Research, Practice, and Principles in the Field of Technology and Aging

Research, Practice, and Principles in the Field of Technology and Aging

Sunkyo Kwon,

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Gerontechnolog y

Gerontechnology

Research, Practice, and Principles in the Field of Technology and Aging

Sunkyo Kwon

Editor

Gerontechnology

T

Topics include, but are not limited to, virtual environments as a research tool, sensation, perception, and cognition research advancements, novel accessibility challenges to information and communication technology, as well as the evolving characteristics of the elderly. These are among the welcome developments addressed in the book. Contributors from around the globe, including the UK, Germany, Japan, Canada, The Netherlands, Korea, the United States, and more, bring unprecedented cross-cultural insight to the intersections of aging phenomena and technology.

Key Features:

• Disseminates empirically proven findings and evidence-based theories, models, and concepts

• Written by world-recognized leaders in the field of technology and aging

• Reflects the global usage of gerontechnological applications

• Includes new technologies, research, and applications for virtual environments, smart homes, assistive technology care, and robotics

• Discusses computer-assisted social engagement, technology-facilitated caregiving, business case examples, and more

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251

ASSISTIVE TECHNOLOGY FOR OLDER PEOPLE

RICHARD DAVIES, RYOKO FUKUDA, HUI-MIN HUA, SUZANNE MARTIN, MAURICE MULVENNA, AND SEBASTIAN MERKEL

KEYWORDS

assistive technology chronic disease care connected health disability

eHealth

electronic assistive technology (EAT) exoskeleton

health care

lifestyle monitoring quality of life (QOL) robotics

smart home telecare telehealth telehealth care

The human race continually strives toward an increased quality of life (QoL) and health, both of which become more susceptible to decline as we evolve to live life longer. Balancing this paradigm shift presents a worldwide problem with factors such as economic drivers, comorbidities, and ever-evolving tech- nology adding to the complexity of potential solutions. As health care makes its early transition into the realms of self-management and is coupled with a clearly identified need in terms of managing long-term chronic conditions,

the role of assistive technology (AT) becomes particularly significant. Such a care provision should become increasingly person-centric and, thus, AT will become more ubiquitous.

This chapter highlights and summarizes these wider trends and goes on to focus on case studies, which emphasize the role, responsibility, and poten- tials that assistive technologies have, particularly in the support of older people.

The several sections focus on different AT areas, describing chronic care as well as the use of telecare and telehealth. This chapter concentrates on “high- tech” AT and not on “low-tech,” such as glasses and wheelchairs, which are listed and partially covered elsewhere (cf. Hammel, 2004, and Chapter 17).

Case studies in AT are given before wearable technology to support older people is explored. Then, a review of the use of physical exoskeletons follows.

The final sections briefly review the use of care robots to aid older people.

ASSISTIVE TECHNOLOGY

Assistive technology (AT) is an umbrella term for any device or system that allows individuals to perform a task that they would otherwise be unable to carry out or that increases the ease and safety with which it can (Cowan &

Turner-Smith, 1999).

Electronic assistive technology (EAT) has been defined as “any item, piece of equipment, product or system, whether acquired commercially, off the shelf, modified or customized, that is used to increase, maintain, or improve func- tional capabilities of individuals with cognitive, physical, or communication disabilities” (Bjørneby, Topo, & Holthe, 1999). We propose that EAT is a subset of AT. This category includes a wide range of devices that integrate infor- mation and communication technologies (ICTs), providing digital products and services over networks, as well as creating dynamic interactive devices.

Historically, environmental control systems, social alarms, and speech aug- mentation devices were the predominant technologies issued to individuals, generally to enhance independence. The range of devices, applications, and their integration into health care services has widened radically, spawning innovation in both device integration and service development. In some instances, full-service models blending care with environmental design, AT, and EAT are emerging to support particular client groups, such as people with dementia. In tandem to the adoption of devices within traditional health care scenarios, ordinary citizens are using services within smart appliances available to the everyday consumer, for example, Fitbit (Fitbit.com) and many health apps available for smartphones such as Map My Run (MapMyRun .com).

