Introduction
The worldwide population over 60 is expected to increase by 2 billion between 2000 and 2050. Interestingly, people in some economically privileged countries, such as the United States and other high-income countries, do not have the same life expectancy as those in countries such as Norway. However, life expectancy does not equate with quality of life and it is important to realize that quality of life varies with age and may be better or worse for elderly people than younger people, depending on their place of residence. Moreover, the elderly in some low- and middle-income countries report a higher quality of life as compared with the elderly in wealthier countries.
The United Nations principles for the elderly include independence, participation, dignity, care, and fulfillment of personal expectations and ambitions. According to these principles the World Health Organization defines “active aging” as “the process of developing and maintaining the functional ability that enables well-being in older age.” Taking into consideration the variability of experience and capability in the elderly, a lifelong approach to healthy living is appropriate to preserve and defend the principles mentioned earlier.
In 1909 Ignatz Nascher proposed the term “geriatrics” for care of the elderly from the Greek words geras (Γῆρας), old age, and iatrikos (Ιατρικός), relating to the physician. He believed using the term geriatrics would help facilitate the same focus on the elderly as the word pediatrics provides to childhood. His goal was to emphasize the necessity of considering senility and its associated disorders apart from maturity and to assign it a separate place in medicine. Accordingly, geriatric rehabilitation is defined as a multidisciplinary set of evaluative, diagnostic, and therapeutic interventions whose purpose is to restore functional ability or enhance residual functional capacity in elderly people with disabling impairments. Elderly individuals with diseases such as stroke or traumatic fractures (e.g., hip fractures) and frail elderly with other primary diagnoses (e.g., chronic obstructive pulmonary disease [COPD], heart failure, and cancer) benefit from geriatric rehabilitation.
Importantly, a gradual or acute functional decline in the community may not always mandate hospitalization but may indicate a need for multidisciplinary rehabilitation. Rehabilitation can reverse functional deterioration due to organic disorders and improve quality of life for older people with or without disability; however, there are many challenges to maintenance of health for aging individuals. Chronic illnesses and disorders such as cardiovascular disease, frailty, osteoporosis, and bladder and bowel incontinence have a higher incidence in the elderly. There is a greater use of health care, medical, and community services, which increases expense. Most elderly individuals suffer from at least one chronic illness and a high percentage have comorbidities requiring regular support from physicians. Additionally, they also must develop their own systems for self-management, remaining healthy through the recognition and interpretation of their own bodily changes, determining how they respond to treatments and when to seek professional health care for new or worsening issues. Some elderly individuals are not able to self-manage, which leads to frequent hospitalizations. Thus it is important to find ways to ensure independence of the elderly and allow them to remain in their homes instead of being institutionalized or hospitalized.
Telerehabilitation in Geriatrics
We live in a knowledgeable society with vast sources of information and communication available in our world. Technology has advanced rapidly and includes many tools to improve the health of the elderly; however, the needs of the elderly in using technology are different than those of the young. Use of the internet in the elderly is associated with better maintenance of physical health, lower rates of mental illness, and higher integration and participation compared to non-use. Furthermore, elderly individuals may benefit from technologies designed for those with movement disorders, memory, hearing, or visual problems associated with aging.
Home monitoring systems can also allow health care professionals to monitor the elderly and recommend specific therapies. Telemonitoring is especially beneficial for patients with chronic diseases that require care coordination or who reside significant distances from their providers. The goal of telemonitoring is to identify and manage disorders, functional decline, and other key changes in medical status and to prevent the need for acute care services in the emergency department or hospital, or long-term care in a nursing facility. Physicians, nursing personnel, or therapists receive a collection of clinical data from the patient that are transmitted, processed, and managed by another health care provider through an interface system. Thus the patient has a constant, albeit indirect, connection to their own provider.
In addition to using telerehabilitation to monitor the vital signs of the elderly at home, it can be used to send and receive information via phone calls, short message service, media message service, internet, and so on, in remote areas (e.g., islands or for people who live hundreds of kilometers from a health care facility). Initial teleconsultations and follow-up appointments with specialists can also help the elderly, particularly in such areas as geriatric psychiatry and psychology, and are being used substantially in long-term care facilities. For the integration of comprehensive system-based telerehabilitation services for the elderly, administrative, clinical, technical, and ethical principles must be taken into consideration; services should include evaluation, assessment, monitoring, prevention, intervention, supervision, education, consultation, and coaching.
