Ambient Assisted Living Technologies, Systems and

Services: A Systematic Literature Review

Alexandra Queirós

, Anabela G. Silva

, Joaquim Alvarelhão

, António Teixeira

and Nelson Pacheco da Rocha

Health Sciences School, University of Aveiro, Campo Universitário, 3810 Aveiro, Portugal

Electronics, Telecommunications and Informatics Department, IEETA, University of Aveiro

Campo Universitário, 3810 Aveiro, Portugal

Health Sciences Department, IEETA, University of Aveiro

Campo Universitário 3810 Aveiro, Portugal

Abstract. This paper intends to demonstrate that it is possible to classify

Ambient Assisted Living (AAL) services using the International Classification

of Functioning, Disability and Health (ICF), in particular its components

activities, participation and environmental factors. For this purpose a systematic

review of the literature on AAL services was undertaken and existing AAL

services summarized and characterized. To be included in this review articles

must have defined innovative concepts or characterized innovative

technologies, products or systems that can contribute to the development of the

AAL paradigm, with the aim of enabling people with specific demands (e.g.

elderly) to live longer in their natural environment. Results indicate that most

publications regarding AAL are technology-oriented with only a few articles

describing applications and scenarios. Results also indicate that it is possible to

link tasks to categories of the ICF components activities, participation and

environmental factors.

1 Introduction

1.1 Ambient Assisted Living

A digital environment with a pervasive and unobtrusive intelligence that is able to

proactively support people in their daily lives is the fundamental idea of the Ambient

Intelligence (AmI) concept [1]. AmI deals with new paradigms where computing

devices are spread everywhere (ubiquity) to allow intelligent and natural interactions

between the human being and the physical environment.

Within the AmI concept, AAL emerges as one of the most important developing

areas. The general goal of AAL solutions is to apply the AmI concept and

technologies to enable people with specific needs (e.g. elderly) to live longer in their

natural environment. In technological terms, the AAL comprises a heterogeneous

field of systems ranging from quite simple devices such as intelligent medication

Queirós A., G. Silva A., Alvarelhão J., Teixeira A. and Pacheco da Rocha N..

Ambient Assisted Living Technologies, Systems and Services: A Systematic Literature Review.

DOI: 10.5220/0003859400140026

In Proceedings of the 2nd International Living Usability Lab Workshop on AAL Latest Solutions, Trends and Applications (AAL-2012), pages 14-26

ISBN: 978-989-8425-93-5

 2012 SCITEPRESS (Science and Technology Publications, Lda.)

dispensers, fall sensors or bed sensors to complex systems such as networked homes

and interactive systems.

The automation in an AAL environment can be viewed as a cycle that goes from

perceiving the state of the environment, to reasoning about it in order to achieve a

specific goal or anticipate outcomes of possible actions, and acting upon the

environment to change its state [2].

Like all intelligent agents, a smart environment relies on sensory data collected

from the real world. The perception of the environment requires that devices are

embedded in the environment with the purpose to allow the interaction of the

occupants with the technology.

When using the sensory data, the technological structure is able to perform

reasoning processes to select actions that can be taken to change the state of the

environment. Therefore, the data collected by the sensors have to be transmitted by a

communication network and pre-processed by a complex technological structure,

which collates and harmonizes data from different devices (it processes the raw data

into more useful knowledge such as models or patterns). To make that information

useful to the occupants of the environment, AAL systems must have a high level of

reasoning and decision-making abilities in order to arrive at a diagnosis and advice or

assist the human beings accordingly [2].

Action execution flows top-down. The action is transmitted by the communication

network to the physical actuators. These change the state of the surrounding

environment according to the instructions received.

Therefore, sensing, communicating and acting are crucial issues in the AAL

paradigm [3, 4]: i) sensing - a sensorial network is indispensable to obtaining accurate

information about the environment and its users; ii) communicating - all the

components of an AAL environment have to be interconnected in order to

communicate among them; iii) acting - any AAL environment must be able to act,

through various types of actuators, in order to achieve its objective.

