• **The Support Services Component**

The support services component aims to provide both seniors and caregivers with information and recommendations specific to the daily life needs of the seniors. It attempts to provide the necessary information specific to the older people's conditions and recommendations for a healthy, independent, and social life, and it also allows the possibility of assessing the mental and behavioral capabilities of the elderly using cognitive tests.

#### *A. Social relationship support and cognitive abilities module*

This module offers the opportunity for the elderly and their caregivers to assess the patient's cognitive abilities and improve their social relationships through interactive tests and relevant information regarding the social aspect of their life. Social networks have a great impact on the quality of life of the elderly, especially in the emotional quality of social relationships. They offer older people the opportunity to renew or develop social contacts and to actively engage in their own community, thus preventing the social isolation of older people and the feeling of loneliness that occurs in the case of retirement, health deterioration, or COVID-19-related quarantine.

The *Social relationship support and cognitive abilities* module covers two sections: (self-)assessment cognitive tests and social support for the elderly.

The purpose of the first section is to allow elderly people to self-assess their cognitive abilities or let their caregivers help them in their evaluation through the provided tests in the RO-SmartAgeing application. Evaluating cognitive abilities or neurological impairments is essential for the elderly, especially in the COVID-19 era, as the mental state or condition can deteriorate.

Among the smart devices encompassed in the smart environment, RO-SmartAgeing has the capability of providing a series of cognitive tests for the patient in order to be evaluated by themselves, or by the caregiver or physician. The cognitive tests integrated into RO-SmartAgeing are either

• developed by medical specialists that use the RO-SmartAgeing system as support in the provision of specialized medical services; or into RO-SmartAgeing are either • developed by medical specialists that use the RO-SmartAgeing system as support in the provision of specialized medical services;

The purpose of the first section is to allow elderly people to self-assess their cognitive abilities or let their caregivers help them in their evaluation through the provided tests in the RO-SmartAgeing application. Evaluating cognitive abilities or neurological impairments is essential for the elderly, especially in the COVID-19 era, as the mental state or

Among the smart devices encompassed in the smart environment, RO-SmartAgeing has the capability of providing a series of cognitive tests for the patient in order to be evaluated by themselves, or by the caregiver or physician. The cognitive tests integrated

• based on some of the most popular screening tools for cognitive impairments, such as *MMSE* [22], *MoCA* [23], and *Mini-Cog* [29] (see Figure 6). or • based on some of the most popular screening tools for cognitive impairments, such as *MMSE* [22], *MoCA* [23], and *Mini-Cog* [29] (see Figure 6).


*Healthcare* **2023**, *11*, x 23 of 34

condition can deteriorate.

**Figure 6.** RO-SmartAgeing (Self-)assessment cognitive tests (in Romanian). **Figure 6.** RO-SmartAgeing (Self-)assessment cognitive tests (in Romanian).

Figure 6 describes the (Self-)assessment cognitive tests (Teste de (auto)evaluare capaciate cognitive) page in the RO-SmartAgeing platform. There are two boxes under the page title for the "Search test (Căutare chestionar)" functionality (the users may search, based on certain keywords, the kind of test that they are looking for) and the "Choose recording (Alege înregistrări)" functionality (the users can select "All the recordings (Toate înregistrările)" option which displays all the tests from the database or choose other options for displaying associated information). Next to these boxes, there is the "Add test (Adăugare test)" button which enables the authorized user to add another test. Below, under the title "Test name (Denumire test)", there is a list of four current available tests: a cognitive assessment test uploaded by one physician (Test de evaluare capacitate cognitive), and the MMSE, MoCA, and Mini-Cog evaluation tests. The "Actions (Acțiuni)" that can be applied to the tests are the following: "Details (Detalii)" (for showing the details of a certain test), "View (Vizualizare)" (for visualizing the test), "Edit (Editare)" (if the physician is authenticated, the "Edit" button is available in order to modify or add information), "Download (Descarcă pdf)" (if the patient wants to download and print the test) and the "Delete (Ștergere)" option (for deleting the test). Figure 6 describes the (Self-)assessment cognitive tests (Teste de (auto)evaluare capaciate cognitive) page in the RO-SmartAgeing platform. There are two boxes under the page title for the "Search test (Căutare chestionar)" functionality (the users may search, based on certain keywords, the kind of test that they are looking for) and the "Chooserecording (Alege înregistrări)" functionality (the users can select "All the recordings (Toate înregistrările)" option which displays all the tests from the database or choose other options for displaying associated information). Next to these boxes, there is the "Add test(Adăugare test)" button which enables the authorized user to add another test. Below, under the title "Test name (Denumire test)", there is a list of four current available tests: a cognitive assessment test uploaded by one physician (Test de evaluare capacitate cognitive), and the MMSE, MoCA, and Mini-Cog evaluation tests. The "Actions (Act,iuni)" that can be applied to the tests are the following: "Details (Detalii)" (for showing the details of a certain test), "View (Vizualizare)" (for visualizing the test), "Edit (Editare)" (if the physician is authenticated, the "Edit" button is available in order to modify or add information), "Download (Descarcă pdf)" (if the patient wants to download and print the test) and the "Delete (S, tergere)" option (for deleting the test).

