Selected literature among the sampling.
\r\n\tHydrogen gas is the key energy source for hydrogen-based society. Ozone dissolved water is expected as the sterilization and cleaning agent that can comply with the new law enacted by the US Food and Drug Administration (FDA). The law “FDA Food Safety Modernization Act” requires sterilization and washing of foods to prevent food poisoning and has a strict provision that vegetables, meat, and fish must be washed with non-chlorine cleaning agents to make E. coli adhering to food down to “zero”. If ozone dissolved water could be successively applied in this field, electrochemistry would make a significant contribution to society.
\r\n\r\n\t
\r\n\tOxygen-enriched water is said to promote the growth of farmed fish. Hydrogen dissolved water is said to be able to efficiently remove minute dust on the silicon wafer when used in combination with ultrasonic irradiation.
\r\n\tAt present researches on direct water electrolysis have shown significant progress. For example, boron-doped diamonds and complex metal oxides are widely used as an electrode, and the interposing polymer electrolyte membrane (PEM) between electrodes has become one of the major processes of water electrolysis.
\r\n\t
\r\n\tThe purpose of this book is to show the latest water electrolysis technology and the future of society applying it.
During the last decade a growing interest in vitamin D-related problems can be observed and a few thousands of scientific publications are dedicated to this task every year.
The alarming statistical data regarding propagation of vitamin D deficiency in all continents and our developing knowledge about novel, non-calcemic actions of vitamin D seem to be two main causes of this phenomenon. Indeed, recent epidemiological studies suggest that worldwide prevalence of inadequate vitamin D status is higher than expected, however it may result from different factors, including geographical location and cultural background.
Since vitamin D skin synthesis, which takes place under the influence of the sun’s ultraviolet B (UVB) radiation, covers as much as 90% of total body needs, inadequate radiation or insufficient cutaneous absorption of UVB are regarded as major causes of vitamin D deficiency.
Air pollution is a chief factor determining the extent of solar UVB that reaches earth surface and several epidemiological data, which represents different populations living in different geographic latitudes, indicate that atmospheric pollution (especially high tropospheric ozone content) may play a significant independent role in the development of vitamin D deficiency. As a result prevalence of D hypovitaminosis among urban residents can be more than twice higher than that of rural inhabitants.
The problem of vitamin D insufficiency has been underestimated for many years and it has been predominantly associated only with bone diseases. Discovery of vitamin D receptor and its identification in a wide number of tissues other than bones led to the designation of novel, so-called “non-calcemic” (e.g. antiproliferative and immunomodulatory), actions of cholecalciferol. Subsequently, there is a growing number of diseases and conditions, development and/or progression of which can be associated with inadequate vitamin D status, including different types of cancers, autoimmune disorders as well as cardiovascular events. Interestingly, prevalence of many of these diseases also positively correlates with the intensity of air pollution. Therefore one can conclude that with the increasing atmospheric pollution grows a number of people in the world who are vitamin D deficient or insufficient and indirectly exposed to several poor health outcomes.
This chapter gives an overview of the literature on this topic and assesses the available data about the association between air pollution, vitamin D status and prevalence of so-called civilization-related diseases. A general information regarding vitamin D metabolism is given first. Next, current definitions of vitamin D status are presented, followed by the alarming statistical data about vitamin D deficiency pandemic and its correlation with the intensity of air pollution and prevalence of common human diseases. To understand possible mechanism linking vitamin D deficiency with these poor health outcomes, first a brief presentation of traditional (calcemic) and novel (“non-calcemic”) actions of vitamin D is given. Subsequently, epidemiological and experimental data regarding the association between vitamin D status and prevalence of bone diseases, different types of cancers, autoimmune disorders and cardiovascular diseases is presented. Finally, therapeutic perspectives and general guidelines about vitamin D supplementation and requirements are included. The chapter ends with a short summary which facts about vitamin D can be generally accepted and which still require more solid scientific background.
In mammals, vitamin D3 (cholecalciferol) is either produced in the skin by the non-enzymatic conversion (photochemical cleavage) of provitamin D (7-dehydrocholesterol) to previtamin D3 under the influence of ultraviolet radiation (290-315nm), or delivered from food sources. In the skin previtamin D3 can also undergo isomerization that results in creation of biologically inactive compounds (lumisterol and tachysterol) and this mechanism prevents from the vitamin D3 overproduction and intoxication after prolonged exposure to sunlight. In the liver vitamin D3 undergoes enzymatic hydroxylation to 25-hydroxyvitamin D3 (25(OH)D3) in the reaction catalyzed by 25-hydroxylase (CYP2R1).
In the tissues that have 1α-hydroxylaze activity (predominantly in kidneys, but also in activated macrophages, colon, prostate, breast, brain as well as in other tissues), 25(OH)D3 is converted to the active vitamin D metabolite – 1,25(OH)2 D3 (calcitriol), whereas hydroxylation in position 24 (by 24-hydroxylase – CYP24) initiates degradation of vitamin D metabolites (Horst & Reinhardt, 1997) [Figure 1]. Efficiency of renal vitamin D3 hydroxylation is regulated by the level of calcium and phosphate ingestion, parathyroid hormone and, in a negative feedback, by circulating levels of 1,25(OH)D3. The extra-renal hydroxylation is determined by local factors e.g cytokines, growth factors as well as by 25(OH)D3 concentration, making it particularly sensitive to vitamin D deficiency (Marques et al., 2010).
The serum 25(OH)D3 concentration is the parameter of choice for the assessment of vitamin D status for several reasons. First of all, it reflects total vitamin D derived from dietary intake and sunlight exposure as well as the conversion of vitamin D from adipose stores in the liver. Furthermore, it is relatively stable and it has a long (2-3 weeks) half-life in circulation. Finally, it was shown in several epidemiological studies that 25(OH)D3 levels correlated best with several clinical conditions.
Definition of vitamin D status has evolved during the last decade. Whereas 25(OH)D3 level
below 10 ng/µl (25nmol/l) is still, indisputably defined as vitamin D deficiency, the ranges of vitamin D sufficiency has been recently modified. For years, 25(OH)D3 levels between 10 ng/µl and 20 ng/µl have been identified as insufficiency (WHO report 2003), however with the recent changes in laboratory reference rages, nowadays vitamin D adequacy is defined as 30 to 76 ng/µl (75nmol/l) and 25(OH)D3 concentrations between 10 and 30 ng/µl are described as insufficiency. Vitamin D intoxication which is extremely rare, occurs when 25(OH)D3 concentrations exceed 150 ng/µl.
The simplified scheme of the vitamin D synthesisCholekalciferol (synthesized in the skin upon the UV radiation or delivered with food undergoes several hydroxylations, firstly in the position 25 in the liver. The next hydroxylation catalyzed by the 1α-hydroxylase (CYP27B1) leads to the synthesis of the active metabolite – 1,25-dihydroxycholekalciferol. The alternative metabolic pathway of 25-hydroxycholekalciferol leads via hydroxylation in position 24 (the reaction is catalyzed by the vitamin D 24-hydroxylase – CYP24).
There are at least two reasons for setting the low end of the normal range of vitamin D levels at 30 ng/µl. First of all, it is suggested that serum concentration of vitamin D over 30 ng/µl guarantees optimal calcium absorption and below this concentration levels of parathyroid hormone (PTH) rise (Rosen, 2011). Secondly, this concentration provides an adequate amount of substrate for the nonrenal conversion of 25(OH)D3 to 1,25(OH)2D3. It is assumed that children have the same requirements as adults, however no comparable studies have been carried out on intestinal calcium absorption and parthyroid hormone levels in children.
During last years vitamin D deficiency and insufficiency has been recognized as a 21st century pandemic and after changing the ranges of vitamin D concentrations defined as normal, it is estimated that this problem concerns as much as 30-50% (according to some sources up to 80%) of the general population (Hollick & Chen, 2008, Ovesen et al., 2003). In a Euronut-Seneca study that compared vitamin D status in elderly citizens in Europe living in latitudes from 350 to more than 600 the mean 25(OH)D3 concentrations ranged from 20 to 60 nmol/l and surprisingly, were higher in the northern countries than in the Mediterranean area (Wielen et al., 1995). This data was confirmed by the results of MORE study conducted in women with osteoporosis (Lips, 2010). In Middle East and in India, vitamin D status correlates with clothing style and is believed to be the lowest among all continents (Arya et al., 2004, Sachan et al., 2005). In South East Asia vitamin D status is generally better (Fraser, 2004). In studies performed in North America several ethnic and life-style related differences in vitamin D status were observed. However, in general, vitamin D deficiency was higher in non-hispanic whites compared to non-hispanic blacks and was in between in Mexican-American (Looker et al., 2008). In Africa, it was reported that the vitamin D status improves from north to south (Prentice et al., 2009) whereas in Australia and Oceania, the trend is opposite (Rockell et al., 2006).
Although studies performed in different continents cannot be exactly compared due to e.g. (i) different methods used to asses 25(OH)D3 concentrations (precision and accuracy may vary depending on the kind of the assay) (ii) seasonal fluctuations in the vitamin D dietary intake (iii) seasonal variations in efficacy of cholekalciferol skin synthesis (it is estimated that in northern latitudes serum 25(OH)D3 levels decline from late summer to midwinter by 20%), some general patterns suggested by these studies can be recognized. In adults, groups at the highest risk of vitamin D deficiency are elderly (especially those in nursing homes) and obese subjects, and those who due to religious habits are wearing clothes covering most of the body (Lips, 2010).
Based on epidemiological studies it is estimated that an average dietary intake of cholecalciferol is as small as only 200 IU per day, thus the main source of vitamin D remains its skin-derived synthesis that covers as much as 90% of body’s total requirements. However it should be emphasized that its efficiency is highly variable and anything that hampers transmission of solar UVB radiation to the earth surface and anything that diminishes the penetration of UVB radiation into the skin will affect efficacy of vitamin D skin synthesis.
Since melanin is extremely efficient in absorbing UVB radiation, individuals with increased skin pigmentation have reduced abilities of vitamin D skin synthesis and are at higher risk of vitamin D deficiency. Appropriate application of sunscreens results in the similar effect. The angle at which the sun reaches the earth has a significant effect on the number of UVB photons that reach the earth surface therefore geographic latitude and season (autumn and winter) as well as agegeographic latitude and season (autumn and winter) as well as age (elderly people have 75% lower concentrations of vitamin D precursor 7-dehydrocholesterol), sex (vitamin D status is usually lower in women) and cultural conditionings (especially practice of purdah that totally prevents exposition of the body to sunlight) are another factors potentially reducing efficacy of vitamin D skin synthesis (Webb, 2006).
Apart from UVB-related vitamin D deficiency, there are several medical or physical conditions which may impair vitamin D status, that include, among others: fat malabsorption, use of anticonvulsant drugs that induce catabolism of vitamin D active metabolites, chronic kidney disease or obesity (fat tissue is known to entrap vitamin D) (Zhang & Naughton, 2010).
Recently the scientists focused their attention on the problem of air pollution as an important factor reducing the amount of UVB radiation reaching the earth surface and therefore correlating with prevalence of vitamin D deficiency.
Air pollution is regarded as a dominant factor influencing the extent of solar UVB reaching earth surface. It was proved by both: observational and prospective studies, performed in different populations living in different geographic latitudes that atmospheric pollution (especially high tropospheric ozone content) may play a significant independent role in the development of vitamin D deficiency. Tropospheric ozone can efficiently absorb UVB radiation and decrease the amount of photons reaching ground level. It was proved that the level of air pollution is inversely related to the extent of solar UVB that reaches earth surface. Since industrial areas are those, of the highest intensity of air pollution, prevalence of D hypovitaminosis among urban residents can be more than twice higher compared to rural inhabitants.
To date, there have been published only 3 studies that attempted to correlate the intensity of air pollution with the prevalence of vitamin D deficiency, however their results are unequivocal.
