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Chapter 9

Telemedicine: A Wayto Improve GlycemicControl amongElderly Diabetics

Sheila Black

CONTENTS

9.1 Introduction ......................................................................................1629.2 Technological Reminders and Sensors ..............................................1639.3 Cognitive Orthotics ..........................................................................164

References ................................................................................................171

control among older diabetics and in reducing the medical complications associ-ated with diabetes. Furthermore, most studies indicate that older diabetics reporthigh satisfaction with various aspects of telemedicine.

9.4 Virtual Medical Offices .....................................................................167

bulk of the evidence indicates that telemedicine is effective in improving glycemicThis contribution discusses the efficacy of telemedicine for elderly diabetics. The

© 2008 by Taylor & Francis Group, LLC

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162 Mobile Telemedicine

9.1 Introduction

Diabetes mellitus has wide ranging consequences including amputations,

cal complications associated with diabetes, recently, the Diabetes Control andComplications Trial Research Group (DCCT) (1993) has emphasized tightcontrol through patient self-management.1 According to experts, diabetics who

extra six years free of kidney damage, an extra eight years of sight, and an extra2

betic Association refers to hemoglobin A1c levels below 7%. To explain further,hemoglobin A1c levels measure the proportion of glycated hemoglobin cells. Acell is glycated if glucose is attached to it. As individuals process sugar, glucosebonds with hemoglobin and it does so in proportion to the glucose in the blood-stream. It takes two to three months for sugar to be removed from these cells;thus, health care professionals reason that A1c levels provide a good estimate ofthe amount of sugar that has remained in the bloodstream over a three-monthperiod.

Maintaining tight control of diabetes is not easy. It requires that patients keeptrack of their food and insulin intake to avoid hypo- or hyperglycemia. Hypergly-

earlier, primarily because diabetes damages blood vessels, which ultimately leads

often result in heart damage, kidney damage, neuropathy, etc. Hypoglycemia (i.e.,low blood sugar), if severe enough and not corrected, can lead to a coma or evendeath.3–4

Older adults are particularly susceptible to diabetes; in fact, close to 20% of5

ing tight control because of the high degree of cognitive resources needed to managediabetes. For example, managing diabetes requires that patients use good prob-lem-solving strategies and that they remember to balance their glucose and insulinintake on a given day. Diabetics also need to remember to check their glucose levels

memory retrieval and in problem-solving skills.2 Telemedicine might be a way to

compensate for such declines.Telemedicine includes using any form of technology that allows health careprofessionals to communicate with patients, including computers, telephones, elec-tronic handheld devices, etc. Often telemedicine is divided into three components:(1) synchronized videoconferencing, (2) remote monitoring, and (3) educationthrough Websites.6 Cognitive aids can also serve as reminders to diabetics that fallunder the rubric “telemedicine.”

are able to maintain tight glycemic control gain an extra five years of life, an

six years free of nerve damage. Tight control as defined by the American Dia-

blindness, and renal failure, etc. In an effort to decrease the untoward medi-

older adults suffer from diabetes. Many of these older adults have difficulty achiev-

cemia (i.e., high blood sugar) can lead to diabetes-related complications described

to the constriction of blood flow. These macro- and micro-vascular complications

and the nutritional value of various foods. There are age-related changes in both

This chapter will focus on various forms of telemedicine including techno-

logical reminders for the healthy older adult and for the memory impaired. These


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technological advances include sensors to monitor cognitively impaired older

tioned technological advances are ideal for diabetics because diabetics have com-plex medical regimens to follow and often forget to perform tasks required tomanage diabetes adequately. As well, diabetes accelerates the aging of the brain.

7

through telemedicine.

9.2 Technological Reminders and Sensors

from memory impairment, but these technological reminders are also appropriatefor older adults without memory impairment.

