Tracking The Tremor: Wearable Technologies in Parkinson’s
For 10 million people worldwide, 1 million of whom live in America, everyday tasks are extremely complicated because they live with Parkinson’s Disease (PD). People with PD experience a wide range of motor symptoms due to loss of nerve cells that produce dopamine, a molecule that is sent between neurons to control limb movements. Loss of dopaminergic neurons causes patients to slowly lose mobility and, in some patients, can also lead to cognitive impairments. Simple tasks like buttoning a shirt become a tedious ordeal and walking abnormalities make falls a constant concern.
While there are definite hallmarks of PD, the development and severity of symptoms varies greatly from patient to patient. This variability means that people can be misdiagnosed and/or placed on treatment regimens that may not be effective. To mitigate these discrepancies, wearable technologies have recently emerged in the world of Parkinson’s as a tool for improving care and quality of life for people living with PD.
SYMPTOM VARIABILITY LEADS TO CHALLENGES IN PARKINSON’S DIAGNOSIS AND TREATMENT
Diagnosing PD still comes with some level of ambiguity despite Parkinsonian symptoms first being described over 200 years ago. Because Parkinson’s symptoms are different in every patient and neurologists rely on visual symptom observation for diagnosis, patients are often required to visit their physician on multiple occasions to reach a definitive diagnosis. Following the diagnostic process, patients must continue visiting their doctor every 3-6 months to monitor symptom progression and adjust medication as needed.
Such a treatment regimen for PD has inherent limitations. Patients are asked to keep diaries to monitor symptoms in between doctor’s visits, which do not capture all symptom variations and can affect subsequent treatment plans. Additionally, continuous symptom monitoring means that patients require geographic accessibility to visit their healthcare provider so frequently.
Not only is the current diagnosis and treatment schematic time consuming, it is also quite expensive. The combined yearly costs associated with Parkinson’s care, a whopping $25 billion dollars per year, indicate a clear need to improve PD treatment. Wearable technologies have emerged in the past several years as a means to lower these costs by improving symptom monitoring and treatment.
IMPLEMENTING WEARABLE TECHNOLOGIES INTO PARKINSON’S CARE IS FEASIBLE
Much of the wearable technology that exists is aimed towards symptom logging. These devices take objective measurements so clinicians do not solely rely on intermittent observations made in the doctor’s office, or patient diaries to manage treatment. “It can be difficult for patients to keep diaries,” says Dr. Chad Christine, a neurologist at UCSF. “It requires individuals to record their motor states every 30 minutes for 3 days while awake.”
A symptom logging system has already seen success with the Fox Insight Wearable, a wristwatch with a companion smartphone app from Intel and the Michael J. Fox Foundation. The system tracks activity level, tremors, gait and nighttime activity. A recent pilot study using this device illustrated that it could efficiently monitor patient symptoms over a long period of time without disruption to their daily lives.
Another tracking device, the Personal Kinetigraph (PKG) wristwatch, monitors bradykinesia, and sleep, while also providing medication reminders. A study using the PKG showed that the watch identified treatable symptoms that were not being addressed in 85% of patients.
The PKG system is also very user friendly. “Patient reactions to the device are overwhelmingly positive,” says Dr. Malcolm Horne, one of the developers of the PKG system. “Patients appreciate that the device reminds them when to take their medication, which needs to be done multiple times a day at specific intervals. The PKG system also assists them in describing their symptoms to their clinicians.”
This second point is particularly salient because many PD patients develop cognitive impairments as the disease progresses, making it more difficult to mentally monitor symptom progression and severity. For this reason, and many others, the PKG system was also shown to improve overall quality of life as compared to patients without a watch.
The user-friendly nature of these devices is widespread. Kinesia 360, a combination of wrist and ankle sensors that measure tremor, dyskinesia and mobility, was widely viewed as both easy to set up and comfortable to wear.
All three of these systems have demonstrated that logging devices can effectively provide symptom information without interfering with patients’ daily lives. Therefore, the patient market would be amenable to incorporating these logging devices into PD care.
WEARABLE DEVICES USED FOR SYMPTOM TREATMENT ARE HIGHLY MARKETABLE
While logging devices are useful for symptom management, much of the benefit is gleaned via consultation with a doctor and direct feedback to the patient from the device is limited. Thus, several products in development are geared towards direct symptom treatment, the most exciting of which is the Emma Watch. This device was created by Haiyan Zhang at Microsoft as a simple wristwatch that causes a dramatic reduction in resting hand tremors.
Devices used for symptom treatment are obviously more lucrative than symptom logging devices. The absence of stored personal information eliminates security concerns and the patient is able to glean a direct benefit from the device without consulting their healthcare provider.
Clinicians and insurers would also benefit from these devices, as PD patients cannot develop tolerance to this type of treatment. Traditionally, patients are prescribed Levodopa, which remains the most effective treatment option for PD. Over time, however, 40% of patients develop tolerance and dyskinesia to the drug. For many patients, this leads to more expensive treatment options, as well as increased outpatient care.
For PD patients, these excess medical costs increase by 16.7% annually. Mitigating symptoms with non-tolerance inducing options could not only decrease costs associated with prescription drugs (~$2800 per year), but also decreases the number of times individuals have to consult their doctors to adjust treatment regimens. Additionally, mechanical treatment options would eliminate the side effects associated with PD medication such as vomiting, blurred vision and mood changes.
