Smart-Home Technologies to Assist Older People to Live Well at Home

Background: With the rapid population ageing that is occurring world-wide, there is increasing interest in “smart home” technologies that can assist older adults to continue living at home with safety and independence. This systematic review and critical evaluation of the world wide literature assesses the effectiveness and feasibility of smart-home technologies for promoting independence, health, well-being and quality of life, in older adults. Methods: A total of 1877 “smart home” publications were identified by the initial search of peer reviewed journals. Of these, 21 met our inclusion criteria for the review and were subject to data extraction and quality assessment. Results: Smart-home technologies included different types of active and passive sensors, monitoring devices, robotics and environmental control systems. One study assessed effectiveness of a smart home technology. Sixteen reported on the feasibility of smart-home technology and four were observational studies. Conclusion: Older adults were reported to readily accept smart-home technologies, especially if they benefited physical activity, independence and function and if privacy concerns were addressed. Given the modest number of objective analyses, there is a need for further scientific analysis of a range of smart home technologies to promote community living. rather than being hospitalized or institutionalized [10]. Smart-home technologies can also promote independent living and safety. This has the potential to optimize quality of life and reduce the stress on agedcare facilities and other health resources [13]. The challenge with smart-home technologies is to create a home environment that is safe and secure to reduce falls, disability, stress, fear or social isolation [14]. Contemporary smart home technology systems are versatile in function and user friendly. Smart home technologies usually aim to perform functions without disturbing the user and without causing any pain, inconvenience or movement restrictions. Martin and colleagues performed a preliminary analysis of the acceptance of smart-home technologies [15]. The results from this review were limited as no studies met inclusion criteria [15]. Given however, the rapid progression of new smart home technologies, a new systematic review of the literature is required. This paper addresses that need by analysing the range of studies undertaken to assess the impact of these technologies on the quality of life experienced by an ageing population accessing these supports. The broader context incorporates consideration of the social and emotional well-being needs of this population. The current review aimed to answer the following research question: “What is the effectiveness of smart-home technologies for Citation: Morris ME, Adair B, Miller K, Ozanne E, Hansen R, et al. (2013) Smart-Home Technologies to Assist Older People to Live Well at Home. Aging Sci 1: 101. doi:10.4172/jasc.1000101

rather than being hospitalized or institutionalized [10]. Smart-home technologies can also promote independent living and safety. This has the potential to optimize quality of life and reduce the stress on agedcare facilities and other health resources [13].
The challenge with smart-home technologies is to create a home environment that is safe and secure to reduce falls, disability, stress, fear or social isolation [14]. Contemporary smart home technology systems are versatile in function and user friendly. Smart home technologies usually aim to perform functions without disturbing the user and without causing any pain, inconvenience or movement restrictions. Martin and colleagues performed a preliminary analysis of the acceptance of smart-home technologies [15]. The results from this review were limited as no studies met inclusion criteria [15]. Given however, the rapid progression of new smart home technologies, a new systematic review of the literature is required. This paper addresses that need by analysing the range of studies undertaken to assess the impact of these technologies on the quality of life experienced by an ageing population accessing these supports. The broader context incorporates consideration of the social and emotional well-being needs of this population. The current review aimed to answer the following research question: "What is the effectiveness of smart-home technologies for promoting health, well-being and quality of life enabling older people to remain living at home and in the community"? Smarthome technologies are generally installed in a person's community based residence. Therefore, we also investigated the feasibility, acceptance and perceptions of these forms of technology in a home environment.

Search strategy
The database search was conducted in November 2012 The following databases were searched: MEDLINE, Web of Science, CINAHL, Scopus, Rehabilitation Reference Center, Nursing Reference Center, Cochrane Central Register of Controlled Trials, Inspec, Compendex, SocINDEX, PsychINFO and Sociological Abstracts. These databases were chosen as they cover a broad range of disciplines ranging from health to social sciences and the life sciences.
A variety of search terms synonymous with keywords such as 'elderly' and 'smart homes' were combined using Boolean logic. An example of the search strategy utilized for the MEDLINE search is given in table 1.

Study selection
A trained reviewer scanned the titles of the entire yield once the search was completed. Duplicates and articles that did not meet inclusion criteria were removed. The titles and abstracts of the remaining articles were then reviewed independently by two trained reviewers against pre-determined inclusion criteria. Studies that were judged to be irrelevant were excluded. If the reviewers were unsure, studies remained for review of the full text. Data extraction and quality assessment were performed for the full texts that met inclusion criteria. Any discrepancies in study inclusion or data extraction were reconciled by mutual agreement.

