risk factors for disruptive behaviors reduces overall costs to the system and overutilization of resources. This research was funded by: Funded through the San Francisco VA
Poster Number: LB - 13
THE APPLICATION OF VIRTUAL REALITY IN GERIATRIC MENTAL HEALTH: THE STATE OF THE EVIDENCE Liana Mathias1; Aniqa Rahman1; Miranda Skurla1; Ipsit Vahia1,2 1
McLean Hospital Harvard Medical School
2
Introduction: In recent years, there has been a rise in the prevalence of cognitive and affective disorders in the ageing population. This has led to an impetus on innovative, scalable and engaging interventions for these disorders, and technology has proved to be a promising frontier. In the past decade, virtual reality (VR) technology has seen a shift from two-dimensional non-immersive projections to three-dimensional fully immersive experiences, allowing for the development of more sophisticated simulations. There have been successful applications of VR in clinical settings with children and teens, including social cognition training for autism, sustained attention in attention-deficit hyperactivity disorder (ADHD), exposure-based therapies for anxiety disorders, and depression pathology. However, VR has been less studied in the geriatric population. The purpose of this study is to determine the existing levels of evidence for use of VR in clinical settings and identify areas where more evidence may guide translation of existing VR interventions for older adults. Methods: This study is a systematic review. We conducted a search on PubMed in December 2018 for peer-reviewed journal articles published in English within the last 10 years. We narrowed the search to VR technology and its applications in older adults, as well as studies of VR in normal aged adults for comparative value. We rejected articles if the title and abstract did not meet inclusion criteria and authors LM, AR and MS agreed by consensus on which articles were relevant. We also used the bibliographies of selected articles to find additional articles that we may have missed in the initial search. We then reviewed article content to classify the articles into appropriate domains of geriatric mental health (content domains) and research objectives (research domains). Results: Based on our review, a total number of 426 articles were found, and 49 met our inclusion criteria related to older adults. We conducted a yearly count for the number of search results to identify if there has been an increase in research in the field. The number of search results by year are positively correlated (see Figure 1). We also identified 5 additional articles which focused on younger adults which we opted to include in the review based on internal consensus amongst all authors that they reflected VR application in domains of mental health that are known to apply to older adults as well. We found that the articles fell across several content domains: Cognition, conditions along the mood spectrum, anxiety, post-traumatic stress disorder (PTSD), and caregiver burden. The research domain with the highest number of articles was VR validity testing (26), followed by cognitive training (18), indicating that these are the VR applications for which the best evidence exists currently. Conclusions: Currently, existing evidence offers clear support for the use of VR as a screening tool for cognitive impairment in older adults, and as a training tool to improve cognitive skills. VR-based tasks demonstrated validity comparable to some traditional paper-based assessments of cognition. Furthermore, there are indications that VR can play a role in delaying the onset of Alzheimer’s Disease (AD), mild cognitive impairment (MCI), and other forms of dementia. More work is needed to refine VR screening capabilities for more specific diagnoses, but the potential for innovation in VR environments and tasks makes VR a promising medium to achieve this specificity. Additionally, there were many different VR environments used across studies, which may show a need for standardization of environments before comparisons can be made between VR simulations. Given the robust evidence of VR as a treatment in affective disorders in younger adults, we see potential for the same intervention in older adult mood spectrum disorders and other psychiatric conditions. Finally, future studies should address key issues surrounding VR use in clinical settings, such as usability, data privacy, and confidentiality. This research was funded by: Anonymous philanthropic donation to McLean Hospital.
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Am J Geriatr Psychiatry 27:3S, March 2019