983630

research-article2021
JAGXXX10.1177/0733464820983630Journal of Applied GerontologyEsfandiari et al.

Systematic Review/Meta-Analysis
Journal of Applied Gerontology

The Effect of Telehealth Interventions 1­–10

© The Author(s) 2021
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https://doi.org/10.1177/0733464820983630
DOI: 10.1177/0733464820983630

Adults with Pre-Frailty or Frailty: A journals.sagepub.com/home/jag

Systematic Review and Meta-Analysis

Elham Esfandiari1,2 , William C. Miller1,2,

and Maureen C. Ashe1

Abstract
Telehealth interventions improve health outcomes by increasing access to care. We conducted a systematic review to
synthesize evidence on the effect of telehealth interventions compared with no intervention or usual care for older adults
with pre-frailty or frailty for physical function, quality of life (QOL), and frailty. We searched for randomized controlled trials
(RCTs) in MEDLINE, PubMed, Embase, CINAHL, Cochrane, PsycINFO, and SPORTDiscus. Two authors reviewed records
and assessed risk of bias. A narrative synthesis of findings was conducted. When appropriate, the standard mean difference
(SMD) was used to compare telehealth interventions with control conditions. We used GRADE to determine the certainty
of the evidence. Twelve RCTs were included. Low certainty evidence highlighted positive effects for the function and mental
component of QOL favoring telehealth interventions (SMD = 0.31, 95% CI = [0.15, 0.47]; and SMD = 0.43, 95% CI =
[0.22, 0.64], respectively). Despite a small positive effect of telehealth interventions, insufficient, and low certainty evidence
precludes making definitive recommendations.

Keywords
technology, health-related quality of life, physical function, mobility, balance

