Psychological Services 2015, Vol. 12, No. 1, 66 –72

In the public domain http://dx.doi.org/10.1037/ser0000015

Outpatient Health Care Utilization in a Sample of Cognitively Impaired Veterans Receiving Care in VHA Geriatric Evaluation and Management Clinics Paul R. King

Christina L. Vair

VA Center for Integrated Healthcare, Buffalo, New York

VA Center for Integrated Healthcare, Buffalo, New York, and The University at Buffalo, State University of New York

Michael Wade

Julie Gass

VA Center for Integrated Healthcare, Buffalo, New York

The University at Buffalo, State University of New York

Laura O. Wray

Anna Kusche, Charito Saludades, and June Chang

VA Center for Integrated Healthcare, Buffalo, New York, and The University at Buffalo, State University of New York

VA Western New York Healthcare System, Buffalo, New York

Within the Veterans Health Administration (VHA), Geriatric Evaluation And Management (GEM) clinics are designed specifically to address the needs of older veterans with complex age-related concerns, including dementia and comorbid medical and mental health conditions. Previous literature describes aging veterans as having greater health care needs compared with age-matched nonveteran samples, and multimorbidity is of particular concern in this population. Using data extracted from electronic medical records (EMRs), the present study describes the demographic characteristics, mental health diagnoses, and health care utilization of a sample of 476 VHA GEM patients with diagnosed cognitive impairment or dementia seen in clinics across Upstate New York. Examination of EMR data demonstrated that in addition to diagnosed cognitive impairment and dementia, over 66% of the sample had at least 1 additional mental health diagnosis coded during the study period. Many were prescribed dementia medications and/or other psychotropic medications, predominantly antidepressants. These veterans utilized a variety of outpatient services, including high rates of mental health consultation subsequent to GEM evaluation, though low rates of mental health follow-up were observed. Results from the current study provide insight into the important role mental health providers such as psychologists and psychiatrists can play as collaborators in interdisciplinary geriatrics care for veterans. Keywords: dementia, integrated health care, interdisciplinary geriatrics care, mental health, veterans

A well-established body of literature demonstrates that veterans served by the Veterans Health Administration (VHA) evidence more medical complexities and disability compared with community-based age-matched samples (e.g., Selim et al., 2004). In addition, older veterans are at particular risk for multimorbidi-

ties (Steinman et al., 2012), with a greater prevalence of cooccurring medical and mental health concerns, including dementia, documented in this population (Sorrell & Durham, 2011; Yaffe et al., 2010). For example, Kunik and colleagues (2003) found that roughly two thirds of older veterans with dementia at a south-

This article was published Online First November 24, 2014. Paul R. King, VA Center for Integrated Healthcare, Buffalo, New York; Christina L. Vair, VA Center for Integrated Healthcare, and Department of Psychology, The University at Buffalo, State University of New York; Michael Wade, Department of Psychology, VA Center for Integrated Healthcare; Julie Gass, Department of Psychology, The University at Buffalo, State University of New York; Laura O. Wray, VA Center for Integrated Healthcare, and Division of Geriatrics/Gerontology, Department of Medicine, School of Medicine & Biomedical Sciences, The University at Buffalo, State University of New York; Anna Kusche, Charito Saludades, and June Chang, VA Western New York Healthcare System, Buffalo, New York. The writing of this article was supported by the Department of Veterans Affairs Office of Academic Affiliations, Advanced Fellow-

ship Program in Mental Illness Research and Treatment, the Department of Veterans Affairs Center for Integrated Healthcare, and the VA Western New York Healthcare System at Buffalo. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government. We thank Johnpatrick Marr, Nicole Mattila, and Glenn Mead for their assistance with data collection, and Evan Plys for his assistance with manuscript review. Correspondence concerning this article should be addressed to Paul R. King, VA Center for Integrated Healthcare (116N), VA Western New York Healthcare System, 3495 Bailey Avenue, Buffalo, NY, 14215. E-mail: [email protected] 66

