2.1.1 Nursing homes versus care homes

According to [12], nursing homes have been recommended to employ higher skilled nurse staffing in their homes, with 24-hour registered nursing care.

As the Balcombe Care Homes defines on its website:1

<sup>1</sup> https://balcombecarehomes.co.uk/about-us/

IoT-Enabled Health Monitoring and Assistive Systems for in Place Aging Dementia Patient… DOI: http://dx.doi.org/10.5772/intechopen.86247

A nursing home will provide all the day-to-day care that you would expect from any care home, but the care is supervised by registered nurses who are on duty all day and all night.

while

1.3 Structure of the chapter

2. Backgrounds and definitions

2.1 Nursing houses and nursing care

staff—see care homes vs nursing homes).

24 hours a day. (NIH-UK)

home.

children.

impairment.

• Functional or mental difficulties.

would not meet the conditions.

2.1.1 Nursing homes versus care homes

https://balcombecarehomes.co.uk/about-us/

home.

1

72

The remainder of the chapter presents in Section 2 some backgrounds and definitions. The research methodology, consisting of a literature review, research data, and system design, is presented in Section 3. Research findings and discussion are presented in Section 4. Section 5 handles a daily personal assistance system, which is designed and implemented to assist patients receiving nursing care at home

According to NIH-UK (National Institute of Health United Kingdom), a nursing home provides hospital-like care services to people (outpatients, elderly, palliative,

A nursing home is a place for people who don't need to be in a hospital but can't be cared for at home. Most nursing homes have nursing aides and skilled nurses on hand

It is worth noting the main risk factors of being admitted to nursing and/or care homes (both are similar but are different regarding the qualification of the care-

• Age: elderly people have more chance of being admitted to a nursing/care

• Low income: people with low income are vulnerable and have not enough possibilities to hire private care workforce to care for them at home.

Precisely for these reasons, they have a higher chance of being admitted to a nursing

• Poor family support: especially in cases where the older adult lacks a spouse or

• Low social activity: isolated people because of cognitive or age-related

Regarding the risk factors of being admitted to nursing or care homes, it is obvious that a group of people can be excluded from being admitted since they

According to [12], nursing homes have been recommended to employ higher

skilled nurse staffing in their homes, with 24-hour registered nursing care.

As the Balcombe Care Homes defines on its website:1

and who is most of the time alone, and Section 6 concludes the study.

Internet of Things (IoT) for Automated and Smart Applications

etc.) that cannot stay in the hospital for any aftercare or for elderly care.

Care homes are staffed 24 hours a day and a proportion of the staff will be qualified care assistants with NVQs (National Vocational Qualifications) at Level 2 or 3.

2.1.2 What is nursing care?

Segen's Medical Dictionary defines nursing care as

A nonspecific term in medicine; among medically qualified doctors in the UK, nursing care generally refers to procedures or medications which are solely or primarily aimed at providing comfort to a patient or alleviating that person's pain, symptoms or distress, and includes the offer of oral nutrition and hydration

Based on the Segen's Medical Dictionary definition of nursing care, nursing care can be assimilated to palliative as well as elderly care. Most elderly people are requesting nursing care due to health conditions such as cognitive impairments that include dementia, Parkinson, blindness, etc. [13, 14]. Though their chance of being admitted to a nursing home is low, modern technology, as well as methodology such as remote care, can assist to provide them with the needed nursing care at their residence place. The question raised is how will this work?

#### 2.2 Elderly and age-related impairments

The demographic structure of the developed countries (DC) or high-income countries (HIC) contains a large number of older (from 85+ years) and elderly (from 60+ years) people than young people (up to 59 years) and a very small number of teenagers (up to 15 years) in their population. The population of older adults is fastly growing in HIC [15], whereas the population in developing or lowand middle-income countries (LMIC) is remaining younger, although the number of young people is decreasing (see the example of Uganda—Figure 1). The median age in LMIC is around 15 years (see Figure 1), while the median age in the European Union (EU) is predicted to pass from 36.5 years in 1995 to 47.6 years in 2060 with an increasing tendency [16]. Thus, EU countries are facing an increasingly elderly population with all related needs like nursing and care homes, accommodated elderly healthcare services, etc.

