In-Home Video Telehealth for Dementia Management: Implications for Rehabilitation

Abstract

Purpose of review:

The progressive nature of dementia requires ongoing care delivered by multidisciplinary teams, including rehabilitation professionals, that is individualized to patient and caregiver needs at various points on the disease trajectory. Video telehealth is a rapidly expanding model of care with the potential to expand dementia best practices by increasing the reach of dementia providers to flexible locations, including patients’ homes. We review recent evidence for in-home video telehealth for patients with dementia and their caregivers with emphasis on implications for rehabilitation professionals.

Recent findings:

Eleven studies were identified that involved video visits into the home targeting patients with dementia and/or their family caregivers. The majority describe protocolized interventions targeting caregivers in a group format over a finite, pre-determined period. For most, the discipline of the interventionist was unclear, though two studies included rehabilitation interventions. While descriptions of utilized technology were often lacking, many reported that devices were issued to participants when needed, and that technical support was provided by study teams. Positive caregiver outcomes were noted but evidence for patient-level outcomes and cost data are mostly lacking.

Summary:

More research is needed to demonstrate implementation of dementia best care practices through in-home video telehealth. Though interventions delivered using in-home video telehealth appear to be effective at addressing caregivers’ psychosocial concerns, the impact on patients and the implications for rehabilitation remain unclear. Larger, more systematic inquiries comparing in-home video telehealth to traditional visit formats are needed to better define best practices.

Introduction

Dementia and its Impact on Function

Dementia prevalence is on the rise, with cases in the United States alone projected to total 13.8 million by 2050. Most patients with dementia live at home supported by unpaid caregivers who provide care valued at $232 billion [1]. A progressive neurodegenerative disorder, dementia poses significant problems for patients, families, and health care teams due to chronic and increasingly deleterious effects on cognitive, physical, social, and emotional functioning. As the disease progresses, day-to-day management becomes increasing complex, given worsening cognition. Decreased judgment and memory often lead to behavioral symptoms such as wandering or stove fires, which can be fatal. Perceptual and motor problems can increase fall risk, and worsening function necessitates caregivers’ increasing assistance with activities of daily living (ADLs) like dressing and bathing. Home safety is also of concern, with increased risk of accident and injury in the home from common household items such as power tools and poisonous substances.

Since age is the number one risk factor for dementia, persons with dementia often have multiple co-occurring physical and mental health conditions and geriatric syndromes common to older adults, such as frailty. Such multi-morbidity puts the person with dementia at increased risk of functional decline and diminished quality of life, with falls and other negative health consequences often necessitating in-patient or out-patient rehabilitation. However, traditional rehabilitation’s emphasis on physical dysfunction may limits its effectiveness, without adequate consideration for the ramifications of diminished cognition. Challenges to working with a person with dementia in a rehabilitation setting include developing realistic expectations and ensuring patient wishes and rights are respected despite cognitive limitations [•• [2]. This requires a shift towards habilitation, which emphasizes continued engagement and preventing loss of function, and away from a rehabilitation approach which expects a return to baseline function. Effective rehabilitation for dementia includes strategies such as capitalizing on implicit learning [3], partnering with caregivers to ensure health and safety, and effective management of co-morbidities, such as pain and mobility impairments, throughout the disease course. The Person-Environment-Occupation model of occupational therapy (OT) practice, which adjusts the activity or environment to maximize individual participation in activities, is well-suited for dementia in that it recognizes the interplay between an individual’s capabilities and strengths and the context in which it is occurring [4]. For example, identifying common household objects such as stoves and knives are potential safety risks due to dementia-related cognitive changes, and the increasing need to partner with caregivers in provision of Activities of Daily Living as the disease progresses, will help to compensate for losses and maximize function as the disease progresses.

