What do we know about apps older adults (60-70, 71-80, >80 years)? How can we use these apps to keep older COVID-19 patients at home, and collect health data - pulse, resp, temp, EKG?

Authors: Sonya Gleicher MS3 UC San Diego School of Medicine, Katie Li

Completed on:  March 27, 2020

Last updated on: Not yet updated

Reviewed by: Marsha-Gail Davis MD

Reviewed on: April 12, 2020

This summary was written as part of the CoRESPOND Earth 2.0 COVID-19 Rapid Response at UC San Diego.  For more information about the project, please visit http://earth2-covid.ucsd.edu

Key findings:

• There are an increasing number of apps for diagnosing, preventing, and managing disease, and while multiple trials have documented their efficacy in older adults, this requires close monitoring and instruction to ensure proper usage. There is strong evidence that using mHealth apps to monitor heart conditions and BP have significant impacts on clinical care and patient outcomes. To ensure that older patients with limited technological experience are able to reap these same benefits, health apps should meet the following criteria:

• Large text font, strong color contrast, and clearly defined touch-navigation areas
• Proper in-person instruction and/or video tutorial on app features
• Combination of automated reminders from electronic devices and reminders from medical care providers1
• Technological support, preferably from a patient’s close contact2

Related topics: None

Summary of findings:

Introduction

• mHealth is defined by the WHO as a “medical and public health practice using the core utility of mobile and wireless devices, such as voice and short messaging service and applications”.3
• Older adults’ ability and willingness to use apps is determined by an interplay between usability, accessibility, design, and need.4

App usability

• Older adults’ usage of mHealth apps can be shaped by functions of the app such as design, simplicity, functionality, and accessibility, as well as features of the patient such as their perceived need of the app.4

Figure 1. Model depicting first time experiences of older adults using mobile medication management applications.4

• Instructions and tutorials help ensure that older adults know how to use mHealth apps

• Video tutorials https://www.youtube.com/watch?v=nui78JqwMHE
• One-on-one in-person introduction to functions of an app
• Explanation of general concepts like tapping and swiping to patients unfamiliar with smartphone technology1
• After a thorough instructional session, users > 60 yo with no experience in smartphones or tablets were able and willing to successfully navigate health apps1

• Technical support

• Personal contact persons are the most important group to answer technical questions. 61% (19/31) of participants in a study of diabetes app usage in adults > 50 yo relied on children, grandchildren, and partners for technical support. 35% relied on peers and friends.2

• Challenges to app usability

• In a qualitative analysis of the user experiences of 32 patients aged 50 and over trying diabetes apps, challenges to app usability were assessed via observation and self-report and summarized in Figure 2.

Figure 2. Issues encountered during app tests (multiple selections possible, n=29)

App accessibility

• When developing mobile apps, special considerations need to be taken to accommodate the needs of older people (65+), due age-related challenges such as decline in vision, hearing, cognitive abilities, and decreased mobility.5

• In 2016, seniors (65 yrs +), 6.6% had a visual disability, 26.9% had a mobility impairment, and 14.9% with a hearing impairment.
• In a study of 29 patients using a mobile app to manage diabetes treatment, 90 percent had difficulty navigating the app, and nearly half reported difficulty in usage from too small text and representation, distinguishing and pressing buttons. 2

Evidence of mHealth efficacy in older populations

• Older people are able and willing to use smartphone technology for medical management

• A 2010 survey by the American Association of Retired Persons showed that 89% of individuals over age 50 use a mobile device with the most common device being a cellphone and 7% using a smartphone. 1 in 10 respondents used an mHealth application to track health measures like weight, blood pressure, blood glucose, but 4 in 10 are interested in using one in the future4 

• Study of 24 CAD patients over 60 yo (mean 73.8 yo) with no prior knowledge of tablet computers showed that both subjective and objective medication adherence increased significantly with use of a medication tracking app on tablet1
• A systematic review which analyzed 48 papers on home health monitoring of older adults found that apps monitoring heart conditions improved patients’ communication of data with clinicians and their BP control. There was not strong evidence that mHealth apps addressed the conditions of the disease or improved health-related quality of life6

• In one study, telemonitoring was associated with fewer emergency department visits in heart failure patients
• In another study, BP was significantly lower in patients using mhealth apps
• Evidence that mhealth apps can address COPD has been conflicting6

• Evidence behind the use of technology alone to improve patient outcomes has been mixed, but the combination of automated reminders from electronic devices with in-person reminders from medical care providers have had more encouraging results1 
• Older adults are less likely to own smartphones, and even less likely to use it for health information.

