Implementation of a Virtual Dementia System of Care in a VA Health Setting

Implementation of a Virtual Dementia System of Care in a VA Health Setting | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Implementation of a Virtual Dementia System of Care in a VA Health Setting James Powers This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6149663/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 28 May, 2025 Read the published version in BMC Geriatrics → Version 1 posted 13 You are reading this latest preprint version Abstract Objective Dementia care remains supportive and geriatric resources are scarce. We describe a dementia system of care consisting of virtual and e-consults working through the primary care provider, as well as providing virtual group caregiver support. These models were developed based on patient and caregiver preferences and necessitated by the Covid public health emergency. Methods A geriatrician supported dementia consult clinic transitioned to a virtual model of care averaging 14 consults monthly. A centrally located caregiver support group providing a 4-week curriculum and delivered in conjunction with a social worker similarly transitioned to virtual support. Primary care providers generated consults and were provided educational consultations regarding dementia diagnoses and management in the primary care setting. Results Between 2018–2024, 1176 consultations were provided during this period as the clinic transitioned from in-person to virtual consultation. Recommendation categories included: 1) diagnostic testing, 2) medication recommendations and deprescribing, 3) referral for formal neuropsychological testing, 4) psychiatric referral for behavioral concerns, 5) primary care management and goals of care, 6) safety considerations, 7) home and community-based services, and 8) caregiver support. Providers continue to send new consultations and request follow-up advice on previous consults. A total of 72 family caregivers participated in the 4-class support curriculum and lived an average of 45 miles from the Medical Center, saving 172 miles/6 hrs driving per caregiver for each 4- class curriculum. Conclusions/Impact Virtual and e-consult dementia care working through the primary care provider, as well as virtual group caregiver support, are feasible, acceptable and sustainable models of dementia care to efficiently utilize scarce geriatrics resources serving a wide geographic area. A virtual dementia system of care may facilitate PCP delivery of supportive care for persons living with dementia, dementia care navigation, and caregiver support. Alzhiemer’s Disease Dementia Care Caregivers Figures Figure 1 Introduction Care for persons living with dementia (PLWD) is challenging and the majority of patients with Alzheimer's Disease are supportively managed in the primary care setting, with 85% of dementia diagnoses provided by primary care providers. 1 The number of PLWD over age 65 is estimated at 6.2 million and is expected to rise to 13.8 million by 2060, 2 creating a burden for primary care providers, as well as an estimated 11 million unpaid family caregivers. 3 There is an inadequate number of specialty providers in Geriatrics, Neurology and Psychiatry to evaluate and manage all PLWD. Primary care providers have a relationship with patients and families and are in a good position to provide supportive care to PLWD and their caregivers, however they may need assistance in this role due to the to the complexities involved in management. Telehealth has been found to enhance access to care and to be effective for behavioral health, education, and caregiver support. 3 – 6 We report a 7-year experience (2018–2024) developing and transitioning to a virtual dementia system of care in a VA health setting. Methods The Department of Veterans Affairs Tennessee Valley Healthcare System (TVHS), is a health care system with 140,000 patients in Middle Tennessee. There are 2 campuses located 40 miles apart, with 20 affiliated community-based outpatient clinics (CBOC’s). An estimated 8,500 dementia patients are cared for at TVHS. Many of these are rural hi-risk, hi-need patients in the TVHS catchment area. In 2011, TVHS developed a geriatric patient-centered medical home model, the geriatric patient-aligned care team (GeriPACT). 7 GeriPACT is a special population PACT within primary care for complex geriatric and other high-risk vulnerable veterans providing integrated, interdisciplinary assessment and longitudinal management, and coordination. The practice is supported by the Department of Veterans Affairs Computerized Patients Record System (CPRS), including the electronic patient portal, My health e vet, with telemedicine capabilities. A geriatrician affiliated with GeriPACT, does the majority of the dementia consults separate from their primary care geriatrics patient panel care, working through the referring PCP in primary care practices and CBOC’s. Neurology sees few primary cognitive disorder patients unless also associated with TBI or movement disorders. Psychiatry sees mainly dementia with behavioral concerns. Initially conceived as an in-person consultation and management service provided by GeriPACT, the dementia clinic transitioned to virtual care necessitated by the Covid 19 pandemic in 2020. Referrals from primary care providers were often triggered by dementia