key: cord-265830-6shiocwr
authors: Frost, Rachael; Nimmons, Danielle; Davies, Nathan
title: Using remote interventions in promoting the health of frail older persons following the COVID-19 lockdown: challenges and solutions
date: 2020-05-25
journal: J Am Med Dir Assoc
DOI: 10.1016/j.jamda.2020.05.038
sha: 
doc_id: 265830
cord_uid: 6shiocwr

In light of the Covid-19 pandemic, many older people across the world are being asked to self-isolate to protect their health. This has led to a rapid reconfiguration of health promotion services, which are diverse in focus, and may include exercise, dietary interventions or psychosocial interventions, towards remote delivery, for example by phone or using computers. Whilst currently they are unable to be safely delivered any other way, there are concerns that these remote interventions may replace face-to-face interventions beyond the end of social restrictions. We advocate caution with taking this forward, particularly for frailer older people.

2 In light of the Covid-19 pandemic, many older people across the world are being asked to self-isolate 3 to protect their health. This has led to a rapid reconfiguration of health promotion services, which 4 are diverse in focus, and may include exercise, dietary interventions or psychosocial interventions, 5 towards remote delivery, for example by phone or using computers. Whilst currently they are 6 unable to be safely delivered any other way, there are concerns that these remote interventions 7 may replace face-to-face interventions beyond the end of social restrictions. We advocate caution 8 with taking this forward, particularly for frailer older people. 9

Evidence of effectiveness for remote interventions for frail older people is promising, but very 10 limited at present. Small randomised controlled trials have shown positive impacts upon quality of 11 life from video exercises with weekly phone calls, 1 improved mental functioning from computer-12 based home exercises, 2 improved balance from home exercise with phone calls 3 and reduced 13 depression from problem solving therapy delivered by videoconferencing. 4 Similarly, for 14 malnourished older people, phone-based nutrition interventions with dieticians improved protein 15 intake and quality of life but not other outcomes in one systematic review of nine studies. 5 However, 16 despite an increase in research on this topic over the last five years, these interventions are rarely 17 compared to face-to-face delivery and small sample sizes often limits the power and generalisability 18 of these studies. Most also included a face-to-face session with a healthcare professional to assess 19 and plan treatment beforehand, 1,3,5 an orientation meeting to ensure the technology works 2 or 20 both. 4 21 Use of remote interventions therefore needs to facilitate rather than replace contacts with 22 healthcare professionals. Phone-based support may be particularly applicable to a population with 23 less internet and computer access, and may improve adherence to independent exercise therapies also showed comparable effects to face-to-face delivery with similar numbers of people 26 completing sessions (49/56 vs 54/63). 4 One systematic review found that mobile health technologies 27 for older people are more acceptable when they facilitate communication with a healthcare provider 28 rather than disrupt it, 7 and a cohort study found that frail older people using teleassistance at home 29 who took up additional specialist telecounselling were almost twice as likely to complete the study 30

after one year (94% vs 44%%). 8 31

There are also known access issues. A recent population-based Finnish study suggested that frail 32 older people are less likely than robust older people to have an internet connection (46% vs 79%), to 33 have used the internet in the last 3 months (34% vs 72%) and have used a computer in the last 12 34 months (30% vs 70%). 9 They also found that frail older people are more likely to hold negative 35 opinions about the usefulness and usability of mobile ICT. This risks a large proportion of the 36 population being excluded. Whilst there is clear evidence of high acceptability scores for remote 37 interventions in those who complete studies, 2,4,6 these can also suffer from high dropout rates, 38 particularly when unsupervised, 3,6 are evaluated mainly for short term interventions and typically 39 lack generalisability to wider populations. 40

Services wishing to use remote delivery must therefore ensure the necessary technology is provided 41 to overcome access barriers, and that its use is supported. Studies have indicated that it is possible 42 to provide equipment such as tablets, laptops or devices connected to the TV, 4,5,10 however studies 43 also frequently report technical failures even in pilot studies, which can be associated with 44 dropouts. 6 Technical support was frequently utilised in feasibility studies, indicating that providing 45 this is an important part of remote intervention delivery. 46

In conclusion, whilst these interventions are potentially effective and received positively by some frail older people, those evaluating or providing services should ensure that digitally underserved 48 older people are not left behind through facilitating contact with healthcare professionals and 49 providing both the technology and technical support needed for interventions to be successful. 50

The authors state that there are no conflicts of interest. 53

Home-based video exercise intervention for 56 community-dwelling frail older women: A randomized controlled trial

User experience, 59 actual use, and effectiveness of an information communication technology-supported home 60 exercise program for pre-frail older adults

Telephone calls make a difference in home balance training 62 outcomes: A randomized trial

Six-month postintervention 64 depression and disability outcomes of in-home telehealth problem-solving therapy for 65 depressed, low-income homebound older adults

Teleassistance 75 for frail elderly people: A usability and customer satisfaction study

Information and Communication Technologies Among Older People With and Without Frailty: 79 A Population-Based Survey

Fit4SurgeryTV At-home Prehabilitation for Frail Older Patients Planned for Colorectal Cancer 82 Surgery: A Pilot Study