Selection criteria
The selection criteria for this review are shown in table 2. Articles were included if they were published in English, in a peer reviewed text, and were available as full works. Because of the rapid progression in technology [16] and the relative lack of information in earlier years [15], articles published before January 2000 was excluded. This study was interested in original information regarding the effectiveness or feasibility of smart-home technologies. Accordingly, the search was limited to intervention or feasibility studies. Narrative reviews and other systematic reviews were excluded as they did not meet inclusion criteria. For the purpose of this review, studies were considered to assess the effectiveness of the smart home technology when they were randomized control trials or if they incorporated an intervention period with an assessment before and afterwards.
'Home' was defined as a person's place of living, according to the Merriam Webster Dictionary [17]. A 'home' environment may include a private residence, supported accommodation, independent living, retirement villages and service-integrated housing. Due to issues with patents and intellectual information and residents not wanting to make permanent modifications to their homes for the purpose of a study, some researchers may choose to use purpose built smart-homes which are often associated with laboratories. Such settings were also included as people were able to live in the 'house' and the setting was therefore considered to be a 'home' environment. Hospital environments and nursing home facilities sometimes provide residents with considerable physical and psychological assistance, often by trained professionals. Consequently studies in nursing homes and hospitals were excluded.
Throughout this study a broad definition of "older people" was adopted as defined by MeSH definitions. These were 'middle-aged' (aged 45-64 years), 'aged' (65-79 years) and 'aged 80+ years' . Thus, studies which included any participants 45 years or older were considered for our systematic review. Tele-rehabilitation and tele-health have been topics of interest in recent years, particularly with the ongoing management of various chronic conditions [18].
This form of technology generally involves interaction with a remote health practitioner and is therefore still reliant on the medical system for support. Consequently, studies of tele-rehabilitation or tele-medicine based management techniques were excluded from this particular review and we reviewed that material separately. There are multiple forms of technology that may help to assist older adults in their home environments. It was beyond the scope of this paper to review the robotics, gaming or social inclusion literature. We have reviewed these separately. Instead, the focus of this paper was specifically on types of technology that can be used in a home environment which either interacts with or provides direct information to the user without the need for another individual.

Data extraction and quality assessment
Data extraction was performed using a customized data extraction form. Details such as the aims of the study, the settings where the study

Keyword Synonyms
Elderly Middle aged or Aged or Aged, 80 and over or Age* or Aging or Elder* or "Older adult*" or "Older person" or "Older people*" Smart-home "Smart home*" or "ambient assisted living" or "ubiquitous home*" or "ubiquitous technology*" or "electronic assistive technology*" or "social alarm" or "telecare social alert platform*" or "environmental control system*" or "automated home environment*" or telehomecare or "Home Automation" Note: Synonyms for the two keywords were combined to create search strategy.

Inclusion Criteria Exclusion Criteria
• Assessed smart-home technologies.
• Published in English and available in full-text from peer review journals.
• Assessed effectiveness or feasibility.
• Set in a home environment.
• Set in other environments such as nursing homes or rehabilitations settings.
• Books, PhD or Masters theses and abstracts from conference presentations.
• Studies focussed on tele-health, tele-medicine or tele-rehabilitation.
• Narrative reviews and other systematic reviews. was performed, the methods of recruitment and sampling, feasibility, outcome measures and results were recorded. When considering the appropriateness of different technologies it may be beneficial to consider the amount of assistance and training required for use. The role of smarthome technologies is often to assist residents by performing a task they are no longer able to do. In this way, many smart-home technologies should be able to work independent of the people who reside in the house. As a result the level of assistance has not been reported in this study. Due to the heterogeneity of results and the lack of randomized controlled trials, a meta-analysis was not feasible in this study. Instead a summative synthesis of results was performed [19].
As this study aimed to highlight intervention studies, the Downs and Black [20] quality checklist was chosen. This tool has been specifically designed to assess the quality of randomized or nonrandomized intervention studies [20]. The tool has 27 items which are generally answered as 'yes' , 'no' or 'unable to determine' . Scores are assigned to each answer and are summed to create a total quality score. The last item of this tool was found to be ambiguous. Similar to previous studies which also used this tool, the last item was removed resulting in a 26-item checklist [16,21,22]. The highest possible score in the revised version of the tool was 27.

