Telemedicine Chapter 14: Telemedicine and Care of Older Persons
This chapter is part of Literature reviews carried out for the Heath Service Executive National Telehealth Steering Group April – July 2020
Sapci, AH, Sapci, HA(2019)[Systematic Review]Innovative Assisted Living Tools, Remote Monitoring Technologies, Artificial Intelligence- Driven Solutions, and Robotic Systems for Aging Societies: Systematic Review 
Background: The increase in life expectancy and recent advancements in technology and medical science have changed the way we deliver health services to the aging societies. Evidence suggests that home telemonitoring can significantly decrease the number of readmissions, and continuous monitoring of older adults’ daily activities and health-related issues might prevent medical emergencies. Objective: The primary objective of this review was to identify advances in assistive technology devices for seniors and aging-in-place technology and to determine the level of evidence for research on remote patient monitoring, smart homes, telecare, and artificially intelligent monitoring systems. Methods: A literature review was conducted using Cumulative Index to Nursing and Allied Health Literature Plus, MEDLINE, EMBASE, Institute of Electrical and Electronics Engineers Xplore, ProQuest Central, Scopus, and Science Direct. Publications related to older people’s care, independent living, and novel assistive technologies were included in the study. Results: A total of 91 publications met the inclusion criteria. In total, four themes emerged from the data: technology acceptance and readiness, novel patient monitoring and smart home technologies, intelligent algorithm and software engineering, and robotics technologies. The results revealed that most studies had poor reference standards without an explicit critical appraisal. Conclusions: The use of ubiquitous in-home monitoring and smart technologies for aged people’s care will increase their independence and the health care services available to them as well as improve frail elderly people’s health care outcomes. This review identified four different themes that require different conceptual approaches to solution development. Although the engineering teams were focused on prototype and algorithm development, the medical science teams were concentrated on outcome research. We also identified the need to develop custom technology solutions for different aging societies. The convergence of medicine and informatics could lead to the development of new interdisciplinary research models and new assistive products for the care of older adults.
Peretz, Det al (2018) [Systematic Review] Determining the Cost of Implementing and Operating a Remote Patient Monitoring Programme for the Elderly With Chronic Conditions: A Systematic Review of Economic Evaluations 
Introduction: Remote patient monitoring (RPM)in conjunction with home nursing visits is becoming increasingly popular for the follow-up of patients with chronic conditions and evidence exists that it improves patients’ health outcomes. Current cost data is reported inconsistently and often gathered from studies of poor methodological quality, making it difficult for decision makers who consider implementing this service in their organizations. This study reviewed the cost of RPM programmes targeting elderly patients with chronic conditions. Methods:After evaluation against the inclusion and exclusion criteria and appraisal against two criteria which are important for economic evaluations, data from selected studies were extracted and grouped into meaningful cost categories, then adjusted to reflect November 2015 US dollars. Results: In the 13 selected studies, the newly-created cost category ‘combined intervention cost’ (reflecting equipment purchasing, servicing and monitoring cost)for the various RPM programmes ranged from US$275-US$7963 per patient per year. The three main findings are: 1. RPM programme costs have decreased since 2004 due to cheaper technology; 2. monitoring a single vital sign is likely to be less costly than monitoring multiple vital signs; and 3. programmes targeting hypertension or congestive heart failure are less costly than those targeting respiratory diseases or multiple conditions. Conclusions: This review recommends that future studies present their cost data with more granularity, that grouping of costs should be minimized and that any assumptions, such as amortization, should be made explicit. In addition, studies should compare programmes with similar characteristics in terms of type of conditions, number of vital signs monitored, etc. for more generalizable results.
Karlsen, C et al (2017) [ Systematic Review] Experiences of CommunityDwelling Older Adults With the Use of Telecare in Home Care Services: A Qualitative Systematic Review 
Background:The aging population will lead to a rise in the number of people with age-related diseases, and increasing demand for home care services. Telecare is seen as a solution to this challenge by promoting aging in place. Nevertheless, there is still a poor understanding of older adults’ experiences with the actual use of telecare. Objective: The aim of this review was to identify and synthesize the best available qualitative evidence of community-dwelling older adults’ experience with the use of telecare in home care services. Inclusion Criteria: This review considered studies that focused on qualitative data, examining older adults’ experiences with the use of active and passive technology devices, such as personal alarms and sensor technology, in the context of home care services. Search Strategy: This review systematically searched the databases Scopus, CINAHL, PsycINFO, and SveMed+ to find both published and unpublished studies in English, Norwegian, Swedish and Danish, from 2005 to 2017. Methodological Quality:Methodological quality of the included studies was assessed independently by two reviewers using the Joanna Briggs Institute Qualitative Assessment and Review Instrument. Data Synthesis:Qualitative research findings were pooled using the Joanna Briggs Institute Qualitative Assessment and Review Instrument, and involved aggregation and synthesis of findings. Results:A total of 118 findings from 11 studies were aggregated into 20 categories. The categories generated seven synthesized findings: 1. Aging in place is desired; however, it may also be related to feeling isolated and lonely. 2. Telecare contributes to safety, security, and aging in place. 3. Privacy is not seen as a problem by most older adults because the technology is intended to help them live safely in their own home. 4. Some telecare devices have side effects, especially new technology. Some devices do not work outside the home, thus limiting active aging. 5. Some older adults experience a misfit between technology and needs. They must see the value of a telecare device to use it. 6. Telecare may enforce an identity with negative connotations on older adults, as frail and helpless people. Autonomy is considered important. 7. Lack of understanding can hamper the correct use of telecare. Specific strategies may be needed. Conclusions:The experiences with the use of telecare are diverse. Findings indicate telecare systems can promote safety and security to age in place that is a wish of many older adults. However, “one size does not fit all”- Telecare systems must fit individual needs, and be supported by service providers to accommodate sustainable use over time.
