A Survey of Tablet Applications for Promoting Successful Aging in Older Adults
Aging well consists of the following components: management of chronic conditions, main-tenance of physical health and cognitive health, and active social engagement. However, the increasinglife expectancy, rising healthcare costs, increasing number of older adults, and decreasing number ofcare providers pose challenges to the maintenance of different components for aging well. To that end,technological innovation can help to augment human need and capability along the different components,and help overcome the potential barriers in aging well. In this paper, we summarize the published studiesfor different tablet-based applications designed specifically for older adults targeting different componentsof aging well. We discuss the strengths and weaknesses of the applications for each component, and identifythe opportunities to develop a cohesive application for addressing the different components of aging well.
Most review articles discuss advantages and disadvantagesof smartphone/tablet based solutions belonging to a specificdomain of ‘‘Successful Aging’’. Dayer et al.  reviewedmedication adherence applications available on differentsmartphone platforms. Joe and Demiris  studied theimpact of mobile phone on health of older adults. A recentreview by Higgins highlighted the usefulness of smartphonesin achieving health and fitness goals . Other reviewsstudy older adults’ touchscreen interactions , . In thissurvey paper, we describe tablet-based studies involving olderadults since the introduction of the iPad in 2010, address-ing different components of ‘‘Successful Aging’’. We alsodiscuss challenges and opportunities in each domain, andconclude with a suggestion for integrating all domains intoa single platform.This paper is organized as follows: Section III describes theusability studies for tablets conducted with older adults andstudies comparing older adult touchscreen performance withlaptop/desktop performance. Sections IV – VII include tablet-based studies within each domain of ‘‘Successful Aging’’.Finally, we conclude by highlighting further research direc-tions and rationalizing the need for and challenges aroundimplementing a tablet-based integrated platform for ‘‘Suc-cessful Aging’’.
With the inception of the iPad (tablet) in 2010 and increasingpopularity of tablets among older adults , it is graduallybecoming important to identify the advantages and chal-lenges faced by older adults in tablet adoption. Few studieshave been conducted to evaluate the usability of tablets forolder adults. One of the initial studies was conducted byWerner et al. in 2012 for evaluating the general usabilityand acceptance of a tablet among older novice users ,. Eleven novice computer users (60 years and above)were recruited to perform a set of predefined tasks thatincluded turning on the tablet, searching with Google,reading and composing an email, and finally searching avideo on YouTube. In general, the study participants foundthe tablet easy to use, and were satisfied with complexityof the study tasks. Due to inexperience, everyone neededsome time to get familiar with the nuances of the device,but the learning experience was easier and faster than theirexpectations. Code Shoppy The magnifying feature was important attributefor readability of the device.In another study, 77 participants (aged between 73–87years) provided qualitative feedback on tablet (iPad) usabil-ity . The participants used the tablet for at least fiveminutes and rated using a 10-point rating scale, 22 recom-mended tablet-based applications. This study found simi-lar findings as , . In addition, the tablet promotedsocial engagement, and increased interpersonal and inter-generational communications. The study also found that theabsence of keys and mouse made the technology (tablet) easyto use. The participants appreciated the mobility using thetablet but found the tablet to be heavy and faced difficul-ties with the screen resolution. In another study, researchersfound that older adults preferred to use applications relatedto lifestyle, technology, digital content, independence andfor gathering information for younger family members .These categories were derived from data based on obser-vations and interviews conducted in 2012-2013 with nineparticipants having less than 2 years of tablet experience. Theparticipants in this study found the downloading applicationsto be easy, and the operating system to be interactive andcustomizable.In addition to these usability evaluation studies, studieshave been conducted to compare older adults’ touchscreenperformance against desktop/mouse performance. For exam-ple, Findlater et al. compared the performance of 20 olderadults and 20 younger adults on four desktop and touchscreentasks: pointing, dragging, crossing and steering . Theyfound that even though the performance of older adults wasslower than that of the younger adults on both the devices,the performance gap was smaller for the