Technological Solutions for Social Isolation Monitoring of Elderly

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This entry is adapted from the peer-reviewed paper 10.3390/s22228802

Social isolation is likely to be one of the most serious health outcomes for the elderly due to the COVID-19 pandemic, especially for seniors living alone at home. In fact, two approaches have been used to assess social isolation. The first is a self-reported survey designed for research purposes. The second approach is the use of monitoring technology.

elderly monitoring social isolation identification of ADLs

1. Introduction

Human beings are fundamentally social creatures who cannot survive without depending on each other. High-quality social connections are essential to the well-being. However, social isolation is widespread and can affect people, especially the elderly who are the most vulnerable population to this problem. It was estimated that approximately 12% of seniors feel socially isolated, according to data from the Canadian Community Health Survey—Healthy Aging 2008/09 ^[1]. Social isolation among seniors is therefore a growing concern, as the COVID-19 pandemic and accompanying physical distancing measures have increased the importance of these topics.

Social isolation can be defined structurally as the absence of social interactions, contacts, and relationships with family, friends, neighbors on an individual level, and with society at large on a broader level ^[2]. Furthermore, the term social isolation is often conflated with loneliness but represents a distinct concept. Social isolation is the objective state of having few social relationships or infrequent social contact with others, and loneliness is a subjective feeling of being isolated ^[3].

Social isolation of the elderly is related to distinct reasons such as age, gender, loss of one’s partner, lack of relationships with family members, friends and neighbors, medical problems, disabilities, rural or urban environment, accessibility to public transport, accessibility to all daily services, low income, low knowledge of modern technologies, heatwave period, infectious diseases, etc.

Social isolation has different impacts on the elderly:

Psychological impacts: the lack of contacts can lead to spending several days without speaking to anyone ^[4] and, as a result, different psychological problems could appear including despair, depression, stress and the lack of self-esteem may result in committing suicide ^[5].
Physical impacts: Social isolation limits the elderly’s relationship with the outside world which leads to a decrease in physical activities that are important for their health and well-being. Consequently, it leads to a decline in physical abilities ^[6].
Health impacts: Social isolation has devastating effects on the health of the elderly, particularly at the nutritional level. Indeed, the risk of malnutrition have increased among the elderly who are socially isolated ^[7].

2. Current Issues in the Elderly Monitoring Systems

2.1. User Needs, Perception and Acceptance

User needs, perception and acceptance are the three factors to take into consideration before designing an elderly monitoring system.

The most important function of an elderly monitoring system is to provide a sense of safety for the elderly themselves and their families, especially for those who live alone. Indeed, the system provides safety by detecting emergencies and alerting caregivers/families such as a fall and/or a decrease in daily activities (meal preparation, daily grooming, etc.). This includes obtaining accurate and complete ADL information. These needs are usually met by the use of a smartphone and various sensors embedded on the body or deployed in the home environment.

The user perception of elderly monitoring system depends on its type (wearable or non-wearable sensor), visibility and privacy. Considering the type, it is preferable to use non-wearable sensors rather than wearable sensors, as they are non-invasive, non-intrusive and contactless. As far as the visibility is concerned, it is important to use miniaturized and wireless sensors and to choose locations that make them quite invisible after a brief period of time. With respect to privacy, the use of cameras and audio recordings is generally not considered as a way to preserve privacy.

A study conducted to obtain older people’s perspectives on the use of sensors ^[8] indicates that older adults surveyed positively evaluate sensor monitoring because it provides a sense of safety, especially for those who live alone and have therefore experienced a lack of this feeling. Participants also expressed relief that the sensors required no action due to their lack of technical knowledge. In addition, participants did not experience the presence of the sensors in their homes as disruptive. Most reported that they did not notice the sensors after a while. In addition, sensors that record their movements at home without cameras or sound recordings are not considered as an invasion of their privacy.

The willingness of the older person to use the elderly monitoring system is influenced by various factors such as concerns about the technology (technical errors, etc.), positive characteristics of the system (e.g., ease of use factors, privacy implications), expected benefits of the technology such as increased safety, need to use the technology (e.g., perceived need to use), social influence (influence of friends and family), and characteristics of the elderly (e.g., past experiences, physical environment). However, the most mentioned factors were social influence and time to try the technology ^[9].