Introduction impairment, and disability (Rockwood et al., 2005). The

Worldwide, the population of older adults, aged 65 years and
older, is rapidly increasing and estimated to reach 2 billion
by 2050 (Kinsella & Phillips, 2005). One of the most chal-
lenging consequences associated with aging is frailty: an “at
risk state” caused by an age-associated accumulation of defi-
cits, such as disease and disability (Rockwood & Mitnitski,
2011). Frailty creates functional impairments for commu-
nity-dwelling older adults (Aihie Sayer et al., 2014), that
could lead to difficulties in completing tasks (activity limita-
tion), or problems with involvement in life situations (par-
ticipation restriction) (Stucki et al., 2002). Based on data
from a systematic review, the prevalence of frailty in com-
munity dwelling adults aged 65 years and older was esti-
mated at approximately 11% of the population and is more
common in older women (Collard et al., 2012).
The two most common measures of physical frailty in the
literature (Clegg et al., 2013; Yaksic et al., 2019) are the
Clinical Frailty Scale (CFS) (Rockwood et al., 2005), and
Fried et al. (2001) phenotype. The CFS is based on clinical
opinion and considers older adults’ comorbidities, cognitive
Fried et al. (2001) phenotype is based on five pre-defined
criteria including, involuntary weight loss, exhaustion,
reduced activity, slow gait speed, and lower grip strength. If
an older adult demonstrates only one or two of the criteria, he
or she is in the pre-frailty stage, a transitional period that may
improve with rehabilitation.
A recent scoping review (Puts et al., 2017) identified differ-
ent approaches, such as exercise-based interventions
(Dorresteijn et al., 2016) and nutritional support (Neelemaat
et al., 2011), may provide benefits for people with frailty, their
families, and society. However, access to such interventions is
Manuscript received: July 13, 2020; final revision received:
November 20, 2020; accepted: December 1, 2020.
1
The University of British Columbia, Vancouver, Canada
2
GF Strong Rehabilitation Centre, Vancouver, British Columbia, Canada
Corresponding Author:
Maureen C. Ashe, Centre for Hip Health and Mobility, The University
of British Columbia, Robert H.N. Ho Research Centre, 5th Floor, 2635
Laurel St., Vancouver, British Columbia, Canada V5Z 1M9.
Email: maureen.ashe@ubc.ca
2 Journal of Applied Gerontology 00(0)
limited for older adults with physical frailty (Passalent et al.,
2010). Telehealth is one means of increasing access to care
and improving health outcomes (Ekeland et al., 2010).
Telehealth is an umbrella term covering health care delivered
remotely, such as telemedicine and a variety of non-physician
services, including mobile health (mHealth, e.g., mobile appli-
cations) and electronic health (eHealth, e.g., patient education
portals) (Weinstein et al., 2014).
To our knowledge, there is only one systematic review on
the effect of telehealth interventions for older adults with
frailty (Barlow et al., 2007), and one systematic review for
the general population of older adults without severe chronic
medical conditions (Muellmann et al., 2018). While the
review for older adults with frailty and telehealth was prom-
ising, it included different study designs in the synthesis
(Barlow et al., 2007). The other review compared eHealth
interventions with non-eHealth interventions or no interven-
tions on physical activity for older adults in the general pop-
ulation. Therefore, these results may not be generalizable for
older adults with frailty (Muellmann et al., 2018).
To address the gap in knowledge for older adults with
frailty and telehealth, we conducted a systematic review of
randomized controlled trials (RCTs) to identify and synthe-
size available evidence. We were particularly interested in
the effect of telehealth on physical function and health-
related quality of life in pre-frail or frail community-dwell-
ing older adults. We further aimed to describe and consider
important contextual information such as definition of frailty
and type of telehealth intervention.
Methods
We conducted a systematic review following the guidelines
established by the Preferred Reporting Items for Systematic
reviews and Meta-Analyses (PRISMA) (Moher et al., 2010),
and registered the title and protocol on PROSPERO
(CRD42018100504).
Eligibility Criteria
We included peer-reviewed RCTs which met the following
criteria: population: community-dwelling older adults, aged
65 years and older, who were identified as pre-frail or frail
(Fried et al., 2001); intervention: health programs delivered
(alone or in combination) remotely by telephone or smart-
phones (i.e., audio/video calls, texts, mobile or tablet appli-
cations [app]), computers (i.e., website, email), or DVD-based
interventions: we did not include interventions that only
focused on nutrition; comparator: no training or usual care;
outcomes: our primary outcome was physical function, that
is, functional ability and behavioral performance, including
functional status assessment, functional impairment, and dis-
ability measured with either self-reported questionnaires or
objective physical performance tests (Paterson & Warburton,
2010). Our secondary outcomes included other functional
domains (e.g., mobility, balance, and physical activity)
(Fairhall et al., 2011), self-report domains (e.g., health-
related quality of life, life satisfaction), falls, and change in
frailty status. When outcomes were measured using different
methods in the same study, we chose data from the objec-
tively measured tools or instruments to include in the
meta-analyses.
Information Sources
We searched the following databases for all languages and
years until 18 March 2020: MEDLINE (Ovid), PubMed,
Embase (Ovid), Cumulative Index to Nursing and Allied
Health Literature (CINAHL), Cochrane Central Register of
Controlled Trials (CENTRAL), PsycINFO, and SPORTDiscus.
The first reviewer (E. E.) conducted a forward and backward
(reference list) citation search for included studies, and two
systematic reviews (Barlow et al., 2007; Muellmann et al.,
2018) and one scoping review (Puts et al., 2017) to find rele-
vant papers for screening. We performed a focused “allintitle”
search for keywords in Google Scholar; and searched Theses
Canada Portal, the ProQuest Dissertations and Theses Global,
the EthOS, registry of clinical trials (clinicaltrials.gov), and
the World Health Organization (WHO) international clinical
trials registry platform (http://www.who.int/ictrp/en/). For
publications in languages other than English, we contacted the
corresponding author for an English version, or used Google
Translate.
Search
The Medical Subject Headings (MeSH) terms, and keywords
for frailty and telehealth were used to develop our search strat-
egy at MEDLINE (Ovid). The search strategy in Supplementary
Figure 1 was used as the foundation for searching the remain-
ing databases.
Study Selection
Covidence (Covidence, Victoria, Australia) was used to
remove duplicates and screen at Level 1 and 2. Two authors
(E. E., M. C. A.) independently screened the titles and abstracts
(Level 1), and excluded citations that did not meet the inclu-
sion criteria; for example, studies with different patient popu-
lations, no telehealth interventions, and study designs other
than an RCT. A third reviewer (W. C. M.) adjudicated any
unresolved discrepancies. We repeated this process for the full
text screening (Level 2), and recorded reasons for exclusion
only at this level. We emailed the corresponding author if we
had any questions.
Data Collection Process and Items
One author (E. E.) extracted data and a research assistant
reviewed it for accuracy. We extracted the following
Esfandiari et al. 3

