Telemedicine overcomes the physical limitations of conventional services by utilizing a variety of applications such as telephone, video- conferencing platforms and wearable devices; here we explore the benefits of telemedicine for people with dementia
During the coronavirus outbreak, the elderly were advised not to go out to receive physical healthcare services due to their higher morbidity and mortality rates,1 especially those with dementia. The main focus of the healthcare system was on coronavirus infection and emergent cases, leading to the suspension of non-urgent chronic disease services, which resulted in the deterioration of their health conditions.
People with dementia experienced an increase in behavioural conditions, such as depression, anxiety, anger, and agitation, during the pandemic, with inadequate routine screening programs and non-pharmacological interventions for dementia as one of the reasons.2 The difficulty of receiving physical services and advances in technology led to the use of telemedicine for people with dementia, particularly those living in remote areas. Many studies on telemedicine for dementia in various forms were conducted during the pandemic as a temporary strategy to address the inadequacy of physical services.
According to the World Health Organization, telemedicine refers to the remote delivery of healthcare services through interactive technology for diagnosis, treatment, and disease prevention, with the goal of achieving universal health coverage.3,4 Telemedicine overcomes the physical limitations of conventional services by utilizing a variety of applications such as telephone, video-conferencing platforms, mobile applications, and wearable devices.
Telemedicine has been used in various healthcare areas, and studies have shown that it can achieve comparable results with physical intervention.5,6 In the 1990s, researchers began exploring the possibility of conducting cognitive assessments via telemedicine, and they continue to study the application of telemedicine on people with dementia achieving promising results in different aspects, e.g., psychological well-being.7
With the increase in the aging population and people with dementia worldwide, telemedicine has become an important approach for researchers to alleviate the burden on the health system. In recent years, the development of consumer technology has enhanced intercommunication technology, spurring researchers to apply innovative technology to people with dementia.
Based on the nature of the service, telemedicine for dementia can be classified into three types: tele-assistance, telerehabilitation, and telemonitoring. Tele-assistance uses intercommunication technology for counselling people with dementia remotely.8 For example, specialists in urban hospitals can diagnose and provide teleconsultation to people with dementia at remote clinics through intercommunication technology. Telerehabilitation is similar to the conventional face-to-face approach but provides training to people with dementia remotely through intercommunication technology.
During the pandemic, health sectors used video conferencing to train people with dementia. Telemonitoring uses technology to collect data remotely to monitor the performance of people with dementia.9 There are two broad categories of telemonitoring devices: portable or wearable devices and fixed or environmental devices located in the designated spot in the home of people with dementia. In this e-book, we discuss the usage of different technologies for the first two types of telemedicine.
Tele-assistance: Diagnosis and assessment
The increasing elderly population highlights the need for more dementia diagnosis services. It was found that diagnosis is often delayed in the early stages of dementia,10 and many people with dementia do not receive a formal diagnosis. Some individuals are misdiagnosed into other reversible medical conditions, such as depression, which can lead to improper treatment and significant harm.11 All of these bring the importance of the diagnosis of dementia.
Primary care doctors are often the first point of contact for people seeking medical advice. A research study found that 50% to 80% of new dementia cases were missed in primary care.12 The complexity of dementia symptoms can make it challenging for primary care physicians to diagnose dementia, especially the rarer forms with atypical clinical presentations, such as younger onset dementia, due to the lack of relevant training and expertise. Dementia specialists, such as geriatricians, neurologists, psycho-geriatricians, and memory clinics, are primarily located in major population regions.
This means people living in rural areas must travel to these regions for assessment and treatment, incurring long travel and waiting times and increased costs for people with dementia and their caregivers. Although some remote regions may have memory clinics with specialists from urban areas coming to visit regularly, time constraints, poor weather conditions, and location can affect specialists and rural residents visiting the memory clinic.13
Telemedicine can be a helpful approach for diagnosing dementia. Researchers have proposed multiple ways to conduct the diagnosis, but the universal principle is the cooperation of healthcare experts between remote and urban areas. Nurses in remote clinics can conduct medical history interviews and pass information to specialist physicians in urban areas before consultation through videoconferencing.
