The World Health Organization considers all those over the age of 60 as older adults [1]. Nowadays, this portion of the population is more numerous than children under the age of 5. This shows a significant growth in population aging, and challenges professionals to make health services available for everyone [2]. Aging provokes multiple brain and cognitive changes that increase the risks of suffering from dementia [3, 4]. Some of the most common cerebral changes include cerebral atrophy (mainly in the prefrontal cortex and hippocampus), reductions in the volume of the brain´s white matter, cerebrovascular changes, structural and functional changes in neurons, reductions and alterations in multiple neurotransmitter systems, and an increase in the accumulation of amyloid plaques and neurofibrillary tangles [3]. Cognitive changes are also heterogeneous during aging, as crystallized cognitive functions (such as vocabulary or general knowledge) tend to remain stable, whereas fluid cognitive functions (such as working memory or processing speed) tend to decline [5]. Moreover, episodic and semantic memory are two core functions that need to be exhaustively studied in older adults, as memory failures (especially coding and storing failures) are key symptoms of neurodegenerative diseases [3]. These changes do not occur in all older adults, nor do they take place with the same intensity [1, 3]. 

As long as this portion of the population grows, so will the health demands and the cognitive complaints [4]. In this way, it is vital to ensure older adults may access high-quality professional care, especially in rural or hard-to-reach areas [6]. Telemedicine can be defined as the use of electronic communications to provide health services remotely. This practice is especially useful to bring specialized services to remote and/or unattended locations, increasing efficiency in chronic disease treatments, and saving time and money [7]. Teleneuropsychology (TNP) is a branch of Telemedicine that consists of administrating neuropsychological tests remotely, using video-teleconference techniques. [8]. Thanks to this modality, people from rural areas or with insufficient resources, and people with mobility difficulties, can access services they could not otherwise [9]. Telemedicine techniques have been used for many years, and nowadays, telemedicine in general, and TNP in particular, are growing fast as a practical means to provide health services remotely. When it comes to older adults or people that have a hard time understanding and handling technology, it has to be taken into consideration that building a good rapport may take longer, as they need more time than younger people to feel comfortable with this environment [10].

The COVID-19 pandemic forced older adults to remain in their homes respecting the social distancing measures (as they belong to the risk group), limiting their access to face-to-face health services, and causing a significant increase in demand for TNP services [11]. If Telemedicine was already an emerging field before the pandemic [12], the COVID-19 context expanded the need and use of TNP services. In Argentina, only health practices considered as essential were allowed: attending memory complaints and neurocognitive assessments were not included in these essential practices. Held in time, this phenomenon represented a serious problem, as an early neurocognitive assessment is an essential tool for diagnostic, treating and monitoring purposes of many neurodegenerative diseases [13].

Considering this situation, one main question arises: are there differences between a face-to-face neurocognitive assessment (FTF) and a virtual neuropsychological assessment (TNP) in older adults? Previous studies concluded that TNP may be a valid instrument to perform neuropsychological assessments, but also strongly suggests that further research on the subject is needed [6, 14-17]. Studies in Latin America are scarce. Recent studies in younger Argentinian adults show that TNP may be a valid way to assess cognitive functions in a remote context [18, 19], but studies replicating these methods in older adults in this region were almost inexistant. In this way, the purpose of this study was to describe and compare FTF and TNP neurocognitive assessment in older adults. The relevance of this investigation lies in its contribution to validating TNP, in a context where demand appears to grow faster than literature.

To compare FTF with the TNP neurocognitive assessment in older adults, a pilot study was conducted following a cross-sectional correlational design. 32 healthy older adults between the ages of 60 and 85 (X=70; SD=6.22) were assessed, with an average educational level of 15.56 years (SD=3.68); 56.25% of the sample were women, and 43.75% were men. Participants were selected by convenience sampling. All participants were assessed with the same neurocognitive battery: Signoret Battery for Mnesic Efficiency (Serial Episodic Memory Subtest and Logic Episodic Memory Subtest), Digit Span Test (forwards and backwards), Wechsler Adult Intelligence Scale WAIS-IV (Matrix Reasoning Subtest), Stroop Test, Boston Naming Test (short version with 12 stimuli), and Verbal Fluency Test (Semantic Fluency Subtest and Phonological Fluency Subtest). Data recollection consisted of assessing the participant’s performance in both modalities; the sample was divided into two equal groups: one of the groups was evaluated firstly with the FTF modality and secondly with the TNP modality, and the other group was assessed in the inverse way. This was done to discard any possible modality or learning effect. The interval between the first administration and the second administration was of at least 5 weeks. For the statistical analysis, Student t-Test and Pearson’s correlations were conducted. Statistical significance was stated with a p value ≤ .05.

