Abstract
Introduction
Alzheimer's disease (AD) is estimated to affect 5.4 million individuals in the United States. 1 Reliable and specific recommendations for diagnosis and management have been developed by specialty groups for various types of dementia. 2 –5 and accuracy of clinical diagnosis by a specialist approaches 90%. 6 However, often these specialists are located in urban areas and access for rural residents can be challenging. 7
Telemedicine has been explored as an alternative to provide consultation for rural providers. A recent review found benefits in access, cost, education, support, outcomes, and quality of care with use of telemedicine. 8 Access to established specialists for those requiring care without needing to increase the numbers of specialists may raise the quality of care while saving money. 8 Clinicians feel comfortable changing their diagnosis and treatment recommendations after telemedicine consultation and this has resulted in improved clinical outcomes. 9,10 Proposed roles for telemedicine in neurology include acute stroke, management of epilepsy, or consultation during hospitalization for neurologic symptoms. 11
Emerging research also suggests a role for telemedicine in the evaluation and management of dementia. 12 Studies have demonstrated reliability of both the neurological examination 13,14 and cognitive testing 15,16 via video-telemedicine (VTM). In addition, comparisons of diagnosis made in-person and via VTM have suggested reliability and validity of this format in diagnosing dementia. 17,18 However, most of these studies had limited neuropsychological testing and limited physical examination and were designed to validate the physical or cognitive examinations for a research project, not for a clinical evaluation.
Our goal was to use VTM to provide access for rural veterans for a specialty memory disorders clinic (MDC) for a comprehensive, multidisciplinary evaluation and to obtain a diagnosis that would simulate an in-person evaluation and could be integrated into the regular clinic setting.
Methods
Setting
Subjects were veterans receiving primary care at the Veterans Administration (VA) community-based outpatient clinic in Eureka, California. Eureka is a city of 26,000 people (2000 census), located 280 miles north of San Francisco. The clinic provides primary care and mental health services to veterans, but specialty services such as dermatology and cardiology require evaluation at the San Francisco Veterans Administration Medical Center (SFVAMC). The SFVAMC MDC is a multidisciplinary clinic which is a site for the state and federally funded Alzheimer's Center at the University of California, San Francisco (UCSF) and evaluates approximately 100 new veterans each year. The MDC is focused on the evaluation of neurodegenerative dementias and serves veterans from San Bruno (south of San Francisco) to Crescent City (close to the Oregon border), covering an extensive 8-county area of Northern California (Fig. 1).
Map of Veterans Administration Medical Center and associated community-based outpatient clinics.
Equipment
The SFVAMC uses Tandberg End point as standard VTM equipment with a mixture of Tandberg classic (older) end points and MXP (newer) end points. All MXP models are capable of doing secure calls. End points range from desktop units (models T1000MXP, T150MXP, T1500MXP) to room-based units (models 880MXP, 2500, 3000, 6000), both of which are used in VTM evaluation of dementia. The SFVAMC unit and the remote clinic unit are in conference rooms that are in the regular clinic space. The Tandberg Scheduler allows prescheduling of the appointment and automatic dialing and connection at the appointed time.
Subjects
The patients were referred by their provider in Eureka for evaluation of cognitive complaints. We included those veterans who were unable to travel to the SFVAMC for in-person evaluation, without significant visual or auditory impairments, with a knowledgeable caregiver and cognitively able to participate in a video evaluation (minimental status exam [MMSE] >12). The patient referrals were reviewed jointly by the remote clinician at the Eureka clinic and the nurse practitioner at the MDC for appropriateness. The patients were then scheduled into the regular MDC clinic schedule for a 2–3 h evaluation. The remote clinician contacted the patient or their caregiver before the appointment, confirming this information and obtaining a detailed history of current illness according to a previously developed format, including onset of symptoms as well as functional and behavioral changes. The remote clinician received in-person and VTM training in administration of the cognitive screening battery. This project was approved by the Institutional Review Board of UCSF and the SFVAMC Research and Development committee.
Procedure
The VTM evaluation was initiated after dial-up between sites and adjustment of the patient, furniture, and camera to permit optimal visualization. Introductions were facilitated by the remote clinician who was in the room at the site with patient and caregiver. The MDC physician began the appointment by obtaining a medical history, including chronology and character of cognitive complaints, functional status, behavioral symptoms, and relevant medical history. The caregiver was interviewed to validate or provide additional information. A focused neurological examination, including assessment of cranial nerves, motor evaluation for tremor, coordination and some components of strength, and gait was then conducted by an MDC physician with the assistance of the remote clinician in Eureka. This was followed by the administration of a neuropsychological battery derived from the usual in-person battery of the MDC (Table 1) and includes detailed assessment of all cognitive domains. On completion of the evaluation, the MDC team conferred and developed a consensus diagnosis and treatment recommendations. These preliminary results were then communicated to the patient and caregiver via VTM by the physician and appropriately documented in the electronic medical record available to the patient's primary care providers. The primary provider was also able to attend the regular postclinic MDC conference via video and review results and discuss treatment and follow-up recommendations. Education and support for caregivers included provision of the usual MDC packet by the remote clinician with educational material including information about diagnosis, prognosis, treatment options, driving, and local resources.