Local healthcare staff can help conduct imaging scans and blood tests and transfer samples to urban laboratories, which are more proficient in interpreting test results. Assessments can be administered by local healthcare experts in clinics or remotely through a videoconferencing platform or phone.
Previous research has yielded promising results in the diagnostic rate of dementia through telemedicine, showing it to be an effective approach to confirming or providing a dementia diagnosis. Around 200 participants were first assessed in person by a specialist and then randomly assigned to another consultation by an independent specialist, either face-to-face or via videoconferencing.14 There was no substantial difference in the diagnosis between the two specialists in both groups, with little discrepancy in the rate among different diagnoses, suggesting that telemedicine is a reliable approach to diagnosing dementia.
Given the variation in assessment tools, standardized tools must be tested before incorporating into diagnosis through interactive communication technology. The Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), and Rowland Universal Dementia Assessment Scale (RUDAS) are reliable cognitive assessment tools that can be administered remotely and the results were similar to those of the face-to-face assessment.15 Clock-drawing test, a validated face-to-face assessment tool, had mixed results when administered through videoconferencing.16,17
A two-year longitudinal study on MMSE found that the video-based cognitive assessment tool was less effective in individuals with advanced-stage dementia,9 suggesting assessment via intercommunication technology is not applicable to all the dementia population.
Telephone is the most commonly used telemedicine approach for cognitive assessment
in the elderly, as they are familiar with phone calls, and it requires limited equipment. Previous research supports the feasibility and utility of conducting telephone-based cognitive assessments and found that some cognitive domains, such as language and verbal memory, are more easily and accurately assessed.18 When evaluating the concordance between telephone-based and in-person cognitive approach, most study results have medium to large correlation. Compared to the face-to-face approach, telephone-based cognitive assessments tend to be briefer and are recommended as a screening test for specific diagnoses to identify individuals with impaired cognition among the gross normal population that needs further and more detailed in-person assessment.
Teleconsultation and follow-up care
Telemedicine is increasingly being used in follow-up care, and teleconsultation is one of the major themes in telemedicine research. The underlying root of teleconsultation with older adults is maintaining their independence to live in the community, in which more than two-thirds of dementia live in their own homes.19 People with dementia have a high hospital admission rate due to their ambulatory care-sensitive condition, and there is a growing number of preventable hospital admissions among those with advanced age and living in remote areas, with underlying reasons such as pneumonia, congestive heart failure, and urinary tract infections.9 Researchers suggest that teleconsultation could help reduce preventable hospital admissions and emergency department visits.
People with dementia and caregivers are more compliant with treatment and receive it for longer periods as teleconsultation saves time travelling to clinics and waiting to see doctors.20 Individuals with dementia are more likely to receive inappropriate and high dosages of antipsychotic drugs in treating behavioural symptoms, which are associated with a higher risk of ischemic events and death.21 Through teleconsultation, specialists could detect harmful treatments for people with dementia by identifying inappropriate drug use approaches, thus lowering the potential risk for harmful health events.
Apart from physical health, teleconsultation could benefit people with dementia in different aspects. Routine follow-up on the condition of people with dementia helps delay the deterioration in cognition and improve quality of life and mental well-being.22 Regular monitoring helps to maintain the condition of people with dementia, thus improving self-efficacy and well-being and lowers the perceived burden of caregivers.
The growth of Telerehabilitation
Telerehabilitation is a growing field of delivering rehabilitation services remotely through interactive communication technology, derived from the broader concept of telemedicine. It is an effective alternative to traditional rehabilitation services, enabling people to receive care at home or other locations. In a systematic review of telerehabilitation, all studies showed improvement in outcomes after people with dementia received intervention through interactive technology.23 Another research study shows that telerehabilitation has a comparable effect to the traditional face-to-face approach in improving the cognitive ability of people with dementia.24 With the advancement of technology, researchers have utilized various types of technology to conduct telerehabilitation on people with dementia.