A number of studies have provided evidence that medication compliance isparticularly problematic for older adults.2,8 Health care professionals have tried toimprove medication compliance by providing educational programs for diabetics;

however, educational programs have not been successful in increasing compliancerates.7

memory aids or cues.7

telephone reminders. For example, Fulmer et al. 7 conducted a study to examine

target participants for this study were frail individuals over 65 with multiple

health problems. Fulmer et al. assigned participants to one of three conditions:

reminders to take their medication and the telephone group received telephone

compliance. MEMS are computerized caps placed on medication bottles torecord removal of the cap from the bottle. Interestingly, all participants took

their medication over 80% of the time initially; however, over time, compliancedropped drastically for the control group but remained high in the two interven-

fairly simple interventions such as telephone call reminders increase complianceamong older adults. Other studies provide evidence that fairly simple remindersincrease compliance. For example, a study conducted by LaVigne and Tapper8 found that automatized voice interactive systems that reminded patients to take

their medication increased compliance among the individuals who received

typical older adult and could benefit from the extra cognitive support provided

the efficacy of telephone reminders versus education in increasing compliance

doctor’s office.

Technological cues and reminders are particularly apt for older adults suffering

Several studies have in fact investigated the efficacy of

adults, and virtual offices through sophisticated computer units. The aforemen-

Therefore, older diabetics probably have more cognitive impairments than the

The most effective intervention to increase compliance rates appears to be

and to determine if certain memory aids were more efficacious than others. The

videophone, telephone, and control. The videophone group received audio-video

reminders. The control group received the usual information presented in the

The Medication Event Monitoring System caps (MEMs) was used to assess

tion groups. Thus, there was a time × group interaction. Surprisingly, there wasno advantage of a videophone over a telephone. This study indicates that even


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patients. Nevertheless, they might be able to provide support by sending outautomated voice messages.

In another study, Piette and Mah9 found that 98% of diabetic patients foundautomated voice messages to be helpful. In the Piette and Mah study, upon receiv-ing an automated call, participants answered questions about glycemic control

phone. If a patient indicated that she was experiencing a complication (e.g., foot

ulcers or chest pains), then the patient received a call from a human professional.Patients also received follow-up calls if they reported a glucose reading above 250.

when there was evidence that patients were exhibiting poor glycemic control.

aspect of diabetes.10,11 Telephone reminders can provide solutions in “real-time.”For example, Long et al.12

that a patient received was determined by the patient’s HbA1c levels. Each call was20 minutes long and patients could query the health care professional about illness

overwhelmingly pleased with the service.

take their medication and in providing assistance with everyday problem-solvingdilemmas. However, there are groups of diabetics who require more than daily

from cognitive orthotics and/or sensors.

9.3 Cognitive Orthotics

A cognitive orthotic is a computerized memory aid that is often used for people13,14 It is

particularly useful with respect to prospective memory, or remembering to do

nondiabetics.15

intake. Many dietitians recommend that diabetics count carbohydrates and restrictfat. However, many older adults are unfamiliar with the nutritional value of food.One research group16 examined the likelihood that an electronic aid would assist

the handheld dietary device for 12 weeks and a control group that did not receive

As indicated earlier, older adults often have difficulty with the problem-solving

conducted a study examining the efficacy of providing

who have difficulty remembering to perform activities of daily living.

dence that older diabetics have more difficulty with this type of memory than

One of the most difficult aspects of diabetes is balancing food and insulin

reminders can be effective in improving compliance is important. Health care

professionals may not have the time or staff available to make personal calls to

Telephone reminders can be very effective in helping diabetics to remember to

automated messages relative to the control group. The fact that automated voice

and diabetic complications by pressing various number options on a Touch-Tone

This was important because patients could receive personal attention immediately

problem-solving support for older diabetics over the phone. The number of calls

and blood sugar levels or the effect of exercise on blood sugar, etc. The patients were

reminders in order to manage their diabetes. Those groups of diabetics may benefit

something. There are age-related changes in prospective memory and there is evi-

patients in maintaining their diet. There was an experimental group that received


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hospital-based monitoring system [DMS]) that would immediately access the nutri-

tional value of food, including calories, carbohydrates, protein, etc., of each itemin the database. Patients in the experimental group actually reduced their HbA1clevels from 8.56 to 7.55 as a result of this monitoring system.