Furthermore, AAL systems must be able; i) to properly distinguish the people

present in the environment; ii) to recognize the individual roles, needs, preferences

and limitations; iii) to recognize situational context; iv) to allow different answers

according to personal needs and situational contexts; v) to anticipate desires and

needs without conscious mediation.

Having all this information about its users, the AAL technological structure will

then be able to decide which services to provide, when and how to provide them and

to whom. This means, that the AAL technological structure should present a broad

range of intelligent functions for user management interface and context awareness

[5].

The existence of a variety of devices, such as sensor or video cameras, poses a set

of complex problems in terms of privacy and security, which require additional

developmental efforts.

An AAL environment comprises numerous invisible devices and ubiquitous

systems. Effective architectures are required to mask the effects of heterogeneous

physical devices, communication networks and intelligent components and systems.

Last but not least, the acceptance of the AAL paradigm is, obviously, closely

related to the quality of the available systems (e.g. private houses and home-care

assistance in the presence of users with different abilities and needs).

1.2 International Classification of Functioning, Disability and Health (ICF)

One of the objectives of AAL services is to improve the performance of a person in

their daily life. The AAL services use advanced technology to make that possible.

However, the focus of these services should be in the task that the person needs to

perform rather than in the technology used to perform it. As mentioned above, the

development of these services intends to give more autonomy and independency and

to increase the quality of life of the elderly. This development should be user-

centered.

The user-centered paradigm is also present in the care delivery where the

International Classification of Functioning, Disability and Health (ICF) will have an

important role [6]. The ICF offers a framework for conceptualizing functioning

associated to health conditions [7] and it considers that there are many factors that

affect and have influence on the individual’s performance and thereby on the

decisions made on the type of service needed or how it should be delivered (e.g. care

staff, relatives, aid appliances and technology).

The ICF structure distinguishes between the body, activities, participation and

contextual factors [8] and considers that they are all part of the individual's

functioning. Additionally, it considers the context (environmental factors and

personal factors) as components that can either enhance or hinder the performance of

the individual, depending on how he or she experiences limitations (e.g. due to

possible weakness, illness and/or handicap).

The environmental factors can have a positive (i.e. be facilitators) or negative

impact (i.e. be barriers) on the individual’s performance as a member of society, on

the individual’s capacity to execute actions or tasks, or on the individual’s body

functions or structures. When coding an environmental factor as a facilitator, issues

such as the accessibility of the resource, and whether access is dependable or

variable, of good or poor quality, should be considered.

In the case of barriers, it might be relevant to take into account how often a factor

hinders the person, whether the hindrance is great or small, or avoidable or not. It

should also be kept in mind that an environmental factor can be a barrier either

because of its presence (e.g. negative attitudes towards people) or its absence (e.g. the

unavailability of a needed service).

The ICF contains 1,424 codes organized according to an alphanumeric system.

Each code begins with a letter that corresponds to its component domain: b (Body

Functions), s (Body Structures), d (Activities and Participation) or e (Environmental

Factors). The letter is followed by between one and five numeric digits. Items are

organized as a nested system so that users can telescope from broad to very detailed

items depending upon the needs presented by particular applications of the ICF. The

broadest descriptor of functioning is represented by the chapter (domain) in which the

item appears. For example, chapter 5 of the Activities and Participation (d)

component of the ICF is Self-care. The next level of coding is what the ICF refers to

as the second level of detail or specification. These codes consist of the letter

indicating the component domain (b, s, d, or e) followed by three numeric digits. The

first numeric digit always corresponds to a chapter in that component domain in

which the code is found. Within the Self-care chapter, the code d540 (Dressing)

represents the second level of detail.

Assuming that AAL services intend to highlight environmental factors, i.e.

technology, to improve participation and quality of life it should be possible to

classify these services, taking into account how they impact on the user activities and

participation, particularly on his/her quality of life [9]. It can also be considered that

the AAL services may be classified as environmental factors, because they are

embedded in the context where a person performs the activities and they may either

facilitate or hinder to the individual’s performance.

