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The American Journal of Accountable Care December 2017
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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.

Dementia is a debilitating and progressive medical condition that is increasing in prevalence due to aging populations worldwide. Although there is currently no medical cure for dementia, there is a great need to improve the care and support provided to persons with dementia (PWD) and their caregivers. PWD are among the highest utilizers of healthcare services, but much of this utilization could be avoided through improved preventive care. Digital health technologies are rapidly growing in development, but their utility in dementia care has yet to be explored in depth. In this article, we identify specific areas of dementia care and propose ways in which digital health technologies can provide needed support to PWD and their caregivers, enabling them to live independently and avoid unnecessary hospitalizations. Despite barriers to adoption, we believe the integration of digital health technologies would greatly enhance dementia care and improve the lives of PWD and their caregivers.

The American Journal of Accountable Care. 2017;5(4):20-25
Dementia is a debilitating, costly, and growing global epidemic affecting patients and their families. Although there are many resources dedicated to finding a cure for neurodegenerative diseases, efforts to improve the care given to persons with dementia (PWD) and their caregivers fall short. However, there is ample opportunity for the adoption and integration of digital health technologies to enable healthcare providers and caregivers to address remaining gaps in dementia care. Within this article, we identify opportunities for the adaptation of existing technologies to address the holistic needs of PWD. 

Dementia: Pathophysiology, Epidemiology, and Current Care 

Dementia is not a specific disease, but a general term to describe a severe decline in brain function that affects one’s memory, behavior, language, judgment, and motor skills. This loss of function results from the damage or death of neurons in the brain.1 There are different types of dementia, but the most common is Alzheimer disease, which accounts for 60% to 70% of all dementia cases.2 At best, a few FDA-approved drugs may temporarily improve symptoms, but there are currently no pharmacologic interventions to slow or cure dementia, an ultimately fatal condition.3 As a result, much of dementia care relies on the management of symptoms associated with disease progression.

Dementia is most common in adults older than 65 years, and the prevalence of dementia increases with age.4 In 2015, there were 46.8 million people worldwide living with dementia, and this number is predicted to double every 20 years, with the largest growth projected to occur in countries with growing elderly populations, such as China and India.5

The current approach to dementia care in the United States fails to provide the support that PWD and their caregivers need. Without any effective medical cure or treatment, these frail individuals are largely neglected in our healthcare system. Consequently, as their condition worsens, poor management causes PWD to become some of the highest utilizers of healthcare services. PWD have, on average, 60% longer stays in the hospital6 and are about 10 times more likely to be placed in a nursing home than people without dementia.7 These differences in healthcare utilization are most prominent in community-residing individuals. Studies indicate that community-residing individuals with dementia are more likely to have a preventable hospitalization or emergency department visit that could have been avoided through better preventive and primary care.8

Not only is the progression of dementia difficult for patients themselves, but it also takes a tremendous toll on their caregivers. Approximately 92% of PWD rely on help from family members or other informal caregivers.3 In 2015, caregivers of PWD provided approximately 18.1 billion hours of unpaid support, with an economic value of about $221.3 billion.3 Dementia caregivers provide significantly more hours of care9 and are more likely to experience financial, emotional, and physical difficulties than non-dementia caregivers.10 Caregiving needs intensify toward the end of the patient’s life, a time of heightened stress when caregivers feel they are on duty all hours of the day. In fact, a significant number of caregivers express relief when their patient with dementia dies.11

There is an acute need, which digital health technologies can potentially fulfill, to provide proactive support for PWD and their caregivers and prevent unnecessary hospitalizations. We examine specific areas of dementia management and emerging and existing technologies that have the potential to enhance dementia care. Many of the technologies we present were not necessarily designed with the patient with dementia in mind. This presents an opportunity for digital health companies to adapt their solutions to serve the needs of this patient population. 

Fall Prevention and Early Detection

Falls occur in approximately 70% to 80% of elderly PWD,12,13 which is approximately twice the fall prevalence in those without dementia.14 Moreover, PWD are more likely to incur serious injuries from falls,14 making falls the leading cause of their hospitalizations.15 Furthermore, PWD who experience falls are 5 times more likely to be institutionalized than PWD who do not experience a fall.16 Thus, it is critical to develop interventions to prevent falls from occurring, monitor patients, and provide prompt medical response to address the situation should a fall occur.