Results
The initial search of the selected databases yielded a total of 1877 publications. The number of articles assessed at each stage of this review is shown in figure 1. Many articles were excluded because they focused on describing different forms of smart-home technology and the electronic architecture behind them, rather than assessing their effectiveness or feasibility [23]. Several studies were initially considered appropriate for inclusion but following more detailed review were excluded for various reasons. One study tested a new program but was excluded because the reviewers felt the technology included more tele-health than smarthome components [24]. A study by Croser et al. [25] was originally included as it investigated the effectiveness of different technologies on activities of daily living in people with various disabilities. On closer review it was noted that although the study included one person older than 45 (58 years old) it also included data from three children (aged 6-13 years) [25]. Theoretically, the feasibility and effectiveness of smart-home technologies may be different in children compared with the elderly. Consequently this study was excluded.

Study characteristics
In total, 21 studies underwent data extraction. A description of each of the articles included in this review is provided in table 3. One assessed the effectiveness of smart-home technologies and was also assessed for its methodological quality [26]. Sixteen studies reported on feasibility or perception of smart-technologies [27][28][29][30][31][32][33][34][35][36][37][38][39][40][41][42][43]. Three studies, based on an observational design, described how smart technologies worked with various participants and often combined qualitative comments regarding feasibility [44][45][46]. One study was described as a cohort study and described the ability to perform activities of daily living using a form of smart-technology [45]. This study did not use a control group or perform comparison measures and therefore was not considered to report on the effectiveness of the smart-home technology [45].
According to the National Health and Medical Research Council of Australia guidelines, the level of evidence of most of the studies was grade IV. Most studies assessed the various sensors available for use in smart-homes. Five studies were set in purpose built smart-homes or residences already incorporating smart-technologies [30,36,41,43,46]. Three studies used focus groups to discuss the potential for smarttechnologies and were therefore not based in any particular setting [27,35,39]. Consequently the settings for these studies were recorded as not applicable.

Participant characteristics
The characteristics of the participants in the included studies are shown in table 4. The sample size ranged 1-78. While some studies included younger people the age of the participants in most studies was over 65 years. The health characteristics of study participants were heterogeneous. Some studies included healthy older adults, while others included participants with neurological deficits. Four studies assessed the perceptions of carriers, facility staff or family members of elderly people [35][36][37][38][39]43].

Feasibility of smart-home technologies
Details regarding the feasibility of smart-technologies as reported in different studies are provided in table 5. Four studies identified possible safety issues. These included an increased risk of tripping on misaligned carpet [30], systems failing during emergencies [37], the possibility that incorrect medication dosages could be taken but not recorded [41] and concerns regarding the functioning of home adaptations during power outages [42]. Nine studies identified privacy issues arising from utilization of smart-home technologies [28,29,[31][32][33][34][35]42,43]. Two reported that privacy was a barrier to people choosing to install and use smart-home technologies [28,29]. Most of the participants reported that cameras and monitoring systems invaded their privacy and left them with a sense that they were being watched.
Many of the studies did not document the cost of the smarttechnologies nor the level of training required to use it. Two reported 'low cost' technology [40,44], one quoted less than $400 [26] and one study reported that the highest price to retro-fit a home was €13500 [42]. Four studies reported satisfactory use with only brief training provided when the technology was installed or before the assessments were performed [26,30,45,46].
Overall the studies that assessed perceptions and acceptability found that smart-home technologies were generally readily accepted    ACS=Arnold-Chiari syndrome, quad=quadriplegia; *=some ages missing in description therefore calculated mean age may be incorrect. Concerns about not being able to open electronic doors with a power outage. Some false alarms noted.
One participant had the ST removed from her home due to privacy concerns. <13500€ ND Note: Intervention study highlighted in bold. *=if study documented whether training was required or provided in order to use the smart-technology; ND=not documented; NA=not applicable because using focus groups to assess perceptions of smart-technology therefore not performed in a particular setting; GPS=global positioning system. and thought to be helpful [28,[30][31][32][33][35][36][37][38][39][40][41][42][43][44][45][46]. The breakdown of the results for these studies is provided in table 6.

Effectiveness of smart-home technologies
One randomized controlled trial was identified in this systematic review [26]. This study compared the change in functional status in people who had smart-technologies installed in their homes compared to those with no home modifications. Results from this study suggest that functional status and cognition deteriorate in the general elderly population and that the use of smart technologies may help to maintain these aspects and encourage ageing in place [26]. The results from this study are shown in table 6.

