Last year, a bank officer phoned Kelli Brown’s brother with a concern: a lot of money was going out of their 87-year-old father’s bank account. 

Their father, a retired accountant, lived alone in Cincinnati. He seemed to be functioning well on his own, continuing to drive and golf twice a week. But when asked about the account, their father explained he’d won $3 million in the Publisher’s Clearinghouse Sweepstakes. He was paying the taxes so he could claim his prize. 

“This scammer had befriended him, and my dad fell for it, hook line and sinker,” Brown said. “He was taking money out of his account to buy gift cards and then sent the codes to the scammer.”  

Efforts to convince him this was a scam didn’t work. He continued sending money, and the family was powerless to stop him. Ultimately, he lost $75,000—most of his life savings. 

“He kept telling us, ‘No, I’ve won this money, you guys just don’t understand how the process works,’” Brown said. 

Finally, they persuaded their father to undergo a neuropsychiatric exam, which revealed he had advanced, stage 5 Alzheimer’s disease with dementia. Neither his physician nor the family had noticed any clues. 

“He had been compensating extremely well,” Brown said. 

A Common Tragedy

The Brown family’s situation is not uncommon. Only 50 percent of all dementia cases are ever medically diagnosed.

And many diagnoses come too late—too late to protect the older adult from scams, to make plans for their future or to start treatment that could slow the progression of the disease. 

“It’s a tragedy when I see patients presenting to me who are already in the moderate to severe stages of Alzheimer’s, where we can only offer palliative or comfort care,” said David Weisman, MD, with Abington Neurological Associates in Abington, PA. “It’s a tragedy because now we have a disease-modifying therapy that can slow the disease.” 

Why aren’t more people diagnosed sooner? Signs of cognitive changes in an older adult can be easily missed or dismissed as normal aging. In some cases, the family may know the older adult has cognitive impairment but, assuming nothing can be done, they don’t pursue a diagnosis. And few primary care physicians (PCPs) perform dementia screening on a routine basis.

Health care leaders are taking note. Programs like Dementia Care Aware in California are working to encourage and train providers to perform screening earlier and more proactively for older patients.

“Dementia is incredibly common, affecting as many as 30 to 50 percent of people over age 85, and there are a number of programs, like ours, where the goal is to identify people with dementia much earlier,” said Anna Chodos, MD, a geriatrician and principal investigator of Dementia Care Aware, which aims to improve detection in older adults with Medi-Cal benefits. 

Sooner, Not Later

Experts say sooner is always better for a dementia screening. 

For one thing, a screening as part of an overall checkup could rule out dementia and avoid needless suffering and worry, according to Ambar Kulshreshtha, MD, associate professor, Department of Family and Preventive Medicine, Emory University School of Medicine. 

“Sometimes what looks like dementia might be a treatable condition, like a urinary tract infection, thyroid disease, depression or the result of medication interactions,” he said. “These can mimic cognitive impairment.” 

Some medications, like sleep meds, sedatives and anticholinergic drugs (used for a variety of conditions from overactive bladder to chronic obstructive pulmonary disease), can temporarily impair cognition. 

“It’s important to report concerns about cognitive loss so that your doctor can rule out other causes that might be easily treated,” Kulshreshtha said. 

A later diagnosis may mean it’s too late for a patient to benefit from newer medications that can slow the progression of disease, such as Leqembi (lecanemab-irmb), a drug approved by the FDA in January 2023 for the treatment of Alzheimer’s. (Leqembi is not prescribed for other types of dementia, such as vascular, frontotemporal or Lewy body.) 

“This is the holy grail that we’ve been hoping for and waiting for forever: a disease-modifying treatment,” said Andrew Ferree, MD, a neurologist in Milford, MA, and an Alzheimer’s researcher. “If the patient has Alzheimer’s, you want to catch that as absolutely early as possible.” 

When dementia goes unrecognized, family stress and resentment can build up for years. 

Ferree cited a common saying in stroke neurology: “Time is brain.” For a patient having a stroke, the sooner they’re treated, the more brain function is likely to be preserved. 