warning signs such as delirium with acute illness, wondering, self-neglect, need for appointment of a fiduciary, and caregiver concerns about behavioral manifestations and need for support services. Consults were received electronically, responded to within 48 hours, and consisted of a thorough review of the electronic health record and provision of an individualized educational consultation to the primary care provider with specific diagnostic and management recommendations. Occasional (1%) telephone or video telehealth (veterans video connect VVC) calls with patients, or telephone contact with providers was provided as requested or when more information was required. (Table 1) Primary care providers were requested to perform on-site diagnostic testing when indicated (i.e. thyroid function tests, B12, neuroimaging) and mental status screening (SLUMS, 8 MMSE, 9 MOCA 10 ) as appropriate. In conjunction with the dementia consult clinic, a caregiver support group was initiated, co-facilitated by the geriatrician and Caregiver Support Program social worker. 11 A 4-class weekly curriculum focused on emotional support, caregiving skills and sharing of best practices, as well as generating clinical referrals and supplying equipment needs for veterans. Similar to the dementia clinic, the caregiver support group became entirely virtual in 2020. Caregivers were referred to the support group by primary care providers as well as nurses and social workers caring for PLWD in other settings. Ethical Approval and Consent to Participate: This study adhered to the Declaration of Helsinki. The Department of Veterans Affairs, Tennessee Valley Healthcare System (TVHS) Institutional Review Board (IRB) has determined this study as a quality improvement initiative and waived informed consent for participants. Results Between 2018–2024, 1176 consultations were provided during this period as the clinic transitioned from in-person to virtual consultation. The service performed a mean 14 consultations monthly with no change pre-and post-Covid. (Fig. 1 ) Table 1. Consultation Modality N = 1176 1% telephone/VVC 1% f2f 5% repeat management questions from PCP 93% educational e-consult to primary care provider Educational consultation responses with diagnostic information including functional assessment staging (FAST 12 ) and specific management recommendations were provided to the referring clinicians including : 1) further diagnostic testing as individually indicated, 2) medication recommendations and deprescribing, 3) referral for formal neuropsychological testing when appropriate, 4) psychiatric referral for severe behavioral concerns, 5) individualized primary care management and goals of care, 6) safety considerations, 7) home and community-based services/social work involvement, and 8) caregiver support. (Table 2) Providers continue to send new consultations and request follow-up advice concerning previous consults, and family caregivers share contact information with each other during the group support sessions. Table 2. Consultation Recommendation Categories Diagnostic testing Medication recommendations and deprescribing Referral for formal neuropsychological testing Psychiatric referral for behavioral concerns Primary care management and goals of care Safety considerations Home and community-based services Caregiver support A total of 72 family caregivers participated in the 4-class support curriculum and lived an average of 45 miles from the Medical Center, saving 172 miles/6 hrs driving per caregiver for each 4- class curriculum. Caregivers were 95% women with an average age of 68. Many shared contact information with each other during the group support sessions. Discussion Telehealth consultation improves access, decreases no-show rates, serves to educate PCP’s 13 and can combine to enhance the caregiver experience of care. 11 Anecdotal comments from patients and caregivers reflect acceptance of virtual care with enhanced access, efficiency, and effectiveness. Alzheimer’s disease is increasingly viewed as a treatable condition maintenance like other chronic diseases including early diagnosis with biomarker confirmation and administration of disease modifying agents. Future developments in the diagnosis and treatment of Alzheimer's disease may help optimize diagnosis and treatment. 14 – 15 However biomarkers appear to change over the course of dementia and in association with risk factors, 16 and evidence that effective interventions for Alzheimer’s with early identification of risk factors is low. 17 Enhancements to the e-consult model for dementia care could include utilization of the Telephone-Montreal Cognitive Assessment (T-MoCA) and Telephone Interview for Cognitive Status (TICS), both of which could be performed remotely or by primary car, and which correlate well with emerging blood biomarkers. 18 In addition, tailored caregiver assessment and referral (TCARE) is an evidence-based software used by federal, state, and private-funded agencies to identify caregivers at risk for burnout, connect them to the right services, and measure the impact of their programs. 