A range of service descriptors is becoming more noticeable as a common language when EAT is used, for example, telecare, connected health, eHealth, telehealth, or telehealth care (see also Chapters 13 and 14). In some instances, these stem from the “technological topography” (for instance, social alarm, smart home, context aware home, or lifestyle monitoring).

Various contributors have suggested ways to conceptualize the AT com- ponents, most of which assume a technology perspective. For example, some focus on the information flow within the home (Dard, 1996), others concen- trate on the technology itself (Barlow, Singh, Bayer, & Curry, 2007), and many emphasize the control and information available to the user (Kohler, 1997).

In Aldrich (2003), a hierarchical classification was proposed from the user perspective, which retains a focus on the functionality of the technology.

Various attainable levels of communication are highlighted and differentia- tion is affirmed between systems that can learn and those that cannot, and those that are constantly aware of users versus those that are not.

According to Mair and Whitten (2000), technological advances have brought about reduced ICT costs, together with devices that offer greater func- tionality and are easier to use. This growth of information technology has led to wide diffusion and application, thus increasing its economic and social impact (OECD, 2007), as well as relevance to health and social care.

Technologies for Chronic Disease Care

Within the realm of health care on the world stage, there are a number of sig- nificant challenges facing the human race, which cut across the socioeconomic, cultural, and spatial divides. One of the most pressing trends is the increase in deaths as a result of chronic diseases, which is projected to rise from 36 million in 2008 to 55 million in 2030 (WHO, 2012).

Chronic diseases as a classification include cardiovascular disease, meta- bolic diseases, cancers, injuries, neurological and psychological disorders (WHO, 2006), all of which are deemed to be an economic burden on both developed and developing nations. They contribute to death, illness, and dis- ability and are among the most prevalent, costly, and preventable health prob- lems. A United Nations report in 2007 suggested “ageing is accompanied by an epidemiological transition—that is to say, a shift—from the predominance of infectious diseases and high maternal and child mortality to that of non- communicable diseases, especially chronic ones” (UN, 2007).

It is estimated that 15 million people suffer a stroke in the world each year, of whom 5 million die and another 5 million become permanently disabled (Internet Stroke Center, 2015). Currently, approximately 382 million people

in the world are diabetic and it is expected to affect 592 million by 2035 (Diabetes UK, 2005). In addition, the prevalence of individuals living with dementia is also projected to increase. Alzheimer’s Disease International has predicted that by 2030, 75 million will have dementia, up from 46 million in 2015 (Alzheimer’s Society, 2015).

AT can play an important role in combating impacts of chronic disease on a person’s function, for example, by its ability to scrutinize personal care via two different approaches. Combining this with EAT provides an opportu- nity to mitigate against the impact of chronic disease. A preventive approach aims to utilize AT for the promotion of a more active lifestyle by addressing older persons’ needs so that they can enjoy a long and healthy life by sustain- ing an increased QoL at home. In addition, a more reactionary and compen- satory model can be adopted to ensure that signs and risk factors are detected early to facilitate timely treatment. Such interventions are excellent economic investments as they can remove the need for more expensive treatments in the future. When technology is used to support the remote management of chronic disease from the hospital to the home, we refer to this as “telehealth”

(see Chapter 13). To support the latter approach, telehealth coupled with the shift toward mHealth can play a substantial role in helping people manage and monitor risks factors such as weight, blood pressure, glucose levels, and heart rate. Monitoring these vital signs facilitates management of long-term health conditions such as chronic heart failure (CHF), chronic obstructive pulmonary disease (COPD), and diabetes. To support the former approach, AT can empower individuals, their families, and caregivers to undertake a more active lifestyle through an increased sense of security and peace of mind.

