**1. Introduction**

SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), spread in China in early December 2019. On 12 January 2020, the World Health Organization (WHO) confirmed that COVID-19 was the cause of respiratory illness in China [1], having a case– death ratio much lower than that of SARS in 2003 [2], but a notably greater transmission, with an important total dying rate [3]. The virus affected more than 250 million people globally, with more than five million deaths having been reported by the WHO [4]. The virus spreads human-to-human, causing flu, fever, cough, and respiratory problems [5,6]. The prevalence of the virus has been prevented through constant lockdowns, which highly affected the economy and small businesses [7,8]. In order to stop the pandemic, selfquarantine in their residences was enforced on normal people, and quarantine in hospitals until full recovery was enforced on people affected by the virus.

**Citation:** Ianculescu, M.; Alexandru, A.; Paraschiv, E.-A. The Potential of the Remote Monitoring Digital Solutions to Sustain the Mental and Emotional Health of the Elderly during and Post COVID-19 Crisis in Romania. *Healthcare* **2023**, *11*, 608. https://doi.org/10.3390/ healthcare11040608

Academic Editor: Daniele Giansanti

Received: 28 December 2022 Revised: 9 February 2023 Accepted: 16 February 2023 Published: 17 February 2023

**Copyright:** © 2023 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

To better understand the pandemic and the impact of COVID-19 on healthcare services in Romania, a short overview is provided: the actions to prevent the spread of the pandemic started in mid-March 2020 (e.g., interdiction of public gatherings, school closure). A state of emergency in Romania was decided, starting on 16 March 2020 [9]. In mid-May 2020, some restrictions were relieved when the state of emergency ended on 14 May 2020 and was changed to a state of alert. Further restrictions were relaxed in the next months. Since an acute increase in the infection rate was observed in the autumn of 2020, several restrictions were reinforced. Schools were re-opened only on 8 February 2021. Between mid-March 2021 and the beginning of March 2022, three waves of cases were noticed in Romania. The wave of cases between 10 August and 20 October 2021 has been the most severe of all infection waves in the COVID-19 pandemic. The pressure on the Romanian healthcare system that achieved its maximum capacity in this wave led to the authorities asking the European Union for help through its Civil Protection Mechanism [10].

Older people were highly affected by COVID-19, and many of them have died [11]. This is due to their low immunity, which is insufficient to fight against the virus. As the risk of mortality in the older population is much higher compared to younger people, protection with social distancing or, if necessary, social isolation is necessary. Loneliness and social isolation may cause many problems, such as mental and emotional problems, disability, cardiovascular diseases, etc., among seniors [12]. The ongoing COVID-19 pandemic has underlined the need for digital technology solutions to diminish the risk of contamination due to close contact [13]. Smart technology (e.g., IoT, mobile phones) has been important for diminishing social isolation, improving the quality of life and self-care, and providing consultation, remote monitoring, and diagnosis for older adults [14].

The numerous restrictions imposed by COVID-19 in many countries led to a damaging effect on the psychological functioning of the elderly [15], loss of social support due to limited contact with other people [16], higher levels of loneliness, which is significantly associated with depression in the elderly [17,18]. Loneliness is considered to be an important risk factor for the exacerbation of a number of health conditions, such as coronary heart disease and stroke [19], and is associated with a 26–50% increased risk of mortality [20].

There are several instruments for assessing the mental and emotional health of the elderly during and post-COVID-19 crisis. They are used to measure her/his cognitive impairments and to screen for dementia or mild cognitive impairments (MCI) for estimating their severity and progression or for following the course of her/his cognitive changes over time. These instruments are used as screening tests, but they need to be used with multiple other screening tests, rather than an isolated one, to confirm a diagnosis of dementia. Some of them are presented below:


excellent for dementia diagnosis (both >0.9), but NACE has a slight net benefit on MCI diagnosis [24].


The entire impact of the COVID-19 pandemic on the wellness and health status of the elderly has not been completely assessed; what is certain is that this impact has been perceived keener among the older persons, taking into consideration all the restrictions imposed by the authorities (including the lockdowns) in their attempt to reduce and control the degree of contagion. Moreover, isolation was also imposed on the elderly by their family and friends, most of the time to protect them from getting ill.

A study performed on 254 persons who were hospitalized in Italy due to SARS-CoV-2 infection revealed that the elderly patients with persistent psychiatric and somatic symptoms perceived these symptoms more strongly in the following six months postinfection, followed by a decrease afterward [29]. Another study performed at Daping Hospital in Chongqing, China, on COVID-19 patients aged 60+ stated that 21% of those who had had a severe form of the disease suffered from progressive cognitive decline afterward; the more severe the SARS-CoV-2 infection, the higher the risk of deterioration of mental health [30].

