Grand Challenges of Our Aging Society: Workshop Summary (2010)

The physical and social aspects of communities will be very relevant to the experience of aging individuals and will be affected by these individuals’ needs, limitations, and resources. Transportation, housing, technology, and social services all need to adapt to the changes that will accompany an aging population.

Sandra Rosenbloom

University of Arizona

The realities of the transportation sector can be examined by first exposing a few widespread myths. The first one is that older people who do not drive take public transportation—this is not the case. Older people who can drive do so, and those who cannot drive ride with others as passengers or they walk. Even people with disabilities rely on the car as either a driver or a passenger. Older people are not major users of public transit. In 2001, public transit accounted for less than 1 percent of all the trips taken by drivers over age 65 and about 10 percent of trips by nondrivers over age 65. The car, by contrast, was the mode of transportation in over 90 percent of trips for drivers over age 65 and about 65 percent of trips for nondrivers over age 65. Walking was the mode of travel for 7 percent of trips among drivers and about 25 percent among nondrivers over age 65. Older people currently account for nearly 15 percent of all drivers in the

United States, and this will increase to about 25 percent in 2030. That figure will be even greater in states with a higher percentage of older people. The importance of these observations is that policy needs to focus on the right issues. If people remain committed to the myth that older people rely on public transit, policies will not address reality.

A second myth is that travel differences between genders are narrowing—this also is not so. Women take fewer trips, travel fewer miles, and drive less than men. These gaps are widening. When they do travel in cars, women are in the passenger seat. This has significant implications for the mobility of aging women and for their safety as drivers. What makes older drivers dangerous is that they drive less. The more one drives, the safer a driver one is. Women report such reasons as anxiety, not medical causes, for giving up driving. Women stop driving earlier and for less specific reasons than men; by contrast, the precipitating event for a man to give up driving is the third stroke or heart attack. Women at all ages are safer drivers and have lower crash rates than men, but they are more likely to be killed in comparable crashes. This is because vehicles have been designed for men. The anthropomorphic dummies used in safety tests were based on male bodies, with implications for torso size and strength. Cars are not designed for women, although they could be, with the aims of reducing anxiety and increasing physical safety. Women respond to traffic safety messages differently and are less comfortable in vehicles and more often need vehicle adjustments. The significance of toppling this myth is that if vehicles and roadways continue to be designed for only a portion of the driving population, that design will not be improving the mobility and safety of all.

A third myth is that older people live in or will move back to central cities—also is false. Currently, 75 percent of older people live in low-density or rural areas, and the trend is increasing. When older people move, they tend to move outward, to lower density suburbs. Retirement communities are being built on the outskirts of metropolitan areas, in locations without ready access to public transit.

A fourth myth is that older drivers are dangerous and have more crashes and that older women drivers are even worse. None of this reflects reality. Per capita, until about age 80 or 85, older people have fewer accidents. And indeed, older drivers are never worse than teenagers. Older people do, however, have higher fatality rates in crashes due to their overall greater fragility. Older people are more likely to die in crashes of comparable severity than younger people, and older women are much more likely to die in crashes of comparable severity than men.

All of these myths need to be dispelled so that sound policies are based on reality. When it comes to transportation practices and the safety of older men and women, customary assumptions are often false. Design-

ing for people as they are requires new research, policies, and design. Because older people drive, it is important to direct efforts at making driving safe for them. Since walking rather than public transit is the actual alternative to driving, pedestrian facilities also need to be improved with older people in mind. Rosenbloom proposed several questions warranting further investigation, including:

• What vehicle and roadway characteristics would keep older people driving safer longer?

• What pedestrian facilities would be genuinely helpful to older people?

Research on vehicle and roadway characteristics includes attention to every aspect of driving, including drivers, vehicles, roadways, signage, and the like. Many of these will differ by sex, because women need different characteristics in the car and roadway than men in order to be safe, confident, and comfortable drivers. Efforts are needed to improve ease and comfort in driving, prevent crashes, and improve crash outcomes.