Computerised cognitive training
Computerised cognitive training adopts a similar protocol as conventional face-to-face cognitive training, attempting to reduce the degeneration in memory, attention, and problem-solving to restore the global functionality of people with dementia. A meta-analysis of twelve randomized controlled trials on computerised cognitive training showed that participants improved in cognitive assessment after the intervention, particularly in the memory domain, in individuals with early Alzheimer’s disease and mild cognitive impairment.25 There was less improvement in other cognitive domains, such as attention, language, and executive functions, which differs from the results of physical cognitive training.
Among all the computerised cognitive training programs, the beneficial effect in people with mild Alzheimer’s disease and mild cognitive impairment is more effective compared to other dementia types and healthy individuals and is the same as conventional cognitive training. Results on the follow-up of computerised cognitive training showed that improvement in cognitive function could last for six to twelve months,26,27 suggesting the intervention could delay the cognitive decline in people with mild Alzheimer’s disease.
Apart from the cognitive assessment, the beneficial effect of computerised cognitive training on people with Alzheimer’s disease could be reflected in the area with changes in neural networks. Individuals receiving four weeks of computerised cognitive training have been examined on the modulation of different indices of cerebral plasticity and global cognitive function.28 There was a significant alternation of cerebral plasticity in individuals, especially in areas that are neural correlated with executive functions, reasoning, and causal reward, which are functions impaired in people with Alzheimer’s disease, suggesting computerised cognitive training is particularly beneficial to this group.
Telerehabilitation via video-conferencing platform
Advancements in internet connection and computer hardware have lowered the threshold
for interacting with individuals through video-conferencing using mobile devices, increasing the delivery of rehabilitation training using teleconferencing platforms. Interventions on physical exercise were first studied on people with dementia and have proven feasibility, acceptability, and a positive effect on enhancing physical activity for people with dementia and their caregivers.29
Cognitive telerehabilitation through video-conferencing platforms also has satisfactory results. Twenty-two elderly people with mild dementia or mild cognitive impairment were randomly assigned to cognitive intervention sessions delivered through video conferencing and face-to-face over six weeks.30 Both groups improved significantly in attention and memory, language, and calculation. Spatial construction was only enhanced in face-to-face intervention, with authors suggesting training on this cognitive area often requires physical guidance, which is difficult to deliver effectively through video conferencing.
During the outbreak of coronavirus, a group of cognitive stimulation therapy (CST) facilitators in New Zealand attempted to transition physical intervention to a virtual programme under the guidance of two CST trainers.31 After two months of trials, around half of the participants successfully transitioned from physical CST to virtual intervention. Another group of researchers interviewed ten groups of people with dementia from different countries on their preference for virtual CST.
The interviewees were open to participating in the virtual intervention once they had received adequate feedback from previous participants and videos or photos of the previous session beforehand,32 suggesting the intervention was feasible to implement.
To enhance the facilitation, researchers offered several suggestions when conducting video-conferencing cognitive training. Due to technological limitations, it is difficult for interveners to manage a large group of people in the online session. Participants may have lower enjoyment as they speak simultaneously or could not participate in the intervention actively. Small groups of participants were recommended in each session to allow optimization of the online experience of participants and their interaction with the intervener.31
Facilitators of virtual CST have observed that some themes of CST are more suitable in the virtual environment, while some are not working well after multiple trials. Participants perform well in sessions involving “show and tell” or objects presented to participants physically, either through delivering the object to the sites of participants or asking them to bring it before the session commences.32
Showing the objects virtually or physically helps spark their conversation after participants view them and increase their engagement in the online sessions. Structured activities or those with visual stimuli are also welcome by participants during the virtual interventions. In the “Faces and Scenes” session, participants compare photos of famous places and discuss the differences and similarities. Participants play “hangman” or fill in the gaps of idioms or saying in the “World Games” session.
The “Identifying Sounds” session requires participants to match items and their associated sound clips. Facilitators reported that the performance of participants was worse in less structured discussion-based activities, particularly for participants with language or communication impairment.
Activities with complicated instructions are also challenging for participants as they may find it difficult to digest or remember all the instructions. It is difficult for facilitators to guide or prompt participants on activities that require participants to complete the task outside the camera view field, as facilitators cannot track each participant’s progress and provide relevant guidance. Caregivers are recommended to accompany participants for support for these challenges.