Records identified through Additional records identified through

database searching other sources
(n = 2765) (n = 33)

Identification
Duplicates removed
(n = 258)

Records excluded
(n = 2426)
Screening

Level 1

Records screened
(n = 2540)
Full-text articles excluded,
with reasons:
- Population not frail (n = 19)
- Wrong setting (n = 3)
- Wrong intervention (n = 21)
Full-text articles - Wrong study design (n = 30)
assessed for eligibility - Wrong outcomes (n = 4)
Eligibility

Level 2

(n = 114) - Conference abstract (n = 17),

commentary (n = 1), or letter
(n = 3)
- Systematic review (n = 3), or
protocol (n = 1)

Studies included in
qualitative synthesis
(n = 12)
Included

Studies included in
quantitative synthesis
(n = 5)

Figure 1.  PRISMA flow diagram for study selection into the systematic review: The titles and abstracts were screened at Level 1 and
excluded if they did not meet the inclusion criteria, such as different patient populations, no telehealth interventions, or study designs
other than an RCT. The full-texts were screened at Level 2 based on the same eligibility criteria.
Note. RCT = randomized controlled trials.

information: author, country, study sample, sampling frame
and recruitment, mean and standard deviation (SD) for age,
sex, gender, outcome measure used to define frailty, descrip-
tion of interventions, data collection timepoints, primary and
secondary outcome measures, reported adverse events or
withdrawals (with reasons), and main results.
Risk of Bias
We used the Cochrane Collaboration’s Risk of Bias tool for
RCTs (Higgins, Savović, et al., 2019). The summary of
assessments was reported as “low risk of bias,” “unclear risk
of bias,” or “high risk of bias.” The risk of bias for incom-
plete outcome data was reported as high, if the attrition rate
was greater than 20%. Two authors (E. E., M. C. A.) indepen-
dently adjudicated scores in Covidence and discussed any
discrepancies. The third reviewer (W. C. M.) adjudicated any
unresolved discrepancies. Concealing group allocation from
participants is a challenge in RCTs involving exercise, physi-
cal activity, and/or telehealth interventions (Baker et al.,
2010). Therefore, we discussed if the knowledge of group
allocation for participants and personnel could change
behavior, and introduce bias (Higgins, Savović, et al., 2019).
Synthesis of Results
We conducted a narrative synthesis of findings, and meta-
analyses when appropriate. We used Review Manager
(RevMan) Version 5.3 (Copenhagen, The Nordic Cochrane
Center, The Cochrane Collaboration, 2014) for meta-analyses.
We used the standardized mean difference (SMD) of change
from baseline for continuous variables, due to different scales,
and 95% confidence intervals (CIs) (Deeks et al., 2019). We
imputed the change from baseline SDs using correlation coef-
ficient if SDs were missing (Higgins, Li, & Deeks, 2019).
Random effects models, using the DerSimonian-Laird (DL)
4 Journal of Applied Gerontology 00(0)
method incorporated in RevMan (Cornell et al., 2014), were
used with the assumption that the observed differences among
studies are due to the intervention effects (Deeks et al., 2019).
We reported the effect estimates and CIs for individual studies
and meta-analysis with the forest plots. The Chi2 (Q) test and
I2 statistic were used to determine the percentage of variability
attributable to included studies (Higgins, Thomas, et al.,
2019). We set the P value less than 0.1 to determine statistical
heterogeneity, due to small number of studies, or an I2 greater
than 50% to quantify substantial heterogeneity (Deeks et al.,
2019). We planned to conduct a sensitivity analysis to investi-
gate differences noted when SMD of final scores versus
change scores from baseline were used. We also planned to
inspect the funnel plot to assess risk of publication bias if we
included >10 studies and conduct the subgroup analysis based
on age groups (65 to 80, and 80 years and older) and frailty
status (prefrailty and frailty).
Two reviewers (E. E., M. C. A.) used the Grading
Recommendations Assessment, Development and Evaluation
(GRADE) rating to summarize the evidence for recommen-
dations (Guyatt et al., 2011); we used GRADEpro GDT
