International Journal of Medical Informatics 100 (2017) 32–45

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International Journal of Medical Informatics

journal homepage: www.ijmijournal.com

Review article

Information technologies for active and assisted living—Influences to

the quality of life of an ageing society
Christian Siegel ∗ , Thomas Ernst Dorner
Medical University of Vienna, Centre for Public Health, Institute of Social Medicine, Kinderspitalgasse 15/1, 1090 Vienna, Austria

a r t i c l e i n f o a b s t r a c t

Article history: Introduction and objectives: The current and upcoming demographic change in industrial countries is a
Received 31 January 2016 challenge for our society, economically as well as socially. The aim of this article is to explore the influences
Received in revised form 6 October 2016 of information and communication technologies applied to contribute to these trends and describe its
Accepted 14 January 2017
impact to the quality of life and subjective health of elderly.
Methods: In a structured literature review on (a) scientific publications and (b) outcome reports of ambient
Keywords:
assisted living projects, we investigated these associations. The results are summarized according to
Ambient assisted living
the multidimensional approach of quality of life considering the bio-psycho-social model of health. The
Quality of life
Subjective health
project outcomes of current initiatives are consolidated and recommendations for future research in the
Independent living field of active and assisted living were issued.
Active and assisted living Results: Current research efforts show that assistive information and communication technologies can
Assistive technologies successfully contribute to all dimensions of elderly’s quality of life. As example technologies can empower
them to control their health problems, compensate functional disabilities and increase their safety. Oth-
erwise, remote-communication could lead to reduced face-to-face communication and social exclusion.
Conclusion: More research using adequate methods: and instruments is needed to demonstrate the iden-
tified effects and to deliver evidence of the impact to the life of the heterogeneous population group of
elderly.
© 2017 Elsevier B.V. All rights reserved.

1. Introduction Within the European Commissions’ action plan ‘Ageing Well in

The World Health Organisation (WHO) identified the demo-
graphic change as one of the biggest challenges for the society in
the western countries [1]. This trend is also intensively discussed by
the European Commission who reported that the ageing population
in its member states will have a tremendous impact on productiv-
ity and economic growth in future [2]. The population part of the
member states aged 65 years and above will increase from 17.4%
in 2010–29.5% in 2060. This could lead to a doubling of the ratio of
dependent elderly (aged 65 years and above relative to aged 15–64)
[3]. The ageing population will put pressure on the social care and
health care systems and will lead to a reduced availability of care
staff in the affected areas. To deal with these challenges information
and communication technologies (ICT) and assistive technologies
will play an important role to help people stay healthy and live
independently at home for a longer time [1].
∗ Corresponding author.
E-mail addresses: christian.siegel@gmx.at (C. Siegel),
thomas.dorner@meduniwien.ac.at (T.E. Dorner).
the Information Society’ a program called ‘Ambient Assisted Living
Joint Research Programme’ (AALJP) was established that has the
aim to develop appropriate ICT solutions. The technologies shall
improve peoples’ quality of life (QOL), increase health and enable
them to live independently in their familiar environment as long
as possible. The AALJP recently was prolonged within the research
program Horizon 2020 under the term ‘active and assisted living’
(AAL) lasting from 2013 to 2020 [4].
The concept of ambient assisted living (respectively the new
term ‘active and assisted living’) includes systems using ICT and
socio-technical services in daily life and working environment to
enable individuals to live an active, socially involved and indepen-
dent life up to old age [5,6]. The range of these technologies include
very sophisticated and quite simple ICT solutions like smart home
systems, applications in the field of tele-health, reminder functions,
fall detection systems, videophones, video game and a lot more.
They all have in common that their objective is to improve the QOL
of the recipient or user. The majority of available studies and project
outcomes of AAL-solutions deal with technical aspects and feasi-
bility engineering and do not provide sufficient data or evaluation
outcomes of the impact to the users’ QOL.

http://dx.doi.org/10.1016/j.ijmedinf.2017.01.012
1386-5056/© 2017 Elsevier B.V. All rights reserved.
 C. Siegel, T.E. Dorner / International Journal of Medical Informatics 100 (2017) 32–45 33

This is why the aim of this review is to analyse possible impacts
of ICT-components, typically used in AAL-solutions, to the health
and QOL of elderly. Due to the integrating and comprehensive char-
acter of AAL-solutions the content partially overlaps what means
that selected papers may be discussed in several sections. Further-
more the evidence of the AAL-related effects to the individuals’
QOL was investigated by conducting a literature search of current
AAL-projects. The pathways and associations between QOL and the
impact of technology are reviewed and summarized according to
the multidimensional model of QOL of the WHO [7]. Possible impli-
cations for further development and research in the field of ICT
and AAL-solutions and QOL were discussed and recommendations
issued.
In the field of health promotion ICT can play several roles in pub-
lic health. It can be used as a medium of intervention (for behaviour
change, e.g. smoking cessation or for the distribution of health
information), as focus of research (seeking for health information),
as a research instrument (electronic surveys), and for theoretical
and conceptual issues (for professional development) [8]. In this
review the character of different ICT solutions as a medium of
intervention to influence the individualı́s QOL is highlighted and
investigated in more detail.
1.1. Definition of QOL
In health promotion and public policy decision making the con-
struct of QOL is used as instrument for evaluation of intervention
outcomes in clinical as well as non-clinical settings [9,10]. The WHO
defines QOL as an “individual’s perception of his or her position in
life in the context of the culture and value systems they are living
and in relation to their goals, expectations, standards and concerns”.
This broad concept is affected by the “physical health, psychological
state, level of independence, social relationship and their relationship
to salient features of their environment” [7].
This definition implies that the process of ageing can affect one
or more of the dimensions of the old person’s subjective QOL. Most
of the frequently used instruments for measurement of QOL- out-
comes, e.g. the WHOQOL- BREF/100 [7,11] questionnaires, cover
the physical, psychological, social and environmental domain that
comply with George L. Engelı́s bio-psycho-social holistic approach
of subjective health [12].
For aged people QOL is an important area of concern because it
reflects their health status and well-being considering the vulner-
able issues of their daily life [13]. It is crucial to understand which
factors lead to their perceived life satisfaction and QOL according
to the individuals’ needs and limitations [14].
The main objective of this study was to identify influences of
AAL-solutions to elderly’s QOL and health and explain the path-
ways of these effects. Therefore first the contributions of ICT to
elderly’s QOL were reviewed and QOL-outcomes of AAL-projects
were analysed.
2. Methods
After initial literature search it became obvious that the QOL-
related available literature in the field of AAL is very rare,
heterogeneous and provides not enough information to conduct
a systematic review on AAL-solutions. This is why we decided to
conduct a narrative review based on a structured literature search
on ICT-solutions usually used in AAL-systems and their impact to
the QOL of elderly. Additionally, all relevant findings of QOL in AAL
research were structured and summarized.
The electronic search including literature databases (from the
year 1998 on) was carried out from March to December 2014. We
considered following databases: The Cochrane Library, Cochrane
Central Register of Controlled Trials, The Cochrane Database of
Systematic Reviews, Pubmed, Web of Science, Medline, SCOPUS,
EMBASE, OvidSP. For search terms and syntax see Table 1. The
Journal of Gerontechnology [15], the resources of the ICT-PSP [16]
and the AALJP-program [4] were searched manually for relevant
information. Furthermore grey literature search was executed to
identify studies, literature and project reports that are not indexed
in the databases listed above, using search engine google scholar.
After removing the duplicates, the remaining articles were
screened to its relevance to the research topic using following cri-
teria:
1- Articles comprising outcomes of medical technologies used in
intramural settings and interventions were excluded (e.g. laparo-
scopic technology, pacemaker and surgery technologies).
The abstracts of the remaining articles were searched for asso-
ciations between technology and its impact to QOL or health.
Technology-focussed articles with no relevance to the research
topic were excluded.
1- Outcomes associated with QOL of current AAL-research were
included
- The cited resources of the articles were searched for relevant
information adding knowledge to the original article and new infor-
mation was included
The remaining articles were thematically summarized to para-
graphs according to the technical setting and areas of application.
In this work the findings were separated into two thematic results
sections: (a) ICT/AAL and QOL in scientific literature and (b) AAL
and QOL in project reports.
The influences and possible impacts to the QOL-dimensions of
the solutions are allocated to the domains of the WHOQOL-BREF
[17] (physical, psychological, social, environmental) and summa-
rized in tables. Moreover recommendations for future research,
gathered during the review, are presented.

