Part I
Steering Committee Report



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Technology for Adaptive Aging Part I Steering Committee Report

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Technology for Adaptive Aging 1 Introduction and Overview PROJECT BACKGROUND It is becoming well known, as we will document later, that the proportion of the population older than age 65 in the United States is increasing at a rapid rate, that increased life expectancy means that a larger segment of this population is over age 85, and that the great majority of older adults choose to continue to live at home rather than be in assisted living facilities or in nursing homes. In American culture, it is both socially valuable and cost-effective to support the independence of this aging population in as many of the aspects of their lives as possible, whether by supporting their continued employment, independent living and healthcare arrangements, access to transportation, or educational enrichment. Many experts predict that technology can and will play an important role in supporting the independence of older adults, but to date there has been only modest evidence that this potential is being realized. The Workshop on Technology for Adaptive Aging was held to further understand the reasons why more progress has not been made and to stimulate further advances. The Need Each year the Administration on Aging of the U.S. Department of Health and Human Services publishes a report entitled A Profile of Older Americans. The facts in Box 1-1 are taken from the 2002 edition of that report.

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Technology for Adaptive Aging BOX 1-1 Some Demographic Facts About Older Americans A. Population The older population (65+) numbered 35.0 million in 2000 (the most recent year for which data are available), an increase of 3.7 million or 12.0 percent since 1990. About one in every eight, or 12.4 percent, of the population is an older American. The number of Americans aged 45-64—who will reach 65 over the next two decades—increased by 34 percent during the 1990-2000 decade. Persons reaching age 65 have an average life expectancy of an additional 17.9 years (19.2 years for females and 16.3 years for males). Older women outnumber older men at 20.6 million older women to 14.4 million older men. By the year 2030, the older population will more than double to about 70 million. The 85+ population is projected to increase from 4.2 million in 2000 to 8.9 million in 2030. Members of minority groups are projected to represent 25 percent of the older population in 2030, up from 16 percent in 2000. B. Living Arrangements About 30 percent (9.7 million) of noninstitutionalized older persons live alone (7.4 million women, 2.4 million men). Almost 400,000 grandparents aged 65 or older had the primary responsibility for their grandchildren who lived with them. C. Income The median income of older persons in 2001 was $19,688 for males and $11,313 for females. Real median income (after adjusting for inflation) fell by 2.6 percent for older people since 2000. It is clear that the population of aging (age 65 and older) adults in the United States is entering a period of rapid growth, as baby boomers age and life expectancy increases. The large growth expected in the “oldest old” will pose special challenges. Given the importance and high costs of healthcare for older adults, applications of technology that could improve health maintenance and healthcare, or reduce the associated costs, would be especially valuable. Many needs of older adults would seem to be amenable to technological solutions. What has been lacking to date is a coherent effort simultaneously to understand these needs and bring together that understanding with the expertise both to design solutions and to successfully bring them to market. The workshop was an effort to begin to do just that.

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Technology for Adaptive Aging The Social Security Administration reported that the major sources of income for older people were Social Security (reported by 90 percent of older persons), income from assets (reported by 59 percent), public and private pensions (reported by 41 percent), and earnings (reported by 22 percent). About 3.4 million older persons lived below the poverty level in 2001. The poverty rate for persons 65+ continued at a historically low rate of 10.1 percent. Another 2.2 million older adults were classified as “near poor” (income between the poverty level and 125 percent of this level). D. Health, Healthcare, and Disability In 2000, among those 65-74 years old, 26.1 percent reported a limitation caused by a chronic condition. Almost half (45.1 percent) of those 75 years and over reported they were limited by chronic conditions. The percentages with disabilities increase sharply with age. Almost three-fourths (73.6 percent) of those aged 80+ report at least one disability. Older people had about four times the number of days of hospitalization (1.8 days) as the under-65 population (0.4 days) in 2000, and their average length of stay was greater as well. Older persons averaged more contacts with doctors in 2000 than did persons of all ages (7.0 contacts versus 3.7 contacts). In 2000, older consumers averaged $3,493 in out-of-pocket healthcare expenses, whereas the total population averaged $2,182 in out-of-pocket costs. Older Americans spent 12.6 percent of their total expenditures on health, more than twice the proportion spent by all consumers (5.5 percent). NOTE: Principal sources of data for the Profile of Older Americans are the U.S. Bureau of the Census, the National Center on Health Statistics, and the Bureau of Labor Statistics. The profile incorporates the latest data available but not all items are updated on an annual basis. SOURCE: Administration on Aging, Profile of Older Americans (2002). Selection of Topics At our first meeting, the steering committee discussed several ways of organizing the workshop content and agreed to assign papers based on domains, or areas of function and activity, that we identified as important in the daily life of older adults. Many candidate domains were proposed, and we eventually selected six: communication, employment, health, learning, living environments, and transportation. The changes people undergo as they age, specifically cognitive and sensory changes and changes in motor performance, were seen as applicable to all of the domains, so we decided to assign these as “overview” papers, eliminating the need for each domain-specific paper to address

