Assisted Living: Technology for Healthy Aging

#### **Chapter 8**

## Perspective Chapter: Telehealth Technologies for the Elderly People

*Ahmadreza Shamsabadi, Esmaeil Mehraeen and Zahra Pashaei*

#### **Abstract**

Home telehealth technology delivers a telemedicine tool for elder adults to take an active role in the management of their chronic diseases. This study aimed to determine the requirements and applications of home telehealth systems to monitor health parameters of the elderly. Electronic databases including PubMed, Scopus, Web of Science complemented by Google Scholar were searched. This systematic review was conducted based on preferred reporting items for systematic reviews and metaanalyses. In this study, 21 articles met the inclusion criteria and were included in the final review. There were 80 different requirements and 15 types of applications to create a home telehealth system specifically for the elderly. The highest frequency of applications element was related to the "blood pressure" (18%) and the lowest frequency related to items such as blood coagulation (1%) monitoring. Other systems` elements were "alert system" (12%), "information analysis" (12%), smartphone (20%), and internet (23%). Recognizing all used requirements and achieved capabilities may assist in designing more effective systems. They might be expanded at national level to meet the elderly's needs at a greater scale.

**Keywords:** elderly, home care service, nursing informatics, telehealth, system requirement

#### **1. Introduction**

The population of elderly is increasingly rising [1, 2]. In 2011, there were about 657 million elderly people in the world, and in 2050, their population is expected to reach about 1.91 billion [3]. Elder adult patients are more affected by multiple acute and chronic conditions and diseases requiring continuous care. This management might be provided by a variety of medical and health professionals in different settings [4, 5]. Over the past few decades, there has been a widespread prevalence of chronic diseases including diabetes, chronic obstructive pulmonary disease (COPD), and cardiovascular diseases in elderly, due to increased life period [6]. Among elderly, chronic diseases that occur simultaneously have increased and caused limitation in their physical activities, social interactions, and general health [7]. This will increase the need of long-term care for elderly [8].

Telehealth (also known as remote health) has been defined as intermediations that allow send and receive remote of health data and supplementary information between a patient and healthcare expert(s) to support in the diagnosis and managing of health

situation [9]. Telehealth in general refers to several technologies, systems, and applications that could be adopted to provide remote support of health care at home [10]. This requires a set of fundamental functionalities, such as remote consultation and diagnosis, as well as the possibility of data gathering for the monitoring of health dimensions and vital signs (e.g., blood pressure, heart rate, and seizure risk). Home telehealth (HTH) is described as "the use of telecommunications by a home care provider to link patients or customers to one or more out-of-home sources of care information, education, or service by means of telephones, computers, interactive television, or some combination of each" [11].

There are several telehealth service delivery models, and each model has different requirements and attributes [12]. Various review studies address information and communication technology (ICT) applications to support elder adult's telehealth at home. The main focuses of these studies include patient self-management [13], ethical considerations [14], facilitators and barriers to telehealth applications [15], elder adult's points of view about ICT applications [16], digital technology for aging in place [17], general review of monitoring technologies [18], and telephone application for communication between nurses and elderly [19]. Therefore, it turns out that there is a lack of review studies in the area of home telehealth system requirements for elderly. This study intends to focus systematically on evidences and experiences to determine applications and requirements of home telehealth system for elderly.

### **2. Methods**

#### **2.1 Aims**

This study was to determine the requirements and applications of home telehealth systems to design and development of an effective system for telemonitoring of health parameters for elderly living at home.

#### **2.2 Design**

A systematic literature review of evidence and experiences.

#### **2.3 Search methods**

An electronic search was carried out in four scientific databases including Scopus, Web of Science and PubMed, Google scholar for English language studies. A researcher with a health information management degree (ARS) designed a Boolean search strategy. Compositions of the following search terms were used:


#### **2.4 Inclusion criteria**

The inclusion criteria were original articles describing telehealth systems for monitoring elderly's health at home published in English language. Only articles that applied a remote monitoring system for elderly living at home were selected and analyzed.

#### **2.5 Exclusion criteria**

Exclusion criteria were studies published in a language other than English, studies published before 2013, studies with no full-text available, and any type of publication other than original article including review papers, conference abstracts, letters, etc. Papers that focused only on those systems aimed to monitor the environmental factors of elderly for remote home monitoring purposes were also excluded.

