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Environmental Design and Assistive Technologies

JULIE A. BROWN

GRAHAM D. ROWLES

AMBER S. MCILWAIN

INTRODUCTION

Long-term care is provided at a variety of levels and in physical settings that include neighborhoods and communities, individual residences, housing for elderly persons, assisted living facilities, skilled nursing facilities, rehabilitation environments, adult day centers, and comprehensive continuing-care communities. These environments provide a continuum of more or less supportive living situations. With the emergence of environmental gerontology over the past three decades (Scheidt & Windley, 2006; Wahl & Weisman, 2003) and the growth of gerontechnology (the study of older adult use and interaction with technology; Bouma, Fozard, & van Bronswijk, 2009), it has become increasingly apparent that the design of living environments and the use of assistive technologies is strongly related to individual well-being and the ability to age in place (sustain residence in a specific location while experiencing changes associated with aging).

The majority of people prefer to age in place (Callahan, 1992; Greenfield, 2012; Pynoos, 1990; Rowles, 1993), but with advancing age and declining physical and sensory capabilities, it becomes difficult for many people to maintain themselves in accustomed surroundings. There are two responses to this situation. One is to move to a more supportive setting; often this is accompanied by considerable stress. A sizable literature exists, dating back more than half a century, which details the increased morbidity and mortality that can result from involuntary relocation (Aldrich & Mendkoff, 1963; Danermark, Ekstrom, & Bodin, 1996). There is also a growing literature on the stresses involved in having to give up possessions accumulated over a lifetime in order to move into a smaller and more manageable environment (Ekerdt, Luborsky, & Lysack, 2011; Ekerdt, Sergeant, Dingle, & Bowen, 2004). A second option is to delay the need to move through supportive environmental design (the physical configuration of built environments) and the use of AT (Freedman, Agree, Martin, & Cornman, 2005; McCreadie & Tinker, 2005). This chapter focuses on such strategies as approaches to facilitating long-term care in familiar settings.

THEORETICAL PERSPECTIVE

A long history of research, stemming from Kurt Lewin’s classic “equation,” B = f (P, E) framing the person–environment relationship, provides a theoretical context for considering the role of environmental design and the use of AT in long-term care (Lewin, 1935). Lewin argued that behavior (B) is a function of the evolving relationship between person (P) and environment (E). In gerontology, a series of theoretical perspectives was developed on the basis of this fundamental proposition (Kahana, 1982; Lawton & Nahemow, 1973; Pastalan, 1970). It was suggested that the physical and social environment shapes the behavior of the individual. In turn, each individual modifies his or her environment, creating a continual transactional process of person → environment → person → environment feedback. In recent years, acknowledgment that the separation of person from environment is somewhat artificial has led to transactional perspectives that emphasize the intimate reciprocity of the relationship and the arbitrariness of the separation (Cutchin, 2004; Dickie, Cutchin, & Humphrey, 2006).

The best-known perspective is the ecological model (Figure 8.1; Lawton & Nahemow, 1973). Lawton and Nahemow conceptualized the person–environment relationship within a needs/press framework. A person’s needs were expressed in terms of his or her level of physiological and psychological competence; for example, physical strength and flexibility and cognitive ability to climb stairs. The environment was considered in terms of the amount of press it exerted; for example, the presence of physical barriers, such as stairs, and context-related challenges to successfully meeting needs. Lawton and Nahemow argued that there was an adaptation level that reflected balance between a given level of competence and level of press. Lawton and Nahemow suggested that a situation of complete adaptation was not necessarily optimal for the individual, as it provided no stimulation or challenge. Their model identified a zone of maximum performance potential for each level of competence (represented by the dark shaded area in Figure 8.1). The lower the individual’s competence, the less environmental press can be tolerated by that individual without maladaptive or negative consequences.

FIGURE 8.1 Lawton and Nahemow’s ecological model.

The ecological model provides a framework in which the trajectory of each individual’s situation with respect to long-term care can be characterized within four interwoven dimensions: (a) personal competence, (b) environmental press, (c) adaptation (personal accommodation or environmental modification), and (d) relocation. These dimensions can be considered on multiple scales and in many different environments. Here, the focus is on neighborhood planning, environmental design, and AT in allowing older adults to sustain the highest possible adaptation level.

