Life-Span Design of Residential Environments for an Aging Population

High-Tech Home Care: Electronic Devices with Implications for the Design of Living Environments

Leigh M. Stewart, M.B.A.
Marketing Manager
and Stephen B. Kaufman
President
HealthTech Services Corporation

The home is rapidly becoming the major site of health care as hospitals discharge patients earlier and treat fewer chronic cases. Increasing numbers of people with chronic illness and disability are at home, with an increasing variety of electronic devices to provide them with support and treatment. Since the types and even the sheer number of these devices have an impact on the living environment, an awareness of current and future health care technologies will allow designers to plan environments to accommodate them.

Before enumerating the technologies required for caring for the most common health conditions, it is appropriate to create a conceptual framework in which to organize the current technologies and assist in forecasting future developments. The framework begins with the concept of functional effectiveness: the ability to accomplish normal activities.

Throughout life, the body is assaulted by accidents and disease, and thrown out of homeostasis. The result is a temporary or permanent decrease in functional level. In most instances, the usual interventions of surgery and medication will restore the body to normal. However, aging affects the body's ability to restore its original integrity. According to Dr. John W. Rowe, president of Mount Sinai Medical Center in New York and one of America's foremost experts on gerontology, "Perhaps the only characteristic of aging by itself is that when homeostasis is lost, it is recovered much more slowly.

Increasingly, innovative interventions that use state-of-the-art technologies are playing a major role in restoring the debilitated person to a normal or near-normal functioning level. The goal of both adaptive design and health care technology is to achieve a higher level of functioning. Electronic health care devices are used to accomplish this goal by 1) preventing disabling incidents, 2) restoring a near-normal functioning level by aiding in treatment and rehabilitation, and 3) maintaining the functional level that has been regained.

Some of the most common health conditions of older adults are listed below Understanding these conditions will enable designers to consider the design implications of electronic devices aimed at preventing, restoring, and maintaining function, especially insofar as those designs can be built into a residence in anticipation of progressive disability. To these recognized conditions will be added some predictions of diseases or health conditions that may become prevalent in the next 20 years. These future problems, in turn, will bring in new electronic devices that will have additional design implications. The devices associated with each of these health conditions will be discussed below under 1) devices that address a single condition; 2) devices that address multiple conditions; and 3) issues raised by the types and number of electronic devices in the home. Both current and future technology will be included. Implicit in this approach is the belief that environmental adaptation will enhance the effectiveness of health care technology, and that, together, design and devices will extend a high level of functioning well throughout the life span.

Figure 1 Chart
Figure 1. Technology's Effect on An Accident or Disease Incident. Technology can increase the rate of recovery and the level of functioning following an accident disease.

Ambulatory problems
Cancer
Compromised digestive function
Diabetes
End stage renal disease
Excessive cholesterol
Extreme frailty
Health disease
Incontinence
Infection
Osteoporosis
Psychological disorders
Respiratory failure
Sleep disorders
Temperature variance
White blood cell variance
Wound healing

Table 1. Common Health Conditions of Older Adults

Devices That Address a Single Condition

The most common or critical health conditions have, of course, received a great deal of attention. Developers have created devices especially for restoring normal functioning in each of these cases. Examples of common or critical conditions are listed below, with descriptions of electronic devices that target them.

Ambulatory Problems

Paralyzed or weak leg muscles can, in some cases, be made to function by electrical stimulation. A portable, miniature computer that controls a model of walking to generate correct movement patterns is currently being developed. A similar kind of gait analyzer can eventually be adapted for the home to provide early detection of the degeneration of walking patterns. This is important because changes in walking patterns are often indications of neurological and muscular problems.

If an individual does not need or want a wheelchair but wants to move about without having to depend on other people, tracks could be installed on the ceiling following the normal traffic patterns, with a support device appropriate for the user. If a building is designed ahead of time with fittings in the I-beams, it is easy to install connections to loadbearing supports. A range of support mechanisms from a ring, as on a subway, to a large sling could he hung from these tracks so that the whole body or other weighty objects may be moved from one room to another. The support device could be on an inertial retractor, like a seat belt mechanism: as long as the strap is pulled slowly, it moves with the walker, but any sudden movement stops it, preventing a fall. The support would be operated by remote control; an operator could call the device from wherever it may have been left.

