Developing Consumer Consensus on Remote Assessment and Management of Physical Function in Older Adults (RAMP): International Modified Delphi Process

Introduction

Maintaining physical function is crucial for older adults to live independently and maintain a good quality of life [1]. Depending on the task examined, up to 50% of older adults may report difficulty with physical function, and more than 10% use walking aids, with an increasing prevalence of functional limitation in older age (eg, ≥80 years) [2]. Older adults with functional limitations are half as likely to engage with their communities, family, and friends [3] and have significantly increased health care costs compared to those without functional limitations [4]. However, assessment and management of physical function receive limited attention in many clinical settings [5-7]. While multimodal exercise is recommended for improving physical function [8], older adults report that lack of access to interventions, facilities, and relevant health care professionals are barriers to participation [9].

Remote health care services enable patient assessment and monitoring without physical co-location [10] and, especially since the COVID-19 pandemic, have been commonly used by older adults [11]. Emerging evidence suggests digital health interventions using technologies such as telephone calls, videoconferencing, wearable devices, and web applications are feasible and effective for supporting older adults to maintain or improve their physical function [12-14]. However, both consumers (ie, older adult end users) and health care professionals face barriers to engagement with digital health interventions, such as low digital literacy, lack of equipment, and unsatisfactory social interactions [15,16]. Furthermore, the design and implementation of digital health technologies for remote care have largely failed to consider the perceptions and experiences of consumers in their design and implementation, impeding large-scale sustained adoption [17].

The Delphi method, a rigorous consensus-building approach [18], is effective for developing recommendations for the delivery of care related to maintaining and improving physical function in older adults based on the insights of both experts and consumers (ie, older adults themselves) [19,20]. Incorporating consumer participation in consensus-building processes helps ensure that subsequent recommendations address end users’ priorities, maximizing the potential for wide adoption and adherence among consumers in health care and community settings [21]. However, no consumer-focused consensus Delphi process has explored the priorities, acceptability, enablers, and barriers for remote assessment and management of physical function from older adults’ perspectives, and there are no consensus guidelines on the delivery of remote care in older adult populations. Thus, this study aimed to develop consumer-informed recommendations for remote assessment and management of physical function in older adults via a modified Delphi process.

Methods

Study Design and Population

The Remote Assessment and Management of Physical Function in Older Adults (RAMP) International Consumer Delphi Process was a modified (2-round) Delphi study. Eligible participants were aged 60 years and older with internet access, residing in any country, and able to complete the survey in the English language.

RAMP was advertised to potential participants via email (consumer mailing lists of the RAMP Working Group), direct invitations (investigator-led conversations with consumers), and social media (Facebook [Meta Platforms, Inc] advertisements; posts on X [X Corp] and LinkedIn [LinkedIn Corp]) between August and November 2023.

Delphi Process

This study’s methodology adhered to that of a previous modified Delphi process where 2 rounds, as demonstrated by common practice in previous Delphi studies [22,23], were sufficient to reach consensus on sarcopenia management [19]. Multimedia Appendix 1 summarizes the study timeline. The Round 1 survey (Multimedia Appendix 2) was co-developed by RAMP Working Group research experts (DS, CH, JF, PJ, and RMD) and consumer experts (RD and PK) and included questions on demographics, health status (including the SARC-F questionnaire [24]), and health care experiences, plus 23 Delphi statements related to physical function and its assessment and management. The first 13 statements relate to physical function generally, while the latter 10 statements refer to remote provision of health care related to physical function. Respondents were asked to report their level of agreement with each Delphi statement via an 11-point Likert scale (0=Strongly disagree, 10=Strongly agree) and could optionally provide a free-text comment explaining their response to each statement.

Round 1 survey responses were analyzed by DS, and the results and proposed Round 2 survey were shared with RAMP Working Group members for feedback. In January 2024, an invitation to participate in the Round 2 survey, which included seven new or modified statements, was emailed to respondents who completed Round 1, along with a summary of the Round 1 results and an explanation of decisions taken in developing the Round 2 statements (Multimedia Appendix 3). Further details on reasons for low or moderate agreement to Round 1 statements and decisions taken are provided in Multimedia Appendix 4. Upon completion of the Round 2 survey (Multimedia Appendix 5), DS analyzed the results, and ED and DS initially developed the final recommendations. Finally, this manuscript, including the developed recommendations, was revised (2 rounds of revisions) and approved by RAMP Working Group members.

