|Year : 2021 | Volume
| Issue : 1 | Page : 3-10
Relevance of the Indian telemedicine guidelines 2020 in psychogeriatric care: A critical appraisal
Sanchari Mukhopadhyay1, Debanjan Banerjee2
1 Department of Integrative Medicine, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
2 Department of Psychiatry, Geriatric Clinic and Services, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
|Date of Submission||26-May-2021|
|Date of Decision||13-Jun-2021|
|Date of Acceptance||26-Jun-2021|
|Date of Web Publication||05-Aug-2021|
Dr. Debanjan Banerjee
Department of Psychiatry, Geriatric Clinic and Services, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
Older people with psychiatric illnesses face unique challenges in terms of clinical, sociocultural, and environmental factors. The Ministry of Health and Family Welfare, Government of India (MoHFw, GOI), has released telemedicine guidelines in April 2020, closely followed by a telepsychiatry operational guidelines as a collaborative effort of the National Institute of Mental Health and Neurosciences, Bengaluru, and the MoHFw, GOI. The current article presents a critical analysis of the provisions in these guidelines relevant to psychogeriatric care. The gray areas in the existing protocols which may hamper their applicability and accessibility in older adults include digital connectivity, continuity of care, patient autonomy and capacity assessment, medical comorbidities, evaluation of dementia, confidentiality, and teleconsultations in the institutionalized elderly. Preexisting challenges are seen to be compounded by the coronavirus disease 2019 pandemic, in addition to the onset of newer psychosocial and clinical adversities. The article also highlights certain recommendations for possible modifications of the guidelines in future. The telepsychiatry guidelines provide a paradigm shift in mental health care. However, the lacunae involved in the care of vulnerable groups such as the geriatric population based on these guidelines need to be reconsidered by all levels of stakeholders supported by evidence-based research.
Keywords: Geriatric psychiatry, guidelines, India, old age, telemedicine, telepsychiatry
|How to cite this article:|
Mukhopadhyay S, Banerjee D. Relevance of the Indian telemedicine guidelines 2020 in psychogeriatric care: A critical appraisal. J Geriatr Ment Health 2021;8:3-10
|How to cite this URL:|
Mukhopadhyay S, Banerjee D. Relevance of the Indian telemedicine guidelines 2020 in psychogeriatric care: A critical appraisal. J Geriatr Ment Health [serial online] 2021 [cited 2021 Dec 9];8:3-10. Available from: https://www.jgmh.org/text.asp?2021/8/1/3/323107
| Aging and Geriatric Mental Health Burden in India|| |
India is rapidly aging as a country due to the demographic shift of reduced mortality and fertility over the last few decades. The 2011 census found 8.6% of the Indian population to be aged 60 years and above, and this proportion is expected to rise to 19.5% by 2050. The absolute increase in the number of older adults is reported in a study to be faster than most other countries as per the population projection. With the rise in the number of people in the older age group, the burden of chronic illnesses is also increasing, including both medical and psychiatric components. Surveys done in northern India reported an average prevalence of mental health problems in older adults to be around 17% and 23% in the urban and rural communities, respectively.,, Overall prevalence has been found ranging from 8% to 43% depending on the study population, diagnostic instrument use, and methodological differences in the studies. [1,3] According to the first wave of Longitudinal Ageing Study of India (LASI), the point prevalence of self-reported diagnosed psychiatric and neurological disorders in people 60 years of age and older is 2.6%. The common mental illnesses in this population are depression, anxiety, and psychosis, in addition to dementia and other neurodegenerative disorders. [2,7] The measured prevalence of depression in older adults (>60 years) is found to be almost ten times the self-reported prevalence as per the LASI. It also showed that the treatment rates of psychiatric and neurological diseases are the lowest, about 40%. Subsyndromal symptoms of psychiatric disorders, such as depression and anxiety, are common in this age group, and further add to the disease burden.