OUTPATIENT HEALTH CARE UTILIZATION IN GEM PATIENTS

central VHA location evidenced other psychiatric comorbidities. Dementia alone, including probable Alzheimer’s disease, vascular, and frontotemporal dementia, has also been linked to increased health care utilization (Fillit, Hill, & Futterman, 2002; Fowler et al., 2012; Hill, Fillit, Shah, del Valle, & Futterman, 2005). Taken together, the intersection of medical and mental health issues can lead to significant challenges for clinical management and result in high rates of health care use (Kessler, Merikangas, & Wang, 2007; Luber et al., 2001). In consideration of the aging veteran population, the need for adequate resources to address age-related medical and mental health concerns will continue to increase as Vietnam-era (currently ages 56 to 74) and other cohorts require more intensive interdisciplinary geriatric care (Elhai, Grubaugh, Richardson, Egede, & Creamer, 2008). Within VHA, primary care serves as the hub for care coordination, though primary care providers face numerous challenges in assessing complex patients and making treatment decisions in this setting. In particular, studies have documented underdetection of dementia in primary care settings (Bradford, Kunik, Schulz, Williams, & Singh, 2009), challenges in differential diagnosis between late-life depression and cognitive impairment (Jorm, 2000), and decreased adherence to treatment among patients with dementia (Arlt, Lindner, Rösler, & von Renteln-Kruse, 2008). Additional challenges exist with regard to medication management, including balancing the risks, benefits, and contraindications associated with use of cholinesterase inhibitors, antipsychotics, benzodiazepines and other sedatives, and aggressive glycemic control efforts (The American Geriatrics Society 2012 Beers Criteria Update Expert Panel, 2012; Kirkman et al., 2012; Maher et al., 2011). Because dementia often co-occurs with other chronic illnesses, which increases the risk of mortality and often demands a significant degree of medical coordination, interdisciplinary assessment and intervention is particularly well-suited to address the multifaceted needs of patients with dementia and their family caregivers. By design, such interdisciplinary specialty geriatric clinical teams are structured to complement the services delivered in primary care. VHA’s Geriatric Evaluation and Management (GEM) clinics are one example of an interdisciplinary approach to care designed to address the specific needs of older veterans with complex age-related concerns (e.g., dementia, multimorbidity, polypharmacy, and frailty). As outlined in VHA policy documents, the goals of outpatient GEM programs are to identify, assess, and address the biopsychosocial needs of frail older veterans at risk for further decline and institutional placement, in service of optimizing health and function, and maximizing independence (Department of Veterans Affairs, 2010). GEM evaluations typically involve interdisciplinary assessment, with management focused on the development and implementation of a collaborative care plan. Implementation may consist of short-term care within the GEM clinic setting or providing focused recommendations to be carried out by other care providers, often within primary care. VHA mandates that GEM teams consist of, at a minimum, a geriatric medical provider, a social worker, and a nurse; however, psychologists, psychiatrists, and other clinicians and allied health professionals may be included as members of an extended interdisciplinary team (Department of Veterans Affairs, 2010). Although larger-scale studies primarily focused on the cost effectiveness and patient outcomes of GEM programs in VHA

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nationwide were previously undertaken (e.g., Cohen et al., 2002; Rizzo & Rowe, 2006), there is a paucity of research on the current clinical practices in GEM clinics, and the interface between GEM and primary care settings. The aim of the present article is to describe the demographic characteristics, mental health diagnoses, and health care utilization in a sample of GEM patients with diagnosed cognitive impairment who receive VHA services.

Method Data was gathered via a retrospective review of VHA electronic medical record (EMR) database. EMR data was extracted from the charts of veterans with diagnosed cognitive impairment seen in VHA GEM clinics across Upstate New York from Fiscal Years 2001 (October 1, 2000) through 2011 (September 30, 2011). Inclusion criteria included (a) age 65 or older, (b) at least one visit to a VA GEM clinic, and (c) documented diagnosis of cognitive impairment as evidenced by clinic encounter(s) coded for International Classification of Diseases, Ninth Revision (ICD-9) diagnostic codes pertaining to mild cognitive impairment or dementia. The Institutional Review Board at the VA Western New York Health care System (Buffalo, NY) reviewed and approved the present study.