Dementia Best Practices

Given dementia’s wholescale impact on patients and families and the prohibitive costs of dementia care compared to other chronic conditions [5], health care system goals are to support patients and families where they live—in the community. As patients with dementia experience progressive functional decline over the span of four to ten or more years, patients and families undergo tremendous changes many of which are not supported or actively addressed by the current health care system. To meet evolving needs, models of dementia best practices call for comprehensive, coordinated care management [•• [6]. Such care focuses on a continual relationship between patients and families and a multidisciplinary team of experts who address the context-specific needs of patients and families across care settings [7]. Identifying the caregiver as the vital link between the health care system and the person with the dementia, and the highly interrelated nature of their health and well-being, best practices in dementia attend to the psychosocial, functional and safety needs of both patients and their family. Such a person-centered model of care would support patients and families by providing individualized care across the disease course [•• [8, 9] ••].

Home-based primary care is a model used in Veterans Health Administration that affords interprofessional providers the opportunity to deliver care in patients’ natural context. Doing so may increase the clinical relevance of care while reducing the burden of attending in-person visits for patients and families [10]. Involving various disciplines, including physicians, nurses, psychologists, social workers, and physical, occupational, and speech therapists, home-based care is of interest in dementia, given the progressive loss of function and the cognitive and behavioral concerns that often make brick-and-mortar clinic visits a challenge. In fact, recent evidence indicates families’ willingness to pay for in-home programs that provide dementia behavioral strategies and support [•• [11]. Rehabilitation professionals are increasingly recognized as valuable team members in the management of chronic conditions [2]. Recognizing that despite disease-related challenges, each individual has preserved strengths which may be physical, social (as in presence of strong family support), or related to a person’s disposition or temperament, rehabilitation professionals aim to promote functional performance, health and quality of life by capitalizing on retained strengths [12]. Given barriers to implementing dementia best practices, which include anticipated geriatric workforce shortages [13] and patients’ difficulty accessing care due to factors such as rurality, innovative strategies to deploy existing providers into the home are needed. Telehealth represents one such innovative strategy.

Telehealth and Dementia

Telehealth is a care strategy in which patients and providers are in different locations connected via technology. In many contexts appearing equivalent to in-person care [• [14], telehealth includes a broad range of modalities from electronic consultation through store-and-forward technology (whereby digital images or other patient data is sent remotely for provider review) to video visits between patient and provider. Telehealth is a growing industry rapidly expanding to serve various populations, including patients with dementia. Beyond formal telehealth, various assistive technologies utilized for patients with dementia include remote monitoring using sensor technology and robots for social support [9]. For years providers have delivered telephone-based caregiver support [15–18], whereas newer modalities such as video-telehealth are of interest due to their ability to integrate voice and picture through web-based videoconferencing software.

Video telehealth is a live, synchronous encounter that employs videoconferencing software. Unlike sensor or internet-based telehealth, video telehealth most closely mimics an in-person health care appointment in that it occurs in real-time, allowing for on-the-spot communication and timely intervention. To date most video telehealth for dementia has occurred between health care facilities, e.g., providers located at major medical centers connected via video to patients at community-based clinics. For several years video telehealth has been employed for assessment of cognition [•• [19] [19–24] or combined diagnosis and disease management [•• [25] [•• [26] [25–31]. Though limited, there is evidence for tele-rehabilitation strategies related to cognitive impairment and dementia [• [32] or older adults in general [•• [33, 34], with most delivering tele-rehabilitation for stroke [35, 36] ••], traumatic brain injury [•• [37], musculoskeletal conditions [•• [38, 39] ••], and lung transplant [40]. Technology has enabled occupational therapy providers to provide home visits as part of pre-admission [41] or discharge from acute settings [• [42], and to deliver a caregiver wellness program [43].

Within Veterans Health Administration (VHA), a pioneer in all telehealth modalities, a record-breaking one million plus telehealth visits occurred in 2018, just under half using video. Recently announcing partnerships with various technology companies and launching a web-based videoconferencing app called “Video on Demand,” VHA has made increasing access to video telehealth into the home a key priority [44]. Building upon the ubiquity of smart phone technology, which has the potential to increase access to minority groups who may only have a smart phone, and the 95% of rural Americans who report having a cellular network while access to broadband internet gaps remain [•• [45], video telehealth is poised to expand in coming years.