#### **2.6 Search outcomes**

In total, 1727 records were retrieved by searching the formerly mentioned databases. From articles found, first, duplicates were removed. Then, the titles and abstracts were screened by two researchers (SRNK, ARS) conforming to the inclusion/ exclusion criteria. In this study, 21 articles met the inclusion criteria and were included in the final review. The process of PRISMA<sup>1</sup> for data collection and analysis was applied (**Figure 1**).

#### **2.7 Quality appraisal**

The full texts of potentially related article were separately evaluated by the same two researchers independently. Contradictions were solved in consultation with researchers who also examined and authenticated the relatedness of all included articles.

#### **2.8 Data abstraction**

Data elements were extracted from selected articles. The extracted criteria were then reviewed by an expert panel including two medical informatics specialists and three health information management specialists who have been involved with other elderly informatics projects. The final classification obtained based on the five researchers' agreement is presented in **Table 1**.

#### **2.9 Synthesis**

The selected articles were analyzed based on five main data variables presenting the applications and requirements of home telehealth monitoring systems for elderly including: applications, nonfunctional requirements (system-oriented and technical features), functional requirements (user-oriented features), devices, and communication infrastructures obtained from telehealth service delivery models and system requirements engineering [40].

<sup>1</sup> Preferred reporting items for systematic reviews and meta-analyses.

**Figure 1.**

*The process of PRISMA for data collection and analysis.*

#### **3. Results**

**Table 1** presents the specific extracted data from the given papers based on seven data element of date of publication, country or project name, applications, nonfunctional requirement, functional requirement, device, and communication infrastructure.

In this study, five different aspects of home telehealth systems designed for aged monitoring were considered and analyzed. These aspects include (a) applications: indicating the purpose of using the system; (b) functional requirement: defines system performance and describes the inputs, behaviors, and outputs of the system for the user [41]; (c) nonfunctional requirement: refers to system architecture made of technical and operational features to make functional requirement working properly [42]; (d) device: specifying the tools that have been mostly used in the systems; and (e) communication infrastructure: implying to the type of networks and the way the information is mostly transmitted from the elderly's home to the central system and roaming from this station to the other parts of the system. Here, we give more information about each of aspects used for mentioned home telehealth system in detail.

According to the data analysis, it was revealed that the most common applications of home telehealth systems were respectively blood pressure (18%) and heart rate









 *CT: Systematized* *11HTTPS: Hypertext Transfer Protocol Secure.*

**Table 1.** *Specific extracted data from the given papers.*

 *of Medicine Clinical Terms.*

*Geriatric Medicine and Healthy Aging*

**120**

**Figure 2.** *Frequency and percentage of mostly usages in home telehealth monitoring systems for elderly (M\* = Monitoring).*

monitoring (15%). The most nonfunctional requirements of these systems included "analysis of information" (12%), and "central database" (11%); the most functional requirements were "display information for the user" and "alert system" (12%), and "personalized services" and "detection of emergency situations" (11%). In addition, results showed that the most commonly used device in the home telehealth systems for the elderly was smart phone (20%) and biomedical sensors (19%); the most widely used communication infrastructure was internet (23%), Bluetooth and Wi-Fi (17%).

Data analysis showed that in recent years (between 2013 and 2019), elderly home telehealth systems have been used by the various countries in the world, mostly in Europe in the form of applied or in progress projects. Furthermore, home telehealth systems for remote monitoring of the elderly living at home were used for a variety of applications. A total of selected articles were analyzed based on 15 parameters. They included blood pressure, heart rate, oxygen saturation, weight, blood sugar, respiration, physical activity, body temperature, electrocardiogram, diet tracking, blood coagulation, galvanic skin response (GSR), electromyogram (EMG), chest impedance, and medication compliance as shown in **Figure 2**.

The functional requirements included "education for the users," "detection of emergency situations," "reminder system," "alert system," "display information for users," "ubiquitous information access," "social and emotional support," "personalized services," "ease of use for elderly," "graphical presentation of outputs," etc. (**Figure 3**).

Nonfunctional requirements included "central database," "information analysis," "user-friendliness," "EPR<sup>2</sup> and PHR<sup>3</sup> development," "web–based design,", "applying

<sup>2</sup> EPR :electronic patient record.

<sup>3</sup> PHR: personal health record.