Version 3.6 (Evidence Prime, Inc).
Risk of Bias in this Review Process
To manage unconscious risk of bias of team members, we
registered the protocol before starting the review, two authors
independently (E. E., M. C. A.) screened at Levels 1 and 2,
and assessed risk of bias, and none of the team members had
publications included in this systematic review.
Results
Study Selection
We identified 2,798 citations based on our search of 7 data-
bases and other sources. After removing duplicates (n =
258), we reviewed 2,540 citations at Level 1, and 114 publi-
cations at Level 2. Overall, 12 RCTs were included in this
review (Figure 1).
Study and Participants Characteristics
All studies were in English, and most studies were conducted
in the United States (n = 5) (Finkelstein et al., 2011; Gellis
et al., 2014; Light et al., 2016; Peterson et al., 2007; Upatising
et al., 2013). Studies included older adults with frailty (n = 8)
(Dorresteijn et al., 2016; Favela et al., 2013; Finkelstein et al.,
2011; Gellis et al., 2014; Laforest et al., 2012; Light et al.,
2016; Markle-Reid et al., 2006; Tchalla et al., 2013), pre-frailty
(n = 1) (Dekker-van Weering et al., 2017), or a mix of frail and
not frail (n = 3) (Comín-Colet et al., 2016; Peterson et al.,
2007; Upatising et al., 2013). These included 1,819 community
dwelling older adults (65+ years), predominantly women, with
frailty, including n = 123 participants considered “pre-frail”
(Dekker-van Weering et al., 2017; Upatising et al., 2013). Mean
age ranged from 69 to 86 years and older; please see supple-
mentary Table 1. Different methods were used to define frailty,
such as aged > 90 years needing caregiver or cut-offs on
Barthel index < 90 (n = 1) (Comín-Colet et al., 2016), or Fried
classification (Fried et al., 2001) (n = 2) (Peterson et al., 2007;
Upatising et al., 2013). Three studies targeted older adults with
pre-frailty or frailty with no formal definition for frailty
(Finkelstein et al., 2011; Gellis et al., 2014; Markle-Reid et al.,
2006); please see supplementary Table 2. Recruitment rate
ranged from 1% (Gellis et al., 2014) to 52.5% (Comín-Colet
et al., 2016) for all possible participants, and the retention rate
for the intervention groups ranged from 68.6% (Dorresteijn
et al., 2016) to 100% (Peterson et al., 2007), and between
62.5% (Laforest et al., 2012) to 100% (Dekker-van Weering
et al., 2017; Peterson et al., 2007; Tchalla et al., 2013), for con-
trol groups. Please see supplementary Table 2.
Description of Interventions
The most common delivery method for health programs was
telephone, (n = 8) (Dorresteijn et al., 2016; Favela et al.,
2013; Gellis et al., 2014; Laforest et al., 2012; Light et al.,
2016; Markle-Reid et al., 2006; Peterson et al., 2007; Tchalla
et al., 2013). Interventions were primarily administered by
health professionals, and the delivered content varied from
falls prevention (n = 3) (Dekker-van Weering et al., 2017;
Dorresteijn et al., 2016; Tchalla et al., 2013), increasing
physical activity (n = 2) (Light et al., 2016; Peterson et al.,
2007), to providing self-management skills for health pro-
motion (n = 7), such as monitoring of health conditions
(Comín-Colet et al., 2016; Upatising et al., 2013), social sup-
port (Laforest et al., 2012), resolving clinical emergency
(Favela et al., 2013), or providing educational resources
(Finkelstein et al., 2011; Gellis et al., 2014; Markle-Reid
et al., 2006). The most frequently used control intervention
was usual care (n = 8) (Comín-Colet et al., 2016; Dekker-
van Weering et al., 2017; Dorresteijn et al., 2016; Finkelstein
et al., 2011; Gellis et al., 2014; Markle-Reid et al., 2006;
Peterson et al., 2007; Upatising et al., 2013). The length of
the interventions varied from 3 (Dekker-van Weering et al.,
2017; Gellis et al., 2014; Light et al., 2016) to 12 months
(Tchalla et al., 2013; Upatising et al., 2013) (Supplementary
Table 1).
Risk of Bias Within Studies
The greatest source of bias were blinding of participants and
personnel (i.e., the performance bias), where 33% of studies
were rated with a high risk of bias (Comín-Colet et al., 2016;
Dorresteijn et al., 2016; Favela et al., 2013; Upatising et al.,