In the tropics, children who live in regions with higher levels of ambient air pollution have been shown to be at increased risk of developing vitamin D-dependent rickets, compared to those living in less polluted areas (Agarwal et al., 2002). Children living in the highly polluted part of Delhi, despite similar types of housing, had significantly lower mean serum concentrations of 25(OH)D3 compared to those living in the less polluted areas of the city. The prevalence of vitamin D deficiency was correlated with the intensity of air pollution that in turn correlated inversely with the amount of UVB light reaching the ground level. None of the children included into the study used any vitamin D supplementation or consumed vitamin D fortified food, so the differences in the vitamin D status of the children cannot be explained by different dietary habits. However the authors did not collect data regarding time which each of individuals spent on exposition to sunlight that seems to be a chief limitation of this work.
In another study performed in adult European citizens of urban areas above 350 N (where cutaneous vitamin D synthesis in winter is nearly negligible), prevalence of vitamin D insufficiency was significantly higher compared to rural residents (38% vs 18%) (Manicourt & Devogealer, 2008). The compared groups did not differ in the mean age, body mass index and amount of time spent outdoor. Therefore the authors concluded that the observed difference in vitamin D status must be due to the efficacy of vitamin D cutaneous synthesis. The main reason of this phenomenon was 3 times higher tropospheric ozone concentration in urban compared to rural areas. These results were confirmed by a subsequent study performed in urban and rural areas of Iran (Hosseinpanah et al., 2010), where air pollution (determined as the high tropospheric ozone content) was found to be an independent, significant risk factor of vitamin D deficiency.
For many years the problem of vitamin D insufficiency has been underestimated, associated only with calcium/phosphorus metabolism and regarded as an area of interest reserved only for pediatricians or orthopedists. However, the last years brought a number of epidemiological studies revealing the unexpected connection between the vitamin D hypovitaminosis and prevalence of several diseases that have forced the scientist to revise their opinions on the mechanism of vitamin D action and its role in the maintenance of body homeostasis (Walters, 1992).
1,25(OH)2D3 may act in target tissues via both genomic and non-genomic mechanisms. The non-genomic mechanism which is still not fully understood, is associated with stimulation of the enzymatic activity of a nonreceptor protein tyrosine kinase Src that results in activation of the mitogen activated protein kinase (MAP) signaling pathway (Gniadecki, 1998). Much more is known about the interaction of 1,25(OH)2D3 with its nuclear receptor VDR (vitamin D receptor).
VDR together with thyroid hormone receptor (TR) and retinoid-X receptor (RXR) belongs to the class II of nuclear receptors family that act as a transcription factors modulating expression of vitamin D-directed genes. Upon binding with 1,25(OH)2D3, the VDR forms a heterodimer with the retinoid-X receptor and translocates from cytoplasm to nucleus where it interacts with vitamin D responsive elements (VDRE) in promoter regions of target genes and regulates their expression (Dusso & Brown, 1998) [Figure 2].
The simplified scheme of activation of the target gene by the vitamin D receptor. The vitamin D receptor (VDR) with vitamin D (VD) binds as a heterodimer with the retinoid X receptor (RXR) specific sequence in the promoter region of the target gene – the vitamin D responsive element (VDRE). Via TATA binding protein (TBP) transcription factor II B (TFIIB), VDR gets in touch with the RNA II polymerase and other transcription factors (not present on these scheme). The transcription level is regulated by the complex of co-activators which bind VDR.
Identification of VDR in the intestine, kidney, bones and parathyroid glands (organs traditionally associated with mineral homeostasis) was not surprising. It is an undisputable fact that vitamin D is essential for maintenance of calcium and phosphorus homeostasis. In response to hypocalcemia-induced secretion of parathyroid hormone, and subsequent increase of CYP27B1 expression and conversion of 25(OH)D3 to an active 1,25(OH)2D3, calcitriol, secreted to circulation, reaches the target cells and, after binding with VDR interacts with VDR-responsive elements in target genes that results in increased calcium and phosphate absorption in gut and in release of calcium and phosphate from the mineral phase of bones. Other actions of vitamin D related to bone metabolism include: inhibition of type 1 collagen synthesis, induction of osteocalcine production, stimulation of monocytes-macrophages differentiation into osteoclasts and production of RANK ligand which mediates in maturation of osteoclast precursors into osteoclasts, responsible for calcium mobilization from bones (Clarke & Kohsla, 2010).
The identification of VDR expression as well as the demonstration of the vitamin D 1α-hydroxylaze (CYP27B1) activity in a wide number of tissues other than bones (including, e.g.: skin, blood cells, prostate, breast, brain and skeletal muscles) started a new era in the understanding of vitamin D action and led to the designation of novel, so-called “non-calcemic” actions of calcitriol.
Nowadays, 1,25(OH)2D3 can be defined as both a hormone (when it is synthesized in kidneys and secreted to the circulation) and as a cytokine. As a cytokine calcitriol participates in the regulation of innate immunity. It is synthesized locally by monocytes-macrophages and in an intracrine manner, via interaction with VDR, modulates immune response towards microbial agents. In vitro studies suggest also crucial role of 1,25(OH)2D3 in regulation of differentiation, maturation and function of other antigen presenting cells – dendritic cells. Other functions of vitamin D in the immune system include: regulation of the differentiation and activation of CD4 lymphocytes, increase in the number and function of regulatory T cells (Treg), reduction in the production Th1-derived cytokines, stimulation of the Th2 helper and natural killer (NK) T cells and probably many others (Marques et al., 2010].
1,25(OH)2D3 has been also shown to have antiproliferative and antiapoptotic properties. Although the exact mechanism by which 1,25(OH)2D3 regulates cellular proliferation is not fully understood and may differ between tissues and cell lines, several pathways have been proposed. In in vitro studies, 1,25(OH)2D3\n\t\t\t\tvia interaction with VDR, increases expression of cyclin-dependant kinase (CDK) inhibitors – e.g.: proteins p21 and p27. It results in keeping the cell in G1/S phase and in prevention of DNA synthesis (see Figure 3) as it was shown in experiments performed on human prostate adenocarcinoma (lymph node, carcinoma, prostate – LNCaP) and on human leukemia U937 cell lines (Zhuang & Burnstein, 1998; Liu et al., 1996). The inhibition of mitogenic signals transmitted via e.g. epithelial growth factor (EGF) receptor, inhibition of prostaglandins, activation of transforming growth factor β (TGF-β) and proteins binding insulin-like growth factor (IGF-BP3) are examples of other (and not only) mechanisms by which vitamin D is able to regulate cell cycle progression (Desprez et al., 1991, Moreno et al., 2006).
Apoptosis is an example of another cellular process which can be regulated by 1,25(OH)2D3, however the exact mechanisms of this phenomenon are still being investigated. Experiments conducted on human breast cancer and on chronic lymphatic leukemia cell lines revealed that 1,25(OH)2D3 is able to inhibit expression of the protooncogen bcl-2 and increase expression of the pro-apoptotic protein Bax (Elstner et al., 1995, Xu et al., 1993). In addition, in breast and prostate cancers cell lines, calcitriol was shown to induce release of cytochrome c in the mechanism that does not depend on kaspases (Spina et al., 2006).
Apart from its engagement in cell proliferation and apoptosis, vitamin D has been also found to be involved in the regulation of cell adhesion and angiogenesis, two other processes important for cancer development and progression. “Anti-invasive” properties of
Inhibition of cell cycle progresion by vitamin DOne of the factors determining the switch between G1 and S phases of the cell cycle is retinoblastoma (Rb) protein phosphorylation that leads to the release of several transcription factors activating genes involved in the cell cycle progression. Rb phosphorylation is catalyzed by the G1 cyclines and cyclin dependent kinases – CDKs. The CDKs activity can be inhibited by the p21 and p27 proteins. Vitamin D with the vitamin D receptor (VDR) binds to the regulatory sequences in the promoters of p21 and p27 genes activating their transcription that leads to the inhibition of the CDKs, lack of Rb phosphorylation and inhibition of the cell cycle progression.
1,25(OH)2D3 has been shown both in in vitro experiments (performed on human breast and lung cancer cell lines) as well as on animal models of prostate and bladder cancers, and include:
inhibition of metalloproteinases and serine proteases,
up-regulation of cadherin E expression,
down-regulation of integrin α6 and β4 expression (Bao, et al., 2006a, Hansen et al., 1994, Konety et al., 2001).
Inhibition of interleukin 8 gene expression (via interaction of 1,25(OH)2D3 with p65 subunit of nuclear factor κB) is proposed as one of potential mechanisms by which calcitriol may interfere with the process of angiogenesis (Bao, et al., 2006b).
Knowledge of novel, non-calcemic actions of vitamin D that were proved in studies in vitro and on animal models, helps to understand the connection between the vitamin D and several human diseases that was reported by epidemiological studies.
Knowledge of traditional and novel, non-calcemic actions of vitamin D that were proved in studies in vitro and on animal models, helps to understand the connection between the vitamin D and several human diseases which was reported by epidemiological studies.
For years vitamin D deficiency deficiency has been predominantly associated with impaired bone mineralization and development of rickets in children as well as osteopenia, osteoporosis and fractures in adults.
The consequences of vitamin D deficiency in mothers can be observed in the fetal skeleton just at the beginning of the 19th week of human gestation, resulting in rachitic phenotype, the severity of which is directly associated with a decreasing 25(OH)D3 level in the maternal circulation (Mahon et al., 2009). Vitamin D levels in infants correlate with vitamin D levels in their mothers during the first two months of life. Later, vitamin D status in babies, like in adults, depends on their diet and exposure to sunlight.
In rickets caused by vitamin D deficiency (a leading cause of rickets), both intestinal calcium absorption and renal phosphate reabsorption are significantly reduced. The decreased levels of serum calcium and phosphorus levels result in decreased bone mineralization. In addition, phosphorus deficiency contributes to the failure of the expected apoptosis of hypertrophic chondrocytes that results in deorganization of the growth plate. Clinical presentation of nutritional rickets depends on the duration and severity of vitamin D deficiency. At the beginning hypocalcemic symptoms are predominant, whereas skeletal deformities become obvious in later, more advanced stages. Classical symptoms of so-called “blooming” rickets include: craniotabes in infants older than 2-3 months, delayed fontanel closure, wrists enlargement, rachitic rosary, delayed teething, carious teeth, enamel hypoplasia, “O”- or “X”-type leg deforminty, kyphosis and narrow pelvis, chest deformities, costal or lower extremity fractures, caput quadratum, frontal bossing, fractures, brown tumor and extremity pain. Extra-skeletal symptoms include: hypotonia, constipation, proximal myopathy, cardiomyopathy and heart failure, myelofibrosis and pancytopenia, growth retardation, hypocalcemic convultions and benign intracranial hypertension (Levine, 2009).
Although full-symptomatic rickets seems to be nowadays a curiosity, epidemiological data indicate that rickets is not a disease of the past, nor it is limited to developing countries. It is estimated that nowadays 5 per 1,000,000 children aged between 6 months and 5 years have rickets, and the main risk factors for its development are breastfeeding and dark carnation. The peak prevalence of vitamin D-deficient rickets is characteristically between 6 and 18 months of age, with a further smaller peak occurring during adolescence (Nield et al., 2006).
In adults vitamin D deficiency can also cause a skeletal mineralization defect, resulting in osteomalacia demonstrating with isolated or global bone discomfort accompanied by joints and muscle pain. However some observational studies conducted in adults and concerning the association between skeletal health and 25(OH)D3 serum levels had conflicting results, suggesting both a strong correlation with the incidence of fractures and falls or only a fair relation (Chung et al., 2009). In general, it is assumed that the decrease of serum 25(OH)D3 concentration that results in the persistent secondary parathyroidism enhances osteoclastogenesis and subsequent bone resorption.
The critical role of vitamin D in bone mineralization is well established, but our growing knowledge about non-calcemic actions of calcitriol led to the elongation of the list of diseases and conditions which development and/or progression can be associated with inadequate vitamin D status, including: different types of cancers, autoimmune disorders, cardiovascular events and probably many others. Interestingly, prevalence of this diseases frequently correlates with intensity of environmental pollution and many of them are diagnosed more frequently in inhabitants of industrial districts compared to rural areas (Pope, 2002, Pope, 2003, Grant, 2006, Ritz, 2010).