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Technology for Adaptive Aging them. In addition, we decided to assign a paper on methodological issues in research on aging and technology, another topic applicable to all specific research areas. There is a great deal of excellent research on technology applications for older adults being performed in Europe, Asia, and elsewhere. However, the limited resources for the workshop led the steering committee to select mostly American researchers as authors, and thus the work of researchers in the United States is emphasized in this report. Research conducted in other countries is frequently cited in the workshop papers, and some authors have worked with foreign scientists, both here and abroad. KEY ISSUES FOR THE ACCEPTANCE OF TECHNOLOGIES As the steering committee continued to explore the topics and issues to be addressed in a workshop, we identified a series of issues that, if not addressed effectively, might pose barriers to the acceptance and therefore the success of a technology in the marketplace. First we considered a series of potential barriers to acceptance of the technology from the perspective of the aging population themselves. These are issues that could affect potential users′ motivation or willingness to try or use a technology, their ability to use it effectively and be satisfied with the results, or other aspects of their interaction with technologies. All workshop authors were asked to address these issues in their papers to the extent that they were relevant. This discussion of potential barriers is not intended to discourage investments in technology, but rather to highlight for innovators not familiar with the literature on the aging population the interesting challenges that are there to be conquered. Control, Autonomy, Agency, Dignity One of this country′s founding principles is the primacy of individual liberty, the inalienable right of the individual to be free to choose. Embedded in this notion is the belief that individuals can, in fact, make independent choices, that we know our own minds, and that we can initiate effective action to bring about a desired outcome without directly harming others. In the arena of aging, these issues are complicated by the onset of certain diseases, such as dementias, and by the life-and-death context in which certain types of decisions are made. Technology will not be used or accepted if it does not respect these individual rights and allow a person to age with dignity.

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Technology for Adaptive Aging Customization Universal design, that is, the design of products and environments to be usable by all people to the greatest extent possible without the need for adaptation or specialized design, is now a national goal. Universal design incorporates the concept of customization in the sense that it specifies design requirements that allow adjustment of information presentation and response modes to accommodate those with differing abilities and preferences. However, there are also individual differences among the aging population that transcend universal design criteria. In the field of aging especially, universal design, while important, is not sufficient because there are many special requirements. Large print does not help the individual with impaired cognitive function who has difficulty remembering the first part of a sentence coherently with the concluding part. Aids for this limitation would be disruptive for more cognitively normal individuals. We need to understand how to take account of the range of abilities, needs, and desires of older users to ensure that the technology can adapt to their individual differences. Culture and Language Applications of new technologies are designed to appeal to potential users. They will not be accepted if they confuse or alienate individuals on the basis of their cultural or language norms. Designs, descriptions, written instructions, and advertisements, for example, present the technology in a particular way. Depending on the cultural diversity of the potential user group, an approach that may appeal to one subgroup may discourage or turn off another. Thus it may be imperative to consider different designs and approaches for different cultural contexts. Expectations and Stereotyping As people age, their expectations of themselves and others may change. These expectations can present major barriers to the acceptance of new technologies. Recent literature has suggested that older adults both stereotype themselves and are stereotyped by others (e.g., with respect to speed of movement, memory, sensory function) and that this stereotyping can often be detrimental to their motivation or performance. There are great individual differences in how people adjust their expectations and in the affect associated with these changes. Also, each individual brings to a technology unique expectations for its performance based on knowledge, beliefs, and experience with that and similar technologies. Expectations need to inform the design and application