• In a Pew Research Study of 3,014 US adults, 45% of adults own smartphones but only 11% of adults 65+ own a smartphone. 7
• As the percentage of cell phone owners who used their phones to search for health information almost doubled between 2010-2012 (17% to 31%), it did not change much within the 65+ age group (8% to 9%)7

• Older adults are less likely to use smartphones to track and manage their health

• 10% of 65+ smartphone owners have an app to track/manage health (vs. 19% of all ages)7

• Adults are more likely to use smartphones for medical information when they have recently faced a medical problem

• 40% of cell phone owners who faced a medical crisis within the last 12 months used phone to search for medical information, whereas 30% who did not face a medical crisis7
• 41% of cell phone owners had a significant health change within the last 12 months used phone to search for medical information, whereas 28% who did not have a significant health change used their phone to find medical information7

Sample Apps/Devices for Remote Monitoring

Heart Rate:

• Heart rate can be measured through photoplethysmography (change of blood flow through optics). Contact photoplethysmography (i.e. fingertip on to the camera), were found to be more accurate than non-contact photoplethysmography.8
• Sample heart rate app monitors through a smartphone camera include

• Heart Rate Monitor (Android)
• Heart Rate Plus (iOS and Android)
• Instant Heart Rate (iOS and Android)
• Cardiio (iOS)

EKG:

• Alivecor: single lead EKG

• Mobile EKG monitor
• Recent FDA approval for use in COVID-19 patients

Respiration rate:

• Masimo was recently granted approval for use of (RRp) respiration rate from the photoplethysmograph.9

Wearable Rings:

• Wellue O2 Ring: continuous monitoring of oxygen saturation, heart rate
• Ouraring: pulse, movement, temperature. Partnering with UCSF for study
• Fitbit (Charge 3, Ionic, Versa, Versa Lite and Versa 2): visualize oxygen variation10

References

1.         Mertens A, Brandl C, Miron-Shatz T, et al. A mobile application improves therapy-adherence rates in elderly patients undergoing rehabilitation: A crossover design study comparing documentation via iPad with paper-based control. Medicine (Baltimore). 2016;95(36). https://journals.lww.com/md-journal/Fulltext/2016/09060/A_mobile_application_improves_therapy_adherence.8.aspx.

2.         Scheibe M, Reichelt J, Bellmann M, Kirch W. Acceptance factors of mobile apps for diabetes by patients aged 50 or older: a qualitative study. Med 20. 2015;4(1):e1. doi:10.2196/med20.3912

3.         Anthony Berauk VL, Murugiah MK, Soh YC, Chuan Sheng Y, Wong TW, Ming LC. Mobile Health Applications for Caring of Older People: Review and Comparison. Ther Innov Regul Sci. 2018;52(3):374-382. doi:10.1177/2168479017725556

4.         Grindrod KA, Li M, Gates A. Evaluating user perceptions of mobile medication management applications with older adults: a usability study. JMIR MHealth UHealth. 2014;2(1):e11. doi:10.2196/mhealth.3048

5.         Okoro CA. Prevalence of Disabilities and Health Care Access by Disability Status and Type Among Adults — United States, 2016. MMWR Morb Mortal Wkly Rep. 2018;67. doi:10.15585/mmwr.mm6732a3

6.         Liu L, Stroulia E, Nikolaidis I, Miguel-Cruz A, Rios Rincon A. Smart homes and home health monitoring technologies for older adults: A systematic review. Int J Med Inf. 2016;91:44-59. doi:10.1016/j.ijmedinf.2016.04.007

7.         Fox S, Duggan M. Main Findings. Pew Res Cent Internet Sci Tech. November 2012. https://www.pewresearch.org/internet/2012/11/08/main-findings-6/. Accessed April 6, 2020.

8.         Coppetti T, Brauchlin A, Müggler S, et al. Accuracy of smartphone apps for heart rate measurement: Eur J Prev Cardiol. May 2017. doi:10.1177/2047487317702044

9.         Masimo gains FDA clearance for new respiration rate measurement system. MassDevice. https://www.massdevice.com/masimo-gains-fda-clearance-for-new-respiration-rate-measurement-system/. Published March 2, 2020. Accessed April 6, 2020.

10.         Russey C. Fitbit Adds Blood Oxygen Monitoring (SPO2) in its Versa, Charge, and Ionic Device. Wearable Technol. January 2020. https://www.wearable-technologies.com/2020/01/fitbit-adds-blood-oxygen-monitoring-spo2-in-its-versa-charge-and-ionic-device/. Accessed April 6, 2020.