Memorandum by Dr Frank Miskelly
INTRODUCTION
Developments in all areas of life usually entail
embracing technology. The Zimmer Frame was arguably the greatest
advance in elderly care in the 20th century. It is also a good
example of an assistive technology. Electronic assistive technologies
will identify the 21st century.
Recent developments in electronic and telecommunication
technology are destined to make a significant contribution to
elderly care both in institutions and in the community. Numerous
electronic aids and devices have become available which improve
patients' safety, security and ability to cope. Systems using
advanced technology to support people at home could benefit both
the patient and the care providers as it is generally accepted
that care in the community is preferable to patients and usually
less expensive than in institutions. Technological innovations
working in partnership with the existing care system will change
the future face of community care
NEW TECHNOLOGY
AND PATIENT
CARE
The successful introduction of a New Technology
aid or device requires the following:
1. A device which successfully detects or
prevents the clinical problem. The main clinical problems in older
people are:
Numerous devices claim to alleviate these problems
and our research is focussed on evaluating the benefits of the
equipment in clinical practice. Many devices are designed for
other purposes and then adapted to healthcare eg, prisoner tagging
systems adapted to patients with dementia. Our experience is that
the device does not always reliably perform what it claims.
2. An available infrastructure: Equipment
will fail if it's usage requires the development of an infrastructure.
The most successful method to introduce equipment systems is on
an existing platform such as the Community Alarm System. The Community
Alarm Service provides the monitoring and response arm of the
system. It has developed an infra-structure of communications,
data-bases, control centres and response networks which is well
established in the United Kingdom and which has gained the confidence
and trust of older people and professionals alike. The community
alarm system provides an ideal framework for bolting on recent
developments in electronic and telecommunication technology so
future generations of the Community Alarm System are likely to
form part of an integrated telecare system
3. Ethical Acceptability: In our research
on Electronic Tracking and Tagging of older people with dementia
a considerable barrier has been ethical or moral objections by
patient interest groups to the use of equipment. These groups
see the increasing use of technology as a substitute to high quality
personal care. Our view is that technology is an additional safety
feature which is utilised alongside the normal care package
4. Cost-effectiveness. Virtually no group
is investigating this issue in the introduction and implementation
of new technologies. There are several reasons for this. Firstly
few groups are conducting proper systematic evaluations when equipment
is introduced. Secondly, health economists are not always available.
THE "NEW
TECHNOLOGY IN
ELDERLY CARE
PROJECT" (NTEC)
This Project is described briefly as it illustrates
the type of equipment under development. The aim of this Project
is to evaluate the benefits of modern aids and devices for older
people living in institutions and the community. We focus on preventing
or detecting:
in frail elderly living in hospitals, residential
and nursing homes or their own homes.
The equipment is individually tailored to the
needs of patients in their own home depending on the results of
a "needs assessment." The Project is a joint venture
between London Borough of Ealing, London Borough of Hammersmith
& Fulham, Ealing Family Housing Association and Imperial College.
The aids and devices we have been evaluating
include:
1. Video-monitoring system. This system
allows people to see each other on their television at the same
time as they speak on the telephone. It is useful where parents
and offspring live some distance apart. For example, it allows
a daughter in Kent to make a "virtual home visit" each
day to her mother in Fulham which would be impossible by commuting
2. Electronic tagging. Alerts a carer when
a person with dementia wanders outside a pre-defined area eg,
a house. They can wander freely within the area. It allows the
carer to perform the housework and only if the person tries to
leave the house are they alerted.
3. Electronic tracking. Locates a person
with dementia who has wandered off provided the person is carrying
a GPS enabled mobile phone. This system can locate people anywhere
in the country with an accuracy of five metres. It allows people
with dementia to go out shopping and if they have not returned
within an expected period we can locate them.
4. Computerised Fall Detection Systems.
A camera attached to a computer continuously monitors the older
person's living area. The computer uses pattern recognition analysis
software to detect events such as falls and intruders. Any untoward
event generates an alert at the Community Alarm Centre.
5. Bed monitors. Electronic devices which
fit under the mattress and alert a carer or nurse when a patient
vacates their bed. These devices prevent falls and accidents at
night.
6. Chair monitors. Electronic devices which
fit under the cushion and alert a carer or nurse when a patient
vacates their chair. These devices prevent falls and accidents
during the day.
7. Health monitors. Electronic devices which
are worn on the wrist and alert a carer when the wearer has a
fall, collapse or faint.
8. Fall detectors. Small bleep sized devices
that fit to the belt and contain a mixture of accelerometers,
impact meters or tilt meters to detect falls.
Some devices has shown substantial benefits
in the care of older people while others have been less successful.
Further evaluation is ongoing and new devices and technologies
are being investigated.