#### **Figure 3.** *Frequency and percentage of mostly functional requirements in home telehealth monitoring systems for elderly.*

#### **Figure 4.**

*Frequency and percentage of mostly nonfunctional requirements in home telehealth monitoring systems for elderly etc.\* including: applying POP – UP (n = 1), service UPnP technology based design (n = 1), animated guide (n = 1), use variety of apps (n = 1), data reduction ability (n = 1), SOCAM & OSGi-based design (n=1), agent-based design (n = 1), applying cloud service (n = 2), push notification ability (n = 1), contact with HIS ability (n = 1), applying SNOMED CT (n = 1), and applying HTTPS (n = 1).*

virtual environment," "management of apps," "creation of user profile," "real-time monitoring," "intelligent performance," "system security," etc. (**Figure 4**).

Different devices were used in elderly health monitoring systems. Seventeen types of devices were mentioned in the articles. They include biomedical sensors, camera, apple iPod, smart phone, PC & laptop, webcam, IoT devices, speaker and microphone, landline phone, pulse-Doppler radar, Intel health guide, broad band router, game controller, activity hub, HTC radar, and X bee PRO S2B module as shown in **Figure 5**.

**Figure 5.** *Frequency and percentage of mostly devices in home telehealth monitoring systems for elderly.*

#### **Figure 6.**

*Frequency and percentage of mostly communications in home telehealth monitoring systems for elderly etc.\* including: Telephone (n = 2), GPS (n = 1), LR-WPANs (n = 2), WLAN (n = 1), Ethernet (n = 2), MMS (n = 1), Cellular network (n = 1).*

According to the architecture of home telehealth systems, various communication infrastructures were used in these systems such as: Internet, Wi-Fi & Wi-Max, SMS, Zig bee, RFID, GSM & GPRS, and Bluetooth, which are shown in **Figure 6**.

#### **4. Discussion**

Home telehealth systems are very much considered, and several large projects are running in various countries. The most abundant applications of elderly remote monitoring system for home telehealth purposes were blood pressure (18%), oxygen saturation (13%), and heart rate (15 %). It is probably due to the importance of examining vital signs for aged people [42]. Hypertension is the most common condition seen in primary care because of its importance; that is, if blood pressure is not timely diagnosed and treated, it might lead to myocardial infarction, kidney failure, stroke, and death [43]. There were various functional requirements that are useroriented features of home telehealth systems; the most common of them were "display information for the users," "alert systems," "detection of emergency situations," and "personalized services." These functional requirements are extremely important for elderly care due to their responsibility for connecting the user with home telehealth system in order to be utilized practically. According to the fact that aged people may have cognitive impairments, low levels of e-literacy and health knowledge [44], applying functional requirements may support them very much by providing more visual perception and showing the outcomes in the form of understandable graphs and appropriate alerts such as time and dose of medication, observation of nutrition, and daily calorie intakes. Applying home telehealth system may induce data production and collection, which may lead to higher quality of data analysis and results in functions such as detection, prediction, and personalized system outcomes.

The technical features of a software are called nonfunctional requirements [41], They provide infrastructure for the best system interaction with the user (the elderly) and support interoperability and security [45]. They have modules in their structure to meet elderly's needs and support. In this study, the most frequent nonfunctional requirements included "information analysis," "central database," "real-time monitoring," "intelligent performance," "system security," "user-friendliness," and "applying virtual environment." In addition, in home telehealth systems for elderly living at home, various devices and communication infrastructures are used depending on the type of applied telehealth model, architecture, and the distance between home and healthcare center [12]. Based on this review, the most common devices were biomedical sensors and smart phone using Internet, Wi-Fi & Wi-max, and Bluetooth, which are highly frequent ways of communication.

The results of reviewing the projects aimed to monitor elder adults living at home revealed that these systems follow various outcomes such as monitoring purpose systems (sweet-home project) [46] and My Heart<sup>4</sup> [46]. They are aimed to monitor health status in senior people for either telecare or telehealth purposes. For instance, My Heart is a telehealth project to prevent cardiovascular disease by supporting elderly people having proper lifestyle and early diagnosis [47]; REACTION<sup>5</sup> is another

<sup>4</sup> MyHeart is a so-called Integrated Project of the European Union aiming to develop intelligent systems for the prevention and monitoring of cardiovascular diseases.