Statistical Analyses

Survey data were assessed for completeness, and all respondents who completed ≥50% of survey questions were included in analyses. Where duplicate responses were identified, the most complete and/or first response was included. Descriptive characteristics were reported as frequencies or percentages for categorical variables and means and SDs or medians and IQR for continuous variables.

Participants with a response ≥7 out of 10 were considered to have agreed with a given statement, and the level of consensus was determined by the proportion of participants who agreed. Round 1 and 2 Delphi statements were classified as having “strong agreement” if ≥80% of participants responded with a score ≥7 out of 10 [19]. These statements were considered to have achieved consensus and were not further modified. In Round 1 only, statements with “moderate” (70%-80% of participants responded ≥7) or “low” (<70% of participants responded ≥7) agreement were revised or rejected. DS reviewed the associated free-text comments and revised the statements based on common reasons for lack of agreement. The revised statements were shared with the RAMP Working Group for approval. In Round 2, all statements that did not achieve “strong agreement” were rejected. All analyses were performed using SPSS Statistics 28 (IBM Corp).

Ethical Considerations

The study was approved by the Deakin University Human Ethics Advisory Group (Reference number: HEAG-H 111_2023) and complied with the Declaration of Helsinki. Potential participants were directed to an online plain language statement defining physical function (ie, “the ability of a person to perform everyday activities”), as well as the study aims and methods. Potential participants provided an electronic signature confirming their informed consent. Those who consented were subsequently emailed a link to the Round 1 Delphi survey (hosted by Qualtrics XM). Participants who completed the Round 1 survey were invited to participate in the Round 2 survey between January and February 2024. Participants who consented but had not completed the Round 1 and 2 surveys were sent a reminder 2 weeks prior to the closing date. Participation was voluntary, and respondents did not receive any form of reimbursement.

Results

Round 1

A total of 861 complete consent forms were received, and the Round 1 Delphi survey subsequently received 716 responses during the Round 1 survey period. Of these responses, 50 (7%) completed less than 50% of the survey, and 12 (2%) were duplicate responses. Thus, 654 of 861 (76%) consented consumers were included in the Round 1 survey analyses. Most of the included respondents (n=644, 98%) completed the entire Round 1 survey, while 10 respondents rated their agreement with the first 13 statements only. Respondents’ mean age was 69.0 (SD 6.0) years, and three-quarters were female (Table 1). Respondents were residing in 15 countries across 5 continents (Australia, Africa, Asia, Europe, and North America), although the majority (81.5%) were from Australia and the United Kingdom. Three-quarters of respondents had completed higher education and around 70% were retired. Over 87% rated their health as good to excellent, but more than 70% perceived their current physical function was “somewhat worse” or “much worse” than when they were 40 years old. The SARC-F instrument demonstrated that approximately 54% of respondents had some functional limitation, and around one-quarter had experienced at least one fall in the past year (Multimedia Appendix 6).

Less than one-third of respondents reported that a health care professional had started a conversation with them about their physical function in the past 5 years, while 38% had initiated a conversation themselves (Table 2). More than 60% had sought information on physical function from sources other than a health care professional. Around 40% of respondents reported having ever completed a physical function assessment with a health care professional, and almost 50% had commenced a supervised exercise program aimed at improving their physical function. The majority of respondents (>60%) had commenced an unsupervised exercise program aimed at improving their physical function.

Over 58% of respondents had participated in a remote health care service, while less than 5% had participated in a remote physical function test, and less than 20% had engaged in remote physical function management such as an exercise program (Figure 1). For respondents who had participated in any form of remote care, telephone calls were most commonly used (77%), with video calls and emails/text messages each used by over 30% of respondents. For respondents who had participated in a remote physical function assessment, video calls were most commonly used (75%), followed by telephone calls (25%). For respondents who had participated in a remote treatment for their physical function, written documents (eg, flyers, brochures, magazines, and books) were most common (46%), followed by video calls (38%) and telephone calls (31%). Regardless of the type of remote care, respondents generally reported positive experiences; 75%-81% rated their experience as somewhat or very positive.

