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Technology and the New Environment for the Elderly Robert L. Kane Everyone from futurists to laymen can recognize the growth of technology. We are already capable of doing more than we can afford to do and often more than we dare. With capability come consequences and choices. Some choices reflect concerns about direct costs are we willing to pay the bill? Other choices raise issues involving more subtle, indirect costs if we change a man- ufacturing process, will a generation be unemployed? Ours is a society accustomed to seeing a problem as a challenge. We climb mountains because they are there; will we use technology for the same reason? We now suffer as a society from technophilia. The level of our passion for technological answers has led us to respond almost instinctively with a technological solution to each problem posed. For a population frequently beset with functional incapacity, as are the elderly, there is no difficulty compiling a list of techno- Togical needs. Deficits in vision call for better lighting. Loss of memory motivates automatic prompts. Instability suggests new architecture and better design. One question to be considered is who should supply and fi- nance the new technology. The commercial response to our aging society is already apparent. Toothpaste ads have shifted from Robert Kane is dean of the School of Public Health, University of Minnesota. 207

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208 ROBERT L. KANE preventing cavities to avoiding plaque. Breakfast cereals pro- mote fiber. In an entrepreneurial system, those things that can find a market are likely to appear. But many of the expensive technologies are charged to the public purse. The rules for per- sonal consumption and public policy are different. How could we choose to forgo technology when it can accom- plish so much? A pair of refractive lenses can allow the myope to get around. A lens implant can restore active life to the cataract sufferer. A radial keratotomy means freedom from glasses. Should we pursue the first two and not the last? Is there a rule for deciding how much technology is appropriate? Examples of technology to improve the environment of the elderly abound. We have mentioned eyeglasses. What about hearing aids? Certainly, more people could profit from them than currently use them, but part of the problem is that too many people profit already. Should society bear the cost of a relatively inexpensive mechanism to facilitate communication? At present Medicare pays for open-heart surgery but not for hearing aids. Why not? For one thing, hearing aids are not very expensive. But Medicare does not cover automobile purchases, either. Surgery is performed by relatively few persons in gener- ally supervised surroundings; hearing aids are widely available. We are tempted to respond impatiently that open-heart surgery saves lives and reduces symptoms, but does a hearing aid not make a major difference in functioning? The recent hearings surrounding cardiac pacemakers illus- trate the power and the problem of medical technology. For the patient with complete heart block, a pacemaker may represent the difference between living and dying. Yet the system can be easily abused. Technology is both potent and lucrative. Once a procedure or a technology is covered by a third party, there is a strong incentive to use it actively. Manufacturers and physi- cians, and even patients, may collude to promote its use. When the level of persuasion reaches bonus payments and inducement gifts, we cannot help but note that we have gone too far. Yet how do we decide to curb our zeal at an earlier stage? We have entered an era of artificial parts. Kidney transplants are commonplace; hearts still get attention. But we are well along in eyes, ears, and other brain functions as well. We can maintain people on respirators for years. Perhaps a better ex- ample is something less exotic, a treatment for the most preva

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TECHNOLOGYANDTHENEWENVIRONMENT 209 lent condition of aging arthritis. It is now possible to replace joints with artificial ones. Some orthopedists argue that aggres- sive replacement surgery can restore fine motor function and ambulation. Encouraged by the experience with hip replace- ments in the elderly, enthusiasts were silastic about treating osteoarthritis. If we shudder at the prospect of extensive and expensive ther- apies, we are likely to be more enthusiastic about preventive technologies with their widely accepted 16:1 value ratio over cures. Age is not a barrier to preventive activities, although many of the most effective actions are better begun earlier in adulthood. Certainly, efforts aimed at screening especially those that require only increased attention to frequently over- looked problems like depression- are appropriate. But so, too, are programs aimed at reducing risks such as smoking, provid- ing nutritional therapy for osteoporosis, or immunizations against influenza pneumonia (Kane et al., 19851. It is difficult to stop progress. Knowledge, especially technical knowledge, seems to increase logarithmically. Engineering prob- lems are solved with increasing speed as equipment is packaged into even smaller units. The progress of social science has not been as rapid. We talk a great deal about costs and benefits and cost-effectiveness, but we avoid facing the critical assumptions that underpin these analyses. How do we measure the value of functioning? It used to be simple. We relied on measures of social productivity earning capacity. Under such a system a rich man is worth more than a poor one; an unemployed person has no value. This kind of human capital approach has obvious limita- tions, especially for the elderly (Avorn, 19841. Yet the techniques proposed to replace it are difficult to use and generally unsatis- factory (Kane and Kane, 19821. Nonetheless, we cannot escape the question of values. If we are to compare the relative benefits of technologies, we must confront the value questions. Koshiand (1985) has remarked on society's inability to think in quantitative terms. He is concerned with our society's failure to appreciate the importance of the scientific approach to prob- lem analysis. How much more difficult is the task of developing a sensitivity to the large numbers. We simply do not think well in quantitative terms. We are a risk-aware society. We go to great lengths to avoid major catastrophes but ignore the daily small-scale disasters. In fact, in 1984 there were only 69 acci

