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Department of Population Health, Luxembourg Institute of Health, Strassen, LuxembourgUniversity of Luxembourg, Faculty of Science, Technology and Medicine, Esch-sur-Alzette, Luxembourg
Address correspondence to Gloria A. Aguayo, MD, PhD, Deep Digital Phenotyping Research Unit, Department of Population Health, Luxembourg Institute of Health, 1A-B, rue Thomas Edison, L-1445 Strassen, Luxembourg.
Digital health interventions (DHIs) are interesting resources to improve various health conditions. However, their use in the older and frail population is still sparse. We aimed to give an overview of DHI used in the frail older population.
Design
Scoping review with PRISMA guidelines based on Population, Concept, and Context.
Setting and participants
We included original studies in English with DHI (concept) on people described as frail (population) in the clinical or community setting (context) and no limitation on date of publication. We searched 3 online databases (PubMed, Scopus, and Web of Science).
Measures
We described DHI in terms of purpose, delivering, content and assessment. We also described frailty assessment and study design.
Results
We included 105 studies that fulfilled our eligibility criteria. The most frequently reported DHIs were with the purpose of monitoring (45; 43%), with a delivery method of sensor-based technologies (59; 56%), with a content of feedback to users (34; 32%), and for assessment of feasibility (57; 54%). Efficacy was reported in 31 (30%) studies and usability/feasibility in 57 (55%) studies. The most common study design was descriptive exploratory for new methodology or technology (24; 23%). There were 14 (13%) randomized controlled trials, with only 4 of 14 studies (29%) showing a low or moderate risk of bias. Frailty assessment using validated scales was reported in only 47 (45%) studies.
Conclusions and Implications
There was much heterogeneity among frailty assessments, study designs, and evaluations of DHIs. There is now a strong need for more standardized approaches to assess frailty, well-structured randomized controlled trials, and proper evaluation and report. This work will contribute to the development of better DHIs in this vulnerable population.
Research agenda for frailty in older adults: toward a better understanding of physiology and etiology: summary from the American Geriatrics Society/National Institute on Aging Research Conference on Frailty in Older Adults.
The prevalence of frailty in the population varies considerably depending on how frailty is measured. In an analysis of the English Longitudinal Study on Aging using 35 frailty scores, the mean prevalence of frailty was 29% in women (range: 1%-72%) and 23% in men (1%-65%).
Therefore, frailty must be detected and treated. To detect frailty, there are many validated frailty scores, based on different concepts. Two main underlying concepts are the frailty phenotype, a physiological model focused on physical frailty using 5 variables,
and the deficit accumulation model, calculating a frailty index comprising at least 30 variables from different domains such as comorbidity, disability, cognition, mood, and social.
Between 2015 and 2050, the number of people aged 60 or older will increase from 900 million to 2 billion, representing up to 22% of the global population.
Many digital health interventions (DHIs) are specifically designed to detect, monitor, and provide care and support for PLFs. There is a wide range of DHIs, such as Internet based or mediated with software and applications.
World Health Organization Classification of digital health interventions v1. 0: a shared language to describe the uses of digital technology for health.
Digital technologies have opened doors to previously inaccessible areas in health care. For instance, “My Day for Seniors” on Alexa, which acts as a vocal assistant, has been used as a virtual screening tool for possible COVID-19 symptoms, because it was designed as daily questionnaires for the older population, although not specifically for PLF.
conducted a systematic review of DHI in the older population and found 45 studies using smartphone applications, websites, connected devices, video consultations, and webinars. They found that one of the biggest barriers to DHI was insufficient support for older people.
Despite the fact that specific digital technologies have been used in the frail population, there are no scoping reviews focused on the frail population, who is more likely to be excluded from the digital world than the older general population.
The main objective of this study was to provide a broad overview of DHIs used for PLF, to identify gaps in the literature and to describe the robustness of the digital approaches. Our objective being broad, we chose to carry out a scoping review rather than a systematic review.
Eligibility Criteria, Information Sources, Search and Selection of Sources of Evidence
We included original studies in English with no limitations on the date of publication. We focused our inclusion criteria on population, concept, and context.
Population was identified as any study that specifies frail population or mentions the related terms for frail, frailty, or frailty syndrome. Concept was any DHI specifically for frail persons and with a participant interaction with or without comparison group. Context included all clinical and community-dwelling settings. We excluded publications without reported results, protocols, editorials, comments, perspectives, reviews, and correspondence (Supplementary Table 1). We searched 3 electronic databases (PubMed, Scopus, and Web of Science) (Supplementary Table 2). We accessed all databases on April 19, 2020.
After database search, search results were imported into an open source online tool (CADIMA).
Then, 2 coauthors (N.L. and G.A.) performed screening by titles and abstracts independently. Full-text screening and selection of included articles was performed in parallel and blinded by 2 coauthors (N.L. and C.G.). Disagreements were discussed and solved with a third coauthor (G.A.).
Data Extraction Process
Data extraction format was created in Microsoft Excel adapting to the template used by Joanna Briggs Institute.
The data extraction form was tested on a small sample of studies and modified based on the feedback of the team. Two authors (N.L. and C.G.) categorized key components of DHI and extracted data independently. The results of data extraction were compared, and if there was any discrepancy, they were discussed and resolved with a third coauthor (G.A.).
Definitions Used for Data Extraction
We extracted data on purpose, mode of delivery, content, and assessment of DHI. The categorizations were not mutually exclusive. Therefore, it is possible that a study reported more than 1 category, for example, more than 1 purpose within a group of DHI delivery.
The purpose of DHI was categorized into frailty detection, monitoring, enhancing health status, communication, care and support, rehabilitation, prevention of falls, and assessing health status.
We also extracted the way of delivering DHI into sensor-based technologies, videoconferencing methods, game-based technologies, mobile applications, web interventions, and other technologies, such as robots and pillbox.
The content of DHI was categorized into goal setting, feedback, rewards, educational information, and self-reporting.
The assessment of DHI was categorized into efficacy, accuracy, usability and feasibility, and user experiences. Full definitions of purposes, content, and assessment are shown in Supplementary Table 3.
We also extracted the following items: first author, year of publication, country, main objectives, and study design. The study design was categorized with the following criteria. Randomized controlled trials (RCTs) were experimental studies (the DHI was decided by the researcher) with randomization. Quasi-experimental studies were defined as experimental studies in which treatment allocation was not randomized. Descriptive exploratory studies were defined as an experimental study where a novel numerical intervention was applied to a small number of participants to test the technical aspects. Validation studies were defined as experimental studies that tested a new application in a small number of participants for acceptability and utility, if they used qualitative research tools such as focus groups, they were defined as qualitative studies. Cross-sectional analysis was defined as an observational study (the DHI was not decided by the researcher but by the participant) where the exposure and the outcome were assessed at the same time. A longitudinal study was defined as an observational study where the exposure and the outcome were analyzed in 2 or more time points.
