CADENZA Symposium 2009 CADENZA Symposium 2009 The Primary Care Approach to The Primary Care Approach to Psychological Problems in the Psychological Problems in the Elderly: From Screening to Elderly: From Screening to Problem-solving Problem-solving Cindy LK Lam, Cindy LK Lam, [email protected][email protected]Weng Y Chin, Tai Pong Lam, Yvonne YC Lo, Weng Y Chin, Tai Pong Lam, Yvonne YC Lo, FMU FMU Peter WH Lee, Department of Psychiatry, Peter WH Lee, Department of Psychiatry, Daniel YT Fong, Department of Nursing Daniel YT Fong, Department of Nursing Studies Studies The University of Hong Kong The University of Hong Kong
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CADENZA Symposium 2009 The Primary Care Approach to Psychological Problems in the Elderly: From Screening to Problem-solving Cindy LK Lam, [email protected].
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CADENZA Symposium 2009CADENZA Symposium 2009
The Primary Care Approach to The Primary Care Approach to Psychological Problems in the Elderly: Psychological Problems in the Elderly:
From Screening to Problem-solvingFrom Screening to Problem-solving
Cindy LK Lam, Cindy LK Lam, [email protected]@hku.hkWeng Y Chin, Tai Pong Lam, Yvonne YC Lo, FMUWeng Y Chin, Tai Pong Lam, Yvonne YC Lo, FMU
Peter WH Lee, Department of Psychiatry, Peter WH Lee, Department of Psychiatry, Daniel YT Fong, Department of Nursing StudiesDaniel YT Fong, Department of Nursing Studies
The University of Hong KongThe University of Hong Kong
AcknowledgmentAcknowledgment
HCPF (# 218016), Food and Health Bureau, the HCPF (# 218016), Food and Health Bureau, the Government of the HKSARGovernment of the HKSAR
Ethics Committee, Faculty of Medicine, the Ethics Committee, Faculty of Medicine, the University of Hong Kong (EC 1293-99).University of Hong Kong (EC 1293-99).
Dr. Stephen WK Chow, Dr. Kevin KL Pang, Dr. Dr. Stephen WK Chow, Dr. Kevin KL Pang, Dr. Johnny CY Lam, Dr. Sam CS Au, Dr. Jacky HH Sze Johnny CY Lam, Dr. Sam CS Au, Dr. Jacky HH Sze and Dr. Brigitte E Schlaikier who provided PST-PC and Dr. Brigitte E Schlaikier who provided PST-PC
Ms. On-On Cheng and Alice OL Cheung for co-Ms. On-On Cheng and Alice OL Cheung for co-ordination of data collection and analysisordination of data collection and analysis
Psychological Problems in the Psychological Problems in the Elderly in Primary CareElderly in Primary Care
From Screening to Problem-solvingFrom Screening to Problem-solving Challenges & opportunities in PC Challenges & opportunities in PC Study on screening & brief PST- PC for Study on screening & brief PST- PC for
elderly with screened positive elderly with screened positive psychological problems psychological problems
Implications for clinical practice & future Implications for clinical practice & future researchresearch
Challenges : Tip of the Iceberg Poverty (1/5 on CSSA) & ill-health (2/3
chronically ill) Suicide rate (32/100,000, 2004) of HK
elderly is second highest in the world 86% victims had psychiatric problems Elderly population survey prevalence
19% screened positive of depression 5% known psychological problems 0.4% known depression
Opportunities in PC 77% consulted within 1 month before
suicide 85% of elderly consulted at least once/yr Mean 5-8 consultations/yr Continuity of care Trusting doctor-patient relationship Whole-person care 20% elderly had psychological problems
150 randomized to 3 x placebo 132 attended ≥1 video session
Study Instruments
Screening by Hospital Anxiety & Depression Scale (HADS): positive if anxiety score ≥3 or depression score ≥6
The MOS SF-36 Health Survey on HRQOL (PCS & MCS)
Structured Q. on monthly consultation rates, sociodemography & co-morbidity
PST-PC record form
Intervention: PST-PC
Three 3-hour training workshops for FM residents 3 structured brief PST-PC sessions (20-45 min)
Establish rapport Identify any psychiatric diagnosis Patient identifies & prioritize problems Patient to think of possible solutions for main problem Suggest more solutions List advantages and disadvantages of each solution Prioritize solutions Settle on the preferred solution: break it down into steps Patient is to work on the first step of the solution
Key FindingsKey Findings UPPE were important: common, impair UPPE were important: common, impair
QOL & increase consultation QOL & increase consultation Screening increased detection, target >2 Screening increased detection, target >2
chronic diseases & married females chronic diseases & married females Majority did not meet DSM IV criteriaMajority did not meet DSM IV criteria Family, health & finance problems Family, health & finance problems Solutions required changes Solutions required changes Brief PST-PC had short-term benefits Brief PST-PC had short-term benefits Group viewing of video improved QOLGroup viewing of video improved QOL
Limited Benefit of Brief PST-PC Limited Benefit of Brief PST-PC Quality of PST: assured in that tasks were Quality of PST: assured in that tasks were
achieved in >80% sessions on random reviewachieved in >80% sessions on random review Many elderly could not identify problem/ solutionMany elderly could not identify problem/ solution 3 sessions of PST-PC were not sufficient?3 sessions of PST-PC were not sufficient? Lack of motivation?Lack of motivation? Milder problems less responsive to treatment? Milder problems less responsive to treatment? Cultural factors?Cultural factors? The placebo intervention was too powerful?The placebo intervention was too powerful?
