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The use of assistive technologies (ATs) to support older people has been fueled by the demographic change and technological progress in many countries. These devices are designed to assist seniors, enable independent living at home or in residential facilities, and improve quality of life by addressing age-related difficulties.
We aimed to evaluate the effectiveness of ATs on relevant outcomes with a focus on frail older adults.
A systematic literature review of randomized controlled trials evaluating ATs was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The Ovid Medline, PsycINFO, SocIndex, CINAHL (Cumulative Index to Nursing and Allied Health Literature), CENTRAL (Cochrane Central Register of Controlled Trials), and IEEEXplore databases were searched from January 1, 2009, to March 15, 2019. ATs were included when aiming to support the domains autonomy, communication, or safety of older people with a mean age ≥65 years. Trials performed within a laboratory setting were excluded. Studies were retrospectively categorized according to the physical frailty status of participants.
A total of 19 trials with a high level of heterogeneity were included in the analysis. Six device categories were identified: mobility, personal disease management, medication, mental support, hearing, and vision. Eight trials showed significant effectiveness in all or some of the primary outcome measures. Personal disease management devices seem to be the most effective, with four out of five studies showing significant improvement of disease-related outcomes. Frailty could only be assessed for seven trials. Studies including participants with significant or severe impairment showed no effectiveness.
Different ATs show some promising results in well-functioning but not in frail older adults, suggesting that the evaluated ATs might not (yet) be suitable for this subgroup. The uncertainty of the effectiveness of ATs and the lack of high-quality research for many promising supportive devices were confirmed in this systematic review. Large studies, also including frail older adults, and clear standards are needed in the future to guide professionals, older users, and their relatives.
PROSPERO CRD42019130249; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=130249
Advancements in medicine and public health have led to a rise in life expectancy and are among the main reasons for the changing demographic structure in many countries. In the European Union, the share of people aged 65 years and over is projected to rise by almost 31 million (or 7%) until 2040, while the overall population is estimated to decrease by approximately 1 million [
The use of assistive technologies (ATs) in older persons’ care has been fueled by these developments, helping to maintain seniors’ autonomy, safety, or communication at home or in residential facilities [
Previous research has shown that, so far, AT is not likely to replace personal care but rather to supplement it [
In this study, we systematically reviewed randomized controlled trials (RCTs) to provide a synthesis of high-quality evidence on the effectiveness of ATs for nonfrail and frail older adults. In this context frailty is defined as “a state of increased vulnerability to poor resolution of homeostasis following a stress, which increases the risk of adverse outcomes including falls, delirium and disability” [
RQ1: What are the primary measures used to evaluate ATs?
RQ2: What types of ATs have effectively influenced autonomy, communication, and/or safety in adults aged 65 years and older?
RQ3: What influence does frailty have on the effectiveness of an AT?
A systematic literature review was performed using the guidelines from the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement [
The following databases were searched: Ovid Medline, PsycINFO, SocIndex, CINAHL (Cumulative Index to Nursing and Allied Health Literature), CENTRAL (Cochrane Central Register of Controlled Trials), and IEEEXplore. The search string was composed of three parts, focusing on age, methodology, and technology, respectively, combined by the operator AND. The three parts were (1) a previously published search filter for geriatric medicine [
Eligible for inclusion were peer-reviewed studies published in English or German between January 1, 2009, and March 15, 2019, reflecting the momentum that research on the effectiveness of AT has gained in the last decade. The date restriction was the only filter used in the database search. We included technologies that can assist with issues regarding autonomy, communication, or safety. Other inclusion criteria were (1) a study population with a mean age of 65 years or higher; (2) the study design being an RCT, including a control group with no intervention, an alternative intervention, or a placebo device; (3) the home of the senior, a residential facility, a nursing home, or similar as the study setting; and (4) any sort of technical, socioeconomic, ethical, or medical outcome measuring the impact of the technology on stakeholders (eg, patients, relatives, nurses, physicians).
Exclusion criteria were (1) studies performed in a laboratory setting; (2) studies analyzing robotics, virtual reality, telemedicine, or lifestyle interventions or technologies for rehabilitative or therapeutic purposes; (3) technologies demanding regular involvement of formal or informal caregivers; and (4) applications that have to be used in periodic training units. These exclusion criteria were selected to focus the analysis on technologies that are affordable and usable for the target population in their daily life without external support from relatives, caregivers, or medical staff.