The term "Elderly people" is defined as adults aged 60+ years, while people aged 65+ years are considered as an elder. Orimo, Hajime et al. had reviewed the definition of the term "elderly" in [17] and found out a correlation between elderly and the request or need of medium to severe nursing care.

According to the conventional definition presented by the authors in contrary to the definition above, the elderly is from 65+ years.

Conventionally, "elderly" has been defined as a chronological age of 65 years old or older, while those from 65 through 74 years old are referred to as "early elderly" and those over 75 years old as "late elderly." [17].

Though the World Health Organization (WHO) considers people aged 60+ years as elderly.

At the moment, there is no United Nations standard numerical criterion, but the UN agreed cutoff is 60+ years to refer to the older population [18].

And arguments follow such as why no one can exactly determine the age at which one has to be considered as elderly.

As a conclusion, it is worth noting that the needs of nursing and care homes are higher in HIC than in LMIC. Therefore, the chapter will more focus on the nursing

IoT-Enabled Health Monitoring and Assistive Systems for in Place Aging Dementia Patient…

Age-related impairment mostly known as cognitive impairment is a group of diseases, which occurs with advancing age. Cognitive impairment can also occur in young people. Mostly age-related cognitive impairments are dementia, Alzheimer's,

Obviously, cognitive impairment progresses with advancing age. In [17], the authors found out that elderly need from 75+ years severe nursing care. Though nursing care shows the potential to improve the individual's quality of life (QoL), most cognitive impairments cannot be cured. The patient, therefore, needs more attention, for example, reminding him to take food and drink enough water, and

In order to better understand why these patients need more nursing care than others, it is worth understanding the symptoms of some cognitive diseases as

Dementia is a progressive health condition mostly in elderly people. Dementia is a consequence of health conditions like Alzheimer and is characterized by cognitive

Dementia is diagnosed only when both memory and another cognitive function are each affected severely enough to interfere with a person's ability to carry out routine daily

Loss of cognitive abilities, including memory, concentration, communication, plan-

Regarding the characteristics of dementia, it is highly requested to assist round the clock people suffering from such health condition in order to protect them against any accident that can result from forgetfulness. On one hand, they need assistance, and on the other hand, they can be refused to being admitted to nursing or care home. Furthermore, keeping these people at home remains challenging. Family members caring for these people are mostly by day time at their own job. In this case, the only solution is to employ care/nursing personnel to care for them during the absence of all family members. It is reportedly known that most "care/ nursing personnel" hired for homecare are poorly skilled and mostly come from a different cultural background as the patient. The question is can all these factors impact the patient's QoL? Especially, can the cultural differences contribute to QoL

Parkinson's disease is one of the best-known and most common diseases of the nervous system. It is a cognitive disease and mostly related to advancing age. James Parkinson, the British physician, described the typical symptoms of the disease for

The Journal of the American Medical Association defines Dementia as

ning, and abstract thinking, resulting from brain injury or from a disease such as Alzheimer's disease or Parkinson's disease. It is sometimes accompanied by emotional

loss? Answering this question is out of the scope of the present study.

Parkinson's, loss of vision, hearing loss, depression, incontinence, etc.

situation in HIC.

follows.

activities.

2.2.1.2 Parkinson's

75

2.2.1.1 Dementia

2.2.1 What is age-related impairment

DOI: http://dx.doi.org/10.5772/intechopen.86247

bringing him to get socialized again.

disturbance and personality changes.

impairment (loss of cognitive capabilities or abilities).

The free dictionary gives a similar definition as

Figure 1.