2 Methods

The objective of this paper is to review the AAL literature and classify the existing

AAL services and to link these services to ICF activities, participation and

environmental factors. In order to achieve these aims, a systematic review of the AAL

literature published after 2007 was undertaken. The main features and areas of the

products and systems described in the literature reviewed which interlink and

improve new or existing technologies and systems were described. The methodology

used to conduct this systematic review is detailed in the following sections.

2.1 Data Sources and Searches

Studies were sought using health databases (PubMed, Web of Science, Academic

Search Complete and Science Direct) and Engineering and Technology databases

(Cite Seer and IEEE Xplore). Two key words were used without language restriction:

Ambient Assisted Living, as this was the main focus of this review, and Ambient

Intelligence because AAL is a sub-area of AmI. This means that technologies such as

user interaction or context awareness that are classified as AmI technologies are also

used in the AAL. However, not all the AmI systems are considered AAL systems.

The search was performed on the 23rd of February of 2011 and included all

references published since the 1st of January 2007. This data limit was established as

2007 was the year the Joint Programme “Ambient Assisted Living” from the

European Union was proposed [10].

2.2 Study Selection

After the initial screening, abstracts were sub classified by AQ, AGS and NPR into

one of 7 areas: i) architectures and frameworks; ii) physical devices; iii) context

awareness; iv) user interaction; v) privacy and security; vi) systems; vii) conceptual

articles. The operational definitions used in this review for each one of these areas

are:

 Architectures and frameworks - abstraction of the structure and rules needed to

reason about AAL systems and how to implement them, including different

middleware approaches. In this class, we also included the articles describing

methodologies required to enable efficient, engineering deployment and runtime

management of ALL systems [11];

 Physical devices - the hardware components required for the implementation of an

AAL system, including networks of sensors and actuators required to collect and

disseminate a range of environmental data [12];

 Context awareness - technologies and methodologies to abstract and model the

situation of a person, place or object considered relevant to the interaction between a

user and a system [13];

 User interaction - technologies and methodologies that enhance the effectiveness

and usability of a system and its interfaces [14];

 Privacy and security - privacy and security challenges imposed by the AAL

implementation [15, 16];

 Systems - practical AAL systems applied in a specified context and with a well

defined aim [17];

 Conceptual articles - innovative concepts related to the AAL or that may

contribute to its development.

Considering that the final aim of AAL is to develop systems to enhance people’s

quality of life, it was decided to do a more detailed analysis of the articles included in

the sub-area systems. These articles were characterized in terms of: objectives, users,

settings, domains, developmental status and whether could be considered as real AAL

services. The activities that the services aimed to facilitate and the environmental

factors considered were also linked to categories from the ICF components activities

and participation and environmental factors, respectively-

3 Included and Excluded Articles

The databases searches resulted in 2427 references, of which 462 were duplicates and

1067 did not meet the inclusion criteria and, therefore, were excluded. Thus, a total of

845 references were included in this review (Figure 1).

Among the excluded articles, there were 28 that, despite not meeting the

previously defined inclusion criteria, were related to AAL and we decided to include

their references for further reading. These were on topics concerning ethical and legal

issues (n=18), market studies (n=8) and assessment of AAL systems (n=2).

3.1 Included Articles

Of the 845 included studies, 192 (23%) were classified as architectures and

frameworks, 130 (15%) as physical devices, 246 (29%) as referring to context

awareness, 113 (13%) as user interaction, 34 (4%) as related to privacy and security,

88 (11%) as systems and 42 (5%) as conceptual papers defining innovative concepts.

The higher number of publications on context awareness may be related to the

knowledge that the individual performance is not only affected by the individual

abilities but also by the characteristics of the environment, which can either facilitate

or hinder the individual performance [8].

Fig. 1. Flow chart for the systematic review.

Table 1. Number of articles in each area and sub-area.

Area and Sub-area

Architecture and Framework (192):

Architecture (152); Design and Development Methodologies (37); Safety (3).

