Teleneurology for Cognitive Care

The neurologic evaluation is rooted in history taking. As DeJong noted in The Neurologic Examination, “A skillfully taken history will frequently indicate the probable diagnosis, even before physical, neurologic, and neurodiagnostic examinations are carried out.”¹ This is perhaps especially true for cognitive neurology. Fortunately, telemedicine largely does not affect the history-taking process. In fact, telemedicine offers some unique advantages—including the ability to obtain “collateral information” and evaluate environmental safety concerns by visual inspection of a patient’s home environment. Telemedicine also allows more convenient follow up for established patients with dementia and limited mobility. An obvious limitation is the inability to perform full neurologic and neuropsychologic examinations, although some adaptations are possible.

Many of us have quickly transitioned to telemedicine, in an expedited manner out of necessity, because of the havoc wreaked by the COVID-19 pandemic. This sudden change has been both disruptive and illuminating—shedding light on the essential (and nonessential) in-person components of our clinical work. This adaptation is a work in progress. Although there are unique challenges posed by the telemedicine platform for the cognitive neurology evaluation, as noted, unexpected benefits have also been seen. In this article, we share our practical experiences “from the trenches” at Penn State Health Milton S. Hershey Medical Center (PSH-MSHMC) in learning to adapt the cognitive neurology evaluation to a telemedicine platform.

Adapted Workflow Procedures

During scheduling there are 2 important considerations. First, it is important to give clear instructions to the schedulers that a caregiver is required to be present for the entire teleneurology visit. Clinic schedulers may not be aware of the special needs of a patient with mild cognitive impairment or mild dementia who require greater assistance during scheduling and telehealth set up. Individuals with cognitive impairment are especially vulnerable to being lost to follow up because of miscommunication or misunderstandings during the scheduling process. Furthermore, extra time may need to be scheduled for the evaluation of a new patient with cognitive concerns, both because of technical challenges of telehealth and the inherently time-consuming nature of a thorough cognitive evaluation. A caregiver needs to be present for the visit to provide a distraction-free environment, give collateral information, and assist with use of the telemedicine platform as needed.

Second, it is important to provide adequate technical support to the caregiver for setting up the telemedicine platform, with consideration to having an alternative platform as a backup. Although it is preferable to use Health Insurance Portability and Accountability Act (HIPAA)-compliant platforms, the Centers for Medicaid & Medicare Services (CMS) relaxed rules and expanded access to telehealth in March and April 2020, in response to and for the duration of the pandemic. The increased access allows use of Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, Zoom, or Skype.^2,3 We have had success with Zoom, in particular, for patients who were unable to complete setup of the primary telemedicine platform in use at PSH-MSHMC (American Well). For those with no access to video, a telephone-only visit is a last resort that is also now allowed by CMS and can be used for some cognitive screening tests.

Adapting the Neuropsychologic Evaluation

Cognitive neurologists work closely with clinical neuropsychologists and often depend on detailed neuropsychologic assessments to help formulate an accurate diagnosis. At PSH-MSHMC, we have implemented adapted neuropsychologic testing procedures and adapted cognitive screening procedures (Table 1). For cognitive screening when video is unavailable, we recommend abbreviated telephone versions of the Montreal Cognitive Assessment test (MoCA).

1. blind version of MoCA (without visual elements),⁴ (T-MoCA: MoCA items not requiring pencil and paper or visual stimulus ,scored out of 22 points, with a cut-off of 19

2. 5-minute MoCA (Hong Kong version),⁵ reliability, and feasibility of the Montreal Cognitive Assessment 5-minute protocol (MoCA 5-minute protocol scored out of 30 points

3. 5-minute MoCA (Montreal version; validated, not yet published), scored out of 15 points, with a cut off of 11

These screening tests can be downloaded at: mocatest.org and completed by a psychometrist, trained medical assistant, nurse, or physician via phone or video before or during the visit.

If a video is available, the full MoCA can be administered, with minor modifications.⁶ First, the tester should identify themself (including their institution and location), confirm the patients’s identity, obtain verbal consent to proceed with testing, and instruct the patient to have a white sheet of paper, pencil, and eraser. For trailmaking tests, the tester shows the trails and says, “Please tell me where the arrow should go next to respect the pattern I am showing you.” For the cube copy test, show the cube design and ask the patient to copy it and hold it up to the camera. For clock drawing, instruct the patient to, “Draw a clock. Put in all the numbers and set the time to 10 past 11.” Have the patient hold it up to the camera for scoring. For animal naming, show the animal pictures and ask the patient to name each. For orientation, instruct them to, “Look straight at the camera and tell me today’s date, day of the week, month, and year.” For place, ask, “What clinic (or institution) am I calling you from?” For city, ask, “What is the city in which our clinic (or institution) is located?” Test procedures for the remainder of the test are as usual.