“The same can be said for Alzheimer’s now,” he said. “The sooner you get that diagnosis and see if you qualify for that treatment, the more likely it could change everything.” For those with other types of dementia, clinical trials of experimental medications can offer hope, but only if the patient is diagnosed. 

A delayed diagnosis may also carry a psychological cost, according to Weisman. By the time dementia is diagnosed, he said, resentment and stress may have already been building among family members for years. 

Diane Ty, MBA, managing director of the Milken Institute Future of Aging, saw that in her own family. 

After retiring from a distinguished career as an engineer, Ty’s father became increasingly difficult. He was verbally abusive toward her mother. The family assumed he just wasn’t adjusting well to the loss of identity that came with early retirement. Finally, after an unexplained parking lot accident, her father was assessed and diagnosed with dementia. 

That was over 17 years ago, but the memory is still raw for Ty. Her voice broke as she recalled the family’s ordeal.

“Before the diagnosis, my mom endured so much distress over my dad’s behavior and verbal abuse,” said Ty. “When she learned of his diagnosis, she was able to forgive him. She became his caregiver and gave it her all. We finally understood that it wasn’t him. It was this terrible disease.”

Making Plans

An early diagnosis also gives families a chance to put safeguards in place to help protect the older adult’s assets from scammers. 

“There’s an entire scam industry in this country, and it’s targeting vulnerable older people, usually those with some cognitive changes,” Chodos said. 

Even without instances of fraud, an older adult’s finances may suffer from poor decisions caused by undiagnosed dementia. Ty noted that her family missed one clue that seems obvious in retrospect: her father started to spend money on luxuries like a new car or a garage repair, a departure from his normally frugal, practical ways. 

In fact, financial problems, like missing routine payments or a lowered credit score, may represent an early predictor of dementia, according to a 2020 study published in JAMA Internal Medicine. The study found that Medicare beneficiaries who went on to be diagnosed with dementia were more likely to have missed payments on bills as early as six years before clinical diagnosis.

Undiagnosed dementia can be especially problematic for “solo agers” without spouses or adult children, or for those who are socially isolated.

“An older adult with undiagnosed dementia may start having difficulty managing their health care,” said Kristen Romea, LCSW, director of supportive services for Alzheimer’s San Diego. “These days it’s very difficult to do without accessing an online portal. They just stop going to the doctor, so that means they’re no longer getting treatment for the other conditions they’re living with. And they become even more isolated.”

Romea added that many older adults put off having their cognition assessed because of stigma or shame, or for fear of losing their driver’s license. In California, for example, health care providers are mandated to report a dementia diagnosis to the DMV.

How Dementia is Diagnosed

When patients express concerns about cognitive issues to a PCP, typically the first step is a cognitive screening test, such as the Montreal Cognitive Assessment (MoCA) or Mini-Cog. Patients are asked to complete tasks on an app or paper-based test that assesses short-term memory, executive function, visuospatial abilities and orientation to time and place. 

If the screening test points to cognitive issues, the physician will refer the patient to a neurologist, psychiatrist or geriatrician for further evaluation. The next step might involve more in-depth cognitive testing, an extensive medical and family history and imaging tests such as a PET scan or MRI.

However, unless a patient reports concerns, most PCPs don’t perform screenings on a routine basis. 

“It’s really hard to do dementia detection and diagnosis in primary care,” said Chodos. “Doctors don’t get a lot of education on dementia during their training. Dementia is a more labor-intensive, complex diagnosis to make.” 

Dementia can’t be diagnosed definitively with a single blood test or scan. Cognitive assessments such as MoCA aren’t “pass” or “fail” tests; they must be considered in the context of the person’s history. An exceptionally well-educated person, for example, may earn a relatively high score, even if their cognitive abilities have declined significantly due to dementia. 

PCPs are not strongly encouraged to perform routine screening. The most recent statement of the US Preventive Services Task Force, which provides preventive care guidelines to physicians, concluded that the evidence was insufficient to recommend routine screening.  

Changes Ahead

Weisman thinks physicians will be more inclined to perform routine screening as they become more aware of new treatments. As recently as the mid-twentieth century, he said, doctors were reluctant to inform patients of a cancer diagnosis, a virtual death sentence with few treatment options. As the stigma attached to dementia recedes, and treatments improve, Weisman thinks doctors will be more proactive. 

