A scoping review of the use of intelligent assistive technologies in rehabilitation practice with older adults

Abstract

Purpose

There is growing interest in intelligent assistive technologies (IATs) in the rehabilitation and support of older adults, however, the factors contributing to or preventing their use in practice are not well understood. This study aimed to develop an overview of current knowledge on barriers and facilitators to the use of smart technologies in rehabilitative practice with older adults.

Materials and Methods

We undertook a scoping review following guidelines proposed by Arksey and O’Malley (2005) and Levac et al. (2010). A computerised literature search was conducted using the Scopus and Ovid databases, yielding 7995 citations. Of these, 94 studies met inclusion criteria. Analysis of extracted data identified themes which were explored in semi-structured interviews with a purposefully selected sample of seven clinical rehabilitation practitioners (three physical therapists, two occupational therapists, and two speech-language pathologists).

Results

Barriers and facilitators to using these technologies were associated with accessibility, reported effectiveness, usability, patient-centred considerations, and staff considerations.

Conclusions

Collaborative efforts of policy-makers, researchers, manufacturers, rehabilitation professionals, and older persons are needed to improve the design of technologies, develop appropriate funding and reimbursement strategies, and minimise barriers to their appropriate use to support independence and quality of life. Any strategies to improve upon barriers to prescribing smart technologies for older people should leverage the expertise of rehabilitation professionals operating at the interface between older people; their health/mobility; their families; and technology-based solutions.

Implications for rehabilitation

• There is growing interest in intelligent assistive technologies (IATs) in the rehabilitation of older adults, as well as barriers to their use in practice.

• Rehabilitation professionals can play a key role in enabling access to IATs by recommending or prescribing their use to their older clients. Strategies to address barriers to the use of IATs for older people should leverage the expertise of rehabilitation professionals operating at the interface between older people, their families, and technology-based solutions.

• Older people and their families require technical support to initiate and continue to use IATs for rehabilitation. While rehabilitation providers may be well-placed to offer this support, they may require time and organizational support to build and maintain expertise in the fast-advancing field of smart technologies for rehabilitation.

• Cost and usability are universal challenges across the types of smart technologies considered in this review. Participatory approaches to involving older people in the design and development of smart assistive technologies contribute to better usability of these technologies. Devices and interventions that leverage more readily available devices and lower-cost components may overcome cost barriers to accessibility.

Keywords:

• Intelligent assistive technology
• rehabilitation
• disability
• older adults
• prescription

Introduction

Worldwide, more than 250 million older people are estimated to live with a moderate to severe disability [1]. Over the past 30 years, demand for rehabilitation grew by 63% [2], contributing to staff shortages and wait lists to receive rehabilitation services [3,4].

In Canada, nearly 90% of older people living with a disability report using an assistive technology (AT), which are devices designed to “maintain or improve an individual’s functioning and independence to facilitate participation and to enhance overall well-being” [5,6]. Assistive technologies have tremendous potential to support meaningful daily activities of individuals who experience functional limitations, to increase independence, and to enable aging-in-place for a growing older adult population [7–9]. AT devices can range from relatively low-tech options, such as a conventional walking cane [10], to sophisticated high-tech devices, such as robotic exoskeletons [11]. By 2050, more than two billion people worldwide will require an assistive technology [12], and though there is evidence of the barriers and facilitators for older adults [13], little is known about the barriers to prescribing these devices to older adults [14].

In many cases, rehabilitation providers enable access to assistive technologies by recommending or prescribing their use to clients. There are challenges, though, in accessing these devices, such as a lack of awareness of AT devices, and differences in power and priorities between providers and consumers of AT devices [15]. These challenges may be felt acutely by older people, who are most likely to need rehabilitation services [2]. Given expected increases in demand for rehabilitative services and assistive technologies, combined with staff shortages, a better understanding of the extreme variability (between 35–86%) of abandonment of AT is warranted [16].

Intelligent assistive technologies (IATs) are a type of AT which harness innovations in communications, robotics, sensors and voice-activated systems into assistive technologies [17]. Ienca and colleagues, in a recent review characterised the rapidly expanding field of IATs into six categories: 1) wearables (smart-watches, GPS necklaces, fall monitoring); 2) handheld devices (tablets, GPS trackers, fitness trackers, smartphones); 3) mobility aids (smart canes, smart wheelchairs with built-in sensors); 4) voice-activated assistants (Siri, Alexa, Google Home); 5) distributed systems (including smart-homes with integrated sensors for light and heat); and 6) situation-specific robots (floor cleaning, soothing, emotional response) [17,18]. Both AT and IAT have showed promising results as a cost-effective health care investment to improve the quality of life for older people [19,20]. Although work has been done on AT adoption and service delivery processes in certain age groups [21,22], to our knowledge, no previous studies have examined the barriers and facilitators to IAT prescription and use among older adults in a rehabilitation context. Though similar barriers, such as cost, access, and privacy, have been shown to affect the use of both AT and IAT by older people [13,17], we feel that given the rate at which smart assistive technology has advanced, a separate discussion of facilitators and barriers to IAT use is warranted. Furthermore, access to assistive technology is legislatively protected as an international human right and allocated government funding in more than 80% of WHO member states [23]. Smart-enabled AT does not enjoy this protection or widespread government support, yet the market for these devices is expected to grow to $5 billion USD by 2031 [24]. As the spectrum of IAT doubles every 5 years [17], in the future, all AT may be technology-enabled, and the distinction between AT and IAT will be redundant. At present, IAT are a unique subset of AT, with potentially different sets of facilitators and barriers to their use. Specifically, an independent discussion of IAT facilitators and barriers is warranted, if governments are to broaden their coverage of IAT, as suggested by Ienca [17], to avoid recreating the expensive, fragmented, inaccessible, and inequitable features of the current global AT market [23,25–28].

Reviews which have focused on older adults have been narrow, investigating the use of IAT devices among older adults with specific diseases, such as dementia and alzheimers [29–31], or specific devices, such as exoskeletons [32–34]. As the first review of factors affecting IAT prescription and use, this paper will provide professionals practicing in the field of rehabilitation with an overview of the barriers and facilitators that may be experienced by older people using these devices. We aimed to identify the barriers and facilitators that influence use -prescription, acquisition, implementation, and adoption- of intelligent assistive technologies (IATs) among older adults for the purpose of rehabilitation.

Materials and methods

Rehabilitation research is heterogeneous, with a wide range of study types (qualitative, quantitative), clinicians involved, health care settings (inpatient, outpatient, acute, long-term care) and publication sites. This diversity makes scoping reviews especially appropriate for rehabilitation research [35]. Scoping reviews are designed to provide information about the breadth and depth of a field of literature and identify priorities for future research [36].

We conducted a scoping review guided by the framework developed by Arksey and O’Malley [37] and refined by Levac and colleagues [36] using the following six steps: defining the research question; identifying relevant studies; study selection; charting the data; collating, summarising and reporting the results; and consultation. Each step is described below:

Step 1: Identify the research question

We asked: What are the facilitators and barriers that exist in rehabilitation settings which influence the prescription, acquisition, implementation, or adoption of intelligent assistive technologies for older adults?

Step 2: Identify relevant studies

The search strategy was developed in consultation with a university health sciences librarian. Search terms included: self-help devices; assistive technology; remote sensing technology; innovation; robotics; medical device; invention; handheld computer; microcomputer; minicomputer; sensory aids; rehabilitation; exercise therapy; physical therapy; physiotherapy; occupational therapy; geriatrics; older adults; elderly; and aged.

The Scopus and Ovid databases were searched for English language studies from 1998 to August 2021, a time frame chosen as reflective of modern AT use in rehabilitative settings.

Step 3: Study selection

Citations and abstracts identified in the search were amalgamated into RefWorks, a web-based reference management software. Four reviewers (MM, LN, KL, LR) screened out studies with irrelevant titles and abstracts. Studies were included if they: addressed assistive technology in a rehabilitative context between 1998-2021; described information-enabled or “smart” assistive technologies and described barriers and facilitators to their use in rehabilitation; the average age of participants was 60 or older, or else persons aged 60 or older and older were the majority of participants; or selected papers which look at older adults, or in the case of articles where no age range is provided, explicitly commented on older adults. Any study type was permitted, and any rehabilitative setting, such as inpatient and outpatient hospital settings, community settings, outpatient therapist practice settings [38], and research instiutions were included. Articles in which the average age was below 60, or did not explicitly investigate older adults were excluded. The age 60 years old was used as a cut off for inclusion to match the United Nations definition of an older person [39]. For the purpose of this review, use of IAT devices will be considered across a continuum of prescription, acquisition, implementation, and adoption. The study selection process is summarised in Figure 1, which is adapted from the PRISMA diagram produced by Moher et al. [40]. Any discrepancies were resolved by discussion between the reviewers, or by referring to a third reviewer.

Figure 1. Article selection process.

The article selection process for the overall scoping review represented in a flow diagram.

Step 4: Charting the data

Reviewers recorded the author(s), country, year, study population, study type, description of the technology, barriers, and facilitators in a data extraction table shown in Table 1.

Table 1. Extracted data.

