The population in the European Region has the highest median age in the world. People in many European countries enjoy some of the highest life expectancies in the world. As life expectancy increases, more people live past 65 years of age and into very old age, greatly increasing the numbers of older people. By 2050, more than one quarter (27%) of the population is expected to be 65 years and older. However, trends in longevity gain are uneven, and gaps between and within countries of the European Region continue to grow. (WHO, 2012)

Figure shows the population pyramids, EU-27, 1 January 2019 (fact) and 2100 (projected). (Eurostat, 2021)
 

                                                                                                                                                                                                                                             

                                                           



The figure shows the old-age-dependency for EU-27 in 2019. This parameter is intent to indicate the ratio between the number of persons aged 65 years or over to the number of persons aged 15-64 years. (Eurostat, 2021)
 

                                                                                                                                                                                                                                                                           
                                                                  



Based on the recent and the expected excessively growing demand the European Union has made the DECISION No 742/2008/EC OF THE EUROPEAN PARLIAMENT AND OF THE COUNCIL of 9 July 2008 on the Community’s participation in a research and development programme undertaken by several Member States aimed at enhancing the quality of life of older people through the use of new information and communication technologies. (742/2008/EC)

According to the Annex I of the Decision the following specific aims has been declared within the Active and Assisted Living (AAL) programme: foster the emergence of innovative ICT-based products, services and systems for ageing well at home, in the community, and at work, thus improving the quality of life, autonomy, participation in social life, skills and employability of older people and reducing the costs of health and social care. This may be based, for example, on innovative utilisation of ICT, new methods of customer interaction or new types of value chains for independent living services. The results of the AAL Joint Programme could also be used by other groups of people, namely people with disabilities. (742/2008/EC)

Information and communication technologies (ICT) solutions can help and support healthy aging via prolonging independent living, enhancing social inclusion and quality of work for carers. (EIP on AHA, 2014)
 

                                                                                                                                                                                                                                                  
                                                                                  

ICT can play supportive role in: (EU: Deliverable 3, 2015)

•    Prevention and Management of Chronic Conditions
•    Social Interaction
•    Independence and Participation in the “Self-Serve Society”
•    Mobility
•    (Self-)Management of Daily Life Activities at Home and
•    Occupation in Life.
 
#1: Telemonitoring

Figure demonstrates the conceptual framework of the relations between eHealth, telehealth, telecare and telemedicine in order to clarify the appropriate definitions. (EU Report on Telemedicine, 2017)
 

                 
                                                                                         
                                                             

1.1.    Telemonitoring

Telemonitoring is not included in the curative scope of telemedicine but in the telecare scope, focusing on the preventive aspect of healthcare. Telemonitoring services empower patients to actively manage their diseases, at the same time as enhancing continuity of care and prevention of future occurrences in the context of chronic disease management. (EU Report on Telemedicine, 2018)

1.2.    Telemonitoring tools

A figure illustrates the product-platform-database triangle which combination is widespread in telemonitoring solutions.
 

                                                       
                                                                       

                                                     
A medical device or a wearable device could be referred as a product on the patient level, this is the stage of data collection. A platform could be an application, which is an intermediary between patient and health care professional (or software) on which the data is shared. Finally, the data is stored in a database ready to be analysed and interpreted by either a healthcare professional or by software. (EU Report on Telemedicine, 2018)

#2: Smart healthcare and technologies

2.1.    Smart healthcare

Smart health care is a health service system that uses technology such as wearable devices, IoT, and mobile internet to dynamically access information, connect people, materials and institutions related to healthcare, and then actively manages and responds to medical ecosystem needs in an intelligent manner. (Tian, 2019)

Figure below shows the broad classification of the smart health-care market based on services, medical devices, technologies used, applications, system management, and end users. (Sundaravadivel, 2018)
 

                                                                                                                 

