International Psychogeriatrics (2012), 24:11, 1708–1724 

C International Psychogeriatric Association 2012

doi:10.1017/S1041610212000981

REVIEW

Telepsychogeriatrics: a new horizon in the care of mental

health problems in the elderly
.........................................................................................................................................................................................................................................................................................................................................................................

Ramón Ramos-Ríos,1 Raimundo Mateos,1,2 David Lojo,3 David K. Conn4,5

and Tim Patterson5
1
Psychogeriatric Unit, Psychiatry Department, Complejo Hospitalario Universitario de Santiago de Compostela (CHUS), Santiago de Compostela, Spain
2
Department of Psychiatry, Universidad de Santiago de Compostela (USC), Santiago de Compostela, Spain
3
Higher Systems and Information Technology Government Body, CHUS, Santiago de Compostela, Spain
4
Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
5
Telehealth Services, Baycrest Centre for Geriatric Care, Toronto, Ontario, Canada

ABSTRACT

Background: The use of telemedicine for the care of mental health problems has developed significantly over
the last decade thanks to the emergence of a number of stable telepsychiatry programs in many countries.
Parallel to this development, this care modality has also targeted specific populations with higher difficulty
in gaining access to mental health services such as the elderly. Telepsychogeriatrics is expected to have an
increasing role in providing care to geographically isolated rural communities, with a particular focus on
long-term care facilities, in light of the high prevalence of psychiatric disorders in these centers and the lack
of available specialized care.
Methods: A thorough search of the literature was conducted using Medline, Web of Science, and PsychINFO
databases in order to gather available evidence on the applicability of telepsychiatry, specifically the use
of videoconferencing for remote consultation, in the elderly population with mental disorders. A succinct
description of the selected studies is given along with a general reflection on the state-of-the-art in the field of
psychogeriatric clinical practice and research.
Results: Research on the use of telemedicine in this age group has taken into account their special characteristics,
and has focused on demonstrating its applicability, the acceptance and satisfaction of elderly users and their
healthcare providers, the possibility of carrying out cognitive and diagnostic assessments, and the efficiency
of these programs.
Conclusions: Despite limited experience, telepsychogeriatrics appears to be a viable option, well accepted by
patients, including those having dementia. More systematized studies are needed in this new field based
on larger sample sizes, including comparison with traditional consultations and assessment of the clinical
outcomes.

Key words: telemedicine, telehealth, e-health, e-medicine, remote consultation, video consultation, videoconferencing, telepsychiatry,
telepsychogeriatrics

Introduction status (American Telemedicine Association (ATA),

2007).
Telepsychiatry One of the fields where telemedicine has had
The American Telemedicine Association defines greater development has been mental healthcare
telemedicine as the use of medical information (Frueh et al., 2000; Monnier et al., 2003; Wootton
exchanged from one site to another via electronic et al., 2003; McGinty et al., 2006). Among the
communications to improve patients’ health reasons explaining this, we may cite the following:

Correspondence should be addressed to: Prof. Raimundo Mateos, Department

of Psychiatry, School of Medicine, ES 15782 Santiago de Compostela, – The very nature of the specialty: Most information
Spain. Phone: +34 981 950 901; Fax: +34 981 951 901. Email:
raimundo.mateos@usc.es. Received 15 Oct 2011; revision requested 28 Nov
can be gathered in an audiovisual manner. In
2011; revised version received 20 Apr 2012; accepted 29 Apr 2012. First addition, laboratory tests or physical examination
published online 12 June 2012. are not often necessary (Norman, 2006).