It is almost a general fact that nowadays, the elderly are much less tech-savvy than the younger generations, which directly leads to fewer possibilities for them to have access to information (including medical information) or social interaction; another element that has to be taken into consideration is the lower number of digital devices used by the elderly, as they might be too expensive or not age-friendly enough. It is not to be neglected either the situation in which an exacerbated access to scientifically unverified and alarmist information, combined with social isolation, leads to increased anxiety, depression, and other emotional and mental problems. So, the lockdowns and restricted access to the outof-home world imposed in different periods of time since the beginning of the COVID-19 pandemic had a strong negative effect on the mental and emotional state of older persons.

Some typical mental health disorders that have been estimated to directly affect people post-SARS-CoV-2 infection are as follows: anxiety, panic attacks, depression, dietary and obsessive–compulsive disorder, personality disorders, paranoia, phobias, psychosis, sleep problems, and suicidal thoughts.

The elderly have been among the most vulnerable group of the population from the point of the mortality and serious physical damage of health status directly associated with SARS-CoV-2 infection; it has already been demonstrated that it is no less true that the degree of morbidity, mortality and accelerated mental decline has increased among them due to social isolation, grown stress and the decrease in cognitive provocation and physical activities.

Since the beginning of the COVID-19 pandemic, a series of surveys have been conducted in Romania regarding how it has affected, especially from a mental and emotional point of view, the population at the global level, but especially the elderly. The isolation and fear of contamination with the SARS-CoV-2 virus, the fear of death, loneliness, the limitation/lack of access to medical services, the accentuation of pre-existing mobility and health problems due to loneliness, as well as the limitations imposed on social life, have affected, in particular, people aged 65+. This was also demonstrated by the surveys carried out by (1) the Romanian Institute for Evaluation and Strategy (IRES)—an independent think tank that conducts surveys on the problems and perceptions of Romanians on current issues; (2) Kantar Romania—a data and evidence-based company that operates in the Marketing Research and Public Opinion Polling sector and provides insights and actionable recommendations to its clients—at the request of the Never Alone Association—Friends of the Elderly—an NGO that supports the cause of the loneliness of the elderly and promotes dignity at any age. The methodology used in such surveys, as well as their results obtained at various times during the COVID-19 pandemic, are presented in the paper.

In order to identify and reduce the effects of the COVID-19 pandemic on older adults (such as emotional and mental decline), the authors propose a procedure for managing the associated risk through RMDS.

Due to the short time since the beginning of the COVID-19 pandemic, no solid assessment of the effects on the mental and emotional state of the elderly following SARS-CoV-2 infection has been performed. Even less, no reliable methodologies have been implemented by which these negative effects, which can significantly influence the health of the elderly in the long term, can be managed, controlled, or annihilated.

As there is a continuous growth of RMDS at the national and international level, in Romania, there are several research gaps in this regard. The lack of correlation between the screening tests for neurodegeneration and evaluating patients' medical data is crucial, as healthcare parameters have an essential role in assessing neurodegeneration. Additionally, considering the fear of contamination with the COVID-19 virus, there are not considerable systems that can remotely monitor the elderly in the comfort of their home. The lack of access or the difficulty in reaching medical services related to prior mobility or healthcare issues composes another gap in providing a good quality of life for the elderly. Moreover, there is also the absence of a complex platform that could not only track health parameters, but also sustain mental or behavioral problems.

According to the above-mentioned gaps, the present research paper aims to meet all the needs that can provide a complex and structured system not only to remotely monitor health parameters, but also to track and screen neurodegenerative-associated patients and sustain them emotionally and socially.

The relevance of such solutions during the pandemic is important in managing older people's wellbeing and mitigating the pressures on the healthcare system [22–28,31–33].

The addressed population mainly consists of older people in need of communication, with mental health problems, and suffering from social isolation [34]. The RMDS has been largely used in the last two years [35,36] for dealing with social isolation and loneliness [37–39] and mental health consultation purposes [40,41] during the crisis. With the help of m-health tools, information [42,43] and self-help [44,45] have been provided to the elderly. Internet access [46,47] and the senior's desire and capabilities [32] are the main factors in the success of such solutions to improve their health and combat the COVID-19 outbreak. Some of the facilitators in the adoption of these solutions are the support from the government and family [33,48,49].