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210 ROBERT L. KANE dents in this country that killed five or more people. Yet we design our public transportation to avoid crashes and deaths. We insist on strict and often redundant life safety codes for the institutions that house our elderly, even when these require- ments may interfere with the quality of life for the residents. When quantification is used as the basis for measuring values, the results are often confusing. Tversky and Kahneman (1981) have documented the problems of getting consistent responses to even simple value dilemmas; nonetheless, it is possible to explore differences among different groups about value-laden issues concerning care of the elderly (Kane et al., forthcoming). The forecasts for technological change are not confined to the health area. One does not need scientific studies to recognize the growth of computers in all phases of our lives. Personal computers are developing almost as rapidly as did the ballpoint pen. It is easy to anticipate that we will be linked in various kinds of networks to exchange information and accomplish daily tasks. This form of technology can have major benefits for seg- ments of the elderly population by creating a new environment in which social isolation can be reduced. For example, it permits a new form of automated home care with telemetric monitoring. Older individuals confined to the house can now participate in various kinds of interactive exchanges with service providers without incurring the high costs necessary for home visits. At the same time, the introduction of new information-process- ing approaches raises the specter of intellectual obsolescence. Stereotypically, older workers are seen as having greater diffi- culty in accommodating to new situations. Anecdotally, one hears about the aversion of older persons to computers and similar machines. They are reported to be less willing to use automated tellers at banks, for example. The recent (1985) report by the Office of Technology Assessment (OTA) challenges this view. It notes several instances in which older individuals have begun to work effectively and enthusiastically with computers. The potential for using such computers for self-care and health edu- cation, as well as for direct communication on the monitoring of physiological and psychological functioning, strongly argues for a more aggressive effort to encourage older people to become comfortable in the computer world. Our own recent experience in conducting pilot tests using computers to screen for cognitive dysfunction confirms the OTA conclusions. We found that older

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TECHNOLOGY AND THE NEW ENVIRONMENT 211 subjects were enthusiastic and adapted well to computerized testing. The challenge is to develop comfortable mechanisms to bridge the man-machine interface. It is also important to recognize that the elderly do not arise de novo. They come as part of a life-cycle transition. The elderly of tomorrow will have been far more exposed to computers dur- ing their earlier lives than is the case with the current genera- tion of older persons. The discomfort with the introduction of new social technologies is not so much an effect of age as it is the effect of novelty across all age groups. This same theme of changing technologies influences the work place. The introduction of increased mechanization can have at least two principal effects. It may alter the nature of the job in such a way that older workers have increasing difficulties in adapting to newer tasks and find themselves uncomfortable be- cause the skills previously in high demand have now been re- placed by automated devices. Automation will often have a more profound effect in reducing the need for manpower. As the num- ber of available jobs decreases, older people are seen as a block- age in the pipeline to upward mobility. Increasing pressures develop for early retirement. Because older workers tend to have accumulated more seniority and have higher rates of pay, em- ployers are often eager to move them out as quickly as possible in order to make room for younger, cheaper workers. The push to early retirement has created a whole new technol- ogy: the technology of leisure. With the increase in life expec- tancy and the tendency toward early retirement, we are now looking at periods of 15 to 25 years of unemployed time. For many this is a period with relatively good incomes but inade- quate stimulation to make the time meaningful. Some have expressed a fear that retirement may lead to increased morbid- ity, but this view is not universally shared. At present the evi- dence to support either position is scanty at best. IMPLICATIONS OF TECHNOLOGY FORECASTS The growth of technology has expanded our definition of the art of the possible. More than ever before, we are in a position to provide more services to more people. Looked at individually, many of these services promise significant benefits. For exam- ple, a recent study of total knee replacement for advanced joint

