As suggested by the workshop title, technology has tremendous potential to foster independence, participation, and health as people age. The first four speakers at the workshop provided perspectives on this potential from widely varying vantage points. Joseph Coughlin, director of the Massachusetts Institute of Technology AgeLab, examined some of the reasons why the many excellent technologies developed in laboratories are not more widely used. Geoff Fernie, professor at the University of Toronto and director of research at the Toronto Rehabilitation Institute–University Health Network, presented specific examples where technology can prevent disabilities and overcome limitations. Majd Alwan, executive director of the LeadingAge Center for Aging Services Technologies, outlined a program aimed at developing, validating, evaluating, and adopting transformative technologies. And Steve Saling, who has amyotrophic lateral sclerosis (ALS) and communicates through a silver dot on his glasses, described the award-winning homes he has helped design for ALS patients. Saling in particular demonstrated that even the most severe physical limitations need not result in disability.
Joseph Coughlin, Ph.D.
Massachusetts Institute of Technology AgeLab
The baby boomers have always been a vocal as well as a large cohort. As they retire, they are more likely than previous generations to demand
a high quality of life as they age—creating a policy and political dilemma that is only going to escalate. This is, he said, becoming a driver of politics and of the market.
Older Americans are living longer today than their grandparents’ and great-grandparents’ generations, but they are also likely to have chronic conditions that will lead to disability. According to Coughlin, of the total U.S. population of about 310 million people, 110 million have a chronic disease, 60 million have two chronic diseases, and 20 million have five or more chronic conditions.1 This convergence of aging and disability, combined with technology, has created an economic and political opportunity to rewrite the narrative of aging. New business models and new technologies can combine to create a future that people will want and enjoy because it responds to their needs. Coughlin argued that successful technologies will appeal to everyone in some way, and individuals will stop regarding these technologies as something only useful for older adults or individuals with disabilities.
People continue to have faith in technology. According to one survey, 90 percent of American baby boomers said that they know how to use technology to make their lives more interesting and enjoyable (Smith and Clurman, 2007). Coughlin argued that the goal is not just to provide additional support but to excite and create a level of living that everyone can aspire to, no matter their level of ability. “If you make good technology,” he said, “it responds to their needs automatically.” Already, technologies are being embedded in clothes, utensils, and even in the human body to make life easier and healthier. Systems worn under clothes can increase strength and flexibility and monitor well-being. Wheelchairs can respond to voice commands to find a person or go to a specified location. A car, a home, a workplace, a nursing home, or a hospital can monitor physical states and intervene when necessary and desired. Telephones can remind people to take their medicine, call their mothers, or do anything else that needs to be done. Robots do not just clean houses; they greet people in offices and aid in physical rehabilitation. In some cases, these are technologies in search of a problem, said Coughlin. But if technologies are smart and connected and provide needed services, regardless of a person’s age, they will be welcomed.
1As Joseph Agostini, senior medical director at Aetna, pointed out later in the workshop, among just Medicare beneficiaries, 27 percent have three to four chronic conditions, and 20 percent have five or more chronic conditions. Together, these groups account for almost 90 percent of Medicare costs. The 20 percent with five or more chronic conditions account for two-thirds of Medicare costs.
The idea, Coughlin said, is to get technology out of the laboratory and into the living room.
The way to find out what people want is to talk with them and watch them. Coughlin and his colleagues use surveys and focus groups to find out what people need and what problems they encounter. A 20-something engineer or product manager may never have considered how difficult it can be to open a bottle, reach for a box of cake mix on the top shelf, or try to use a credit card reader in a drugstore checkout line. Stores can be redesigned to have the things older people need on middle shelves, lighting that makes it easier to see, and carpeting that is less likely to cause falls. Walkers can be designed to fold into canes so that older people do not need to station walking devices in all the parts of a house where they are needed.