19 TCARE partners with Area Agencies on Aging and community partners to deliver its caregiver support platform to communities of caregivers. There remains a large need for screening strategies for appropriate candidates for new treatments, care navigation, and support services for caregivers and PLWD. For individuals receiving newer modalities of treatment including monoclonal antibodies directed at amyloid, there is also a great need for support services for caregivers as well as PLWD. Limitations This model was developed in a VA care system and may not be applicable to all healthcare systems. Virtual dementia care may not appropriate for all patients such as those with severe behavioral disturbances and comorbidities including polytrauma, psychiatric disorders and PTSD. Additionally, some patient and caregiver concerns may not be able to be addressed by the PCP such as those for whom the goals of care includes consideration of anti-amyloid treatment. Finally, telehealth and virtual educational consultation for dementia care require a skilled consultant familiar with primary care and knowledgeable about VA and local home and community-based resources. Conclusion While we embrace future advancements in the diagnosis and treatment of dementia, there is a large unmet need for continued supportive care for PLWD, dementia care navigation, and caregiver support. Virtual primary dementia care is feasible, acceptable, and effective and may help to address this need. A virtual dementia system of care may facilitate PCP delivery of supportive care for PLWD, dementia care navigation, and caregiver support. Declarations ORCHID ID # 000000025305602x Acknowledgement : This submission and all statements are those of the author and do not necessarily reflect the opinions of the Department of Veterans Affairs Consent for Publication: NA - no personal identifiers are included in this manuscript Declaration of Conflict of Interest : None. As a federal employee, the author claims no copy right privileges. Funding Statement: This study was partially funded by the Health Resources Services Administration (HRSA) Geriatric Workforce Enhancement Program (GWEP) 6 U1QHP53068-01-00 Ethical Approval and Consent to Participate: This study adhered to the Declaration of Helsinki. The Department of Veterans Affairs, Tennessee Valley Healthcare System (TVHS) Institutional Review Board (IRB) has determined this study as a quality improvement initiative and waived informed consent for participants. Data Availability: All data included in this study are available by request from the author. References Drabo EF, Barthold D, Joyce G, Ferido P, Chang Chui H, Zissimopoulos J. Longitudinal analysis of dementia diagnosis and specialty care among racially diverse Medicare beneficiaries. Alzheimers Dement. 2019 Nov;15(11):1402-1411. doi: 10.1016/j.jalz.2019.07.005. Epub 2019 Sep 4. PMID: 31494079; PMCID: PMC6874742. Alzheimer's disease facts and figures. Alzheimers Dement. 2021 Mar;17(3):327-406. doi: 10.1002/alz.12328. Epub 2021 Mar 23. PMID: 33756057. Liang J, Aranda MP. The Use of Telehealth Among People Living With Dementia-Caregiver Dyads During the COVID-19 Pandemic: Scoping Review J Med Internet Res 2023;25:e45045 doi: 10.2196/45045. Palmer CS, Brown Levey SM, Kostiuk M, Zisner AR, Tolle LW, Richey RM, Callan S. Virtual Care for Behavioral Health Conditions. Prim Care. 2022 Dec;49(4):641-657. doi: 10.1016/j.pop.2022.04.008. Epub 2022 Oct 20. PMID: 36357068; PMCID: PMC9581698. Haleem A, Javaid M, Singh RP, Suman R. Telemedicine for healthcare: Capabilities, features, barriers, and applications. Sens Int. 2021;2:100117. doi: 10.1016/j.sintl.2021.100117. Epub 2021 Jul 24. PMID: 34806053; PMCID: PMC8590973. Callaghan T, McCord C, Washburn D, Goidel K, Schmit C, Nuzhath T, Spiegelman A, Scobee J. The Changing Nature of Telehealth Use by Primary Care Physicians in the United States. J Prim Care Community Health. 2022 Jan-Dec;13:21501319221110418. doi: 10.1177/21501319221110418. PMID: 35795898; PMCID: PMC9274427. Powers JS, Moseley M, Abraham L, Azubike, N, Buckner, J, Xie C . Implementation of a Geriatric Patient-Centered Medical Home. OMB Geriatrics 2018, volume 2, issue 3 doi:10.21926/obm.geriatr.1803008. Tariq SH, Tumosa N, Chibnall JT, Perry MH 3rd, Morley JE. Comparison of the Saint Louis University mental status examination and the mini-mental state examination for detecting dementia and mild neurocognitive disorder--a pilot study. Am J Geriatr Psychiatry. 2006 Nov;14(11):900-10. doi: 10.1097/01.JGP.0000221510.33817.86. PMID: 17068312. Folstein MF, Folstein SE, McHugh PR. Mini-mental state. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12:189–98. Nasreddine ZS, Phillips NA, Bédirian V, Charbonneau S, Whitehead V, Collin I, Cummings JL, Chertkow H. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc. 2005 Apr;53(4):695-9. doi: 10.1111/j.1532-5415.2005.53221.x. Erratum in: J Am Geriatr Soc. 2019 Sep;67(9):1991. doi: 10.1111/jgs.15925. PMID: 15817019. Van Houtven CH, Smith VA, Lindquist JH, Chapman JG, Hendrix C, Hastings SN, Oddone EZ, King HA, Shepherd-Banigan M, Weinberger M. Family Caregiver Skills Training to Improve Experiences of Care: a Randomized Clinical Trial. J Gen Intern Med. 2019 Oct;34(10):2114-2122. doi: 10.1007/s11606-019-05209-x. Epub 2019 Aug 6. PMID: 31388914; PMCID: PMC6816649. Reisberg B. Functional assessment staging (FAST). Psychopharmacol Bull 24: 653-9, 1988 Mackwood MB, Nagpal AS, Yuen J, Cancino RS. Virtual Access to Subspecialty Care. Prim Care. 2022 Dec;49(4):557-573. doi: 10.1016/j.pop.2022.05.001. Epub 2022 Oct 20. PMID: 36357061; PMCID: PMC9581700. Palmqvist S, Tideman P, Mattsson-Carlgren N, et al. Blood Biomarkers to Detect Alzheimer Disease in Primary Care and Secondary Care. JAMA. 2024;332(15):1245–1257. Doi:10.1001/jama.2024.13855. Salloway S, Rowe C, Burns JM. Are Blood Tests for Alzheimer Disease Ready for Prime Time? JAMA. 2024;332(15):1240–1241. doi:10.1001/jama.2024.12814. Lu Y, Pike JR, Chen J, et al. Changes in Alzheimer Disease Blood Biomarkers and Associations With Incident All-Cause Dementia. JAMA. 2024;332(15):1258–1269. Doi:10.1001/jama.2024.6619. Plassman BL, Williams JW Jr, Burke JR, Holsinger T, Benjamin S. Systematic review: factors associated with risk for and possible prevention of cognitive decline in later life. Ann Intern Med. 2010 Aug 3;153(3):182-93. doi: 10.7326/0003-4819-153-3-201008030-00258. Epub 2010 Jun 14. PMID: 20547887. Chappelle SD, Gigliotti C, Léger GC, Peavy GM, Jacobs DM, Banks SJ, Little EA, Galasko D, Salmon DP. Comparison of the telephone-Montreal Cognitive Assessment (T-MoCA) and Telephone Interview for Cognitive Status (TICS) as screening tests for early Alzheimer's disease. Alzheimers Dement. 2023 Oct;19(10):4599-4608. doi: 10.1002/alz.13039. Epub 2023 Mar 20. PMID: 36939111; PMCID: PMC10509307. Tailored caregiver assessment and referral. https://www.tcare.ai/customers/government-agencies (Accessed 11/17/24). Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 28 May, 2025 Read the published version in BMC Geriatrics → Version 1 posted Editorial decision: Revision requested 30 Apr, 2025 Reviews received at journal 23 Apr, 2025 Reviews received at journal 21 Apr, 2025 Reviewers agreed at journal 13 Apr, 2025 Reviewers agreed at journal 08 Apr, 2025 Reviewers agreed at journal 08 Apr, 2025 Reviews received at journal 05 Apr, 2025 Reviewers agreed at journal 31 Mar, 2025 Reviewers invited by journal 31 Mar, 2025 Editor assigned by journal 31 Mar, 2025 Editor invited by journal 30 Mar, 2025 Submission checks completed at journal 24 Mar, 2025 First submitted to journal 24 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6149663","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":436553359,"identity":"d1e5d1cf-1302-472a-a2d8-3d26a2a4b6a3","order_by":0,"name":"James Powers","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4klEQVRIiWNgGAWjYBACxgZk3geStTDOINlKZh6iVLWfTnz4g+GOnMHx3sefbdsOR/M3MB/7+AWfw3pyNxvzMDwzNjhz3Ew6t+1w7owDbMmzZfBpacjdJs3AcDhx2400NuacM4dzNzDwGDNL4NPS/3b7zx8gLfefMX+2IErLjNxtDDxgW9gYpBkqIFoY8YU244y3m6V5DJ4Z259JY5PsqUjPnXGYLZkZjw4Gw/7cjR9/VNyRk2w/xvzhh4F1bn9782HGH/i0NIBIgwNIQswEIkgeQh1AFcVryygYBaNgFIw4AAA/nU7XcTFvrwAAAABJRU5ErkJggg==","orcid":"","institution":"VA Tennessee Valley Healthcare System","correspondingAuthor":true,"prefix":"","firstName":"James","middleName":"","lastName":"Powers","suffix":""}],"badges":[],"createdAt":"2025-03-04 00:38:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6149663/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6149663/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12877-025-06034-0","type":"published","date":"2025-05-28T15:57:51+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":79678649,"identity":"5c370bfa-f9e1-4101-82e4-2f6cfb0af486","added_by":"auto","created_at":"2025-04-01 12:29:55","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":11581,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003emean 14 consultations monthly with no significant change pre and post covid\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6149663/v1/bef4f5c9c2a7cee9954d722b.png"},{"id":83783546,"identity":"cf37bfcb-3c97-4fb5-804f-ddf78b946fe2","added_by":"auto","created_at":"2025-06-02 16:11:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":398066,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6149663/v1/90e0739e-1149-43ed-ac9a-2577484e5bfb.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Implementation of a Virtual Dementia System of Care in a VA Health Setting","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCare for persons living with dementia (PLWD) is challenging and the majority of patients with Alzheimer's Disease are supportively managed in the primary care setting, with 85% of dementia diagnoses provided by primary care providers.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003eThe number of PLWD over age 65 is estimated at 6.2\u0026nbsp;million and is expected to rise to 13.8\u0026nbsp;million by 2060,\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e creating a burden for primary care providers, as well as an estimated 11\u0026nbsp;million unpaid family caregivers.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e There is an inadequate number of specialty providers in Geriatrics, Neurology and Psychiatry to evaluate and manage all PLWD. Primary care providers have a relationship with patients and families and are in a good position to provide supportive care to PLWD and their caregivers, however they may need assistance in this role due to the to the complexities involved in management. Telehealth has been found to enhance access to care and to be effective for behavioral health, education, and caregiver support.\u003csup\u003e\u003cspan additionalcitationids=\"CR4 CR5\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e We report a 7-year experience (2018\u0026ndash;2024) developing and transitioning to a virtual dementia system of care in a VA health setting.