In addition, chronological or "official" definitions of aging can differ widely from traditional or community definitions of when a person is older. We will follow the lead of the developed worlds, for better or worse, and use the pensionable age limit often used by governments to set a standard for the definition [18].

According to the United Nations projection, about 79% of the world elder population aged 60 years or over will live in LMIC by 2050 [19]. Therefore, 20% of them will live in HIC.

Analyzing the population distribution (Figure 6 in [19]) reveals that in countries like Germany, population will count more aging people while an LMIC's population like Uganda's population will remain young.

#### IoT-Enabled Health Monitoring and Assistive Systems for in Place Aging Dementia Patient… DOI: http://dx.doi.org/10.5772/intechopen.86247

As a conclusion, it is worth noting that the needs of nursing and care homes are higher in HIC than in LMIC. Therefore, the chapter will more focus on the nursing situation in HIC.

## 2.2.1 What is age-related impairment

Age-related impairment mostly known as cognitive impairment is a group of diseases, which occurs with advancing age. Cognitive impairment can also occur in young people. Mostly age-related cognitive impairments are dementia, Alzheimer's, Parkinson's, loss of vision, hearing loss, depression, incontinence, etc.

Obviously, cognitive impairment progresses with advancing age. In [17], the authors found out that elderly need from 75+ years severe nursing care. Though nursing care shows the potential to improve the individual's quality of life (QoL), most cognitive impairments cannot be cured. The patient, therefore, needs more attention, for example, reminding him to take food and drink enough water, and bringing him to get socialized again.

In order to better understand why these patients need more nursing care than others, it is worth understanding the symptoms of some cognitive diseases as follows.

#### 2.2.1.1 Dementia

Dementia is a progressive health condition mostly in elderly people. Dementia is a consequence of health conditions like Alzheimer and is characterized by cognitive impairment (loss of cognitive capabilities or abilities).

The Journal of the American Medical Association defines Dementia as

Dementia is diagnosed only when both memory and another cognitive function are each affected severely enough to interfere with a person's ability to carry out routine daily activities.

The free dictionary gives a similar definition as

Loss of cognitive abilities, including memory, concentration, communication, planning, and abstract thinking, resulting from brain injury or from a disease such as Alzheimer's disease or Parkinson's disease. It is sometimes accompanied by emotional disturbance and personality changes.

Regarding the characteristics of dementia, it is highly requested to assist round the clock people suffering from such health condition in order to protect them against any accident that can result from forgetfulness. On one hand, they need assistance, and on the other hand, they can be refused to being admitted to nursing or care home. Furthermore, keeping these people at home remains challenging. Family members caring for these people are mostly by day time at their own job. In this case, the only solution is to employ care/nursing personnel to care for them during the absence of all family members. It is reportedly known that most "care/ nursing personnel" hired for homecare are poorly skilled and mostly come from a different cultural background as the patient. The question is can all these factors impact the patient's QoL? Especially, can the cultural differences contribute to QoL loss? Answering this question is out of the scope of the present study.

#### 2.2.1.2 Parkinson's

Parkinson's disease is one of the best-known and most common diseases of the nervous system. It is a cognitive disease and mostly related to advancing age. James Parkinson, the British physician, described the typical symptoms of the disease for

In addition, chronological or "official" definitions of aging can differ widely from traditional or community definitions of when a person is older. We will follow the lead of the developed worlds, for better or worse, and use the pensionable age limit often used by

Projection on demographic change LMIC versus HIC (from 1950 to 2050) [source [19]].

According to the United Nations projection, about 79% of the world elder population aged 60 years or over will live in LMIC by 2050 [19]. Therefore, 20% of

Analyzing the population distribution (Figure 6 in [19]) reveals that in countries like Germany, population will count more aging people while an LMIC's population

governments to set a standard for the definition [18].

Internet of Things (IoT) for Automated and Smart Applications

like Uganda's population will remain young.

them will live in HIC.