Medical devices or wearable devices are used on the patient level to monitor and collect data. The efficient integration of these product through wireless technologies can help in implementing remote health monitoring through the Internet of Things (IoT). The medical devices used to implement smart health care can be classified as on-body sensors or stationary medical devices. On-body sensors are usually in vitro or in vivo biosensors that are attached to the human body for physiological monitoring. In vitro sensors are externally attached to the human body while in vivo sensors are implantable devices that are placed inside the body. (Sundaravadivel, 2018)

2.2.    Smart technologies

The figure shows four potential categories for smart systems with some examples which are relevant from our point of view. (Chen, 2020)
 

                                                                                           


Among smart devices the most widely adopted one is smart phones and mobile health care apps. Target population for health care apps could be 1) consumers or patients, 2) health care professionals and 3) system designer or administrator. There are wide variety of available functions for consumers such as medication compliance, mobile and home monitoring, home care and managing certain conditions. (Chen, 2020)

The advent of IoT has enabled the design of connected and integrated smart health monitoring systems. These smart health monitoring systems could be realized in a smart home context to render long-term care to the elderly population.

A smart home environment with preventive and diagnostic capabilities is able to reduce the burden on caregivers, cost of assisted living facilities, and support the concept of ”Aging in Place”. Moreover, the ability to monitoring and managing one’s health promotes a sense of independence which improves the quality of life for older adults. (Nath, 2021)

 #3: Monitoring and health assessment

Telemonitoring is not included in the curative scope of telemedicine but in the telecare scope, focusing on the preventive aspect of healthcare.

The first stage of telemonitoring chain is the data acquisition using an appropriate sensor followed by the transmission of this data from patient to clinician/software. After integration of the data with other data describing the state of the patient an appropriate action, or response should be taken in the care of the patient. Data storage appears as a final stage during monitoring. (EU Report on Telemedicine, 2017)
 

 

                                                                               

Sensors used to remotely collect patients’ condition data can do so continuously or intermittently, with it even being possible to determine the time of the next measurement based on the last value collected. The process of health data measurement and collection may be automatic, or manual, in which case the patient records the data and transmits it by telephone or a networked system to a healthcare provider. Health data can be continuously transmitted to the clinician (through store-and-forward or real-time mode), or only in exceptional and urgent cases, when a potentially dangerous occurrence in a patient’s health condition is detected. The integration of the data received is usually performed by a computer or a health professional. Telemonitoring services (as well as teletriage) are not usually primarily performed by physicians, who are only involved when patients present signs of health deterioration. In conclusion, telemonitoring services empower patients to actively manage their diseases, at the same time as enhancing continuity of care and prevention of future occurrences in the context of chronic disease management. (EU Report on Telemedicine, 2017)


3.1. Domains for monitoring technologies for Older Adults

The Center for Aging Services Technologies (CAST) categorized home-based monitoring technologies for older adults into three broad domains shown in the figure.
 

                                                                                                                    

                                                                          


Home-based safety monitoring technologies include fall detection and prevention systems, both push-button and accelerometer-based wearable, and sensor-based embedded environmental systems, mobility aids for wheelchairs, and smoke and temperature monitors.
Health and wellness monitoring technologies include:

•    wearable activity monitors using accelerometers and sensors;
•    non-wearable, embedded sensor activity monitors to track activities of daily living (ADL), instrumental activities of daily living (IADL), and other behaviors;
•    hybrid wearable/environmental systems with radio-frequency identification (RFID) readers and tagging of environmental objects to monitor ADL performance;
•    ambulatory monitors to record and transmit physiological data;
•    passive environmental non-wearable systems like bed monitors for clinical sleep assessment;
•    medication compliance systems that monitor intake and provide prompts and reminders; and
•    cognitive assessment/orthotics devices.

Social connectedness monitoring is a relatively new area of application and involves the use of sensors to facilitate awareness and interaction between remote family members.

