The undoubted growing percentage of senior population has been obvious in the modern society during the last few decades. Ambient Assisted Living technologies arise as a promising means of elderly care, thereby reducing both carers' workload and public health services costs. LongLastingMemories, an EU funded project, aimed at alleviating senior people mental and physical health problems by integrating state of the art computer-aided technology and prolonging their independent living by providing a smart home solution. Five rounds of multicentric pilots were planned and conducted in order to test that objectives such as accessibility, user acceptance and perceived effectiveness of the service were met by the final LLM prototype. A questionnaire survey was conducted after each pilot with several stakeholders, such as senior subjects and formal carers, proving the wide acceptance of our service and its applicability in the domain of elderly healthcare.
Keywords: Long Lasting Memories, mild cognitive impairment, seniors, ambient assisted living, pilot study, accessibility, user acceptance, carers, qualitative survey
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The provision of qualitative healthcare services has always paid attention to the human dignity and mostly to human life. Recently a lot of changes had occurred regarding the trends of the healthcare domain. One of the most prevalent changes that had taken place is the growing population of elderly people. According to the United Nations population division report, there is a significant increase of elderly people in Europe and according to estimations the number of people aged 80+ (80 or older) will be 4.4% in 2050, while nowadays observed to be 1.6%. In addition by the year of 2050, the number of people in the Europe aged 65 and older is estimated to grow by 70% (United Nations Populations Division). Greece is one of the EU countries that with the highest proportion of older adults (65+) as compared to the nation's entire population. This conclusion stems from data residing in the European Commission statistical services. More specifically, according to Eurostat, Greek people aged 65 or older represent 18.9% of the country's total population in 2010 (15% was the representing percentage back in 1995). By the year of 2030, it is expected that elderly people in Greece will represent a much larger portion of the society, with estimates rising up to 24% (General Secretariat of National Statistical Service of Greece, 2005).
Another interesting feature that deserves attention is independent living and family structure. The change in the living arrangements of the Greek elderly over the last few years was dramatic: according to the Greek Household Budget Survey (General Secretariat of National Statistical Service of Greece, 2012), the percentage of elderly people living independently, single or as couples, has increased from about 46 per cent in 1974 to 68 per cent in 1999. Intergenerational co-residence has traditionally been a significant source of family support for elderly people. By co-residing with their adult children, the elderly can enjoy financial and social support, companionship and personal care. In the latter half of the 20th century, there was a substantial decline in the percentage of elderly people who lived with their adult children.
Population ageing has major implications on health services, employment and society as a whole (Daniilidou, N.V., et al.,2003). Elderly health has been associated with specific patterns of morbidity, chronic non-contagious diseases comprising most of the cases. The heavier burden of disease among the elderly population in high-income countries is considered to derive (in descending order) from ischemic heart disease, cerebrovascular disease, depression, Alzheimer's disease (and other forms of dementia), lung and respiratory tract cancers, hearing loss, chronic obstructive pulmonary disease, diabetes mellitus, alcohol abuse and osteoarthritis(Lopez, A.D., et al.,2006).
All these statistics, reveal the need for an integrated system care in order to improve health and quality of life focusing exclusively on older people. The major challenge in the near future will be to care for healthy and active aging worldwide by enabling older people to live longer in their home environment, thus keeping their independence as well as reducing costs to public health and social care systems.
One is lead towards this direction when information and communication technology (ICT) is used within the health care system, thereby contributing to better and more efficient health care services for all, and especially elderly people (Branko G Celler, Nigel H Lovell & Jim Basilakis,2003). The aging population is a major challenge for human societies; this may be tackled by recent developments in information and communication technology (ICT) in order to assist independent living of the elderly, while maintaining quality of life and confidence. Due to the significant increase in demand for health care for the elderly, we can expect a strong demand for Assistive Technologies Living - both to reduce the unit costs of home care and to facilitate the work of informal caregivers, and sometimes to replace the last one with objects of ICT. The early indications show that if used correctly e.g. tele-health systems can deliver a 15% reduction in Accidents & Emergency Units visits, a 20% reduction in emergency admissions, a 14% reduction in elective admissions, a 14% reduction in bed days and an 8% reduction in tariff costs. More strikingly they also demonstrate a 45% reduction in mortality rates (Panagiotis D. Bamidis, Evdokimos I. Konstantinidis, Antonis Billis, 2011; Health, D.o.,2011).