Physical Devices (130):

Sensors Network (75); Robotic (32), New technologies (23).

Context-awareness (246):

Environment (18); Location / Tracking (32); Identity Management (12); Identity Management and

Location (8); Detection of Specific Events and Situations (18); Activity / Interactions (41); Human

Behavior (25); Emotions (10); Reasoning (82).

User Interaction (113):

New Interfaces (52); Personalized Information (7); Design (44); Evaluation (10).

Privacy and Security (34).

Systems (88).

Conceptual papers (42):

Sensors network (2); User Interaction (6); Technology Development (6); Context awareness (2); Living

Lab (5); Future Challenges for the AAL Systems (21).

It was necessary to sub-divide the major 7 areas identified in the study selection

because the areas they covered very broad subjects. Thus, the main area of

architectures and frameworks was sub-divided into architecture, design and

developmental methodologies and safety. The main area of physical devices was sub-

divided into sensors networks, robotics and new technologies. Context-awareness

technologies were sub-classified into environment, identity management and location,

location/tracking, detection of specific events and situations, activity/interaction,

human behavior, emotions and reasoning. User interaction included the sub-areas of

new interfaces, personalized information, design and evaluation of user interfaces.

AAL systems included the issues of security and privacy related to the individual and

to the context so that the user receives adequate support. However, there were not

clearly distinct areas of research within this topic and, consequently, the articles were

not sub-classified. A total of 42 articles were classified as conceptual papers on the

following sub-areas: sensors network, user interaction, technology development,

context awareness, living lab and future challenges for the AAL systems. A total of

88 articles were classified as systems. The Table 1 shows the number of articles

identified by area and sub-area.

4 Results and Discussion

As AAL is related to the complex interaction of a variety of technology and system

components that aim to enhance people’s life we decided to perform a more detailed

analysis of the articles classified as systems as referred in the methodology.

Most systems were intended for use both indoor and outdoor in any environment

or at home. This may be related with an attempt to improve people’s life in their

natural environment. The system described by Chuan-Jun and Bo-Jung [18] is to be

used in outdoor environment and allows the location of the elderly anywhere in the

community. Caregivers may locate care-receivers easily in a community with RFID

while a Mobile Agent furnishes timely and accurate information for care provision.

Systems were conceived to be used in a variety of areas with the general aim of

directly or indirectly improve the individuals’ quality of life. Most systems were

conceived to help care delivery either by health professionals or by any formal or

non-formal caregiver. Most of these aimed at monitoring and controlling biological

signs and behaviors’ such as heart rate or falls. The ultimate goal is to provide the

caregiver with accurate, up to date information so that the right care can be delivered

at the right time. The remaining systems are on very diverse areas with very diverse

objectives such as security, information, domotics, user interface, entertainment,

mobility, shopping, self-care, culture, tourism, involvement in community events,

physical activities and education.

The World Health Organization (WHO) defined Health, Participation and

Security as the three pillars of a policy framework for active ageing. The ALLIANCE

Project supported by the European Commission, that aimed to coordinate a European

AAL Community, also defends that this three areas are very important to the elderly

[19]. When considering the scope of the analyzed systems, one was classified as

Security, while the others were classified as Health or Participation. Interestingly, a

high percentage of articles describe systems that aim to enhance fundamental

activities such as involvement in community events, self-care or mobility. This may

indicate that the priority of existing systems is to facilitate the fundamental activities

of an individual. However a few studies also describe systems that aim to facilitate

activities more related to quality of life (e.g. physical activities or tourism). These

studies use technologies that take advantage of existing knowledge on context

awareness. For example, the research presented by Ahn [20] is a novel approach to

evaluate customer aid functions with agent-based models of customer behavior and

evolution strategies that builds on existing knowledge on context-awareness

technology. Agent-based modeling is used to imitate users' rational behavior at

Internet stores with regard to browsing and collecting product information.

