Manish Shah, MD, MPH: Telemedicine for the Dementia Population

Manish Shah, MD, MPH

An embrace to the future of healthcare could decrease a dated burden among geriatric patients.

In a recent interview with MD Magazine® sister publication NeurologyLive® while at the 2019 Alzheimer’s Association International Conference (AAIC) in Los Angeles, CA, Manish Shah, MD, MPH—John & Tashia Morgridge Vice Chair of Emergency Medicine Research at the University of Wisconsin-Madison School of Medicine and Public Health—explained the potential benefit of improved telehealth options for older patients.

More specifically, Shah detailed how more in-depth, far-reaching telemedicine measures could benefit the dementia patient population and others who may not actually be suitable for emergency care situations—even during an emergency.

Dementia and the ER: Limitations and anxiety

Shah: So, one of the things that’s pretty well known out there is older adults struggle to get acute illness care. And with patients with dementia it’s even harder for them, right? So you have symptoms develop, you feel ill, you call your primary care provider and it’s going to potentially take a little while to get in to be seen or you call your self- specialty provider and it’s going to take a little bit to get in to be seen that combined with the fact they often have functional limitations, transportation limitations, result in us seeing them in the emergency department pretty regularly. We’re happy to take care of them.

I think we actually do the best job possible we can to take care of them, but when a person has dementia, the emergency environments challenging. Right? The noise, that’s unfamiliar, it’s disruptive even with the geriatric ED initiatives. Food and water may not be readily available. And it just becomes really stressful and who knows where that can go necessarily. So, the question that we really started thinking of is how can we provide emergency care to these individuals without that added stress, without that piece that necessarily just makes it a bad experience for them or makes it challenging for them and even for their care giver potentially?

Telemedicine and its potential to improve patient comfort

And so, one thing that’s been tossed around for a long time has been telemedicine. And as the technologies improve, what we had done a few years back has done a study in general with older adults as can we use telemedicine to replace ED visits and even urgent care type visits. And we found 18% reduction in ED utilization when we did that study. The question we started to ask just this last year was well, ‘what about people with dementia,’ right?

They’re even more vulnerable than your average older adult, maybe it works really well for them or maybe it doesn’t. And, to our pleasure, what we saw was is that telemedicine, that our telemedicine program when we gave it to these folks in the intervention groups reduced ED visits by 24% per year, which was really fantastic to see.

It’s not Facetime—it's high-intensity telemedicine

Now, I think there’s an important caveat to throw in here. So, telemedicine—when the average person thinks of it, that maybe your insurance plan offers you, it’s basically video conferencing, right? So, it depends what the backend software is, but it’s basically like FaceTime and you talk to a provider on the other end and that’s what it is.

What we’re doing, which is why we call this high-intensity telemedicine, is we actually sent a technician out to the patient’s side, they would collect the information, they would collect pictures, sounds, belly sounds, heart sounds, lung sounds, pictures of, you know, eardrums, video of people doing things, and then they would link that up with the provider that’s provided the telemedicine care of the physician or the advanced practice provider.

So, this had a much higher level of capability than what the average individual gets from the most commercial serviced currently. And, so, there’s a little difference I think is an important caveat to understand, but we felt it was very important for folks that have multiple medical problems, that have multiple medications, can this person do a medication reconciliation that may need some testing or something like that, and so, we found it worked great.

“You can’t change the world reanalyzing other data”

The challenge with this recent study of course is we’re just analyzing data from a previous study, and so that is a limitation. Ideally, someone either needs to replicate this, or think about whether this could have, essentially be a false positive result. We personally don’t think so, that the single is so strong, and it makes so much sense to us, then we think we’ve found a real significant finding here. But you can’t change the world with just re-analyzing other data out there necessarily.

So, the researcher in me kind of is a little bit cautious about this, but I think that it’s fantastic and it changes the game, right? If you can just take care of people in their home, it’s the easiest possible. It’s a comfortable environment, you don’t have to travel. And I think with, for folks with dementia, that can be a complete game changer, then the environment we put them in at a hospital.

“We’ve gone to the moon since this model had come out:” Revolutionizing healthcare delivery

So, I think there’s really 2 models in my mind there. One is to actually have the staff at the facility be that technician. We really explore that in the research study, and the partners we work with actually cautioned us against that for a variety of reasons. But I think it could still work. I think it just needs to be in the right environment and you need to figure out what is going to work in your community. The other model, which actually has a little bit more flexibility is to have it almost be like a utility model, right?

So, the utility company owns the power lines, but who generates the electricity and who actually uses the electricity can change. And the advantage in my mind, thinking very long-term in thinking big, is why not be able to provide this type of service to people who live in their own homes? In that case, you’re not going to have that nurse or a nursing aid or someone in fact we have in these facilities.

And so, the advantage would be that if you have these folks independent, I mean you know, not to use a brand name, but Uber could be this provider, quite honestly. They could really go to these senior living communities. They could go to Jane Doe at her home and help her out there or whatever the case might be.

And, even though I’m not involved with these, I’ve heard of a few companies out there advertising and what not that are exactly looking at this and some health systems that are exactly looking at this as a way to really change how we deliver healthcare. Because, if you think about it right, so the current model of healthcare we have of everyone coming to the doctor, to the hospital, we’ve gone to the moon since that model had come out. Why not change how we deliver healthcare so it’s much more convenient, much easier, much less stressful. I think that’s where the potential is, long-term.