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Technology for Adaptive Aging of technological solutions and the way in which they are marketed and introduced to potential users. Privacy Privacy issues have been a focus of growing concern as new information technologies gain more widespread use. Whenever use of a technology involves communicating information of a personal nature, it directly affects the acceptance of a technology. Apprehension that private information (e.g., health, financial, or personal data) may be captured by persons or organizations for uses other than those intended by the user, without the user′s knowledge or consent, is one of the unintended consequences of improving the flow of information necessary for sound decisions. For example, a technological application, such as a medical monitoring system, may require that users provide information they regard as sensitive and would rather not share. Systems need to be developed, applied, and marketed with the assurance that an appropriate level (and perception) of privacy will be maintained. The factors that influence individual privacy concerns also need to be better understood. Safety It seems obvious that no technology should be made available to seniors if it presents an unreasonable risk of danger or harm to its user, whether in normal operation or as a result of the failure or malfunction of a technology in use. From the perspective of the user, even the perception of risk presents a barrier to acceptance. Nevertheless, some technologies that are now being made available to consumers could pose safety problems, especially for older users. One example is the attention distraction implicit in the proliferation of information displays (navigation aids, restaurant listings, Internet access) now being introduced in automobiles. Issues of safety in design must be addressed as well as methods of conveying hazards to older users through instruction and warning systems. Training How much training is required to make use of a technology? If it is excessive, the technology may be improperly used or not used at all. Thoughtful design of training is especially important for older adults. Good training motivates and empowers people to use technology; poor training may discourage them. Training must be appropriate to its audience′s knowledge, skills, and abilities, as well as to what the audience wants and needs to learn. With a DVD player a failure to do this may be

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Technology for Adaptive Aging only an annoyance, but with a glucose monitoring system it can have life-threatening consequences. There are special considerations in designing appropriate instructional materials and programs for this audience that go beyond universal design to take account of perceptual and cognitive aging. It is particularly important to minimize the need for dividing attention across instructional materials, make appropriate use of memory aids so that working memory is not overburdened, and provide fundamental knowledge that older users may lack. Trust The degree of trust the older person places in another person, a device, a service, a procedure, or a system may be measured by expressed or observed satisfaction, acceptance, or willingness to use. Typically, trust increases as individuals accumulate exposure, familiarity, and a history of successful use of a technology. However, trust can be weakened or destroyed by unreliability, unpredictability, or excessive complexity. Distrust may lead to lack of acceptance or reliance on the technology. There is also the potential for “over-trust,” or an inappropriate dependence on technology, which could have serious consequences if the technology fails. Usability There are countless examples in which a lack of product usability has led to a failure of a product in the marketplace. The barriers to successful usability among older adults are even higher than for the general population. Many factors (e.g., preference, ease and speed of learning, success probability when experienced) are important in determining the ease with which users can learn and use a product. Training, usability, and customization are mutually interactive. Improved usability results in reduced need for training, while additional customization may make effective usability more challenging and require more extensive training. Keeping technological supports simple and easy to use should be integral to meeting the needs of the aging population. ISSUES FOR THE SUCCESSFUL INTRODUCTION OF NEW TECHNOLOGIES In addition to potential barriers from the user′s perspective, many other considerations can limit the likelihood that new technologies will successfully make the transition from research into marketable products. Here we consider the practical and economic issues that are potential barriers to the introduction of new technology in this domain.

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Technology for Adaptive Aging Technology Transfer from Research to Manufacturing Researchers who have ideas for useful products for older adults and who develop a product through the prototype stage may underestimate the time and cost to bring a new idea to market. Having a good idea that “works” at the laboratory prototype stage is only the very beginning of a progression of efforts necessary to get a product into the hands of a user at an affordable price. These costs include the need to engineer for reliability and safety as well as for manufacturability. If one starts with a laboratory prototype, the development path will be somewhat different depending on the extent to which novel hardware is involved. Consider first a product that is primarily software. After user testing and refinement of the prototype, there will be a point at which the decision to actually produce a product will be made. This will be based on input and analysis from the marketing and sales organizations, from the development team who must estimate the development cost and schedule, and from a variety of other sources. Factors to be considered are reliability, safety, production cost, potential for market penetration, and so on. The outcome of this stage is not only the go-no-go decision, but also definitions of the target market, a concept of operation, a financial pro forma (estimating the magnitude of the return on investment as a function of time), hardware and operating systems to be supported, production software language, target performance specifications, and initial requirements documents that specify what features will and will not be included. The next stage is detailed design of the software during which the detailed requirements are fleshed out, an architecture defined, and software specifications written. When this stage is complete, the actual coding can begin and, ideally in parallel with software development, technical documentation should be developed. However, the process is far from complete when the coding is done. A lengthy process of testing ensues, including repeatedly exploring each aspect of the functionality to ensure that it is operating as intended and then testing the product and the documentation to ensure that they meet usability, performance, and safety goals. Usability testing is especially important when the market is the aging population. Product testing concludes with a phase of “beta testing,” in which the product is released selectively to potential market segments for prerelease evaluation. Mean-while, marketing and sales are operating in parallel with the developers to formulate the distribution, marketing, and advertising plans. When the product involves significant manufactured hardware, many of the same steps are accomplished, but there are added decisions about produceability and ease of manufacturing as well as the specification and design of the entire manufacturing process, including the design and