“I think there was a time when doctors thought, ‘Why bother the patient if we can’t do anything about dementia?’” he said. “Now we have something we can do about it.”

Ty notes progress on other fronts that could help change the picture. Researchers are developing new tools that will make diagnosis more accessible and precise, such as a simple blood test to detect biomarkers of disease pathology. Similarly, digital cognitive assessment tools are allowing doctors to move away from paper-based tools, which require someone to be present to administer, observe and interpret the results. Early use suggests these digital tools offer more accuracy in terms of prediction, automated scoring and interpretation. 

Proactive Approach 

In the meantime, patients and families must approach this issue proactively. 

The first step is to become aware of the signs of dementia—and how they differ from normal aging. Nearly everyone over 65 will experience some measure of forgetfulness and mild cognitive decline. It’s normal for an older person to misplace the car keys from time to time. For a person with dementia, however, memory loss begins to disrupt daily life. The person may put the keys in the refrigerator or accuse others of stealing them. 

People with a family history of dementia should consider asking for baseline screening even before they experience symptoms.

“I would be screening before they even start forgetting their keys, before they have any memory problems,” Ferree said. 

Ty is hopeful that, one day, brain health screenings will become as routine as blood pressure checks for adults 65 and older. Until then, patients and their families need to report any symptoms of cognitive change and request evaluation.

“Individuals who are concerned about their memory, or a loved one’s memory, should make an appointment with their health care provider for a thorough cognitive evaluation,” according to the Alzheimer’s Association. 

A Cautionary Tale

Today, Kelli Brown’s father resides in assisted living. Family members continue to pay off his debts. 

Brown is hopeful the scammers will be caught. While dementia robbed her father of his ability to recognize the scam, his accounting habits remained intact. He kept detailed records of all the transactions with the scammer—receipts from every FedEx package received and every gift card he’d purchased. She hopes those records will enable law enforcement to bring the scammer to justice. 

Meanwhile, Brown is sharing her story on Facebook as a cautionary tale, urging friends to pursue dementia screening and assessment for family members who may be affected. 

“With early detection, we could have prevented Dad from giving away his retirement savings,” she said.  

As a human resources executive, Carole Leskin traveled around the world and worked with a diverse group of interesting people. She never married and never had children, but life was full. Then a recession ended her career at age 65. Leskin floundered. 

“I was out of work, without purpose, bored and desperately lonely,” she said. “Sometimes my only human interaction was with someone in line at the supermarket.”

To meet people, Leskin took a class at the Jewish Community Center near her home in Moorestown, NJ. Initial attempts to connect failed; she introduced herself but got nowhere. Finally, she met four women who welcomed her into their group. For years, the group shared countless hours of conversation, lunches and road trips. 

Then, one by one, all the other women in the group died. Leskin developed health problems that left her homebound. Once again, she was lonely and desperate for connection. 

Leskin’s struggle is not only common, it has massive societal implications. A growing body of research points to the importance of social connections for the health and well-being of older adults. 

“Isolation can be as deadly as obesity and smoking,” said Kasley Killam, MPH, a social scientist and the executive director of Social Health Labs, a nonprofit working to address loneliness and social connection. “In fact, its health consequences cost Medicare an estimated $6.7 billion each year. We need to take better care of older adults’ social well-being.”

Social connections were the key predictor of a long, healthy and happy life in the Harvard Study of Adult Development, which began in 1938 and closely followed hundreds of men over the course of their lives. Those in the study who were more socially connected to family, friends and community were happier, physically healthier and lived longer than those who were less connected. Other research links loneliness with greater sensitivity to pain, suppression of the immune system, diminished brain function and less effective sleep. The evidence is so compelling that one expert called loneliness a public health emergency. 

Since the pandemic, American men are in the middle of a “friendship recession.”

“Loneliness kills,” said Robert Waldinger, MD, the Harvard study’s director. “And the sad fact is that at any given time, more than one in five Americans will report that they’re lonely.”

Lane McCullough, 61, was one of those lonely people. After his divorce last year, he found himself spending his evenings alone at home, bingeing Netflix or staring at the walls. He tried going to a few bars; that proved expensive and fruitless. He tried a singles group; people in the group didn’t seem friendly. 