| Need for Telepsychiatry in Geriatric Population|| |
Telepsychiatry is a need of the hour across all age groups. The geriatric age group, however, presents with some additional attributes, including both needs and challenges. A systematic review in 2020 found five domains of barriers to mental health-care access in older adults. They were knowledge, awareness, and attitude-related, comorbid medical illness-related, health-care provider-related, extrinsic (transportation, cost, and dependence on caregivers), and sociocultural barriers (like those in the minority groups). The most important intrinsic factors identified were negative attitude toward mental health care and perceived need for treatment. Brenes et al. reported lack of awareness, stigma, mistrust, discomfort in sharing personal information with an outsider, cost of treatment, accessibility in terms of distance, and lack of knowledge regarding the appropriate treatment setting as impeding mental health-care seeking in the rural older population. Young olds experienced more barriers than the oldest old. However, extrinsic factors also play a significant role in forming and maintaining the barrier. This is more relevant in developing countries like India, where a larger share of the older population resides in rural areas with poor access to health care. As per the recent and ongoing LASI, health insurance and social security coverages are significantly low for the older adults with catastrophic out-of-pocket health spending in almost 35% of households having older adults. These factors further contribute to poor mental health-care access. About 11% of older adults report at least one functional limitation which increases reliance on caregivers. The current number of psychiatrists in India is estimated to be around 0.75/100,000 population. The mental health infrastructure is inadequate. Old age-specific psychiatry services are also insufficient all over the country. As per the Dementia India report 2010, the numbers of dementia residential care centers, day-care centers, memory clinics, and helplines are considerably low. The pandemic, in addition, is taking a toll on the access and availability of mental health-care services in older adults. A shift to telepsychiatry may address these barriers, even including stigma and prejudice.
Along with the general need for telepsychiatry in older adults, it is mandatory to discuss the current coronavirus disease 2019 (COVID-19) pandemic. A myriad of difficulties has arisen in seeking mental health care in this situation due to the spread of infection, mandatory social distancing, increased need for maintaining hygiene, lockdown in different areas, lack of proximity of caregivers for health-care needs, reduced access to medicines, financial difficulties, and so on. [14,15] Telemode of mental health-care access is thus acknowledged worldwide to be important in bridging the treatment gap. [16,17] Older adults in long-term care present with another set of difficulties such as poor administrative control of and staff training in the spread of infection, unrestricted and often obligatory physical contacts with other residents or staff, and unavailability of medical or psychiatry professionals for consultation. Telemental health service provision has since been tested in various countries on various older populations for feasibility and efficacy. Most of the studies found it effective and feasible, though certain complications have come up pertaining to this population. These are the presence of cognitive impairment, sensory deficits, lack of technological sophistication and related support, problems with capacity assessment, inability to evaluate nonverbal gestures as part of the mental state examination, doubtful personal space and boundary maintenance during the consultation, unclear laws and regulations regarding “do's and don'ts” of tele-health care in multiple states and countries, risks of digital data theft and breach of confidentiality, influence over shared decision-making, and cost. [19,20] A study from Canada on comprehensive care, including the adoption of virtual medical care, remote social engagement, and digital programming, found it to be feasible and beneficial in long-term care older residents. Similar findings are reported in another study from Thailand. Another study on video consultation for older persons with mental illness (PMI) concluded that though tainted with multiple complications, telepsychiatry still offers several advantages, especially in the current context. Different digital platforms to connect family members to older adults residing in nursing homes are proven to have positive effects on the patients, mainly those with dementia, due to social contact. Meuldijka et al. reported that the service of online and telehealth interventions in older people's mental health in Australia faced certain challenges during the pandemic, including disruption of services and burden on staff. The barriers therein included privacy concerns, lack of access to technology and poor knowledge thereof, and reservations in patients and the staff regarding telehealth. However, adequate infrastructure, imparting knowledge to both the patients and the staff, increasing awareness, and developing self-help resources to make the care affordable and easy are suggested as ways forward. Several other studies from all over the world reported telepsychiatry to be applicable and acceptable, useful, satisfactory, and often as good as physical consultation.,, Telepsychiatry services are found to have significant potentials in cognitive assessment, medical in-patient and long-term care consultation, psychotherapy and caregiver support provision, and geriatric-specific services like dementia care.