– Accessibility: There are isolated areas or com-
munities that have difficulty in gaining access to
mental health services (Schopp et al., 2005; Hilty
et al., 2006b). This isolation may not be just
geographically based but also cultural, as is the case,
for instance, in areas with a significant immigrant
population (Shore and Manson, 2005; Hilty et al.,
2006a; Shore et al., 2006).
– Cost-effectiveness: The aim is to reduce the need
for specialists to travel to these areas. Thus, a more
efficient use of professional time is achieved and
expenses deriving from traveling are reduced.
– Importance of general practitioners’ role in the
care of mental health problems (due to its
high prevalence). Videoconferencing is a meeting
point between these professionals and specialists,
thus improving doctor’s training and patient’s
understanding (Norman, 2006). It is an opportunity
for the general practitioner to treat the patient acting
in collaboration with the psychiatrist (Hilty et al.,
2006a). Patient referral that overloads specialized
care is thus prevented and a communication channel
is established through which the general practitioner
may acquire new clinical skills (Hilty et al., 2006b).
Telepsychiatry is that area of telemedicine which
has explored the use of communications technology
in mental health service delivery, and the technology
most often used has been videoconferencing
(Wootton et al., 2003; Melaka et al., 2009). The
first telepsychiatry programs date back to the 1960s
(Wittson and Benschoter, 1972). These programs
were not continued mainly due to technical and
financial constraints. Its application was considered
financially unfeasible until not long ago (Werner
and Anderson, 1998).
As a result of technical progress over the last
two decades, together with the improvement of
communication technology and the reduction in
transmission costs and equipment, telepsychiatry
programs have emerged again. Until recently, most
ongoing projects use videoconference with ISDN
(Integrated Services Digital Network) technology.
However, the use of IP (Internet Protocol) network
technology, with suitable security measures and
guaranteed service quality, may lead to a cost
reduction (Hilty et al., 2004; McGinty et al., 2006).
This care modality has been utilized in large
regions with scattered population, where rural areas
may be underserved regarding mental health (for in-
stance, in the USA (Cruz et al., 2005), Canada (Ur-
ness et al., 2004), Australia (Clarke, 1997; Janca,
2000)); in islands, due to the limited accessibility to
specialized care and the high cost of traveling (De las
Cuevas et al., 2003a; 2003b); for the care of more
or less closed communities where it is preferable
to see the subjects in their environment (such
as prisons (Leonard, 2004) and nursing homes
for the elderly or veterans’ homes) or for specific
Telepsychogeriatrics 1709
population groups (such as immigrants or certain
ethnic groups (Shore et al., 2007; Mucic, 2010)).
Existing research on the application of
telepsychiatry to the general population shows
that it is well accepted by users (De las Cuevas
et al., 2003a; Greenwood et al., 2004; Hyler and
Gangure, 2005; Urness et al., 2006), that diagnoses
are reliable, that it is possible to provide treatment
(Fortney et al., 2007; O’Reilly et al., 2007), and
that there is good cost-effectiveness (Hyler and
Gangure, 2003). However, more studies are
necessary so as to prove that remote consultation
by videoconferencing is equivalent to face-to-face
consultation and in order to assess the clinical
course under this care mode. Furthermore, ethical
and legal issues regarding its application (Frueh
et al., 2000; Monnier et al., 2003) must be solved.
Nowadays, its use is only recommended when
there are considerable difficulties in carrying out
face-to-face consultation (Janca, 2000).
Telepsychogeriatrics
The application of telepsychiatry to elderly care
has been the object of special interest for a
number of reasons. Old age groups account for
an important proportion of the population in rural
and geographical areas distant from centers where
specialized care is provided (Liu et al., 2006). These
individuals are frequently afflicted by more than one
condition, the problems are often of chronic nature
requiring repeated monitoring but they cannot
usually travel on their own, which makes traveling
difficult and expensive (Wootton et al., 2003).
This, together with other prejudices regarding
elderly mental health that attribute certain disorders
to normal aging, leads to a failure in referring
them for specialized consultations. Unrecognized
depression, behavioral aspects of dementia,
multiple medical and psychiatric comorbidities, and
treatment complications are very common among
nursing home residents. In these facilities, difficulty
gaining access to specialized attention is also a
common occurrence (Jones, 1999). Thus, we are
faced with a situation where the most vulnerable
subjects are the ones facing the greatest difficulties
to gain access to mental health services (Jones and
Colenda, 1997; Jones and Ruskin, 2001; Sumner,
2001; Jones, 2002; Snowdon, 2010).
The capacity of telepsychiatry to overcome geo-
graphical distances, to render travel unnecessary,
and to act as a support to the professionals
practicing in remote areas makes it a solution worth
looking into. The main applications of telepsycho-
geriatrics up to now have been the provision of care
to the elderly in rural areas in the context of major
telepsychiatry programs, care to nursing homes
1710 R. Ramos-Ríos et al.
located in remote areas, or with poor access to spe-
cialized care and conducting diagnosis assessment
programs, mainly focused on detecting dementia
(Shulman et al., 2006; Vilalta-Franch et al., 2007).
Objectives
The overview described above on the possible
applications of telepsychogeriatrics poses challenges
and specific research questions in this field of
telemedicine that can be summarized as follows:
(1) Are telepsychiatry programs used for general
population care applicable to the elderly? What
are the main applications of videoconferencing in
psychogeriatric care at present?
(2) Is it feasible to render psychogeriatric services to
nursing homes for the elderly via videoconferencing?
(3) What is the validity of psychopathologic assessments
made via videoconference? And specifically, are
cognitive assessments made through this system
reliable?
(4) Has the geriatric population more difficulty
accepting care through this system? How will
subjects with cognitive impairment respond to the
videoconferencing situation?
The purpose of this paper was to review existing
literature on these questions and to sketch a general
overview of the current situation in this field,
paying special attention to psychogeriatric care via
videoconferencing in nursing homes for the elderly.
Search procedure
A search for references was carried out in the Web
of Knowledge (including Medline, PsychInfo, and
ISI Web of Science) in May 2008 and updated in
July 2011 including the following expression in the
field “topic”:
(1) (Telepsy∗ ) yielding 361 records,
(2) (Teleconferenc∗ or teleconsult∗ or telediagnos∗
or telehealth∗ or telehomecare or telemed∗ or
videoconferenc∗ ) AND (mental∗ or psychiatr∗
or psychol∗ or psychos∗ or psychot∗ or dement∗ or
alzheimer∗ or “cognitive impairment” or depress∗
or personalit∗ or neuros∗ or neurotic∗ or anxiety or
somatoform or obsessi∗ or bipolar or dissociative
or “sleep disorder∗ ” or ((alcohol or drug∗ or
substance∗ ) and (abuse or misuse or dependen∗ or
consumption))) with 1489 records and
(3) (Telepsych∗ or teleassistance or telecare or
teleconferenc∗ or teleconsult∗ or telediagnos∗
or telehealth∗ or telehomecare or telemed∗ or
videoconferenc∗ ) AND (telenurs∗ or “long term
care” or “care home” or “nursing facilit∗ ” or
“nursing home∗ ”) yielding 199 references.
On the basis of the title and abstract content,
research papers that focused in the use of
videoconferencing for providing psychiatric care
or assessment to a geriatric population were
selected. Also, other types of papers (including
editorials or letters), dealing with the development
of telepsychiatry programs in adult community
population or telemedicine in institutionalized
population, were considered. Papers that focused
in the use of telemedicine with other specific
populations (like children or prisoners, for example)
and those based in the use of other technologies
(like telephone) were excluded for analysis or
more detailed description, preferring to restrict the
review to videoconferencing because of its growing
interest and the lack of previous review papers
on this field. A total of 241 papers were found;
45 of these focused specifically in the application
of telemedicine to geriatric populations, whether
institutionalized or not.
The search was completed by using Google
Scholar and manual review of information from
scientific meetings and crossed references, which
resulted in 15 additional references.
It was not feasible to carry out a meta-
analytic review to answer the questions regarding
applicability and validity of telepsychogeriatrics
because of methodological heterogeneity of the
studies included, the lack of consistent quantitative
data in some of them, different types of information
reported in the original papers, different scales
applied to the samples, and outcome measurements
considered. So the results of the review are
presented in a narrative way.
Results of the literature study
Telepsychiatry in community elderly
populations
No references to specific telepsychogeriatric
programs with elderly populations living in the
community were found in the literature reviewed.
Attention was paid only to community patients and
their caregivers at a day care center for patients
with dementia described below (Lee et al., 2000).
Data on geriatric consultations in some of the major
telepsychiatry programs can be obtained although
it accounts for only a small part of the total
consultations carried out. For instance, it amounts
to 10% of the teleconsultations made in the
telepsychiatry service in Alberta (Canada) (Simpson
et al., 2001) or 11.4% of a telepsychiatry program
with rural areas conducted at the University of
California, Davis, between 1996 and 2002 (Hilty
et al., 2006b).