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In this paper we discuss how services built during an EU-funded project, namely Long Lasting Memories (LLM), may act as an integration platform of existing technological achievements in the field of computer-aided physical/cognitive training of elderly as well as ambient assisted living (AAL) solutions. The LLM main objectives include among others countermeasures against cognitive decline, physical health deterioration and monitoring for fall detection at seniors' premises, thus acting as both a proactive and reactive shield against any health-related problems. Results regarding its perceived effectiveness from the perspective of several stakeholders' -including carers and elderly- are fathered through questionnaires. Main outcomes of this survey show that LLM is a very promising solution as it has an overall impact on seniors' health, its interfaces are appealing to seniors, most of its functions were easy to learn how to operate, which led to the conclusion that adoption to LLM technology does not seem to be a barrier for seniors to perform LLM training activities. In the next few sections the following topics are covered: firstly a short review on existing ICT for aging, mainly focusing on assistive technologies, takes place along with a short paragraph describing the adoption rates of elderly towards new technologies. The materials and methods section outlines the methodology followed regarding the evaluation of the LLM service, targeting at accessibility and user acceptance aspects and the stakeholders' opinion. The Results section presents the main outcome measures of the questionnaires that were distributed during the piloting phases of the LLM project while main points of the LLM objectives in the light of the above results are thoroughly discussed in the final section.
ASSISTIVE TECHNOLOGY TARGETING ELDERLY POPULATION
During the past decade, substantial advances have taken place towards applying technology to meet the needs of elderly people living independently. In parallel and in accordance to e-Health solutions, the field of Ambient-Assisted Living (AAL) has been developed, aiming on alleviating the difficulties of everyday life for the elderly or people with disabilities in general. Two AAL research projects that are already finalized are AttentiaNet and Seniority, aiming to improve quality of life of elderly citizens in Europe using advanced tele-monitoring and telecommunications technology. A different research and development project named MobilAlarm follows a different approach, integrating hand-operated alarm beacons, GPS, mobile telephony, wearable electronics and rapid reaction centres to provide elderly subjects with peace of mind, self-confidence in living independently, and emergency assistance should they happen to require it. Several research teams have proposed the use of variable sensor networks, from audio and movement to micro- and nano-sensors in order to detect common accidents associated with elderly people in their home environment, such as accidental falls. Projects such as Netcarity (Cappelletti A, Lepri B, Mana N, Pianesi F, & Zancanaro M, 2008), INHOME ( Vergados D, Alevizos A, Mariolis A, & Caragiozidis M, 2008), EMERGE (Schwappach DL, Blaudszun A, Conen D, Ebner H, Eichler K, & Hochreutener MA, 2003) and OLDES (OLDES EU project, 2009) belong in this category. Another approach, aimed at boosting the elderly subjects' confidence for independent living, involves RFID tags and non-invasive systems to detect mobility problems and provide early as well as emergency solutions to hazards at home (projects Confidence, SMILING). Companionable EU project attempts to synergistically combine the strengths of a mobile robotic companion with the advantages of a stationary smart home, improving the elder person's interaction with the supporting technology infrastructure.