The MMSE is easily downloadable from the RO-SmartAgeing platform. It is administered with the assistance of the caregiver in order to assure the robustness of the answers, and via telehealth, it supports the patients for whom distance, expenses, or mobility are considered obstacles to proceeding with face-to-face in-hospital visits. Thus, the elderly patient who is monitored using the RO-SmartAgeing system can be periodically evaluated in terms of the following cognitive functions: time and space orientation, enrollment, awareness and calculation, recall, praxis, and language.

RO-SmartAgeing also provides the possibility of downloading the MoCA test. The test is performed by the elderly patient assisted by the caretaker and, optionally, via videoconference, by the physician. The results of the MoCA test can provide information in addition to the evaluations of the mental state of the patient obtained following the use of other tests accessible through the RO-SmarAgeing system, such as the level of orientation, short-term memory, visuospatial capacity, abstraction, attention, or use of language. short-term memory, visuospatial capacity, abstraction, attention, or use of language. The Mini-Cog test can be easily downloaded from the RO-SmartAgeing platform. As the elderly patient (assisted by the caretaker) has only to repeat three words and draw a clock, this test can be easily performed and interpreted in a step-wise fashion. It provides

The MMSE is easily downloadable from the RO-SmartAgeing platform. It is administered with the assistance of the caregiver in order to assure the robustness of the answers, and via telehealth, it supports the patients for whom distance, expenses, or mobility are considered obstacles to proceeding with face-to-face in-hospital visits. Thus, the elderly patient who is monitored using the RO-SmartAgeing system can be periodically evaluated in terms of the following cognitive functions: time and space orientation, en-

RO-SmartAgeing also provides the possibility of downloading the MoCA test. The test is performed by the elderly patient assisted by the caretaker and, optionally, via videoconference, by the physician. The results of the MoCA test can provide information in addition to the evaluations of the mental state of the patient obtained following the use of other tests accessible through the RO-SmarAgeing system, such as the level of orientation,

The Mini-Cog test can be easily downloaded from the RO-SmartAgeing platform. As the elderly patient (assisted by the caretaker) has only to repeat three words and draw a clock, this test can be easily performed and interpreted in a step-wise fashion. It provides a neuropsychological evaluation of the patient, which contributes in a reliable way to the early diagnosis of some cognitive disorders. a neuropsychological evaluation of the patient, which contributes in a reliable way to the early diagnosis of some cognitive disorders. The second section of the *Social relationship support and cognitive abilities* module aims to synthesize the benefits brought to the elderly by ensuring quality social support (see Figure 7), and thus the advantages brought by the social involvement of the elderly in the

The second section of the *Social relationship support and cognitive abilities* module aims to synthesize the benefits brought to the elderly by ensuring quality social support (see Figure 7), and thus the advantages brought by the social involvement of the elderly in the community, the facilitation of new social contacts, as well as the benefits of intergenerational activities are provided. community, the facilitation of new social contacts, as well as the benefits of intergenerational activities are provided. The presented information aims to offer the necessary support for the development of social relationships (with physicians, relatives, friends, and people with similar concerns), such as the elderly's access to support groups.

*Healthcare* **2023**, *11*, x 24 of 34

rollment, awareness and calculation, recall, praxis, and language.