In the context of the COVID-19 pandemic, the Non-invasive Monitoring System and Health Assessment of the Elderly in a Smart Environment (RO-SmartAgeing) is implemented as a tailored patient-centric RMDS aiming at assessing and the health management of older patients that are living at home. While its two main components include quite a

large range of functionalities able to address primary healthcare issues and support for healthy, independent, and active aging, the potential mental and emotional disorders of the elderly can be identified, evaluated, and tackled both by the elderly, and their supporting people, including the medical staff. The system gathers health, motion, and environmental data from IoT sensors and devices, transmits them, and stores them to the cloud platform for advanced data analysis applications. The IoT-based sensors and devices are programmed to send the data, via an Application Programming Interface (API), to the RO-SmartAgeing database and can be further visualized and analyzed in the web platform. The services provided to the seniors consist of medical assistance and support provided by using a safe, customizable smart environment. The beneficiaries of such services are older persons, their current healthcare specialists, and caretakers/family [50].

As the COVID-19 crisis had such a dramatic impact on individuals and the societal, medical, and social systems in Romania, the development and implementation of digital solutions and technology targeted to support remote health monitoring of the elderly have been accelerated, and gained larger accessibility among citizens and health professionals. Moreover, the research in this field has been boosted, and digital healthcare solutions have been developed or improved to sustain remote care of the elderly, as briefly illustrated in Table 1.

**Table 1.** Short synthesis of some projects that reflect the state-of-the-art in Romania in the field of research aimed at the remote health monitoring of the elderly.



The list of abbreviations used in this paper is presented in Table 2.


**Table 2.** Abbreviations used in this paper.

The aim of this paper is to propose a procedure for the identification and mitigation of the risk of emotional and mental long-term decline of the elderly after SARS-CoV-2 infection that comprises RMDS. The necessity of taking into consideration the results of COVID-19-related surveys and the implementation of appropriate RMDS into this procedure is presented and justified. The RO-SmartAgeing system is an illustration of an RMDS for addressing improved preventative and proactive support for diminishing this risk.

The content of the paper is organized as follows: the methodology used to estimate the effects of the COVID-19 crisis on a sample of the Romanian aged population, obtained from some surveys, is presented in Section 2.1. Issues that can sustain the management of the elderly's risk of emotional and mental long-term decline after SARS-CoV-2 infection and the steps of a procedure for managing the elderly's risk of emotional and mental long-term decline after SARS-CoV-2 infection are proposed in Section 2.2. The importance of involving RMDS in the management of seniors' health and the steps for implementing functionalities provided by them are presented in Section 2.3. The effects of the pandemic on representative samples of the Romanian elderly, obtained as results of some surveys, are presented in Section 3.1. The results of this approach are described in Sections 3.2.1 and 3.2.2 by using the capabilities of the RO-SmartAgeing system to address preventative and proactive support for diminishing this decline. Section 4 is a discussion section dealing with the presentation of the main findings of the paper, strengths, drawbacks, as well as lines for future work. Section 5 concludes the paper. The references are included at the end of the paper.

#### **2. Materials and Methods**

#### *2.1. Effects of COVID-19 Crisis on a Sample of Romanian Aged Population—Results of Methodology Used in Some Surveys*

According to the data published by the National Institute of Statistics (INS) on the International Day of the Elderly, on 1 January 2020 [57], people aged 65 and over in Romania represented 19% of the country's resident population. Among the elderly, men totaled 15.7% of all men resident in Romania, and women 22.1% of all women resident in Romania. The segment of the population aged 80 and over represented 4.8% of the total population. Of the total number of people aged 80 and over, 34.8% were men, and 65.2% were women. The household structure based on the occupational status of the head of the household shows that pensioners represent 40.9%

The share of the population over 65 years of age in Romania, according to the statistical data from the 2022 Census published by the National Institute of Statistics (INS) [58], represents almost 20% of the total population.

Thus, according to the INS, the demographic aging process has deepened in recent years, noting the increase in the share of the elderly population (aged 65 and over).

The perceptions of Romanians regarding the COVID-19 pandemic have been constantly evaluated, starting from March 2020; until now, more than 30 studies have been carried out focusing on the way in which the life of Romanians, but also of the society perceived as a whole, was affected, in different aspects, by the pandemic. We briefly present the methodology of three of these studies and present aspects related to the influences of the COVID-19 pandemic on a sample of population aged 65+. Sample type was simple, random population satisfying the following criteria of eligibility for participation in this study: (i) people currently residing in Romania (aged 65 years and above) of either gender, (ii) comprehension of this study's goal, and (iii) consent to participate in this study.