HISTORICAL CONTEXT

Enhancing the quality of living environments through environmental design and technology is not new. Our cave-dwelling ancestors almost certainly modified their immediate surroundings to maximize their comfort and safety. Throughout history, the design of communities, neighborhoods, and residences has constantly evolved in relation to local climatic conditions, terrain, perceived comfort needs of inhabitants, and local culture (Rapoport, 1990).

Optimal planning of communities and the design of accessible and people-friendly neighborhoods and residences received a boost in the early 20th century with the emergence of town planning. In 1917, the American City Planning Institute was incorporated (renamed the American Institute of Planners in 1939), and in 1934 the American Society of Planning Officials was incorporated. These organizations thrived during an era of urban renewal and new town planning (Gans, 1968; Osborn & Whittick, 1970; Wilson, 1966) and merged in 1978 to form the American Planning Association.

Focus on a smaller, more local, and intimate scale and concern with the design of individual residences was boosted in the post-World War II era through a growing environmental design movement. This movement came together with the development of environmental psychology as a discipline in the 1970s, the emergence of organizations such as the Environmental Design Research Association, founded in 1968, and the initial publications of the scientific journals Environment and Behavior, first issue published in 1969, and the Journal of Environmental Psychology, first issue published in 1981.

Growing sophistication of community planning and environmental design (in parallel with increasing recognition of the needs of an aging population) stimulated interest in environmental design for older adults. Concern with providing special housing options resulted in federal intervention and an era, spanning the 1950s through the 1970s, of construction of age-segregated housing. Much of this housing was developed in the inner city on space vacated by urban renewal. High-rise residential complexes, such as Victoria Plaza in San Antonio, Texas, the subject of Frances Carp’s seminal treatise, became major features of the urban landscape (Carp, 1972; Jephcott, 1971).

There was also increased interest in the way individual dwellings were designed to accommodate the special needs of older adults. This focus resulted in a corpus of knowledge on the construction or adaptation of residences to accommodate the declining physical capabilities of older adults (Lawton, Newcomer, & Byerts, 1976; Regnier, 2003; Regnier & Pynoos, 1987). Simple modifications, such as ensuring that shelves are low enough for older adults to reach without fear of falling, that window sills facilitate easy visual access to the outside by persons in a wheelchair, that door knobs are replaced by levers, and that supportive rails are provided to minimize the risk of falls, have been supplemented by increasingly sophisticated design strategies, including universal design and smart homes (Fisk, 2001; Sanford, 2012; Story, 1998). Many of these innovations enable older adults to age in place far longer than might otherwise be the case. Published guidelines for environmental safety in the home by organizations such as AARP have been accompanied by the formation of companies that provide home environmental assessments; for example, Eval-U-Safe, a company based in Louisville, Kentucky, offers a three-step comprehensive evaluation to help make home environments safer and more comfortable for residents.

THE ROLE OF COMMUNITY ENVIRONMENTS IN FACILITATING LONG-TERM CARE

Designing, building, and maintaining age-friendly environments is central to addressing the needs, challenges, and preferences of an aging and/or disabled population. In this section, we examine elements of environmental design as a resource for making the environmental setting an implicit component of long-term care through the support it provides to maintaining independence.

AGE-FRIENDLY COMMUNITIES

Enabling older adults and persons with disabilities to successfully age in place in community settings is no easy task. A range of environmental barriers limit the ability of those who are frail to remain engaged in their communities; such barriers reinforce segregation and exclusion. The possibility of social isolation, especially for older adults and persons with disabilities who live alone, can be increased by the lack of access to the exterior environment and is linked to poor health, decreased life quality and well-being, and even mortality. Common barriers include a lack of appropriately sited and designed affordable housing options, poor physical access to resources and services, and inadequate mobility alternatives, including public transportation and well-maintained sidewalks. The timing brevity of many “Walk”/“Don’t Walk” signs, difficulties with escalators, doors to public buildings that require Herculean strength to open, the prevalence of unnecessary steps and high curbs, long distances that must be negotiated in airports, and the cognitively overloaded environments of shopping malls are also well-known barriers. Comprehensive community planning and age-friendly design can remove such barriers (Kochera & Bright, 2006). With the adoption of aging in place as a public policy goal, “governments and international organizations now agree that supporting older people to continue to live in the community for as long as possible makes both economic and social sense” (Lui, Everingham, Warburton, Cuthill, & Bartlett, 2009, p. 116).