FP7 project HERMES (Jianmin Jiang, Arjan Geven & Shaoyan Zhang, 2009) aims at providing an integrated approach to cognitive care, based on assistive technology that reduces age-related decline of cognitive capabilities. HERMES offers cognitive training through games, while also supporting them in indoor as well as outdoor environments, when necessary. Support for elderly people with cognitive impairment, particularly mild dementia and Alzheimer's disease, is provided by COGKNOW (Meiland,F.J.M., Reinersmann,A., Bergvall-Kareborn, B. et. Al,2007) which aims to develop a cognitive prosthetic device which will help elders "navigate through their day". Automated reminders, communication support and anomaly detection software are features incorporated into the system, aimed at fulfilling this promise. NETCARITY (FP7) (Marquis-Faulkes, F., McKenna, S.J., Newell, A.F. & Gregor, P., 2005) is a project researching and testing technologies which will help elderly people to improve their wellbeing, independence, safety and health at home. OASIS (FP7) (Silvio Bonfiglio , Giovanni Pioggia, 2008) is an open architecture for accessible services integration and standardisation which aims revolutionise the interoperability, quality, breadth and usability of services for all daily activities of the elderly. 12 different types of services are integrated. SOFTCARE (AAL joint program) implements a solution for chronic condition monitoring, especially fall detection and behaviour pattern recognition in combination with emergency calling using internet telephony.
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Besides AAL systems, a second assistive approach has been introduced in the field of ICT solutions for the elderly, comprising systems that aim on helping identify, monitor and compensate for psychiatric conditions such as depression and age-related mild cognitive decline. In accordance with mainstream e-Inclusion targets, this approach's objective is to retain elderly people socially active and more self-reliant for a wider period of time. Examples of such projects are Long Lasting Memories (LLM) and Vital Mind (VM), which provide cognitive training based on psychiatric/geriatric medical counsel, a TV-set and advanced ICT. The reasoning for both projects is to enable elderly citizens to exercise actively and autonomously in front of their television set, a device with which they are already familiar.
Technology adoption by the elderly
Elderly are called to adapt themselves to new technology. It is widely accepted that elderly individuals show low adoption to new technologies compared to younger generations, either because they do not have the technological experience or because of their current health status (Kontaxakis, B.P. & G.N. Christodoulidou, 2000; McKenzie, B. & J. Campbell,1987; Cutler, D.M. & E. Meara). Moreover, apart from the complexity of new technology, contributing factors to the low adjustment of the new technologies include difficulties stemming from demographic characteristics such as geographical location, education income or possible disabilities. The list can be further extended by adding the lack of incentives and appropriate training. (Roupa, Z., et al., 2000) reported findings on their research on the field of the use of technology by the elderly. The sample of the research consisted of 300 subjects aged 65-85+ years from Greece. The data collection method consisted of a questionnaire related to the demographic characteristics, the use of technology and the health of the participants. Regarding the use of electrical device by gender, 54.1% of women and 81.3% of men used wireless phone while almost all the respondents reported that they were able to handle the TV. Regarding ATM usage (automatic teller machines), only 4% answered that they "do not ever use" ATMs. More in detail, regarding the use of mobile phones 59.4% of women and 93.3% of men used mobile phone.
According to survey data findings made available by the governmental non-profit Observatory for the Greek Information Society (Observatory for the Greek Information Society, 2012), 4% of elderly people in Greece (2009-2010) use a computer while 5% making use of Internet. The elderly usage of Internet on 2005 was 1%. Additionally, 4% of them visit social networks. On the other hand the reason of the 40% of the elderly that do not use a computer is the lack of skills, while 27.5% are not willing to use one.
MATERIALS AND METHODS
The LLM service was designed according to guidelines for providing senior citizens greater support towards their independent living (Panagiotis D. Bamidis, Evdokimos I. Konstantinidis, Antonis Billis, 2011). The heart of this service is an integrated ICT platform which combines state-of-the-art cognitive exercises with physical activity in the framework of an advanced ambient assisted living environment (Konstantinidis E.I., Billis A., Hlauschek W., Panek P., & Bamidis P.D.,2010). By enforcing the unprecedented approach of simultaneously inducing neural and corporal stimulation in a safe and controlled environment, this platform delivers an effective countermeasure against age-related cognitive decline. Moreover, the service utilizes a number of remotely operated screens, which are embedded in the independent living environment and connected to modern training equipment (Wii remote controller wii balance board, Microsoft kinect, etc) (Billis A.S., Konstantinidis E.I. & Mouzakidis C.,2010). Light exercise is combined with a targeted set of cognitive exercises, while the environment's sensors ensure the safe and enduring application of this training, adjusting, intervening or providing motivation according to each person and situation.
