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[1].Telemedicine can be effective at reducing avoidable hospitalizations and health deterioration due to the ability to see acute patient issues with less wait time[2] . 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[3].

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[4].

• 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[5]

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.