The population was described with the size of the study sample, the age and sex of the participants, the frailty assessment tools, and frailty status. The concept was described with the purpose of DHI, the method of delivery, the content, and the assessment of DHI. The context was categorized into a clinical or community environment.
Critical Appraisal of Individual Sources of Evidence and Reporting Efficacy
The sources of evidence were described in a general context (quantitative and qualitative studies) and in a more specific assessment for RCT, longitudinal, and cross-sectional observational studies. The Cochrane Risk of Bias Tool for Randomized Trials (RoB 2),
were used for assessing RCT, longitudinal observational, and cross-sectional studies, respectively. Two researchers performed the critical appraisal (N.L. and G.A.).
We further analyzed results in terms of efficacy, accuracy, or feasibility in RCTs and cross-sectional or longitudinal studies that reported frailty assessment with a validated score.
Results
Search Results
We found 2392 articles from 3 databases (PubMed (n=302), Scopus (n=1661), and Web of Science (n=429). We removed 578 duplicates and 1336 articles after title and abstract screening. Among the remaining 478 articles eligible for full text screening, we excluded 373 articles. Most common reasons were that they were not about DHI (n=102), they did not have results on the interventions (n=91), and they did not specify or mention frailty in the participants (n=79). Finally, we included 105 articles for this scoping review (Supplementary Figure 1 and Supplementary Table 4).
Characteristics of Included Studies
The total number of participants was 13,104, with the age of participants ranging from 29 to 93 years. We included articles published in peer-reviewed journals (n=89) as well as those presented in international conferences (n=16).
Context was described as follows: 28 (27%) studies were based in clinical settings, 68 (65%) were in community settings, 2 (2%) in both contexts, and 7 (7%) did not report context. Among participants in community settings, 37 (35%) lived in their homes without help, 7 (7%) were community dwelling needing help, 7 (7%) lived in retirement homes, 13 (12%) lived in nursery homes, and 4 (4%) reported community dwelling without other information. Forty-eight studies (46%) were performed in participants needing long-term care services, 18 (17%) were based on participants with cognitive impairment, 6 (6%) were based on participants with disability, and 37 (35%) were based on participants with other chronic conditions (Supplementary Table 4).
In the 1990s, DHI began to appear along with computerized scale systems. Then, other DHI appeared such as robots and games. In the 2000s and beyond, real-time teleconferencing and multimedia programs appeared, followed by sensors. In the 2010s and beyond, the most important tool that emerged was the use of smartphones and, more recently, vocal biomarkers (Figure 1).
Fig. 1Digital health interventions for people living with frailty over the years (based on the year of publication).
Geographical Distribution and Years of Publication
There were overall 22 countries, which contributed to at least 1 individual study. The United States of America was the most represented country (24; 23%). By continent, Europe leads the geographical distribution (56; 53%), followed by America (30; 29%), Asia (10; 10%), and Oceania (2; 2%) (Supplementary Figure 2). Studies were published between 1996 and 2020. The numbers of records per year were below 5 in earlier years. From 2012, the number started to climb above 5 and reached the peak in 2017 (Supplementary Figure 3).
Frailty Assessment
Frailty assessment was reported in 47 (45%) and 17 (16%) with and without using a validated tool respectively (Table 1). The most frequent tool was the Phenotype of Frailty score (23; 22%). Among the 64 studies that reported frailty assessment, 27 (42%) described the population as mixed (frail, prefrail, and nonfrail), 24 (38%) as frail, 3 (5%) as prefrail, and in 10 (17%) it was unclear.
Table 1Validated Frailty Assessment Tools Used in the 105 Included Studies
A short physical performance battery assessing lower extremity function: Association with self-reported disability and prediction of mortality and nursing home admission.
Purposes of DHI included monitoring (45; 43%), communication (41; 39%), care and support (40; 38%), assessing health status (37; 35%), frailty detection (30; 29%), enhancing health status (29; 28%), prevention of falls (11; 11%), and rehabilitation (7; 7%).
Delivering of DHI was reported as sensor-based technologies (59; 56%), other technologies, such as robots and electronic pillbox (43; 41%), videoconferencing technology (18; 17%), mobile applications (15; 14%), web-based technology (15; 14%), and game-based technology (6; 6%). The major purpose of the studies (where description was not mutually exclusive) in sensor-based technology studies was for frailty monitoring (32 studies). Videoconferencing technology was mostly used for communication purposes (16 studies). Among the studies using game-based technology, 4 were aimed at enhancing the health status. Of the studies that featured mobile applications, the most common purposes were frailty detection (7 studies) and monitoring (7 studies). Among those on web-based technology, the stated purpose in 13 studies was communication. Other technologies such as robots and pillboxes were used mainly for monitoring (22 studies) and care and support (22 studies). Figure 2 shows the number of studies for each group as we defined above, covering the modes of delivery and the purpose of DHI.
Fig. 2Distribution of digital health intervention types by purpose of use for people living with frailty. The categories were not mutually exclusive because it is possible that a study reported more than 1 mode of digital technology, or had more than 1 purpose for the digital intervention used, or both. The purposes of frailty detection, enhancing health status, and assessing health status were observed in all forms of digital technologies. The most common delivery of frailty intervention was through sensor-based technologies.
Content of DHI was found in 64 (61%) studies. Content was reported as feedback to users in 34 (32%) studies, educational information in 15 (14%) studies, self-reporting in 8 studies (8%), rewarding experiences in 4 studies (4%), and goal-setting for users in 3 studies (3%).
Assessment of DHI was reported as efficacy in 31 studies (30%), accuracy in 23 studies (22%), usability and feasibility studies in 57 studies (54%), user experiences, such as qualitative interviews and satisfaction surveys, in 24 studies (23%) and cost analysis in 7 studies (7%). Figure 3 summarizes findings on purpose, mode of delivery, and content of DHI.
Fig. 3Purpose, mode of delivery, and content of digital health interventions. Diagram presenting the main data items with the number of studies reported for each. There are 8 purposes for DHI, 6 modes of delivery of DHI, and 5 types of content used in DHI. The categories were not mutually exclusive because it is possible that a study reported more than 1 purpose or mode of delivery or content of DHI used.