2013), followed by outcome assessment (i.e., the detection
bias), where 25% of the studies were rated with a high risk of
bias (Dekker-van Weering et al., 2017; Favela et al., 2013;
Upatising et al., 2013) (Figure 2).
Esfandiari et al. 5
Figure 2.  (a) Overall risk of bias. (b) Risk of bias for individual studies.
Synthesis of Results
No study reported measuring adverse events, and only one
study reported no adverse events occurred during the trial
(Tchalla et al., 2013). One study compared the difference
between gender (women vs. men) (Tchalla et al., 2013), and
found no significant association between gender and falls in
univariate analysis (p = .128) (Tchalla et al., 2013).
Improvement in function (Dorresteijn et al., 2016; Gellis
et al., 2014; Laforest et al., 2012; Markle-Reid et al., 2006),
balance (Light et al., 2016), mobility (Tchalla et al., 2013),
physical activity (Dorresteijn et al., 2016), health-related
quality of life (Comín-Colet et al., 2016; Dekker-van Weering
et al., 2017; Markle-Reid et al., 2006), a decrease in falls
incidence (Dorresteijn et al., 2016; Tchalla et al., 2013), or
frailty status (Favela et al., 2013; Peterson et al., 2007), were
identified in 10 studies. Outcomes of interest were not avail-
able for all studies, therefore we could only conduct the
meta-analysis for function using four studies (Dekker-van
Weering et al., 2017; Dorresteijn et al., 2016; Laforest et al.,
2012; Markle-Reid et al., 2006), physical and mental compo-
nents of quality of life including, two (Dekker-van Weering
et al., 2017; Markle-Reid et al., 2006) and three studies
(Dekker-van Weering et al., 2017; Gellis et al., 2014; Markle-
Reid et al., 2006), respectively. We completed a narrative
synthesis of findings for the seven remining studies. Below,
we review and tabulate the results by outcome. A detailed
summary is provided in supplementary Table 3. Due to the
small number of studies it was not possible to conduct sub-
group analyses based on age or frailty status.
Primary outcome
Function. Physical function and behavioral performance
were reported in seven studies (Comín-Colet et al., 2016;
Dekker-van Weering et al., 2017; Dorresteijn et al., 2016;
Gellis et al., 2014; Laforest et al., 2012; Markle-Reid et al.,
2006; Upatising et al., 2013). Three studies consistently
reported telehealth interventions did not improve function (as
measured by the European self-care behavior scale, Comín-
Colet et al., 2016, or EQ-5D-3L, Dekker-van Weering et al.,
2017), or functional decline with frailty and mortality states
(Upatising et al., 2013). However, four studies reported
telehealth interventions improved function compared with
a control group as measured by the Western Ontario and
McMaster Universities Osteoarthritis Index (Laforest et al.,
2012), 18-item Groningen Activity Restriction Scale (Dor-
resteijn et al., 2016), Personal Resource Questionnaire 85
(Markle-Reid et al., 2006), or Social Problem-Solving Inven-
tory-Revised (Gellis et al., 2014).
There was low certainty for a small positive change in
favor of the telehealth intervention in function, Figure 3(a), 4
studies (Dekker-van Weering et al., 2017; Dorresteijn et al.,
2016; Laforest et al., 2012; Markle-Reid et al., 2006), 647
participants: SMD = 0.31 [95% CI = 0.15, 0.47], p =.0001.
Results showed little to no heterogeneity between studies
(Chi2 = 2.19, p = .53, I2 = 0%). We performed sensitivity
analysis on final scores of function; no effect of telehealth
interventions compared with control was observed (635 par-
ticipants: SMD = -0.04 95% CI = [-0.20, 0.12], p = .64).
The GRADE summary of evidence is provided in Table 1.
Secondary outcomes
Quality of life.  Four studies assessed the effect of tele-
health interventions on quality of life measured with the
Minnesota Living with Health Failure Questionnaire
(Comín-Colet et al., 2016), SF-12 (Dekker-van Weering
et al., 2017; Gellis et al., 2014), or SF-36 (Markle-Reid
et al., 2006). All studies, except one (Gellis et al., 2014)
reported enhanced quality of life. The one exception
reported a 12-week depression care management program
6 Journal of Applied Gerontology 00(0)