NTEC EQUIPMENT EVALUATIONS
Sites | Bed
Monitors
| Chair
Monitors
| Video | Tagging
| Tracking |
Residential | x
| x |
| x |
|
Nursing | x |
x |
| |
|
Sheltered | x
| x |
| |
|
Hospital | x
| x |
| |
|
Community |
| | x
| x | x
|
Why Is There A Need For Technology?
1. Demographics. The Western World is ageing, family
sizes are smaller and the number of younger people to provide
care is reducing. In future, some care functions will be automated
using equipment rather than carers.
2. Healthcare costs. It can be more cost-effective to
provide routine care for a client at home than in an institutional
setting. Maintaining some people at home with care will only be
possible with the assistance of technology
3. Quality of Life. People prefer to live at home close
to their family and friends. Many people who may have entered
a residential or nursing home following an accident or a bout
of illness might be able to live independently in the comfort
of their own homes if they were provided with a suitable level
of technology support.
4. Telecare and Telemedicine can provide long-term monitoring
of older people living in the community. Developing the use of
technology in the community allows people to be treated and cared
for at home rather than in hospital. The quality of care received
at home is often better than in hospital. This isn't because hospital
staff are less skilled or professional; rather, it is because
the home environment is more conducive to good personal care.
Memorandum by The Queen Mother Research Centre for Information
Technology to Support Older People
Although all technologies can impact on older people,
this evidence will concentrate on Communications and Information
Technology (C & IT).
1. SUMMARY
The applications of research in technology and design to
improve the quality of life of older people
Information technology appears to have made an enormous impact
on every aspect of society in the developed world. A more detailed
examination of statistics, however, indicates that some groups
are not benefiting from these advances. This situation has been
referred to as the Digital Dividethe divide between those
groups of people who benefit from Information Technology and those
who do not or cannot access it. The Digital Divide has many causes,
including economic disadvantage, but inappropriate software and
human factors engineering has also played a major part in exacerbating
the gap between those people who benefit greatly from computer
technology and those who are excluded. It is this aspect of the
application of the applications of research on which this submission
will focus.
2. CURRENT INFORMATION
TECHNOLOGY PRODUCTS
Much current information technology appears to have been
designed by and for young men who are besotted by technology,
and are more interested in playing with it, and exploring what
the software can do, rather than achieving a particular goal.
Many older people and people and people with disabilities,
however, lack the visual acuity, manual dexterity, and cognitive
ability successfully to operate much modern technology. Many find
the Windows environment, and the software associated with it,
very confusing and difficult or impossible to use. Most mobile
telephones require good vision and a high level of dexterity and
video tape recorders are well known for providing many usability
problems for older people.
In addition to the requirement for standard information technology
products to be more usable by older people, the needs and wants
of people who are in the "autumn" of their lives are
not necessarily the same as those of younger people for whom these
products have traditionally been designed, Specialised products
are also needed which are designed to enhance independence and
quality of life for older and disabled people.
Many people have developed very low expectations of older
and disabled people's interest in and ability to use information
technology products. A major cause of this, however, is government's
and industry's lack of sensitivity to the particular needs and
wants of older people and hence the inappropriate nature and poor
usability of most products for older people. In general, the problem
is not that older people are unwilling to use "new technology."
The problem is that they are overwhelmed and frightened by the
manifestations of technology which have been designed by people
who do not understood the needs and abilities of older people.
3. THE POTENTIAL
OF INFORMATION
TECHNOLOGY PRODUCTS
3.1 Technology can make essential and non-essential services
more accessible to disabled and elderly people who traditionally
receive a poorer than average level of service, or may be excluded
altogether from receiving these services due, for example to mobility
visual or hearing problems. The services which are particularly
relevant to older and disabled people include:
(a) Social communicationmany older people suffer
from social isolation , and appropriate electronic communication
methodsmobile phones, email, chat rooms could provide substantial
social and psychological support to isolated older people
(b) e-governmenttechnology is increasingly being
seen as a way of reducing costs and increasing efficiency of government,
and at the same time a way of increasing participation in democracy
by excluded or disaffected groups. On-line public information
and electronic voting systems are examples of technologies that
can enhance social inclusion.
(c) Support for the older workforcethere are good
economic reasons for expanding the older workforce, but this can
only be achieved if the workplace is appropriate for the older
person.
(d) Healthcaree-health applications can facilitate
remote care and monitoring for disabled and elderly people, who
may in any case need a higher than average level of care. At the
same time, enhanced accessibility to on-line quality health information
and decision support tools can lead to a more informed patient,
who can as a result play an increasingly active role in their
own care.
(e) Bankingon-line banking facilities can allow
people to manage finances from home, reducing the need for a potentially
difficult journey to a bank. Automatic teller machines (ATMs)
allow direct and independent access at any time of the day to
account information and cash, and increasingly offer additional
banking-related facilities.