Procedure Once eligible records were identified, we extracted relevant chart data (i.e., patient demographics, cognitive screening scores, health care utilization variables pertaining to outpatient clinical care, and prescription for common dementia and other psychotropic medications). Clinical care variables included the number and type of follow-up visits to VA outpatient clinics (i.e., primary care, emergency room, and adult day health care). The period of record observation began with each veteran’s first VA GEM encounter. On average, 1.5 years of chart data were available for each patient (see Table 1).

Analysis Chi-square tests evaluated frequency distributions of demographic variables. Infrequently observed and nonspecific diagnoses (e.g., senile psychosis, dementia with Lewy bodies) were collapsed into a single category of “Other Dementia.” In calculating health care utilization, we coded the number of visits to various clinics over the course of the observation period, and treated these as count variables. Negative binomial regression models were constructed to account for variation observed in these counts, and means and standard errors were calculated for each with adjustments based on length of case observation. Calculation of time between appointments was contingent upon recorded follow-up visits, and patients without follow-up data were excluded from these analyses. Where indicated, the number of days between visits was linearly transformed into months or years. Counts for each clinic were then organized based on service type (i.e., medical, mental health, support/ other). Pharmacy data were coded dichotomously (i.e., prescribed vs. not prescribed), so that frequencies of prescriptions for dementia and psychotropic medications could be calculated for descriptive purposes. The level of significance was set at ␣ ⫽ .05, and all analyses were performed with SAS version 9.3 (SAS Institute Inc., Cary, NC).

KING ET AL.

68 Table 1 Selected Sample Characteristics Variable

n (%)

Sex Male Female Race Black or African American Native Hawaiian or other Pacific Islander White Race unknowna Ethnicity Hispanic or Latino Not Hispanic or Latino Ethnicity unknownb Branch of service Air Force Army Marine Corps Navy Otherc

Age at first GEM visit Age at last GEM visit Age at deathd Months elapsed between GEM intake and deathd,e Mini-Mental Status Exam score at intakef Years of follow-up observation

p value ⬍.001

453 (95) 23 (5) 37 (7.8) 1 (.2) 398 (84) 40 (8.3) 3 (0.7) 432 (90.7) 41 (8.5)

⬍.001

⬍.001

⬍.001

46 (9.6) 292 (61.3) 31 (6.5) 97 (20.3) 10 (2.1) Mean (SD)

Range

81.4 (5.8) 81.7 (5.8) 83.6 (5.7)

65 to 98 65 to 98 66 to 97

29.9 (23.0) 19.2 (6.1) 1.5 (1.1)

0 to 120 0 to 30 0 to 3

Note. GEM ⫽ geriatric evaluation and management. No data found ⫽ 30, declined by patient ⫽ 7, unknown by patient ⫽ 3. b No data found ⫽ 25, declined by patient ⫽ 12, unknown by patient ⫽ 4. c Coast Guard ⫽ 6, Merchant Marine ⫽ 1, Other ⫽ 2, Missing ⫽ 1. d Date of death available for 273 patients. e Median ⫽ 26.00; skewness ⫽ 0.97; 25th percentile ⫽ 11 months, 50th percentile ⫽ 26 months, 75th percentile ⫽ 44.5 months. f Score at intake available for 291 patients; skewness ⫽ ⫺0.74. a

Results Sample Characteristics A total of 476 of 1,554 available GEM records met inclusion criteria (i.e., age ⱖ65, recorded diagnosis of cognitive impairment). Of these, the majority were Caucasian (84%), male (95%), and Army veterans (61%), with an average age of 81.4 years (SD ⫽ 5.8, range ⫽ 65.5 to 98.5) at initial GEM encounter. Mini-Mental Status Exam scores were the most commonly reported cognitive screens (n ⫽ 291), with an average score at intake of 19.2 (SD ⫽ 6.1, range ⫽ 0 to 30). Of the final sample, 273 (57%) patients died within the study observation period, with an average age at death of 83.6 years (SD ⫽ 5.7). A median value of 26 months elapsed between GEM intake and date of death. Of patients who died during the record observation period, 25% were deceased within 11 months of intake, and 75% were deceased within 44.5 months. Table 1 provides a summary of these demographic characteristics. The most common dementia and cognitive impairment diagnoses recorded were vascular (32%) and unspecified dementia (32%), followed by probable Alzheimer’s disease (26%). Cases of mild cognitive impairment, frontotemporal dementia, and Pick’s disease were less frequently documented (9%, 1.6%, and 0.4%,

respectively). More than 66% of patients had at least one mental health diagnosis coded during the study period, with over 56% having two or more mental health diagnoses coded. Depression was the most frequent single diagnosis coded (27%), although a variety of other mental health diagnoses were commonly coded at encounters as well. Table 2 summarizes these results.