“It’s difficult to get and keep friends,” he said. “Where do you go? What do you do? There’s no guide for this.”

While that’s not strictly the case—books and resources on friendship abound—it’s true that loneliness affects men more than women, according to Killam. One study of over 46,000 people in more than 200 countries found that loneliness was more common among men. Post-pandemic, American men are in the middle of a “friendship recession.” Men’s social circles have shrunk since 1990, and the percentage of men without any close friends has risen.      

Friendships are especially critical for older adults who don’t have adult children or close family members. Wendl Kornfeld, 74, and her husband have no children. Having cared for their aging mothers, she saw how vulnerable people can become later in life. That inspired her to start Community as Family, an education model for older adults who don’t have children or family, at her synagogue in New York. As participants met weekly to learn to navigate their older years, they naturally formed supportive relationships. After eight years as a group, the members sit shiva together, hold house keys for each other or pick each other up from the hospital. Now Kornfeld advises other nonprofits as they adopt the approach. 

Making the first move may be daunting or awkward. That’s inevitable. “If you really want friends, you have to be motivated,” said Kornfeld. “You’re going to have to get outside your comfort zone. It won’t come naturally. Friends need to be replenished, because life takes them away from you.”

Challenging at Any Age

Making friends is hard for adults of any age. As a young mother in the 1990s, Marla Paul remembers filling out an emergency card for her daughter’s school shortly after a move to a Chicago suburb. There were spaces for three neighborhood contacts; she didn’t have a single name to write. That inspired Paul to write an essay for the Chicago Tribune, which sparked a flurry of letters from readers who shared her struggle, and ultimately led Paul to write a book, The Friendship Crisis: Finding, Making, and Keeping Friends When You’re Not a Kid Anymore (2005). 

Almost 30 years later, Paul says it’s still challenging to make friends but in different ways. Her daughter is grown; social connections through her daughter’s school or activities have long disappeared.

Sometimes the best way to make friends is to get involved in local groups that are doing things that interest you.

“When you’re older, you have to be more proactive,” she said. “If you’re retired, you are not organically seeing people every day on a job. You have to work harder to find people. Virtually every new life chapter has the potential to disrupt friendships: moving, leaving an office to stay home, divorce, the death of a spouse, retirement, illness.”  

That was the case for Mina Gupta, 82, a retired microbiologist. She had no trouble making friends until she and her husband moved from the Dallas area to a suburb of Seattle in 2013. The new home was closer to grandchildren, but their social network was thousands of miles away in Texas. 

“It was horrible,” she said. “I knew almost everyone in the Indian community in the Dallas area. Here, I just couldn’t seem to connect with people.”

For Gupta, the solution was getting involved. She began volunteering at a hospital nursery, snuggling the babies of mothers with substance addictions, which led to friendships with the staff and fellow volunteers. Later, to meet fellow gardeners, she put an invitation on NextDoor (a neighborhood-based social media platform) and started a garden club. 

Getting involved also helped Donna Bearden, 75, after she and her husband relocated to Loveland, CO, 10 years ago. She found friends by joining and teaching classes in photography, art and writing. It wasn’t hard to meet people, given that those in the classes shared her passions. Bearden adds that she also learned to advocate for herself in group situations to make sure she was connecting. She wears a hearing aid; if she can’t hear well, she’ll ask people at her book club to speak up. 

“Hearing loss can make you feel so isolated and left out,” she said. “It didn’t come easy, but I’ve learned to be a little bit assertive.” 

Fishing for Friends

Showing up—whether for a singles group, a volunteer job or a community college class —is a first step but doesn’t automatically lead to friendships. Converting acquaintances into friends requires intentional effort.

“Friend-finding is like fishing,” writes Hope Kelaher, LCSW, in Here to Make Friends: How to Make Friends as an Adult (2020). “Casting out the line and, several reels and hooks in, waiting for a bite. And some days … you don’t catch anything at all.” 