Figure 1.

74

the first time in 1817 and gave his name to the disease. Like a most cognitive disease, is a slowly progressive neurological disease that affects certain areas of the brain. The main symptom of Parkinson's disease is the movement disorder.

People suffering from Parkinson's disease are, therefore, dependent on other people since they are limited in their movement. Furthermore, they can lose the sense of smelling and mostly suffer from Dementia, depression, and anxiety.

#### 2.3 Technologies enabling home automation

The main role of home automation is to control and manage devices at the local network(s) in the house. It can enable remote interactions with the network in order to access some information or to set command. For example, one can remotely ask his fridge or the fridge can send him a grocery list. Many technologies are included in home automation. Technologies like wireless sensor networks, videos, and connected devices support smart home automation paradigm. In [20], Toschi et al. reviewed the technologies that enabled a machine-to-machine (M2M)-based house automation. According to the authors, home automation is tending beyond connecting autonomous toward smart process and devices.

In this section, two technologies are briefly presented. In prior, the term automation is defined.

### 2.3.1 What is smart home automation?

In [21], Vasseur and Dunkels defined home automation as follows:

Home automation is an area of multiple and diverse applications that include lighting control, security and access control, comfort and convenience, energy management, remote home management, and aging independently and assisted living.

unique addressing schemes, are able to interact with each other and cooperate with their

IoT-Enabled Health Monitoring and Assistive Systems for in Place Aging Dementia Patient…

Internet of health things (IoHT) is designed for medical data gathering and processing. IoHT connects unconnected health means with network connectivity ability. Digital and physical medical objects can thus network with each other in collaborating for data collection, processing, and storage. IoHT is a special case of the Internet of things (IoT) that combines health technologies and IoT and takes full advantage of IoT technology like the ability to initiate actions based on collected and

IoT finds its application already in the medical world as Istepanian et al. discussed in [25]. Williams et al. have defined the healthcare Internet of things (also

always being connected, to improve patient care whilst reducing costs [26]."

tion layer, (ii) gateway layer, and (iii) IoT platform layer.

an IoT-enabled healthcare data perception system.

"…the new embedded sensing capabilities of devices together with the availability of

The common architecture of IoT consists of sensors and actuators called things. Things are located at the data perception level. Behind the things are placed the IoTgateways and data acquisition systems, followed by the edge IT and the data center (commonly on a remote server) and cloud. There are three (03) layers: (i) percep-

IoT has the potential to enable home automation in collecting and processing data as well as to autonomously request actuators to execute some tasks for example temperature control by regulating the heater according to the set (for patient

IoT presents various domain-specific architectures that use various technologies and areas such as RFID, service-oriented architecture, wireless sensor network, supply chain management, industry, healthcare, smart city, logistics, connected living, big data, cloud computing, social computing, and security. Figure 3 shows

neighbors to reach common goals."

Sample of home control devices (source: [21]/Figure 23.1).

DOI: http://dx.doi.org/10.5772/intechopen.86247

called IoHT—Internet of health things) as

comfortable) room temperature.

77

analyzed data [24].

Figure 2.

In the context of nursing care, home automation (HA) is a network system and application that includes at the first place bio-signal monitoring, well-being control, and other medical means like medication intake, physical exercises, etc. Further, HA includes temperature management, patient-safety, and security by preventing dangerous actions like leaving furnace or gas on, going out without adequate wearing.

Figure 2 (Source Figure 23.1 in [21]) presents a sample of home control devices. In [22], Pham et al. defined smart home automation as an environment contextrelated data for precise health monitoring. They write:

A smart home environment provides ample contextual data related to a resident's health, which allows more accurate health monitoring than only using physiological signals.

They further presented cloud-based home automation that collects bio-signals and location information in order to accurately monitor nursing home residents.