The research study included a qualitative part (in-depth interviews with people from the representative age segment) and a quantitative part (survey based on Computer Assisted Telephone Interviewing among the elderly) for a national representative sample. A well-structured, closed-ended, and self-reported questionnaire was created, including questions about COVID-19-related characteristics and perceptions. Each survey takes approximately 10–15 min to finish. Prior to the interview, study participants provided verbal consent over the phone. Participants were thoroughly instructed on the process and purpose of this study and agreed that their information would be kept confidential and anonymous. Participants were not compensated for their participation in the research and were free to withdraw at any moment without providing evidence. Those who refused to consent were not authorized to participate in the survey.

A sample of questions used in the three analyzed Romanian surveys is illustrated in Table 3.


**Table 3.** A sample of questions used in Romanian surveys.

*2.2. Managing the Elderly's Risk of Emotional and Mental Long-Term Decline after SARS-CoV-2 Infection*

Among the most important issues to be identified in order to define a procedure for better management of the emotional and mental long-term decline after SARS-CoV-2 infection is to determine what the most relevant risk factors considering the specificities of the lifestyle and age-related dysfunctionalities of the elderly are. Since the beginning of the COVID-19 crisis, data and information have been collected or become available from local, regional, national, or international surveys or studies based on surveys from self-reports of the patients infected with SARS-CoV-2 [62]. For a better foundation, research and studies that correlate the medical history of elderly patients with new cognitive symptoms and disorders appeared after the SARS-CoV-2 infection started to develop. Special attention is paid to risk factors before and after infection. For instance, in a recent study addressing the long-term sequelae clustering phenotypes for appropriate care management post this type of infection, associated risk factors have been identified and classified [63].

In this context, the most relevant identified *risk factors* are as follows:


The level of impact on the elderly that these risk factors might have depends directly on both their medical history and cognitive and social status, but also on their adaptability and self-sufficiency.

In order to mitigate the psycho-social and mental wellness impact of SARS-CoV-2 infection on older persons, some basic actions must be performed/initiated:


In the context of the COVID-19 pandemic, *RMDS* proved to be a progressive model of care, as they can ensure, in the safest way, continuous monitoring and management of the health status. The elderly patients have been one of the most important potential target users of RMDSs; because of the imposed restrictions and isolation, these solutions for providing healthcare have been perfectly capable of creating a personalized framework in which an older patient is observed, consulted, and monitored non-invasively, constantly, or periodically, depending on the evolution of their state of health. Thus, unnecessary hospitalization or direct human contact in clinics or medical offices could be diminished.

In terms of monitoring and managing the mental and emotional disorders activated or aggravated by the COVID-19 pandemic, in two years, RMDSs have been able to demonstrate how their functionalities could support adaptive behaviors, social relationships, informational necessities, engagement in usual daily activities, increased self-abilities to

cope with cognitive issues, and direct real-time link among healthcare providers, patients, and their families.

It is now time to step forward toward proper management of the risk of the decline that those elderly patients with mental and emotional disorders—that were influenced by the SARS-CoV-2 infection—may have in the long term. Moreover, the opportunities and benefits in this domain brought by ICT in healthcare domain should be reflected by integrating the capabilities of RMDSs among different levels, phases, and activities of this management.

Proposed Procedure for Managing the Risk of Mental and Emotional Long-Term Decline during and after SARS-CoV-2 Infection

Although there are many strategies and procedures recommended by health authorities and specialists for decreasing the cognitive decline of the elderly, taking into consideration the short period of time since the beginning of COVID-19 pandemic, there are not many risk management plans addressing this domain in an integrated way, comprising comprehensive aspects that define the state of cognitive health and its evolution. Most of the strategies, procedures, and programs that aim to manage the mental and emotional status of the elderly refer to recommendations directed towards several health areas: controlling the risk factors, lifestyle (sleep, nutrition, and dietary habits), daily activities (physical activity, social participation, and relationship), and cognitive support and stimulation.

Our proposed procedure for managing the risk of mental and emotional long-term decline during and after SARS-CoV-2 infection is intended to cover a larger range of aspects that are associated with these cognitive disorders, starting with its design, comprising the management of the identified mental dysfunctionalities in conjunction with other comorbidities of the elderly, and periodical assessment of the outcomes and feedback of the procedure, and last but not least, formulating potential proposals for improving medical practices, but also the political instruments that govern the field of medical and social care for the elderly.

As is presented in Figure 1, the proposed procedure is designed to be scalable and able to evolve continuously according to the necessities at the individual or group level of elderly patients or, depending on the social/healthcare context, being provided with several steps that allow its improvement and upgrade.

