Adapting Telemedicine for Dementia During COVID-19

In part 1 of this interview, the associate director of the Center for the Aging Brain at Montefiore Medical Center discussed how she adapted quickly to optimizing telemedicine for elderly patients with Alzheimer disease and cognitive decline.

By: Marco Meglio
Neurology Live, Published: June 25, 2020

In times of the ongoing pandemic and social distancing, telemedicine has shielded those with Alzheimer disease and cognitive decline from unnecessary exposure while also allowing providers to link their patients to much–needed community services. In addition, clinicians have been able to learn more about the at–home living of their patients while providing key medical advice on navigating the healthcare system.

Jessica Zwerling, MD, MS, associate director, Center for the Aging Brain, Montefiore Medical Center, has adapted quickly and optimized telemedicine for her patients by creating an easy–to–follow how–to guide to ease patients and caregivers into video visits. This is just 1 of the many ways she has helped smooth the transition for elderly patients from in–person visits to telemedicine.

In part 1 of a 2–part interview with “NeurologyLive”, Zwerling breaks down how the center continued to adapt throughout the pandemic, and what motivates her to provide for not only the patient, but the caregiver as well.

“NeurologyLive”: Can you describe the unique challenges of adapting telehealth care in this patient population? What were some strategies you used to mitigate issues related to this transition?

Jessica Zwerling, MD, MS: At baseline, we have our patients go through a series of evaluations from a multidisciplinary perspective, which is really nice in the complex care of the older adult. We don’t think of some of the medical issues that could impact the health of older adults.

During this time, we had a social worker who was our behavioral care manager on the phone with me to do coordinated calls. As we met some challenges in creating that comprehensive evaluation, we had to get the buy–in from the caregivers and the patients, mainly because those with cognitive impairments can have sets of delusions or paranoia. Culturally, a video visit may not be acceptable, so we had to navigate the barriers.

First, we identified a health care proxy for a caregiver. There were times that we may have had 3 to 4 people on a call in which we would have a caregiver in 1 location, our the behavioral care manager in another, myself in another, and then a family member of the patient who was designated as someone that can help with the technology. Most of the time we used tele–video, but also used telephone communication, too. We would sometimes speak to the caregiver beforehand if there was sensitive information that we didn’t want to trigger the patient with. Overall, it provided a unique opportunity. In developing this complex evaluation, we had to think about the teaching as well as our institution.

Residents and fellows would be added to our calls to deliver that care and supervise them, but it also allowed a transformative teaching that needs to be done. That was definitely a challenge, but for me it was wonderful. From a personal perspective as someone whose grandmother had Alzheimer disease, when you have a patient who’s cognitively impaired coming into the office, you understand that it is a full–time job. It sometimes took 3 hours to get her out of the house, she would get to the door and you were back to square 1 because there was a behavioral issue. The convenience of an appointment and a caregiver not missing a day of work because they had to travel to the appointment is huge. This allows clinicians to see the barriers that were in their home whether there was hoarding or if they were doing a gated exam and they were navigating the apartment. Did they forget their cane or walker? What did the house look like and how do they navigate through the home? This provided a nice insight into more of a comprehensive care of the older adult.

How did you adapt your typical visit, specifically conducting neuropsychological testing? What are the challenges associated with doing that virtually versus in–person?

Some of the thinking exercises can definitely be nerve–racking. There can be that extra anxiety that comes with a face–to–face visit, but we’re still able to perform and deliver neuropsychological testing in multiple languages over the phone. We didn’t have any change to any of those validated measures that were delivered, but we did need to consider that if you have a broadband connection, that your processing speed is slow, and your connection may be bad as result. But we were able to navigate through that testing and our delivery still remains the same. In addition, we use a brief screening instrument, which is a picture memory impairments screen, that is delivered via video on the phone. We were also able to show our patients the imaging, so they were able to see pictures of their brain by sharing screens. This allowed us to walk them through what we would have shown them in the office.

Can you speak more to your personal connection to Alzheimer disease?

My grandmother had Alzheimer, and my uncle who passed away from a heart attack was her directed home caretaker. We all helped out, I cared for her, made her appointments, bathed her, dyed her hair and what not. He, unfortunately, passed away 7 years before she did, but when I opened the center and when I focus my research, it’s always with the caregiver in mind–trying to focus on their health as well.

When we were on these calls for COVID–19, there were lots of worries about food insecurity, and a lot of intergenerational families that had opted to live in a different area because they didn’t want to bring the risk to an older adult. That caused older adults to struggle to have access to food. We had to work with food delivery companies and learn about different community organizations that were active that could assist with getting food to our older adults. We navigated through that, while also trying to keep up with what community services were available during this time. Patients were scared that they would not be able to get their refills. Other scares included whether their document was going to go to a hospital, the overall fear of a hospital if a loved one needs assistance, whether a loved one with dementia will have someone accompanying them and so on. There was a lot of working through that understanding. It gave me the opportunity with the caregiver on the phone to ask about their health because some of them were not linked but had risk factors that were associated with COVID–19. A lot of them did not have a defined primary care doctor simply because they were taking care of an older relative, which gave us a chance to educate them.