Operating video-conferencing platforms is challenging for people with dementia, given the deterioration of cognitive function and low digital literacy. Family caregivers could act as assistant and support people with dementia when having virtual cognitive training at home.
Interveners could provide additional technology support, including training on the operation before the online session, checking with each participant routinely to see if they can see and hear from each other at the start of the session, paying attention to the experience of technology of participants during the session, and providing dementia-friendly instructions on accessing the platform.31
People with dementia overusing video-conferencing cognitive training may experience “Zoom fatigue,” with symptoms of dry eyes, headaches, problems with concentration, and slow processing.33 To prevent over-usage, researchers suggest the maximal length of each video-conferencing session should be 45 minutes,31 while the physical cognitive stimulation therapy usually lasts for 50 to 60 minutes.
Virtual reality in telerehabilitation
The usage of virtual reality as a telerehabilitation device to stimulate neuroplasticity has become increasingly popular in recent years. This technology offers an alternative to traditional telerehabilitation approaches by providing multi-sensory, real-time stimulation during health procedures. Participants use input devices, such as joysticks, to control their avatar and perform tasks in a virtual environment.
It is particularly useful for training people with dementia in daily living activities, helping to restore or preserve their ability to stay autonomous and self-reliant. Using non-immersive virtual reality technology, studies have shown that people with dementia can successfully re-learn cooking and reduce cooking errors, thereby limiting the negative consequences of failure of the daily activity, such as injuries and depression.34-36
Numerous research has been conducted in the effect of cognitive function in virtual reality telerehabilitation for people with dementia, achieving promising results in various cognitive functions, particularly the spatial processing.37 A literature review of twenty-two studies involving 564 individuals with neurocognitive disorders found improvements in various cognitive domains, as well as psychological aspects such as anxiety and well-being.38
Despite the significant benefits of virtual reality telerehabilitation for people with dementia,
the current technological limitations restrict its widespread application. Exposure to virtual reality may cause motion sickness, oculomotor disturbances, dizziness, disorientation, and nausea,39 which can disrupt the sensory system and induce short-term changes in sensory, motor, and perceptual abilities. Additionally, high-speed internet connections are required for real-time interaction, which may not be available in all regions. Interactive devices such as joysticks and gloves are not commonly found in households, especially those with older people who are less likely to use technology.
To make virtual reality telerehabilitation more accessible, hardware platforms and open software need to be more widely available, as the wider diffusion of these technologies would lower costs and improve access to virtual reality technology. With these advancements, virtual reality telerehabilitation could become a valuable tool for improving the cognitive and psychological well-being of people with dementia.
Future direction of telemedicine on dementia
The outbreak of coronavirus has accelerated the development and application of telemedicine, providing people with dementia and their caregivers with more options for personalized health services. To facilitate this development, stakeholders should pay attention to the below problems.
Telemedicine software developers
Telemedicine requires users to have adequate hearing, vision, and cognitive and motor abilities to interact with service providers. This poses a challenge for people with dementia, whose deterioration in these functions can affect the beneficial effects of telemedicine. Age-related hearing loss and visual impairment are highly prevalent in people with dementia and can lead to negative consequences during telemedicine,40,41 such as inaccurate cognitive function assessments, misunderstandings of instructions, and restrictions on the ability of people with dementia and their caregivers to enact treatment plans.
Telemedicine software developers can address these challenges by maximizing communication accessibility. For individuals with hearing impairments, telemedicine software can provide caption services using automatic speech recognition, integrate headsets, speakers, and personal sound amplifiers that individuals can adjust based on their hearing needs. Developers can also offer functions with magnification adjustment, lighting, and glare on screens to assist individuals with visual impairments.
During the development process, software developers should include the opinions of people with dementia, conduct user testing with this group on accessing electronic devices and the internet, and follow their instructions during the intervention. By doing so, developers can ensure that their software is tailored to the specific needs of people with dementia, making telemedicine more accessible and effective for this population.
Telemedicine service providers
People with advanced age or dementia generally have low digital literacy, which can deter them from using telemedicine. To increase their willingness to use telemedicine, service providers can provide additional support in different stages of the process.