This brings us to the discussion of telepsychiatry services for older adults in the Indian context. A previous viewpoint has described studies from India on telemental health services in this population, with reasonable feasibility and benefits experienced in them. However, the nitty-gritties and lacunae of the legal provisions for Indian psychogeriatric care based on these guidelines have not been particularly discussed. Therefore, the authors here will put forward a brief discussion on the same. These are only related to geriatric mental health care. General caveats with relation to psychiatric care and the guidelines have already been detailed earlier. Before delving into the current provisions and challenges of teleservice in geriatric psychiatry in India, we give a summary of the salient points of the telemedicine guidelines released by the Government of India in 2020 in the next section.
| Telemedicine 2020 Guidelines|| |
The guidelines have defined telemedicine, telehealth, and registered medical practitioners (RMP). [25,26] They are laid down primarily to help enable RMPs to effectively use telemedicine to improve health-care service and access. An RMP is one enrolled in the state or national medical register under the Indian Medical Council Act 1956. Telemedicine encompasses assessment, prevention, treatment, research, and continuing education for health-care providers as per the World Health Organization. Telehealth includes in its ambit medical care, education, health information, and self-care with the help of tele- and digital communication services. The Indian telemedicine guidelines have excluded any technological device or software specification, data management standards, application of digital technology in surgical or invasive procedures, research and evaluation, and continuing education of health-care providers. One prerequisite is to train all RMPs, likely taking on telemedicine, in the same within 3 years of enactment of the guidelines. Any mode of consultation, including video, audio, or text, is allowed as per convenience and the RMP's discretion. Two types of consultation are described here, namely, first and follow-up consultations, with slight differences in protocols. The consultation may be initiated by the patient, a caregiver, an RMP, or a health worker. Except for the first case, an explicit consent from the patient is required for willingness to undergo consultation. On initiation, the first work is to verify the credentials of the other party, for both the patient or proxy consultation-seeker and the RMP. Afterward, a verification of the informed consent (IC) is mandatory. This is followed by a quick assessment of any emergency medical situation and appropriate management by counseling or referral to in-person emergency services. In case there is no emergency, the consultation is carried out in terms of history, examination, and management. The RMP can rely on his/her clinical judgment regarding which mode of teleconsultation is the most suitable for a proper diagnosis and treatment. Laboratory or radiological investigations can be advised as they fit. Asynchronous online communication like sending photographs, mails, or likewise can be used to procure extra information as required for a comprehensive assessment. Once the RMP is satisfied to be able to reach an adequate diagnosis, medications can be prescribed. Medicines are mentioned under lists “O” (can be prescribed with any mode of teleconsultation, and are commonly available over-the-counter or similar drugs), “A” (can be prescribed on first video consultation, or any mode during follow-up; contains relatively safe medicines with low potentials for abuse), “B” (prescribed only on follow-up, maybe in addition to the already ongoing drugs for similar condition), and prohibited (drugs contained in the Schedule X of Drug and Cosmetic Acts and Rules, and narcotics and psychotropics under the Narcotic Drugs and Psychotropic Substances Act). The guideline annexure contains a sample of the type of medicines covered under each list. If the RMP deems it clinically important, the patient may be provided health education, counseling, and referred to the nearby in-person consultation services. The guideline recommends the RMP to uphold the patients' rights, exercise appropriate clinical judgment for continuation or referral of a patient, conduct telemedicine with the same principles as physical consultation, and act in the best interest of patients. In addition, there are certain recommendations for maintaining patient records and protection against breaches of digital privacy.
| Application of the Guidelines to Telepsychogeriatrics|| |
The release of the telemedicine guidelines was a very important and timely step by the government to facilitate medical care beyond physical barriers. The National Institute of Mental Health and Neurosciences, Bengaluru, together with the Ministry of Health and Family Welfare, Government of India (GOI), released a set of operational guidelines for telepsychiatry in May 2020, in keeping with the telemedicine recommendations by the GOI. In this, the lists of drugs are modified to suit the purpose of psychiatry care. We discuss the applicability of both telemedicine and telepsychiatry guidelines in geriatric psychiatry. To begin with, both the guidelines are surprisingly silent about older adults. No specific clause of provision has been mentioned in either of them. It has been suggested in the telepsychiatry guidelines to follow the mental health-care act (MHCA), 2017, for legal references. However, the act also does not give any age-specific recommendation or provisions for the geriatric population apart from general statements on the promotion of geriatric mental health care in various districts, rehabilitation, and improved health-care access for senior citizens. Thus, there are several areas where telepsychiatry for older adults may give rise to ambiguity while implementation. The case vignettes in [Table 1] illustrate three such different scenarios. While these are not exclusive, they are commonly encountered in clinical practice.