Of the 88 abstracts classified as systems, 77 described systems that use existing or

new technologies to solve very specific problems (e.g. a robot to assist elderly in a

particular daily activity). The other 11 articles (Table 2) describe systems showing a

higher level of complexity and aggregating functions to answer to a broad range of

needs in daily life situations [21]; [22]; [23]; [24]; [25]; [26]; [27]; [28]; [29]; [30];

[31]. An example is the system described by Bravo et al. [23] that is to be used in a

day centre or at home to monitor the behavior of patients with Alzheimer disease as

well as their vital signs. This information is then sent to caregivers and allows them to

identify emergency situations and provide the appropriate care. However, the system

is also used to assist patients in daily activities in order to promote their autonomy.

Table 2. Objectives of the AAL systems found.

Objective Article

Diagnose, prevent and treat patients with diabetes mellitus [21].

Personal assistant [22].

Complement and support daily activities [23]; [24]; [25]

Promote well-being and health [26]; [30].

Monitor and collect vital signals [27].

Promote autonomy [28].

Promote participation [29].

Assist tourism [31].

One of the objectives of this paper was to analyze the 11 articles considered as

real AAL services and describe the activities and participation that these services aim

to improve. As mentioned above, it is possible to link the tasks involved in the AAL

services and categories of the ICF component activities and participation. The

activities and participation found in the articles were linked to the following

categories: Focusing attention (d160); Reading (d163); Writing (d170); Calculating

(d172); Solving problems (d175); Caring for body parts (d520); Looking after for

one’s health (d570); Caring for household objects (d650); Assisting others (d660);

Informal social relationship (d750); Family relationship (d760); Community life

(d910); Recreation and leisure (d920); and Religion and spirituality (d930).

Table 3 shows the activities and participation presented in the articles linked to the

ICF categories.

As referred in the introduction, external factors can contribute to improve person’s

performance (i.e. the context where the tasks are completed may influence the

performance of a person). The concept of AAL can be defined as the use of

technologies to improve a person’s performance in a specific life situation. Thus, it is

possible to link the AAL services to ICF’s environmental factors.

Table 3. ICF’s activities and participation described in the articles classified as real AAL

systems.

Activities and Participation Articles

d160, d163, d166, d170, d172, d175 [27].

d520 [21].

d570 [21]; [22]; [26]; [28]; [29].

d650 [22]; [28].

d660 [23]; [24]; [27].

d750, d760, d930 [29].

d910 [22]; [26]; [29].

d920 [21]; [22]; [26]; [29]; [31].

When analyzing the 11 articles classified as AAL services, it was possible to

identify 10 environmental factors, according to the ICF: Products and technology for

personal use in daily living (e115); Design, construction and building products and

technology for gaining access to facilities in buildings for private use (e1551);

Immediate family (e310); Extended family (e315); Friends (e320); Acquaintances,

peers, colleagues, neighbours and community members (e325); Health professionals

(e355); Transportation services (e5400); Social security services (e5700); and Health

services (e5800). Table 4 presents the environmental factors classified according to

the ICF.

Table 4. ICF’s environmental factors described in the articles classified as real AAL systems.

Environmental Factors Articles

e115 [21]; [22]; [26]; [27]; [29]; [31].

e1551 [21]; [22]; [26]; [27].

e310 [24]; [29].

e315, e320, e325, e5700 [29].

e355 [23]; [24].

e5400 [31].

e5800 [21]; [23]; [24]; [26]; [27].

It is clear from Tables 3 and 4 that the activities, participation and environmental

factors described in real AAL systems are only a small part of those described in the

ICF.

5 Conclusions

The results of this systematic review indicate that there is a great amount of literature

on AAL encompassing very diverse areas.

Most of the literature on AAL is technology-oriented, what is reflected in the high

number of articles on specific components (89%) when compared to only 88 articles

(11%) on complete systems. In addition, a considerable number of these 88 articles

on systems focus on how the technology can be used in the AAL context instead of

looking at the users’ needs and proposing ways in which the technology can be used

to solve them. The focus is on the technology rather than on the person.