LEGSys and BalanSens. Two of the most common causes of falls are gait and balance disturbances.13 Recent technological developments enable clinicians to conveniently assess gait and balance in elderly patients and take proactive measures to prevent falls. LEGSys and BalanSens are portable gait and balance evaluation systems, respectively. Studies have shown that these wearable technologies are viable alternatives to camera-based motion analysis in determining center of mass trajectory.17 Whereas camera-based motion analysis requires a laboratory setup, LEGSys and BalanSens enable clinicians to perform comprehensive gait and balance assessments in virtually any space, including a patient’s home, and automatically generate a detailed fall risk and balance assessment. With these technologies, clinicians can make prompt assessments and recommendations to keep patients safe in their home. Other portable motion analysis technologies include Physilog and MotionNode. 

QMedic. When falls do occur, it is important to provide emergency services promptly. QMedic is a medical alert service worn as a simple wristband or pendant with an emergency button that alerts a 24/7 call center when pressed. A 2-way communication base station allows a nurse triage and care management team to communicate with the user and determine the appropriate course of action. QMedic also detects subtle deviances from the user’s baseline sleep and activity levels, at which point the call center is notified to determine whether an intervention is needed. QMedic is waterproof and has a battery life of 2 years. The simplicity and low maintenance of the device may have contributed to the finding that QMedic users are 3 times more likely to wear the device 24/7 than users of traditional medical alert services.18 GreatCall Lively Wearable is another medical alert service that can be connected via Bluetooth to the user’s smartphone. 

Existing wearable technologies, like Apple’s market-leading smartwatch, have many of the same and some additional technological capabilities compared with the QMedic and GreatCall Lively devices. Given its open software development platform and robust App Store, the Apple Watch presents new possibilities for software developers to create innovative solutions for PWD and their caregivers using existing, stylish, and stigma-free wearable technologies. For example, hardware such as the Apple Watch or the Samsung Gear S3 can be tailored through the use of apps to address issues such as fall prevention and wandering. 

CleverCare. This device is an example of a smartwatch specifically configured to help those with dementia and other memory impairments. CleverCare uses Global Positioning System (GPS) and cellular technology to monitor the user’s location. Medication and task reminders can be customized to trigger alerts at appropriate times of the day. CleverCare offers a Carer’s Dashboard through which caregivers can set important reminders, track their loved one’s location and movement, and define “Safety” and “Danger” zones so that they can be notified if unwanted movement occurs. Additionally, if the user presses and holds any of the buttons on the watch, the user will be connected with a 24/7 emergency response call center where a responder will speak to the user through the watch and determine the appropriate course of action.

Wandering Prevention

Wandering is a common behavior in PWD which can threaten their health and safety. Although there is not one universal definition for wandering, it generally refers to a frequent, repetitive, and disordered locomotive behavior that manifests in lapping, random, or pacing patterns, which sometimes results in leaving home and getting lost.19 It has been estimated that about 20% of PWD wander.20 However, studies suggest that this prevalence increases in people with severe dementia and in community-residing patients with dementia.21 Studies have shown that wandering behavior often leads to adverse health outcomes, such as injury,22 malnutrition,23 sleep disturbance,24 social isolation,25 and earlier institutionalization.26 By utilizing digital health technology to closely monitor PWD who are prone to wandering, caregivers may help keep their loved ones safe while also enabling their independence for as long as possible.

GPS SmartSole. This device is a sole insert for shoes that uses GPS and cellular technology to monitor users. It checks the user’s location every 10 minutes and updates the location data in an app on a caregiver’s smartphone. Caregivers can designate geozones, and when the GPS SmartSole enters or exits these geozones, alerts will be sent to the caregivers via e-mail or text message. GPS SmartSole also offers a “Concierge Monitoring Service,” which, in the case of an emergency, can assist caregivers to locate the user and notify emergency services. 

SafeWander. This bed exit alarm sensor detects changes in body position and instantly alerts caregivers when a PWD attempts to leave his or her bed. A small sensor securely and discreetly attaches to the patient’s clothing, and a Wi-Fi–connected gateway plugged into an outlet near the patient’s bed sends an alert to an app on the caregiver’s mobile device whenever a change in body position is detected. Caregivers can view a historical log of bed exits and simultaneously monitor several SafeWander devices on 1 platform, which may be valuable for staff of care facilities. 

Activities of Daily Living 

As dementia progresses, PWD need increasingly more assistance with activities of daily living (ADLs), such as grooming, bathing, and feeding. PWD, on average, need caregiving assistance with 2 ADLs and 4 instrumental activities of daily living (IADLs), such as shopping, cooking, and managing medications.27 Healthcare technology has the potential to improve the quality of life of PWD by providing assistance with ADLs and IADLs and closely monitoring health risk factors, thereby enabling them to live independently for as long as possible.

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