|Table 1: Case scenarios of psychogeriatric teleconsultation illustrating ambiguity based on the telepsychiatry/telemedicine 2020 guidelines|
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The first that comes to notice is the use of digital platforms and various hardware and software necessary for a teleconsultation (S1.4.1 and s. 1.4.2 of the telemedicine guidelines). Around 86% of older adults in India were found to be digitally illiterate by the Agewell Foundation. Nair et al. have discussed the difficulties of older adults in learning new technologies and getting adapted to its use, despite their interest to learn. Thus, using telemode for consultation without promotion of digital literacy is often not an easy task for this age group, which is applicable for older adults with psychiatric illness as well. Moreover, approximately 70% of the older individuals in India stay in rural areas. Amenities like stable and fast internet and also backup electricity cannot be uniformly ensured across all those areas. Transcending geographical barriers with telepsychiatry and providing health-care access to all will not be achievable in that case. Many of the senior citizens are habitually and traditionally accustomed to in-person health care and the perceived satisfaction in virtual consultations may vary. Frequent connectivity disruptions and inability to complete consultations may further interrupt the therapeutic rapport, even more essential in geriatric care. Telepsychotherapy may face similar problems.
Continuity of care
The next problem arises with the dichotomy between first and follow-up consultations wherein the differential procedures have at least one setback relevant to geriatric psychiatry. It is not permissible for a patient's family or caregivers to initiate the first consultation without the presence of the patient. This is immensely important from both clinical and medicolegal points of view. Capacity assessment, too, is allowed on video consultation only. However, older adults with psychiatric disorders may often not be willing to seek consultation due to incapacity, stigma, mistrust, lack of awareness, or inherent belief system. [10,35] In case there is a pressing need for intervention to avoid harm despite the patient's unwillingness, telemedicine cannot be used for that. Another scenario is an older adult with severe depression or psychosis where the psychopathology interferes with seeking consultation, in which the capacity or lack of it needs to be established before going on to the treatment as per MHCA 2017. In the follow-up consultation, however, the guidelines have the provision for proxy consultation if the individual has been diagnosed with moderate or severe dementia (Sec 6.2). In other cases, an authorization letter from the patient is required which often may not be feasible with older adults. Even for individuals with mild dementia, chronic depression, and severe frailty, it may not always be possible to comprehend and discuss their concerns with the psychiatrist themselves. A significant proportion of morbidity in the geriatric population comes from the depression–dementia continuum, which leads to another potential “gray zone” in the assessment of capacity and clinical evaluation in virtual consultations.
Autonomy and capacity
As per the MHCA 2017, if a patient lacks the capacity, the nominated representative chosen by the person in his/her advanced directive earlier will take proxy decisions on the patient's behalf regarding consultation, treatment, and the likes. IC should be voluntary, autonomous, and with adequate information as the name suggests. For an RMP or a psychiatrist, assessment of undue influence is difficult on teleconsultation. The older adults may be accompanied by a caregiver, or a family member may be present in the vicinity even if the patient is interviewed alone. Ruling out breaches of confidentiality, coercion, subtle influence of other stakeholders on the patient's verbal accounts, or elderly maltreatment is a herculean and often impossible task. This may have significant legal implications. The scenario is all the more relevant for patients with dementia with a considerable number having severe cognitive deficits hampering capacity. The MHCA is not yet adequately implemented all over the country, and no accessible database of advanced directives or nominated representatives is there. The telepsychiatry standard operating guidelines recommend only an in-person first consultation for patients who do not have the capacity to consent. This inevitably restricts the scope of telepsychiatry for several older adults, more so in the current pandemic situation worldwide and the postpandemic aftermath.
Sensory impairment is a common problem in old age. Two-thirds of the older United States (US) population have two or more sensory impairments. LASI first wave reported a 55% self-reported prevalence of eye-related problems and 10% of hearing difficulties. Audiovisual consultation, without physical proximity to clarify any doubt, may be a hindrance to a proper rapport, assessment, and management. Technical and network troubles causing poor video or audio quality may add to this problem.