Health Care and Medication Utilization As shown in Table 3, the typical patient had more than 46 outpatient clinical encounters (SE ⫽ 2.5) over an average of 1.5 years of chart observation. Seventy-eight percent had primary care visits, with an average of 3.3 months between appointments (SE ⫽ .2, range ⫽ 0 to 28.9). More than half of the patients had just a single GEM visit (58%); the remainder were followed for an average of 1.5 years (SD ⫽ 1.1, range ⫽ 0 to 3). Nearly half of the sample was followed conjointly by rehabilitative and restorative specialists, such as physical or occupational therapists (46%), and many also used adult day health services (37%). Several had at least one emergency room visit (22%) or a clinical pharmacy review (23%). Specialty consultative services such as other dementia clinics (18%), neurology (17%), and geriatric clinics (15%) were used by a smaller, but still noteworthy, proportion of patients. Imaging studies were completed during the observation period for relatively few patients (6%). Nearly half (49%) of the sample had contact with a mental health professional, which included contact with a primary care mental health integrated provider, though mental health services were most frequently provided through specialty care (30%) or a psychogeriatric clinic (22%). Most of the individuals who had contact with a mental health professional had been diagnosed with a mental health disorder, though a minority (18%) did not have any mental health diagnosis attached to a mental health encounter. On average, 4.4 months elapsed between mental health visits (SE ⫽ 0.5, range ⫽ 0 to 34). Patients

Table 2 Frequency and Types of Cognitive Impairment and Mental Health Diagnoses Variable Frequencies of observed cognitive impairment Alzheimer’s disease Frontotemporal dementia Pick’s disease Vascular dementia Other dementia Mild cognitive impairment/Mild neurocognitive disorder frequencies of observed mental health diagnoses Adjustment disorder Alcohol abuse Anxiety Bipolar disorder Depression PTSD Schizophrenia Other diagnosis Any mental health diagnosis Depression ⫹ PTSD Any other combination

n (%) 127 (26.0) 8 (1.6) 2 (0.4) 157 (32.0) 156 (32.0) 45 (9.0) 29 (6.1) 13 (2.7) 47 (9.9) 1 (0.2) 127 (27.0) 25 (5.3) 11 (2.3) 239 (50.2) 316 (66.4) 11 (2.3) 269 (56.5)

Note. Other mental health diagnoses consisted of unspecified mood disorder, obsessive– compulsive disorder, panic disorder, and other unspecified conditions. PTSD ⫽ posttraumatic stress disorder.

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Table 3 Outpatient Health Care Utilization Among Geriatric Evaluation and Management (GEM) Clinic Patients

Variable Medical Any medical Emergency room Imaging Primary care General internal medicine Neurology Neurosurgery Cardiology Physical medicine and rehabilitation Geriatric specialty clinic Alzheimer’s/dementia clinic GEM Mental health (MH) Any MH Primary care MH Specialty MH Substance abuse treatment Day treatment/PRRC/ MHICM Psychogeriatric clinic Support/other consult Clinical pharmacy Audiology Speech pathology PT/OT/kinesiotherapy Social work Adult day health care Total health care encounters

Combined sample (n ⫽ 476)

Patients w/ MH diagnosis (n ⫽ 316)

n

%

Mean (SE)

n

%

Mean (SE)

n

%

Mean (SE)

p value

476 106 286 369 29 82 2 57 31 70 84 476

100 22 6 78 6 17 0.4 12 7 15 18 100

7.4 (0.3)a 0.4 (0.1) 1.5 (0.1) 3.2 (0.1)b ⬍0.1 (⬍0.1) 0.28 (⬍0.1) ⬍0.1 (⬍0.1) 0.2 (0.1) 0.1 (⬍0.1) 0.3 (0.1) 0.2 (⬍.01) 1.3 (0.1)c