Two authors (MLF and VM) independently screened all records and the studies selected for full-text analysis. Discrepancies were discussed and a third person was consulted, if necessary, until consensus was reached. Data extraction was carried out independently by both authors. The effectiveness of devices was recorded by extracting outcome data and statistical significance for primary outcome measures (
In cases of missing data, authors were contacted via email up to twice. The study population’s frailty status was categorized retrospectively according to their functional level into one of the four following categories: not impaired/independent (nonfrail), slightly impaired (prefrail), significantly impaired, and severely impaired/disabled (frail) [
After removal of duplicates, the search yielded 11,399 records. No articles were identified through other sources as described above. A total of 54 full texts were assessed for eligibility, 21 of which were included in the review (
PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) diagram for the study selection process.
Having a mean age ≥65 years as an inclusion criterion for our search, there were still large differences in the inclusion criteria at the study level: ≥18 years in three studies [
Most studies had participants’ homes as their study site (n=14). The investigation period varied from 1 month [
Overview of included studies, describing the study design and participants.
Study | Year | Country | Study design | Study participants | |||||
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|
|
Study type | Group design | Setting | Participants |
Age (years), mean (SD) | ||
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|
|
|
|
|
|
IGa | CGb | |
Scheffer et al [ |
2012 | Netherlands | Full | Parallel group | Home | 203 | 80.8 (9.0) | 81.2 (9.3) | |
Mira et al [ |
2014 | Spain | Full | Parallel group | Home | 102 | 70.9 (8.0) | 72.9 (6.0) | |
Hägglund et al [ |
2015 | Sweden | Full | Parallel group | Home | 82 | 75.0 (8.0) | 76.0 (7.0) | |
Humes et al [ |
2017 | United States | Full | Parallel group | Home | 163 | 68.9 (5.9) | 69.5 (6.7) | |
Rantz et al [ |
2017 | United States | Full | Parallel group | Nursing home | 171 | 83.6 (9.4) | 86 (8.0) | |
Ong et al [ |
2018 | Singapore | Full | Parallel group | Home | 197 | 77.0 | 77.0 | |
Levine et al [ |
2016 | United States | Full | Delayed-start | Home | 54 | 71.5 (12.2) | 70.5 (10.5) | |
Adrait et al [ |
2017 | France | Full | Delayed-start | Home | 51 | 83.0 (6.2) | 82.3 (7.2) | |
Elston et al [ |
2010 | United Kingdom | Full | Crossoverc | Home | 42 | 71.5 (11.3) | 70.4 (8.7) | |
Bray et al [ |
2017 | United Kingdom | Full | Crossoverd | Home | 100 | 69.79 (19.97) | 72.94 (16.63) | |
Tchalla et al [ |
2013 | France | Pilot | Parallel group | Home | 96 | 87.8 (6.5) | 85.3 (6.3) | |
Goldstein et al [ |
2014 | United States | Pilot | Parallel group | Home | 60 | 69.0 (10.6) | 69.6 (11.3) | |
Lam et al [ |
2016 | United States | Pilot | Parallel group | Home | 134 | 68.9 (13.2) | 71.1 (13.0) | |
Or and Tao [ |
2016 | Hong Kong | Pilot | Parallel group | Home | 63 | 69.3 (9.7) | 69.7 (10.2) | |
Lauriks et al [ |
2018 | Netherlands | Pilot | Parallel group | Nursing home | 54 | 84.3 (5.6) | 83.1 (7.1) | |
Schoon et al [ |
2018 | Netherlands | Pilot | Parallel group | Home and nursing home | 86 | 79.9 (5.5) | 80.9 (7.0) | |
Brath et al [ |
2013 | Austria | Pilot | Crossoverc | Home | 77 | 69.4 (4.8) | 69.4 (4.8) | |
Davison et al [ |
2015 | Australia | Pilot | Crossoverc | Nursing home | 16 | 86.0 (5.2) | 86.0 (5.2) | |
Van der Ploeg et al [ |
2016 | Australia | Pilot | Crossoverd | Nursing home | 17 | 86.7 (range 83.0-93.0) | 86.7 (range 83.0- 93.0) |
aIG: intervention group.
bCG: control group.
cCrossover study with expected carryover effect.
dCrossover study without expected carryover effect.
Frailty assessment.