<sup>5</sup> REACTION:Remote Accessibility to Diabetes Management and Therapy in Operational healthcare Networks.

telehealth project to support long-term management of diabetes in elderly cases through using wearable's device, continuous blood glucose monitoring sensors, and automated closed-loop delivery of insulin [48]. However, other well-known elderly monitoring projects are for telecare purposes, they have, particularly in Europe, focused on elderly people's life quality improvement besides extending their independent life through equipping their home and environment [46]. For example, SOPRANO<sup>6</sup> is another project in Europe to develop home environment to support assistive technology using service-oriented architecture (SOA) [49]. InCASA<sup>7</sup> project supports elderly to live longer in their home via increasing their self-confidence [40].

Based on what we learned in this review, the telecare system is composed of telehealth systems which are different, according to the care provided to user. Due to the distinct entity of telecare and telehealth [50, 51], we focused on telehealth as a part of telecare for elderly living at home. Home telehealth system is composed of three parts including elderly home section, service center, and monitoring unit in a healthcare provider center [25, 40]. These three parts are connected to each other and linked to their related devices. The devices are linked too. We focused on one device, which might be a smartphone in elderly's hand; the device encompasses nonfunctional and functional features. Based on the capabilities of a device, different applications would be provided to a user through various communication infrastructures. In fact, the more nonfunctional capabilities are embedded, the more functional features are supported by the device providing more applications for elder adult's remote care at home. Although studied systems are capable of providing various monitoring and care, there is still a need to use new technologies including internet of thing and internet of humans to enhance home telehealth systems. Further research is suggested to proceed this primarily schematic suggestion of home telehealth system for elderly.

#### **5. Limitations**

In this study, only requirements and applications of home telehealth systems for elderly living at home were investigated, and further studies are required to examine the effect of these systems on aged people quality of life. Furthermore, in this review, we only focused on home care, and more study might be needed to explore the requirement of telehealth system for nursing home. Another limitation is not studying environmental factors affecting elderly home care and only emphasizing on requirements and applications for health-related factors.

#### **6. Conclusion**

Home telehealth systems for monitoring elderly are a type of telemedicine system specifically used for monitoring aged people. They encompass various technologies connected to elderly's home in order to provide different cares. Recognizing all used requirements and achieved capabilities may assist designing more effective systems.

<sup>6</sup> SOPRANO: Service-oriented Programmable Smart Environments for Older Europeans.

<sup>7</sup> InCASA: integrated network for completely assisted senior citizen`s anatomy.

They might be expanded in national level to meet elderly's needs in greater scale. Introduced elements of home telehealth system may support developers, nurses, and decision-makers to understand which infrastructure is appropriate for required usages based on available resources and facilities.

### **Author details**

Ahmadreza Shamsabadi<sup>1</sup> , Esmaeil Mehraeen<sup>1</sup> \* and Zahra Pashaei<sup>3</sup>

1 Department of Health Information Technology, Esfarayen Faculty of Medical Sciences, Esfarayen, Iran

2 Department of Health Information Technology, Khalkhal University of Medical Sciences, Khalkhal, Iran

3 Iranian Research Center for HIV/AIDS, Iranian Institute for Reduction of High Risk Behaviors, Tehran University of Medical Sciences, Tehran, Iran

\*Address all correspondence to: es.mehraeen@gmail.com

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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### *Edited by Élvio Rúbio Gouveia, Bruna Raquel Gouveia, Adilson Marques and Andreas Ihle*

*Geriatric Medicine and Healthy Aging* supports the idea that living a long and healthy life is considered the foremost challenge of societies worldwide. Promoting healthy aging strategies, which involves enhancing physical, mental, and social well-being in older adults, is discussed throughout the book, considering different approaches. Among a range of practical strategies for promoting healthy aging, physical activity is considered a key recommendation for developing sustainable policies and action programs at the community level. As such, the book discusses how increasing physical activity is necessary to maintain functional and cognitive abilities and social activities in older age. The book also examines assisted living technologies to support healthy aging, giving special attention to innovative information and communications technology (ICT)-based products. Recent evidence shows the transformative power of assisted living technologies in people's physical, mental, and social lives. By the end of this book, readers will have a solid grasp of the relationship between healthy aging, physical activity, functional fitness, cognitive function, and assisted living technologies. They will understand how these concepts function as vital structural elements for the sustainability of health and the enhancement of quality of life in older people.

Published in London, UK © 2023 IntechOpen © Brilt / iStock

Geriatric Medicine and Healthy Aging

Geriatric Medicine and

Healthy Aging

*Edited by Élvio Rúbio Gouveia, Bruna Raquel Gouveia, Adilson Marques* 

*and Andreas Ihle*