Late last month, Apple announced CareKit, a new tool that gives anyone with an iPhone the power to take an active role in managing their own health. Apple now makes it easy for patients to keep up with care plans, track symptoms and medications, and share that information with a care team -- all from a mobile device.
The first apps available on Apple's CareKit and ResearchKit focus almost exclusively on chronic diseases such as diabetes, chronic obstructive pulmonary disease (COPD), and Parkinson's disease -- and for good reason. Diabetes represents a $245 billion health care cost annually in the U.S. alone, with the bulk of that figure driven by direct costs from poor management of the disease. The ability to predict which patients should be directed into different levels of care, such as supported management versus self-management, is critical to controlling cost and improving patient outcomes.
Can Apple's CareKit Do It All?
Today, digital technologies are tremendously useful in monitoring the daily changes and needs of certain health conditions. However, this also means that health care providers now need more tools to effectively engage patients, as buy-in to self-manage conditions outside the clinic has become critical to health outcomes. So far, most health care apps are focusing on gathering very traditional biometric data: glucose monitoring and medication compliance in diabetes, physical activity, heart rate, and sleep patterns in COPD. However, we must remember that the ability to self-manage any disease hinges on the ability to learn, understand, remember, and act. Critical to self-managing a disease -- and yes, using an app such as CareKit -- is cognition. Let's not forget about our brains, the control center that dictates whether we have the capacity to log our activities or complete the surveys found in Apple's CareKit.
So, why isn't cognitive screening included in CareKit? Simple: It is locked inside decades old analog processes that require a clinician and costs thousands of dollars for the most basic screen. Fortunately, new digital health care solutions are being created in order to solve this problem. Savonix, for example, is a mobile, evidence-based cognitive assessment that serves as a valuable companion to other metrics associated with chronic diseases like blood glucose for diabetes and blood pressure for hypertension.
The More Data, The Better
Why is cognitive data as critical in managing health as other metrics like blood glucose or blood pressure? First, we know that cognition plays a major role in being able to remember and complete daily tasks. In fact, a recent opinion piece posted by the National Institute of Health called for cognitive assessment and ongoing monitoring of cognition in a variety of chronic diseases such as COPD, heart disease and diabetes. Deficits in attention and mental flexibility predict non-adherence to taking a daily medication. These findings have been replicated across many clinical populations: patients taking once daily lipid-lowering medications, diabetic patients on multiple medications, and breast cancer patients on hormonal therapy (Stilley et al., 2010).
Let's look at one high-impact example, diabetes. Today, standard protocol provides that diabetes be largely self-managed through diet, exercise, and medications. However, cognitive changes throughout the diabetes course are common, particularly to verbal memory and psychomotor function (Kodl & Seaquest, 2008).
A review of 12 studies looking at the relationship between cognitive traits and diabetes self-management found that cognitive measures of executive function, memory, and low scores on tests of global cognitive functioning showed significant correlations with multiple areas of diabetes self-management. Patients with lower cognitive function demonstrated poor diabetes knowledge, insulin dose adjustment skills, and the ability to learn to perform insulin injections (Tomlin & Sinclair, 2016).
Even more alarmingly, cognitively impaired patients were less likely to manage low blood sugar events when sick (Hewitt et al., 2011). In comparison with cognitively healthy diabetics, patients with cognitive impairment were less likely to follow diet and exercise plans or be involved in diabetes self-care and monitoring (Feil et al., 2009; Sinclair et al., 2000).
Even subtle cognitive weaknesses show an effect. Patients that did not meet the criteria for cognitive impairment, but ranked lower for selective attention and executive function had lower rates of medication adherence (Rosen et al., 2003). Difficulties with memory are also associated with inaccurate blood glucose reporting (Kazlauskaite et al., 2009). Clearly, cognitive data can provide a powerful tool for predicting behaviors in many health conditions and can be used to build better models to improve outcomes.
Apple's CareKit will "enable people to actively manage their own medical conditions." Whether we are measuring a patient's ability to reliably self-medicate or detecting changes in emotions or cognitive decline - neuro-cognitive function is a critical facet of actively managing medical conditions. Quite simply, we can't understand, fix or even care for what we can't see. Apple, let's shine a light on neuro-cognitive function.
Mylea Charvat is CEO and Founder of Savonix. She completed her Ph.D. Fellowship in Clinical Neuroscience at Stanford School of Medicine and was an early employee at Preview Travel - now Travelocity.
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Co-Author Desiree Li is an MD candidate at Stanford School of Medicine and the Clinical Design Manager at Savonix. She works at the intersection of digital technologies, behavioral health, and chronic disease.
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