e-Health interventions for healthy aging: a systematic review

Prospect studies foresee a worldwide growth of people aged over 60 years to at least 2 billion by 2050 [1]. More people are living longer and want to stay active and healthy to fully participate in life. However, decline in the biological, physiological, and cognitive systems inherent to aging may limit full social, cultural, and intellectual engagement in older persons [2]. Therefore, supportive strategies are needed to warrant a good quality of life. Healthy aging (HA) is defined as “the process of optimizing opportunities for physical, social and mental health to enable older people to take an active part in society without discrimination and to enjoy an independent and good quality of life” [3]. HA includes an active engagement with life, optimal cognitive and physical functioning, and low risk of disease that enables older people to participate within their limitations and continue to be physically, cognitively, socially, and spiritually active [4]. Ensuring HA for the population should be a priority in high-income countries today, but also in low-income countries that foresee aging of their population in the near future [5].

Worldwide, baby boomers are reaching the retirement age while policies are levied to keep older adults active in prolonging the working period (i.e., in Greece, France, Denmark) [6‐8]. This cohort and onward generations in the “early old age” (defined by the WHO as people aged 50 years or above) [9] increasingly use information and communication technologies (ICT) in their daily activities [10]. With the rapid development of ICTs, which are getting more accessible and easier to use for these older adults, there is a huge potential to develop e-Health interventions targeting the growing population of 50 years and above. The WHO defines e-Health as the electronic exchange of health-related data collected or analyzed through electronic connectivity to improve the efficiency and effectiveness of healthcare delivery [11].

The rise in chronic conditions, which intensify in the last years of life, constitutes a contemporary challenge for health and welfare systems as it has profound implications for the planning and delivery of health and social care. A wide range of literature evidences that a longer life expectancy increases chronic health conditions and pressures the health system in terms of limited resources [12, 13] and public and private spending [14, 15]. Various studies associate steadily spending growth to medical payment schemes [16] or merely to old age with comorbidities [15]. Nevertheless, the World Health Organization (WHO) Brasilia Declaration on Ageing in 1996 stated that “healthy older persons are a resource for their families, their communities and the economy” [17]. In view of these challenges and opportunities, following the United Nations members’ meeting on Aging in Madrid in 2002, the WHO has proposed an active aging policy framework [18] and an age-friendly program plan in 2007 [9].

Among the interventions dedicated to maintain and improve older adults’ active lifestyles and health, those incorporating e-Health receive increasing attention because of their potential to support empowerment and the recognition of their central role in today’s society [19]. There are many examples of successful e-Health applications for health care and health promotion, such as telemedicine, electronic health records, virtual interventions, and personal health monitoring. With respect to HA, e-Health interventions offer older adults the opportunity to access health information and receive health and social care at home. These interactive interventions can empower, engage, and educate older adults [19].

In synthesizing the latest updates, Lattanzio et al. [20] highlight three main domains of development related to advances in technological innovation to support care: (1) disease management, (2) intelligent devices to improve autonomous living and mobility in older persons, and (3) specific needs for active aging. Among common e-Health interventions in support of HA, some are designed for virtual physical exercise [21, 22], and others promote networking [23], an active lifestyle [24], or independence [25]. Interestingly, recent studies contend a high intention to adopt e-Health interventions among older adults [26] and recognize these interventions to be relevant, adapted, and safe to use by these older users [27‐30]. Furthermore, e-Health tools are designed to be more portable and lighter [21, 22]. Other authors reported that they offer independence and confidence [27]. Nevertheless, despite technological developments and the multiplication of e-Health applications targeting older adults, knowledge on their effectiveness for supporting HA and its related outcomes has not been synthesized. There is an imperative to determine how e-Health can be used to improve old-age wellbeing.

Technologies that use ubiquitous computing and personalized algorithms play an important role in motivating people to adopt and maintain healthy behaviors as they age [31]. A systematic review of Web 2.0 interventions for chronic disease self-management in older adults found benefits on psychological outcomes as self-efficacy and quality of life, as well as on health behaviors (e.g., physical activity) [32]. Likewise, electronic games could offer huge opportunities for involving older people with cognitive and/or physical disabilities in activities that may support them to participate actively in everyday life [8]. A systematic review found some evidence regarding the effectiveness of exergames, digital gaming systems requiring physical exertion to play the game (e.g., Wii™ games), in improving physical health in older persons [33]. Preschl et al.’s literature review of e-Health interventions targeting depression, anxiety disorders, and dementia in older adults found limited evidence of their effectiveness from high-quality studies, but promising results from smaller studies [34].

