COVID-19 has posed significant challenges to those who provide psychological services to older adults. Historically, the majority of doctoral-level training for psychology trainees has been executed predominantly in a face-to-face format. Most of the scientific literature published on psychology training is from the perspective that trainees will use this in-person modality. Yet, due to safety precautions and physical distancing restrictions, telehealth through audio and/or video modalities has proven beneficial for individuals who now have significantly decreased access to in-person care. During the COVID-19 pandemic, psychology trainees face unique training and clinical challenges when working with older adults via telehealth. These include issues related to risk, technology literacy, engagement, privacy issues, and environmental distractions.
When working with older adults, it is crucial to assess for medical and psychiatric risk during the initial appointment and as needed during future therapy sessions. However, as a trainee, it can be difficult to manage these risks with a supervisor who may or may not be on a telehealth call. For patients with known psychiatric or medical risks such as suicidal or homicidal ideation or history of medical illness, it is important to make sure the supervising attending clinician is available and accessible during telehealth appointments. Moreover, it is helpful to confirm the best emergency contact, closest emergency room, and physical location of the patient from the start of the appointment to ensure the quickest care possible if needed.
Although many older adults now have access to a computer, tablet, or iPad, not all may be equally savvy in their ability to use these devices effectively. Technology literacy, knowledge, and the speed at which an older adult can process and execute instructions may be slower and more limited compared to their younger counterparts. It is helpful to encourage older adults to check the quality of their internet connectivity prior to the session and establish a backup plan, such as a telephone session, in the case of technological glitches. If this is not possible, it may be necessary to reschedule the session to a later time. Checking for internet connectivity, sound quality, and video prior to the appointment also allows for more time to be dedicated to the administration of assessments or engagement with the intervention during the session. An internet connectivity check can be facilitated by providing the older adult with technical support before and during the session including written instructions and being careful not to overload them with too many verbal instructions at once.
Hearing issues should always be considered when treating older adults. It is crucial to confirm that they are using all necessary sensory aids such as eyeglasses, hearing aids, or a pocket talker to ensure the best quality communication and to avoid over-pathologizing because of auditory comprehension problems. However, when using phone or video communications, if the audio becomes distorted, it can be difficult to maintain the validity of the assessment results. At the beginning of a session, it is wise to make sure that the patient can adequately hear you and that you can hear the patient as well. You may need to speak more slowly and slightly louder than you would if you were meeting in person. The quality of the communication should also be evaluated when conducting assessments via video that involves visual stimuli. As trainees, we should check for video delays and be aware if the visual quality is degraded prior to any test administration.
In telehealth contexts, there is an ongoing discussion about privacy and confidentiality issues within our profession. With older adults, privacy concerns may be amplified due to sensory issues or cognitive impairment. For example, there is the issue of whether an older adult with hearing impairment should wear hearing aids or headphones. In instances where headphones are not compatible with hearing aids, it is recommended that the patient be encouraged to use his or her hearing aids and not use their headphones. When treating older adults with hearing impairments who may have family members in close proximity, it is recommended to maintain privacy that older adults use headphones if the audio volume and clarity are sufficient for the session.
Knowledge of your patient’s ability to follow multi-step instructions to complete sequences of tasks involving technology is useful. Receiving treatment via telehealth can often be overwhelming and intimidating for older adults. As the provider, you may need to obtain consent from the patient for someone at home to assist them with the technology. It is also important while working with an older adult via telehealth to break complex tasks into more simple, manageable parts to avoid making them anxious and to address the technological issues. Additionally, it may be necessary to repeat information several times to ensure comprehension. A teach-back approach may be helpful to understand what your patient retained and is able to act on once the session is over. If your patient seems overwhelmed during their telehealth session, it may be helpful to use some grounding or mindfulness techniques.
For both the trainee and patient, it is of utmost importance to survey the surrounding environment and attempt to limit external distractions of any kind during a telehealth session. For older adults, this is particularly salient given normative decreases in processing speed and sensory functioning. Having a neutral colored background for the patient may help reduce attentional or cognitive distractions. Additionally, using closed captioning and a white noise machine may be beneficial in decreasing external distractions and potential privacy issues. Free white noise applications can be downloaded onto most smart devices. Establishing a sense of routine that we greatly miss from face-to-face encounters (e.g., walking the patient from the waiting room to the treatment room) can create a sense of a shared experience and can also provide structure.
For trainees working with this population during COVID-19, it may be helpful to establish a designated space with specific materials for telehealth appointments to provide a sense of structure and routine while working from home. Additionally, having a centering or grounding routine for before and after telehealth sessions can be crucial in terms of setting work boundaries or when orienting to upcoming sessions and reviewing past sessions. Importantly, time away from the computer is important – stretch, move around, stay hydrated, and decompress as much as possible between appointments given the strain associated with staring at a screen intently for extended periods of time.