Neuropsychological Assessment in Times of Social Distancing: What Can Telemedicine Offer to Older Adults?

Neuropsychological assessment is responsible for exploring cognitive performance through the administration of standardized tests. It collaborates with the clinical diagnosis and delivers objective information on cognitive deficits and abilities. Telemedicine is a tool that can be used to distribute medicine in a different and novel way to any part of the world and is especially useful for places where physical access to hospitals is difficult or impossible. The use of technology for neuropsychological evaluation is growing at an accelerated rate, both due to the advancement of technological facilities and, currently, due to the present health emergency context. Older adults where the first group to get confined, so they are protected from the daily activities that may be associated to the COVID-19 virus, but an interesting paradox has arisen: older adults are confined at home for protection, but with this measure, many of them are not able to receive medical attention. Given the growing demand to provide services in virtual mode due to the COVID-19 pandemic, it is important to review the usefulness teleneuropsychology and its benefits for attending older adults with cognitive complaints or a dementia diagnosis. Teleneuropsychology is a novel approach and the literature on this professional practice is still very limited, since to date there are few research studies on the use of this modality.

Keywords: Cognitive complaints; COVID-19; Neuropsychological assessment; Older adults; Telemedicine

Origin and objectives of teleneuropsychology

Telemedicine is a tool that can be used as a way to distribute medicine in a different and novel way to any part of the world, and it is especially useful for inaccessible places where people are not able to visit a specialist or a nearby hospital [1]. Telemedicine was originally thought as a way to assist people living in rural areas. This sort of clinical attention offered the possibility of connecting these people with specialized medical care, avoiding the transport of patients, allowing the reduction of economic cost and loss of time [2].

As time went by, advances in technologies and the availability of broadband connections in most homes and workplaces expanded telemedicine services bringing a whole new paradigm on how clinical attention may be offered [3]. For the past decade, the use of internet in the daily work of neuropsychologists acquired more relevance, and the use of technology in the assessment-treatment process became more and more common in the professional practice [4]. Psychological treatment via telemedicine has been demonstrating its efficacy and satisfaction comparable to that of face-to-face attention in a wide variety of clinical settings and with specific populations, in the same way that its use has been shown to be effective for the diagnosis and treatment of various mental disorders [5]. The effectiveness and feasibility of the use of technology in psychological evaluation, diagnosis and treatment has promoted its use in other areas of psychology, such as neuropsychology. Teleneuropsychology is defined as the use of audiovisual technology to establish clinical contact with patients to carry out neuropsychological assessments and treatments, recognizing that this has reduced accessibility problems and has allowed the provision of health services in contexts of social distancing [6]. Neuropsychologists perform a variety of roles in different hospital and outpatient settings, either virtually or in person. When a neuropsychologist assesses a patient with a cognitive complaint or a suspected brain damage, the main objectives are to detect and characterize cognitive performance, guide a differential diagnosis and offer recommendations (to the patient and to the family) on daily life activities [7]. Computerized and virtual neuropsychological practices have been slowly integrated into research and professional activities bringing with it the development of computer-based versions of tests that until then could only be carried out using paper and pencil [8.9].

COVID-19, social distancing, and neurocognitive assessment

The COVID-19 pandemic is a global health crisis that has created sudden and unique challenges within the field of clinical neuropsychology. In this context, added to the novelty of this type of virtual approaches, studying the use of teleneuropsychology is relevant and necessary. Currently, the COVID-19 pandemic has profoundly impacted the world, causing significant changes in the daily functioning of society. The policies of social distancing have had enormous repercussions in the health sector, being that these had to be incorporated in a continuous process of modernization, where the field of neuropsychology had to evolve rapidly to incorporate evaluations to be carried out virtually. The various circumstances due to the health emergency confinement required that this care modality, which was before seen just as an alternative, had to become more effective in the face of the high demand [10]. In this way, the pandemic has pushed neuropsychology to become a discipline to evolve beyond traditional settings. In this context, teleneuropsychology could make it possible to measure and monitor cognition performance from home and may also help to identify the optimal time for a comprehensive face to face assessment [11]. Social distancing requirements associated from the COVID-19 pandemic persisted for a long time (and still persist in some countries), and future sanitary contexts may require patients and professionals to have a solid communication system to continue treatment virtually. In this sense, it is essential to have virtual alternatives available for neuropsychology which will improve the access to neuropsychological services [12].