To date, to the best of our knowledge, there does not exist a systematic review that addresses the effectiveness of a range of e-Health interventions for supporting HA in all of its dimensions (e.g., physical, social, cognitive). Previous reviews [32‐34] provide a starting point for a comprehensive systematic review that could map up current scientific evidence on e-Health interventions for HA.

This systematic review intends to clarify the role of e-Health interventions in promoting HA among older adults. It targets two main objectives: (1) to identify and systematically summarize the best available evidence on the effectiveness of e-Health interventions on outcomes related to HA, as well as adverse effects related to these interventions, and (2) to explore how specific e-Health interventions (e.g., age-friendly, community interventions) and their characteristics (e.g., mode of implementation) may be implemented to effectively impact HA.

This systematic review was conducted based on the Cochrane Collaboration methods [35]. The review protocol was registered in PROSPERO (registration number: CRD42016033163). We used the PRISMA checklist [36] (see Supplementary file 1) to ensure reporting of all relevant information related to the systematic review. We also consulted the Synthesis Without Meta-analysis (SWiM) guidelines [37] to guide the use of alternative synthesis methods.

Figure 1 shows the study selection flow diagram. The initial search led to 7039 potentially relevant citations. After screening titles and abstracts, 60 publications were kept for further assessment, of which 10 articles were finally retained for the review [24, 42‐50]. An updated search ran in May 2018 resulted in the inclusion of three additional peer-review publications [51‐53] and one thesis [54].

In total, 21 peer-review articles and one thesis—stemmed from 14 studies—were finally retained. The list of excluded publications and reasons for exclusion is provided in Appendix (Supplementary file 3).

The characteristics of the 14 included studies are presented in Table 1. Five studies were conducted in the USA [24, 43‐45, 54], one in Japan [52], and the remaining eight in Europe [42, 46‐51]. Among European studies, three were conducted in the Netherlands [48, 49, 51], two in the UK [47, 53], and one in three countries (Greece, Spain, and Sweden) [42]. Furthermore, three studies presented different parts of their results in distinct publications: (i) Wijsman et al. [51, 62, 63], (ii) van het Reve et al. [50, 60, 61], and (iii) Peels et al. [48, 55‐57].

When appraising the quality of the retained studies, we first noted that great variation existed with regard to sample size with a minimum of 14 and a maximum of 1729 participants. Seven studies had small samples (n < 100)―for a total number of 3645 participants aged between 50 and 88 years old. Also, in the majority of studies, the samples comprised more women than men. Second, as shown in Fig. 2, the risk of bias was moderate to high across the studies, but the source of bias varied. The blinding (participants, personnel, or outcomes assessor) bias was present at a high risk or unclear in most studies. Sequence generation and allocation concealment were variable among the studies, which means that the potential selection biases were foreseeable in half of the studies. Finally, potential risk of bias related to incomplete outcome data and selective outcome was low in a large majority of studies, meaning that there was a low risk of reporting bias. We also noted the use of a wide range of validated questionnaires (such as quality of life: RAND 36; physical and psychological well-being: SF-36; wellbeing: SPF-IL scale) and non-validated rating scales (such as behavioral change self-assessment, IT literacy, engagement in activity) to assess the impact of the interventions.

The main objectives of this systematic review were to summarize the best available evidence on the effectiveness of e-Health interventions on HA and to explore how specific e-Health interventions may be implemented to effectively impact HA. To the best of our knowledge, this systematic review is the first to consider the overall effect of e-Health interventions on several dimensions related to healthy aging in older adults.

In this systematic review, we identified a broad variety of interventions that focused on promoting PA and other healthy behaviors, engaging in lifestyle change, and improving physical, psychological, and social wellbeing, which adds to existing literature [65‐69]. Overall, most of the included studies were of moderate quality due either to their small sample size, the multiple-component nature of the interventions, their short duration, and the variable quality of the study designs [35].

For healthy older adults, our findings show positive effects of e-Health technology to promote healthy behaviors such as stimulating PA and awareness of PA, to enhance knowledge, and to facilitate behavior change and enhance psychological wellbeing. The use of the Center for Technology and Aging [39] classification system in our work enables the comparison of competing technologies. Furthermore, this classification used in telemedicine and e-Health fields may also facilitate communication among researchers, clinicians, and other users and target the specific technology’s contribution to the health and wellbeing of older adults.

