In a blog for people interested in ways to diagnose dementia, and the use of remote methods of assessment, Lucy Beishon, specialist trainee in geriatric medicine and NIHR Academic Clinical Lecturer in Geriatric medicine, talks about evidence on assessing people for dementia by phone and video call, reflects on her experiences during the pandemic, and looks to the future.
Diagnosing dementia during the pandemic
The Covid-19 pandemic was a challenging time for all areas of health care. One of the areas that isn’t talked about as much is what happened to some aspects of routine care. For example, people being assessed for a diagnosis of dementia in a memory clinic. Before the pandemic, a typical assessment for dementia would include a detailed face-to-face history and examination with the patient, brain scans, blood tests, and a face-to-face memory and thinking test. During the pandemic, much of these face-to-face parts were replaced by telephone interviews and assessments.
I was one such doctor trying to grapple with a mixture face-to-face and telephone or video call (remote consultations) based assessments with patients and their carers. During the pandemic, I used remote consultations on a daily basis to help me communicate sometimes very difficult conversations with relatives and loved ones. This was one of the aspects of my work I found most difficult during the pandemic.
Diagnosing dementia has its own unique challenges and I realised how much I relied on eye contact and body language to help build a picture of the person and reach a diagnosis of dementia. There is a remote consultation that particularly sticks out for me, during an assessment of “orientation”, or the patient’s awareness of where they are. I asked the patient: “…and where are you at the moment?”, he replied: “I’m currently sitting in the Aldi© car park in Newquay, Cornwall”. The only other people in the car were his grandchildren who were enthusiastically shouting out their confirmation for me in the background! This made me think though, how did I know where he was? It sounded so specific it almost had to be true, or was he lost and confused? And how old were his grandchildren and could they reliably confirm this information for me?
One of the key advantages demonstrated by this interaction is that sitting in my home office in Leicester I was able to assess someone for a diagnosis of dementia sat in supermarket car park 267 miles away. But how good was this assessment and was this good enough for me to base a diagnose of dementia on? This was the question we asked in our recent Cochrane ReviewCochrane Reviews are systematic reviews. In systematic reviews we search for and summarize studies that answer a specific research question (e.g. is paracetamol effective and safe for treating back pain?). The studies are identified, assessed, and summarized by using a systematic and predefined approach. They inform recommendations for healthcare and research. on remote assessment of memory and thinking (cognitive assessment) to help diagnose dementia.
What evidence did we find for remote assessment?
In our Cochrane Review Diagnostic test accuracy of remote, multidomain cognitive assessment (telephone and video call) for dementia (published April 2022) we aimed to assess the accuracy of any memory or thinking test that was delivered by a telephone or video call to diagnose dementia, and to see how remote assessment compared with face-to-face.
Lots of tools (or tests) but little evidence
We found there was a wide range of such tests available, but not many studies had assessed the same test. This made it difficult to put the findings of these studies together (meta-analyse), to work out how accurate these tools are to help diagnose dementia.
One of the most common tests used over the phone is called the Modified Telephone Interview for Cognitive Status or “TICS-m” for short. This test is used around the world for both research studies and in the clinic to help diagnose dementia remotely. This was also the same test I was using to assess my patient 267 miles away. One of the most surprising results from this review for me was the lack of studies that met our criteria to be included in this review. In our review, we were only able to include one studyAn investigation of a healthcare problem. There are different types of studies used to answer research questions, for example randomised controlled trials or observational studies. which assessed the TICS-m, but this study did not provide any measures of test accuracy, that is how good it is at diagnosing dementia. This made me think about how widely many of these remote assessment tools are used around the world but how surprisingly little evidence there is for us to do so!
Remote assessment for dementia compared with face-to-face
Most of the studies we looked at in this review did not compare how the tools stacked up against a full face-to-face assessment for dementia. Instead, studies simply compared a face-to-face memory test with the same test delivered by phone or video call. Surprisingly, even when the exact same test is delivered by phone or video-call, the accuracy is not identical as to when it is delivered face-to-face. This suggests that something about the way the test is delivered, perhaps that body language or eye contact I often felt was missing in my assessments, affects how well the test can diagnose dementia.
During the pandemic, many places used telephone assessments, and some hospitals were able to set-up video calls, but this depends on whether the patient has access to video call technology at the other end. This raises important questions about how we can make sure all patients have access to good technology so all patients are receiving the same quality of healthcare.
Quite a few studies looked at telephone versions of the Mini-Mental State Examination. Until recently, this test was used commonly around the world in memory clinics, and by general practitioners to help pick up and diagnose dementia. It was also used regularly for research studies, until problems with copyright fees emerged and better tools have now been developed to pick up earlier signs of dementia. This means telephone versions of these tests might suffer the same problems, and many of these studies took place over 10 years ago. So with technology constantly changing and upgrading faster than your mobile phone contract ends, how relevant are these studies really in today’s age of modern technology?
The future of remote assessment
From the evidence in our review, we were not able to say that one particular memory test delivered by telephone or video call to help diagnose dementia is better than another. The review also did not find enough evidence to suggest that a diagnosis of dementia should be replaced by a telephone or video call test, and these should always be followed-up with a full assessment for dementia in clinical practice.
We identified one recent study of a relatively new memory test called the Free-Cog. This test has been designed to remain freely available and avoid many of the copyright and training fees put in place for other commonly used tests. This test had good accuracy for picking up dementia, but this was based on only one study undertaken so far. Ideally, we need more studies looking at how well newer tests, such as the Free-Cog, perform for diagnosing dementia, particularly using more modern smartphones, apps, and tablets.
However, moving to remote assessment is still not a direct replacement for a face-to-face assessment, as we found when comparing tests delivered remotely compared to face-to-face. Although this may be convenient for patients and clinicians, we need to make sure that patients still receive good quality assessments and that all patients are able to access the same level of remote assessment. These tools are promising for the future of dementia assessment, particularly with recent challenges we have experienced in the Covid-19 pandemic. However, we need to carefully consider all the implications of remote assessments for patients, clinicians, and researchers before using them to fully replace traditional face-to-face assessments.
If you are interested in opportunities to take part in dementia research, you can find out more here at Join Dementia Research
Reference: Beishon LC, Elliott E, Hietamies TM, Mc Ardle R, O’Mahony A, Elliott AR, Quinn TJ. Diagnostic test accuracy of remote, multidomain cognitive assessment (telephone and video call) for dementia. Cochrane Database of Systematic ReviewsIn systematic reviews we search for and summarize studies that answer a specific research question (e.g. is paracetamol effective and safe for treating back pain?). The studies are identified, assessed, and summarized by using a systematic and predefined approach. They inform recommendations for healthcare and research. 2022, Issue 4. Art. No.: CD013724. DOI: 10.1002/14651858.CD013724.pub2. Accessed 04 May 2022.
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Lucy Beishon declares current funding for salary from the NIHR on an academic clinical lectureship.