Symptom treatment devices have the potential to change the way Parkinson’s symptoms are mitigated that would be both more comfortable for the patient, and more cost effective.
WEARABLE DEVICES HAVE THE POTENTIAL TO REDUCE PARKINSON’S ASSOCIATED MEDICAL COSTS
Wearable devices have enormous potential for reducing costs associated with PD care. The average cost of Parkinson’s related medical expenses is ~$22,000 per patient, a more than two-fold increase compared to healthy individuals. As most patients develop tolerance to the limited number of Parkinson’s medications that are available over time, Parkinson’s related surgery is becoming more common and costs up to $100,000 per patient.
Because Parkinson’s is a chronic condition, there are significant costs associated with PD treatment over time. This combined with the fact that people with Parkinson’s are expected to double by 2030, and people over the age of 65 (the predominant age group at risk for development of PD) are increasing in the US, means treatment costs associated with PD will steadily increase over the next several years. Therefore, accurate monitoring of Parkinson’s is critical to keep costs associated with PD care low.
Strictly medical treatment (medications, surgery etc) for Parkinson’s is covered via Medicare for eligible patients. The diagnostic process, which is lengthy and varying, is only covered at 80% until the patient’s deductible is met. Wearables could have a significant impact on decreasing time to diagnosis and could ultimately help lower diagnostic costs by providing a quantitative metric to assess PD.
Medicare also covers some assistive technology used in the home. As medication management devices are included under this umbrella, it is possible that wearable devices may be covered in the future. According to Dr. Horne, “Wearable devices, like the PKG system, will provide significant savings to the overall health system by decreasing the costs associated with complications resulting from treatment regimens that are not fully optimized.”
Among PD patients who are privately insured, however, a large burden of the cost is placed on employers, and is comparable to costs associated with individuals who have pancreatic cancer. Among newly diagnosed patients this is approximately $7300 per year, but increases to about $26,000 per year in patients with advanced symptoms. In both early and late stage patients, prescription drugs make up approximately half of the cost burden.
Additionally, PD patients also cost their employers around $3300 in the year after diagnosis due to medically related absenteeism. Wearable devices, particularly those used for symptom treatment, could mitigate employer costs, by increasing the number of productive years an individual has after diagnosis. Technologies like the Emma Watch could be particularly beneficial for individuals with early onset Parkinson’s. Thus, symptom treatment devices would be lucrative not only for patients, but also for employers.
As PD wearable technologies are still in their infancy, they have not yet been embraced by the insurance industry, even though predictors indicate that technology-based objective measures will lower healthcare costs. Ultimately, 63% of the top insurance executives believe that wearable technologies will be widely incorporated into the insurance industry. In order for these devices to be reimbursed by insurers, however, technology developers have to clearly show that they enhance diagnostics, reduce costs and improve patients’ quality of life. As these technologies move past the clinical study phase, highlighting their ability to lower cost and improve quality of life will be key for successful incorporation into the insurance marketplace.
While it is ideal for patients to have insurance companies cover the cost of these devices, patients are likely to pay for these devices out of pocket. Most PD related wearables are still in development, so the exact market is unknown. However, families already spend approximately $10,000 on non-medical Parkinson’s care, suggesting a substantial market for technologies to improve PD patient quality of life.
Wearable technologies have the opportunity to decrease costs associated with PD care for not only patients, but also employers, by either decreasing the amount of time patients are placed on ineffective treatment regimens or directly treating particular symptoms.
THE BEST PATH FORWARD FOR WEARABLES IN PARKINSON’S CARE
If wearable technologies are to be widely adopted in the world of PD care, they must be poised to undergo rapid updates to keep up with evolving technological advancements, in addition to highlighting their ability to improve quality of life. For example, logging devices may consider combining with symptom treatment systems to ensure that user engagement with the device continues beyond initial interest, while still providing important symptom management information to clinicians.
Wearables also have the potential to mitigate the considerable unmet need in PD diagnosis and future technology developers may consider expanding into this space. Approximately 35% of people are improperly diagnosed. This is partly due to the fact that while 85% of people have idiopathic PD, the remaining 15% can fall into 7 subcategories. Many of these diseases exhibit PD like symptoms, but are distinct diseases that require different treatments. Using wearable devices to categorize patients into subcategories such as slow progression, fast progression etc., at the outset of diagnosis could be critical for decreasing cost waste associated with misdiagnosis. While these devices do not have the ability to categorize patients just yet, studies have shown that tremors are distinctive in typical and atypical Parkinsonism and can be observed in 70% of patients at early stages of disease.
Wearable technologies are still new to the field of PD care, but they have enormous potential to impact the lives of patients by helping them better manage and treat this chronic condition. While there are certainly barriers to overcome, wearables in general are becoming more commonplace in our every day lives. Why not utilize them to better manage tricky medical conditions?
Parkinson’s care is a particularly amenable market because the lack of definitive and long-term treatment options represents an important niche to fill. Wearable devices could be the precision medicine tactic that is critical for significantly improving the lives of the millions of people living with Parkinson’s disease.
By: Pallavi Penumetcha, B.S.
Biotech Connection Bay Area Science Communication Fellow
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