Table 1
Search Syntax for Structured Literature Search.

(“QOL” OR “Quality of Life” OR “wellness” OR “wellbeing”) AND (“AAL” OR “Ambient Assisted Living” OR “Ambient Assisted Technology” OR “Ambient Assistive
Technology”)

(“QOL” OR “Quality of Life” OR “wellness” OR “wellbeing”) AND (“ICT” OR “information and communication technology”) AND (“elderly” OR “aged” OR “senior”)
(“QOL” OR “Quality of Life” OR “wellness” OR “wellbeing”) AND (“telecommunications technology” OR “telecommunication technology”) AND (“elderly” OR “aged” OR
“senior” OR “old”)
(“QOL” OR “Quality of Life” OR “wellness” OR “wellbeing”) AND (“eHealth” OR “e-health”) AND (“elderly” OR “aged” OR “senior” OR “homebound” OR “old”)
(“QOL” OR “Quality of Life” OR “wellness” OR “wellbeing”) AND (“technology” AND (“assistive” OR “assisted”)) AND (“elderly” OR “aged” OR “senior” OR “old”)
(“QOL” OR “Quality of Life” OR “wellness” OR “wellbeing”) AND (“Independent living” AND “technology”) AND (“elderly” OR “aged” OR “senior” OR “homebound” OR “old”)
(“QOL” OR “Quality of Life” OR “wellness” OR “wellbeing”) AND (“residential home” AND “technology )¨ AND (‘elderly’ OR “aged” OR “senior” OR “homebound” OR “old”)
(“QOL” OR “Quality of Life” OR “wellness” OR “wellbeing”) AND (“robotics” OR “robot”) NOT (“surgery” OR “rehabilitation” OR “laparoscopic”) AND (“elderly” OR “aged”
OR “senior” OR “homebound”)
(“QOL” OR “Quality of Life” OR “wellness” OR “wellbeing”) AND (“smart home” OR “smart homes” OR “intelligent home”)
(“QOL” OR “Quality of Life” OR “wellness” OR “wellbeing”) AND (“gerontechnology” OR “gerontotechnology”)
“project” AND (“joint programme” OR “joint program” OR “ambient assisted living”)
34 C. Siegel, T.E. Dorner / International Journal of Medical Informatics 100 (2017) 32–45
3. Results literature review
The search in the databases resulted in a total amount of 1153
articles. After clean-up according to the defined selection criteria
74 articles remained in total.
This section summarizes the findings of ICT-associated QOL-
impacts. The findings are outlined beginning with the simplest
technologies (e.g. Basic ICT) to more complex solutions usually used
as modules in AAL-systems (e.g. Environmental Control Systems
and Tele-Health solutions).
3.1. Basic ICT and entertainment aspects
A wide range of ICT solutions is already in use in elderly’s
daily life. Beneath home-based technologies like television, radio
or microwave ovens there are also common computer-based tech-
nologies, e.g. internet, email or computer games.
Matlabi et al. examined the influence of home-based tech-
nologies in assisted living homes to its influences to the QOL of
aged people (n = 160, aged 55 years and above). These technolo-
gies include all electronic devices from the washing machine to
the electronic door opener. They reported that a higher level of
QOL, reported on SEIQOL- (Schedule for Evaluation of Individual
QOL) and CASP-19 scores, was associated with the multiple use of
home-based technologies. The more technologies the participants
used, the higher was the level of QOL (SEIQOL p = 0.016, CASP-19
p = 0.001). The health status of elderly did not correlate with the
number of used of technologies [18].
Internet-based technologies can enable people changing their
health behaviour by interventions, self-help programs and tailored
health-related information provision by matching personal data
to possible interventions. Health can be improved by increasing
people’s knowledge about their health issues and thereby chang-
ing their attitudes in attempts (e.g. to support smoking cessation).
Health information can help people to make decisions regarding
their own health and thereby can lead to improved health literacy
[19].
Computer-based ICT applications that are already available
for almost everybody had been examined in a Japanese study
[20] (n = 84; mean = 73.0 years, SD = 5.3) that sought to show a
cross-connection between well-being and ICT in relation to its
counterparts in daily life activities (e.g. online newspaper vs.
printed newspaper). They used the PEAQ (Personally Expressive
Activities Questionnaire) in combination with scales for perceived
usefulness and attitudes toward computers. The correlation analy-
sis showed that reading online newspaper and chatting online via
computers increased older adults’ wellbeing and the impact cor-
related with their corresponding pendants in daily life activities
(p < 0.002). Online shopping and writing emails did not have signif-
icant effects to the wellbeing of the participants. The opportunity
of playing online games was excluded from this analysis, but the
authors stated that entertainment by games may have some effects
to the wellbeing of elderly by providing funny activities or getting
physically active (e.g. by tele-care applications) [20].
The hypothesis that computer games could have beneficial
impact to older adults’ life was investigated in a scoping review [21]
outlining possible correlations between digital games and cognitive
benefits of elderly. Following this approach different genre games
can contribute to and train different cognitive skills of elderly. For
example action games could train cognitive skills like eye-hand
coordination, mental rotation, response speed, and visual attention.
The genre of strategy games can have effects on supervisory skills
and working memory retrieval. Nevertheless, no evidence of cog-
nitive improvements by playing simple games (e.g. card games) or
complex computer games (e.g. first-person-shooter) were shown
[21].
Beneath cognitive benefits, computer games can contribute to
elderlyı́s leisure or entertainment and improve seniorsı́ perceptive
faculty. In general elderly do need appropriate ways to communi-
cate with their social environment. Depending on their infirmities
and lifestyles they have specific needs to communicate. When play-
ing computer games a higher amount of time is spent on social
conversation not related to the game. This finding indicates possible
positive effects to elderlyı́s sociability [22].
3.2. Social communication systems
In the course of the age-related decline in mobility and upcom-
ing limitations in physical functioning the social environment and
contacts of elderly decrease over time. At this point communication
solutions, beneath conventional phones, could provide beneficial
effects to keep in touch with family and friends. Meyer and Schulze
[23] showed in a qualitative analysis of smart homes that the
usage of video phones can foster social relationships. These sys-
tems can give aged people the possibility to feel less lonely by
having regularly video-based talks to relatives, friends, neighbours
or caregivers. In residential settings increased social support via ICT
could lead to a decreased level of social isolation and depression in
elderly and can have positive effects to health and satisfaction in
life [24].
A study of nursing home residents (n = 33, aged 65 years and
above) identified that the participants as well as their families have
a strong need for better or more contact with each other and there is
the willingness on both sides to try to enhance communication via
conventional telecommunication technologies (e.g. the telephone)
instead of video-based solutions. Nevertheless, 13 persons reported
to be interested to try the communication via webcam in future
[25].
From the perspective of care staff the fear was articulated
that social communication systems could reduce or replace the
face-to-face communication. This is a critical aspect because in a
care-relationship genuineness is needed to contribute to the per-
sonal closeness and intimacy required in care-situations. Beside
the possibility of social communication systems of maintaining a
remote dialogue to elderly living in their own homes, care staff fears
that ICT could increase loneliness by being made socially ‘captive’
in their living environment [26].
A qualitative interview-based study with highly aged residents
in a home care unit (n = 17, mean age = 87 years) showed, that oth-
erwise the participation in an ICT pilot or project could lead to
an increased level of social participation realized by taking part
in trainings and social activities facilitating ICT solutions. They