Components of Neuropsychological Battery
SFVAMC, San Francisco Veterans Administration Medical Center; VTM, video-telemedicine; CVLTII, California Verbal Learning Test.
Results
All patients traveled to the Eureka VA clinic with an involved caregiver and underwent VTM neurological and cognitive examination. Fifteen patients were evaluated using the telemedicine procedure (Table 2). Eleven of the 15 had no prior evaluation of their cognitive complaints and minimal screening was available from the referring site. The patients were all male, with a mean age of 79.1 years (range 71–88 years) and mean education of 12.5 years (range 8–19 years). The mean MMSE was 22.8 (range 12–27).
Results of Video-Telemedicine Evaluation
AD, Alzheimer's disease; MCI, mild cognitive impairment; PTSD, post traumatic stress disorder.
Based on review of data gathered through VTM and chart-review, clinical diagnoses were arrived at for each patient by MDC staff (Table 2). Two were determined to meet criteria for Cognitive Disorder NOS (not otherwise specified) or mild cognitive impairment, 12 met criteria for dementia (5 with vascular etiology, 4 with AD, 2 with mixed AD/vascular dementia [VD], 1 other), and 1 was assessed as cognitively normal. The treatment recommendations included control of vascular risk factors, medication for depression, cholinesterase inhibitors, and memantine. Eureka clinic providers collaborated in the postclinic discussion via video. In 8/9 cases (89%) where medications were recommended, chart review indicated that providers made these changes. Four of the remaining cases had no follow-up at the VA. Informal feedback from patients and providers was obtained via the remote clinician and indicated satisfaction with the evaluation and appreciation that the service could be provided locally. In addition, providers expressed appreciation for access to the postclinic conference and opportunity to discuss cases with the MDC team.
Discussion
In a collaboration involving our specialty service in dementia evaluation and care and a rural community clinic, we have demonstrated that it is feasible to simulate an in-person evaluation for dementia via VTM in a manner that integrates this technology into an existing clinical setting. Although limited screening tools are available online or for phone use, we are unaware of any full diagnostic assessments that can be easily implemented. With the support of a clinician at the remote site, we were able to provide key information, relevant clinical diagnosis, and treatment recommendations for patients with cognitive impairment. The potential for clinically valid VTM evaluation in dementia has been reported. 11,18 –20 A specialist with expertise in cognitive assessment has been proposed as the most important ingredient. 21 Experts suggest that the difference when compared with a face-to-face consultation is probably small when compared to clinical competency and experience. 11 In our study, the facilitation by a trained, dedicated clinician at the rural site and integration into our state-of-the-art multidisciplinary clinic permitted patients in a remote area to receive virtually all the advantages of a specialty clinic evaluation while remaining in their local community. Previous research suggests that most patients are very satisfied with this method and prefer it to traveling, 18,22 and informal interviews with our clinic patients suggest that this was true for our sample. The inclusion of local providers in postclinic discussion allowed for education and consultation that facilitates the care of that patient and may impact that provider's care of other individuals in the future. This was a unique component to our evaluation and feedback from providers was overwhelmingly positive. In the future, follow-up by Vtel could provide additional benefit and support to patients and local providers.
There are some limitations in the utilization of this technology. It is difficult to perform certain parts of the neurological examination, for example, neuromuscular tone. In our situation, there were providers at the remote site who could help in gathering this information if necessary. In addition, this technology is limited in patients with significant sensory and auditory problems or those with more severe confusion or communication impairment has been identified and continues to prevent it from being more generally applied. The availability of trained professional staff at two sites and careful prescreening of potential patients are important ingredients in the successful utilization of a telemedicine adjunct to an MDC. Future technology might integrate home telehealth to further expand accessibility in even more rural settings. 2 More investigation concerning the validity of diagnostic impressions arrived at through its use in this population is also needed. Finally, it can be difficult to disclose the diagnosis of a serious neuropsychiatric disorder in a physically removed manner. In a survey of literature on doctor–patient communication with telemedicine, nonverbal behavior and lack of touch were the only categories reported as not satisfactory. 23 This may be mitigated by the presence of clinically aware and sensitive staff facilitators at the remote clinical site during disclosure of diagnosis who could provide comfort and support.
Preliminary research has validated this technology in dementia diagnosis but the focus has been on demonstrating reliability of techniques and procedures. Our experience suggests that a VTM evaluation can largely replicate an in-person evaluation and be integrated into a traditional clinic format. In addition, we were able to provide a forum for provider communication to facilitate management and education. Although not currently recorded, video of these evaluations could be useful for review by the team as well as useful for education and research purposes. Further studies are recommended to validate the assessment procedures and confirm consistency between diagnostic impressions arrived at through VTM and face-to-face examination. However, this technology shows promise in providing a quality and cost-effective alternative to in-person evaluation of rural veterans.
Footnotes
Disclosure Statement
No competing financial interests exist.