First Author, Country (Year)	Population Studied	Description of Technology	Study Type	Barriers	Facilitators
Various IAT Devices
Alqahtani (2019), The United States [61]	Older adults (but included 18+) and people with dementia with mobility impairments using AT.	Various assistive technologies reviewed: Powered/smart wheelchairs, exoskeletons, robots.	Literature review.	-Cost (smart wheelchair, exoskeleton, robot). -Privacy concerns. -Difficult to use. -Ease of use/don and doffing (exoskeleton). -Cumbersome technologies (weight, speed, size). -Personnel and resources in the AT sectors. -Negative attitudes towards mobility IAT.	-Addressing priorities of users (co-design). -Knowledge/ awareness of brain machine interface improved acceptance.
Bharucha (2009), The United States [45]	Older adults with dementia	Cognitive aids, physiological sensors, environmental sensors, advanced integrated sensor systems, wearable radiofrequency transmitters, proactive activity toolkit.	Review	-Most are still in the design or trial phase and not commercially available yet. -Prototype devices still have a significant failure rate. -Most AT are developed for younger people with non-progressive brain injuries. -Older adults minimize personal need when offered devices. -Health monitoring technologies raise ethical and privacy considerations.	-Cognitive aids possess customizable multimodal display and prompt delivery systems. -Physiological sensors can catch deviations from normal before it’s too late. -Unobstructed, passive devices are easy to accommodate in everyday life. -Low-cost environmental sensors for a single factor are widely available. -integrated sensor systems can provide peace of mind to caregivers.
Garçon (2016), Low-and Middle-Income Countries [26]	WHO conducted a survey on assistive and medical devices for older people (defined as older than 60 years) in six countries—China, Malaysia, Japan, the Philippines, the Republic of Korea, and Viet Nam.	Assistive health technology (AHT) and medical devices (MD).	Literature review of expert consultations.	-Lack of financial schemes for purchasing these must be addressed. -ATs fail to respond to a growing demand for innovative devices affordable devices for home-based care and for settings where no specialized human resources are available. -One size fits all approach. -Legislation has focused only on individuals with disabilities, excluding nondisabled older adults. -Being able to successfully use some AT may necessitate adaptations of the home and other environments. -Although AT for vision, hearing, and mobility are reasonably available and utilized, many of the other product categories (speech, mental, environment) are limited in their availability, not available at all in certain countries/settings, and access to AHT advice is variable. -Technology (including AHT) for older people has often been simply “overlaid” on existing systems and care approaches. -Older people may need more than one AD, for example, a hearing aid in addition to a pair of spectacles, or vice versa. But these Ats are seldom available in one place, thus creating avoidable difficulties in accessing them. -Concerns of autonomy. -Concerns of privacy. -Lack of personnel who are appropriately trained to provide AD to older people. -Many countries need much greater official awareness of older adults’ needs and preferences.	-Reduced informal/formal caregiver time. -Adaptable to increasing declines in function/capacity. -Easily integrated into daily living. -Ensure that appropriate policies that incorporate AHT and MD are adopted and implemented. -Affordability. -Products and services must meet stringent criteria to respond to the needs and preferences of older populations. These criteria are availability, accessibility, adaptability, acceptability, affordability, safety, and quality of both products and related services. -AHT services are accessible to OA, in terms of both geographical location and physical accessibility. -Having options for AT. -Promoting low-cost devices. -Education and training of health personnel are critical to deliver the best outcomes from AHT for older people. -Robust evidence of the most effective utilization of new assistive technologies for older people to provide balance to the aggressive marketing in some countries for this rapidly growing sector.
Halvorsrud (2021), Norway [92]	83 older adults, average age 85.	Various AT and IAT devices: TVs, social alarms, mobile phones, stove timers, electronic medical dispensers, PCs and tablet computers.	Survey and qualitative interviews.	-Fear of causing false alarm limited the use of an embedded social alarm. -Concerns over privacy and surveillance.	-Presence of a social alarm IAT lead to a greater sense of safety.
Holthe (2018), Norway [52]	13 family caregivers of people with young onset dementia.	4 Categories of AT and IAT devices: Safety and security (Sensor technology, GPS tracker), simple user interfaces (Automatic Calender), visual reminders (Digital calender), auditive reminders (talking wrist watch, medicine dispenser with alarm).	Qualitative repeating semi-structured interviews.	-Little caregiver knowledge regarding available AT/IAT. -Process of acquiring IAT was confusing, too much information. -Some IAT too complicated.	-Good timing of provision would increase the success of incorporating AT/IAT into everyday life.
Khanuja (2018), The United States [56]	Comprehensive review of all adults over 65 then community-dwelling elderly adults who are found to be at risk for but have no previous history of falls, finally, adults who have experienced falls in the past.	Tools utilized in improving balance and gait.	Database searches.	-Cost of devices. -Underreporting of falls can delay interventions.	-Reduces the fear of falling. -Decrease incidents of falls. -Improved mobility. -Wearables and smartphone applications can provide clinicians with current and continuous assessments of gait, balance, and fall symptoms. -More precise prescribing based on data obtained through technology. -Technology allows more precise and effective screening measurements for individuals with neurological disorders or with mobility problems.
Krishnaswami (2020), The United States [4]	Older adults with cardiovascular disease.	Various IAT devices: mobile health, remote patient monitoring.	Literature review.	-Declines in cognition can limit older adults understanding of devices. -Benefits of offsite rehab through digital medians is still not well known.
Nauha (2016), Finland [107]	5 participants in an assisted living facility, average age 78, and 4 participants in a home setting, average age 78. All with memory impairment.	Various IAT devices: Smart flower stand, safety phone, GPS tracking bracelet, web chat computer, short range audio alarm connected to devices, motion sensor reminder.	Questionnaires, diaries, and logged data.	-Smart flower stand was too sensitive, several false alarms lead to abandonment. -Safety phone encountered several false alarms. -GPS tracker suffered from connectivity issues. -Battery drains quickly when smart phone/tablet devices were used.
Peek (2017), Netherlands [58]	33 community-dwelling seniors.	Various devices: personal alarm, electronic chair lift, home and personal care devices, remote controlled power socket, motorized rolling shutters, home fitness equipment, laptops, tablets, transportation devices.	Semi-structured interviews.	-Individual’s concerns about reliability, lifespan, power consumption and cost of technology. -Fear using assistive technology would make them appear old or frail.	-Family members and peers advising and supporting the adoption of technology.
Robinson (2013), United Kingdom [60]	The oldest old.	Assistive technology.	Review of current practice.	-Ethical issues around mental capacity to make decisions when prescribing devices. -Privacy concerns. -Lack of information for oldest old on available assistive devices. -Cost of device.	-Reduce accidents. -Enable independence. -Enhance quality of life following hospital discharge. -Limit need for personal assistance. -Aging in place reduces cost. -Low cost technologies proven beneficial for individuals with dementia. -Resources have been developed to help professionals disseminate information on AT.
Scott (2018), Australia [59]	Patients with sarcopenia.	Traditional devices and emerging technologies.	Review.	-Lack of access to AT. -Cost of AT. -Security concerns regarding sensitive personal health data. -Poor self-efficacy and perceptions that AT is too challenging. -Environmental factors such as poor street conditions are barriers to older adults using a walking aid. -Limited shelf life of 3D food printer materials. -Ongoing use of AT especially devices like electronic let chairs may accelerate muscle atrophy. -Mobility aids may increase falls through misuse. -High abandonment rates for using AT which may be minimized by appropriate training and monitoring of use.	-Can help minimize functional decline. -Smart home technology allows older adults to continue living independently through voice activation. -Wearables and device applications allow clinicians to access activity data remotely and monitor patient adherence. -Video gaming and virtual reality can make exercise more enjoyable. -3D food printers allow patients to make food at home and can change the texture to make it more appealing. -Regular follow-up and training can decrease abandonment, 37% to 10% abandonment.
Sriram (2019), United Kingdom [65]	2016 Informal caregivers for people with dementia ranging from 19 to 91 from 56 studies.	IAT devices for people with dementia: Assistive robots, wearable sensors, social robot, smartphone, tablets, smart calendar, smart watch, smart home management system, motion sensors, trackers.	Systematic review.	-IAT could replace the personal component of caring. -Technical familiarity. -Security concerns. -Cost.	-Safety of person with dementia is more important than their autonomy for caregivers. -IAT devices for safety, such as trackers, were most appreciated by caregivers. -IAT removes burden from caregivers. -Promotes independence for people living with dementia. -Caregiver disposition to continuously use IAT with their loved one.
Tangcharoensathien (2018), Thailand [27]	Low- and middle-income countries.	Assistive technology.	Perspectives paper.	-Lack of accessibility in low- and middle-income countries due to low demand and low supply. -High costs and lack of government funding. -Lack of trained personnel in LMIC. -Use is hindered by effectiveness and suitability; social stigma and privacy; usability and computer literacy. -Culture and language.	-Provides independence.
Tomšič (2018), Slovenia [100]	6 participants between 75-85, have had a stroke and use AT paid for by health insurance.	Assistive devices and technologies that: enabled mobility, supported social contacts and social participation, facilitated personal care, and facilitated kitchen-based activities.	In-depth qualitative interviews.	-Ageism and myths about older adults and technology. -Reduced physical abilities after stroke causing AT to be “forced” on people. -Use of devices and technologies cause stress. -Interrupts daily routine. -Causes discomfort. -Low digital literacy causing skepticism and distrust. -Poor esthetic properties.	-A social network to inspire and support learning new AT. -Assistance from a family member or caregiver when using AT. -Leads to increase independence. -Improved physical and mental well-being. -Preserved and trained cognitive abilities.
van der Cammen (2017), The Netherlands [99]	Older adults.	Assistive technology.	Information Article.	-Fear that a practitioner’s job will be replaced by technology.	-Reduce stigma around new devices and technology→ can be overcome by an inclusive design which can be used for younger and older people. -Iterative engagement with stakeholders in the design and delivery of services. -Identifying a common need and set of outcomes across care settings and with patient. -Collaboration between clinicians and designers, academia and industry.
Wang (2018), The United States [68]	Older adults who wish to age in place.	Smartphone enabled IAT (sensor, applications, wearable trackers, monitoring, tele-health) and remote monitoring.	Editorial.	-Safety. -Security. -Privacy. -Cost of the device. -Many technologies designed for younger audience and adopted to older adults. -Some IAT too complex. -Physician information overload due to the amount of data captured by monitoring/mobile/wearable IAT. -Lack of evidence for some technologies.	-Data transfer for more integrated care of older adults in multiple settings. -Interoperability of the system to receive data -ease of use. -Iterative design must be conducted, but systematically.
Xiong (2018), Canada [69]	40 Chinese family caregivers for persons with dementia, average age 62.	Various IAT and AT devices: Medication dispenser, GPS tracker.	Cross-sectional survey.	-Cost of the technology.	-Ease of installation. -Easy to learn to use. -Pleasing aesthetics. -Clear operating instructions. -Reliability. -Customizability.
Wearable IAT devices
Cherniack (2011), The United States [43]	Elderly with cognitive or neurologic disorders.	Virtual Reality.	Review of literature.	-Limited evidence that VR results in improvement of task in cognitively impaired. -Most technologies are only in the trial phase and not commercially available. -Not tested enough to prove more beneficial than other methods of assessment. -Simulators can cause motion sickness. -Head-mounted display potentially causing cataracts, eye strain, auditory injury and injury to spine/neck/head. -Cost of device. -Time to set up the device.	-VR offers greater safety than conventional testing or treatment. -Improves ADLs -Robotic animals can provide comfort and relieve agitation. -Ease of use by trainer and patient.
Hall (2019), United Kingdom [63]	146 Older adults and 10 long-term care sector staff.	Wearable garment-based fall protection device with embedded mobile connectivity, emergency alert, and data recording.	Group consultation with participants, Patient and public involvement (PPI).	-Older adults felt the IAT was unnecessary, felt they had not yet reached the point of concern. -Older adults felt the IAT was a visible sign of aging, stigma. -Aesthetic concerns override desire for protection. -People with cognitive impairments may not be able to wear the IAT. -Bulky/uncomfortable IAT limiting desire to use. -Poor connectivity to wireless networks may limit the useability of the IAT. -IAT and required accessories were expensive.	-For people with prior falls, IAT may provide reassurance/safety. -Ability to independently select garment for the IAT.
Jie (2019), The Netherlands [111]	15 people with cognitive and or physical limitations as a result of stroke, 2/3 of which were over 65.	Sensor biofeedback system to promote independence and practice gait.	Case report.		-Reminders and extra information beneficial to tester/participants. -Personalization of the device. -Font and aesthetics of the app. -Feedback from the app would provide motivation to continue rehab through the app.
Olsson (2016), Sweden [72]	11 persons with mild dementia living in their homes.	Passive positioning alarm.	Informal conversational interviews.	-Small battery limits the possibility to constant send the position. -Sense of being surveilled: ‘Big brother is watching you’. -Cost of device and who should pay. -Uncertainty as to when the “right” time is to introduce the alarm.	-Retaining autonomy. -SMS was sent to the receiver if the transmitter battery was low. -Loudspeaker function to get in contact with PwMD. -Increase relatives perceived feeling of safety and security. -Can assist if PwMD fell and needed to contact relative. -Ability to remain connected in community which increases well-being.
Rupal (2017), Canada [55]	Older adults.	Assistive exoskeletons.	Analysis of different assistive exoskeletons.	-Lack of options. -Costs. -Weight of AT. -Heavy battery when used outdoors. -Lack of comfort. -Cost concerns. -Size of exoskeleton. -Movements look robot-like (don’t want to wear in public). -General purpose or multi-purpose devices are not likely to be effective.	-Ease of equipping/taking off the exoskeleton. -Customizable for each patient (adjust amount of resistance). -Feelings of safety. -Minimal changes to home environment. -Easily integrated into lifestyle. -Feelings of independence. -Encourages physical activity. -Supports daily activities. -Ability to wear suit without help. -Testable by users before adoption. -Rent/lease options available for each exoskeleton. -Certified exoskeletons. -Long-term power supply. -Noise-free. -Durability of the device.
Thilo (2018), Switzerland [104]	15 community dwelling adults who could walk with or without aids, average age 81.	Wearable sensor enabled fall detector.	Field testing followed by qualitative focus group interviews.	-Battery life was too short: desire for a several days/weeks rather than a couple days. -Smartphone battery too short. -Connectivity between sensor and smartphone limiting: too short of a range.	-Comfort of the device when in use: size, weight and material. -Individualize color, font size and contrast of the app. -Application content was clear, comprehensible, and readable.
Sejunaite (2017), Germany [106]	Female and male patients with dementia of any kind or depressive disorder with subjective cognitive deficits were included.	The navigational device Google Glass.	Observation and questionnaire.	-Limited battery power. -Screen turns dark after 8 seconds ad needs to be double tapped.	-Easy to use. -Provide autonomy and ability to perform ADLs. -Sufficient training sessions.
Handhelds
Amlani (2019), The United States [102]	Older adults (50-80) with hearing loss and no history of middle ear pathology and passed a cognitive screening test. 15 who hadn’t used hearing device in a year, and 15 who had never used.	Smartphone based hearing amplification device.	Pre-post assessment and questionnaire.	-Bulkiness of the IAT perceived as a limitation to use.	-Trial period with the IAT produced reductions in perceived barriers and improvements in perceived benefits from the use of amplification devices in people who had stopped using amplification devices and those who never had. -Increased motivation to participate in social settings.
Arthanat (2019), The United States [62]	3 Stakeholder groups. Older adults being trained to use information communication technology (ICT), Care providers, and ICT trainers.	Handheld information communication technologies for tele-rehab delivery.	Semi-structured interviews.	-Older adult reluctance to accept innovations in technology. -Fears about competency and capacity, anxiety around privacy and abuse/scams. -Fear of breaking the device. -Lack of means to purchase. -Information overload when teaching (patience required).	-Previous experience with tech enabled current use. -Social participation with family motivated and reinforced use of ICT.
Cajita (2017), The United States [124]	65 or older and had a history of heart failure.	Mobile technology.	Survey.		-Perceived ease and usefulness of mHealth. -Easy to use, to the degree that untrained consumers could use them. -Doctor recommendation to use mHealth. -Participatory approach with older adult when designing mHealth intervention and collaborate with experts in human factors engineering.
Cinini (2019), Italy [94]	Adults aged over 65 (65-81/87) in Italy.	ICTs and caregiver robots.	Structured interviews.		-Active user engagement during the development of new technology to support OAs is beneficial to the acceptance of the tool. -Aesthetically pleasing (cute) devices more acceptable to older adults.