We found that 24 (23%) were descriptive exploratory studies (new methodology or technology), 20 (19%) were validation studies, 16 (15%) were cross-sectional, 14 (13%) were RCT, 10 (10%) were quasi-experimental, 8 (8%) were qualitative research, 4 (4%) were observational longitudinal studies, and 9 (9%) were another type of study (Supplementary Table 4). The RCTs showed a wide range of low risk of bias (0%-100%). Only 4 of 14 studies (29%) showed a low or moderate risk of bias (Supplementary Figure 4). The quality of the cross-sectional studies ranged from 10% to 70%, with 9 of 16 studies (56%) scoring 5 of 10 stars or more (Supplementary Table 5). The quality of the longitudinal studies ranged from 22% to 89%, with 2 of 4 studies (50%) scoring 5 of 9 stars or more (Supplementary Table 6).
Efficacy, Accuracy, and Feasibility
RCT studies that showed good efficacy were an exercise program based on a game system,
Preventing and managing indoor falls with home-based technologies in mild and moderate Alzheimer's disease patients: Pilot study in a community dwelling.
Efficacy of simple home-based technologies combined with a monitoring assistive center in decreasing falls in a frail elderly population (results of the Esoppe study).
23 prefrail individuals with certain degree of disability and mean age = 77 y (SD 5.3), 61% women
PHF
High
Two intervention groups: (a) Wii-fit exercise (exercise gaming system) at home and (b) seated exercise (with trainers)
Usual physical activity
Physical functioning tests
Better results for intervention group. Wii-fit exercises were similar to seated exercise and both were superior to the control group for maintaining or improving physical functioning.
Six-minute walk distance increased ES 0.6 (seated); ES 0.4 (Wii) and decreased in control group.
Preventing and managing indoor falls with home-based technologies in mild and moderate Alzheimer's disease patients: Pilot study in a community dwelling.
96 frail individuals with mean age 86.6 ± 6.5 y, 77% women, living with Alzheimer's disease
PHF
High
Nightlight path and tele-assistance service
A fall reduction program
Falls
Better results for the intervention group. The use of a light path significatively reduced the incidence of falls in older participants with Alzheimer's
OR 0.37 (0.15-0.88) of incident falls in intervention group
27 frail individuals (mean age 81.3 y, SD 6.9), 67% women
FI
High
Visual computer feedback training
Traditional balance training
Physical functioning tests
Most of results did not show differences between groups. Control group was superior in balance measures. Visual computer feedback training showed high efficacy in training-specific performance (not tested in the control group).
Timed and up go ES = 0.0154; 80% increase in balance in control, 400% increase in a training-specific task performance in intervention
A randomized controlled trial of telemonitoring in older adults with multiple health issues to prevent hospitalizations and emergency department visits.
36 prefrail individuals with mean age 70.9 y (SD 3.5) and 69.2 y (SD 3.8) (control and intervention group), 61% women
GFI
Low
Home exercise program using computer/tablet, 3 times a week during 12 wk
Usual care
Use of the intervention, adherence/user experience, and quality of life
Intervention showed excellent adherence and intervention group showed better mental quality of life.
Acceptability: average score SUS 84.2 (±13.3). Adherence: 68%. Quality of life (mental) better in intervention group, other quality of life domains, no difference.
Quality assessment performed with an adapted version for cross-sectional studies of the Newcastle-Ottawa Scale (a score of ≥6 was considered to be a high-quality study).
20 individuals, 50% women with mean age 83.6, SD 4.0; frailty was assessed but not reported
FI
3
Centralized mobile system using mobile phone capabilities and integrating other frailty indicators
Frailty assessment
Relative good ability to predict frailty from mobile device data. The system architecture was able to provide frailty diagnosis (most representative similarity degrees: 73.4% and 71.6% considering 61 frailty factors).
14 frail (mean age 83.7 y, SD 6.4) and 16 nonfrail (mean age 70.3 y, SD 3.3) individuals
PHF
6
A gyroscope, a magnetometer, and an accelerometer in the iPhone 4
Mobility assessment
Able to detect differences in turning transitions (acceleration and gyroscope-based) between frail and nonfrail individuals during the timed up and go test (P values < .05)
An Internet of Things infrastructure for gait characterization in assisted living environments and its application in the discovery of associations between frailty and cognition.
Int J Distrib Sens Netw.2019; 15 (1550147719883544)
124 frail and prefrail individuals with mean age 75.9 y, SD 6.6
PHF
7
Inertial and pressure sensors and balance assessments using a touchscreen mobile device
Falls
Very good accuracy when combining methods (timed up and go, 5 times sit to stand and quiet standing balance) 93.94% (95% CI: 91.16%-96.51%) for the male model and 84.14% (95% CI: 82.11%-86.33%) for the female model
32 inpatients with different frailty status (frail, prefrail and nonfrail), mean age 78.1 y, SD 7.8
FI
6
3 motion sensors (an ankle-worn accelerometer, a thigh-worn accelerometer, and a pedometer)
Walking speed and characteristics
The ankle-worn accelerometer overestimated steps (median error 1%, IQR 3%-13%) and was more accurate than a thigh-worn triaxial accelerometer and a pedometer. The other motion sensors underestimated steps (median error 40%, IQR 51%-35%; and 38%, IQR 93%-27%, respectively).
25 frail and nonfrail individuals with mean age 71 y, SD 6; 56% were frail
TFI
7
Remote monitoring device
Mobility
Good general performance to measure mobility levels. Cluster analysis showed that mobility index measured with the device was associated not only with physical frailty but also with social frailty
10 individuals, including 1 prefrail and 9 nonfrail, with mean age 68.7 y, SD 5.5
GFI
2
Hip-worn accelerometer, smartphone application
30 d
Experience of pleasure while doing physical activity
Able to detect physical activity and location. Outdoor activities were associated with higher physical activity than indoor activities (P < .001). Performing leisure activities, being outdoors, and not alone significantly predicted pleasure in daily life (all P's < .05).
39,000 individuals with mean age 80 y; 53% with cognitive impairment, and 75% had disability and a mean FI = 0.44.
FI
3
Telemedicine: web-based clinical decision support system
24 mo
Feasibility of telemedicine calculated as rate of initial consultation
Feasible intervention. The estimated overall rate of initial consultation was 1.83 cases per occupied bed per year and 2.66 review cases per occupied bed per year.
Efficacy of simple home-based technologies combined with a monitoring assistive center in decreasing falls in a frail elderly population (results of the Esoppe study).
