Psychogeriatric care in times of COVID. Lessons learned and proposals for similar situations.

"At a time when in-person healthcare has been limited as much as possible, the priority in many places has been to ensure that consultations can continue safely. For this reason, telemed-icine has been favored over in-person consultations. Efforts have been made to maintain in-person consultations in cases of decompensation, severe cases, cases where patients have dif-ficulty understanding and following instructions given telematically, and initial consultations to strengthen the therapeutic bond. The number and proportion of face-to-face consultations has been increasing as the epidemiological situation has allowed it. Telepsychiatry, which has become widely accepted and has proven effective in psychiat-ric care(), has been one of the most widely used resources during the pandemic. It has taken the form of telephone calls and, to a much lesser extent, video calls. However, subtle differences in body language, facial expressions and mild vocal inflections are harder to detect using digital technology(). Accessibility also represents a significant limitation to the use of these methods for providing healthcare. Elderly patients with a low income, lower level of education and poorer access to the internet, and who are less familiar with new technol-ogies, may have less access to the necessary technology than others3. Fortunately, this is changing and we also see among the elderly the possibility of using social networks and other types of new technologies that would allow close contact and maintain communication in this way. It is essential that appointments for telephone or telematic consultations are respected. Many elderly people have felt abandoned due to the burden placed on healthcare institutions and they need to know that they will be contacted and when, so consultations must take place on the agreed date at the agreed time. Despite the difficulties arising in their implementation, we believe that these technologies are here to stay(). However, the rollout of telepsychiatry has encountered barriers such as the digital gap affecting elderly people, sensory issues in psychogeriatric patients and cognitive dete-rioration in some patients()(). Likewise, and given its novelty, so that telepsychiatry is carried out in the most efficient way possible, we also consider it convenient to train professionals in this work tool. Support from relatives and carers, who have often accompanied patients during inter-views, has facilitated access to technology. It has also enabled psychoeducation to be provided for relatives and carers, giving them a more comprehensive understanding of patients’ conditions and tools for providing care (encouraging physical exercise, healthy habits, sleep hygiene, cogni-tive stimulation activities). Involving relatives and carers has probably improved adherence to treatment regimens and enhanced the detection and prevention of relapse and deterioration. Fi-nally, it has also represented a source of emotional support for carers, as other authors have demonstrated4. Nevertheless, in some cases, the minimum standards of effectiveness and safety in telepsychiatry have not been met or it has not been possible to deliver the service at all. There-fore, in cases considered to be of sufficient clinical relevance, we recommend that in-person consultations are carried out with stringent safety measures in place to protect patients. Among these measures are the use of safe corridors and specific time slots reserved for elderly people. It is important to note that some elderly patients prefer to attend Health Centers in person if given the option, as they believe that their issues will be better understood and addressed than via telematic channels. One of the main objectives throughout the pandemic has been to maintain continuity of care. Reductions in in-person consultations during the first wave of the pandemic and fear of visiting Health Centers, specialist doctors and hospitals among patients have given rise to re-duced mental health demand and fewer check-ups and follow-up consultations. As patient refer-rals to specialists have declined, warning measures and coordination with primary care centres must be put in place to make it easier for patients to access specialist services. These measures could be the facilitation of contact and appointment control mechanisms, the use of corporate emails and e-consultation systems and, of course, reinforcing coordination programs between professionals. Although the severity of this situation varies between patients, in some cases it has had a significant impact as chronic treatment which helped to stabilize the patient’s pathology is inter-rupted or their treatment regimens are altered, increasing the risk of morbimortality. In addition to the efforts made by all healthcare services to implement and carry out telematic consultations to ensure continuity of care, lists of patients needing continuity of care should be drawn up to detect gaps in their supervision. In addition, it is recommended that information resources, telephone calls, mobile notifications, reminders of priority requests for analyses and diagnostic tests and reminders of appointments and referrals to specialists are put in place. Another problem relates to the difficulty of conducting routine tests and follow-up tests as part of treatment protocols in-volving lithium, valproic acid, clozapine and other psychotropic drugs. While the COVID-19 crisis continues, we recommend assessing the risks and benefits of patients attending Health Centers for tests on an individual basis to limit potential exposure to SARS-CoV-2. In our view, nursing home residents should take priority, as the pandemic has had a greater impact on them than on others()(), and their care has been prioritized. The use of video and telephone calls to nursing homes, which have involved doctors and/or carers as well as patients, has been another very useful tool. This method has two benefits. On the one hand, it allows col-legial interviews to take place with doctors from nursing homes acting as facilitators in the pa-tient’s telematic care. On the other hand it helps patients to understand basic concepts relating to illness and self-preservation, which elderly people can struggle with(). Throughout the pandemic, special consideration has been given to social isolation and loneliness. It is recommended that social isolation is specifically addressed in telephone inter-views to facilitate detection. When cases are detected, attempts have been made to put patients in contact with social services and volunteer networks, while extra emphasis has been placed on psychoeducation for patients and relatives/carers during consultations and videocalls. Depending on the facilities available to them, it may be helpful for Mental Health Centers to organize telematic or in-person group activities with a small number of participants, offering support and information on psychoeducational and occupational themes. Lockdowns have led to significant disruption to healthy habits. Elderly people in particular have experienced a dramatic reduction in physical activity. It is very important to encourage pa-tients to carry out physical exercise at home: they should stand up and walk around every hour and perform stretching exercises once or twice a day. Support should also be provided to ensure that they have a healthy, balanced diet. Geriatric patients have been shown to experience more disordered sleeping during the pandemic. This is most likely due to a worsening of existing psychopathologies such as depres-sion or anxiety, as well as to insufficient activity. We believe that educating patients about healthy habits and sleep hygiene measures via telephone calls or videoconferences with healthcare pro-fessionals can play an important role in addressing these situations. This educational task must also involve finding non-pharmacological measures to avoid an increase in prescriptions of hyp-notic medication, as has happened in many cases. The pandemic has given rise to situations of high complexity and risk, such as bereave-ment. Bereavements have become more common for obvious reasons, with a concomitant rise in referrals for problems relating to grief(). Many people are often unable to rely on family and social support and may be prevented from performing the usual rituals to say goodbye to their loved ones, making it harder to grieve and increasing the risk of developing complicated grief. Bereaved patients were given special care, involving early detection and intervention provided telematically, either individually or in groups, with referrals from intensive care units and hospitals when these were deemed necessary by healthcare professionals. During the pandemic, there has been a growing trend for higher doses of anti-psychotic and anxiolytic drugs to be prescribed. This has led to increased risk, given the difficulties in guar-anteeing regular check-ups and conducting laboratory tests, electrocardiograms, etc(). Some authors have recommended avoiding starting or adjusting treatment regimens for behavioral changes or cognitive deterioration during this period(). In order to address the difficulties high-lighted by several authors, we recommend paying closer attention to reviewing pharmacological treatment regimens to ensure that prescriptions issued during periods of flare-up do not become chronic. This frequently occurs with antipsychotics, as stated in the Document of the Spanish Society of Psychogeriatrics on the Use of Antipsychotics in the Elderly() Particular attention should be paid to patients with cognitive deterioration. They require well-established, specialized interventions to ensure that they receive adequate clinical care6. During this time, closer attention has been paid to the difficulties involved in managing the behav-ioral changes associated with this deterioration. These behavioral changes may worsen as a re-sult of factors"