Older PMIs often have multiple medical morbidities. [2,7] Grover et al. in a study of 488 older patients with depression found that more than 70% had at least one medical comorbidity. Hypertension and diabetes mellitus were the most common. [40,41] In patients with any serious mental illness, the literature has found a high prevalence of physical comorbidities. The implication is that physical and neurological examinations are as important as psychiatric evaluation in this age group. Treatment of modifiable etiology of geriatric depression, late-onset psychosis, and dementia (e.g., vitamin B12 deficiency, hypothyroidism, and cardiovascular disorders) are crucial. Inability to conduct a thorough general and systemic examination is a key shortfall of telepsychiatry, which is more relevant in the older adults. A comprehensive understanding of the “dementia syndrome” is not possible without a detailed neurological examination.
Dementia and behavioral and psychiatric symptoms in dementia
A considerable number of older adults live with dementia across the world, with Alzheimer's dementia (AD) contributing to 50%–60% of all. [7,43] Its prevalence doubles every five years after 60 years of age. The overall prevalence of dementia in persons aged 60 years and above is 1% in India. The service gap, however, is almost 90% as estimated in 2010. Acetyl cholinesterase inhibitors (donepezil, galantamine, and rivastigmine) and memantine, an NMDA receptor antagonist, are US-Food and Drug Administration approved for the treatment of AD. However, these drugs come under the list “B,” i.e. they can be prescribed on follow-up consultation only. The list “A” antidepressants contain escitalopram, imipramine, and fluoxetine, but not sertraline, venlafaxine, or mirtazapine which are also commonly used in older adults. [7,44] List “A” oral antipsychotics contain haloperidol, risperidone, and olanzapine, which are associated with significant extrapyramidal and/or cardiometabolic side effects, more in the context of geriatric population. Short-acting benzodiazepines like lorazepam are advised in the older adults, if at all, for acute management of anxiety, psychosis, or mood symptoms. However, none of those are there in the list “A.” It is evident that this particular population was not specifically considered when laying down the recommendations. Some may argue that antidementia drugs are often not started in the first consultation. However, considering the high dropout rate in health care, poor awareness about dementia, and many presentations with advanced neurocognitive disorders in our country, the first consultation is often the only chance at interventions. Psychoeducation, caregiver interventions, and patient-centered therapies form a major component of dementia care. Many of these are hands-on and difficult to adopt in virtual settings.
Prescription confidentiality is another issue with older adults after the consultation. Older adults may have significant functional limitation (24%–48% as per LASI first wave), with mobility restriction being the most common. Maintaining confidentiality when transmitting the prescription online or procuring the medicines from the pharmacy may be problematic in that case, from both the clinician's and the patient's perspectives. The other important consideration is that of wandering behavior found frequently in neurocognitive disorders. Various platforms and guidelines have suggested detailed records of their identities and associated information for better search protocols if they wander away. Considering data sharing in virtual platforms carry its own risk, the guidelines need to be equipped more with storage and sharing of such sensitive information in these vulnerable groups. Autonomy, private space for communication, and dignity of the older persons assume immense importance in psychogeriatric evaluations, and need considerations in the teleguidelines.
Due to the lacunae in the teleguidelines about psychiatric care in the elderly, the psychiatrist often faces ethical issues in discussion and documentation of sensitive topics such as palliative care, end-of-life considerations, assisted deaths in severe dementias, prognosis of neurocognitive disorders, genetic testing for dementias, elder abuse, testamentary capacity, and psychosexual disorders. These are more difficult in institutional and custodial settings with collaborative consultations. Cyberspace may also compromise autonomy and privacy in the elderly, more so in individuals with reduced capacity that may impair dignified mental health care. Advance care planning in cases of early onset dementias can also be affected and needs provisions in the existing guidelines.