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThe Department of Veterans Affairs Tennessee Valley Healthcare System (TVHS), is a health care system with 140,000 patients in Middle Tennessee. There are 2 campuses located 40 miles apart, with 20 affiliated community-based outpatient clinics (CBOC\u0026rsquo;s). An estimated 8,500 dementia patients are cared for at TVHS. Many of these are rural hi-risk, hi-need patients in the TVHS catchment area.\u003c/p\u003e \u003cp\u003eIn 2011, TVHS developed a geriatric patient-centered medical home model, the geriatric patient-aligned care team (GeriPACT). \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e GeriPACT is a special population PACT within primary care for complex geriatric and other high-risk vulnerable veterans providing integrated, interdisciplinary assessment and longitudinal management, and coordination. The practice is supported by the Department of Veterans Affairs Computerized Patients Record System (CPRS), including the electronic patient portal, \u003cem\u003eMy\u003c/em\u003e health\u003cem\u003ee\u003c/em\u003evet, with telemedicine capabilities.\u003c/p\u003e \u003cp\u003eA geriatrician affiliated with GeriPACT, does the majority of the dementia consults separate from their primary care geriatrics patient panel care, working through the referring PCP in primary care practices and CBOC\u0026rsquo;s. Neurology sees few primary cognitive disorder patients unless also associated with TBI or movement disorders. Psychiatry sees mainly dementia with behavioral concerns.\u003c/p\u003e \u003cp\u003eInitially conceived as an in-person consultation and management service provided by GeriPACT, the dementia clinic transitioned to virtual care necessitated by the Covid 19 pandemic in 2020. Referrals from primary care providers were often triggered by dementia warning signs such as delirium with acute illness, wondering, self-neglect, need for appointment of a fiduciary, and caregiver concerns about behavioral manifestations and need for support services.\u003c/p\u003e \u003cp\u003eConsults were received electronically, responded to within 48 hours, and consisted of a thorough review of the electronic health record and provision of an individualized educational consultation to the primary care provider with specific diagnostic and management recommendations. Occasional (1%) telephone or video telehealth (veterans video connect VVC) calls with patients, or telephone contact with providers was provided as requested or when more information was required. (Table\u0026nbsp;1)\u003c/p\u003e \u003cp\u003ePrimary care providers were requested to perform on-site diagnostic testing when indicated (i.e. thyroid function tests, B12, neuroimaging) and mental status screening (SLUMS,\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e MMSE,\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e MOCA\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e) as appropriate.\u003c/p\u003e \u003cp\u003eIn conjunction with the dementia consult clinic, a caregiver support group was initiated, co-facilitated by the geriatrician and Caregiver Support Program social worker.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e A 4-class weekly curriculum focused on emotional support, caregiving skills and sharing of best practices, as well as generating clinical referrals and supplying equipment needs for veterans. Similar to the dementia clinic, the caregiver support group became entirely virtual in 2020. Caregivers were referred to the support group by primary care providers as well as nurses and social workers caring for PLWD in other settings.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEthical Approval and Consent to Participate:\u003c/strong\u003e \u003cp\u003e This study adhered to the Declaration of Helsinki. The Department of Veterans Affairs, Tennessee Valley Healthcare System (TVHS) Institutional Review Board (IRB) has determined this study as a quality improvement initiative and waived informed consent for participants.\u003c/p\u003e \u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eBetween 2018\u0026ndash;2024, 1176 consultations were provided during this period as the clinic transitioned from in-person to virtual consultation. The service performed a mean 14 consultations monthly with no change pre-and post-Covid. (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cb\u003eTable\u0026nbsp;1. Consultation Modality\u003c/b\u003e \u003c/p\u003e\n\u003cp\u003eN = 1176\u003c/p\u003e\n\u003cp\u003e1% telephone/VVC\u003c/p\u003e \u003cp\u003e1% f2f\u003c/p\u003e \u003cp\u003e5% repeat management questions from PCP\u003c/p\u003e \u003cp\u003e93% educational e-consult to primary care provider\u003c/p\u003e \n\u003cp\u003eEducational consultation responses with diagnostic information including functional assessment staging (FAST\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e) and specific management recommendations were provided to the referring clinicians including : 1) further diagnostic testing as individually indicated, 2) medication recommendations and deprescribing, 3) referral for formal neuropsychological testing when appropriate, 4) psychiatric referral for severe behavioral concerns, 5) individualized primary care management and goals of care, 6) safety considerations, 7) home and community-based services/social work involvement, and 8) caregiver support. (Table\u0026nbsp;2) Providers continue to send new consultations and request follow-up advice concerning previous consults, and family caregivers share contact information with each other during the group support sessions.