The Conn and Patterson group at Baycrest
in Toronto has been providing psychogeriatric
care to a community population and, to a lesser
extent, to institutionalized elderly individuals via
videoconference since 2000 in Northern Ontario
(Canada) (Conn and Bilas, 2000; Conn and Bilas,
2001; Bilas and Conn, 2002). At the beginning
of this program, patients were referred by primary
care doctors for specialized consultations. The
two doctors involved were asked to assess this
experience using a 5-item Likert scale. They were
quite satisfied with it and they also had the
impression that patients, in turn, were quite satisfied
with the consultations. Since 2002, they have been
responsible for providing this service in a region
with a radius of 750 miles with a highly scattered
and aged population with no access to a specialist
in geriatric psychiatry. This region is divided into
areas where community workers provide a link
between community demands and the telemedicine
service. The aim of the program was not only to
provide access to specialized consultation but rather
to provide support and training to caregivers and to
the different sociohealth service providers. During
the first six years of the program, evaluations of both
clinical consultations and educational sessions have
remained consistently positive.
Psychogeriatric care in nursing homes for the
elderly
Among the telemedicine programs developed in the
last decade, care in nursing homes for the elderly
has figured prominently. This system is believed
to decrease costs and inconvenience resulting
from patients having to travel to hospitals where
specialized consultations are located, presentations
to emergency rooms, and hospital admissions. It
is well-known that there is a high prevalence of
mental health problems in nursing homes, which
makes the involvement of specialists to provide
proper diagnosis and care of these patients necessary
(Jones, 1999). In many cases, psychiatric care to
these centers has consisted of onsite visits by a
psychiatrist, which involves a high cost and is
inefficient. Thus the need, both of nursing homes
and specialists, to optimize, simplify, and reduce
costs of psychogeriatric care explains the interest
in developing liaison programs between specialized
services and nursing homes via videoconferencing
(Table 1).
Jones (1999) reports her experience in telepsy-
chiatry care in a nursing home and presents a brief
summary of two cases. She emphasizes how apart
from reducing the need to travel, this care modality
is an important support for professionals at the
nursing homes. This can be done since a quick
Telepsychogeriatrics 1711
answer is provided and consultations are held more
frequently. The fact that a nurse or someone from
the staff must be present in the teleconsultation
emerges as a negative aspect as staff is already
overburdened.
Lee et al. (2000) published the results of a
telemedicine program for patients with dementia
conducted in Korea. Videoconference consultations
were provided for two years in two places: a nursing
home for the elderly (160 patients) and a day care
center with an average of 20 patients per day, where
other community patients and/or their families were
also cared for. As well as diagnostic interviews and
therapeutic actions, psychoeducation, and advice to
professional caregivers and families were provided.
The main purpose of the study was to assess the
functioning of the program by focusing on the
following variables: degree of acceptance by users,
reliability of diagnostic assessments conducted, and
effectiveness of the interventions carried out via
videoconference. Despite the fact that patients with
dementia were tense or frightened at the beginning
of the examination, they progressively appeared to
be more comfortable with this system. The nursing
staff soon became accustomed to videoconference
and was satisfied with the mode in which
information was transmitted. Among caregivers
who attended classes through videoconference,
46% were of the opinion that this modality was
as effective as or more effective than face-to-
face classes. Results for the scales applied from
videoconference and face-to-face interaction were
compared and significantly correlated. A complete
concordance was obtained for dementia diagnosis.
Two measurements were made regarding the
assessment of clinical outcome. In the case of
patients from the nursing homes, the assessment
of a daily behavior check list made by caregivers
was gathered at the beginning and was compared
with the one produced after six months in the
program. Eighty-two percent of patients showed an
improvement in scores for that scale after receiving
treatment. In the case of patients in the outpatient
facility, the Zarit scale for caregiver burden was
applied. Half of the patients who were administered
the scale showed a reduction in scores after six
months.
Tang et al. reported the results of psychogeriatric
care carried out in the context of a pilot telemedicine
study carried out in a nursing home for the
elderly in Hong Kong (Hui et al., 2001; Tang
et al., 2001; Hui and Woo, 2002) where geriatric,
dermatology, nursing, physiotherapy, occupational
therapy, and podology consultations were offered.
One hundred forty-nine psychiatric assessments
of residents in the nursing home were done via
videoconference. After each interview, the elderly
 1712
R. Ramos-Ríos et al.
Table 1. Telepsychiatry studies in nursing homes for the elderly
N/MEAN PROTOCOLS AND
STUDY PLACE AGE TYPE OF STUDY TECHNOLOGY SCALES USED RESULTS/CONCLUSIONS
........................................................................................................................................................................................................................................................................................................................................................................................................................................................

Jones (1999) North Carolina 2 Report of two cases ISDN 128 kbps – Higher speed in care. More support
(USA) for staff.
Lee et al. (2000) South Korea 140 Pilot prospective study T1 1.544 mbps CDR Nurse satisfaction.
(two years) SBT Correlation between face-to-face
BDS assessment and videoconference.
Zarit Scale Residents’ behavior improvement.
Decrease of caregiver’s burden.
Tang et al. (2001) Hong Kong 45 Pilot prospective study ISDN 512 kbps Satisfaction surveys Well accepted by users and staff
(one year) when they learn how to use
technology.
Cost reduction.
Johnston et al. (2001) North Carolina 40/79.3 Pilot study (two years) ISDN 128 kbps MMSE Well accepted by users and staff.
(USA) Better use of psychiatrist’s time.
Lyketsos et al. (2001) Maryland (USA) – Pilot study (one year) Standard telephone – The number of residents admitted to
lines hospitals is reduced.
Trinkle (2003) Virginia (USA) – Program description Low-cost Information exchange Broadband technology needed for a
videoconference protocols. proper assessment.
Satisfaction surveys.
Rabinowitz et al. (2004) Vermont (USA) 24/81 Pilot study ISDN 384 kbps MDS Use of MDS favored
communication between staff and
consultant.
High satisfaction of users, staff,
and consultant.
Yeung et al. (2009) Massachusetts 9/77 Pilot study ISDN 384 kbps CGI-I Satisfaction Six subjects were much improved at
(USA) surveys. the end of follow-up visits.
High satisfaction.
Rabinowitz et al. (2010) Vermont 106/77.5 Cost-effectiveness ISDN 384 kbps – Cost and time savings exceeded the
New York (USA) analysis cost of the videoconferences.
(consolidated
program)
BDS = Blessed Dementia Scale; CDR = Clinical Dementia Rating; CGI-I = Clinical Global Impressions-Improvement Scale; MDS = Minimum Data Set; MMSE = Mini-Mental State
Examination; SBT = Short Blessed Test.