316 87 216 261 24 67 2 45 26 50 62 316

100 28 68 83 8 21 0.6 14 8 16 20 100

7.7 (.3) 0.4 (0.1) 1.6 (0.1) 3.3 (0.2) ⬍0.1 (⬍.1) 0.2 (⬍.1) ⬍0.1 (⬍.1) 0.2 (⬍.1) ⬍0.1 (⬍.1) 0.3 (⬍.1) 0.2 (⬍.1) 1.4 (0.2)

160 19 70 108 5 15 0 12 5 20 22 160

100 12 44 68 3 9 0 8 3 13 14 100

6.6 (.5) 0.2 (0.1) 1.3 (0.2) 3.1 (0.2) ⬍0.1 (⬍.1) 0.3 (⬍.1) 0 (0) ⬍.1 (⬍.1) ⬍0.1 (⬍.1) 0.3 (⬍.1) 0.2 (⬍.1) 1.2 (0.3)

.087 .043 .226 .500 .336 .294 NA .071 .351 .850 .530 .692

234 38 143 2 7 104

49 8 30 0.4 1.5 22

1.7 (0.25)d 0.1 (⬍0.1) 0.9 (0.1) ⬍0.1 (⬍0.1) 0.2 (0.2) 0.4 (⬍0.1)

192 35 124 2 7 84

61 11 39 0.6 2 27

2.1 (0.3) 0.2 (0.1) 1.2 (0.2) ⬍0.1 (⬍.1) 0.3 (0.2) 0.4 (⬍.1)

42 3 19 0 0 20

26 2 12 0 0 13

0.4 (0.2) ⬍0.1 (⬍.1) 0.2 (0.1) 0 (0) 0 (0) 0.3 (⬍.1)

.004 .035 .008 NA NA .169

111 102 25 217 12 175 476

23 21 5 46 2.5 37 100

0.3 (0.1) 0.4 (⬍0.1) ⬍0.1 (⬍0.1) 6.7 (1.0) ⬍0.1 (⬍0.1) 12 (1.3) 46.6 (2.5)

86 76 22 175 6 131 316

0.3 (⬍.1) 0.4 (⬍.1) 0.1 (⬍.1) 8.2 (1.4) ⬍.1 (⬍.1) 12.9 (1.6) 51.2 (3.1)

25 26 3 42 6 44 160

16 16 2 26 4 28 100

0.3 (.1) 0.3 (⬍.1) ⬍.1 (⬍.1) 2.5 (1.3) ⬍.1 (⬍.1) 9.4 (2.3) 33.4 (4.2)

.571 .504 .112 .026 .736 .240 .002

27 24 7 55 2 41 100

Patients w/o MH diagnosis (n ⫽ 160)

Note. 275 patients (58%) only had a single GEM encounter. The average time (in months) between GEM visits and primary care visits was 3.6 (range ⫽ 0 to 33.1). MH ⫽ mental health; MHICM ⫽ Mental Health Intensive Case Management; NA ⫽ not applicable; OT ⫽ occupational therapy; PRRC ⫽ Psychosocial Rehabilitation and Recovery Center; PT ⫽ physical therapy. a Time between visits M ⫽ 2.1 months (range ⫽ 0 to 25.1), SE ⫽ 0.1, n ⫽ 431. b Time between visits M ⫽ 3.3 months (range ⫽ 0 to 28.9), SE ⫽ 0.2, n ⫽ 298. c Time between visits M ⫽ 3.2 months (range ⫽ 0 to 30.6), SE ⫽ 0.3, n ⫽ 201. d Time between visits M ⫽ 4.4 months (range ⫽ 0 to 34), SE ⫽ 0.5, n ⫽ 137.