“Fishing” for friends is more effective when approached with intentionality and positivity. Research shows that people who think friendships happen organically—based on luck—are lonelier, according to Marisa Franco, author of Platonic: How Understanding Your Attachment Style Can Help You Make and Keep Friends (2022). She advises friend-seekers to beware the “liking gap.” Research shows that, when strangers interact, they’re often more liked by the other person than they assume. By contrast, thinking positively becomes a self-fulfilling prophecy. 

“When people do assume others will like them, they tend to become warmer, friendlier and more open,” Franco writes. 

Developing friendships takes time and effort. One study estimates it takes 50 hours of interaction just to make a casual friend, and 200 hours of time together to create a close friendship. 

Persistence, along with trial and error, finally paid off for Lane McCullough. He found another singles group, Phase 2 Singles 50+, aimed at fostering friendships, not dating. The group boasts a busy calendar of outings and several subgroups based on different interests. Now McCullough goes out at least twice a week, one night playing pickleball and the other socializing. 

“It’s a great group,” he said. “We just clicked.” 

If you’re open to friendships with people who aren’t your age, you’ll have more potential friends to connect with.  

Social scientist Killam urges older adults to cultivate habits that strengthen “social muscles.” Studies show that people feel happier when they spend at least 10 minutes on the phone a few times a week or connect with people five times a day, whether in person, with a text or an email. 

Kelaher also advises older adults to look beyond their peers for their pool of possible new friends. She cites an acquaintance in her 70s who chatted with younger neighbors and occasionally babysat; now there’s a steady stream of visitors of all ages in her home. 

When people are open to friendships of any age, “it really expands the universe of potential friends,” adds Irene Levine, a former clinical psychologist and the author of Best Friends Forever (2009). Intergenerational friendships also offer extra benefits; younger friends may have different perspectives and may appreciate the wisdom and experience of an older person. 

In addition, be open to places to find connections: join an exercise class, alumni group, group travel, volunteer project, or local fan groups for sports teams. If possible, select activities that meet several times or on a regular basis, advises Franco. Faces will grow familiar, increasing the chances of connection.

Online Lifelines

Happily, the Internet opened options for connecting, virtually and in person. During the COVID-19 pandemic, many older adults learned to use new technology platforms, like Zoom and FaceTime. Apps like Meetup, Friender and BarkHappy (for dog lovers) help connect people with common interests. Neighborhood platforms also offer a place to start. 

A word of caution: take care when venturing online to meet people, says Thomas Preininger, LCSW, a counselor at the Ecumenical Center, a mental health agency in San Antonio, TX. Online scammers target lonely older adults: he knows several who lost tens of thousands of dollars to fraudsters who posed as empathetic friends, gained their trust and then asked for money. 

“If someone asks you for money, cut them off right away,” he advises.

For Carole Leskin, now 77, virtual connections became her lifeline after her friends died. She’s housebound due to a stroke and heart failure but has new friends all over the world. She connects via Facebook and through her blog posts on sites like Jewish Sacred Aging. Virtual acquaintances gradually evolved into close friends; she keeps in touch regularly via Zoom, texts and email. Recently, Leskin talked for hours on the phone with a friend in Melbourne, Australia. They’ve never met in person but share common interests in nature and in wetlands, in particular. 

“There is something about this kind of communication that allows for greater sharing,” she said. “It is more thoughtful, uninterrupted and open. In a way, I am closer to these people than I was to my now deceased friends.” 

As a retired registered nurse, Donna Bening, 81, has known for decades that telemedicine was coming. Her expectations have been realized this year.

Bening had two virtual visits via videoconference: first with her primary care physician for a routine checkup, and later with her rheumatologist for a follow-up to track the progress of her rheumatoid arthritis. Bening loved the convenience. Her primary care physician, Bening noticed, checked on her from home, casually dressed, sans the usual white coat.

“Neither of us had to get dressed for the appointment,” Bening said.

Millions of older Americans tried telemedicine for the first time in 2020. Due to the pandemic, medical providers quickly pivoted to virtual visits to minimize potential exposure to COVID-19 for vulnerable older patients, and Medicare expanded its coverage to reimburse for telemedicine visits, which were previously not covered.

“The pandemic took something that was ready to launch in some form and accelerated the adoption of the new technology,” said Joshua Septimus, MD, a primary and internal medicine physician at Houston Methodist Hospital who sees many older adult patients. “I think it will have a lasting impact.”

