Is Telemedicine Here to Stay for Alzheimer and Dementia Care?

Jessica Zwerling, MD

The impact of telemedicine has undoubtedly been felt across the breadth of medicine over the past year as the pandemic forced both patients and physicians to convert their standard visits into the new, virtual world. Although many had been calling for the field to utilize telemedicine as a tool to improve care, any long-term impacts of its integration are only now being recognized.

For patients with Alzheimer disease (AD) and dementia, telemedicine comes with several benefits and challenges. Although virtual visits allow for these patients to easily see their provider without the difficulties of travel, many are elderly and may find the technology to be slightly out of their normal routine. Additionally, many of these patients have either a family member or healthcare professional acting as their caregiver, adding another person into the complexities of this experience.

Jessica Zwerling, MD, director, Center for Excellence for Alzheimer's Disease, and associate director, Center for the Aging Brain, Montefiore Medical Center, is one such physician who has been able to utilize telemedicine for her patients. She shared her insight and knowledge of it for this patient population, detailing the challenges to overcome and state of its use, with NeurologyLive in this interview.

NeurologyLive: How has telemedicine impacted the physician-patient-caregiver relationship, in your experience?

Jessica Zwerling, MD: Right from the get-go, the relationship that we have with our patients relies also on the caregivers—that dyad is so important. We really did flip the switch to telemedicine, and we engaged both the patient and the caregiver, and it was a wonderful opportunity. We really saw the gamut of some patients who have moved into facilities because they didn't have the home health aides that were allowed to be in the home due to the restrictions of virus concerns or the family’s personal preferences. Some patients moved in with their loved ones or their caregivers, whether it was a neighbor or a relative of theirs. We were able to navigate it quite differently. For those that were separated in space with patients, we also ended up having the ability to use telemedicine to have a paired visit not only with myself, but with my social worker, as well as additional family members on technology calls, which is absolutely phenomenal.

It’s something that I hope is sustainable for the future, especially as caregivers are burdened with leaving for a day of work. I was like a caregiver myself, and to get my grandmother to an appointment is a day's event. It was hoping that there wouldn't be a behavioral issue, that you could leave the house. To have to be able to go to someone's house or be in your office and still have that visit, have the home health aide present if the patient can't be present, and navigate technology, and to have multiple folks on the call, is so helpful in guiding the care of the patient and caregiver. I really hope, fingers crossed, that this is here to stay.

In your experience, are those benefits enough to encourage the continued use of telemedicine for these patients?

I think it will be here to stay. We created what we call a “C-care model.” It is a continuity of care for the at-home elderly. We paired our social worker with myself on the same phone call and we address falls and mobility, weight loss, sleep and behavioral disturbances, and medication reviews—whether it was polypharmacy or not. We looked at domestic violence and elder abuse, caregiver stress, and then we were able to link with community-based organizations. That interview is so important and so key. When you look at hospitalizations and risk for all-cause death with patients with cognitive impairment or depression, the benefits outweigh the burden of the call. I hope that that is here to stay.

As far as the acceptance rate, we ran a full clinical trial program that we've flipped immediately to on-the-phone, and it had a 100% acceptance rate. That was in an under-resourced, diverse, and frail population, and it had a 100% acceptance rate with wonderful outcomes and that was using technology to treat our most frail population.

Have the challenges of implementing telemedicine—from small to large—been manageable to this point, and are any lingering that need to be addressed?

I definitely think one of the barriers is using it. I had a wonderful support staff that was able to preeducate patients and caregivers on the use of technology, so I think that eased the burden on the calls at the height of the pandemic when it was my social worker and myself delivering our visits in English and Spanish over the phone. That was a little bit more challenging and required about 10 minutes, initially, at least of our visit of navigating. Then, of course, it's things like the angle of the camera and making sure that when I did a gait evaluation that I could look into the home that I was able to get a full shot. It’s like what I see sometimes with my kids on Zoom, where I just see the forehead and above. Getting that full visual to evaluate the whole individual is important.

There are definitely tweaks and challenges, and that can be built into the visit and workflows can be adjusted so that support staff can help. But I really think it's such an added value that the burden of adapting the technology is just a minor point of it.

How have social determinants of health impacted the care and the access to telemedicine for these patients? And has telehealth helped fill in some of those gaps when used in a hybrid manner?

I think you're only as good as your community-based organization. I really believe in the take-the-hammer and knock-down-the-walls approach between your institutions and community-based organizations. Get to know the leaders in the community so that you’re able to navigate. We even did webinars on vaccine hesitancy, and we went into senior housing. That's important. You can bring access to patients just like we bring the vaccines directly to the patient's door. Helping in the navigating for senior centers for important appointments, having healthcare navigators help with that so that you can bring the technology to patients is extremely important.

Our region, even in Montefiore is not just our immediate surrounding area and the Bronx, it’s also the Hudson Valley region, and there are regions in Ulster County, Sullivan County, Dutchess County where access is to care is a challenge. There's a similar burden and a geographic burden. But I do want to highlight that even with this, we were able to engage a community of older adults that were 79 years and older that were 38% Hispanic, 46% non-Hispanic Black, and 30.9% of patients who identified that they had Spanish as a first language. These were patients that were culturally and educationally diverse, maybe not familiar with technology, but really engaged in a program to address not only cognitive health, but mental health and a focus on social determinants of health. What I want to drive home is that when you have social determinants of health, it must be culturally relevant. We need to be able to bring those resources that are culturally relevant to our patients.

Do you find that the community is willing to engage in those efforts?

Even though we're underserved, it's such a rich community. I've been here for over 20 years at Montefiore Health System, and even during the height of the pandemic, via Zoom, we had 99% of Black participants participate in what we call a “stakeholder studio.” Those are our community members that we got together, and we wanted to talk about depression and older adults, and what it means to them. What words can be used? What would sink well with the community so we can really do community participatory research? How can that help guide the care that we're delivering at Montefiore, and how can we have an understanding of what would work? What may be the barriers and how can we improve?

On the same note, at our CEAD, or Center for Excellence for Alzheimer's Disease, we have representation of patients with mild cognitive impairment as well as caregivers. They're direct stakeholders when we guide a policy within our center of excellence. That's so key. I have not reached a barrier with them, and in fact, it's been a diverse group of individuals who have been guiding their own care and the care of their fellow community members with our experts. It's been extremely rewarding.

Transcript edited for clarity.