All these technologies are either on the market or near to being on the market, but many have trouble being accepted. As a familiar example, Coughlin cited the personal emergency response systems designed to alert emergency workers in the case of an accident. Such systems were created in the 1960s and further developed in the two decades after that. Yet the market penetration of the technology among Americans 65 and older is just 2 percent, said Coughlin. Even in the United Kingdom, where the National Health Service will pay for the technology, the penetration rate is just 15 percent. Thus, even a technology that is obvious, easy, relatively affordable, and sensible has not spread widely. Until such technologies are available at such places as Best Buy and Brookstone, Coughlin said, the market will have failed the people who could benefit from those devices.
New Solutions Bring New Challenges
The acquisition and use of new technologies by older adults and individuals with disabilities is often framed as a purely rational act based on facts and fear, but this is not true of the general marketplace. For example, people buy many foods that are not good for them but simply taste good. Also, people may buy products because they enjoy and learn from the shopping experience. For example, when people go to an Apple store, they seek help at the “genius bar” which allows them to ask questions without feeling foolish. In contrast, many assistive technologies are presented as something needed only by older adults and individuals with disabilities, not everyone else. The idea, said Coughlin, is to take advantage of teachable moments, make engaging with technology fun, and let people enjoy themselves. Similarly, he showed a photograph of an insurance company office in which people can have a cup of coffee and sit down beside a fireplace to talk with an agent. Such approaches engage more than the rational desire to make an economic transaction. Coughlin argued that this is not done
very well in presenting assistive technologies to older adults and individuals with disabilities.
For many technologies associated with disabilities and aging, people have to select the technology, find a way to pay for it, install it, and fix or replace it if it breaks. Such technologies do not come with a Geek Squad that can make the technology work. Furthermore, because families are smaller today than in the past, fewer children are present to care for parents, and many of them live farther away and have jobs. Today, the fastest growing number of households in America consists of women 65 and older living alone. Many of these women do not have sons, daughters, sons-in-law, or daughters-in-law nearby who can come over and help them get a technology to work.
The challenge is to make technology easy. Technologies can detect that a person’s gait has changed and that he or she is about to fall or that a person’s diet has changed. But how will that information be used? Family caregivers can easily be overwhelmed by such information. The daughter taking care of an elderly parent is looking for solutions, not data, said Coughlin.
Creating data rather than solutions also raises questions of liability, safety, and risk. For example, can caregivers or family members trust a technology? Is the technology reliable? Can a caregiver check with an elderly charge less often than before the technology was used? Will technology create greater social isolation as a result? As Coughlin put it, “Do you trust the cloud with your mother?” The law uses a concept known as the “reasonable man standard,” which holds that the typical member of a community ought to be able to use a technology without risk. But what if the typical user of a technology is a 67-year-old woman who is short and frail and has three or four chronic conditions? Is a new standard of reliability needed to get technologies into homes and manage risk?
Coughlin also mentioned that as more technologies are in use, people may tend to ignore the multiple alarms that occur often and are usually, but not always, false. Bad outcomes may become more likely when people rely on technologies too much.
Technologies need support and services in the community, not just in sales or call centers, if they are going to be used. Even if a technology is widely distributed, many people may need help to use that technology. If people want to age in place in their communities, the technologies they need have to be available and supported in those communities.
Many of the best ideas for technology come from people who deal with the problems those technologies could solve, said Coughlin. The people who best understand the problems of aging and disability are those who live and work in communities of aging and individuals with disabilities. Researchers develop wonderful ideas, but innovation is putting practical
ideas into use. Unless a technology is at use in a living room or community, it is not an innovation.
Also, new technologies often require a new workforce. For example, most medical students are still not being taught much about telemedicine,2 even though these technologies will be a major part of the future of medicine. Moreover, if students are not taught much about telemedicine, the technology will be less widely adopted than it could be and will provide fewer benefits. Coughlin stated, “Until we can get telemedicine to be called medicine, it is still going to be something new and different.” In the future, health care providers will need to be systems integrators, but they are not being prepared for that future today. Coughlin looked to a new profession that would combine clinical and data expertise. No such programs exist today, but the need will become increasingly clear.
