Case Report Telerehabilitation for Geriatric with Dementia and Long Covid-19

Rehabilitation is crucial for individuals who have survived COVID-19, particularly those who are older and have pre-existing health conditions. These survivors may experience long COVID symptoms up to four months after infection and face difficulties in undergoing conventional rehabilitation methods due to limitations in mobility, lack of social interaction, and inadequate healthcare accessibility. As a result, telerehabilitation (TR) has arisen as an alternate form of care. This case report intends to present empirical evidence on the enhancement of functional status in a geriatric long COVID patient following telerehabilitation. We present a case of an elderly woman with underlying dementia who developed long COVID symptoms including dyspnea and mobility impairment. Considering the circumstances of the COVID-19 pandemic, telerehabilitation is a more suitable option than traditional rehabilitation approaches. Our telerehabilitation program consists of a three-week plan that involves tailored exercise sessions based on the patient's follow-up monitoring report derived from their logbook. The program comprises active mobilization, respiratory and aerobic exercises, as well as a range of motion exercises. After three sessions of TR supervised by family and professional caregivers, we could see improvement in her Physical Mobility Scale (PMS). After 20 days, the patient's PMS score increased by 3 points. The patient experienced functional improvement, characterized by proper body alignment and enhanced cardiorespiratory function. She exhibited enthusiasm and a greater inclination to engage in diverse forms of physical activity when aided by her caregiver. Our patient did not experience any negative occurrences throughout the entire duration of the telerehabilitation sessions.


INTRODUCTION
The coronavirus disease 2019 (COVID-19) infects more than 600 million people globally. 1Even though most COVID-19 patients recover fully from the disease, approximately 5-10% experience prolonged symptoms for several months following the acute COVID-19 phase, defined as long COVID-19 syndrome. 2ny survivors, especially those of older age with long COVID, need rehabilitation.

Rehabilitation has immense
importance, taking into consideration the demographics, comorbidities, severity, involvement, and impairments of the body system affected.Considering the duration of the disease, the rehabilitation program and goal setting would differ based on the duration of the disease (e.g., acute, subacute, and chronic/post-COVID) accordingly. 3Physical Medicine and Rehabilitation specialists (PMR) make functional diagnoses regarding the patient's disability and potential through holistic assessment.They then establish objectives based on the patient's condition.Mostly, the rehabilitation goal is to achieve optimal functionality after experiencing both acute and chronic illnesses while simultaneously mitigating the risk of further complications. 4ring the COVID-19 pandemic, rehabilitation services had to face the challenge of providing the usual care with limitations for inpatient rehabilitation.
Providers needed to find a solution to address rehabilitation intervention using technology as one source of communication method. 5,6he development of telemedicine in physical medicine and rehabilitation services, which includes teleconsultation, telemonitoring, and telehomecare, is increasing worldwide.
Telerehabilitation (TR) is a component of telemedicine that utilizes computer-based technologies to enhance rehabilitation treatments provided by physiatrists. 6plementation of TR has been shown to provide new opportunities that have better effectiveness in improving accessibility and creating the least restrictive environment. 7study shows TR is superior or similar to conventional rehabilitation in clinical outcomes and is used as a complementary therapy or as an alternative treatment.More importantly, TR provides access to rehabilitation services for a large number of patients with immobility during the COVID-19 pandemic. 8,9e advantages of telerehabilitation    infection can lead to significant functional loss with a higher disability in basic activities of daily life, and it is associated with a higher caregiving burden. 14Post-COVID-19 patients had a higher prevalence of reported fair or poor general health (32.9%), poorer physical health (44.1%), and difficulty with physical activities (32.3%). 15Functional decline was observed by 34.95% of the population after 10 months and 5.8% during 6 months. 16sides the physical aspect, the neurocognitive disorder is at risk of declining after the first 30 days of illness.
Global cognitive impairment and executive dysfunction are both correlated with the severity of the COVID-19 infection, which is age-dependent. 17 this case, the patient was an old woman.
Our patient was already diagnosed with dementia, which worsened her cognitive function after the COVID-19 infection.
The term "dementia" refers to a broad category of symptoms that appear when certain diseases or disorders affect the brain.It is a prevalent degenerative disorder among elderly individuals. 16,18The gradual progression of dementia and its associated pathological alterations affect the cognitive, memory, and behavioral functions of elderly individuals.This disorder has a substantial impact on the elderly's capacity to perform everyday tasks, necessitating the presence of a companion in their daily routines. 19 impingement and can manifest suddenly after an accident or as a consequence of chronic, recurrent overuse activities. 23tator cuff injuries affect patients in a manner that is dependent on their age.The prevalence rates rise from 5% to 10% in those below the age of 20 and surpass 60% in individuals aged 80 years and above. 24e primary treatment modality for nonoperative rotator cuff syndrome is physical therapy (PT).Physical therapy The resultant augmentation in pelvic motion in the older ladies had a good impact on their balancing. 30e seemed to be more passionate and willing to do various kinds of exercises with support from her caregiver.No adverse event was shown in our patient during the whole telerehabilitation sessions.
A minimally improved PMS score may be due to caregiver factors.Under these conditions, a caregiver plays a crucial role in providing care for elderly patients with dementia (PWDs), particularly in Indonesia, where healthcare services for dementia care are limited.Consequently, the healthcare system heavily depends on informal caregivers to assist those with disabilities, with the responsibility typically falling on family members such as spouses, children, and relatives.However, there is now a lack of attention towards caregivers, failing to identify and address the significant challenges they experience. 31rthermore, it was our firm conviction that successful rehabilitation is related to the ability of the caregiver.
This case report involves a patient caregiver who works as a home worker.
There is currently no legislative framework in Indonesia that regulates the profession of caregivers.In Indonesia, household workers may be classified as domestic workers, but there is no formal legislation governing their employment as workers. 32In addition, domestic staff are seldom identified as workers (pekerja), but rather as mere assistants (pembantu).Referring to domestic workers as "helpers" perpetuates cultural reluctance to establish a formalized The physical mobility scale (PMS) assesses the functional capacity of elderly individuals.The dependability and validity of scientific studies have been shown and substantiated. 11During the assessment, she displayed an inability to maintain an upright sitting position, with her neck flexed at a 45-degree angle.Based on the physical examination, the target was to improve the ability of the patient to sit upright and lean back and eventually wean the oxygen used.The plan routine included exercise towards sitting upright and leaning back for 30 minutes per day.On the second TR (September 10, 2021), her mobility improved.The patient did not need an oxygen supply anymore.She could sit upright in a wheelchair for an hour.Both her hands and feet were more active.Despite that, she complained of pain in her right shoulder joint and proximal and distal biceps.Thus, rotator cuff tendinitis was suspected.She was treated with topical NSAID.Her TR program was adjusted to include an active-assisted range of motion exercises (ROM) for 20 repetitions per day and sitting upright exercises for 30 minutes per day.On the third TR (September 17, 2021), she was able to stabilize her neck and trunk.The muscle strength of the lower limbs seemed functional, even though there was some inadequate initiation of movement and purposeful movement of the lower leg.That condition made it necessary to introduce the static bike exercise to her TR routine.Exercise was continued with a target of 30 minutes daily as tolerated, stimulating neck control in a prone position with a pillow on the chest and a simple massage on the back.Modifications were made to the ergo cycle pedal by including panels, enabling caretakers to pedal using either their hands or feet while maintaining an ergonomic posture.After three weeks of TR, rehabilitation targets such as mobility improvement, upright sitting, and oxygen weaning were achieved.In addition, her rotator cuff tendinitis, which occurred in the second week, has now completely recovered.

