Abstract
The human population of the planet is aging. In 2010 about 8% of the population, or 524 million, was over the age of 65 years, but by 2050 that number may be tripled to 1.5 billion, or 16% of the population. The population ages because of longevity promoted by sharp reduction in mortality early in life, dramatic reduction in infectious disease mortality, and steady improvement in diagnosis and management of cancer, cardiovascular disease, and chronic disease. The phenomenon is not restricted to the developed world. In fact, the shift is more marked in the less developed world, which may expect an increase of 25% in the elderly population between 2010 and 2050. Let us celebrate!! Right? Well, there are problems. Although the aging population is huge, all is not well. Among older people 92% have at least one chronic disease, and 77% have at least two. Despite great improvements in morbidity for chronic disease, we are left with the great enemy of function: dementia. There is no cure for dementia, and our understanding of this great thief of intellect and vitality has a prevalence of 3% at 65 years of age and rising to 30% at 85 years of age. People of that latter age and beyond constitute the most rapid increase in the demographic. 1
So not only are the elderly numerous, but they are often sick and tend to get demented, with no cure in sight. The cost of healthcare for the elderly is quite a bit higher than for younger people, with higher rates of medical encounters, medication, hospitalization, and the need for chronic care. Because the United States is facing a healthcare cost over 17% of the Gross Domestic Product, any anticipated increase in healthcare costs is untenable. In fact, we lack the human resources in medicine to even remotely meet the need for the elderly. There is a brave organization of specialists who struggle with the problems of health in the elderly. They are the geriatricians. Their numbers are small, with only 6,000 members of the American Geriatric Society, and the specialty fellowship from the American Board of Medical Specialties within Internal Medicine attracted fewer than 300 Fellows last year.
Clearly the great disease burden of the elderly is chronic disease. The review of evidence for telemedicine in chronic disease was amply presented by Bashshur et al. 2 Success for telemedicine was specifically presented by the Rochester group. 3 There is no better tool or practical approach to the huge increases in demand for services among the elderly than telemedicine. Enhanced efficiency in access and the great power of longitudinal care are making telemedicine the inevitable at least partial solution to the problem at hand.
Telemedicine can be the right answer in four areas. First, the behavior support for health maintenance and adherence to a medical regimen is abundantly in evidence. The advantages are obvious with social media for control of smoking addiction, weight control, exercise, and general empowerment of patients in a close electronic relationship to a therapeutic program. Second, the home can become a place of surveillance and early recognition of problems, allowing the elderly to maintain their independence in the home long after institutionalization would otherwise be required. Recognition of falls, problems of gait, rehabilitation, and nutrition are easy matters for sensors and electronic connection to health management facilities. Sensing can track movement, location, and signs of deterioration in dementia. Third, telemedicine can greatly increase the effectiveness of in-person home health visits to link the nurse with health managers for management of wounds, skin care, changes in medication regimen, and timely use of transfer to a health facility when necessary. Electronic linkage to a management facility that can issue orders could be a great saver of time and lives. Fourth, linkage of inpatients with geriatric problems can gain from teleconsultation with the rare geriatric practitioners to coordinate complex care and facilitate orderly and effective discharge plans.
Some would say the elderly are not particularly adept in using social media, sensing, and computer connectivity. This is probably true for the very old, but the upcoming baby boomers who began turning 65 in 2010 are different. This generation embraced the cell phone, personal computing, and the Internet to make those entities successful in their generation. This upcoming group created the market for information advances and can be expected to be facile with some special attention in using electronic means for ongoing management of their health. A great problem of aging is, of course, dementia. The condition can be addressed of course through telemedicine. However, much research is needed in slowing the course of dementia through exercise of neuroplasticity and behavior modification.
We hope to see substantial research in telemedicine with regard to the elderly. The field is ripe and ready. Studies in technology adaptation, specific sensing, early alerts, and integration of home healthcare and central management systems with patient education are badly needed. The data for the elderly and best practice publications are not nearly so numerous or compelling as those for other age groups. Perhaps a Special Interest Group in the American Telemedicine Association (ATA) could dedicate itself to the issues. The educational programs of the ATA, including the accredited education centers, could be encouraged to include didactic material on the special aspect of telemedicine for the elderly. In the interaction of the policy groups with planners for Medicare, perhaps more attention could be paid to the specific health advantages and needs in the geriatric age group. We might encourage funding of research in geriatric telemedicine to build a better case and better practices for the painful costs of healthcare in this group and how they might be alleviated through telemedicine. Certainly the American Geriatric Society, a new Special Interest Group at the ATA, and the ATA generally could interact to produce practice guidelines and perhaps curricular content for the geriatric practitioner.
We hope in the coming years to see the field of geriatric telemedicine come into its own with evidence-based technology, programs, and sound outcomes of best practices. Let us encourage the promulgation of geriatric telemedicine activities, and we will see yet another great stride in healthcare through the use of prudent and well-managed programs in geriatric telemedicine. The elderly were there for us when they were young. Let us be there for them in the years to come. They may not be working or financially productive, but they are precious to our society, and perhaps their perceived lack of contribution is in reality underutilization of a talented and experienced pool of citizens who made us what we are today and could be tomorrow.