Only 5% of respondents reported that they would not be willing to participate in remote physical function tests and treatments (Multimedia Appendix 7), with optional comments indicating that this was due to concerns regarding lack of supervision, safety, lack of necessary technologies and technological familiarity, data privacy, hearing and visual problems, potential costs, and insufficient space in the home. Amongst those willing to participate in such interventions, videos (eg, on a website or DVD) were the most preferred delivery method (78%). Approximately 4% were willing to use other approaches; free-text comments indicated that these could include digital voice assistants, wearable devices, webinars, smart televisions, and wall charts. The most common perceived positives of remote tests and treatments, selected by over 80% of respondents, were the convenience of not needing to travel to appointments and the flexibility to perform assessments and exercises when suitable. Some (<4%) respondents nominated other positives in free-text comments, including avoiding body shaming or embarrassment when exercising, self-motivation, empowerment and autonomy for managing exercise, and better use of health care professionals’ time. Regarding negatives of remote care, the lack of personalized guidance during exercises was reported by half (51%) of respondents, and concerns regarding the potential ineffectiveness of interventions and a lack of social interaction and motivation were each reported by more than 40%. Approximately 14% of respondents cited other potential negatives, including costs and/or lack of access to necessary equipment and technological devices, lack of confidence in performing exercises correctly, low motivation to exercise, lack of engagement with programs and health care professionals, and insufficient space to perform exercises at home.

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Figure 2 and Table 3 present respondents’ reported agreement with the 23 Delphi statements from Round 1. Statements related to the importance of physical function for maintaining overall quality of life, participating in activities in the community and home, and engaging with family and friends (Statements 1.01-1.06) had the highest proportion (97%-100%) of respondents who reported agreement (response ≥7 out of 10) in this round and were accepted. Consensus was also achieved that poor physical function can be prevented and reversed (Statements 1.07 and 1.08; both 86% agreement) and that respondents would discuss with their health care professionals if concerned about their physical function (Statement 1.09; 80% agreement). There was moderate agreement that respondents would like access to information on how to test their physical function (Statement 1.10; 78% agreement) and low agreement that having better access to information would assist in conversations with health care professionals (Statement 1.12; 69% agreement). However, there was strong agreement that respondents would like access to information on how to improve their physical function (Statement 1.11; 86% agreement) and that having better access to information would assist in managing their physical function independently (Statement 1.13; 81% agreement).

Regarding remote provision of health care, almost 80% of respondents agreed that they would be willing to participate in remote physical function tests, but this statement (Statement 1.14) did not meet the criterion for consensus. There was strong agreement that physical function tests would be safe to perform without direct supervision (Statement 1.15; 86% agreement) but only low agreement that respondents would be willing to participate in a remote exercise program that was always (Statement 1.16; 50% agreement) or sometimes (Statement 1.17; 63% agreement) supervised, and moderate agreement that they would be willing to participate in an unsupervised exercise program (Statement 1.18; 72% agreement). There was also low or moderate agreement that respondents would be happy to participate in a remote exercise program in a group setting (Statement 1.19; 45% agreement) or individually (Statement 1.20; 77% agreement). Finally, low proportions of respondents agreed that they would be concerned about their privacy and security when using technology to participate in remote care (Statement 1.22; 21% agreement) or that remote physical function tests or exercise programs would be difficult to perform in their home (Statement 1.23; 16% agreement).

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Round 2

Following Round 1, 13 of 23 statements were accepted to have achieved consensus with strong agreement. It was determined that statements 1.22 and 1.23 had such low agreement that they should be rejected rather than modified and presented again in Round 2. Other statements that achieved moderate or low agreement (Statements 1.10, 1.12, 1.14, 1.16, 1.17, 1.18, 1.19, and 1.20) were modified. In brief, Statements 1.10, 1.12, and 1.14 were revised into Statements 2.10, 2.12, and 2.14, respectively. Statements 1.16, 1.17, and 1.18, which covered similar concepts regarding remote exercise supervision, were merged into a single revised statement (Statement 2.16). Statements 1.19 and 1.20 covered similar concepts regarding preferences for participating in remote exercise individually or in a group setting and were revised into a single statement (Statement 2.19). Finally, based on common themes identified in free-text responses to several statements across Round 1, 2 new statements were introduced for Round 2: Statement 2.24 explored the importance for consumers that remote physical function tests have been demonstrated to be safe and accurate, and Statement 2.25 explored the importance of having access to necessary information and resources to support participation in remote exercise programs. Multimedia Appendices 3 and 4 provide further details on the development of Round 2 Delphi statements.

