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Md Fadzil, N.H.; Shahar, S.; Rajikan, R.; Singh, D.K.A.; Mat Ludin, A.F.; Subramaniam, P.; Ibrahim, N.; , .; Ali, N.M. Usage of Telerehabilitation. Encyclopedia. Available online: https://encyclopedia.pub/entry/22280 (accessed on 20 May 2024).
Md Fadzil NH, Shahar S, Rajikan R, Singh DKA, Mat Ludin AF, Subramaniam P, et al. Usage of Telerehabilitation. Encyclopedia. Available at: https://encyclopedia.pub/entry/22280. Accessed May 20, 2024.
Md Fadzil, Nurul Hidayah, Suzana Shahar, Roslee Rajikan, Devinder Kaur Ajit Singh, Arimi Fitri Mat Ludin, Ponnusamy Subramaniam, Norhayati Ibrahim,  , Nazlena Mohamad Ali. "Usage of Telerehabilitation" Encyclopedia, https://encyclopedia.pub/entry/22280 (accessed May 20, 2024).
Md Fadzil, N.H., Shahar, S., Rajikan, R., Singh, D.K.A., Mat Ludin, A.F., Subramaniam, P., Ibrahim, N., , ., & Ali, N.M. (2022, April 26). Usage of Telerehabilitation. In Encyclopedia. https://encyclopedia.pub/entry/22280
Md Fadzil, Nurul Hidayah, et al. "Usage of Telerehabilitation." Encyclopedia. Web. 26 April, 2022.
Usage of Telerehabilitation
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This entry is adapted from the peer-reviewed paper 10.3390/ijerph19074000

Telerehabilitation is an alternative platform of telecommunication-based practice that could provide alternatives in delivering health education and care for clients or individuals either in clinical, community or home care settings.

telerehabilitation telehealth telemedicine older adults elderly cognitive impairment mild cognitive impairment cognitive frailty