There are many ways that telerehabilitation can help the elderly. In addition to other purposes, telerehabilitation can be used for remote clinical assessment of the individual’s functional abilities in their environment and for clinical therapy. Telerehabilitation can help solve issues that impact elderly people with mobility disorders, lack of transportation to rehabilitation facilities and services, and a mismatch of provider availability with patient numbers. Telerehabilitation allows the provision of rehabilitation services to clients residing long distances from a rehabilitation center or a health center, overcoming a lack of trained clinicians in a specific region. This is especially important for remote, underserved populations and may improve health conditions and quality of life and prevent complications due to lack of care. Closer interaction of patients and caregivers and/or families with physicians and therapists and improved follow-up can also be facilitated. Mobility impairments lead to social isolation and telerehabilitation has been shown to help elderly, disabled persons who usually stay at home to engage with other persons via groups or therapy. The elderly are also prone to falling from balance disorders related to neurological diseases, such as stroke or vestibular problems causing dizziness with standing. Medications can also cause problems with orthostasis and dizziness and telerehabilitation has proved effective in preventing falls.
Telerehabilitation can be utilized to monitor individuals with disorders such as chronic pain, spinal stenosis, stroke, amputation, Parkinson’s disease, and dementia. Additionally, there is evidence about the beneficial use of telerehabilitation for pain reduction in chronic nonmalignant musculoskeletal pain, low back pain, lumbar stenosis, neck pain, and osteoarthritis.
Promising results for enhancing outcomes beyond those from face-to-face interventions in the natural environment include increased patient participation, providing care in the patient’s own environment, and increasing patient satisfaction. For some individuals, rehabilitation service delivery at home is at least as effective as delivery of this service in hospital, and in some cases adds contextual factors that enhance rehabilitation and outcomes. For example, due to shortened lengths of stay in acute inpatient rehabilitation, shifting care to a lower-cost health setting with the addition of videoconferencing is often possible. Videoconferencing has also been used in the elderly with chronic diseases to provide specialty care at home. Moreover, with expectations for the aging population and health care expenditures to grow in the future, telehealth may assist in solving the looming health care crisis by allowing for services at home, decreasing costs, and the need for travel and saving time.
Telerehabilitation can be used to improve quality of life and people’s overall ability for socialization. Aging, with or without a disability, can lead to social isolation at home. Interaction through telerehabilitation with a therapist may be challenging for those with severe disabilities; however, interactive e-communication may result in some patients feeling as if the therapist was in their room and thereby support the elderly individual. Group therapy has also been utilized to provide the elderly an opportunity to meet and interact while performing activities, thus allowing the participants to get to know each other and begin to develop friendships. Fig. 11.1 presents the group program “Online Fellowship” organized from Médecins du Monde Greece and supported by TIMA—Charitable Foundation (Vaduz, Liechtenstein). Through the “Online Fellowship,” isolated elderly people of the Greek population were joined in virtual teams to provide companionship and discussion groups. Group members perform simple activities, such as drinking coffee online at a specific time of day. The technology used is simple, suitable for the elderly, and it is hoped that this may be a permanent solution to assist this population. A web application for “Online Fellowship” was created and a tablet device was given to each participant to connect via video call. The team includes psychologists and nurses, as well as the specialized physicians of Médecins du Monde Greece staff. In addition to group video chat, each elderly individual may have one-on-one counseling sessions with the physician or psychologist. Of note, the application also provides the ability to listen to recorded books. Another benefit of telerehabilitation is providing support to the caregivers of the elderly, since being a caregiver is a physically and emotionally draining job and a virtual team of telerehabilitation specialists can decrease a caregiver’s sense of isolation and insecurity.
Telerehabilitation in the elderly has benefits in many clinical areas. Studies investigating the use of telerehabilitation for elderly people in various clinical areas were presented in a comprehensive review. In cardiology, telehealth may be successful in prevention programs to decrease cardiac risk factors, increasing exercise levels for heart failure patients and reducing anxiety levels after cardiac surgery. In neurology, telehealth has a positive effect on caregivers of persons with ischemic stroke in problem-solving skills and preparedness, mental health and social functioning. In breast cancer patients, improved physical activity and decreased fatigue have been reported and in urological conditions improved continence of post-prostatectomy patients and older women was documented, with results equivalent to those from face-to-face care. Physical and functional improvements have been documented in knee arthroplasty rehabilitation and an individualized intervention promoted greater physical activity versus a general training intervention in persons with fibromyalgia or rheumatoid arthritis.