Emmerson (2018), Australia [123]	10 stroke patients who participated in a RCT testing an exercise program using tablet devices in upper limb rehab.	Touch screen tablet computer for upper limb rehab.	Semi-structured interviews.	-Older adults anxious when using the tablet. -New technology was difficult to use.	-Removed some caregiver burden as less supervision was required. -Use of IAT provided motivation to continue rehab. -Caregiver provision of technical support aided use.
Gélinas-Bronsard (2018), Canada [51]	10 participants. 5 AT users average age 75 and 5 caregivers average age 63.	Internet-based intervention mediated through handheld devices.	Qualitative semi-structured interviews within a needs assessment.	-Lack of ICT in healthcare institutions. -May increase physician burden, increased demand for follow-up with the same amount of personnel time.	-ICT IAT allowed participants to choose their access to interventions, easier access than conventional AT. -Physician data access, otherwise only available in person. -Remote communication through smartphone would remove transportation barriers. -Reduced caregiver burden by lowering the need for transportation.
Hawley-Hague (2020), United Kingdom [96]	Phase 1. 12 older adults, Phase 2. 5 health professionals and 8 older adults Phase 3. 7 older adults at risk of fall enrolled in a rehab center.	Motivational smart-phone app to support patient exercise.	3 phase design: 1. Analyze necessary components for app. 2. co-design app with patients and providers. 3. implement app with older adults at risk of fall.	-Smartphones may cause fear in older adults. -Arthritic patients may struggle to use smartphones. -Physicians had little experience with smart-phone based rehab.	-Personalization of exercise programs is important to patients. -Including users in designing apps encourages use. -Family support is important for building patient confidence using IAT. -App could be used to monitor activity, and physicians could provide encouragement based on this.
Imbeault (2018), Canada [54]	65-year-old woman with Alzheimer’s disease.	Calendar application on tablet.	Observations and participant journal logs.	-Choosing device as vast selection is overwhelming. -Initial intimidation/frustration using tablet. -Adoption of a new technology can be complex and multidimensional. -Tablets require an investment in time during the rehabilitation process.	-Role playing exercises to simulate using device in daily living situations. -Improvement in memory and ability to perform memory-related tasks. -Tablets are easily available.
Inskip (2017), Canada [49]	26 patients, average age 71.5, undergoing pulmonary rehabilitation and 26 healthcare providers, average age 43.	Smartphone mediated telehealthcare for pulmonary rehabilitation.	Focus groups.	-Professionals fear technology enabled communication can increase workload. -Professionals may lack expertise in using tele-rehab.	-Biosensors can provide feedback to patients about rehab and exercise progression. -Tele-health based rehab could be more customizable. -Improve access to those who may be geographically isolated from rehab services.
Isaković (2016), Slovenia [126]	Persons with diabetes (50+).	DeStress Assistant (DeSA) (diabetes application).	Adapted questionnaire.	-Use of images as buttons confuses people. -Lack of assistance when introducing the AT. -AT developed without involving older adults (high usability barriers common when OA not involved in whole process). -Fear of technology. -OA more hesitant to click around on the app to figure things out, worried they would break/undo something.	-Including a ‘welcome wizard’ to introduce an app. -Large text. -High contrast between text and background (visibility). -Input checking (ensuring no errors). -Caregivers are also trained in using the AT. -Combine symbols and text. -Built-in accessibility support on modern devices can make apps more usable. -Helpful tips and explanations the user can access if they forget how to operate the app.
Jørgensen (2018), Denmark [97]	14 , average age 65.3, 9 with Rheumatoid arthritis, 4 had Psoriatic arthritis, 1 had ankylosing spondylitis.	Sensor enabled medication injector for arthritic diseases.	3 phase design approach: concept mapping, participatory design, stakeholder evaluation. Focus group and individual interview data collection.	-Concerns around privacy and monitoring.	-Aesthetics of the device. -Portability of the device. -Ergonomics of the device, handleability for people with reduced hand mobility. -Reminders for medication delivery. -Easy legibility.
Kringle (2019), The United States [119]	5 community dwelling people between the ages of 57 and 81, who had had a stroke.	Smart phone/tablet mediated mobile rehabilitation service, iADAPTS, designed to aid stroke survivors with goal setting.	Descriptive case series.	-Due to lack of familiarity, some participants required additional training. -Memory impairments made using the application/device difficult.	-Prior use of technology.
Lemke (2019), New Zealand [103]	6 people had recently experienced stroke, between the ages of 60 and 82.	Smartphone ICT devices used in everyday life and rehab.	Semi-structured interviews and observations.	-Fine-motor skill impairment from stroke make use challenging. -Large/bulkiness of the device further limits use due to motor impairment. -Speed impairments.	-Larger font for those with visual impairments.
Maidment (2019), United Kingdom [53]	20 adults, average age 62.25, 13 males, with mild to moderate hearing loss.	Smartphone mediated/connected hearing devices.	Device trial and semi-structured interviews.	-Lack of awareness of the existence of IAT devices. -Perception that technology is for younger generations. -Smartphone mediated device was cumbersome to use. -Cost of the device.	-Previous experience with technology aids the use and uptake of IAT. -Simple and intuitive design enables use. -Adjustability of the IAT device. -Smartphone component of the IAT may remove stigma of hearing loss and hearing aid use.
Mallet (2018), Canada [120]	33 people who had recently had a stroke, average age 69.5.	Tablet based post-stroke communication therapy device.	Open ended survey.		-Training and assistance is helpful to promote patient use.
Martín-Lesende (2017), Spain [78]	Adult housebound patients with heart failure and/or chronic lung disease with a history of at least 2 hospital admission in the previous year.	Telemonitoring using smartphones to a specific Web-platform.	Daily self-monitoring, and questionnaire.		-Decrease in hospital admissions and emergency department attendance. -Reduction of length of the hospital stays. -Early detection and treatment of exacerbating factors. -Healthcare professionals and patients/relatives high level of satisfaction with telemonitoring.
McGrath (2018), Canada [64]	19 participants. 10 older adults with age related vision loss, 6 caregivers, 1 healthcare provider, and 2 industry professionals.	Low-vision assistive devices.	Field notes from a technology workshop including: show and tell, technology interaction, and app assessment	-Poor usability may lead to abandonment -Lack of portability may lead to abandonment -Lack of training may lead to abandonment -Concerns of privacy when using apps -Many low vision aids were prohibitively expensive	-Simplicity and intuitive design. -Large print buttons. -Aesthetics of low vision aids: discrete, fashionable, non-obtrusive.
Ng (2017), Canada & USA [57]	(a) patients adopting the connected hearing aid, and (b) professionals adopting the connected hearing aid.	Smartphone-connected hearing aids.	Semi-structured interviews and grey literature.	-Cost of the device. -Clinicians perception of candidacy heuristics. -Patient frustrations related to smartphone integration and increased effort to manage their devices. -Fear of surveillance and privacy.	-Patient’s comfort and competence with their smartphone. -Improvements in the technology. -Spent more time with patients and got to know them better based on questions asked for prescribing purposes. -Hearing aids when linked to technology reduced stigma and increase use.
Okonji (2019), Nigeria [25]	443 people between 20 and 92 with visual impairments, average age 60.	Assistive computer technologies.	Qualitative interviews and questionnaire.	-Lack of interest. -Self-perception of not needing the IAT. -Lack of training. -IAT devices not available. -High cost of IATs.	-Training programs for IAT use could increase use. -IAT tailored to the environment of the user. -Caregiver training.
Øksnebjerg (2020), Denmark [88]	112 participants dementia, average age 68, and 98 caregivers.	Dementia management app for mobile devices.	Use patterns, qualitative survey, and log data.	-Difficulty using the device led to non-adoption.	-Time from diagnosis impacts adoption of IAT, shorter interval more likely to adopt. -Caregiver participation in the IAT use lead to greater acceptance for participants.
Philips (2018), Belgium [50]	18 people with cochlear implants above the age of 60.	Application for cochlear implants mediated through handheld tablets.	Baseline questionnaire and follow-up.		-Motivation of the participant. -Choice/autonomy in how the app was used. -Accessibility of the app.
Pludwinski (2016), Canada [110]	People with T2D (mean age male = 63.5, mean age female = 55.8).	Smartphone software for management of T2D.	Semi-structured interviews.	-Comorbidities that conflict with management of diabetes.	-Ability to share health data. -Training on how to use the AT. -Reminder messages. -Increased self-awareness. -Quick/immediate feedback from a health coach on diet choices. -Encouragement from a health coach. -Health coach support reduced feelings of isolation. -Increased happiness. -Feedback specific to individuals. -Health coach gave feelings that someone was “always watching”, which increased accountability. -Educational moments with health coach (i.e., exercise suggestions, diet suggestions to maintain blood sugar). -Increased control over condition. -Motivation outside of app activities (joining other programs). -Strong relationship developed with health coach.
Quintana (2020), Spain & Sweden [105]	19 persons with cognitive impairment and their caregivers, average age 77.5.	Tablet mediated app for mild cognitive impairment.	Clinical usability test followed by four-week home app testing.	-Fear of using tablets and mis-clicking. -Tablet was too small.	-Familiarity with similar technologies. -Portability of small tablet. -Thorough introduction to the app crucial to facilitate use.
Raghunath (2019), The United States [98]	Twenty people with varying levels of cognitive ability, above the age of 54.	Tablet mediated memory notebook app incorporating distributed smart sensor.	Logged app data, questionnaires to assess satisfaction and usability and qualitative participant feedback.		-Iterative design reduced the amount of time it took to complete tasks. -User interface being large enough to be intelligible and interact with. -Simple verbiage in instructions. -Simplified to improve ease of use. -App provides motivation to support continued use.
Rawstorn (2018), New Zealand [108]	162 people with coronary heart disease, 82 of which were allocated to receive the intervention.	Sensory enabled IAT for exercise based telerehabilitation of coronary heart disease.	2-arm noninferioiry randomized controlled trial.	-Battery life challenging. -Poor connectivity: Bluetooth and wireless. -some participants would have valued additional supports during the intervention and after transitioning to independent use.	-Ease of use of the sensor. -Comfort of the sensor. -Desire for app function that would facilitate social interaction. -Flexible accessibility. -Individualized approach to prescribing exercise increased motivation to adhere.
Reyes (2018), Canada [116]	Mobile applications focused on balance.	Balance apps.	Mobile Application Rating Scale	-No instructions on app usage or provide background information about balance. -No Android balance apps available limiting accessibility.	-Gamification and score sharing through social media engaged users. -App customization. -Advanced graphics and auditory design. -Detailed written and audible instructions for app usage and balance information.
Seaborn (2016), Canada [70]	Older powered chair users (55+), majority above 60.	Mixed reality games that involve power mobility and modern facilitating technologies, such as tablets and smartphones.	Focus groups, Questionnaires.	-Stigma around using a powered chair. -Machine makes loud noises that can be embarrassing. -Highly sensitive controls causing unintentional movement. -Concern for safety. -Environmental barriers. -Hinders social life. -Older individuals perceive technology as something for younger people. -Privacy concerns. -Lack of support from family (i.e., family not confident in their ability to learn about tech). -Believed new technology would be too expensive. -Perceived difficulty in learning new tech. -Inability to use most smartphones (because of poor grip, poor vision, inability to use touchscreen).	-Ease of use. -Use without assistance. -AT that allows family/friends to see patient’s perspective. -AT that facilitates interaction with friends/family. -Learning activities turned into games (learning how to use powered chair in tricky situations). -Being shown what to do rather than told. -In-person training on powered chair use. -Initial uncertainties can be alleviated by demonstrating the tech to the patient. -Increasing awareness of low-cost versions of devices and providing senior discounts.
Searcy (2019), The United States [114]	Adults with cardiovascular disease.	Smartphone mediated mobile health tools for cardiac disease and rehabilitation.	Literature Review.		-Mobile health technologies can increase participation in cardiac rehabilitation. -Remote monitoring allows physicians to consult with patients virtually.
Smallfield (2017), The United States [42]	10 participants who are 65 or older, self-identify as having a low vision and use at least one optical magnifier.	Low vision devices.	Semi-structured interviews.	-Progressive nature of low vision causes nonuse to occur. -Participants not receiving training on the device.	-Benefit from technology that accommodates for progressive visual decline.
Span (2018), The Netherlands [125]	People with mild to moderate dementia.	The DecideGuide, a responsive web tool for supporting shared decision-making in a dementia context.	Semi-structured interviews and focus groups, field notes, observational records, and a logbook.		-Can provide greater autonomy for the user. -Facilitates communication. -When people with dementia were helping with the design they showed no signs of distress using the device.
van den Houten (2018), The Netherlands [80]	Intermittent claudication patients currently under supervised exercise therapy with a physiotherapist.	Smart phones apps.	Questionnaires.		-Being younger and having higher education facilitates use. -Track physical activity and life style information for patients and PT to review.
Virgili (2018), Italy [67]	Older adults with low vision, average age 71.	Low-vision aids.	Cochrane review with pooled fixed-effect model.	-Portable near vision aids could not be proven more cost-effective than comparators. -Cost when compared to the short shelf life of LVA IATs.	-Decreased difficulty of use with portable devices. -Portability. -Usability. -Ability to tailor the use of the LVA to different viewing situations. -User training.
Zhou (2019), China [91]	118 people with recent stroke, average age 64.	Caregiver mediated smartphone application for stroke rehabilitation.	A multicenter prospective, randomized open, blinded outcome assessed, controlled trial.	-Provision of care with application could not be proven more effective than conventional care.
Mobility Aids
Krishnan (2014), India [47]	Older adults with mobility limitations.	Mobility assistive devices and self-transfer robotic systems.	Review.	-Automated wheelchairs that rely on environmental cues can fail to work due to damage to guidance system. -For the ROAD robot, patient can only travel in a predetermined path. -Safety risks such as patient slipping through robot arms. -Assistive device can only perform a specific task. -Assistive devices that hang from the ceiling require infrastructure modifications. -Cost of the device. -Some are only prototypes and are not yet commercialized. -Battery life. -Fear of older adults to use devices. -Complexity of device.	-Leveraged freedom chair provides enough torque to conquer steep hills and soft grounds. -Voice command or eye control for those who cannot use their hands. -Decrease caregiver burden and injury. -Provide independence in ADLs. -ROAD robot provides better balance and less risk of collision with the subject.
Distributed Systems
Berridge (2019), The United States [131]	Older adults and their adult children. All had multiple chronic conditions.	In-home surveillance technologies. Distributed systems. Trackers.	Structured interviews.	-Older adult concerns over privacy for the use of wearable sensors and web-enabled surveillance cameras.
Braley (2018), The United States [118]	Persons with dementia, average age 74.6. average mild dementia.	Distributed sensor and computer enabled prompting system to aid PWD in completing IADls.	Observation.	-Task completion failed when prompting system was not specific enough to the user (not accounting for level of impairment or type of prompt needed). -Level of impairment impeding prompt recognition from participants.
Chan (2008), France [46]	Older adults and disabled peoples worldwide.	Smart homes.	Review.	-Still in development or trial. -Not used in practice so barriers have not been uncovered. -Provider being unsatisfied with device. -Importance of reliability of measurement systems. -Consistent habits are necessary for the system to work. -IR sensors only effective if the subject lives alone. -Challenge of interoperability among different systems. -Lack of standardization and licensure requirement causing confusing legal issues for telemedicine→no specific legislation in Canada.	-Better quality of life through independence. -Technology that can control multiple elements throughout the house. -Can notice functional decline and call for intervention. -Being discrete, quiet, passive and fully automated. -Easy to use and data easily acquired. -Continuous monitoring. -User has ability to cancel false alarms. -System that includes adjustable reminders. -Collect data on patient that clinicians can access remotely. -Improve medication and health care compliance rate. -Waterproof. -Long battery life. -Humanoid robots could serve as companions and pet robots could be a source of entertainment. -Robots with legs to navigate rough terrain. -More cost-effective than placing people in healthcare institution.
Choukou (2021), Canada [130]	Community dwelling older adults, caregivers, rehabilitation professionals.	Ambient assisted living technologies: pressure sensors, activity sensors, monitoring technologies.	Scoping review.	-There needs to be a common framework to evaluate AALT IATs that take into account the interests and concerns of intended users.
Etingen (2018), The United States [122]	Veterans with a spinal cord injury or disorder.	Environmental control unit.	Questionnaire.	-Device or its features not working. -Unreliability of internet. -Lack of training on device.	-Provides independence. -Easy to use.
Evans (2016), The United States [84]	Older adults 55 years of age and over with and without heart failure.	An integrated, real-time monitoring system, telehealth system.	Questionnaire.	-Attitudinal/cognitive barriers to technology. -Constant wireless connection necessary.	-A clear medical reason for adopting the AT. -Emphasis of importance of AT by physicians. -Medical trends increase adoption and adherence of AT (i.e., used a weight scale often because of the trend of weight and health). -Support and training.