The main service is comprised of three independent components: i) the cognitive training component, ii) the physical training component and iii) the independent living component. These three independent components meet the proposed service by means of a server side system. A service oriented architecture introduces a framework for providing a flexible system for AAL and the healthcare providers and specialists. Additionally, another undertaking of the system is the different user's role management in order to provide the appropriate information to the applicable person, being the elder, the care giver, the relative etc.
The systems installation utilizes state-of-the-art hardware and software technology. The main interface between the LLM system and the users is a touch screen. All system functionalities, including home environment management, cognitive training and physical exercising performance monitoring, are displayed and set from the Local User Interface, which is a touch screen. Remote User Interfaces for communicating with the relatives, care takers or authorities in the case of an emergency.
The main aim of the system is to offer support not only to elderly people but also to their relatives and families. Apart from providing monitoring of day-to-day activities of senior citizens, the service supports their self-esteem and alleviates symptoms relevant to cognitive degeneration. As a result, facilitates their interaction with society and thus alleviates their loneliness and potential depression.
The service is designed to provide its features to elderly people living at home, staying at day care centers or being hospitalized in a simple user-friendly way. Though these three categories significantly differ from one another they can all utilize the proposed platform, by gaining different benefits each time. During the testing trial period, a bi amount of participants utilized the day care centers intervention.
The pilot was conducted in five countries (Austria, France, Greece, Spain, and Cyprus) and the total Participants included in the study were 821.
The LLM project is, at its core, focused upon pilot testing the LLM solution, comprised of an independent living solution, a cognitive training component, and a physical training component (Antonis S. Billis, Evdokimos I. Konstantinidis & Aristea I. Ladas, 2011). The pilot tests that were carried out focused not only to the technical validation of the system, but mainly to the evaluation and measurement of qualitative indicators of the LLM solution, including usability, satisfaction evaluation, social impact, user acceptance both carers and seniors, accessibility and therapeutic outcomes. Furthermore, a part of the LLM pilot purposes included the testing of the deployment process by setting a sound scientific methodology for measuring its impact while conducting the trials and measuring the impact of the LLM intervention to the cognitive and physical abilities of the user using the developed standardized testing material. A set of metrics targeting to end user's feedback and health impact were defined in order to form the evaluation analysis against the achieved usability and the impact on health (physical, cognitive, emotional results). The end user's feedback metrics included usability, acceptance and satisfaction and accessibility while the scientific metrics (health impact) included neuropsychological testing, quality of life related to improvement in cognitive, motor and social function indices and autonomy and improvement of experimental group in standardized cognitive function and cognitive/motor activity in daily living relative to control groups. Finally, one of the main LLM's objectives was to demonstrate the potential impact of the LLM service. LLM used pilots as segmented deployments with the end aim of carrying out the validation of the LLM platform providing ICT services for an Independent Living, addressed to elders, people with cognitive problems or mild dementia and their care providers. The LLM systems formed as an entertainment, as a therapy supplement, gaming as a means of social cohesion, as part of healthy life style, as a hazard protection mechanism, as an alternative way to call for assistance (emergencies), as a healthy life style enrichment, as a means of Mental Health Care provision, as a therapy supplement, as a means of improving the sense of well-being.
On the other hand, the pilot phase of the LLM took into account the stakeholders which are composed of several profiles including hospitals and clinics (geriatrics & psychologists departments), public authorities (day care centres, residences, tutelage flats, national health services), seniors' communities (retirement houses; residential facilities) and private families.