The diagram presented in Figure 1 is detailed as follows:

The steps in designing the proposed procedure consist of clearly defining the *scope, objectives, estimated results, and target users of the risk management.* Briefly, it aims to better support the elderly with mental and emotional problems induced or aggravated by SARS-CoV-2 infection or COVID-19 pandemic.

It is supposed to become an efficient tool:


Not less important is the estimated impact on improved policy instruments, research, education, or other types of clinical practice.

For a real-time response and a clear vision of the current situation of the local healthcare ecosystem (with a focus on mental and emotional issues), *implementation of feasibility and market study* should be performed, followed by *development of businesses and implementing plans*. In this phase, the results of national surveys—targeted for evaluating different issues related to the impact of COVID-19 pandemic on the elderly (as those presented in Sections 2 and 3 of this paper)—are important for identifying the most relevant aspect and approaches. Thus, the risk management plan targeted for the mental and emotional long-term decline is designed, structured, adapted to local conditions, and developed in accordance with the real requirements of this category of vulnerable patients, but also those of medical and social service providers.

As it was stated previously*, the assessment of the risk for mental and emotional decline after SARS-CoV-2 infection* has crucial importance for managing the associated long-term decline. The results of related surveys, mental status tools for evaluating cognition (such as MMSE, MoCA, ADL, Free-Cog or Anxiety and fear of COVID scale—AMICO), or wearables/smart devices able to assess physiological changes through continuous remote monitoring are sources for generating a reliable identification of these risk factors. These factors should be concatenated with all the other risk factors used for evaluating the mental or emotional status of elderly patients, without necessarily being related to COVID-19.

Some of the above-mentioned risk factors are the same: age, gender, medical history, education, health status (including pre-existing mental and emotional disorders), way of living (with aspects related to loneliness, social relationship, and economic status), access to medical and social assistance, and access to digital technology, level of IT and health literacy, or ageism influences. Once identified, all these risk factors must be prioritized.

The *selection of targeted category of the elderly or individuals* aims to better implement risk management according to the main scope of the healthcare provider that applies this plan. This procedure can be used for improved management of mental and emotional disorders of a particular elderly patient or for a specific category of older patients, depending on the level at which it is applied and by whom it is applied (a physician, a medical unit or at the level of the health insurance system).

Once the targeted elderly patient(s) is/are selected, *an evaluation of their health status* is carried out with the help of traditional medicine, but also with the help of digital technology, including RMDSs.

The results of the evaluation of the health status corroborated the identified and prioritized risk factors are the basis for a reliable *diagnosis of mental and emotional decline*.

In this phase of the procedure, an evaluation of the current situation is performed. If no decline in mental and emotional status of the elderly patients that were previously infected with SARS-CoV-2 is identified, it returns to the step in which a patient or category of patients is selected.

If a decline is identified, the next phase of the procedure is activated, i.e., the management of mental and emotional health during and after COVID-19 pandemic. This one is structured in two parts: (1) appropriate healthcare assistance and services and (2) monitoring of the risk management plan.

(1) Appropriate healthcare assistance and services start with *actions for sustaining mental and emotional health*. Some of these most representative actions are:


These actions should be followed by *analyses of mental and emotional health*. These analyses imply:


The results of this phase of the procedure are evaluated in order to establish the state of mental and emotional wellness. If it is better or stable, the actions for sustaining mental and emotional health proved to be reliable, and they continue to be applied. If the mental and emotional wellness is worse, the possible reason is looked for:


In both cases, the procedure is resumed accordingly.

(2) The Monitoring phase implies *periodical track of the progress of the management*. It is performed based on comprehensive questionnaires, surveys, and direct feedback for the implied users/actors. An assessment of the results is performed. If the results are not improved (i.e., the state of mental and emotional health of the elderly patients is not better or the healthcare resources have not become more efficient), it means that the whole risk management plan should be improved, so the procedure is restarted from the beginning in order to be refined or updated.

If the risk management proves to be improved, the next step consists of the *embedment and refinement of the proposed procedure in clinical good practices*.

In parallel*, longitudinal studies for the assessment of the efficiency and impact of risk management* must be performed. Between these two last phases of the procedure, real-time targeted information is shifted, shared, and used, aiming for the refinement of the procedure.

As the procedure is implemented in a medical unit, and in time it demonstrates its efficacy, reliability, and efficiency, it becomes a good clinical practice; the more good practices, the more new *learning from them* can be obtained.

