Smart technologies driving open design

The concept of an open and safe residential care facility is becoming a reality thanks to the emergence of new technologies – but there are several considerations, writes Dr Darragh O’Brien.

In a rapidly evolving consumer-led system, aged care facilities face the challenge of balancing a resident’s safety with their desire for autonomy. Before getting carried away with complex support systems, it is worth remembering that the primary purpose of technology is to help maintain our independence, for as long as possible.

Emerging technologies can potentially help with achieving this balance, through the creation of more supportive care environments—but only in the context of an advanced care planning process that respects and accommodates individual choice, wherever possible.

In one research project, undertaken by Canadian health scientist, Dr Elaine Wiersma, in 2008, we glimpse the potential importance of a supportive environment, particularly for people with dementia.

Having embedded herself in the secure cognitive support unit of a veteran’s hospital for four months, Dr Wiersma examined how a change of place might affect residents and staff, when they moved to a lake-side summer camp setting. All of the participating residents had some form of dementia.

For many of the residents the most common interpretation of the care facility was that it was restrictive. One resident, Ed, had some strong feelings about his experience of confinement:

“The only thing is, you can’t get out when you want to. That’s the only thing. Otherwise, it’s perfectly, I mean, your doors are locked, and you’re imprisoned, more or less, can’t say there’s anything I dislike. Anything I dislike is you can’t get out when you want to unless you have an escort with you. And then you can only go out on the grounds and the escort has to be with you all the time.”

Despite his confusion, another resident, Michael, was even more eloquent about his experience of being confined in the facility:

Dr Wiersma: Is there anything you dislike about this place?
Michael: It’s confining aspect.
Dr Wiersma: How is it confining?
Michael: Just look around you right now. How many walls do you see?

At the summer camp, as might be expected, the absence of locked doors was recognised by residents as liberating. However, the way in which this new sense of freedom immediately affected the quality of life of both residents and staff was more remarkable. When reminiscing in the institution, residents focused on work, duty and other non-personal topics. At the camp, reminiscing dramatically shifted to focus on family, childhood experiences, and other types of personal and emotional experience, revealing much more about who the residents were.

In the long-term care facility, relationships between staff and residents were seen as functional and staff members were focused on solving problems and completing tasks. In contrast, at the summer camp, these relationships became more positive and supportive, characterised by equality, personal interactions and attention, reciprocity, and trust. Despite initial concerns about the apparent hazards of an open environment, staff eventually reported they felt less stressed that they did in the secure unit. As a consequence of this research, the care facility made changes to the way in which they delivered their structured leisure programs, enabling residents to make choices that suited them at a given moment in time.

Dr Wiersma argues that place is not only physical, it is deeply connected to our sense of self. Accordingly, place incorporates the social environment as well as the physical. Although limited in scope, this study is not alone in pointing out the benefits of more open environments for both residents and staff alike.

Until recently, the concept of an open – and equally safe – residential care facility has not been possible, but with the emergence of new location-based technologies, that idea is now becoming a reality.

“Smart” technologies

The concept of the “smart home” refers to residential settings where technology is embedded in the physical infrastructure, facilitating passive monitoring of residents without the need for individuals to learn how to operate a device. Such monitoring allows for the remote observation of daily living and mobility patterns, highlighting unusual activities or events and triggering an intervention to avoid potentially adverse events.

Smart systems primarily utilise sensor technologies—the most common being motion, pressure and heat sensors, sensors detecting electricity and water consumption but also restlessness in bed or respiration. These “fixed” technologies are already being used in residential care facilities around the world.

However, new “wearable” technologies have begun to emerge that could revolutionise the aged care sector. Some of these devices have been designed for use in healthcare, but others come from the gaming industry. As a result, we now have the capacity to monitor a resident’s location, speed, direction, gait and their vital signs—to the point that care givers will not always need a direct line of sight. A resident can move more freely through a facility and out into a secure garden area—the benefits of which are well documented. If there is an event that requires attention, then care givers can receive an automatic notification, indicating the severity of that event and the amount of attention required.

As these technologies become more widespread, they will have a significant impact on the layout of residential care facilities, potentially allowing more open and flexible environments for residents to move through. A person’s level of access could be managed based on the needs and capabilities of each resident. With wearable, gesture-based systems, staff or residents could control doors, TV, heating, lighting and even noise levels, with a wave of their hand, eliminating the need for more complex remote control mechanisms. Previously internalised, secure units could open onto shared gardens and even to other units. An individual with moderate dementia, would not as restricted by the limitations of a system designed for those at a more severe stage of the disease.

Although yet to be embraced in Australia, numerous smart home initiatives have been trialled in the US and Europe, not only as academic research but as business models for retirement communities and assisted living facilities. One of the earliest initiatives was the Aware Home at the Georgia Institute of Technology, which explored technologies that sense and identify potential crises, assist a senior adult’s memory and track behavioral trends.

