Providing memory assessment services during COVID-19

On 11 March 2020 the World Health Organisation described infection from SARS-CoV-2 leading to the clinical syndrome of COVID-19 as a pandemic (“Timeline of WHO’s response to COVID-19,” 2020). At the time of writing, this disease has accounted for over 10 million cases and 500,000 deaths worldwide (“COVID-19 Map - Johns Hopkins Coronavirus Resource Center,” 2020) and has led to profound changes in healthcare delivery. Risks of viral transmission during face-to-face contact have to be weighed against the benefits from that encounter. This balance becomes more nuanced with the possibility of assessing patients remotely using the telephone or videoconferencing. Here the risk of viral transmission is removed, but the trade-off becomes one of whether the quality of the assessment is so degraded as to make the risk of face-to-face assessment worthwhile. A further factor to consider is the vulnerability of the patients being seen. Some risk factors for mortality from COVID-19 are clear, of which perhaps the greatest is advanced age (Zhou et al., 2020). Patients presenting with impaired cognition represent a high-risk group from SARS-CoV-2 infection, but there are clear benefits to memory assessment for patients and carers (Park M.H., n.d.). Dementia is a major cause of mortality and morbidity in its own right, and there are therefore likely negative effects of failing to assess patients with cognitive impairment. How can we maximise the benefits of memory assessments whilst minimising the risks of infection?

Some early guidance on the principles of remote assessment has already emerged, for example from the General Medical Council (Remote Consultations - GMC, n.d). In order to begin to address this problem in memory assessment services specifically, a group of clinicians including representatives from neurology, psychiatry, psychology and General Practice from UK memory assessment services were drawn together by the national clinical director for dementia (AB) on 30^th April 2020 to share early experience and start to document the discussion (Memory Service Assessments: A New Way Of Working 1 Memory Service Assessments: A New Way Of Working, n.d.). This editorial is not intended as a clinical guideline. Instead, it is a reflection of some of the issues discussed by the group and potential ways forwards designed to stimulate debate amongst interested clinicians, and ultimately the development of firmer advice based on emerging evidence and experience.

General principles endorsed by the group were that services must be needs led; ensure equity of access and be continuously monitored and assessed. A successful remote service requires changes to the key components of the diagnostic pathway including history; cognitive assessment; neuropsychological assessment; brain scans; blood tests; and peri-diagnostic and post diagnostic support. We will deal with each of these in turn.

For many patients obtaining the history of the presenting complaint, as well as collateral information from the family, can be done remotely as easily as it can be in person. However, there are some exceptions. These include significant sensory impairment or aphasia and where there is the need for an interpreter. Taking a history remotely may require a disciplined approach to use the time most efficiently. The informant questionnaire on cognitive decline in the elderly (IQCODE), a validated tool for detailing onset and progression of symptoms, may be helpful in quickly gaining the desired information (Harrison et al., 2016).

There are a number of telephone-based assessments of cognition available, many of which have been validated (Castanho et al., 2014). Some are adapted variants of commonly used tools such as the Mini Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA). Some have been specifically developed or adapted for use on the telephone (e.g. the Telephone Interview for Cognitive Status, TICS, and the modified version, TICSM) which correlate with the MMSE. The National Institute of Health and Care Excellence, UK (NICE) has outlined the tests for which there is an evidence base (Dementia: assessment, management and support for people living with dementia and their carers | Guidance | NICE, 2018).Where a video consultation is feasible, it is often easier to negotiate a more traditional test such as the Addenbrooke’s Cognitive Examination (ACE). A remote version of the ACE is available (“Dementia test - Brain and Mind Centre,” n.d.).

A good cognitive assessment involves more than formal testing. Some nuances may be lost on the telephone and be less easy to detect on a remote video assessment, though this may be an acceptable trade-off for the improved infection control this offers. There may be significant advantages to conducting more detailed neuropsychological assessment by video conferencing rather than telephone, given the greater comparability to face-to-face interaction. The British Psychological Society (BPS) Division of Neuropsychology has produced guidance regarding the remote administration of neuropsychological assessments(Psychological assessment undertaken remotely, 2020). These again underline the need for a careful consideration of the risks and benefits of remote neuropsychological assessment. The examination is of course not limited to assessment of cognition. More extensive mental state examination to consider other mental disorder and physical examination are further challenges to consider remotely and will have relevance beyond the context of memory assessment services.