Many experts believe telemedicine will continue to play a bigger role in medical care for older adults after the pandemic, especially if Medicare maintains its coverage. But while telemedicine offers many advantages to older adults, some worry an overzealous push for widespread adoption could leave some patients behind or push them toward virtual visits even when they really need to be seen in person.

“I worry that people are being blinded by the efficiencies [telemedicine] creates to the limitations,” Septimus said.

Advantages of Virtual Visits

Telemedicine is the use of communications technology to deliver health care to patients at a distance. Virtual visits typically involve video and audio communication, via a laptop or desktop computer, tablet (such as an iPad) or smartphone, but may also include medical visits conducted by telephone. Some expand the definition of telemedicine to include written communication between patients and doctors via email or an online portal.

Early studies indicate that patients are responding positively to virtual interactions.
For many older adults, the biggest and most obvious benefit of telemedicine is the ability to consult a doctor or other medical professional without leaving home.

“Traveling to a clinic or doctor’s office can be an exhausting task for older adults,” said Jessica Voit, MD, an assistant professor in the Department of Internal Medicine at UT Southwestern Medical Center in Dallas who specializes in geriatrics. “Some patients need a family member to take off work to bring them in.”

Eulaine Hall, 87, of Dallas likes that advantage. When her annual checkup took place over the telephone a few months ago, she didn’t need to arrange transportation to the doctor’s office via the city’s transit service for seniors. Hall, who has macular degeneration, can no longer drive.

“Avoiding the trip was major,” she said. “And I felt like the doctor spent more time with me and asked really detailed questions.”

Other advantages: doctors can conduct visits from wherever they are, saving time and money. With the patient’s permission, a third party—another medical specialist or a family member—can easily be pulled into a virtual visit.

“You could have multiple physicians in a consultation with the patient at once, instead of having the patient make multiple visits to multiple doctors,” said L. Arick Forrest, MD, vice dean of clinical affairs at the Ohio State University College of Medicine. “Telemedicine offers the possibility of a more patient-centric approach.”

Telemedicine makes it easier for patients and doctors to have frequent, brief check-ins.

Another advantage: doctors can glean a better sense of a patient’s living situation through a video visit.

“I enjoy seeing patients in their homes,” said Voit. “I get insight into their daily lives. I meet their pets. I might notice things like how it’s a challenge for a patient to stand up from a soft couch, or a throw rug on the floor that might cause a fall.”

Before the pandemic, all visits were conducted in person at Voit’s clinic. Once the pandemic hit, the clinic quickly moved most appointments to videoconference or telephone. Now, it’s a hybrid—the clinic provides some appointments in person when needed and others via telemedicine. Nurses triage appointment scheduling to determine which visits need to take place in person and which can easily and safely be conducted virtually.

“Telemedicine works well for a follow-up visit—for example, if we’re trying a new medication and need to see how the patient is doing with it,” Voit said. “But if I need to listen to the patient’s heart and lungs, or it’s a complex case, I need to see the patient in person.”

Another advantage for older adults: telemedicine makes it easier for patients and doctors to have frequent, brief check-ins.

“As you get older, you get more chronic conditions, and managing those via telemedicine, rather than deferring follow-up until your next doctor visit, is a big advantage,” said Forrest. “With telemedicine, there are more ways to be in constant connection.”

Forrest added that patients can often monitor their vital signs from home, thanks to new, consumer-oriented gadgets, such heart rate monitors, blood pressure cuffs, blood glucose monitoring, or digital pulse oximeters to measure blood oxygen levels. However, insurance coverage for these devices varies.

Technological Challenges

When Rosie Kroft, 80, called to schedule a doctor’s appointment last May, the scheduler told her she’d need to see the doctor via videoconference. Kroft’s cell phone doesn’t have video capabilities, so she enlisted her son to come to her house with his smartphone for the appointment.

“I was pleasantly surprised by how well the visit went, but it would’ve been easier for me to just go to the clinic,” she said.

While many older adults are tech savvy—and many more have become adept with FaceTime, Zoom or other video platforms during the pandemic, to stay in touch with family—some lack the skills or the devices needed to connect with telemedicine. Forrest notes that about 40 percent of patients over 65 in his clinic chose to conduct their virtual visits via telephone, rather than video—about twice as many compared to those patients under 30.

