Assistive and Smart Technologies: Improving Older Adults’ Quality of Life

**sub**Assistive Technologies to Improve Function**endsub** Helen Hoenig, MD, Assistant Professor, Division of Geriatrics, Department of Medicine, Duke University, and the Center on Aging and Human Development, Duke University Medical Center, Durham, NC, began by discussing several categories of assistive devices. These mechanisms include mobility aids, walkers, and canes; bathroom equipment, such as raised toilet seats, bathtub benches, and hand-held showers; self-care devices, including reachers, long-handled sock aids and button aids; and augmentative devices, such as hearing aids and eyeglasses. Assistive technology is used commonly. A survey of community-dwelling older people in Great Britain (Edwards NI, Jones DA; Age Ageing, 1998) found that, exclusive of eyeglasses and hearing aids, 74% of the participants reported using some type of assistive device, with the most common being nonslip bathmats (55%), canes (30%), and bars in the bathroom (24%). In 1996, reimbursement for over $6 billion worth of equipment was requested from Medicare, an increase of 26% over billing in 1995. There are several reasons why the use of assistive technology is increasing at such as rapid pace, according to Dr. Hoenig. First, and perhaps foremost, there has been an explosion in design options over the last two decades. Second, and in some ways related to enhanced design and options, assistive technology may improve activities of daily living (ADLs), and thus, reduce the use of personal assistance. Dr. Hoenig reviewed the different types of walkers that are currently available. A walker with four wheels, sometimes called the “rollator,” has brakes on the handles that provide more safety than pushing a pedal to brake, which in some instances would cause the walker to tip over. This type of walker can be particularly helpful for people with cardiopulmonary disorders, as they often have good grasping ability and coordination to manipulate the hand brakes. However, the four-wheel walker is a bit more unstable than a two-wheel walker or a standard frame walker, and thus, may not be suitable for those with particular weaknesses or coordination problems. The advantage of the three-wheel walker is its high maneuverability and somewhat narrower width. This walker is useful for those who must ambulate in a home setting, and for those with fairly good balance and hand coordination. However, it is not optimal for community mobility because it does not have a seat, nor is it useful for someone who lacks the coordination needed to manipulate it. Another variation on the four-wheel walker involves bars all the way around the aid. This type of walker is useful for those who have problems balancing and walking, but who are cognitively intact. Devices that are in development include a walker with a “seeing eye” on its front, which would obviously be helpful for those who are visually impaired; a wheelchair that manually converts from a seated to a standing position; and another chair that changes position through a motorized variant. Other wheelchair devices are also undergoing changes. A new design option includes a chair with cantilevered wheels that provide a particularly small turning radius. This wheelchair is useful for people who participate in sports such as tennis or basketball. The potential for aerodynamic wheelchairs made out of lightweight materials could enable even those who are paralyzed to waterski. “These design options enhance the utility for specific circumstances and the diversity of circumstances that people are able to access,” stated Dr. Hoenig. The speaker then focused on the data pertaining to the potential of these devices to improve ADL function. One randomized trial (Mann WC, Ottenbacher KJ, Fraas L, et al; Arch Fam Med, 1999) studied a group of homebound elders and provided them with home visits and access to diverse kinds of equipment. Trends for improvement in function were found; however, this study included a small sample size, and only found statistical significance in one ADL. Limited data exists on specific devices, but Alexander and colleagues (J Am Geriatr Soc, 1996) have shown that higher seats decrease the difficulty with rising to stand, providing further evidence for the importance of providing people with raised toilet seats, bathtub benches, etc. Dr. Hoenig and her colleagues at Duke University carried out a large database analysis to determine if the use of these assistive devices reduces the use of personal assistance (Am J Public Health, under review). Using the National Long Term Care Survey (Center for Dempgraphic Studies, Duke University), which examined 2300 community-dwelling elders who had one or more limitations in their ADLs, and controlling for a variety of sociodemographic and health characteristics, including the number of ADL deficits and cognitive impairment, the researchers found that elders who reported utilizing any equipment for their impaired ADLs also reported needing 3.8 fewer hours per week of personal assistance. Some problems can present with assistive technologies. Difficulties with a device, problems with acquisition, and availability limitations, both in acquiring the device and in even being made aware of its existence, are common problems. Devices may not fit properly, may be in disrepair, or may have poor functionality for the desired function. Cost can be an issue, as many third-party reimbursers, including Medicare, do not pay for many of the devices that might be helpful, and often do not pay for installation. The speaker and colleagues conducted a study that examined the problems that may affect wheelchair use (Hoenig H, Pieper C, Zolkewitz M, et al; J Am Geriatr Soc, 2002). Patients who received a prescription for a new wheelchair were interviewed within two weeks following receipt of the wheelchair. They were asked about wheelchair use both in the home and in other locations. Information was also obtained regarding sociodemographic and medical char??