More recently, Agarwala, Greenberg, and Ho17 have developed a new innova-tive orthotic, a context-aware pill bottle that allows both clients and caregivers to

does not move the pill box at the assigned time, the patient receives increasinglyobtrusive alerts. A medication monitor, which informs the caregiver when the pillbottle has been removed from the stand, is placed in the caregiver’s home.

If the client fails to take the medication despite the increasingly obtrusive alerts,

cation monitor device. To stop the blinking, the caregiver must touch the device andcan act upon the alert by sending a message that will be delivered back to the client.Obviously, this reminder could greatly assist in reminding diabetic patients to taketheir medication, check their blood sugar, etc.

Rhodes18 has also designed a device that would be helpful for diabetics—aremembrance agent, basically an electronic reminder. A remembrance agent wouldbe helpful for diabetics because of their long list of daily prospective memory taskssuch as remembering to monitor glucose levels, to take medications, to exercise, etc.

device that provides reminder aids and schedules for busy professionals. However,

agent lists appropriate grocery items to buy. However, if the client is in the kitchen,then the remembrance agent provides reminders appropriate for that location (e.g.,reminders about cooking).

in terms of their medication, but who are for the most part mentally and physicallyhealthy enough to live independently without much assistance. However, a num-ber of older diabetics need more than fairly simple cognitive orthotics to live inde-

devices are ideal for older adults who have severe enough memory impairments thattheir families worry about their ability to live independently but do not think that

the severity of the impairment warrants placement in a health care facility.

identification (RFID) tag that provides information about when the pill should betaken and possible side effects.

the device is different from a PDA in that it is equipped with sensors that determine

such a device. The experimental group was provided with an electronic diary (i.e.,

monitor medication management. The device consists of a pill bottle stand that isconnected to a computer. The device audibly reminds elderly individuals to taketheir medication. The plastic pill bottles are augmented with a radio frequency

This device provides reminders to patients in an interesting way. If the client

then the caregiver is contacted. The caregiver is alerted by the blinking of the medi-

This remembrance agent resembles a personal digital assistant (PDA), the popular

the location of the user. The sensors provide notes and reminders to the user basedon the location. Thus, if the client is in the supermarket, then the remembrance

The devices discussed heretofore are available for clients who may need reminders

pendently. These groups of older adults need fairly intensive monitoring. This nextsubsection focuses on new devices that allow continual, 24-hour monitoring. These


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the movements of an older person and even send alerts if anything is awry (e.g., a

the house (e.g., on a ceiling). Interestingly, these motion detectors use a computeralgorithm to track and ultimately learn a person’s usual behavior. After learningthe person’s behaviors, the computer sends an alert when the person deviates from

person is in the bathroom too long, etc.19

One study 20 examined how such sensors would actually operate in the home.

mation Research Center at the University of Virginia as a prototype of living envi-

were placed in every room and responded to any movement; each time the sensorresponded, the date, time, and duration of the sensor activation was forwarded tohealth care professionals and caregivers via a computer. After examining the pat-tern of sensor activation over a number of days, investigators were able to makereasonable predictions about regular activities such as cooking and eating dinnerbased on the pattern of sensor activation.

important. One of the pitfalls of diabetes is hypo- or hyperglycemia, which couldrender a patient delirious. If a patient deviated too much from her daily activities,concerned caregivers could be alerted. More recently, Yang and Rhee21 developed a

tinuously and the signals are sent to a computer for observation. Along the same line,Gatzoulis and Lymberis22 have developed unobtrusive sensors that can be worn byindividuals who require constant monitoring. One of the more innovative systems

includes wireless garments embedded with textile sensors that continuously monitorbiomedical signs such as respiration. Again, all of the medical information gleanedvia the wearable sensors is forwarded back to health care professionals or caregivers.