Age-friendly communities (sometimes called “livable communities”) improve the lives of community-dwelling older adults. A growing literature on age-friendly communities (enabling and supportive community environments for all age groups and abilities) suggests that communities should have adequate and affordable housing options for all residents and should include a variety of senior apartments, assisted living alternatives, and quality skilled nursing facilities that facilitate aging in place in a familiar neighborhood (Alley, Liebig, Pynoos, Banergee, & Hee Choi, 2007; Pynoos, Caraviello, & Cicero, 2009). There should be options for downsizing by moving into smaller accommodations or care facilities within familiar communities of residence. Age-friendly communities should be accessible through the provision of older adult-friendly transportation options, well-placed and well-designed sidewalks, sufficient handicapped parking, and easily accessible health and social services resources. Indeed, cities should provide additional supportive services to neighborhoods with high densities of older adults, such as naturally occurring retirement communities (NORCs).

In their review of different characteristics of age-friendly communities, Lui et al. (2009) discuss integration of the physical and social environment through policies, structures, and services intended to develop environments that meet the challenges and needs of older adult and disabled populations (Table 8.1). A survey conducted by AARP Public Policy Institute asked community-dwelling respondents to grade their communities on a number of features and opportunities (AARP, 2003). Respondents most often gave poor grades for dependable public transportation, nearby grocery stores and drugstores, available entertainment opportunities, and well-planned sidewalks. Communities were also marked down if they lacked community hospitals, affordable housing, and sufficient variety in housing options (AARP, 2003). A livable community would, therefore, have affordable and appropriate housing, supportive community features and services, and sufficient mobility options—all of which would work together to facilitate the independence and civic and social engagement of older adults (Kochera & Bright, 2006).

TABLE 8.1 Key Features of an Age-Friendly Community

The World Health Organization defines an age-friendly city as an inclusive and accessible urban environment that promotes active aging and has developed an extensive guide that cities can use to evaluate their age friendliness, plan for age-friendly community development, and track progress as changes are implemented (World Health Organization, 2007a, 2007b; see also, Chapter 1). New York City was the first city to be certified by the WHO as age friendly and it serves as a model for other cities, both nationally and internationally. As part of New York’s age-friendly initiative, approximately 1,000 benches were proposed to be installed at bus stops and in commercial districts and neighborhoods with high concentrations of older adults. The goal was to reinvigorate the city’s sidewalks, making the city more walkable and livable for its older citizens (Mays, 2011). Other city initiatives include improving the reliability of elevator and escalator service to increase accessibility to subway stations, installing public restrooms at key citywide locations, redesigning major street intersections to boost crossing safety for older pedestrians, and providing bus service for easier access to grocery stores (Age-Friendly NYC, 2011).

Community Facilities

Key elements of age-friendly communities that are supportive of long-term care are the community facilities they sustain. Support resources, such as senior centers and adult day service centers, are increasingly essential features of community-based long-term care (see Chapter 7). A senior center is a place where older adults in a community can gather for physical activities, socialization, and a wide array of medical and social services (Pardasani, Sporre, & Thompson, 2009). Senior centers help many older adults remain engaged in their communities while interacting as part of a community. Adult day centers provide social and health services to adults in need of supervised day care outside of the home environment. In the United States, adult day centers have been promoted by the National Adult Day Services Association as “a viable community-based care option for people with disabilities within the larger constellation of long-term care services” (www.nadsa.org). Senior centers and adult day centers cater to individuals with different needs and requirements. Senior centers target older adults who want to remain engaged, whereas adult day service centers provide care for adults with functional impairments who require supervised care.

Flexibility is fundamental to both senior center and adult day service center design. In particular, the need for design that is responsive to the needs of different age cohorts with diverse capabilities and expectations has resulted in a transformation of the design and functionality of senior centers, as centers increasingly cater to more active older populations (Hostetler, 2011). Spaces designed for quilting and crocheting are being complemented by gymnasia, computer rooms, and coffee shops providing lattes, which fulfill the needs of new generations of older adults (Gallow, 2012). Complementing these needs with those of frail older adults with significant physical and cognitive impairment is fast becoming the focus of the design of contemporary senior centers and adult day centers.