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Technology for Adaptive Aging construction of production and assembly lines. There is an entire design and development process associated with manufacture that is accomplished in concert with the actual product development process. Reflection on this complex of processes reveals just what a significant decision it is to begin product development, because it sets in motion a very large commitment to follow through to successful deployment. It illustrates why there have to be large segments of the aging population for whom the product is attractive before a new product decision is undertaken. At the same time, we should not lose sight of the fact that future generations will be much more computer savvy than today′s older adults, and they may present a considerably larger and more stable market for technological support as they reach senior status. Legal Constraints If there are liability issues associated with the use of a given technology, they will have serious consequences for the willingness of manufacturers to offer the technology, as well as for user acceptance. These issues may affect the manner in which a technological solution should be designed, used, marketed, and supported. For example, what are the implications of an “easy-to-use” glucose monitor that is used improperly and gives erroneous readings, leading to adverse health effects? The Market Is a Moving Target Gerontologists use the term cohort to refer to a birth cohort, those people born at approximately the same historical time. Older people in a particular cohort may have a different reaction to technological innovation because they have had different opportunities to learn about and use various technologies. For example, those currently over age 70 may have completed their working years without ever having learned to use computers or a cellular phone. Those now about to retire have had very different experiences, and one can expect that future cohorts will have still different experiences and perspectives to consider. A product developer needs to take account of the fact that the target audience is not static, but changing as new cohorts move into senior status. Defining Products That Can Be Customized In addition to changes with cohort, as noted above customization may be needed to overcome barriers to individual differences in the acceptance of technology. This need for customization may become a barrier to the development and marketing of products for an older market, because highly adapt-

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Technology for Adaptive Aging technology is its ability to provide vast amounts of information. For example, sensors and monitoring devices can inform caregivers or others about a person′s location, what he or she is doing, and even their biological and physical functioning. Such information can be very useful in helping older patients evaluate their own status or in providing a relative or healthcare professional with assurances that all is well. However, information also has the potential for creating anxiety, distress, guilt, or, alternatively, a false sense of security. There may be too much information for an individual to process, leading to anxiety and distress. The information may be ambiguous or inconsistent, making it difficult to interpret, and it may even be unreliable. From a social perspective, the mere availability of monitoring technology may put pressure on older persons to be monitored when they wish not to be, and it can put pressure on family members to monitor their relatives in ways they may not wish to be monitored. Need for data reduction and integration. The technical capacity now exists to generate vast amounts of data about older persons and their environment, but having data is not the same as having useful information. Success in developing hardware to generate data is not matched by a corresponding ability to convert data to useful information. In other words, the capacity of current hardware far exceeds the capacity of the available software. Thus, much more effort is needed in developing the means to reduce and integrate data to make it useful in decision making. Moreover, the data reduction and integration will vary for different users. An older person with some functional impairment is likely to need more data reduction and decision support than a family member or a healthcare professional. Ethical, liability, and acceptability issues. For technology to be useful, it should facilitate decision making and ultimately impact behavior. This raises questions about who is responsible for wrong decisions or actions, particularly if they are the result of a technological failure. The ubiquitous presence of sensing and monitoring devices has the potential of undermining privacy. Individuals may be monitored without their consent or awareness. Although this already happens in public spaces, what are the implications of being monitored in private spaces such as someone′s home or office? A challenge is to develop technologies that also provide feedback to the person about what is being monitored and when. New technology is often expensive. There are already large socioeconomic disparities in the health and well-being of older persons. Will the availability of useful but costly technology further widen the gap between people who do and do not have access to this resource? Technology has the potential of undermining functioning in older persons. Most older individuals are very resilient and are able to develop compensatory adaptive strategies for dealing with life challenges. Technology that provides too much support has the potential of eroding these