Fudickar, S et al (2020) [Clinical Trial] Validation of the Ambient TUG Chair With Light Barriers and Force Sensors in a Clinical Trial 
To initiate appropriate interventions and avoid physical decline, comprehensive measurements are needed to detect functional changes in elderly people at the earliest possible stage. The established Timed UpandGo (TUG) test takes little time and, due to its standardized and easy procedure, can be conducted by elderly people in their own homes without clinical guidance. Therefore, cheap light barriers (LBs) and force sensors (FSs) are well suited ambient sensors that could easily be attached to existing (arm)chairs to measure and report TUG times in order to identify functional decline. We validated the sensitivity of these sensors in a clinical trial with 100 elderlies aged 58-92 years with a mean of 74 (±6.78) years by comparing the sensor-based results with standard TUG measurements using a stopwatch. We further evaluated the accuracy enhancement when calibrating the algorithm via a mixed linear model. With calibration, the LBs achieved a root mean square error (RMSE) of 0.83 s, compared to 1.90 s without, and the FSs achieved 0.90 s compared to 2.12 s without. The suitability of measuring accurate TUG times with each of the ambient sensors and of measuring TUG regularly in the homes of elderly people could be confirmed.
Macis, S et al (2020) Design and Usability Assessment of a Multi-Device SOA-Based Telecare Framework for the Elderly 
Telemonitoring is a branch of telehealth that aims at remotely monitoring vital signs, which is important for chronically ill patients and the elderly living alone. The available standalone devices and applications for the selfmonitoring of health parameters largely suffer from interoperability problems; meanwhile, telemonitoring medical devices are expensive, selfcontained, and are not integrated into user-friendly technological platforms for the end user. This paper presents the technical aspects and usability assessment of the telemonitoring features of the HEREiAM platform, which supports heterogeneous information technology systems. By exploiting a service-oriented architecture, the measured parameters collected by off the-shelf Bluetooth medical devices are sent as XML documents to a private cloud that implements an interoperable health service infrastructure, which is compliant with the most recent healthcare standards and security protocols. This Android-based system is designed to be accessible both via TV and portable devices, and includes other utilities designed to support the elderly living alone. Four usability assessment sessions with quality validated questionnaires were performed to accurately understand the ease of use, usefulness, acceptance, and quality of the proposed system. The results reveal that our system achieved very high usability scores even at its first use, and the scores did not significantly change over time during a field trial that lasted for four months, reinforcing the idea of an intuitive design. At the end of such a trial, the user-experience questionnaire achieved excellent scores in all aspects with respect to the benchmark. Good results were also reported by general practitioners who assessed the quality of their remote interfaces for telemonitoring.
Tun, SYY et al (2020) [Review] Internet of Things (IoT) Applications for Elderly Care: A Reflective Review 
Increasing in elderly population put extra pressure on healthcare systems globally in terms of operational costs and resources. To minimize this pressure and provide efficient healthcare services, the application of the Internet of Things (IoT) and wearable technology could be promising. These technologies have the potential to improve the quality of life of the elderly population while reducing strain on healthcare systems and minimizing their operational cost. Although IoT and wearable applications for elderly healthcare purposes were reviewed previously, there is a further need to summarize their current applications in this fast-developing area. This paper provides a comprehensive overview of IoT and wearable technologies’ applications including the types of data collected and the types of devices for elderly healthcare. This paper provides insights into existing areas of IoT/wearable applications while presenting new research opportunities in emerging areas of applications, such as robotic technology and integrated applications. The analysis in this paper could be useful to healthcare solution designers and developers in defining technology supported futuristic healthcare strategies to serve elderly people and increasing their quality of life.
Ben Hassen, H et al (2019) An E-health System for Monitoring Elderly Health Based on Internet of Things and Fog Computing 
With the significant increase in the number of elderly in the world and the resulting health problems of these increasing, finding technical solutions to address this problem has become a pressing necessity, particularly in the field of health care. This paper proposes an e-health system for monitoring elderly health based on the Internet of Things (IoT) and Fog computing. The system was developed using Mysignals HW V2 platform and an Android app that plays the role of Fog server, which enables the collection of physiological parameters and general health parameters from elderly periodically. This Android app enables also the elderly and their families to follow their health, and they can also communicate with health care providers and receive recommendations, notifications and alerts. By evaluating this system, we find the most users they consider useful, easy to use and learn, suggesting that our proposal can improve the quality of health care for elderly.
