Amelia Paveley is an Academic Clinical Fellow working in Bath/Bristol. Harriet Hall is an anaesthetic Core Trainee based in London. They share an interest in perioperative care for older people, and patient and public involvement and engagement.
Digital health tools are transforming healthcare, but are they transforming it for everyone? For older surgical patients, who often live with frailty, multimorbidity, sensory and cognitive impairment, the answer is far from clear. Yet older people account for a substantial number of those having surgery every year.
From surgical clinics delivered via telemedicine, online preassessment and virtual prehabilitation courses, to patient portal apps - new digital health tools are being designed and rolled out across the perioperative pathway at pace. These tools have the potential to streamline services and provide convenience for many patients. However, if the tools themselves aren’t designed with older people in mind or tested with older adults as users, they may not be fit for purpose.
We know that older adults are a diverse group. Many use smartphones, apps and the internet in their day-to-day lives. But there is a digital divide: a disproportionate number are digitally excluded compared with younger age groups. This means a lack of access to digital devices, potential issues of affordability, and a resulting lack of digital literacy. Of all UK adults who have no basic digital skills, over three quarters of them are aged 65 and over; a third of UK adults aged over 75 years do not use the Internet; and 29% of older people feel left behind by services moving online.
While organisations such as OFCOM and Age UK have investigated digital inclusion among the general older adult population, little research has been done specifically in the perioperative population. Our review summarises the current research around digital access and digital health literacy among older adults having surgery. We also planned to find out this group’s opinions on digital technology, and what may help or stop them from using it during their perioperative journey.
Perhaps the most striking finding of our review was the absence of data to answer these questions. While many perioperative digital tools were being investigated, we did not find any studies that looked into the digital health literacy of older adult surgical patients, using validated tools. Many studies also made methodological choices which exclude parts of the perioperative population. Huge gains have been made in geriatric medicine to highlight the need for inclusion of older adults in research. Unfortunately, we still see exclusion of the “oldest old”, those living with frailty, multimorbidity or cognitive impairment, as well as patients without access to their own devices or the internet. These are our patients with the highest surgical risk, who may have the most to gain from improvements. To avoid compounding digital ageism, we need to strongly advocate for digital tools and research to be co-designed with a diverse range of older adults.
While older people were less likely than younger patients to choose and use digital tools, it was encouraging to find that they also expressed positivity. The potential benefits discussed were wide-ranging, from improved access to healthcare teams, additional support and guidance, and empowering patients in their surgical journey. These benefits could have a major impact for older people, who typically have a much higher burden of clinic appointments, travel time and cost. This is a hopeful finding given the increasingly digital nature of the perioperative space and our world. In order for everyone to benefit, some individuals will need additional support, whether through family or carer input, or pathways with the flexibility to allow non-digital routes.
Older people are not a minority concern in perioperative care, they are its mainstream. Moving forward, it is essential that digital perioperative tools are co-designed with those who stand to gain the most from using them. With so many advances in technology available, and so many potential benefits for older people, the future looks bright. Through more inclusive research practices and developing tools that work for all older people, this digital future will be better for everyone.
You can read the systematic review in full on the Age and Ageing journal website: What is known about digital literacy, digital inclusion and attitudes to digital health tools among older adults undergoing surgery? A systematic review and narrative synthesis
