General results
Categories of ETs
In analyzing the results of our in-depth web search, we recognized that the ETs could be grouped into four main categories: Conventional Monitoring Techniques (CMTs), Unconventional Monitoring Techniques (UNMTs), Virtual Reality Technologies (VRTs), and Socially Assistive Robots (SARs).
CMTs refer to the set of techniques allowing a continuous observation of older adults (physiological and physical) condition performed through the use of traditional devices, such as the oximeter or the glucometer, integrated into or accompanied by a technological platform. CMTs are able to monitor older adults’ condition in their everyday lives and communicate relevant health and behavioural information in real time to health-care professionals or reference family members. They include the traditional devices used for telemedicine, to track physiological parameters or administer medicines.
UNMTs, instead, refer to the subcategory of monitoring techniques which perform their monitoring functions in a more pervasive manner. Examples of UNMTs are wearable devices – products controlled by electronic components and often equipped with GPS trackers, which are incorporated into clothing or worn on the body like accessories; but also Ambient Intelligence systems, defined as the sets of different physical environments (e.g. homes) interacting with people through computing devices, capturing pervasive information over the elder daily life.
The third category, VRTs, refers to the use of headsets that create 3D environments, in which the elder is fully immersed for therapeutic or entertainment purposes.
Finally, SARs represent the last frontier of aged care. SARs are defined as robots that provide assistance to older people, primarily through social or physical interaction. They can be used as companionship tools or to help in different tasks of the everyday life.
We classified each technology we found in one of these categories, and we observed the distribution which follows. The comprehensive list of ETs included in the review with the specification of category/function is reported in supplementary information (see Additional File
1).
Monitoring Techniques (see Table
3) constitute a significant majority of all ETs. Among the technologies belonging to this category, some are CMTs, but most of them are UNMTs. Examples of technologies which can be found in the CMTs category are CollegaMENTI for Silver Age and CuraMI.Tech. UNMTs, instead, include for example: Amyko and Canary Care.
The second largest category of ETs is that of SARs (see Table
3), and, among them, the ones which can be classified as Service-Type Robots (e.g. Alfred and Care-O-Bot 3), are more than double the ones which are classified as Companion-Type Robots (e.g. Paro and Pepper).
VRTs represent a small fraction of all ETs (see Table
3), as this category includes only eight technologies, e.g. Granny Vision and Kaleido.
Monitoring | 182 | 82 |
1 | CMTs | 38 | 17 |
2 | UNMTs | 144 | 65 |
SARs | 34 | 15 |
1 | Companion-type | 7 | 3 |
2 | Service-type | 28 | 12 |
VRTs | 8 | 3 |
Functions of ETs
Most technologies present more than one use, since several ETs bring together in a single device a combination features which make the technology useful on several fronts: these devices have therefore been included in the count for multiple functions (for instance, most wearable devices have both GPS tracking and fall detection functions). ETs’ most common functions are listed in Table
4.
Monitoring | 133 | 60 |
Emergency detection &/or calls | 76 | 34 |
Fall detection | 72 | 32 |
Assistance in managing healthcare (e.g. giving reminders) | 51 | 23 |
GPS Tracking | 38 | 17 |
Social connectivity & communication (with family, caregivers, friends, etc.) | 34 | 15 |
Predictive analytics (memorizing habits & prescribing insights) | 26 | 11 |
Companionship & interaction | 25 | 11 |
Cognitive training, stimulation & rehabilitation | 24 | 11 |
Entertainment | 20 | 9 |
Collecting healthcare data | 19 | 8 |
Psycho-social support & coaching | 15 | 7 |
Assistance in practical activities (e.g. delivering objects) | 13 | 6 |
Physical rehabilitation & exercise | 11 | 5 |
Planning | 7 | 3 |
Robotic Manipulationb | 4 | 2 |
Helping and alerting nurses and caregivers | 2 | 1 |
Communication with healthcare professional | 1 | < 1 |
A large amount of technologies have monitoring functions, which we distinguish between what we referred to as “passive monitoring” and “active monitoring”, in relation to the extent the elderly person is involved in the monitoring activity. Passive monitoring refers to technologies which can monitor health and wellbeing automatically, so they do not require any action from the elders (e.g., domotic systems or environment sensors). Active monitoring, instead, implies that the elder is actively involved in managing the technology and monitoring his health (i.e., through wearables), therefore some digital literacy is necessary.