Bleda, AL et al (2019) Enabling Heart Self-Monitoring for All and for AALPortable Device Within a Complete Telemedicine System 
During the last decades there has been a rapidly growing elderly population and the number of patients with chronic heart-related diseases has exploded. Many of them (such as those with congestive heart failure or some types of arrhythmias) require close medical supervision, thus imposing a big burden on healthcare costs in most western economies. Specifically, continuous or frequent Arterial Blood Pressure (ABP) and electrocardiogram (ECG) monitoring are important tools in the follow-up of many of these patients. In this work, we present a novel remote non-ambulatory and clinically validated heart self-monitoring system, which allows ABP and ECG monitoring to effectively identify clinically relevant arrhythmias. The system integrates digital transmission of the ECG and tensiometer measurements, within a patient-comfortable support, easy to recharge and with a multifunction software, all of them aiming to adapt for elderly people. The main novelty is that both physiological variables (ABP and ECG) are simultaneously measured in an ambulatory environment, which to our best knowledge is not readily available in the clinical market. Different processing techniques were implemented to analyze the heart rhythm, including pause detection, rhythm alterations and atrial fibrillation, hence allowing early detection of these diseases. Our results achieved clinical quality both for inlab hardware testing and for ambulatory scenario validations. The proposed active assisted living (AAL) Sensor-based system is an end-to-end multidisciplinary system, fully connected to a platform and tested by the clinical team from beginning to end.
Chkeir, A et al (2019) In-home Physical Frailty Monitoring: Relevance With Respect to Clinical Tests 
Background: Frailty detection and remote monitoring are of major importance for slowing down, and/or even stopping the frailty process in home-dwelling older people. Taking the Fried’s criteria as a reference, this work aims to compare the results produced by a technological set (ARPEGE Pack) with those obtained by usual clinical tests, as well as to discuss the ability of the Pack to be used for long-run frailty remote monitoring. Methods: 194 participants were given a number of geriatric tests and asked to make use of the ARPEGE technological tools as well as reference clinical tools to feed Fried’s indicators. Spearman or Pearson’s correlation coefficients were used to compare the ARPEGE results to the reference ones, depending on data statistical characteristics. Results: Good correlations were obtained for measurements of weight (0.99), grip strength (0.89) and walking speed (0.79). Results are much less satisfactory for evaluation of physical activity and exhaustion (Spearman correlation coefficients 0.25 and 0.41, respectively). Conclusion: Correlations regarding weight, grip strength and walking speed confirm the validity of the data produced by the ARPEGE Pack to feed Fried’s criteria. Assessing activity level and exhaustion from an abbreviated questionnaire is still questionable. However, for long-run monitoring other methods of evaluation can be explored. Beyond the quantitative results, the ARPEGE Pack has been proved to be acceptable and motivating in such a long-term frailty monitoring.
Majumder, S, Deen, MJ (2019) [Review] Smartphone Sensors for Health Monitoring and Diagnosis 
Over the past few decades, we have witnessed a dramatic rise in life expectancy owing to significant advances in medical science and technology, medicine as well as increased awareness about nutrition, education, and environmental and personal hygiene. Consequently, the elderly population in many countries are expected to rise rapidly in the coming years. A rapidly rising elderly demographics is expected to adversely affect the socioeconomic systems of many nations in terms of costs associated with their healthcare and wellbeing. In addition, diseases related to the cardiovascular system, eye, respiratory system, skin and mental health are widespread globally. However, most of these diseases can be avoided and/or properly managed through continuous monitoring. In order to enable continuous health monitoring as well as to serve growing healthcare needs; affordable, non-invasive and easy-to-use healthcare solutions are critical. The ever-increasing penetration of smartphones, coupled with embedded sensors and modern communication technologies, make it an attractive technology for enabling continuous and remote monitoring of an individual’s health and wellbeing with negligible additional costs. In this paper, we present a comprehensive review of the state-of-the-art research and developments in smartphone-sensor based healthcare technologies. A discussion on regulatory policies for medical devices and their implications in smartphone-based healthcare systems is presented. Finally, some future research perspectives and concerns regarding smartphone-based healthcare systems are described.
Mardini, MT et al (2019) [Review] A Survey of Healthcare Monitoring Systems for Chronically Ill Patients and Elderly 
The demand of healthcare systems for chronically ill patients and elderly has increased in the last few years. This demand is derived by the necessity to allow patients and elderly to be independent in their homes without the help of their relatives or caregivers. The prosperity of the information technology plays an essential role in healthcare by providing continuous monitoring and alerting mechanisms. In this paper, we survey the most recent applications in healthcare monitoring. We organize the applications into categories and present their common architecture. Moreover, we explain the standards used and challenges faced in this field. Finally, we make a comparison between the presented applications and discuss the possible future research paths.