concluded that ICT can act as a vehicle for social stimulation and
boundary object to facilitate communication between residents
and their families [27].
Within a video-based tele-mentoring project the role of ICT
as an actor for social stimulation was investigated. Students
and unemployed were instructed to practice a second language
(French or English) by elderly suffering on chronic diseases (stu-
dents/unemployed: n = 18, age: 14–25 years; elderly: n = 18, age:
59–82 years). This Canadian study came to the conclusion that the
intergenerational communication had positive and motivational
influences for both parties and exceeded the experiences in con-
ventional mentoring programs for youth. The aged people felt more
connected to the youth and reported on behaviour change of their
mentees and increased language skills by speaking French and
English. These programs could provide a possibility to assess and
improve social relationships in context of chronic disease manage-
ment and showed that video communication technologies can be
an icebreaker for getting in touch with elderly persons. The aged
people reported that they enjoyed the teaching and learning from
the youth to be an enlightening experience. A proportion of 88%
 C. Siegel, T.E. Dorner / International Journal of Medical Informatics 100 (2017) 32–45
of the young tele-mentees described that the system had positive
impact on their own personal development because of learning
from the elderly [28].
There are also systems to socially support people with chronic
diseases (not only elderly) that are currently under investigation.
The results of the impact analysis of a video-conferencing system
for children and young people in palliative home care showed that
this technology can be considered as a mechanism to support access
around the clock and can be seen as a way to deliver a person cen-
tred social care when combined with tele-medicine processes (e.g.
to support access to health professionals’ advice) [29].
3.3. Mobile phones for better health
Today a lot of older people use cell and smart phones that pro-
vide possibilities to keep social contacts but they can also have
beneficial effects to the users’ subjective health. This operational
area of use is known under the term ‘mHealth’ where smart phones
can provide beneficial components and applications to personal
healthcare.
A review on smart phone health applications provided an
overview of these ICT solutions [30]. Patients have the possibility
to access health information and therefore can actively partici-
pate in their own care by receiving services to change their health
behaviour. Mobile phones are useful for monitoring and diagnos-
ing health conditions for physicians who work far away from the
patient’s home. The internet is accessible by mHealth applications
and can act as a vehicle to increase medical education to improve
physicians’ diagnostic skills and education as well as health infor-
mation for the patient. Smart phone applications give hints for
lifestyles, fitness, chronic disease management (e.g. diabetes or
cardiovascular diseases) and give the opportunity of public health
surveillance [30].
Another review on mHealth dealt with the enhancement
of communication between health services and consumers and
showed that there are benefits regarding adherence to medical
appointments when getting reminded by short message service
(SMS) [31].
Smart phone applications can be used to monitor user health,
enable patients to access their health information, actively par-
ticipate in their own care and maintain contact to health care
professionals [32].
Evidence of mHealth which seek to improve health outcomes
was discussed by Tomlinson et al. [33]. They stated that there was
lack of appropriate theories and evidence how health behaviour can
be influenced by smart phone applications. Moreover implemen-
tation strategies must be developed to establish ways of possible
interventions in future [33].
3.4. Smart homes and environmental monitoring systems
Smart home solutions and environmental monitoring and con-
trolling systems are technologies that provide a wide range of
functions based on sensors and other devices in residential settings.
They are developed and evaluated with the aim to be a possible
way to enhance comfort and security for elderly as well as younger
people [23]. These ICT solutions can also monitor residents by pro-
viding tele-health applications to improve their QOL and promote
physical independence. Thus they can address clinical syndromes
of frailty and dementia by providing help in emergency situations
and providing assurance systems (e.g. fall detectors, vital data anal-
ysis, behaviour monitoring). Additional it has the aim to reduce care
giver burden [34].
By comparing smart home projects to the hierarchy of needs
according to Maslow it was identified that most of these solutions
are addressing physiological needs, safety/security concerns and
35
social relationships by providing integrated monitoring and tele-
health solutions. Two projects were identified addressing esteem
(by cognitive training) and one covering self-actualization (by
entertainment) [35].
A review examining environmental control systems (e.g.
encompassing electronic door openers and smoke-detectors) and
smart homes to its impact to activity, participation and QOL out-
comes of impaired persons identified 11 heterogeneous studies.
The authors reported that only one study was found showing
that interventions based on smart homes increase participatory
behaviour and activity. Also instrumented activities of daily liv-
ing (IADLs) and socializing behaviour increased. Nevertheless, the
identified studies had limited scientific quality so that the results
couldn’t be consolidated [36].
Another literature study seeking to explore the effectiveness of
smart home technologies for health and social care support iden-
tified that those technologies have the purpose to facilitate and
support the delivery of a broad range of health and social care ser-
vices. The real purpose of these solutions is to facilitate functional
independence and enhancing QOL by enabling users to receive ser-
vices or to inform service providers (e.g. the physician about health
status) [37].
The reviewed literature of smart homes and ambient assisted
living applications showed that these technologies can support
patient and family empowerment as they allow them to be actively
involved in their own healthcare. By giving older adults the oppor-
tunity to have increased access to health information (activities of
daily living (ADL), wellbeing, social interaction) they are involved
in shared decision making and are not anymore only the recipient
of strict clinical decisions of health experts [38].
Demiris and Hensel reported that smart homes could lead to
a reduced social interaction or may substitute personal care and
communication. They summarized that smart home technologies
could be recognized as obtrusive technology in the residents’ famil-
iar surroundings which leads to negative psychological dynamics
regarding the home environment as a private and personal space
[39].
3.5. Robotics
In the future, robots will play an important role in our society.
There is a range from service robots that provide support for daily
activities of elderly to robots that act as social companions. For ser-
vice robots no relevant literature regarding QOL and health was
found. Nevertheless it can be assumed that there are effects to the
comfort and environment of elderly if robots provide assistance.
The field of social robots who act as companions like an ani-
mal (e.g. a seal-like robot) can affect health of elderly and people
with dementia. Especially mental health problems are addressed
by these gadgets by impacting emotional, physiological and social
health. Their social service provision can affect the psychological
wellbeing of people, improve their mood and can act as a vehi-
cle for social connection and communication. This role of robots is
especially applicable in nursing settings where pets are prohibited
[40].
The effectiveness of robots for dementia was investigated by
Broekens et al. [41] as well as Bemelmans et al. [42] who dis-