Hattink (2016), Netherlands, Belgium, & Germany [81]	Persons with either mild cognitive impairment (MCI) or dementia and informal caregivers (62-96).	The full Rosetta system consisted of the following three subsystems designed to support people throughout the disease process, and on different need domains: The Elderly Day Navigator (EDN); The Early Detection System (EDS) software; The Unattended Autonomous Surveillance system – Advanced Awareness and Prevention – System (UASAAPS).	Semi-structured questionnaires.	-People like the system but still too many glitches to implement it successfully. -OA found it hard to understand components (system is too complicated). -Concerns of privacy: “what are these people installing in my house?” -Discomfort when red light on camera turns on. -Outdated graphics. -Reception issues with mobile devices. -Components of the system don’t meet expectations (i.e., supposed to detect falls but will not if person continues to move while on the floor).	-Availability of technical support if something malfunctions. -Safety and comfort (i.e., caregivers felt comfort knowing that there was “an extra set of eyes” on their loved one). -Keeping the person at home longer. -Training on the use of the device. -EDS (sensors in home) that are unobtrusive (i.e., not aware that you are being monitored). -EDS allowed caregivers to track sleeping/eating habits Promotes feelings of self-sufficiency.
Maia (2019), Brazil [86]	4 studies including older adults with dementia.	4 types of IAT: nighttime monitoring, voice command technologies, multifunctional distributed system, navigation assistance robot.	Systematic review.		-Caregiver involvement is important during development. -Verbal prompt system, improvements in medication management for those with cognitive impairments. -Verbal prompt system improved ADLs. -Multi-functional system reduced caregiver burden and increased trust and safety.
Stefanov (2004), International [73]	Older persons and persons with physical disabilities.	Smart houses and other AT.	Review.	-Wheelchair-mounted robots are heavy and wide. -Cognitive load of user can become reduced if robot does most tasks. -Rehabilitation robots have highs cost. -Rehab robots have low efficiency. -Sensor system for automatically guided wheelchairs are complex to install. -Many devices only prototypes and tested with nondisabled people. -AT difficulties in recognizing human intention.	-Feels like a normal house not part of a hospital/assistive care facility. -Improve quality of life. -Reduce medical care costs per person. -Can be used preventatively for early recognition of health issues. -Improves communication to facilitate verbal communication between nondisabled people and those with speech and hearing disorders. -Virtual reality systems can provide emotional relief.
Situation Specific Robots
Bedaf (2015), The Netherlands [44]	Independent living elderly people with no cognitive decline.	Robot designed for elderly or smart technology if able to perform physical activity.	Systematic review.	-Limited available on the market. -Questionable whether robots that focus on self-care or fall detection or interpersonal interactions are the best option for these domain as not cost effective.
Bedaf (2018), The Netherlands [101]	Older adults 60+ with no cognitive decline, living at home, receiving, home care. Also informal and professional caregivers.	Care-O-Bot, a supportive robot with embedded sensors capable of supervising environments in real time.	Survey and interviews.		-Supportive robots should mirror human interactions, adapt to differences in the individual (not one size fits all).
Bedaf (2019), The Netherlands, France, & United Kingdom [113]	Older adults aged 60+, living at home and receiving homecare. Informal and professional caregivers.	Care-O-Bot, a supportive robot with embedded sensors capable of supervising environments in real time.	Focus groups.	-Patient environment would require modification if a robot were to be introduced. -Robot was not aesthetically pleasing.	-Robot should be adjustable to the user’s preference. -Desire for physicians to have access to recorded data housed on the robot.
Crea (2017), Italy [82]	Post-stroke patients (avg 71).	NEUROExos Elbow Module exoskeleton (NEEM System).	Clinical assessment and questionnaire.		-Decreased effort for therapists (including supervising multiple patients at once). -Repeatability of treatment. -Optimization of healthcare resources. -Aid in recovery assessment.
D’Onofrio (2018), Italy & Japan [117]	17 older adults with mild or no cognitive impairment, 36 informal and formal caregivers.	Social robots.	Pre-structured interviews.	-Older adult inability to manage the device. -Fear of robots replacing people.	-Robot should be individualized to the participant. Individualized approach to aiding cognitively impaired goal setting.
Eftring (2016), Sweden, Austria, & Greece [74]	Seniors living alone, 70 + years old, who in the near future will need assistance in order to be able to stay in their own homes.	Social assistive robot.	Participatory action research (Questionnaires, interviews)	-User requirements that could not be fulfilled were: -The robot should be able to grasp objects from high shelves, e. g. sheets from high cupboards (due to stability problems or size). -The robot should be able to carry shopping bags from the grocery store (due to project limitation). -The robot should be stable so it can give mobility support (due to stability problems, size and risk of injuries using a prototype alone). -High reliability (due to sensor reliability when sensors were adapted to fit inside the robot head and due to programming complexity). -Size of the robot (should be able to fit through narrow doorways). -Terrain gets in the way (i.e., carpet, outdoor barriers). -Robot prototypes are expensive to develop and lab set-ups are too simplified to detect and solve problems in real life.	-Multimodal interaction to meet the needs of the hearing/visually impaired (e.g., touchscreen, speech and gestures, messages verbally and visually communicated) -Completion of tasks the patient would be unable to do alone. -Reliability. -Appealing and easy to use. -Appearance of the robot (anthropomorphic features including emotional expression, not looking down on the person interacting, soft with no sharp edges, easy to clean, neutral colours). -Ergonomic positioning of the touchscreen. -Ability to search for and pick up objects. -Although they enjoyed social interaction with the robot, the touchscreen was more reliable so was used more. -Ability to clear the floor of objects (fall hazards), show and check physical exercises, transport objects between rooms, remind patient to take medication/drink water, provide a safety checklist about how the senior could improve safety in the home. -Increase feelings of safety by: searching the person 3h after last interaction, making an emergency call to a list of pre-defined phone numbers, calming the user in an emergency, reminders for important meetings (i.e., doctor). -Adaption to individual preference. -Decreased feelings of loneliness.
Fan (2016), The United States [83]	Community-residing older adults, some with MCI or dementia (66-94).	A multi-user engagement-based robotic coach system architecture (ROCARE).	Survey.	-Speech recognition for few phrases, have to speak loudly and doesn’t recognize accents.	-Adaptable to each individual. -Able to measure recovery. -Informal caregivers can operate the AT Involves family/friends in rehabilitation.
Fiorini (2019), Italy & The Netherlands [93]	20 older adults and 34 informal and formal caregivers.	Assistive robots for older adult independence.	Semi-structured interviews.	-Resistance from older adults due to still feeling independent. -Fear of becoming more dependent if using a robot. -Fear that social contact with caregivers will diminish as the robot fills that role. -Robot is obtrusive and may attract unwanted attention to the older adult. -Caregivers fear robots will diminish social contact.	-Robotic aid can help to motivate older adults. -Robotic aids, that can call for help, help foster a sense of security. -Reduce caregiver burden. -Easy to use interfaces, otherwise demotivating if complicated. -Personalized behavior.
Franceschini (2018), Italy [128]	Stroke patients aged 18 and 80.	Upper limb Robot assisted Therapy.	Demographic and clinical records and clinical assessment.	-Greater impairment and disability.	-Provides independence. -Having fine motor skills.
García-Soler (2018), Germany, Italy, & Spain [95]	215 participants. Older adults, family caregivers, professional caregivers, and health professionals.	Semi-autonomous service robot for domestic environments.	Interviews and focus groups.		-Including stakeholders in the design and decision-making portion of robotic assistant development is essential to establishing the functionality of a robot. -Remote access to records. -Customizable on/off system.
Gerling (2016), Austria [112]	older adults with cognitive impairment, therapists in the long-term care home.	robotic pacesetting for an indoor walking group.	Focus groups.	-Older adults preferred human assistance in terms of cooking, personal hygiene and leisure activities. -Inviting residents to engage with technology in a social setting was problematic (e. g. participants felt self-conscious). -Concerns of privacy. -Participants forgot about their plan of action during navigation through the menu due to dementia and thus needed support from the therapists. -There were several instances in which technical problems impacted therapists perception of the robot. -Many participants were anthropomorphizing the robot in terms of abilities to hold a conversation. -People in wheelchairs cannot easily get out of the way of a robot and people using a walking aid are limited in their agility and ability to circumvent a robot.	-Older adults prefer robot assistance for instrumental tasks, such as housekeeping (e.g., garden work and cleaning), for manipulation of objects (e.g., picking up and moving heavy items, finding and fetching items) and reminder functions. -Appreciated the entertainment function of the robot and feedback showed that the robot had a positive influence on the participating older adults, animating them to sing or dance along, clapping their hands or whistle to the rhythm of the music. -Increases motivation and participation.
Huang (2021), Taiwan [129]	36 older adults, average age 72, who live independently.	Assistive robots for ADL support.	Interviews and questionnaires.		-Robotic IAT can aid in loneliness and socialization. -Perception that robot can help with most ADLs.
Hudson (2020), The United States [127]	20 lonely community dwelling older adults, average age 76, who use a robotic pet.	Robotic pet.	Semi-structured interviews.	-Use of the pet may be stigmatizing.	-Can have a robotic pet in locations where a live pet may not be permitted. -Pet was easy to use and interact with.
Lo (2019), Australia [75]	213 stroke patients above the age of 18 who used robotic devices. 4 of 5 included studies had participants predominantly over the age of 60.	Any robotic device: robotic exoskeleton, end-effectors.	Systematic review.	-Conventional therapy favored over robotic in mild and moderate stroke patients.	-Lower cost for robotic therapy when compared to conventional therapy for 4 of 5 studies. -Dominance ranking shows that the majority of the robotic rehab interventions should be favored. -Weighted cost benefit shows that the robotic interventions are moderately dominant over conventional for all but mild/moderate patients. -Weighted health benefit shows robotic interventions are dominant.
Melkas (2020), Finland [115]	Older adults in care homes and geriatric rehabilitation hospital, 40 care workers (n = 35) and clients (n = 5).	Care robot.	Semi-participatory observation sessions and focus group interviews, analyzed using a qualitative Human Impact Assessment approach.	-Excessive time and personnel resource requirements. -Robot too small for older adults with vision impairments. -Robot to quiet for older adults with hearing impairment. -Care provider attitudes towards the use of technology in rehabilitation. -Fear from clients.	-Reduce care provider burden, allows them to outsource some labor onto the robot.
Mordoch (2013), Canada [89]	Dementia patients in long term care.	Social robots.	Literature review.	-Evidence isn’t strong. -Unsure how to fully utilize the robot. -Decrease staff burn out. -Ethical considerations.	-Increase social interactive behavior. -Regulate anxiety, depression and agitation. -Decease in stress. -Improved neuroactivity. -Improved mood. -Provide motivation. -Substitute for real animals that are not allowed in facilities.
Nasr (2016), United Kingdom, Italy, & The Netherlands [85]	Ten stroke survivors and their family carers (60-77).	A to-be-designed robotic technology for home-based rehabilitation of the hand and wrist.	Cultural probes and interviews.		-Feelings of normalcy. -Ability to be independent. -Ability to perform ADLs. -Confirmation from therapists (and family) that they are improving and doing well. -Hopes to regain abilities. -Device ability to facilitate interaction with professionals was motivating and desired. -Willingness to try new technologies. -Involvement of end-users is critical to surmount implementation problems. Those with tech experience before their stroke had better attitudes towards home rehab systems, see it as enabling their independence. -Stroke patients very motivated by the potential to regain capacities. -Tech needs to incorporate goals, give feedback, enable competition with other patients, have constant feedback with health care: human interaction very important for motivation.
Pradhan (2021), India [48]	People undergoing rehabilitation for various ailments: brain injury, chronic pain, stroke, tremor.	Internet of Things technologies and robotics.	Literature review.	-Cost of robotic rehab is still higher compared to alternatives. -People with limited mobility cannot visit hospital frequently to utilize the tech.	-Augmented reality could increase engagement and participation in the rehabilitation process. -Remote access may improve accessibility.
Swinnen (2017), Belgium [90]	(1) stroke patients who have experience with RAGT (avg 65) (2) stroke patients who have no experience with RAGT (avg 67) (3) therapists who have experience with RAGT (avg 38).	robot-assisted gait training (RAGT).	Questionnaire	-Feelings of nervousness/tension/pressure when using AT. -Time consuming to set up (takes time away from therapy).	-Easy for therapists to learn. -Easy for patients to learn. -Interest and enjoyment in product. -Perceived competence in using the AT. -Patient effort in therapy. -Perceived value and usefulness. -Ease of use. -Satisfaction with preliminary results (improvements). -High motivation to use the AT. -Easy to remember how to use the device after initial training.
Tedesco Triccas (2018), United Kingdom [87]	21 people who had experienced a stroke with upper body impairments, mean age 64.2.	Upper-limb robot rehabilitation therapy using transcranial direct current stimulation (tDCS).	Face to face interview using open and closed questions.	-tDCS component of the IAT made participants feel as though they looked odd. -Robot therapy tiring, frustrating, difficult. -Poor graphical design of the computer game potion of the IAT. -tDCS component cumbersome.	-Upper-limb therapy perceived as being the source of most benefits, compared to tDCS. -Therapy may have improved ability to perform some ADLs: dressing.
Tuisku (2018), Finland [66]	39 healthcare personnel who had experience with the IAT, and the general public.	Social/exercise robot.	Empirical case study.	-Cannot replace human contact. -Cost of a robotic tool compared to income. -Safety of care when using a robotic IAT. -Fear of robotic care from the public and care providers. -Time required of care providers to learn how to use IAT.	-Care providers support the use of robotic IAT in their practice.
van Patten (2020), The United States [79]	Older adults with dementia.	Home-based cognitively assistive robots.	Literature review.	-Fear of robotic devices due to media. -Older adults are slower to adopt to new technologies. -Assistive device use may be stigmatizing, signals dependency and fragility. -Robots which are too large and too human-like may cause uneasiness. -Substitution for human contact. -Privacy concerns.	-Home robots can reduce healthcare utilization. -Interactions with people who use robots/robots may reduce reluctance to use. -Younger people may be more accepting of robotic devices as they enter old age. -Ease of use. -Adjustability. -Small size. -Anthropomorphic design. -Behavior/mood matching. -IAT robots provide motivation. -Reminder functionality desirable for those with cognitive impairments.
Wang (2017), Canada [76]	Older adults with mild-to-moderate Alzheimer’s Disorder and their caregivers.	Customed designed Assistive robots to provide tele-operated stepwise prompting.	Semi-structured interviews.	-Concerns about reliability and maintenance. -Caregivers questioned whether it could adapt to the varying degree of users. -Cost-effectiveness. -Preference for assistance from a human. -Person with AD concerned the robot will replace the social interaction she has from family while she is still cognitively aware. -Stigma associated with using assistive device.	-Robot’s embodied physical presence can help to make interactions more socially engaging, effective, and acceptable. -Prevented a move to a care home. -Social presence of the robot could induce feelings of comfort for the older adult. -Beneficial for context specific activities ex. dressing. -Decrease conflict between caregiver and person with AD.
Werner (2020), Germany [121]	25 older adults, average age 77.9, who were dependent in bathing.	Sensor enabled assistive bathing robot.	Quasi-experimental single-group pre/post assessment.	-Cognitive function impacts gestural ability for IAT use. -High gerontechnology anxiety impacted ability.	-Training was highly beneficial to ability to use bathing IAT.
Wu (2016), France [77]	Older adults (63-88 years) with mild cognitive impairment (MCI).	Assistive robot.	Focus groups and interviews.	-Lack of trust in robots. -Did not see added value for robots if functionalities could be fulfilled by existing systems (diary, cell, GPS). -Makes them feel like their life is terminated. -Perceived to be for ‘people who are very handicapped’. -Associate the robot with disability and loneliness (stigma). -Wanted human presence/contact (i.e., robot cannot replace therapist). -Considered a necessary evil as there is a lack of caregivers to care for older adults. -Robot diminishes autonomy (deskilling by doing everything for them). -Shift from independence to service use is a big change. -Fear of social isolation if using robot. -Robot seen is non-human, cannot establish a relationship. l	-Robots as helpers. -Provides cognitive stimulation. -Motivation and encouragement to do cognitive exercises.
Yasuhara (2019), Japan [109]	Older adults who use caring healthcare robots.	Caring healthcare robots.	Review.	-Legal frameworks develop slowly. -Potential leak of personal data.	-Mimic human speech. -Engage in touching. -Appearance that causes familiarity but does not cause aversion. -Conform to safety standards.
Yurkewich (2019), Canada [71]	Five acute and chronic stroke survivors with hand impairments.	Wearable robotic orthosis glove.	Co-design and clinical assessment.		-Co-design. -Motivation to perform daily tasks and independence. -Portability. -Light weight, non-fatiguing. -Affordability.

