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Enhancing Dementia Care Through Digital Health
Shannen Kim, BA; Omid B. Toloui, MPH, MBA; and Sachin Jain, MD, MBA, FACP
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Enhancing Dementia Care Through Digital Health

Shannen Kim, BA; Omid B. Toloui, MPH, MBA; and Sachin Jain, MD, MBA, FACP
There is ample opportunity to integrate digital health technologies into dementia care to promote independent living and prevent unnecessary healthcare utilization.
Smart-home devices and platforms. Although not specifically designed for dementia care, smart-home devices are powerful tools that can enable PWD to live independently in their home for as long as possible. Smart-home devices include appliances, lighting, air conditioning, and heating that can be controlled remotely using wireless technologies and programmed to follow a specific schedule. Smart-home devices are typically connected to a central hub that is controlled by a smartphone, Web-based dashboard, or mounted terminal. Some devices that may be useful for PWD are smart-home sensors that can detect whether doors, cabinets, or windows are left open. Additionally, water leak, carbon monoxide, and smoke detectors can send alerts if levels deviate from normal. Smart-home devices can enable PWD and their caregivers to monitor and manage many of the devices and appliances in their home to help maintain a safe environment and prevent accidents. 

Tile. This small Bluetooth tracker attaches to and helps users locate important items, such as wallets or house keys, using a smartphone app. If the item is within Bluetooth range (50-150 feet), the Tile emits a loud tune until the item is located. If the Tile is not within range, a map in the Tile app will show where the item was last detected. Users can also use Tile’s crowd-sourcing feature to help locate the item. In addition to Tile, there are other Bluetooth trackers available, including Protag Duet, Chipolo, and TrackR bravo. These Bluetooth trackers can enable PWD to locate valuable objects in their home and enhance their ability to live independently.

GoLivePhone and GoLiveAssist. GoLivePhone is a mobile app that transforms a user’s smartphone into a powerful remote monitoring tool to enable independent living. It can be used for fall and wandering prevention, activity monitoring, and medication reminders. The GoLivePhone app monitors fall risk through anomaly detection and trend analysis of movement patterns. Wandering prevention is accomplished through a geo-fencing feature that notifies both the user and caregiver when the user leaves a geo-fenced area and then provides the user with directions home. The app also enables an emergency button that is always visible on the smartphone and, when pressed, can alert caregivers in the case of an emergency. GoLiveAssist is a Web-based platform that provides real-time insight into the health metrics and trends of a GoLivePhone user, which can be a valuable tool for caregivers. 

Mood and Cognition

It is estimated that between 50% and 80% of PWD experience psychiatric symptoms, such as anxiety, depression, and psychosis.28 Psychiatric symptoms have been shown to lead to functional impairment,29 earlier institutionalization,30 and accelerated progression of the dementia disease process.31 Major depression is particularly prevalent in PWD. Studies estimate that between 20% and 30% of people with Alzheimer disease suffer from major depression,28,32 whereas it is estimated that only 5% of community-residing elderly adults without Alzheimer disease have major depression.33 In addition to decreasing quality of life for the patient, these symptoms also increase caregiver burden and depression.34 Thus, finding innovative ways to address the psychiatric symptoms of dementia can have beneficial effects on the lives of both patients and their caregivers.

PARO. This interactive robot provides the benefits of animal therapy without the maintenance required of a live animal. PARO weighs approximately 6 pounds and is shaped as a baby harp seal with white synthetic fur and large beady eyes. PARO has different sensors that detect touch, light, sound, temperature, and posture. PARO can move its head and flippers, purr when stroked, and alter its activity levels based on the time of day. PARO also has some learning capabilities, such as responding to its name. Surveys and other early studies show promise in PARO’s ability to improve users’ cognition and mood, particularly in elderly populations.35-37 Findings of a recent study indicated that regular interaction with PARO reduced anxiety and depression and alleviated the need for pain and psychoactive medications in elderly patients with mild to moderate dementia.38 Other examples of therapy robots include Joy For All Companion Pets and Ollie the Baby Otter.

IndependaTV. PWD are at significant risk of social isolation and loneliness, which contribute to increased mortality in elderly adults.39 IndependaTV is a smart TV device that allows patients to message, video chat, and virtually attend events with their friends and family through their television. IndependaTV also allows patients to immediately contact their caregiver in emergencies. Leveraging this technology delivers much-needed social connection to PWD in the comfort of their own home. The IndependaTV platform can be integrated with other wireless health devices and home monitoring sensors to create a more robust monitoring tool.