194 individuals with mean age 84.9 y, SD 6.5; frail and prefrail
PHF
8
Light path coupled with tele-assistance
12 mo
Falls
Reduction in falls at home, OR 0.33, 95% CI 0.17-0.65, P value = .001
AUC, area under the curve; ES, effect size; FI, Frailty Index; GFI, Groningen Frailty Indicator; OR, odds ratio; PHF, Phenotype of Frailty; SD, standard deviation; SUS, System Usability Scale; TFI, Tilburg Frailty Indicator.
∗ Risk of bias evaluated with ROB 2 Revised Cochrane risk-of-bias tool for randomized trials.
† Quality assessment performed with an adapted version for cross-sectional studies of the Newcastle-Ottawa Scale (a score of ≥6 was considered to be a high-quality study).
‡ Quality assessment performed with the Newcastle-Ottawa Scale for longitudinal studies (a score of ≥6 was considered to be a high-quality study).
In this scoping review, we were able to map DHI in PLF. We found that DHIs have been used for many purposes and delivery means, with relatively few studies evaluating usability and feasibility. We found that despite the studies claimed to be for PLF, some studies did not report frailty assessment.
The role of DHI has been studied in the frail population with specific health conditions or issues such as palliative care in oncology,
performed a qualitative review on telecare at home for community-dwelling older people. These studies focused either on particular interventions or on the frail population with specific underlying conditions.
We found 2 scoping reviews about mobile health applications.
Neither of these reviews focused on frailty but they rather included older people in general. We found 1 scoping review, with a primary interest on frailty, that focused on the functionality and mobility of prefrail and frail older people.
Based on these literature findings, this scoping review is fulfilling the gaps to present a wider and, therefore, more comprehensive range of DHI for the frail population in general.
Frailty prevalence measured with the Phenotype of Frailty score was reported to be 15%, 10%, and 7.4% in the USA,
respectively. We found that research work in digital health technologies for PLF were mostly concentrated in regions with a high frailty prevalence. Moreover, we found that the availability of DHI seemed to be limited to industrialized countries and regions. The pooled prevalence of frailty in community-dwelling older adults among upper middle-income countries was reported to be 13%. However, there was information of frailty status in only 1 study from a low-income country. Therefore, this review reveals the need for research in low-income countries that also have PLF often with digital literacy issues, who may be perhaps even more likely to be reluctant to use DHI.
Prevalence of frailty and prefrailty among community-dwelling older adults in low-income and middle-income countries: A systematic review and meta-analysis.
From 2012 onwards, we observed a rising trend in the number of publications. Moreover, 78% (n=82) of the studies were published after 2012. Because digital health has become a popular area of research over the decade, as recognized by the World Health Organization,
we believe that it is also important to describe the current and future contribution of DHI for vulnerable populations.
Researchers in the United Kingdom found that public digital websites for health and social care used limited visual representations for older people, which means they were not considered main users of those websites and therefore they were excluded.
An explanation for this exclusion can be the assumption that at an advanced age, the ability to use technology on computers, tablets, and smartphones may be reduced.
Understanding factors affecting patient and public engagement and recruitment to digital health interventions: A systematic review of qualitative studies.
reviewed qualitative research studies on patient engagement in DHI and identified 4 main determinants of success: motivation, personal values, recruitment approach, and quality of the DHI. When the goal of engagement is well defined with flexible methods for participants, involvement of the PLF in research is not only possible but also above all necessary to match what is important to end users.
Research priorities chosen by PLF focused on the prevention and management of frailty, the prevention of hospitalizations, and the adaptation of health care and housing systems to improve quality of life.
We hope that future research in digital health will not only include frail populations as the target of DHI, but will also involve them in the design and validation of digital tools intended for them.
We found out that 39% of studies did not specify frailty assessment or define frailty among their participants even though they used “frail” and its related terms throughout their studies. This may reflect the lack of knowledge about what frailty is to researchers. Additionally, in some studies, the concept of frailty was used in the context of other clinical conditions such as cancer or dementia. This is consistent with the findings from previous review papers
where the term frailty was loosely based on different concepts and tools, or simply assigned to old participants without mentioning a frailty assessment. We found great heterogeneity in reporting and choosing a frailty score and in the nature of the frailty assessment. This makes it difficult to screen and collect evidence about whether study participants were frail or not.
In this review, we found that DHIs were mostly used for monitoring and for providing care and support. PLF frequently have several comorbidities,
Frailty and pre-frailty in middle-aged and older adults and its association with multimorbidity and mortality: A prospective analysis of 493 737 UK Biobank participants.
Among several DHIs, sensors were featured most frequently for diagnosis and for monitoring and assessing health status in frail persons. Another type of DHI was video conferencing, which was mainly used for communication purposes as well as for other purposes such as providing care and support, and enhancing health status, for example, home-based tele-yoga to improve patients with chronic diseases. We did not find any review related to video-conferencing technologies. Because it is more widely used nowadays, we highlighted that its efficiency or cost-effectiveness can be further reviewed in future research.
The World Health Organization recommends that DHI should be carefully evaluated.
We found high variability of study designs and quality. Many were described as experimental or pilot studies. We found very few RCTs assessing efficacy or usability and even fewer with low risk of bias. In addition, there were very few studies on the cost-effectiveness of DHI. These results suggest that there is room for improvement in the search for DHI for PLF.
Overall, we reported that DHI used in PLF were rather complex and diverse in terms of technologies used, project designs, testing procedures, and outcomes measures. In a review on parameters and measurements in screening, monitoring, and prevention of frailty, Dasenbrock et al argued that a consistent use of frailty scores was required.
We strongly support this argument in this review. World Health Organization have already provided recommendations and guidance on DHI on health system strengthening and for researchers
We think that this study has many strengths. This scoping review strictly followed the PRISMA-ScR guideline (Supplementary Table 7). We included 3 databases, in order to cover a wide scope and provide as comprehensive a review as possible to date. One limitation is that we may not have identified all relevant articles in the published literature, because of heterogeneity in the concepts and definition of frailty as well as complexity of DHI. Another limitation is that we only included studies in English. This was based mainly on a recent publication, which found that excluding non–English language studies from systematic reviews did not have a significant effect on findings and conclusions.
We have compiled a wide variety of information that can be used for future research on DHI for PLF. In addition, this review provides a deeper and better understanding of this area. In the age of digital technologies, it is undeniable that PLF should benefit from DHI. We believe it is essential to gather stronger evidence that new technologies are delivering the desired results and to balance those benefits with the risks and costs. In addition, user satisfaction should be further explored by involving end users (ie, PLF) in the design of the tools. We believe there is a need for well-designed and methodologically sound clinical trials that collect more evidence among PLF.
Acknowledgment
We thank our colleagues from the Luxembourg Institute of Health for their support in conducting this scoping review.
