Telehealth Access and Use Among Older Adults Post-COVID-19: Heterogenous Effects on Cognitive Functioning

Background: The extension of Medicare telehealth waivers, following the COVID-19 public health emergency, presents an unprecedented opportunity to examine the longitudinal relationship between telehealth usage and cognitive functioning in later life. We analyzed transitions in telehealth use and investigated whether associations between telehealth use and cognitive functioning vary across different levels of cognitive performance. Methods: Using a longitudinal cohort design with data from the National Health and Aging Trends Study (2021-2023), we examined patterns of telehealth access and use among Medicare beneficiaries aged 70+ (N = 3,116). Cognitive functioning was assessed using a comprehensive battery measuring memory, orientation, and executive function. We categorized telehealth access/use into four categories: (1) no access to internet-enabled devices, (2) basic use (email/texting only), (3) broader internet use without telehealth, and (4) telehealth use. Using unconditional quantile regression with fixed effects, we examined associations between telehealth access/use and cognitive functioning across the cognitive performance distribution. Results: While 64% of telehealth users maintained their usage over consecutive years, 44% of those without device access remained without access. Compared to basic internet use, lack of access to internet-enabled devices was associated with cognitive decline (b = -0.64, p < 0.05), whereas telehealth use was associated with better cognitive functioning (b = 0.57, p < 0.01). The association between telehealth use and cognitive functioning was only significant at the lower end of the cognitive distribution (10th percentile: b = 1.43, p < 0.01), with no significant associations observed at higher levels. Conclusions: The stable nature of digital access and usage over time-with most older adults either maintaining their initial level or showing limited upward mobility in digital engagement-underscores the importance of early intervention to promote internet access and skills. Telehealth use was linked to cognitive benefits only at the lower end of the distribution, suggesting the importance of targeted interventions to promote telehealth access among the older population at risk of cognitive impairment.