Incontinence

One of the most often-cited reasons for committing someone to a nursing home is incontinence. Three products are already on the market that can radically improve or even cure incontinence through electrostimulation of the Kegel muscles. The treatment can be performed at night, every night for two weeks, and then intermittently if the need returns. This is the first of several devices that may have design implications for the bedroom.

Wound Healing

Another device that could be located in the bedroom will offer hope for sufferers of bed sores or other skin lesions that heal slowly, if at all. It has been demonstrated that a gentle flow of electricity stimulates skin cell regeneration with less scarring. A small battery with two electrodes could heal a sore while it is still small.

Sleep Disorders

An elderly person may need a breathing monitor not only for sleep apnea syndromes but also because respiratory arrest often precedes cardiac arrest. If respiratory arrest is treated immediately, cardiac arrest can sometimes be prevented. However, if caregivers do not recognize respiratory arrest in an emergency and begin cardiac treatment, the failure to restore respiration can bring on cardiac arrest.

There are four types of breathing monitors that will awaken a sleeper in danger. The most reliable methodologies include the following:

A band around the chest and abdomen. The movements of both areas, recorded through the bands, give a full picture of breathing patterns.
A sensor that detects chest vibrations. This is less intrusive than a band but not as reliable.
A sensor mounted on the nose that records temperature or air flow pressure changes.
Electrodes on either side of the chest that record breathing activity.

Respiratory Failure

Respiratory therapy defines the largest category of home care products. The expenditures for equipment and supplies is forecasted to increase from $800 million in 1987 to $1 billion in 1993.

Approximately 60 percent of the patients will receive concentrated oxygen through either a face mask or a nasal cannula. Although the cannula provides more freedom for the person, the oxygen flow it permits can only be estimated; with the face mask, the volume of oxygen is determined by the mask's design. In either case, the patient's comfort and bronchial clearance require the gas to be humidified by passing through water. This creates not only a shock hazard but also the risk of tipping over the bottle and drowning oneself. A more comfortable living environment could be created by linking an oxygen generator to a window air conditioner/ humidifier and raising the oxygen level of an entire room. The person could then live normal life in that room, hooking up the portable device only when going out.

Cancer Screening

Several of the conditions currently being treated in the United States are preventable with proper health maintenance. Many people consciously ignore activities that could save their own lives. Women over 50 know that they should be checking for breast tumors at least every six months. Often they give the excuse that they do not have confidence in their ability to palpate the breast properly. A noninvasive instrument being developed in Japan can help. A special cup is used to gently massage the breast tissue and report any abnormalities with a sensitivity five times greater than that of a human. Another device that should be useful in cancer screening is the "intelligent toilet," now being developed in Japan. This toilet contains sensors that can detect occult blood and thereby screen for colon cancer.

Osteoporosis

A great deal of attention is paid to preventing the elderly from falling, especially to avoid breaking bones. Preventing falls, however, will not prevent broken bones. Often the bone, brittle with age, breaks first and causes the fall. Thus, since concern for falls will never be eliminated, there is a need to cushion the fall and alert a caregiver.

Now that airbags have become a popular and widely recommended feature on automobiles, it is possible to think of installing them on stairs. Moreover, wherever elderly people fall, there is a high probability that they will be either unconscious or unable to move and thus unable to activate a personal emergency button. A fall detector that senses acceleration, change of position, and impact could automatically report to a caregiver.

Heart Disease

Home heart monitoring is predicted to be the second highest growth area for medical equipment. The most sophisticated devices are those that high-risk patients can carry with them. With the battery-powered device placed directly on the chest, an electro cardiogram (EKG) may be obtained rapidly and easily, even in an emergency, since no cable or EKG electrodes are required. When a patient feels an arrhythmia, he or she can call a phone number, put the device in place, and transmit the reading over the telephone lines to a central station. A health care professional will review the reading and then give instructions or send out emergency personnel.