Mulasso, A et al (2019) [Comparative Study] A Comparison Between an ICT Tool and a Traditional Physical Measure for Frailty Evaluation in Older Adults 
Background: Frailty is a clinical condition among older adults defined as the loss of resources in one or more domains (ie, physical, psychological and social domains) of individual functioning. In frail subjects, emergency situations and mobility levels need to be carefully monitored. This study aimed to: 1. evaluate differences in the mobility index (MI) provided by ADAMO system, an innovative remote monitoring device for older adults; 2. compare the association of the MI and a traditional physical measure with frailty. Methods: Twenty-five community-dwelling older adults (71 ± 6 years; 60% women) wore ADAMO continuously for a week. The time percentage spent in Low, Moderate and Vigorous Activities was assessed using ADAMO system. Walking ability and frailty were measured using the 400 m walk test and the Tilburg Frailty Indicator, respectively. Results: Controlling for age and gender, the ANCOVA showed that frail and robust participants were different for Low (frail = 58.8%, robust = 42.0%, p < 0.001), Moderate (frail = 25.5%, robust = 33.8%, p = 0.008), and Vigorous Activity (frail = 15.7%, robust = 24.2%, p = 0.035). Using cluster analysis, participants were divided into two groups, one with higher and one with lower mobility. Controlling for age and gender, linear regression showed that the MI clusters were associated with total (β = 0.571, p = 0.002), physical (β = 0.381, p = 0.031) and social (β = 0.652, p < 0.001)frailty; and the 400 m walk test was just associated with total (β = 0.404, p = 0.043) and physical frailty (β = 0.668, p = 0.002). Conclusion: ADAMO system seems to be a suitable time tracking that allows to measure mobility levels in a non-intrusive way providing wider information on individual health status and specifically on frailty. For the frail individuals with an important loss of resources in physical domain, this innovative device may represent a considerable help in preventing physical consequences and in monitoring functional status.
Zhou, H. et al (2019) Instrumented Trail-Making Task: Application of Wearable Sensor to Determine Physical Frailty Phenotypes 
Background: The physical frailty assessment tools that are currently available are often time consuming to use with limited feasibility. Objective: To address these limitations, an instrumented trail-making task (iTMT) platform was developed using wearable technology to automate quantification of frailty phenotypes without the need of a frailty walking test. Methods: Sixty-one older adults (age = 72.8 ± 9.9 years, body mass index [BMI] = 27.4 ± 4.9 kg/m2) were recruited. According to the Fried Frailty Criteria, 39% of participants were determined as robust and 61% as nonrobust (pre-frail or frail). In addition, 17 young subjects (age = 29.0 ± 7.2 years, BMI = 26.2 ± 4.6 kg/m2) were recruited to determine the healthy benchmark. The iTMT included reaching 5 indexed circles (including numbers 1-to-3 and letters A and B placed in random orders), which virtually appeared on a computer-screen, by rotating one’s ankle-joint while standing. By using an ankle-worn inertial sensor, 3D ankle-rotation was estimated and mapped into navigation of a computer-cursor in real-time (100 Hz), allowing subjects to navigate the computer-cursor to perform the iTMT. The ankle-sensor was also used for quantifying ankle-rotation velocity (representing slowness), its decline during the test (representing exhaustion), and ankle-velocity variability (representing movement inefficiency), as well as the power (representing weakness) generated during the test. Comparative assessments included Fried frailty phenotypes and gait assessment. Results: All subjects were able to complete the iTMT, with an average completion time of 125 ± 85 s. The iTMT-derived parameters were able to identify the presence and absence of slowness, exhaustion, weakness, and inactivity phenotypes (Cohen’s d effect size = 0.90-1.40). The iTMT Velocity was significantly different between groups (d = 0.62-1.47). Significant correlation was observed between the iTMT Velocity and gait speed (r = 0.684 p < 0.001). The iTMT-derived parameters and age together enabled significant distinguishing of non-robust cases with area under curve of 0.834, sensitivity of 83%, and specificity of 67%. Conclusion: This study demonstrated a non-gait-based wearable platform to objectively quantify frailty phenotypes and determine physical frailty, using a quick and practical test. This platform may address the hurdles of conventional physical frailty phenotypes methods by replacing the conventional frailty walking test with an automated and objective process that reduces the time of assessment and is more practical for those with mobility limitations.
Armstrong, D et al (2018) [Review] Potential Applications of Smart Multifunctional Wearable Materials to Gerontology 
Smart multifunctional materials can play a constructive role in addressing some very important aging-related issues. Aging affects the ability of older adults to continue to live safely and economically in their own residences for as long as possible. Thus, there will be a greater need for preventive, acute, rehabilitative, and long-term health care services for older adults as well as a need for tools to enable them to function independently during daily activities. The objective of this paper is, thus, to present a comprehensive review of some potential smart materials and their areas of applications to gerontology. Thus, brief descriptions of various currently available multifunctional smart materials and their possible applications to aging related problems are presented. It is concluded that some of the most important applications to geriatrics may be in various sensing scenarios to collect health-related feedback or information and provide personalized care. Further described are the applications of wearable technologies to aging-related needs, including devices for home rehabilitation, remote monitoring, social well-being, frailty monitoring, monitoring of diabetes and wound healing and fall detection or prediction. It is also concluded that wearable technologies, when combined with an appropriate application and with appropriate feedback, may help improve activities and functions of older patients with chronic diseases. Finally, it is noted that methods developed to measure what one collectively manages in this population may provide a foundation to establish new definitions of quality of life.