Supplementary Fig. 4Quality assessment of randomized controlled trials with intention to treat design evaluating efficacy of digital interventions in PLF (ROB 2 Revised Cochrane risk-of-bias tool for randomized trials).
Supplementary Table 1Summary of Criteria Based on Population, Concept and Context
Eligibility Criteria
Exclusion Criteria
Population
Studies with participants identified as frail or prefrail or studies aimed at frail populations
Studies with participants identifying sarcopenia only and not frailty.
Concept
Digital health intervention:
-
used by frail person, at risk of frailty
-
for any purpose related to frailty
Digital health interventions that do not involve direct interaction with patients, such as database management. Digital imagining interventions that are primarily used for diagnosis of other diseases such as X rays, computerized tomography, magnetic resonance imaging, echocardiograms, etc. Nondigital intervention for frailty (telephone-based), biomarkers, and serological testing
Context
Community or clinical setting, inclusive of any publication date, geographic region, gender, age and study design
Supplementary Table 2PubMed Search Strategy Accessed to all Databases
Final Query in PubMed (Last Accessed on April 19, 2020)
Items Found
((Frailty[MH]) OR (Frail[TW] OR Frailties[TW] OR Frailness[TW]) OR ("Frailty Syndrome"[TW]) OR (Debility[TW] OR Debilities[TW])) AND ((telemedicine[MH] OR telecommunications[MH]) OR ("digital health"[TW] OR "mobile app"[TW] OR "mobile apps"[TW] OR "mobile application"[TW] OR "mobile applications"[TW] OR ehealth[TW] OR "e-health"[TW] OR "m-health"[TW] OR mhealth[TW] OR "mobile health"[TW]) OR (Computers, Handheld[MH]) OR (Reminder Systems[MH]) OR (smartphone[TW] OR smartphones[TW] OR internet[TW] OR "web-based"[TW] OR "electronic monitoring"[TW] OR "reminder device"[TW] OR "reminder devices"[TW] OR "reminder system"[TW] OR "reminder systems"[TW]) OR "helping hand"[TW]) OR (internet[TW] OR "mobile phone"[TW] OR "mobile phones"[TW] OR "cd-rom software"[TW] OR "cd-rom softwares"[TW] OR "internet website"[TW] OR "internet websites"[TW] OR "computer based clinical protocol"[TW] OR "computer based clinical protocols"[TW] OR "e-mail contact"[TW] OR "e-mail contacts"[TW] OR "sms based system"[TW] OR "mms based system"[TW] OR "sms based systems"[TW] OR "mms based systems"[TW] OR "telemedicine platform"[TW] OR "telemedicine platforms"[TW] OR "new technologies"[TW] OR "advanced telehealth approaches"[TW] OR "eHealth intervention"[TW] OR "eHealth interventions"[TW] OR "text message"[TW] OR "text messages"[TW] OR "monitoring device"[TW] OR "monitoring devices"[TW] OR "mobile application"[TW] OR "mobile applications"[TW] OR "computer program"[TW] OR "computer programs"[TW] OR "computer program"[TW] OR "computer programmes"[TW] OR "digital assistant"[TW] OR "digital assistants"[TW]) OR ("health website"[TW] OR "health websites"[TW]))
Evaluate the acceptability of care solutions for the older population living in retirement homes, consisting of e-health and m-health services
QR
Italy
YOD
No
—
10 frail individuals with mean age 80.4
A mobile application for nutrition, a portable electroencephalogram headset, a Nintendo Wii Balance Board, a chest strap for cardiorespiratory monitoring, and, an indoor localization system.
Confronting the transition: Improving quality of life for the elderly with an interactive multisensory environment—a case study. International Conference on Universal Access in Human-Computer Interaction.
Trace the cognitive attributes in old population by comparing results from writing tests on tablets
DES
Japan
YOD
No
—
6 frail individuals with age range 77-92 y
Six kinds of spiral tracing tasks (using an active type of stylus pen with a fine nib, the tablet device with a 7-inch touch panel and a 213-dpi resolution)
Efficacy of simple home-based technologies combined with a monitoring assistive center in decreasing falls in a frail elderly population (results of the Esoppe study).
Preventing and managing indoor falls with home-based technologies in mild and moderate Alzheimer's disease patients: Pilot study in a community dwelling.
Instrumented trail-making task to differentiate persons with no cognitive impairment, amnestic mild cognitive impairment, and Alzheimer disease: A proof of concept study.
Analyze the practical use of sensor-based instrumental trial-making task among older population with 3 different cognitive conditions to inspect functional decline
DES
USA
Yes
Yes
PHF
10 individuals with mild cognitive impairment (mean age 85.2, 80% prefrail or frail), 9 individuals with Alzheimer's disease (mean age 80.8 y, 90% prefrail or frail) and 11 healthy individuals (mean age 80.5 y, 55% prefrail or frail)
Instrumented trail-making task platform, using wearable sensor and human-machine interface technology
Perform a randomized controlled trial to assess how home telemonitoring contributes to slowing down the adverse outcomes of frailty process in older community
RCT
USA
Yes
Yes
PHF
194 individuals (mean age 80.4 y, SD 8.3) with different frailty status and chronic conditions, 54.1% women
Observe the smartphone-based measurements of physical activities and compare with standard survey-based tools and clinical performance measures for frailty
VAL
USA
Yes
Yes
PHF
22 robust (age range 50-90 y) and 18 frail (age range 61-100 y) individuals
An intrinsic 3-dimensional (3D) accelerometer, a tablet computer (iPad), Nokia N79 mobile phones
Effects of an interactive computer game exercise regimen on balance impairment in frail community-dwelling older adults: A randomized controlled trial.
Compare the differences in disability and motor function between a group of older men who receive a telehealth intervention and a group of older men without intervention
CC
USA
No
No
—
111 frail individuals with mean age 72.7 y, SD 9.3
Telemonitor from American Telecare with 2-way audio-video connectivity, a videophone with 2-way audio-video connectivity without biometric monitoring
Clinical
Yes
Hypertension, diabetes, respiratory, and heart disease
Impact on clinical events and healthcare costs of adding telemedicine to multidisciplinary disease management programmes for heart failure: Results of a randomized controlled trial.
Long-term care: how to improve the quality of life with mobile and e-health services. Paper presented at: 2018 14th International Conference on Wireless and Mobile Computing.