touchscreen thanthat for the desktop. The older adults found steering task withdesktop and dragging with touchscreen as the most difficult task. A decrease in error rate for older adults was reportedusing the touchscreen over that with a desktop. Further, therewas no significant difference in error rates using the touch-screen among younger and older adults. There was also nosignificant difference in subjective difficulty (measured usinga rating given by the participant for each task) among tasksusing touchscreen in older adults, and also between older andyounger adults.Kobayashi et al. compared the touchscreen performancebetween a tablet (large touchscreen device) and a smartphone(small touchscreen device) among nineteen participants in aweek-long study . They found that, on both devices, drag-ging and pinching (zoom in and out) was easier than tapping(click on a target for a small period of time), even thoughthe former action required greater hand movement. This isin contrast with the findings for older adults with motordisabilities . The performance on all the tasks improvedafter a week of practice for both the devices. For all tasks, thecompletion time was significantly lower on a tablet versus ona smartphone, primarily because of the larger screen size.Despite these positive findings, tablets may pose severalchallenges to the older adults. Israel  have highlightedsome barriers associated with using tablets, including com-plexity of the technology, software complications and fear ofharming the screen/tablet. Favilla et al. reported some diffi-culties faced by older adults in using tablet touchscreens .Firstly, the capacitive screens do not provide any hapticresponse . Secondly, finger swiping, one of the most com-mon movements for capacitive screens, is normally difficultfor older adults . Further, older adults, especially thosewith dementia and reduced motoring abilities, may find itdifficult to exert and maintain sustained pressure on a touch-screen . They may also find the tablet heavy and screenresolution unoptimal (glare) . To manage the weight,older adults either use some form of support (table/pillow) oravoid hand-holding the tablet , . Finally, older adultsfind difficult to type using the onscreen keyboard .
The management of chronic conditions involves a numberof tasks including adhering to a medication regimen andmanaging disease symptoms. In this section, we focus ondescribing medication management applications becausethe majority of older adults take a large number of pre-scribed medications , arising from multiple chronicconditions . The multiple chronic conditions and thehigh number of prescribed medications often result in acomplex medical regimen, which often leads to medicationnon-adherence –. Medication non-adherence canaffect physical health of the older adults because it precludesthe intended therapeutic benefits of the prescribed medi-cations and often results in co-morbid chronic conditions.Further, it also increases healthcare costs  and the ratesof hospital readmission 
Maintaining physical health involves doing physical activitiesand eating healthy. In fact, about two-thirds of the factorsfor aging well depends on one’s lifestyle . In olderadults, regular and moderate intensity of physical activityhas been shown to reduce the risks of the onset of chronicconditions like cardiovascular disease , type II diabetes, osteoporosis , hypertension , depression ,and rheumatoid arthritis ; weight maintenance/obesity; and improved cognitive function . It also posi-tively impacts quality of life , promotes independentliving among older adults  and reduces risk of mortality. In spite of benefits from physical activity, sedentarylifestyle (lack of physical activity) is quite prevalent amongolder adults in United States. In fact, according to the 2014Behavioral Risk Factor Surveillance System (BRFSS), only14.4 percent of older adults, aged between 65-74 years, andonly 7.9 percent of adults, aged 75 years or more, met therecommended levels of physical activity (both aerobic andmuscle-strengthening activities) . Thus, to promote phys-ical activity among older adults (under Healthy People 2010initiative) ; low-cost, effective and sustainable interven-tions have been developed. These interventions (computer-tailored) have been proven to positively change physicalactivity among older adults.A number of tablet-based applications have been designedto promote physical exercise among older adults –.For instance, Silveira et al. developed a tablet-based appli-cation, ActiveLifestyle to aid strength exercise among olderadults , . It assists and monitors the older adultsduring autonomous home-based physical workouts. Step-by-step instructions and a video demonstrating an exercise helpthe user perform the exercise. Upon completion of the exer-cise, the user provides feedback on his/her performance. Theuser’s progress towards the goals set by the user is shownthrough a metaphor of a flower. The flower grows at the end ofevery workout session. Further, the flower