There has been a lot of attention surrounding a new study in Frontiers in Neurology validating that the Brain Care Score, or BCS, can help assess a person’s risk of developing dementia or stroke as they age.
But what happens next?
Dr. Alvaro Pascual-Leone, a practicing neurologist, chief physician and co-founder of Linus Health, and professor of neurology at Harvard Medical School, has a plan. It is a testing regimen in digital form that doctors can deliver to patients on iPads, with a digital clock test being a central component.
Linus Health’s digital cognitive assessment platform supports early detection and intervention in brain health. It can be used anywhere within a health care system as a screening tool – within the emergency department or in a PCP or neurologist office – to identify mild cognitive impairment early for earlier interventions and better outcomes, Pascual-Leone said.
We interviewed Pascual-Leone to find out more about this digital testing regime and what he hopes it will achieve.
Q. What was the problem you were trying to address when you came up with the iPad-based digital screening for mild cognitive impairment?
A. Brain-related disability is the leading cause of disability, more than cancer and cardiovascular disease combined. The disability caused by Alzheimer’s disease and other forms of dementia is the number one disability because it threatens to take away not only our mobility and vitality, but also the core of who we are.
But despite this reality, our status quo approach to brain health to prevent this devastating disability has been proven to fail because it tends to be highly reactive. As patients and caregivers, we typically wait until we are overwhelmed by symptoms or problems, or until our loved ones are overwhelmed, and it is too late to do anything meaningful.
When we seek help, it usually comes in the form of a referral to a specialist, of which there is a huge shortage. Even when a preventive approach is taken, whether due to a family history of dementia or general concerns, this is often done without evidence-based guidance tailored to our health profile and so is not as effective as it could be.
What Linus Health had in mind is to take a lesson from motorsport and implement the idea of the ‘pit stop’. It wasn’t until the 1960s that the Wood Brothers Racing team standardized the “pit stop” process to prevent malfunctions during races, even though the sport had been popular for decades.
Brain health needed a similar preventive approach, anticipating problems and receiving periodic assessments in a highly focused, targeted and actionable manner.
But like the modern pit stop, ultimately, brain health evaluation must be prompt and timely, with meaningful action taken when early signs of mild cognitive impairment (MCI) are detected. While an assessment alone could be useful, primary care physicians need much more data and tools to put patients and families on an effective and personalized care pathway.
We concluded early on that AI-based digital health technology was the best method to generate and analyze an abundance of such data in a short time.
Q. How does the digital screening for mild cognitive impairment work? How does this differ from the manual version?
A. The platform is based on the paper clock drawing test, where the provider asks the patient to draw a clock face on a piece of paper, including all the numbers and hands arranged at a specific time. Before our technology was developed, the evidence showed that the test was a reliable indicator of cognitive impairment.
Despite its simplicity, it involves many neurocognitive activities, which use our memory, planning, executive functions and visuospatial skills, all of which must come together to understand the instructions and complete the task.
However, the greater value of the test comes from the fact that a trained physician watches the patient perform the test, including the hesitations, doubts, and corrections we make, all of which are even more informative than the final drawing. This is known as the Boston Process Approach – assessing the way we solve a task, rather than simply evaluating the end product.
Yet recording and interpreting key moments from the drawing process requires expertise and time that most general practitioners do not have, while the waiting time for an appointment with a neuropsychologist, neurologist or other brain health specialist is usually many months.
Using an iPad and a digital pen, the technology can capture and interpret hundreds of measurements from the patient’s digital clock drawing in less than three minutes. This is much more meaningful information than could ever be gleaned from a paper test.
The technology can detect subtle signals such as variations in hand movements, pressure on the screen, placement of numbers, how the circle is drawn and other relevant findings. After the test, healthcare providers and patients receive a green, yellow or red score.
If cognitive impairment is identified, the technology provides an evidence-based action plan, including recommendations on next steps, which typically include personalized lifestyle interventions related to exercise, nutrition, cognitive skill-building activities, a hearing test, recommendations for further laboratory testing or brain research. imaging if indicated, etc. Depending on the findings, a referral to a specialist may be recommended, but this is not always necessary for all patients.