Quality assessment
Most of the articles identified in this review were qualitative and few were intervention studies. The investigation by Tomita et al. [26] scored 18 points out of a possible 27. Several factors were not reported in the article, which impacted on the overall quality assessment score. These included the lack of investigation or reporting of adverse events and the brief description of the source population, blinding, recruitment and sampling methodology.

Discussion
This systematic review highlights the wide range of smart home technologies currently available to support older adults to live at home. These included passive and active sensors, monitoring systems, environmental control systems and electronic aids to daily living. While a large number of appliances may be available, the review also identified the relatively small number of studies that actually investigated their effectiveness at helping the older adults to live independently at home.
The majority of articles identified in this systematic review were qualitative in design. Some documented whether older adults were able to use smart-home technologies. Other articles addressed the preferences for different technologies and the overall acceptability of devices in the home environment. Qualitative research assists evidence-based, patient-centred care [47,48] and is arguably crucial when attempting to implement changes in the homes of older people. This systematic review found that older adults and health professionals considered smart home technologies to be beneficial. These forms of technology were thought to increase safety and security around the home. Many participants felt that smart-technologies may help to improve their independence. While it was not formally addressed in the identified studies, it is possible that improvements in safety, security and independence may also have a positive effect on quality of life in this population.
The results of this review identify important feasibility issues that should be considered in the development and implementation of the smart home technologies. The primary barrier to the adoption of smarthome technologies by older adults was privacy concerns [28,29,[31][32][33][34][35]39,42,43]. Privacy is therefore a crucial consideration in the design of future smart-home technologies. Most smart-home technologies could be used with little assistance or training. Some safety concerns were identified related to malfunctioning of technology; highlighting the importance of contingency systems for events such as power outages. While the included articles reported varied costs, there were few reports about the cost of smart-technologies. With further commercialization, it is possible that the cost of smart home technologies will reduce, thereby increasing their availability and utilization in home environments.
The results showed that smart-home technologies could accurately detect abnormal movement or behaviours [44] and were appropriate methods to control various electronic devices [45,46]. To date, one randomized controlled trial has been performed to assess the effectiveness of smart-home technologies in an elderly population [26]. Longitudinal studies are likely to be required to adequately assess the effectiveness of smart-technologies. Moreover, multiple factors, such as finances, social circumstances, family and level of independence are considered when a person chooses where they will live. For example, a study may assess how long people with smart-technologies can live in their own homes compared with people who do not live in a smarthome. Even if the smart-technologies can physically assist a person, they may move out due to financial stress or to be closer to family members. Future studies may need to consider these aspects in their design, and at least comment on confounders if they cannot be controlled.
Many of the studies identified in this review were performed in North America or Europe. More research may be beneficial to assess the feasibility of smart-technologies specifically in Oceania and Africa. Recently, Western governments have recommended major expansion of housing support services [49]. For example, the Australian agedcare housing industry is now incorporating new technologies to assist older people to live more independently at home and in supported accommodation [50]. Theoretically, people living in rural or remote areas may have different experiences to smart-technologies to people in larger cities. It may also be appropriate to consider assessing the feasibility and effectiveness of smart-home technologies in different communities as well as different countries.
One limitation of this study was the decision to limit the search to articles published in English. The technological advances often found in other regions, such as Asia, may mean that other studies have been conducted on this topic but have been published in other languages and were consequently missed. Given the volume of articles, it was not feasible to include all forms of technology that may assist elderly people to live at home. As a consequence, articles reporting on studies  of telemedicine were kept for a separate analysis. There appears to be some cross-over between technologies considered under the guise of telehealth and those under smart-homes. The exclusion criteria and search terminology created a manageable yield for this review but may have resulted in the exclusion of important articles of what some researchers may consider to be smart-home technologies. While appropriate for this review, limiting the articles to studies set in a home environment may have excluded important results collected during laboratory-based investigations.

Conclusion
A variety of smart-home technologies are available that are readily accepted by older adults and their family members, healthcare professionals and carriers. The feasibility and utilization of smart-technologies can be improved by addressing issues related to safety and privacy. In addition, exploring how feelings of safety and more control over one's life contributes to social and emotional well-being as well as the capacity to continue participating in outside interests and activities. While the outcomes and cost effectiveness of these forms of technology remains to be assessed, they appear to show some potential for helping older adults to live longer, safely and independently in their own homes.