with a mental health diagnosis had significantly greater mean mental health visits than those without a mental health diagnosis, though rates of follow-up appeared low (i.e., M ⫽ 2.1, SE ⫽ 0.3 for any mental health visit; M ⫽ 1.2, SE ⫽ 0.2 for specialty mental health visits). Substantially higher rates of rehabilitation services (physical therapy/ occupational therapy/kinesiotherapy) were observed in patients with mental health diagnoses (8.2 vs. 2.5 visits, p ⫽ .026) when compared with patients with no mental health diagnosis. Patients with a mental health diagnosis also had significantly more ER visits (0.4 vs. 0.2 per year, p ⫽ .043), though the practical significance of this finding may be minimal as overall rates of ER use were low. Notably, patients with a mental health condition evidenced 53% more total health care encounters than those without. Table 4 displays counts of prescriptions for common dementia medications during the study period. Half of all patients were prescribed donepezil with a smaller proportion having been prescribed memantine (22%). Relatively few were prescribed galantamine (6.1%) or rivastigimine (4.6%). Combinations were infrequent, though 13.5% of the sample was prescribed both donepezil and memantine. Only one of the 476 patients had been trialed on all four dementia medications included in the study during the observation period. However, because only raw counts were calculated, it is

plausible that these data reflect patients who had been trialed on more than one medication across the study observation period (e.g., a patient would be counted in rows for both galantamine and donepezil if he or she had received a prescription for galantamine but switched to donepezil). In addition to dementia medications, more than 45% of the sample was prescribed an antidepressant, the bulk of which were selective serotonin reuptake inhibitors. More than one quarter were prescribed an antipsychotic. Anticonvulsants, benzodiazepines, and other sedative-hypnotics were less frequently prescribed (see Table 4).

Discussion The present study conducted a retrospective review of EMRs to examine demographic information and outpatient health care utilization in a sample of 476 veterans with cognitive impairment seen in VHA Geriatric Evaluation and Management and primary care clinics across Upstate New York. Our results demonstrate that the current sample of veterans utilized a variety of outpatient services at frequent intervals during the study period, on average, nearly 47 clinical encounters per patient. The bulk of these patients were regularly followed by VA primary care providers, and many evidenced use of

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70 Table 4 Use of Dementia and Mental Health Medications Among Geriatric Evaluation and Management (GEM) Patients With Cognitive Impairment Medication Dementia medications Donepezil Galantamine Memantine Rivastigmine Combinations Donepezil ⫹ Memantine Galantamine ⫹ Memantine Other combinations Psychotropic medications Anticonvulsants Antidepressants Antipsychotics Sedative hypnotics (Any) Benzodiazepine derivatives Other

n (%) 238 (50) 29 (6.1) 103 (22.0) 22 (4.6) 64 (13.5) 10 (2.1) 12 (5.0) 82 (17.2) 216 (45.4) 128 (26.9) 74 (15.6) 50 (10.5) 34 (7.1)

Note. Numbers in the table represent whether a patient had a prescription for any of the above medications during the study period.

restorative and rehabilitative services, such as physical and occupational therapy. These specific results related to health care utilization are not surprising given the clinical complexity typically described in older veteran samples (Selim et al., 2004). However, a novel finding was that veterans with co-occurring dementia and other mental health conditions evidenced substantial elevations in total health care utilization (i.e., more than 1.5 times as many total encounters than those without mental health conditions) that were not uniquely attributable to mental health service delivery. Compared with other prevalence estimates in community and veteran samples, which suggest Alzheimer’s disease is the most common dementia diagnosis (Jak, Filoteo, Bondi, & Delis, 2012), vascular dementia comprised the largest proportion of the present sample (32% compared with 11.9% cited in Jak et al., 2012), followed by Alzheimer’s disease (26%). Indeed, previous examinations of veteran samples (e.g., Selim et al., 2004) have documented high rates of cardiovascular conditions such as hypertension, hyperlipidemia, diabetes, and congestive heart failure—in some cases exceeding 25% (Byers & Yaffe, 2014)—all of which are established risk factors for the development of vascular dementia. There was also a large group of less common or unspecified dementia diagnoses (32%) indicated, though this finding is consistent with Butler, Kowall, Lawler, Michael Gaziano, and Driver’s (2012) work. It is plausible that the relative frequency of vascular and other dementia diagnoses in the present sample may reflect greater patient and/or provider need for interdisciplinary GEM consultation for these conditions (i.e., clinical complexity), an artifact of local or regional diagnostic practices, or be related to sampling error. In addition to diagnoses of dementia or mild cognitive impairment, over 66% of our sample also had an encounter coded for another mental health diagnosis, most frequently depression. Also, well over half of the sample had clinical encounters coded for two or more mental health conditions during the study period. Nearly half of the sample had outpatient mental health treatment subsequent to initial GEM contact, with the majority seen in specialty mental health