Telerehabilitation studies on chronic pain reported a significant beneficial long-term effect on work capacity, considered an important outcome for individuals with complex, long-term problems. In COPD patients with a risk of hospital readmission, the use of telehealth resulted in fewer emergency admissions and primary care visits along with improvements in health-related quality of life. A case control study provided evidence suggesting that home telerehabilitation, linked to care coordination, could improve the functional and cognitive status of frail older individuals. Another review on telerehabilitation in community-based patients with various diseases found improved outcomes similar or better than traditional interventions. Reviews of telehealth studies in the elderly are summarized in Table 11.1 .
| Study, Country | N | Intervention | Type of Study | Findings |
|---|---|---|---|---|
| N/A | Telerehabilitation program for cardiac patients | Review of 37 studies | Feasible and effective additional and/or alternative form of rehabilitation vs. conventional in-hospital CR |
| 442 | Assessed the efficacy of telerehabilitation for patients after TKA compared with FTF rehabilitation | Metaanalysis of 4 RCTs | Improved WOMAC, extension range and quadriceps strength compared to FTF rehabilitation |
| 224 | To identify and summarize ADL telemonitoring, and review the effects of ADL telemonitoring systems on telecare of the elderly | Review of 25 studies | Most ADL telemonitoring studies reported benefits for care |
| 11324 | The effects of various telemanagement programs for patients with COPD | Review of 46 RCTs | Telemonitoring in COPD is difficult; other services received by patients (GP network, home care, access to hospital, social care) need to be considered |
| 933 | To determine whether the use of telerehabilitation leads to improved ability to perform activities of daily living amongst stroke survivors | Cochrane review of 10 trials | Evidence was insufficient to draw conclusions on the effects of the intervention on mobility, HRQoL, or participant satisfaction. No studies evaluated the cost-effectiveness of telerehabilitation |
Studies of telerehabilitation related to musculoskeletal concerns have demonstrated comparable outcomes and patient satisfaction with physical visits. Feasibility of measurement of pain, swelling, range of motion (ROM), muscle strength, balance, gait, and functional outcomes has been demonstrated with overall good concurrent validity. Interrater and intrarater reliability showed good to excellent levels for telerehabilitation for low back pain, ankle disorders, elbow disorders, total knee replacement, and nonarticular lower limb disorders. Effectiveness of telerehabilitation was documented in improving function after total knee replacement; moreover, there was good patient satisfaction. A recent metaanalysis assessed the efficacy of telerehabilitation for patients after total knee arthroplasty compared with face-to-face rehabilitation. In four randomized controlled trials involving 442 patients comparable pain relief, improvement in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and significantly higher extension ROM and quadriceps strength were noted and they recommended telerehabilitation for patients after total knee arthroplasty.
Telerehabilitation has also been studied for overall wellness in aging. A 24-week telerehabilitation program significantly decreased the risk of emergency hospital admissions and GP visits and improved quality of life in a cohort of 128 (64 intervention, 64 control) cognitively intact older persons who were independent in ambulation but had known risk factors for deconditioning and readmission. The care plan included: (1) an individually tailored exercise program of stretching and strengthening, balance training, and walking; (2) a nursing intervention to facilitate the exercise program and develop a transitional care plan emphasizing functional ability and need for assistance with activities of daily living (ADL); and (3) postdischarge follow-up consisting of nurse home visits, weekly phone calls for 1 month, followed by monthly follow-up for the next 5 months. Another case control study evaluated the extent to which 111 frail elderly men (primary diagnoses of hypertension, diabetes, respiratory disease, or heart disease) receiving home-telehealth technology had improved functional and cognitive outcomes compared to 115 similar age-matched controls, who did not receive home-telehealth. After 1 year, improvements in both instrumental activities of daily living (IADL) tasks (using the telephone, getting to a place out of walking distance, shopping for groceries or clothes, preparing meals, doing housework, taking medicine, and handling money) and ADL independence were found in the intervention group. Moreover, over the same time the home-telehealth group experienced significantly greater improvements in measures of cognitive status (cognitive subscale of the Functional Independence Measure); however, no significant effect in cognition (measured by Mini Mental State Examination) was found.
A systematic review of telerehabilitation interventions found that home-based telerehabilitation is promising in improving the health of stroke patients and in supporting caregivers. Health professionals and participants reported high levels of satisfaction and acceptance of telerehabilitation interventions. A metaanalysis revealed no significant differences between telerehabilitation and control groups in the Barthel index, Berg balance scale, Fugl-Meyer upper extremity scale, and stroke impact scale scores; however, more studies were necessary to evaluate health-related quality of life and cost-effectiveness. Similarly, a recent Cochrane review of telerehabilitation after stroke concluded that short-term posthospital discharge telerehabilitation programs have not documented reduced depressive symptoms, improved quality of life, or independence in ADL in comparison to usual care. No serious adverse events were related to telerehabilitation; however, this remains an area where more studies are needed.
Cardiac telerehabilitation (CR) appears feasible and effective in addition or alternatively to conventional in-hospital cardiac rehabilitation; however, studies of safety and cost-effectiveness are lacking. A program for veterans showed that a nurse-directed home telerehabilitation management program for veterans with chronic systolic heart failure resulted in a significant reduction in hospitalization rates, improvement in symptoms, and medication compliance, despite a high incidence of comorbidities.