resident was questioned about their satisfaction with
the interview. Among those who answered, 80%
stated that they were satisfied with the consultation.
There were no differences regarding interview
acceptance between dementia subjects and non-
dementia subjects who were able to answer the
questions. This result is consistent with the result of
another study which found similar satisfaction levels
between these two groups, though the possibility
that dementia subjects may be more uncomfortable
in the videoconference situation is acknowledged
(Jones et al., 2002). At the end of the study,
the nursing staff filled in a questionnaire on their
satisfaction with the program resulting in a positive
evaluation. Financially, emphasis was made on the
considerable cost reduction, which was even higher
than that reported by other telepsychogeriactric
programs; one of the explanations that authors
suggest for this is the use of the connection for
consultations in other specialties (a total of 1,001
telemedicine consultations were done in a year).
Johnston et al. reported their two-year care
experience in a nursing home for the elderly in a
rural area (Johnston and Jones, 2001; Johnston,
2003). This paper provides important lessons about
the application of a telepsychogeriatrics program.
Prior to the start of the program in the nursing
home, care was being provided in the form of a
monthly visit that required traveling time and that
was sometimes cancelled due to weather conditions.
These circumstances favored the development of
a telepsychiatry project at the nursing home. A
protocol was agreed with the nursing home staff
to request consultations. The staff decided which
patients needed a consultation and also requested
their checkups. A nurse – generally the same person
– accompanied the patient to the interviews. At
the beginning, clinical data were obtained through
an interview with staff before the patient came
in. Later, clinical material was faxed prior to the
consultation, and the interview with the nurse had
the purpose of completing those data that the
psychiatrist considered necessary after reading the
material sent. The presence of staff in the room with
the patient not only helped carry out the interview,
but it also allowed observation of how the patient
interacted in a face-to-face situation. Whenever
possible, relatives of the patient were also invited to
take part and they provided valuable information for
the medical record. After the consultation, as well as
the instructions given orally, a written copy was sent
to be included in the patient’s record. Seventy-one
consultations were carried out to 40 patients. More
frequent reasons for the consultation were behavior
disorders associated with dementia, and second,
affective disorders. Most patients, including those
with cognitive impairment, were able to focus their
Telepsychogeriatrics 1713
attention on the screen; only advanced dementia
patients showed difficulty, since they already had
difficulty in paying attention to staff members at
the nursing home or responding to any command.
The program was favorably assessed by all the
parties involved. Psychiatrist’s time was used more
efficiently and a higher frequency of consultations
was attained and patients included in the program
were properly diagnosed and treated.
Lyketsos et al. (2001) reported a videoconfer-
encing program linking a long-term care facility for
patients with dementia and the inpatient psychiatric
care unit where they were admitted when presenting
with significant behavior disorders that could not
be handled at the long-term facility. The purpose
of this program was to reduce the number of
admissions and the duration of patients’ stays in
the acute psychiatric unit, as well as improving the
continuum of care. The number of admissions and
the total number of stays in hospital were reduced in
the first year of operation. Mean stay only increased
due to the admission of more serious patients.
Trinkle described his experience in implement-
ing a telepsychiatry project with rural nursing
homes in the state of Virginia (Mitka, 2003;
Trinkle, 2003). Written forms to ease information
transmission between nursing home staff and the
doctor were developed. Surveys to assess the
results of teleconsultations including satisfaction
of patient, caregivers, and staff at the nursing
homes and comparison to actual onsite visits
were administered. The need to use broadband
technology to achieve a transmission quality that
allows for the interview to be properly carried out
was emphasized in this experience.
Rabinowitz et al. (2004) reported their
experience in care at a rural nursing home in
the state of Vermont, which had no access
to psychiatric care. The role of protocols to
assess the resident’s functional and clinical state
for the application of telepsychogeriatric care
is emphasized as a facilitating resource. The
Minimum Data Set (MDS) was used in this case.
A total of 31 consultations were done. Resident,
nursing staff, and consultant satisfaction was high.
Even dementia patients accepted the interview and
were properly assessed. The use of MDS improved
communication between nursing home staff and
consultant, since they were using a common
language, thus facilitating early identification of
residents’ problems. A study of cost-effectiveness
was published by the same group reporting the
activity carried out between November 2002
and July 2008 (Rabinowitz et al., 2010). Costs
of equipment, line fees, travel time, fuel cost,
personnel costs (attendants required to transport
the nursing home resident), and physician visits
1714 R. Ramos-Ríos et al.
cost were taken account in the analyses. Authors
calculate that at least $13,000 would have been
saved if the residents had been taken to the
psychiatrist’s consulting room and up to $232,000
if the psychiatrist traveled to the nursing home.
In the study, reference was also made to the fact
that the scheme was very favorably accepted by
residents, relatives, and nursing home staff. They
furthermore note that there were fewer than ten
significant technical problems.
Yeung et al. (2009) studied the application of
telepsychiatry to provide linguistically and culturally
appropriate mental health services to Chinese
immigrants in a nursing home in the USA. Nine
subjects were enrolled and it was feasible to use
videoconferencing to provide follow-up interviews
for eight of the nine enrolled subjects (88.9%).
Efficacy of interventions was also assessed with
good outcomes. Patients (or their families) and
the nursing staff were highly satisfied. Authors
stated that videoconferencing could be the best
means for ethnic minority elderly adults to gain
access to appropriate mental health assistance
and emphasize a multidisciplinary approach and
educative interventions as determining factors of the
success of the study.
Although it does not deal with telepsychiatry
in nursing homes for the elderly, but rather with
the general telemedicine framework in these type
of facilities, it is interesting to cite the work
carried out by Sävenstedt and colleagues in a
telecare program in nursing homes for the elderly
in northern Sweden in view of the reflections
they make on communication and interactions
among geriatricians, nurses, the elderly, and their
families in the videoconference. In order to
assess the interaction between the geriatrician
and nurses, several consultations were recorded
and their content analyzed (Sävenstedt et al.,
2002). It is worth emphasizing that one of the
conclusions is that the role of nurses takes on an
increased importance in telemedicine programs, as
mediators between the patient, who frequently has
communication problems, and the doctor. Nurses
also adopt a more active position by preparing
clinical material before the interview and identifying
the most useful information for the consultant
doctor. The importance of mutual trust between
nursing staff and the geriatrician is also highlighted.
Later studies analyzed the content of com-
munications between family members or nursing
staff and institutionalized patients with cognitive
impairment or dementia (Sävenstedt et al., 2003;
Sävenstedt et al., 2005). It was found that
teleconference interaction could increase the
attention of cognitively impaired persons and also
increase focus and communication, concluding that
videoconference is possible with dementia patients
and that there are a series of factors facilitating it.
Diagnostic assessment via videoconference
Although there is extensive experience on diagnostic
assessment via videoconference in adult populations
(Matsuura et al., 2000; Kobak, 2004) and available
evidence shows that good communication between
doctor and patient is possible in most cases
(Wootton et al., 2003; Anthony et al., 2010;
Garcia-Lizana and Muñoz-Mayorga, 2010), studies
aimed at geriatric population are scarce (Table 2).
This issue is important since it is not possible
to extrapolate those results to this population
due to the difficulties that diagnosing depression
or cognitive impairment may impose, as these
conditions need a greater amount of visual
information (behavior assessment, facial expression,
psychomotility) (Alessi, 2001; Jones, 2003; Cruz
et al., 2004). Moreover, high prevalence of visual
and hearing impairment in these patients (Ball et al.,
1998) and frequent fluctuations of consciousness
level can make the assessments difficult (Jones,
2001). These subjects also are particularly vulner-
able to the side effects of drugs. The possibility of
carrying out a neurological examination through
videoconferencing, particularly the assessment of
Parkinson’s symptoms, is of special interest (Hubble
et al., 1993).
In a meta-analysis of 14 studies with a total of
500 patients where the diagnostic interview done via
videoconferencing was compared to the in-person
interview, only three of them included geriatric
patients (72 patients) (Montani et al., 1997; Grob
et al., 2001; Jones et al., 2001; Hyler and Gangure,
2005).
Jones et al. (1996) reported the results
of the first study carried out to demonstrate
the possibility of making psychiatric diagnostic
assessments in a geriatric population. Using a
low-cost videoconferencing system, the Hamilton
Depression Rating Scale and the Brief Psychiatric
Rating Scale (BPRS) were administered; scores
obtained via videoconference and those rated by
an examiner in the same room as the patient
were compared. Significant correlation coefficients
were obtained for all measures. This group later
administered the major depression subsection of the
Structured Clinical Interview for DSM Disorders
(SCID) to a larger sample, demonstrating the
reliability of the interview (Jones et al., 1997;
Jones, 1999). As to acceptance by patients, they
stated that they were comfortable with the interview
and thought that the psychiatrist was able to
understand their problem. However, they said that
they preferred the face-to-face consultation.
Table 2. Diagnostic assessment studies in geriatric populations via videoconference
N/MEAN
STUDY AGE (YR) SAMPLE ORIGIN DESIGN SCALES USED TECHNOLOGY RESULTS
...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Jones et al. 10 Patients hospitalized in a Video versus face to face HDRS Low-cost Significant correlations between BPRS
(1996) psychogeriatric unit. BPRS videoconferencing scores (r = 0.82) and HDRS scores
(r = 0.90).
Jones (1999) 56 Patients hospitalized in a Video versus face to face Major depression High reliability demonstrated by significant
psychogeriatric unit. section of the κ values for all symptoms.
SCID
Lee et al. 13–15 5–6 patients from a nursing Video versus face to face BDS T1 1.544 mbps Hundred percent agreement between
(2000) (depending home CDR dementia diagnosis. High correlation in
on test) 7–9 patients from an SBT scale scores.
outpatient center Clinical diagnosis
Jones et al. 30/66.4 Patients hospitalized in a Video versus face to face BPRS ISDN 128 kbps Significant correlation in scores (r = 0.83),
(2001) psychogeriatric unit. but correlation for subjective items
(r = 0.95) higher than for observational
items (r = 0.72).
Menon et al. 24/>60 Patients hospitalized in a Two groups. One examined HDRS Ordinary telephone Similar variation coefficients for the two
(2001) medical unit. twice face to face. Another GDS-15 lines. groups.
examined once face to face SPMSQ
and once by video.
Grob et al. 27/69 Veterans’ home Two groups. One examined BPRS ISDN 384 kbps Psychiatric assessment as reliable when
(2001) twice face to face. Another MMSE carried out via videoconference as in
examined once face to face GDS face-to-face modality.
and once by video.
Saligari et al. 20/>65 Patients admitted in general Video versus face to face MMSE ISDN 128–384 kbps Significant correlation in scores. For MMSE
(2002) hospitals. GDS r = 0.90; for GDS r = 0.78.
Recommendation of a minimum
bandwidth of 384 kbps for the assessment.
Shores et al. 16/78 Veterans’ home Video versus face to face Clinical interview High-speed T1 line Hundred percent agreement between
(2004) DSM-IV criteria diagnosis made.
Clock drawing
SBT
Loh et al. 20/78.8 Community population Video versus face to face Clinical interview ISDN 384 kbps High agreement in diagnosis of dementia