1. Introduction

Older adults are mostly defined by the age of 60 and above [1]. With advanced global development of information technology, there will be an advantage to apply these technology in improving or extending services to the older population [2]. In the past few years, many senior citizens opted to live with their family members and gradually settled down; however, others may have to live more independently due to several factors such as migration of children post-marriage or children pursuing studies or working in other places [3][4]. Problems arise when they face multiple chronic conditions or acute illnesses, which can increase the likelihood of being dependent on others and affect the quality of life of both the older adults and their caregivers. Integrated health care monitoring technology such as mobile health (mHealth) can overcome these obstacles among the ageing population and promote their wellbeing [5][6].
Telerehabilitation is an alternative platform of telecommunication-based practice that could provide alternatives in delivering health education and care for clients or individuals either in clinical, community or home care settings [7][8]. It is a rapidly developing discipline that has become a key part of telemedicine and e-health [9]. It covers the scope of therapeutic intervention, management of disease, coordination of care, caregiver training and education, patient networking and consultation by multidisciplinary professionals [8][10]. In conformity with research findings, the implementation of telemedicine was feasible in delivering care among older adults [11]. It can enhance the communication between users, enable access to information, accelerate task completion and has an interactive interface [12]. Some challenges in delivering telerehabilitation among older adults were internet access, familiarity towards technology and digital literacy [13].
Cognitive frailty (CF) is considered as a precursor of neurodegenerative processes that involved simultaneous in the presence of frailty in both physical and cognitive domains [14]. It may be prescribed as the occurrence of both cognitive impairment and pre-frailty, before progressing to dementia [15][16][17]. It can also be described by lower grip strength, lower gait speed, weak lower limb muscle strength and impaired delayed recall [15]. The prevalence of frailty among community-dwelling older adults is increasing over the world where by, estimated range from 1.0 to 22.0% [18][19]. Cognitive frailty renders individuals to become more susceptible to adverse health outcomes for instances, falls, other physiological disability, hospitalizations and mortality [19][20][21]. In Malaysia, the prevalence of cognitively pre-frail and frail of multi-ethnic older adults was 37.4% and 2.2%, respectively [22]. There are a number of risk factors related to the occurrence of cognitive frailty including vascular disease, lifestyle factors such as sleep pattern, physical activity, smoking status, psychosocial performance, poor nutritional status, and recently oxidative stress [23][24][25]. Recent findings indicated that malnutrition and depression were related to cognitive frailty [26]. Compared to this research, the other risk factors of cognitive frailty were advanced age, low intake of niacin, limited social support, depression and lower functional status [23].
On the other hand, mild cognitive impairment (MCI) is known as a transitional state between normal aging and dementia [27][28]. As mentioned by Petersen et al. (1999), early detection of MCI can be manifested by memory disturbance and memory disorder among older adults [29]. Recently, a meta-analysis study indicated that the prevalence of MCI among older population was between 3% and 42% globally [30]. In Malaysia, seven out of ten older adults was presented with MCI and more prevalent among advanced age group, low education level, stay alone and low level of life satisfaction [31]. Lower intake of fruits and vegetables and less participation in calorie restriction were also the risk factors of MCI among older adults in Malaysia [32]. In addition, MCI can lead to severe memory regression, physical dysfunction, impaired mental health and low quality of life [33]. There are some interventions to prevent MCI had been introduced such as pharmacological intervention, over-the-counter (OTC) supplementation, physical, cognitive activity and cognitive stimulation and reminiscence therapy [34][35][36][37][38][39]. In later life, enhanced cognitive engagement is related to decreased risk for MCI [40].
The reversal of CF is possible using a multi-domain intervention [23]. Meanwhile, MCI reversion rate to cognitively normal was different among age groups [41]. In the present, there is no reliable evidence that a single intervention can curb this problem as the risk factors are multidomain consisting of physical, nutritional, cognitive and psychosocial aspects [42][43][44][45][46][47]. Improvement of muscle strength and energy are the main indicators of reversal of cognitive frailty when a combined intervention is applied. Presently, a multi-domain intervention is in progress to examine the possibility of reversing cognitive frailty among Malaysian older adults [48].
Similarly, implementation of telerehabilitation among older adults with CF and MCI is still ongoing and had indicated some advantages such as feeling of assurance and safety, providing diagnosis, treatment, education and rehabilitation including access to care either in rural or urban areas, as well as reduce cost for both healthcare providers and patients [49][50]. Nevertheless, there are some barriers that require attention in implementing telerehabilitation among older adults which include self-efficacy, digital literacy, experience, frequency of usage and reliance on guidance [51][52]. Moreover, more randomized controlled trials, larger numbers of participants and trial designs that reduce bias are needed to evaluate effectiveness of mobile health intervention for individuals with cognitive impairment [53]. Study indicated that social support can facilitate older adults to use digital technology [54]. Research implementing telerehabilitation to address CF and MCI among older adults is still limited. There are increasing reports suggesting the need of telerehabilitation services, the development of telerehabilitation interventions and support for people with disabling conditions that potentially limit access to rehabilitation services. In addition, the current COVID-19 pandemic, in which older adults are the vulnerable group, has placed pressure for more services related to better care and communication with older adults to be delivered effectively through telerehabilitation [55].