settings. These findings are consistent with other research that documents high rates of co-occurrence between dementia and other mental health diagnoses, particularly depression (Wright & Persad, 2007). A growing body of literature describes that depression may be a prodrome for dementia, and that some severe geriatric depression may manifest as pseudodementia with symptoms of pronounced memory impairment and affective disturbance (Wright & Persad, 2007). The complicated relationship between geriatric depression and dementia highlights the importance of detection of mental health concerns among older adults in determining accurate diagnoses and appropriate treatment strategies. Despite the finding that nearly half of the sample received mental health treatment, and nearly one third had contact with a specialty mental health provider during the study observation period, overall rates of mental health follow-up appeared to be relatively infrequent, with a span of more than 4 months between episodes of care. At a minimum, our findings with regard to the prevalence of mental health concerns, combined with previous literature and the well-established links between physical and emotional health, strengthen the argument for consistent integration of mental health services into interdisciplinary geriatric care. Currently, GEM policy stipulates that the core team of a geriatric provider, social worker, and nurse may be expanded to include providers from psychology and psychiatry (Department of Veterans Affairs, 2010). Our data suggest that mental health providers likely have numerous opportunities to fulfill a potentially underserved need in GEM. Psychologists in particular are uniquely positioned to conduct and interpret cognitive assessments, assist in differential diagnosis between depression and dementia, and provide specific behavioral recommendations for both mental health and medical conditions (Areán & Gum, 2013). In turn, psychiatrists can serve an important role in determining appropriate psychopharmacological management strategies for co-occurring dementia and mental health diagnoses (GS [AGS], 2013, 2014). In line with the aforementioned American Geriatrics Society (AGS, 2013, 2014) recommendations, psychologists are capable of conducting cognitive assessments to evaluate response to treatment with cholinesterase inhibitors, and psychiatrists are important partners in determining the utility of medication management involving antipsychotics and benzodiazepines. A potential need for medication review may exist, given the relative frequency of antipsychotic use we observed (26.9%), despite that antipsychotics are typically contraindicated for managing behavioral problems unless other interventions have failed or if patients are at risk of harming themselves or others (The American Geriatrics Society 2012 Beers Criteria Update Expert Panel, 2012). Data from the current study presents the opportunity to inform clinical practices in several other ways. Exploring descriptive data provides the chance to assess actual use of services, as well as to identify potential gaps in care. Further, such data can be useful in informing quality improvement activities and implementing clinical practices to enhance population-specific concerns. In this study, we observed frequent use of outpatient medical services. Although this is to be expected, the course of clinical care may vary widely based on the complexity of an individual case. Primary care providers typically manage the bulk of care for older veterans, though high need and/or high service utilizers may stand to benefit from consultation with or treatment from an interdisciplinary team. Our results demonstrate typically infrequent contacts with GEM services within one large geographic area, and greater care provided through primary care, indicating the potential value in linkage between these services for