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Hospitalization of elderly individuals can lead to enduring functional decline and a reduction in quality of life.13COVID-19

(
strengthening the rotator cuff and periscapular stabilizers, along with exercises to improve range of motion.Initial non-surgical treatment also involves the utilization of non-steroidal anti-.Moreover, the TR program was modified to incorporate an active-assisted range of motion exercises (ROM) for 20 repetitions daily and sitting upright activities for 30 minutes daily.It was discovered during the third rehabilitation session that the patient was given static bike training due to inadequate initiation of movement and purposeful movement of the lower leg.Utilizing static bikes for exercise is a safe and effective measure for older persons, yielding enhancements in cardiovascular and pulmonary well-being and beneficial impacts on muscular and skeletal health.Stationary bicycling is highly recommended for older adults as it effectively stimulates cardiorespiratory adaptations and carries a relatively low risk of injury. 27Additionally, it has been demonstrated that stationary bicycling, when utilized for moderateintensity continuous training (MICT) high-intensity interval training (HIIT), can lead to strength improvements in older adults. 28,29An empirical investigation has shown that engaging in stationary bicycle exercise can effectively mitigate the risk of falls among seniors by enhancing their balance.The group that used stationary bicycles showed a statistically significant improvement in their Berg Balance Scale score compared to the group that used treadmills.This can be attributed to the fact that the bicycle exercise involved maintaining balance on a narrow saddle, whereas the treadmill exercise required stable weight movement utilizing both feet.30Furthermore, the cycling exercise involves the alternating weight transfer between the right and left lower extremities, where a saddle influences the position of the body's mass.This exercise has a more significant impact on the pelvis's sideways tilting motion than walking on a treadmill.

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relationship between domestic workers and their employers, many of whom share familial or ancestral ties.Employers perceive their duty as paternalistic, providing protection, sustenance, housing, education, and remuneration to domestic workers in exchange for their labor.The job contacts in question have a paternal nature, as they predominantly take place within family homes and are not regarded as economically productive.Consequently, study conducted by Moriichi demonstrates that providing education to caregivers would enhance the outcome of therapeutic rehabilitation. 35Nonetheless, a cross-sectional study examining caregivers of older individuals with dementia revealed that caregivers commonly experience burden.This burden was found to be influenced by several factors, including the caregiver's perception of social support, their educational attainment, the presence of behavioral and psychological symptoms of dementia (BPSD), and the gender of individuals with cognitive impairment.Given the potential growth of the PWD population, future studies must discover efficient ways and resources to alleviate the load on caregivers.Furthermore, it is necessary to explore the identification of the BPSD and how the various phases of dementia contribute to the strain on caregivers.The management of depression in caregivers can be accomplished.By doing so, healthcare practitioners can modify their approach to identify and tackle the caregiver burden. 31The development of telemedicine in Indonesia was started in 2015 and regulated by the Ministry of Health Regulation No. 20/2019. 36Since the pandemic of COVID-19, the importance of telemedicine seems to be crucial and widens the opportunity to expand the use of telemedicine, which refers to the Letter of Announcement of the Indonesian Ministry of Health, Indonesia Medical Council, and Indonesian PMR Association (PERDOSRI).Since the use of telemedicine has become more frequent, Cipto Mangunkusumo General Hospital Jakarta has developed the telemedicine platform named SiapDok RSCM.It is an application that facilitates face-to-face teleconsultation anywhere and anytime.