Consultation between health-care worker and psychiatrist
Sec 6.3 of the guidelines enable a health-care worker (nurse, allied health professional, auxiliary nurse midwife, etc.) to initiate telepsychiatry consultation with a psychiatrist both for independent and supported assessment. This is a welcome move that helps in community settings, rehabilitation centers, dementia care homes, old age homes, and other custodial settings. Appropriate identity validation, capacity assessment, and patient's consent (or that of the nominated representative) are needed for the same. These provisions without some flexibilities, though necessary, can impede the opportunity for many of the institutionalized elderly to avail telepsychiatry consultations. Collaborative consultations at old-age care homes often do not come under the purview of Sec. 94, 100-104 MHCA 2017 (as mentioned in the current telepsychiatry guidelines), and in the absence of advance directives and reduced capacity, can lead to underdiagnosis and mismanagement [[Table 1]: Case 3].
Despite an increase in geriatric psychiatric research, it is still far from being conclusive in most of the diseases and their managements. Thus, research needs to be continued for a better clinical implementation and a more comprehensive mental health care. Telepsychiatry and telemedicine in India, at present, do not provide for research options so vital in treatment guidelines and policy-making. With the continued pandemic, it can act as a stumbling block on the way of generating more robust evidence in different aspects of old age psychiatry.
It is critical to consider telepsychiatry in light of the current COVID-19 pandemic, the very premise when the guidelines came to life. Access to health care is jeopardized in most of the places since a year now due to the rules and regulations related to the prevention of infection spread, inequitably affecting vulnerable groups of people. [47,48] Physical distancing is mandated with lockdowns in different states in India, thus further obstructing physical consultation seeking. During this time, it is of utmost importance to utilize telepsychiatry and telemedicine to the fullest potentials. There is evidence of higher mortality, worsened morbidities, disruptions in daily routines, stress due to social isolation, increased depression and anxiety, grief, exacerbation of preexisting psychiatric illnesses, and inaccessibility of health-care resources in older adults, though it is argued that they are more resilient than the younger ones. However, the data have mostly covered the initial phase of the pandemic, and thus, the possibility of a long-term adverse mental health outcome cannot be ruled out. There are a few psychological issues particularly relevant for older adults. Grief, retirement, and loneliness are some of them. Loss of a loved one, compounded with the absence of other close family members like children in the close proximity, can lead to mental health crises in the pandemic. Inability to participate in social and community activities may hinder the collective grieving often required for the resolution. [51,52] Continuing mental health care is vital in this scenario and should be considered one of the primary goals, aided by telepsychiatry. Implementation of the guidelines with respect to physicians and mental health professionals who consult geriatric patients is also a challenge. A recent qualitative study among Indian physicians providing dementia care during the lockdown period last year reported that though majority of the participants considered telepsychiatry as the “future of dementia care”, more than 90% were ambiguous about the telepsychiatry guidelines with perceived difficulties in using them. This was more so for the primary care physicians who already struggle with the ambit of dementia management, and virtual consultations can lead to may technical, medicolegal, and ethical concerns.
Having discussed the challenges with the current legal provisions, it is important to point out the benefits of them as well. The formulation of telemedicine and telepsychiatry guidelines, in itself, is a commendable step forward. It gives a legal framework for doctors and patients alike to enhance the scope of health-care access. The allowance of any mode of consultation depending on the preference and comfort of the clinician and the patient is helpful, more so in older adults with age-old habit of and comfort in using certain modes communication more than others. The authors highlight certain recommendations in [Table 2] which may be considered when improvising the guidelines considering older adults with psychiatric illnesses. [27, 29, 32]
|Table 2: Possible recommendations for consideration related to the telemedicine/telepsychiatry guidelines 2020 and psychogeriatric care|
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| Conclusion|| |
Telemedicine is of dire need at this time of pandemic for the entire population. The relevance and requirement are even higher for older adults. There are various hindrances specific to the neuropsychiatric and socioenvironmental conditions of the older population. Those need to be addressed in future guideline amendments. Modification of umbrella strategies is needed for the geriatric age group. The telemedicine or telepsychiatry guidelines at present are undoubtedly promising in bringing about a paradigm shift in the mental health care. Further research into their use, implementation, and challenges is warranted in the coming days to understand the needs for further modifications. No guidelines are in all means perfect; however in a rapidly aging nation like India, it is imperative to consider the geriatric population with unique mental health-care needs when devising and using virtual consultation norms. Interestingly, this vulnerable group and their caregivers will probably benefit the most by it. The lacunae therein should be discussed and strategies devised, by all the stakeholders involved, to make mental health truly universal beyond the barriers of geography, culture, and age.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]