The observational study conducted in 1941 reported that living at higher latitudes (where vitamin D skin synthesis is impaired) is associated with an increased risk of the development and dying of many common cancers including colon, prostate, ovarian and breast cancers (Apperly, 1941).
This observation was followed by the epidemiological studies performed in Europe and in the North America, assessing influence of many potential risk factors for incidence of cancers (e.g. smoking, alcohol consumption, economic burdens and environmental pollution) revealing that morbidity of several cancers (including colon, gastric, lung and breast carcinomas) is inversely associated with exposition to UVB radiation (Grant, 2003, Grant, 2005, Grant & Garland, 2006, Grant, 2009).
Next, on the one hand, another epidemiological prospective, study proved that vitamin D insufficiency (25(OH)D3 concentrations below 20ng/ml) is associated with 30-50% higher risk of colorectal cancers (Garland et al., 2009). On the other hand, it was shown in a meta-analysis that appropriate (>400 IU) or increased (>1000 IU) vitamin D intake may be associated with a decreased risk of colon, breast, pancreas, esophagus and non-Hodgkin lymphomas (Garland et al., 2006, Giovannucci et al., 2006, Holick & Chen, 2008). It is estimated that the daily intake of 2000 IU of vitamin D would lead to 25% reduction in incidence of breast cancer and 27% reduction in incidence of colorectal cancer (Garland, 2009). Association of vitamin D deficiency with prevalence of breast, skin and prostate carcinomas has been also reported, however the concentrations at which the increased risk has been observed varied. Moreover, there are studies suggesting a U-shaped association between vitamin D concentration and cancers risk, pointing that some individuals may be adversely affected by elevated 25(OH)D3 concentrations with respect to risk of prostate, breast, pancreas and esophagus cancers (Toner et al., 2010). This inconsistency may be caused by inadequate consideration of modifiers of 25(OH)D3 concentrations. Therefore, to date, there is not yet sufficient evidence to recommend high-dose vitamin D supplementation for the prevention of cancer.
The hypothesis, about the connection between the vitamin D deficiency and cancer development, based on the observational data, has been confirmed by the in vitro studies described in the previous section and by experiments on animal models. For example: in vitamin D deficient Balb/c mice, injected with MC-26 colon cancer cells, the tumor growth was accelerated, compared to vitamin D sufficient animals. In addition, vitamin D sufficient animals presented higher intra-tumor expression of VDR and CYP27B1, which suggests possible autocrine/paracrine cell growth regulation by vitamin D (Tangpricha et al., 2005). In turn mice with vdr knock-out (mutation that eliminates genomic action of 1,25(OH)2D3) have been found to be more susceptible to develop leukemias, breast and skin cancers under the influence of common carcinogens compared to wild-type animals (Welsh et al., 2004).
Discovery of anti-cancer properties of vitamin D (that has no antioxidant properties) required a modification of a classic two-hit model of cancerogenesis, that provides that development of cancer depends on both: activation of proto-oncogenes and deactivation of tumor suppressing genes. Therefore, in context of vitamin D, a novel model of cancer pathogenesis has been proposed – a so-called: the Disjunction-Initiation-Natural Selection-Metastasis-Involution-Transition (DINO-MIT) model. This model is based on the classical concepts of carcinogenesis like initiation and promotion, however it includes also the life cycle of malignancies and provides an explanation of the ability of vitamin D to prevent or arrest the development of cancer (described in detail by Garland et al., 2006).
Similarly to carcinomas, prevalence of some autoimmune disorders such as multiple sclerosis and type 1 diabetes mellitus also correlates with the geographical latitudes. It has been proposed that vitamin D deficiency can disturb the immunological equilibrium and therefore contribute to the development of autoimmunity (e.g. by exacerbation of Th1 immune response) (Cantorna, 2004). In order to understand the complexity of these mechanism, again, insights from animal models of common human autoimmune diseases occurred to be particularly helpful.
Vitamin D deprivation leads to the acceleration of the development of experimental allergic encephalomyelitis (EAE – an animal model of multiple sclerosis) in mice immunized with myelin antigens (e.g. MOG35-55) (Cantorna et al., 1996). In turn, supplementation with active vitamin D metabolite and its analogs may favorably influence the course of autoimmune diseases or even prevent their occurrence. In mice immunization with type 2 collagen leads to the development of collagen induced arthritis (CIA – an animal model of rheumatoid arthritis), however, if the animals are given 1,25(OH)2D3 till the 14th day after immunization, they do not present any symptoms of arthritis at all. If 1,25(OH)2D3 is given to mice with symptomatic artritis, it may alleviate the disease course (Cantorna et al., 1998). Similar evidence comes from the studies performed in nonobese diabetic (NOD) mice that due to the autoimmune inflammation and destruction of pancreatic islets develop insulin-dependent type 1 diabetes. In young subjects, administration of 1,25(OH)2D3 till the third week after birth may completely prevent development of diabetes whereas in mature mice leads to the 50% reduction of inflammatory infiltrates in the pancreatic islets, compared with placebo-treated animals (Gregori et al., 2002). Reduction of T cells infiltration and decrease in the number of demyelinization sites has been also found in spinal cords of mice with experimental allergic encephalomyelitis treated with vitamin D analogs, compared to wild type animals (Mattner et al., 2000).
In humans, epidemiological data revealed that multiple sclerosis morbidity in Caucasians is significantly higher in less insolated areas, and the course of disease correlates with seasonal fluctuation of 25(OH)D3 serum concentrations (exacerbations in spring when 25(OH)D3 concentrations are the lowest) (Cantorna, 2008). Similarly, in patients with systemic lupus erythematosus (SLE) severe vitamin D deficiency has been reported by many authors, and it correlates with disease activity (Kamen, 2010).
In contrary, like in epidemiological studies performed in different cancers, adequate consumption of cholecalciferol (400 IU per day) was shown, in a prospective study, to decrease a risk of multiple sclerosis development (relative risk – RR 0.59) (Munger et al., 2004). Vitamin D deficiency during the first year of life was found also to be a severe risk factor of type 1 diabetes whereas its proper administration in early childhood may reduce the risk of the development of this disease by 78% (RR 0.12) (Hypponen et al., 2001). A correlation between the adequate vitamin D intake and lower risk of the development of rheumatoid arthrits (RR=0.67) was reported (Merlino et al., 2004), however it was not confirmed by further studies [Costenbader, 2008]. Inconsistent are also results of the studies regarding the association between vitamin D intake during pregnancy and risk of type 1 diabetes in the offspring as well as with prevalence of other autoimmune disorders.
These discrepancies may be owed to the fact that, like in carcinogenesis, vitamin D deficiency is probably not the chief trigger in the development of autoimmunity. This hypothesis is supported by the in vivo experiments, where animals with vitamin D deficiency or with the knock-out of vdr gene do not present autoimmune disorders spontaneously and require other stimuli to develop autoimmunity. However these animals may present more severe disease phenotype of autoimmune disorders, as it was shown in mice depleted with IL-10 gene (animal model of inflammatory bowel diseases – IBD) (Froicu & Cantorna, 2007).
Cardiovascular diseases are the most common cause of mortality and morbidity worldwide. There is also a growing number of evidence that vitamin D deficiency can be associated with development of several cardiovascular diseases including hypertension, ischemic heart disease and cardiac hypertrophy.
In vitro studies revealed that addition of 1,25(OH)2D3 to the cardiomyocyte cells culture resulted in: inhibition of cell proliferation, enhanced cardiomyocyte formation, decrease of apoptosis and cell-cycle associated genes’ expression. In turn animals with vdr gene knock-out were shown to develop cardiac hypertrophy, display hypertension as well as increased serum angiotensin and tissue renin levels. These studies suggest that vitamin D via its influence on cardiac and vascular structure and function may modulate cardiovascular risk (Artaza et al., 2009).
Observational studies reported a strong association between vitamin D hypovitaminosis and other traditional cardiovascular risk factors. Moreover, according to other reports, vitamin D deficiency is a predictor of all-cause and cardiovascular mortality, whereas vitamin D adequacy is associated with 43% reduction in cardiometabolic disorders (Parker et al., 2010).
The importance of vitamin D status in context of coronary artery disease is well established based on observational studies that reported:
inverse correlation of mortality from ischemic heart disease and the exposure to sunlight (Fleck, 1989),
high prevalence of vitamin D deficiency in patients with ischemic heart disease (Kendrick et al., 2009),
increased risk of sudden cardiac death, heart failure and fatal stroke in patients with ischemic heart disease who were vitamin D deficient (Pilz et al., 2008).
A correlation between the time of exposition to UVB radiation and decrease in blood pressure was also observed (Krause et al., 1998) and vitamin D replacement in deficient subjects led to a significant improvement of flow-mediated dilatation of the brachial artery that suggested an influence of vitamin D on vascular smooth cells (Tarcin et al., 2009). Indeed, it was shown on animal models that active vitamin D metabolite inhibits rennin expression in the juxtaglomerular apparatus and may prevent proliferation of vascular smooth muscle cells (Li et al., 2002; Carthy et al., 1989). Both, small retrospective observational studies and a large, cross-sectional study, confirmed that the mean blood pressure vary inversely with serum 25(OH)D3 concentrations and the association remained significant after adjustment for age, gender, race, ethnicity and physical activity (Scragg et al., 2007, Reddy Vanga et al., 2010).
Additionaly, individuals with vitamin D insufficiency have been found to higher prevalence of peripheral artery disease (Melamed et al., 2008) and worse outcomes in end-stage heart failure (Zittermann et al., 2008).
Encouraging epidemiological data coming from observational studies, linking vitamin D deficiency with common human diseases, rose a hope that calcitriol and its derivates may be useful in everyday clinical practice (Holick, 2004, Holick, 2007). However, to date bone diseases are the only examples where administration of vitamin D is generally accepted for treatment.
In order to restore vitamin D reserve in rickets two methods of treatment are proposed. In a low dosage and long-term therapy model, vitamin D is administered 1000-10000 IU/day (dose depends on age) for 2-3 months. After that period 400 IU/day therapy is recommended to maintain the serum vitamin D level. Another regimen, reserved mainly for patients suspected of poor compliance, includes 100 000 - 600 000 IU of vitamin D in a single dose (Wharton & Bishop, 2003).
Prospective, randomized, placebo-controlled trials provided evidence supporting the benefit of vitamin D supplementation in patients with osteoporosis (LaCroix et al., 2009, Meier et al., 2004, Jackson et al., 2006). Data regarding a beneficial effect of calcium plus vitamin D on bone density in postmenopausal women and older men is consistent, however reports on fracture risk are more variable. Reduction in frequency of fractures was reported in some studies (Larsen et al., 2004) whereas large randomized trials have not shown any association between vitamin D supplementation and reduction in fracture risk. Additionally, in many of these trials, it is difficult to differentiate the effect of calcium from that of vitamin D. Nevertheless, in the Women\'s Health Initiative (the largest of the available trials) subgroup analysis revealed that calcium and vitamin D supplementation was associated with reduced fracture incidence in those subjects who were most compliant (Jackson et al., 2006).
Although the optimal serum concentration of 25(OH)D3 in patients with osteoporosis is not clear, based upon meta-analyses, one approach to vitamin D supplementation would be to give 400-800 IU daily with a target serum 25(OH)D3 concentration >20 ng/ml. Older individuals with greater risk may require higher amounts that allow to maintain serum levels of 25(OH)D3 from 30 to 40 ng/ml (Dawson-Hughes, 2005). Yearly high-dose of vitamin D (e.g. 500,000 IU) for the osteoporosis treatment is not recommended.