2.2. Architecture Selection and Requirements

The design of an elderly monitoring system requires the application of several features. The overall architecture of the system must meet the following requirements:

Heterogeneity: it refers to the fact that IoT systems are composed of different components with different communication protocols, and despite this diversity, they can be integrated into a single system.
Interoperability: it refers to the ability of the system to provide easy and understandable interfaces by all IoT components and to exchange data between them.
Maintainability: it refers to the ability of the system to work despite the updates to its components or the addition of new components and therefore to maintain it over time.
Scalability: it refers to the ability of the system to work as intended despite the changes in the number of users or in the hardware or software.
Reliability: it refers to the ability of the system to consistently perform as expected and therefore be trusted.
Efficiency: it refers to the ability of the system to perform in the best feasible way by optimizing time and resources.
Effectiveness: it refers to the ability of the system to function as intended or to produce the expected results.
Security: it refers to the ability of the system to ensure the security of data when it is transferred or saved as it relates to the privacy of users.
Adaptability: it refers to the system’s ability to meet the needs of each senior, as this type of project must be personalized to the individual’s profile.
Usability: it refers to the ability of the system to be easy to use for the elderly, regardless of their knowledge of technology. In addition, the system should consider having a function for sharing data and notifying caregivers in case of an emergency so that seniors feel safe in their homes.
Accuracy: it refers to the ability of the system to provide the adapted services to seniors despite the different profiles and requests of each.

The choice of the system architecture has an impact on the satisfaction of these requirements. That is why, among the different infrastructures proposed, middleware is preferred to facilitate the homogenization of the different technologies and to satisfy the prerequisite characteristics ^[10].

2.3. Hardware and Software Considerations

The choice of hardware depends on two main criteria: cost and convenience.

In terms of cost, the price of the system must be affordable for a large number of expected customers. The installation process of the distinct parts of the system should be considered in the choice of materials, because the easier the installation, the less expensive it will be, thus reducing the overall cost of the system. In addition, for parts that rely on disposable batteries, the lower the power consumption, the fewer battery replacement operations and the lower the system cost. An Australian study of 13 people aged 65 years and older found that the cost of purchasing the system and maintaining it at home was a significant concern for the participants ^[11].

In terms of comfort, user desire is always to reduce maintenance, if possible, because when they buy an electronic system, they think that its reliability will be exceptionally long. In addition, the non-wearable, wireless and miniaturized system will be the right choice; the system that requires no or few interventions is the most needed because of the seniors’ lack of technological knowledge.

Software development depends on two main criteria: effectiveness and efficiency.

The software must be able to operate efficiently at all stages, from data collection and analysis to adaptive response to the detection of any problems. In addition, the software must be efficient in optimizing power consumption especially for sensors that use disposable batteries to send data. Finally, an optimized algorithm is needed to identify ADLs and respond in real time to the detection of a problem.

2.4. Ethical Considerations

With the technological advances, sensor-based approaches are now used in clinical practice, research, and to monitor the health of people in homes around the world. Even though technology has its benefits, it cannot neglect the ethical practices. The first concern is the ability of sensors to collect rich information about the lives of older people. For example, a video camera that can identify every ADL in its field of view is considered an invasive sensor. Second, protecting access to research participants’ data is an ongoing privacy concern for all researchers.

This is because anonymity is not always possible. In fact, it can be difficult to manage clinically relevant data to maximize benefits while minimizing the potential for disclosure to third parties. In addition, it is difficult to ensure secure communication during the research process ^[12]. The third concern is security risk. This is the biggest threat to personal information in the event of a hacking operation, despite the use of encryption software, or if someone accidentally retrieves the participant’s smartphone. A single instance of security breach can negatively impact trust and participation in this type of research ^[12].

3. Monitoring System Features

Automatic ADL classification is a crucial component of assisted living technologies (AAL). It allows monitoring the daily life of older people and detecting any changes in their behavior to encourage them to live independently and safely at home. Many studies on AAL focus on different ADLs, such as bathing, grooming, mobility inside and outside the house, eating, etc.

3.1. Meal-Taking Process

The recognition of the activity of eating is particularly important to monitor the health of the elderly. Indeed, nutrition has a significant impact on physical health, memory and mental functions. Good nutrition can boost immunity, fight disease-causing toxins, weight control, and reduce the risk of heart disease, stroke, high blood pressure, type-2 diabetes, bone loss, Alzheimer’s disease and cancer ^[13]. Unfortunately, undernutrition is common among the elderly and represents a problem that is not yet well studied. For example, the prevalence of undernutrition is estimated in France to be between 3% and 10% for the elderly people staying at home and between 15% and 38% for residents of nursing homes ^[14]. Identifying all the 12 activities related to eating is the best way to analyze them correctly. The meal-taking process is composed of 4 ADLs: shopping, cooking, eating and dishwashing.