Regarding pedestrian facilities, it has been presumed that people will consistently engage in walking only if it is purposeful (for example, to a grocery store). Thus if people do not live in communities where they can do purposeful walking, engineering for walking is considered a waste of time. However, recent studies suggest that people who walk for leisure are actually doing it more than people who walk for purpose. People living in adult retirement communities, for example, walk more than people living in central cities. More research is needed on why older people who walk are doing so. Safety and security are key issues: older people drive to malls to walk because malls provide safety and security. Proper research questions, then, would address their safety and security concerns. This might include enforcement of existing traffic laws. The provision of a physical environment that facilitates walking in suburbs where people are aging in place is another priority. This includes sidewalks and lowered curbs. For crossing streets, crosswalks with islands in the middle or the means to extend the walk signal (which are usually timed for how long it takes an 18- to 24-year-old to cross) can make a significant difference for older pedestrians. Separating bicyclists and skaters from pedestrians is also important, as these can also be hazards for older people.

“As long as we’re not dealing with these kinds of micro-issues in the pedestrian environment and the auto environment,” Rosenbloom concluded, “we’re dooming a lot of older people to immobility. And we need to deal with the real issues and not the issues that we think are the problem.”

Joseph F. Coughlin

AgeLab

Massachusetts Institute of Technology

How can communities monitor, manage, and motivate older people? New technologies will play a role, but much of the technological innovation is already accomplished or in process. Lags in organizational capacity and national policy are far more worrisome. Coughlin presented three areas of inquiry:

1. Do current public and private aging service providers have the organizational capacity to meet new aging demands and utilize new technologies and processes? Are the caring professions getting the relevant training, and are service providers developing innovative business models to deliver the new services?

2. How might national policy facilitate innovation in aging products and services (e.g., user-centered design, technology development, engineering, creative delivery systems)?

3. How do societies and individuals address policy lag and the difference between what technology can do versus what people want done?

With these questions in mind, increased longevity may be viewed as a systems success. The increase in longevity has been achieved due to multiple public systems, including clean water delivery, sanitation, delivery of health care services, and medical technology. A similar systems approach can be applied to the challenges of global population aging. Society needs to think about multiple integrated systems that will allow people to live well across the entire life span.

Currently, systems are fragmented. Even when the needs of an aging population are anticipated, they are not being acted on. For example, an ongoing survey of metropolitan planning organizations reveals that professional planners are well aware that the aging population will need a different transportation system. Nonetheless, they confirm that their regions are not adequately funding changes in infrastructure, vehicles, or services to meet those needs.

An integrated systems approach would match technological innovations to needs across the life span, including quality aging. Older adults have a pyramid of needs that might be addressed by appropriate technological innovations. At the bottom tier are health needs, which could be matched by telemedicine and a range of aids that assist patients in making decisions about their health care. At the next tier, the need for safety is

matched by smart housing, personal emergency response systems, and ubiquitous health monitoring. Proceeding up the pyramid, the need for connectivity addresses people’s desire to lead meaningful lives and connect with others. Relevant innovations at this tier include communication technologies, transportation alternatives, and livable communities. The need to make a contribution—perhaps by working, whether full- or parttime; volunteering and civic engagement; or caring for grandchildren—occupies the penultimate tier of the pyramid. Education technologies and methods of cognitive enhancement would help meet this need. At the pinnacle of the pyramid is the need to leave a legacy. Cross-generation learning and creative media models will facilitate this.

Technology-enabled innovations and intelligent devices will also affect people’s lives as they age. Many of these are already available and in use. They include shirts with sensors that can perform an electrocardiogram, implantable sensors that monitor blood pressure, and devices in cars that monitor the physiological functions of the driver. Spoons have been developed that can measure the viscosity of fat content and send the calorie count via the Internet to a doctor, family member, or other caregiver. Smart toilets evaluate stool and urine for glucose count and fiber content, uploading that information via the Internet. Specially equipped stuffed animals can monitor blood pressure and provide reminders to take medications. Smart grocery carts take personal diet and health data and provide information relevant to deciding on purchases by scanning products and evaluating them in light of an individual’s health history. “The idea,” according to Coughlin, “is the right information at the right time to make the right choice.”