Around 2006, the paradigm shift toward self-management had started to evolve, which aims to empower individuals and offer greater control and free- dom for the management of their own conditions. Self-management research focuses on addressing the needs and wants of individuals in relation to their complex long-term conditions caused by, for example, stroke, COPD, demen- tia, Parkinson’s disease, diabetes, pain management, and other chronic con- ditions. At the onset of this paradigm, the complexity of needs in relation to a single chronic condition was so vast that research had to adopt a single approach for helping to reduce and manage it. With further research and understanding of each chronic condition in isolation, thoughts began to turn toward comorbidities, a term used when more than one disease or medical con- dition is diagnosed for the same individual. This research is presently push- ing the boundaries of knowledge within the self-management paradigm. For example, diabetes and hypertension are two conditions that can quite fre- quently co-occur. To help manage these conditions, individuals need dietary

restrictions and a physical activity increase, which individuals find most difficult. Therefore, the combination of diabetes and hypertension presents an overwhelming challenge to individuals, who manage two (or more) conditions, which is—in the vast majority of cases—quite demanding. The remainder of this central theme will focus on assimilating some of the broad trends in the key areas of telecare, telehealth, mobile health, and self-management where AT plays a central and influencing role.

Telecare

As the name suggests, telecare (TC) is the ability to provide care to individu- als at a distance with the overarching aim of improving QoL while maintain- ing an economic benefit that will be sustainable. TC, in its infancy, focused on the introduction of EAT, primarily in the form of sensors and actuators.

Initially the focus was on alarms and alerts, going to a remote monitoring station for assistance in instances of falls, floods, or fire. In a following evolu- tion, additional sensors were integrated to record both personal and environ- mental information within the home, while overall management and a home hub were connected to a centralized service to handle connectivity. Typical sensors can detect events such as falls, bed occupancy, activities of daily liv- ing, epileptic fits, fires, as well as water, smoke, or gas leaks. According to the Telecare Services Association (TSA) in the United Kingdom (UK), approxi- mately 1.7 million UK citizens relied on some form of TC to help protect, sup- port, and care for people in their own homes.

Personal alarms also fall under the umbrella of TC, capable of offering a personal security level that can provide a better QoL through increased peace of mind (see Chapter 14). The TSA reported how TC in general can result in this increased peace of mind for both individuals and their caregivers. A quotation from that report comments on an elderly gentleman living on his own, suffering from various conditions including dementia. In a letter, his son wrote:

Because sadly my father’s mental health is failing (on reflection extremely fast) the installer and the support sections are enabling my father to stay in his own home safely (which is what he wants), if he were to go into a “Home” I am sure his health would go down very fast and any self dignity he has would go. In fact I think it would kill him!

Traditionally, these kinds of pendant and fall detectors are designed to be functional and fit for purpose, often resulting in plastic cases with large red buttons adorned on their front to be ultimately hung around the neck of elderly

individuals: functional, but not aesthetically appealing. The stigma attached with wearing these devices often results in them not being employed. In addition, families are concerned that individuals are being identified as vul- nerable or stigmatized, which does not offer them the security and reassur- ance for which they are looking (see Chapter 16).

In reality, simple stand-alone devices can make a significant difference as to how care is provided for frail and vulnerable people at home. Consider, for example, caring for an elderly parent who is living with dementia for whom nocturnal wakening and wanting to get up and move around is common. This scenario presents risks to the individual and, indeed, often generates signifi- cant stress to caregivers. Using a pressure mat placed beside a caregiver and providing either an audible alarm or vibration, is a simple way to enable her or him to be attentive and yet relaxed enough to get restful sleep. It is clear from the introduction of more stylish devices that the need for these to become part of an individual’s everyday life is increasing. The chart in Figure 12.1 provides

Frail elderly 7%

Hypertension 5%

Asthma 3%

COPD 3%

Chronic back pain 1%

Dementia 1%

Arthritis 1%

Diabetes 31%

Heart disease 29%

Assorted 10%

Depression 9%

Figure 12.1 Types of telecare studies.