Adapting dementia best practices—ongoing, highly collaborative, individualized, coordinated care delivered by a multi-disciplinary team of providers—to a video telehealth platform has the potential to greatly improve the health and quality of life of persons with dementia and their family caregivers. To facilitate effective adaptation of dementia care, including the integration of rehabilitation professionals, to a telehealth platform, it is imperative to explore the extent to which in-home video telehealth is currently utilized to support patients with dementia and their caregivers. Therefore, the purpose of this review is to summarize recent literature related to in-home video telehealth delivered to this population.

Methods

We conducted a scoping study utilizing the Arksey and O’Malley framework [46] which was further developed by Levac et al [47]. Pursuant to Stage 1, our overarching research question and related sub-questions guiding this scoping study were:

1. What is the state of recent evidence regarding in-home video telehealth for patients with dementia and their caregivers?

   1. What interventions are being conducted using in-home video telehealth, to whom, and by what types of providers?
   2. What types of technology are being utilized to provide in-home video telehealth (hardware, software), and who owns/provides the technology?
   3. What outcomes are being gathered, and what are their findings?

For Stages 2 and 3, we developed and refined a comprehensive search strategy through an iterative process. For a list of search terms, see Supplement 1. A search of the scientific literature up to February 2019 was conducted in six databases (PubMed, PsycINFO, Cumulative Index to Nursing and Allied Health Literature [CINAHL], EMBASE, AgeLine, and Cochrane Database of Systematic Reviews). Inclusion criteria were full-text articles, written in English, found in peer-reviewed journals, retrospectively reporting on interventions delivered via live, synchronous video, into the home of persons with dementia and/or their caregivers as the primary study population. We then narrowed our findings to the last five years to emphasize recent evidence. We collaboratively developed fields for a data charting form through an initial review of approximately twenty-five sources (Stage 4). Our final agreed upon data extraction fields included methods, sample size, outcomes, key findings, provider type, target of intervention, encounter purpose (i.e., description of intervention), hardware and software utilized, dementia type, and patient location (e.g., country).

Results

The initial search identified 1612 results (after de-duplicating) which were then double-screened for title and abstract by M.E.G. and L.R.M. Of these, 1451 were excluded mostly for either not including synchronous video telehealth or not having dementia as the primary study population. The full-text of 161 articles was reviewed by M.E.G. and L.R.M. to determine eligibility, and 150 were excluded for reasons such as not a full-text article (e.g., a conferencing proceeding) or the video intervention was not delivered into the home. See Figure 1 for a diagram of searches with reasons for excluding. Eleven items met the criteria for inclusion, of which seven were pilot studies, including two randomized control trials (RCTs), one evaluation, and a feasibility pilot. Two were qualitative— a descriptive formative evaluation and a mixed methods study. Sample sizes ranged from five to 110. For a summary of included study details, please see Table 1. For more in-depth study details, see Supplement 2.

Figure 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram of searches.

Table 1.

In-home video telehealth to persons with dementia (PWD) and their caregivers. For more details, please see Supplement 2.

