In this disabled post-hospital discharge cohort of older adults with physical therapy goals, a VVC-based assessment and enrollment for a mobility/physical activity intervention program was feasible.
Need for VVC data in older adults: comorbidities, cognitive impairment, and caregiver participation.
In recent surveys, only 1/3 of VA Telehealth tablet users were over age 65, and comorbid Veterans, i.e. those with ≥7 chronic conditions, were less likely to use their tablets (14). Recently, of 118 older Veterans (mean age 73) appointed to outpatient visits during COVID-19, 63 (53%) were willing and able to participate in a VVC appointment; of note, 30 (26%) had cognitive impairment or dementia (15). Of the 35 VVC appointments scheduled, 27/35 (77%) were successfully completed but 13 of these 27 (48%) received support from a caregiver.
Telehealth for exercise and rehabilitation
Use of telehealth for exercise in specific diseases (such as cancer) is well-accepted and has been adapted to a number of modalities, including web-based, mobile applications, text messaging, and telephone interventions (16). Video telehealth rehabilitation services, particularly physical therapy, are growing, although there are few studies that include older adults over age 80 (17). These programs may also include other interventions beyond exercise that may help to improve rehabilitation outcomes. For example, video-based telehealth pulmonary rehabilitation for COPD reduced 30-day rehospitalization and included educational content in addition to the exercise instruction (18). Interventions which lead to increased physical activity and reduced sedentary behavior use many of these same telehealth modalities, but tend to exclude older adults of more advanced age (e.g. >70 years), multiple comorbidities (versus single diseases such as diabetes mellitus), and those with cognitive impairment and/or who require caregiver support (6).
Videoconference connectivity issues
Over 2/3 of the participants used VA-supplied tablets. Yet, connectivity/communication concerns were nevertheless common. These concerns were identified as reasons for some Veterans declining participation or disenrolling early. While half of the Veterans were fully successful in VVC (n = 23), 1/3 of these (n = 8) and an additional group with at least one failed connection (n = 11) requested in-person visits for assistance. One-quarter (n = 11) had no VVC success and sought help for tablet troubleshooting, and half of these (n = 6) eventually “gave up” trying to connect; computer literacy issues and physical impairment (particularly dexterity) were described prominently in this group. On the other hand, Veterans with at least mild cognitive impairment (based on MoCA scores) were present in all connectivity groups and most of these used caregiver support to facilitate VVC. From these data we conclude that a substantial proportion of these post-discharge older Veterans need technical support, to include in-person support for many. Yet, VVC seems feasible in those with mild or clinically significant cognitive impairment, assuming the presence of a caregiver. In fact, most of those more recently recruited (1/3 of the entire sample) did not have a caregiver to assist. Some Veterans may refuse to engage in VVC or not ever succeed, even with caregiver support; some caregivers might have also been impaired or lack computer literacy and thus not be able to assist the participant with VVC. Because of the focus on VVC, essentially none of the participants or caregivers used any of the more recent personalized telehealth applications, such as MyHealtheVet, to communicate with the team. This is consistent with our concern, citing nationally representative data in those 65 and older, that use of technology such as email, text messaging or internet is decreased in those with limitations in physical capacity and greater disability, particularly those with vision impairment and memory limitations (19). Given that these data reflect use from 2017-early 2020, we acknowledge that ease of use of VVC (as well as My HealtheVet) has and continues to advance greatly and that future studies of this impaired cohort may find greater engagement and success in using VVC and other telehealth modalities.
Modifications for VVC assessment
VVC modifications for MoCA: Instead of choosing a more limited MoCA tool (such as the “blind” MoCA), we chose to develop practical, VVC-compatible modifications, such as for the visuospatial/executive portion. The result was that over half of the concurrent, non-medical record MoCA tests (18/32) were done via videoconference. Note that videoconference MoCA administration with analogous modifications has been piloted in patients with mild-severe Alzheimer disease and found to be feasible and reliable in the presence of a caregiver (20); in the present study, most participants with mild cognitive impairment, and essentially all participants with clinically significant cognitive impairment had caregiver assistance for MoCA assessment. In terms of the effect of VVC modifications on test outcome, only one participant whose MoCA was conducted via VVC lost more than 1 point (scoring a 1 out of 5) on the visuospatial/executive function component. Nevertheless, home-based “real-world” VVC MoCA administration still needs to be compared further to standard MoCA administration, and may eventually be considered in future required MoCA training and certification.
VVC modifications for SPPB: Due to the lack of guidelines to quantitatively assess mobility using a videoconference interface, the SPPB was adapted, particularly in regards to gait speed determination. Mobility testing via videoconference (including VVC) has become common, although to our knowledge, there are few comparisons of face to face versus “real world” home VVC. Video conference based assessments of components of the SPPB, such as the chair rise test, are already being adopted (21). A key issue is how to handle timed performance, which, assuming a stable WiFi connection with sufficient bandwidth, should be possible, but might require additional cues in the event of a time delay for start and stop times. Note however that the SPPB data from this post-hospital VVC cohort is remarkably similar to a cohort identified to undergo rehabilitation for mobility and physical activity, both inpatient and outpatient via telehealth devices, and whose SPPB was evaluated in person (22). Note also that participants were enrolling in an intervention, thus serving as their own control, and VVC assessment modifications were planned to be continued throughout the 6 month follow-up.
Extent of cohort impairment
As expected, this post-hospital discharge cohort of older adults with rehabilitation needs had evidence of ADL disability and mobility impairments. Mobility (SPPB) performance (the chair rise scores in particular) and the number of steps per day were in the markedly low/impaired range, while the percent time spent in sedentary activity was high. These results are similar to those in rehabilitation patients provided with telehealth modalities post-hospital discharge (22).
In terms of other assessments at baseline, consistent with a medically complex cohort was the high number of medications, and despite the help of a caregiver in at about ½ of the participants, medication discrepancies and inappropriate medications were still found. Not surprisingly, the social complexity was equally high with the need for complex social work interventions.
A major strength is the targeting of an older, recently hospitalized, disabled cohort with rehabilitation needs, and who might benefit from a videoconference-based intervention. The inclusion of cognitively impaired individuals, using a caregiver support model, is also important to consider. Integrating this important cohort with disability and rehabilitation potential with a videoconference assessment and intervention seems critical to larger uptake of the VVC model.
A few features of this pilot study changed over time, including the requirement of a caregiver and the amount of in-person assessment utilized. With careful instruction, the actigraphy placement was eventually completed remotely and still provided valid data. Given the relative novelty of the program and our relative inexperience with videoconference versions of parts of the assessment, these changes were probably inevitable. These have been carefully documented and noted above and thought not to result in a systematic bias of the results.
Delay in enrollment, assessment, and rehabilitation
Completion of enrollment and consent was delayed, completed usually 1–3 weeks post-charge. Baseline assessments were completed within 1–2 weeks of completed enrollment. While the protocol was initially designed to recruit participants prior to discharge, discharge plan variability, inconsistent contact with the inpatient, and patient preference to return home prior to consent required other recruitment approaches. These approaches included a telephone call, meeting at a follow-up outpatient appointment, or an introduction letter with team member phone follow-up. These might be expected in this functionally impaired, medically and socially complex cohort. An effect of the delay of functional outcomes at baseline is unlikely given there may also have been a delay in the participant receiving outpatient or home-based therapy.