Source: Barlow, Singh, Bayer, and Curry (2007).

an overview of the range of pathologies that people who took part in TC stud- ies were living with; such research was conducted at the homes of frail elders who had long-term conditions.

Out of the 98 studies that were included in the review by Barlow et al.

(2007), diabetes and heart disease accounted for almost two thirds. Although this systematic review was conducted in 2007, it provides clear evidence that a significant range of chronic conditions such as dementia are not being prop- erly addressed. The report suggests that there is insufficient rigorous evi- dence about the impact of alert systems and fall detectors on individuals. While the majority of the studies were randomized control trials, they were often hampered by small sample sizes with a short follow-up period. In addition, most of them focused on diabetes and heart disease, providing less evidence on conditions such as hypertension, asthma, COPD, chronic back pain, and dementia.

Telecare Case Study

The Department of Health in the United Kingdom funded the Whole Systems Demonstrator (WSD) program to evaluate integrated care and to provide fur- ther insight into the effectiveness of TC and telehealth. A number of evalua- tion strands were conducted to examine the former, scrutinizing patients’

health-related quality of life (HRQoL), psychological outcomes, use of health and social care services, as well as cost-effectiveness (compare Chapter 13).

All participants (N = 889) within the intervention group received a Tunstall Lifeline Connect or Connect+ base unit and pendant/bracelet alarms along- side a selection of up to 27 peripherals, depending on their needs. The equip- ment was classified into four categories: (a) functional monitoring (e.g., fall detector or medication dispenser), (b) security monitoring (e.g., property exit sensor), (c) environmental monitoring (e.g., smoke or heat detector), and (d) stand-alone devices (e.g., key safe or big button phone). A needs assessment analysis was carried out for all individuals to determine which TC devices should be allocated to them. Complete data from the sensors and alarms were automatically sent to the monitoring center via telephone lines, which followed up on all alerts 24 hours per day by attempting to make contact with indi- viduals either via the base unit or by phone.

One of the evaluation strands examined the effect of TC on HRQoL, anxi- ety, and depressive symptoms over 12 months in patients who received social care (Hirani et al., 2014). This work found that TC has the potential for a small benefit toward or limiting the decline of HRQoL, as well as depressive symp- toms for older and social care populations.

Telehealth

The aim of telehealth is to facilitate the diagnosis, assessment, and monitoring of patients at home through the remote exchange of health data such as vital signs (see Chapter 13). Typically, telehealth involves the use of technology to monitor vital signs over a sustained period of time to help manage and control long-term conditions such as COPD, CHF, hypertension, and diabetes.

Within the UK, a WSD program has been set up by the Department of Health to investigate the potential of telehealth. One of their reports revealed that, if telehealth can be executed and delivered properly, the following ensues:

a substantial mortality and hospital admissions reduction, as well as a decrease in the number of bed days and less time spent in cases of accidents or emer- gencies. The study took place across 179 general practices in three areas of England and involved 3,230 people with diabetes, COPD, or heart failure between May 2008 and November 2009 (Steventon et al., 2012). Across the three sites, there was no attempt made to standardize the telehealth equip- ment used as the focus of the study to determine or examine any differences between specific devices or monitoring systems. Although each site used dif- ferent protocols to allocate the telehealth peripheral equipment, they all made use of pulse oximeters for COPD, a glucometer for diabetes, and weight scales for heart failure. All participants were also provided with a blood pressure monitor.