Coughlin concluded with several recommendations he thought could pave the way toward such a future. He said that we need a new agency, focused on innovation, that would go beyond the Small Business Innovation Research (SBIR) model. Such an agency should help get innovations into homes and communities, in part by working with businesses to make technologies available and usable. Such an agency could establish a national agenda and get the attention of major companies to make innovations affordable, usable, and available. It could bring business, government, and the research community together to take ideas from the laboratory to the living room.
He also advocated increased support for research on both new technologies and ways of getting those technologies used. This effort will require support for marketing and product development so that imagination is converted into innovation. In addition, we need a community-based network to make the business case for an innovation.
A nationwide education initiative should link technology development in universities to the service professionals working in communities, Coughlin recommended. Today, few universities that train nurses, social workers, gerontologists, or physicians offer courses in telemedicine or other technologies.
Coughlin offered several additional policy recommendations:
2“Telemedicine and telehealth both describe the use of medical information exchanged from one site to another via electronic communications to improve patients’ health status. Although evolving, telemedicine is sometimes associated with direct patient clinical services and telehealth is sometimes associated with a broader definition of remote healthcare services” (ATA, 2013).
- Facilitate public–private partnerships to create a smart-buyer guide of systems and service innovations for caregivers, users, and social media communities.
- Ensure technological equity and affordability through, for example, the leveraged procurement power of public agencies.
- Develop legal frameworks to address emerging issues of risk, privacy, data ownership, consent, and competence.
Coughlin closed by issuing a call to action that focuses on a dream for the future and is not just a call for more investment in research. With luck, everyone eventually will age. Leveraging political will, economic opportunity, and technological potential is therefore not just about older adults and individuals with disabilities, but about everyone. People need passion, urgency, and leadership to act on the idea that everyone should live longer and better.
Geoff Fernie, B.Sc., Ph.D., MI.Mech.E., C.Eng., P.Eng., CCE University of Toronto and Toronto Rehabilitation Institute–University Health Network
Whether a person starts off with a disability or not, he or she will probably end up with one, and probably more than one, exacerbated by multiple minor or major complications. Technology can counter these disabilities both by preventing disabilities and by providing people who have limitations with as much mobility and freedom as possible. Both approaches will become increasingly important as the percentage of older people in the population increases and as families continue to live in widely separated locations. Fernie explored the potential of technology by looking at several diverse examples.
Fernie stated that sleep apnea affects around 7 percent of middle-aged men and a somewhat lower percentage of middle-aged women. He further stated that only 10 to 20 percent of people with sleep apnea are ever diagnosed, but their condition places them at higher risk for heart attacks, stroke, and accidents. As a result of its prevalence and effects, sleep apnea is a huge public health issue.
To receive an official diagnosis of sleep apnea, people need to go to a sleep clinic and be tested while they are sleeping. Unfortunately, the procedure is expensive and can be difficult to arrange. To address these
challenges, more than a dozen competitive products have been developed to test for sleep apnea at home, such as masks that measure the amount of air flowing past a sensor. Alternative methods of treating the disorder are also being developed, offering the potential to greatly reduce this serious condition.
Many people in hospitals acquire infections (also known as nosocomial infections) when they are being treated for something else. Many of these infections, which may kill nearly 100,000 people annually in the United States (Klevens et al., 2007), are caused by health care workers who carry an infection from one site to another because of a failure to wash their hands.
Fernie and his colleagues have developed an inexpensive technology that uses light-emitting diodes to send a coded message whenever health care workers cross a threshold, such as the door to a patient’s room. If the workers have not washed their hands, badges they are wearing vibrate. When they wash their hands, the hand-washing machines emit another signal, and their badges turn green. In this way, other workers and patients know that someone has followed good hand hygiene, which can be very difficult in a busy environment where nurses can be expected to wash their hands up to 120 times in a shift. Fernie related that in a recently completed 12-month trial on a 50-bed unit that was already reporting high levels of hand washing, he and his colleagues found that the technology more than doubled hand hygiene.
Very few older people who fall and break a hip ever return to regular mobility again, and a significant proportion die within a year. Both stairs and ice are major contributors to such falls, but technology can reduce the risk substantially. A careful study of the rise and run of different steps by Fernie and his colleagues revealed a sixfold decrease in accidents as the run (the horizontal dimension) of steps is increased. Making steps deeper— through changes in building codes, for example—is a straightforward way of decreasing falls and reducing disability.
