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, clklam@hku.hkclklam@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

but 48% undiagnosed

Is it important?

Is screening useful?

Is PST-PC effective?

Courtesy of photolibrary@hku.hk

Unrecognized Psychological Problems in the Elderly (UPPE)

Screening & PST-PC for UPPE in PC

Aims & Objectives Prevalence & risk factors Impact on HRQOL & consultation rates Nature of the problems Effectiveness of brief PST- PC for

elderly patients screened positive of psychological problems

1371 screened negative

482 HADS screened positive

5225 consecutive GOPC patients aged 60+

1473 refused, 1614 not eligible, 285 incomplete interviews

183 Refused RCT 299 Agreed to RCT

149 randomized to3x PST-PC 132 attended ≥1 PST-PC sessions

Blinded assessment at week 6, 12, 26 & 52; 69% completion

Blinded assessment at week 6, 12, 26 & 52; 71% completion

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

Results

Courtesy of photolibrary@hku.hk

Sen = 80%

Spec = 90% True +ve True -ve Total

HADS +ve 339 143 482 (26%) (95%CI 24,28)

HADS -ve 84 1287 1371

Total 423 (23%) (95%CI 13,34)

1430 1853

Prevalence of UPPE in PC

Baseline Characteristics of Subjects

1.5 (1.7)1.5 (1.3)1.4 (1.1)1.23 (1.1) §Monthly WM consult (SD)

51.1 (12)51.9 (12.8)49.2(12.3)62.1 (6.7)§SF-36 MCS mean (SD)

33.4 (13.2)#37.2 (13.3)36.8 (13.6)43.5 (10.9)§SF-36 PCS mean (SD)

4.7 (4.0)3.9 (3.5) *4.9 (4.4) *1.1 (1.4)§HDAS mean DS (SD)

4.9 (3.1)4.7 (2.8)5.0 (3.7)0.4 (1.7) §HADS mean AS (SD)

21.324.027.512.5 §>2 chronic disease %

6561.365.862.4§Married, living spouse %

67.2#51.355.747.9§No formal educ %

38.341.345.055.9§Gender (% male)

72.2 (7.5)72.0 (7.1)71.6 (6.5)72.8 (6.8)Age, mean (SD)

Refused(n=183)

Video(n=150)

PST-PC(n=149)

Negative(n=1372)

§, *, # Significant difference between PSC & video groups, HADS positive & negative groups, and RCT & refused RCT groups, respectively

Risk Factors of UPPE(Adjusted Odds Ratio by Multivariate Logistic Regression)

All subjects(n=1805)

Men(n=949)

Women(n=856)

> 2 chronic diseases

3.05 (2.10, 4.42)

1.97 (1.20,3.25)

2.28 (1.47, 3.53)

Female 1.99 (1.56,2.54)

----- ----

≥70 years old N.S. 0.97 (0.95, 1.00)

N.S.

Living with spouse

1.51(1.19,1.93)

N.S. 1.52 (1.13, 2.05)

No formal educ 1.34 (1.07, 1.69)

N.S. N.S.

Adj. R square 0.08 0.06 0.06

Adjusted Effects UPPE on HRQOL & Monthly Consultation Rates

Multivariate linear regression coefficients (95% CI)

SF-36 PCS

SF-36 MCS

Total WM Consult.

Episodic consult.

CM consult.

HADS +ve

-6.28(-5.15, -7.45)

-11.27 (-10.37, -12.17)

0.16 (0.03, 0.29)

0.25(0.13, 0.37)

0.25(0.12, 0.34)

Heart dx

-4.19 (-2.55, -5.83)

N.S. N.S. N.S. N.S.