Networking and Communications (WiMob).2018; : 12-19
Enhance the well-being of older frail population through mobile phone, wearable sensors, and tablets to provide customized monitoring and rehabilitation care
QR
Italy
YOD
No
—
10 frail individuals (mean age 80.4 y) with unclear frailty status
A mobile application for nutrition, a portable electroencephalogram headset, a Nintendo Wii Balance Board, a chest strap for cardiorespiratory monitoring, a smartphone/tablet collecting sensor data, and an indoor localization system
Examine the results of home-based tele-yoga program via videoconferencing for patients with chronic lung and heart conditions
QE
USA
No
No
—
7 individuals (mean age 73 y, SD 14.3) with unclear frailty status
Multipoint videoconferencing via DocBox technology (a hard drive box connected to the participant's television and remotely controlled by a technician)
Community (home)
Yes
Chronic obstructive pulmonary disease and heart failure
Investigate the effects of a community medical and educational program, including telehealth, in reducing or preventing the frailty of older people in the community
CRS
USA
No
No
—
107 frail individuals older than 65 y of age
A tele-health unit that is the size of a breadbox and allows regular physical assessments in the convenience of one's home by providing 2-way audio and visual interface
VALUE: virtual assisted living umbrella for the elderly-user patterns. Paper presented at: 2006 International Conference of the IEEE Engineering in Medicine and Biology Society.
Assess the acceptability of a home telecare program among frail individuals
QR
USA
No
No
—
25 frail individuals with mean age 80.3 y, SD 6.6
PC platform with a broadband connection, videoconferencing software, and a web camera, videoconferencing unit, blood pressure cuffs, pulse oximeters, spirometers, glucometers, and scales
Assess a home telecare service in frail older participants compared with usual care
RCT
USA
YOD
No
—
40 frail individuals with average age of those completing the study, 79 y (range 60-99 y)
Web portal that facilitated subjects' access to health education resources, a telehealth nurse, and electronic ordering of various health and community services
Community (home)
Yes
One or more chronic conditions, had functional limitations
Assess the feasibility of an integrated health care system using sensors in frail older people at home
DES
UK
Yes
Yes
EFS
36 frail individuals with mean age 82 y, SD 10
A home gateway, a remote server to store patient data, and a clinician portal to view and manage patient data and records. Gateway and sensors: pulse oximeter, motion sensor, bed sensor, glucose meter, weight scale, medication dispenser, blood pressure meter
Introduce an easy-to-use bedside instrument to inspect swallowing in the older population in the hospitals
VAL
France
No
No
—
14 individuals (age range 75-100 y) with unclear frailty status
Computer-assisted respiratory inductance plethysmography (RIP) system (which includes sensor in elasticized jacket that could easily be worn by the patients over their usual clothing)
Compare the accuracy of a mobility index measured with a remote monitoring device with the gold standard measure (traditional physical functioning measures)
CRS
Italy
Yes
Yes
TFI
25 frail and nonfrail individuals with mean age 71 y, SD 6; 56% were frail
ADAMO system (includes a base station, and a care watch with sensors, ie, triaxial accelerometer)
Demonstrate the wearable technology by using sensors for monitoring mobility and estimating risk of falls in the older community, especially with diabetes
VAL
USA
YOD
No
—
8 individuals (mean age 77 y, SD 7) with unclear frailty status
A physical activity monitoring system that includes a lightweight, small sensor unit and an embedded battery, which allows recording of data on a memory unit
Assess the feasibility, usability, and acceptability of a tablet for evaluating frailty
QE
USA
Yes
Yes
FI
165 frail and nonfrail individuals with mean age 72 y, SD 6.5
A platform (collects both ePRO and clinical data, which are processed by a rules engine that enables display of results back to clinicians in a dynamic summary)
My smart age with HIV: An innovative mobile and IoMT framework for patient's empowerment. Paper presented at: 2017 IEEE 3rd International Forum on Research and Technologies for Society and Industry (RTSI).
Assess the effects of a telecare service on frail population compared with frail individuals who did not use the service
QE
Israel
YOD
No
—
389 frail individuals with mean age 79.6 y, SD 7.4
Unified Communication System (to conduct audio and video calls with patients), tele-medical sensors, such as tablets and transmitting glucometers, electronic pill organizers
Accuracy of Teledentistry for diagnosing dental pathology using direct examination as a gold standard: Results of the Tel-e-dent study of older adults living in nursing homes.
A combination of indoor localization and wearable sensor–based physical activity recognition to assess older patients undergoing subacute rehabilitation: Baseline study results.
Analyze the frailty assessment of frail older patients by using tablet-based manual dexterity test
QE
Poland
Yes
Yes
PHF
14 frail individuals with mean age 83 y, SD 7, range 62-93
Physical obstacle, superimposed over a tablet screen and a software application, displaying 2 fields on the tablet screen and acquiring the measurements
A randomized controlled trial of telemonitoring in older adults with multiple health issues to prevent hospitalizations and emergency department visits.
Analyze the effect on hospitalizations of a telemonitoring intervention in frail elderly people compared to usual care
RCT
USA
Yes
Yes
FI
102 frail individuals with mean age 80.3 y, SD 8.9
Intel Health Guide, a device that had real-time videoconference capability. Peripheral devices (scales, blood pressure cuff, glucometer, pulse oximeter, and peak flow). A health website.
Community and clinical
Yes
Multiple comorbidities (respiratory, diabetes, heart failure and renal)
Randomized controlled study on usability and benefits of the smart home technology for older population with chronic illnesses
RCT
USA
No
No
—
34 individuals (mean age 72 y, SD 6), with unclear frailty status
Stand-alone products, including door and window sensors, a motion sensor, a power flash, and a wall switch for manual control for lighting connected to a motion detector
Community (home)
Yes
Chronic health conditions without cognitive impairment
Observe the practicality of frailty assessment by tablet-based software for older population in emergency care
VAL
Canada
Yes
Yes
CGA-FI and CFS
325 individuals (mean age 75.8 y, SD 7.6) with unclear frailty status
Software suite that includes digital versions of existing frailty and functional assessments, installed in 10.1-inch screen tablets manufactured by Samsung
Examine the reasons for the failures of a telehealth program for an older and frail population
RCT
Australia
No
No
—
43 individuals including clients and carers (mean age 81 y), with unclear frailty status
A telehealth equipment, a Tunstall monitor, programed with questions for the participants, 4 peripherals accompanied the telehealth equipment; these measured weight, blood pressure, heart rate and oxygen.