The LLM Service is being developed and tested in this project, including pilot testing directly with end-users. This pilot test included testing of all aspects of the service and product.
Short surveys conducted at the end of each trial iteration in order to examine LLM service acceptance and ease of use by the end users, being both seniors and therapists. Furthermore, at the end of the whole set of trials interviews held with each participant in order to define useful characteristics of LLM service. Characteristics that were investigated include: user acceptance, accessibility, whether seniors believe the LLM service can help them improve their overall health (really important issue for elderly people), entertainment during LLM training and impact in social activities. After collection of the user survey inputs, the surveys were scored, with inputs from each survey entered into a spreadsheet, providing raw data for each of the sections.
The main objectives of the surveys were to ensure that the form factors employed are considered attractive by users, the user experience with the solution is positive, encouraging compliance with a recommended programme for that user, end-user response and accessibility. The usability evaluation asked the individual to respond to questions that reflected on the users' interactions with the LLM technical system. Both positively and negatively oriented questions were asked, and these included if the LLM was difficult to learn how to use, if it was difficult to be used without help, if the instructions given by the computer were clear, understandable and easy to follow, if the LLM was easy to use and finally if the letters on the screen were easy to read. In addition, several other types of questions were included in the section referring to the appearance, user-friendliness and adaptability of the program. Indicative question include if it took the user less than 10 days to learn how to use the LLM system without help, if the design colors and images on screen were visual appealing, if the user would characterize the LLM computer programs as warm and friendly and if the computerized intervention was adapting to the user's abilities. The amount of days needed from the user to learn how to use the LLM without help in conjunction with the easiness of using the physical intervention peripherals reflects the workload required to learn how to use the LLM. Finally, the open-ended questions concerning recommendations on cognitive and physical intervention provided the LLM team with insights and direct feedback on usability and similar issues.
This satisfaction evaluation of the survey asked the individual to respond to questions that reflected on overall levels of satisfaction with and desire to use the LLM system. The survey's questions/statements included: how beneficial do the users' believe the LLM was for them, how often would they use it, if the LLM made them feel confident about using new technologies, if the LLM was amusing, if they preferred to spend their time by doing something else instead of using the LLM and if the LLM met their expectations.
The social integration section of the survey asked the individual to respond to questions that reflected on the impact of LLM on the individual's social connections. The questions that compose this section are if the LLM enables the elderly to enrich their means of communication and if the LLM had improved their social life and/or met new people. Furthermore, several open-ended questions were asked in this section regarding describing the benefits gained by the LLM and the drawbacks (if any) which would discourage someone from using it. At the end of the survey, two open-ended questions were included to elicit benefits and drawbacks from the users on their overall experience with LLM.
Furthermore, the elder participants' survey is complemented by the pilot staff survey which fulfills a more comprehensive approach to the LLM. A survey was conducted for staff members involved in the pilot iteration, focused upon assessing the performance of LLM in the areas of usability and satisfaction.
Apart from questions that were scored using a scale or Yes/No responses, several open-ended questions were asked to elicit qualitative feedback that could aid in advancing the LLM solution during the balance of the pilot. The sample size for the pilot staff survey was small (2 trial staff members in Spain, 5 in Greece-Thessaloniki, 2 in Cyprus). Thus, to increase statistical power, the non-parametric test for differences among independent samples (Kruskal-Wallis test) was used to analyze the data. The usability evaluation section of the survey asked the pilot staff member to respond to questions that reflected on the users' interactions with the LLM technical system. The set of the question/statements include if the LLM was easy to use, if the instructions given by the system were clear and understandable, if the participants could use LLM without help, how much time did they spend to learn the LLM system, if it was more easy for supervising/helping the participants after the first week and if the LLM system's computer programs were warm and friendly.