In observational studies, sufficient exposition to UVB radiation and vitamin D adequacy have been found to improve prognosis in cancer patients. A study assessing the survival rates for several cancers (including breast, colon, prostate, lung carcinomas and Hodgkin’s lymphoma) revealed that patients diagnosed in autumn had approximately 30% higher 18-month survival rate than those diagnosed in winter or spring (Robsahm et al., 2004, Porojnicu et al, 2007).
Results of recent observational studies, reporting that maintenance of 25(OH)D3 levels about 30ng/ml may be crucial in the prevention of breast, colon and prostate carcinomas (Garland, 2009), together with newly discovered, proapoptotic and anti-proliferative properties of vitamin D stimulate hope that 1,25(OH)2D3 and its analogues will have practical application in treatment of cancers. Severe hypercalcemia has occurred to be the chief limitation for the common use of vitamin D derivates in oncology and therefore vitamin D analogues are used mainly in combination with other anti-cancer drugs in reduced doses. Both in vitro and in vivo studies suggest that addition of vitamin D may potentializate action of many drugs commonly used in cancer treatment, including e.g: dexamethasone, docetaxel, paclitaxel, tamoxifen, retinoids, platinium derivatives and others (Gewirtz et.al., 2002). Administration of 1,25(OH)2D3 may also sensitize cancer cells to radiotherapy as it was shown in prostate cancer line LNCaP or breast cancer line MCF-7 (Dunlap et al., 2003, Polar et al., 2003).
Numerous vitamin D analogs with minimal calcemic activity have been designed with intent to be applied in cancer therapy and some of them have been found to be effective in inhibiting tumor growth (e.g. colon) in animal models. Some of them are tested for treatment (e.g. calcipotriol administered locally in skin metastases of breast cancer) however to date, no active analogs of vitamin D have been proved to be efficacious for the treatment of any human cancer by themselves.
No prospective, randomized, double-blind study has been conducted in order to asses the anticancer potential of vitamin D analogues in humans. However, in a small pilot study performed in 7 patients with prostate cancer, daily administration of 0.5-2.5 μg/24h of 1,25(OH)2D3 per 6 to 15 months, resulted in significant reduction of prostate specific antigen (PSA) concentration in 6 individuals (Gross et al., 1998). In another study, 37 patients with prostate cancer insensitive to androgens, were given sequentially 0.5 μg of 1,25(OH)2D3 (day 1) and 36 mg/m3 of docetaxel (day 2) during 6 following weeks and put on diet containing 400-500 mg of calcium per day. In 30 of them (81%) a significant reduction of PSA concentration was observed after 8 weeks from the beginning of the treatment (Beer et al., 2003).
Despite solid clinical and experimental evidence regarding the positive influence of vitamin D derivates on the development and progression of autoimmune disorders, to date vitamin D is not routinely administered in their treatment.
The only disease with partially autoimmune pathogenesis, where vitamin D and its analogs are generally accepted for the treatment is psoriasis. Both systemic and topical administration of vitamin D and its analogs leads to the significant improvement in 70-80% of the treated patients, measured by the Total Severity Score (TSS) or Psoriasis Area Severity Index (PASI) (Ashcroft et al., 2000). Administration of vitamin D for treatment of other autoimmune diseases is still experimental since in humans only small and non-controlled studies have been conducted. For instance, in a an open study performed in 19 patients with rheumatoid arthritis, addition of alphacalcidol (1α(OH)D3) to the traditional disease-modifying anti-rheumatic drugs for three months, resulted in a significant reduction of symptoms in 89% of patients (45% achieved complete remission and 44% had satisfactory results) without side effects (Andjelkovic et al., 1999). There is also one report on a positive influence of 1,25(OH)2D3 on thyroid hormones levels in patients with autoimmune hyperthyroidism, who acquired the treatment in order to improve bone mineral density (Kelman & Lane, 2005).
To date, studies evaluating influence of vitamin D supplementation on cardiovascular health are few and have inconsistent results. Observational studies reported that individuals who take oral vitamin D supplementation have lower blood pressure and some interventional trials found a correlation between oral vitamin D administration or increased exposure to UVB and decrease of blood pressure. However, this phenomenon was not confirmed by a large prospective studies and a meta-analysis on prevalence of hypertension and vitamin D intake (Forman et al., 2005, Witham et al., 2009). Vitamin D supplementation seemed also to have no effect on the risk of cardiovascular mortality (La Croix et al., 2009).
The recognition of vitamin D deficiency as a worldwide problem rises a task of means of its supplementation. Historically, fortification of milk in the 1930s with vitamin D was effective in eradicating rickets in Europe and US. However, after an unexpected outbreak of hypercalcemia in British children in the 1950s caused by the excessive vitamin D consumption from fortified food, fortification of dairy products with vitamin D had been forbidden (Holick, 2010).This situation was probably caused by the imperfection of methods applied to assess the vitamin D concentration in food at that time.
Naturally the main source of vitamin D are wild-caught, not farm-raised oily fish, e.g. salmon, mackerel, herring, and oils from fish. However, since no quality control over vitamin D content in natural products is available, they are not recommended as reliable sources of vitamin D supplementation. In many countries dairy products, juices, bread and other products are fortified with vitamin D.
The recommendations of American Institute of Medicine from 1999 state that all children and adults up to the age of 50 should consume 200 IU of vitamin D daily, whereas individuals aged 51-70 and those who are over 71 years old, 400 IU and 600 IU, respectively. However, these amounts have been insufficient in prevention of osteomalacia and osteoporosis, and therefore many experts now suggest that, in the absence of the adequate sun exposure, as much as 800-1000 IU of vitamin D per day is needed for healthy individuals, regardless of age (Holick and Chen, 2008). In case of diseases leading to vitamin D mal-absorption or sequestration in fat tissue (obesity), higher doses may be required. In aspect of cancer prevention, the National Academy of Sciences-Institute of Medicine (USA) recommends even 2000-4000 IU/day (Garland, 2009). It is estimated that raising the mean population level of 25(OH)D3 up to 42 ng/ml would result in 18% reduction in all-cause mortality, 25% reduction in prevalence of cancers and cardiovascular diseases, 15% in morbidity of diabetes and a prevalence of multiple sclerosis would be reduced by half (Grant & Schuitemaker, 2010), however approaching this vitamin D status would require supplementation of 2500-4000 IU of cholecalciferol per day.
According to the nutritional guidelines established during the 14th vitamin D workshop in 09, appropriate vitamin D status should be achieved rather through supplementation than diet fortification and rather through the use of vitamin D3 than vitamin D2. It is suggested that vitamin D2 is in half less effective than vitamin D3 in maintaining the 25(OH)D3 serum levels and therefore it should be administered in higher doses. Moreover, all evidence reported to date on the efficacy of vitamin D in e.g. cancer prevention has been based on vitamin D3. To verify this theory, a number of prospective vitamin D replacement trials with vitamin D2 and vitamin D3 has been conducted (Adams & Hewison, 2010).
In the treatment of evident vitamin D deficiency 50 000 IU of vitamin D is recommended weekly for 8 weeks, resulting usually in 25(OH)D3 concentration of 30 ng/ml, and after 50 000 IU of vitamin D every 2 weeks to maintain its level. It has been estimated that for every 100 IU of vitamin D ingested, there is an increase in the blood level of 25(OH)D3 of 1 ng/ml and sensible exposure to sunlight is more effective in raising blood levels of 25(OH)D3 than 1000 IU vitamin D3 taken daily for adults of most skin types. However, with the growing intensity of atmospheric pollution, which as it was shown above, is a chief factor limiting the amount of UVB radiation reaching the earth surface, obtaining appropriate amount of vitamin D from skin synthesis is getting more and more challenging.
Based on the available observational and experimental data regarding the connection between the air pollution, vitamin D status and related health consequences, following statements can be formulated:
the worldwide problem of vitamin D deficiency can be partially explained by the growing intensity of atmospheric pollution, however this observation is based only on the results of relatively small studies and should be replicated in larger scale,
both: vitamin D deficiency and intensity of air pollution correlate with prevalence of common human diseases including different types of cancers, cardiovascular and autoimmune diseases that was confirmed by large, prospective studies and meta–analyses,
association between vitamin D status and extra–skeletal health outcomes can be explained by the molecular mechanism of vitamin D action that exceed bone metabolism,
despite promising results of in vitro and in vivo studies regarding the favourable influence of vitamin D supplementation on prevalence and course of different diseases, its therapeutic application is still limited only to the treatment of bone diseases,
novel definition of vitamin D insufficiency together with the increasing intensity of the atmospheric pollution that impairs vitamin D skin synthesis and with epidemiological data regarding the benefits of vitamin D intake should result soon in the novel guidelines regarding vitamin D supplementation.
Nursing care is facing (is going through) an unprecedented crisis in terms of lack of skilled (health) care workforces. Like all high-income countries (HIC), Germany is going through the said crisis, which is continuously accentuating year after year. The workforce’s needs for long-term care in German nursing houses have been estimated in [1] for the period from 2009 to 2030, expecting an increase:
from 94.000 to 331.000 professional nursing and
from 157.000 to 298.000 care staff.
Elke Peters et al. have estimated in [2] the number of people living in Germany requesting nursing care to 3 million and to 5 million by 2050. The authors present a recent assessment of the nursing care services at nursing homes and at patient’s home and point out the needs for patients to live at home despite the benefit of all care services.
In November 2016, in Mondorf-les-Bains (Germany), a workshop [3] on nursing care had taken place. The topic of the workshop was: Nursing Care at the (German) border Regions? (Ger. Pflege an der Grenze?). The workshop’s main objectives were to strengthen the social aspect of nursing care and to more consider the nursing care to be taken place at the place of residence of the patient because of the demographic change and economic as well as employment market policy change. The said workshop pointed out that the share of family nursing care (also called care at home) is very small in comparison with ambulant nursing care. This means, family members do not care for their member requesting for nursing care. One of the main reasons leading to this situation is that the person requesting nursing care at home is living alone. Furthermore, direct family members are requested to participate in care costs. In order to participate, they must work to gain the necessary financial means to face the costs. This situation drives sometimes the family members to employ care staff without or with beginner’s care skills to care their parents at home or they send their parents aboard to East-European countries since the nursing care costs are cheaper there though caring at home for a person is not as easy as one can think. Prof. Dr. Eckart Hammer points out in [4] that many dementia patients are subjected to violence by family members who are caring for them at home. By analyzing this book section, one can understand why the German government put effort to solve the care workforce issues faced in order to admit enough nursing care requesting people to the care or nursing homes. Thus, family members who are not able to care for their patients can send them to a nursing/care home. They obviously also want to help the family to decently and lovingly care for their patients and protect the patient against as well as prevent violence. Violence can result from stress faced by the caring person. And the causes of stress are multiple. Violence also occurs in nursing care houses.
People with advanced dementia have complex needs [5]. Schmidt et al. have investigated the needs in a recent study. The study shows the evidence that people with advanced dementia are requesting monitoring round the clock even for a simple activity like “food intake.” At nursing care house, monitoring is guaranteed. But what happens if those people are living at their regular residence? This research question is justified by the results carried out by [6], which point out the causes of nursing care workforce shortage and provide recommendations to overcome the issues faced. In [7], the author recommends a series of solutions to fix the workforce shortage. One of these solutions is to use telemedicine to overcome the shortage of issues faced. He writes
Other solutions proposed to reduce the effects of shortages include the use of telemedicine to reach far-away neurologists (though this is unlikely to reduce workloads), the development of artificial intelligence to help in making diagnoses, and expanding neurological care to include non-neurologist physicians and advanced practitioners (specially trained nurses and physicians’ assistants)…
The recommended solutions are intended for neurology, though some of them can suite other medical fields.