Potential Challenges

There are a number of potential barriers and challenges to the adoption of digital health technology for dementia patients, which include:

Cost of the technology. Dementia places a great financial burden on families and caregivers: 41% of dementia caregivers have a household income of $50,000 or less, and caregivers, on average, lose over $15,000 in annual income due to sacrifices made to meet the demands of caregiving.3 Whereas more simple devices, such as Tile, are sold for about $25, more complex devices, such as the medical alert service QMedic, require an initial set-up fee and a monthly maintenance fee. The most expensive devices, such as PARO, can cost as much as $6000. Many of these devices are not yet reimbursed by Medicare or commercial health insurance companies. Although it may be difficult for individual patients and caregivers to afford these devices, there may be a financial case for health systems or payers to provide these devices to proactively care for their patients and reduce unnecessary healthcare utilization.

Device management. The management of multiple devices may be another challenge for PWD and their caregivers. Many digital health devices are point solutions and are not integrated with other complementary devices or services. As such, each device has its own dashboard or app that collects and analyzes the data from the individual device. However, if a user has 3 such devices, they would need to run 3 separate applications in order to review the data from each device. To allow for a more seamless experience and ultimately more effective condition management, developers should integrate multiple existing digital health tools, tailored for the dementia population, into one common platform. In addition to working to pursue integrated platforms for enhanced management of multiple devices, developers should also strive to create interfaces that are simple and intuitive for elderly users and their caregivers. 

Acceptance and adaptation. Although there are many assistive technologies that are being developed to support daily living for elderly adults, perhaps the key determinant for success of technological implementation is acceptance of the technology itself.40 However, health technology has not been widely adopted by older adults,41 and various studies have speculated about the factors that contribute to the adoption of technology within this population.42-44 Some of these factors include living environment, physical and mental health status, and opinions of family and health professionals. PWD may be particularly hesitant to adopt technology, as there is a prevalent fear of failure and making mistakes, especially misusing technology, in this population.45 Furthermore, it is difficult for PWD and caregivers to alter their routines, which may impede the integration of technology into their daily lives.45

However, studies suggest that the main driving force of technology adoption is its perceived need.46,47 That is, the technology must clearly address a specific need, and PWD and their caregivers must perceive the technology as useful to them. As caregivers assume an integral role in the care of PWD, it is necessary to understand the specific needs of the caregiver–patient dyad and develop technological tools that meet those needs most effectively, while clearly communicating the potential impact of the technology.

Healthcare delivery. Implementing these technologies in a widespread and sustainable way ideally requires a holistic redesign of how dementia care is delivered and reimbursed. The dominant model of fee-for-service healthcare, in which providers are only reimbursed for billable services and supplies, often does not allow health systems to provide nonbillable digital health technologies to their patients, despite proven health benefits. However, value-based care models, in which reimbursement for a given population of patients is provided via lump-sum payments, allow health systems the flexibility and incentives to deploy traditionally nonbillable technologies to optimize patient outcomes. For example, CareMore Health, based in Cerritos, California, has an innovative care model that allows digital health technologies to be readily integrated into healthcare delivery. For its Medicare beneficiaries, CareMore receives a fixed, risk-adjusted payment per member from the federal government, allowing it the freedom to allocate those funds toward the effective management of their member population. This payment model promotes the development of creative solutions to improve members’ health and prevent unnecessary hospitalizations. Additionally, as an integrated health plan and care delivery system, CareMore regularly interacts with its most chronically ill patients and is able to implement innovative solutions directly into the care delivery process. There is ample opportunity to integrate digital health technology into healthcare delivery, but payment models and delivery systems must be structured to support these solutions. 

Conclusions and Future Directions

Although there is tremendous potential for digital health technology to augment dementia care, the adoption and integration of this technology does not come without challenges, especially for PWD. Ultimately, each individual with dementia needs to be assessed for his or her particular needs, and the appropriate technology must be introduced within that individual’s financial and adaptive capabilities. 

In this article, we have identified opportunities to integrate digital health technology into current dementia care and adapt existing technologies to serve this population. We challenge the digital health industry to recognize the various needs of PWD and their caregivers and to create solutions that ultimately enable safe, independent living and prevent unnecessary hospitalizations. In the absence of a pharmaceutical cure for dementia, we must strive to develop innovative solutions to improve the quality of life for individuals and families affected by dementia.

Author Affiliations: University of California, San Francisco School of Medicine (SK), San Francisco, CA; CareMore Health (OT, SJ), Cerritos, CA.

Source of Funding: None.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (SK, SJ); drafting of the manuscript (SK); critical revision of the manuscript for important intellectual content (SK, OT, SJ); and supervision (OT, SJ). 

Send Correspondence to: Shannen Kim, BA, University of California, San Francisco School of Medicine, 1559 8th Ave #1, San Francisco, CA 94122. E-mail: shannen.kim@ucsf.edu.
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