Telepsychogeriatrics
(2005) MMSE (κ = 0.80).
GDS
Informant
Questionnaire
Martin-Khan 42/70 Patients referred to a memory Two groups: Face to face Clinical interview IP or ISDN 384 No difference in inter-rater reliability for the
et al. (2007) clinic under the suspicion (FtF) versus FtF and FtF DSM-IV kbps diagnosis of dementia between the two
of dementia. versus video. criteria groups.

BDS = Blessed Dementia Scale; BPRS = Brief Psychiatric Rating Scale; CDR = Clinical Dementia Rating; GDS = Geriatric Depression Scale; HDRS = Hamilton Depression Rating Scale;
MMSE = Mini-Mental State Examination; SBT = Short Blessed Test; SCID = Structured Clinical Interview for DSM Disorders; SPMSQ = Short Portable Mental Status Questionnaire.

1715
1716 R. Ramos-Ríos et al.
These studies have already suggested that
interviews based on the oral account of symptoms
by the patient would be more reliable than the
assessment of other types of information requiring
visual evaluation of behavior and subject’s attitude.
A subsequent study where BPRS scores obtained
via videoconference and face to face were compared
goes into these issues in depth (Jones et al., 2001).
Two types of items were distinguished in the
interview: those only requiring oral information
provided by the patient and those requiring the
observation of their behavior. Inter-rater reliability
for total BPRS score was similar for the examiners.
However, it was lower for observational items.
The conclusion was drawn that the use of
narrow-band technology did not guarantee enough
image quality to conduct a satisfactory diagnosis
assessment of elderly patients. This same group later
used broadband technology in a small sample of
20 patients in a nursing home for the elderly. They
achieved an acceptable accuracy in the assessment
of depression, cognitive impairment, and movement
disorders (Jones, 2003).
Menon et al. (2001) carried out a study to
evaluate the reliability of depressive symptoms and
cognitive function assessment by using a low-
cost videophone system. They administered the
short version of the Geriatric Depression Scale
(GDS-15), the Hamilton Depression Rating Scale
(HDRS), and the Short Portable Mental Status
Questionnaire (SPMSQ) for cognitive assessment.
The coefficients of variation for GDS and HDRS
were similar for the two groups. This was not the
case, though, for SPMSQ, although agreement was
higher in the videoconference group.
As to satisfaction with the consultation, most
subjects did not show any preference between the
two assessment systems. They admitted, though,
that should they live in a distant place, they would
prefer videoconference.
Saligari et al. (2002) reported the results after a
first-year implementation of a cognitive assessment
program in an elderly population in Western
Australia, a very large territory with highly scattered
population. In the first trial, conducted with
20 patients admitted to two general hospitals,
the goals were to demonstrate the validity of
Mini-Mental State Examination (MMSE) and the
GDS via videoconferencing as assessment tools
in subjects with cognitive impairment, and to
establish the necessary technical requirements to
carry out the examination. Videoconferencing and
face-to-face consultations were performed by two
geriatricians on the same day. Although high
correlations in MMSE scores and GDS were
obtained via videoconferencing, a statistical analysis
applied to these results to evaluate the degree of
concordance between the two examinations (Loh
et al., 2004) concluded that there were differences
between the two assessment methods that may have
repercussions on clinical decision-making. One of
the explanations provided by the authors for these
results are the fluctuating level of functioning of
patients included, coming from medical wards, with
cases under the suspicion of delirium. Thus, it
is emphasized that assessment was possible and
that it was probable that in many common clinical
situations, as opposed to medical patients admitted
to hospital, differences with teleconsultation are not
relevant. It was also concluded that a minimum
bandwidth of 384 kbps was necessary for the
audio and image quality to be adequate for the
examination.
Later, this group conducted a study to
demonstrate the accuracy of dementia diagnosis
made via videoconferencing (Loh et al., 2005). A
group of geriatricians conducted face-to-face and
videoconference assessments of 20 patients. Ten
patients were diagnosed with Alzheimer’s disease
at the face-to-face consultation and nine of them
were detected via videoconference. Taking face-to-
face assessment as the golden standard, it resulted
in a κ coefficient of concordance between the two
methods of 0.80 (Loh et al., 2007).
Demonstrating the reliability of diagnostic
interviews conducted via videoconference seems to
be a pre-requisite for the implementation of care
programs to specific populations, such as nursing
home population. This need led Grob et al. to
conduct a study in order to establish the validity of
the MMSE, the BPRS, and the GDS in a veterans’
home in Maryland (USA) (Grob et al., 2001).
Test–retest of the three scales, measured using a
correlation coefficient, had statistical significance
in the two groups formed. Authors conclude that
the psychiatric assessment was as reliable when
conducted via videoconference as face to face.
Shores et al. (2004) carried out a prospective
study with two Washington State veterans’
homes that compared the diagnostic reliability
of videoconference to an in-person examination
for dementia. Those residents that had already
been diagnosed with dementia were excluded
from the study. An initial screening with the 7-
minute Screen (n = 83) was conducted. Subjects
who screened positive were included in the study.
Geriatric psychiatrists carried out a videoconference
assessment and another, who was blind to
the result of the previous one, an in-person
assessment. Telemedicine diagnoses were in 100%
agreement with the diagnoses from in-person
clinical examinations, including the dementia
subtype. Twelve of the 16 residents were diagnosed
with dementia, so it was concluded that there