A more recent development is the design and implementation of smart home applications. These involve integrated networks of sensors—which may include a combination of safety, health and wellness, and social connectedness technologies — installed into homes or apartments to simultaneously and continuously monitor environmental conditions, daily activity patterns, vital signs, sleep patterns, etc. over the long term. (Czaja, Springer, 2013)

3.2.    What do we monitor?

Smart monitoring tools such as context-aware HSH and assisted living systems for a population like the elderly aim to monitor and evaluate their health condition and abilities to carry out daily activities. Figure resumes the types and activities in Health Monitoring Systems. (Mshali, 2018)
                                                                                                                                                      

                                                                                                                                                                   
                                                                        


In the geriatric domain, the health and wellness status of individuals is measured by the so-called dependency evaluation level, which can be defined as the ability of a person to achieve elementary tasks of daily living without the help of a third party. (Mshali, 2014)

The activities of daily living (ADL) category refers to the routines and basic tasks performed every day, such as eating, dressing, washing, brushing teeth, washing hand/face, drying hair, toileting, sleeping. (Katz, 1963) The instrumental activities of daily living (IADL) category refers to tasks required to live in a community such as meal preparation, houskeeping, laundry, telephone, medication use. (Lawton, 1970) IADL abilities are usually lost before ADL activities. Therefore the majority of assisted living systems for the elderly incorporate the monitoring and detection of activities of daily living activities, either partially or entirely. (Mshali, 2018)

Ambulatory activities are activities that are related to the subject’s motion and posture. The ambulatory activities are often used within a motion tracking and fall detection system. These activities can be divided into three different groups shown in the figure. (Mshali, 2018)

                                                                                                    
                                                                      


Mental functions are also used in health monitoring systems, such as memory and comprehension. These functions do not imply the achievement of an action by the subject but they can be deduced based on the overall behaviour and the subject’s ability perform other activities. For instance, the ability of the subject to regularly take medication on time can indicate his memory abilities. (Mshali, 2018)

Monitoring community is related to physiological activities such as cardiac and brain activities. This type is used in real-time monitoring to retrieve the direct individual health parameters especially those with chronic diseases. (Mshali, 2018)

Ambient assisted living (AAL) applications monitor and evaluate a list of basic daily activities allowing a person to live independently and they provide services involving caregivers. Movement tracking and fall detection (MTFD) systems detect ambulatory activities, including dynamic activities, static postures, location tracking and accidental falls. Finally physiological health monitoring (PHS) systems use real-time applications for monitoring and diagnosing vital signs for dependent and chronically ill ones. (Mshali, 2018)

3.3.    What to use to monitor? Sensors, intreconnected networks

As it was previously discussed monitoring consists of three steps: data collection (product), data sharing/transmission (platform) and data storage /analysis (database). Within this modul only the first step – data collection or product - is introduced while neither platform nor database is covered.
Various sources could be used to gather the information related to the physical status, behaviour, environment, performed activities. Data sources may be classified according to their collection method (direct and indirect), event type (frequency mode), source type (physical or virtual) and sensor data.

Direct methods collecting data from hardware and sensors attached locally without intermediaries, indirect methods use a middleware-based infrastructure where the system collects sensor data from additional software or hardware sources.
With regards to data collection, data can be generated based on three event types:

•    constant - continuous video stream),
•    interval data is sent periodically - sensing and sending heart performance every 20 seconds with an ECG sensor, or
•    instant - when a certain event occurs (light switch, door detection sensor).

Based on the source type physical sensors use data relating to the subject and their environment, virtual sources refer to other data sources, such as existing health records, historical data. Sensor data can have different formats, such as numerical, categorical, graphics, video, etc. Next figure presents sensor types. (Mshali, 2018)
 

                                                                                                                                                      


There are three main classes of interconnected networks: (Mshali, 2018)

•    Personal Sensor Networks (PSN)
PSNs are used to detect human daily activities and measure conditions in the subject’s environment.

•    Body Sensor Networks (BSN)
BSNs are used to monitor vital signs and health conditions by measuring physiological parameters and detecting ambulatory activities.

•    Multimedia Devices (MD).
MDs monitor movements, environmental changes and increases the interaction between the monitored person and the e-health application.

Selected sensors and devices are integrated into home objects and infrastructure and connected using network technologies. Each sensor is responsible for one or more task at the same time.