Gokalp, H et al (2018) Integrated Telehealth and Telecare for Monitoring Frail Elderly With Chronic Disease 
Objective: To investigate the potential of an integrated care system that acquires vital clinical signs and habits data to support independent living for elderly people with chronic disease. Materials and Methods:We developed an IEEE 11073 standards-based telemonitoring platform for monitoring vital signs and activity data of elderly living alone in their home. The platform has important features for monitoring the elderly: unobtrusive, simple, elderly friendly, plug and play interoperable, and self-integration of sensors. Thirtysix (36) patients in a primary care practice in the UK (mean [standard deviation] age, 82  years) with congestive heart failure (CHF) or chronic obstructive pulmonary disease (COPD) were provided with clinical sensors to measure the vital signs for their disease (blood pressure [BP] and weight for CHF, and oxygen saturation for COPD) and one passive infrared (PIR) motion sensor and/or a chair/bed sensor were installed in a patient’s home to obtain their activity data. The patients were asked to take one measurement each day of their vital signs in the morning before breakfast. All data were automatically transmitted wirelessly to the remote server and displayed on a clinical portal for clinicians to monitor each patient. An alert algorithm detected outliers in the data and indicated alerts on the portal. Patient data have been analyzed retrospectively following hospital admission, emergency room visit or death, to determine whether the data could predict the event. Results:Data of patients who were monitored for a long period and had interventions were analyzed to identify useful parameters and develop algorithms to define alert rules. Twenty of the 36 participants had a clinical referral during the time of monitoring; 16 of them received some type of intervention. The most common reason for intervention was due to low oxygen levels for patients with COPD and high BP levels for CHF. Activity data were found to contain information on the well-being of patients, in particular for those with COPD. During exacerbation the activity level from PIR sensors increased slightly, and there was a decrease in bed occupancy. One subject with CHF who felt unwell spent most of the day in the bedroom. Conclusions:Our results suggest that integrated care monitoring technologies have a potential for providing improved care and can have positive impact on well-being of the elderly by enabling timely intervention. Long-term BP and pulse oximetry data could indicate exacerbation and lead to effective intervention; physical activity data provided important information on the well-being of patients. However, there remains a need for better understanding of long-term variations in vital signs and activity data to establish intervention protocols for improved disease management.
Lhotska, L et al (2018)[Cast Study] Personalized Monitoring and Assistive Systems: Case Study of Efficient Home Solutions 
The rapid emergence and proliferation of connected medical devices and their application in healthcare are already part of the Healthcare Internet of Things (IoT) – as this area started to be named. Their true impact on patient care and other aspects of healthcare remains to be seen and is highly dependent on the quality and relevancy of the data acquired. There is also the trend of application of IoT in telemedicine and home care environment. Currently many research groups focus on design and development of various solutions that can assist elderly and handicapped people in their home environment. However, many of these solutions are sophisticated and require advanced users that are able to control the device, handle error states and exceptions. They are frequently using expensive technologies that are good for laboratory environment but they are not affordable for many elderly or handicapped persons. In the paper we will analyze the current situation, present identified needs of elderly population and propose potential solutions. On a case study of efficient home solution of a personalized and assistive system we will show possibilities of technologically simple solutions using off-the-shelf devices and elements.
Mukherjee, R et al (2018) [Clinical Trial] A Universal Noninvasive Continuous Blood Pressure Measurement System for Remote Healthcare Monitoring 
Background: The effectiveness of any remote healthcare monitoring system depends on how much accurate, patient-friendly, versatile, and cost effective measurement it is delivering. There has always been a huge demand for such a long-term noninvasive remote blood pressure (BP) measurement system, which could be used worldwide in the remote healthcare industry. Thus, noninvasive continuous BP measurement and remote monitoring have become an emerging area in the remote healthcare industry. Introduction: Photoplethysmography-based (PPG)BP measurement is a continuous, unobtrusive, patient-friendly, and cost-effective solution. However, BP measurements through PPG sensors are not much reliable and accurate due to some major limitations such as pressure disturbance, motion artifacts, and variations in human skin tone. Materials and Methods:A novel reflective PPG sensor has been developed to eliminate the above mentioned pressure disturbance and motion artifacts during the BP measurement. Considering the variations of the human skin tone across demography, a novel algorithm has been developed to make the BP measurement accurate and reliable. The training dataset captured 186 subjects’ data and the trial dataset captured another new 102 subjects’ data. Results and Discussion: The overall accuracy achieved by using the proposed method is nearly 98%. Thus, demonstrating the efficacy of the proposed method. Conclusions:The developed BP monitoring system is quite accurate, reliable, cost-effective, handy, and user friendly. It is also expected that this system would be quite useful to monitor the BP of infants, elderly people, patients having wounds, burn injury, or in the intensive care unit environment.
