Ebook: Telehealth for our Ageing Society

We offer this volume as a set of new insights on a wide variety of recent research addressing the topic of “Telehealth for our Ageing Society”. We believe this area of Telehealth has been somewhat neglected, in favour of more direct mainstream work on classical primary and acute care Telehealth applications, and the use of Telehealth in numerous clinical speciality areas. The work included here all has direct relevance to usage by or for the aged sector, aged from mid-fifties upwards. Within that scope, the papers included here contain a wide variety of Telehealth across various modes of delivery including classic videoconferencing, personal monitoring, online and apps, social media and virtual reality.

This contribution appears at a time when health issues for our Ageing population are receiving much public attention, with the looming “burden of care” sparking ideas on new approaches in health care for the elderly. The recent changes in aged and community care funding and administrative regimes in Australia (and elsewhere) have prompted discussion on new types of services and associated new delivery models. Consumer empowerment of the elderly through access to information and services online has changed the way the market positions itself and responds to demands of individuals. Rapid increase of digital literacy and appetite for use of digital resources amongst older citizens has encouraged the diversification of remote health care options. The growing burden of care needs has led the care industry sector to diversify its offerings and investigate strategic alignments in research and development.

The Global Telehealth series of international meetings which commenced in 2010 have each focussed on different topics in Telehealth, in recognition of the diversity of this area. This volume contains a selection of the papers presented at the 5th Global Telehealth meeting, held in Adelaide, Australia on Friday 24 November 2017 as part of a week long programme of events on the theme of “Ageing Well”. The purpose of the meeting was to share knowledge of complementary research endeavours and to foster interaction between different groups undertaking research in this emerging topic area. The meeting was arranged as a colloquium of recent and current work undertaken by representatives of leading Australian researchers and research groups who are “pushing the boundaries” on Telehealth. Full papers were submitted and subject to peer review by a panel of international scientific experts, prior to acceptance for publication. We invite readers to seek out other papers appearing in earlier volumes of this series, many of which will be relevant to the same areas of Telehealth.

The conference organisers wish to acknowledge the generous sponsorship of South Australian Government through SA Health Office of Ageing, as well as the support of Flinders University, The University of Adelaide, and University of South Australia.

Maayken E.L. van den Berg & Anthony J. Maeder

Flinders University, Adelaide, Australia

The CSIRO National NBN Telehealth Trial investigated the effects of introducing at home telemonitoring of vital signs for the management of a heterogeneous group of chronically ill patients. Patients suffering from a wide range of chronic conditions who were frequently admitted to hospital, were selected from nominated hospital lists. The impact of telemonitoring was analysed using a wide range of health and wellbeing outcomes as well as numerous health economic metrics derived from Medicare Medical Benefits Scheme (MBS) and Pharmaceutical Benefits Scheme (PBS) data and Hospital Health Roundtable data. Data was also recorded from the telemonitoring system used in the trial, and the administration of questionnaires. The impact of this intervention on the patients, carers and clinicians involved in their care was quantitatively and qualitatively analysed and documented. There were no significant differences between test and control patients at baseline. Test patients were monitored for an average of 276 days with 75% of patients monitored for more than 6 months. Test patients 1 year after the start of their intervention showed a 46.3% reduction in rate of predicted medical expenditure, a 25.5% reduction in the rate of predicted pharmaceutical expenditure, a 53.2% reduction in the rate of predicted unscheduled admission to hospital, a 67.9% reduction in the predicted rate of LOS when admitted to hospital, and a reduction in mortality of between 41.3% and 44.5% relative to control patients. Control patients did not demonstrate any significant change in their predicted trajectory for any of the above variables. In addition, this project reports on the effect of workplace culture and capacity for innovation and organizational change management in successfully integrating a new model of care with long established service models.

Background: In a series of studies over the past decade we have measured the effectiveness of telehealth for elderly heart failure patients (>70 years) on rehospitalisation, mortality, adherence, satisfaction, cost effectiveness, health related quality of life, age and types of technology.

Methods: Evidence has been derived from a Cochrane systematic review and meta-analysis (1 original and 2 updates: 2007–2016), two sub-analysis of this data and a large NHMRC funded multicentre randomised controlled trial (CHAT study 2010).