**Figure 7.** Recommendations regarding the provision of social support for the elderly (in Romanian).

**Figure 7.** Recommendations regarding the provision of social support for the elderly (in Romanian). The presented information aims to offer the necessary support for the development of social relationships (with physicians, relatives, friends, and people with similar concerns), such as the elderly's access to support groups.

In the above figure, the page entitled "Recommendations regarding the provision of social support for the elderly (Recomandări privind asigurarea suportului social pentru vârstnic)" enables the user to search for certain information on the webpage, but also to select data based on the "Search information (Căutare informat,ii suport social)" box and "Select recording (Alege înregistrări)" box, respectively. The "Add information (Adăugare informat,ii)" button allows any authorized user to introduce relevant information. The recommendations for social support are displayed under the title "Recommendation name (Denumire recomandare)", containing relevant information about ideas for establishing social interactions among the elderly (for example, information about various seniors' clubs (Clubul Seniorilor "Mihai Eminesccu" – Sectorul 6, Bucures,ti), day centers for old persons (Centrul de zi "Clubul Seniorilor Covasna", Sector 4, Bucures,ti), etc.). Some Actions (Act,iuni) are available for the authorized user. All the recommendations are associated with the "View (Vizualizare)" button that enables the display of the accessed data. Although

all the information stored in the RO-SmartAgeing platform can be modified only by the authorized health specialist that introduced it, some recommendations can be edited (the "Edit (Editare)" button) or erased (the "Delete (S, tergere)" button) only by the webpage administrator.

#### *B. Support services for elderly people*

This category of services will provide informative and interactive support for the conditions and problems faced by the elderly to help them strengthen a healthy and independent life. The subcomponent will allow the elderly to self-assess their quality of life using interactive questionnaires.

The quality of life of the elderly includes both subjective elements (psychological wellbeing, autonomy, the activity carried out pursuing a certain goal, social relationships, spirituality, and identity) and objective elements (physical and care environment, physical and mental health, level of functioning, and socio-economic status).

The *Support services for elderly people* module covers three sections: information on aging-related conditions, healthy and independent living information, and quality of life and wellbeing self-assessment questionnaires.

The purpose of the first section is to provide anyone interested with basic information about the most important conditions, as well as their specificities, associated with aging. It is important that the specifics of a geriatric condition be understood by non-medical, elderly, or other interested people (see Figure 8). *Healthcare* **2023**, *11*, x 26 of 34


**Figure 8.** Information on aging-related conditions section (in Romanian). **Figure 8.** Information on aging-related conditions section (in Romanian).

In the above figure, the "Ageing-related health conditions (Afecțiuni associate îmbătrânirii)" webpage displays the "Search condition (Căutare afecțiune)" and "Select recording (Alege înregistrări)" boxes, as well as the "Add health condition (Adăugare afecțiune)" button for authorized users. Below, under the title "Health condition name (Denumire afecțiune)", a list of such health conditions from the RO-SmartAgeing database is displayed: diabetes (Diabet), hypertension (Hipertensiune arterială), osteoporosis (Osteoporoză), dementia (Demență), and Parkinson's disease (Boala Parkinson). On the right, there are the actions available for these items: the "View (Vizualizare)" button for displaying the stored information, and the "Edit (Editare)" and "Delete (Ștergere)" buttons available for an authenticated user in order to modify that record. In the above figure, the "Ageing-related health conditions (Afect,iuni associate îmbătrânirii)" webpage displays the "Search condition (Căutare afect,iune)" and "Select recording (Alege înregistrări)" boxes, as well as the "Add health condition (Adăugare afect,iune)" button for authorized users. Below, under the title "Health condition name (Denumire afect,iune)", a list of such health conditions from the RO-SmartAgeing database is displayed: diabetes (Diabet), hypertension (Hipertensiune arterială), osteoporosis (Osteoporoză), dementia (Dement,ă), and Parkinson's disease (Boala Parkinson). On the right, there are the actions available for these items: the "View (Vizualizare)" button for displaying the stored information, and the "Edit (Editare)" and "Delete (S, tergere)" buttons available for an authenticated user in order to modify that record.