Step 5: Collating summarising, and reporting the results

Reviewers used an inductive thematic approach to identify, analyse and report on themes related to facilitators and barriers to prescription, acquisition, implementation, and adoption of assistive technologies [41]. Reviewers familiarised themselves with the data by making notes about the extraction table and debriefing with one another during the extraction process. Reviewers individually coded the data in the extraction table, and then met as a group to collate codes into themes [41]. After collating the themes, the reviewers agreed to names, and definitions for each theme [41].

Step 6: Consultation

The final stage of the review included consulting with rehabilitation professionals to obtain their perspectives on the facilitators and barriers to IAT use in rehabilitation settings with older adults. Key informants included occupational therapists, physiotherapists, and speech-language pathologists whose scope of practice included the prescription and acquisition of both assistive technologies and intelligent assistive technologies. Purposeful sampling was used to obtain two or more professionals from each of the three specialties. To be included in the consultation, professions must have had clinical experience related to prescription and recommendation of assistive technologies, possess knowledge of assistive devices, be fluent in English, and be able to provide informed consent. Semi-structured interviews were used to collect data from participants, with an interview guide including questions related to how much experience professionals had with assistive technologies, how well informed they are regarding intelligent assistive technologies, what works well in practice for intelligent and traditional assistive technologies, and what are the most prominent barriers to their use and implementation. Participants were not provided the results of the scoping review prior to their interviews to ensure that responses were that of the respondent alone, and not impacted by the initial research findings. Rather, findings were reflected in the interview prompts, where data and details surrounding the barriers and facilitators to IAT use, as identified in the scoping review, were translated to questions which were then posed to participants. This was done to collect unbiased opinions from the consulting clinicians. Interviews were conducted over the phone and were audio-taped for transcription. Thematic analysis was used to analyse interview data [41]. Interview results were then integrated with the results of the scoping review, using excerpts and quotes from interviews to support and reinforce findings identified in the review. Ethics clearance was provided by the University of Waterloo Office of Research Ethics (ORE# 30529).

Results

Two databases, Scopus (5485) and Ovid (2510), were searched for articles published between January 1998 and August 2021, generating 7995 articles, of which 5281 were screened for title and abstract, 538 were screened for full-text, and 94 were included in the qualitative synthesis. See Figure 1 for the combined study selection process. A sample of 40 articles with a Cohen’s Kappa of 0.61, demonstrated substantial agreement between reviewers (MM, LR).

Ienca’s typology was instructive in categorising the types of IATs found in this review [17]. This review included 33 studies on handheld devices, 27 on situation-specific robots, 9 on distributed systems, 7 studies on wearables, one study about intelligent mobility aids, and no studies on voice-activated assistants. In 17 of the included studies, multiple categories of IATs were discussed.

Included studies were published in 27 different countries, predominantly the United States (n = 21), Canada (n = 15), and the Netherlands (n = 10), and used 20 different study designs, predominantly qualitative interviews (n = 23), reviews (n = 18), and surveys (n = 11). The IAT users represented by the included studies experienced a variety of conditions including: Alzheimer’s/dementia (n = 17), stroke (n = 15), and heart failure (n = 4). Other IAT users included people living with: diabetes, sarcopenia, hearing loss, low vision, and people living with disabilities. The average age of participants within included studies ranged from 60.1 years [25], to 85.8 years [42].

Key informants included seven clinical rehabilitation practitioners [three physical therapists (PTs), two occupational therapists (OTs), and two speech-language pathologists (SLPs)] working in the Canadian province of Ontario. Experience amongst the professionals consulted ranged from five to 30 years; two participants taught in universities. All participants were female, with the exception of one physical therapist.

We identified five main themes in the data that help categorise facilitators and barriers to prescribing IAT: accessibility, effectiveness, usability, patient-centred considerations, and staff considerations. These are presented below, in Table 2, along with related sub-themes.

Table 2. Themes and sub-themes.

Accessibility	Effectiveness	Usability	Staff Considerations	Patient-Centred Considerations
Awareness and access	Cost-Effectiveness	Participatory approaches to designing IAT	Role in prescription	Patient’s environment
Cost	Effectiveness for Health Systems	Design features	Staff training	Motivation
	Effectiveness for Older Individuals	Individualized, adjustable AT	Staff knowledge and awareness	Beliefs and attitudes
		Patient training and support		Stigma

Accessibility

Many of the articles discussed prescribing IATs in rehabilitation as enabled or constrained by issues of access. This theme contained findings about awareness of what IATs are available, as well as costs of IATs and how to pay for and acquire them. The theme of accessibility is summarized in Table 3.

Table 3. Accessibility summary.

Accessibility
	Barriers	Facilitators
Awareness and access	-Low access to products in development. -Geographical disparities in access. -Low client awareness of IAT devices. -Variety may be overwhelming.	-Computer/internet-based services easily accessed. -Low-cost widespread components, such as single-factor sensors. -Institutions could own and provide greater access to expensive devices through leasing to patients.
Cost	-High cost produced barriers to accessing devices. -Unclear insurance coverage exacerbated costs of IAT devices.	-Affordable devices, such as a wearable robotic glove, were considered facilitators to use. -Designing technologies to be low-cost and providing discounts enable use. -Fast transitions from research to practice mitigates high costs for robotic devices.

Awareness and access

Many articles contained findings about the problems of accessing technologies that are in the research and development stage and are not yet commercially available [43–47]. Some articles indicated that low and middle-income countries may not have implemented policy frameworks related to assistive technology in general, may have low supplies of IATs, and/or difficulties evaluating available technologies [25–27]. Additionally, some people with limited mobility may struggle to access IAT devices located in hospitals or rehabilitation centres [48]. Internet-based services and treatments offered by computers, tablets, or smartphones were reported to be currently accessible, or as a way to improve future accessibility [49–51], though they may be lacking in healthcare institutions [51]. Rehabilitation mediated through commonly available handheld devices may be able to improve access to those who are geographically more isolated [49]. Some studies found that users’ awareness of available IAT devices was limited, making it more difficult to access devices [52,53]. In places with a wide variety of IATs available, patients may be overwhelmed by the choice among many options [52]. Some studies discussed strategies to enhance access to IATs, such as leveraging the widespread availability of smartphones or tablets as platforms to deliver rehabilitation services, as well as remote access to tele-operated devices [48,54]. Another study cited the low-cost and widespread availability of single-factor sensors to enable IAT prescription and use [45]. One study indicated that health institutions owning, leasing or renting IAT, especially for high-tech, high-cost IATs such as robotics or exoskeletons, would improve access [55].

