Covid-19 has drastically accelerated research and development of digital health tools used in the patient’s home to treat acute illness and/or manage chronic conditions. Two categories that have experienced rapid growth are digital therapeutics, which are prescribed alone or in tandem with pharmaceutical therapy, and virtual care solutions such as remote patient monitoring tools.

Providers, payers and investors are excited about these technologies because both can be delivered in the comfort of the patient’s home by incorporating the personal mobile technologies patients are already familiar with and use regularly. The major question though, especially for solutions designed for long-term use of more than a month or two, is: Will patients keep using them? Digital health technology may “wow” providers, payers and pharma—but what about the patients, and their family caregivers?

There are multiple use cases for these technologies. Mild cognitive impairment (MCI) caused by Alzheimer’s disease, for example, is a particularly challenging chronic condition to manage for providers and caregivers and one without an effective pharmaceutical clinical pathway. As such, digital health companies are developing new technology solutions that can be used at home to stimulate brain activity with the goal of slowing progression of the disease.

Of course, patient engagement and nonadherence challenges physicians have faced for more than a century with traditional medical treatments also are challenges for digital health technology developers. That is why digital tools must use techniques such as gamification to create a personalized experiencef for patients, so they interact with them and provide active data that complements passive data collection and continuous monitoring. As McKinsey describes, bringing such a healthcare ecosystem to life requires a robust “engagement layer” to “deliver a personalized and integrated experience to consumers, enhance provider productivity, engage formal and informal caregivers, and improve outcomes and affordability.”

By fostering engagement and delivering a compelling experience, the patient will continue to use digital tools as prescribed and experience improved health outcomes, whether it’s through virtual care and remote patient monitoring or prescription digital therapy.

Neurogenerative disease ideal use case

Approximately 12% to 18% of individuals aged 60 years or older are living with MCI, which is manifested in early memory loss or other cognitive ability loss (such as language or visual/spatial perception) in individuals who are still able to live independently, according to the Alzheimer’s Association. While a challenging condition in itself, MCI is also an early indicator of potential Alzheimer’s Disease or other types of dementia. What is also concerning is the prevalence of MCI is increasing across the U.S. From 1996 to 2014, cognitive impairment increased for women from 18.7% to 21.2%  and by 17.6% to 21.0% for men, according to an epidemiological analysis published in 2020. Similarly, dementia rates increased by 1.7% for women and 2% for men.

MCI can be upsetting and burdensome to manage for individuals with the condition, but also for caregivers in the home. A three-year study of caregivers for those with MCI found between 21.1% and 29.5% reported a clinically significant level of burden over the study, more so if they had other health and social determinants of health challenges. Worse yet, caregivers compared to non-caregivers are more likely to be absent from work or have worse performance, be less physically active, visit the emergency department and more often have depression, insomnia, anxiety and pain.

Healthcare has made enormous strides in recent decades in managing the most burdensome conditions that face us including heart disease, respiratory illnesses and many types of cancer thanks to new medications and other treatments. MCI, Alzheimer’s Disease and dementia, however, continue to challenge both providers and pharmaceutical companies.

A 2018 review of literature published in the American Family Physician concluded that “none of the medications… prevented or delayed cognitive decline, cognitive impairment, or dementia.” These results were echoed in another 2018 study in the Canadian Medical Association Journal (CMAJ) which examined eight randomized clinical trials and three companion reports about cognitive enhancers and determined that the evidence showed the medications “did not improve cognition or function among patients with mild cognitive impairment and were associated with a greater risk of gastrointestinal harms.”

Digital tools showing promise

There is growing evidence, however, around how digital tools can slow the progression of the disease. A meta-analysis of studies of older adults using computerized cognitive training revealed small to moderate positive effects on global cognitive function, memory, working memory and executive function. Importantly, an even earlier study of patients with memory-related MCI found that playing a specific game on a tablet over four weeks not only improved memory, but researchers concluded the gamification aspect “maximizes engagement with cognitive training by increasing motivation.”

The challenge though is that not all cognitive-behavioral therapies work the same for every patient and there needs to be a very specific personalized and dynamic care path for an individual. Using artificial intelligence, machine learning and novel biomarkers can support and accelerate optimal personalized therapy when supported by a virtual care team specialized in neurodegenerative disease. Employing gamification techniques and cognitive tasks on a smartphone or tablet fosters engagement while enabling the patients’ clinicians to remotely monitor their cognitive function and intervene as needed using personalized cognitive rehabilitation techniques.

Algorithms can then personalize each patient’s therapy by automatically adjusting, or titrating, the therapeutic mobile-based activities based on the emerging novel digital biomarkers tied to cognitive function, mood and behavior. For example, adjustments could be made to the number and type of tasks and games that are offered, based on the speed of the patient’s finger movements, time to complete games or tasks, and their facial expression identified through the device camera.

Digital tools for MCI can also incorporate approaches such as reminiscence therapy, which uses images from the patient’s past to evoke positive memories and emotions, which have been shown to improve cognitive functioning. The patient’s family caregiver may also have access to an app where they can monitor the patient’s adherence and even contribute to reminiscence therapy by uploading family photos and videos.

Although patients and clinicians need to be the primary concern in developing and prescribing these digital therapies, patients’ families, who are most often the caregivers in the home, are an important consideration. To protect caregivers’ mental and physical health and maximize their engagement, the technology needs to be as intuitive to operate for them as it is for the patient. The digital health tool should also offer educational content and self-care techniques that help caregivers manage their family member with a neurodegenerative condition.

While the era of using digital health tools to manage MCI and perhaps prevent greater cognitive decline is just beginning, it is a promising new therapeutic direction for a very complex condition. The more these solutions are developed and studied, it seems clear, however, that the most effective technology will be the systems that individuals with MCI and their caregivers consistently enjoy using over the long term. Only through engagement can providers and digital health innovators expect to slow cognitive decline and bring about better outcomes.

Photo: SIphotography, Getty Images