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212 ROBERT L. KANE disease among chronic arthritis patients suggests that the sur- gical procedure improves psychological well-being by reducing or eliminating knee pain. Investigators argue that these quaTity- of-life improvements may be enough to offset the annual cost of the procedure. Positive outcomes are expressed in terms of re- ductions in anxiety, depression, fatigue, and psychosomatic com- plaints as well as an improvement in family relationships and participation in social activities-an impressive array of benefits (Christianson, 19851. Although we may find fault with studies that rely simply on before-and-after measures, the problem is less with the method- ology of the research than with the implications of the findings. Are we now to embark on a series of similar ventures in which most of the several hundred joints in the body are tested for their replaceability? We have the capacity to maintain respira- tor-dependent individuals for Tong periods of time. Many of these individuals can function productively with such maintenance. Are we going to ration such care and on what grounds? Prior to 1972 we used just such a rationing approach with the treatment of end-stage renal disease. Under those circum- stances, the elderly were generally excluded from access to such treatment, although they were the only group covered under Medicare at the time. With the passage of the 1972 amendments to the Social Security Act, however, coverage was expanded to all age groups. Ironically, the elderly, the only group whose ben- efits did not change, suddenly were offered ready access to treat- ment that had previously been denied. The difference was the expansion in the supply of treatment facilities for end-stage renal disease. Looking back, many social commentators have identified the decision to cover this disease as a policy mistake. The Medicare program now faces similar decisions about cover- ing other categories of intervention, especially other forms of organ transplantation. The study by Aaron and Schwartz (1984) of health care ration- ing in the United Kingdom raises the specter of similar ap- proaches in this country. Until now the United States has oper- ated on a different ethic. Given our inherent entrepreneurial nature, Americans have been quick to promote any intervention that appears to respond to a need or attract a market. A first line of defense may lie in challenging the efficacy of any given intervention. Yet many of these therapies will indeed

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TECHNOIDGYANDTNENEWENVIRONMENT 213 prove to be efficacious. The real issue will revolve around the relative efficacy of one strategy over another. More and more we are hearing concerns that our society cannot afford all the things it wants to do. As our capacity for providing more care increases, the pressure to make difficult choices will increase as well. In some instances, this choice is being expressed as a competi- tion between different age groups. For example, a magazine article criticized expenditures on the elderly at the expense of children (Preston, 19841. These accusations of intergenerational inequity open a Pandora's box of questions about the obligations of one generation for another. Part of the issue involves the question of whose resources are at stake. We are seeing people enter the retirement years at increasing levels of affluence supported by private as well as public funds. In the main, we have generally argued that deci- sions made about the disposition of private funds were the re- sponsibility of the individual, whereas those involving public funds used a different set of criteria. As private outlays influ- ence the rate of demand for public support, however, this distinc- tion may be rapidly evaporating. The question then becomes one of how we will ration rather than whether we will ration. Up to now, much of the power in the area of health care has been placed in the hands of care providers, particularly physicians. The push toward capitated systems of health care and the active involvement of employers in seeking to control the costs of care have created a new envi- ronment with new players but no evidence of new rules. In the past, we have argued that prepaid health care systems provided consumer protection by permitting the consumer to leave when- ever he was dissatisfied. However, closer inspection suggests that this consumer protection is illusory. A consumer frustrated at not receiving expensive care to which he feels entitled may exercise his departure option, but the prepaid system is happy to see him go as a liability. Thus, decision making must find a way to encompass the value systems of both the consumer and the provider-payer. To accomplish this end, we need a better articulation of the relative value preferences of all of the groups concerned. For the elderly worker the growth of technology represents a danger of obsolescence based on the rapid turnover of knowl- edge. Old skills are no longer valued and may prove to be imped

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214 ROBERT L. KANE iments if they are held too tightly. The introduction of machin- ery for manual performance and computations places a great emphasis on the speed of performance, one area in which age has been shown to be associated with deterioration in function. These factors, coupled with a major expansion of the work force created by the maturing of the baby boom generation, produce a condition of worker excess that produces additional pressures for early retirement. The challenge to society is thus to cope with a generation of retired, productive individuals. A number of suggestions have been offered as to how we might respond to this situation. We have been encouraged to think of the "third age" as an opportunity to develop new career pat- terns. Some have suggested that the natural life history of an individual should include a shift to a second and even a third career as a source of regeneration. None of these suggestions has dealt with the question of an excess labor force, however, nor with the competition presented by younger workers for a berth in the second career slot. Another suggestion has been to advocate volunteerism. A va- riety of options have been presented. In some cases the volun- teerism is purely altruistic, or at least it has as its major reward the satisfaction that comes from doing something meaningful. In other circumstances, volunteer work produces credits that can be cashed in for services when the volunteer himself be- comes dependent. Volunteerism is enormously popular with the current administration, which is dedicated to reducing public expenditures on social services, but it carries with it a potential stigma in a society in which we are used to paying for things we value. Much of the experience with volunteers in general sug- gests that they are expensive to maintain and difficult to direct toward the really unpleasant jobs. There is a fine line to be walked between volunteering and coercion. Especially for those dependent on public pensions or other forms of public support, the incentives to volunteer may become stronger than the inter- nal motivation. GENERAL ISSUES Gerontologists have pointed out the need to differentiate be- tween age groups and cohorts. As we begin to Took toward the