Food shopping: This is the activity where the person goes to the market to buy different ingredients to cook or to buy already prepared meals. For the elderly, food shopping is not a simple activity, but it is considered an important social event where they can interact with others, as the risk of isolation increases. In fact, for some older people living alone, it is the only opportunity for social interaction. In ^[15], the authors mention that older people consider the social element and experience of food shopping as a positive factor. The social aspect of food shopping is particularly important to this age group and regular social interaction is recognized as a key element in maintaining mental and physical wellbeing.
Cooking: The skill or activity of preparing and heating food for eating. Cooking has many physical, emotional, mental and health benefits. This process begins with planning what to cook and what ingredients are needed and if there is a need to go shopping. Then, the person mixes the required ingredients according to a recipe and focuses on the meal until it is properly prepared. This is a good physical and mental exercise. A study of older women in Taiwan found that those who cooked more frequently are engaged in more health-promoting behaviors, such as socializing, and fewer health risk behaviors, such as smoking ^[16]. In addition, cooking is an opportunity for socialization: seniors can collaborate with each other during meal preparation and sharing food with neighbors and friends is a form of social bonding. Finally, meal preparation allows the seniors to use healthy and fresh ingredients, and thus eat delicious and nutritious meals that they prepared, which they can be proud of. A survey conducted by the University of Michigan National Poll on Healthy Aging in December 2019 shows that many adults between the ages of 50 and 80 reported enjoying cooking (71%) ^[17].
Eating: It provides energy to the body. It is important for older adults to stay as active and healthy as possible. Although it is recognized that good nutrition is important for successful aging, malnutrition is one of the greatest threats to the health, autonomy, and well-being of older adults ^[18]. For the elderly, malnutrition is not the consequence of a lack of food, but of a deterioration in the desire to eat and is related to several factors such as serious health conditions, medication side effects, lack of exercise, difficulties in chewing, swallowing or self-eating, depression, loneliness, and social isolation ^[19]. Monitoring the eating activity in the elderly is essential to ensuring their well-being.
Dishwashing: this involves cleaning the dishes of food remains on plates. This can be done manually by hand in the sink or automatically by the dishwasher. Although dishwashing is a light activity, it can be a good physical activity for the elderly that helps prolong their lives. In a U.S. study conducted by the University at Buffalo of more than 6000 white, African American and Hispanic women aged 63 to 99 years, researchers found a significantly lower risk of death for those who were active, even while performing light activity, than in those who were inactive ^[20].

A use survey conducted by the French National Bureau of Statistics between 2009 and 2010 ^[21] revealed that the daily time related to the meal-taking activity (shopping, cooking, eating and washing dishes) among people aged 60 years and older is nearly 4 h per day. In fact, men aged 60 years and older spend 24 min shopping, 13 min cooking, 154 min eating and 13 min washing dishes each day. In comparison, women 60 and older spend 21 min shopping, 72 min cooking, 141 min eating and 25 min washing dishes each day. This finding reveals that older men spend less time on household chores than older women, particularly as far as cooking is concerned.

3.2. Mobility

Mobility is the ability to move around easily. It can be classified into two types: functional mobility and community mobility. Functional mobility, a basic activity of daily living, is defined as moving from one position or location to another while performing ADLs, such as in-bed mobility, wheelchair mobility, and transfers (e.g., wheelchair, bed, car, bathtub, toilet, tub/shower, chair, floor). It also includes functional ambulation and carrying objects ^[22]. Community mobility, considered as an instrumental activity of daily living (IADL), is defined as moving around the community and using public or private transportation, such as driving, walking, biking, or accessing and riding in buses, taxi cabs, or other transportation systems ^[22]. Mobility is important for maintaining self-care and an independent and autonomous lifestyle. In fact, mobility is the key point to performing basic ADLs such as feeding, dressing, toileting and personal hygiene but also the instrumental ADLs such as shopping, preparing meals and cleaning the kitchen after meals.

In addition, regular mobility and activity, even mild physical activity such as walking, improves mental and cardiovascular health, controls weight, maintains healthy bones and muscle strength, reduces the risk of falls and increases social interaction ^[23].

Furthermore, there is a mobility gap between older men and women. In fact, mobility disability is more frequent in women than in men according to a study done in different places around the world ^[24].