Using telemedicine to overcome workforce shortage implies to keep a patient at his residence or at the care unit with only primary care services. A further research question rising here is what is the quality of life (QoL) of patients treated at home? Is it worth treating dementia patients at home instead of a nursing care home? Rebecca Palm et al. investigated in [8] the environment as a factor impacting the health-related QoL regarding nursing care for dementia patients. The study reveals that the structural and organizational characteristics of care units may impact the QoL though the study does clearly prove through empirical evidence that the care unit’s structure and organization influence the QoL. However, to our best knowledge, no study has investigated the impact of homecare on the health-related QoL based on the QoL measurement metrics pointed out in [8] such as temperature, noise, lightning, familiarity, adequate space, and opportunities to participate in domestic activities; it could be subsequently deduced that if the patient’s residence place also provides the same environmental criteria as temperature, familiarity, sufficient food, and water, etc., the patient treated at home will undergo the same health-related QoL. In [9], the authors investigated the impact small-scaled nursing care homes have on health outcome-related QoL. They found out that moving from large-scaled to a small-scaled nursing house can improve the aspect of the QoL by reducing the anxiety. This study allows us to conclude that a patient treated at home in his family circle and habituated residence place has less anxiety and better QoL.
It is obvious that patients requesting nursing care can receive nursing care at their residence places with a better health-related QoL. The factors impacting the QoL are well known though caring for dementia, Parkinson’s disease, and elderly patients suffering from possible cognitive impairments is a challenging task. The research question raised here is how to assess the factors impacting the QoL for better health outcome?
The literature review on technologies in nursing care or commonly in healthcare reveals that nursing care at home for dementia and elderly patients can take benefit of the technology (cf. section methodology/literature review).
Homecare is increasingly getting attention among the population for multiple reasons such as the nursing care crisis. This research mainly aims at proposing smart home automation enabled personalized homecare solution for a better quality of life (QoL) for the patient and for assisting the patient’s family members to cost-effectively and efficiently care for their patients at home without any impairment of QoL. Furthermore, this study pursues the objectives to assess the impacts of being assisted by home automation system on the QoL of all involving family members.
This study contributes to the multidimensionality of the concept of the smart home where many dimensions of home automation have been considered. The study focuses on many aspects of home automation such as energy saving [10, 11], temperature management, and regulation, security, and safety by managing the entrance, control doors, and windows.
Additionally, the study creates an environment for well-being for people limited in the movement.
The remainder of the chapter presents in Section 2 some backgrounds and definitions. The research methodology, consisting of a literature review, research data, and system design, is presented in Section 3. Research findings and discussion are presented in Section 4. Section 5 handles a daily personal assistance system, which is designed and implemented to assist patients receiving nursing care at home and who is most of the time alone, and Section 6 concludes the study.
According to NIH-UK (National Institute of Health United Kingdom), a nursing home provides hospital-like care services to people (outpatients, elderly, palliative, etc.) that cannot stay in the hospital for any aftercare or for elderly care.
A nursing home is a place for people who don\'t need to be in a hospital but can\'t be cared for at home. Most nursing homes have nursing aides and skilled nurses on hand 24 hours a day. (NIH-UK)
It is worth noting the main risk factors of being admitted to nursing and/or care homes (both are similar but are different regarding the qualification of the care-staff—see care homes vs nursing homes).
Age: elderly people have more chance of being admitted to a nursing/care home.
Low income: people with low income are vulnerable and have not enough possibilities to hire private care workforce to care for them at home.
Precisely for these reasons, they have a higher chance of being admitted to a nursing home.
Poor family support: especially in cases where the older adult lacks a spouse or children.
Low social activity: isolated people because of cognitive or age-related impairment.
Functional or mental difficulties.
Regarding the risk factors of being admitted to nursing or care homes, it is obvious that a group of people can be excluded from being admitted since they would not meet the conditions.
According to [12], nursing homes have been recommended to employ higher skilled nurse staffing in their homes, with 24-hour registered nursing care.
As the Balcombe Care Homes defines on its website:1
A nursing home will provide all the day-to-day care that you would expect from any care home, but the care is supervised by registered nurses who are on duty all day and all night.
while
Care homes are staffed 24 hours a day and a proportion of the staff will be qualified care assistants with NVQs (National Vocational Qualifications) at Level 2 or 3.
Segen’s Medical Dictionary defines nursing care as
A nonspecific term in medicine; among medically qualified doctors in the UK, nursing care generally refers to procedures or medications which are solely or primarily aimed at providing comfort to a patient or alleviating that person’s pain, symptoms or distress, and includes the offer of oral nutrition and hydration
Based on the Segen’s Medical Dictionary definition of nursing care, nursing care can be assimilated to palliative as well as elderly care. Most elderly people are requesting nursing care due to health conditions such as cognitive impairments that include dementia, Parkinson, blindness, etc. [13, 14]. Though their chance of being admitted to a nursing home is low, modern technology, as well as methodology such as remote care, can assist to provide them with the needed nursing care at their residence place. The question raised is how will this work?
The demographic structure of the developed countries (DC) or high-income countries (HIC) contains a large number of older (from 85+ years) and elderly (from 60+ years) people than young people (up to 59 years) and a very small number of teenagers (up to 15 years) in their population. The population of older adults is fastly growing in HIC [15], whereas the population in developing or low- and middle-income countries (LMIC) is remaining younger, although the number of young people is decreasing (see the example of Uganda—Figure 1). The median age in LMIC is around 15 years (see Figure 1), while the median age in the European Union (EU) is predicted to pass from 36.5 years in 1995 to 47.6 years in 2060 with an increasing tendency [16]. Thus, EU countries are facing an increasingly elderly population with all related needs like nursing and care homes, accommodated elderly healthcare services, etc.
Projection on demographic change LMIC versus HIC (from 1950 to 2050) [source [19]].
The term “Elderly people” is defined as adults aged 60+ years, while people aged 65+ years are considered as an elder. Orimo, Hajime et al. had reviewed the definition of the term “elderly” in [17] and found out a correlation between elderly and the request or need of medium to severe nursing care.
According to the conventional definition presented by the authors in contrary to the definition above, the elderly is from 65+ years.
Conventionally, “elderly” has been defined as a chronological age of 65 years old or older, while those from 65 through 74 years old are referred to as “early elderly” and those over 75 years old as “late elderly.” [17].
Though the World Health Organization (WHO) considers people aged 60+ years as elderly.
At the moment, there is no United Nations standard numerical criterion, but the UN agreed cutoff is 60+ years to refer to the older population [18].
And arguments follow such as why no one can exactly determine the age at which one has to be considered as elderly.
In addition, chronological or “official” definitions of aging can differ widely from traditional or community definitions of when a person is older. We will follow the lead of the developed worlds, for better or worse, and use the pensionable age limit often used by governments to set a standard for the definition [18].
According to the United Nations projection, about 79% of the world elder population aged 60 years or over will live in LMIC by 2050 [19]. Therefore, 20% of them will live in HIC.
Analyzing the population distribution (Figure 6 in [19]) reveals that in countries like Germany, population will count more aging people while an LMIC’s population like Uganda’s population will remain young.
As a conclusion, it is worth noting that the needs of nursing and care homes are higher in HIC than in LMIC. Therefore, the chapter will more focus on the nursing situation in HIC.
Age-related impairment mostly known as cognitive impairment is a group of diseases, which occurs with advancing age. Cognitive impairment can also occur in young people. Mostly age-related cognitive impairments are dementia, Alzheimer’s, Parkinson’s, loss of vision, hearing loss, depression, incontinence, etc.
Obviously, cognitive impairment progresses with advancing age. In [17], the authors found out that elderly need from 75+ years severe nursing care. Though nursing care shows the potential to improve the individual’s quality of life (QoL), most cognitive impairments cannot be cured. The patient, therefore, needs more attention, for example, reminding him to take food and drink enough water, and bringing him to get socialized again.
In order to better understand why these patients need more nursing care than others, it is worth understanding the symptoms of some cognitive diseases as follows.
Dementia is a progressive health condition mostly in elderly people. Dementia is a consequence of health conditions like Alzheimer and is characterized by cognitive impairment (loss of cognitive capabilities or abilities).
The Journal of the American Medical Association defines Dementia as
Dementia is diagnosed only when both memory and another cognitive function are each affected severely enough to interfere with a person’s ability to carry out routine daily activities.
The free dictionary gives a similar definition as
Loss of cognitive abilities, including memory, concentration, communication, planning, and abstract thinking, resulting from brain injury or from a disease such as Alzheimer’s disease or Parkinson’s disease. It is sometimes accompanied by emotional disturbance and personality changes.
Regarding the characteristics of dementia, it is highly requested to assist round the clock people suffering from such health condition in order to protect them against any accident that can result from forgetfulness. On one hand, they need assistance, and on the other hand, they can be refused to being admitted to nursing or care home. Furthermore, keeping these people at home remains challenging. Family members caring for these people are mostly by day time at their own job. In this case, the only solution is to employ care/nursing personnel to care for them during the absence of all family members. It is reportedly known that most “care/nursing personnel” hired for homecare are poorly skilled and mostly come from a different cultural background as the patient. The question is can all these factors impact the patient’s QoL? Especially, can the cultural differences contribute to QoL loss? Answering this question is out of the scope of the present study.
Parkinson’s disease is one of the best-known and most common diseases of the nervous system. It is a cognitive disease and mostly related to advancing age. James Parkinson, the British physician, described the typical symptoms of the disease for the first time in 1817 and gave his name to the disease. Like a most cognitive disease, is a slowly progressive neurological disease that affects certain areas of the brain. The main symptom of Parkinson’s disease is the movement disorder.
People suffering from Parkinson’s disease are, therefore, dependent on other people since they are limited in their movement. Furthermore, they can lose the sense of smelling and mostly suffer from Dementia, depression, and anxiety.
The main role of home automation is to control and manage devices at the local network(s) in the house. It can enable remote interactions with the network in order to access some information or to set command. For example, one can remotely ask his fridge or the fridge can send him a grocery list. Many technologies are included in home automation. Technologies like wireless sensor networks, videos, and connected devices support smart home automation paradigm. In [20], Toschi et al. reviewed the technologies that enabled a machine-to-machine (M2M)-based house automation. According to the authors, home automation is tending beyond connecting autonomous toward smart process and devices.
In this section, two technologies are briefly presented. In prior, the term automation is defined.
In [21], Vasseur and Dunkels defined home automation as follows:
Home automation is an area of multiple and diverse applications that include lighting control, security and access control, comfort and convenience, energy management, remote home management, and aging independently and assisted living.
In the context of nursing care, home automation (HA) is a network system and application that includes at the first place bio-signal monitoring, well-being control, and other medical means like medication intake, physical exercises, etc. Further, HA includes temperature management, patient-safety, and security by preventing dangerous actions like leaving furnace or gas on, going out without adequate wearing.
Figure 2 (Source Figure 23.1 in [21]) presents a sample of home control devices.
In [22], Pham et al. defined smart home automation as an environment context-related data for precise health monitoring. They write:
A smart home environment provides ample contextual data related to a resident’s health, which allows more accurate health monitoring than only using physiological signals.
They further presented cloud-based home automation that collects bio-signals and location information in order to accurately monitor nursing home residents.
Sample of home control devices (source: [21]/Figure 23.1).
The Internet of things is a paradigm for autonomous data gathering and processing. In [23], Luigi Atzori et al. had defined the Internet of things as follows:
“The Internet of Things (IoT) is a novel paradigm that is rapidly gaining ground in the scenario of modern wireless telecommunications. The basic idea of this concept is the pervasive presence around us of a variety of things or objects, such as Radio-Frequency IDentification (RFID) tags, sensors, actuators, mobile phones, etc., which, through unique addressing schemes, are able to interact with each other and cooperate with their neighbors to reach common goals.”
Internet of health things (IoHT) is designed for medical data gathering and processing. IoHT connects unconnected health means with network connectivity ability. Digital and physical medical objects can thus network with each other in collaborating for data collection, processing, and storage. IoHT is a special case of the Internet of things (IoT) that combines health technologies and IoT and takes full advantage of IoT technology like the ability to initiate actions based on collected and analyzed data [24].
IoT finds its application already in the medical world as Istepanian et al. discussed in [25]. Williams et al. have defined the healthcare Internet of things (also called IoHT—Internet of health things) as
“…the new embedded sensing capabilities of devices together with the availability of always being connected, to improve patient care whilst reducing costs [26].”