Known psych

illness*

-2.86(-1.20, -4.53)

-8.41(-6.35, -10.46)

0.49 (0.24, 0.73)

------- -------

* Results from population survey 1998

Psychiatric Diagnosis

Frequency (%)

Dysthymia 17 14.3

Anxiety disorder 10 8.4

Major depression 7 5.9

Mixed Depression & Anxiety 4 3.4

Adjustment Disorder 2 1.7

Hypochondriasis 1 0.8

Others 8 6.7

None 70 58.8

Total 119 100.0

Problems of Living Frequency (N=119) (%)

Ill health 28 23.5

Financial hardship 20 16.8

Problems of family members 20 16.8

Poor family relationship 17 14.3

Loneliness / boredom 14 11.8

Worries 14 11.8

Health problems of family 13 10.9

Depression / psychological trauma 10 8.4

Poor social relationship 4 3.4

Aging / feeling of uselessness 5 4.2

Others 5 4.2

None 36 30.3

Solutions Frequency (N=119) (%)

Healthy life style 30 25.2

Communicate with family 22 18.5

Build social network / EHC 15 12.6

Medical advice/ health information 11 9.2

Reassure patient 9 7.6

Develop interests 8 6.7

Find a new job/ saving 6 5.0

Positive thinking 5 4.2

seek help from social workers 3 2.5

Others 9 7.6

None 13 10.9

Changes in SF-36 & HADS Scores from Baseline

  PST-PC Placebo (Video)  

Wk 6 Wk 12 Wk 52 Wk 6 Wk 12 Wk 52

SF-36 PCS

0.7(-1.01,2.41)

-0.11(-1.98,1.76)

-0.54(-2.18,1.09)

2.25*(0.75,3.76)

3.1*(1.52,4.69)

0.8(-0.96,2.56)

SF-36 MCS

2.64*(0.84,4.44)

1.91(0.01,3.81)

0.74(-1.26,2.74)

0.64(-1.23,2.5)

0.29(-1.58,2.16)

1.07(-0.7,2.84)

HADS AS

-0.97*(-1.52,-0.43)

-1.09*(-1.7,-0.49)

-1.17*(-1.84,-0.51)

-1.37*(-1.83,-0.9)

-1.46*(-1.94,-0.98)

-1.58*(-2.09,-1.07)

HADS DS

0.36(-0.28,0.99)

0.6(-0.06,1.26)

1.13*(0.39,1.88)

0.79*(0.12,1.47)

0.87*(0.19,1.56)

1.4*(0.67,2.13)

* Significant difference after adjusting for multiplicity by Holm’s procedure, baseline DS and MH, socio-demographics and co-morbidity

 PST-PC Placebo (Video)

 Wk 6 Wk 12 Wk 52 Wk 6 Wk 12 Wk 52

Total 0.01(-0.09,0.11)

-0.08(-0.18,0.03)

0.03(-0.07,0.13)

0.01(-0.09,0.12)

0.06(-0.06,0.17)

0.04(-0.08,0.17)

All WM -2.58(-5.71,0.56)

-2.1(-5.49,1.29)

-1.3(-4.95,2.34)

-0.54(-3.37,2.29)

-1.16(-4.26,1.94)

-0.47(-3.3,2.36)

WM episodic -0.06

(-0.16,0.03)-0.09

(-0.19,0.02)-0.11

(-0.22,0)0.05

(-0.05,0.15)0.01

(-0.1,0.12)-0.03

(-0.15,0.09)

CM 0.16

(-0.04,0.36)0.11

(-0.09,0.32)0.77

(-0.53,2.08)0.57

(-0.74,1.88)1.24

(-0.59,3.07)0.53

(-0.79,1.84)

Changes in Monthly Consultations

No Significant difference in consultation rates from baseline

Adjusted Difference in outcomes of PST-PC vs. Placebo (video) Groups

Outcome variable Difference (95% CI) p-value

SF-36 PCS -1.48 (-3.25,0.30) 0.103

SF-36 MCS -0.51 (-2.36,1.35) 0.592

HADS AS 0.41 (-0.14,0.96) 0.146

HADS DS 0.01 (-0.71,0.74) 0.972

Total consultation -0.07 (-0.17,0.02) 0.129

All WM consultation 0.50 (-2.20,3.19) 0.717

Episodic WM consultation -0.09* (-0.17,-0.002) 0.045

CM consultation -0.22 (-1.27,0.83) 0.684

* Significant by linear mixed effects analysis adjusting for baseline DS & MH scores, sociodemography and co-morbidity

Is it important?

Is screening useful?

Is PST-PC effective?

Courtesy of photolibrary@hku.hk

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)