AGE-FRIENDLY RESIDENCES

As individuals transition into old age, their residence becomes an increasingly meaningful space as an increasing proportion of each day, often in excess of 80%, is spent in this location (Oswald & Wahl, 2005). For many older adults, particularly those having spent lengthy residence in a single dwelling, this location becomes the physical locus of life and a place that, because of its familiarity, can be easily negotiated as capabilities decline. The residence also becomes a repository of meaning, as it transforms into a “home,” providing a sense of centering, ownership, privacy, security, refuge, control, familiarity, and comfort in a world that is increasingly difficult to negotiate (Rowles & Chaudhury, 2005; Zingmark, Norberg, & Sandman, 1995).

The design of home space and the possessions it contains become critical elements in the preservation of identity (Rowles & Watkins, 2003; Rubinstein & de Medeiros, 2005). It is increasingly acknowledged that the physical internal design and layout of residences for older adults can facilitate the process of making the “spaces” of residences into “places” (Rowles & Bernard, 2013). Places that hold significant meaning facilitate extended ability to remain in a familiar residence, sometimes for far longer that objective measures of physical capability would indicate are possible (Rowles, Oswald, & Hunter, 2003; Rowles & Watkins, 2003). As people become frail, competence declines, environmental press increases, and the disruption of an intimate physical and psychological familiarity with a home and the objects it contains can become quite stressful (Ekerdt et al., 2012).

Environmental Design and Home Modification

Given the significance of a residence as home, it is important for the physical design and layout of spaces where older adults live to be accommodating of both normative and disease-related physical and cognitive changes that occur with advancing age. Many individuals live in residences that were not designed to accommodate mobility limitations. Indeed, there is increasing concern that the spacious two-story “McMansions” that characterize many affluent contemporary American suburban landscapes represent “Peter Pan” housing, residences designed on the assumption that people never grow old.

A variety of design innovations and accommodations make dwellings more age friendly and suitable for persons with disabilities. The WHO summarizes essential features for elder-friendly housing in its guide to global age-friendly cities, and similar design recommendations are provided in a number of other guides and publications (Danziger & Chaudhury, 2009; Kim, Ahn, Steinhoff, & Lee, 2014; Kochera, 2002; Sanford, Pynoos, Tejral, & Browne, 2002; World Health Organization, 2007a). In general, housing should be designed to be consistent with and equipped to withstand local environmental conditions. There should be adequate space to move about freely—space adaptable to the changing needs of older adults that includes level surfaces, wide passages accessible to wheelchairs, and appropriately designed bathrooms and kitchens. A plethora of specific home modifications are possible, including removing door thresholds, discarding throw rugs, providing accessible shelves, installing lazy Susans, adjusting the height of countertops, providing chairs with arms that make rising easy, removing hazardous items from stairs to reduce the risk of tripping, improving lighting, using levers rather than rounded door knobs, installing grab bars in bathrooms, providing elevated toilet seats and portable shower seats, adding handrails on stairs and on outside steps, and installing stair elevators (Figure 8.2).

FIGURE 8.2 Home modification to facilitate aging in place.

Source: Rob Caswell © 2009, www.alliswell.com Used with permission.

The WHO also identifies a set of contextual prerequisites for ensuring that appropriate housing modification can be achieved, noting that housing should be modified as needed, modifications should be affordable, equipment for modifications should be readily available, and financial assistance should be provided to those who need to make modifications. Finally, resources should be available to educate everyone involved about the ways in which housing can be modified to meet the specific needs of older adults (WHO, 2007a).

Of course, the optimum solution to the dilemma of making residences age friendly and supportive of long-term care is to ensure that dwellings are constructed in the first place to ensure the needs of individuals with reduced abilities. Universal design—design that is accessible to all users, regardless of age or ability—is intended to achieve this outcome (Sanford, 2012; Steinfeld, & Maisel, 2012). The development of universal design can be traced to the barrier-free movement of the 1950s that brought designing for people with disabilities to the attention of public policy and design practices. An example of barrier-free, or accessible, design would be a wheelchair ramp installed alongside the steps of a building entrance. Although barrier-free design remained focused on design for people with moderate to severe physical disabilities, universal design emerged as design for all people regardless of ability.