The common architecture of IoT consists of sensors and actuators called things. Things are located at the data perception level. Behind the things are placed the IoT-gateways and data acquisition systems, followed by the edge IT and the data center (commonly on a remote server) and cloud. There are three (03) layers: (i) perception layer, (ii) gateway layer, and (iii) IoT platform layer.
IoT has the potential to enable home automation in collecting and processing data as well as to autonomously request actuators to execute some tasks for example temperature control by regulating the heater according to the set (for patient comfortable) room temperature.
IoT presents various domain-specific architectures that use various technologies and areas such as RFID, service-oriented architecture, wireless sensor network, supply chain management, industry, healthcare, smart city, logistics, connected living, big data, cloud computing, social computing, and security. Figure 3 shows an IoT-enabled healthcare data perception system.
Healthcare domain specific IoT architecture (source: [27]).
Wireless sensor networks (WSNs) find their use in smart home automation application since a while. They are used for medical application and devices to measure the patient’s vital parameter. Bio-signals like body temperature, blood pressure, pulse oximetry, ECG, and breathing activity can autonomously and event-based automatically and seamless be measured.
Clinics, hospitals, and care/nursing homes can remotely use end-point devices like video and audio devices to assist family members to care for their sick member at home. Thus, home automation systems can be connected to medical emergency stations at clinics and hospitals close to the patient’s residence place and regularly forward the patient’s critical data gathered by WSMs and BANs. How this works is presented by Moghadam et al. in [28] where they have designed and implemented a communication system single and multi-antenna in a BAN. They wrote:
“an energy efficient data transmission technique for communication between a single-antenna medical sensor/microrobot inside the body to a multi-antenna receiver on the body surface through non-homogeneous propagation environment.”
Transmitting over multiple spatial and temporal scales is challenging in advanced health informatics [29] though advancement achieved in the Internet of things (IoT) protocols like LoRaWAN with platforms like the things network (TTN) [
Wireless body area network (WBAN) is part of wireless sensor networks (WSNs) that can enable monitoring and collecting the patient bio-signal. This has been shown in a previous study [30] where a wireless sensor network system has been used at a cardiologic intensive care unit (CICU) for collecting and monitoring, round the clock, cardiologic activities in-patients. WSNs were connected to the patients and thus bio-signals have been collected in real time. This study has shown the feasibility of using WSNs and WBNs in home automation.
The main objectives behind the research questions are on one hand to investigate the tendency toward homecare regarding the nursing care homes and care workforce shortage and on the other hand to additionally investigate challenges and issues people are facing in homecare. Homecare is when family members care for their sick member at home. The needs in terms of appropriate solutions to overcome challenges and issues faced by caring for patients in homecare are assessed.
Q1: What is the tendency for homecare regarding the current nursing care crisis facing HIC?
Three nursing care options are noticed in Germany: (i) nursing care residences with 24 h registered care services and (ii) homecare with the assistance of ambulant nursing staff for a couple of hours per day. Many families hire care personnel from abroad (e.g., Yugoslavia, Budapest, and Ukraine), mostly with beginner’s skills or no skills at all to care for their sick parents. Family members also care for the patient following medical instructions, (iii) regarding nursing care homes practiced fees, many families send their sick parents abroad in East European countries.
Q2: What challenges and issues are facing homecare?
Caring for a patient in homecare can be challenging for family members since many patients request round the clock nursing care. This is a full-time job. This study aims at investigating the challenges and issues that can be faced in such a situation.
Q3: Is it worth caring for dementia patients in homecare instead of at nursing care home?
Dementia patients are forgetful. They can forget to take food and drink water. They could forget to turn off a furnace or turn on a heater. Regarding these issues, it is worth assessing how to handle dementia patients.
Q4: What is the quality of life (QoL) of patients treated in homecare?
Many studies investigated the patient’s QoL in nursing homes. Measuring or assessing the QoL level of patients in homecare is not achieved. This study aims at assessing it.
Q5: How to assess the factors impacting the health-related QoL for homecare?
There are well-established metrics for assessing the level of QoL in the nursing context though patient in homecare is exposed to additional environmental means. Therefore, it matters to investigate the impact of the QoL of other members on the QoL of the patient. Furthermore, can noise negatively impact the QoL in homecare? A grand-mutter (an elderly) will not be disturbed by a crying grand-child. It is, therefore, important to analyze which criteria are contributing to measuring the QoL in the case of homecare.
Q6: Can the technology assist to overcome homecare-related challenges and issues?
Round the clock care cannot be achieved by one person. It is a challenge. Previous studies have shown evidence for using the technology in healthcare to deliver care at remote, to monitor 24 h a day intensive care patients, etc. Many works have been achieved regarding mental health sensing and assessment, etc. In the present context, this study aims at investigating how home automation supported solution can assist in homecare and overcome challenges and issues faced.
H1: The tendency to care for patients in homecare is on increase since the nursing crisis.
The study would like to verify if the nursing crisis has impacted the family member behavior.
H2: Smart automation home technology assists in homecare and impacts the QoL of both family members and the patient.
H3: Smart home automation enables to combine occupation (job) and caring adequately (efficiently and effectively) for a patient at home.
Measuring the quality of services of nursing/care homes is out of the scope of this study, whereas only assessment of the patient’s QoL in homecare before and after using the proposed solution constitutes the scope of the present work.
This section presents the conducted literature review on the smart home automation for healthcare purposes. Additionally, data have been collected using semi-structured interview methodology with the objectives to answer the research question and verify the hypotheses.
In order to conduct a quantitative and qualitative literature review, papers have been sampled using snowball technology. Each found paper provides with numerous other papers through its references. Appropriate papers were thus found and used for the purpose of this study.
Papers were sought on three major bases: (i) home automation for medical applications, energy, security in the smart home, and trends in the smart home at cities. Beyond the technical part, papers dealing with the nursing care home, homecare, quality of life in nursing residences, and user satisfaction toward the nursing care are the main expressions used to find papers in the better academic literature database.
Table 1 summarizes the important papers reviewed.
Pos. | Title | Abstract | Year of publication | Reference |
---|---|---|---|---|
1 | Design of an IoT smart home system | This paper basically deals with the design of an IoT smart home system (IoTSHS) which can provide the remote control to smart home through mobile, infrared (IR) remote control as well as with PC/laptop. | 2018 | [31] |
2 | A systematic review of the smart home literature: A user perspective | To facilitate the implementation and adoption of smart home technology, it is important to examine the user’s perspective and the current state of smart homes. Given the fast pace with which the literature has been developing in this area, there is a strong need to revisit the literature. The aim of this paper is to systematically review the smart home literature and survey the current state of play from the users’ perspective. | 2019 | [11] |
3 | Implementation of Smart home automation system on FPGA board using IoT | There has been a rapid introduction of network-enabled digital technologies in home automation. These technologies provide a lot of opportunities to improvise the connectivity of devices within the home. Internet helps to bring in with an immediate solution for many problems and also able to connect from any of the remote places which contribute to overall cost reduction and energy consumption. Intelligence based on microprocessors is used by home automation to incorporate electronic structures in the household. | 2018 | [32] |
4 | Smart home technologies in everyday life: do they address key energy challenges in households? | This paper interrogates their contribution to the ambitious carbon emission reduction efforts required under the 1.5 _C mitigation pathway set by the Paris Agreement and their suitability for energy poverty alleviation goals. In contrast to aspirational claims for a ‘smart utopia’ of greener, less energy-intensive, and more comfortable homes currently present in market and policy discourses, we argue that SHTs may reinforce unsustainable energy consumption patterns in the residential sector, which are not easily accessible by vulnerable consumers, and do little to help the ‘energy poor’ secure adequate and affordable access to energy at home. | 2018 | [32] |
5 | Environmental impacts and benefits of smart home automation: life cycle assessment of home energy management system | This paper discusses the life-cycle environmental impact of home energy management system (HEMS), in terms of its potential benefits and detrimental impacts. It is the expectation that adapting smart home automation (SHA) would lead to reduced electricity usage in the household and overall environmental advantages. | — | [33] |
6 | A review of smart homes—present state and future challenges | In the era of information technology, the elderly and disabled can be monitored with numerous intelligent devices. Sensors can be implanted into their home for continuous mobility assistance and nonobtrusive disease prevention. Modern sensor-embedded houses, or smart houses, cannot only assist people with reduced physical functions but help resolve the social isolation they face. They are capable of providing assistance without limiting or disturbing the resident’s daily routine, giving him or her greater comfort, pleasure, and well-being. This article presents an international selection of leading smart home projects, as well as the associated technologies of wearable/implantable monitoring systems and assistive robotics. The latter are often designed as components of the larger smart home environment. The paper will conclude by discussing the future challenges of the domain. | 2008 | [10] |
7 | Home automation networks: A survey | Home automation networks provide a promising opportunity in designing smart home systems and applications. In this context, machine-to-machine (M2M) networks are emerging as an efficient means to provide automated communication among distributed ubiquitous devices in a standardized manner, but none have been adopted universally. In an effort to present the technologies used in the M2M and home integration environment, this paper presents the home area network elements and definitions and reviews the standards, architectures, and initiatives created to enable M2M communication and integration in several different environments, especially at the smart home domain. This paper points out the differences between them and identifies trends for the future. | 2017 | [20] |
Selected literature among the sampling.
A semi-structured interview was conducted. Patients living at home as well as at nursing care home, care and nursing staffs, and people on the street were interviewed. The data collection was carried anonymously in accordance with the operative data privacy regulation in the country.
The data collection method has included questionnaires with a mixture of closed-ended (yes or no questions) and open-ended questions. Nursing home residents and patients in homecare were interviewed. Data were thus collected about nursing place tendencies and health-related as well as patient’s quality of life with regard to the residence place: nursing home or homecare. No data on the quality of services in any nursing were collected.
Quality of experience (QoE/QoX) or the satisfaction level is commonly based on a subjective appreciation of the quality of services. Patient’s quality of life can be subjective somehow. For example, two distinct persons can differently appreciate noise or the presence of other people. Some elderly can feel uncomfortable when the nurse is a foreigner and ignore some elementary cultural rules. Therefore, nursing home residents were especially interviewed about their feeling, about what makes them feel uncomfortable in order to detect the impacts on their quality of life.
An important point was to determine their subjectivity level toward what makes them feel uncomfortable. Furthermore, test participants were asked about any discomfort the system has caused to them as well as if they feel observed or patronized.
This approach is the more appropriate method to sample the research cohort since sensible data were (anonymously) collected, and for this reason, precisely, it is difficult to find people willing to provide with their medical data. Participants have been selected on the basis of trust in the person who recruits them.
Table 2 summarizes the nursing home resident’s cohort. A total of 33 patients were selected and classified per age range and gender. Table 3 shows the structure of the patients in homecare. A total of 30 patients were selected. The two cohorts were interviewed for investigating the health-related QoL in nursing homes or in homecare as well as their preference in terms of staying at residence or living at home with their family.
Age range | Total cohort size N = 33 | |||
---|---|---|---|---|
N = 17 | N = 16 | |||
Female | Male | |||
Number | Health conditions | Number | Health conditions | |
< 50 | 2 | 1 Victim of road accident (outpatient) | 4 | 1 Heart attack |
1 Physically disabled | 1 Depression | |||
2 Schizophrenia | ||||
50–64 | 4 | 2 Dementia (early stage) | 5 | 2 Depression |
1 Blindness + anxiety | 2 Physically disabled | |||
1 Not diagnosed with a mental disorder | 1 Anxiety | |||
65–80 | 5 | 3 Alzheimer | 4 | 2 Alzheimer |
2 Anxiety | 2 Depression | |||
>80 | 6 | 3 Parkinson’s disease Advanced dementia | 3 | 2 Alzheimer |
3 Alzheimer | 1 Advanced dementia |
Nursing home residents (cohort structure and diseases they are suffering from).