- acteristics, prior wheelchair use, methods used to propel the wheelchair, and environmental characteristics. The investigators found that those who usually required help to propel their wheelchair were much less likely to use the device in the home setting. Those who had adapted their home for their wheelchair were three times more likely to report using the device in the home. “Personal and environmental factors were predictive of wheelchair use, and some of these factors appear to be those that might be amenable to change, potentially improving the benefit that our patients receive from prescribed devices,” stated Dr. Hoenig. She recommended some steps that might improve the use of assistive devices. When patients arrive for visits, physicians should check their mobility aids for proper fit and appropriate usage. For example, people who use a cane usually have some type of pain and mild or unilateral weakness. Individuals with walkers are more likely to have a bilateral problem and perhaps some coordination difficulties, but are able to tolerate some weight. Simple criteria for assessing how well the device fits can be determined by observation, and include: Is the walker being carried instead of pushed? Is the cane tip falling apart or nonexistent? Is the patient’s elbow up by his or her shoulder? Physical therapy should be considered for problems related to mobility aids, and occupational therapy should be sought if there is difficulty with a self-care aid. Clinicians can then help train the patient in the proper usage of the device or provide another item that will be more useful and effective. **sub**Autonomy Versus Risk: How Smart Home Technologies Can Help **endsub** Lydia Lundberg, owner of Elite Care, a residential care facility in Milwaukee, OR, with the vision of fundamentally changing housing and health care for the elderly, began by describing the design of a building that fosters intimacy and independence for residents. “We are operating under a social model versus an institutional model of long-term care. We believe in resident empowerment and engagement, and designed the environment to match the residents’ preferences,” she stated. The Creating Autonomy Risk Equilibrium (CARE) system is a comprehensive solution to the current demand for more service at less cost, coupled with the vision of restoring the autonomy of the elderly and minimizing their risk, while recording and documenting procedures required by their physician and regulatory agencies. CARE utilizes a variety of tracking and assistive technologies that are incorporated into the facility. The design is meant to be an extended-family residence; there are 12 resident suites with live-in caregivers available. The residence utilizes technology that is nonintrusive and pervasive, both inside and outside of the facility. Because these facilities are to some degree a restraint for elderly people, there are no hallways in the residence. “It is much easier to go from your room to the dining room if it is only 20 feet versus 100 feet,” stated Ms. Lundberg. The family kitchen and dining room are also combined, similar to a “real” home. There are remote control fans, motion detectors, and infrared detectors to determine if the resident is in his or her suite. Bedrooms have hospital-grade wiring in the event hospital equipment is necessary for end-of-life care. Bathrooms are designed with warm, nonslip floors. In the kitchens, technology is used to shut off the stove if a resident is not supposed to be using it. This technology provides several benefits. The independence of residents is prolonged, there is an early warning system in place for the detection of health problems, and the social network for the elderly is strong. Labor and utility costs are also reduced by automating the environment. The facility utilizes an inexpensive network of personal computers (PCs) with touch screens. Each resident suite has a PC, as do the common areas. The homepage of the PC is composed of icons, one of which allows an individual to call for “Help.” When the icon is pressed, a message appears on the screen telling the resident that the nurse call is being processed. The caregiver, either on his or her personal digital assistant (PDA) or on another touch screen, pushes “Accept.” It can now be recognized who is answering the call. Once the assistance is rendered, the caregiver has also created a record of the care. “We keep track of when the call was placed, where it was placed from, when it was acknowledged, who responded, how long it took to respond, and how long the caregiver was with the resident. This is a very incredible tool,” stated Ms. Lundberg. The “walk-about watch” allows workers to locate residents in real time, and can also minimize the risks to residents by turning the lights on and off and locking doors. For example, when a resident who is not supposed to go off campus approaches the edge of the property, the screen pops up on the computer in the house and tells the staff who is trying to leave. The interface to the caregivers is the desktop PC or a wireless PDA. Administration can run reports to show what the caregivers have been doing, and also how the needs of a resident may change. If a resident is frequently getting out of bed, this may indicate restlessness or pain. Caregivers can also be tracked, and the amount of time they spend in a patient’s room can be ascertained to determine if they are properly performing their duties and spending enough time handling residents’ concerns. Currently, CARE system users are the residents, the families, management, and staff, but in the future, physicians and the staf of health care facilities may also participate in the system. Future business development could include paperless charting and medication tracking. Because of its health, economic, and social benefits, pervasive computing will become the domain of the elderly before it will be used by the general population. It has proven to be successful in the elderly population due to its acceptability by the residents, and has offered the