The displayed centralized information on the main conditions associated with aging can be accessed by anyone without the need to be registered. It is the authorized user

The second section, healthy and independent living information, aims to gather all the relevant information for elderly users and their caregivers in order to support the process of active and independent aging through a series of preventive measures and recom-

The information is mostly related to chronic conditions and premature aging, considered risk factors for mental and behavioral health degeneration: alcohol and tobacco consumption, unhealthy diets, and the inclusion of physical exercises in daily activities. In addition to this, cognitive health—the ability to think, learn and retain clearly—is an

Cognitive health is only one aspect of overall brain health. Brain health can be affected by age-related brain changes, injuries such as stroke or traumatic brain injury, mood disorders such as depression, substance use disorder (drug addiction), and diseases such as Alzheimer's disease. While there are some factors that affect brain health that cannot be changed, there are many lifestyle aspects that could make a difference. This section

awareness of the risks associated with aging and offer support for better management of

mendations toward monitoring their health status.

important component of carrying out everyday activities.

one's own health condition in order to sustain his/her mental health.

The displayed centralized information on the main conditions associated with aging can be accessed by anyone without the need to be registered. It is the authorized user (physician or healthcare provider) who will enter this structured information in a way that is as accessible as possible to the elderly. In this context, this can increase the level of awareness of the risks associated with aging and offer support for better management of one's own health condition in order to sustain his/her mental health.

The second section, healthy and independent living information, aims to gather all the relevant information for elderly users and their caregivers in order to support the process of active and independent aging through a series of preventive measures and recommendations toward monitoring their health status.

The information is mostly related to chronic conditions and premature aging, considered risk factors for mental and behavioral health degeneration: alcohol and tobacco consumption, unhealthy diets, and the inclusion of physical exercises in daily activities. In addition to this, cognitive health—the ability to think, learn and retain clearly—is an important component of carrying out everyday activities.

Cognitive health is only one aspect of overall brain health. Brain health can be affected by age-related brain changes, injuries such as stroke or traumatic brain injury, mood disorders such as depression, substance use disorder (drug addiction), and diseases such as Alzheimer's disease. While there are some factors that affect brain health that cannot be changed, there are many lifestyle aspects that could make a difference. This section presents information and recommendations to improve the cognitive ability of the elderly (see Figure 9). *Healthcare* **2023**, *11*, x 27 of 34 presents information and recommendations to improve the cognitive ability of the elderly (see Figure 9).


**Figure 9.** Healthy and independent living information section (in Romanian). **Figure 9.** Healthy and independent living information section (in Romanian).

Figure 9 displays the "Recommendations for living a healthy and independent life (Recomandări pentru o viață sănătoasă și independentă)" module. The user has access to the boxes for "Search recommendation (Căutare recomandare)" and "Select recording (Alege înregistrare)" functionalities that are useful in the case of a list with a lot of recordings from the database. The button for "Add a recommendation (Adăugare recomandare)" allows the authenticated user to upload the related information into the RO-SmartAgeing database. The displayed list under the title "Recommendation name (Denumire recomandare)", contains three recommendations: "Cognitive health and the elderly (Sănătatea cognitivă și persoanele vârstnice)", "Advices for improving memory (Sfaturi pentru îmbunătățirea memoriei)", and "Minor cognitive deficit (Deficit cognitive minor)". As previously mentioned, the available buttons for these recommendations are as follows: "View (Vizualizare)" to visualize the stored information, "Edit (Editare)" and "Delete (Ștergere)" to modify the information by the authorized users. Figure 9 displays the "Recommendations for living a healthy and independent life (Recomandări pentru o viat,ă sănătoasă s,i independentă)" module. The user has access to the boxes for "Search recommendation (Căutare recomandare)" and "Select recording (Alege înregistrare)" functionalities that are useful in the case of a list with a lot of recordings from the database. The button for "Add a recommendation (Adăugare recomandare)" allows the authenticated user to upload the related information into the RO-SmartAgeing database. The displayed list under the title "Recommendation name (Denumire recomandare)", contains three recommendations: "Cognitive health and the elderly (Sănătatea cognitivă s,i persoanele vârstnice)", "Advices for improving memory (Sfaturi pentru îmbunătăt,irea memoriei)", and "Minor cognitive deficit (Deficit cognitive minor)". As previously mentioned, the available buttons for these recommendations are as follows: "View (Vizualizare)" to visualize the stored information, "Edit (Editare)" and "Delete (S, tergere)" to modify the information by the authorized users.