Age range | Total cohort size N = 30 | |||
---|---|---|---|---|
N = 14 | N = 16 | |||
Female | Male | |||
Number | Health conditions | Number | Health conditions | |
< 50 | 4 | 3 Heart attack | 7 | 2 Heart attack |
1 Physically disabled | 3 Depression | |||
2 Blindness | ||||
50–64 | 5 | 2 Mental disorder (early stage) | 5 | 2 Depression |
2 Anxiety | 2 Physically Disabled | |||
1 Physically disabled | 1 Anxiety | |||
65–80 | 3 | 2 Alzheimer | 3 | Depression |
1 Anxiety | ||||
> 80 | 2 | 1 Parkinson’s disease | 1 | 1 Alzheimer |
1 Alzheimer |
Homecare patients (cohort structure and diseases they are suffering from).
Table 4 presents the cohort for investigating challenges and issues faced by homecare.
Assessment method | Total cohort size N = 515 | ||
---|---|---|---|
N = 50 | N = 68 | N = 397 | |
Care staff* | Nursing staff`* | Other individuals** | |
Paper-based questionnaires | 45 | 60 | 385 |
1:1 semi-structural interview | 5 | 8 | 12 |
Nursing staff and people interviewed on the street.
Only people that are caring or have cared for a family member were selected to participate.
Only staff involved in homecare.
Table 5 presents an overview of the structure of the testing cohort. According to [17], elderly people aged 75+ years request severe nursing care. Based on this finding, the testing cohort is split into two groups: (i) < 65 year old participants and (ii) 65+ year old participants. All test participants are living at home. Participants living or having poor family support as well as participants with good family support have been selected. The objective was to verify to what extent the proposed solution can assist the patient even if he has no support. Furthermore, the limitations of the proposed system need to be tested in terms of to what extent the third person is needed so that they can fully assist the patient.
Age range | Gender | Participants | Family support | Dementia | Other cognitive diseases | NCD/CD | |||
---|---|---|---|---|---|---|---|---|---|
Good | Poor | Yes | No | Yes | No | ||||
<65 | Female | 6 | 5 | 1 | 1 | 5 | 4 | 1 | Diabetes |
Male | 9 | 4 | 5 | 0 | 9 | 7 | 2 | Heart diseases diabetes | |
>65 | Female | 11 | 8 | 3 | 3 | 8 | 8 | 3 | |
Male | 7 | 2 | 5 | 1 | 6 | 6 | 1 |
The testing cohort.
NCD, non-communicable diseases; CD, communicable diseases/infectious diseases. No data collected on CDs.
This section summarizes the different questionnaires (Tables 6–8) used for the different surveys. At nursing homes and at participant’s home (case of homecare), the questionnaires were used in 1:1 structured interview followed by a semi-structured interview. Distractor or control questions are inserted into the questionnaire in order to detect discrepancies in the responses and thus filter the biased responses (Tables 6–8).
Pos. | Questions | Observations |
---|---|---|
1 | What do you most of all miss here? | Check how many patients prefer staying at home instead of living at the residence |
2 | Do your relatives visit you? | |
3 | How often do your parents visit you? | |
4 | Do you have any close friends here? | Socialization measurement |
5 | Are you missing your former friends? | Socialization, if he misses his former friends, this means he does not find a one here |
6 | Do you miss your parents, children, and grandchildren? | If yes, it means he does not receive enough or regular visits |
7 | Do you like living here? | |
8 | Do you have enough space for you? | |
9 | Are you missing your home? | |
10 | Do you receive enough and regularly food and water? | |
11 | What did you eat today? | Check if he is forgetful in order to consider or not the responses above |
12 | How do you feel today? | Assess the quality-of-life related to the patient’s health state and care services he is provided with |
13 | Are the nurses nice to you? | |
14 | Which nurse is your best friend? |
Questionnaire for patients.
Pos. | Questions | Observations |
---|---|---|
1 | Do you face any challenge during the admission process? | Assess how hard is it to get admitted to a nursing home |
2 | Would you prefer caring for your parent in homecare? If yes, why? If no, why? | Assess the tendency for homecare And find out why they have a tendency for one or other |
3 | Are you more confident to let care for your parent in a nursing home? If yes, what gives you that confidence? If no, why? Do you have no trust in nursing? | |
4 | Do you have a job? If yes, full-time or part-time? | Determine how one can manage both activities |
5 | If you respond to questions 2 and 4 by yes, then continue here; otherwise, go to the next question. How could you care for your parent in homecare and go to your job or on holidays? | |
6 | Have you ever experienced caring for a parent at home? If yes, how challenging was this? | Find out the real challenges people who experienced homecare are facing |
7 | Do you have any idea about which challenges and issues can be faced in homecare? If yes, which ones? | Challenges and issues in homecare. Home automation system should help to overcome these issues |
8 | Can modern information technology assist in homecare? If yes, how? | Determine the most needed functionality |
Questionnaire for no-care staff to check their tendency for homecare or nursing care homes.
Pos. | Questions | Observations |
---|---|---|
1 | Which challenges and issues are you facing daily? | |
2 | Do you have any technical assistance? | |
3 | How do you monitor the residents around the clock? | |
4 | Do you often assess the health-related quality of life of each patient? | |
5 | How many admissions do you register every year? | Assess the admission tendency |
6 | What is the admission tendency? | |
7 | How can you explain the tendency? |
Questionnaire for care-staff to investigate the trend toward the admission application.
Data analysis was made using IBM SPSS Statistics. Data were cleaned up; biased responses were not included in the analysis. Data dealing with a tendency for care at home as well as at nursing were accordingly classified. An AVG of the scores each category reaches was built. Before building the AVG, the different scores per category (stay at home or living at a nursing residence) obtained were compared with each other. The tendencies were plotted for visual analysis.
Participants (Table 5) were selected using a snowball approach.
The action research methodology was applied for the testing. The system was adjusted according to the results in a phase and re-tested in the next phase. The test lasted one (01) week in the first phase. Data were collected and analyzed. The second phase took one (01) week again and findings from phase 1 were worked into phase 2.
At the end of each phase, a quantitative and qualitative analysis was performed. Patient’s quality of life (QoL) and satisfaction level were measured in the light of the defined metrics (Table 9).
Quality of life measurement metrics | Description |
---|---|
Food and water intake | This metric verifies how many times the participant failed to take food and water. |
Medication intake | Does the participant follow the medical instructions and take the medicine as prescribed? |
Physical activities | Does the participant go out for physical activities or perform some at home? |
Socialization | How many social contacts the patient has? Does he connect to other people or is he isolated? |
Room temperature management | Does the system correctly learn from the participant preferences and set the temperature accordingly? |
Noise and lighting control | Noise and light can make the individual feel uncomfortable |
Familiarity | How familiar is the place to the individual |
Accident rate | Does the system assist and prevent the participant from accident such as injury with a knife, fall down, etc.? |
Emergency management | Does the system correctly detect emergency cases and thus manage the emergency? |
Bio-signal gathering and data quality |
Quality of life measurement metrics.
An important point was to involve participants living alone or having poor family support as well as those who have good family support. The objective to do so was to test if the system is well designed to assist people living alone too and how they are comfortable toward using the system (usability).
In order to measure and asses the impacts of the proposed solution on the quality of life, a set of quality of life metrics were defined. The results of the experiment were analyzed in light of these metrics.
Authorization and written informed participant consents were received from all major participants and their parents. An ad-hoc ethics committee at the involved clinics examined the request to conduct such an interview involving home’s residents and approved it. Resident’s parents also approved the study.
This section presents the study findings and discusses the results in light of data analytics.
The literature review has pointed out that only a few previous types of research consider the multidimensionality of the concept of the smart home. Mostly the studies are focused on one aspect of smart home such as energy management [11].
A total of 656 abstracts and 239 full papers (journal and conference papers) were reviewed. Only 41 papers were retained having met the requirement of the present study. Unfortunately, only two papers have discussed many dimensions of smart homes. The rest mostly handle the topic of energy management at home. Smart home for elderly people is well considered in many papers, but the papers have failed to consider the multidimensionality of the concept of “aging at home”.
Regarding the results, a novel solution considering the multidimensionality is therefore highly needed.
The interview with nursing home residents has revealed that elderly people prefer staying at home in their familiar and usual social environment (familiarity) and take care of their health by themselves as long as they are able to though only participants with good family support and those who have children, grandchildren, and good social contacts have the wish to stay at home as long as possible. However, alone living people, poor people, and people having no family support feel comfortable at the nursing residence.
Table 10 summarizes the results of the interview. Up to 91% of people living alone prefer residing in nursing homes, while more than 91% of people with good family support prefer staying at home with their family members.
Category | Social status | Number | Preferences | |
---|---|---|---|---|
Living at nursing care home | Staying at home | |||
Nursing home residents (33 participants) | Poor family support Poor (financial) Have lived alone | 21 | 17 (85%) | 4 (15%) |
Rich Good family support Good social contact | 12 | 01 (8.3%) | 11 (91.7%) | |
Homecare participants (30 participants) | Living alone | 23 | 21 (91.30%) | 2 (8.70%) |
Living with family | 7 | 0 | 7 (100%) |
Participant’s preferences toward living in nursing homes or staying at home.
Beyond the research questions, three (03) hypotheses were set. One hypothesis concerns the tendency for homecare as well as for nursing care home.
H1: The tendency to care for patients in homecare is on increase since the nursing crisis.
The study verifies on the light of interview results the hypothesis H1. The survey was carried out to investigate the impact of the nursing crisis on the family member behavior toward the nursing care option for their patients.
The surveys point out the following results:
There exist two categories of care: (i) stationary and (ii) ambulant nursing care [34].
People traditionally choose nursing residences for many reasons: (i) many people are living alone or have poor family support, (ii) the patient is at the end of life and needs severe intensive and palliative care, (iii) the care level (Ger. Pflegestufe).
A total of 118 healthcare staffs were interviewed. A total of 397 individuals on the street were also interviewed. A total of 56.78% of the interviewed care personnel admitted that the number of applicants for being admitted to a nursing home is being slowly decreasing, while 58.69% of people interviewed on the street prefer to care for relatives in homecare.
Tables 11 and 12 show the tendencies of nursing care. The results obtained have confirmed the hypothesis H1.
Assessment method | N = 118 | ||
---|---|---|---|
Application for being admitted in nursing care residence | |||
Decreasing | Increasing | Stable | |
Care personnel | 67 (56.78%) | 23 (19.50) | 28 (23.72) |
Tendency viewed by healthcare staff.
Assessment method | N = 397 | |||
---|---|---|---|---|
Care experience | Care for sick family members in homecare | |||
Prefer | Do not prefer | Prefer going abroad | ||
People on the street | 200 experienced with nursing homes | 233 (58.69%) | 97 (24.43%) | 67 (16.87%) |
197 not experienced with nursing homes |
Preference of caring for a patient at home.
The quantitative results regarding challenges and the number of people that reported these challenges and issues by caring for a family member are summarized in Table 13 (Diagram 1). The quantitative data analysis reveals that very few people in home care are faced with data collection issues. This means data are rarely collected in home care. Thus, patients laying at home do not produce patient-centric data. The few data there produce is patient-centered. It is though known that patient-centered data are subjective, incomplete, and sometimes biased [27, 35].
Pos. | N = 397 | |||
---|---|---|---|---|
Challenges and issues | Number (%) | Comments | ||
1 | Nocturnal rest | 397 (100%) | The family members have no rest. They can sleep well since assisted by the machine | |
2 | Emergency issues | 375 (99.5%) | Patient-centric data are collected. | |
3 | Limited round the clock nursing | 397 (100%) | x | |
4 | Inaccurate collected data | 40 (10.07%) | x | |
5 | Combining job and care for a family member | The system shows potential to assist people in caring for their in parents aging in place | ||
Only part-time | 317 (80.01%) | |||
Stress | 397 (100%) | |||
Financial issue | 298 (74.81%) | |||
6 | Loss of quality of life | 397 (100%) | ||
7 | Limited social activities | 290 (73.04%) | ||
8 | Depression | 15 (3.8%) |
Challenges and issues faced in homecare.