covered qualitative evidence that companion robots can lead to
increased health by decreased level of distress, increased positive
mood and decreased loneliness. Moreover, they have the effect
to increase communication activities with others and facilitat-
ing the rethinking of the past. There are also effects to elderly’s
health because of alleviated stress and increased immune system
response. Some studies reported on a decreased score on existing
dementia measurement scales. One study explicitly summarized
that a companion robot elicited memories about the participants’
36 C. Siegel, T.E. Dorner / International Journal of Medical Informatics 100 (2017) 32–45
life. Other studies reported of positive findings with regards to
social ties between the elderly in homes (measured by the fre-
quency of contact between the elderly) as well as between the
elderly and their family members. In those cases the companion
typically can act as topic of conversation [41–43].
3.6. Tele-health and human monitoring
Findings according to technologies in the field of tele-health,
tele-care and tele-rehabilitation solutions are subsumed in this sec-
tion. Furthermore, emergency call solutions and fall detectors are
outlined that primarily address security and safety needs.
A qualitative focus group study of a 40 year old emergency
response systems (n = 45, 67–97 years) used in Swedish nursing
homes showed that feelings of anxiety, fear and insecurity were
associated with inadequate designed and unreliable systems. By
providing new reliable and personalized alarm systems with posi-
tioning sensors allow elderly to move within a larger range around
their homes and therefore increase their level of perceived inde-
pendence [44].
An experiment with 14 participants (aged 20–80 years) investi-
gated the accuracy of a monitoring system for localizing cognitively
impaired people. The results showed that the system would pro-
vide a higher level of safety for aged people. There were also
other research attempts for behaviour monitoring of cognitively
impaired elderly in smart homes but there are no results available
regarding health outcomes or QOL [45].
Other systems autonomously evaluate different scenarios of
activities of daily living. Here video caption and environmental sen-
sors are combined to identify the different movement actions and
postures of a person. This unobtrusive system is able to identify a
defined set of ADLs which could work as a behaviour monitoring
system as well as a fall detector [46].
In future, fall detection and fall-prevention systems will also
have the task to quantify physical fall risks in the elderly, and there-
fore will give experts the possibility to react in time if mobility
declines [47].
A descriptive paper outlining a software application for
behaviour monitoring of diabetes patients (activity, diet, exercise
compliance) came to the conclusion that this system can improve
the effectiveness of diabetes self-management education and pro-
vide relevant health information to health care professionals. This
can be realized by recording and analysing health-related data and
giving recommendations to the patient to support behaviour alter-
ation [48].
There are still other prototypes for diabetes mellitus monitor-
ing under investigation that analyse sensor-gathered health data of
patients to react to new situations. These systems give patients and
physicians the possibility to apply the correct therapy to changed
needs and behaviour in short term [49].
Another field of tele-health is the monitoring of chronic heart
diseases. A systematic review on tele-monitoring of chronic heart
failures investigated its benefit to the study population. In all
included randomized controlled trials it could be identified that
the QOL of the study population improved when using the pro-
vided solutions. Moreover, the identified studies reported on better
medicine compliance and less hospitalization rates compared to
the control groups [50].
An article describing the possibilities for home hospice patients
and their families identified several areas where monitoring can
act as a facilitator. Some of these are: functional (e.g. sleep quality),
safety (e.g. detecting environmental hazards), physiological (e.g.
vital parameters), and security (e.g. alerting of intruders). The aim
of monitoring technologies is to enhance autonomy by generating
data that enable just-in-time interventions and provide residents
adequate support. They also have the potential to empower the
elderly, caregivers and family to getting more involved in daily care
[39].
A cross-sectional study [51] using the questionnaire survey
approach analysed the QOL and acceptance of tele-care solutions
in a group of 53 elderly. The results showed statistical correlation
between the technology acceptance (perceived usefulness, user
attitudes, willingness to continue use) and the social and environ-
mental domains of QOL (␴ = 0.57, p < 0.01). The authors explained
that elderly can benefit from tele-care because of obtaining health
knowledge and health information, feeling more secure, and having
the possibility to control their health problems [51].
It was shown that an ICT solution to assess wellness of resi-
dents in care facilities can promote social interactions among users
and build a platform of conversation. Furthermore, it can reduce
the need for separate monitoring equipment in the care home. In
a sample of community-dwelling elderly people (n = 27, mean age:
88.2 years) a tele-health application (‘tele-health kiosk’) was used
to assess older peoples’ wellness. The participants had the possi-
bility to measure vital data and to monitor it on their own. The
included persons (aged 62 years and above) used the systems for
8 weeks. The results showed associations across wellness-related
parameter like cognitive, functional and physical conditions. They
expressed to get more knowledge about their wellness status and
to understand how to be compared to their peers. They asked to
get information about possible health interventions (e.g. educa-
tional suggestions) based on the gathered data to address their
individual problems. Thus, this ICT-intervention can act as a tool
for self-management what is very important in elderly care. Dur-
ing the study, alerts due to health parameter, lead to adjustments
in medication and better monitoring of blood pressure [52].
In future, tele-health and human monitoring has the potential to
create a pervasive, user-centred and preventive healthcare model.
This will be available all the time and everywhere to support health-
care professionals by providing long term monitoring in natural
environments. Patients will be empowered to play an active role in
their healthcare to manage occurred illness and maintain wellness
[53].
3.7. Assistive ICT for dementia and dependent people
The need for preventive as well as therapeutic ICT for chronic
diseases like dementia will grow tremendously [54]. Mollenkopf
et al. postulated in a literature review of ICT for dementia that these
solutions have the possibility to enhance QOL by providing more
independency, safety, social contacts and stimulate activities [14].
To enhance QOL of cognitive impaired and people with demen-
tia it is necessary to address a broad spectrum of the problems of
the target groups (e.g. like depressions associated with neurode-
generative diseases like dementia). Some of the main contributors
to depressions and difficulty with medication schedules are lone-
liness, boredom, isolation and low social interaction. Here, ICT
could be used to provide personalized support to time orientation,
sensory awareness, communication and recreational activities for
entertainment [55].
Assistive ICT-based technologies can provide support to people
with dementia in several areas of information provision: sup-
port regarding their symptoms of dementia, social contact, health
monitoring and perceived safety. ICT can lead to increased self-
confidence and the support for social contacts can be effectively
realized. As an example, simplified (mobile) phones, videophones
or (entertainment-) robots, localization technology and monitor-
ing systems are proven to result in enhanced feelings of safety, less