Figure 3.  Forest plot of the effect of telehealth interventions on change scores of (a) function/behavioral performance, (b) physical and
(c) mental components of health-related quality of life.

Table 1.  GRADE Evidence Profile of Studies Included in the Meta-Analyze.

Certainty assessment
Number of
participants Risk of Publication Overall certainty
Outcome (studies) bias Inconsistency Indirectness Imprecision bias of evidence
Physical function/ 647 (4 studies) Seriousa Not serious Seriousb Not serious None ⨁⨁◯◯ LOW
behavioral performance
Physical component of 273 (2 studies) Seriousa Seriousc Not serious Seriousd None ⨁◯◯◯ VERY
quality of life LOW
Mental component of 366 (3 studies) Seriousa Seriousc Not serious Seriousd None ⨁◯◯◯ VERY
quality of life LOW

Note. GRADE: High quality: very confident that the estimate of effect will not be changed by further research. Moderate quality: moderately confident
that the estimate of effect close to the true effect and further research may change the estimate. Low quality: limited confident in the effect estimate and
further research will likely change the estimate. Very low quality: very little confident in the effect estimate.
a
The weight and sample of studies were reasonable in quantitative analysis; we downgrade one level due to high risk of bias.
b
We downgrade one level due to variety of outcome measurement tools including patient reported tools and performance-based tools.
c
We downgrade one level due to small number of studies.
d
We downgrade one level due to small number of studies and wide confidence intervals.