In the late 1990s, advocates of universal design, specifically a working group of architects, product designers, engineers, and environmental design researchers at North Carolina State University’s Center for Universal Design, developed seven principles of universal design (Connell et al., 1997; Steinfeld & Maisel, 2012; Story, 1998). These principles formalized a language for talking about universal design that is becoming increasingly utilized throughout the world. The first principle, equitable use, means the design must be useful and marketable to people with diverse abilities. An example of equitable use would be step-free level entrances into a residence. The second principle, flexibility in use, requires that designs accommodate a wide range of individual preferences and abilities. An example of flexibility in use would be kitchen countertops adjustable to provide easy access at both sitting and standing heights. The third principle is simple and intuitive use. Design features must be easy to understand, regardless of the user’s experience, knowledge, language skills, or current concentration level. An example of simple and intuitive use would be lever handles on door knobs and faucets. The fourth principle, perceptible information, focuses on communication. Designs must communicate necessary information effectively to the user, regardless of ambient conditions or the user’s sensory ability. An example of perceptible information would be a thermostat providing tactile, visual, and audible instructions. The fifth principle of universal design is high tolerance for error. Universal design minimizes hazards and the adverse consequences of accidental or unintended actions. An example of tolerance for error would be antiscald temperature and pressure-balanced shower valves. Designs that can be used efficiently and comfortably with minimal effort and minimum potential for fatigue exemplify the sixth principle, low physical effort. Examples of low physical effort would be touch lamps and rocker light switches. Finally, universal design mandates accessibility—sufficient size and space for approach and use. This principle mandates appropriate space for reach, manipulation, and use regardless of the user’s body size, posture, or mobility. For example, doorways and hallways must be wide enough to accommodate wheelchairs and walkers.

Increased interest in universal design is one aspect of a gradual transformation in the construction of dwellings that is making them increasingly supportive of sustained long-term care. Over time, advances in technology are allowing us to reduce the “press” of the environment and make residences supportive of persons with reduced levels of competence, thus enabling them to age in place for far longer than would otherwise be the case. A key element of this process has been harnessing AT.

THE EXPANDING ROLE OF ASSISTIVE TECHNOLOGIES

The word technology often brings to mind visions of sophisticated electronic devices, and although this may be accurate in many instances, technology has broad and varied applications. AT encompasses a wide range of devices used in everyday life to aid in the execution of specific tasks. Humans have been using AT for thousands of years, millennia before the invention of the computer chip. The composition of the assistive device is not important; rather, function and purpose determine whether a device can be classified as AT. For example, one of the most common AT devices is the cane. This simple tool can aid an individual with mobility or stability problems. AT can also be quite complicated, such as sensors embedded in the home environment to monitor a resident’s every move so that the environment can adjust to the particular needs of the individual. The Technology Related Assistance for Individuals with Disabilities Act of 1992 defines AT as “any device or piece of equipment, whether acquired commercially off the shelf, modified, or customized, that is used to increase, maintain, or improve functional capabilities of individuals with disabilities” (20 U.S.C. Chapter 33, Section 1401 [250]). Examples of AT, as described in this broad definition, include devices used in the daily lives of many people such as hearing aids, walkers, and prescription glasses. Less obvious, but no less important, are grab bars in a shower, daily-labeled pill dispensers, and closed-captioned television programming. At a higher level of sophistication are electronic-based devices, such as medical-alert call devices, that can be worn by persons who are medically vulnerable or living alone.

The rapid advancement and proliferation of new technologies, coupled with the demographic trend toward increase in the numbers of persons in need of long-term care assistance, means that AT is becoming a significant component of the long-term care landscape. And, in the future, the attractiveness of AT is likely to be magnified as a component of long-term care in view of the anticipated decline in the availability of caregivers, both in the workforce and in families (Fleming, Evans, & Chutka, 2003; Lee et al., 2006).

ASSISTIVE TECHNOLOGY: FOR WHOM?