Elsewhere, researchers from the UK, Ireland, Finland, Lithuania and Norway combined their efforts for the ENABLE project, which promoted the wellbeing of people with early dementia with several features such as a locator for lost objects, a temperature monitor and an automatic bedroom light.

Similarly, in the US state of Missouri, an independent living environment called TigerPlace was built in 2004 as a special facility where residents could age in place, with care provided by a collaborating home care agency with registered nurse care coordination services on site. Motion, heat and bed sensors, gait monitors and traditional telehealth monitoring devices are used in the individual apartments to monitor residents’ well-being over time.

Finally, as part of the HEALTH-E (Home based Environmental and Assisted Living Technologies for Healthy Elders) project at the University of Washington, researchers installed various sensor technologies in apartments of older adults who live in retirement communities in Seattle. The technologies include regular motion sensors to detect how one moves from one room to another, or within a room.

Other features, such as electricity sensors that can detect electricity consumption by electricity source and water sensors that detect water consumption by water source, allow the detection of activities including meal preparation or bathroom visits with the level of detail that simple motion sensors cannot provide. The comprehensive information generated by these types of sensors enable the assessment of overall mobility and activity level in the home. Additionally the integration of door sensors can provide information on visitors and time spent outside the home.

Complex data analysis and pattern recognition techniques allow not only the detection of activities but also potential changes over time calling for a timely intervention.

Indeed the HEALTH-E project identified several cases where the technology was proven helpful. One case included the detection of urinary tract infection as was manifested by a significant increase in bathroom visits during the night. Another example included a resident who showed increased sedentary behaviour during the day with increased time in bed in the morning and afternoon. The resident decided to share the data with her healthcare provider and this led to an adjustment in her medication plan.

Overall, participants had no concerns about privacy and indicated they quickly forgot the sensors were installed in their homes. None of the participants withdrew from the study, and during regular periodic interviews participants expressed no concerns for privacy or confidentiality, they did however emphasise that they would like to choose with whom they share data generated from the smart home system.

Important considerations

The successful adoption of smart home technology depends to a large extent on older adult’s acceptance of the concept. It is often assumed that systems capturing detailed information about one’s daily activities may not be welcome due to privacy concerns; yet research shows that older adults can embrace “smart” technologies when they see a purpose and need. Some studies indicate a willingness to compromise certain levels of privacy, in order to gain support for personal independence. Even a device that is considered by family members to be intrusive is likely to be accepted by an older adult if they viewed it as necessary to support a need.

The research and development agenda for smart technologies must include ethical considerations for their design and implementation.

There are legitimate concerns that smart technologies may result in a reduction of social interaction, or may provide tools that substitute for personal forms of care and communication. However, in the case of residential care facilities, the use of monitoring technology may encourage social interaction within that communal setting, because of the potential liberty that comes with it.

The extent to which smart technologies lessen the sense of personal responsibility on the part of the residents or their caregivers must also be weighed against real or perceived benefits. It is possible that caregivers may become less vigilant in monitoring health changes in the people they are responsible for.

Likewise, issues of individual freedom, personal autonomy, informed consent, and confidentiality have to be examined in the context of the target population. For residents with schizophrenia—a condition that causes distortion of reality in the form of delusions of persecution—surveillance technologies may exacerbate such symptoms. Similarly, while passive monitoring may be most beneficial for people with dementia or other cognitive limitations to ensure their well-being and monitor wandering or other accidents, often the decision for this intense monitoring is made by a relative or friend who has decisional authority.

The diffusion of smart home technologies calls for effective advance care planning that involves the older person from day one, particularly in the early stages of dementia. In these cases, tracking technologies may function as cognitive support systems to prolong independence in the setting of their choice. As the field evolves, it becomes apparent that while earlier applications focused on extensive monitoring of residents—where the results became available to healthcare providers only—recent trends pursue a more patient empowering approach as systems allow older adults to be in charge of the frequency and terms of monitoring, and to determine who has access to the resulting data. The inclusion of family members in these processes introduces new roles and dimensions for distant caregiving.

The concept of digitally augmented homes in the context of healthcare is relatively new and requires further research to address important questions, including those of health outcomes, clinical algorithms to indicate potential health problems, user perceptions and acceptance, and ethical implications. Although technological advances may support ageing and promote quality of life for older adults, we need to ensure that the design and implementation of such applications are not determined simply by technological advances but by the actual needs of older adults and their families.

Dr Darragh O’Brien is director of Architectural Research Consultancy. This article draws on research by Dr O’Brien and Professor George Demiris, first published in The Evidence Based Design Journal.