Today's designers, planners, and architects have at their command impressive tools of high technology that can help transform living spaces for the elderly to enhance their independence and self-sufficiency. But the technology brings with it significant questions about practical applications, costs, ethical considerations, and acceptance by those whom the technology is intended to assist.
Two presentations at the second plenary session on high technology examined the immediate and potential applications of two computer systems that hold the promise of expanding the capabilities of their users. The presentations also raised the practical, medical, and legal issues that arise with the use of such technology.
Douglas Chute of Drexel University in Philadelphia, Pennsylvania, and Leigh Stewart and Stephen Kaufman of Illinois-based Health Tech reviewed technologies that help maintain the independence of older persons with physical limitations and help assist with their rehabilitation. Chute's paper, "ProsthesisWare: Personal Computer Support for Independent Living" (this volume), demonstrates the use of ProsthesisWare for cognitively impaired elderly persons. Stewart and Kaufman's paper.
"High tech Home Care: Electronic Devices with Implications for the Design of Living Environments" (this volume), introduces "HANC," a device designed to foster independent functioning among persons who are mildly impaired.
ProsthesisWare: Personal Computer Support for Independent Living
(D. Chute and M. Bliss)
ProsthesisWare has its greatest potential for people with cognitive and central nervous system limitations, says Chute in his paper. He has used the concept with brain-injured patients. But, Chute adds, the most difficult and expensive aspect of using the computer as a prosthetic aid is customizing it for each patient and for each specific limitation in that person's daily functioning.
As a basis for the ProsthesisWare concept, Chute describes the use of a Macintosh computer with HyperCard programming. Concept software like ProsthesisWare, he says, provides "a whole battery of active strategies to complement the goal of limited dependency in an independent living environment." However, Chute continues, implementation of ProsthesisWare raises questions, such as:
Chute also contends that implementing ProsthesisWare will require incorporating computer training into the neuropsychology college curriculum. Other barriers to implementation include liability issues and user acceptance.
High-Tech Home Care: Electronic Devices with Implications for the Design of Living Environments
(L. Stewart and S. Kaufman)
This paper introduces "HANC," or Home Assisted Nursing Care, "a system that gives the home health-care patient easier access to electronic devices for self-care," in Stewart's words. Stewart discusses the use of HANC in various health maintenance activities, such as assisting the patient and health-care professionals in monitoring vital signs (e.g., taking patient's blood pressure) and in ensuring medical compliance (e.g., reminding patients of medication times).
The authors review the technology of a number of devices that address a single condition or multiple conditions, such as:
Stewart also discusses several issues raised by the use of electronic devices in the home, such as the heavy use of energy that may be needed, and space and aesthetic considerations. She concludes that the value of HANC is its ability to integrate the devices she has described, making it possible for the homecare patient to team only one user system.
The discussants evaluated high-tech applications by function or by the service they provide. They also emphasized ethical, cost, and other concerns planners and designers must consider when deciding whether high technology is appropriate in the homes of older adults.
The high-tech devices discussed were broken down into three categories:
Health Care Technology
According to the participants, health care is one of the most appropriate areas for the application of high technology for the elderly population. The literature on the aging process has documented extensively the increase in physical and cognitive limitations and debilitation with age. These, in turn, limit or eliminate the ability of many older persons to live independently. Consequently, many older people require medical or other care to maintain adequate levels of functioning.
Whether in the home or in a specialized health-care setting, discussants determined that tech. neurology can be invaluable to the health-care professional, the caregiver, and/or the patient in maintaining the patient's health. Two of the major advantages of technology are:
Discussants said that only a small percentage of elderly people are in nursing homes or specialized care facilities. The vast majority of the elderly live in their own homes and prefer to do so for as long as possible. Thus, management of health care for the elderly should not be considered solely in term of hospital or nursing home environments.
A major role of high technology, according to the discussants, could be a prosthetic one: aiding older people in the performance of activities of dairy living (ADLs). The graphics, video capabilities, and user-friendly attributes of computers make high-tech assistance available, for instance, through memory cueing, a step-by-step guide for following the sequence of tasks to fulfill specific ADLS. As an example, an elderly diabetic may require memory cueing to reinforce mastery of the sequence of activities necessary for self-injection of insulin.
Well elderly people, like their younger counterparts, have many concerns besides health, asserted the discussants. They still carry on certain social or professional activities that may also need be managed efficiently. Chute referred to the role of the computer for social activities-in promoting interaction among people, for example, through playing games or establishing communications. Additionally, Stewart and Kaufman pointed out the capacity of HANC, including:
Environmental Control: Safety and Security Technology
Discussants agreed that as people grow older, they may be forced to restrict their activities to the home. This increases their chances of sustaining injuries from various home-related accidents. Many of these accidents stem from a combination of age-related deficiencies (e.g., visual, auditory, muscular-skeletal) and poor ergonomics (e.g., bad lighting, steep steps, poorly located controls such as lighting switches). Although correction of ergonomic problems may not require a high-tech solution, technology might improve an older person's safety by increasing that person's control of home conditions.
