Telemedicine in Dementia Care: Here to Stay?

Jessica Zwerling, MD, MS

This is the second of a 2-part interview. For part 1 of this interview, click here.

While telemedicine has continued to be a care revelation for clinicians during the COVID-19 pandemic, the future of its use in clinical care remains to be seen. Although it has proven to be and safe and effective method to continue patient care across many neurological disease states, there are still significant limitations standing in the way of high-quality care.

Jessica Zwerling, MD, MS, associate director of the Center for the Aging Brain at Montefiore Medical Center, sees plenty of use for telemedicine at her practice following the pandemic, especially because of her remote location. Her implemented telemedicine strategies have enabled her and her colleagues to understand more about their patients' at-home setting, which is a key component of care for those with cognitive decline or Alzheimer disease (AD).

In part 2 of this interview, Zwerling describes the advantages telemedicine has had specifically on those with cognitive decline or AD, and why it can continue to serve as a useful and effective tool going forward.

NeurologyLive: Did virtual visits allow you to have a greater perspective on patient home life and care? How did that influence your care recommendations?

Jessica Zwerling, MD, MS: Oh, absolutely. I’ve had patients that were discharged from some hospitals after COVID-19 who continued to struggle without a formal rehab program. I saw that their gait made them at risk for a fall, and they needed to be set on a gait training program. These referrals for programs led to our Montefiore post COVID-19 rehab program being set up. I was able to watch them on video and assess their gait and navigation of obstacles in their home environment. This was a “safety evaluation” on video. As you know fall is a risk factor for morbidity and mortality in older adults. A cognitive and gait assessment are crucial aspects of the evaluation of the older adults and adaptable to telemedicine. To note, our care was delivered with our behavioral care manager/social worker on the telemedicine visit. Issues such as caregiver stress, food insecurity, health care proxy and power of attorney, referrals to community organizations were handled as well in the SAME visit. To note — we delivered these in both English and Spanish to keep in mind cultural competence.

Is telemedicine something that you would consider incorporating into your practice more regularly as an alternative for patients, especially for those who may not be able to travel for appointments?

Absolutely. My territory is not only the Bronx, but it includes 7 counties in the Hudson Valley region. To get to my offices from Ulster county, is an hour and a half trip. Allowing for some visits to occur via telemedicine, will provide comprehensive care to those that would not have been able to access previously. We’re able to extend our evaluation of patients and bring neuropsychological testing via telehealth to these patients. There are very few neuropsychologists and geriatric psychiatrists in some of the New York state regions. Being able to deliver that care to patients in their remote environment via telehealth is crucial. I think about the folks who due to severe behavioral manifestations of neurodegenerative disease and who have caregivers struggling to bring them in for appointments. My colleague Dr. Weiss has been a pioneer in this field. One of my grants funded through the Leslie R. Samuels and Fan fox foundation supports the role of a neuropsychology post doctoral program and we are delivering cognitive exams in Spanish and other languages through telemedicine. Providing culturally appropriate care is crucial.

Telehealth could be especially beneficial for those who have advanced stages of dementia such as more geriatric syndromes, neurology frailty, swallowing difficulty, failure to thrive. Seeing that patient in their home may be a way to assess and deliver care in not only a culturally sensitive manner, but also still provide that state-of-the-art care even through telemedicine. Patients will still be seen in the office but telemedicine is a different option that should complement in office exams.

Is there anything we should know about how your practice has changed throughout the pandemic?

I think in neurology our “code of arms” is usually the reflex hammer, but in telemedicine you can’t use a reflex hammer. You can look at gait for sure, but as neurologists and geriatric neurologists, we’ve been thinking about ways to deliver culturally competent and complex care to older adults for so long. This just reinforces our skills and oftentimes makes us be more intentional about complex syndromes that need more consideration. In the pandemic, when patients had difficulty getting their medical doctors, we continued to provide that type of care to the frail individual in a coordinated matter.

Transcript edited for clarity.