Chuan De Foo ^1,2* Krishaa Logan ² Ewa Kosycarz ³ Jin Yuan Wang ⁴ Beatrix Tang Si Ik ² Ken Wah Teo ^5,6,7*

• ¹ Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
• ² Duke-NUS Medical School, Singapore, Singapore
• ³ Warsaw School of Economics, Warsaw, Poland
• ⁴ National University of Singapore, Singapore, Singapore
• ⁵ MOH Office for Healthcare Transformation, Singapore,, singapore, Singapore
• ⁶ Preventive Medicine, National University Health System, Singapore, Singapore
• ⁷ Division of Population Health and Integrated care, Singapore General Hospital, singapore, Singapore

The shifting sands of health Living longer and free of morbidity should not be an esoteric ideology, thanks to advances in public health and medical science. However, societies, as a whole, remain dismally unprepared for this demographic transition. The Global Roadmap of Healthy Longevity calls for a multidisciplinary push to shift the gravity from merely coping with ageing populations towards enabling successful and sustainable ageing for all [1], [2]. Artificial intelligence and other digital technologies (AIDT) stand out as pivotal forces with the potential to drive a paradigm shift in healthcare by improving medical care, addressing social isolation, enhancing mental wellness for seniors and reducing the financial gap in health systems. The toll of ageing cannot be dismissed. There remain pervasive public health concerns constituting loneliness and social exclusion experienced by seniors that precipitate a myriad of health impairments [3], [4], [5]. Ultimately, neglecting non-medical determinants of health directly exacerbates age-related illnesses, robbing seniors of healthy, fulfilling years of life [3], [4]. In this digital era, where social interactions are increasingly in the digital space, elders often find themselves excluded, albeit unintentionally, due to a lack of tech-savviness and access to digital technology [6]. The inevitable divide and means to narrow it Seniors are often stereotyped as needing to be more receptive to new technologies. However, being born into an analogue world as the starting point is in stark contrast to the digital landscape that younger generations grew up in. The rise in digitalisation in healthcare has evoked an emotional toll on seniors, leading to feelings of inadequacy, isolation and diminished self-efficacy. Limited digital literacy, physical challenges and unfamiliarity impede their ability to effectively utilise the wave of health applications such as telemedicine, health monitoring wearables and online payment claimant systems, restricting their autonomy in managing their health [7]. As governments realise the indisputable economic and healthcare burden attributed to this group, more health and non-health initiatives aimed at digitally aiding elder health have been implemented. Singapore stands out in this regard, particularly in its use of AI. The Silver Infocomm Initiative in Singapore exemplifies this by hosting Intergenerational IT bootcamps, pairing tech-savvy young adults with elders, providing a comfortable environment to acquire digital skills, engage with health and social online applications, and gain self-efficacy in the digital climate [8]. Such initiatives are also widely implemented in neighbourhood Active Ageing Centres and CareCorners, both serving as one-stop-shops for seniors to receive paraclinical and social empowerment [9]. Linking seniors to such facilities that are easily reachable due to proximity to their residential estates promotes accessibility to senior-friendly digital literacy activities. Furthermore, such interactions foster intergenerational connectivity and shift ageist perspectives by facilitating mutual exchange of knowledge, expertise, values, and skills. Another facet of the campaign promotes a culture of volunteerism through the training of seniors as Silver Infocomm Wellness Ambassadors (SIWAs) [10], [11]. SIWAs inspire and encourage their peers to embrace digital technology for social networking, blogging, discovering online communities with shared interests and using platforms for critical tasks such as e-banking and telemedicine. SIWAs create a more empathetic space, especially for more reserved elders, empowering them to stay connected and informed in today’s digital age. It is important to recapitulate that technology is not a substitute for another human being, but it can greatly assist in establishing and maintaining a relationship. Intergenerational bonding, such as spending time with one’s grandchildren and video gaming together, drastically enhances the biopsychosocial well-being of elders through creating shared experiences, developing mutual compassion and empathy, and keeping them cognitively stimulated and socially connected [12]. Another good example is Kinsome, an AI application that facilitates online interactions between grandparents and their grandchildren by offering customised icebreakers, shared activities, and in-app interactions designed to encourage bonding and strengthen relationships [13]. A separate application, MaestroAI, utilises the PoseNet machine learning model to digitalise and gamify tai chi, bringing together people of different ages to tackle depression and the lack of intergenerational interaction [14]. Delving into mental health innovations, Lions Befrienders’, a social service agency, utilises AI through the Opsis Emotion AI service to analyse the facial expressions of seniors during video calls, detecting non-verbal cues of stress, depression and anxiety to provide targeted mental health services [15], [16]. During the COVID-19 pandemic, Lions Befrienders also distributed devices to elders, enabling communication to prevent social isolation, providing medication reminders and facilitating tele-consultations [17]. This enhanced accessibility to digital