Results: Within the studies included in the meta-analysis the mean age was 70 or more years in eight of the 16 (n=2,659/5,613; 47%) involving structured telephone support studies and four of the 11 (n=894/2,710; 33%) Telemonitoring studies. Structured telephone support (RR 0.80; 95% CI=0.63-1.00) and Telemonitoring (RR 0.56; 95% CI=0.41-0.76) interventions reduced mortality. Structured telephone support interventions reduced heart failure-related hospitalizations (RR 0.81; 95% CI=0.67-0.99). Four different types of non-invasive remote monitoring technologies were identified, including structured telephone calls, videophone, interactive voice response devices, and Telemonitoring. Structured telephone calls and Telemonitoring were effective in reducing the risk of all-cause mortality (relative risk [RR]=0.87; 95% confidence interval [CI], 0.75–1.01; p=0.06; and RR=0.62; 95% CI, 0.50–0.77; p<0.0001, respectively) and heart failure–related hospitalizations (RR=0.77; 95% CI, 0.68–0.87;p<0.001; and RR=0.75; 95% CI, 0.63–0.91; p=0.003, respectively). Videophone and interactive voice response technologies were not effective. Only 3% of this elderly group (mean age 74.7+/−9.3 years) were unable to learn or competently use the technology. Adherence was reported between 55.1%and 98.5%. Participant satisfaction with Telehealth was reported between 76% and 97%.

Conclusion: These studies show that elderly patients can adapt quickly to telehealth, find its use an acceptable part of their healthcare routine, and are able to maintain good adherence for at least 12 months. These findings support the use of telehealth as part of a comprehensive chronic heart failure management programme.goes here.

Background: This regional pilot site ‘end-user attitudes’ study explored nurses' experiences and impressions of using the Nurses' Behavioural Assistant (NBA) (a knowledge-based, interactive ehealth system) to assist them to better respond to behavioural and psychological symptoms of dementia (BPSD) and will be reported here.

Methods: Focus groups were conducted, followed by a four-week pilot site ‘end-user attitudes’ trial of the NBA at a regional aged care residential facility (ACRF). Brief interviews were conducted with consenting nursing staff.

Results: Focus group feedback (N = 10) required only minor cosmetic changes to the NBA prototype. Post pilot site end-user interview data (N = 10) indicated that the regional ACRF nurses were positive and enthusiastic about the NBA, however several issues were also identified.

Conclusions: Overall the results supported the utility of the NBA to promote a person centred care approach to managing BPSD. Slight modifications may be required to maximise its uptake across all ACRF nursing staff.

In rural Australia, knowledge and utilisation of support by informal carers is lacking. During the caregiving period, socioemotional support from family and friends plays an important role in sustaining caregiving activities. Post-care, these social networks facilitate adjustment to role change and dealing with grief. Developing and improving access to peer support to enable carers to effectively cope with the challenges of caring may positively influence their caring experience. The primary objective of this project is to examine the response of isolated rural carers for older people with dementia to a videoconference (VC) based peer support and information program. Will participation in the program improve self-efficacy, quality of life, and mental health? Secondary objectives are to develop a VC based peer support program for isolated rural carers for older people with dementia, using a co-design approach; and to assess the feasibility of VC technology for enhancing social support to family caregivers in their homes. This project will collaboratively co-design and evaluate a facilitated VC peer support and information program to carers of people with dementia within rural areas. Carers will be recruited through community health and care providers. Program development will use an information sharing approach to facilitate social interaction. A focus of the project is to use off-the-shelf technology which will be more accessible than specialised bespoke solutions that are currently popular in this area of research. A mixed methods repeated measures randomized wait list design will be used to evaluate the project. The primary outcomes are self-efficacy, quality of life, and mental health. Secondary outcomes are perceived social support and user satisfaction with the technology, and intention to continue VC interaction.

Background: The present study was undertaken to build an evidence base focusing on an ageing population who are using or have used consumer wearables to collect and manage information about their personal health status. The primary objective was to understand the health self-management requirements, frailty and age related changes, and the health information support provided by consumer wearable devices, specifically in the context of older adults living independently.

Method: The study aimed to recruit older adults to respond to an online questionnaire. Inclusion criteria for the selection of study participants were: Aged 55 or over, independent living, and currently using or having used a wearable device or devices for health self-management in the past year. The online survey questionnaire represented a cross-section of variables in three sections: (1) Use of wearables for health monitoring, (2) Demographics and (3) Health, physical condition and wellness. A subset of the questions was drawn from the Tilburg Frailty Indicator.

Results: Summary findings from the completed questionnaires suggest the use of wearable health information supports aspects of health self-management activities among independent living seniors. Personal variations and user characteristics in the extent and consistency of the use of wearable information, and user experience in the process, was more difficult to extrapolate, for example, in health information sharing.