Among participants who completed Round 1, 526 (80%) completed Round 2. No notable differences were observed between the Round 2 and Round 1 respondents, respectively, for age (mean = 69.3, SD 5.7 vs 69.0, SD 6.0 years) or SARC-F score (median 1.0, IQR 0.0-2.0 vs median 1.0, IQR 0.0-2.0). In Round 2, respondents were asked to rate their physical function compared with when they completed the Round 1 survey (mean interval between survey completions was 117.2, SD 21.5 days). The majority (68%) reported that their physical function was neither better nor worse, while 13% reported their physical function was somewhat or much better, and 19% reported that it was somewhat or much worse.

Figure 3 and Table 4 summarize participant responses to the Round 2 Delphi statements. Respondents strongly agreed that they would like access to instructions on how to test their own physical function and monitor changes (Statement 2.10; 85% agreement) and that having access to information on physical function would allow them to have more informed conversations with health care professionals (Statement 2.12; 82% agreement). Respondents also strongly agreed they would be willing to participate in a remote test of their physical function (Statement 2.14; 83% agreement) and to participate in a remote exercise program suited to their preferences at the time (Statement 2.16; 82% agreement). However, there was only moderate agreement that respondents would be willing to participate in remote exercise programs with a group or individually (Statement 2.19; 72% agreement) and that they would be more likely to participate in a remote physical function test if they were confident that the test was safe and accurate to perform alone (Statement 2.24; 77% agreement). Finally, there was strong agreement that respondents would be more likely to participate in a remote exercise program if they had access to necessary information and resources, including technology and exercise equipment (Statement 2.25; 80% agreement).

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Summary of Delphi Outcomes and Recommendations

Five of seven Round 2 statements achieved consensus (ie, ≥80% agreement), and 2 (2.19 and 2.24) were rejected with moderate agreement. Thus, including the 13 statements accepted in Round 1, a total of 18 statements achieved consensus in this Delphi process and provided a basis for the 7 recommendations relevant to health care professionals, researchers, and policymakers developed by the RAMP Working Group and presented in Table 5.

Discussion

Principal Results

The World Health Organization’s global strategy on digital health stresses the importance of person-centered approaches where end users are engaged in the design and development phases of digital health approaches [25]. This consumer-focused Delphi process demonstrated that older adults recognize physical function as a health priority and are generally accepting of remote assessment and management, including the use of digital health approaches. Based on these findings, the RAMP Working Group has developed 7 recommendations for researchers, health care professionals, and policymakers to guide remote assessment and management of physical function.

Comparison with Prior Work

Consistent with previous health care professional surveys showing that assessment and management of physical function are infrequently performed in clinical settings [7], our Round 1 survey demonstrated less than half of older adult respondents had received any health care professional-led assessment or intervention for physical function. Even fewer had participated in a remote physical function assessment (<5%) or intervention (<20%). This is despite almost 60% of respondents having participated in some form of remote care, likely due to increased general digital health use during and since the COVID-19 pandemic [11]. For those respondents who had participated in remote physical function care, several methods were reported, likely influenced by their appropriateness for the desired outcome. For example, video calls were most commonly used for remote physical function assessments whereas written documents were most commonly used for remote interventions. Respondents reported receptiveness to a range of different remote care approaches, and less than 5% stated they would not be willing to participate in any remote care for physical function. Key facilitators for remote care included convenience and flexibility in scheduling, while barriers included lack of guidance and motivation as reported previously [26]. Based on the Delphi statements that achieved consensus, seven recommendations for remote care of physical function in older adults were developed. The above barriers and facilitators should be considered when seeking to implement these recommendations in research, clinical care, and policy. Our findings are consistent with a recent position statement on telehealth policy for older adults, which highlights the need for dedicated policies to address common barriers to telehealth among older adults [27].