was a 14.5% prevalence of undiagnosed dementia
in residential care (12/83). This relatively high
prevalence of undiagnosed cases, together with the
fact that there was an admission protocol to these
facilities which included MDS and MMSE and that
patients’ mean scores in the MMSE were 22.4 ±
3.9, reveal the capacity of telemedicine to diagnose
dementia at early stages. It also supports one of the
hypotheses underlying the development of this kind
of program, namely, that lack of access to specialist
care results in many psychiatric diagnoses going
unnoticed in residential care facilities.
They also reported data on satisfaction and
acceptance. All the residents participating in the
study agreed that they preferred this system to
traveling to visit the psychiatrist in person and stated
that they would like to have further care through
videoconference. Staff at the facilities that took part
in the program valued the project as highly positive
since their communication and access to specialist
services improved. It was so positive that once the
research funds were finished, the decision was made
to finance this service.
Martin-Khan et al. (2007) conducted a pilot
study comparing inter-rater reliability for the
diagnosis of dementia via videoconference with
inter-rater reliability in a face-to-face assessment.
Moderate concordance between diagnoses conduc-
ted in person (κ = 0.53) was found. Concordance
was slightly higher between diagnoses conducted
in person and remotely (κ = 0.63). The inter-rater
reliability achieved in both cases was regarded
as good since these were dubious cases referred
to assessment under the suspicion of incipient
dementia. An IP connection and an ISDN
connection at 384 kbps were used alternatively in
this study. The image quality was poor in two video
consultations using the IP connection.
This same group later examined whether there
was any change in the diagnoses made when
conducting a complete physical and neurological
examination (Martin-Khan et al., 2008). All
the dementia diagnoses were confirmed. The
physical examination resulted in a change in
the dementia type diagnosis (between Alzheimer’s
disease and vascular dementia) only in two cases.
Authors conclude that there seems to be no
great differences between face-to-face assessment
and videoconference assessment and that physical
examination is not essential to make a diagnosis
of dementia, but it is indeed necessary to define
dementia type.
Cognitive assessment
When using telecommunication technology to
provide care to the geriatric population, one of
Telepsychogeriatrics 1717
the issues raised is whether it is possible to
apply cognitive assessment tests or whether their
results will be contaminated by this approach
(Jacobsen et al., 2003). The possibility of using
videoconference to carry out this type of assessment
takes on a special relevance due to the need to
make dementia screening as widely available as
possible, particularly since the introduction of anti-
Alzheimer drugs which are believed to be more
efficient in early stages of the disease (Ball and
McLaren, 1997). Another difficulty when assessing
patients in remote areas or rural nursing homes is
the lack of professionals trained in administering
neuropsychological tests. This forces them to travel
long distances to have their diagnostic assessment
fulfilled (Schopp et al., 2000; Brebner and Seymour,
2001).
For these reasons, it is interesting to review
studies focusing on this aspect, although these are
scarce at present and their interpretation is limited
by small sample sizes (Table 3). Most of them have
focused on screening tests, and more studies aimed
at demonstrating the reliability of more complex
neuropsychological batteries are needed (Tyrrell
et al., 2001).
The first study on remote cognitive testing
was conducted in 1993 in a sample of 11 adult
psychiatric patients to which MMSE was applied
in person and over videoconferencing. A strong
correlation between the two tests was obtained,
which was encouraging for test application via
videoconferencing (Ball et al., 1993).
Three groups reported their results in the
application of screening tests through videoconfer-
encing. Montani et al. (1996) compared the results
obtained in the MMSE and the clock drawing test
via a closed television circuit and in a standard
consultation. A decreased performance in both tests
was observed in the video consultation context and
though there were minor differences, these were
significant. It was pointed out that a decrease in
attention that mainly interfered with recall tasks
and in the clock drawing test was one of the main
difficulties. Hearing impairment also influenced the
test, which was particularly observed in repetition
items. However, the conclusion was that if technical
difficulties were solved, audio and image quality
were optimum and patient’s sensory impairment
were taken into account, it would be possible to
apply these tests to these subjects.
This same group later published their opinion
on the psychological impact of this assessment
modality (Montani et al., 1997). It was found
that in a phrase writing item in the MMSE
in the video consultation situation, phrases were
more descriptive and did not express emotions,
which, however, was frequent in the face-to-face
 1718
R. Ramos-Ríos et al.
Table 3. Cognitive assessment studies in geriatric populations via videoconference
N/MEAN
STUDY AGE (YR) SAMPLE ORIGIN DESIGN SCALES USED TECHNOLOGY RESULTS
.......................................................................................................................................................................................................................................................................................................................................................................................................................................................

Montani 15/88 Patients hospitalized in a Video versus face to face MMSE Two hospital rooms MMSE scores higher in in-person
et al. (1997) medical unit. (one week interval) CD linked by coaxial administration, though high correlation
cable. (r = 0.95) between video and
face-to-face scores.
Both patients and examiners preferred
face-to-face consultations.
Ball et al. 8/73 Patients from a Video versus face to face CAMCOG ISDN 128 kbps Correlation between video and
(1998) psychogeriatric unit. (one week difference) face-to-face scores: r = 0.75.
Fifty percent dementia.
Hildebrand 29/>60 Healthy volunteers Video versus face to face RAVLT ISDN 336–384 kbps Small difference in scores except for CD.
et al. (2004) (two weeks interval) CWAT Forty-four percent of volunteers preferred
VOC and MR of in-person assessment.
WAIS-III
CD
BTA
Kirk et al. 39 Patients with incipient Video versus face to face MMSE – Mean MMSE was significantly higher at
(2005) dementia in a memory in-person consultations.
clinic in a rural area.
Cullum et al. 33/73 Outpatients: Video versus face to face MMSE – High correlation (r > 0.60) between the
(2006) 14 MCI (consecutively) HVLT-R two application for all tests but category
19 AD CD fluency test and HVLT-R retention
Digit Span test.
BNT Kappa for the clock drawing was mild
Letter and (κ = 0.48).
category
fluency
AD = Alzheimer’s disease; BNT = Boston Naming Test; BTA = Brief Test of Attention; CAMCOG = Cambridge Cognitive Examination; CD = Clock Drawing test; CWAT = Controlled Word
Association Test; HVLT-R = Hopkins Verbal Learning Test-Revised; MCI = Mild Cognitive Impairment; MMSE = Mini-Mental State Examination; RAVLT = Rey Auditory Verbal Learning
Test; VOC and MR of WAIS-III = Vocabulary subtest and Matrix Reasoning subtest of the third edition of the Wechsler Adult Intelligence Scale.