The last module, Quality of life and wellbeing self-assessment questionnaires, provides anyone interested with relevant questionnaires to self-evaluate the level of their quality of life and overall wellbeing. This module offers the possibility to increase the

The questionnaires in this module refer to physical and psychological health, social

The impact of the pandemic on the psycho-emotional state of seniors due to poor physical or mental health and accentuated by several risk factors that generated anxiety, loneliness, depression, fear of health problems, infection, or even death, was mentioned as an outcome of some surveys undertaken in Romania during or after the COVID-19 pandemic. The elderly in Romania say that during this period, they felt anxious and agitated to a greater extent than before the pandemic, they felt sad, depressed, or hopeless more than before the pandemic, and they felt that they could not stop worrying or keep

Such a result constitutes the basis of the participatory design of new RDMSs. The elderly have to be actively involved in the design process to help ensure that the result

relationships, and the elderly person's home environment.

meets their needs and is usable even during pandemic periods.

**4. Discussion** 

their worries under control.

helps them in making decisions about the management of their own health.

The last module, Quality of life and wellbeing self-assessment questionnaires, provides anyone interested with relevant questionnaires to self-evaluate the level of their quality of life and overall wellbeing. This module offers the possibility to increase the awareness of the elderly concerning the risks associated with aging, and as a result, it helps them in making decisions about the management of their own health.

The questionnaires in this module refer to physical and psychological health, social relationships, and the elderly person's home environment.

#### **4. Discussion**

The impact of the pandemic on the psycho-emotional state of seniors due to poor physical or mental health and accentuated by several risk factors that generated anxiety, loneliness, depression, fear of health problems, infection, or even death, was mentioned as an outcome of some surveys undertaken in Romania during or after the COVID-19 pandemic. The elderly in Romania say that during this period, they felt anxious and agitated to a greater extent than before the pandemic, they felt sad, depressed, or hopeless more than before the pandemic, and they felt that they could not stop worrying or keep their worries under control.

Such a result constitutes the basis of the participatory design of new RDMSs. The elderly have to be actively involved in the design process to help ensure that the result meets their needs and is usable even during pandemic periods.

Our proposed procedure for managing the elderly's risk of mental and emotional long-term decline after SARS-CoV-2 infection *creates a framework* for the development of personalized, proactive models specific to certain cognitive conditions, aiming to perform the following:


Among the most representative *barriers* to a successful implementation of the proposed procedure for managing the elderly patient's risk of mental and emotional long-term decline after SARS-CoV-2 infections are the following:


The efficient management of the risk of mental and emotional long-term decline after SARS-CoV-2 infection is definitively based on the deep implication of the elderly patient and their attending physicians.

As the COVID-19 pandemic may impact not only the elderly's health, but also their mental health and wellbeing, remote health monitoring is necessary to assess and keep them updated with their vital signs and key information regarding social support, their cognitive state, or recommendations for a healthy and independent life.

In order to be proactive, preventative, personalized, and participative, a supporting RMDS must rely on their demands and necessities from the design stage. A participative approach allows the specification of the most appropriate technical and (non-)functional criteria and the identification of a large range of risks (for instance, the risk of triggering false alerts or ignoring age-friendly functionalities).

The RO-SmartAgeing system is an RMDS in which the patient design replaced the patient centricity and in which the elderly patients with potential progressive cognitive impairments are engaged in advanced personalized care models.

RO-SmartAgeing incorporates the development and validation of a system for monitoring and evaluating the health status of the elderly that integrates non-invasive, wearable physiological (Withings MoveECG smartwatch, Withings Sleep Analyzer, Withings Thermo, Withings Body+ Smart Scale, and Withings Blood Pressure Monitor) devices and movement sensors (gait band) to collect medical parameters, to monitor daily activities and lifestyle of the person, all integrated into a smart environment as well as a cloud platform for data storage and aggregation. An added value brought by RO-SmartAgeing is the possibility of (self-)assessing the mental and emotional health of the elderly, considering the vulnerability of their mental state in terms of the COVID-19 pandemic. This assessment is corroborated by physical evaluations, lifestyle, daily activities, and medical history, and thus, a broad range of comprehensive information is established and prepared for further analytics and supporting healthcare functionalities.

Monitoring a wide range of health parameters and offering constant and necessary information regarding the daily life, medical and social needs of the elderly, RO-SmartAgeing is a challenging solution for sustaining mental and behavioral health in times of COVID-19, especially in Romania.