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Technology for Adaptive Aging adaptive capacities. Successful technological supports will maximize people′s independent functioning and perhaps sense and adapt to changes over time in their needs and abilities. Learning Learning will continue to play a vital role in the lives of tomorrow′s elders. As described in the paper by Sherry Willis, there are three general arenas in which this learning will be carried out. First, having considerable leisure time as well as a desire for knowledge and information, older adults will be learning informally about matters, such as health and travel, that are important to their everyday lives. Second, older learners are expected to need training and retraining that will enhance their employability and work efficiency. Finally, and overlapping both of these domains, along with the rest of the population, older adults will be learning to use technologies to support a variety of activities, including learning about other matters. The diverse learning needs of older adults make it likely that the nature of learning itself will be quite variable. Traditional, highly structured learning is exemplified by the numerous formal courses and training programs available on the World Wide Web. A very different model is the spontaneously organized, nonhierarchical community of learners, who meet virtually or in person to pursue a common interest or problem, often without a designated teacher. This latter approach to learning is often more motivating and effective. However, a suggestion that traditional learning environments should be eliminated ignores relations between task demands, learner characteristics, and the learning environment. That is, a student-centered approach to learning may be ideal for highly motivated and cognitively robust individuals who have general learning goals that emphasize problem solving over the performance of specific and concrete tasks. This same approach may not work at all for teaching entry-level computer skills to those with cognitive deficits and no background knowledge. The match among task demands, environmental affordances, and individual abilities is especially important when discussion centers on technology and the older learner. There have been some remarkable recent efforts to clearly delineate the physical, perceptual, and cognitive requirements of technology-mediated tasks, such as banking and blood glucose monitoring. Similar research needs to be carried out on the use of the Internet, synchronous and asynchronous learning applications (e.g., NetMeeting, Vclass, and CentraOne), and immersive environments such as driving simulators. Some of the learning tasks enabled through these technologies are highly structured and linear, whereas others are ill defined. Only by clearly

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Technology for Adaptive Aging understanding the demands of these tasks can technologies be efficiently built to enable them for users of all ages. Task demands can rarely be separated completely from the environments in which they are carried out, and this is certainly true in the area of technology for learning among older adults. Many of the technologies discussed in the paper by Willis have substantial divided attention, working memory, and task-switching requirements that can be reduced through intelligent design. Acknowledging the need for matching technology to the older learner, there have been several sets of guidelines for web-site development, in-vehicle telematics systems, and automated phone response systems. This research needs to be continued so that the older person is not left muddling through a learning tool that is filled with bells and whistles or heavy with content but cannot be used. Learning environments can be optimized to task demands only when the understanding of user abilities is sufficient. Although there have been some attempts to find the predictors of individual differences in searching web sites and databases, these are small in number and do not extend to more complex learning tasks and applications. Researchers do not know if age-related changes in speed of processing, verbal and visual spatial memory, attention, and executive control account for individual differences in the performance of these tasks. Developing that knowledge base will help both designers and users. There are two particularly interesting ways in which research could focus on individual differences that affect the older learner. The first concerns preferences for structure in learning. It may be that many older adults prefer highly structured tasks and environments, so that learner-centered and loosely organized materials are less effective. The second research area deals with mental models of technological entities. Engineers and software designers, as well as people who have grown up with technology, have highly detailed representations of such constructs as links and cookies, file management, logical structures, and so on. It is possible that imparting these models to older users will confuse them early in learning, but it may in the long run give them a better understanding of the technology that is being used to support their learning. If this makes learning less frustrating and more enjoyable, then everyone will benefit. There is the persistent issue of cohort-based delay in exposure and access to technology. Certainly tomorrow′s elders will comfortably and frequently use today′s technologies, such as the web, automatic teller machines, and personal data assistants. They may not face the same barriers to access and use that challenge many older people today, although they will still be susceptible to age-related changes in movement control, perception, and cognition that impact interactions with technology. Moreover, technology will continue to develop, elders will continue to move