Participants were asked to take clinical readings from these devices on a daily basis. In addition to telemonitoring, a set-top box connected to their television was used to provide educational messages and, subsequently, symp- toms were assessed through a questionnaire. At the end of each session, clini- cal readings from devices and the symptoms questionnaires were securely uploaded to a monitoring center, each staffed with specialist nurses and community matrons who had been trained to respond using protocols that acted upon the information uploaded by patients. The outcome of the study highlighted that introducing a broad class of telehealth technologies could be associated with a reduction in mortality rates and emergency hospital admission. In addition, there was a significant reduction in hospital bed days for telehealth intervention patients, which was reflected by the overall reduced admission rates. Another study part of the WSD program aimed to assess the effect of home-based telehealth on health-related QoL, anxiety, and depressive symptoms over 12 months in patients with long-term conditions (Cartwright et al., 2013). The participants were patients with COPD, diabetes, or CHF, as it is has well been documented that in these conditions, health-related QoL is reduced, as well as anxiety and depression elevated (Ferrer et al., 1997;

Glasgow, Ruggiero, Eakin, Dryfoos, & Chobanian, 1997; Heo, Moser, Lennie,

Zarnbroski, & Chung, 2007; Konstam, Moser, & De Jong, 2005; Lloyd, Dyer, &

Barnett, 2000; Mikkelsen, Middelboe, Pisinger, & Stage, 2004; Peyrot & Rubin, 1997; Putman-Casdorph & McCrone, 2009; Rutledge, Reis, Linke, Greenberg, &

Mills, 2006).

The sample included subgroups of patients with comorbidities of at least two of three long-term conditions to facilitate further disease-specific analy- sis. Participants were allocated up to four telehealth peripheral monitoring devices, depending on their known diagnosis of COPD, diabetes, and heart failure. Additionally, local protocols played a role in this distribution of the devices, which consisted of the following: a pulse oximeter for COPD, a glu- cometer for diabetes, and weight scales for CHF. Blood pressure monitors were also given to most patients, regardless of their long-term condition. The study ran over a 12-month period, assessing the participants’ QoL psychological outcomes, and it found that the introduction of telehealth did not demonstrate improvements in relation to usual care. However, concerns that telehealth is contributing to a potentially harmful effect are completely unfounded for the majority of patients. In addition to this study, another one aimed to assess the cost-effectiveness of telehealth for patients with long-term conditions. The cost of telehealth was higher than that of usual care, but the QoL gains were simi- lar to those for patients receiving usual care. Therefore, it seems that the introduction of telehealth for long-term conditions is, at the time of this writ- ing, not cost-effective.

Assistive Technology Case Studies

The following section details some ongoing research within the AT area and looks at a number of case studies.

The first case study scrutinized the use of smart home technology (see also Chapter 11) by ambient sensors and how such data could be collected, stored, and analyzed to infer information about clinically validated health met- rics (Walsh, Kealy, Loane, Doyle, & Bond, 2014). A total of 16 smart homes were built to accommodate over 100 ambient sensors and actuators in each apart- ment. These were not simulated living environments, but real permanent homes. The sensors included passive infrared (PIR) ones that trigger upon move- ment, contact sensors that notify when a door opens, light switch sensors, water and electricity sensors, brightness and temperature sensors.

Looking at data from four different 28-day periods and standard health questionnaires to assess anxiety, sleep quality, depression, loneliness, cogni- tion, QoL, and independent living skills, the following was found: Sensor data provided information about light switch firing, number of transitions within the home, nocturnal movement, and length of time spent in any particular

room. There were a number of significant correlations between these sensory measures and the health questionnaire scores. For example, the number of light switch firings was positively associated with anxiety, which suggests restlessness and—as a result—turning the light switches on and off more fre- quently. Another feature that correlated highly was spending more time in the living room, which was related to increased loneliness. Interventions may be triggered when a particular condition such as elevated loneliness levels has been detected. For example, the system could prompt the resident with a mes- sage, suggesting to call a friend or directly inform him or her that the resident may be lonely above a “normal” extent.