with daily telemonitoring of health conditions and 8-weeks
of telephone calls did not improve quality of life for older
adults with frailty (Gellis et al., 2014).
The effect of telehealth interventions compared with
usual care was equivalent for the physical component of
quality of life change score, Figure 3(b), two studies
(Dekker-van Weering et al., 2017; Markle-Reid et al., 2006),
273 participants: SMD = 0.06, 95% CI = [-0.18, 0.30], p =
.62, very low certainty. Results showed little to no heteroge-
neity between studies (Chi2 = 0.57, p=.45, I2=0%).
Sensitivity analysis, involving final scores, did not change
the results (SMD = 0.12 [95% CI = -0.12, 0.36], p = .33).
The very low certainty of evidence including three studies
(Dekker-van Weering et al., 2017; Gellis et al., 2014;
Markle-Reid et al., 2006), highlighted telehealth interven-
tions were better at improving the mental component of
quality of life from baseline than usual care (Figure 3(c)),
366 participants: SMD = 0.43 (95% CI = [0.22, 0.64],
p < .0001). There was little to no heterogeneity between
studies (Chi2 = 1.52, p = .47, I2 = 0%). The sensitivity
analysis (conducted by using final instead of change scores)
showed no difference between telehealth interventions and
usual care (366 participants: SMD = 0.21 95% CI = -0.14,
0.57], p = .24) with substantial heterogeneity among studies
(Chi2 = 4.31, p = .12, I2 = 54%). GRADE ratings are pro-
vided in Table 1.
Esfandiari et al. 7
Balance.  Light et al. (2016) tested the effect of telehealth
intervention on balance, (measured with the Berg Balance
Test) for older adults with frailty, and reported 12 weeks
of telephone (calls to support a home exercise program)
increased balance in older adults with frailty.
Falls.  Two studies reported the effect of telehealth inter-
ventions on reducing fall incidence for older adults with
frailty (Dorresteijn et al., 2016; Tchalla et al., 2013). Tchalla
et al. (2013) tested the effect of using a nightlight path with
telephone calls for assistance to reduce fall rates compared
with an in-person fall reduction program. Dorresteijn et al.
(2016) explored the effect of a balance exercise DVD, with
three home visits and four telephone calls, to address fall
incidence reported as number of falls compared with usual
care. Though inconclusive, both studies noted telehealth
interventions decreased falls occurrence.
Mobility.  Tchalla et al. (2013) reported a 54-week study
using a nightlight path with telephone calls for assistance,
increased walking performance, measured by the Timed-Up
and Go test, in older adults with frailty.
Physical activity. Two studies assessed the effect of tele-
health intervention on physical activity for older adults with
frailty (Dorresteijn et al., 2016; Tchalla et al., 2013). Tchalla
et al. (2013) reported physical activity, measured with the
Lawton Activities of Daily Living (ADL), did not increase
with a telephone call intervention. However, Dorresteijn
et al. (2016) reported a home-based balance exercise pro-
gram, with three nursing home visits and four telephone
calls, increased ADLs measured with the Groningen Activity
Restriction Scale, after 12 months.
Frailty status. Three studies explored the effect of tele-
health interventions on frailty status (Favela et al., 2013;
Peterson et al., 2007; Upatising et al., 2013), measured with
the Fried theoretical framework (Fried et al., 2001). Favela
et al. (2013) noted a 36-week nurse home visit program, along
with an alert button and telephone calls decreased frailty pro-
gression. Likewise, Peterson et al. (2007) observed a 24-week
physical activity counseling group, with follow-up telephone
calls, decreased frailty progression in older adults with frailty.
Conversely, Upatising et al. (2013) found that 54-weeks of
telemonitoring of health conditions resulted in lower frailty
status, in older adults with pre-frailty and frailty.
Adherence.  Only one study reported adherence. Dekker-
van Weering et al. (2017) reported 68% adherence to a
12-week web-based self-management exercise program,
measured with completion of the training session by watch-
ing exercise videos, for older adults with pre-frailty.
Satisfaction. There were only two studies that explored
older adults’ satisfaction with telehealth interventions: (a)
a 36-week web-based educational resource with videocon-
ferencing and monitoring, and measured with a 6-item sat-
isfaction questionnaire (Finkelstein et al., 2011), and (b) a
20-week telephone call for monitoring and depression man-
agement, as measured with the Home Care Client Satisfac-
tion Instrument (Gellis et al., 2014). Neither study reported
significant differences in satisfaction between telehealth
intervention and usual care.
Discussion
Summary of Evidence
The aim of this review was to evaluate the effectiveness of
telehealth interventions versus control interventions in
improving physical function, quality of life, and frailty status
among older adults with pre-frailty or frailty. Using technol-
ogy to support health care in people with pre-frailty and
frailty was effective for improving physical function and
behavioral performance (four studies [Dekker-van Weering
et al., 2017; Dorresteijn et al., 2016; Laforest et al., 2012;
Markle-Reid et al., 2006); 647 participants], and the mental