The satisfaction evaluation section of the survey asked the pilot staff member to respond to questions that reflected on overall levels of satisfaction with and desire to use the LLM system. The survey asked the pilot staff to answer how beneficial did they believe the LLM was for the participants, if the participants seemed to enjoyed their sessions with the LLM, if it was boring for the participants and if they found the LLM helpful in training elderly people physically and mentally.
Finally, in each pilot staff survey several questions were included that could not be scored on a statistical basis, including questions that provided the LLM team with insights and direct feedback on usability and similar issues, as observations of the pilot staff, looking at the broad experience of the users with whom they worked. Several suggestions focused on making the programs more appealing, describing the drawbacks and encountered difficulties.
User Survey Results
The User Survey results are key indicators of the quality assurance of the LLM solution from a user acceptance and usability perspective. During the course of the project, these data enabled us to understand how the user perceived the solution and make usability-related modifications over the course of the various iterations, following a user-centered approach to design LLM final service. The following sections provide an outline of the user survey mainly focusing on user acceptance, satisfaction and social impact. It has to be noted that an Expected Mean value is juxtaposed to the Mean value to demonstrate the deviation of the results from the neutral value. More specifically, Mean value is the actual mean result of all the questions in the survey section, and Expected Mean is the value that would be anticipated if all the answers indicated a rating that was equally positive or negative.
The usability evaluation reveals that on average almost all of the LLM participants rated the LLM as being easy to learn how to use, easy to use without help and the instructions were clear, understandable and easy to read. Additionally, all participant perceived the complete LLM or its components (cognitive or physical) as easy to learn how to use and easy to use without help.
Table 1: S1 - Usability Evaluation Results
Additionally, as can be clearly seen in Figure 1, the vast majority of the participants replied that "yes", the LLM program was user-friendly and that the environment (i.e. pictures, colours) was warm and friendly.
Figure 1. Most participants from both trial sites replied positively in questions regarding the appearance and user-friendliness of the LLM program.
Moreover, Figure 2 depicts that most participants perceived both the physical and the cognitive training programs as being rather easy to learn how to use and well adapting to each user's abilities.
Figure 2. Almost all participants from all the trial sites replied positively in questions regarding the adaptability of the LLM program and the workload required to learn how to use it.
Responses/suggestions to our open questions for specific usability improvements included recommendations for the physical exercise concerning content variability and for the cognitive exercise to be more localized.
Regarding the satisfaction evaluation section the scoring process included normalising the responses to reflect a higher number for positive responses than negative ones (i.e., value of 1 for most negative to value of 5 for most positive). Therefore the results follow:
Table 2: S3 - Satisfaction Evaluation Results
Most of them believed that training with LLM was beneficial for them, most participants would use LLM more than once a week if they had it at home, most felt LLM was amusing and they enjoyed their sessions with it and on average LLM met their expectations. In sum, the majority of participants felt quite satisfied with LLM.
Participants who trained with the Physical exercise of LLM scored significantly higher in this section compared to those who trained with the Cognitive exercise t(38)= 2.626, p= .012 (see Figure 3).
Figure 3. Participants who trained with the Physical exercise of LLM were significantly more satisfied than those who trained with the Cognitive LLM exercise.
The results concerning the social integration results were as follows:
Table 3: S6 - Social Integration Results
In all installations, which mostly were in day care centers, the majority of participants scored higher than the expected mean in this section (see Table 3), believing that training with LLM improved their social life quite a bit. Participants who trained with the Physical exercise of LLM scored significantly higher in this section compared to those who trained with the Cognitive exercise (see Figure 4).
Figure 4. Mean scores on the Social Integration component of LLM were significantly higher for those who trained with the Physical exercise than those who used either the Cognitive or the complete LLM exercise.