Through the use of implants, heart patients with extremely weak circulation or those awaiting transplants are being raised to more normal functioning at home. The newest implants for the heart are the left ventricular assist devices, which provide additional flow pressure when needed to complete circulation. Today, a percutaneous wire provides power to an implanted battery. In the future, the user may be untethered from an external power generator; instead, current will be induced to empower the pump through a battery-operated belt of coiled wires. implanted around the abdomen. The implanted battery should be able to carry a charge long enough for sleep and showering. Such normal functioning would allow patients to become healthy before receiving a new heart, making them better able to recover from the trauma of heart transplant surgery.

End-Stage Renal Disease

Increasingly, the treatment of choice for renal failure is home peritoneal dialysis, in which the abdominal cavity is filled with a solution that draws out wastes and then is itself emptied. Today, patients learn to care for catheters and manage the solutions that are delivered to the home. For the future, however, scientists are expecting the breakthroughs to come in hemodialysis, a process of pumping the blood through a filter that currently requires complex machinery about the size of a bookcase. Such breakthroughs will make this process far more accessible for patients to use at home.

Devices That Address Multiple Conditions

Just as Alvin Toffler's book Future Shock expresses the undeniable truth of rapid change, the acquired immunodeficiency syndrome (AIDS) epidemic expresses the undeniable truth of new diseases. At its best, technology for home care will be able to address multiple conditions, current and potential. Listed below are some of the electronic devices that can meet the challenge of change.

Filters

The use of filters at home will become more and more commonplace. The cause of this increased use will be the dermatological crisis that is coming, the result of extended contact with pollutants in air and water. On an even more serious note, Dr. Daniel Perl at the Mount Sinai Medical Center in New York, who is searching for a link between pollution and Alzheimer's disease, reports: "We know very little about what we're exposed to in the way of airborne aluminum. Studies like this both reflect and promote dramatic advances in public awareness of, interest in, and understanding of health. People will soon want the quality of air and water quantified in the same way that food is currently being labeled. We should expect to see communities offering an "environmental audit" for the home, similar to the energy audit that many utilities offer today. The appropriate response to a substandard audit will be to install state-of-the-art air and water filters.

Intravenous Infusion Systems

Home care patients receive intravenous (IV) antibiotics, chemotherapy, and total parenteral nutrition on regimens that can last from two weeks to 15 years or more. To receive this treatment, however, they must use pumps, poles, and tubes that were designed for hospital use. Usually they jerry-rig their own transport device to maneuver around the carpets and stairs of their living environment. Adequate storage space for the large quantity of disposable supplies is also a problem. In the future, new delivery systems will be designed to adapt these therapies to the home for the comfort and convenience of the patients.

Monitors

The therapies just mentioned all begin with a hospital admission. Increasingly, treatment regimens will begin in the home. Even experimental drugs will be introduced in the home environment rather than in the clinic. The Food and Drug Administration recently approved a drug for treating patients with severe schizophrenia who fail to respond to standard antipsychotic medications. The drug reduces hallucinations, delusions, disordered thinking, social withdrawal, and apathy. With it, those individuals can now leave the hospitals to enter community rehabilitation programs. However, because about I percent of the 200,000 patients taking the drug develop a potentially fatal drop in infection-fighting white blood cells, all patients on the drug must be monitored closely.

Monitors are the key to home health care. Through monitoring, caregivers can quickly detect when patients deviate from the norm. Blood pressure and weight are important health indicators. Temperature monitoring is also important, not only for fevers but also for accidental hypothermia in the elderly. New devices will measure white blood cell counts and cholesterol at home. Advanced biosensors will be able to report more than simple alcohol levels in exhalation; they will also detect gaseous products of digestion and metabolism as an aid to diagnosis. The experimental intelligent toilets (see above) will be able to automatically analyze excreta composition. Early appropriate interventions mean a shorter rehabilitation time or even prevention of assault.

Telecommunications

All of these monitoring measurements must be linked to automatic reporting. The inadequacy of alarm systems that feature a manual call button has already been discussed. In the future, devices will act on their own initiative. In Swedish retirement centers, a refrigerator or toilet that is unused in a given number of hours sends an alarm to a caregiver. Any of the more sophisticated monitors mentioned above can be programmed to report if readings fall outside parameters set by a doctor.