AT devices can compensate for minor physical or mental deficiencies or serve as a means of accident prevention. For example, balance tends to wane with age and is the cause of one of the leading problems for older adults within their home—fall-related injuries (Stevens, Mahoney, & Ehrenreich, 2014). Therefore, it is important for devices to be placed within the home or with the person to help prevent falls or notify caregivers that a fall has occurred (Hawley-Hague, Boulton, Hall, Pfeiffer, & Todd, 2014). In this case, AT might be in the form of a rail along the stairs, a rubber slip mat placed beneath a rug, or a call device to alert a caregiver.

If a disability affects a person to the extent that he or she is no longer able to adequately care for him- or herself, then independent living is at risk. Although a caregiver may monitor health status or assist the individual with daily activities, not everyone may have someone at his or her disposal or even want personal care. In this case, a variety of AT devices, from monitoring technologies to home modifications, may be an option for the older adult, yet there are a number of factors to consider, such as the user’s level of self-efficacy with the product.

With each generation, there is a proliferation and advancement in the sophistication of technology; with exposure and use comes a corresponding comfort level with that technology. Because of earlier exposure to and lifelong familiarity with technology, younger people are likely to be more receptive to the most current technology than someone from an older generation. For example, the younger members of the baby boom generation are more likely to feel at ease with sophisticated forms of AT than older adults from previous generations. Nonetheless, it is important to be cautious about generalized assumptions of technological self-efficacy with any population. Some older adults view the acceptance of assistive devices as an insult or weakness, whereas others come to embrace the opportunity to resume or continue a life of independence. For example, some older adults are reluctant to use hearing aids because they feel that they symbolize aging and personal decline, whereas others have no concerns about employing such a technology (Jenstad & Moon, 2011).

Even if an older adult is open to the concept of incorporating AT into his or her life, there may be a financial issue that inhibits use. Affordability is a primary consideration for many older adults, even for devices that are on the lower end of the cost spectrum. In addition, insurance may not cover the cost of devices that would aid the older adult. Yet, this does not necessarily deter an individual from achieving a desired goal. Instead of relying on an off-the-shelf product, compensation for a compromised capability may derive from a “homemade” product. For example, something as simple as a kitchen drawer can serve as an AT. An older adult who has arthritic hands may have difficulty gripping a bowl for mixing purposes. In this case, it can be wedged in a top drawer to provide stability for the task. Another example includes hanging a cord or tassel on the switch of a lamp. This can be both a visual and tactile cue for an individual who may otherwise have a difficult time locating the exact location of or gripping the switch.

CLASSIFYING ASSISTIVE TECHNOLOGY

Numerous approaches have been attempted in classifying AT for older adults and other vulnerable populations (Bougie, 2008; Bouma et al., 2009; Schulz et al., 2014). One way is to group items based on type of impairment or compromised function. Another is to consider the environment in which the technology is used. Yet another, introduced by Bouma et al. (2009), pioneers in the emergent field of gerontechnology, focused on the overall goal or life domain in which the technology is used. Taking additional aspects of technological progress into account, such as elder-friendly communities, universally designed residences, and smart homes, makes classification even more complex because such holistic environments may not make individual impairments as noticeable and make it difficult to explicitly distinguish among diverse elements of assistive support due to more multifaceted and accommodating overall design (Hammel, 2004).

The most recent classification focuses on two major themes: life domains (physical and mental health, mobility, social connectedness, safety, and everyday activities and leisure) and the functional purposes of technologies “monitoring or measuring the environment or the individual, … diagnosing or screening to identify problems, needs or desires, … and … treating or intervening to address identified problems, needs or desires” (Table 8.2; Schulz et al., 2014, p. 4). As the authors note, it is possible to identify specific technologies that would be applicable to every cell within this matrix and there are few, if any, technologies that would not be embraced by the model.