Study | Frailty | |
|
Scale | Frailty statusa |
Mira et al [ |
Barthel ADLb | Slightly impaired (prefrail) |
Hägglund et al [ |
Short-Form 36 Physical | Slightly impaired (prefrail) |
Rantz et al [ |
Gait speedc | Severely impaired (frail) |
Adrait et al [ |
Lawton-IADLd | Significantly impaired (frail) |
Elston et al [ |
Gait speed | Slightly impaired (prefrail) |
Tchalla et al [ |
Lawton-IADLe | Slightly impaired (prefrail) |
Schoon et al [ |
Fried Frailty Score | 18.6% of participants frail at baseline |
aCategorized according to a method proposed by Brefka et al [
bADL: activities of daily living.
cCollection of ADL and IADL also mentioned with no data reported but provided by the authors upon request.
dIADL: instrumental activities of daily living.
eTimed-Up-and-Go test also performed with inconclusive results.
The 19 selected trials evaluated devices representing the following six domains: (1) mobility (n=5 [
Significant effectiveness was only reported in a pilot study for a nightlight path, which reduced falls among older people classified as slightly impaired/prefrail who had mild and moderate Alzheimer disease (odds ratio 0.73, 95% CI 0.15-0.88) [
A system consisting of a tablet computer connected to a patient scale was effective for participants classified as slightly impaired/prefrail who had heart failure. Both primary endpoints, the effect on self-care behavior and health-related QoL, improved in the intervention group after a 90-day trial. System adherence was high with a median of 88% (IQR 78%-96%) [
A study of a tablet-based app for medication self-management reported a significant improvement in adherence as well as the number of missed doses (27.3% reduction in the intervention group) in a slightly impaired/prefrail population. A reduction of medication errors was only found for patients with a higher error rate prior to the study. Although the mean satisfaction score with the AT in the intervention group was high (8.5 out of 10), 59% (30/51) of intervention group participants required assistance using the AT and almost 12% (6/51) stated that the device did not help at all [
A multimedia device with personalized music, videos, messages, and pictures installed by family members was tested in a pilot sample of 11 nursing home residents. Almost half of the participants needed assistance operating the device due to limited sensory or cognitive abilities. Nevertheless, staff and family members agreed they would recommend the AT for residents with dementia. During the 2-month crossover period, depression and anxiety were significantly reduced in the intervention group. However, a carryover effect seems likely, and no data are available for the precrossover phase of the study [
Humes et al [
A portable electronic vision enhancement system was compared to conventional optical magnifiers in a crossover trial that was published in two articles [
Judgment of risk of bias categories for each included study presented as percentages across all included studies.
Judgment of risk of bias categories for each included study, ordered by assistive technology category and publication year.
From the available information, it appears that testing an AT often purports difficulties with blinding participants and personnel. Nevertheless, unblinded studies are considered to have a higher RoB. In six studies, outcome assessors were not blinded, although it would have been possible [
A total of 70 primary outcome measures were extracted from the 19 trials (
Overview of interventions, domain(s) of interest, and outcomes studied in the included trials.
Study | Intervention | Control | Domain(s) of interest | (Primary) outcome(s)a | ||||
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Ab | Sc | Cd |
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Elston et al [ |
Metronome for the improvement of QoLe in people with Parkinson disease | Usual medication | ✓ | ✓ |
|
Parkinson disease mobility, QoL | |
|
Scheffer et al [ |
Mobile safety alarm with a drop sensor for community-dwelling older persons | No mobile safety alarm | ✓ | ✓ |
|
Frequency of going outside | |
|
Tchalla et al [ |
Nightlight path for patients with Alzheimer disease | No nightlight path |
|
✓ |
|
Fall incidence | |
|
Lauriks et al [ |
Assistive home technology for people with dementia living in group homes | No assistive home technology |
|
✓ |
|
QoL (self-rated, observed by caregiver); assessment of need for older persons; number and location of fall incidents; use of restraints; caregiver job satisfaction, workload, and general health | |
|
Schoon et al [ |
Gait speed monitoring and feedback device for older people at risk for falling | No gait speed monitoring | ✓ | ✓ |
|
Subjective general health and mental well-being; number of weekly measurements (compliance); fall incidence; incidence of injurious falls; fear of falling | |
|
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|
Hägglund et al [ |
Home intervention system for patients with heart failure | Standard heart failure information |
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✓ |
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Heart failure self-care behavior; health-related QoL | |
|
Levine et al [ |
Automated self-management monitor for blood glucose for low-income seniors | No automated self-management monitor for blood glucose | ✓ | ✓ |
|
Glycated hemoglobin level; frequency of self-monitoring of blood glucose | |