Recommendations for Researchers, Health Care Professionals, and Policymakers

Recognize That Physical Function Is an Important Health Priority for Older Adults

Over 97% of respondents strongly agreed physical function was integral to their overall quality of life and their ability to participate in activities with family and friends and in the community, to exercise, and to complete self-care tasks. This recommendation is in line with the World Report on Ageing and Health [28], which emphasizes that maximizing functional ability is a priority for older adults.

Recognize That Older Adults are Aware it Is Possible to Prevent, Delay, and Reverse Declines in Physical Function

Over 86% of respondents strongly agreed that it is possible to slow down or prevent poor physical function and that if someone already has poor physical function, it is possible to improve it. This knowledge may encourage older adults to engage in physical function care [29] and health care professionals should leverage it to promote and implement individually tailored strategies to maintain or improve physical function.

Regularly Engage Older Adults in Discussions About Their Physical Function

Respondents strongly agreed that they would raise concerns about their physical function with health care professionals and that access to information about physical function would help them initiate these conversations. Previous research has highlighted the importance that older adults place on mutual goal setting with health care professionals regarding their physical function [29], and that aligning care with patient priorities can lead to better health outcomes [30]. Health care professionals may require upskilling to ensure effective collaboration with consumers on identifying causes and symptoms of poor physical function and promoting benefits and strategies for maintaining physical function [8].

Provide Older Adults With Accessible and Reliable Information on How to Monitor and Maintain Their Physical Function

In addition to conversations with health care professionals, respondents reported a desire for information on how to independently monitor and maintain their physical function. Previous research has highlighted the importance of providing physical function information and advice to patients [30]. It is necessary to develop and promote appropriate resources that empower older adults to monitor and maintain their physical function.

For Older Adults Who Have Concerns About Their Physical Function, Facilitate Physical Function Assessments In-Person and/or Remotely Considering Feasibility and Consumer Preferences

There is a lack of data on the acceptability and appropriateness of remote physical function assessment [31]. In this study, however, respondents agreed they would be willing to participate in a remote physical function assessment if they were concerned about it. Remote assessment of physical function for older adults can be as reliable as face-to-face assessments [32,33] although further research is required to identify the most appropriate physical function tests, protocols, and communication platforms to support reliable remote physical function assessment, as well as facilitators and barriers to implementation in home and community settings.

Facilitate In-Person and/or Remote Exercise Programs for Improving Older Adults’ Physical Function Considering Feasibility, Consumer Preferences, and Supervision Requirements

Round 1 statements regarding remote exercise programs with set levels of supervision (ie, always, sometimes, or not supervised) or a set format (ie, individual or group-based) achieved only low to moderate agreement, reflecting the varied preferences for exercise among older adults [34]. Remotely delivered exercise programs with varying levels of synchronous and asynchronous exercise may be beneficial for community-dwelling older adults who do not have access to exercise facilities or prefer exercising alone and/or at home [35]. Remote programs can support novel and engaging exercise approaches such as integrating exercise into everyday activities [36], “exercise snacking” [12,13] and gamification [37], and may also incorporate other behavioral and educational interventions such as nutrition counseling [38].

Many medical professionals lack knowledge on exercise prescription [39]. Referral of patients to an exercise professional with experience in supporting older adults to exercise via remote care should be a consideration for clinicians who do not feel qualified to prescribe exercise. Upskilling exercise professionals in effectively delivering exercise via remote care and providing access to requisite resources and equipment is also important to build capacity for remote management of physical function.

Ensure That Older Adults Participating in Remote Assessments or Exercise for Physical Function Have Access to, or Are Provided With, Appropriate Support, Technology, and/or Equipment

Respondents believed it was safe and feasible for them to perform remote physical function assessments and exercise programs, and contrary to previous research [40], had relatively low agreement (<21%) that privacy was a concern. Nevertheless, ensuring remote care is administered by secure technologies and adheres to privacy laws is an important consideration for health care professionals to reduce barriers for those who do have concerns. Most of our respondents strongly agreed that they were comfortable using technology to participate in remote tests and treatments for their physical function. Technological literacy can be a barrier to participation in remote health assessments [26] and further research is required to identify approaches to overcoming technological barriers to remote care. Our results demonstrate that older adults agree that access to appropriate instructions, technology, and equipment would increase the likelihood of participation in remote programs. These findings suggest that older adults can successfully participate in remotely delivered exercise programs if appropriate support is provided. This can include standby technical assistance and technology orientation sessions, especially in the early stages of the program [41]. This support can potentially be integrated into existing funding models to support remote care which have increased internationally, particularly following the COVID-19 pandemic, although further development of policy and reimbursement mechanisms is needed for sustainable integration [42].