One of the most sophisticated sensor/automated reminding devices is PEARL,an automatic robot that can be used by frail and cognitively impaired individu-als.13,14,23,24

researchers involved with this project wanted to create a robot that would assistelderly individuals who were in their home. PEARL is equipped with two Pentium

computers, sonar sensors, microphones, a speech recognition system, and stereocamera systems. Most importantly, PEARL is equipped with the Autominder soft-

ware that provides reminders to cognitively impaired elderly individuals.

have been reminder systems since the 1960s.23 However, the new Autominder sys-

ties such that it becomes aware of the length of time that clients spend on variousactivities and it becomes aware of the sequence of activities. Autominder has three

components: a plan manager (which stores a client’s scheduled activities), a client

tem takes advantage of artificial intelligence (AI). It models the client’s daily activi-

Examples of such devices are activity monitoring systems. These systems track

fall). These systems rely on motion detectors mounted in an obscure location in

expected behavior. Thus, the monitoring system can send an alert to a caregiver if a

This study took place in the “smart house” that was created by the Medical Auto-

ronments for individuals who are physically and/or mentally impaired. The sensors

The fact that investigators can infer the activity of clients in “smart homes” is

sensor that could be worn as a ring. This “ring” measures oxygenated blood flow con-

Pearl was recently constructed via a multidisciplinary team project. The

Autominder provides reminders to people about their daily activities. There


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modeler (uses information about a client’s observable behavior to update his or herschedule), and personal cognitive orthotics (reminds patients about what they are

programmed to estimate how long activities should take. Reminders are generatedif an activity takes longer than normal or if an individual is not in a room wherethe activity usually takes place. Sensors for Autominder are deployed via PEARL.Sensor information can be sent to the caregiver throughout the day.

ligence allows Autominder to make intelligent judgments about when a reminder

every three hours and, based on the client’s regular routine, the system “knows”the individual watches a two-hour television program on a particular day, thesystem might remind the client before the television program begins and thereby

ligence, autominder can issue reminders at a time most convenient for the client.PEARL was piloted at Longwood Health Care Center13 and was a very valuableaddition to the facility.

helpful for older diabetics who are mildly forgetful or very impaired and actuallyrequire constant monitoring through technology. However, what about diabetics

have a very complex medical regimen because of multiple health problems? Is there

A number of complex technological systems are currently being tested with olderadults. Initially, there was some concern about designing complex technology forthe elderly because the elderly were viewed as being less technological savvy thanyounger adults. Furthermore, due to age-related changes in working memory, andprocessing speed,25,26 older adults grasp information at a slower rate than youngeradults. In fact, as Stronge, Rogers, and Fisk 27 point out, some age-related changes inmotor dexterity might impede older adults’ ability to utilize the technology associ-

ated with complex telemedicine systems.In fact, Kaufman et al.28 reviewed a complex telemedicine program that involved

examined the usability of this telemedicine system in 25 diabetic patients’ homesand discovered that successful usage of the program required the patient to complete

to the unit and enjoyed the video visits with health care professionals. However,

supposed to do). Due to the artificial intelligence component, Autominder can be

who may be cognitively intact but have difficulty traveling to a doctor’s office or

a way that technology could bring the medical office to their home?

9.4 Virtual Medical Offices

participants had some difficulties due in part to age-related changes in cognition and

The reminders have to be initiated by the caregiver; however, the artificial intel-

is needed. Thus, if an elderly person has to be reminded to go to the bathroom

avoid interrupting the client’s television program. Thus, due to artificial intel-

Thus, the bulk of the evidence indicates that cognitive orthotics can be very

creating a virtual office in the patient’s home. Their main concern was the extent to

15 subtasks. They found that participants could readily use the glucometers attached

which elderly patients would adapt to sophisticated new computer technology. They


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the mouse (perceptual–motoric skills), understanding how the entire system worked