Implications for Clinical Practice & Future Research
Need for PC-relevant diagnostic taxonomy Psychological diagnosis & treatment cannot be
separated from physical & social problems Little indications for drugs A multi-disciplinary system approach integrated
with routine PC Family interventions are needed The family doctor’s role in detection, motivation,
co-ordination & maintenance
Primary Care for HK…the way forwardPrimary Care for HK…the way forwardThursday, 15 Oct 2009 2:00 – 4:30 pm
Officiating Guests of HonourDr York Chow, Secretary for Food and Health, Professor Raymond Liang, President, HKAM
Keynote by Prof. Barbara Starfield“Measuring Primary Care & Its Benefits”
Forum Discussion
Cheung Kung Hai Conference Centre L.K.S. Faculty of Medicine, HKU
21 Sassoon Rd, HK. www.hku.hk/fmunit
PublicationsPublications Lam CLK, Lee PWH, Fong DYT, Lam TP.Lam CLK, Lee PWH, Fong DYT, Lam TP. A randomised A randomised
controlled trial on the effectiveness of screening and brief controlled trial on the effectiveness of screening and brief problem-solving counselling for elderly patients with problem-solving counselling for elderly patients with undiagnosed psychological problems in primary care. H K Med undiagnosed psychological problems in primary care. H K Med J 2008; 14(6) Suppl: 31-35.J 2008; 14(6) Suppl: 31-35.
Lam CLK, Chin WY, Lee PWH, Lo YYC, Fong DYT, Lam TP.Lam CLK, Chin WY, Lee PWH, Lo YYC, Fong DYT, Lam TP. Unrecognized psychological problems impair quality of life Unrecognized psychological problems impair quality of life and increase consultation rates in Chinese elderly patients. and increase consultation rates in Chinese elderly patients. Int J Geriatr Psychiatry 2009; 24:979-989.Int J Geriatr Psychiatry 2009; 24:979-989.
Lam CLK, Fong DYT, Chin WY, Lee PWH, Lam ETP, Lo YYC.Lam CLK, Fong DYT, Chin WY, Lee PWH, Lam ETP, Lo YYC. Brief Problem-solving Treatment in Primary Care (PST-PC) Brief Problem-solving Treatment in Primary Care (PST-PC) Was Not More Effective than Placebo for Elderly Patients Was Not More Effective than Placebo for Elderly Patients Screened - Positive of Psychological Problems.Screened - Positive of Psychological Problems. Int J Geriatr Int J Geriatr Psychiatry (in press)Psychiatry (in press)
HRQOL by HADS ClassificationMean (SD) SF-36 Scores
PF RP BP GH VT SF RE MH PCS MCS
All n=1853
76.9(19.6
)73.1
(38.9)74.9 (28.3)
61.6 (22.7)
70.97 (21.8)
89.1 (22.4)
85.2 (32.8
)83.6
(17.9)41.5
(12.1)59.1( 9.9)
HADS +ven=482
67.9 (22.4
)
52.7 (43.3)
61.4 (31.2)
47.3(23.4)
55.1 (21.5)
76.4 (29.8)
63.2 (44.3
)
66.7 (20.9)
35.6 (13.4)
50.7 (12.4)
HADS -ven=1371
80.1(17.4
)
80.3 (34.5)
79.6(25.6)
66.6(20.2)
76.6(18.9)
93.6(16.9)
92.9(23.1
)
89.6(11.9)
43.5(10.9)
62.1(6.7)
All differences between groups significant (p<0.001) by 2-sample t testAll differences between groups significant (p<0.001) by 2-sample t test
Consultations by HADS Classification
In last month
Total WM Episodic WM
Chronic WM FU
Chinese Medicine
All
(n=1853)
1.30
(1.21)
0.63
(1.15)
0.67
(0.61)
0.21
(1.24)
HADS +ve(n=482)
1.48
(1.41) *
0.86
(1.32)*
0.61
(0.71)
0.41
(1.94)*
HADS -ve(n=1371)
1.24
(1.12) *
0.55
(1.07)*
0.69
(0.59)
0.14
(0.84)*
* Significant (p<0.05) by 2-sample t test
Problems 1st common solution 2nd common solution
ill health / health-related problems (28)
healthy life style (16) Medical advice/ health information (7)
worries (14) healthy life style (5) communicate with family (5)
depression/ psychol trauma (10)
healthy life style (4) communicate with family (3)
loneliness / boring (14)
healthy life style (7) build social network /EHC (5)
health problems of family members (13)
communicate with family (7)
healthy life style (4)
Problems of family members (20)
communicate with family (8)
Reassurance to patient (4)
poor family relationship (17)
healthy life style (5) communicate with family (3)
financial difficulties (20)
healthy life style (4) communicate with family (4)