Improving Dementia Knowledge in Diverse Populations Through Telemedicine

James E. Galvin, MD, MPH

This is a 2-part interview. For part 1, click here.

Rural populations are, on average, older than urban populations and have higher rates of chronic conditions such as hypertension, diabetes, traumatic brain injury, and depression.¹ These communities also experience higher rates of alcoholism and tobacco use and lower levels of formal educational attainment than urban populations.² Combined, these documented risk factors have suggested that rural communities may be disproportionally affected by Alzheimer disease and related dementias.

To address the gaps in dementia education, detention, and treatment, investigators employed the MoCA-T telephone app in a rural Floridian community as a means of cognitive screening. Of the 60 individuals who completed cognitive screening using the MoCA-T, 15 (25%) were found to be at risk for memory impairment. Twelve (80%) of the 15 participants assessed as being at risk went on to follow-up with their provider.

NeurologyLive sat down with study investigator James E. Galvin, MD, MPH, director, Comprehensive Center for Brain Health, University of Miami Miller School of Medicine, to understand more about the results and the overall topic of improving dementia education in areas with documented disparities. He also spoke upon the misconceptions regarding age and its role in the risk of Alzheimer disease and related dementias.

NeurologyLive: Were you shocked to see the profound impact the MoCA-T app had on improving dementia knowledge?

James E. Galvin, MD, MPH: One of my areas of interest is in health disparities. Some of my projects have focused on the African American and Hispanic communities. Another aspect is looking in rural communities. I had NIH-funded grants to look at rural communities alongside Dr. Lisa Wiese, PhD, RN, PHNA-BC, CNE, who’s the first author on the abstract. She grew up in Appalachia, so she has a great interest in rural communities. The Florida rural communities are very different sociodemographic wise than traditional Midwestern rural communities, which are largely White whereas in central Florida, the population living on the sugar cane and citrus farms are largely non-White. It’s a mix of Afro-Caribbean, African American, and Hispanic—mostly Central, Mexican, and Central American.

The central and Mexican American population tend to be a bit more of the migrant farmers, while the African American and Afro-Caribbean communities tend to live there their whole lives. They have a unique aspect in that they were born, raised, lived, and died in these rural communities. We were interested in figuring out what the risks of Alzheimer disease are, and what would be ways that we’d be able to assess people and raise their awareness of the disease, all within the context of a global pandemic. In the Lake Okeechobee glades area, it’s been devastatingly hard hit by disease and its already a medically underserved region to begin. There are little resources and they as a community, have been reluctant to have outsides come in and do things.

We’ve had to develop a host of strategies to conduct remote assessments as we wait for the pandemic to eventually move on. We’ve been trying to devise several ways of doing this, one being the MoCA-T app. You are limited by doing something on the phone or by Zoom because you don’t have that face-to-face interaction, but if you want to do research and make an impact on the community, you must first raise the awareness of that disease. If there’s no awareness, you can’t go anywhere. The first step is raising awareness, raising health literacy, making people understand something about the disease and then making it resonate with them as a personal issue. That requires understanding their knowledge of the disease, giving them information, have them complete an assessment, and then decide who has a problem and who doesn’t. Then, what kind of services may that person benefit from?

The approach for the abstract was, “How do we use these remote tools to get into a community that, to this point, has shut itself off from the rest of the world because of the devastating effects of COVID-19?” These people have a lot of risk factors for vascular disease and Alzheimer disease. We’re just beginning to understand whether COVID is also a future risk factor for those same diseases. Overall, we need to get into the community but respect their wishes. This was a way of allowing us to interview and examine people from a remote location.

Which aspects of dementia do you feel the general public, specifically those within rural communities, still need more information/awareness on?

I could spend hours talking about this topic, but there are 2 fundamental things that are important to get across to the public, and unfortunately, in many cases, the medical profession is not fully aware as well. Firstly, diseases like Alzheimer disease are not inevitable with age. Age itself doesn’t cause a memory disorder. Something is causing that memory disorder, but age is the greatest risk factor. People who are old who have memory problems don’t have memory problems because they’re old, they have memory problems because they’re something causing that problem. It could be Alzheimer disease, stroke, head injury, or a lot of other things, but it’s not age.

Age is the greatest risk factor. The first part is this disentanglement of what’s age and what’s a problem. That’s the first part. The second part is that while age is a great risk factor, there are things that we can do to build a better brain as we age. We say that at age 85, there’s roughly a 40% risk of Alzheimer disease. That means 4 in 10 people get it, but that also means 6 in 10 people don’t get it. Thinking about these resilience and vulnerability factors are critical. The 2 most important take-home messages that people aren’t aware of is that this is not inevitable with age and there are a lot of things we can control as we age, which probably factor into that inevitability. It’s not genetics, it’s these other things that we have control over. If we can control 40% of the things, we should worry about those, while we should ignore the 60% of things we can’t control. It’s never too early, it’s never too late, but it’s probably better to be too early than too late.

Transcript edited for clarity.

REFERENCES

1. Meit M, Knudson A, Gilbert T, et al. The Rural Health Reform Policy Research Center: The 2014 Update of the Rural-Urban Chartbook. RHRC; 2014.

2. Norton S, Matthews FE, Barnes DE, Yaffe K, Brayne C. Potential for primary prevention of Alzheimer’s disease: an analysis of population-based data. Lancet Neurol. 2014;13(8):788-794. doi:10.1016/S1474-4422(14)70136-X