|
Or and Tao [ |
Tablet computer–based self-monitoring system for type 2 diabetes mellitus and/or hypertension | Conventional self-monitoring method | ✓ | ✓ |
|
Glycated hemoglobin level; fasting blood glucose level; blood pressure; diabetes/ hypertension knowledge; self-monitoring frequency | |
|
Rantz et al [ |
Nonwearable sensor system to monitor the status of older persons | Usual care |
|
✓ |
|
Walking speed; GAITRitef; QoL; depression; mental state; ADLg and IADLh; hand grip | |
|
Ong et al [ |
Medical alert protection system for older people living at home alone | Telephone follow-up |
|
✓ |
|
Emergency department visits; number of hospitalizations; total length of stay for admitted patients | |
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||||||||
|
Brath et al [ |
Mobile health–based electronic medication blisters for patients with diabetes | Standard medication blisters, routine care, handwritten medication intake diaries |
|
✓ |
|
Medication adherence | |
|
Goldstein et al [ |
Telemedicine medication reminder systems: electronic pillbox, smartphone app for older adults with heart failure | Silent pillbox or silent smartphone | ✓ | ✓ |
|
Medication adherence | |
|
Mira et al [ |
Medication self-management app for older adults taking multiple medications | Oral and written information on safe medication use | ✓ | ✓ |
|
Self-perceived health status; medication adherence; medication errors; missed doses | |
|
Lam et al [ |
Talking pill bottle for patients with hypertension | Usual care | ✓ | ✓ |
|
Self-efficacy for appropriate medication use; medication adherence; refill adherence; medication knowledge; blood pressure | |
|
||||||||
|
Davison et al [ |
Personalized multimedia device for people with dementia | Social control: weekly 30-min visits from researchers (reading, discussing things) |
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✓ | Agitation; depression in dementia; anxiety in dementia | |
|
Van der Ploeg et al [ |
Internet video chat (Skype) for nursing home residents with dementia | Landline telephone |
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✓ | Agitation; call duration | |
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Adrait et al [ |
Active hearing aid for patients with Alzheimer disease | Inactive hearing aid |
|
|
✓ | Neuropsychiatric symptoms; IADL |
|
|
Humes et al [ |
Best-practice hearing aid and over-the-counter models | Placebo device |
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✓ | Hearing aid performance and benefit | |
|
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Bray et al [ |
Portable electronic vision enhancement system for people with visual impairments | Optical magnifiers | ✓ |
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|
Near-vision visual function; vision-related QoL; cost-effectiveness and cost-utility; maximum reading speed; frequency of use |
aIf no distinction between primary and secondary outcomes was made, all outcomes are listed.
bA: autonomy.
cS: safety.
dC: communication.
eQoL: quality of life.
fAutomatic measurement of certain variables (eg, velocity, step length) while participants walk across the GAITRite Mat.
gADL: activities of daily living.
hIADL: instrumental activities of daily living.
Unfortunately, six outcome measures from crossover studies with expected carryover could not be analyzed due to a lack of data for the first phase of the study. Of the remaining 64 outcomes, 13 (20%) showed a significantly positive effect of the AT in the categories efficacy, usability, and QoL. However, considering the RoB, seven of those outcomes, covering all three categories, might be impacted [
Statistically significant outcome measures including a judgment of high risk of bias (RoB).
Outcome measure | Outcome category | Reason for high RoB | ||
|
Not applicable (no high RoB) | |||
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Near-vision visual function | Efficacy |
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Vision-related QoLa | QoL |
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Frequency of use | Usability |
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Cost-effectiveness (near-vision visual function vs carer and intervention costs) | Economic |
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No blinding; all dropouts in IGb | |||
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Heart failure self-care behavior | Efficacy |
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|
|
Health-related QoL | QoLb |
|
|
Hearing aid performance/benefit (Humes et al [ |
Efficacy | Per-protocol analysis; recruitment through newspaper ads | ||
Usage frequency (Levine et al [ |
Usability | No blinding; risk of recruitment bias (people who refused to participate were older, had lower glycated hemoglobin levels, and were less likely to be African American) | ||
|
Not applicable (no high RoB) | |||
|
Medication adherence | Efficacy |
|
|
|
Medication errors | Efficacy |
|
|
Total length of stay for admitted patients (Ong et al [ |
Efficacy | No blinding (allocation was discussed with the participants); very high dropout rates in IG (32% vs 1% in the CGc), resulting in a change in the IG:CG ratio from 1:1 to 1:3 | ||
Decrease of diastolic blood pressure (Or and Tao [ |
Efficacy | No blinding | ||
Fall incidence (Tchalla et al [ |
Efficacy | No blinding |
aQoL: quality of life.
bIG: intervention group.
cCG: Control group.