Community (home)
Yes
Chronic disease and at risk of being admitted into residential care
Participants Without Other Conditions, Cognitive Impairment or Disability (52 Studies)
Appraise the performance of a monitoring system and data management system for older population
DES
Greece, UK, Italy, France, Singapore, Spain
No
No
—
24 individuals with unclear frailty status
Personal Data Capturing System (using a Samsung A5 2017 smartphone, and application "Android City4Age App" that collects data related to body motility and indoor/outdoor localization)
Discover the link between daily mobility and pleasure among everyday life of the older population by using sensors and smartphones during 30 consecutive days
LS
NL
Yes
Yes
GFI
10 individuals, including 1 prefrail and 9 nonfrail, with mean age 68.7 y, SD 5.5
The Activity Coach, a system composed of a hip-worn 3-axial accelerometer and a smartphone application
Balance quality assessment as an early indicator of physical frailty in older people. Paper presented at: 2016 38th Annual International Conference of the IEEE Engineering in Medicine and Biology Society (EMBC).
Assess variability of an instrumented smartphone application to measure physical movements during the timed get up and go test in frail and nonfrail participants
CRS
Spain
Yes
Yes
PHF
14 frail (mean age 83.7 y, SD 6.4) and 16 nonfrail (mean age 70.3 y, SD 3.3) individuals
Kinematics and dynamic complexity of postural transitions in frail elderly subjects. Paper presented at: 2007 29th Annual International Conference of the IEEE Engineering in Medicine and Biology Society.
Propose a single wearable sensor-based method to monitor postural changes in frail older community
VAL
Switzerland
Yes
Yes
PHF
10 frail individuals with mean age 81.3 y, SD 4.76
ASUR, Autonomous Sensing Unit Recorder (includes a 2D accelerometer, a 1D gyroscope, and electronics (memory, batteries), allowing 8 h of continuous data logging)
Kinect-based gait analysis for automatic frailty syndrome assessment. Paper presented at: 2016 IEEE International Conference on Image Processing (ICIP).
Quantifying activity levels of community-dwelling seniors through beacon monitoring. Paper presented at: 2019 International Conference on Information Networking (ICOIN).
Introduce the Bluetooth-interface monitoring system, which can be widely implemented with low-budget, for community-dwelling older population who are frail and lives alone
VAL
Singapore
No
No
—
81 individuals (older than 50 y of age) with unclear frailty status
Bluetooth low-energy (BLE) beacons, Android mobile application, the MQ Telemetry Transport, web monitoring dashboard, system monitoring framework
Assess walking parameters with a device worn at the waist in 2 groups of people: frail and healthy
DES
Spain
No
No
—
5 prefrail and 5 nonfrail individuals with mean ages 85 y (SD 2.7) and 29 y (SD 2.8) respectively
Internet of Things infrastructure for gait characterization (includes a set of wearable inertial sensors (nodes) connected to the same wireless local area network [WLAN])
An Internet of Things infrastructure for gait characterization in assisted living environments and its application in the discovery of associations between frailty and cognition.
Int J Distrib Sens Netw.2019; 15 (1550147719883544)
Introduce a mobile application that can predict the physical tiredness felt by older people during walking
DES
Mexico
No
No
—
3 individuals (mean age 68 y, SD 6.1) with unclear frailty status
An electrical pulse reader to monitor heart rate and 2 cell phones with a 3-axes accelerometer. A mobile application that allows the user to report their perception of physical fatigue.
Introduce a set of devices with wireless sensor network to investigate frailty in old population at home
DES
Taiwan
Yes
No
—
309 individuals, <65 y of age, with unclear frailty status
Home-based wireless frailty detection system (eScale, ePad, eChair, and eReach wireless devices, and the integrated measurement system: includes wireless routers and the Home-Gateway)
Develop an interactive computerized software that contains a variety of functions to provide older frail populations with information and communication support
DES
NL
No
No
—
33 individuals (age range 65-88 y) with unclear frailty status
A telecommunication platform (an interactive software on a standard PC)
An adaptable AR user interface to face the challenge of ageing workers in manufacturing. In: International Conference on Human Aspects of IT for the Aged Population.
Measuring the impact of icts on the quality of life of ageing people with mild dementia. In: International Conference on Smart Homes and Health Telematics.
Evaluation of ambulatory function by using the shoe device. In: 5th European Conference of the International Federation for Medical and Biological Engineering.
Introduce the communication application for older population for social interaction
MM
Canada
No
No
—
5 frail individuals with mean age 87.2 y, SD 4.8, range 81-93
An accessible Android tablet-based communication app (supports asynchronous communication, enabling users to send a “wave,” audio, video, and images captured with the tablet)
ACTIDOM—A microsystem based on MEMS for activity monitoring of the frail elderly in their daily life. Paper presented at: The 26th Annual International Conference of the IEEE Engineering in Medicine and Biology Society.
Evaluate the feasibility of a virtual reality system combining physical and cognitive therapy for frail people
VAL
Italy
No
No
—
5 individuals (mean age 70 y, SD 11.7) with unclear frailty status
A cycle-ergometer, a board connecting the button to the computer and an Xbox controller. A Cave Automatic Virtual Environment, a room-sized cube with 3D visualization, and a tracking system.
Implementation of an innovative web-based conference table for community-dwelling frail older people, their informal caregivers and professionals: a process evaluation.
Describe the outcomes, barriers, and enablers of a health and wellness information portal for frail older individuals
MM
NL
Yes
Yes
ETOS
290 frail older individuals (mean age 81.2 y, SD 5.7) and 158 health care professionals
Health and Welfare Information Portal (ZWIP), a shared Electronic Health Record combined with a communication tool for community-dwelling frail older people and primary care professionals
Compare the outcomes (physical, mobility, mental and social markers as well as frequency of fall accidents) from 2 different exercises participated by old population
RCT
USA
YOD
No
—
72 individuals (mean age 76.9 y, SD 4.8) and 64 individuals (mean age 76.3 y, SD 5.1)
Evaluation of Sigfox LPWAN for sensor-enabled homes to identify at risk community dwelling seniors. Paper presented at: 2019 IEEE 44th Conference on Local Computer Networks (LCN).
Evaluate an indoor locating system for accuracy in room estimation and for ability to assess frailty
VAL
Greece, Cyprus, France
Yes
Yes
PHF
117 nonfrail, 131 prefrail, and 23 frail individuals with mean ages of 76.8 ± 5.2 y (males) and 76.7 ± 5.4 y (females)
Indoor localization system including a small passive Bluetooth low-energy devices, an application for setting up the localization installation and collecting RSS fingerprints, an application for real time, and a cloud service
Assessing the frailty of older people using bluetooth beacons data. Paper presented at: 2018 14th International Conference on Wireless and Mobile Computing.