A high number of systems are conceived to help care delivery either by health

professionals or any formal or non-formal caregiver. This is probably related to the

continuous ageing of the population. With ageing there is a decrease in functioning

associated with an increase in a variety of chronic diseases which leads to a higher

consumption of healthcare services [32]. This challenges the traditional healthcare

system. It is likely that the scarcity and costs of health resources compromise the

ability of the health system to appropriately respond to a population that not only

wants to live longer, but to live with autonomy and quality of life [33]. Furthermore,

AAL systems can contribute to the reorientation of health systems that are currently

organized around acute, episodic experiences of disease, by allowing the

development of a broad range of systems promoting care prevention and care

promotion and home-caregiver support [34]. A considerable number of

technologies/systems are developed for elderly users or users with disabilities, what

may be related with the previously referred demographic changes and constitute an

attempt to answer to the specific needs of these users. However, the emphasis needs

to shift from specific groups of users to the general user/population by developing

intelligent systems with the technology embedded in the environment that can

automatically select the output and input information and mode according to the

specific needs and characteristics of the users, in line with the principles of the

Design for All [35]. Therefore, AAL technologies would be usable by all people,

independently of their abilities, age or health condition. This will contribute to

decrease the price of this technology which is one of the main barriers to its

widespread use. Interestingly, an important step towards this direction is being given

by using the intelligent AAL component (e.g. context awareness and user interaction)

to develop technologies that consider not only the person, but the activity being

performed and the context in which it is taking place. This is in line with the WHO

International Classification of Functioning, which sees the environment as a crucial

factor modulating the person’s activity and participation as a member of the society

[8].

The activities and participation considered in the AAL systems indicate that these

services are directly related to the Health and Participation areas of the WHO’s

definition of active ageing. Only one activity and participation was found related to

the Security area. This can be explained because one of the main objectives of AAL

is to improve the active ageing what requires the creation of services adapted to the

needs of the elderly using advanced technology, like sensors, monitoring devices or

communication technologies. Most of the activities and participation that were

implicit in communication or participation in society can also be seen as a way to

promote health. For example, Busuoli [26] describes a service that is related to the

virtual communities and aims to improve the knowledge on diabetes; Dadlani [27]

uses computer games to cognitively stimulate the elderly. In what concerns security it

is more difficult to identify activities and participation that can translate the feeling of

security by the point of view of the caregiver. Services that refer to security were

linked to the category d660 (Assisting others) of the component activity and

participation. Other possibility would have been to link it to a personal factor related

to emotions, personality and personal characteristics of a person.

Considering the presence of environmental factors in AAL services it was clear

that technologies and services that use actuators, sensors, and cameras may be

classified as e115 (Products and technology for personal use in daily living) or e1551

(Design, construction and building products and technology for gaining access to

facilities in buildings for private use). These two environmental factors were present

in all the articles describing AAL services. One explanation for this is, as argued by

Bravo [24], “the idea is that the user should focus on the task and that technology

should disappear”. The other environmental factors that were identified are related to

the activities and participation and aimed to improve relationship, community life,

recreation and leisure. Obviously, social support networks (formal or informal) have a

major impact in these activities and according to the ICF can be classified as

environmental factors.

To summarize, this review of existing literature on AAL highlights the need to

rethink the future research approach on the development of AAL systems in order to

take advantage of already existent technologies and systems. The difficulty found

when classifying the articles also suggests the need for a common classification that

could be used to characterize existing AAL systems. Furthermore, according to what

was described in the previous sections, the needed requirements to deliver viable,

adaptative and personalized AAL systems are still not fulfilled. There is a general

tendency to develop AAL systems from the scratch with specific solutions. Therefore,

there is a need for a normalized and coherent technological sub-stratum over which

AAL systems could be developed to answer the real demands of the users.

Acknowledgements

This work is part of the COMPETE - Program Operacional Factores de

Competitiviade and the European Union (FEDER) under QREN Living Usability Lab

for Next Generation Networks (LUL) (http://www.livinglab.pt) and QREN Primary

Healthcare ALL Services (AAL4ALL) (http://www.aal4all.org/).

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