The challenges of diagnosing and treating Alzheimer’s patients, many of whom are older than 60 — a demographic particularly vulnerable to the dangers of COVID-19 — increase exponentially during a pandemic. Like the rest of the medical community, the Stony Brook Center of Excellence for Alzheimer’s Disease (CEAD) had no choice but to find a path forward. And though the new normal has yet to reveal itself fully, CEAD has gotten a glimpse of what the future of Alzheimer’s treatment might hold.
“The main thing that we’ve done is move to telehealth and hybrid approaches to provide care for our patients, which is particularly important because they’re a vulnerable population,” said Nikhil Palekar, CEAD’s medical director. “That’s been a countrywide initiative. We’ll have to see whether this remains a long-term trend in healthcare that goes beyond COVID-19.”
Palekar said that while telehealth opens new doors for many patient demographics, it presents unique challenges for the Alzheimer’s community.
“Telehealth is much easier when you have younger people who are more comfortable with these technologies,” he said. “Our population is older and they often have cognitive problems, which makes it more difficult for them to access telehealth or telemedicine.”
Palekar said that to serve these patients, his group must also be well-versed in a wide range of technologies. Most important, they must be flexible.
“We use Microsoft Teams whenever possible,” said Palekar. “However, if the patient is more comfortable with Zoom, we’ll use that. It’s all based on what’s available to them so they can continue to receive the best care possible while staying safe.”
Nicole Absar, a neuropsychiatrist and clinical assistant professor at the Renaissance School of Medicine at Stony Brook University, said doctors who treat Alzheimer’s and dementia patients must be particularly cognizant of what the effects of COVID might be moving forward.
“We can’t be sure yet, but it’s possible that there are neurological repercussions regarding COVID-19,” she said. “There are several case studies on patients in their late 60s and early 70s who contracted COVID-19 and then suffered microhemorrhages in the white matter. That’s a new onset in the study. These are just case studies, but Alzheimer’s and other forms of dementia bring significant comorbidity. We’re still learning a lot of the vascular consequences of COVID, which may cause dementia to worsen.”
Absar also cited the case of a patient who was treated for COVID and has since recovered. The patient is only 63 years old with no history of psychiatric or neurological issues.
“Over the past six months, she has exhibited rapidly progressive dementia symptoms,” said Absar. “It could be nothing related to COVID, and she has other risk factors. However, it’s worth noting that she can pinpoint that her symptoms started right after she was diagnosed with COVID. That could be a coincidence, but we need to be aware of it and consider all possibilities.”
One complication: Confusion is often a symptom of COVID-19. To that end, Palekar added that there have been reports from Europe about neurocognitive and neuropsychiatric disorders post-COVID.
“We know now that the virus affects the neurons and causes inflammatory changes as well as microhemorrhages in the brain,” he said. “COVID is not only a respiratory disease but also an immunological disease that causes changes in immune function as well as affecting blood clotting. As a result, patients have suffered strokes and embolisms in their lungs. Like pulmonary embolisms, cardiac manifestations of COVID have been pretty significant.”
Palekar said that Stony Brook has one of the lowest mortality rates of COVID in the New York area, something he attributes to the very early use of full-dose thrombolytics — medicines used for the emergency treatment of strokes caused by blood clots, heart attacks or massive pulmonary embolisms. In respect to telehealth, Palekar said that while it’s too early to project how it will evolve, telehealth overall has been a successful platform.
“It has increased access to care and allows flexibility since people don’t have to take time away from work; they can just connect with their physicians using an iPad or laptop,” he said. “However, some of our older population prefer an office visit as they want to see their physician in person, as do we. But we have to weigh the risks and the benefits that go with it, particularly because we are treating a very vulnerable population.”
Palekar pointed out another critical area that has been impacted — research.
“The clinical trials at the Center have been on pause during this entire period,” he said. “The Hospital recently resumed human subject trials again with a strong focus on keeping research participants safe by strictly following CDC guidelines.”
For those who treat Alzheimer’s and dementia patients, perhaps the biggest challenge has been in assessing patients, whereby medical professionals would typically spend hours doing various neurocognitive tests.
“Telehealth has made assessment much more difficult,” said Christopher Christodoulou, a neuropsychologist and assistant research professor of psychiatry and behavioral health and neurology who provides neuropsychological evaluations and consults with the CEAD team. “The face-to-face contact is especially important for those patients and technology. Despite all the new things it enables, it also limits how much we can do. At the same time, we all have the convenience of being able to just log in without having to leave home.”
“One of the things that we did at the beginning of the pandemic was to attempt to move some of our neuropsychological assessments to a virtual environment, which was being done across the field,” said Sara Weisenbach, a neuropsychologist and associate professor of psychiatry and behavioral health. “In person, you’re sitting across the table from someone administering an auditory memory measure or a visual memory measure. These are validated in in-person environments. In a virtual environment, some tests like word-list learning measures can reasonably be administered, but other tests like visual memory measures or things that involve sorting or other kinds of manual manipulation are really impossible to do virtually. We’ve tried to adapt our assessments so that we could get as comprehensive of a profile of someone’s cognitive functioning as possible in a virtual environment, but we know there are limitations there.”
Weisenbach said that recently some individuals have resumed coming in to the office. “I saw my first patient yesterday in person, and I was wearing a face mask and a full face shield. I really looked like I was going into a toxic environment,” she said. Weisenbach also said that while that visit was with a younger patient who had adequate visual and hearing capacity and was able to get through the assessment with minimal difficulty, that may not be the case for patients who are more compromised.
“If this was someone with a hearing impairment, and I’m speaking through a face shield and a mask, we’re increasing the anxiety in something that is already an anxiety-provoking situation for these patients,” she said. “These factors can change the way we think about the validity of the results. It has really drastically impacted the way neuropsychology is being practiced right now.”
Palekar said that one clear benefit of telehealth is the ability to provide care to more people, which is possible due to the recent advances in telehealth technology. Assisted living facilities offer an environment that is particularly suited to this.
“There are some assisted living facilities that have large patient populations,” he said. “We have successfully used our telehealth system to provide much needed services to these patients within the safety of their residence thus eliminating the need to travel to a doctor’s office or clinic.”
One major advantage on the assisted living side of the story is the availability of staff at these facilities to help the senior population connect to the telehealth platform. This action can be challenging at times, especially in the context of cognitive impairments.
“If the staff out there can set this up for the patients, it really increases the amount of people we can provide care for,” he said. Palekar also points out that telehealth eliminates geographic boundaries.
“You don’t need to be within 10 miles for it to be convenient for you,” he said. “You can be in the next county or anywhere in the state. I think this will change the way health systems will practice. If someone who lives in the Adirondacks or Buffalo wants to be seen by one of our providers, we can make that happen.”
Despite its growing pains, telehealth will likely be an important part of treating not only Alzheimer’s and dementia patients, but an aging population that is expanding not only on Long Island, but also across the country and internationally.
“There are 64 assisted living facilities on Long Island right now, and that number is growing,” said Daphne Perry, CEAD’s program director.
“New ones are springing up every month, so there’s a lot of work to be done with this patient population. Telehealth is still a new concept. People are becoming more familiar with it and people are becoming more accepting of it” she said. “As we move forward, these rough edges will be sorted out and there will be more standardization and a higher comfort level. I think this will be a real lasting change in medicine.”
— Robert Emproto