Rob Dillard

DocwireNews

The COVID-19 pandemic ushered in the age of telemedicine citing benefits, such as reducing logistical and travel costs for older and rural patients while maintaining access to care. Studies have also demonstrated the effectiveness of treating neurodegenerative diseases such as dementia and Parkinson’s disease via telemedicine.
DocWire News spoke with George Grossberg, MD, the Samuel W. Fordyce professor and director of Geriatric Psychiatry in the Department of Psychiatry at Saint Louis University School of Medicine, who co-authored two such studies. Dr. Grossberg, a geriatric psychiatrist, spoke about the clinical implications of these findings, and about the impact COVID has had on telemedicine.
DocWire: Can you provide us with some background on yourself?
Dr. George Grossberg: I am a geriatric psychiatrist. I work in an academic setting at St. Louis University. Some of your audience may or may not know what a geriatric psychiatrist is, but the field of geriatric psychiatry kind of brings together geriatric medicine, neurology, and psychiatry, as they all kind of intertwine and come together in a typical kind of 85 year old and her and his family. Geriatric psychiatrists do a lot of different things clinically. They work with outpatients. They work in inpatient units, but a large part of the portfolio is also working as a consultant in nursing homes, long-term care facilities. I do all those things. I do clinical work. I teach, and I also have a research portfolio, all of that at St. Louis University&#8217;s School of Medicine.
How has the COVID-19 pandemic changed telemedicine?
It&#8217;s an interesting phenomenon. Thank you for asking. I can tell you that, it&#8217;ll be two years this March, up until two years ago, March, which was at the beginning, but at the height of the lockdowns because of the COVID pandemic, up until that time, I personally had never done a virtual health appointment with anyone. I was naive to Zoom, which we&#8217;re using today. I was naive to other platforms, but all of a sudden, almost overnight, our clinics closed. Our outpatient clinic closed. And not only that, but our teaching nursing homes and nursing homes around the country also went on total lockdown. Not only not permitting us to visit our patients in person, but not permitting family members to visit their loved ones. In fact, patients were locked down to their rooms.
So, we had to figure out, I had to figure out how am I going to continue to see my outpatients? How am I going to continue to see my nursing home patients and people in long term care? And of course, the virtual medium really lends itself to being able to see people, either people who can&#8217;t get to us for one reason or another or during a crisis situation like the COVID pandemic.
Talk to us about the two studies you co-authored which demonstrated the efficacy of telemedicine in treating neurodegenerative diseases.
Let me just give you a little background, if I might. I was able to bring together and to share a consensus conference of some experts in the field of geriatrics, geriatric medicine, geriatric neurology, geriatric psychiatry, nursing, as well as long term care, family medicine. There were seven of us that represented each of those arenas. And our goal was to see what can we recommend to our colleagues about best practices in applying telehealth or virtual health to diagnosing our patients, both outpatients, as well as those in nursing home or long term care [inaudible 00:03:29]. Those with Parkinson&#8217;s disease who maybe also are having behavioral symptoms or maybe are now starting to show what we call psychotic symptoms, things like hearing things, maybe seeing things, imagining things. These are symptoms that are very disturbing and very disruptive to patients as well as to their caregivers, whether it&#8217;s the family at home or the professional caregivers in the long term care environment.
That&#8217;s where the two papers originated. One was to really look at best practices in the outpatient clinic, in the office, the &#8220;virtual office&#8221; setting and the other is to work with our colleagues, nurses, and others in long term care, to be able to apply best practices relative to virtual or telehealth in being able to help this very needy population.
Is there any current research you&#8217;re involved in that you would like to make our audience aware of?
I think there are some practical things and then, there are other things that are kind of a little bit more futuristic, looking to the future of telehealth. The practical aspects of it are, and I think all of us agreed that we don&#8217;t think that telehealth is going to be going away even once, hopefully COVID is behind us. We think that telehealth will continue to be a key player, a major phenomenon, as far as being able to see patients, particularly are geriatric patients, particularly patients who live far away, particularly patients who may not have access to transportation. A lot of our older patients are dependent on family or others to bring them to the office setting. Then, it&#8217;s, of course, very, very difficult to get to nursing home patients because many nursing homes are in rural areas, areas where there may not be healthcare providers. There may not be doctors.