The main functionalities of the RO-SmartAgeing system that can reliably support the management of the elderly's risk of emotional and mental long-term decline after SARS-CoV-2 infection are as follows:


Based on the stored data, additional functionalities are implemented that allow the following support services:


The RO-SmartAgeing system has the following main features:


**Limitations**: As the RO-SmartAgeing pilot system has just been completed and since it has been tested only in a laboratory environment, only some of the steps from the proposed procedure for managing the elderly's risk of emotional and long-term decline after SARS-CoV-2 infection could be implemented.

**Future work**: The RO-SmartAgeing system will be implemented in a clinical environment, as it is already discussed with some legal entities and physicians from private and public clinics. In this respect, some preliminary stipulations and action plans have been initiated with the National Institute of Gerontology and Geriatrics "Ana Aslan" and Hospice Care for the Elderly of the Bucharest Municipality "Academician Nicolae Cajal". After a representative number of elderly patients (the target number for the beginning is 100) are enrolled in a legally established trial, we estimate that in three months after the beginning of the monitoring and management of the mental and emotional health of an elderly person with the support of the RO-SmartAgeing system, the first periodical track progress of the management can be initiated. The appropriate periodicity for this tracking will be established according to the physicians' demands and evaluations. The phase for embedment and refinement of the procedure in good clinical practices is estimated to first start after another three months.

#### **5. Conclusions**

The COVID-19 pandemic has had a significant impact on the elderly, with potentially dramatic long-term repercussions on their mental and emotional health. The impact of the pandemic on the psycho-emotional state of Romanian seniors is due to the lack of predictability, the avalanche of information, often contradictory, and the imposition of restrictions that some people have never faced during their lives, were elements that generated, in the two years, states of fear, anxiety or stress. Since the spring of 2020, in a relatively short interval, various surveys addressed to the elderly population have revealed multiple negative and aggravating effects on their emotional or mental balance, wellbeing, and quality of life. The results of these surveys can constitute part of a new framework able to support more efficiently elderly patient-centered management, adapted to the dysfunctions and challenges brought by this new pandemic in a society that was already in an accelerated aging.

The proposed procedure for the management of the risk of a mental and emotional long-term decline of the elderly following SARS-CoV-2 infection is based on an integrated and complex system of information, recent research results, and knowledge regarding the mental and emotional health of elderly patients. The proposed procedure is scalable and perfectible through the periodic analysis of the results of the management of mental and emotional health, through sequential reiteration in the case of identifying inappropriate results, and through longitudinal studies for the assessment of the efficiency and impact of the management. The integration of RMDSs in multiple phases of the procedure gives it new capabilities that support the approach to mental and emotional health through personalized, preventive, and proactive healthcare services. An RMDS such as the RO-SmartAgeing system is a concrete example of the benefits that non-intrusive monitoring of the health status, lifestyle, and daily activities of an elderly patient, combined with support services for sustaining some social relationships and an active and independent life, with a real-time dynamic link to the medical staff, can bring to the efficiency of the management of the elderly's mental and emotional health. The RO-SmartAgeing system is to be continuously developed and completed with new functionalities based on new information and requirements resulting from new research, surveys, and medical specifications aimed at remote monitoring of elderly patients.

**Author Contributions:** Conceptualization, M.I. and A.A.; data curation, E.-A.P.; investigation, M.I., E.-A.P. and A.A.; methodology, M.I. and E.-A.P.; project administration, M.I.; software, E.-A.P.; supervision, A.A.; writing—original draft, M.I., E.-A.P. and A.A.; writing—review and editing, A.A. All authors have read and agreed to the published version of the manuscript.

**Funding:** The authors gratefully acknowledge the contribution of the Romanian Ministry of Research, Innovation and Digitization for funding the following project: RO-SmartAgeing—"Non-Invasive Monitoring System and Health Assessment of the Elderly in a Smart Environment" (contract no. 3N/06.02.2019 (PN 19 37 03 01)) for the period 2019–2022.

**Institutional Review Board Statement:** Not applicable.

**Informed Consent Statement:** Not applicable.

**Data Availability Statement:** Not applicable.

**Conflicts of Interest:** The authors declare no conflict of interest.

#### **References**


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