The second most common functions are emergency detection and/or emergency calls, provided for example by HomeGuardian and Kompai Robot. In addition, a fraction of identified devices can specifically detect falls (e.g., HOBBIT and Kanega).
Some technologies give support and assistance in managing healthcare: ElliQ and Romeo, for instance, can send reminders and help patients to comply with medical prescriptions, in this way facilitating the caregivers’ work.
Other important functions are improvement of social connectivity and communication. SARs, such as Care-O-Bot 3 and ElliQ, can contribute to satisfying older adults’ need for companionship, interaction and/or entertainment.
Several devices provide cognitive training, facilitate stimulation and rehabilitation, or give psycho-social support and coaching. Others can help in physical rehabilitation and exercise.
A fraction of technologies can assist in practical and manual activities such as picking up and delivering objects to patients. Some ETs can also open jars, grasp different utensils, and perform even quite difficult tasks such as preparing a meal. These latter, more complicated functions are referred to as robotic manipulation and are performed especially by Alfred and Tiago Robot, which are equipped with proper robotic arms.
Some devices can collect healthcare data, memorize habits and offer insights, giving also predicting analytics. Mymedbook, Sara and Visavis, in particular, give assistance in planning.
Finally, another emerging feature is GPS tracking, which is present in a high number of technologies.
Target of ETs
With regard to the target, we did not observe significant differences in the gender of the target population, as all technologies are equally suitable for males and females. However, we did notice a differentiation of the target in relation to the degree of older adults’ autonomy (see Table
5).
All seniors: Autonomous seniors; Semi-autonomous seniors; Seniors with MCI and/or Dementia and/or Alzheimer’s disease | 175 | 79 |
Autonomous seniors Semi-autonomous seniors | 24 | 11 |
Semi-autonomous seniors Seniors with MCI and/or Dementia and/or Alzheimer’s disease | 5 | 2 |
Seniors with MCI and/or Dementia and/or Alzheimer’s disease | 14 | 6 |
Autonomous seniors | 2 | 1 |
Semi-autonomous seniors | 2 | 1 |
And, while some websites clearly state the target for which the ETs are designed, in other cases this was inferred from the technologies’ characteristics.
A major portion of technologies are developed for all seniors: autonomous, semi-autonomous, and seniors with Mild Cognitive Impairment (MCI) and/or Dementia and/or Alzheimer’s disease.
The rest of the technologies are more specifically targeted to certain subgroups of seniors: some are intended for autonomous and semi-autonomous seniors (e.g., Alfred and MAGIC-GLASS), while others are intended for semi-autonomous seniors and seniors with MCI and/or Dementia and/or Alzheimer’s disease (e.g., CareMat and Ti-Seguo).
Some ETs are designed exclusively for one specific group of seniors: for seniors with MCI and/or Dementia and/or Alzheimer’s disease only (e.g., AngelSense and SensorNet), for autonomous seniors only (MoveCare and NoonCare), or for semi-autonomous seniors only (Vitalerter and Robear).
Time of development and its relation to COVID-19 pandemic
ETs for elderly care were mainly developed before the COVID-19 pandemic (Table
6). Nevertheless, in proportion, it is noteworthy that 14% of all ETs have been developed during the pandemic. Of these, the majority are UNMTs: in particular, 10 technologies are wearable devices, while 11 UNMTs are Ambient Intelligence devices. Finally, one technology (Aph-Alarm) consists of both wearable sensors and environmental sensors. Of the remaining technologies developed during the pandemic, 4 are CMTs, 4 are SARs and, finally, only 1 is VRT.