Robotics

Robots incorporate many of the technologies described above. Joseph Engleberger, the father of industrial robots, said at the recent 20th International Symposium on Robotics in Japan: "Robots are on the verge of making their long-awaited escape from fact ories into everyday life. They will have enormous impact helping the aged and handicapped."

Potential tasks for robots in health care are endless. Robots can open packages (including medicines), fetch and carry, and even provide physical therapy.

"Roscoe" is the name of a robot that fetches and carries at the Danbury Hospital in Connecticut. Roscoe navigates the environment, avoiding obstacles, as it totes objects for the personnel. Roscoe even uses the elevator. A similar device at home could attach itself to a stair lift to bring articles from another floor and could even guide someone with diminished eyesight around furniture.

Eating and personal hygiene are two areas in which the elderly want most to preserve the dignity of being an adult. In 1984, a robot demonstrated to members of Congress that it could, on verbal command, pick up a salt shaker and season a plate of food; it even brought a drink of water to its operator. Although critics fear depersonalization with robots, for some functions nonhuman assistance is actually preferred. Most people would rather manage the transition from wheelchair to toilet with an electronic lift than a nurse. Most people would rather have an electronic device brush their teeth than the help of a son or daughter. A person who can direct the action of a device is still independent, maintaining normal functioning and retaining control over life.

Interactive Video

A device is being developed that can also take the place of a trainer in rehabilitation therapy and maintenance exercise. A program that gives instructions and analyzes responses will even be able to perform preliminary diagnosis in conjunction with an expert system.

Another situation in which a person could benefit from a mechanical rather than a human assistant occurs when a nurse explains to a patient a required procedure, such as how to clean and use an implanted catheter. Few people of any age learn after only one demonstration, and many feel inhibited about asking for repetition. Video training allows them to stop and repeat a section or replay the whole program with no embarrassment.

As video compact disc players become more available and sophisticated they will lead a home patient through exercises, giving feedback on heart rate and adjusting the pace according to exact needs for maintenance. For a person recovering from a heart attack or stroke, an interactive rehabilitation program that adjusts to body responses can speed the recovery of normal functioning. A video training system is never tired, bored, or judgmental.

Voice Synthesis

A synthesized voice can help a person with impaired vision by "reading" labels or any other printed matter presented to an electronic eye. It can also help with another weakness that many elderly people would prefer to keep private: the need for reminders. Sometimes it is the content of the reminder that is embarrassing: it would be annoying to have a person tell an otherwise independent patient every two hours to go to the bathroom. Yet that is probably one of the best ways to avoid the even greater embarrassment of incontinence. An electronic device can perform this service discreetly.

Other times it is not the content of the reminder but the need to be reminded itself that is annoying. An electronic device can be programmed for any memory assistance desirable. A very important reminder that a device can give concerns taking medications not only when to take them, but also which ones to take. The U.S. Department of Health and Human Services commissioned a report last year on drug use problems, which are major contributors to increasing health care costs. The greatest difficulty cited in the report is lack of compliance: a patient does not follow through and take the prescribed medication. Getting distracted, losing instruction sheets, or confusing the containers all contribute to the common phenomenon of an older person with a shoe box-full of unidentifiable pills. A patient's condition worsens because he or she has not followed, or been able to follow, the treatment originally prescribed. And a more severe condition is a more costly one. The person may be institutionalized just to ensure medication compliance.

A device at home could not only remind a patient at the proper time but also deliver the proper prescribed medications. At the preset time, a small packet of all pills to be taken at the moment would roll out of the machine as a voice pronounced the reminder. If the patient did not take the package on cue, the device would automatically call the family or the doctor.

Issues Raised by the Types and Number of Electronic Devices in the Home

This section presents several unresolved issues in need of investigation.

Energy

Electrical use in the home has dramatically increased since its introduction in the 1930s. The degree of this increase has begun to level off because of miniaturization and transistors. But when load-bearing equipment such as has been described here is installed in the home, the angle will again rise sharply. There may be design implications for an increased number of outlets and a greater power supply.

Alternatively, the problem of energy may be solved by developing new ways of charging the devices. Microwave transmission of energy to devices is one possibility. Low-power chips that get energy from radio waves generated into the air is another. And technology is bringing a finer focus of broadcasting and antenna pickup.