As for the qualitative results, several answers that were provided by the elderly people on benefits and drawbacks of the LLM service were summarized to the following: "the physical exercise was demanding for participants with bad health condition", "it was very user friendly", "the physical training component helped me a lot", "took my mind off my problems", "I learned how to use a computer", " reduced my stress", "felt more self-confident", "my legs strengthened from the physical exercise", "my shoulders and arms benefited from the physical exercise", "the fact that I was successful in the cognitive exercises made me happy", memory improvements, improved in mobility, "my mind started "working" again" (it had almost stopped working), "my body shape changed", "some improvements in cognition", "my endurance improved", "I liked the training (both physical and mental)", specific cognitive improvements: "I can hold more information in my mind", many physical benefits (e.g. arms function better, are strengthened), " it was a pleasant activity that benefited my memory", muscle/physical pains were reduced, seniors became skilled in using new technologies, control of arterial tension, distraction from negative thoughts, perceived improvements in memory, attention and concentration, "I would like to continue participating", "offered me wellness", "the training hour was my hour", "made me feel younger", "made me feel stronger", " a new experience", perceived improvements in flexibility, strength, endurance, balance, "can't get better than this", "the program has no drawbacks", "could not wait to come to the training every day!", perceived improvements in memory and concentration, "learnt to use the computer & intend to continue using it!".
Below are reported benefits that participants attributed to the social environment (i.e. day care centre, in a group) that LLM training took place, thus stressing the preference of elderly individuals to use LLM mostly in such environments instead of more isolated ones such as their house. Some of the reported benefits include: "broke the routine" (finally did not stay at home all day), "I liked the company in the sessions", "very satisfied with the trial attendants" ("they were all fantastic"), "my mood improved", "sad to finish the program, all the trial attendants were very patient and loving", "very warm & friendly training program", "made me feel very happy", "excited to get out of the house", "I made new acquaintances", " happy to be in a group", "meet new people and exercise", "PTC only: socializing helped me deal better with the distress I feel for my husband's death".
Pilot Staff survey results
The results of the pilot staff survey seem to be in conjunction with the elder surveys' results.
The usability evaluation revealed that all trial staff members from all trial sites consistently evaluated the usability of LLM as well above the mean. That is, they believed that the LLM system was easy to learn how to use, after the first week of the iteration one trial staff member was enough to supervise the trials and the user environment was visually appealing, warm and friendly. Importantly, all trial staff members had already learnt how to use LLM in the first or second iterations, which probably inflated their usability scores. This suggests that extensive training of a staff member prior to using the LLM indeed results in easier operation of the LLM platform.
Furthermore, all staff members from all trial sites rated LLM above the expected mean concerning the satisfaction evaluation. That is, all staff members believed that participants seemed to enjoy their training with LLM, that it is beneficial for them and that LLM is useful in training elderly people cognitively as well as physically. No statistically significant differences were found among the ratings of staff members, meaning that they all were highly satisfied with LLM.
Concerning the open-ended question, some of the main points raised were the following. Suggestions on improvements included: "Use auditory instead of written instructions for the physical exercises and include positive auditory reinforcement". Moreover, drawbacks specifically identified that would discourage someone from using LLM included that some exercises were repeated, thus boring, using the Wii components (e.g. wearing the Wii remote from arm to leg) is difficult for this population and the program is difficult to use without assistance; staff needed to assist for 2 weeks of the iteration.
It should be noted that during the pilot phase fewer additional suggestions were made for improvement of LLM. It is anticipated that this result is in part based upon the fact that some issues have been addressed within the LLM system as it has been improved iteratively. However, it is also expected that this result partially reflects a survey fatigue on the part of the LLM pilot staff.
Elderly people face a lot of comorbidities that many times lead to loss of independence, social exclusion and institutionalization and finally to their death. Chronic diseases that are most of the times prevalent at the elderly population, e.g. cardiovascular diseases, diabetes, dementia, demand that constant monitoring of their health status takes place. This means that a lot of resources (formal personnel workload, money spent from insurance funds due to hospitalization services and so on) are withholded in order to provide the appropriate care to the chronic elderly patients needing it at any time. However, ICT and especially cutting edge biomedical engineering technologies, such as Ambient Assisted Living solutions may play a key role in order to drastically low the costs derived from the morbidity of senior population and the need for constant healthcare provision.