The impact of lockdown and the social distancing policy in older adults’ health

The COVID-19 outbreak disrupted violently in the healthcare systems and caused a deep economic and social depression [13]. During early 2020, lockdown and social distancing were the first policies that most countries adopted to slow down the spread of the virus, while massive communication services advised the general population to avoid going out if it was not urgent [14]. Older adults were considered part of the most vulnerable population and these policies were targeted mainly to them. These measures might have prevented older adults from getting infected, but also impacted negatively in the follow-up of previous health conditions and the need of attention of new medical needs, such as novel cognitive complaints. In this way, professionals had to think of a way to offer continuity of care while protecting this vulnerable population from getting infected [15,16]. During lockdown, non-urgent procedures and most face-to-face visits were suspended, leaving many patients in front of a different dangerous situation: a drastic drop in spontaneous and non-urgent visits to the health care centers [14]. In this context, telemedicine has become critical when providing care and continuity to this vulnerable groups [17,18], and raised concerns about the way illnesses are categorized: is Alzheimer disease or Parkinson disease more or less urgent to attend than a respiratory syndrome? When should older adults with cognitive complaints or cognitive disabilities attend to a medical care health center?[15,17]. Mild cognitive impairment is an intermediate state between normal cognitive ageing and dementia and is a risk factor to progress to dementia in the years following the diagnosis [19]. In this way, early assessment and treatment of mild cognitive impairment in older adults is critical and must be addressed as a pending priority that must be revised in the actual context [16]. Reports around the world show that many patients with chronic diseases delayed their face-to-face visits to their doctors because of fear of getting infected [20-23]. The neglect of patients with neurologic and cognitive complaints has been alarming from early 2020 onwards, and leave health care professionals facing four main pending issues [15]: a) manage the morbimortality of the COVID-19 pandemic, b) consider how non-COVID-19 risk factors (such as hypertension, diabetes, stroke, etc.) must be approached, c) think how we may compensate the care of chronic diseases in older adults (such as cognitive impairment) that were mistreated during times of social distancing, and d) face the post COVID-19 stress effects in health professionals and patients.

Usefulness and limitations of teleneuropsychology

Currently, the applications of teleneuropsychology are growing, but the literature published over the years is still not conclusive regarding the representativeness of cognitive performance through virtual administration and the correlation between this setting and the face-to-face setting [24]. At present, teleneuropsychology is still in development and, despite its many benefits, it has not become a part of the routine of the health care professionals [25]. There is evidence that neuropsychological assessments can produce reliable and valid evaluations [26-33]. In the other hand, some studies have shown subtle differences in task performance when comparing face-to-face assessments with those of tele neuropsychology [34- 38]. The benefits of teleneuropsychology include convenience, user satisfaction, potential cost reductions, and improved access (for geographic reasons). In this way, research findings suggest greater patient acceptability with virtual methods, with 15% of older adults feeling less anxious, 7% finding it easier to concentrate, and a 29% reporting that the assessment was more interesting and fun by participating in video-based assessments [39]. Justice-related problems also arise in terms of equitable access to care through teleneuropsychology: while having access to technology (electronic devices, internet connection) can be a barrier to virtual services, difficult access to transportation may be a barrier to face-to-face services [16].

During the last two years and especially due to the COVID-19 pandemic, telemedicine and particularly teleneuropsychology have been showing several benefits in the possibility of offering health care services to older adults that cannot access face-to-face visits. Future studies should profoundly analyze local validity and representativeness of teleneuropsychology protocols to facilitate neurocognitive assessment utilizing virtual platforms [16]. Before the COVID-19 pandemic, the American Psychological Association and the Joint Task Force for the Development of Telepsychology Guidelines addressed this issue and gave professionals some guidelines for the adequate offer of virtual services, but the acute nature of the actual context left clear that those guidelines were somehow limited and insufficient [16]. In this context and due to the unprecedent need of novel ways to treat our patients, teleneuropsychology is showing a strong will of expansion, even after the COVID-19 pandemic. Future studies must address the analysis of validity and reliability of this type of attention compared to the face-to-face traditional evaluation, as teleneuropsychology has arrived to stay as a novel form of healthcare delivery.

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