Table 2:

Barriers to virtual direct-to-home care for patients with Alzheimer disease and related dementias

BarrierSuggested solution(s)
1. Technological access, literacy and interference
  • Limited access to technological devices or Internet services

  • Limited technological literacy

  • Patient or family resistance

  • Technical interference

  • Suggest accessing technology through family, friends or local health care centres62,63

  • Provide resources, support or education to improve technological literacy among patients and families63

  • Technologically prepare patients and families:

    • Involve telehealth technicians26,60,64

    • Send instructions ahead of time63,65

  • Discuss back-up plan should technology fail14,64

2. The physician–patient therapeutic alliance
  • Reduced interpersonal engagement

  • Issues of patient privacy, confidentiality and security of information

  • Employ verbal and nonverbal strategies to improve virtual patient–physician relationship66,67

  • “Webside manner” training for health care providers6769

  • Use encrypted virtual interfaces that satisfy legal requirements for confidentiality of patient data14,68

  • Obtain verbal informed consent for virtual care14,64

  • Encourage private area for patient visit and opportunity to speak alone14

3. Diagnostic challenges
  • Inaccuracies because of nonstandardized conditions of the virtual encounter

  • Adapting paper-based cognitive assessment tests for virtual administration

  • Limitations of teleneurological examination

  • Screen for hearing and vision impairments, and encourage use of sensory aids (glasses, hearing aids) before virtual assessment14,70,71

  • Document uncertainties; verify in person, when possible64

  • Have patients print written components of cognitive assessments in advance20,26

  • Use webcam and screen sharing for visual display26,27,47

  • Adapt tests as necessary,26,64 without altering cognitive construct being tested71

  • Follow suggested guidelines for virtual neurologic examination72,73

  • Use clinical judgment to convert to in-person assessments14,64,68

4. The COVID-19 pandemic
  • Increase in frequency of BPSD10

  • Reduced availability of caregivers to facilitate virtual encounter

  • Use virtual visits to educate patients and caregivers about BPSD management techniques51

  • Include caregivers virtually with 3-way calling14,70

  • Note: BPSD = behavioural and psychological symptoms of dementia, VTC = videoteleconferencing.