For nearly 4 decades, the unifying focus of the 2-site New England Geriatric Research Education and Clinical Center (GRECC) has been on dementia and related disorders. Veterans with dementia are an extremely vulnerable population with high rates of health care use that is projected to total > $203 billion in the U.S. in 2013.1 Their caregivers are also among the most burdened, having provided about 17.5 billion hours of unpaid care in 2012, which is valued at more than $216 billion.1 Additionally, spouses, who are the most common caregivers of persons with dementia, often experience poor health outcomes related to the experience of living with the afflicted spouse.2
Currently > 200,000 VA patients have dementia, and that number is expected to increase.3 Dementia is largely a disease of the elderly; thus, many veterans with dementia also have other medical and orthopedic conditions that increase their frailty and decrease their mobility. Behavioral and psychological symptoms are present in > 75% of people with dementia, contributing to the relative isolation of both those with dementia and their families.4
Disruption in routine and removal from familiar surroundings can cause many patients, particularly in the moderate stages of dementia, to become disoriented and agitated. For these patients, VA clinics can be unsettling and may reveal behavior that is not the same as the veterans’ behavior at home. For these reasons, veterans with dementia likely may benefit from remote access to health care via telehealth. However, current telehealth applications for this population are vastly underdeveloped.
Video Dementia Management
Many GRECCs and other VA geriatric programs provide video-based dementia evaluations and management at community-based outpatient clinics (CBOCs) affiliated with their medical centers. At this point, close to a dozen GRECC and geriatric programs nationally have geriatric psychiatrists, geriatricians, or neurologists conducting such visits from their office or clinic space with video links to a telehealth-enabled room in the corresponding CBOC.
The visits usually entail having the veteran and, when appropriate, a family member check in at the local CBOC for the appointment and receiving assistance throughout the video visit from the telehealth technician at the CBOC.
The technician assists with the technical aspects of the encounter, including establishing and maintaining the video link to the VA medical center (VAMC), and often is trained to administer a brief standardized mental status assessment. The telehealth technician also helps pass along the physician’s written recommendations to the veteran and family once the recommendation summary has been sent by e-mail or printed on the CBOC printer. These VAMC-CBOC video telehealth programs have been very popular with veterans, particularly those in rural settings, since traveling to the CBOC is usually more convenient.
Home-based Video Program
While CBOC-based video telehealth programs expand the population of veterans able to benefit from specialty dementia care, any travel out of the home can be challenging or disruptive for many veterans and their families. In addition, the performance and demeanor of a veteran with dementia in a clinic setting is sometimes different from that which the family describes as their more typical behavior at home.
A new in-home video telehealth program developed by the GRECC at the Edith Nourse Rogers Memorial Veterans Hospital in Bedford is addressing these issues. The Bedford site of the New England GRECC offers in-home clinical video telehealth services to community-dwelling veterans and caregivers as an extension of their Interdisciplinary Memory Assessment Continuity Clinic (IMACC). Currently, the percentage of IMACC veterans/caregivers who have voluntarily signed up for the program is nearly 30%. About 70% of the families that have enrolled to date have their video visits with their spouse caregivers.
Veterans participating in the home video telehealth program have had at least 1 in-person visit at the Bedford IMACC before being invited to join. Veterans and their caregivers are invited to participate in the GRECC home telehealth program either at the time of an in-person IMACC visit or afterward via a telephone call from either a provider or a member of the telehealth staff.
Telehealth visits are offered as a supplement to regularly scheduled in-person visits, not as a substitute. The frequency of telehealth visits is individualized, depending on the medical status of the veteran and preferences of the caregiver. Some participating families, finding the telehealth format much more convenient, have asked whether they could postpone upcoming in-person visits at the VAMC. Many patients are particularly interested in minimizing medical visits in the winter months in New England.
Case Example
A male World War II veteran with moderate stage dementia lived with his wife in an apartment down the street from his adult son and daughter-in-law. His son and daughter-in-law visited and helped with the veteran’s care most days, but his wife was his primary caregiver. However, due to her own mobility issues, she was unable to attend the veteran’s in-person IMACC initial evaluation or subsequent follow-up visit.