To describe and study the performance of older adults in both modalities, a Student t-Test was conducted to analyse if the cognitive test scores were different whether they were done face-to-face or remotely.

Table 1: Student t-Test for the difference analysis between FTF and TNP sessions in the neuropsychological assessments.

Note: FTF= face to face assessment; TNP= teleneuropsychological assessment; X= mean; SD= standard deviation; t= t Test value; Df= degrees of freedom; p= p value (significant when ≤ .05); BME= Signoret Battery for Mnesic Efficiency)

Table 2: Pearson´s Correlation between the scores from the tests administered virtually (TNP) and face to face (FTF).

Note: r = Pearson´s Correlation; p = p value (significant when ≤ .05); BME= Signoret Battery for Mnesic Efficiency)

As it is clear in Table 2, a positive and statistically significant correlation was observed across all the tests (p ≤ 0.05). The results of the r value of Pearson's correlation show a moderate positive correlation between the FTF and TNP administration of backwards Digit Span (r = 0.34) and forward Digit Span (r = 0.41), while the other tests showed a strong positive correlation: Boston Naming Test (r = 0.57), Stroop Test (r = 0.63), Semantic Fluency (r = 0.64), BME Logic Episodic Memory (immediate recall) (r = 0.66), BME Serial Episodic Memory (recognition) (r = 0.71), Matrix Reasoning (r = 0.86) and Phonological Fluency (r = 0.87).

This pilot study shows that TNP is a valid instrument to perform neurocognitive assessments in older adults, which matches with previous studies conclusions [6, 14-17]. COVID-19 caused a major increase in TNP demands [11], a demand that was already increasing before the pandemic [12] and is expected to grow even more in the current context. This modality would allow professionals to reach those who cannot access a traditional FTF neurocognitive assessment. Even though TNP has important benefits, it has some limitations that need to be considered. The three main challenges of TNP in older adults are lack of familiarity with technology, needing a third person for assistance and reduced access to the right kind of technology [14]. During the recruitment of participants of the present study, many participants had to be excluded because they didn’t own the kind of devices that were needed (computer or tablet), nor someone to help them with the virtual session. On the other hand, there were two cases in which the TNP assessment had to be interrupted because of internet connection issues.

As previously mentioned, older adults have higher risks of suffering dementia due to cerebral and cognitive changes that may come with aging [4]. Although the population aging phenomenon is associated with an increase in chronic pathologies, it also causes a greater need of ensuring that older adults can age healthy and successfully. Having this in mind, being able to access neurocognitive assessments and treatments in the present time and the near future will be important for two reasons. From a clinical point of view, neurocognitive assessments can distinguish between normal and pathologic aging, give prognoses, and design a rehabilitation plan according to the patient’s needs [20, 21]. From the healthy or successful aging perspective, neurocognitive assessments are vital as they provide a comprehensive, systematised and evidence-based approach that can evaluate cognitive functioning [20] to identify onset difficulties on time and make sure that the older adult can maintain as much independence as possible. This second reason is as important as the first one because older adults tend to seek as much autonomy as possible, a fact that becomes threatened when cognitive difficulties begin to appear [3].

The absence of differences between FTF and TNP tests scores allows us to infer that TNP is a valid instrument that may be used with older adults, and may be a useful tool to answer to the growing demand caused by population aging and the epidemiological experience that COVID-19 has left. Further research is still needed in the TNP field, and future studies should replicate these methods with larger samples of the country and the region. It would be also valuable to replicate this study with patients with cognitive complaints, as this and previous studies were conducted with healthy adults [6, 14-17].

In conclusion, the results obtained in this study show that TNP can be used to perform neurocognitive assessment remotely with older adults. Validating this modality is crucial at present times because it allows people to access professional health services that may improve their quality of life. As aging is part of life, the need to guarantee access to neurocognitive assessments ends, sooner or later, including us all.

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