This is, in fact, the concept underlying the "automated house", namely, use of high technology to allow persons to monitor and control all electrical devices and components in the home. For instance, an elderly person going from one room of the house to another would be able to turn lights on along the way and at the destination, and then once that destination has been reached, to turn lights off where they are not needed. This capability also exists with retrofit switches that detect motion and body heat as a person enters or leaves an area. Discussants felt that providing such control to elderly people, especially to those who have problems of mobility or other functional impairments or those who simply want to make their lives easier, would increase their independence and safety in the home.
Discussants said that the effective use of high technology in the design of home environments holds much promise, but the realization of its goals will require the resolution of several concerns. These include:
Identifying ethical issues in high technology: The capability of high technology to intervene in people's lives also raises certain ethical and legal issues and questions. These become particularly important in a health-care context because of accidents that may result from the use of high-tech applications.
Many legal and ethical problems may be avoided or at least reduced if the high-tech application is used in a monitoring or assistive role with a human in primary control.
In addition to liability issues, ethical considerations can arise about a machine replacing a person (a caregiver). Discussants made clear that instead of replacing caregivers, these devices should support them by reducing the need for hands-on assistance and improving the independent functioning of the recipient.
Concerns about who or what is responsible for computer-related failures that affect the user are difficult to overcome. Clearly, many of these ethical and legal questions will need to be worked out before widespread implementation of high-tech applications occurs, particularly for those applications where the risks of error are high.
Setting criteria for using high tech or low-tech solutions: New technology is often rushed into use in many environments (i.e., the "technological imperative") before costs are compared with the benefits that will result. In this case, as the presenters pointed out, high technology should be used primarily as a prosthetic device and not merely for its own sake. Before a high-tech solution is applied to a problem, one should determine whether a low-tech answer would be just as effective, less costly, and more appropriate.
Designing User-Friendly High Technology: Once a high-tech solution is selected, the potential user should be involved with the experts in the technology in guiding its design. The primary aim in designing a high-tech solution is to fulfill as efficiently as possible the function for which it was created. This objective is best served when the operation and impact of the high-tech solution meet the user's needs.
Achieving ease of use while satisfying precise user needs will require flexibility and customization of the high-tech product. All of the presenters said customization was a major goal in the design of an effective high-tech solution. If the customized software design is fixed or unyielding, a user's changing needs cannot be met unless one converts to a new piece of software or hardware. Thus, the system should be flexible in other words, easily programmed. The user or others acting for the user should not need to be programming experts to modify the functions of a particular software. But such flexibility in modifying software again raises legal issues, such as liability if the technology fails or makes errors.
One of the major objectives of high-tech solutions is to give the user some control over his or her environment, said the discussants. Therefore, designing software in which the user, rather than the software program, determines the pace of interaction is a must. This is particularly important for elderly people who may have suffered certain cognitive and sensory losses that could affect their ability to use high technology, especially if they become frustrated. Additionally, allowing individuals to set the pace themselves, instead of having the machine do it, adds a certain human touch to the high-tech product. HANC's voice input and the verbal response features that Stewart and Kaufman demonstrated also show how human touch can be achieved. Especially convincing are systems in which the machine's verbal responses are as close to human voice modulation and rate of speech as the technology permits.
Encouraging User Acceptance: The discussants explored the issue of the elderly person's acceptance of high-tech solutions. Reticence about using high technology may derive from:
The discussants agreed that these factors can only may be responsible for some anxiety about high technology, but also may effectively diminish or eliminate an elderly person's interest in being involved in the design of high-tech applications intended to help that person. Relevant agencies can disseminate information that will help elderly users understand and accept these solutions.
Reducing the Cost of High Technology: According to the participants, the successful operation of high technology in any environment requires that cost/benefit analyses not only precede implementation but follow it as well. Only through successful validation (e.g., outcome research) and successive follow-ups can one ascertain that a particular high-tech intervention performs the function for which it was designed.
The use of computer technologies can often hampered by cost. For example, SpeechWare cost only $39.95, if a person already has a computer system. If not, it can cost an additional $3,000 to $4000 to purchase the system. Furthermore, customizing software to meet the specific functional needs of patient can be expensive.
The cost of high technology has practical as well as ethical and legal implications, asserted the discussants. Lack of money may mean systems can not be put into place or will be delayed. If such terms are necessary, who will pay the cost? Government agencies? Insurance companies? Consumers? If consumers bear most of the costs, will the poor have equal access to these applications?
The session concluded with the discussants' delineation of the following guidelines that identify steps that need to be taken before large-scale acceptance and implementation of high technologies can occur.
High technologies have a useful and important purpose in the modem world, including applications as prosthetic and assistive devices for use in residential settings. But high-tech applications are not always the best options available to improve independence among older persons, especially those who are functionally limited. Before such technologies are put into place, one needs to determine whether their design and use are appropriate for the needs of most older persons. They may be most effective in reducing the tasks of caregivers or the time caregivers must devote to caregiving.