Teleneuropsychologic examinations can be done in modified form and are scheduled much like regular clinic visits via HIPAA-compliant platforms. Teleneuropsychologic examinations typically encompass interview, review of history, and an array of neurocognitive tests to assess domains of concern (eg, attention, working memory, spatial cognition, language, memory, and executive functions). Measures such as the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS)⁷, California Verbal Learning Test (CVLT),⁸ and Stroop,⁹ among others, can be administered with modifications including a combination of mailing select materials in advance and using screen sharing for visual and timed content. This is relevant for naming (eg, Boston Naming Test [BNT])¹⁰ and semantics tests (eg, Camels and Cactus¹¹, an open access version of Pyramids and Palm Trees Test [PPTT]¹²). Appropriate service codes are recognized as well. Interestingly, in a review and meta-analysis of a dozen studies comparing in-clinic and teleneuropsychology testing,¹³ there were no statistically significant differences in results. Although this is encouraging, there are several moderating factors that must be kept in mind. As with the neurologic examination, a distraction-free setting is crucial, and assistance with technical operation may be necessary. Neuropsychologists can also provide continuing follow-up care for behavioral management of individuals with dementia, postconcussive symptoms or syndromes, and many other cognitive disorders via telemedicine.

Adapted History-Taking Procedures

Bringing the cognitive neurologist into the patient’s home virtually yields some unintended and unexpected benefits Naturalistic observations of the home environment provide “collateral information” that can add to the “gestalt” of the history. For example, observing empty whiskey bottles may be a clue to consider substance abuse as a contribution to cognitive impairment, prompting extra care when taking social history. Observing disarray in the home can raise concern for a decreased functional level that could be secondary to neuropsychiatric symptoms, either from a primary psychiatric disorder or a neurologic disorder with prominent behavioral manifestations, such as frontotemporal dementia (FTD).

Patients often do not recall medications and doses, especially those who have cognitive impairment. Teleneurology allows the patient’s caregiver to physically inspect pill bottles and medication organizers to ascertain actual medication administration practices. Medication adherence is poor among older patients with dementia in general.¹⁴ One study found higher levels of adherence in individuals with mild dementia who received telehealth monitoring vs individuals with mild dementia who did not have telehealth monitoring.¹⁵

For patients with more advanced dementia or prominent behavioral and psychologic symptoms of dementia (BPSD), the ability to visually assess the home for safety can be valuable. It can be helpful to ask the caregiver whether there have been falls, injuries, or specific safety concerns regarding the home environment. Once a concern is identified, video can be used to inspect the area of concern, and even selectively tour (with permission) frequently trafficked areas of the house to evaluate for safety concerns. This additional information represents what Kinoshita described as the viewpoint of daily life¹⁶ and should be incorporated in the overall care plan for people with dementia, especially for those with BPSD. Safety concerns identified during telehealth visits can be subsequently addressed through local agencies, that may provide home modifications.

Adapted Neurologic Examination Tailored to Cognitive Complaints

In a 2009 editorial, Dr. Christopher Hawkes stated he did little to no physical or neurologic examination in many of his new patients, particularly those with dementia (60% not examined).¹⁷ As one can imagine, this editorial generated much dialogue, including a response by Dr. Charles Warlow, entitled Why I Have Not Stopped Examining Patients.¹⁸ Dr. Warlow noted that the neurologic examination served a variety of purposes beyond looking for specific signs, including providing time to think and ask additional questions clarifying the history and time to observe the patient closely without social discomfort. Warlow suggested that the ritual “laying on of hands” impresses and reassures a patient of the value and worth of coming to see a specialist, stating that patients “come to hospital ‘to be examined’ not ‘to be interrogated.’ ”

It is true that people with early stages of Alzheimer disease (AD) often have nonfocal examinations. Given that AD is the most common dementia, it is understandable why Dr. Hawkes would conclude the neurologic examination may be of limited utility for dementia. We believe, however, that the neurologic examination provides vital information for distinguishing among the dementias, particularly for nonAlzheimer dementias and at the earlier stages of disease. An excellent general overview of the teleneurology examination is shown in Dr. Reichwein’s instructional video.¹⁹ For the patient with cognitive impairment, specific neurologic signs pertinent to the cognitive evaluation are listed in Table 2.