Figure describes the purpose for the three network categories, including the sensors, devices and data format.
 

 

                                                                                              
        
                                                
 

PSNs or environmental sensors capture data regarding the subject and their environment. PSNs can be placed in a living environment or attached to different home objects such as sofa, table, bed etc. Daily living activities can be measured by observing elderly in their environment in this specific location. Here are some examples: (Mshali, 2018)

•    Passive infrared (PIR) sensors are most frequently used for detecting the person’s presence monitoring ADL. (Noury 2012)
•    Radio-frequency identification (RFID) is used to identify users and/or objects of the HSH environment (Hsu, 2011)
•    Pressure and ultrasonic sensors can be attached to home objects to track their locations and track user locaton by it.
•    Contact switches are used to detect the subject’s interactions with other objects in the space such as door, window, etc.
•    Environmental sensors are used for additional dimensions such as light, temperature, humidity. They are deployed in different places to monitor environmental conditions and identify daily activities.
•    Power sensors are used to measure and manage energy consumption and to detect the usage of electrical devices using On/Off events.

BSNs use wearable sensors carried by monitored persons. These sensors are used to provide a continuous flow of information about real-time health conditions. They are often embedded into accessories such as clothes, belts, watches, or glasses. BSN often use inertial measurement units such as accelerometers for detecting ambulatory activities or vital sign devices such as heart rate sensors for monitoring the health condition of the subject. Accelerometers and gyroscopes are the most common inertial sensors used to monitor movements and body postures such as standing, sitting, and walking.

Global positioning systems (GPS) can also be used as wearable sensors to monitor location-based activities in an open or mobile environment.

Several biosensors are used to monitor the vital signs of patients and the elderly, such as heart rate, oxygen saturation, blood pressure, blood glucose, body temperature, weight, etc. Wearable sensors have been embedded into watches, shirts, belts etc. Such sensors provide real-time physiological information related to the health condition of the monitored subject. Various biosensors are used such as:

•    electrocardiography sensors (ECG) used to monitor cardiac activity,
•    electroencephalography sensors (EEG) used to monitor brain activity,
•    electromyography sensors (EMG) used to monitor muscle activity,
•    electrooculography sensors (EOG) used to monitor eye movements.
•    pulse oximeters are used to measure the oxygen level of the blood
•    photoplethysmography sensors (EPG) are used to monitor the rate of blood flow. (Mshali, 2018)

MDs monitor movements, environmental changes and increases the interaction between the monitored person and the e-health application. Integrated appliances can be electrical or electronic devices such as cameras, microphones, telephones, speakers and TV sets create a platform for the exchange of data between the person and the system.

•    Multimedia-based approaches encompass visual and audio sensing devices (e.g. cameras and microphones).
•    Soundbased detection methods can be used to monitor some activities of daily living.
•    Vision-based methods have a much wider scope and are used for posture recognition, human presence, movement and fall detection, and the monitoring of complex activities. (Mshali, 2018)

In a smart home non-wearable, embedded sensor activity monitors are able to track activities of daily living (ADL), instrumental activities of daily living (IADL), and other behaviors. The ambient sensors that are used for elderly care can be placed in different locations in a smart home to monitor human behavior or health status. Figure shows one potential setup of a smart apartment for elderly care based on different ambient sensors (Uddin, 2018)
 

                                                     


#4: Tools - examples

4.1.    Passive infrared sensors

A passive infrared sensor (PIR sensor) is an electronic sensor that measures infrared light radiating from objects in its field of view. PIRs are most often used in motion detectors. (https://en.wikipedia.org/wiki/Passive_ infrared_ sensor )
 

 

                                             


4.2.    Radio-frequency identification


Radio Frequency Identification (RFID) sensors, integrating the features of Wireless Information and Power Transfer (WIPT), object identification and energy efficient sensing capabilities. RFID sensor tags featuring contactless sensing, wireless information transfer, wireless powered, light weight, non-line-of-sight transmission, flexible and pasteable. RFID technology is freqently used in in devices such as wearable and implanted sensing devices e.g. for glucose monitoring, blood pressure, intraocular pressure, and on-skin monitoring discrimination of breath anomalies. (Cui, 2019)
 