On icy surfaces, footwear can make the difference between staying upright and falling. Fernie and his colleagues have tested, in a simulation chamber, different boots and shoes on icy surfaces at different angles. Most footwear, including some expensive styles advertised as designed for snow and ice, give way on slopes of about 5 degrees. But one of the boots tested could go up and down 20 degrees of slope. With parts of Canada and the
United States covered by snow and ice for substantial portions of the year, this simple technology could prevent many falls and deaths.
Another major cause of accidents is distracted walking, especially as people spend more time talking and texting on cell phones as they walk. As Fernie pointed out, the human brain is not good at dividing attention between different types of activities. For example, if someone’s hearing diminishes, that person is more likely to fall. There is a fair bit of evidence that this may be due, in part, to the brain devoting more attention to interpreting the auditory environment. Fernie’s group is therefore working on hearing aids that amplify only what someone is looking at. It has also developed a simulator in which someone can walk through a virtual Toronto while encountering a very precise soundscape. Another simulator can create extremely realistic driving environments—complete with unexpected challenges—which can be used in research designed to help older drivers remain safe behind the wheel.
Technologies for Caregivers
Finally, Fernie talked about technologies that can help caregivers for people who have disabilities, including family members who are caring for parents or other relatives. Family caregivers are the largest labor force in health care, and they often suffer physically and psychologically in their roles. For example, caregiving has an even higher back injury rate than mining, with many injuries caused by lifting and moving people. Electronic devices can monitor and communicate various physiological parameters and activity levels, relieving at least some of the responsibilities and stress on caregivers. Also, new devices for lifting people can obviate the need for as much heavy physical labor. Fernie demonstrated an inflatable device that can extend a strap underneath a prone person so that the person does not need to be lifted. The strap then can be attached to a lifting device.
Common tasks are often the most difficult and complex when accommodating a disability, such as going to the bathroom or getting out of bed. Fernie demonstrated a system of portable lifts and supports that can be installed in a home to make these tasks easier. But much more work needs to be done in such areas, he added. High technology is not necessarily the answer to every problem. Relatively simple technologies are still desperately needed to solve common but extremely complex problems, and these technologies need to be inexpensive if they are to be widely used.
Majd Alwan, Ph.D.
LeadingAge Center for Aging Services Technologies
The Center for Aging Services Technologies (CAST) is a program of LeadingAge that brings more than 6,000 service providers together with technology companies and researchers to expedite the process of developing, validating, evaluating, and adopting appropriate technologies that can transform aging; LeadingAge members serve more than 4 million seniors on a daily basis.3 CAST has four strategic fronts: research, policy, standards, and education.
Research is aimed at identifying available technologies and assessing their value and the barriers to their development and adoption. A user-centered approach to design takes into account not only the needs of the end users but also their requirements and preferences. Technologies are evaluated in living laboratories within the provider organizations serving older adults and individuals with disabilities.
In the area of policy, the program advocates for the removal of barriers to the adoption of technologies at the federal, state, and local levels. It also works on standards for interoperability and interconnectivity to ensure that these technologies are capable of providing continuity of information and care when used by multiple care provider organizations. In education, it focuses on educating providers and professional caregivers.
Technology-Enabled Care Models
After the passage of the health care reform bill, CAST conducted strategic scenario planning and identified three categories of care models that are likely to become mainstream and the enabling technologies. The first category consists of integrated and coordinated health care delivery. Under health care reform, accountable care organizations that bundle payments are representative of this model. The second category consists of community-based support services such as home care. In this case, services are delivered on an as-needed basis. The third category consists of real estate–based models where technologies are used on campuses to improve efficiencies and to leverage the capabilities to deliver services outside campuses.
All three models benefit from the use of interoperable electronic health records through which health information can be exchanged. In addition, remote patient monitoring and telehealth can manage chronic conditions, stabilize newly discharged patients, and encourage self-management. Care coordination tools allow for shared care planning and care coordination across care settings.