Conclusion: Responses to the survey do not indicate widespread use of information from consumer wearables for health self-management among older adults. However, among the respondents, more than half were willing to participate in a follow-up interview by a researcher on their wearable health information use. Further research will explore what they have to say about this information use in relation to frailty and age related changes, and about the way that such information may be integrated into health and aged care support systems.

The 2011 Productivity Commission report, Caring for Older Australians, observed that as the number of older Australians rises and the demand for aged care services increases, there will be a commensurate increase in demand for a well-trained aged care workforce. One of the significant issues impacting upon the ability of the aged services sector to respond to a growing number of older adults is to attract and retain sufficient numbers of staff. A number of factors are acknowledged to contribute to a failure of the aged care sector to attract and retain workers including: poor sector reputation, poor working conditions, including high client-staff ratios, a lack of career paths and professional development opportunities and low rates of remuneration. Poor perceptions about working in the aged care sector (e.g. that aged care nursing is less glamorous than nursing in the acute care sector) appear to develop early, with many nursing students indicating that they do not view aged care as an attractive career choice. Undergraduate nursing students have often found clinical placements in aged care unsatisfactory and unsettling, dissuading them from considering aged care as an employment option on graduation. In the following we describe one way we have attempted to address this issue by training undergraduate health sciences students (occupational therapy, nursing) to deliver a physical activity program to residents of an aged care facility using a novel telerehabilitation technology that enables remote prescription and monitoring of exercise programs. The main purpose of this quality assurance trial was to explore the feasibility and safety of supervised use of a novel telerehabilitation exercise system with older adults living in residential aged care. Four residents were recruited into the study and all displayed limitations in mobility, balance, strength and endurance. None had any had previous experience with computer games or interactive technologies. Resident diagnoses included multiple chronic health conditions and mild cognitive impairment. Over the six-week period, only one session was declined by a resident, providing an overall adherence rate of 98.5%. According to the resident's scores of perceived level of enjoyment, at the end of the first week the program was rated as always enjoyable by 75% of the residents. At the conclusion of the program, 100% responded as always enjoying the exercises and activities. Active sitting and standing time for residents across the program increased markedly. A novel finding from our study is that senior undergraduate students are capable of designing and delivering telerehabilitation programs to residents in aged care facilities. Whilst attention has been given to telesimulation in undergraduate preparation (where learners are off site and connected to simulated laboratory), our trial opens opportunities for a further paradigm shift towards teleplacement.

By the 2050, it is estimated that the proportion of people over the age of 80 will have risen from 3.9% to 9.1% of population of Organisation for Economic Cooperation and Development countries. A large proportion of these people will need significant help to manage various chronic illnesses, including dementia, heart disease, diabetes, limited physical movement and many others. Current approaches typically focus on acute episodes of illness and are not well designed to provide adequately for daily living care support. In our rapidly ageing society, a critical need exists for effective, affordable, scalable and safe in-home and in-residential care solutions leveraging a range of current and emerging sensor, interaction and integration technologies. Key aims are to support the ageing to live longer in their own homes; make daily challenges associated with ageing less limiting through use of technology supports; better support carers – both professional and family – in providing monitoring, proactive intervention, and community connectedness; enable in-home and in-residential care organisations to scale their support services and better use their workforces; and ultimately provide better quality of life. Deakin University researchers have been investigating a range of emerging technologies and platforms to realise this vision, which we in broad terms coin Digital Enhanced Living, in the ageing space but also supporting those with anxiety and depression, sleep disorders, various chronic diseases, recovery from injury, and various predictive analytics. A Smart Home solution, carried out in conjunction with a local start-up, has produced and trialled a novel sensor, interaction, and AI-based technology. Virtual Reality (VR) solutions have been used to support carers in the set-up of dementia-friendly homes, in conjunction with Alzheimers Australia. Activity and nutrition solutions, including the use of conversational agents, have been used to build dialogue to engage and change behaviour. Predictive analytics, in conjunction with major hospitals, have been applied to large medical datasets to better support professionals making judgements around discharge outcomes. A set of lessons have been learned from the design, deployment and trialing of these diverse solutions and new development approaches have been crafted to address the challenges faced. In particular, we found that there is a need to consider user emotional expectations as first-class citizens and create methodologies that consider the user needs during the creation of the software solutions. We find that quality and emotional aspects have to be engineered into the solution, rather than added after a technical solution is deployed.