TABLE 8.2 Technology Applications to Important Life Domains

Most consumers of supportive technologies—older adults, persons with disabilities, and caregivers—are not familiar with the intricacies of academic taxonomies. In most cases, with little awareness of the full array of options available, how does one begin to identify and procure an appropriate AT? For example, if an older adult with moderate vision loss needs a stove with a large display to indicate burner levels (assuming an awareness of this need), there would be at least three possibilities for this circumstance within AT classification. First, the decrease of visual acuity would constitute impairment. Second, the item under consideration is within the kitchen (environment). Finally, the act of cooking (function and goal) would be regarded as an activity of daily living. One consumer-oriented way of simplifying this issue is by considering the physical composition of the device. Low- and high-assistive technology (also known as low technology and high technology) refers to the level of sophistication of the aid. Low AT would include many of the common tools used by older adults and persons with disabilities that can be found in everyday environments: railings, ergonomically designed tools, T-faucets, and straws, for example. Because these items require the user to manipulate the device, these technologies are regarded as active. In contrast, high AT indicates a component of modern or cutting-edge technology, such as a light timer, a voice-activated remote control, or even a house embedded with sensors to monitor movement. A user may not directly interact with these devices, much less be aware of these technologies, if they are seamlessly incorporated within the environment; these are considered to be passive technologies. Whether a device is regarded as low or high technology, active or passive, is not of primary importance. Rather, the availability of these items and willingness of the older adult to adopt these devices into regular use within his or her daily life is the paramount consideration.

ADVANCING AT THE SPEED OF LIGHT

Once an item of high status, the cell phone is now so common that it rivals the traditional landline; it is used by persons across the age spectrum. Although the sleek lines of modern fashion dominate the interface design of these devices, there are a number of cell phones that have been designed with the unique needs of less able users in mind. Some now have larger displays, textured buttons, vibrations to alert the user, or an emergency button that transmits a signal to a designated receiver. Computers and even digital games are becoming more commonplace within the personal environment of older adults (Brown, 2014). Tools such as these can be regarded as AT depending on their purpose and use. For example, the use of communicating or generating a document via a computer may be more comfortable as compared to writing by hand, especially when utilizing a feature such as speech-to-text. Yet, there are high-tech devices on the market now that do more for the older adult than just serve as a means to communicate (computers) or engage in exercise/physical therapy (digital games).

By no means ubiquitous, but slowly generating attention, the use of robots is increasing and can serve to assist older adults with basic functions such as reading documents, retrieving an item, or even serving as a source of companionship (Brose et al., 2010). One of the key issues in the use of such technologies is the degree to which they will achieve acceptance by older adults and populations of persons with disabilities (Flandorfer, 2012; Neven, 2010). Even more fundamental are questions regarding the social and emotional consequences of the use of robots. There is concern that as economic pressures to harness this option increase, it would “most likely ensure that the result was a decrease in the amount of human contact experienced by older persons being cared for, which itself would be detrimental to their wellbeing” (Sparrow & Sparrow, 2006, p. 141).

Modern forms of AT are increasingly incorporating sensors, which are becoming a building block for advanced passive systems designed to monitor the individual and assess functional needs on a regular basis. A common sensor found within many homes today is an alarm system. When activated, it alerts the homeowner that a sensor has been tripped, possibly indicating an intruder. Over the years, similar technology has been modified to alert the homeowner of potentially dangerous situations, such as stove settings that indicate prolonged use. In addition, sensors can now be embedded within the home to serve a variety of alternate functions. This includes sensors that help eliminate or simplify difficult tasks within the home, warn the individual or his or her caregiver of a specific need, or monitor activities for health purposes. Such sensors can range from options as “simple” as an automatic water faucet for a person with arthritis of the hand, or self-dimming lights, pressure mats, or sensing devices that remotely indicate to a caregiver that the adult is out of bed. These are often referred to as smart home technologies.

Smart home technology is wide ranging and has the potential to help keep older adults and persons with disabilities in their private residences even after the onset of cognitive and physical decline. Although smart homes support the health, safety, and independence of older adults, they may also transform their lives to being constantly monitored and managed, as well as motivated to maintain health and wellness (Coughlin, D’Ambrosio, Reimer, & Pratt, 2007). Smart home sensors, for example, can be placed in the floor, in walls, in furniture, and in appliances. Sensors can monitor an older adult’s activities of daily living without intrusive cameras or microphones, thereby protecting privacy. Examples of practical uses of smart home technologies include motion sensors that can monitor mobility patterns within the home environment, gait monitors that can detect ambulatory changes and detect falls, pressure sensors that can determine how long a person sits or lies in the same position, temperature sensors that can detect whether the stove is left on or the refrigerator is left open, and humidity sensors that can monitor how often the shower is used. We anticipate that as these technologies become more widely employed, they will become relatively inexpensive in comparison to other forms of direct interpersonal caregiving. Not only will they save time and resources for both the older or disabled adult, but also they will save on travel to and from the home and enable formal caregivers to simultaneously monitor multiple individuals in different locations.