                                                      



Another example for an implanted RFID sensor tag is the implantable continuous intraocular pressure (IOP) monitoring system. (Agarwal, 2018)
 

                                                     


A figure shows a flexible on-skin sensor system that can measure metabolites (glucose, lactate) and electrolytes (sodium, potassium ions) in sweat, calibrate the data based upon skin temperature and sync the results in real time to a smartphone. This non-invasive monitoring of multiple biochemicals in sweat is able to make a real-time assessment of the physiological state of the wearer, and could alert users. (UC Berkeley)
 

                                                             


4.3.    Ultrasonic sensors

Pressure sensors in smart homes could be detecting bed presence.

                                                             


Flexible force sensors could be applied both in vivo and in vitro. In vivo measuring ECG could prevent and treat cardiovascular diseases, monitoring heart rhythm to correct arrhythmia, measuring pressure on bone could treat osteoporosis, fractures and promote cell proliferation. Force sencor could be positioned many different place on human body in vitro. Pluse is measured on wrist in order to diagnose cardiovascular disease, measuring strain distribution on knee or elbow could detect posture and movement during postoperative rehabilitation, or measuring sound vibration on throat could identify demage vocal cords or could recognise voice. (Chen, 2020)

It is priority to prevent the elderly from meeting with serious accidents and, even if they have accidents, to detect occurrence of accidents promptly. Activities of the elderly in either their home or a nursing room could be monitored continuously so their accidents would be avoided or minimized if the system can recognize and notify the accident-prone activities to caregivers beforehand. Figure shows the monitoring system in the nursing home to observe activities of the elderly people using ultrasonic sensors. (Hori, 2005)
 

                                                              

4.4.    Contact switches

Contact switches are are used to detect the elderly interactions with other objects e.g. monitoring activities of daily living and falls. As an example emergency call button specially designed to elderly to send alarm information. The mobile app receives the alarm information immediately the family can know there is an emergency situation.
 

                                                                       

Environmental sensors are used for additional dimensions such as light, temperature, humidity, they are deployed in different places to monitor environmental conditions and identify daily activities.
 

                                                                      


4.5.    Wearable sensors - smart safety

Biosensors are used to monitor the vital signs of patients and the elderly, such as heart rate, oxygen saturation, blood pressure, blood glucose, body temperature, weight, etc. Such sensors provide real-time physiological information related to the health condition of the monitored subject. Wearable sensors have been embedded into smart tools.

4.5.1.    ECG

Electrocardiography sensors (ECG) used to monitor cardiac activity. A presented flexible wireless ECG sensor is expected to lead to the advent of smaller, lighter and more comfortable wearable systems. (Patel, 2012) ECG

                                                                       


4.5.2.    Smart ring

A smart ring measures sleep and monitor rate and skin temperature.

                                                                      

4.5.3.    Smart bracelet, smart watch

Smartwatches perform a multitude of functions both as a fitness tracker and health monitoring tool. Figure shows different built-in sensors in smartwatch such as pedometer, GPS, bioimpedance sensor, sleep monitor, calorie counter, heart rate sensor. (Smartwatches, https://www.taggdigital.com)

                                                              

4.5.4.    Smart phones

Smartphone-based ECG monitoring system allows low power ECG sensors to communicate wirelessly with the phone. With increasing computational and storage capacity and ubiquitous connectivity, smart phones are expected to enable continuous health monitoring.
 

                                                                 


Built-in sensors allow for active and/or passive sensing of several health parameters and health conditions. A smartphone-sensor based healthcare technologies are able to monitor wilde variety of health issues such as cardiovascular activity (camera), eye health (camera), respiratory and lung health (camera), skin health (camera), daily activity and fall (motion sensors), sleep (motion sensors), ear health (microphone), cognitive function and mental health (motion sensors, camera, GPS). Figure shows the built-in sensors in a typical present-day smartphone. (Majumder, 2019)