has a mood status,reflecting the daily mood of the user, entered at the end of theentire workout session. The application provides group andindividualized motivational messages to the user for helpinghim/her achieve the workout goals.Thirteen older adults (70 years and older), with no severeillnesses were trained to use theActiveLifestyleapplicationfor two weeks, for performing balance and strength exercises.11 out of 13 enrolled participants completed the study. Themajority of the participants intended to use the applicationagain and would recommend it to their friends/family. Theparticipants also appreciated the training videos. However,they did not like the sound of the alarm. The participantsappreciated the flower metaphor and felt it motivating. Thesocial group motivated the participants as well. However, themood status of the flower did not have a high impact on theirmotivation.Further evaluation ofActiveLifestylehas been performedwith 44 older adults . This was the first study assess-ing the effectiveness of a tablet-based health interventionfor older adults. Three treatment groups were compared:(a.) an individual group receiving the individual version (onlyindividual motivational strategies); (b.) a social group usingthe social version (both individual and group motivationalstrategies); and (c.) a control group that performed exercisesusing printed instructions with no motivational strategies.33 older adults completed the study, with the highest attritionrate in the control group. The study found statistically sig-nificant differences in adherence to the training plans (ratioof completed workout sessions by each participant dividedby the total number of possible training sessions) betweenthe social and control groups, and between individual andcontrol groups. However, there was no significant differ-ence in this adherence between the social and the individualgroups. There was an overall increase in gait speed for allthe participants at the conclusion of the study, though therewas no significant difference between the three groups. Theself-motivational strategies worked best for the individualgroup while the social motivation suited the social group,although the majority of the participants in the individualgroup felt that it would be more motivated to use the socialversion. There was only a significant change in the behaviorscore among the social group. Thus, based on the results ofthe study, it can be concluded that a combination of phys-ical exercise and IT enabled motivational strategies can beeffective.In another tablet-based application, Embodied Conversa-tional Agent (ECA) was used to motivate older adults towalk . ECA is an animated character that simulates face-to-face conversations using voice, hand gesture, gaze cues,and other nonverbal behavior. A study with 263 older adultswas conducted to test the effectiveness of this application.The intervention group received a tablet computer with theECA application installed for first two months of the study, apedometer for recording the walking steps, and a data cablefor connecting the pedometer with the tablet. The controlgroup only received a pedometer. Interviews were conductedat the end of 2 months and 12 months of the study. The aver-age steps recorded by the intervention group were greater thanthat by the control group for both evaluation time points, eventhough there was a decrease in average steps recorded from2 months to 12 months. However, the decrease in averagecount (in both groups) specifically occurred among par-ticipants with inadequate health literacy. An increase wasobserved for participants with high literacy. The participantsin the intervention group were satisfied with ECA.An eight week study by Korean researchers has demon-strated the effectiveness of an iPad based exercise program inimproving cognitive status, and exercise self-efficacy amongthe intervention group . Sixteen participants in the inter-vention participated weekly in a 30-minute group exercisetraining class in a senior living. They performed one exer-cise at least 3 times a week watching training videos onan iPad. Ten participants in the control group were partof a once-a-week group-based yoga program at the seniorcenter.Crandall et al. developed a tablet-based application calledBingocize, a combination of Bingo and exercise, developedto promote exercise and health education simultaneously.A number selected in this application corresponded to ahealth question or an exercise to be performed by the partic-ipants . A study with 8 participants in the experimentalgroup and 7 participants in the control group was conductedfor 10 weeks to test the effectiveness of the application.The study found a significant difference in functional perfor-mance and gait velocity between the two groups. However, nodifference was observed in arm curl movement. However, thestudy proved the effectiveness of a multi-modal application(combining health education and exercise) but the findingscannot be generalized due to the small sample size.