consultation. Ten patients stated they preferred
face-to-face consultation, as it was more personal.
Six patients felt uncomfortable by the presence of
the equipment. On the positive side, four patients
found the video entertaining or that it had a
magical appeal. Both the interviewer and the room
observer considered the patient was more anxious
in the video consultation context and their general
impression in a ten-point scale on the course of the
interview was significantly higher in the case of the
in-person consultation. From the examiner’s point
of view, it was pointed out that poor audio quality
meant that some instructions had to be repeated;
that attention was reduced by the need to operate
the equipment and by the strategy chosen to create
a false sensation of eye contact (directly looking at
the camera on top of television).
Kirk et al. (2005) obtained significantly lower
mean scores in the MMSE when administered at
distance as compared to conventional application.
The conclusion was drawn that this variation
in results should be taken into account when
conducting this assessment via videoconference.
One retrospective study, using the tests of
99 patients from the records of a Geriatric
Psychiatry unit, was designed to verify how
assessment via videoconference may influence
scoring in written parts of the MMSE (Ball and
Tyrrell, 1999). The item of phrase writing and
pentagons were scored on paper in a faxed copy and
via videoconference (ISDN line with a bandwidth of
128 kbps). Sentences were reliably scored over the
fax (κ = 0.80) and over videoconference (κ = 0.70)
as compared to the face-to-face modality. However,
though reliability over the fax was acceptable in
the case of the drawing (κ = 0.71), the same
did not happen over videoconference (κ = 0.47).
These results warn us of the possibility of bias in
test scorings that require pencil and paper, when
assessed via videoconference, particularly when it is
a low-cost system. Such a limitation should be taken
into account and alternatives should be suggested to
overcome it, for instance, the auxiliary use of a fax
or a scanner for these remote assessments.
Ball and Puffett (1998) conducted a small study
to demonstrate the applicability of the Cambridge
Cognitive Examination (CAMCOG) test, the
cognitive assessment section the Cambridge Index
of Mental Disorder in the Elderly (CAMDEX), via
videoconferencing. It was taken into account that
one of the major difficulties would be the need
to present image material to complete several test
tasks. For this reason, among others, there was an
assistant in the same room as the patient, who would
show the material to the subject again, should the
patient make a mistake when shown on the screen.
Fairly high correlations were found in the scores
Telepsychogeriatrics 1719
obtained by both systems (r = 0.75), even when
results that had been improved by repetition in the
presentation of visual stimuli (r = 0.72) were not
included. Authors concluded that despite the small
sample size and the technical difficulties they faced,
the CAMDEX seems to be an applicable interview
via videoconference without major modifications.
Only two studies centered on the feasibility of
neuropsychological batteries via videoconference.
Hildebrand et al. (2004) administered a selection
of tests and subtests where a series of functions the
authors deemed significant for daily living activities
were evaluated. Volunteers were randomly distrib-
uted to receive the test first via videoconference or
face to face. Except for the case of the clock drawing
test, mean difference between scoring in the two
examinations was minor. Closer limits of agreement
in most measures were reported in the subgroup
to which face-to-face tests were first applied. This
result may be explained by decreased performance
owing to the fact that newness of doing the tests is
coupled with the newness of video consultation. It
was concluded that assessment results were reliable
in those tests evaluating verbal skills, whereas major
differences emerged in the visual-spatial test.
Another study was performed to evaluate
the possibility of using a brief battery of
neuropsychological tests to assess patients with
cognitive impairment via videoconference (Cullum
et al., 2006). The mean scores were similar
for all tests in the two situations with the
exception of the retention percentage in the Verbal
Learning Test which was higher in its in-person
modality (but it was statistically non-significant).
A high correlation was obtained (r > 0.60)
between the two applications for most of the tests
selected. No participant expressed any difficulty
or concern regarding teleconsultation, although
several indicated a preference for personal contact.
The authors conclude by pointing out that it is
possible to successfully and reliably administer
multiple brief neuropsychological tests other than
the ones commonly used for the assessment of
patients with Alzheimer’s disease (AD) or Mild
Cognitive Impairment (MCI).
Discussion
(1) The application of videoconferencing for the
psychiatric care of geriatric population is a new
emerging field with limited studies available. Most
of them focused on the development of liaison
programs with nursing facilities and in the feasibility
of the assessments performed on hospitalized
patients. Few studies were carried out in the
community (Conn and Bilas, 2001; Loh et al.,
2005). There is a lack of studies assessing the
1720 R. Ramos-Ríos et al.
outcome of the interventions (Lee et al., 2000)
or focusing on specific tasks such as providing
support to caregivers (other than nurses) (Lee et al.,
2000; Bilas and Conn, 2002). There are inherent
difficulties to assessing this population group that
only seem to be overcome by technological advances
that are taking place in recent years. Among
these, it is worth mentioning the importance of
assessing psychomotility, attitude, and behavior in
the interview, which was poor with narrow-band
systems (Jones et al., 2001; Saligari et al., 2002;
Trinkle, 2003). New studies showing optimization
with current technologies are necessary. While IP is
the connectivity of the future, one must consider
the availability of broadcast bandwidth in an IP
or ISDN format in both sending and receiving
locations (Martin-Khan et al., 2007).
Another difficulty is the high frequency of
communication problems in the elderly population,
such as visual or hearing impairment. Further
studies that evaluate their results in these patients
are required to provide an answer to the question
of whether it is possible to generalize telepsychiatry
programs to the whole of this population group.
(2) There are important needs regarding psychiatric
care in nursing homes for the elderly which are
noted by psychiatrists, nursing homes’ staff, and
users. Telepsychiatry is a possible option to meet
these needs. Initial experiences are highly positive
to the extent that these are feasible and are quite
valid in diagnostic terms. Only two studies report
quantitative data of cost-effectiveness (Tang et al.,
2001; Rabinowitz et al., 2010), although with the
information available, it is not risky to forecast that
they are reasonably cost-effective, since after the
initial cost of buying equipment, the reduction of
traveling costs and the better use of time devoted
by the geriatric psychiatrist compensate for the
implementation of these programs (Johnston and
Jones, 2001). Another reason to think that they
will be efficient is that using videoconferencing is
economical and easy to organize when users are
located in only one place. One possibility to improve
its cost-effectiveness is the multidisciplinary use of
telecare equipment installed in nursing homes for
other specialties (Tang et al., 2001; Rabinowitz
et al., 2010). From the staff’s standpoint, the
advantages are not only reducing the need to travel
and waiting time for consultation, but also allowing
better communication with the consultant, higher
involvement in decision-making, and increased
support (Jones, 1999; Lee et al., 2000; Tang
et al., 2001; Sävenstedt et al., 2002; Yeung
et al., 2009). It is interesting to note the opinion
of some professionals in this field who state
that despite limited data on the effectiveness,
efficiency, and acceptability by patients and staff
of this care modality, this option is preferable
to the current reality where a great part of the
geriatric population having mental health problems,
that is, the institutionalized population, has great
difficulties accessing specialized care (Mitka, 2003;
Wootton et al., 2003; Snowdon, 2010).
(3) There are several studies on the validity of specific
diagnostic interviews for the elderly (Table 2)
and on cognitive tests (Table 3). In general, they
conclude that they seem to be both feasible and
fairly reliable; but their interpretation is limited
because of the small size of samples used (range
8–56 with a median of 24 subjects assessed)
and their origin, mainly psychogeriatric inpatients
(Jones et al., 1996; Ball et al., 1998; Jones,
1999; Jones et al., 2001) or medical geriatric
hospitalized patients (Montani et al., 1997; Menon
et al., 2001; Saligari et al., 2002). More studies
must be conducted on the validation of larger-
size clinical and community samples where a more
varied clinical sample is reflected and bias due to
random and other circumstances beyond the test
are minimized. Only four studies (Lee et al., 2000;
Shores et al., 2004; Loh et al., 2005; Martin-Khan
et al., 2007) informed on the reliability of diagnoses
made via videoconference. So, similarly, further
studies are needed on this issue that will ultimately
determine whether this care modality turns into a
common clinical practice.
(4) Regarding the satisfaction with and acceptance of
teleconsultation by patients, the few papers that
focused on this issue (Saligari et al., 2002; Trinkle,
2003) or presented quantitative data (Tang et al.,
2001; Shores et al., 2004, Yeung et al., 2009) concur
that in general they accept it. Studies also indicate
that although they prefer face-to-face interviews
(Montani et al., 1997; Hildebrand et al., 2004),
most patients will opt for it rather than having
to travel (Menon et al., 2001). Instead of limited
data (Tang et al., 2001), it seems that there are
no important differences between subjects with or
without dementia who are able to answer questions
and most dementia patients accept the interview
and can be assessed via videoconference (Lee et al.,
2000; Jones et al., 2002; Rabinowitz et al., 2010).
In the cases of advanced dementia, there is no
consensus about the possibility of directing their
attention with existing divergent opinions (Johnston
and Jones, 2001; Sävenstedt et al., 2003; Sävenstedt
et al., 2005). Anyway, the participation of a caregiver
familiarized with the patient is needed as in in-
person consultations.
Conclusion
At a practical level and by way of summary upon
reviewing the literature on the field, the following
recommendations could be made:
– For clinicians: The use of telepsychiatry, and
specifically, videoconferencing in psychogeriatrics
entails a number of challenges and a greater
complexity than in the case of its application
with other patients. Cognitive deficits and somatic
pathologies have a greater bearing, which means