(f) Educationat a basic level, the Internet allows
independent access to an enormous amount of information on a myriad
of topics. Through e-learning applications, formal education,
whether primary, secondary or tertiary may be made accessible
to a wider section of society, and delivered in a way best suited
to a learner with specific access needs.
(g) Commercethrough e-commerce web sites, independent
access can be gained to on-line grocery stores, bookshops, clothing
retailers; tickets for rail, bus, air or sea travel can be bought
in advance. On-line auction services allow for an almost unimaginable
variety of realand virtualproducts to be bought
or sold.
(h) Dementiaalthough in its infancy research in
the UK and the USA is beginning to show that information technology
can provide support for people with dementia.
(i) Interactive televisionthis could provide a
method for many older people to access services and information
such as those listed above.
Other examples of applications of information technology
for older people can be found in the Appendix.
3.2 It should be noted that a major user of government
and e-health services are older and disabled people, and if the
software provided for e-government is not usable by this group
of people, it will have a very low up-take, and alternative manual
systems will have to be in place, which will be expensive and
inefficient. In addition lack of mobility and/or social isolation
can mean that the introduction of usable web-based Banking Education
and Commerce can make a much greater difference to the lives of
older and disabled people than the rest of the population.
3.3 In addition usable web-based services could substantially
reduce the social isolation of older people. This could be achieved,
for example, by providing appropriate entertainment, by such technologies
as mobile phones, interactive television, on-line chat rooms,
and multi-user gaming environments. Currently, however, such technology
is almost exclusively aimed at the younger age groups and able-bodied
people. This results in increased exclusion of the people who
who would most benefit most from improved access to web based
services.
3.4 There is very little business software which takes
into account the needs of older people, and the provision for
disabled people is often less than adequate. This impacts negatively
on the older worker, and the possibilities of extending active
working life.
4. RESEARCH INFORMING
POLICY
4.1 Foresight ExerciseDecember 2000.
In December 2000, the Ageing Panel of the DTI's Foresight
programme reported to government. Appendix I contains extracts
from their report (The Age ShiftPriorities for Action,
DTI December 2000). This report calls for research programmes
to be expanded, including the EPSRC EQUAL (extending the quality
of active life) programme, and that "there should be manadory
inclusivity during periods of rapid technological development
(eg e-commerce)", and that "Government has a role to
play as a promoter and exemplar of good practice."
It is not clear to this author that very much has changed
since that document was produced. Unfortunately, unlike other
Foresight Panels, the Ageing Population Panel was discontinued.
The author has no evidence that the expertise on the Communications
and Information Technology from the Ageing Population Panel has
subsequently been used in the other Foresight panels which were
continued.
The EQUAL project has continued, as recommended, and an EQUAL
network has been formed of interested researchers. It is gratifying
to note that there is to be an expansion of the EQUAL initiative
involving other research councils. The percentage of the EPSRC
and other research councils' budgets devoted to the C & IT
needs of older people, however, is still miniscule compared with
the percentage of the population who may benefit from such research.
The vast majority of the research funding into ageing is focussed
on drug and other medical interventions to alleviate the effects
of old age.
4.2 e-Government
The current guidelines for UK Government Web sites published
by the Office of the e-Envoy state the Government's policy as
being that Web sites should be as accessible as possible.( Office
of the e-Envoy "Guidelines for UK Government Web sites").
In the 2004 survey into the accessibility of UK web sites by the
Disability Rights Commission (DRC), however, it was found that:
"81 per cent of web sites evaluated failed to satisfy
even the most basic Web Accessibility Initiative Category":
(DRC 2004, p37).
4.3 Ofcom and Digital Television
A major way in which C & IT will be provided to the public
in the future is via digital television, and the access to programmes,
will be via Electronic Programme Guides. It is satisfying to note
that Ofcom has produced a Statement on Code on Electronic Programme
Guides26 July 2004, and a Code of Practice on Electronic
Programme Guides. However this guide focuses only on certain groups
of disabled people. Its General Principles refer to"people
with disabilities effecting their sight and hearing or both"
The main report has no mention whatsoever of older people,
nor people with motoric and/or cognitive impairments which also
effect significant numbers of older people. Indeed in the response
to consultation comments (33) Ofcom states that it "sympathises
with Age concerns view that EPG code should be extended to cover
accessibility by people with dexterity and cognitive impairments,
but this goes beyond the remit set by the Communications Act.
By the same token we are not able to prescribe standards for remote
controls". Both of these caveats provide a major shortfall
in the requirements for many older people to successfully access
and enjoy televisiona situation which, if it continues,
will severely compromise the possibilities of switching off analogue
television (to which government is committed) exacerbated by older
people being a major group not wishing to change to digital television.