Authors/ Year	Intervention; Provider type	Population	Design	Technology; Ownership	Outcomes	Results	Country
Austrom et al, 2015	Caregiver education and support--group; Psychologist	5 caregivers	Pilot	Desktop computer w/cable/broadband, Cisco MOVI program; Given to participants	Caregiver depression, anxiety, health and quality of life, burden, self-efficacy	Most caregiver outcomes (e.g., anxiety and depression) improved; positive views of group and format	US
Czaja, Loewenstein, Schulz, Nair, & Perdomo, 2013	Caregiver education and support—group; certified interventionists	110 caregivers	Pilot Randomize d Control Trial (RCT)	CISCO IP 7900 videophone connected to DSL; Given to participants	Caregiver depression, burden, caregiving aspects, social support, program evaluation questionnaire	Intervention group improved on certain outcomes; technology easy to use	US
Damianakis, Wilson & Marziali, 2018	Caregiver support group; gerontological social workers	24 caregivers	Qualitative	Unknown	Qualitative content analysis of video-recorded sessions	Themes addressed caregivers’ spirituality and meaningfulness of care; no outcomes gathered regarding technology	Canada
Dowling, Merrilees, Mastick, Chang, Hubbard & Moskowitz, 2014	Caregiver education- 1:1; Trained clinical nurse specialists and psychologist	24 caregivers	Pilot RCT	Personal computer or given; videoconferencing software unspecified	Caregiver positive and negative affect, depression, stress, distress, burden, and program evaluation	Improved intervention group scores on post-intervention; video format well-received	US
Griffiths, Whitney, Kovaleva & Hepburn, 2016	Caregiver education—group; trained facilitator	30 family caregivers; expert reviewers	Pilot evaluation	Facility loaned iPad	Caregiver burden, depression, anxiety, competence, PWD symptoms, and program evaluation	Decreased negative caregiver outcomes, increased positive outcomes; Expert review indicated adherence to original protocol	US
Griffiths, Kovaleva, Higgins, Langston & Hepburn, 2018	Caregiver education—group; trained facilitator	57 caregivers; includes sample (n=22) from Griffiths et al, 2016	Pilot feasibility	Phase I: Loaner iPads; Phase II: Caregiver-owned computer/mobile phone Software: Not specified	Caregiver burden, depression, competence, PWD symptoms	Decreased negative caregiver outcomes; greater improvements noted for PWD with worse/more advanced dementia	US
Kovaleva, Blevins, Griffiths & Hepburn, 2019	Caregiver education- -group; facilitator not specified	36 caregivers	Descriptive qualitative formative evaluation	Not reported	Semi-structured interviews; online survey; email and chat communications	Overall positive assessment of program, with themes highlighting barriers and facilitators	US
Lindauer, Seelye, Lyons, Dodge, Mattek, Mincks, Kaye & Erten-Lyons, 2017	Patient and caregiver assessment—1:1; clinician type unspecified	28 persons with dementia 28 caregivers	Pilot	Caregiver-owned computer/loaner iPad; Cisco Jabber Telepresence Platform	Patient cognition, dementia stage, mood, and dementia symptoms Caregiver burden and grief	Good to excellent reliability between video and in-person administration in all measures; video feasible despite technical challenges	US
Lindauer, Croff, Mincks, Mattek, Shofner,	Caregiver education—1:1; advanced practice nurse	20 family caregivers	Mixed methods	Caregiver-owned computers/tablets or loaner iPads; unspecified software	Caregiver burden, depression, desire to institutionalize, satisfaction; cost; feasibility (survey and focus groups)	Some reduced caregiver negative outcomes, but no change in others; cost savings; positive caregiver rating	US
Bouranis & Teri, 2018
Meyer, Getz, Brennan, Tang, Hu & Friedman, 2016	Language and cognitive rehabilitation; facilitator discipline not specified	17 persons with subtype of primary progressive aphasia	Case series	Laptop, speaker, and pad (facility given); software VSee	Language and cognitive tests, including measures of phonological and orthographic treatement	Positive treatment effects noted in all groups--- telerehabilitation and in-person	US
Rogalski, Saxon, McKenna, Wieneke, Rademaker, Corden, Borio, Mesulam & Khayum, 2016	Communication rehabilitation; Speech Language Pathologist (SLP)	31 persons with primary progressive aphasia and family caregivers	Pilot	Hardware: Unspecified Software: Internet-based videoconferencing (unspecified)	Measures of functional communication; semistructured post-intervention interview	SLP and participant-reported gains in functional communication; increased confidence in communication; gains sustained over time	US & Canada

Content of Interventions and Study Location

Eight of the eleven included studies provided caregiver education, support and/or skill-building, adapting prior in-person programs for videoconferencing. Most were delivered in groups versus one-to-one. Austrom et al. [48] drew upon work developing a care coordination model for dementia to provide weekly caregiver psychoeducational support groups delivered by a psychologist over six months. Each session was organized with the following structure: check-in/introductions, education based on group participant identified needs, question and answer, and sharing and support, groups included occasional guest speakers on related topics. Czaja, Loewenstein, Schulz, Nair and Perdomo [49] provided a program modeled after the evidence-based intervention, Resources for Enhancing Alzheimer’s Caregiver Health (REACH II), which was also adapted for use within Veterans Health Administration [16]. Czaja et al.’s telehealth version included five caregiver support groups using videophone, delivered to Hispanic and African-American caregivers of persons with dementia. Facilitators were certified interventionists (specific discipline not specified).