To our knowledge, this systematic review is the first to collect and synthesize evidence exclusively from RCTs evaluating the effectiveness of ATs for older adults in a realistic living environment (ie, no laboratory setting), taking into account participants’ frailty status. More than 11,000 records were identified from a broad range of databases with different focuses. Only 19 RCTs fulfilled the inclusion criteria. The selected trials were very heterogeneous with respect to the ATs applied as well as the outcomes, which made it difficult to summarize the evidence [
Many older citizens wish to remain independent and continue living at home for as long as possible [
Considering other existing research, hearing aids seem to be an effective way to improve the domain of communication in adults aged 65 years and older [
Regarding frailty of older adults (RQ3), only one study included this population characterization in their evaluation of a gait speed feedback device [
Altogether, our results indicate that ATs might not yet suitably address the needs of frail older adults. A possible explanation is the fact that ATs are not usually developed with the specific needs of this population in mind. A recent systematic review on the use of communication technologies to improve social well-being in older adults found that more off-the-shelf products exist than devices designed specifically for older adults [
We also showed that the evaluation of an AT is usually unidimensional (RQ1). Many factors, especially social, economic, or ethical aspects, are hardly investigated [
The unclear findings on the effectiveness of ATs for older adults align with those of other systematic literature reviews on the topic [
There is a lack of a uniform definition concerning ATs for older people. This makes searching for and selecting suitable studies difficult, and increases the risk of missing relevant research. The search string resulted in almost 11,400 records. Only 19 were selected for the review, indicating an insufficient precision caused on the one hand by the lack of standardized terminology and on the other hand by the vast amount of existing literature evaluating AT in clinical settings rather than in the home environment. Additionally, the technologies considered in this analysis are heterogenous, thus limiting the possibilities for analysis, in particular the performance of a GRADE (Grading of Recommendations, Assessment, Development and Evaluations) assessment to rate the certainty of evidence as suggested by the Cochrane Collaboration. The number of trials per device type is not sufficient to form a definite conclusion of the effectiveness of AT. When the analysis for this review was performed, the new RoB 2 tool from the Cochrane Collaboration [
Researchers, politicians, and health care professionals across the globe have high hopes for AT to support older adults. Many devices are freely available on the market and are often used even though the effectiveness is not supported by current research, as shown in this review. The number of available RCTs evaluating ATs in older populations is limited and many only include a small number of study participants. Further studies with larger, well-characterized samples of older adults are necessary to allow for further stratification (eg, for frailty). Additionally, it is important to expand the focus and include economic, social, ethical, and technological aspects besides the medical outcomes. Formal and informal caregivers may, in some cases, benefit from AT even more than the older adults themselves and should therefore be included in future studies. The new Medical Devices Regulation of the European Union includes stricter controls and requires an evaluation of all medical devices before certification. In this context, our review intends to add value by identifying the current gaps in the literature, emphasizing the importance of addressing several health-related dimensions while taking into account the heterogeneity of older adults by providing a good characterization of the participants with respect to frailty.
PRISMA Checklist.
Search string.
Crossover vote.
Excluded articles based on full-text review.
Quantitative outcome data.
assistive technology
Cochrane Central Register of Controlled Trials
Cumulative Index to Nursing and Allied Health Literature
Grading of Recommendations, Assessment, Development and Evaluations
Preferred Reporting Items for Systematic Reviews and Meta-Analyses
quality of life
randomized controlled trial
risk of bias
This study was partially supported through funds from the German Federal Ministry of Education and Research for the project Future City 2030 (grant 13ZS0054A). The funding party neither influenced the study design, data collection, analysis, or interpretation nor the writing of the manuscript.
MLF, MD, and DD developed the study design and determined the inclusion and exclusion criteria. MLF and VM developed and tested the search strategy, independently screened the records, and selected the final trials to be included in the analysis. MLF and VM extracted the data and performed the RoB analysis. MD and DD were consulted in case of discrepancies. SB assisted with the frailty assessment. MLF prepared the manuscript and all authors read and commented on the final manuscript.
None declared.