that the procedure may not be confined to
medical teleconsultation with the patient. When
designing telepsychogeriatric programs, a method
for obtaining a medical, psychiatric, and social
history must be designed as well as allowing
for other essential individuals who are involved
in the assessment (family caregivers, formal
caregivers, nurses, primary care and nursing home
doctors, other consultants, and social workers).
The objective is holistic diagnosis and treatment
recommendations and that as much information
is garnered via teleconsultation as possible in the
case of a specialist face-to-face consultation. If
well designed forms are used, data are adequately
transmitted through telematic channels (fax and
the Internet) and those providing care to patients
participate in the consultations, the quality of
the information obtained, the care provided, and
the satisfaction of the persons involved may be
even greater than in the case of face-to-face
consultations (Lee et al., 2000; Rabinowitz et al.,
2010). Therefore, the care model required in
telepsychiatry should not be simply consultation by
the psychiatrist (which could be adequate in other
applications of telepsychiatry where the patient
has greater autonomy) but consultation-liaison and
collaboration with other care providers (Hilty et al.,
2006b). For greater efficiency in these programs, it
should be borne in mind that these patient are often
in day care centers or nursing homes (Lee et al.,
2000) and that they often have multiple pathologies
that must be assessed by different professionals
(Tang et al., 2001). Furthermore, we should not
lose sight of the fact that for telepsychogeriatrics
not every technology is valid and there is consensus
on the need to resort to broadband (Jones,
2003). Even using cutting-edge technology, care
should be administered cautiously in the case of
advanced dementia patients, patients with serious
sensory deficits or those having disorders affecting
psychomotor activity (Jones and Ruskin, 2001).
– For researchers: More studies using larger sample
sizes are required, thus allowing the application
of stronger statistical methods, using long-term
longitudinal follow-up and assessment of the clinical
outcome, with the emergence of specific protocols
to develop telepsychogeriatric programs and to
evaluate satisfaction of all persons involved and with
more information on cost-effectiveness (Hilty et al.,
2004; Shulman et al., 2006).
Among the different possibilities offered by
telepsychiatry, it seems likely that the field of
psychogeriatrics will be at the forefront experiencing
greater growth in the foreseeable future. This
is partly due to the increase in the geriatric
population, partly due to the fact that the next
generation forming this group will be more
technologically literate, and also thanks to the
progressive development of technologic systems,
the purpose of which will be to eventually increase
Telepsychogeriatrics 1721
the autonomy of the elderly (Pulier, 2007).
Ultimately, the important practical question is not
whether to use telepsychiatry instead of traditional
in-person assessment and therapy. Rather, the
questions to ask are, when, where, for whom, and
how to blend these technologies with traditional
treatment in order to provide better access and
quality to mental health services (Maheu et al.,
2005).
Conflict of interest
None.
Description of authors’ roles
This research has been done as part of a research-
action pilot study on telepsychogeriatrics conceived
and led by Raimundo Mateos. Raimundo Mateos
designed the literature search and all authors
worked in the literature review; Drs. Raimundo
Mateos, Ramón Ramos-Ríos, and David Conn
focused on the clinical aspects and David Lojo
and Tim Patterson on the technical aspects of the
reviewed papers. Ramón Ramos and Raimundo
Mateos drafted the paper; all the authors reviewed
and contributed to the final version of the
publication.
Acknowledgments
The research-action project on telepsychogeriatrics
has been founded by the Servicio de Saúde
Mental, Subdirección Xeral de Saúde Mental e
Drogodependencias, Xunta de Galicia (Galician
Ministery of Health) with the involvement of
the Higher Systems and IT Government Body
of the CHUS University Hospital. Authors are
particularly grateful to Dr. Fernando Marquez for
his continuous support to this project.
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