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Study of an old Man's Profile - Galleria degli Uffizi - Firenze
The telemedicine in geriatric care: updating the progresses usefulness Torna agli editoriali

di
Anna Giulia Cattaneo, DBSM, University of Insubria, Varese, Italy

The term telemedicine is the neologism used to indicate the exchange of health information with electronic means, involving different programs, technologies and persons.
The use of electronic means to communicate between general practitioners and specialized centers (the referral and medical education services) or the consultation of a doctor by a outpatient or its care givers via telecommunications is the simplest and oldest area in this field.
Newer technologies are available or under study, their exploitation appears in some cases of interest for the geriatric care.

The simplest case involves common media - radio, television - or, more focused on patient's needs, personal phone calls and relationships with the web. The aged person, or its care givers, can use the phone or be instructed to use special web connection to obtain standard or personalized instructions for improving welfare. While useful, this kind of "distance learning" can eventually suffer from insufficient control, for the privacy in managing sensitive data and for the quality of the services, if not given by a sufficiently qualified team.

A further step is the use of tele-rehabilitation after discharge from acute care at the hospital, for example after bone surgery or cardiovascular events, when the limited mobility added to the age can seriously affect the ability to reach the outpatient clinic for periodical updating.

More sophisticated are the systems for continuous monitoring of patients with unstable conditions, whose health conditions can eventually promptly became critical and life threatening. The telemedicine offers for the first time a non invasive technique to keep in constant contact outpatients with unstable conditions, and those at risk of rapidly evolving and life threatening conditions and their care givers, without interfering with the daily activities of the patient. Thus, this last can attend to its normal activity, including eventual job and leisure without interrupting the contact with the care centre.
An increasing number of vital or metabolic parameters can be registered, the marketed sensor systems more diffuse at the present are those monitoring the cardiovascular conditions (as pulse, blood pressure, electrocardiography, oxygen saturation in blood), and those for metabolic control, especially dedicated to diabetics.
The simplest model of a telemedicine system includes a miniaturized, portable sensor (e.g. electrodes, glycaemia and metabolite automatic meter) with a transmitter, carried by the patient, a receiving antenna placed in the central (e.g. the emergency room of a hospital) and an intervention team, resident (e.g. a consultant physician or nurse) or mobile (e.g. an ambulance).
The portable devices became more and more sophisticated and easy to carry, the transmitter is often incorporated to send automatically data, without the need of a manual intervention. It can also be independently built: for example the patient or the care giver can send data through a personal computer, when needed. Data are collected periodically or in real time by a central, and the medical team alerted when a prompt intervention is needed, or simply notified about the health conditions of the subjects taken in care. The team can intervene directly or plan an update of the therapy discussing it with the subject.

The USA database of clinical trials, freely accessible, lists a considerable number of trials aimed to the evaluation of the advantages, if any, of these technology in comparison with more traditional schemas for care, several of them admit older subjects or are especially designed for the geriatric care.
The previously described main fields of exploitations of telemedicine are validated by consulting this database: most trials are aimed to evaluate the goodness of remote care for orthopaedic consultation and follow-up, follow-up of subjects affected by chronic obstructive pulmonary diseases or sleep apnea, or the successfulness of the cure of pressure sores. Special devices are tested to monitor subjects affected by hypertension, chronic heart failure, or type 2 diabetes mellitus. Rehabilitation after stroke and acute heart failure are also considered as remote, education, therapy control and updating.

A newer area of interest is the remote control of the home environment for aged person suffering from dementia or visual impairment. The field presents some rational, and however it seems to be of ethical concern. The noise of continuous control of the every-day life should be carefully evaluated, especially for poorly adaptive and poorly consentient individuals, as patients affected by dementia.

While the telemedicine seems to be of particular interest in countries with rural or poorly populated regions, the geographical distribution of trials involves also industrialized regions, especially in the USA. One of the most active countries seems to be the South Korea, whose government has recently validated the adequacy of the resources o telemedicine for the needs of its territory. In Europe the field is followed with interest by France, Norway and Russia, among others. While not being a remote rural region, the heavy populated Italy should not be absent from the largest multicentered trials, to avoid the flourishing of self-made, poorly controlled and poorly validated habits in a medical area involving an increasing number of its inhabitants.

Anna Giulia Cattaneo, DBSM, University of Insubria, Varese, Italy

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