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TECHNOLOGY AND THE NEW ENVIRONMENT 215 future and its implications for the aged, we must be careful to distinguish which group of the aged we are addressing. It is dangerous to extrapolate from our current experiences with the elderly toward those who will be elderly in one or two decades. These future elderly may age with a number of different char- acteristics. Physiologically, they may be quite different from those who have gone before them. For example, they have been exposed to a higher level of socioeconomic status and better medical care than ever before. Although some have argued that advances in medical care will reduce mortality at the expense of morbidity by allowing the less fit to survive, others have suggested that, indeed, those surviving into old age may bring to it much healthier bodies. Not only are the bodies of the elderly likely to be different; so, too, are their psyches. The last several decades have witnessed a society very much steeped in consumerism. If old age is asso- ciated with dependency, how much greater will be the depend- ency of those who are bred to depend on external agencies for services at much younger ages? In some parts of the United States today, it is fashionable to have a manager for one's fi- nances, one's diet, one's exercise, and even one's personal life. What can we expect such a well-managed individual to be like when he becomes old and dependent? We have already seen the emergence of the major market forces in response to the increasing amount of leisure time avail- able to people during their working years. What can we expect of technology for leisure time amidst a group of individuals with few other commitments? Information technology may become focused on re-education not for careers but for the pleasure of learning and the entertainment value derived therefrom. Ma- chines may become companions, adapting themselves to the needs and demands of their users, providing a bridge to the outside world that compensates for various disabilities. The same machines may serve as prods and reminders to encourage indi- viduals to pursue invigorating activities that maintain function and maximize health. As we move into an era of increasing electronic communica- tion, we may see ourselves giving up much of our traditional patterns of social contact. It is difficult to estimate the effect of this kind of electronic social isolation on the elderly. Anecdotal

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216 ROBERT L. KANE evidence suggests that programs such as the call-in radio shows provide an important vehicle by which older, housebound indi- viduals stay in contact with society. A more sophisticated link- age by telephone or electronic media that goes beyond electronic mail to put people into visual communication may overcome much of the social isolation that has plagued the disabled el- derly until now. The ability to interact with machines as well as with other people may provide the elderly with a much more patient, reinforcing set of social partners than they have expe- rienced before. One of the choices we make as a society is the degree to which we can and will steer the development and direction of technol- ogy. Looking back over the last several decades, we have seen several good examples of specific, goal-directed technology in programs like the space program. To some extent the by-prod- ucts of the technological investment have spun off into some civilian applications. Certainly, the development of the com- puter industry and the microchip are direct by-products of that activity. That program was undertaken in a spirit of competi- tion. Somehow success in space was equated with maintaining the preeminence of our culture. Although it is not easy to see how one can readily develop an analogous argument, it is tempt- ing to speculate on how we might mobilize our society in quest of a better life for the elderly as a test of our national spirit. If such activity and commitment could be viewed as evidence of the power of society, we might find ourselves embarking on a program that would benefit us and our children. REFERENCES Aaron, H. J., and W. B. Schwartz. 1984. The Painful Prescription. Rationing Hospital Care. Washington, D.C.: Brookings Institution. Avorn, J. 1984. Benefit and cost analysis in geriatric care. New England Journal of Medicine 310:1295-1301. Christianson, C. L., et al. 1985. Total Knee Replacement Study. PB85-236909/A5. McLean, Va.: National Technical Information Service. Kane, R. L., R. M. Bell, and S. Z. Riegla. Forthcoming. Value Preferences for Nurs ing Home Outcomes. Gerontologist. Kane, R. L., and R. A. Kane. 1982. Values and Longterm Care. Lexington, Mass.: D.C. Heath. Kane, R. L., R. A. Kane, and S. B. Arnold. 1985. "Prevention and the Elderly: Risk Factors." Health Services Research 19 (Part 2):945-1006. Koshland, D. E., Jr. 1985. "Scientific Literacy." Science 230:391.

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TECHNOLOGY AND THE NEW ENVIRONMENT 217 Office of Technology Assessment. 1985. Technology and Aging in America Washing- ton, D.C.: U.S. Congress. Preston, S. H. 1984. "Children and the Elderly in the U.S." Scientific American 251:44-49. Tversky, A., and D. Kahneman. 1981. "The Training of Decisions and the Psychology of Choice." Science 211:453-458.