Three of the eleven included studies described results of Tele-Savvy, an adaptation of the Savvy Caregiver Program [50–52]. Savvy Caregiver is a protocolized psychoeducational program with asynchronous and synchronous program components, including a caregiver support group delivered in-person in the original and using videoconferencing in Tele-Savvy. Video-conferenced sessions employed a didactic, lecture-style format followed by group discussion led by a trained facilitator. Of interest, in addition to caregiver-level outcomes, Griffiths, Whitney, Kovaleva and Hepburn also reported on Tele-Savvy’s adherence to the original program’s protocol [50]. Similarly, Lindauer et al. presented findings from their adaptation of STAR (Staff Training in Assisted Living Residences), a staff training program devised in the United Kingdom [53], which was later developed into a program for informal caregivers called STAR-C. STAR-C consisted of in-home visits followed by telephone sessions [54]. In so-called STAR-C-TM (STAR-C telemedicine version), an advanced practice nurse provided eight weekly, hour-long, individualized educational sessions organized around themes from the original protocol, including behavioral dementia symptoms, challenging aspects of care, problem-solving strategies, and communication [55]. Damianakis, Wilson and Marziali also delivered a group-based program, Caring for Others, to caregivers with loved ones with a mix of Alzheimer’s dementia and frontotemporal dementia. The curriculum included skill-building in addressing challenges, coping with the emotional consequences of providing care, and strategies for caregiver self-care [56].

In addition to Lindauer et al., Dowling et al. was one of two groups providing one-to-one sessions. The Dowling team delivered five weekly one-to-one sessions as part of their program, Life Enhancing Activities for Family Caregivers (LEAF). LEAF is a positive affect intervention designed to increase caregivers’ ability to identify and build upon positive moments and to take a strengths-based approach to day-to-day disease management and coping [57]. All studies, other than Damianakis et al. and Rogalski et al. [58] (discussed below) were based in the United States, with the former occurring in Canada and the latter reaching caregivers in both the U.S. and Canada.

The three remaining studies were individualized, one comparing in-person and video-conferenced assessment of the caregiver and the person with dementia [59] and two providing in-home rehabilitation [58, 60]. In their pilot, Lindauer et al. [59] administered a modified Montreal Cognitive Assessment and the Geriatric Depression Scale to patients. Caregiver assessments gathered both patient-level outcomes (the caregiver report component of the Clinical Dementia Rating Scale and the Revised Memory and Behavior Problems Checklist), and caregiver assessment of burden and grief. Meyer, Getz, Brennan, Tang, Hu and Friedman [60] compared in-person and video-conferenced phonological and orthographic treatment sessions for persons with Primary Progressive Aphasia (PPA) provided over six months by an interventionist of unspecified discipline. Rogalski et al. [58] also provided individualized communication treatment to persons primarily with PPA, delivered by a Speech Language Pathologist (SLP) using an integrated web-based platform with a videoconferencing component. For study details, please see Table 1 and Supplement 2.

Technology

For the most part, scant technological details were provided. Technology information was absent in two studies [52, 56], perhaps because the studies were not focused on technological feasibility. It is worthy of note that eight of eleven studies reported loaning or giving a device to participants if they did not have one or if their personal device lacked sufficient broadband for videoconferencing. For example, computers or laptops were reportedly provided to participants in several studies [48, 57, 60] or loaners tablets (specified as iPads) were issued [50, 51, 55, 59]. Czaja et al. [49] provided a videophone device to participants. In the second phase of developing Tele-Savvy, Griffiths et al. [51] shifted from providing loaner iPads to utilizing caregivers’ own computer or mobile phone (the only study to reference use of a smartphone). Utilized software was described in only three studies, with videoconferencing programs including Cisco MOVI [48], Cisco Jabber Telepresence [59], and VSee [60]. Additional peripherals such as headphones and a camera [59], or a microphone speaker and pad [60], were provided in two studies.