\u003c/p\u003e \u003cp\u003e \u003cb\u003eTable\u0026nbsp;2. Consultation Recommendation Categories\u003c/b\u003e \u003c/p\u003e \u003cp\u003eDiagnostic testing\u003c/p\u003e \u003cp\u003eMedication recommendations and deprescribing\u003c/p\u003e \u003cp\u003eReferral for formal neuropsychological testing\u003c/p\u003e \u003cp\u003ePsychiatric referral for behavioral concerns\u003c/p\u003e \u003cp\u003ePrimary care management and goals of care\u003c/p\u003e \u003cp\u003eSafety considerations\u003c/p\u003e \u003cp\u003eHome and community-based services\u003c/p\u003e \u003cp\u003eCaregiver support\u003c/p\u003e \u003cp\u003eA total of 72 family caregivers participated in the 4-class support curriculum and lived an average of 45 miles from the Medical Center, saving 172 miles/6 hrs driving per caregiver for each 4- class curriculum. Caregivers were 95% women with an average age of 68. Many shared contact information with each other during the group support sessions.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eTelehealth consultation improves access, decreases no-show rates, serves to educate PCP\u0026rsquo;s\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e and can combine to enhance the caregiver experience of care.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e Anecdotal comments from patients and caregivers reflect acceptance of virtual care with enhanced access, efficiency, and effectiveness.\u003c/p\u003e \u003cp\u003eAlzheimer\u0026rsquo;s disease is increasingly viewed as a treatable condition maintenance like other chronic diseases including early diagnosis with biomarker confirmation and administration of disease modifying agents. Future developments in the diagnosis and treatment of Alzheimer's disease may help optimize diagnosis and treatment.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e However biomarkers appear to change over the course of dementia and in association with risk factors,\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e and evidence that effective interventions for Alzheimer\u0026rsquo;s with early identification of risk factors is low.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eEnhancements to the e-consult model for dementia care could include utilization of the Telephone-Montreal Cognitive Assessment (T-MoCA) and Telephone Interview for Cognitive Status (TICS), both of which could be performed remotely or by primary car, and which correlate well with emerging blood biomarkers. \u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e In addition, tailored caregiver assessment and referral (TCARE) is an evidence-based software used by federal, state, and private-funded agencies to identify caregivers at risk for burnout, connect them to the right services, and measure the impact of their programs. \u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e TCARE partners with Area Agencies on Aging and community partners to deliver its caregiver support platform to communities of caregivers.\u003c/p\u003e \u003cp\u003eThere remains a large need for screening strategies for appropriate candidates for new treatments, care navigation, and support services for caregivers and PLWD. For individuals receiving newer modalities of treatment including monoclonal antibodies directed at amyloid, there is also a great need for support services for caregivers as well as PLWD.\u003c/p\u003e\n\u003ch3\u003eLimitations\u003c/h3\u003e\n\u003cp\u003eThis model was developed in a VA care system and may not be applicable to all healthcare systems. Virtual dementia care may not appropriate for all patients such as those with severe behavioral disturbances and comorbidities including polytrauma, psychiatric disorders and PTSD. Additionally, some patient and caregiver concerns may not be able to be addressed by the PCP such as those for whom the goals of care includes consideration of anti-amyloid treatment. Finally, telehealth and virtual educational consultation for dementia care require a skilled consultant familiar with primary care and knowledgeable about VA and local home and community-based resources.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWhile we embrace future advancements in the diagnosis and treatment of dementia, there is a large unmet need for continued supportive care for PLWD, dementia care navigation, and caregiver support. Virtual primary dementia care is feasible, acceptable, and effective and may help to address this need. A virtual dementia system of care may facilitate PCP delivery of supportive care for PLWD, dementia care navigation, and caregiver support.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eORCHID ID\u003c/strong\u003e# 000000025305602x\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e: This submission and all statements are those of the author and do not necessarily reflect the opinions of the Department of Veterans Affairs\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication:\u0026nbsp;\u003c/strong\u003eNA - no personal identifiers are included in this manuscript\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of Conflict of Interest\u003c/strong\u003e: None. \u0026nbsp;As a federal employee, the author claims no copy right privileges.