Digital health: about the inequality of the elderly

Marco Inzitari
 

"The prioritization of care for COVID-19 changed the doctor-patient relationship reducing scheduled face-to-face visits for the detection and monitoring of chronic diseases, of almost 41%. To return to pre-pandemic levels of diagnosis and management of chronic diseases, primary health care services would have to reorganize themselves and carry out specific actions for the groups at greatest risk. I quote verbatim an interesting recent article by the group of Dr. Antoni Sisó, current president of the Catalan Society of Family and Community Medicine (CAMFiC) and an outstanding researcher.

What will be the real role of digital technologies and virtual environments in the care of the elderly in this reorganization? I have shared the reflections of this post with Carme Carrión (@CarmeCarrion), professor of Health Sciences and principal investigator of the UOC's health lab, an expert in digital health, with whom we have undertaken some collaborative projects to promote healthy aging. Certainly, her expert outlook can add value (and credibility!) to my reflections.

Looking to the future, to create a good mix of face-to-face and remote care, we must be aware of the real added value of technology and of this new way of serving people. But we also have to consider their limitations to overcome them. As Elena Torrente reminded us just before the pandemic, digital health is one of the objectives of the WHO, in line with the UN Sustainable Development Goals. Remote or partially remote care is also possible for people with chronic pathologies, and healthy lifestyle habits can even be promoted remotely, also in the elderly.

Regarding the ability and willingness to use technology by older people, myths and realities intermingle, initially convinced that older people and technology are profoundly divorced worlds. Now, suddenly, we are demystifying it, as if the fact that many "old people" we know use WhatsApp certifies their digital training. Probably, the fundamental point is that talking about "old people" is not correct, we are mixing a great diversity in a single group: people of 65 and 85 years old, robust or frail, healthy or sick, with more or less support and social network, with greater or lesser skills and technological knowledge, with more or less economic and technological resources.

The data we have, which unfortunately are scarce in our context(Catalonia, Spain, southern Europe in general), tells us that:

1. The digital readiness of older people worsens with age so that the skills of an 85-year-old generally cannot be compared to that of a 70-year-old.
2. As is always the case in ageing, chronological age is not everything: cognitive decline or lack of confidence in one's digital abilities (as well as probably other factors) play a role.
3. The digital divide is worse for older people than for other disadvantaged groups, and it is clear that when old age joins disability and poverty, the divide can lead to total exclusion.

To give greater consistency to the three statements made, a recent article, well structured, by researchers from the Geriatrics Division of the University of California San Francisco (UCSF) and published in the journal JAMA Internal Medicine shows that, in 4,525 older people in the United States assessed in 2018, "digital readiness" (defined as "having sensory deficits of such magnitude that they cannot use the telephone or watch TV, suffering from dementia, not having tools that connect to the Internet or not knowing how to use them or not having used email, messaging, or the internet at all in the last month) was potentially seven times worse in people aged 85 and older, compared to those aged 65-74. It was also potentially worse in men than in women, as well as, as might be expected, in less-educated, lower-income, poorer health, and non-white people.

Other factors, such as cognitive impairment or lack of confidence in one's ability to use technology, would reduce the possibility of contacting friends or other people, searching for information, using digital banking, or shopping on the Internet, in a representative sample of older people in Germany.

If we move to Korea, it turns out that the digital divide (low "digital literacy" or digital skills) in older people is greater than that of other "technologically disadvantaged" groups, such as people with disabilities, low income, peasants, or fishermen, and which has increased over the years. Regarding the priorities, it seems that always considering the reality of Korea, training towards use is more urgent than access.

For the people with the profile that we have described, non-face-to-face attention would be more easily diverted towards telephone attention, in case of need for remote visits.On the other hand, particularly in people with complex needs, the same UCSF article highlights that telephone attention is not and will not be enough. In addition, this group will surely not be favoured in the new contact channels and visit requests through electronic tools.

For the future, we think that:

1. In the field of care, an adequate balance is necessary between different modes of health care provision, especially for people with chronic multiple morbidities and complex needs. This correct mix has to be reconsidered for all users of health organizations. We talk about personalized medicine, but we focus a lot on biomedical aspects; on the other hand, we often do not consider the way each person interacts with professionals and the system. When should you use digital tools and when not? Who can and wants to use them? What changes must be made to offer personalized attention to each group of people? The organization of these aspects must derive from an agreement between the health system and the professionals, especially in the case of primary care and other specialities on an outpatient basis. Practitioners, with evidence in hand and with user participation, need to define this “new way of working” and how it applies to their direct local context, which will be different from many others. We also think that remote care of other pathologies to specific segments of the population can "free up" time so that professionals can dedicate themselves to attending the most complex ones in person, a principle that is consistent with one of the pillars of the Topol Report on digital health, about which Tino Martí enlightened us a few months ago.

2. Concerning technology innovation, we will witness a further expansion of digital tools, some of which are better known, such as mobile applications, and others that seem more futuristic, such as virtual reality, which can have added value for people who live in the community and who spend much of their time alone. These tools can help the "care continuum". They can be elements that favour physical activity, a healthier diet, they can make them feel more connected or they do not have to go to their health centre periodically. It is necessary, however, to follow some guidelines to be able to develop and evaluate them:

• The tools must result from the interaction between different agents, especially the users and their caregivers, the professionals who possess the knowledge, the companies, and the administrations.
• It is necessary to identify what determines a person's resort to technology to take care of their health and which people will never resort to such tools.
• Methodologically robust studies must be designed and evidence generated on which tools are effective and which are not sufficiently safe.

For all these reasons, and to implement effective strategies, we need more research with specific data from the territory, from Catalonia in our case, and well-conducted innovation processes.

As I had already pointed out on this page, "coffee for everyone" is not a good recipe and we are currently putting all people over 65 years of age in the same bag, which means that we consider that, for exemple, 19% of the population of Catalonia is homogeneous. And it is not.