Razjouyan, J et al (2018) [Cohort Study] Wearable Sensors and the
Assessment of Frailty Among Vulnerable Older Adults: An Observational Cohort Study 
Background: The geriatric syndrome of frailty is one of the greatest challenges facing the U.S. aging population. Frailty in older adults is associated with higher adverse outcomes, such as mortality and hospitalization. Identifying precise early indicators of pre-frailty and measures of specific frailty components are of key importance to enable targeted interventions and remediation. We hypothesize that sensor-derived parameters, measured by a pendant accelerometer device in the home setting, are sensitive to identifying pre-frailty. Methods: Using the Fried frailty phenotype criteria, 153 community-dwelling, ambulatory older adults were classified as pre-frail (51%), frail (22%), or non-frail (27%). A pendant sensor was used to monitor the at home physical activity, using a chest acceleration over 48 h. An algorithm was developed to quantify physical activity pattern (PAP), physical activity behavior (PAB), and sleep quality parameters. Statistically significant parameters were selected to discriminate the pre-frail from frail and non-frail adults.Results: The stepping parameters, walking parameters, PAB parameters (sedentary and moderate-to-vigorous activity), and the combined parameters reached and area under the curve of 0.87, 0.85, 0.85, and 0.88, respectively, for identifying pre-frail adults. No sleep parameters discriminated the pre-frail from the rest of the adults. Conclusions: This study demonstrates that a pendant sensor can identify pre-frailty via daily home monitoring. These findings may open new opportunities in order to remotely measure and track frailty via telehealth technologies.
Zhong, Ret al (2018) Application of Smart Bracelet to Monitor Frailty Related Gait Parameters of Older Chinese Adults: A Preliminary Study 
Aim: Smart bracelets are popular today. Based on their built-in motion sensors, they can serve as a cost-effective method of gait assessment in home-based care. Few studies have applied smart bracelets in the gait assessment of older Chinese adults. The present study aimed to: 1. establish reference gait parameters of older Chinese adults using smart bracelets under single and dual task; and 2. explore the differences in gait parameters among non-frail and pre-frail Chinese older adults. Methods: A total of 50 community-dwelling older Chinese adults aged ≥50 years wore a smart bracelet sensor in the L3 region of the back and underwent a 10-m walking test under single- and dual-task conditions. Participants were preliminarily classified into non-frail and pre-frail groups based on the Fatigue, Resistance, Ambulation, Illnesses and Loss of Weight scale. Gait parameters including average walking speed, step frequency, root mean square (RMS), acceleration amplitude variability, step variability, step regularity and step symmetry were calculated based on the data exported from the bracelet. Results: Multivariate analysis of covariance (mancova) analysis showed that older adults had significantly decreased speed and step frequency (P < 0.05) under the dual cognitive task condition. Pre-frail older adults showed significantly decreased speed, mediolateral RMS, vertical RMS, anteroposterior RMS, vertical amplitude variability and vertical step regularity compared with non-frail older adults (P < 0.05). Conclusions:The present study suggested that the decline in gait parameters as a result of frailty could be detected by the smart bracelet sensor.
Deng, YY et al (2017) Internet of Things (IoT) Based Design of a Secure and Lightweight Body Area Network (BAN)Healthcare System 
As sensor networks and cloud computation technologies have rapidly developed over recent years, many services and applications integrating these technologies into daily life have come together as an Internet of Things (IoT). At the same time, aging populations have increased the need for expanded and more efficient elderly care services. Fortunately, elderly people can now wear sensing devices which relay data to a personal wireless device, forming a body area network (BAN). These personal wireless devices collect and integrate patients’ personal physiological data, and then transmit the data to the backend of the network for related diagnostics. However, a great deal of the information transmitted by such systems is sensitive data, and must therefore be subject to stringent security protocols. Protecting this data from unauthorized access is thus an important issue in IoT-related research. In regard to a cloud healthcare environment, scholars have proposed a secure mechanism to protect sensitive patient information. Their schemes provide a general architecture; however, these previous schemes still have some vulnerability, and thus cannot guarantee complete security. This paper proposes a secure and lightweight body-sensor network based on the Internet of Things for cloud healthcare environments, in order to address the vulnerabilities discovered in previous schemes. The proposed authentication mechanism is applied to a medical reader to provide a more comprehensive architecture while also providing mutual authentication, and guaranteeing data integrity, user untraceability, and forward and backward secrecy, in addition to being resistant to replay attack.