The provision of information was often at the core of the e-Health interventions. Still, there is a need to consider factors related to technology adoption by the older persons, such as interest in learning information and IT literacy [70]. In that line, Vaportzis et al. [71] warned about the following barriers related to IT adoption by older people: lack of instructions and knowledge, health-related barriers, cost, complexity of the technology, lack of social interaction, and communication. Furthermore, Hawley-Hague et al. [72] suggested to consider intrinsic factors related to older adults’ attitudes around control, independence and perceived need/requirements for safety, and their motivation to use and go on using technologies. Several authors also identified some extrinsic factors, including usability, feedback gained, and costs, as important elements supporting older adults’ attitudes and perceptions towards IT use [73, 74].

Other reviews have looked at the impact of ICT use by older people either on physical [75, 76] or on social dimensions [77, 78]. With respect to physical dimensions, the integrative review by Skjaeret et al. [75] found positive effects of exergaming on balance and gait and no major adverse effects. However, the number of included studies was low and most were of limited quality. Nevertheless, PA delivered through e-Health was found to improve adherence to exercise [76].

Chen and Shultz [77] found that ICT use was positively affecting social support, social connectedness, and social isolation among the elderly. However, the effect of ICT on loneliness was inconclusive, with some studies indicating a negative impact. Li et al. [78] reviewed the impact of exergames for older adults on social aspects and found generally positive impacts on loneliness, social connection, and attitudes towards others.

Although the evidence from our synthesis suggests that e-Health interventions are promising, we are still facing several challenges for large-scale implementation of these solutions among older adults. First, there is still a need to strengthen digital health literacy [79, 80]. It is important to recognize that a lack of competence or limitation is often attributed to age-related cognitive decline [81, 82]. Critical competence is needed to effectively evaluate health information [83, 84]. Second, several methodological challenges remain for the evaluation of e-Health intervention. As e-Health interventions are at the intersection of biomedical, behavioral, computing, and engineering research, methods drawn from all these disciplines are required. Experimental designs such as RCTs to evaluate e-Health interventions are cost and time consuming, but remain important for demonstrating their effectiveness and cost-effectiveness [11, 85]. Furthermore, Murray et al. recommend to undertake RCT only after ensuring that the intervention and its delivery package are stable, the intervention can be implemented with high fidelity, and when there is a reasonable likelihood that the overall benefits will be clinically meaningful [86]. Finally, the question of access to Internet arises. The digital divide [87] and the ongoing debate regarding the differences between users and nonusers of online health information among older adults [88], which could reinforce existing social differences, should be considered.

Although it provides a useful synthesis of the current evidence regarding e-Health interventions targeting healthy older adults, this review has some limitations. First, we excluded publications published in languages other than English, Dutch, Spanish, and French. This may have limited the scope of our investigation, but we consider that important international trials were captured by looking at the references of all included studies and searching manually in specialized journals. Second, an important limitation is related to our broad inclusion criteria, which led to include interventions that are quite heterogeneous. Our sample included participants from a wide age range—50 years old and above—thus some interventions might not be applicable to all age groups. This has limited a straightforward comparison and hindered a meta-analysis. However, the use of the Center for Technology and Aging [39] classification helped us to organize the results in a more coherent manner. Based on the types of technologies used and the nature of the interventions, it could be useful to promote a more structured taxonomy to present e-Health interventions in the literature, which could facilitate the identification of relevant studies and the aggregation of their results to inform decisions.

Finally, as the last search was conducted in April 2018, it is possible that more recent trials were not included. We conducted a rapid literature search in PubMed in March 2020 looking for potentially relevant studies published after the last update and identified one published study [89] and six published protocols [90‐95], which indicates that several trials of e-Health interventions for HA are currently ongoing. We thus recommend to update this systematic review within the next 2 years as more evidence is likely to change the conclusions of the present systematic review.

This systematic review contributes to the evidence-base regarding the effectiveness of e-Health interventions in supporting HA. From our perspective, the critical question is how to best shape and direct our efforts to optimize the development and application of these technologies considering older adults’ digital health literacy. As it is an emerging field, the evidence base on e-Health interventions for promoting HA is subject to quick evolution. The pace of technology development is rapid, and the technology could become obsolete at the time the results appear. Thus, innovative evaluation methods are needed to produce high-quality evidence in an appropriate timeframe in order to inform decisions regarding the implementation of effective technologies for HA.