Telehealth: remote assessments of physical function and frailty measures

Objective measures of function are critical to both the clinical care of older adults and to research on healthy aging and physical frailty.  While telehealth had already been on the rise in recent years, the COVID-19 pandemic skyrocketed the use of remote and virtual assessments, creating an urgent need to adapt methods for patient care and research data collection to the new environments. Clinicians and investigators, struggling with the need to collect functional information remotely over video conferencing or by telephone, need guidance regarding the safety, feasibility and utility of various options and measures.

With support from the Gerontological Society of America (GSA) Innovation Fund: The Generativity Effect and sponsorship from the GSA Technology and Aging Interest Group, we set out to summarize existing evidence-based recommendations for the safe, accurate administration of objective functional measures during a synchronous, remote visit. We also aimed to summarize alternative subjective assessments that are highly correlated to objective measures but more easily obtained during virtual patient interactions. Our ultimate goal was to develop a set of tip sheets for the administration of functional and frailty assessments during a remote clinical or research visit.

We focused on the components of three commonly-administered objective measures of physical functional and frailty in clinical and research settings: the Short Physical Performance Battery (3-meter or 4-meter usual walk, 5-repeated chair stands, 3 static balance poses), the Timed Up and Go, and the Physical Frailty Phenotype (15-foot usual walk, grip strength).  Our approach included crowdsourcing and literature review on 1) the feasibility, safety, and accuracy of virtual assessments using or adapting these objective measures; 2) the correlation of selected subjective and objective measures of function.

With a collaborating team of interdisciplinary investigators from 10 different U.S. institutions, we completed the literature reviews and summarized our findings.  In brief summary, we found the following:

• Feasibility, safety, accuracy of virtual assessments: Very limited existing guidelines were uncovered for the administration of virtual functional and frailty measures. Therefore, we created a reference list to guide clinicians and researchers to related expert recommendations on the remote, telehealth administration of assessment and care generally. Important considerations include sensory, cognitive, and physical limitations, as well as adequate physical space and available supervision.
• Correlation of selected subjective and objective measures of function: Moderate correlations were found between objective performance tests and self-reported measures, except for with grip strength, which had only low correlations with self-reported function. No studies reported extremely high correlations which suggests the different modalities reflect related but distinct domains of function. Small sample sizes / clinical settings can affect generalizability.  Self-reported measures can serve as screening tools for persons at potential risk for functional deficits and when safety concerns preclude virtual objective testing.

Based on these findings, we developed a set of tip sheets that recommend a stepwise approach to the remote / virtual assessment of physical function / frailty for care and/or research purposes. Initial safety screening questions can help identify individuals who may be at the highest risk of injury or who are unlikely to be able to successfully complete the testing during a virtual video call. For this group, we provide a list of subjective functional and frailty questions that have reasonable correlation to act as a surrogate assessment until in-person measures can be safely conducted.  For others, we included a list of supplies needed to carry out testing at home and provided simple instructions for objective measures. The presence of a caregiver or helper on the patient’s or study participant’s end is highly advised.

In conclusion, Telehealth is here to stay. A significant advantage is that the ability to conduct remote visits broadens the reach of geriatric assessment to those who do not have access to local specialized geriatric care, but we need to strengthen our clinical and research methods with additional testing of reliability, reproducibility and safety of remote assessment tools.

We hope you will review the full report and tip sheet that resulted from this work. And we hope that clinicians and researchers will consider standard approaches such as those outlined in the tip sheets in order to help standardize administration protocols and allow better comparison of data across clinical and research samples.

• Tip Sheets on Virtual Functional and Frailty Measurement: https://www.geron.org/images/documents/TechSIGtipsheet.pdf 
• Summary Report: https://www.geron.org/images/documents/VirtualFunctionalandFrailtyMeasureBestPractices.docx

Blog post by Brian Buta, with great thanks to project leader, Megan Huisingh-Scheetz, and to our collaborators and co-authors on this project: Abdulaziz Abaoud, Karen Bandeen-Roche, Margaret Danilovich, John Hall, Erin Harrell, Louise Hawkley, Helen Lach, Michelle Martinchek, Aarti Mathur, Nabiel Mir, Carrie Nieman, Pamela Toto, and Walter Boot.