Dementia has become increasingly a public health concern that, because of the aging of the population, is predicted to more than double worldwide over the next 30 years. (1)
The evaluation and management of dementia requires frequent interaction with family members and other caregivers to address caregiving needs, behavioral disturbances, loss of function, and access to community resources such as respite care. It also requires monitoring for potential complications that can arise during the course of neurodegenerative disease. Early diagnosis, treatment, and follow-up of dementia patients can reduce health care costs, increase the quality of life for patients, and reduce caregiver burden. (2)
Dementia detection in primary care settings remains low (3, 4)
and the quality of care for dementia is lower than for other conditions. (5, 6)
The dementia diagnostic workup is even more difficult for rural patients, involving consultations with multiple specialists over extended time periods. (7)
Limited access to specialists means that responsibility for early diagnosis and treatment will fall on primary care physicians. (8)
Rural primary care physicians identify limited access to consultants and limited community support and education resources as major barriers to dementia diagnosis and treatment. (9)
The issue of provision of dementia care to persons in rural or other remote settings is now being addressed by videoconferencing (VC).
Substantial progress has been made in VC-based administration of neuropsychological testing to older adults, including the administration of the Mini-mental State Examination and tests of verbal learning, verbal fluency, vocabulary, visuospatial reasoning, attention, and clock drawing. (10, 11, 12)
VC evaluation of language has also been performed with AD patients. (13)
There is a small literature on the use of videoconferencing (VC) to diagnose and treat cognitive disorders in older adults (14, 15, 16, 17)
including a publication on the diagnosis of Alzheimer disease (AD) in persons with Down syndrome. (18)
A description of several programs follows.
Morgan and colleagues (17)
described the development and implementation over 3 years of a multidisciplinary clinic for rural and remote Canadian patients in which direct patient examination of 137 persons at a tertiary care center was augmented by a pre-clinic and follow up VC interaction between clinic staff and caregivers. VC was compared with face-to-face evaluation in 140 subjects seen over 2 years and rates of agreement in diagnosis ranged from 76–89%. (14)
PC-based VC equipment (Cruiser, version 4, VCON) was connected by ISDN lines at 384 kbit/s. Subjects were 20 persons over 65 years of age with good hearing and eyesight who had been referred by general practitioners because of cognitive impairment. Assessment tools included the Standardized Mini-mental State Examination, Geriatric Depression Scale, Katz Assessment of Daily Living, Instrumental ADL Assessment and the Informant Questionnaire for Cognitive decline in the Elderly. Although the direct method included a physical examination by a specialist geriatrician, there were no significant differences in diagnosis between the 2 methods (κ = 0.8, p <0.0001), and there was good agreement on each of the assessment instruments. Nine subjects were diagnosed as AD on direct examination and 10 on VC evaluation. A similar study comparing face-to-face evaluations by geriatricians with VC diagnosis showed 100% agreement of dementia diagnosis. (16)
The present study reports 5 years using VC technology in diagnosing and treating adult members of the Choctaw Nation who presented with symptoms or complaints of cognitive impairment. Since February 2001, members of the UT Southwestern Alzheimer’s Disease Center faculty in Dallas, Texas have operated a federally funded memory clinic at the Choctaw Nation Healthcare Center in Talihina, Oklahoma, in the southeastern part of the state. Our mission was to provide clinical service as a means to obtain longitudinal data for our own research and for the database of the National Alzheimer’s Coordinating Center. Our use of VC technology was prompted by logistical and manpower issues. The 3.5 hour travel time by automobile to and from Dallas, Texas to Talihina limited our clinic duration and frequency, causing long waits between referral and evaluation and making it difficult to follow patients closely. We made use of the Choctaw Nation VC network connecting the Choctaw Nation Healthcare Center in Talihina to 3 outpatient clinics. The Choctaw Nation had a 1.5 Mbps connection from the commodity Internet cloud to their firewall. There were Polycom VC setups with 35” monitors in 3 clinics, all connected by a dedicated T-1 to a video bridge behind their firewall. This network had already enabled interchange of radiologic images among the four sites in addition to VC. Through OneNet, the Oklahoma telecommunications network for education and government, specialty services including eye care, orthopedics, cardiology and diabetes care had become available to the Choctaw Nation.
In January 2005, we began a monthly VC clinic. Using a conference room in the Choctaw Nation Healthcare Center and the Medical Television Studio at UT Southwestern Center, we connected with the Choctaw Nation’s VC link using Internet Protocol ITU-T H.323, packet-based multimedia communications systems. The digital VC connection is a bi-directional 384 kb/s made from our campus intranet to the commodity Internet cloud. The Choctaw Nation Healthcare Center has a 1.5 Mb/s connection to the commodity Internet. We initially experienced difficulty with pixilation and both sound and motion delay, but these have largely been eliminated due to improvements in VC technology.