The interviewed practitioners discussed trialling technology as a way to improve patients’ access to technology: “they get the trial with whatever the equipment is, and they realise how great it is - they feel safer, they just feel better, and then they end up buying the equipment” - [OT1].

Cost

High cost to individuals was listed as a barrier to accessibility of IAT in a considerable proportion of the studies in this review [25,27,43,47,48,53,55–69]. Cost of IATs was the barrier most frequently cited in a focus group study of older powered chair users [70]. Conversely, the affordability of a wearable robotic orthosis glove was considered a facilitator by participants [71]. Designing technologies to be low-cost [26] and making them more affordable through discounts for certain groups were seen as enablers of IAT use [70].

Study informants also emphasised the importance of cost as a barrier to discussing or prescribing IAT with clients: “it’s almost unethical to say ‘oh yes, this is really good for you’ but then it costs you $10,000 and it’s not under insurance so people cannot buy it; you’re not going to set someone up with something that you know is ultimately out of reach” – [PT1]; “we have to be good resource allocators with the funding available” – [SLP1]. Available funding is often constrained by the time required to acquire it: “even if they do qualify for funding it is a lengthy process to get that funding – it will take up to six months to a year or sometimes longer” - [OT1].

Costs of IATs were reportedly exacerbated when coverage was unclear, or not available through government or private insurance [27,72]. Examples of high-cost technologies include robots and exoskeletons, the latter costing between $30,000 and $100,000) [55,73]. Wearable low-vision assistive devices, in one study, were regarded by patients as prohibitively expensive to use [64]. Transitioning robots quickly out of controlled labs into real-world settings was suggested to mitigate costs [74].

Accessibility by tech type

In terms of accessibility, the included studies showed that, across all technology types, device cost was a barrier to their prescription and use [43,47,48,58,62,63]. This was more pronounced with situation-specific robots [55,73], and less so with wearable and handheld devices, which are more ubiquitous and accessible [48,49,71]. Devices and interventions that leverage more readily available devices and lower-cost components may overcome barriers to accessibility [45,54].

Effectiveness

The following topics related to effectiveness were discussed within articles and by key informants: cost-effectiveness, how well IATs work for the health care system, and how well IATs work for older individuals. The theme of effectiveness is summarized in Table 4.

Table 4. Effectiveness summary.

Effectiveness
	Barriers	Facilitators
Cost-effectiveness	-Cost-effectiveness reports were mixed. -Unclear data could impede implementation in the health system.	-Devices which delay institutionalization could be more cost effective.
Effectiveness for the health system	-Lack of evidence for some intervention types, such as mobile and connected technologies.	-IAT found to reduce: hospitalization, emergency department visits, healthcare utilization, and length of stay. -Able to track clinical outcomes. -Robotic stroke rehabilitation favoured over conventional delivery for patients with severe disability.
Effectiveness for older individuals	-Timing of device provision impacts successful incorporation and use. -Uncertain outcomes for robot assisted rehabilitation devices. -Some studies found IAT rehabilitation devices were not more beneficial than usual therapy.	-Several devices show effectiveness in improving activities of daily living.

Cost-effectiveness

Reports of the cost-effectiveness of IAT were mixed. Some studies found that IATs contribute to lower care costs [73,75], whereas other studies reported IATs as not cost-effective [76]. Other studies brought up the consideration that IATs that delay or prevent 24-hour care or placement into institutional care should be considered cost-effective [44,46,60,77]. Ambiguous reports of cost-effectiveness data could be problematic for health systems with high evidence thresholds, as described in the following quote by PT3: “our organisation wants to see something that’s evidence-based. They are not interested in starting something that’s novel or undeveloped” - [PT3].

Effectiveness for health systems

System-level cost-considerations affect the prescription and use of IATs. Some studies reported that IAT use impacted health systems by: reducing hospitalisation [78]; decreasing emergency department and rehabilitation visits [78], reducing healthcare utilisation [79], and contributing to shorter lengths of hospital stay [78]. IATs were reported as beneficial to track important clinical outcomes including gait, balance and fall risk [56], physical activity [80], sleeping and eating [81]. One review reported that, across five different studies, robotic devices in stroke rehabilitation should be favoured over conventional delivery [75]. This same review reported cost and health benefits of the robotic intervention, for all but mild or moderate stroke patients [75]. Data produced by some types of IATs were reported to quantify recovery [82,83] and contribute to earlier or preventive treatment through their ability to detect frailty or functional decline, or to manage symptom changes in chronic disease [45,46,73,78,84].

Informants preferred technology with evidence of benefits, or which are accepted as best practice, as illustrated by PT1: “If there was a new device that was deemed to be best practice in stroke rehab, we would try to arrange education, if we can, implement it locally and regionally.” - [PT1]. One author reported a lack of evidence for the effectiveness and efficacy of mobile and connected health technologies for older adults aging in place [68].

Effectiveness for older individuals

A variety of different types of smart assistive technologies were reported to improve older people’s ability to complete their activities of daily living, including a wrist robot [85], a distributed system [86], a mobility aid [47], a social robot [76], a virtual reality system [43], and upper-limb rehabilitation robots [87]. Other studies reported that IAT could improve medication adherence among older adults through custom reminders [46] and could lead to more precise prescription by health care providers [46,56]. The timing with which IAT devices are introduced impacts their successful incorporation and use [52,87,88].

Uncertain outcomes for older people were reported in some of the included studies. For example, a systematic review reported that, though robotic exoskeleton rehabilitation should be favored in the majority of stroke patients, conventional therapy is preferred for mild and moderate stroke patients [75]. Other studies reported weak evidence for using IATs such as social robots for persons living with dementia in long-term care, and virtual reality technologies or older adults with neurological disorders [43,89]. In some studies, outcomes of IAT use were reportedly not more beneficial than usual forms of therapy, such as one study which measured the task-performance of people with cognitive impairment using virtual reality, a study of stroke patients using robot-assisted gait therapy, and another study where stroke survivors completed smartphone-based caregiver-mediated rehabilitation [43,90,91]. Some included studies reported mixed findings on IAT use and safety. A road robot, a social alarm, an assistive robot, a wearable fall detector, a home integration system, a wearable virtual reality system and an ICT system were reported to contribute to greater feelings of safety [43,47,60,63,92,93], while one study that covered multiple types of IATs reported concerns for safety among participants due to privacy concerns and functionality limitations [59].

Effectiveness by tech type

The reported effectiveness of IAT devices varied greatly. Studies reported that all device types, besides voice-activated systems and handheld devices, improved activities of daily living for those who used them [43,47,85,86]. Wearable devices were reported to improve safety for older individuals but were also cost prohibitive [43]. Of all tech types, situation-specific robots were the most common type of tech within the theme of effectiveness, though that data was conflicting. Robotic-assisted rehabilitation was purported to have superior effectiveness in stroke rehabilitation for severely afflicted patients [75], however some studies reported a weak evidence base for upper-limb rehabilitation robots [89].

Usability

Studies found many factors when designing and developing IATs that can facilitate their prescription and use by older adults. These features include participatory approaches to IAT design; design features; individualised, adaptable IATs; and training/support for IAT use. The theme of usability is summarized in Table 5.

Table 5. Usability summary.

Usability
	Barriers	Facilitators
Participatory approaches to designing IAT		-Including end-users in the design process can improve implementation. -Iterative and participatory design process including user and caregivers.
Design features	-Devices being aesthetically unpleasing increases resistance to use. -Short battery life. -Devices which were too anthropomorphic caused uneasiness. -The degree of a patient’s disability may limit their ability to use IAT, such as hand impairments when using touchscreens.	-Universal design to ensure technology is ambient, discreet, and unobtrusive. -Simple and intuitive design. -Portability. -Robotic IATs should be small, slightly anthropomorphised, possess the ability to communicate, and maintain safety standards. -Individualized prompts and patient reminder functionalities. -Interoperability and communication with the broader health system. -Easy to use interfaces.
Individualized, adjustable AT	-Devices designed for a younger population may not adapt well to use by older adults.	-Adjustability of interventions to suit each patient.
Patient training and support	-Information overload during training limits acquisition and acceptance.	-Training can increase familiarity and alleviate uncertainty with IAT devices. -Ease of installation. -Ease of use and reliability. -Technical support and training for patient caregivers. -Ongoing technical support.

Participatory approaches to designing IAT

Many of the included studies referenced a participatory approach between engineers and manufacturers with end-users, older adults and caregivers as a way to improve implementation [45,46,60,61,71,72,76,85,86,89,94–96]. For example, participatory approaches were noted in robot implementation [85] and in designing a handheld sensor-enabled medication injector [97]. Studies found participatory approaches should be iterative, with continued engagement throughout development, design and delivery of the IAT as was completed in the development of several self-management applications [68,80,98,99].

Design features

Some studies identified specific design approaches, which could contribute to more useful IATs. Universal design creates usable AT for all ages; values-based design (an extension of this approach) focuses on values identified by users [45]. Universal design features would ensure the technology was ambient, discreet and unobtrusive, which were seen as important for IATs in the home of a patient [45,46,81].

IAT that was not aesthetically pleasing [63,64,69,94,97,100,101], bulky [53,55,63,102,103], or cumbersome [87] could increase resistance to use, potentially leading to abandonment. Simple, intuitive design and instruction was reported as enabling continued use of IAT devices [53,64,69,98]. For a sensor-enabled wearable fall detector, the small size and light weight of the device contributed to usability [104]. A key informant confirmed size was a limiting factor to IAT use, in their experience: “the device was so cumbersome, they had no room to store it” - [PT1]. The findings of one study, though, suggested that aesthetic properties may be more important to younger populations than older adults [74]. The desire for portable IAT was expressed by some studies in this review [64,67,71,97,105]. For IAT to be portable for an older adult, it may need to be lightweight or require minimal strength to operate [71]. Tensions exist between the desire for a lightweight, portable IAT and one with a long battery life, which may make the device heavier [55]. One review found that portable low-vision aids may not be as cost-effective as their non-portable comparators, though they were easier to use [67]. A short battery life [72,104,106–108] and limited storage capacity [72,106] of an IAT were seen as barriers to use. One study found that older adults may be opposed to smaller devices, such as tablets [105]. Regarding robotic IATs, older adults were reported to desire small, slightly anthropomorphised devices, that possess the ability to communicate similarly to human caregivers while maintaining safety standards [79,109]. However, robots that were large and too anthropomorphic were found to cause uneasiness [79,109].

Studies emphasised the desire for IAT with the capability to send patients reminders about the timing of medication delivery, diet choices, and their health goals, and able to function as a panic button to enhance safety [72,79,97,110,111]. Individualised prompts, based on health history, to help manage chronic diseases were seen as desirable features [46,110]. The ability to cancel false alarms, which are common, was also identified as a desired feature [46,81,107].

IAT that enabled communication with the health care system was seen as useful [85]. Studies discussed the relevance of IAT that is interoperable with the wider healthcare system as a facilitator to use [68]. The desire for interoperable IAT, though, was reported among concerns about privacy issues of having health information stored and shared confidentially [45,46,60,68,110,112].

Healthcare providers were reported as preferring IAT which was developed and reviewed by clinicians; and had the ability to: access patient data remotely; print graphs of patient data [46,51,68,95,96,113,114]; and perform real-time assessments of gait-speed and balance [56]. Patients, similarly, preferred IAT devices which allowed them to access their own health records [95] and share their own health data [110]

Easy to use IAT interfaces were an important consideration, in terms of graphics, color and text size [47,64,81,87,93,97,98,103,104,111]. There were examples among included studies where IAT was not usable by older people. For example: patients who had trouble using their hands could not use a touch screen [47,103]; voice-recognition was unable to understand accented speech or speech affected by disability [83,103,112]; some IAT could not be used by people with visual impairments [71,115]; or hearing impairments [115]. For people with rheumatic diseases, the ergonomics of IAT devices were considered essential due to limitations in hand mobility [97].

Individualised, adjustable at

Many studies identified the necessity of an adjustable IAT that could be individualized to each patient through smartphones, app interfaces, provided information, behaviour and delivery, or motorized devices [25,49,50,53,63,67,69,72,74,79,87,93,95,96,101,104,108,111,113,116,117]. This may be particularly relevant for older people with changing health statuses [55,118]. Some studies identified problems when an IAT was designed for a younger population, finding it did not adapt well for use by older adults [45,68]. Adaptability was also shown to be a priority for family caregivers, and helpful to physiotherapists in managing different capabilities of stroke patients [76,82].

Patient training & support

Older adults may require training to install and use IAT; one of the key informants felt that older persons would likely require greater training than younger persons because “the comfort level of the older population is very different” - [PT3], and they were seen as “not as tech savvy” – [SLP2]. Training can increase familiarity and alleviate uncertainty about IAT use [70]. Many studies reported training older people on IAT as a facilitator to use [25,26,67,70,81,84,102,105,106,110,119–121] though the number of studies where patients did not receive training on IAT [25,26,42,64,122] suggests it may not be widespread or adequate. In one study, ease of installation and ease of training was noted as a facilitator to use [69]. Some studies found that information overload during IAT device selection and training may be a barrier to the acquisition and acceptance of smart devices [52,62]. To this end, it was reported that concise language [104], without medical jargon, was desired or beneficial to patients using IAT [98]. Providing technical support and training to caregivers may also aid in the uptake and continued use of IAT [25,123]. Additionally, support from family and caregivers was reported as an important component of patient confidence in using IAT [96]. Easy-to-use technologies that would not require training or would be simple enough for those with less technology experience could readily adopt them, were also discussed in some studies [43,124].