In addition to hardware and software utilized, several studies reported providing technology assistance. In Austrom et al. [48], in-home software training and installation was provided by a research assistant who also called participants before each session to assist with log-in. Dowling et al. [57] called participants to assist with downloading software and to train them to utilize the program, while Griffiths et al. [50] provided in-home caregiver training in downloading lessons and videoconferencing software used for group sessions. Meyer et al. [60] delivered necessary technology to participants’ homes, with the researcher assisting with log-in and set-up of technology.

Lindauer et al. also discussed implications for virtual care into the home on the caregiver-person with dementia dyad. In their study of in-home assessment of the person with dementia, caregivers were reportedly involved in administering patient assessments, which may affect the evaluation process and caregiver burden. Similarly, these authors indicated that headphones were used to prevent the person with dementia from overhearing sensitive questions, which may not be a factor or an acceptable solution in an in-person clinic visit [59]. In their study adapting STAR-C, Lindauer et al. reported caregiver difficulty finding activities for the person with dementia to do while caregivers were participating in the program, highlighting another consideration for in-home video telehealth that may differ from a brick-and-mortar clinic [55].

Outcomes and Results

Caregiver Outcomes

Studies with caregivers as the primary study population gathered a range of both negative (e.g., burden) and positive (e.g., well-being) caregiver outcomes, mostly focusing on psychosocial endpoints. Caregiver outcomes most often included depression and burden [48–51, 55, 57, 59], anxiety or stress [48, 50], with other caregiver outcomes including: perceived health and quality of life, and self-efficacy or competence [48, 50, 51]; positive aspects of caregiving and social support [49]; affect [57]; grief [59]; and, desire to institutionalize [55]. Mostly positive caregiver outcomes post-intervention were reported by Austrom et al. [48], except for a slight increase in caregiver burden and mental health outcomes staying the same. Czaja et al. [49] found reductions in caregiver burden and increased social support and skills but no difference in depression. Dowling et al.’s [57] positive findings on caregiver affect, burden, and stress were sustained one month post-intervention, while Griffiths et al. in their studies of Tele-Savvy reported positive outcomes related to caregiver burden, depression, anxiety, behavioral and psychological symptoms of dementia (BPSD), and improved caregiver competence [50, 51], with greater gains noted for caregivers of loved ones with higher baseline BPSD and more advanced dementia [51]. While Lindauer et al. [55] reported no significant changes to caregiver depressive symptoms, burden, or desire to institutionalize, decreased frequency and caregiver reaction to BPSD was found.

Person with Dementia Outcomes

In addition to behavioral and psychological symptoms of dementia [50, 51, 59] operationalized by two studies as reflective of caregiver burden [49, 55], patient-level outcomes were scarce. Kovaleva et al. [61] gathered qualitative data regarding caregivers’ perceptions of the impact of Tele-Savvy on their loved one’s well-being. Lindauer et al. [59] gathered patient cognition, mood, and depression through direct assessment and patient dementia stage through caregiver report as part of their study comparing in-person and video-delivered patient and caregiver assessment. For the latter, good to excellent reliability was found between the two modalities. Other patient-level outcomes obtained in the two studies involving rehabilitation of patients with Primary Progressive Aphasia (PPA) included noted improvements in both tele-rehab and in-person language and cognitive tests in Meyer et al.’s study of phonological and orthographic treatment for dementia-related aphasia [60]. Rogalski et al. [58] reported gains in functional communication, confidence communicating, and maintenance of expressive language after SLP-facilitated communication treatment, findings which reflected both SLP and patient-report.

Other Outcomes

Feasibility or program acceptance data were gathered in seven studies, with caregivers reporting positive experiences with overall program [48, 50, 52, 55] and the video format [49, 57, 59]. Damianakis et al. [56] also qualitatively analyzed video-recorded group sessions for emergent themes (including spirituality and meaningfulness related to caregiving), whereas Griffiths et al., in their study examining fidelity of Tele-Savvy to the original protocol using expert reviewers [50] found Tele-Savvy maintained or improved upon the original. Only one study, Lindauer et al. [55], included cost data, reporting an estimated cost savings for STAR-C-TM (the telehealth version) of $1150 per caregiver compared to the estimated cost of in-person STAR-C. For complete study details, please see Table 1 and Supplement 2.