So, it became apparent that what we were doing now is something that we&#8217;re going to continue to do in the future, particularly in making it easier and safer for older adults to access a healthcare provider, whether in the outpatient setting, in the office, or in the long term care environment, such as the skilled nursing facility. So, we learned that this is something that we can do. It&#8217;s something that we can do well. We learned that it&#8217;s something that&#8217;s very user friendly because the environments that we go into, particularly long term care, we can not only work with the patient, we can [inaudible 00:06:07] and at the same time, work with the staff.
I&#8217;ll give you a great example of something we can&#8217;t do when we&#8217;re not doing the virtual visits, is that with virtual visits, we can even bring in various family members that are living remotely. I&#8217;m reminded of one patient [inaudible 00:06:24] who was having some behavioral symptomatology, where it was very, very helpful to everyone to have her daughter who lived in Canada, was on the same Zoom call with us, together with my students. It&#8217;s also a great teaching modality because we could have medical students and residents and others together with the staff at the facility, together with the family, all looking at the same patient, all looking at what we see symptomatically, putting our heads together to see what we can recommend therapeutically. So, there are a lot of things that we can do virtually, a lot of benefits for the patient, the family, and the care partners virtually that we can&#8217;t do in the office, that we often can&#8217;t even do when we are going in person to the nursing home as far as visits there.
What are the clinical implications of the findings of these studies?
We&#8217;re working on a lot of different things, not necessarily all virtual healthcare related. My main area of interest has been in degenerative brain diseases, including things like Parkinson&#8217;s disease, as well as Alzheimer&#8217;s disease. One of the areas of research that we&#8217;re very involved with right now, which I think would be of interest to your audience is how do we diagnose not just psychosis, that&#8217;s what these conferences and these papers were all about in a condition like Parkinson&#8217;s disease, but how do we diagnose dementia? How do we diagnose cognitive impairment in an older adult that has either Parkinson&#8217;s or maybe the beginnings of Alzheimer&#8217;s disease. And, how do we do it in not only statistically significant, but a clinically meaningful manner with an instrument that&#8217;s useful and short, relatively abbreviated for clinicians to employ either virtually or in the office setting.
We&#8217;ve actually developed a new instrument, which has been validated in older adults who don&#8217;t have dementia. It&#8217;s called the St. Louis University AMSAT. It&#8217;s a five item quantifiable questionnaire, takes less than one minute and it&#8217;s as sensitive to picking up depression as the much more lengthy, much more complicated tools. In fact, it&#8217;s being adopted by the American Academy of Emergency Room Physicians as a way to screen for depression in the emergency room among older adults. But, we&#8217;re now pioneering the same instrument to see if it can actually diagnose depression against a background of dementia, whether in Parkinson&#8217;s disease or Alzheimer&#8217;s disease or Lewy Body disease, the various dementia type disorders in older adults. We&#8217;re very excited about the preliminary data with that instrument.
Any closing thoughts?
No. First, I want to thank you for having me. I think you asked the absolutely best questions, and I want to leave the audience with the notion, particularly the healthcare providers in the audience, don&#8217;t just think about telehealth or virtual medicine as something that&#8217;s only going to be with us while we&#8217;re still dealing with the COVID epidemic or pandemic. Think of it as something as a tool that has a lot of potential for the future, especially in applying it with audiences that have difficulty getting to us, or they&#8217;re in places where we can&#8217;t get to them physically, i.e. remote or more rural areas. It has great potential both for diagnosing as well as in treating this very vulnerable population. Thank you very much.

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