The rapid ageing of the population is a worldwide inexorable demographic transformation. At a time of immense social, political and economic change, the growing elderly population is at the forefront of global burden, placing an increasing strain on the federal, state, and local budgets. Many public policy responses to the impending ageing epidemic have begun, particularly with regards to dementia prevention and quality of life for older adults. However, to date, the fruition of such efforts remains to be discovered. Indeed, there is a need to find more novel and multifaceted ways of understanding the fragmentary changes and underlying mechanisms in the biopsychosocial contexts of ageing. Discovering better ways to measure these intricate domains will create better insight into how to improve clinical and public health information systems for the development of more personalisation support and services across the continuum of aged care. Technology now permeates all aspects of our everyday living. Digital footprints are data arising as a by-product of interactions we do as part of everyday living. The digital traces we live behind, be it on internet, social media, on mobile phone apps, as well as in health records (EHRs) could be used to infer how we behave and interact with environment, and how we feel in different situations. Commercial sector has very successfully used these footprints in the advertisement and marketing space. This type of information may provide clinicians with an unobtrusive way of monitoring older adults in their daily living, and provide an alternative means to traditional self-report and expert-rated assessment. In this paper we present two innovative digital footprint applications, Actionable Intime Insights and the SAIL Mobile app, which aim to facilitate “Ageing in Place” through adaptive, dynamic, early intervention strategies. These systems are devised to unveil contextual indicators of how a person is functioning mentally, socially, behaviourally and physically in their own environment, as to as assist those with chronic conditions better self-manage by facilitating assistance with care and medication needs just in time.

Australian population aged over 65 years is 14% (3.3 million) and this expected to increase to 21% by 2053 (8.3 million), of which 1.9% to 4.2% is attributed to Australians over 85 years. With increase in ageing, there is high prevalence in long-term health conditions and more likely multiple visits to the doctors or the hospitals, particularly when one's functional condition declines. This adds burden to the already stretched health system such as the overcrowding of emergency departments in hospitals. This is partly due to many ageing patients with high care needs occupying significant number of hospital beds because they are waiting for entry to the limited placements in residential care. To address this increase in ageing population and its impact in the society, the Australian government has funded aged care reforms for initiatives for older community stay at home longer. Recently, this was implemented through consumer directed age care reform. Advances in information and communication technologies, particularly in the advancement of lifestyle technologies and its increased use, show promise in the uptake of telehealth approach to support older people to live longer in their homes. In 2011, CSIRO took the initiative to a develop consumer designed innovative platform that would assist and support the older community in their functional ability and health for day to day living in their home environment. This platform was called the Smarter Safer Homes technology. The Smarter Safer Homes platform infers the Activities of Daily Living information from a passive sensor-enabled environment and correlates the information with home-based health monitoring measurements. The use of sensors enables the information to be captured in an unobtrusive manner. This information is then provided to the individual in the household through an iPad application while information can also be shared with formal and informal carers. The platform has undergone a few pilot studies to explore an objective and individualised approach to Activities of daily living based on an individual's profile and its applicability in multi-resident home setting in individual's in regional Queensland. Furthermore, the platform is being validated in a clinical study for its application in the aged care service in various geographical settings such as in urban and remote communities. This paper describes the platform, outcomes of pilot studies, and its future application.

Longevity is a valuable resource for society, as older people are increasingly looking for new ways to contribute after retirement. Their contribution is however dependent upon their physical health, mental health and wellbeing. The potential role that mental health and wellbeing, two separate but interrelated constructs, play often are both under-recognised and insufficiently targeted. Positive ageing is a positive and constructive view of ageing, where older people actively work on maintaining a positive attitude, work towards keeping fit and healthy, and strive to maximize their wellbeing. Interventions stimulating positive ageing show promising results for both mental health and wellbeing, and telehealth can play an important role in improving the reach and effectiveness of positive ageing interventions. Telehealth solutions can also help researchers reliably measure and better understand the drivers of wellbeing at individual and population levels; results that can both form the basis for advancing the field of positive ageing and help inform public policy.

Freezing of gait (FOG) is an episodic gait disturbance affecting initiation and continuation of locomotion in many Parkinson's disease (PD) patients, causing falls and a poor quality of life. FOG can be experienced on turning and start hesitation, passing through doorways or crowded areas dual tasking, and in stressful situations. Electroencephalography (EEG) offers an innovative technique that may be able to effectively foresee an impending FOG. From data of 16 PD patients, using directed transfer function (DTF) and independent component analysis (ICA) as data pre-processing, and an optimal Bayesian neural network as a predictor of a transition of 5 seconds before the impending FOG occurs in 11 in-group PD patients, we achieved sensitivity and specificity of 85.86% and 80.25% respectively in the test set (5 out-group PD patients). This study therefore contributes to the development of a non-invasive device to prevent freezing of gait in PD.