Q. What results have you seen so far where hospitals, healthcare systems and group practices use the iPad-based technology? What are the outcomes in the process and in patients?
A. The digital clock test builds on many decades of extensive experience with the paper-and-pencil version of the same task. Digital clock testing technology was developed and extensively studied at Lahey Hospital & Medical Center, affiliated with Tufts Medical School, and MIT.
The findings of the digital clock test have appeared in more than 20 peer-reviewed, scientific publications and new studies continue to be published every year. For example, start in 2024 an article published in Alzheimer’s Research and Therapyresearchers concluded that the digital clock test performed better than the Mini-Mental State Examination (a paper test) in detecting early signs of MCI.
In these studies, researchers and providers have found that although the tests are very brief and easy to implement in a rapid outpatient setting, they are extremely sensitive due to the abundance of data collected and analyzed.
Research has shown that the test is more sensitive than a standard battery of neurocognitive tests, which in some cases typically require much more time to administer, over many hours.
Additionally, providers have found that the technology can detect early signs of MCI with great precision and sensitivity in adults over 65 years of age, as well as in younger age groups from diverse racial and cultural backgrounds.
Due to its high sensitivity and short duration, it is a highly accepted diagnostic tool among physicians, who also realize that tests are easily repeatable to compare results over time. Because no significant training is required, medical assistants or technicians can oversee the test, while the physician can then easily review the results with the patient at the point of care.
The results are particularly attractive to healthcare providers as they provide them with a valuable tool in supporting an accurate diagnostic decision and providing a highly personalized prognosis and care plan.
Thanks to the fact that the Linus Health platform records multiple types of signals and metrics, for example the patient’s pressure on the pen, how they hold the pen, drawing consistency and pauses, the amount of pressure applied to the pen with the pen, tablet, the size, position and orientation of the different drawn elements, etc., it is then possible to apply machine learning and generate different algorithms to assess different aspects of brain health all in parallel, known as ‘a multiplex of insights’.
For example, in addition to determining whether a patient is cognitively impaired, the analytics technology can quantify the patient’s risk of progressing to deeper dementia and distinguish between different conditions, giving primary care physicians without specialized training or experience an incredibly powerful triage tool.
This insight can support a more informed referral to a neurologist or other specialist, so that more targeted and relevant research can be performed. The care process is then more efficient, which makes it possible to rule out whether the patient’s cognitive disorder is caused by, for example, a thyroid disorder, sleep apnea or a depressive disorder.
This saves time for healthcare providers, as well as patients who are so emotionally invested and motivated to find an accurate diagnosis and an effective care plan to slow the progression of their condition.
Q. What do you think the future looks like for digital health in the treatment of cognitive disorders?
a. A prevention-focused “pit stop model” I referred to earlier is where brain health management is headed. Preventive care has been the mantra for cardiovascular disease for decades. As a result, although heart disease is still the No. 1 killer, as healthcare providers we are much better at managing conditions such as hypertension, hyperlipidemia, heart failure, and others.
However, the same cannot be said for neurocognitive disorders, which remain far too reactive in their approach and tend to make pharmacological, behavioral and lifestyle interventions more difficult to implement and less effective.
Digital health technology will shift the management approach to dementia and brain health to a preventative care paradigm that empowers primary care physicians to take that lead. With accurate and highly personalized digital health tools, we can help patients and caregivers manage their condition, as well as earlier define their brain health goals to tailor interventions.
This is an important factor because patients’ reasons for slowing the progression of their condition will vary, as will the activities of daily living that they want to continue participating in and enjoying for as long as possible.
By approaching the condition from a personal and preventive attitude, we can deliver the interventions, guidance, coaching and treatments that enable patients to stay in their race for as long as possible and continue to enrich and enhance their lives and the lives of their loved ones. pursue the activities they find most satisfying.
Follow Bill’s HIT coverage on LinkedIn: Bill Siwicki
Email him: bsiwicki@himss.org
Healthcare IT News is a HIMSS Media publication.