Number of participants facing challenges and issues in homecare.
H2: Smart automation home technology assists in homecare and impact the QoL of both family members and the patient.
The testing has confirmed the hypothesis (H2) regarding the user satisfaction‘s level and the quality of life (QoL) at both patient side and family side. Table 14 (Diagram 2), Table 15 (Diagram 3), and Table 16 show detailed results.
Comparison of patient’s quality of life before and after applying the proposed solution.
QoL level.
Metric [Link to Table 14 (column YES in after test)] | Cohort sampled after the test. It contains people having good metrics. | ||
---|---|---|---|
Total participants | Participants with good QoL and the family support level they received during the test | ||
Poor | Good | ||
Food and water intake [L1] | N = 22 | 7 | 15 |
Medication intake [L2] | N = 23 | 5 | 18 |
Physical activities [L3] | N = 11 | 2 | 9 |
Socialization [L4] | N = 13 | 3 | 10 |
Results | About 7 have good QoL among 30 Patients after the test About 18 have good QoL among 30 Patients after the test |
Impact of family support level on the patient’s QoL.
Impact of family support on the QoL.
N = 45 (patient’s relatives) | ||
---|---|---|
Metrics | Before the test (Survey + 5 days observation) | After the test (Data provided by the system + observation) |
Quality of life | Average | Very good |
Socialization | Few | Good |
Nocturnal rest | Bad | Very good |
Emergency management (quick medical assistance) | Bad | Good |
Quality of communication with doctors | Bad | Improved |
Bio-signal gathering and data quality | Worst | Improved (good) |
Job situation | Worst (no job, part-time job) | Good (mostly full time) |
Financial issues | Bad | Improved |
Depression | Highly depressive | Less depressive |
Comparison of family member’s quality of life before and after applying the proposed solution.
H3: Smart home automation enables to combine job outside and adequately (efficiently and effectively) care for the patient in homecare.
The hypothesis is verified. Working family members can partially, full-time, work at home (home office), or go to the job and also care for a member.
Overall, broad satisfaction is noticed among the participants and their relations.
The solution shows positive impacts on the quality of life (Good++, 36.6% started physical activities and 43.33% re-socialize). Due to the solution, 36.6% reconnect to physical activities, which means an increment of 23.3%. Nevertheless, about 62% remains without physical activities.
The solution has the pottential to assist people in combining full-time or parttime job with caring for a family member in home care. Since many people aging in place still have the ability and capability to walk and can go out and back home alone, the system assists them and monitor their health condition in order to timely alerte parents and medical doctors in the case of emergency. The results had also shown evidence of improving the quality of life. An upcoming paper will report work conducted on this topic.
This section presents the concept of a multidimensional smart home automation Internet of health things for assisting dementia patients and elderly to “aging well at home”. Additionally, the solution should assist the patient’s family members to care for them and go to their occupation as usual.
The section presents the system requirements, features, concept, and architectural view.
The need analysis including the analysis of collected data leads to define the following system requirements and features, which the smart home solution for elderly and dementia patients will provide. As shown above, the health-related quality of life (QoL) is measurable by means of:
The nutrition level (intake of food and water): elderly and/or dementia patient is the most forgetful and could forget to take food and regularly drink water. This can cause severe health issues.
Medication adherence: medication adherence level influences patient health outcomes. Dementia patient who adheres to the prescribed medication could have comfortable days.
Physical activities and socialization level: both influence the patient’s QoL.
Family support: Makes the patient feel more confident, secure, and safe. This is a factor impacting the patient’s QoL.
Space and comfort: More space is a comfort that prevents anxiety in an individual since small space limits activities and movements.
Regarding the QoL measurement metrics, the following system requirements have been defined:
Qualitatively and quantitatively assess a patient’s QoL level
Provide daily living assistance
Support patient empowerment and autonomy
Positively impact patient’s health outcomes
Collect patient-centric data and information for accommodated and personalized health care services
Further, assist family members to efficiently and effectively care for their sick member at home
The main system-relevant requirement is to provide patients with a cheaper, simple, and better usability by considering their cognitive impairment like eye, hearing, and feeling impairment, restricted movement, etc. Additionally, the proposed solution should work online and offline.
According to the system concept, the following features are provided to meet the requirements above.
A designed water and food dispenser monitors the patient and can provide him with the food he needs. The system ensures that the patient drinks enough water so as to prevent him from feeling thirsty.
Day menu presented.
The patient chooses a menu or the system selects 3 favorites based on historical data collected.
Food is ordered at the close restaurant and registered for the program.
Food is delivered.
Food is stored in the special fridge (WaFoD).
At an appropriate time, the food is warmed.
The patient is served.
In case a family member is at home and wants to care for the patient, WaFoD sends an alert to the member.
In the case of ordering food, then food order process will run otherwise the food dispenser will run.
Similar to food intake, a drug dispenser is equipped with a high-resolution camera which logs the drug intake. A future extension will automatically perform anomaly detection on recorded films.
The medication intake is then logged. The logs are sent to the family member and the doctor.
Special TV programs are displayed at certain times of the day to help the patient to train himself. The patient wears a body-area-networking (BAN) equipped with bio-sensors and accelerometer, which continually controls the position of the patient in order to detect if the patient is falling down or lying on the bed.
For dementia patients, no outdoor program is set.
Temperature control is a well-achieved domain application in smart home automation. Existing devices and systems are added to the network.
This feature prevents any noise and controls the lighting.
Doors and windows are controlled and closed when too noisy.
A smartphone-based application plays the role of a reminder and assistant. It follows the patient everywhere. Based on the patient calendar, this application can autonomously and automatically plan the whole day for the patient.
It can look for an appointment with the treating doctor for the next medical visit. The application is parametrizable.
This section presents the concept of the proposed systems and gives an overview of its architecture.
The system features (i) a data perception unit, (ii) water, food, and medication management unit, and (iii) outside and inside activities.
IoT-enabled patient-monitoring systems present many advantages for the patient and for treating care personnel. Patient-centric data are collected. Personalized care can be based on these data. Actually, healthcare professionals base their treatment on patient-centered data, which can be biased since they are subjective. Further diagnoses are therefore needed or performed to verify the patient-centered data. Patient-centered data are data provided by the patient through narratives, while patient-centric data are data collected using modern information technologies like (wireless) body area network (W-BAN) or (wireless) sensor networks (WSNs).
Aging persons are often forgetful and thus provide mostly biased information when they are requested to report on their health conditions. Though in a smart home automation enabled healthcare solution for “aging well,” collecting patient-centric data in an autonomous way is mandatory. In a previous study [35], various advantages of collecting patient-centric data were discussed. The healthcare personal gets a complete picture of the patient’s health condition and can thus pose the right diagnosis.
Based on the requirement above, the proposed concept provides a patient-centric data collector in terms of sensors connected with the patient that fully collects any bio-signal as well as positions data and sends the data to a record system at the remote. A duplicated copy of the data is saved on the local server and serves as training data for a machine learning (ML) routing. Additionally, a set of networking capable video recorders are used to collect the patient’s body expressions, behaviors, mimic, and any physical activities. These data are also used by the ML algorithm to predict patient’s behaviors, expectations, and physiological needs (like thirst, hunger, going to the toilet, etc.).
Sensors (in a body area network) connect the patient to an IoT-gateway that transfers the collected data, using the MQTT protocol, to the local server. We talk of edge-computing that happens at the edge. Collected data are processed and stored on the local server. Using the CoApp protocol, data are sent to the cloud. Treating care/nursing homes or medical doctor as well as patient’s family members can access the data and can send data to the local server, which would use received data to regulate some connected devices.
For “food and water intake”, a smart device is designed. This device combines microwaves and the fridge. The device called water and food dispenser (WaFoD) with networking ability is connected to the patient’s smartphone and the local server, which in turn is connected to a remote server at the cloud that connects the home to the outside and can dispatch information and data in the whole network. WaFoD can learn from the individual’s behaviors and preferences.
WaFoD is connected to the IoT gateway and can collect data, transfer data, and receive data from a remote unit (system or individual). Registered behaviors build the training data for a machine learning processor (ML) located on the local server, the master in the entire network. The ML processor predicts patient menus, proposes menus to the patient, and can order at the registered restaurant the selected menu. All proposed services to the patient are based on his behaviors and preferences.
WaFoD is designed to remind the patient to regularly drink water. It dispenses water or soft drinks. It can warm food and serve the food to the patient. The system logs each nutrition behavior and sends at the end of the day an activity journal, or in the case of emergency (that means the patient does not drink for a while or refuse to take food), it alerts the nursing home close to the patient’s residence.
The patient is provided with a touchscreen that displays TV programs and can display the pictures of menus proposed by WaFoD.
The entire system is designed following the Internet of things (IoT) paradigm: (i) data collection unit(s) and (ii) IoT-gateway place between the local server. The local server is a light copy of the remote server at the cloud, which can perform complex and memory consuming computing activities; (iii) the IoT platform at the cloud.
A copy of data like room temperature, updated patient’s preferences, etc. that are needed for any computing action are stored at the local server.
The patient is provided with a set of accelerometers (sensors to determine his position- fall down, laying , staying, seating, etc.). with the objective to detect, predict if the patient is falling down or will. Furthermore, other sensors like “Feuer alrm” have been used to monitor fire harzard.
A drug dispenser is provided. The dispenser is connected to the IoT-gateway via Bluetooth. It features an alarm and can remind the patient to take his medicine. The medication intake is logged and a protocol is stored on the network. Family members can be informed if the patient does not take the medicine on time, thus, action can be taken to help the patient to take the medicine. Care/nursing homes are also connected to the dispenser via the le cloud and can get alerted when the patient refuses to take the medicine.
The local server is connected to a touchscreen TV. It can display physical activity programs, which can let the patient to also do so, for example, activities like a walk in the room, some light movements, etc.
Elderly people need real socialization. They need therefore to go out and meet other people. The solution proposed feature a smartphone-based application that manages and looks for senior-meeting close to residence place. This application integrates Google Maps that drives the patient to the meeting and takes him back home.
Similar is done with medical visit.
The architectural view presents 4 layers (Figure 4).
Bio-signals, behavior, preferences, room temperature, physical activities, food, water, and medication intake data are collected at this stage through sensors.
The data collected data are forwarded to the aggregation stage.
At this stage, collected data are aggregated, filtered, cleaned up, processed, and pre-stored.
Processed data from the prior stage are used here, but also forwarded the cloud.
Stages A, B, and C happen in the local area (patient residence). In order to enable communication with the remote side, data are forwarded to the cloud. A communication line is, therefore, open between C and D.
Family members, restaurants, nursing homes, and all people authorized to deal with the stored data can access the data through the cloud.
Architectural view of the proposed system.
This topic will be discussed in the upcoming paper.
This study has investigated the state-of-the-art of “ageing well at home.” Many previous studies had archived interesting works on making the “home” comfortable and smarter for elderly and dementia patients. Though most of the previous works have failed in providing a complete solution of smart home automation (multidimensionality of the concept of the smart home) for people requesting homecare, this study covers this limitation and shows that smart home automation can impact the patient’s and his family member’s QoL in a positive way. People staying alone at home as well as those living in nursing care homes would take benefits from such a solution.
The future works aim at launching a human hologram in the program to assist the patient. The patient would though see a family member and can receive from him any instructions or discuss with him. As Table 15 shows, the presence of a family member has a great impact on the patient’s health-related quality of life and thus on his health outcomes.
Setting and remotely regulating the room temperature is well achieved though patient temperature feeling also depends on the treatment he is under. Certain drug or after-physical activities make the patient feel warm or hot. There exists no system that can automatically and autonomously recognize that the patient’s room temperature is not more appropriate. Therefore, we plan to design a wearable that can verify if the patient is feeling cold or hot and thus regulate the heater.
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