Monitoring systems, particularly those that provide health feedback to a caregiver, may be the deciding factor in whether an older adult is able to remain in his or her home if declining health becomes an issue (Sixsmith et al., 2007). There are now sensors that can be attached to “everyday use” items or locations: if a sensor is not triggered in a device, a toothbrush, for example, the caregiver knows the care receiver has not used it and can intervene. In addition, a sensor that is not triggered, or is triggered at an atypical time, can be charted to identify potential problematic patterns of behavior, which can be a signal for other health issues, including cognitive decline.

The use of sensing technologies to alert health care professionals via a remote system began in the 1970s with the personal emergency response system (PERS) and rose to popularity among older adults in the 1980s (Parker & Sabata, 2004). The technology entailed an older adult wearing a remote device with a call button that he or she could press if there was a perceived need. This alerted a monitoring station and allowed a two-way conversation via a speakerphone in the home. Although this form of AT offered a sense of security for many, technology advance has produced systems exponentially more sophisticated. For example, the traditional cane has come a long way, it can now be outfitted with a GPS to assist the adult with navigation in his or her community, or to send signals of that location to a caregiver. The same is also being done with devices designed to appear as jewelry worn on the adult; these serve a dual purpose: fashion statement and GPS tracking device that can be activated if help is needed.

The technologies found in smart homes have become commonplace within the AT market and now include devices that serve an array of functions of benefit to aging and disabled individuals: as safety alarms, as informational sensors, as mechanisms for remote monitoring, and as sources for telecommunication for health maintenance and socialization. The use of these technologies in combination has resulted in initiatives to create model smart homes that are fully automated and push the boundaries of technological support (Chan, Campo, Esteve, & Fourniols, 2009; Park et al., 2007). The ultimate expression of such composite technology aspirations is the recent exploration of the potential for creating ambient assisted living (AAL) environments (Cardinaux, Bhowmik, Abhayaratne, & Hawley, 2011). Such environments move beyond the components of smart homes because they create a residence in which the environment is embedded with a single integrated system of networked sensors throughout the dwelling programmed specifically to the needs and preferences of the user(s) (Sixsmith & Müller, 2008). This sophisticated passive form of AT not only monitors the user, but anticipates his or her needs and automatically adjusts devices within the home to meet those needs without immediate direction from the user. In addition, the system can be programmed to interact with the user so that adjustments within the home can alter individual settings in accordance with the user’s preference; settings such as the height of a cabinet, the temperature of a room, or the amount of light within an area.

We can envisage a future scenario of smart homes and AAL. Upon awakening, appropriate lighting illuminates 89-year-old Connie’s bedroom while her vital signs are recorded and transmitted to a caregiver 12 miles away. As she gets out of bed and moves to her bathroom, sensors in the floor simultaneously measure speed and gait while the lights automatically adjust for safe navigation. Meanwhile, her coffee begins to brew in the kitchen and the temperature in this room adjusts automatically to the level she prefers when she is sitting by the window and having her breakfast. Her vitamins and medications are automatically dispensed into a small weight-sensored cup with a visual or audible alarm that goes off until it registers as empty. When this has occurred, her caregiver is informed through an automatic text to her cell phone.

This kind of monitoring activity and environmental adjustment would continue throughout Connie’s day to ensure her well-being while maintaining her independence without the need for direct contact with a caregiver. Connie’s robot, designed to assist her with key movements, such as rising from her chair and giving her something to hold on to as she is guided across the room, allows her to navigate her home with ease and autonomy. Later in the day, she is able to participate in a “telehealth” consultation with her physician’s assistant who is able to monitor her status via her in-home camera. And, as evening approaches, Connie spends a couple of hours interacting with her friends through the sophisticated telecommunication and conferencing resources that are built into her living room (see Case Study 8.1).

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