CAST identified future-ready, technology-enabled care models (LeadingAge CAST, 2011a) and then collected a number of real-life case studies of providers who are implementing these models (LeadingAge CAST, 2011b). In addition, a report prepared for the U.S. Department of Health and Human Services systematically looks at care issues prevalent among older adults and individuals with disabilities—falls, chronic disease management, medication management, sensory impairment, cognitive impairment, functional decline and loss of independence, and depression— and examines the efficacy and cost-effectiveness of technologies for each (LeadingAge CAST, 2012). The report also has a chapter on barriers to the development and adoption of technologies, along with strategies to overcome these barriers. A major finding of the report concerns the variability of evidence. Some technologies have strong evidence of efficacy, and others have less evidence. Some are proven to be cost-effective, but cost-effectiveness often depends on the operational and business model in which these technologies are used. For example, remote patient monitoring and telehealth have the strongest evidence of cost-effectiveness, but most of the evidence comes from studies of the Department of Veterans Affairs, which may not be generalizable.
The biggest barrier to the adoption of these technologies, said Alwan, is the absence of business models that are conducive to their adoption. Strategic partnerships among acute, postacute, and long-term services and support are key to the use of these technologies. In addition, adoption of technologies is slow because of such barriers as the lack of awareness not only among consumers but among caregivers, physicians, and discharge planners. Technical issues related to usability, competency in using technologies, and interoperability also contribute to slower adoption.
High-Tech Aging: Improving Lives Today (Video)
Alwan played a video featuring technologies that are commercially available today and are being used by provider organizations, though on a smaller scale than in the integrated fashion envisioned in the near future.4 The video featured the use of electronic medical records to coordinate treatment and rehabilitation for a stroke. It also demonstrated the use of
telehealth technologies, in-home sensors, a medication dispenser, and a personal emergency response system with automatic fall detection to care for a person recovering from a stroke and relieve the demands on caregivers. The idea behind the movie, said Alwan, was to stimulate strategic partnerships to make these technologies and their widespread adoption a reality.
Leonard Florence Center for Living
Steve Saling was diagnosed with ALS in 2006, when he was 38. Given a life expectancy of 3 to 5 years, he decided to change how ALS patients live their lives. He teamed up with the chief executive officer of the Chelsea Jewish Foundation, Barry Berman, and together they designed and built the award-winning Leonard Florence Center for Living.5 The residences within the center are fully automated to provide unprecedented levels of independence and productivity. As cofounder of the ALS Residence Initiative, Saling is working to replicate the residences around the country. Recently he arranged a tour of the center for Steve Gleason, a former professional football player who was diagnosed with ALS. As a result, a second ALS residence is scheduled to open in New Orleans.
Saling’s exclusive means of communication for the past 3 years has been a software program called Dasher, which enables him to control a computer with a silver dot on his glasses. For the workshop, he composed a presentation that he played for the participants:
You may think this computer voice is sometimes difficult to understand, but I am sure you will find it easier to understand than my southern accent. I grew up just outside Atlanta and lived there until 7 years ago. I went to college at Auburn University to become a landscape architect. My work focused on designing public spaces like public parks and urban spaces. My specialty was in designing places that are fully accessible for people with disabilities. So the irony never escapes me that I am now a direct beneficiary of my previous professional work. When I was diagnosed just over 6 years ago, I had researched ALS to know that in a few years I would be totally paralyzed, unable to speak, and maybe unable to breathe. I was told that it was invariably fatal, with an average lifespan of 3 to 5 years after diagnosis. However, I knew that technology existed that would keep me alive pretty much as long as I wanted. I didn’t yet understand why someone would choose death over needing a ventilator to breathe for them. Instead of being filled with grief because of my doctor’s grim prognosis, I took it as a challenge and something to be proven wrong.