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Technology for Adaptive Aging out of educational and work settings, and thus future generations of older learners will still have to cope with technology lag. How learning experts and technology developers can reduce the effects of this lag is a central challenge, the solution to which will benefit not only older adults, but poor, disabled, and geographically isolated people. Living Environments In this paper, Ann Horgas and Gregory Abowd describe technology for use in an older adult′s living environment. It includes a discussion of technology for such settings as assisted living and nursing homes, but, consistent with the fact that the vast majority of older adults live in their own homes, the focus is on technology for use in the home. A major goal of such technology is extending the period during which people can age in place, that is, remain safely in their homes. Toward this end, the technology helps compensate not only for motor and sensory deficits but also, importantly, for cognitive decline: there is a growing body of research that aims to develop cognitive aids to help ensure that older adults perform necessary routine daily activities. An additional key goal of the technology is to support the caregivers of older adults. In many cases, caregiving is provided by an aging spouse, while in many others, it is provided by adult children who do not reside with their parents. Cognitive aids can support this latter group by providing them with frequent, detailed information about their parents′ activities and status. This in turn supports aging in place, because adult children are more satisfied with such living arrangements when they can monitor their parents′ well-being. The maturity of the technology described varies, from devices and systems that are nearly ready to be marketed to concepts and prototypes that are still in the design and development stages in the laboratory. Before becoming widely used, however, all the technology discussed must overcome four key challenges: Cost. In most cases, the major expenses of the technologies described are not hardware-related, and when they are, these costs can be mitigated by economies of scale. Potentially more intractable expenses arise from the need to customize the technologies to individual users, a requirement that is closely related to the second challenge. Universal design principles do not apply in a straightforward manner to cognitive aids, since by definition these systems must represent the details of their users′ daily activities. Ease of use. It is essential that the technologies be made completely transparent to use, and, if the user is to install them, they need to be

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Technology for Adaptive Aging transparent to install as well. One way to facilitate this is by customizing a system to a user′s particular situation, but customization can be expensive. Advanced machine-learning techniques may help mitigate this problem by automating the customization process. Reliability. Reliability is essential for technologies that are put into the home, where technical support staff are not immediately available. Although we are all familiar with the frustrating experience of dealing with unreliable software systems, we also deal daily with many instances of highly reliable technology. Cable television is one example. In addition, the design of “self-healing systems” is a very active current area of research, and there is similarly a large body of knowledge on the design of fault-tolerant systems. These and related engineering techniques will play a large role in the development of future technologies for the living environment. Privacy. Many of the technologies described in this paper involve extensive monitoring of the routine daily activities of an older adult. Clearly, such monitoring raises important privacy concerns that will need to be addressed by technology designers to ensure that the rights and dignity of the users of the technology are respected. Although these challenges are significant, it should not be forgotten that the technology that gives rise to them is being created to handle equally significant challenges that result from the dramatic demographic shifts currently under way. As the proportion of older adults skyrockets, there will not be enough younger adults to serve as full-time caregivers in the home, and technology will have to take up some of the slack. The technology discussed in this paper—if it is able to meet the four classes of challenges mentioned above—offers the hope of a better and safer quality of day-to-day life, in the home, for many older adults. Transportation The paper by Joachim Meyer starts from the assumption that transportation is more than getting from point A to point B. Mobility is an integral part of everyday independent living. In the United States, transportation is defined as “automobility,” wherein more than 92 percent of the public choose the car as their primary mode of transport. The next wave of retirees, the baby boomers, have been defined by the automobile since their youth, and today as adults most live in the suburbs or rural areas where alternatives to the car are few or nonexistent. However, the natural aging process and age-related conditions may affect the capacity of older drivers to operate a vehicle safely and comfortably. Meyer discusses both the promise and the challenges associated with the introduction of new in-vehicle technologies to assist the older driver. Although the

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Technology for Adaptive Aging major focus is on the automobile because of its importance in American life, other modes of transport are also important to many seniors, and some discussion is presented concerning public transportation. WHAT CAN BE LEARNED FROM THE WORKSHOP The vision for the workshop was the identification of a list of exciting new technologies to support the aging population that could be recommended for immediate transition to application in the range of settings studied by the workshop participants. No such list was forthcoming from the invited papers or the workshop discussion. On one hand, we heard about the promising new directions in miniaturization, electronic connectivity, and software sophistication that would enable all kinds of communications aids and sensory instrumentation to enhance social support from relatives and peers, monitoring and control of health care and medication administration in the homes where seniors prefer to live independently, and potentially to enhance their instrumental activities of daily living and quality of life. On the other hand, in each domain we heard about the serious challenges that the development of truly useful technological support would encounter, from trust, privacy, and safety to acculturation, autonomy, and dignity. At this stage in the field, there is simply not enough mutual understanding between specialists in aging research and technology developers to enable sensible, prioritized development of such a list. Instead, in the paragraphs that follow we suggest the kinds of further developments that are required and some of the means to accomplish those developments that the steering committee considers to have the greatest potential to bring about the most useful and usable technological support of the aging population. Multidisciplinary Focus Although we of course already knew this at some level, the workshop strongly reinforced the fact that producing technology that is genuinely supportive of the aging population is a many-faceted problem that requires multidisciplinary effort across the developmental spectrum, from basic research to evaluation of operating products in use in the field. The nation′s current approach, as it is with many problems, is to “let a thousand flowers bloom.” However, in this domain, such an approach has the effect of letting available technology seek its own market, and as discussed above, there are too many reasons, involving both user acceptance and economic reality, why such an approach will facilitate only the most widely applicable technological supports. There are many ways government agencies can play a role in promot-