In this paper a user/patient-centric approach is presented regarding the provision of an integrated ICT service targeting to the geriatric healthcare provision. The proposed service was designed in the perspective of becoming a systemic solution for independent living and active ageing. The integration of the existing components should provide a high-quality innovative service, actively improving the quality of life of the elderly and prolonging the time they can remain independent at home, while respecting ethical and legal boundaries. For this reason, LLM platform was tested thoroughly through a number of pilot rounds in 4 different countries demonstrating its impact across several EU countries and wider acceptance by all involved parties such as elderly users and their informal/formal caregivers.
Survey analysis showed that on average: training with the LLM platform made the participants feel positive (emotions such as joy, fun, calm); LLM training software was easy to learn how to use, the user environment was warm and friendly, the instructions were clear and well adapting to the users' needs; LLM was perceived as beneficial for them and met their expectations; and finally participants felt that in general LLM helped them improve their social life. It has to be stated that also carers' opinions seem to be in line with seniors' attitude towards LLM usability and satisfaction issues.
All the above findings help us conclude that LLM platform is properly formed in a way that suits the special needs of elderly and may shield any technological barriers from end users. Potential impact on seniors' overall health is under investigation, since the analysis of pre- and post-trial clinical exams is under way. Future publication of this research may highlight the major health impact of the LLM intervention strategy against any age-related health problems such as cognitive decline or geriatric depression, thus showing the catalytic proactive and reactive role of LLM in geriatric healthcare.
The work presented in this paper may be partially complemented by another research project that our team is involved in, the USEFIL EU project (USEFILProject Official Web Site). More specifically, in geriatric healthcare it is of utmost importance to timely recognize early signs of pathological status and the transition of a healthy individual to an ill one.
USEFIL system's (Artikis, A., et al.,2012) main target is the development of seniors' daily functioning supporting services and closing the loop between seniors and their caregivers, by incorporating a messaging service to the caregivers regarding the health status of seniors and suggesting personalized actions upon certain types of events detected by the USEFIL system. One possible action may be the LLM intervention. Therefore, LLM is highly correlated with USEFIL technology since intervention is complemented by the in time recognition of the need for treatment. This may have significant extensions, especially regarding mental illness' healthcare provision, since recent findings (Bradford, A., et al., 2009) indicate that mental illness remains undiagnosed most of the times because some physicians lack the necessary experience in diagnosing and treating mental diseases, which may result in increased morbidity. Finally, there is a lot of confusion and lack of public awareness as far as mental health conditions are concerned, which can make it even more difficult for a patient to approach a physician's office to begin with. Delayed diagnosis could probably mean an increase in risk for cognitive decline, loss of independence and finally death.
The role of the caregiver is very crucial for a qualitative provision of healthcare. Technological platforms are a valuable tool in the caregiver's hands. Proper education of caregivers on recent technological advances may further improve the healthcare provision chain. This is what DISCOVER research project (DISCOVER Project Official Web Site) promises to succeed in. Discover promises the creation of new educational services for the elderly caregivers in order to help them develop new digital skills and add value to the whole healthcare system. Existing eLearning platforms will be used in order to store, repurpose, share and semantically describe both experiences and content that has been obtained during LLM project. Main outcomes of the projects include: digital skill improvement, improvement of communication and support of elderly people caregivers through virtual and live social networks. Seniors may as a result benefit as the quality of the healthcare provision and subsequently of their health will gradually ameliorate.
Future plans of combining different sorts of technologies either patient-centric or caregiver-centric make us believe that will significantly strengthen the impact of biomedical technologies on the quality of the offered healthcare to the seniors, by providing a holistic and fully integrated health information system addressing their and their caregivers needs.