#### 2.3.2 Internet of things and the common architecture

The Internet of things is a paradigm for autonomous data gathering and processing. In [23], Luigi Atzori et al. had defined the Internet of things as follows:

"The Internet of Things (IoT) is a novel paradigm that is rapidly gaining ground in the scenario of modern wireless telecommunications. The basic idea of this concept is the pervasive presence around us of a variety of things or objects, such as Radio-Frequency IDentification (RFID) tags, sensors, actuators, mobile phones, etc., which, through

IoT-Enabled Health Monitoring and Assistive Systems for in Place Aging Dementia Patient… DOI: http://dx.doi.org/10.5772/intechopen.86247

#### Figure 2.

the first time in 1817 and gave his name to the disease. Like a most cognitive disease, is a slowly progressive neurological disease that affects certain areas of the brain.

People suffering from Parkinson's disease are, therefore, dependent on other people since they are limited in their movement. Furthermore, they can lose the sense of smelling and mostly suffer from Dementia, depression, and anxiety.

The main role of home automation is to control and manage devices at the local network(s) in the house. It can enable remote interactions with the network in order to access some information or to set command. For example, one can

machine-to-machine (M2M)-based house automation. According to the authors, home automation is tending beyond connecting autonomous toward smart process

In this section, two technologies are briefly presented. In prior, the term auto-

Home automation is an area of multiple and diverse applications that include lighting control, security and access control, comfort and convenience, energy management, remote

In the context of nursing care, home automation (HA) is a network system and application that includes at the first place bio-signal monitoring, well-being control, and other medical means like medication intake, physical exercises, etc. Further,

Figure 2 (Source Figure 23.1 in [21]) presents a sample of home control devices. In [22], Pham et al. defined smart home automation as an environment context-

A smart home environment provides ample contextual data related to a resident's health, which allows more accurate health monitoring than only using physiological

The main symptom of Parkinson's disease is the movement disorder.

remotely ask his fridge or the fridge can send him a grocery list. Many technologies are included in home automation. Technologies like wireless sensor networks, videos, and connected devices support smart home automation

paradigm. In [20], Toschi et al. reviewed the technologies that enabled a

In [21], Vasseur and Dunkels defined home automation as follows:

HA includes temperature management, patient-safety, and security by

They further presented cloud-based home automation that collects bio-signals and location information in order to accurately monitor nursing

The Internet of things is a paradigm for autonomous data gathering and processing. In [23], Luigi Atzori et al. had defined the Internet of things as follows: "The Internet of Things (IoT) is a novel paradigm that is rapidly gaining ground in the scenario of modern wireless telecommunications. The basic idea of this concept is the pervasive presence around us of a variety of things or objects, such as Radio-Frequency IDentification (RFID) tags, sensors, actuators, mobile phones, etc., which, through

preventing dangerous actions like leaving furnace or gas on, going out without

home management, and aging independently and assisted living.

related data for precise health monitoring. They write:

2.3.2 Internet of things and the common architecture

2.3 Technologies enabling home automation

Internet of Things (IoT) for Automated and Smart Applications

and devices.

mation is defined.

adequate wearing.

signals.

76

home residents.

2.3.1 What is smart home automation?

Sample of home control devices (source: [21]/Figure 23.1).

unique addressing schemes, are able to interact with each other and cooperate with their neighbors to reach common goals."

Internet of health things (IoHT) is designed for medical data gathering and processing. IoHT connects unconnected health means with network connectivity ability. Digital and physical medical objects can thus network with each other in collaborating for data collection, processing, and storage. IoHT is a special case of the Internet of things (IoT) that combines health technologies and IoT and takes full advantage of IoT technology like the ability to initiate actions based on collected and analyzed data [24].

IoT finds its application already in the medical world as Istepanian et al. discussed in [25]. Williams et al. have defined the healthcare Internet of things (also called IoHT—Internet of health things) as

"…the new embedded sensing capabilities of devices together with the availability of always being connected, to improve patient care whilst reducing costs [26]."