fear and anxiety [56].
Elderly subjects with memory problems often rely on handwrit-
ten notes or diaries as this is a way to get self-support for their
problems and limitations. If ICT is provided that reminds the person
 C. Siegel, T.E. Dorner / International Journal of Medical Informatics 100 (2017) 32–45
to do daily activities (e.g. tooth brushing), to participate on mean-
ingful events or helps them with daily tasks and situations, those
people may act more independently. They may be less confused
and will gain a better QOL. Furthermore, caregivers could attain
less burden by getting supported by ICT [57].
To address the threat of social isolation of people with demen-
tia, an active listening system which shows reminiscence videos
was evaluated within a case study. The results of the presented
cases (n = 2, female, 84 and 94 years), based on the Gottfries-Bråne-
Steen (GBS) scale, showed that the values of emotional blunting
and lability had been reduced by the system. Additionally, there
were positive effects to mood, motivation, anxiety and restlessness
during study duration of 40 days [58].
In a technology wish-list of elderly persons, developed within
the project INDEPENDENT, it became obvious that people in dif-
ferent stages of dementia have very different requirements for
technical interventions. They concluded that social network and
support of the environment have the greatest chance to contribute
to the QOL of the individuals by providing conversational memory
aids and building up a window to the world. Here, connected digital
picture frames and video-based conversations, sequence assisting
devices and even a simple music player could be useful for people
with dementia [59].
An interview-based study with 14 spousal elderly caregivers liv-
ing with a person suffering from dementia identified three areas
were ICT could improve QOL of caregivers and health of elderly:
(1) addressing support needs, (2) reducing social isolation, (3) fos-
tering relationship between patient and caregiver. The authors
highlighted the importance of information provision for caregivers
by the internet and new media to get adequate information about
the related illness, regarding disease-related services and public
resources. Furthermore the need for a non-intrusive channel to
share information and discuss issues between caregivers had been
articulated. To reduce social isolation ICT can help to feel connected
to a wider community. Technologies can provide a personal assur-
ance by informing the caregiver that the ill person is well when
leaving the house. ICT has the possibility to provide entertainment
and engaging tools that could be used to stay connected to a social
network. Social technologies enforce relationships by providing
tools to share experiences and support communications by pre-
served memories (e.g. reminiscence). At least social interactions
can be enhanced by a low barrier interface to get a view of the
world (e.g. webcam of a zoo) [60].
A paper focusing on assistive technologies in dementia sought to
categorize different solutions to their impact on dementia. Some of
these technologies are smart homes with pattern-analysis (e.g. to
recognize signs of dementia), electronic calendars (e.g. for medica-
tion management), registering water taps (e.g. ensuring adequate
nutrition), gas and water sensors (for home safety issues) and
mobile phones (social communication). The authors concluded that
for these different solutions there is a strong potential to positively
influence QOL of elderly. Especially in tasks that require learning
and decision making, ICT can be beneficial by enabling aged people
to get support [61].
A RCT with 36 elderly (median = 80 years) reported on a relation-
ship of cognitive improvement of people with dementia symptoms
and the use of memory training, based on a virtual reality envi-
ronment. The use of computers and the internet had no effect on
cognitive improvement to healthy elderly but to those with symp-
toms of dementia. Several studies investigating the wellbeing and
QOL of elderly using ICT (e.g. internet trainings) didn’t show signif-
icant results, except one, which dealt with a computer course and
assessed the general life satisfaction for elderly aged 70 years and
above [62].
Following a case by case study approach of 5 persons with
dementia, their health-related data (gathered by the Short Form 12
37
Questionnaire) was compared to the data gathered by sensors. They
identified congruence between activity patterns and health param-
eters of the participants. The system was proved as a valuable tool
for early illness detection in the study population. [63].
The social engagement, access to health information, opportu-
nities for leisure and independent living is very crucial for persons
with disabilities. Nevertheless, for dependent people it would be of
more interest to live more autonomously than getting more social
support. Social networking is associated with positive health out-
comes which leads to involvement in leisure activities. The ability
of staying mobile is very important for aged people and is a major
challenge for visual impaired elderly. Here, ICT could play an impor-
tant role to support people finding their way home autonomously.
A study of a wearable garment prototype that helps severe visually
impaired people to navigate in their environment was conducted
with 47 study participants aged 55 years and above (mean = 63.8
years, SD = 8.7). The authors identified that the participants’ main
needs were to locate people, finding a host, getting refreshments
and joining games. To address these needs, the gadget was recog-
nized as a tool to help to engage with their social environment and
therefore activate people to be socially involved [64].
In general, people with physical limitations tend to use assistive
technology and technical aids according to the level of severity of
their impairments [65]. These aids provide them the possibility to
enhance functioning and reduce isolation and therefore enhance
their QOL [66,67].
4. Results project review
This section summarizes the findings regarding elderly’s QOL-
and health outcomes of completed and ongoing AAL- and ICT-
projects. The results are presented in Table 2. These projects
typically aim to combine the technical solutions outlined in the pre-
vious sections and investigate the impact of the system to the QOL
of a group of older people. In some of the conducted studies also
the QOL-outcomes of affected caregivers had been investigated.
However, those results are not included in this review. Most of the
systems combine technologies to control and monitor the envi-
ronment (e.g. smart homes devices, smoke alarms, etc.), human
and health monitoring solutions (e.g. blood pressure meter, glu-
cometer, weighting scale, etc.) and social communication solutions
(e.g. videophones). All projects were funded by programs of the
European Commission (e.g. CIP – Competitiveness and Innovation
Framework Program, ICT-PSP) or national funding programs (e.g.
BENEFIT-Program of Austria).
4.1. Methods applied in the projects
For QOL- evaluation, a broad spectrum of instruments were
applied in the studies. In the projects, intervention-based and tar-
get group specific questionnaires were used. For QOL- and health-
evaluation following instruments were applied: SF-12 (Short Form
12-questionnaire), SF-36, WHO-5, SEL (Skalen zur Erfassung der
Lebensqualitaet), WHOQOL-BREF, WHOQOL-OLD, EQ-5D, PHQ-9
(Patient Health Questionnaire). To study the physical and mental
limitations of the population following questionnaires were used
in the identified projects: WHODAS 2.0 (World Health Organization
Disability Assessment Schedule), HADS (Hospital Anxiety depres-
sion Scale), various scales for activities of daily living (ADL) and
instrumented activities of daily living (IADL), PSQI (Pittsburgh Sleep
Quality Index), NCT (Number Connection Test of the Nuremberg
Ageing Inventory), BASDEC (Brief Assessment Schedule Depression
Cards), FES-I (Falls Efficacy Scale International).
The EFS (Edmonton Frail Scale) and MMSE (Mini-Mental
State Examination) scores were typically used to monitor the
 38
Table 2
QOL-Outcomes of AAL-Projects.