This technology goes nowhere without an equally smart business model. For example, stuffed animals that monitor blood pressure are provided free by Panasonic to customers of Tokyo Electric Power who are part of a program to monitor congestive heart failure. The device connects 60,000 households in the metropolitan Tokyo area to Tokyo University Hospital for monitoring. The household pays a service fee for the health monitoring. As this kind of monitoring becomes ubiquitous in homes, retail sites, and transportation, the biggest asset of the private sector, its supply chain and logistic platforms, needs to be fully used. Coughlin urged, “Wal-Mart, Rite Aid, CVS, these places have supply chains and presence and trust in places we can’t even begin to dream of.”

These technologies have had various rates of penetration. For example, a fast-growing segment of social networking via the Internet involves baby boomers looking for information and advice on health, caregiving, and financial management. Virtual communities addressing health are on the rise. Televisions and cell phones also facilitate penetration. Using these, an individual can get a consultation with a dietitian, or measure

blood pressure and glucose level, or send health information to caregivers. Platforms to collect and report key bio-vital data are multiplying. Their widespread distribution will enable individuals to get useful consultations with professionals as needed and allow absent caregivers to monitor their elderly charges.

Several nations are investing in such technological innovation and the organizational capacity to deliver it. The United Kingdom is a top investor in organizational capacity (e.g., the processes, procedures, and information technology to improve delivery systems), whereas Singapore invests heavily in technology (e.g., the development of new devices to improve the health and well-being of older adults). For example, the United Kingdom initiated a multibillion-pound sterling investment in a new information technology infrastructure to improve efficiencies in the National Health Service for scheduling, movement of test results, etc. One of the most noted symbols of this investment is the provision of a personal computer to every primary care physician. Although it looks like a technology investment, it is actually an investment in the current capacity to deliver care. Japan is high on investments in both technology and organizational capacity; the United States remains low on both. The United States needs to invest far more robustly in both technological innovations and in the training of how to use them.

Professional caregivers, including doctors, nurses, and social workers, should be trained in the use of technologies relevant to the care of older people. The educational structure in the health professions needs to be restructured, Coughlin argued, to incorporate attention to technology. “If we don’t stop calling telemedicine ‘telemedicine,’ until we call it medicine, it’s always going to be something different and out of the ordinary.”

Technological innovations will also figure in ethical debates about individual and public health. If people make poor health choices or engage in poor health behaviors, despite the assistance of technology to provide full and correct information at the point of decision or to facilitate healthier behaviors, then what is the responsibility of society to that individual? How will the social contract around longevity be rewritten? With technologies that can monitor behavior, such as food purchases or driving practices or basic mobility, Coughlin cautioned, “Be careful what you ask for, we may actually deliver it.”

Coughlin closed with four questions for research and public policy regarding aging and technological innovation.

1. Acceptability: Does society want to make use of these new technologies? Some of them raise issues of desirability, such as privacy, independence, and dignity.

2. Availability: What are the best ways to make new technologies widely available?

3. Adequacy: How ready are public and private institutions to integrate new technologies, for example in education, clinical management, and service delivery?

4. Affordability: How does one ensure that new technologies are equitably distributed for the broadest social benefit, across income brackets, cultures, and education levels?

In subsequent discussion, Coughlin responded to a geriatrician who expressed reservations about the flood of extraneous data provided by the new monitoring technologies. As a provider, this speaker remarked, these technologies are “in a sense, my worst nightmare.” Coughlin concurred that the situation can become “data, data everywhere and not a drop of knowledge,” noting that technology often solves one problem and creates two more. Data visualization and translation are the next challenges. He sees a need for a new level of professional dedicated to translating data into knowledge. The distillation of information at different levels will be imperative so that it can be of greatest use to the physician, the intermediary caregiver, and the patient.

In responding to a question about end-users and the distribution of these new technologies, Coughlin noted that the consumer is often not the older adult, but rather his or her caregiver. The technologies thus have implications for the labor force participation of caregivers. Adult children or other informal caregivers will be able to remain uninterrupted at work while monitoring an aged parent or other older adult.

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