Diraco, G et al (2017) A Radar-Based Smart Sensor for Unobtrusive Elderly Monitoring in Ambient Assisted Living Applications 
Continuous in-home monitoring of older adults living alone aims to improve their quality of life and independence, by detecting early signs of illness and functional decline or emergency conditions. To meet requirements for technology acceptance by seniors (unobtrusiveness, non-intrusiveness, and privacy-preservation), this study presents and discusses a new smart sensor system for the detection of abnormalities during daily activities, based on ultra-wideband radar providing rich, not privacy-sensitive, information useful for sensing both cardiorespiratory and body movements, regardless of ambient lighting conditions and physical obstructions (through-wall sensing). The radar sensing is a very promising technology, enabling the measurement of vital signs and body movements at a distance, and thus meeting both requirements of unobtrusiveness and accuracy. In particular, impulse-radio ultra-wideband radar has attracted considerable attention in recent years thanks to many properties that make it useful for assisted living purposes. The proposed sensing system, evaluated in meaningful assisted living scenarios by involving 30 participants, exhibited the ability to detect vital signs, to discriminate among dangerous situations and activities of daily living, and to accommodate individual physical characteristics and habits. The reported results show that vital signs can be detected also while carrying out daily activities or after a fall event (post-fall phase), with accuracy varying according to the level of movements, reaching up to 95% and 91% in detecting respiration and heart rates, respectively. Similarly, good results were achieved in fall detection by using the micro-motion signature and unsupervised learning, with sensitivity and specificity greater than 97% and 90%, respectively.
Haghi, M et al (2017) [Review] Wearable Devices in Medical Internet of Things: Scientific Research and Commercially Available Devices 
Objectives: Wearable devices are currently at the heart of just about every discussion related to the Internet of Things. The requirement for self-health monitoring and preventive medicine is increasing due to the projected dramatic increase in the number of elderly people until 2020. Developed technologies are truly able to reduce the overall costs for prevention and monitoring. This is possible by constantly monitoring health indicators in various areas, and in particular, wearable devices are considered to carry this task out. These wearable devices and mobile apps now have been integrated with telemedicine and telehealth efficiently, to structure the medical Internet of Things. This paper reviews wearable health care devices both in scientific papers and commercial efforts. Methods: MIoT is demonstrated through a defined architecture design, including hardware and software dealing with wearable devices, sensors, smart phones, medical application, and medical station analyzers for further diagnosis and data storage. Results: Wearables, with the help of improved technology have been developed greatly and are considered reliable tools for long-term health monitoring systems. These are applied in the observation of a large variety of health monitoring indicators in the environment, vital signs, and fitness. Conclusions: Wearable devices are now used for a wide range of healthcare observation. One of the most important elements essential in data collection is the sensor. During recent years with improvement in semiconductor technology, sensors have made investigation of a full range of parameters closer to realization.
Kumari, P et al (2017) [Review] Increasing Trend of Wearables and Multimodal Interface for Human Activity Monitoring: A Review 
Activity recognition technology is one of the most important technologies for life-logging and for the care of elderly persons. Elderly people prefer to live in their own houses, within their own locality. If, they are capable to do so, several benefits can follow in terms of society and economy. However, living alone may have high risks. Wearable sensors have been developed to overcome these risks and these sensors are supposed to be ready for medical uses. It can help in monitoring the wellness of elderly persons living alone by unobtrusively monitoring their daily activities. The study aims to review the increasing trends of wearable devices and need of multimodal recognition for continuous or discontinuous monitoring of human activity, biological signals such as Electroencephalogram (EEG), Electrooculogram (EOG), Electromyogram (EMG), Electrocardiogram (ECG) and parameters along with other symptoms. This can provide necessary assistance in times of ominous need, which is crucial for the advancement of disease-diagnosis and treatment. Shared control architecture with multimodal interface can be used for application in more complex environment where more number of commands is to be used to control with better results in terms of controlling.
Majumder, S et al (2017)[Review] Smart Homes for Elderly HealthcareRecent Advances and Research Challenges 
Advancements in medical science and technology, medicine and public health coupled with increased consciousness about nutrition and environmental and personal hygiene have paved the way for the dramatic increase in life expectancy globally in the past several decades. However, increased life expectancy has given rise to an increasing aging population, thus jeopardizing the socio-economic structure of many countries in terms of costs associated with elderly healthcare and wellbeing. In order to cope with the growing need for elderly healthcare services, it is essential to develop affordable, unobtrusive and easy-to-use healthcare solutions. Smart homes, which incorporate environmental and wearable medical sensors, actuators, and modern communication and information technologies, can enable continuous and remote monitoring of elderly health and wellbeing at a low cost. Smart homes may allow the elderly to stay in their comfortable home environments instead of expensive and limited healthcare facilities. Healthcare personnel can also keep track of the overall health condition of the elderly in real-time and provide feedback and support from distant facilities. In this paper, we have presented a comprehensive review on the state-of-the-art research and development in smart home based remote healthcare technologies.
Majumder, S et al (2017) Wearable Sensors for Remote Health Monitoring 
Life expectancy in most countries has been increasing continually over the several few decades thanks to significant improvements in medicine, public health, as well as personal and environmental hygiene. However, increased life expectancy combined with falling birth rates are expected to engender a large aging demographic in the near future that would impose significant burdens on the socio-economic structure of these countries. Therefore, it is essential to develop cost-effective, easy-to-use systems for the sake of elderly healthcare and well-being. Remote health monitoring, based on noninvasive and wearable sensors, actuators and modern communication and information technologies offers an efficient and cost-effective solution that allows the elderly to continue to live in their comfortable home environment instead of expensive healthcare facilities. These systems will also allow healthcare personnel to monitor important physiological signs of their patients in real time, assess health conditions and provide feedback from distant facilities. In this paper, we have presented and compared several low-cost and non-invasive health and activity monitoring systems that were reported in recent years. A survey on textile-based sensors that can potentially be used in wearable systems is also presented. Finally, compatibility of several communication technologies as well as future perspectives and research challenges in remote monitoring systems will be discussed.