health and increased familiarity empowers older Singaporeans to take charge of their health by providing avenues to achieve their biopsychosocial needs. Nonetheless, despite such targeted initiatives, broader challenges remain. A survey by Singapore Eye Research Institute (SERI) found that while telemedicine could reduce unnecessary clinic visits, 55% of seniors above 60 were unlikely to adopt digital health services, primarily due to technological difficulties and lack of trust in AI [18]. Overcoming this requires a multi-faceted approach, including live demonstrations, caregiver support and user-friendly interfaces to make digital inclusion a standard for equitable healthcare access. AIDT policies must not be tokenistic Despite the benefits AIDTs bring, the health system must be cognizant of their unintended consequences. Firstly, there is some level of irony in the digital marvel of AI and IT; in reality, they have been shown to result in more social isolation. From early models like ELIZA and PARRY in the 1960s and 1970s to not-so-modern advancements such as EBER and Charlie, there have been vast improvements in the ability of chatbots to provide empathetic companionship and cognitive support to seniors [19]. However, all that glitters is not gold - the allure of digital alternatives poses significant risks. Some powerful enough to mimic the voices, faces and mental models of your closest family and peers can play the devil in seniors who only hoped for physical company. Furthermore, AI’s capacity to perpetuate fraudulent activities underscores the sinister aspects of technological integration. In Singapore, videos of prominent figures like former Prime Minister Lee have been manipulated for financial gain, illustrating how misinformation and private information can be compromised through clickbait [20]. The proliferation of highly sophisticated deepfake technologies poses a significant threat, particularly to vulnerable groups who cannot distinguish the mainstream from the fake outlets. This challenge is compounded by the cognitive decline accompanying ageing, resulting in a higher effort demand for seniors to discern and judge the validity of incoming information [21]. Moreover, their lack of digital literacy exacerbates their susceptibility to falling prey to such fraudulent schemes, causing immense financial losses, psychological trauma and a poignant breakdown in trust [21]. These factors can likely contribute to increased stress and decline in AIDT uptake. It is crucial to remain alert to the potential pitfalls of AIDTs or AI-generated content, as they may portend the dehumanisation of medical care. The authors acknowledge, as healthcare gatekeepers, that AIDT is not a replacement for the human touch. As the saying goes, a kind gesture (human spirit) can reach a wound that only compassion can heal. AIDT-driven solutions have served the vital role of enhancing access to health information and promoting continuous health management, as demonstrated by digital literacy programs among seniors [22]. However, incorporating human-in-the-loop clinical decision-making is vital, as there are significant concerns that AI could perpetuate biases and neglect the human elements. The AI Ethics Guidelines Global Inventory discussed how the lack of fair representation of seniors exacerbates the digital divide and leads to avoidable disparities. This occurs through the homogeneous grouping and reinforcement of negative stereotypes about the cognitive psychological decline in seniors [23]. These concerns have become particularly pertinent when appropriating AIDTs to improve the quality of life of seniors through tools such as virtual games and digital inclusion programs. Whilst these tools have been shown to improve cognition, extensively relying on them for emotional and social support could diminish meaningful human interactions. Such programs should be supplemented by existing social networks and opportunities that enhance social inclusion by augmenting the authenticity of physical connections. Turkle warns that electronic companions may reduce the quality of relationships and instead increase feelings of isolation and loneliness [24]. Thus, despite the substantial benefits AIDTs offer, healthcare practitioners must ensure that these tools complement rather than replace the compassionate human touch essential for holistic human care. Despite numerous digital inclusion programmes, there persists a misconception that seniors are technophobic and disinterested in adopting new technologies, whereas in reality, they have shown eagerness and a strong desire to embrace the digital age [6]. It is essential to critically examine whether current technological solutions effectively accommodate the diverse cognitive, sensory and physical needs of seniors rather than perpetuating digital ageism through flawed design and implementation processes. Unfortunately, biases are created in the training of generative AIDT models, including large language models, due to the lack of comprehensive, representative data on seniors. This stems from ineffective and incomplete data handling and ageist assumptions that oversimplify elders as a uniform group without considering their immense diversity and nuanced lived experiences [6]. Additionally, sampling bias fraught by media under-representation and polarised age-coding favouring younger-associated adjectives leads to semantic bias influenced by marketing and political sectors, skewing the usability and effectiveness of AIDT models [6]. Shifting from a universal design approach to participatory design, where seniors are empowered to advocate for their needs through active contribution to product development, can endeavour higher-quality products that are more readily accepted, increasing interoperability and lowering barriers to adoption.