A U.S. Time–Location Patterns study conducted in six cities indicates that adults aged 65 years and older spend 78% of their time at home, which is high compared to adults aged between 45 and 65 years who spend 66% of their time at home. This result is understandable since seniors are usually retired, have limited social contacts and therefore prefer to spend the majority of their time at home ^[25].

3.3. Social Isolation and Loneliness

3.3.1. Definitions

Human beings are social animals and the biological, psychological, and social systems have evolved to thrive in collaborative networks of people ^[26]. Yet, many people suffer from social isolation and loneliness, especially the elderly. While social isolation and loneliness are closely related, they do not mean the same thing. According to the National Institute for Health Research in the United Kingdom, isolation is a lack of social contact or support, whereas loneliness is the feeling of being alone and isolated (it is possible to feel lonely in a room full of people) ^[27]. A report published by the National Academies of Sciences, Engineering, and Medicine (NASEM) in the United States prior to the COVID-19 epidemic indicated that 24% of community-dwelling adults aged 65 and older in the United States (approximately 7.7 million people) were socially isolated and 43% of Americans aged 60 and older report feeling lonely (approximately 13.7 million people) ^[28]. With the COVID-19 pandemic, these numbers increased dramatically due to the stay-at-home orders, social distancing, and banning visits for nursing home residents. Social isolation and loneliness are likely to impact the health of the elderly.

3.3.2. Risk Factors for Social Isolation/Loneliness

Older people are vulnerable to social isolation and loneliness due to numerous factors such as living alone, death of the partner, living far from family and friends, living in a rural area, reduced mobility, chronic diseases, digital exclusion, etc. Indeed, the report published by NASEM in the United States indicates that being unmarried, male, having low education and low income is independently associated with social isolation ^[28]. In addition, the status of social isolation and loneliness depends on gender. Indeed, according to a 2014 report in England ^[29], 14% of men and 11% of women aged 50 and over experienced a moderate to high degree of social isolation (older men are more isolated than older women); 48% of men and 54% of women aged 50 and over experienced some degree of loneliness (older women are more lonely than older men). In addition, the use of new technologies, especially social networks, has become an important means of communication nowadays. A report conducted by the Pew research center in the USA in 2013 revealed that 27% of all Americans ages 65 and older are on social networking sites. Regarding the use of social networking, older women are more likely than older men to use social networking sites: 52% of female internet users aged 65 and over adopt social networking sites compared to 39% of older men ^[30].

Furthermore, the French association “Petits Frères des Pauvres” released a report about the links between loneliness, isolation of the elderly, and the territories ^[31]. It indicates that loneliness is amplified in certain areas and particularly affects elderly over 85 (mainly women) who live alone, belong to less privileged socio-professional categories (with income below 1000€ per month), live in social housing, and have no access to internet.

In addition, there are significant differences in the components of isolation depending on the territory. In urban areas, isolation is worsened by the weakening of solidarity and neighborly relations, the replacement of local shops by shopping malls in the suburbs, the feeling of insecurity, the crowded public transport and its inaccessibility, particularly for people with reduced mobility. For example, 24% of people aged 60 and over living in apartments in France can spend days without talking to anyone (the national average being 19%) ^[31]. In rural areas, even though solidarity between people is stronger, the lack of public and health services, local shops and public transport, and the fact of losing the autonomy to drive the car due to aging reinforce isolation ^[31].

3.3.3. Social Isolation/Loneliness Evaluation

Different measurement scales have been developed to assess social isolation/loneliness (SI/L) and most of them are self-report questionnaires that were designed for research purposes. The measurement scales developed for the assessment of SI/L are summarized below.

The Berkman–Syme Social Network Index (SNI) is a self-reported questionnaire that measures the level of social isolation. It is a composite measure of four types of social ties: marital status, sociability (number and frequency of contacts with children, close relatives, and close friends), religious group membership, and membership in other community organizations. The SNI scale allows researchers to categorize individuals into four levels of social isolation: socially isolated (individuals with few intimate contacts—unmarried, fewer than six friends or relatives, and no church or community group membership); moderately isolated; moderately integrated, and socially integrated ^[32]^[33].

The Lubben Social Network Scale (LSNS) is a 10-item instrument designed to measure social isolation in older adults that addresses the size, closeness and frequency of contacts in the respondent’s social network. Six-item (LSNS-6), twelve-item (LSNS-R) and eighteen-item (LSNS-18) versions of this scale were published after the LSNS. The LSNS was modified to become the LSNS-R to better specify and distinguish the nature of family, friendship and neighborhood social networks. In addition, the LSNS-6 was developed as a short form for clinicians and the LSNS-18 as a long form for research purposes ^[34]^[35]^[36]^[37].