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Statement:\u003c/strong\u003e This study was partially funded by the Health Resources Services Administration (HRSA) Geriatric Workforce Enhancement Program (GWEP) 6 U1QHP53068-01-00\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval and Consent to Participate:\u0026nbsp;\u003c/strong\u003eThis study adhered to the Declaration of Helsinki.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eThe Department of Veterans Affairs, Tennessee Valley Healthcare System (TVHS) Institutional Review Board (IRB) has determined this study as a quality improvement initiative and waived informed consent for participants. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability:\u0026nbsp;\u003c/strong\u003eAll data included in this study are available by request from the author.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eDrabo EF, Barthold D, Joyce G, Ferido P, Chang Chui H, Zissimopoulos J. Longitudinal analysis of dementia diagnosis and specialty care among racially diverse Medicare beneficiaries. Alzheimers Dement. 2019 Nov;15(11):1402-1411. doi: 10.1016/j.jalz.2019.07.005. Epub 2019 Sep 4. PMID: 31494079; PMCID: PMC6874742. \u003c/li\u003e\n\u003cli\u003eAlzheimer\u0026apos;s disease facts and figures. Alzheimers Dement. 2021 Mar;17(3):327-406. doi: 10.1002/alz.12328. Epub 2021 Mar 23. PMID: 33756057. \u003c/li\u003e\n\u003cli\u003eLiang J, Aranda MP. The Use of Telehealth Among People Living With Dementia-Caregiver Dyads During the COVID-19 Pandemic: Scoping Review\u003cbr\u003eJ Med Internet Res 2023;25:e45045 doi: 10.2196/45045.\u003c/li\u003e\n\u003cli\u003ePalmer CS, Brown Levey SM, Kostiuk M, Zisner AR, Tolle LW, Richey RM, Callan S. Virtual Care for Behavioral Health Conditions. Prim Care. 2022 Dec;49(4):641-657. doi: 10.1016/j.pop.2022.04.008. Epub 2022 Oct 20. PMID: 36357068; PMCID: PMC9581698.\u003c/li\u003e\n\u003cli\u003eHaleem A, Javaid M, Singh RP, Suman R. Telemedicine for healthcare: Capabilities, features, barriers, and applications. Sens Int. 2021;2:100117. doi: 10.1016/j.sintl.2021.100117. Epub 2021 Jul 24. PMID: 34806053; PMCID: PMC8590973. \u003c/li\u003e\n\u003cli\u003eCallaghan T, McCord C, Washburn D, Goidel K, Schmit C, Nuzhath T, Spiegelman A, Scobee J. The Changing Nature of Telehealth Use by Primary Care Physicians in the United States. J Prim Care Community Health. 2022 Jan-Dec;13:21501319221110418. doi: 10.1177/21501319221110418. PMID: 35795898; PMCID: PMC9274427.\u003c/li\u003e\n\u003cli\u003ePowers JS, Moseley M, Abraham L, Azubike, N, Buckner, J, Xie C\u003cstrong\u003e.\u003c/strong\u003e Implementation of a Geriatric Patient-Centered Medical Home. OMB Geriatrics 2018, volume 2, issue 3 doi:10.21926/obm.geriatr.1803008.\u003c/li\u003e\n\u003cli\u003eTariq SH, Tumosa N, Chibnall JT, Perry MH 3rd, Morley JE. Comparison of the Saint Louis University mental status examination and the mini-mental state examination for detecting dementia and mild neurocognitive disorder--a pilot study. Am J Geriatr Psychiatry. 2006 Nov;14(11):900-10. doi: 10.1097/01.JGP.0000221510.33817.86. PMID: 17068312.\u003c/li\u003e\n\u003cli\u003eFolstein MF, Folstein SE, McHugh PR. Mini-mental state. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12:189\u0026ndash;98.\u003c/li\u003e\n\u003cli\u003eNasreddine ZS, Phillips NA, B\u0026eacute;dirian V, Charbonneau S, Whitehead V, Collin I, Cummings JL, Chertkow H. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc. 2005 Apr;53(4):695-9. doi: 10.1111/j.1532-5415.2005.53221.x. Erratum in: J Am Geriatr Soc. 2019 Sep;67(9):1991. doi: 10.1111/jgs.15925. PMID: 15817019.\u003c/li\u003e\n\u003cli\u003eVan Houtven CH, Smith VA, Lindquist JH, Chapman JG, Hendrix C, Hastings SN, Oddone EZ, King HA, Shepherd-Banigan M, Weinberger M. Family Caregiver Skills Training to Improve Experiences of Care: a Randomized Clinical Trial. J Gen Intern Med. 2019 Oct;34(10):2114-2122. doi: 10.1007/s11606-019-05209-x. Epub 2019 Aug 6. PMID: 31388914; PMCID: PMC6816649.\u003c/li\u003e\n\u003cli\u003eReisberg B. Functional assessment staging (FAST). Psychopharmacol Bull 24: 653-9, 1988\u003c/li\u003e\n\u003cli\u003eMackwood MB, Nagpal AS, Yuen J, Cancino RS. Virtual Access to Subspecialty Care. Prim Care. 2022 Dec;49(4):557-573. doi: 10.1016/j.pop.2022.05.001. Epub 2022 Oct 20. PMID: 36357061; PMCID: PMC9581700.\u003c/li\u003e\n\u003cli\u003ePalmqvist S, Tideman P, Mattsson-Carlgren N, et al. Blood Biomarkers to Detect Alzheimer Disease in Primary Care and Secondary Care. \u003cem\u003eJAMA.\u003c/em\u003e 2024;332(15):1245\u0026ndash;1257. Doi:10.1001/jama.2024.13855. \u003c/li\u003e\n\u003cli\u003eSalloway S, Rowe C, Burns JM. Are Blood Tests for Alzheimer Disease Ready for Prime Time? \u003cem\u003eJAMA.\u003c/em\u003e 2024;332(15):1240\u0026ndash;1241. doi:10.1001/jama.2024.12814.\u003c/li\u003e\n\u003cli\u003eLu Y, Pike JR, Chen J, et al. Changes in Alzheimer Disease Blood Biomarkers and Associations With Incident All-Cause Dementia. \u003cem\u003eJAMA.\u003c/em\u003e 2024;332(15):1258\u0026ndash;1269. Doi:10.1001/jama.2024.6619.\u003c/li\u003e\n\u003cli\u003ePlassman BL, Williams JW Jr, Burke JR, Holsinger T, Benjamin S. Systematic review: factors associated with risk for and possible prevention of cognitive decline in later life. Ann Intern Med. 2010 Aug 3;153(3):182-93. doi: 10.7326/0003-4819-153-3-201008030-00258. Epub 2010 Jun 14. PMID: 20547887.