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Technology for Adaptive Aging ing this kind of multidisciplinary collaboration. First, they could foster mutual education among industrial technologists and specialists in aging research in government and university laboratories. University faculty could be supported to spend summers or sabbatical leaves on site in industrial settings where potentially relevant technology is being developed. Graduate student training grants could be focused specifically on multidisciplinary training in laboratories conducting aging research, together with internships in industrial and field settings where potential technology interventions are being developed and evaluated. Specific work groups, workshops such as this one, and conferences could be sponsored to promote education across disciplines among established experts. Second, government agencies could sponsor unconventional types of translational research and development that explicitly call for collaboration between technologists with ideas for product innovations and experienced specialists in research on aging. There is great interest among some of the major U.S. corporations in tapping into the growing market created by the aging population, but they lack the expertise needed to develop products that are truly responsive to the needs of the aging population. Program projects are an existing funding mechanism that is suitable for this purpose, but they would require that sufficient resources be committed to support both halves of the venture, the corporate developers and the specialists in gerontology. Thoughtful negotiation of the allocation of intellectual property rights is another prerequisite. Without this kind of support, it is unlikely that these sorts of collaborations will happen serendipitously. Collaborative Ethnographic Studies There is a need for research studies employing sophisticated, structured observation, taking the user′s perspective in settings in which the aging population is found, in order to understand the real needs, the impact of the physical and social environment, and the range of individual differences that must be accommodated. Recently a new breed of ethnographers has become involved in collecting this kind of information for the design of computer-supported applications across a wide variety of settings. But without an understanding of the potential of technology, such studies will lack a focus. What is needed is collaborative research in realistic settings with observation and input from technologists who can educate the observers and the users about potential technical innovation and at the same time learn what the needs are and begin to shape the available technology to be responsive. It is difficult for users to articulate what will be useful to them without some examples of what is practical and feasible. With multiple prototypes to examine, they can interpolate and extrapolate from examples to recommend valuable innovations. Fur-

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Technology for Adaptive Aging thermore, this kind of human factors approach to a “requirements analysis” from the perspective of older users should become an integral part of the technology development process. Formative Premarket Evaluation Studies Another kind of study need spans the range from research to prototype application. Once a product idea has reached the prototype stage, there is a need for the equivalent of what in the software industry is called beta testing—that is, testing by the intended user population in real-life situations. This beta testing needs to be carried out by an interdisciplinary team that works in the aging user′s environment, and it needs to include specialists who understand the aging population and specialists in the conduct of formative evaluation. Such evaluation is not directed at assessment of the final outcome but rather attempts to discover the modifications to the technology that will enhance its effectiveness. Such studies will also reveal potential behavioral changes required of the users themselves to make the technology successful. Speakers at the workshop identified the need for more advanced evaluative methodologies to support such studies. It was mentioned repeatedly that the goal is a change on some outcome that is important to the life of an individual—in the activities of daily living or their overall “quality of life”—but clear definitions or evaluative criteria are not available to assess these features. The problem is complicated further by the fact that the introduction of technology will represent a change agent that will cause the aging population to adapt and change. The measurement regimens needed to take account of these potential dynamics have yet to be developed, and should be a priority for the National Institute on Aging. Systems Implementation Studies There is a third kind of study that is needed to support technology transition into widespread use. It is the study of actual “pilot” systems implementation in the broader setting with the opportunity to observe the impacts across the organizations and agencies that will be impacted. It was suggested that technology might be a primary means for integrating healthcare delivery in hospitals and clinics with primary healthcare in the home, or eventually for permitting significantly more care to be provided in the home and less in traditional healthcare environments. It has even been suggested that a change is needed in the overall healthcare delivery model to make affordable healthcare available to older adults. If system changes such as these are to be effected—and there are opportunities to do so across the domains in which the aging population potentially will