While it was a necessity during the pandemic, “When it’s done by phone, it’s just not as effective,” he said.

In-person visits will always be important. Doctors often pick up subtle physical or behavioral cues that might not come across via telemedicine.

Technology is a barrier for telemedicine for a significant number of older adults in the United States, according to a University of California, San Francisco study.

“Video visits require patients to have the knowledge to get online, operate and troubleshoot audiovisual equipment, and communicate with the cues available in person,” the study reported. “Many older adults may be unable to do this because of disabilities or inexperience with technology. An equitable health system should recognize that for some … in-person visits are already difficult, and telemedicine may be impossible.”

The study estimated that, in 2018, 13 million older adults in the United States were not ready for video visits, mostly due to lack of experience with technology or not owning the right devices.

“Telecommunication devices should be covered as a medical necessity, especially given the correlation between poverty and telemedicine unreadiness,” the study recommended.

The study also noted that older patients are more likely than younger patients to have hearing or vision loss or dementia, which can make telemedicine virtually impossible, unless someone is available to assist with the technology.

Permanent Change or Emergency Stopgap?

Many medical visits that initially took place via telephone or videoconference during the pandemic are now returning to in-person appointments, as clinics put safety protocols in place. That’s how it should be, doctors say.

“One concern of mine is that a lot of virtual care is being done [during the pandemic] for respiratory infections, where the patients really should be examined,” said Septimus. “The value of examining someone’s lymph nodes, throat or chest, that’s something you can’t replicate with technology.”

Going forward, the challenge will be striking the right balance—using telemedicine where appropriate, but making sure patients are seen in person when necessary. And determining whether telemedicine will work for a specific visit isn’t always an easy call. It depends on the situation and may vary from one patient to another. For example, a dermatologist might be able to effectively follow up via video with an established patient with a confirmed diagnosis—such as acne or an eczema flare-up—but a suspicious mole or other skin lesion must be examined in person.

“It’s really up to the practitioner to decide who needs an in-person visit,” said Carmel Dyer, MD, geriatrician with UT Physicians/McGovern Medical School at UTHealth in Houston. “We don’t want a patient who needs to be seen forced into telemedicine. On the other hand, we don’t want to drag them down here to the clinic if it’s not necessary.”

Some experts worry that, given the lower cost of telemedicine visits, insurers may eventually push patients to use this route more and more often, even when they really need to be seen by a physician. Physical examinations and personal interactions will always be important for good medical care. Physicians often pick up on subtle physical or behavioral cues that might not come across via video.

“Telemedicine is not a substitute for an in-person visit,” said Forrest. “It’s a complement.”

Geriatrician Carmel Dyer, MD, suggests that patients ask a family member or friend to join them for virtual visits, to be a second set of ears.

Septimus recalled a patient who seemed nervous and fidgety during an exam; when confronted, the patient confessed that he had a drug addiction.

“I never would have noticed that, had I not been with him in person,” he said.

To help make a virtual visit more thorough and successful, Dyer advises patients to prepare just as carefully as they would for an in-person appointment.

Helpful preparation may include:

• Sitting in a quiet, well-lit location, with the TV off and as few distractions as possible
• Checking vital signs (blood pressure, temperature, oxygen levels, heart rate and weight) before the visit begins
• Writing out a list of questions for the doctor
• Having an up-to-date list of medications
• Wearing hearing aids or glasses, when applicable

Dyer also suggests that a patient could ask a family member or friend to join the visit to be a second set of ears, or to hold the video device if a doctor needs to see the patient’s gait or a hard-to-reach spot on the body.

Before ending the visit, Dyer advises patients to repeat the doctor’s instructions aloud, to confirm they’re understanding them correctly, and to make sure they are clear on what next steps to follow.

Even in these uncertain times, Dyer recommends that patients see a physician in person at least once a year, and more often if they have a condition that requires it. She also thinks first visits should take place in person.

“Establishing a rapport with a new patient is a bit more challenging via FaceTime,” she said. “In person, you can look the patient in the eye.”