component of quality of life (three studies, Dekker-van
Weering et al., 2017; Gellis et al., 2014; Markle-Reid et al.,
2006); 366 participants] compared with baseline. However,
the quality of evidence was very low to low. Our sensitivity
analyses identified no effect of telehealth interventions com-
pared with control on final scores. Further research in this
area is likely to change the certainty of evidence on the effect
estimate. While encouraging, these results must be viewed
cautiously, as there is limited evidence overall, and three
studies did not report any formal definition for frailty which
could affect the overall findings of this review. Furthermore,
the generalizability of findings is limited to community-
dwelling older women, and insufficient data and heterogene-
ity of outcome measures and interventions precluded making
definitive recommendations.
Laver et al. (2020) in a Cochrane systematic review of
telerehabilitation for people after stroke reported no differ-
ence in ADLs, balance, and health-related quality of life.
However, they suggested telehealth is a reasonable way of
service delivery for people with limited access to resources
and can improve rehabilitation services for people living in
remote areas. Important findings emerging from our review,
despite the very low to low certainty of evidence, suggest
telehealth intervention is a practical model of health care
delivery for older adults with pre-frailty or frailty and has
potentially useful clinical applications.
Cost is a potential issue for providing telehealth services
(Henderson et al., 2013). However, the COVID-19 pandemic
highlighted a clear need for care delivered remotely (e.g.,
telehealth) (Makhni et al., 2020). There is insufficient evi-
dence to determine the cost-effectiveness of telehealth ser-
vices for older adults with frailty. Although the cost analysis
of videoconferencing fracture clinics showed the savings for
8 Journal of Applied Gerontology 00(0)
health services by limiting the unnecessary hospital transfers
(McGill & North, 2012), the implementation and mainte-
nance of telehealth care programs need considerable invest-
ment (Makhni et al., 2020). Moreover, the health professionals,
patients, and insurance companies need to be aligned and
trained to solve the challenges of implementation (Makhni
et al., 2020). We recommend future studies determine effec-
tive telehealth implementation strategies, and cost-effective-
ness of telehealth interventions.
Our review highlighted a high rate of retention for study
participants, which is critical to inform practice. Although
from our review little can be discerned on the factors, such as
the intensity and frequency of program which are attributable
to program adherence and study retention; A Cochrane
review by McCabe et al. (2020) on telehealth for adults with
chronic obstructive pulmonary disease concluded remote
delivery improved health-related quality of life and activity,
but it is important to sustain engagement with technology
over time. As telehealth advances, it is important to focus on
implementation factors related to program delivery, adop-
tion, and sustainability.
Limitations
Despite our comprehensive methodology, we may have
missed studies including older adults who were frail but did
not report a frailty definition, or identify the population as
frail (Mohlman & Basch, 2020). Furthermore, we excluded
studies using telehealth nutritional interventions for frailty
(Neelemaat et al., 2011). As there was heterogeneity in the
instruments or outcomes chosen to define frailty, the observed
findings cannot be generalized to all older adults with frailty.
Moreover, studies did not report collecting and adjudicating
adverse events, therefore we cannot comment on harms asso-
ciated with telehealth interventions. Due to the limited num-
ber of studies, with high variability between outcomes, we
were not able to include all studies in a quantitative synthe-
sis. Finally, standard deviations for change scores were miss-
ing in the majority of included studies; however, it is
acceptable to impute this variable (Furukawa et al., 2006).
Conclusion and Implications
We highlight a knowledge and health care gap for telehealth
interventions for older adults with frailty. More accessible
health care interventions may improve function and the men-
tal component of quality of life compared with baseline.
However, evidence is still insufficient to advise health care
professionals. This review highlights that telehealth technol-
ogies can potentially benefit people with frailty. Moreover, it
seems reasonable to suggest that telehealth programs can
assist in providing care (remotely) for older adults with func-
tional limitations.
Acknowledgments
We acknowledge doctoral support for Elham Esfandiari from AGE-
WELL: Canada’s Technology and Aging Network. Associate
Professor Ashe gratefully acknowledges the support of the Canada
Research Chairs program. The protocol of this review is registered
on PROSPERO [CRD42018100504].
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
ORCID iDs
Elham Esfandiari https://orcid.org/0000-0001-7623-1639
Maureen C. Ashe https://orcid.org/0000-0002-6820-4435
Supplemental Material
Supplemental material for this article is available online.
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