Project Type of resource Study design QOL-evaluation- Participants Intervention (system QOL- and health- outcomes
(Program) (methods and description)
Instruments)

DREAMING Final project report RCT SF-36v2 age: 65+ years Environmental monitoring SF36v2:
Project and final trial duration: 30 months HADS intervention n = 138 Human and health vitality and mental health
(ICT-PSP) evaluation evaluation: user satisfaction control n = 137 monitoring increased + 2.5 points by p < 0.01)
[68–70] begin, midterm, end questionnaire COPD, chronic heart Mobile alarm and physical health: no effect
6 sites in: MMSE failure, diabetes localisation HADS:
Denmark, Estonia, Communication and depression: −1.1 points in
Germany, Italy, Spain, videoconferencing intervention + 0.8 points in control
Sweden anxiety: no effect
Qualitative:
improved feeling of safety no

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differences btw. groups in clinical
events (e.g. hospital admissions)
IN CASA Pilot evaluation prospective cohort study SF36v2 age: 65+ years Environmental monitoring SF36v2:
(ICT-PSP) report duration: 6 months EQ- 5D (only one site) (mean 71 years) Health and human - health perception: +7%
[75,76] evaluation: Qualitative interview n = 204 monitoring - physical health: +6%
begin, end EFS COPD, congestive heart Tele-rehabilitation Qualitative:
5 sites in: failure CHF, cancer, frailty, treatment and tele-care - less affected by emotional
France, Greece, Italy, Spain, social vulnerable Communication and problems
United Kingdom videoconferencing system - less depressed feelings during
(social housing support) enrolment of service
- improvements in own emotional
handling of chronic condition
- medical sites: improved health,
saved time due to avoided visits
- social sites: improved social
aspects
- 40% reported of increased access
to health professionals
EQ-5D (only health monitoring f.
CHF):
- more secure, independent and
self-confident
Home Sweet Trial Evaluation RCT SF36v2 age: 65+ Environmental monitoring SF36v2:
Home Report, Clinical & duration: 24 months, HADS intervention n = 62 and control - mental health: improved
(ICT-PSP) QOL Impact evaluation: EFS control n = 67 Human and health (p = 0.07); in control: no
[71–74] Assessment begin, midterm, end mild or moderate frail monitoring improvement
4 sites in: elderly Emergency call system and HADS:
Belgium, Spain, Ireland, navigation system - anxiety-score: less in
Italy Mental and cognitive intervention than in control
training (change p < 0.05)
Communication and
videoconferencing system
ISISEMD Clinical Study, Pilot RCT QOL-AD age: 60+ years Environmental monitoring Outcomes dependent on site:
(ICT-PSP) evaluation report duration: 15 months Katz-scale (ADL) (mean age 62,23 and control QOL-AD:
[77,78] evaluation: Lawton&Brody- scale (SD = 13.13) Mobile localization system improvement in QOL-AD from 43%
begin, midterm, end (IADL) intervention n = 31 Tele-care service to 70% subjective improvement
4 sites in: MMSE control n = 26 Reminder functions and Katz-scale:
Denmark, United Kingdom, Living in home dwelling brain games 62.5 to 80% maintained their basic
Greece, Finland with cognitive deficits or Communication and ADLs
mild dementia videoconferencing system 12.5% improved ADLs
Lawton & Brody-scale:
14.3 to 40.0% improved IADLs
75.0% percent declined in IADLs
COMMONWELL Pilot outcome different designs SF-12 age: 65+ years Health and human SF-12:
(ICT-PSP) [79] report depending on site: BASDEC UK: n = 87 (COPD) Monitoring mental health improved (UK); no
qualitative, mixed methods Qualitative interviews Spain: n = 500 (emergency tele-care services effect in other sites
or longitudinal and focus groups call) Emergency call system physical health declined (p < 0.001)
quasi-experiments Netherlands: n = 68 due to nature of COPD; no effect in
duration: 6–9 months Germany: no information other sites
evaluation: found BASDEC (UK):
begin, 3rd month, 6th improved as sense of security and
month, end reassurance
7 sites in: level of depression decreased over
United Kingdom (UK), time (p < 0.003)
Germany, Netherlands, Qualitative:

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Spain alarm system increases feeling of
being save (Spain)
79% reported pos. benefits to
health by health monitoring
system
1% reported negative effects to
health
hospital admission avoidance in
168 instances because of
tele-health monitoring
28% reported they had received
treatment earlier than they would
have had before tele-monitoring
ALADIN Report on test Pilot experiment WHO-5 age: 65 − 84 years Ambient lighting WHO-5:
(FP6-Progr.) results and the duration: 3 months SEL n = 12 assistance (scalable with - wellbeing increased from
[80–82] evaluation and evaluation: PSQI sensors for environmental baseline to final measurement
results of the pilot begin, end NCT control) (p < 0.01)
study (prototype 12 households in Germany, physical fitness: heart Mental training tasks to SEL:
testing) Austria, Italy rate control the system - general QOL increased (p < 0.05)
variability NCT:
measurement - mental fitness increased
(p < 0.001)
PSQI: no impact
physical fitness:
- no impact
Qualitative:
- participate in project influences
mood
REAAL Evaluation Report qualitative longitudinal qualitative interviews age: 61+ years Emergency call system Qualitative:
(BENEFIT) study with pre- and (10 pre, 12 (61–86 years) Environmental control increased feeling of being secure
[83] post-interviews (before post-intervention) n = 16 system because of emergency call system
moving to new home) moving to a new assisted Social communication and automatic switching devices
1 site in Upper Austria living home with an system (oven, water tap)
AAL-system no changes to subjective health
status
social support better because of
new home
more autonomy and privacy
because of new home (barrier free
home) → technology in most cases
not used

39
 40
Table 2 (Continued)

Project Type of resource Study design QOL-evaluation- Participants Intervention (system QOL- and health- outcomes
(Program) (methods and description)
Instruments)