The Steptoe Social Isolation Index was created by Steptoe and colleagues (2013) to measure social isolation. It is a five-item scale, which focuses on marital status/cohabitation, monthly contact (including face-to-face, by telephone, or written/emailed) with children, other family, and friends, and participation in social clubs, resident groups, religious groups, or committees ^[38].

The revised UCLA (University of California, Los Angeles) loneliness scale is a commonly used measure of loneliness. It consists of a 20-item questionnaire with four response categories each. A shortened version of this questionnaire, the Three-Item UCLA Loneliness Scale, is being developed for use in telephone surveys ^[39]^[40].

The de Jong Gierveld Loneliness Scale is an 11-item self-administered questionnaire for measuring loneliness. It was developed using the Weiss’ (1973) distinction ^[41] between social and emotional loneliness. It was designed for use with older adults and has been assessed with individuals aged 18 and older. To avoid boredom when using the instrument in large surveys, a short version consisting of 6 items was proposed by the authors. Three statements measure the emotional loneliness and the others focus on the social loneliness, each with three choices: yes, more or less, and no. Focusing on both emotional and social loneliness may provide insight into why a person may experience loneliness ^[42]^[43].

There are other different scales which are used to measure the social isolation and loneliness, which were inspired by the above scales. Using validated tools in the assessment of social isolation and loneliness is of the utmost importance. Using an invalidated tool, or just parts of the existing tools, or a tool designed to assess loneliness in a study that is actually examining social isolation may yield inaccurate results.

In addition, technological advances such as machine learning, electronic health records, and predictive analytics hold promise as potential ways to identify social isolation and loneliness. For example, a study using natural language processing techniques to identify mentions of social isolation in clinical notes of prostate cancer patients aged 18 years and older showed satisfactory results in identifying socially isolated patients ^[44].

Despite the fact that there are different measurement scales developed to assess social isolation/loneliness, they have some limitations. In fact, there are concerns about the quality and appropriateness of current tools, as they were developed decades ago and may not account for new modes of interaction and communication (e.g., social media, instant messaging, video conferencing) ^[3]. In addition, they are considered as self-report questionnaires and therefore subjective. Furthermore, surveys offer discontinuous observation about the status of the person and therefore cannot detect any problem as social isolation and loneliness may be episodic for some.

3.3.4. Health Impacts of Social Isolation and Loneliness

Increasing evidence demonstrates that social isolation and loneliness are linked to major health risks such as depression, anxiety ^[45], cardiovascular diseases, mental health problems ^[46], and death ^[47]. For example, cumulative data from 70 independent prospective studies with 3,407,134 participants followed for an average of 7 years revealed a significant effect of social isolation and loneliness. After accounting for multiple covariates, the increased probability of death was 26% for self-reported loneliness and 29% for social isolation.

Another health impact of SI/L is decreased mobility. Indeed, any decrease in the physical activity of the elderly has an enormous impact on their autonomy, their ability to live alone at home, and their quality of life. When elderly people suffer from SI/L, they have a limited social network. Consequently, they left their homes less than other people. And with the containment orders due to COVID-19 pandemic, the problem has worsened. This implies muscle loss, decreased physical abilities and fear of falling. The elderly does not want to go out anymore. Thus, they enter a vicious circle where isolation worsens isolation ^[48]. Furthermore, an English Longitudinal Study on Ageing reveals that older people who experience high levels of loneliness have an increased risk of becoming physically frail ^[49].

Furthermore, SI/L are major risk factors for malnutrition. Elderly people lose the desire to prepare meals and eat, or they eat little and feel less and less hungry. A study of a total of 1200 randomly selected individuals aged ≥65 years living in rural Lebanon showed that social isolation and loneliness are two independent risk factors for malnutrition in the elderly. The odds of malnutrition were increased by 1.6 in elderly people considered socially isolated and a risk of malnutrition was almost 1.2 times higher in those reporting higher levels of loneliness ^[7].

The report “ISOLATION OF THE ELDERLY: THE EFFECTS OF CONTAINMENT” by the French association “Petits Frères des Pauvres” indicates that in this period of COVID-19 crisis, many French people have experienced what many elderly people experience all year round, and the fight against isolation is a powerful weapon of prevention ^[48].

The consequences of social isolation and loneliness for the health of older people will also have an impact on the cost of medical care. Indeed, a recent report in the United States estimates that social isolation of the elderly is associated with an additional $6.7 billion in federal expenditures per year ^[50].

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