All the committed information, data, and knowledge generated by the embedment and refinement of the proposed procedure in good clinical practices, longitudinal studies for the assessment of the efficiency and impact of risk management, and learning from good practices have great potential to sustain *improved policy instruments, research, education, and other types of clinical practice*. Additionally, starting from these improvements, the proposed procedure itself can be improved starting from different levels, as it is presented in Figure 1 in the areas where the information flux connectors are shown.

This approach sustains the scalability and flexibility of the proposed procedure.

### *2.3. Steps for Implementing Functionalities Provided by RMDSs in Accordance with the Proposed Procedure*

Designing and implementing an RMDS targeted to support the management of mental and emotional disorders related to SARS-CoV-2 infection can be naturally integrated into the consecutive phases of the proposed procedure. Some of cases were already mentioned previously. Here are all the phases in the proposed procedure (presented in the diagram from Figure 1 in which the RMDSs can be used/implied:


of Artificial Intelligence or Big Data Analytics that can be included as capabilities in RMDSs;

	- *Monitoring of the risk management plan*—namely, the *Periodical track progress of the management* and *the Longitudinal studies for the assessment of the efficiency and impact of the management* can be sustained by specific functionalities provided by RMDSs, such as targeted questionnaires or statistics based on the users' feedback, medical outcomes, and financial and human resources involved in the medical care given to the elderly due to mental and emotional disorders associated with COVID-19. *the management* can be sustained by specific functionalities provided by RMDSs, such as targeted questionnaires or statistics based on the users' feedback, medical outcomes, and financial and human resources involved in the medical care given to the elderly due to mental and emotional disorders associated with COVID-19. In conclusion, for a successful implementation of dedicated RMDSs for sustaining

In conclusion, for a successful implementation of dedicated RMDSs for sustaining long-term personalized management of mental and emotional decline, their targeted users should be involved throughout the entire development cycle, from the definition of technical and (non)functional requirements and specifications, to testing in laboratory and real conditions and, in the longer term, to the upgrades required by the dynamism of the field of smart devices and emerging technologies. No less important is the need for the RMDS architecture to be scalable, flexible, secure, reusable, agile, robust, and age-friendly in order to be easily adapted and integrated into different clinical environments or elderly's homes. long-term personalized management of mental and emotional decline, their targeted users should be involved throughout the entire development cycle, from the definition of technical and (non)functional requirements and specifications, to testing in laboratory and real conditions and, in the longer term, to the upgrades required by the dynamism of the field of smart devices and emerging technologies. No less important is the need for the RMDS architecture to be scalable, flexible, secure, reusable, agile, robust, and age-friendly in order to be easily adapted and integrated into different clinical environments or elderly's homes.

#### **3. Results 3. Results**

*3.1. Results from a Sample of Romanian Surveys on COVID-19 3.1. Results from a Sample of Romanian Surveys on COVID-19* 

(a) Results from IRES SURVEY "A month of loneliness" [59] (a). Results from IRES SURVEY "A month of loneliness" [59]

The collected data proved that the elderly (aged 65+) are the ones who, during this period, also face greater health problems than before the COVID-19 pandemic, experiencing, in high proportions, feelings of loneliness and fear of death caused by SARS-CoV-2 infection, but also the fear of a food crisis (see Figures 2 and 3). The collected data proved that the elderly (aged 65+) are the ones who, during this period, also face greater health problems than before the COVID-19 pandemic, experiencing, in high proportions, feelings of loneliness and fear of death caused by SARS-CoV-2 infection, but also the fear of a food crisis (see Figures 2 and 3).

**Figure 2.** How did you get through most of the first 30 days of the pandemic? **Figure 2.** How did you get through most of the first 30 days of the pandemic?

**Figure 3.** Since declaring the state of emergency, have you felt any of the following states/feelings?

It can be observed from Figure 2 that the fear of infection or death caused by SARS-CoV-2 infection, the feeling of loneliness, the fear of a food crisis, and the existence of bigger health problems have higher percentages in the case of the elderly than in the rest of the entire population. Such problems have a strong impact on their psycho-emotional state.

(b) Results from IRES SURVEY "Romanians after 2 years of COVID-19" [60]

According to the research, one in four people aged 65+ in the urban environment, that is, over 450,000 people, face a high degree of loneliness, and 36% of respondents feel an average degree of loneliness.

Factors such as poor health status or the loss of a life partner contribute to restricting social interactions, such that 28% of the elderly end up socializing with a maximum of four people in a whole month.

Oppressive loneliness affects the elderly, including their health: thus, one in four seniors declare that they have poor physical and mental health. Among people with a high degree of loneliness, 39% have physical problems. Health problems cause one to spend more time indoors: 64% of seniors spend most of their time performing household activities such as cooking or cleaning, occupations used as mechanisms to combat loneliness.