Before using telemedicine, service providers can offer training on the telemedicine software to help people with dementia and their caregivers become familiar with the operation and relevant terminology. In a systematic review, all studies with telemedicine visits at home included a pre-visit orientation by staff to install the telemedicine software, conduct trials, and troubleshoot technological difficulties.23
Caregivers are also invited to join the orientation, given their role in assisting people with dementia when using telemedicine. An individual assessment of the user’s function could be conducted before the orientation to address specific sensory and technological needs. To enhance their skills in operating the software, service providers can provide detailed written instructions for users to follow when using telemedicine. Additionally, real-time support can be offered during telemedicine sessions to troubleshoot sudden technological issues.
By providing additional support and training, service providers can help people with dementia and their caregivers overcome digital literacy barriers and feel more confident in using telemedicine. This can lead to improved access to healthcare services and better health outcomes for this population.
Government regulations and telemedicine
Currently, most countries do not have government regulations on telemedicine and data privacy.42 This can hinder the use of telemedicine by people with dementia and their caregivers, who may be concerned about the risk of personal information leakage and stigmatization from others. To encourage the use of telemedicine, governments should initiate legislation on telemedicine to regulate service providers and protect the privacy of people with dementia. The regulations should require telemedicine service providers to clearly explain to users how data is transferred, shared, and accessed.
Despite the widespread use of consumer technology, high financial costs can still deter
the use of telemedicine in healthcare sectors and by people with dementia. The input and output of telemedicine require a stable internet connection and a device for operating interactive communicative technology, which may not be available and may require infrastructure development.
One study reported that a lack of broadband and electronic devices was one of the reasons people with dementia refused to use telemedicine.43 The setup and operation of telemedicine require continuous financial support, but the lack of funding for this new approach can hinder sectors from offering remote care. Governments can offer financial support to mobilize service sectors and people with dementia. This can include building internet infrastructure facilities and offering subsidies to telemedicine service providers for the operation and purchase of electronic devices. By doing so, governments can help to overcome the financial barriers to telemedicine and increase its accessibility to people with dementia and their caregivers.
Researchers and their continuing work on telemedicine
Most of the recent research on telemedicine was conducted during the outbreak of the coronavirus pandemic. Given the specific conditions and challenges encountered during the pandemic, the results of these studies may not be applicable after the pandemic. Therefore, more studies should be conducted after the pandemic, particularly those focusing on the effect of telemedicine on cognition, psychological well-being, and preference, which may have different results after the resume of social interaction.
The location of telemedicine delivery for people with dementia could also be shifted to the home setting. In many studies before the pandemic, participants received the intervention in research labs or rural clinics. Since the outbreak of the pandemic has increased the delivery of telemedicine in the home setting, future research could focus on enhancing the facilitation of in-home delivery of telemedicine, thereby increasing its usage by people with dementia and their caregivers.
Long-term effects could be another focus of future research on telemedicine. Most studies on telemedicine for people with dementia are cross-sectional, and it is unclear whether the promising results in cognitive and neuropsychological domains can last after the research study. Studies on computerised cognitive training have indicated that the duration of the lasting effect on the cognitive function of people with dementia is uncertain.44 Therefore, longitudinal studies on telemedicine could examine the short-term and long-term effects on people with dementia and their caregivers, providing valuable insights into the efficacy and sustainability of telemedicine.
Improving quality of life for those with dementia and their carers
Advancements in technology mean that people with dementia can now enjoy health services in innovative ways. The promising results of interventions using various forms of interactive communication technologies on people with dementia indicate the success of receiving remote care of this population.
Despite the comparable results between telemedicine and face-to-face approaches, telemedicine should not be considered a replacement for conventional interventions. The two approaches should integrate to improve efficiency and effectiveness in the intervention of people with dementia.
The outbreak of the coronavirus pandemic has accelerated the application of interactive communication technology worldwide, including in the care of people with dementia. As stakeholders continue to explore the potential of telemedicine in dementia care, they should also examine the current limitations of the technology to inform future development. By doing so, stakeholders can continue to advance the use of telemedicine in dementia care and improve the quality of life for people with dementia and their caregivers.