Role-playing, strategising how to fit IAT into the daily environment, group workshops about IAT use, and practising task success were mentioned as positive, even enjoyable, components of in-person training [47,54,70,125]. Take-home resources including leaflets, detailed written instructions; a checklist outlining device features; and accessible tips in case someone forgets how to operate the IAT, facilitated older adults’ training [116,126].

Ongoing technical support and managing patients’ expectations about the duration of support were important features of training people for IAT use [81]. Participants in one study found that support following the cessation of the trial (while participants transitioned to independent use) would have been beneficial [108]. Key informants echoed the importance of training and support for older people as a facilitator for their older patients to use IAT in the following quotes from SLP2: “there are some companies that offer technologies with all of the necessary training, and then they will continue and support it, so for me I look for that for my elderly clients” – [SLP2] “I don’t tend to prescribe devices that come from agencies that don’t have this support in place” – [SLP2]. OT1 described the importance of clients having an opportunity for a hands-on trial of the equipment: “What happens is they get the trial with whatever the equipment is, and they realise how great it is – they feel safer, they just feel better, and then they end up buying the equipment. Otherwise, they chase me out of the house saying get out of here – I’m not paying money for this!” - [OT1]. Informants also emphasised the importance of having follow-up or resources available if problems are encountered later on: “People get training initially but then they forget, because if you don’t use it all the time, when you come to use it again then you may forget how to use it. So that ongoing follow up or opportunity to go back and remember how to use things is important.” - [OT2].

Usability, ease of use, and reliability were essential to the adoption of IAT devices [61,64,67–69,79,108,127], and were also emphasised by the key informants. For example, OT1 talked about the time required to learn the technology and to teach the client to use it: “Ease of use is important, you don’t want it to be more work” - [OT1]. OT2 discussed how the complexity of the technology could be a challenge for implementation: “I’m always in awe at what engineers and computer scientists and such can do but if devices are too complex then the client may not use them to their full function…There’s a lot of stuff around usability that determines whether the technology will be used or not, reliability is one of them; is it easy to use, is it easy to learn how to use, are there a few steps or many?” – [OT2]. Complex features of a technology may be an aid to its adaptability and versatility, but might also be a barrier to its use in practice.

For some people, certain limitations (visual; cognitive; pain; comorbidities; injuries; fine motor control; hearing; anxiety) made IAT use difficult or impossible [4,63,87,96,103,119,121]. In one study, worsening limitations made older people more willing to try a range of IAT, which may present an opportunity for IAT uptake [128].

Usability by tech type

Device usability was a facilitator for the majority of device types. The ease of use of device interfaces was described as a facilitator to use by all five included technology types: situation specific robots [87,93], distributed systems [81], wearable devices [104,111], handheld devices [64,97,98,103], and mobility aids [47]. The benefits of a participatory design process on implementing distributed systems [46,86], handhelds [94], and wearables were marked [72]; support for a participatory design was most pronounced within the category of situation-specific robots [71,85,89,95]. Aesthetics and bulkiness of devices were considerations for handheld [94,102] and wearable devices [55,63], and unobtrusiveness was considered a facilitator to distributed systems [46]. The adjustability of prescribed devices was identified as a facilitator for use of situation-specific robots [101,117], and for wearable [72] and handheld devices [53]. Training of older adults was important for handheld devices [102], wearables [106], distributed systems [81], and situation-specific robots [121].

Staff considerations

Staff-related considerations included their role in prescribing IAT, training requirements, and staff knowledge and awareness of IAT. The theme of staff considerations is summarized in Table 6.

Table 6. Staff considerations.

Staff Considerations
	Barriers	Facilitators
Role in prescription	-Lack of experience with smartphone and technology-enabled devices. -Concerns about incorporating robotic rehabilitation, despite eagerness. -ICT based devices can increase physician burden through increased demand and excessive data.	-Clinician recommendations and attitudes can support initial use and reduce abandonment. -Outsourcing some tasks and responsibilities, such as instruction, decreases physician burden.
Staff training	-Researching and familiarising professionals with IAT.
Staff knowledge and awareness	-Limited knowledge of which IAT devices to recommend. -Legal frameworks for AI-based IAT.

Role in prescription

Rehabilitation professionals mediate the relationship between older adults and their use of IAT, as they often prescribe or recommend IAT. Clinician recommendations can initiate and reassure patients about IAT use and reduce abandonment of IAT [84,124]. One study found that a provider’s attitude and perception of IAT can mediate prescription and use, where, perceiving a robotic IAT device unfavourably, caused some providers to withdraw from using it [115]. Follow-up with older patients about IAT use increases their adherence, with abandonment dropping from 37% to 10% [59]. Some providers may lack experience in providing rehabilitation through smartphone and technology-enabled medias [49,96]. One study found, concerning a social and exercise robot, that although providers were eager to incorporate robotic IATs into practice, there were still concerns held by the general population regarding safety, the replacement of human care providers by robots, and an overall prevailing fear of robotic devices [66]. The use of ICT-based IAT may also increase provider burden due to increased demand for follow-up [49,51], and large amounts of data produced by such technologies [68]. However, care robot IATs were reported to have the potential to reduce care provider burden, by providing opportunities to outsource some tasks and responsibilities, such as providing exercise instructions to patients [115].

Staff training

One of the informants felt that the amount of training and support available could vary significantly depending on the size of the centre: “We are very blessed here having a ton of support in the background but I can imagine that if you were at a smaller centre that would be a huge problem.” - [PT3]. Key informant OT1 reinforced the importance of staff training on the technology: “We would need training on it so we become experts on it and can teach our clients how to use it best” – [OT1].

Educating and training personnel was identified as critical to ensuring best outcomes for older adults, though training programs may not sufficiently incorporate the requirements of older adults [26]. Despite their proximity to and influence on older people, some studies outlined challenges associated with training rehabilitation professionals on IAT. For example, studies found that it is challenging for therapists to allocate time to research and familiarise themselves with current IAT [66,115], which was echoed by our study informants: “we just don’t have the time, not that everything needs to be spoon fed, but the reality is that we don’t have time to just sit and look at articles, it just doesn’t happen” – [PT2]; “I mean the time it takes to just try and to keep updated on this stuff, there’s such a demand to see more people, to get them in quicker, to do things more efficiently” - [OT1].

Staff knowledge and awareness

In some studies, therapists felt they had limited awareness of IAT products to recommend, while other studies mentioned a shortage of staff knowledgeable in set-up and training of older people [4,27,61]. Key informants indicated that previous experience and associated comfort levels with IATs had a significant effect on the level of acceptance and training required: “some therapists are a lot more comfortable with technology and others are not, and it goes with age usually, some of the older therapists are like ‘I’m not touching that!’ which I think is quite common” - [PT2]. The lack of legal frameworks for the use of robotic healthcare IAT, and the speed at which these frameworks can be developed in comparison to the development of IATs, has also raised concerns [109].

Staff considerations by tech type

There were several staff considerations for the prescription of different IAT types. Handheld devices were found to have barriers for staff involved in prescribing IAT devices, as they may lack experience in using handheld devices [49,96], and the increased demand for follow-up through the use of such devices may increase care provider burden [49,51]. Similarly, rehabilitation professionals had difficulty researching situation-specific robots [66,115], and lacked awareness of situation-specific robots and mobility aids [61].

Patient-centred considerations

This theme includes results related to patients or users of IATS, such as their home environment, their motivation, beliefs and attitudes, and the stigma associated with IAT use as an older person. The theme of patient-centred considerations is summarized in Table 7.

Table 7. Patient-centered considerations summary.

Patient-centred Considerations
	Barriers	Facilitators
Patient’s environment	-Home modification to integrate IAT. -Motorised IAT inability to navigate different surfaces. -Poor wireless connections.	-Tailoring IAT devices to user environments.
Motivation	-Lack of motivation from some older adults to use IAT. -There is a need for frameworks to evaluate IAT devices.	-Desire for increased or preserved independence, activities of daily living, and aging in place motivates use. -Desire to reduce caregiver burden. -Support from friends and family in adopting and operating IAT. -IAT use to promote socializing with friends and family, and to promote leisure.
Beliefs and attitudes	-IAT use can be intimidating, stressful, or induce fear and anxiety. -Belief that IAT is too difficult to use. -Perception that IAT is for young people. -Scepticism from low digital literacy. -Scepticism surrounding privacy and surveillance. -Older adults do not want IAT devices to replace care received from their family.	-More experience with technology prior to IAT prescription.
Stigma	-Visibility of IAT deters use. -Public use of IAT produced self-consciousness, negative attention, and pity. -Older adults felt IAT use broadcasted that they were frail. -Self-perception of being too old for IAT.	-Advocacy to reduce stigma. -Interactions with others who use IAT devices.

Patient’s environment

Many studies discussed how aspects of the patient’s environment can prevent them from using IAT. In some studies, the patient’s home environment would require modifications or renovations to integrate IAT [47,113]. One study recommended developing and tailoring IAT devices to the environment of the users [25]. Examples of specific aspects of homes which impede IAT use include: inability of a motorised IAT to navigate different terrains such as carpet or stairs [74] and weak or no wireless internet and Bluetooth [63,104,107,108,122]. Key informants’ shared concern about lack of wireless internet as potentially problematic for their patients: “how many of the clients will actually have internet at home?” - [PT2]. “It’s always tricky because some of these technologies are connected to Wi-Fi but sometimes it’s hard to have those things in place, these technologies can be great but not everyone has access to that” - [OT1].

Two studies, one investigating patients who had experienced spinal cord injuries and another reviewing the use of smart homes for older adults and people with disabilities, found that distributed systems provide independence [122] and improved quality of life through their use [46]. Another study found that interactive robot pets may bypass the environmental barriers experienced with owning conventional pets [127].

Motivation

Studies discussed patients’ motivations for using IAT as well as motivation as a by-product of IAT use [50,79,123]. Studies discussed the desire for increased or preserved independence as a source of motivation for IAT use [27,71,72,122,128]. Other studies mentioned IAT use as motivating to complete activities of daily living [71,106] and to age in place in one’s own home [76,129]. Feedback provided through app-based IAT was seen as a way to improve motivation for continued use [98,111].

Some studies mentioned family caregivers as influential in a patient’s motivation. Patients are motivated to use IAT to improve their caregivers’ experience. For example, in some studies social and assistive robots reduced conflict and burden [76,93], while distributed systems enhanced caregivers’ quality of sleep [81] and reduced burden [47,51,65]. Similarly, a multi-functional system was reported to reduce caregiver burden and improve perceptions of safety and trust [86]. Study subjects were motivated to use IAT to offer peace of mind to caregivers not living with the patient, and to demonstrate to family that they were progressing in their rehabilitation [85,123].

Family or friend caregivers can act as a source of motivation for IAT use in rehabilitation by supporting older adults to adopt or operate the IAT [59,62,65,83,88]. IAT use was also reported as beneficial to caregivers by reducing injuries and burden incurred in the process of caring for IAT users [47]. Key informants we interviewed described care partners as a resource to motivate and troubleshoot for older adult clients. For example, OT2 said: “you have to think about who can help the person problem-solve or help them learn how to do it and set it up if they need assistance” - [OT2].

Some study subjects were motivated to use IAT for social purposes, to connect with friends and family, to reduce loneliness, or as a means to engage in leisure activities [108,129]. Some studies discussed how rehabilitation involving exercise games helped to motivate older adults to exercise, as they enjoyed competing with friends and family [59,116]. Other studies showed that human-like robots or robotic animals could provide comfort, entertainment or relieve agitation for some older adults [43,46,76,93].

Included studies outlined the ways that IAT used in rehabilitation can be motivating for older adults to develop abilities, change behaviour, complete more rehabilitation activities, join new programs or stimulate learning to use new types of IAT [89,102,110]. Stroke patients in particular, may be motivated by IAT use in rehabilitation to regain previous capacities [85]. One study indicated that there is a need for frameworks to evaluate IAT devices, particularly ones which account for the intended users [130].

Beliefs and attitudes

Some papers discussed how different beliefs or attitudes of patients mediated their IAT use or non-use. For older adults in many of the included studies, IAT was intimidating or fear-inducing to try [47,54,62,79,88,92,96,105,115,117,126]. For some older people, IAT use can cause stress [26,100], or anxiety [123]. For example, in some studies, older adults were worried about breaking something by clicking around on a tablet [62,100,105]. These beliefs are echoed in other studies where patients believed an IAT was too difficult to use or learn [52,81,123] or they lacked the confidence to try to learn [59]. Other studies showed that some older adults believed IAT was for young people [53,62,70], that they were unable to manage IAT [117] or that it would be distracting, or burdensome to have to manage IAT [57,112]. Some included studies reported, older adults minimised their need for rehabilitative devices [25,45,63,93], or outright had little interest in using IAT devices [25].