Their routine looks like this: 43% go for a walk exclusively around the house or in the park, 33% watch TV, and only 27% have activities outside the home, including gardening or other hobbies.

Those who experience a high degree of loneliness leave the house even less (18%).

(c) Results from KANTAR ROMANIA, at the request of the Never Alone—Friends of the Elderly Association [61]

In the context of the possibility that the intensity of the current pandemic will decrease in the next period, the survey wanted to evaluate, at the same time, the degree of concern regarding the current pandemic, but also the possibility of a new pandemic, as well as the time horizon in which Romanians expect the current pandemic to end.

The results show that although the COVID-19 pandemic had a significant impact on the health and psycho-emotional state of Romanians, 21% of older Romanians are no longer worried at all about the current pandemic. At the moment, 58% are worried about a war in the region.

More than half (53%) of the elderly participants in the IRES study believe that the current pandemic will end this year. At the same time, however, one in three older people in Romania (36%) believe that the emergence of a new pandemic in the near future is very likely.

The results regarding the degree of concern of the 65+ population relative to the COVID-19 pandemic are presented in Table 4.


**Table 4.** Degree of concern of the 65+ population relative to the COVID-19 pandemic.

Regarding the good changes brought about by the COVID-19 pandemic among the elderly, they are mainly related to the time available to be spent with the family and to the way of protecting their health more during the pandemic.

Regarding the bad changes brought about by the COVID-19 pandemic among the elderly, they are mainly related to the restrictions and limitations of movement, the limitations imposed on social life and interaction with others, the limitation of access to medical services, the alteration of the state of health, the states of stress related to the fear of not contacting the virus and the pain related to the death of a close person.

The elderly in Romania believe that they have learned something new thanks to the pandemic, something that they would not have learned in another context. Along with the functional elements related to respecting the hygiene rules and maintaining social distance or those related to health or saving money, many aspects aimed at empathy and the relationship with other people are also included.

Freedom of movement is the first aspect that Romanian seniors have in mind when they are asked what would be the first thing they would do when all the restrictions in Romania are lifted.

### *3.2. Assistance of the Elderly through Dedicated Functionalities of RO-SmartAgeing System* 3.2.1. Brief Presentation of RO-SmartAgeing System

As the isolation and apprehension brought on by the pandemic have strongly influenced the mental health and wellbeing of the elderly, even though it is still an uncertain situation to visit them in person, it is critical to keep a regular connection in order to look after any changes or signs that could lead to a senior's mental or behavioral health concern. In this context, an RMDS for sustaining the mental health of the elderly in their home environment is an enhanced necessity.

RO-SmartAgeing is a system designed to offer personalized in-home services for an elderly person, based on the remote monitoring of various health and ambient parameters and daily activities, across a range of preventative and proactive features targeted to sustain a healthy, independent, and active life; specific requirements for the elderly in order to avoid unexpected concerns related to their mental or behavioral problems.

The smart environment encompassed into the system gathers a set of devices that can be customized and tailored according to elderly patients' health and needs. Their most important technical characteristics are presented as follows:

• Withings MoveECG smartwatch [65]: With a diameter of 38 mm and a weight of 32 g, it can be used to track health parameters (Electrocardiogram—ECG sensor) as well as daily activity information (altimeter and accelerometer sensors). Based on Bluetooth Low Energy (BLE) syncing with a smartphone, it is considered a smartwatch for monitoring day and night activity; daily activity information (altimeter and accelerometer sensors). Based on Bluetooth Low Energy (BLE) syncing with a smartphone, it is considered a smartwatch for monitoring day and night activity;

• Withings MoveECG smartwatch [65]: With a diameter of 38 mm and a weight of 32 g, it can be used to track health parameters (Electrocardiogram—ECG sensor) as well as

*Healthcare* **2023**, *11*, x 18 of 34


The HealthMate application collects all the data from the Withings-related devices, and the RO-SmartAgeing system is configured in order to transmit the information into the Cloud database for additional analysis and processing. The HealthMate application collects all the data from the Withings-related devices, and the RO-SmartAgeing system is configured in order to transmit the information into the Cloud database for additional analysis and processing.

The gait band is also programmed to send the relevant data into the Cloud database. The RO-SmartAgeing Cloud database is integrated into the ICIPRO Cloud platform [70], and it is configured to collect a wide range of data (see Figure 4). The gait band is also programmed to send the relevant data into the Cloud database. The RO-SmartAgeing Cloud database is integrated into the ICIPRO Cloud platform [70], and it is configured to collect a wide range of data (see Figure 4).


