Telemedicine and Geriatric Care - #99Take Quiz
Older adults may have fewer options for transportation to medical appointments. Telemedicine (telephone or audio-visual communication) can improve patient health, lower healthcare costs, reduce wait times, reach a broader geographic region, and limit unnecessary exposures of patients to infection.
In 2010, the baby boomer generation started turning 65. This generation has more experience using technology. Many own smart phones, tablets and at least for part of their adult life have been exposed to the internet. As the adult population ages, we anticipate a growing comfort level with technology and telemedicine.
Benefits of Telemedicine:
In certain situations (older adults with diabetes, hypertension, pain, congestive heart failure, cancer care, stroke rehabilitation, or dementia), telemedicine may reduce emergency visits, hospitalizations, and medical complications while improving quality of life when compared to office visits.Telemedicine can be effective at reducing avoidable hospitalizations and health deterioration due to the ability to see acute patient issues with less wait time . It can also be useful for geriatric consults resulting in more screening, new diagnoses of dementia, medication changes and quicker follow up. All while being less costly than in person clinic visits.
Physical Examination via Telemedicine:
A physical exam can be performed via telephone or video visits pending the patient’s ability to cooperate and caregiver support if needed. For full review please see: Uptake of Virtual Visits in A Geriatric Primary Care Clinic During the COVID‐19 Pandemic.
- Vital signs/blood sugar: reported per home monitoring equipment
- General: alert or lethargic, cooperative, talkative, distress
- HEENT: hearing ability, voice quality, corrective devices, oral hygiene, dentition
- Respiratory: cough or audible wheezing, oxygen use, respiratory effort
- Cardiovascular: presence of edema
- Abdominal: distension, obesity
- Musculoskeletal: contractures, active range of motion, ambulate if safe to do so
- Neurological: orientation, cognitive testing, eye movements, presence of tremor, language fluency
- Psychiatric: attention, insight, judgement, mood, appearance
Cognitive and Psychological Examination via Telemedicine:
- Careful attention to the patient’s conversation and speech during the history taking portion of the visit provides information about memory, judgement, executive functioning, reasoning, and other cognitive domains.
- Screening tests may be used as well and include:
- Mini-Cog Assessment (3 item recall, plus clock draw test)
- Montreal Cognitive Assessment (MoCA) abbreviated telephone or audio-visual versions (https://www.mocatest.org)
- 2 item Depression Screen (“Do you feel depressed”, “Have you lost interest in doing things”)
- Geriatric Depression screen-short form (15 item)
Limitations of Telemedicine
- Disruption of established clinical routines, workflows, and changes in the patient-provider relationship
- Cognitive impairment
- Adjustments to consider: May require family or caregiver involvement
- Hearing impairment
- Adjustments to consider: Patients wear headphones, write notes in chat box, send written summary of visit
- Physical exam findings have not been validated for reliability
- Varying internet accessibility
- Uncertain reimbursement pre and post COVID-19 Pandemic
- COVID pandemic Wavier 1135 expanded Medicare telehealth services to pay for broader circumstances which has now ended. Previously only covered in limited capacity.
Impact on Practice
While the traditional clinic model does not easily reconfigure to telemedicine, the use of dedicated staff and protocols can enable a smoother transition. As the population ages and people continue to live in wide geographic locations, telemedicine is likely inevitable and here to stay. Telemedicine should be considered a powerful tool in our current and future practice.
Older adults and providers in outpatient settings.
Increase provider comfort in use of virtual visit technology in patient care visits. Improve the physical exam and cognitive assessment during telemedicine visits.
Telemedicine was given its name by Kenneth Bird in 1975 and the American Telemedicine Association was established in 1994.
By the year 2030, 55% of the US population is expected to be >65 years old while the geriatric trained work force is decreasing. Geriatricians will need to consider additional ways to take care of older adults. This fast fact aims to educate health care providers on ways to use telemedicine in care of older adults.
- Identify opportunities for care provided via telemedicine.
- List physical exam findings to note during a telemedicine visit.
- List cognitive and depression screens available during a telemedicine visit.
Review of Systems (ROS)
 Merrell, Ronald C. “Geriatric Telemedicine: Background and Evidence for Telemedicine as a Way to Address the Challenges of Geriatrics.” Healthcare informatics research vol. 21,4 (2015): 223-9. doi:10.4258/hir.2015.21.4.223
2 Lillicrap L, Hunter C, Goldswain P. Improving geriatric care and reducing hospitalisations in regional and remote areas: The benefits of telehealth. Journal of Telemedicine and Telecare. October 2019. doi:10.1177/1357633X19881588
3 Betkus G, Freeman S, Martin-Khan M, et al. Comparison of in-person and telegeriatric follow-up consultations. Journal of Telemedicine and Telecare. October 2020. doi:10.1177/1357633X20965416
4 Dewar, Shenbagam et al. “Uptake of Virtual Visits in A Geriatric Primary Care Clinic During the COVID-19 Pandemic.” Journal of the American Geriatrics Society vol. 68,7 (2020): 1392-1394. doi:10.1111/jgs.16534
6 Merrell, Ronald C. “Geriatric Telemedicine: Background and Evidence for Telemedicine as a Way to Address the Challenges of Geriatrics.” Healthcare informatics research vol. 21,4 (2015): 223-9. doi:10.4258/hir.2015.21.4.223
7 Lester, P. E., Dharmarajan, T. S., & Weinstein, E. (2020). The looming geriatrician shortage: Ramifications and solutions. Journal of aging and health, 32(9), 1052-1062.89 Merrell, Ronald C. “Geriatric Telemedicine: Background and Evidence for Telemedicine as a Way to Address the Challenges of Geriatrics.” Healthcare informatics research vol. 21,4 (2015): 223-9. doi:10.4258/hir.2015.21.4.223