Table 6
Time of development
Before COVID-19 pandemic | 191 | 86 |
During COVID-19 pandemic | 31 | 14 |
Some additional information was collected about the location where the identified ETs were first developed and the type of funding they received.
Considering the locations (see Table
7), we may notice that a large percentage of technologies come from two countries: Italy (e.g. CloudIA, E.CA.RE, Kibi Wear, Robot R1, WiMHome) and the USA (e.g. Alexa Together, AngelSense, LUNA lights, Pria, QuietCare). As mentioned above, such a high percentage of Italian technologies may be certainly explained on the basis that the keywords search was performed both in English and in Italian, so as to purposedly identify the largest possible number of technologies developed in Italy. A further analysis of selected Italian ETs showed that a good share of them were developed in Lombardy.
Other countries which represent locations for ETs development are: the UK, Switzerland, France and Israel, Germany, Finland, Australia, Czech Republic, Spain, Japan, China, Belgium, India, Denmark and South Korea, Austria, Ireland, the Netherlands, Norway, Singapore, Tunisia, Turkey, United Arab Emirates.
Finally, some technologies were the result of multi-national projects sponsored by the European Union (EU).
USA | 76 | 34 |
ITALY | Total | Lombardy | Total | Lombardy |
41 | 13 | 18 | 6 |
UK | 34 | 15 |
MULTI-NATIONAL (EU PROJECTS) | 13 | 6 |
SWITZERLAND | 9 | 4 |
FRANCE | 5 | 2 |
ISRAEL | 5 | 2 |
AUSTRALIA | 4 | 2 |
GERMANY | 4 | 2 |
FINLAND | 4 | 2 |
CZECH REPUBLIC | 3 | 1 |
JAPAN | 3 | 1 |
SPAIN | 3 | 1 |
BELGIUM | 2 | 1 |
CHINA | 2 | 1 |
DENMARK | 2 | 1 |
INDIA | 2 | 1 |
SOUTH KOREA | 2 | 1 |
AUSTRIA | 1 | < 1 |
IRELAND | 1 | < 1 |
THE NETHERLANDS | 1 | < 1 |
NORWAY | 1 | < 1 |
SINGAPORE | 1 | < 1 |
TUNISIA | 1 | < 1 |
TURKEY | 1 | < 1 |
UNITED ARAB EMIRATES | 1 | < 1 |
Given the focus on Italy, deriving from the rationale of the project in which this work is framed, it is interesting to note which technologies have been developed on the Italian soil. Our findings show that in Italy (and in Lombardy, in particular) mostly UNMTs were developed, of which 15 are Ambient Intelligence technologies, 10 are wearable devices, and one technology has a twofold function, presenting both wearable and Ambient Intelligence components. CMTs represent the second most numerous ETs class (8 devices). Concerning the other two categories, we identified only one VRT and two SARs (service type), of which one is combined with components of Ambient Intelligence.
As to the development period, the growing interest in ETs for the elderly care is shown by the fact that 30% of the 41 technologies developed in Italy (N = 12) were designed and marketed during the pandemic time. All of these 12 ETs are monitoring technologies, of which 8 belong to UNMTs.
Regarding sources of funding (see Table
8), our analysis shows that private companies are responsible for funding a significant share of ETs (e.g., Amyko and Romeo), plus a few technologies which were developed by a partnership of private companies (GAP and BrainMEE). A second smaller group of ETs were the result of research projects launched in response to national and international calls, funded by universities, profit and non-profit partners, etc. (e.g., CollegaMENTI and MARIO). The remaining technologies are roughly half resulting from projects of research institutes and/or universities (e.g. Care-O-Bot 3 and Robot R1) and half resulting projects of non-profit associations and/or universities and/or research institutes and/or private companies (e.g., CuraMi.Tech and Isidora).
