Telemedicine Checklist May Smooth Visits With Older Patients

Jake Remaly

August 17, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

During the pandemic, physicians have raced to set up or expand telemedicine, uncovering both advantages and shortcomings. Now experts have developed a checklist of more than a dozen ideas to facilitate effective virtual visits with older adults.

Although many of the suggestions, published online in The Annals of Internal Medicine, are useful for all patients, Carrie Nieman, MD, MPH, and Esther S. Oh, MD, PhD, developed the list with older patients in mind.

"I have a number of patients into their 90s and with hearing loss, and we have had very successful video-based telemedicine visits," Nieman, with the Cochlear Center for Hearing and Public Health at Johns Hopkins Bloomberg School of Public Health in Baltimore, Maryland, said in an email. "Age should not be considered synonymous with inability or unwillingness to use technology."

Among their recommendations:

  • Assume some degree of hearing loss, which affects about two thirds of adults aged 70 years and older.

  • Ask patients to wear headphones or a headset or confirm that they are wearing their hearing aids and are in a quiet location.

  • Use a headset.

  • When possible, use video and have the camera focused on your face.

  • Use captioning when available and provide a written summary of key points and instructions.

  • Pay attention to cues, such as nodding along or looking to a loved one, that suggest a patient may not be following the conversation.

"If cognitive impairment is suspected, several screening tools can be used over the telephone to identify individuals who may need more comprehensive, in-person assessment," write Nieman and Oh, with the Division of Geriatric Medicine and Gerontology at Johns Hopkins University School of Medicine. For example, data suggest that a modified version of the Mini–Mental State Examination and the Delirium Symptom Interview could be useful tools. "A formal diagnosis of dementia is not recommended solely based on a telephone-based cognitive screening," however, Nieman and Oh say.

For patients with hearing loss, video visits avoid a current limitation of in-person visits: face masks that hinder patients' ability to read lips and other visual cues. "For many of us, we rely on these types of cues more than we think," Nieman said in an email interview.

"When you have doubts about whether you and your patient are on the same page, check in with the patient," Nieman said. "When appropriate, having a loved one or a care partner join an encounter, or at least a portion of the encounter, can be helpful to both the patient and the provider."

Many Older Patients Unprepared

Millions of older patients may not have been ready for the rapid shift to telemedicine brought on by COVID-19, a recent study in JAMA Internal Medicine suggests. Between 32% and 38% of older adults in the United States may not have been ready for video visits, largely because of inexperience with technology. Approximately 20% could have difficulty with telephone visits because of problems hearing or communicating or because of dementia.

Kenneth Lam, MD, of the Division of Geriatrics at the University of California, San Francisco (UCSF), and colleagues arrived at these estimates after analyzing data from more than 4500 participants in the National Health and Aging Trends Study that was conducted in 2018. The study is nationally representative of Medicare beneficiaries aged 65 years or older.

The aim of the study "was to call attention to what clinicians were already experiencing on the front lines," Lam said. In an email, he imagined two scenarios based on his colleagues' accounts of telemedicine visits.

In one case, a 72-year-old woman logs into Zoom Health on her iPad without any trouble. "She explains she just pushed on the URL and everything loaded up and you have a great visit," Lam said. "This is likely to be the case for over 50% of the older people you see; I share this picture to combat ageism, which is, truthfully, just inaccurate stereotyping of older people and gets in the way of actionable, data-driven policies.

"However, for around 1 in 3 older adults (and closer to 3 out of every 4 of those over the age of 85), you will book an appointment and they will say they don't have an email address or a computer or know how to go online," Lam said. "Or suppose they decide to try it out.... Come appointment time, you log on and they pick up, but now their sound doesn't work. They keep saying they can see you but they can't hear you.... They accidentally hang up. You place another call, and they ask if you can switch to a phone conversation instead."

By phone, the physician can address concerns about the patient's blood pressure, which the patient has been measuring daily. "But when it comes to looking at the swelling in their legs, you're out of luck, and you've been on this call for 45 minutes," Lam said.

Have a Backup Plan

Making sure patients are prepared and having a backup plan can help, said Kaitlin Willham, MD, an assistant professor of geriatrics at UCSF and the San Francisco VA Medical Center.

She says older patients fall into a wide range of categories in terms of skills and access to equipment. Knowing which category a patient falls into and having relevant support available to troubleshoot are important.

During the pandemic, Willham has conducted many more telemedicine visits with patients who are at their place of residence, whether a private home or a residential care facility. "Even outside of the current crisis, there are benefits to home video visits," Willham said. "A home video visit can provide a more holistic view of the patient than an office visit, allowing the clinician to see how the person lives, what they might be challenged by. It allows the clinician to identify areas of intervention, and if there is a care partner, involving that person in the plan. If the visit starts without major technical or communication barriers, they are generally very well received."

For patients with problems hearing for whom headphones or amplification devices are not available, "using a landline for the audio portion of the visit can help, as can having someone with the patient reiterate what was said," Willham suggested. "Many video platforms also enable the clinician to type messages or share a screen with a live document. These options can work well when there is very severe or complete lack of hearing."

Sometimes an in-person visit is the right way to go, even when technical hurdles can be overcome.

"Although many older adults are willing and able to learn to use telemedicine, an equitable health system should recognize that for some, such as those with dementia and social isolation, in-person visits are already difficult and telemedicine may be impossible," Lam and coauthors write. "For these patients, clinics and geriatric models of care such as home visits are essential."

Nieman, Oh, and one of Lam's coauthors have received funding from the National Institutes of Health. Oh also has received funding from the Roberts Family Fund. Nieman serves as a board member of the nonprofit organization Access HEARS and is on the board of trustees of the Hearing Loss Association of America.

Ann Intern Med. Published online August 11, 2020. Abstract

JAMA Intern Med. Published online August 3, 2020. Full text

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