\u003c/li\u003e\n\u003cli\u003eChappelle SD, Gigliotti C, L\u0026eacute;ger GC, Peavy GM, Jacobs DM, Banks SJ, Little EA, Galasko D, Salmon DP. Comparison of the telephone-Montreal Cognitive Assessment (T-MoCA) and Telephone Interview for Cognitive Status (TICS) as screening tests for early Alzheimer\u0026apos;s disease. Alzheimers Dement. 2023 Oct;19(10):4599-4608. doi: 10.1002/alz.13039. Epub 2023 Mar 20. PMID: 36939111; PMCID: PMC10509307.\u003c/li\u003e\n\u003cli\u003eTailored caregiver assessment and referral. https://www.tcare.ai/customers/government-agencies (Accessed 11/17/24).\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Alzhiemer’s Disease, Dementia Care, Caregivers","lastPublishedDoi":"10.21203/rs.3.rs-6149663/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6149663/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDementia care remains supportive and geriatric resources are scarce. We describe a dementia system of care consisting of virtual and e-consults working through the primary care provider, as well as providing virtual group caregiver support. These models were developed based on patient and caregiver preferences and necessitated by the Covid public health emergency.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA geriatrician supported dementia consult clinic transitioned to a virtual model of care averaging 14 consults monthly. A centrally located caregiver support group providing a 4-week curriculum and delivered in conjunction with a social worker similarly transitioned to virtual support. Primary care providers generated consults and were provided educational consultations regarding dementia diagnoses and management in the primary care setting.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBetween 2018–2024, 1176 consultations were provided during this period as the clinic transitioned from in-person to virtual consultation. Recommendation categories included: 1) diagnostic testing, 2) medication recommendations and deprescribing, 3) referral for formal neuropsychological testing, 4) psychiatric referral for behavioral concerns, 5) primary care management and goals of care, 6) safety considerations, 7) home and community-based services, and 8) caregiver support. Providers continue to send new consultations and request follow-up advice on previous consults. A total of 72 family caregivers participated in the 4-class support curriculum and lived an average of 45 miles from the Medical Center, saving 172 miles/6 hrs driving per caregiver for each 4- class curriculum.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions/Impact\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eVirtual and e-consult dementia care working through the primary care provider, as well as virtual group caregiver support, are feasible, acceptable and sustainable models of dementia care to efficiently utilize scarce geriatrics resources serving a wide geographic area. A virtual dementia system of care may facilitate PCP delivery of supportive care for persons living with dementia, dementia care navigation, and caregiver support.\u003c/p\u003e","manuscriptTitle":"Implementation of a Virtual Dementia System of Care in a VA Health Setting","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-01 12:29:51","doi":"10.21203/rs.3.rs-6149663/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-04-30T10:25:15+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-23T19:45:49+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-21T18:51:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"331003311558676065336010681560485315101","date":"2025-04-13T18:41:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"208933295591326546761976092545273078854","date":"2025-04-08T16:47:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"275022652101165461082657861582704420720","date":"2025-04-08T13:39:38+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-05T21:31:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"221374539492464861798720094157403863743","date":"2025-04-01T03:25:01+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-03-31T14:36:07+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-03-31T14:13:16+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-03-31T00:15:48+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-24T16:12:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Geriatrics","date":"2025-03-24T16:10:54+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"534b1ebb-4fb5-4e97-a983-1ded8fcf96da","owner":[],"postedDate":"April 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-06-02T16:09:23+00:00","versionOfRecord":{"articleIdentity":"rs-6149663","link":"https://doi.org/10.1186/s12877-025-06034-0","journal":{"identity":"bmc-geriatrics","isVorOnly":false,"title":"BMC Geriatrics"},"publishedOn":"2025-05-28 15:57:51","publishedOnDateReadable":"May 28th, 2025"},"versionCreatedAt":"2025-04-01 12:29:51","video":"","vorDoi":"10.1186/s12877-025-06034-0","vorDoiUrl":"https://doi.org/10.1186/s12877-025-06034-0","workflowStages":[]},"version":"v1","identity":"rs-6149663","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6149663","identity":"rs-6149663","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}