Networking and Communications (WiMob).2018; : 5-11
Compare the use, user experience, and quality of life of prefrail older adults who received an intervention from an online exercise program vs a similar group of participants who did not receive the intervention
RCT
NL
Yes
Yes
GFI
36 prefrail individuals with mean age 70.9 y (SD 3.5) and 69.2 y (SD 3.8) (control and intervention group)
Technology-supported self-management exercise program using computer/tablet
Balance quality assessment as an early indicator of physical frailty in older people. Paper presented at: 2016 38th Annual International Conference of the IEEE Engineering in Medicine and Biology Society (EMBC).
An Internet of Things infrastructure for gait characterization in assisted living environments and its application in the discovery of associations between frailty and cognition.
Int J Distrib Sens Netw.2019; 15 (1550147719883544)
Accuracy of Teledentistry for diagnosing dental pathology using direct examination as a gold standard: Results of the Tel-e-dent study of older adults living in nursing homes.
A combination of indoor localization and wearable sensor–based physical activity recognition to assess older patients undergoing subacute rehabilitation: Baseline study results.
ACTIDOM—A microsystem based on MEMS for activity monitoring of the frail elderly in their daily life. Paper presented at: The 26th Annual International Conference of the IEEE Engineering in Medicine and Biology Society.
Provide a structured summary that includes (as applicable): background, objectives, eligibility criteria, sources of evidence, charting methods, results, and conclusions that relate to the review questions and objectives.
1
Introduction
Rationale
3
Describe the rationale for the review in the context of what is already known. Explain why the review questions/objectives lend themselves to a scoping review approach.
3
Objectives
4
Provide an explicit statement of the questions and objectives being addressed with reference to their key elements (eg, population or participants, concepts, and context) or other relevant key elements used to conceptualize the review questions and/or objectives.
3
Methods
Protocol and registration
5
Indicate whether a review protocol exists; state if and where it can be accessed (eg, a Web address); and if available, provide registration information, including the registration number.
4
Eligibility criteria
6
Specify characteristics of the sources of evidence used as eligibility criteria (eg, years considered, language, and publication status), and provide a rationale.
Where sources of evidence (see second footnote) are compiled from, such as bibliographic databases, social media platforms, and websites.
7
Describe all information sources in the search (eg, databases with dates of coverage and contact with authors to identify additional sources), as well as the date the most recent search was executed.
4
Search
8
Present the full electronic search strategy for at least 1 database, including any limits used, such that it could be repeated.
A more inclusive/heterogeneous term used to account for the different types of evidence or data sources (eg, quantitative and/or qualitative research, expert opinion, and policy documents) that may be eligible in a scoping review as opposed to only studies. This is not to be confused with information sources (see first footnote).
9
State the process for selecting sources of evidence (ie, screening and eligibility) included in the scoping review.
The frameworks by Arksey and O’Malley6 and Levac and colleagues7 and the JBI guidance4,5 refer to the process of data extraction in a scoping review as data charting.
10
Describe the methods of charting data from the included sources of evidence (eg, calibrated forms or forms that have been tested by the team before their use, and whether data charting was done independently or in duplicate) and any processes for obtaining and confirming data from investigators.
4-6
Data items
11
List and define all variables for which data were sought and any assumptions and simplifications made.
The process of systematically examining research evidence to assess its validity, results, and relevance before using it to inform a decision. This term is used for items 12 and 19 instead of "risk of bias" (which is more applicable to systematic reviews of interventions) to include and acknowledge the various sources of evidence that may be used in a scoping review (eg, quantitative and/or qualitative research, expert opinion, and policy document).
12
If done, provide a rationale for conducting a critical appraisal of included sources of evidence; describe the methods used and how this information was used in any data synthesis (if appropriate).
7
Synthesis of results
13
Describe the methods of handling and summarizing the data that were charted.
Give numbers of sources of evidence screened, assessed for eligibility, and included in the review, with reasons for exclusions at each stage, ideally using a flow diagram.
Summarize the main results (including an overview of concepts, themes, and types of evidence available), link to the review questions and objectives, and consider the relevance to key groups.
11-13
Limitations
20
Discuss the limitations of the scoping review process.
14
Conclusions
21
Provide a general interpretation of the results with respect to the review questions and objectives, as well as potential implications and/or next steps.
14
Funding
Funding
22
Describe sources of funding for the included sources of evidence, as well as sources of funding for the scoping review. Describe the role of the funders of the scoping review.
Title page
JBI, Joanna Briggs Institute; PRISMA-ScR, Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews.
Source: Tricco AC, Lillie E, Zarin W, et al. PRISMA Extension for Scoping Reviews (PRISMAScR): Checklist and Explanation. Ann Intern Med 2018;169:467–473.
∗ Where sources of evidence (see second footnote) are compiled from, such as bibliographic databases, social media platforms, and websites.
† A more inclusive/heterogeneous term used to account for the different types of evidence or data sources (eg, quantitative and/or qualitative research, expert opinion, and policy documents) that may be eligible in a scoping review as opposed to only studies. This is not to be confused with information sources (see first footnote).
refer to the process of data extraction in a scoping review as data charting.
§ The process of systematically examining research evidence to assess its validity, results, and relevance before using it to inform a decision. This term is used for items 12 and 19 instead of "risk of bias" (which is more applicable to systematic reviews of interventions) to include and acknowledge the various sources of evidence that may be used in a scoping review (eg, quantitative and/or qualitative research, expert opinion, and policy document).
Research agenda for frailty in older adults: toward a better understanding of physiology and etiology: summary from the American Geriatrics Society/National Institute on Aging Research Conference on Frailty in Older Adults.
A short physical performance battery assessing lower extremity function: Association with self-reported disability and prediction of mortality and nursing home admission.
Preventing and managing indoor falls with home-based technologies in mild and moderate Alzheimer's disease patients: Pilot study in a community dwelling.
Efficacy of simple home-based technologies combined with a monitoring assistive center in decreasing falls in a frail elderly population (results of the Esoppe study).
A randomized controlled trial of telemonitoring in older adults with multiple health issues to prevent hospitalizations and emergency department visits.
Prevalence of frailty and prefrailty among community-dwelling older adults in low-income and middle-income countries: A systematic review and meta-analysis.
Understanding factors affecting patient and public engagement and recruitment to digital health interventions: A systematic review of qualitative studies.
Frailty and pre-frailty in middle-aged and older adults and its association with multimorbidity and mortality: A prospective analysis of 493 737 UK Biobank participants.
An Internet of Things infrastructure for gait characterization in assisted living environments and its application in the discovery of associations between frailty and cognition.
Int J Distrib Sens Netw.2019; 15 (1550147719883544)
The Luxembourg Institute of Health funded this study. The Lions Club Luxembourg supported a co-author (Catherine Goetzinger) with a doctoral grant. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
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