(mental models) and health literacy (which goes back to age-related changes in read-ing comprehension). To explain further, several of the older adults were hampered by

understanding how the Internet worked (e.g., the user needs to click hyperlinked

28

Studies have been conducted in which memory-impaired younger adults received

memory impairments relative to healthy younger adults29 were capable of mastering

that older adults (who as a group learn at a slower rate than younger adults) will

master the technology associated with complex telemedicine units.30

Probably the most publicized telemedicine study focusing on telemedicine forolder adults was the one conducted by Columbia University, titled the Informatics

the IDEAT project tried to improve glycemic control among a wide cross section ofdiabetics by designing a very user-friendly computer/electronic system that included

all three facets of telemedicine. All of the diabetics were Medicare recipients who lived in underserved areas,

with some of the recipients living in poor areas of New York City and some recipi-ents living in rural counties within New York state.31

wanted to integrate all of the components so that elderly patients, with no computer

to operate the computer for the most part without using a mouse or a keyboard.

Instead, they had “four launch buttons”: answer video call, send data from glucoseand blood pressure meters, connect to Website, and reboot computer. In fact, upon

values” to doctors and other health care specialists.

gram in helping diabetics achieve glycemic control. One of the primary reasons

lack of experience with computers. For example, the participants had difficulty using

health literacy because they did not understand the significance of blood pressure orglucometer readings. Also, with regard to mental models, older adults had difficulty

words to find out more information about a particular topic).

diabetics the opportunity to become more proficient in managing their disease.

the complex technology needed to access a “virtual office.” However these indi-

require significantly more training to master the technology associated with “virtualoffices.” However, studies indicate that with the proper training, older adults can

However, the study also indicates that a minimal amount of proficiency may benecessary for patients to take full advantage of telemedicine.

study indicates that telemedicine affords older

Recently, several studies have examined the effectiveness of the IDEAT pro-

Thus, the Kaufman et al.

medical care through telemedicine. These studies indicate that participants with

viduals require more training than a typical younger adult. Thus, it is probably true

for Diabetes Education and Telemedicine Project (IDEAT). The investigators in

The focal point of this inter-vention was the home telemedicine unit (HTU). The inventors of this product

turning on the computer, the patient was immediately connected to the Web. The

experience, would have no difficulty using the technology. The patients are able

installation of the computer and the training was performed by home care nurses.The home care nurse received a constant stream of data informing them of patients’health status. The nurses had guidelines to follow in terms of reporting “worrisome


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that such a program should improve glycemic control is that it reduces the extent to which diabetics have to rely on episodic memory (i.e., memory for episodes in one’s

life) and engage in problem solving. If they have a question that involves problemsolving, they could consult one of the professionals through the IDEAT program.

et al.30 In this study, participants were either in the usual care condition or involvedin the IDEAT program described earlier. Patients in the usual care condition receivedinformation about diabetes, similar to the educational information given to diabetics

health care professionals and their A1c levels were forwarded to health care profes-

indicated that even individuals who were controlling their diabetes fairly well couldimprove glycemic control with the extra support provided by the IDEAT program.

Most of the work investigating telemedicine among the elderly has not been assophisticated as the IDEAT project at Columbia University. For example, severalVA hospitals received a grant to implement a telemedicine program called the Care

Coordination approach. In the Care Coordination approach, the nurse coordinatormaintains frequent contact with a patient through telemedicine and feeds informa-tion back to a doctor. One of the reasons that health care providers have been inter-ested in this approach is that it might actually prevent complications from complexdiseases such as diabetes. In one study,32 conducted by Chumbler et al., participants

were older veteran diabetics who were already experiencing health problems in thatthey had been to the emergency room or had been admitted to the hospital twice

receiving intense monitoring on a weekly basis and the other group receiving lessintense monitoring on a daily basis.

Patients and caregivers in the weekly monitoring condition were trained to usean instant camera to take snapshots of wounds; the pictures were mailed weeklyto the care coordinator. Upon receiving the pictures, the care coordinator woulddecide if further treatment was necessary. Patients were also followed through thediabetic clinic.