C. Siegel, T.E. Dorner / International Journal of Medical Informatics 100 (2017) 32–45
I-DONT-FALL Medical and RCT, 4 arms WHOQOL-BREF age: 65+ years Fall detection system FES-I:
(CIP) Scientific duration: 9 months FES-I (mean = 77,95 years; Fall prevention services - fear of falling reduced (mixed and
[84,85] evaluation report, evaluation: Tinetti-scale SD = 8.9) and technical assistant for physical treatment (p = 0.004,
evaluation begin, end 6MWT (6 min walk n = 209 physical training p = 0.05)
framework 4 sites in Italy, Spain, test) 3 treatment groups: (knowledge management, Tinetti-scale:
Greece, Serbia Barthel-Index (ADLs) n = 160 (physical, cognitive fall prevention warnings - risk of falling reduced for mixed
Qualitative & mixed training) and tele-rehabilitation) treatment arm (p = 0.04)
MMSE control: n = 49 6MWT:
stroke patients, clinical - improved mobility in treatment
diseases and cognitive groups (p = 0.06, p = 0.04)
decline WHOQOL-BREF, Barthel-index,
MMSE, number of falls:
- no results available
ISTOP-FALLS Study protocol RCT EQ-5D age: 65+ years Fall prevention exercise currently no results published
(FP7-Progr.) duration: 4 months WHODAS 2.0 n = 160 (intervention and game
[86,87] evaluation: PHQ-9 control) Fall risk assessment and
begin, midterm, end FES-I prediction system
3 sites in: Germany, Spain, Personal health advisor
Australia
ModuLAAr Study protocol Pre-post assessment, EQ5D age: 60+ years Environmental monitoring currently no results published
(BENEFIT) longitudinal WHOQOL-BREF nursing level < = 4 and control
[89] quasi-experimental cohort WHOQOL-OLD n = 50 Human and health
study Qualitative interviews living in assisted living monitoring
duration: 18 months and homes Mobile/stationary
evaluation: focus groups emergency and localization
2 pre-assessments, begin, System
midterm, end) 7 sites in Fall detection system
Eastern Austria Reminder functions and
social interaction
applications
Communication and
videoconferencing system
 C. Siegel, T.E. Dorner / International Journal of Medical Informatics 100 (2017) 32–45
inclusion/exclusion-criteria of the participants. In each of the listed
projects the amount of female participants was tremendously
higher than the proportion of male participants.
Additionally, several projects and studies included qualita-
tive approaches for evaluation (interviews, focus groups). For five
projects, randomized controlled trials (RCTs) with several assess-
ment points during intervention period had been conducted. All
of these studies were carried out in different sites in European
countries.
4.2. Description of the projects
The DREAMING project encompassed a total number of partici-
pants reaching from 23 to 80 persons per location. All participating
people suffered from chronic diseases like COPD, chronic heart fail-
ure or diabetes mellitus. The installed technical modules had been
chosen according to the individual needs of the participants. In
this study, an improvement in QOL has been found over the study-
duration compared to the control group. The two dimensions that
had been positively affected the SF36 were the domains ‘mental
health’ and ‘vitality’. Nevertheless, the effect size of the results was
small. Additionally, a satisfaction survey showed that the partici-
pants felt safer by owning an alarm system [68–70].
Another RCT including elderly with chronic conditions, the
HOME-SWEET-HOME project, also showed that mental health was
positively affected over the study duration compared to the control
group. In addition to DREAMING, there was an additional emer-
gency call system and the possibility to control the environment
via electronic door openers and window actuators. The authors
assumed that the emergency call system influenced the anxiety
score of the HADS [71–74].
The IN CASA project addressed people who suffered from
chronic diseases and frailty and who were living at home. At
each site, other disease-groups of participants received different
services. The physical health increased for the people receiving
tele-rehabilitation and care (COPD, cancer) and the social param-
eters increased for the group of socially vulnerable people (e.g. by
avoided unnecessary visits of care staff). [75,76]
The outcomes of the ISISEMD project that focused on people
with dementia, showed improvement in the mental health compo-
nent of the SF-36. There were also positive or at least maintaining
effects to ADLs in most cases which could be caused by the tele-
care services, reminders and brain games. They outlined that the
medication management improved for some participants and their
social life status remained the same [77,78].
The COMMONWELL project reported positive impacts of a tele-
care service for COPD-patients on mental health. Furthermore, the
level of depression decreased in the study population in one site.
The perceived feeling of being secure increased and hospital admis-
sions reduced over study duration [79].
The evaluation of a sensor-based smart lighting system for
elderly found a significant increase in well-being. The project did
also focus on the participants’ sleep quality that could be affected
by lighting ICTs. These results were qualified to be interpreted with
caution because of some other possible variables like social inter-
action with the study population during the project and the small
study sample. Social project-related contact over study duration
may play an important role of the reported positive impact [80–82].
The qualitative evaluation of the REAAL-project encompassed
people that moved to a new assisted living home equipped with an
AAL-system. The results showed only one technology-related out-
come because the system wasn’t used by the elderly. The authors
reported that technologies that have to be used − on his/her own −
will not be used by the elderly. The environmental control system
with its automatic secure-switches and the emergency call system
lead to an increased feeling of safety [83].
41
A solution for fall prevention and detection for people with cog-
nitive problems was analysed in the project I-DON’T-FALL. The
authors reported that this system had positive effects because of
reduced fear of falling, reduced risk of falling and improved mobility
[84,85].
4.3. Upcoming pilot evaluations
The projects ISTOP-FALLS [86,87] and FATE (Fall Detector for
the Elder) [88] will focus on the detection of falls and fall-
related aspects and could deliver additional results regarding
fall-prevention by ICT. Moreover, the ModuLAAr-project [89] is cur-
rently under investigation and could provide enriching facts to the
QOL-impact of ICT. There will be two new testing regions in Austria
that will focus on the evaluation of QOL in ICT-projects too [90].
In the year 2013, the huge international AAL project ReAAL (same
acronym as the Austrian project, see Table 2) started. It will contain
six pilot sites and in sum 7000 users. The systems will be based on
the UNIVERSAAL platform [91] already developed in the AALJP and
will be extensively evaluated [92,93].
5. Discussion and recommendations
The results of this review are synthesized and presented in
Table 3. We showed that ICT and AAL-solutions can contribute
to individuals’ QOL by providing a broad range of impacts in
the domains physical health, social participation, environmental
aspects and psychological health. Most of the found studies in the
field of ‘ICT and AAL for elderly’ report positive outcomes. Because
of the rarely mentioned threatening or negative effects to elderly’s
QOL in the project reports and study outcomes (e.g. reduced face-
to-face communication) there could be a publication bias caused
by economic or political reasons as well as scientific issues (publi-
cations of negative results is not as likely as beneficial outcomes).
As an example the project reports showed that almost no partici-
pant had concerns about possible negative effects to their privacy
or data security by ICT solutions.
As it is the nature of complex interventions, it is often not pos-
sible to show improvements to QOL and health that directly result
from influences of the ICT solutions [54]. As an example, Frisardi
et al. reported that there is still no evidence of the effects of smart
homes regarding health outcomes [34]. The impact of ICT solu-
tions is often difficult to measure and sometimes it is intangible
[94]. Almost all projects dealt with technical problems what could
be caused by the fact that the technical development and clinical
investigation analyses were combined.
Most identified articles were based on case reports and uncon-
trolled studies as already identified in Lauriks et al. [56]. This is
why more quantitative as well as research including mixed-method
approaches has to be done to cope with the increasing demand
of these solutions in the future. Furthermore, a higher number of
participants should be included to get appropriate results [95].
Nevertheless, some studies report that more qualitative meth-
ods including interviews are strongly recommended for future
research on tele-care and AAL [51]. When acquiring study partic-
ipants it must be taken into account that most analysed projects
reported on high dropout rates. Main reasons for lost-to-follow-up
were death, illness or because of moving to a nursing home. Espe-
cially depressed people tend to quit and affect the dropout rate
[68,73]. Adequate instruments to measure anxiety and depression
should be applied when including this kind of participants. It is
also strongly recommended to conduct larger, high quality and if
possible multicentre studies with RCT designs or longitudinal
cohort studies to prove evidence of new AAL-solutions [36].
42 C. Siegel, T.E. Dorner / International Journal of Medical Informatics 100 (2017) 32–45

Table 3
Pathways of QOL-Impact of ICT.