Conclusions

The aim of this study was to present recent evidence for in-home video telehealth for dementia as a promising alternative to deliver dementia best practices—care that is coordinated, ongoing, multidisciplinary, and increasingly targets the caregiver. Describing a potential role for video telehealth in both dementia diagnosis and disease management, studies included here emphasize a strong role in providing caregiver support and practical strategies for day-to-day management. Since video telehealth can be delivered in the comfort of the individual’s home, it has the potential to reach populations that face access challenges. While these extant studies highlight several promising features of in-home video telehealth, they also demonstrate a discrepancy between dementia care guidelines and implementation via video telehealth.

Out of the eleven studies included here, most were protocolized caregiver education or support programs delivered in a group format. While group-based care may be more cost-effective, and provide caregivers opportunities for social engagement (which may be of interest particularly for isolated caregivers [•• [62]), group-based programming may not allow for as much individualized intervention, a hallmark of dementia best care practices. Protocolized programs are also limited in their ability to flexibly meet the changing needs of persons with dementia and their caregivers, which vary and will tend to increase as the disease progresses.

Included studies primarily addressed caregiver-level outcomes. While aligning with dementia best practices in targeting the caregiver, inclusion of patient perspectives and patient clinical outcomes is important to highlight the impact of video telehealth to support the quality of life of the person with dementia. Since we recognize the reciprocal nature of caregiver and patient well-being, improved patient outcomes—specifically related to safety and behaviors—through provision of in-home video telehealth will likely affect caregivers in a positive way as well. Additionally, longitudinal, patient-level outcomes such as time to institutionalization and utilization of health care (e.g., emergency room visits), related to increased caregiver skills, knowledge, and efficacy, may bolster the case for use of in-home video telehealth.

Though limited information was provided on cost, most studies provided iPads or other technology to families, and such resources may not be available across care settings outside of research. Further, many studies provided technological support to caregivers, but descriptions of the extent of such support were not included. Comprehensive and comparative cost analysis that takes into account the full range of delivery costs (e.g., administrative, technological support, device and other technology features) between in-person and telehealth, such as reported elsewhere [63, 64], are needed in order to support video telehealth as cost savings for patients, families, and/or the health care system. In addition, systematic technological feasibility data for in-home video telehealth would inform development of similar interventions, as many studies indicated there were technological problems but did not elaborate on their extent or nature.

While the range of caregiver assessments painted a holistic picture of caregiver psychosocial outcomes, and a few studies included caregiver self-efficacy, most did not report on caregiver skills. Though improvements in caregiver psychological outcomes are important, demonstrating caregivers’ successful implementation of behavioral and other strategies through outcomes such as decreased behavioral and psychological symptoms of dementia behaviors, reduced instances of wandering, and increased skill in completing caregiving tasks may foster broader adoption of video telehealth. Further most studies did not directly compare in-person to video telehealth and only two randomized control trials were included, demonstrating a need for larger scale, more high-quality studies.

Implications for Rehabilitation Practice

Provider discipline when included indicates that multidisciplinary teams are not currently involved in delivering in-home video telehealth. Though two studies included rehabilitation strategies, only one study specifically cited involvement of a rehabilitation professional [58]. A comprehensive dementia care framework has ample opportunity for rehabilitation professionals as part of an interprofessional team. Patients with dementia have expressed interest in telehealth to provide cognitive rehabilitation [• [65]. Occupational therapy practitioners have a distinct role in dementia care providing home assessment and modification [•• [66], intervening to address behaviors and to prevent falls [•• [67], and supporting caregivers through training in safe and effective provision of activities and daily living [•• [68]. Given that workforce shortages affect all disciplines, video telehealth may afford rehabilitation providers a way to increase their reach to effectively support patients and families in navigating the dementia journey.