Parvaneh, S et al (2017) Postural Transitions During Activities of Daily Living Could Identify Frailty Status: Application of Wearable Technology to Identify Frailty During Unsupervised Condition 
Background: Impairment of physical function is a major indicator of frailty. Functional performance tests have been shown to be useful for identification of frailty in older adults. However, these tests are often not translatable into unsupervised and remote monitoring of frailty status at home and/or community settings. Objective: In this study, we explored daily postural transition quantified using a chest-worn wearable technology to identify frailty in community-dwelling older adults. Methods: Spontaneous daily physical activity was monitored over 24 h in 120 community-dwelling elderly (age: 78 ± 8 years) using an unobtrusive wearable sensor (PAMSys™, BioSensics LLC, Watertown, MA, USA). Participants were classified as non-frail and pre-frail/frail using Fried’s criteria. A validated software package was used to identify body postures and postural transition between each independent postural activity such as sit-to-stand, stand-to-sit, stand-to-walk, and walk-to-stand. The transition from walking to sitting was further classified as quick sitting and cautious sitting based on presence/absence of a standing posture pause between sitting and walking. A general linear model univariate test was used for between-group comparison. Pearson’s correlation was used to determine the association between sensor-derived parameters and age. Logistic regression model was used to identify independent predictors of frailty. Results: According to Fried’s criteria, 63% of participants were pre-frail/frail. The total number of postural transitions, stand-to-walk, and walk-to-stand were, respectively, 25.2, 30.2, and 30.6% lower in the pre-frail/frail group when compared to the non-frail group (p < 0.05, Cohen’s d = 0.73-0.79). Furthermore, the ratio of cautious sitting was significantly higher by 6.2% in pre-frail/frail compared to non-frail (p = 0.025, Cohen’s d = 0.22). Total number of postural transitions and the ratio of cautious sitting also showed significant negative and positive correlations with age, respectively (r = -0.51 and 0.29, p < 0.05). After applying a logistic regression model, among tested parameters, walk-to-stand (odds ratio [OR] = 0.997 p = 0.013), quick sitting (OR = 1.036, p = 0.05), and age (OR = 1.073, p = 0.016) were recognized as independent variables to identify frailty status. Conclusions: This study demonstrated that daily number of specific postural transitions such as walk-to-stand and quick sitting could be used for monitoring frailty status by unsupervised monitoring of daily physical activity. Further study is warranted to explore whether tracking the daily number of specific postural transitions is also sensitive to track change in the status of frailty over time.
Lai, YL et al (2015) An Intelligent Health Monitoring System Using RadioFrequency Identification Technology 
Long-term care (LTC)for the elderly has become extremely important in recent years. It is necessary for the different physiological monitoring systems to be integrated on the same interface to help oversee and manage the elderly’s needs. This paper presents a novel health monitoring system for LTC services using radio-frequency identification (RFID)technology. Dual-band RFID protocols were included in the system, in which the highfrequency (HF) band of 13.56 MHz was used to identify individuals and the microwave band of 2.45 GHz was used to monitor physiological information. Distinct physiological data, including oxyhemoglobin saturation by pulse oximetry (SpO2), blood pressure, blood sugar, electrocardiogram (ECG) readings, body temperature, and respiration rate, were monitored by various biosensors. The intelligent RFID health monitoring system provided the features of the real-time acquisition of biomedical signals and the identification of personal information pertaining to the elderly and patients in nursing homes.
Peetom, KK et al (2015) [Review] Literature Review on Monitoring
Technologies and Their Outcomes in Independently Living Elderly
Purpose: To obtain insight into what kind of monitoring technologies exist to monitor activity in-home, what the characteristics and aims of applying these technologies are, what kind of research has been conducted on their effects and what kind of outcomes are reported. Methods: A systematic document search was conducted within the scientific databases Pubmed, Embase, Cochrane, PsycINFO and Cinahl, complemented by Google Scholar. Documents were included in this review if they reported on monitoring technologies that detect activities of daily living (ADL) or significant events, eg falls, of elderly people in-home, with the aim of prolonging independent living. Results: Five main types of monitoring technologies were identified: PIR motion sensors, body-worn sensors, pressure sensors, video monitoring and sound recognition. In addition, multicomponent technologies and smart home technologies were identified. Research into the use of monitoring technologies is widespread, but in its infancy, consisting mainly of smallscale studies and including few longitudinal studies. Conclusions: Monitoring technology is a promising field, with applications to the long-term care of elderly persons. However, monitoring technologies have to be brought to the next level, with longitudinal studies that evaluate their (cost-)effectiveness to demonstrate the potential to prolong independent living of elderly persons.
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