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Introduction Measurement-based care, which encompasses the use of self-report scales for tracking patients’ responses to treatment, has been systematically reviewed in the context of primary care where it has been shown to enhance communication between providers and patients1. Among older adults with mood disorders, pain and somatic symptoms are common and often under-recognized2,3. Scales for monitoring mood, anxiety and physical symptoms have been well validated in older adults with psychiatric disorders within inpatient and outpatient settings. In the palliative care context, the Edmonton Symptom Assessment Scale (ESAS) and the Patient Dignity Inventory (PDI) are commonly used to track burden of symptoms and impact of illness on dignity. We explore the utility and relevance of using self-rating scales as part of a measurement-based care initiative in geriatric mental health at Baycrest, an academic health sciences centre in Toronto, Canada. We examine the relationship between depression, anxiety and somatic symptoms and introduce the use of the ESAS and PDI in a non-palliative care context. 1) Wray LO et al. Enhancing implementation of measurement-based mental health care in primary care: a mixed-methods randomized effectiveness evaluation of implementation facilitation. BMC Health Serv Res. 2018; 18: 753. 2) Chodosh J, Solomon DH, Roth CP et al. The quality of medical care provide to vulnerable older patients with chronic pain. J Am Geriatric Soc. 2004; 52:756-761. 3) Meeks TW, Dunn LB, Kim DS et al. Chronic Pain and Depression among geriatric psychiatry inpatients. Int J of Geriatr Psychiatry. 2008; 23:637-642. Methods Participants were recruited from an inpatient geriatric mental health unit and an outpatient day hospital for mood and related disorders. Self-report rating scales tracking mood, anxiety and somatic symptoms were completed, including the Geriatric Depression Scale (GDS), Geriatric Anxiety Inventory (GAI), the ESAS and the PDI. Demographic characteristics were gathered from a retrospective chart review. Inpatient and outpatient groups were compared using Fisher's exact test for categorical variables and Wilcoxon tests for continuous variables. Longitudinal cross-sectional models used generalized estimating equations and an exchangeable working correlation (WC) matrix to adjust for repeated measures within patient across time. Cross-sectional models including time-varying covariates measured concurrently with the outcome and were adjusted for baseline values for age, number of comorbidities and medications and level of cognition. Results Data were obtained for 33 English speaking patients (inpatients N=17, outpatients N=16) with a mean age of 76.5 (SD=6.1), 69.7 % female and 48.5% married. Inpatients had a significantly higher number of comorbidities than outpatients. Self-reported scales were measured from 1 to 17 weeks (mean number of weeks was 8.2, SD=4.7). At baseline, prevalence of moderate to severe ESAS symptoms (4 or higher score) ranged from 19% to 75% (Table 1). Higher GDS scores were significantly correlated with self-ratings for poor dignity and high anxiety (p GDS and PDI scores had a similar pattern to the mean ESAS pain item score across time (Figure 1). Mean scores for all the scores increased indicating worse scores for those remaining under follow up. Some example longitudinal modelling results are as follows: GDS scores decreased over time but less rapidly for patients reporting a higher degree of pain (p=0.02, WC=0.80). PDI scores decreased across time but higher PDI scores were associated with higher ESAS drowsiness (p=0.002, WC=0.82). Conclusions Self-report scales yielded relevant clinical information including the high physical symptom burden experienced by older adults in geriatric mental health inpatient and outpatient settings. This study suggests there is value in using self-report rating scales to track mood, anxiety, dignity, pain and other symptoms. Measurement-based care can create a dialogue between patient and clinician about symptom variability over time, and its usage in geriatric psychiatry warrants further exploration. In our study, there was an association between subjective distress experienced by participants and underlying pain. Over time, Geriatric Depression Scale scores tended to remain elevated for patients who simultaneously reported higher pain. As well, the Edmonton Symptom Assessment Scale was highly correlated across time with the GDS. Incorporating a palliative care lens may suggest new approaches to care and have relevance to inpatient and outpatient geriatric mental health settings where burden of symptoms is high. While our study is limited by its small sample size, the use of self-report scales commonly used in palliative care within a geriatric mental health context merits replication in other settings. This research was funded by A stipend was provided by Baycrest's Department of Psychiatry's Academic Development Fund. |