In addition although the Independent Television Commission
was for many years committed to and financially supported external
long term research into the needs of older people, it is not clear
that Ofcom intends to continue such long term research in the
area of accessibility and usability of digital television for
older viewers.
5. PRIORITIES AND
GAPS IN
RESEARCH
For the reasons adduced above, there needs to be substantially
increased priority for information technology to be developed
which is usable by and appropriate for older people and will extend
the quality of their lives.
5.1 The key challenges for research in this area indicated
by the foresight report were:
To be customer led not technology driven.
To design for inclusion taking into account the
full range of user's needs and perceptions.
To produce simple reliable systems.
To design systems where the use of advanced technology
is invisible in terms of both operation and cost.
5.2 The Disability Discrimination act tends to focus
on young disabled peoplewhereas older people who are not
"disabled" also require "reasonable adjustments
if they are to be able to fully realise the benefits of information
technology.
5.3 Similarly there is a major concentration on health
care rather than social care, and this again is less appropriate
for older people.
5.4 Old age is not a "health problem" which
can be "cured". Barring sudden unexpected death, old
people are likely to go through a period where they need support
rather than aggressive medical interventions, and thus more emphasis
needs to be placed on non-medical ways of improving quality of
lifean area where information (and other) technologies
can play a major part.
5.5 These are not trivial challenges, and major long
term research is required to address these issues, as well as
a commitment to apply the lessons learnt in research into government
and industrial products and services. There are some isolated
examples of good examples and practice, both in software and websites,
but this is not widespread, and there is clear evidence of a lack
of awareness in the need to develop accessible technology. At
the same time levels of knowledge in effective inclusive design
techniques are also disappointingly low. The constant appearance
of new technologies also can increase the barriers to uptake by
older and disabled people. [The most striking example from the
history of computing is that before the windows environment was
introduced many blind people were able to use computers both for
work and leisure using speech synthesizers. The introduction of
Windows, with at that stage no consideration of the needs of blind
people, led to numbers of blind people being sacked because they
could no longer use the companies computer systems. It was many
years before Windows became accessible to blind people].
5.6 The major characteristics of older people in relation
to their use of technology needs to be carefully mapped and subject
to longitudinal studies which consider:
The individual variability of physical, sensory,
and cognitive functionality of people increases with increasing
age.
The rate of decline in that functionality (that
begins to occur at a surprising early age) can increase significantly
as people move into the "older" category.
The more widely appearing problems with cognition,
eg, dementia, memory dysfunction, the ability to learn new techniques.
The effects of multiple minor (and sometimes major)
impairments which can interact, at a human computer interaction
level to produce a handicap that is greater than the effects of
the individual impairments [Research into accessibility focused
on single impairments will not always provide appropriate solutions].
The significantly different needs and wants of
older people due to the stage of their lives they have reached.
How the environments in which older people live
and work change their usable functionalityeg the need to
use a walking frame, to avoid long periods of standing, or the
need to wear warm gloves.
5.7 Long term studies are needed of how older people
use technology and the relationship between their abilities and
the requirements of new technology, including sensory motoric
and cognitive performance and, importantly, combinations of these.
These should include longitudinal studies about how older people's
use of technology changes, for example with early introduction
of support for dementia.
6. RESEARCH CAPABILITY
6.1 Research capability must be increased and this will
only happen if more funds are focussed on it. In comparison with
the resources available for medical and biochemical research,
the funding available from governmental and charitable sources
for technology to support older people is derisory, and relatively
low compared to other technological strands, and there is little
or no promise of long-term funding. There is also a lack of industrial
support because, with one or two major exceptions, researching
into the needs of older people is not seen as in the commercial
interest of the company (despite all the publicity) and/or too
expensive and/or they do not understand the needs of this group
of consumers.
This means that "high flying" researchers are not
attracted to the field. Researchers need to be encouraged to see
the excitement of working in this field, and to be assured of
the long term benefit of working in this important field.
Thus an EQUAL type initiative should be a permanent and expanding
funding as part of EPSRC remit.
6.2 Centres of Excellence need to be set up with core
funding to enable them to conduct innovative research without
the constraints of constantly having to obtain funding for specific
projects. Biochemical research has shown the effects of such core
funding can have both on increasing the recruitment to the field
but also to the innovations which are made, and similar initiatives
are needed in research into technological support for older people.
7. RESEARCH CO-ORDINATION
There is some co-ordination of the research, such as the
equal network, which could be built on, but the major challenge
is increasing the quality and quantity of the research being done.
8. CONCLUSION
The appendix contains an overview of research at Dundee University
and describes the UTOPIA project funded by the Scottish Higher
Education Funding Council. UTOPIA is an acronym for "Usable
Technology for older people: inclusive and appropriate".
The search for this "utopia" would make a major contribution
to improving older people's active life.
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