A second case study focused on a particular cohort of elderly patients who had mild to moderate levels of dementia (Boyd et al., 2014). Its main objective was to design and develop a video link system by involving elders in a user- centered design process. A number of focus groups consisting of people with dementia, their caregivers, and professionals were held, which resulted in four designs aimed to be intuitive and familiar. The first was a touch-screen com- puter with a microphone and speakers, and the second replaced the micro- phone and speakers with a traditional phone handset. The third solution was in the form of a physical window complete with a real frame and curtains behind which there was a screen; these tangible items provided a mechanism to control sound and vision. The fourth and final concept was based on a television model with a screen that would interrupt a normal TV program when there was an incoming call.

The third case study looked at decoupling existing AT software from everyday microprocessor-controlled systems such as computers, smartphones, and tablets (Mulfari, Celesti, Fazio, Villari, & Puliafito, 2014). The platform allowed users with disabilities to interact with AT devices and software and it enabled them to control an everyday computer system. The system was based on a hardware platform that uses the human interface device (HID) protocol to map input for supporting the control of a traditional mouse and/or keyboard.

A prime example is the use of voice recognition software, running on a mobile device, to recognize and map voice commands on mouse actions such as left, right, up, down, and click.

Wearable Technology

Advances in miniaturization and processing power of computing devices have accelerated the introduction of wearable technology. This market has huge potential and could span the entire EAT sector as it offers the possibility to alter the form factor of every such device on the market to become more inte- grated, including everyday objects such as clothes and jewelry. The research

and retail market is so vast that even the area of robotics has already become partially “wearable,” which is a significant focus producing solutions for the health and fitness market niches. However, there is a lot of cutting-edge research directed toward some of the most vulnerable groups in society, such as those suffering from a spinal cord injury (SCI). The following case study looks at the safety and feasibility of using a bionic exoskeleton to help aid ambulation after an SCI.

Wearable Case Study

A traumatic event such as an SCI most often leaves those affected with the sudden inability to walk. Recovery of walking becomes a top priority as it affects independence and QoL. There are several wearable mobile exoskele- tons; these include Ekso™, HAL™ (Hybrid Assistive Limb Robot), ReWalk™, and Rex™. These systems offer individuals the ability to stand upright and make technologically assisted steps, although all of them require the user to have at least some upper extremity function. The exoskeleton suit from Ekso (Figure 12.2) can be donned in 5 minutes and weighs 50 pounds, although

Figure 12.2 Ekso exoskeleton bionic suit.

Source: Reproduced with the permission of Ekso Bionics, Copyright 2015.

the wearer is not supporting its weight. The system employs a number of different modes such as FirstStep, ActiveStep, and ProStep. The FirstStep mode is controlled by the therapist and actuates the step by pressing a but- ton; this is often used in the first session with the user, progressing from sit-to-stand, then walking, and—finally—the use of crutches. The ActiveStep mode allows the user to take direct control of his or her steps via control but- tons built into a walker frame or crutches. Lastly, the ProStep mode allows a follow-up of the steps, achieved through the user’s forward and lateral hip movements.

The following theme blends in with the transition to wearable robotics by focusing directly on robotics for older adults.

Robotic Assistive Technology

Robots are occupying a bigger part of our daily lives (Sakurai, 2007). These are generally defined as machines capable of carrying out a complex action series automatically, especially those programmable by a computer (e.g., ISO, 2012).

Biomimetics is the imitation of models, systems, and elements within nature to assist in solving otherwise more complex human problems. The design and development of robotics follows this nature-inspired philosophy and has led to robots often mimicking human movement and other functions. The follow- ing are also regarded as types of robots: devices that require human operation but look like human beings, powered suits, or exoskeletons, and even com- puter programs or software applications that accomplish complex series of tasks by automation (Yamada, 2007).

Robots were traditionally used for production and manufacturing pur- poses. They were often found in factories or assembly lines and did not extend to assisting individuals at home in their daily lives. Since then, robots have been adapted over time to become more prevalent in various forms, particu- larly to compensate for the lack of human resources at home environments.

Among the most popular applications are cleaning robots, while others offer companionship and communication functionality. Expected benefits would be to reduce the loneliness of older adults who are living alone and, also, to provide a level of security, as well as monitoring.