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Technology for Adaptive Aging meet new technologies—there is a need for collaborative multidisciplinary “model implementation” studies among the organizations and agencies that will be impacted. Technology transition can have impacts where they are least suspected. In a hospital in which computer-supported drug ordering was to be introduced, an interdisciplinary study was undertaken while the technology was being introduced to understand the broad potential positive and negative impacts of its introduction. The evaluation extended not only to the pharmacy and the doctors who would be using the system, but also to potential impacts throughout the hospital. Transitioning technology to the systems affecting the aging population will require the same kind of care in evaluation to ensure that the positive impacts outweigh the negative ones. Improvements in Infrastructure There is a need for substantial improvements in physical and electronic infrastructure before much of the potential of technological contributions can be achieved. The Americans with Disabilities Act and related legislation are making giant strides in improving physical accessibility in public spaces, but few new homes are being built with wheelchair access in mind and few existing private homes can accommodate even the most fundamental physical access needs without serious renovation. Advanced communications technology was frequently mentioned in the workshop, not just by the speakers on that topic but also in the discussions of living environments, healthcare, and transportation. However, the application of communications technology presumes the availability of the infrastructure to support it. It was argued that broadband access can be assumed to be available in the home in the next few years, but at what cost, with what user interfaces, and with what technical support to the population that may already be having difficulty with the activities of everyday living? It would also be useful to investigate ways to site or design environments suitable for older persons that encourage them to stay engaged in educational activities, stimulating leisure pursuits, or fitness activities. Some housing has been strategically placed near colleges or universities, where access to educational or intellectually challenging resources is easily available, but other approaches could also be considered. Need for Training and Instruction Although a goal of design may be to develop products that do not require training, this is probably an inappropriate goal. The best-designed product, especially if it is complex, is going to require some training. A better goal

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Technology for Adaptive Aging is to ensure that the documentation and instructional support that is provided with the product itself is well designed. Older adults are generally more willing to use technologies if training is provided, but we need to better understand their specific training needs—how, when, and if training for older adults should differ from training for younger or middle-aged adults. A recurrent theme of the workshop reflected the importance of providing training and instruction for the use of technology by older adults. Manuals and on-line help systems are notoriously ineffective and difficult to use—this aspect of technology development often receives short shrift in the design process. Moreover, system error messages are often vague or confusing and sometimes misleading. Users must be taught how to interact with the technology and to understand sufficiently well how the system works to be able to tell when it is not working properly. Training and instruction must be developed following instructional design principles, and such education must be tailored to usage patterns; that is, if a system is used infrequently, the instructions must be easily accessible and interpretable. If the consequences of misuse are extremely critical, users must be trained to the level of perfect performance. Issues of retention over time and the potential need for refresher training must also be addressed. Future developments in this area should also focus on the potential for the technology itself to provide user training, sometimes referred to as “embedded training.” The device could serve as a “coach” for the user by providing specific feedback and guidance when errors are made or introducing new features of the system only after the user becomes proficient with the basics. Human Factors Tools and Techniques The discipline of human factors is a multidisciplinary approach to design that puts the user at the center of the design process with the goal of developing safe, effective, and efficient user-system interactions. Within this discipline are tools and techniques that can be used to increase the likelihood that technologies will be designed to meet the needs of the users and that users will be able to safely and effectively use the technologies because they are designed well and accompanied by help systems, manuals, and instructions that are efficacious. Such tools and techniques include needs analysis to fully understand what the system should do and how it should do it; person analysis to recognize the capabilities and limitations of the target user population; task analysis to detail the components of tasks and ensure that the system functionality is appropriate, the expectations of the user are considered, and that error messages are clear at each point in the process; and in-

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Technology for Adaptive Aging structional analysis to determine the form, content, and medium that will provide effective instructions for initial learning, retention over time, troubleshooting, and system maintenance. The techniques of iterative, user-centered design and user testing provide methods of ensuring that systems will be usable. There are documented components to usability that provide guidance for design: learnability, efficiency, memorability, error avoidance, and satisfaction. Techniques such as rapid prototyping to develop mock representations of a product can be used to identify critical flaws early in the design process. Similarly, “wizard-of-oz” methods may be used to mimic what the system will do to measure user behaviors and expectation, prior to the expense of building the final product. Practitioners with these skills should be involved throughout the technology development process, whether it is the development of a single web site or the development of the smart home of the future. SUMMARY These are exciting times for researchers and practitioners who are interested in making a difference in the lives of aging citizens. As this workshop has attested, technological opportunities abound, and it is likely that, whether the multidisciplinary communities that have a stake in making them successful participate or not, many of these technologies will reach the marketplace and some of them will be imposed on the older population in the interests of efficiency and cost-effectiveness. It is up to the readers of this workshop report to make sure that these technologies are developed in ways that will ensure their success and to ensure that future cohorts of the population age with greater dignity, feelings of self-worth, accomplishment, and happiness.