Teleneurologic Examination for Cognitive Evaluation

Mental Status. The mental status examination can be completed without significant adaptations for telemedicine. For a refresher, refer to Blumenfeld’s videos on the topic.²⁰

Cranial Nerves. Instruct patient to face the camera with their head still and look with the eyes only in all cardinal directions. Impaired smooth pursuit and intrusive saccades (square-wave jerks) suggest parkinsonian syndromes. Vertical gaze palsy may be progressive supranuclear palsy (PSP). Facial asymmetry can suggest focal structural lesions. Difficulty sustaining tongue protrusion may suggest a movement disorder (eg, Huntington disease [HD]. Tongue fasciculations in a patient with behavioral disinhibition may suggest FTD-motor neuron disease (MND) (ie, amyotrophic lateral sclerosis [ALS]). Dysarthria may be due to vascular insult or neurodegeneration.

Motor. Arrange camera to allow a full body view and observe carefully for resting tremor of hands or feet or other hyperkinetic movements. Instruct patient to extend hands in outstretched position to assess pronator drift and then postural tremor. The inability to properly assess tone is a major limitation. Although it cannot give a definitive assessment, it may be useful to ask the patient to flick their wrists as though shaking water off and observe for increased tone.²¹ Bradykinesia can be assessed with finger or toe tapping, hand opening and closing or pronation and supination. It can be helpful to physically demonstrate these tasks.²¹ Although confrontational strength testing is not possible, other techniques can assess strength (eg, observing patient standing up from seated position with arms crossed against chest, single-leg stand, and heel and toe walking). Pronator drift, lower extremity drift, and impaired finger and foot tapping may be subtle signs of weakness potentially localizing to the corticospinal tract. Asymmetric weakness may suggest an occult vascular event or other structural lesion.

Sensory. Sensory testing should be undertaken only with the assistance of a caregiver, because self-administered sensory stimulation is unlikely to be reliable. Asymmetric sensory loss may suggest a focal structural lesion. With a particularly helpful assistant, it may be possible to assess for cortical sensory signs (astereognosis and agraphesthesia), which may suggest the corticobasal syndrome (CBS). Even without explicit sensory assessment, difficulty with the Romberg test, which can be completed during gait assessment, indicates proprioceptive dysfunction of the dorsal columns that is seen in subacute combined degeneration of the spinal cord and associated peripheral neuropathy secondary to vitamin B₁₂ deficiency.

Coordination. Coordination is easily assessed after testing pronator drift. Instruct patient to touch their nose then bring their hand back to an outstretched position; observe for dysmetria or intention tremor. Cerebellar dysfunction, secondary to a structural lesion or metabolic insult (eg, chronic alcoholism or phenytoin use), may cause cerebellar cognitive affective syndrome (CCAS).²²

Gait. Caution the caregiver to stand at the ready during the entire gait assessment to prevent a potential fall. When assessing gait, observe the posture, stance (narrow or wide-based), and stride length. Sometimes when gait appears normal, the additional challenge of tandem gait can bring out subtle deficits, such as dystonia, chorea, or rest tremor. Pay close attention for signs of parkinsonism, including a stooped posture, decreased arm swing, narrow base, festinating steps, and turning en-bloc. Gait evaluation is also important for assessing other etiologies of dysfunction (cerebellar ataxia) and for its overall usefulness as an assessment of strength and function.

Conclusions

With modified workflows, adapted neuropsychologic testing, and use of the telehealth platform the neurologic evaluation can be initiated at the earliest possible time for earlier opportunities to provide appropriate symptomatic management. This is especially true for treating neuropsychiatric symptoms of dementia, which may reduce unwanted healthcare utilization (eg, unnecessary emergency department visits or hospitalizations). A key limitation of teleneurology, however, is the inability to conduct full neurologic and neuropsychologic exams, which may limit diagnostic certainty in some cases. Furthermore, for complicated care-planning or in-depth counseling of patients and their family members, teleneurology will not reproduce the impact of or need for an in-person clinic visit. Despite these limitations, telehealth has certain unique advantages for the care of patients with cognitive impairment and will likely remain a fixture in cognitive care in the years to come.