Another important area focuses on research and development for nursing care robots, which is increasing due to population aging, pressure on caregiv- ers, and the demand on health care systems. This is evidenced by the prevail- ing support for their development, provided by departments such as the Japanese Ministry of Economy, Trade and Industry, and the Ministry of Health, Labour and Welfare. Nursing care robots can be classified into those that

provide help for caregivers to support care recipients, and those that promote communication and/or a level of monitoring security to those being cared for (Wada, Takasawa, & Shibata, 2014). The following paragraphs provide an over- view of these types of nursing care robots.

One of the most difficult tasks in nursing care is moving the patient from the bed to a wheelchair and back again. It frequently causes back problems for the helper and, in the worst case, can lead to time off work or even job loss because of handicaps incurred by the care given that strained the caregiver’s physique. With the assistance of transfer robots, such problems can be avoided.

In 2014, the costs and operation difficulties prevented their introduction into regular nursing care settings. In addition, there are other factors such as the time needed to complete a task, which can often take longer as compared to human caregivers. Any kind of transfer or lift can be uncomfortable for care receivers and may enhance fear levels. However, transfer robots’ perfor- mance is being improved. For instance, the prototype transfer robot RIBA employs silicon rubber on the parts that are in direct contact with the care receivers, and tactile sensors give feedback to operators (Mukai, Hirano, Nakashima, Sakaida, & Guo, 2014). The robots’ movement is adjusted to reduce uncomfortable swings as much as possible, which helps to make oper- ation easier.

In Japan, there is a common belief held by caregivers that care is better delivered by humans than by robots. If we consider emotional elements such as reassurance and genuine warmth of care to be important during tasks, then it is reasonable to assume that it really is only humans who can deliver this level of care (Beppu & Fukuda, 2008). However, when thinking that safety and functionality can be just as or even more important, which is the case for many patients, then robots can offer a more consistent and safe transfer. A hybrid solution would be to combine both elements of human and robotic care into one entity. This can be achieved through robotic suits that increase care- givers’ control and power to overcome time-consuming problems while reduc- ing fear on the part of the patient. The exoskeletons described previously are used mainly for the rehabilitation of patients, but they are becoming more common as a support mechanism for caregivers (Sankai, 2011).

In order to protect caregivers from back problems, there are regulations put in place to restrict or avoid any manual lifting. Countries such as Australia and Denmark employ such policies (ANF, 2012), but these are expanding to other countries as well, which makes the role of transfer robots more significant.

Another key area that requires support is meal times, where robots can also provide assistance. Typically, the patient may be able to operate a joystick

or a large button to pick up a meal and to move a spoon of food to the mouth.

Another meal assistance robot can be operated by face movements and employs chopsticks (Yamazaki, Fukushima, & Masuda, 2012).

Some robotic AT offers support in communication and monitoring. A famous example of a robot in this field is called Paro, a seal robot that promotes social interaction by reacting to human beings differently with the help of vari- ous sensors and artificial intelligence. Such “emotional” reactions can soothe users in times of distress; its effectiveness has been experimentally validated and, as a result, many nursing homes are now using Paro (Wada, Shibata, Musha, & Kimura, 2008).

Robotics bear the possibility to aid older adults’ daily lives in various ways. It is important to determine which part or function for an older person should be assisted; too much may lead to disuse of human functions. It is pre- ferred to support areas of declining functionality and to maintain remaining functions, with careful thought given to where assistive technologies can be optimally applied. Assistive technologies should decrease burden, making both care recipients and caregivers happy. The European Commission has a track record of funding innovative research into novel technologies for home- based health care that will support people at home. Within the FP7 (Framework Programme 7) and Horizon 2020, there are examples of attempts to integrate devices and create multimodal adaptive systems either to serve the fluctuating needs of a single individual or to enable system and services access for a wide range of people. A current example includes the AIDE project (www .aidepro ject.eu), which has the ambition to offer exoskeletons and robotic arms to end users living with neurological problems. In an attempt to offer inclusive sys- tems, many modes of activation are being offered, for example, using electro- myography or brain–computer interfaces that gather brain waves to evoke a system response.