2. Usage of Telerehabilitation

Older adults perceived digital health care technology as a supportive platform for them to reside independently, have better communication and provide sense of security, but some may require further support to explore the technology. The intervention study using digital health technology from this research indicated that the quality of life among participants improved compared to the control group [42]. In this research, participants in the control group who received conventional behavioral change via face-to-face were reported giving burden to the caregivers [42]. Another study revealed that ICT platforms used to conduct telerehabilitation was suitable to be implemented among MCI patients as drop-out rate in the control group was higher when compared to telerehabilitation intervention group [56].
Furthermore, prior to implementation of telerehabilitation among these target population, researchers should understand their motivation and readiness towards digital or technology literacy as their generation was raised with different types of technology such as television, radio and telephone compared to current technology such as personal computers, notebook, and tablets including video conferencing and apps. Adults with cognitive frailty are normally older, have lower education levels and different opinions towards information and communication technology (ICT) used [57]. A study was aimed to investigate the readiness towards telehealth among older adults and found that self-efficacy and digital literacy are essential elements to be considered in ICT applications [57]. Lack of technical resources and participants’ condition are also other elements that need to be emphasized for implementation of telerehabilitation despite current modern technology [58]. However, in terms of online interventions, participants’ compliance and adherence towards intervention might be challenging as it is dependent on the social support from family, peers and community [59][60]. Besides that, availability of device is one of the crucial components to conduct telemedicine which can be either through mobile phone, tablet or personal computer [61].
Despite a lack of familiarity with tablet computers, older adults were comfortable with the technology [62]. It was reported in a systematic review that most interventions related to mobile health applications highlighted improvement in their evaluation on health outcomes among people with Mild Cognitive Impairment (MCI), Alzheimer’s disease and dementias [53]. This is in line with a research reported that telemedicine is an applicable tool to nurture older adults efficiently in reducing risk of depressive symptoms and enhancing social functioning and also improving cognitive and nutritional statuses [63]. This contributes to reducing vascular diseases and exacerbation of pre-existing chronic illnesses. In respect to improving cognitive status via the use of technology, more recent research has reported that the main methods and technologies used were telemedicine, virtual reality, augmented reality and digital games [64].
People with cognitive impairment who utilize digital technology may have better health outcomes and statuses with less depression and sociodemographic variables [65]. A study revealed that older adults utilize digital technology to support their memory [65]. They were enthusiastic to utilize digital technologies if they could recognize their benefits and had access to the technology [66]. Older adults who receive education via ICT platform enhanced their nutrition and cognition function [67][68]. In general, this population utilizes smartphones and tablets more frequently, but has limited capability to use specific apps or software to support memory [61]. Mobile technologies could impart the basic physiology and security but lack in self-regard and agency [69]. Most studies reported smartphone technology with text messaging was among the most preferred and available to be used in ICT based intervention or application to improve health [70][71][72][73]. Healthcare providers sending notifications through SMS or short message service was accepted and suitable to be utilized [74]. Nevertheless, a senior friendly web-based application targeting community dwelling senior citizens was also reported as a feasible tool to educate older adults about non-pharmacological approaches for memory improvement [75]. Further explanation related to benefits of using digital technology in delivering online education must be conducted among these target population. To ensure their compliance, assistance during session must be provided as well as send reminders and notifications [76]. Participants were also required to answer adherence questionnaire to determine their understanding towards related topics [76].
Virtual Cognitive (VC) Health Study has indicated that a digital intervention can be carried out from baseline until completion with presence of accessibility of internet-connected device [44]. Some of the participants who did not own any devices could still access information and internet technology nearby in libraries or community centers [44]. In addition, the researchers also affirmed that adoption of digitally delivered multi-domain lifestyle interventions provides an opportunity to lessen people’s medical burden and delay the onset of disease, but whether it may alleviate the prevalence of disease remains unknown [44]. Most multi-domain trials were conducted in a face to face mode such as Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability (FINGER), Multidomain Alzheimer Preventive Trial (MAPT), Prevention of Dementia by Intensive Vascular Care (preDIVA) and Sub-study of Systolic Blood Pressure Intervention Trial (SPRINT-MIND) [24][77][78]. One of the requirements in both FINGER and PreDIVA was commitment to a clinic appointment which could have restricted involvement of older adults who had difficulty to attend because travel costs and physical limitations to their mobility. Other present ongoing multidomain trials that are connected to WorldWide-FINGERS initiative are examining Internet-based interventions [79]. For example, Maintain Your Brain (MYB) which targeted multiple risk factors for dementia and Alzheimer disease using web-based technology among Australian older adults over 3 years [80]. In this trial, the intervention domains emphasized on physical activity, nutrition, cognition, mental health like depression and lifestyle risk factors such as smoking and heavy drinking. Participants in the intervention group received the module consisting of Dubbed “Physical Activity”, “Nutrition’, “Peace of Mind” and “Brain Training”. In addition, other protocol randomized controlled studies with multi-domain of telerehabilitation intervention were also outlined to conduct the same goal which is to counteract cognitive dysfunction and enhance quality of life such as Games for Older Adults Active Life (GOAL) Project and TV-AssistDem [81][82]. Telerehabilitation was found to be feasible among people with mild cognitive impairment or vascular cognitive impairment [56].
Some limitations needed to be addressed in this research. Firstly, the researchers identified the low number of articles being analyzed here. The term of cognitive frailty was newly introduced in 2013 and the articles related to this topic is still limited. Secondly, since the target population was cognitively frail older adults, interaction with their caregivers’ have not been considered in most of the studies. Previous studies reported an encouraging future among caregivers in managing dementia patients using in-home telehealth. Hence, the researchers suggested that future studies should address the implications of telerehabilitation intervention among cognitively frail patients, their caregivers, healthcare professionals and stakeholders.

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NURUL HIDAYAH MD FADZIL
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Suzana Shahar
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Roslee Rajikan
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Devinder Kaur Ajit Singh
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Arimi Fitri Mat Ludin
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Ponnusamy Subramaniam
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Norhayati Ibrahim
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Nazlena Mohamad Ali
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Update Date: 26 Apr 2022
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