Weight and Space Planning

Robots and other large equipment will add weight and take up space. Preinstalled fittings for the walker tracks mentioned above is only one example of prior planning to accommodate the future upgrade of technology. Market acceptance of these design features may then require the housing and electronics industries to set standards. The effect would be similar to having standard items on cars, even if the buyer does not use them or uses the item for a different purpose-for example, use of the glove compar tment for storing maps.

Workspace

Especially for more complex therapies such as IV therapy, patients will need a convenient place that they can turn into a sterile field for preparation and administration of the therapy. One issue, then, is design for easier infection control in these places. People may also need medicine cabinets adapted for unusual equipment and supplies, and countertops for analyzers and other devices.

Wireless Communications

Future telecommunications may not need the design adaptations for wires that all the references to remote monitoring imply. A radio transmitter and antenna on the roof may handle all sending and receiving functions.

Aesthetics

Many times the presence of a support device announces the disability of the resident. Devices can interfere with the atmosphere or visual effect a person has created in the home. Design solutions are needed.

Integration

A chronically ill person often needs several devices and may require help setting them up and using them to full effect. The problem is that these devices were designed for use in hospitals and by trained medical personnel. Use of these devices by patients at home is, therefore, often inhibited by the sophisticated and complicated actions required to operate them. Moreover, each device may have a unique set of instructions. These devices should instead be made easily accessible to older persons. Ultimately, technology and design should provide a way to link devices together, creating one access point and instruction system. Integration can facilitate selfcare and thereby help both the older person and the caregiver.

HANC: A Home Assisted Nursing Care Device

HealthTech is developing a system that gives the home health care patient easier access to electronic devices for self-care. The system consists of HANC (Home Assisted Nursing Care), which today is networked via ordinary telephone lines to a central station. HANC can integrate virtually all the devices mentioned above: vital signs monitoring, medication delivery, emergency response, telephone communications, and scheduling of activities. A computerbased, voice-activated device, HANC manages these various activities in a friendly way, speaking and listening in a conversational and companionlike manner.

Designed to interface with computer-ready monitoring and therapeutic devices such as IV pumps, HANC can be configured to monitor weight, EKG, blood glucose, and blood oxygen. As new technologies for blood testing and biochemical analysis become available, they can readily be added to HANC's repertoire of monitoring and therapeutic capability. For the home care patient, then, it is only necessary to learn one user system. If the person can talk to HANC, all the devices in the home are accessible. Adding new devices does not require learning new instructions.

HANC records all interactions with the patient, building a history of the person's changing conditions. With nonemergency data, HANC unobtrusively charts a person's health status and transfers it to a central station; emergency information is transmitted immediately. The physician can access the patient's records over the telephone (or modem) at the central station and adjust a treatment program. In this way, HANC is responsive to the changing needs of both patient and physician.

If a person has several chronic conditions and is on multiple medications, and if compliance is a concern, prescriptions can be programmed into HANC. HANC delivers the prescribed medication in the proper dosage at the fight time and then ascertains that the medications are taken. If blood pressure monitoring is needed, HANC prompts the patient to take his or her blood pressure with HANC at the specified times. Yet HANC also lets the person maintain control by allowing for a range of times, acceptable to the physician, when these activities can be performed. If HANC announces a task at an inconvenient moment, the person can tell HANC "not now," and HANC will wait.

The HANC system can enable more patients to stay at home and take a more active role in their own health care. Health care providers have more information on patient status and the assurance of the quality of care. The burden on family caregivers is reduced, and, in fact, the caregiving capability of families can be enhanced.

Summary and Conclusions

High-tech home care brings electronic devices into the living environment, making demands on the space and its inhabitants that could be met through adaptive design and technological integration. Both design and technology development should be guided by the concept of functional effectiveness, which technology serves to maintain or regain. Design of environments must take into account current and future states, current and future devices, and the issues raised by the proliferation of electronic devices in the home.

We at HealthTech believe we have a solution to the technological challenge of integrating these devices, making them accessible to the user as new and more equipment becomes part of home care. The parallel challenge to designers is to accommodate this increase in the type and number of home health care devices since the definition of "state-of-the-art" is guaranteed to change.

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