**Figure 4.** ROSmartAgeing Cloud database illustration of a series of consecutive measurements of multiple parameters performed with the devices.

After the data are gathered into the Cloud database, they can be further visualized in the RO-SmartAgeing platform. The RO-SmartAgeing platform has five types of users: the physician, patient, caregiver, specialist physician, and administrator. Each type of user can access a module corresponding to his role and needs to authenticate in order to visualize/edit the information. The main page of the platform is presented in Figure 5, and it contains both the support services component and the medical component, which are described in the next subchapter. physician, patient, caregiver, specialist physician, and administrator. Each type of user can access a module corresponding to his role and needs to authenticate in order to visualize/edit the information. The main page of the platform is presented in Figure 5, and it contains both the support services component and the medical component, which are described in the next subchapter.

**Figure 4.** ROSmartAgeing Cloud database illustration of a series of consecutive measurements of

After the data are gathered into the Cloud database, they can be further visualized in the RO-SmartAgeing platform. The RO-SmartAgeing platform has five types of users: the

*Healthcare* **2023**, *11*, x 19 of 34

multiple parameters performed with the devices.

**Figure 5.** The main page of the RO-SmartAgeing platform (in Romanian). **Figure 5.** The main page of the RO-SmartAgeing platform (in Romanian).

In the above figure, the left side of the main page describes the menu of the platform: the button towards the Home page, the "Support Services" button (with the following sub-menu options: "Elderly support", "Caretakers support", "Social support", "Fall prevention" and "Useful information") and the "Medical Services" button (with the following sub-menu options: "Physician", "Patient", "Caretaker", "Specialist physician" categories for specific authentication). In the center, there is the logo of RO-SmartAgeing, as well as a description of the system. Other relevant links and information can be found in the footer area of this page. In the above figure, the left side of the main page describes the menu of the platform: the button towards the Home page, the "Support Services" button (with the following submenu options: "Elderly support", "Caretakers support", "Social support", "Fall prevention" and "Useful information") and the "Medical Services" button (with the following sub-menu options: "Physician", "Patient", "Caretaker", "Specialist physician" categories for specific authentication). In the center, there is the logo of RO-SmartAgeing, as well as a description of the system. Other relevant links and information can be found in the footer area of this page.

#### 3.2.2. Specific Capabilities of RO-SmartAgeing System

Various factors can lead to a significant increase in the risk of developing mental health problems. However, a preventative approach through maintaining a good quality of life for one individual can have an enormous impact on his/her behavior and mental state over time. The remote monitoring of a person who is prone to mental decline is a serious aspect that needs to be taken into consideration when it comes to diminishing the risk of emotional and mental long-term decline after a SARS-CoV-2 infection. 3.2.2. Specific Capabilities of RO-SmartAgeing SystemVarious factors can lead to a significant increase in the risk of developing mental healthproblems. However, a preventative approach through maintaining a good quality of life for one individual can have an enormous impact on his/her behavior and mental state over time. The remote monitoring of a person who is prone to mental decline is a serious aspect that needs to be taken into consideration when it comes to diminishing the risk of emotional and mental long-term decline after a SARS-CoV-2 infection.

The RO-SmartAgeing system is provided with specific capabilities for addressing improved preventative and proactive support for diminishing the risk of emotional and mental long-term decline after SARS-CoV-2 infection. The RO-SmartAgeing system is provided with specific capabilities for addressing improved preventative and proactive support for diminishing the risk of emotional and mental long-term decline after SARS-CoV-2 infection.

RO-SmartAgeing has a significant impact through the novel integrated solutions regarding monitoring, wellbeing, and support services enabling an enhanced patient quality of life, especially for the elderly who need to improve and sustain not only their medical health but also their mental health, wellbeing, and behavioral health, as well as their social skills.

The RO-SmartAgeing system encompasses the medical and support service components. The medical component aims to incorporate in a single point, with controlled access, a series of functionalities adapted to each type of user (physician, elderly person, caregiver/family member, specialist physician). It is designed to support personalized monitoring and management of a senior's health in a friendly environment. In addition to this, the support services component is focused on providing specific information and recommendations related to the daily life needs of the elderly: information on aging-related conditions and diseases and recommendations for healthy, independent, social living.

Monitoring mental illness symptoms is very important because they can influence emotions, thoughts, or behaviors among the elderly; there are sensors, wearable devices (RO-SmartAgeing smart environment), questionnaires, and cognitive tests encompassed into the RO-SmartAgeing system that could track and sustain the quality of life of the patients.