Private Companies | 187 | 84 |
Research projects in response to national and international calls for proposals with universities, profit and non-profit partners, etc. | 21 | 9 |
Projects of non-profit associations and/or universities and/or research institutes and/or private companies | 6 | 3 |
Projects of research institutes and/or universities | 6 | 3 |
Partnership of private companies | 2 | 1 |
Finally, as to the developmental stage, we found that a large proportion of ETs are already on the market; the remaining are still in the project phase, except for one technology, which is out of market (Pepper the robot).
Safety
Feeling safer when being alone is a need that is keenly felt by most people when getting older. Therefore, the first and most common expected result when introducing technology in the care of an older person is greater safety, both from a physical and a psychological point of view [
28]. A good portion of ETs aims at increasing the elder’s safety during everyday life activities, especially those wearables and technologies with monitoring functions, fall and emergency detection functions, or GPS tracking functions (i.e. SEREMY, Tahoma 2.0, Ti-Seguo, etc.). Other ETs, such as cognitive and emotional assistive systems or smart health monitoring systems, further contribute to the sense of relief and greater security (i.e. care.coach, HealthyTogether, etc.).
ETs with monitoring functions increase safety because they enable constant monitoring of the vital parameters and health condition of the elderly, whether healthy or ill. In this way, these devices can reduce older adults’ physical vulnerability, related to “bodily deterioration”, i.e. “non-pathological and pathological physical/physiological decline” [
25, p. 11].
Knowing that their health condition is being monitored, the elderly can feel calmer and safer: they know their caregivers are constantly updated on their status and ready to intervene in case of emergency. Accordingly, ETs reinforce a sense of security, instilling peace of mind and reducing the stress associated with the perception of an instable psycho-physical condition. In this sense, ETs can also tame the psychological vulnerability of the elderly, which is related to emotional factors (e.g., anxiety and fear of being unsafe, especially in the absence of caregivers) and to experiential components, for instance, feeling a ‘decaying body’ [
25, p. 11].
In line with these considerations about safety and physical and psychological well-being, most of the technologies developed during the COVID-19 health emergency are UNMTs. The necessary imposition of containment measures, aimed at avoiding virus transmission, has in fact made health monitoring and verification more complex, thus potentially putting elderly people at risk. The design and development of UNMTs has been a useful aid to partially overcome these problems, which affected both the independent (or partially independent) elderly living in private homes and the institutionalised elderly. In fact, UNMTs make it possible to check health parameters remotely, avoiding the risk of infection for both elderly people and caregivers and/or family members. Nevertheless, the development of CMTs and SARs during the pandemic has also been a useful resource, from other points of view, and it should be seen in this same light.
By increasing the physical and psychological well-being of the elderly and their protection, ETs also have a potential positive impact on older adults’ Quality of Life. Therefore, in the light of the principles of biomedical ethics [
26], undoubtedly the use of these tools promotes the principle of
beneficence. A positive impact can be observed also with regard to
non maleficence: by constantly monitoring older adults, ETs allow prevention and emergency response, thus enhancing safety and protection of older adults, especially of the frailest ones [
15].
Independence and active aging
Despite the physical and psychological limitations which might accompany old age, elderly people do not want to lose their independence and wish to live their lives without being overly reliant upon others. For this reason, many ETs seek to enable seniors to live in their houses independently, by performing all those tasks for which they would require the help of a caregiver or a family member [
19,
29] SARs, such as Mylo, Hector, HOBBIT, Romeo etc., are important tools for assisting and providing support to elders both from a practical and from a psychological standpoint. All the ETs with prevention functions (e.g., Zibrio, CarePredict Tempo) also preserve older people’s independence as they avoid the worsening and further decrease of their residual capacities. Wearables, instead, like AngelSense and In Touch, give seniors the freedom to move around and even leave their houses, while being monitored for safety. This increases elders’ independence and promotes their active and healthy aging, while also relieving caregivers and family members from worry and the need to be constantly present.