The principles as to when a brain scan is appropriate are the same for remote assessments as for assessments in person. The clinician needs to discuss with the patient and the family the risks and benefits of having a scan (which now include the potential risks of SARS-CoV-2 transmission inherent in visiting a hospital setting), whether it is urgent or can be deferred, and the likelihood that the result will change a management plan.

A further complication may be availability of imaging. Given the fixed number of scanners and the possible decrease in capacity due to increased infection control measures, imaging providers are likely to use triage to maximise resource, and scans in this patient group may not be prioritised. The likelihood is therefore that less scans will be performed for this indication. Guidance is available on this difficult question, but it is likely to be one area of debate as it represents a clear change of practice and opinions of how useful imaging is in any particular case will vary between clinicians (Orleans-Foli, Isaacs, & Cook, 2018).

The disruption to services caused by COVID-19 has led to a need for greater flexibility in deciding what is an acceptable time-lag between screening blood tests and assessment. These tests are likely to remain essential as it will be difficult to make a secure diagnosis of dementia without them and easily reversible causes, such as thyroid dysfunction, would be missed. However, increased flexibility is likely to be justified rather than sticking to a rigid time-frame in which they should have been conducted (for example the last 6 months). Instead blood tests performed during the lifetime of the cognitive symptoms may be considered acceptable.

The delivery of a diagnosis of dementia and the way it is communicated is a critical point for patients and their families and may be more challenging remotely. This may require more time, as will some other issues outlined above, and this should be allowed for. Remote assessment may require use of technology that patients are not familiar with careful consideration needs to be given as to how the access is made as simple as possible. If assessment can be achieved remotely further thought is needed to see how ongoing support may build on that by providing more remote resources whilst ensuring these are accessible to users of all levels of education and where English may not be a first language.

Clinicians may feel anxious about prescribing treatment without having physically examined the patient and some treatments involve side-effects where examination is directly related to safety, for example pulse taking. However, many treatments can still be safely started even without direct examination. These include acetylcholinesterase inhibitors (AChEI) where an ECG will in many cases increase risk of infection with little clinical benefit, certainly if remote assessment of basic physiological parameters (for example by use of a simple pulse oximeter) is possible (Rowland, Rigby, Harper, & Rowland, 2007). Prescribing memantine might be more straight forward than initiating an AChEI if there is a recent estimated glomerular filtration rate, although the difference in indication should be considered. Other treatment options also remain feasible, for example treatment of depression and anxiety. Reducing poly-pharmacy and anti-cholinergic burden can also often be safely initiated after a remote assessment. National Institute of Health and Care Excellence (NICE) recommends that carers should be offered a psycho-education and skills training programme. These can be provided remotely, for example Strategies for Relatives Intervention (START) can be delivered via a telephone or video consultation.

The advent of SARS-CoV-2 has provided a challenge to established ways of working. Not every patient can be assumed to have access to technology. Whilst ownership and ability to use a telephone is widespread, video consultations require more preparation and can raise privacy issues. Security of the technology is an essential component to consider.

These are early days for considering acceptability to patients, carers, or clinicians. This is an area which needs more thorough exploration, though our earliest surveys in Cambridgeshire UK suggest the majority of our older patients are willing to consider remote assessment and we are actively collecting data on patient and staff experience.

Remote assessment has been primarily driven as a response to the pandemic, but it has bought some unexpected benefits. Patients and carers have commented on the ease of remote assessment versus travel to clinics and difficulties with parking. Remote assessments similarly cut travel for clinicians which can decrease costs and increase productivity.

In the face of the health risks posed by SARS-CoV-2, remote consultation provides at least a partial solution. It does have limitations, not least the challenge of how to manage patients who cannot access such an assessment. The effectiveness of these services will no doubt improve with more experience and research which in turn is likely to inform more detailed guidance. Here we do not seek to be definitive about clinical practice, but instead to start the debate.

Benjamin Russell Underwood
Gnodde Goldman Sachs Translational Neuroscience Unit, Fulbourn Hospital, Cambridge, UK
[email protected]

Amanda Thompsell
South London and Maudsley NHS Foundation Trust, London, UK
Emad Sidhom
Cambridge University, Clinical Neurosciences, Cambridge, UK
Gnodde Goldman Sachs Neurotranslational Unit, Windsor Research Unit, Fulbourn Hospital, Cambridge, UK

Alistair Burns
Department of Psychiatry, University of Manchester, Manchester, UK