How to provide telehealth to older adults

Telehealth allows patients across the lifespan to receive care remotely in a manner that is often more accessible and convenient than in-person care. A common misconception is that older adults have either no interest in the use of technology or cannot use technology platforms. Current data indicate otherwise; in fact, most older adults (7 in 10) have and utilize a computer, smart phone, or tablet with internet access at home. However, when it comes to the use of telehealth, there is limited reach among older adults (e.g., only 11% feel comfortable using telehealth).

Beyond reimbursement limitations with health insurance, barriers to telehealth among older adults include provider misperceptions of interest, lack of telehealth training/orientation in older adults, and telehealth platforms that do not account for the needs of older adults.

Here are some factors to consider and strategies to implement when providing telehealth to older adults.

• Most older adults experience age-related changes in vision, hearing, touch, perception, mobility, and balance. Many of these declines begin at age 40.
• For older adults, there may be difficulties with light perception, sensitivity to glare, reduced acuity, and impaired focus on nearby objects.
• Discriminating between background noises becomes more difficult as we age, and low-level sounds are muffled. And for some, there is increased risk of developing Tinnitus, which can make certain sounds difficult to discern.
• There are also changes to muscle strength and tone that make muscles stiffer and less limber.

• Most older adults experience some cognitive changes as a part of the normal aging process, such as slowed speed of processing, difficulty in multitasking, and small declines in episodic memory, which generally do not interfere with everyday functioning. However, many cognitive abilities, including semantic memory, reasoning, problem solving, and executive functioning are preserved well into late life. The relatively minor cognitive changes that occur with aging should not prevent use of telehealth by older adults.
• Even adults who experience conditions such as mild cognitive impairment (MCI) can successfully learn new skills, especially if they use compensatory strategies like making notes or using reminders. This could include making reminders about telehealth appointment times in their calendar and using a series of written notes about how to start their computer or tablet and launch a telehealth application.
• There are some older adults whose cognitive impairments may be too advanced to use telehealth successfully (for instance, in severe dementia). However, some older adults with mild forms of dementia can use telehealth effectively with some modifications or adjustments. For instance, they may need a family member’s assistance to set up the telehealth account or to get the telehealth session started.

• Don’t assume older adults are uninterested in telehealth.
• Just as you do with all patients, meet older adults where they are and talk about the pros and cons of telehealth. Provide a clear explanation of what to expect and let them know that most people experience a few “bumps” adjusting to new technology but you’ve been able to successfully work with people with this modality.
• Providing technology support requires additional resources early in treatment but avoids delays on the day of the appointment, so plan to provide additional instruction and individual tech support. Though telehealth platforms may not be intuitive to older adults, many can successfully use them. Contact the older adult over the telephone prior to the appointment to provide verbal instructions, test the telehealth platform, and ensure the older adult understands and is comfortable with the technology. Support staff may be able to do this step. Additional benefits include increasing older adults’ access to care and promoting treatment continuity by overcoming barriers to in-person sessions.
• Prior to the appointment, provide older adults with written instructions for using telehealth (you may find this beneficial for all your patients). Instructions that use concise language, a larger font size, and include screen shots of each step of the process may be particularly helpful.
• Older adults using telehealth technology will benefit from visual presentation modifications (e.g., raise display/screen illumination, use matte surfaces instead of glossy surfaces).
• Auditory enhancements may also help the user experience (e.g., adjust volume settings, offer closed captioning options with enhanced text size, consider the use of headphone sets).
• You can provide these suggestions in the initial written information or discuss during the setting up session.
• When using a video platform, a neutral, not “busy” visual background for you will ensure the older adult with visual challenges is better able to focus on you and not other stimuli in the background. Similarly, reducing noise on the provider’s end reduces auditory interference for the patient. Be aware of noises such as HVAC, white noise generators, and other sounds and seek to minimize these with the position of your equipment and the use of headphones.
• To curb pain from muscle stiffness, ask your patient if they need movement accommodations for their sessions (e.g., allow time for stretching, invite older adults to use items that may be of comfort like heating pads, comfortable chairs, etc.).
• Providing an end-of-session summary of the goals, reading, and exercises to be completed between sessions can be advantageous for all clients but especially valuable for older adults.

• Directly acknowledge that telehealth sessions can feel awkward. Reassure older adults that most people feel increasingly comfortable over time.
• Attempt to look directly at the camera as much as possible to mimic eye contact.
• Use clarifying and reflective techniques to avoid miscommunication and misinterpretation of the older adult’s emotions. Clarify ambiguous body language verbally with the acknowledgement that telehealth can make communication more difficult (e.g., “I want to make sure I understand how you are feeling. Meeting over video can make that more difficult since I can’t see you completely. You seem to be frustrated—is that how you are feeling?”).

Implementing these strategies could increase the likelihood of older adults successfully engaging in and benefiting from telehealth.