The boost of independence, in the context of principlism, can be regarded as promotion of the principle of
autonomy, intended as older adults’ self-determination and capacity for autonomous action. Indeed, ETs allow the elderly to keep carrying out daily tasks and engaging in their favourite activities (e.g., doing physical activity and/or meeting friends and/or cooking) in partial independence. By allowing older adults to maintain a certain degree of autonomy, ETs can also have a positive impact on the principle of
beneficence [
26]: performing more activities on their own, supported by ETs but without the intervention of a caregiver, helps older adults retain certain abilities and prevents their early deterioration. In this way, the use of ETs reduces seniors’ perception of losing control and being increasingly dependent on others, a feeling which is typically associated with the relational vulnerability of the elderly [
25], as emphasised by relational care ethics approaches. ETs can therefore be said to tame this kind of vulnerability by allowing older adults to feel more self-reliant.
Even during the pandemic, ETs (especially CMTs, UNMTs and SARs) have made an important contribution. Indeed, they have enabled the elderly to partially compensate for the absence of care at home or for the lack of assistance from family members and/or caregivers, caused by the measures to contain the spread of SARS-CoV-2.
Connectedness
Considering older adults’ need for relationships, companionship and interaction, many ETs have been developed to enhance their connections with family, friends, as well as caregivers and healthcare professionals. ETs such as VitalBand and Care-O-Bot 3 make it a lot easier for seniors to get in touch with their loved ones, both through messages and videocalls. This reduces older adults’ isolation and allows them to remotely communicate more often with family members. Many technologies and platforms, like MoveCare and CollegaMENTI for Silver Age, are also designed to create virtual networks between seniors and build a community, in order to facilitate their participation in social activities.
The impact that ETs have on connectedness, from an ethical point of view, and specifically in the context of relational care ethics approaches, translates into implications for
relational autonomy, as personal self-determination and freedom can be regarded as dynamic phenomena that can only flourish in the context of human relationships [
30]. In fact, by facilitating communication with caregivers, relatives and friends, ETs enable older adults to be more actively involved in their circle of relationships. The creation of a stronger network of relationships, achieved through the use of ETs, also reduces the elderly’s sense of loneliness. This may prompt older adults feeling less vulnerable from the psychological standpoint [
25], as negative feelings connected to isolation and loneliness are reduced. Relational vulnerability may also appear tamed: older adults may feel vulnerable because they lack “adequate family support” and/or because they live alone and feel lonely [
25, p. 11]: with ETs, social relations can be easily cultivated even at a distance, fulfilling the elderly’s need for company and support.
The pandemic experience, in this regard, brought to the light these advantages of ETs. The various types of ETs, in fact, enabled the elderly to fulfil their need for sociability, to maintain relationships with family and friends, and to meet their need to cultivate social activities, even during the period of physical distancing.
Cost and efficiency
As the costs of healthcare services are ever rising, the introduction of technology in the care of the elderly needs to be considered also in terms of cost-effectiveness. Cost reduction, indeed, is one of the main interests among patients, families, and healthcare managers. ETs could be beneficial as they have the potential to create significant cost savings. Many home-based monitoring systems (e.g., SmartCare, Salute a casa, Independa Health Hub) can be used for telemedicine and accessed by physicians and nurses, sparing older adults the need to reach hospitals and doctors’ offices for visits, saving time and travel costs. The dissemination of technology can make it possible to guarantee health services even for those living in rural areas. Furthermore, technologies with fall prevention functions (e.g., Zibrio) avoid hospitalisation and the related costs. Finally, the introduction of SARs partially caters to the rising demand for healthcare workers.
Considerations in terms of cost and efficiency raise questions of public health ethics. This approach considers older adults’ vulnerability as a multi-layered condition that results also from socio-economic factors. Undoubtedly, reflecting on the positive outcomes outlined above, the implementation of ETs can have a positive impact also from this point of view, taming the socio-economic vulnerabilities of the elderly.
The pandemic context emphasized the benefits of ETs also in relation to the socio-economic dimension: technological devices allowed the remote management of some care practices, thus proving their cost-efficiency compared to traditional visits and monitoring in hospital. As to the social component, ETs made it possible to prevent infection.