ability to accommodate residents who were previously in locked Alzheimer’s facilities. The capability now exists to deal with problems as they arise, and to figure out how to use the technologies to address them. **sub**Computer-Based Services to Promote Quality of Life**endsub** According to David Lansdale, PhD, Founder and President, LinkingAges, Palo Alto, CA, the Internet provides a huge opportunity for older adults. Although there exists the notion of the “digital divide,” there are many possibilities available when the appropriate technology is made accessible to the older population. Data from the U.S. Department of Commerce has shown that use of the Internet has increased among older individuals, but there is still a large portion who do not utilize the Web, particularly those who are 75 and older. One of the goals of using the Internet with older persons should be to mobilize its utility to enhance self-efficacy among this population, and to help them more effectively deal with their own chronic conditions. Dr. Lansdale compared this situation to a similar situation where people reach the point at which they can no longer drive and must give up their car keys, but now, they can be provided with an alternate set of keys. “[These] keys allow you to keep connected, and [give] access to the information superhighway. You can keep driving, you can stay connected,” he added. The barriers to Internet use in the older population are daunting, including issues with cost and installation, and once online, issues of security and privacy. One organization that has initiated actions to fight these barriers is Senior Net, which has 220 learning centers throughout the country. These centers utilize a peer-based approach where senior citizens work with other senior citizens. The focus of Senior Net has traditionally been those people who can afford to buy a computer and who are mobile enough to get to a learning center. Dr. Lansdale spoke about the concept of the disablement process, which functions mainly as a downward spiral—pathology leading to impairments, leading to functional limitations, leading to disability. The Internet can be a powerful intervention in fighting this cycle. When people think of “health,” they need to think beyond just biomedical issues, and advance their thoughts toward psychosocial components. A computer is a vehicle that provides access to the Internet, which is transformed into social connectedness. The idea is to have people master the computer early on before pathology comes into place, and in turn, initiate self-efficacy, and potentially reduce the intensity of the downward spiral. “Taking control of our own situation…has tremendous application for quality of life,” said the speaker. “This is where the Internet is a tremendous opportunity that is vastly undertapped.” Another program that was created to promote community and quality of life for elders in community and institutional settings is called LinkingAges. In an attempt to introduce lower-income seniors to the Internet, several programs have been launched in Florida in communal dining situations. As people age, they become increasingly interested in relationships with family members and grandchildren. The LinkingAges program is an outcome of support groups where people expressed loneliness and helplessness from missing their loved ones, due to physical distance and lack of a social network, and has become a vehicle for reconnecting these older people. Hands-on learning is paramount to the online process, and can be conducted in a group setting by utilizing a large-screen television connected to an Internet station, and placing people around the television. As mentioned, the Internet provides social connectedness, both for the people in that immediate setting as they work to master the technology, and for their family networks. Dr. Lansdale described one assisted-living facility where a similar program was initiated for residents who averaged approximately 87-89 years of age. A train-the-trainer academy included a 12-week course, during which individual e-mails were shared with other participants in the group. “In one case, we watched three great-grandchildren be born, we watched a family member pass away, and we watched an engagement of one of her grandchildren. That has really brought the group together,” the speaker said. In another instance, a veteran residing in a nursing center relayed that, as his mastery of the keyboard expanded, he was more able to manage his own chronic illness. His ability to type and master the Internet provided him with increased confidence to change his colostomy bag. “We have got a long way to go as far as the human interface and usability issues are concerned,” Dr. Lansdale stated. However, “elders can master the technology when it is personalized.” These programs provide an opportunity for older persons to give back, not just by teaching each other, but also to their families, and by creating an oral history, and thus, an “intergenerational bridge.” The speaker closed with a case of an elderly wheelchair-bound woman who was learning to use the Internet in a large group setting. She had received an e-mail from her grandson in Ecuador. Because her fingers were so curled by arthritis, she was barely able to push any keys. But with her thumb, she pushed the enter key, retrieved the e-mail, and saw that her grandson was expecting his first child. The woman took a pencil, wrapped tape around it, and holding it between her thumb and forefinger, tapped out her e-mail messages. The vision, urged Dr. Lansdale, is that Internet access will be available in every nursing home and retirement facility, to give people that “window” for social connection. Volunteers will be a key resource to keep the elderly in the loop as part of a community, which can make a difference in both their lives and in the lives of others in that community. “We have a lot of work to do in terms of creating content on the Internet that is going to give people access to health information and quality of life,” he said.