A central challenge is scaling up assistive technologies. For instance, the implementation and diffusion of TC/telehealth still fall behind the expecta- tions of policymakers and developers—especially in the European Union (Wherton et al., 2015). Although several European and national programs promote the research and development of innovative solutions, products and services have not yet been elevated in quality. The reasons for this lack of proliferation are complex and many different barriers hinder the diffu- sion of innovative approaches. Considering the EU, several studies (Broens et al., 2007; Merkel & Enste, 2015; Reginatto, 2012) have tried to categorize barriers into different domains, including technical (e.g., missing support, usability issues), economic (e.g., missing reimbursement), and organizational ones (e.g., lack of leadership), as well as acceptance barriers and challenges related to the outer context (policy and legislation frameworks).

CONCLUSIONS

In this chapter, the area of AT has been explored within the context of care of older people. AT is a broad area. We focused more on advanced electronic AT. Currently, such EATs are used to support people suffering from multiple chronic diseases and they offer support in the daily management of long-term care needs arising from diseases. There is a degree of overlap with TC and telehealth, which is increasing as communication technologies offer new and lower cost methods of bringing together services for older people, under- pinned by assistive technologies.

This chapter also presented several case studies, some in ATs generally, with two specific case studies: one in TC and one in wearable assistive tech- nologies. The final sections presented new areas of work in assistive tech- nologies, including the rapidly growing fields of wearable technologies and robotic assistive technologies.

In terms of technologies’ capabilities to support older people for the man- agement of their long-term care conditions, AT has evolved a great deal from its origins in home alarm technology. The home-based AT infrastructure offers care support, specifically designed for catering to the care of older people with specific diseases and comorbidities, by augmenting memory and physical capa- bility and by connecting individuals to their social circles.

In view of gerontechnology as a discipline—and the scope of this book—

it has become clear that AT plays a central part. This is underlined by the fact that different chapters, at least to some extent, refer to different assistive devices. This includes Chapter 4 on intra- and intergenerational contexts of aging written by Huber et al.; Chapter 13 on telehealth by Charness; Chapter 17, focusing on health promotion and disease prevention by McCallum, Agree, and Coppola; and Chapter 18, written by Schmidt, Claßen, and Wahl, which deals with the possibilities of technology in supporting persons with cogni- tive impairments.

Recommendations

In addition, we can offer some recommendations for both researchers and practitioners. The motivation for this is that AT has to reach a broad audience to truly unfold its potential. As shown, there are many barriers that negatively affect AT’s scaling-up that need to be tackled. Involved actors do not only have to be aware of technical and financial challenges, but also of regulative restrictions and—arguably most important—devices need to be adopted and used by the end users (primary and secondary). As described in Chapter 16 of this book, technology acceptance cannot be taken for granted, as it is

influenced by several factors. A strong facilitator for adoption is the potential benefit of AT or, in other words, its positive impact on QoL. Cost-effectiveness is also of particular relevance. Therefore, it is a central challenge to demon- strate that AT not only helps people, but that it can also lead to a significant reduction of individual as well as societal costs. Otherwise, older individuals or others involved in aiding them will not be reimbursed by health and care insurances, and thus, AT may not be implemented by organizations (e.g., nursing homes). Therefore, we advise that a strong focus be laid on sound empirical evidence, the development of evaluation models, and approaches covering all of the aspects mentioned previously.

The examples of case studies given in this chapter underline the fact that user-centered design processes are an important aspect of AT development.

Different methods of user integration, such as focus groups (for an opposing view, see Chapter 6) involving people with dementia, their caregivers, and professional staff, help to (a) better understand the needs of the target group, (b) avoid at least some of the previously mentioned barriers, and (c) raise awareness of new products.

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