ICT-solution QOL-impact of ICT-solution Pathway of QOL-impact Affected QOL-Domain Reference

Home-based technology
Internet
Online chatting, online
newspaper
Computer games
Video phones,
conventional phones
mHealth solutions
Smart
homes/environmental
monitoring
Social robots
Emergency call, fall
detection and fall
prevention
Tele-health monitoring
Behaviour monitoring
Tele-care
Dementia memory aids,
reminder functions,
conversational aids
Localizing systems
Mobility aids for visual
impaired
Taking part in AAL-projects
enabling comfort
provide health information
social inclusion
information provision
cognitive benefits
social inclusion
improve mood
decreased depression, feeling
less lonely, ICT as boundary
object
increased depression and
loneliness (−)
change health behaviour
communication with care
professionals
feeling safer
facilitate functional
independence
social inclusion
increase healthcare
social exclusion (−)
obtrusiveness (−)
improving mental health
improved communication
perceived independence,
feeling safer, less anxiety, less
insecurity
provide a training solution for
prevention
providing overview of health
parameters; health literacy
improvement
improved self-management
with chronic conditions
change behaviour (e.g. for
dementia, diabetes)
Health literacy and care
reactions
control health problem
compensate functional
disabilities
providing helping hand
social inclusion
increases safety
staying mobile
social participation
the more technology used the better the QOL QOL general [18]
change health behaviour and increase health physical [19,60]
literacy by information provision
increased wellbeing by being socially involved social [20]
and informed psychological
train cognitive skills physical [21,22]
communicate during game social psychological
being entertained and having fun
improved social participation, stay in contact social [23–25,27]
with social environment psychological [26]
reduced face-to-face communication
participate in own care, health information physical [30–32]
provision, social
better appointment compliance, improved
communication with professionals
safety concerns by alarms psychological [35,37,38]
cognitive training physical [39]
increased participatory behaviour and activity social
facilitate health and care services physical
reduced face-to-face communication, social
substitute personal care and communication, psychological
unfamiliar objects in environment environmental
having a companion: improving mood, less social [40–43]
lonely, reduced stress psychological
perceived safety and security increases; psychological physical [44,84,85]
getting help in critical situations
reduce fear of falling, reduced risk of falling
and improved mobility
health parameters monitored and controlled physical [48–50,68–70,75,76]
improves health knowledge psychological
better medicine and exercise compliance
apply correct therapy
less hospitalization (esp. for chronic diseases,
COPD, diabetes, chronic heart failure, etc.)
increased compliance to exercises, diet, sleep physical [39,48,49,61]
quality etc. by provided information
illness detection, decline detection of chronic
diseases
appropriate reactions on changed
needs/functional overview (dementia)
empower people by providing individual physical [51,52]
health/care information
alerts if parameters no in range, adaption of
medication if necessary
increased medicine compliance by reminders psychological [58–62]
dementia aids and ICT-based reminiscence social
treatments lead to reduced emotional
blunting, lability, better mood, less anxiety,
less loneliness,
Increased self confidence
Video phones provide a window to the world,
experiences can be shared
finding lost persons, react just in time physical [56,68–70]
providing a ‘helping hand’ for daily navigation physical [64]
increased social participation and inclusion by social [27]
participating in projects and associated
trainings

The review showed a heterogeneously range of evaluation
methods and instruments that address the different needs of the
participants and technology-associated areas of action (e.g. nurs-
ing homes). If the investigation framework allows, we recommend
for upcoming projects to follow the ‘QOL Assessment Framework
for Assistive Technologies for Independent Living’ [96].
There is also a lack of investigations how ICT could support com-
munication between caregiver and care-recipient [60] what should
be taken into account in future projects.
As described in [34,97–99], there is more research needed to
determine the accurate dimensions of the influence of AAL and
assistive ICT and establish evidence. This field is an increasing inter-
disciplinary area of research and we still have to learn in which
ways ICT impacts QOL and health, what influences ICT has to QOL
(especially for people with dementia) and how the results have to
be interpreted.
A strong association between technology acceptance and QOL
could be shown by Chou et al. [51]. Elderly people who perceived
technical solutions as useful tools for improvement of their health
status and really using these technologies had positive opinions
regarding their interpersonal relationships and their living envi-
ronment.
 C. Siegel, T.E. Dorner / International Journal of Medical Informatics 100 (2017) 32–45
Wardt et al. [100] reported that the role of wellbeing in use of
new technologies needs to be investigated in more depth because
of a lack of related studies. More research is needed to explore
the needs of elderly to ensure that available products meet their
requirements. Research has to be based on human subjects that
reach from elderly with limitations, disabilities and frailty to the
generation of ‘baby boomers’ and chronically ill people [101].
6. Conclusion
The findings of this review indicate that there are many pos-
sible ICT-associated positive impacts to the individual’s QOL and
subjective health. The summarized literature shows that ICT and
AAL-solutions for elderly do not only encompass questions about
technical aspects that have to be taken into account in projects.
Future customers and recipients must be involved in development,
before rollout, so that ICT can successfully contribute to QOL and
health. Current projects and evaluation studies show that complex
AAL-solutions can be evaluated sufficiently and contribute to the
wellbeing of elderly and chronically ill people. Nevertheless, there
is still a lack of evidence of how subjective QOL can be influenced.
For future research and development of ICT and AAL-systems we
recommend to describe the pathways how technologies affect the
different domains of the participant’s QOL and not only rely on
outcomes of measurement scales.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
CS is the main author of this manuscript. CS did the literature
search and summarized the results. TD participated in the crit-
ical review of the manuscript. Both authors approved the final
manuscript.
Summary points
What was known before this study?
• Ambient Assisted Living solutions are developed aiming to
improve the health and quality of life of dependent as well as
active elderly
• Previous research primarily focusses on technical issues instead
of investigating the effects of assistive technologies to the aged
individual
• Recent reviews of information and communication technologies
do mainly focus on single functions of ambient assisted living
solutions (e.g. smart homes, tele-medicine)
What did this study add to our body of knowledge?
• The results of this review indicate that elderly’s quality of life
and health can be positively and negatively impacted by mod-
ern information and communication technologies and assistive
systems
• Projects and evaluation studies of Ambient Assisted Living
solutions are often evaluated extensively but show a very het-
erogeneous variety of applied scientific methods
• The technology-focused research approach is one reason for the
lack of knowledge of how information and communication tech-
nologies can influence quality of life of elderly
43
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