Whilst few pulmonary rehabilitation programs are currently offering telerehabilitation, this is likely to grow as telehealth applications become increasingly accessible to patients and clinicians. In COPD patients, teleconsultations have been shown to be an effective means to assess patients’ disease prior to the initiation of pulmonary rehabilitation, and telehealth pulmonary rehabilitation has been shown to be as effective as institution-based pulmonary rehabilitation at improving functional exercise capacity and health-related quality of life.
Telemonitoring Studies
A rehabilitation plan may need adjustments during therapy and remote telemonitoring can provide information on selected physiological parameters. Telerehabilitation may be used for geriatric patients with neurological conditions such as stroke or spinal cord injury to monitor symptoms like pain and spasticity. Technology may be used diagnostically by monitoring elderly patients’ health parameters and vital signs in their homes. With home equipment, heart rate, ECG, blood pressure, pulse oxygenation, glucose, temperature, and other parameters can be monitored. Having the ability to monitor specific parameters supports diagnostic efforts and can facilitate rapid access to urgent consultation and triage. Identification of worsening heart failure in an elderly population produced a similar outcome to “usual” and decreased clinic and emergency room visits and unplanned rehospitalizations for heart failure. Another study examined the feasibility and acceptability of monitoring hypertension in the elderly by transmitting blood pressure and bodyweight data to a server that was monitored remotely by nurses. Around 92% of participants indicated improvements in their health due to the system and providers noted ease in monitoring health and preventing hospital readmissions. Studies have also found improvements in glycemic control, increased awareness of diabetes mellitus, and improved quality of life in persons with diabetes. A feedback system for patients with type 2 diabetes initiating insulin therapy is also useful. Patients self-monitor their blood glucose levels, transmit their readings by telephone or internet, and the provider evaluates results and recommends dose titration via telephone or internet.
In contrast, Bashshur et al. reported that the use of telemonitoring is superior to office visits in terms of emergency visits, hospitalizations, complications, and quality of life for diabetes, hypertension, pain, congestive heart failure, cancer care, rehabilitation after stroke, and dementia. They documented better results compared with office visits in all the aforementioned chronic diseases, emergency situations, and hospitalizations, providing key findings regarding the effects of telemonitoring in cardiac heart failure (CHF), stroke, and COPD. Data strongly support that telemonitoring of patients with CHF is likely to reduce mortality and morbidity and is cost-effective for these chronic illnesses. Importantly, this review was used by US Congressional Committees in policy decisions and telemonitoring is a covered service in the US Medicare program.
Technical improvements have been documented in methods for detecting changes in ADL; however, few clinical benefits have been documented through these systems.
Telerehabilitation can be used to provide seniors in long-term facilities or hospice programs access to rehabilitation specialists and palliative care providers without leaving their home or a facility. Remote health monitoring and management seems exceptionally promising for individuals with terminal illness because follow-up of patients with chronic conditions is often difficult. In summary, telerehabilitation can facilitate follow-up for elderly persons in many different scenarios by eliminating a need for travel.
Performing a Geriatric Telerehabilitation Visit
Performance of a telerehabilitation visit involves unique preparation when working with the elderly. Clinicians performing virtual visits must be aware of the difficulties older adults may have using technology. The elderly are a heterogenic group and visual and auditory impairments, anxiety, lack of privacy, lack of dexterity, and cognitive issues may impede the patient’s use of telehealth devices. Thus the potential for the use of telerehabilitation must be individually assessed. Having knowledge of the patient’s health condition, capabilities, and history is important in virtual visits. Additionally, the presence of a family person or carer to help in case of technical problems or difficulties is also important for persons with severe disabilities.
Informed consent should be taken prior to a telehealth visit and an emergency phone number should be available. Patients must be educated to choose a comfortable, quiet place for their visit. It may be beneficial to take vital signs—temperature, heart rate, blood pressure, weight, and blood sugar—using home equipment. It is helpful to have patients write their questions prior to visits and keep their medication available and it may be appropriate to ask for a log of the patient’s vitals or pain levels. Visits may be private or grouped. Group sessions for therapy purposes can be beneficial to maximize the use of highly skilled resources. At the end of the visit, it is especially important to have elderly patients repeat instructions and confirm that they are properly informed about the need for laboratory studies or for a follow-up visit.
Each patient and provider must overcome any personal hesitation to embrace telerehabilitation, concerns about security, user friendliness, and the possible need for specialized training. Barriers to the use of telehealth can include font size and difficulty in reading, the need to use devices with widgets and mice, and difficulties in using and handling smartphones. Moreover, cultural and religious issues may be a barrier. The elderly can have delayed responses, and a lack of immediate feedback and technical problems may lead to frustration and reduce motivation ( Table 11.2 ).