The common architecture of IoT consists of sensors and actuators called things. Things are located at the data perception level. Behind the things are placed the IoTgateways and data acquisition systems, followed by the edge IT and the data center (commonly on a remote server) and cloud. There are three (03) layers: (i) perception layer, (ii) gateway layer, and (iii) IoT platform layer.

IoT has the potential to enable home automation in collecting and processing data as well as to autonomously request actuators to execute some tasks for example temperature control by regulating the heater according to the set (for patient comfortable) room temperature.

IoT presents various domain-specific architectures that use various technologies and areas such as RFID, service-oriented architecture, wireless sensor network, supply chain management, industry, healthcare, smart city, logistics, connected living, big data, cloud computing, social computing, and security. Figure 3 shows an IoT-enabled healthcare data perception system.

Clinics, hospitals, and care/nursing homes can remotely use end-point devices like video and audio devices to assist family members to care for their sick member at home. Thus, home automation systems can be connected to medical emergency stations at clinics and hospitals close to the patient's residence place and regularly forward the patient's critical data gathered by WSMs and BANs. How this works is presented by Moghadam et al. in [28] where they have designed and implemented a

IoT-Enabled Health Monitoring and Assistive Systems for in Place Aging Dementia Patient…

"an energy efficient data transmission technique for communication between a singleantenna medical sensor/microrobot inside the body to a multi-antenna receiver on the

The main objectives behind the research questions are on one hand to investigate the tendency toward homecare regarding the nursing care homes and care workforce shortage and on the other hand to additionally investigate challenges and issues people are facing in homecare. Homecare is when family members care for their sick member at home. The needs in terms of appropriate solutions to overcome challenges and issues faced by caring for patients in homecare are assessed.

Q1: What is the tendency for homecare regarding the current nursing care crisis

Three nursing care options are noticed in Germany: (i) nursing care residences with 24 h registered care services and (ii) homecare with the assistance of ambulant nursing staff for a couple of hours per day. Many families hire care personnel from abroad (e.g., Yugoslavia, Budapest, and Ukraine), mostly with beginner's skills or no skills at all to care for their sick parents. Family members also care for the patient following medical instructions, (iii) regarding nursing care homes practiced fees,

Caring for a patient in homecare can be challenging for family members since many patients request round the clock nursing care. This is a full-time job. This study aims at investigating the challenges and issues that can be faced in such a

Q3: Is it worth caring for dementia patients in homecare instead of at nursing

Dementia patients are forgetful. They can forget to take food and drink water. They could forget to turn off a furnace or turn on a heater. Regarding these issues, it

Q4: What is the quality of life (QoL) of patients treated in homecare?

many families send their sick parents abroad in East European countries.

Q2: What challenges and issues are facing homecare?

is worth assessing how to handle dementia patients.

communication system single and multi-antenna in a BAN. They wrote:

Transmitting over multiple spatial and temporal scales is challenging in advanced health informatics [29] though advancement achieved in the Internet of things (IoT) protocols like LoRaWAN with platforms like the things network (TTN) [https://www.thethingsnetwork.org/] eases transferring data today. Wireless body area network (WBAN) is part of wireless sensor networks (WSNs) that can enable monitoring and collecting the patient bio-signal. This has been shown in a previous study [30] where a wireless sensor network system has been used at a cardiologic intensive care unit (CICU) for collecting and monitoring, round the clock, cardiologic activities in-patients. WSNs were connected to the patients and thus bio-signals have been collected in real time. This study has shown

body surface through non-homogeneous propagation environment."

DOI: http://dx.doi.org/10.5772/intechopen.86247

the feasibility of using WSNs and WBNs in home automation.

3. Research questions, hypotheses, and scopes

3.1 Questions

facing HIC?

situation.

care home?

79

Figure 3. Healthcare domain specific IoT architecture (source: [27]).
