COMMENTARY

How Alzheimer's Care Has Changed During COVID-19

Richard Isaacson, MD; Ronald C. Peterson, MD, PhD

Disclosures

June 15, 2020

This transcript has been edited for clarity.

Ronald C. Peterson, MD, PhD: This is a challenging time for all of us, especially for patients with Alzheimer's disease, their care providers, and the clinicians who care for people with Alzheimer's disease.

You can imagine a situation where someone has difficulty perhaps comprehending the world around him or her in general, and then throw a COVID infectious disease situation on that particular environment, and you have a complicated situation.

In particular, people with Alzheimer's disease may have difficulty comprehending what's going on around them. When we start talking about things like social distancing, wearing a mask, and frequent handwashing, they may not understand exactly why we're doing this or whether they should be doing it. They may forget to continue to do it or take their mask off frequently.

Richard S. Isaacson, MD: In my practice, I'm talking to caregivers, partners, loved ones, husbands, and wives all the time. Being stuck in the house for weeks and months on end is tricky. There's more agitation and more anxiety. The neuropsychiatric component of Alzheimer's is something that we really have to manage.

Peterson: Evaluating a new patient, with perhaps Alzheimer's disease being the diagnosis, can be particularly challenging at this time. Often, we are using videoconferencing or telephone interviews, which are clearly suboptimal.

Isaacson: Generally, patients with dementia and their caregivers are older, and they sometimes have less familiarity with using video and other telemedicine components. We've had more glitches and more trouble connecting, so oftentimes we've had to actually transition to a telephone.

Peterson: Of course, conducting a clinical exam via a video is challenging as well. We can do a modified mental status exam and leave out some parts, perhaps, that require motor or visuospatial skills. Generally, memory, attention, concentration, and language can be assessed reasonably well remotely.

Isaacson: About 80%-90% of neurologic diagnoses are made based on the history. There's no issue with taking a detailed history via telemedicine. By understanding progressive short-term memory decline and other changes in sleep or behavior, psychiatric symptoms with other premonitory symptoms, noncognitive complaints, and risk factors for Alzheimer's disease, it's possible to make a reasonably reliable diagnosis of possible Alzheimer's disease.

We've actually used screen-sharing software and Zoom. We use Zoom to have the video interview part and we use screen-sharing software for patients with either minimal cognitive complaints or normal cognition—we've actually redeployed the cognitive tests—and we can get about 80%-85% of the testing done.

Peterson: There are certain challenges with assessing visuospatial skills. Having the person draw a box or a clock can be difficult when you're asking them to do it verbally rather than having them actually copy a picture. You can draw a box or a clock and show it to them on the video screen, but again, it's a bit more difficult.

If you have someone with moderate disease or severe disease, they may have a great deal of difficulty understanding what the assessment is and what's going on. Of course, many individuals at that level may also have anosognosia and really not appreciate that anything is wrong with them. Hence, the whole assessment becomes useless to them.

These are issues that compound the problem. There's comprehension and there's the ability to pay attention and to concentrate on what's going on.

Isaacson: The other part that's been challenging is, when do you decide to go to the hospital and seek medical care? I have one patient who literally lives two blocks down the road who had a cough and he didn't have a fever—his temperature was 99.9 °F. He had Alzheimer's disease and other vascular issues. He had high cholesterol, high blood pressure. He had borderline diabetes, even early diabetes.

This person has multiple medical conditions. If he goes to the hospital to be evaluated for COVID-19, we have to remember that he will be admitted alone, there will be no visitors, and there will be no advocate for this patient.

We had a heart-to-heart conversation with his son who was in Dallas and on the Zoom call. We decided collaboratively that until the fever goes above 104 °F or until there was shortness of breath, the goal was to try to keep him at home for as long as possible because of the psychological trauma and the disruption in being admitted—even for observation—in a crowded hospital with no visitors and no one to provide a collaborative history.

We really struggled. I think in a normal situation, we would have said to go to the ER or to an urgent care facility. For a 91-year-old man with moderate Alzheimer's disease, if he goes to the emergency room, that could be it. That was a tough one. We ended up keeping him at home.

There are certainly unique challenges that we're facing when it comes to COVID-19 and dementia. There are many challenges, but that was a recent example that rings true.

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