32 was not followed by a diabetic clinic nor was this

group required to send pictures of wounds. However, this group received general

equipped with a telemonitoring system that allowed weekly glucose monitoring

ence between the daily monitoring group and the weekly monitoring group wasthat patients in this group answered questions daily about their glycemic control

assess the patient’s knowledge, symptoms, and behavior in regard to chronic disease

One of the first studies to evaluate the IDEAT program was conducted by Shea

in doctors’ offices. As indicated earlier, those in the IDEAT program consulted with

A1c levels, and lipid levels significantly more than those in the control group. Specifi-

and that provided two-way audio-video connectivity. However, the main differ-

sionals on a regular basis. Those in the IDEAT program reduced their cholesterol,

cally, A1c levels decreased from 7.35 to 6.97% in the intervention group. This study

within 12 months. The diabetics were divided into two groups with one group

The daily monitoring group

information about managing diabetes via a home messaging system. They were

and individuals in the weekly monitoring condition did not. The answers to thequestions were forwarded to their care coordinator. The questions were designed to


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questions and made decisions about the necessity of further intervention.

were decreased 15%. Interestingly, even though there was a decline in hospitaliza-tions among the daily monitoring group relative to the weekly monitoring group,there was no evidence that glycemic control was better in the daily monitoring

tion among individuals in the daily monitoring group relative to the weekly moni-toring group. Barnett et al.33 also found that diabetics who were monitored daily

were hospitalized less than controls (matched for severity of diabetic symptoms).Mease2 conducted a study using technology and environmental support similar tothat used in the IDEAT program. Mease and colleagues used equipment approved bythe Federal Drug Administration for the monitoring of diabetes, the Avia 20/20 andthe Avia 10/10. Only diabetics with hemoglobin A1c levels above 8% were includedin the study. It should be noted that individuals who have levels above 8% are sig-

in the 6 to 8% range. It should also be noted that Mease excluded individuals who

were not able to use the equipment properly after training and individuals who had a

On a weekly basis the patients in the treatment group received telemonitoring

case manager counseled the patients about their nutritional intake and medication

episodes each week.Patients in the telemedicine program also used technology to maintain contact

with their physicians. In fact, the two physicians visited the patients once a month

received the home telemedicine system reduced A1c levels by 16%, and their weight

One of the reasons that the Mease2 study and the Shea et al.30 study were suc-cessful in lowering A1c levels might be that these interventions provided regular

feedback and counseling for patients about diet and management of blood sugar32 study appeared to focus more on serious complications

rather than day-to-day management of diabetes.

the medication management and quality of life of diabetics. Interestingly, theChumbler et al.32 and the Shea et al.30 studies indicate that older adults can eventake advantage of fairly complex telemedicine systems. However, it is crucial thatdesigners of such systems be aware of age-related changes in learning new informa-

nificantly more likely to experience complications than diabetics who have A1c levels

Although the control group reduced A1c levels, the reduction was not significant.

tion and cohort differences in experience with technology.

management. The care coordinator or health buddy reviewed the answers to the

The investigators found that hospital admission rates were 52% lower in thedaily versus weekly monitoring group. The diabetes-related emergency room visits

group. That is, the hemoglobin A1c levels were not better from pre-post interven-

psychiatric history. The average age of participants in this study was 61.

compliance. The case manager also reviewed each patient’s well-being and glycemic

through telemonitoring. The outcome measures included the HbA1c values, micro-albumin, creatinine, and lipid panel. The results indicated that individuals who

by 4%. The reduction in A1c levels was significant in the telemedicine group.

levels. The Chumbler et al.

The consensus from all of the data is that telemedicine can definitely improve

visits from the case manager, which included both voice and video interaction. The


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of life of older diabetics and older adults in general. With advances in computer

technology, concerned caregivers and health care professionals can now keep trackof an elderly person’s vital signs and ability to maintain glycemic control. Hope-fully, telemedicine will become more widespread in the near future. If telemedicine

were readily available, older adults would be able to live in their own home longer, which would improve their quality of life. A number of studies indicate that olderadults fare better emotionally when allowed to age in place. Furthermore, telemedi-cine would allow doctors in rural areas to obtain information via teleconferences,Email, etc., that otherwise would be inaccessible to them. Telemedicine appears

to be the wave of the future. It has the capacity to greatly enrich the lives of olderdiabetics.

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