ALS is a neurodegenerative condition that slowly makes the nerves that control movement stop working. I knew that I would have a power wheelchair when I became too weak to move on my own. I knew that I would always be able to communicate through a computer like the great Stephen Hawking. I also knew that compact portable ventilators would breathe for me when my diaphragm becomes too weak to pump my lungs. I admit to thinking that I had it all figured out 6 years ago—that was until I started shifting my research from how I was going to live to where was I going to live. I was shocked to find out that in my home state of Georgia, there was not a single facility where I could live when the time came that I needed a ventilator to breathe for me. My shock turned to despair when I finally met someone with ALS living on a vent in a chronic hospital. Here was a young guy like me whose mind remained sharp even though his body had failed him completely. I was horrified to learn that he was rarely, if ever, out of his bed but stayed in a small room that he shared with a 90-year-old gentleman. It had been a year since he felt the sun on his face and 2 years since he had a proper shower. I finally began to understand why so few people choose to take advantage of readily available technology to extend their life. The options for long-term care are so bleak that death is preferable to being left in bed, staring at the ceiling, technically kept alive but essentially warehoused, out of sight, out of mind.
I was determined to find a better way to live with my ALS. I never felt that ALS would be the end of my life, just a change in its direction. Sometimes, it is better to be lucky than good. There is no way I can have hoped to be as successful as I have been. I was very able, 6 months after my diagnosis, when I met Barry Berman, who ran a nursing home and wanted to build something brand new that would specialize in younger disabled people. I was a little hesitant when Barry suggested that this new place would be a nursing home. The only thing I knew about nursing homes came from visiting my grandmother.
She lived in a really nice place, but it was certainly nothing I aspired to. Barry began telling me about a new concept called a greenhouse, and I was intrigued. No matter how nice it sounded, I knew that it would have to provide vent support and be fully automated so that I wouldn’t become a prisoner in my own body. Barry quickly agreed to both, and a wonderful partnership was born that in 3 short years would create the first, and so far only, fully automated, skilled-service ALS residence in the world. I couldn’t believe my good fortune at having my dream fulfilled by being asked to design the perfect environment in which for me to grow old. As an architect and accessibility expert professionally, with a passion for technology, and newly included as a disabled person, I felt like the offer was a gift for which I was particularly well suited.
In addition to consulting with the architects on accessibility, I accepted responsibility for designing the automation system. The design of the automation was challenging, but I would have it no other way. We hired
a home automation company to create a customized automation solution that met a demanding set of specifications that I had outlined. I not only wanted to have control of everything, I wanted to make sure that any device with an Internet connection would be able to control the system with no software to install and no hardware required to be attached. The result is called PEAC,6 and I hope and expect that it will transform the mobility for the physically disabled. My home is fully automated, so once I am helped into my wheelchair every morning, I am independent and able to move freely until I go to bed late that night. I have full control of my lights, doors, and thermostat. I can open and close my window shades and have complete control of my flat-screen home theater. I can call for assistance or help. All of this I can do from my computer with slight movements of my head or movement of my eyes.
If it is electrical, I can control it. Even the elevators are fully automated so that I can call the elevator and select the floor from my computer. I may be paralyzed, but I am free. PEAC is currently being marketed to other health care facilities, and I highly recommend it. It dramatically reduces the demand on staff by eliminating the calls for help every time someone wants a light on or the channel changed. Freedom is good for everyone.
As awesome and amazing is the freedom and independence provided by PEAC, it is the people who make it a home. I share a house with nine other friends, and we have people there 24/7 who are like family to help us however we ask. Barry and his administration made it their highest priority to hire the kindest, most compassionate staff. It really is an extended family. ALS does not have to be fatal anymore, and the ALS residence makes the best possible life out of a challenging situation.
Until medicine proves otherwise, technology is the cure. The same as anyone, I want independence. Despite my obvious disability, the ALS residence provides the maximum possible freedom and independence, so I have a life instead of worrying about my personal survival.
My doctor told me to get my affairs in order. Instead, I have founded the ALS Residence Initiative with the mission to inspire replication across the country. The second fully automated, vent-ready ALS residence will open in New Orleans in 2 months, and there are more being planned. We don’t have to wait for the future to use technology that provides freedom and independence. The future is now. The challenge now is to make it common and usual. Thank you for your time, and remember, life is good.