Recommendations for Future Studies

Based on the current results, it is recommended that future research, informed by collaboration with consumers, caregivers, health care professionals, and policymakers should focus on, but not be limited to, the following outcomes:

• Identifying and addressing barriers to accessibility of remote physical function assessment and management for older populations, particularly in culturally and linguistically diverse populations, those with socioeconomic disadvantage, those from low-middle-income countries, and/or those with low technology literacy or with limited access to technology
• Determining optimal approaches (including protocols and technologies) to delivering remote care for physical function to ensure validity and reliability of assessments and effectiveness and safety of interventions
• Exploring cost-effectiveness and implementation processes to embed remote care for physical function across varying levels of health care internationally
• Developing evidence-based guidelines and health promotion strategies for remote physical function assessment and management in older adults

Strengths and Limitations

Our modified Delphi study was co-developed with health care consumers and incorporated 2 rounds of iterative and anonymous questionnaires and controlled feedback to create consensus. Our study adhered to quality evaluation metrics for Delphi methodology [22] and included an international population of older adults. A high level of agreement (80%) was set a priori for acceptance of statements. There was low attrition of participants between Delphi rounds (<20%), suggesting the respondents were engaged and interested in sharing their views on physical function assessment and management.

Despite these strengths, there were limitations to our study. Given our survey was electronic, the participants required internet access and were likely technologically savvy, and thus a selection bias may be present. Respondents were from 15 generally high-income countries, with the majority residing in Australia and the United Kingdom, a large proportion (76%) were tertiary-educated, and all were English-speaking. It is not known if results are generalizable to those with lower socioeconomic status and/or non–English-speaking individuals. Our respondents also included a large proportion of women (76%), so it may not accurately reflect the views and experiences of older men. Similarly, less than 5% of respondents were aged 80 years or older, and less than 7% had a SARC-F score ≥4 (symptomatic of poor physical function) [24]. However, comparable SARC-F data in our study (median 1, IQR 0-2, proportion with score ≥4=7%) and other similar cohorts (median 0, IQR 1-2, proportion with score ≥4=6%-15%) [24] suggests the level of poor physical function in our sample is generally representative of community-dwelling older adults. Overall, further research investigating remote physical function care preferences in more diverse populations is required to understand the unique and common barriers, enablers, and needs, which would help to enable more widespread adoption of remote methods. This should include research in men, non–English speakers, the oldest old, those with poorer health and/or digital literacy, those with poorer access to health care and/or technology, and those with poor physical function. Furthermore, effective strategies to address technology access, digital literacy, and support needs for these vulnerable populations need to be explored. This may include reducing access barriers through device and internet connectivity provision, improving digital health literacy through ongoing human coaching and troubleshooting support, and co-designing content, interfaces, and delivery models with underserved communities [43].

The current study captures respondents’ preferences and intentions, but not their behaviors or health outcomes. Future research is therefore needed to evaluate engagement with remote physical function interventions among older adults in the real world, as well as the effectiveness of such interventions for relevant health outcomes. The study was also focused on consumer perspectives and does not capture the perspectives of other stakeholders involved in delivering care to older adults (eg, health care professionals and policymakers), which are critical to translating research into practice. To address this, the RAMP working group has recently completed a Delphi process investigating the views of experts involved in the care of older adults (manuscript under review).

Conclusions

This international consumer Delphi process achieved consensus on 18 Delphi statements, which were synthesized into 7 recommendations for health care professionals, researchers, and policymakers to inform remote assessment and management of physical function in older adults. Further research on the feasibility and integration of remote delivery of physical function assessment and exercise programs is required, and this should be co-designed with older adults and other relevant stakeholders. Furthermore, given the recommendations reflect the sample of predominantly highly educated and digitally literate volunteers from high-income countries, further research is also required to explore their generalizability to more diverse older adult populations.