'High-Intensity' Telemedicine Curbs ED Use in Dementia Patients

Megan Brooks

July 22, 2019

LOS ANGELES — Providing comprehensive remote care via telemedicine to older adults with dementia significantly cuts emergency department (ED) visits, new research suggests.

During a period of about 3 years, access to a unique telemedicine program reduced ED visits in seniors with dementia by about 24% per year.

"This was fantastic to see," Manish Shah, MD, MPH, professor of emergency medicine, population health sciences, and geriatrics and chair of emergency medicine research, University of Wisconsin–Madison School of Medicine and Public Health, told Medscape Medical News.

Shah presented the study here at the Alzheimer's Association International Conference (AAIC) 2019.

More Than Just Face Time

Rates of ED use for acute illnesses are higher among individuals with dementia than among their counterparts who do not have dementia, said Shah. He also noted that the ED is a particularly stressful setting for dementia patients.

"For the patient with dementia, taking them out of their familiar home environment to an emergency department is very disruptive and enough to throw off their equilibrium," he said.

Hoping to cut ED use by dementia patients, the investigators developed a "high-intensity" acute care telemedicine program that offers extensive services.

A trained clinical technician conducts an initial in-person visit with the patient, takes a medical history, and conducts a medication review. In addition, patients undergo a thorough physical examination.

The information is uploaded into a medical records system that can be accessed by the telemedicine program's physician, physician assistants, or nurse practitioners.

"This is far more than just videoconferencing or face time, which is why we call it high-intensity telemedicine," said Shah.

A telemedicine "visit" starts with a call for assistance from the patient, caregiver, or staff member of the senior living community. A physician or registered nurse conducts a telephone evaluation of the problem and determines whether it can be addressed via telemedicine of whether it requires a traditional care path.

The telemedicine physician can order laboratory tests or x-rays, medicine, or other interventions, such as antibiotics, and can provide care instructions.

The researchers studied 731 patients with dementia (median age, 86 years) who were cared for in a primary care geriatrics practice at 22 senior living communities. Of these, 214 study participants had access to telemedicine care, and 517 did not (control patients).

A total of 201 telemedicine visits were conducted during the study. Over 3.5 years, adjusted rates of use of EDs per person-year were significantly reduced in the telemedicine group, as were rates of "treat and release" visits and hospital admissions, compared to the control group. The intervention did not change the number of face-to-face visits to the patients' primary care physicians.

Table. Adjusted ED Use Rates per Person-Year Over 3.5 Years

Outcome Control (95% CI) Telemedicine (95% CI) P Value
ED visits +4.5% (-2.8 to +13) -23.7% (-39 to -4.1) .006
Treat & Release -2.2% (-10 to 6.8) -20% (-42 to +9.7) .225
Admission +11.3% (+1.4 to +22) -25% (-44 to -6.0) .005


Looking ahead, the team wants to further optimize the telemedicine services for dementia patients and conduct a cost-effectiveness analysis.

Important Tool for Seniors

"Telemedicine is becoming an important tool in many areas of medicine, including Alzheimer's disease," Rebecca Edelmayer, PhD, director of scientific engagement for the Alzheimer's Association, told Medscape Medical News.

"Continuing to develop these types of tools will be an important way to reach people who maybe don't have access to local experts. This is particularly true in rural communities," said Edelmayer.

She noted that the Alzheimer's Association has developed Project ECHO (Extension for Community Healthcare Outcomes), a telementoring program that is helping to educate physicians about dementia and how they can provide the best care and support for those living with dementia and for their caregivers.

With Project ECHO, expert multidisciplinary specialist teams and primary care practices come together in regularly scheduled collaborative, interactive learning sessions to share information and learn from each other via case-based discussions and brief didactic presentations.

The Alzheimer's Association also offers a helpline that phsicians, patients, and caregivers can access 24 hours a day, 365 days a year. "We get over 300,000 calls a year," said Edelmayer.

"Questions run the gamut of what people are reading in the news about Alzheimer's disease to how to find the best doctors to how they get financial or legal advice, or whether they just need help navigating through a difficult situation with a family member in that moment," she noted.

The study was funded by the Agency for Healthcare Research and Quality and the National Institute on Aging. Shah and Edelmayer have disclosed no relevant financial relationships.

Alzheimer's Association International Conference (AAIC) 2019. Abstract O1-11-06. Presented July 14, 2019.

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