As might be expected, more experience using technology before the onset of conditions requiring IAT use [53,62,65,105,119], was reported as a facilitator to using IAT for rehabilitation [61,85]. Those with lower digital literacy were more likely to be sceptical towards technology, influencing their AT use [27,100]. Robotic IAT generated scepticism as older adults felt their skills and social lives might deteriorate [69,77].

Key informants we interviewed mentioned the importance of reassurance and persuasion to influence older patients’ beliefs about IATs: “There’s certainly a lot to do though with educating this population to help them understand that it’s not a bigger headache than it is worth”- [SLP2].

Some studies reported that older adults and researchers felt sceptical about the surveillance and privacy aspect of IAT [57,61,64,65,68,72,79,92,97,109,131], for example, the sensitivity of sharing personal health data [59]. One study reported that older people were willing to look past the sensitivity of sharing health information if it meant they could communicate with their health care providers outside appointments [84]. Other studies found that caregivers and people with dementia were not concerned about privacy or surveillance by IAT [65,70,81]. In fact, one study found that, amongst caregivers of people with dementia, safety was more important than the privacy or autonomy of the person they care for, and that safety IATs, such as trackers, were most appreciated [65].

Older adults’ beliefs about IAT were influenced by family caregivers. In three studies, older adults reported they did not want IAT use to replace the help they received from their family [76,93,123]. Some studies found that caregivers may fear that the use of assistive robots could contribute to reduced social connnection for older adults [79,93], or replace the personal component of caring for someone with dementia [65].

Stigma

Included studies listed social stigma surrounding the visibility of IAT as a deterrent to IAT use [27,53,63,76,79,87,93,127]. Using IAT publicly made older adults feel self-conscious [112], led to negative attention, and unwanted pity [77]. Smartphone-connected hearing aids and robots are examples of stigmatised IAT reported in included studies [53,77]. Ageist ideas about older adults were also mentioned; some study participants felt that IAT use would signal they were old and frail, while others reported self-stigmatising ideas (e.g., “I’m too old for that”) as a deterrent to IAT use [58,100]. One study mentioned that media portrayals of older people and technology, as well as advocacy campaigns, could increase public knowledge about disability, and reduce the stigma around IAT use as a signal of dependence [81]. Additionally, for home-based cognitively assistive robots, interactions with people already using similar devices promoted interest and a desire to use those IAT devices [79]. Smartphone-mediated hearing devices may also provide a means to reduce the stigma of IAT use due to the ubiquity of smartphones [53].

Patient-centred considerations by tech type

Use of all tech types was affected by factors relating to the patients who used IAT devices. Both mobility aids [47] and situation-specific robots [113] were negatively impacted by the physical environment in which they were used, and wearables [63,104], handhelds [108], and distributed systems [122] were impacted by wireless infrastructure. Conversely, one situation-specific robot, a robotic pet, was found to be better suited to patient environments than its living analogue [127]. Some IAT types, such as handheld devices [123], aided in motivating older adults, however, the visibility of some handheld-mediated devices also stigmatised older adults who used them [53]. The use of handheld [54,62,88,96,105,126] and situation-specific [79,115,117] robotic IAT devices was described as inducing fear in older adults, due to concerns of breaking the device [62] and the potential of device use increasing social isolation [77].

Discussion

This paper sought to identify facilitators and barriers influencing the prescription, acquisition, implementation, and adoption of smart assistive technologies among older adults for rehabilitation and found that IAT use was mediated by external forces such as cost, accessibility and usability of IAT, as well as intrinsic factors such as motivation, beliefs, attitudes, and stigma. This review found many studies that made recommendations to future technology developers, including the importance of individualised, adjustable technology which fits a patient’s home environment. To take advantage of the important role rehabilitation professionals play in influencing IAT use by older adults, they should be supported to understand available, effective IATs to recommend to their patients. Additionally, older people require support from rehabilitation professionals and/or through IAT-producing companies to continue to use these technologies on their own.

The Unified Theory of Acceptance and Use of Technology (UTAUT) is a synthesis of leading technology acceptance theory, that identifies factors that facilitate or constrain someone’s intention and use of technology in workplace contexts and has been widely applied and replicated [132]. The UTAUT2 provides a similar framework for technology acceptance in a consumer setting and can be used to situate the findings of this review. The UTAUT2 proposes seven constructs that weigh on the behavioural intention to use a technology: performance expectancy, effort expectancy, social influence, facilitating conditions, hedonic motivation (fun), price value, and habit [132]. These constructs are moderated by age, gender and experience [132].

Our theme about the patient-centredness of IATs aligned with the performance expectancy construct. Older adults are motivated by their desire for independence [71,72,100,122,128], thus, IAT should be presented as a tool that helps to preserve this. Studies referenced many domains (physical, psychological and health system) where IAT use can be impactful, countering the idea some older people had that IAT use signals dependence. Rehabilitation professionals we interviewed emphasised the role they play in motivating older people to consider IATs. By persuading them that the technology will provide benefits, clinicians increase older people’s performance expectancy, assuring them that using smart technology for rehabilitation will not be a “bigger headache than it’s worth” – [SLP2].

The UTAUT2 proposes that intention to use technology is driven by experience, or the perception about the previous passage of time. This aligns with our findings about patient beliefs and attitudes suggesting that older adults with previous experience using technology were more likely to engage in IAT use. Our findings show that many studies recognize the benefits to training older people on IAT use [25,67,70,83,84,102,105,106,119–121], but some studies [26,42,122] reported that older adults did not receive training on IAT. We recommend creating opportunities for older adults to gain digital literacy skills (build experience using technology) to enable IAT adoption.

In the eyes of technology developers, older adults represent an untapped market who are expected to spend $645 billion dollars by 2050 on technology [133]. It may be important for device companies to know that support and training play a role in clinicians’ decisions about which IATs to prescribe to which older people. To better market IATs to older people, ongoing training, support, and troubleshooting could be important considerations.

The UTAUT2 proposes that fun, pleasure or enjoyment mediate consumers’ use of IAT, which corresponded with our results about patient beliefs, attitudes and stigma. These themes contained information about unenjoyable aspects of IAT use, specifically, that it could be fear-inducing, difficult or time consuming to learn [47,54,62,79,81,88,92,93,96,105,115,117,126]. Ageist attitudes that IAT use may signal dependence or frailty, or internalised ideas about technology being for young people were found in this review [58,100]. Stigma and lack of self-efficacy around technology use may contribute to a lack of hedonic motivation for older people, creating barriers to IAT use. Awareness to increase public knowledge about disability, and to reduce the stigma around IAT use as a signal of dependence, would contribute to increased IAT use [81].

Our findings around the patients’ environment corresponded closely with UTAUT2’s facilitating conditions, literally, the physical support to use IAT. These findings covered how physical aspects of a patient’s home such as narrow passageways, stairs, or a weak internet signal [74,122] may impede IAT use. As older adults overwhelmingly prefer to age in place in their own homes [134] and the alternative (institutional care) is costly to publicly funded health care systems [135], supporting their IAT-enabled independence through tax credits or home modification grants could help governments avoid costs.

Our theme containing results about staff training corresponds with the social influence construct of the UTAUT2. Rehabilitation professionals can represent what the UTAUT2 calls, an ‘important other’ and can play a critical role in influencing older adults’ technology use. To play this role, rehabilitation professionals need knowledge regarding current best practices and the ability to translate them into their own clinical practice. Multi-component knowledge translation interventions have been used to support this, wherein self-perceived knowledge and self-perceived practice behaviours of rehabilitation professionals are observed [136]. This knowledge will become even more important as assistive technology is increasingly developed to support older adults.

The findings from the clinicians emphasise the role that care partners have as a social influence in older people’s use of smart assistive technology. It is evident (across themes of patient attitudes and beliefs, motivation, outcomes, usability and patient training) that family caregivers may also represent an important other influencing older adults’ technology use. Family-centred AT decision-making is commonplace when providing AT to children [22] but our research suggests this practise is important to facilitate older adults’ adoption of IAT as well. Older people may be motivated by family caregivers to use IAT for rehabilitation and to engage with others socially. Our findings suggest that IAT use is perceived by some older people as a form of reciprocity to family caregivers: a way to enable independence, reduce burden of family caregivers, and demonstrate commitment to their rehabilitation [47,65,76,83,85].

Our theme around usability aligns with the idea of effort expectancy (or ease of use): including patient training; design considerations, and individualised/adjustable technology. Results from these sections of the review emphasise the importance of participatory approaches to developing technologies that are easy to use and easy to change, as the functional ability of older patients is variable [45,46,60,72,76,85,124]. Our findings emphasise that older adults may require in-person support and/or practice to learn technology before using it on their own [70,83,84,106,110], and those older people who have more practice or experience using technology (for example, through previous employment) may be more comfortable and more likely to use IATs for rehabilitation activities [85,108]. Key informants emphasised the role that usability and training have played in their experience working with older people.

The UTAUT2 discusses the trade-off between monetary cost and quality of products or services as price value, which overlaps with our findings about the accessibility of IAT. The UTAUT2 seems to presume access to technology, which our review showed was complex. Access to technology is complicated by awareness of what IAT are available, what government supports are available for IAT, and understanding how to select suitable IAT from many commercial options [26,27,53,54]. Furthermore, costs of IAT can be prohibitive, aligning with previous author’s findings which cite cost as the reason for nearly 20% of unmet needs in disability supports for older Canadians [5,28]. Our findings suggest a central access point for IAT purchasing, which could include clear information about which IAT may be reimbursable, and for whom, could increase IAT use [27,72]. Additionally, health systems leasing or renting IATs could make their use more affordable [55].

Our categorisation of the findings did not overlap with UTAUT2 constructs entirely. Gender did not play prominently in our theming of results, which the UTAUT2 shows as moderating the relationship between consumers and their intention to use AT. Our results did not demonstrate culture or ethnicity as a moderating factor in older people’s IAT use for rehabilitation as [137] have suggested. Future research is warranted in this area as the digital divide may be more pronounced in certain groups, precluding access to smart technology for use in rehabilitation.

Our results may be of specific relevance in the context of the COVID-19 pandemic that has spread rapidly through long-term care homes, killing thousands of older people [138]. As older people and their families navigate care decisions, they may pay special attention to delay or avoid placement into institutional care, enhancing the relevance of recommendations to support IAT adoption. IAT use can contribute to reduced pain, increased cognition, and better participation in rehabilitation activities [100,114]. Gamifying rehabilitation could increase enjoyment and preserve functional mobility in older people who may be encouraged by their governments to stay at home to minimise COVID-19 exposure. In Canada, telerehabilitation options are being explored to support people in their rehabilitation from COVID-19 [139].

Our research showed that patients were motivated to use IAT to connect with friends and family, to reduce loneliness, or to participate in social settings [26,70,74,102]. Stay-at-home orders designed to minimise COVID-19 exposure could represent an opportunity to engage in IAT use for rehabilitation purposes, and reduce the social isolation associated with limited in-person connection [140].

Limitations

Although our search strategy was focused on returning articles about older people, this review did not explicitly seek to capture information regarding the impact of gender or ethnicty on the prescription of IAT devices. Gender, as well as age and experience, are recognized as key constructs in the acceptance of technology and play a pivotal role in modifying a patient’s use of an IAT device [132]. Future research should investigate the intersection of age, ethnicity, and gender on the prescription, acquisition, implementation, and adoption of intelligent assistive technologies in older adults undergoing rehabilitation.

This review did not place any geographic restrictions on the search strategy. It is important to acknowledge that the countries covered operate with very different health care systems and correspondingly different frameworks, policies and regulations regarding developing, assessing, implementing and reimbursing IAT, which could limit the applicability of the findings. In low and middle-income countries, IAT prescription may be crowded out by other health-priorities. Additionally, this review did not attempt to assess or evaluate the quality of the evidence include within the review. As such, results should be considered emblematic of the state of research conducted regarding the use of IAT devices with older adults in rehabilitation. This should be especially noted for the effectiveness results of the review, where no aggregation was conducted to identify whether individual IAT types were statistically effective.

Conclusions

This study outlines the breadth and depth of the literature surrounding IAT prescription, acquisition, implementation, and adoption for older people undergoing rehabilitation, detailing how cost, access, home environment, attitude, stigma, technology development, adaptability of technology, motivation, training (staff and patient) and usability interact to influence IAT adoption. This scoping review is strengthened by consultation with clinical rehabilitation providers, who provided context on how facilitators and barriers appear in and resonate with their practice. Any strategies to improve upon barriers to prescribing smart technologies for older people should leverage the expertise of rehabilitation professionals operating at the interface between older people; their health/mobility; their families; and technology-based solutions. We offer practical insight on the ways rehabilitation practitioners and health systems can enable older adults’ IAT use, to promote their good health and independent living for as long as possible.

Acknowledgements

We are grateful to University of Waterloo Health Sciences Librarian Jackie Stapleton for advice on our search strategy. Larissa Nagora, Kassandra Lemmon and Melissa Koch were of great assistance during data analysis.

Disclosure statement

The authors report there are no competing interests to declare.

Additional information

Funding

This study was funded in part by the AGE-WELL Network (www.agewell-nce.ca), which is funded by the Government of Canada’s Networks of Centres of Excellence (NCE) Program.