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specific treatment recommendations for aging veterans. As indicated in GEM policy (Department of Veterans Affairs, 2010), implementation of treatment recommendations and ongoing management may improve patient outcomes, and may also have the potential to reduce the number of visits to other consultative clinics and help avoid unnecessary duplication of services, which, in turn, may also reduce cost. One avenue that has yet to be explored in the literature is how to determine the most appropriate time to initiate a referral to interdisciplinary geriatrics care. VHA GEM policy documents indicate that the optimal point to provide interdisciplinary care to maximally benefit from these comprehensive services hovers between the time frames of when a patient is “too well” and “too sick” (Department of Veterans Affairs, 2010, p. 2). This determination may be challenging to make, given that such classifications vary by patient needs and the clinical judgment of referring providers. Although specific referral criteria may exist at both the local and national levels, there are not clearly defined determinants of what makes any one patient versus another too sick or too well. Clearly, older patients with multiple medical problems are already at increased risk for morbidity. Our results demonstrate that most patients referred for GEM services were already in their early 80s, and that more than half of patients died within the study period. Potential clinical action items include (a) educating primary care providers of the benefits and availability of formal and informal consultation (including electronic chart review consultation) with interdisciplinary geriatrics specialty providers; (b) lowering thresholds for interdisciplinary team referral in order to optimize care at an earlier time point for the benefit of both patients and caregivers; (c) considering the benefits of outpatient GEM programs in active implementation of care plans, possibly inclusive of longer-term patient follow-up if indicated and as resources are available; and (d) considering the benefits of earlier and/or more consistent use of mental health services for mood and behavioral management, to include medication review and optimization. Alternatively, GEM clinics may be strategically positioned to help initiate entry into palliative care and Hospice programming, which aligns with VHA Geriatrics and Extended Care strategic plans to increase overall access to such programming for all veterans at the national level (Shay, Hyduke, & Burris, 2013). There are several limitations within our study that merit mention. First, we examined only chart data beginning with veterans’ first GEM encounter. We are thus unable to comment on prior VHA care and any care delivered outside of VHA. This is especially germane to pharmacy data, as we are unable to comment on issues such as specific reasoning for use of dementia medications, other psychotropics, or drug combinations, and changes in prescribing over time. Additionally, data on comanagement of care by providers outside VHA was not available for the current study, and thus overall health care utilization may be underrepresented. Second, there is an important distinction between what is documented in patient charts and the actual services delivered. Although chart documentation and encounter coding may reliably record that services were delivered, database studies are unable to capture the full context and purpose of a clinical encounter, as was the case for the 42 patients in our study who received mental health services without a mental health diagnosis. Third, as is the case with other retrospective reviews, our data were subject to variation and potential errors in coding and diagnostic practices, including specific coding of dementia and mental health diagnoses. In particular, this was evidenced in the fact that some

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patients had multiple different dementia diagnoses over the study period. However, it is entirely plausible that multiple diagnostic codes may also be a result of diagnostic refinement over time. Lastly, GEM team composition likely varies from location to location, and we are unable to account for clinic-level variation in diagnostic practices and services provided. Some clinics or clinicians may in fact be providing more robust services, delivering short-term mental health care, or following cases for varying lengths of time. Because we only explored a subsample of GEM patients treated for cognitive impairment in one restricted geographic area, we are also unable to comment on referral and care utilization practices in an otherwise medically complex but cognitively intact group of patients who would also qualify for GEM services. As such, our findings are not necessarily generalizable to the larger demographic of veterans served by VHA GEM clinics. Despite these limitations, our study provides meaningful insights into health care utilization practices in a high-need, medically and psychiatrically complex sample of older veterans. In keeping with Selim et al.’s (2004) description of the aging veteran population, the present study describes recent GEM patient demographics and care needs that could be useful in designing services and systems of care to address the complex biopsychosocial care demands of aging veterans. Though the majority of the present sample was comprised of World War II and Korean War-era veterans, an additional future consideration involves determining the potential challenges associated with providing care for an aging Vietnam-era veteran cohort. Of particular concern is the well-documented rate of co-occurrence of posttraumatic stress disorder and substance misuse and abuse in this population (e.g., McFall, Mackay, & Donovan, 1992), and how these comorbidities may influence the development of dementia, further complicating multimorbidity and the care needs and use of the health care system (King, 1986; Sorrell & Durham, 2011; Yaffe et al., 2010). Previous literature has documented higher rates of service utilization for each of these mental health conditions separately (Elhai et al., 2008; Kessler et al., 2007), as well as higher rates of mental health care utilization in Vietnam-era and younger cohorts compared with older generations of veterans (Sorrell & Durham, 2011). Thus, there is a growing need for future studies to identify best practices in simultaneously managing these conditions from both an interdisciplinary and population-based standpoint. In particular, future research that considers how best to integrate the services of psychology and psychiatry into interdisciplinary geriatric specialty care is paramount. Additional studies that examine outcomes related to care coordination, impact on health care expenditures, and patient and caregiver quality of life will further add understanding of the value of geriatric interdisciplinary care in VHA.

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Received March 14, 2014 Revision received September 11, 2014 Accepted October 14, 2014 䡲