IT applications that support aging in place: seven categories of need

1. IT applications that support aging in place:seven categories of need Mike Rosen Outgoing Director Rehabilitation Engineering Labs National Rehabilitation Hospital Disclaimer: This talk is about meeting the needs of elders by using technology. Therefore it will focus on technology. It is, however, the position of the speaker, his colleagues and family that IT must be applied in the context of an integrated consumer-centered system of health care and support for independent living.

2. Seven killer app’s that support life and living • Emergency detection and response-cuing • Activity tracking for status monitoring • Task sampling for status monitoring • Health maintenance • Cognitive support in ADL’s • Enhanced communication with the outside • Access to information and stimulation Note: first three are about service delivery; last three are assistive; fourth one can be either depending on one’s model of health care.

3. First application … • Emergency detection and response-cuing • Activity tracking for status monitoring • Task sampling for status monitoring • Health maintenance • Cognitive support in ADL’s • Enhanced communication with the outside • Access to information and stimulation Talking Lights

4. For example: • Critical medical events (e.g. stroke, coronary, diabetic coma) • incapacitated • some capacities intact • Falls • conscious but immobile • at home • away • unconscious • at home • away • Wandering (secondary to dementia) • aware • unaware Note 1: Engineering challenges vary dramatically across these examples; e.g. sensor integration and knowledge-based processing for automated fall detection. Note 2: Automated solutions must take into account the costs of false positives and false negatives.

5. Second application … • Emergency detection and response-cuing • Activity tracking for status monitoring • Task sampling for status monitoring • Health maintenance • Cognitive support in ADL’s • Enhanced communication with the outside • Access to information and stimulation

6. Note 1: This kind of instrumented monitoring may be felt as less intrusive than video. Note 2: Wireless solutions are nearly essential. Note 3: Either modular retro-fittable senor products (like X10) or “smart home” integrated systems*. For example: • Detection, timing, counting of environmental use, e.g. bed, chair, bathroom use … • to sample elder’s energy and engagement • to note indications of depression • to track the progress of rehab or disease state • In situ motion analysis • Crude cumulative accelerometry for overall (“Actigraphs”) • Targeted processing of wearable sensor signals to detect/measure particular symptoms, e.g. tremor, spasticity, o.c.d. … *MIT, GA Tech, Intel, GE, Rochester

7. Third application … • Emergency detection and response-cuing • Activity tracking for status monitoring • Task sampling for status monitoring • Health maintenance • Cognitive support in ADL’s • Enhanced communication with the outside • Access to information and stimulation

8. the premise… • Unobtrusive monitoring of selected ADL’s in the home is technically feasible and practical. • Performance of ADLs is the most direct and ecologically valid indicator of functional status (and rehab outcome). • ADL event time records can be processed to return meaningful estimates of global functional status for display to OTs and other remote service providers … • without video

9. NRH project design … • First: develop and demonstrate a prototype sensor package and data-acquisition hardware and software for installation in a kitchen: done “Wired Independence Square” at NRH

10. micro-switch unobtrusivesensors: so far just switches Is the stove on? in-line flow switch magnetic proximity switch Is the faucet running? Is the cabinet open?

11. project design … • Then: formulate and validate estimators • Hypothesize performance metrics (PMs) based on timing and counting • Regress linear combinations of PMs against AMPS sub-scores (as the validated standard measure) across subjects • Test the hypothesis: look for correlations between PMs and AMPS scores; i.e. show that our objective automated sampling of selected task performance can estimate overall function

12. possible performance metrics … • Durations, e.g. event-to-event • Counts, e.g. # times refrigerator was opened • Categorical: yes/no • Spatial distance moved • Rates, events per time • Normalized by optimal or norm or “contract” with therapist

13. status … • Sensor package in place in Independence Square at NRH … • with funding from NIDRR via the RERC on Telerehab, and from the U.S. Army Medical Research and Materiel Command • OT research partner, trained in AMPS (Assessment of Motor and Process Skills), has tested five subjects with left CVA • In-home validation studies proposed, both cross-subject and longitudinal

14. development plan … • Bring to market the CARE package (Collection of Adls for Remote Evaluation): • Wireless switch package • Data logging and transfer box (H.323 protocol) • Hub-site data capture and processing software • Interactive display software for OTs and other service providers

15. Fourth application … • Emergency detection and response-cuing • Activity tracking for status monitoring • Task sampling for status monitoring • Health maintenance • Cognitive support in ADL’s • Enhanced communication with the outside • Access to information and stimulation

16. *MIT MANUS, Greg Burdea’s hand and foot systems, Dave Reinkensmeyer’s Java Therapy For example: • Sensing of medication use and prescribed therapeutic activities to monitor compliance • “Home health technology” for regular sampling of physiological signals and video visits • integrated into home environment, e.g. the smart toilet • special purpose table-top • wearable • implanted • Telerehab, e.g. • speech pathology • psychological counseling • neuropsych evaluation • wound management • assistive technology assessment • follow-up post-discharge • web-enabled video-enhanced robotic PT* Note 1: an engineering challenge is the processing of instrumentation signals to yield clinician-friendly results; OR educate clinicians to be instrumentation-friendly Note 2: always-on streaming video monitoring may be viewed as Big Brother by some, Guardian Angel by others.

17. Fifth application … • Emergency detection and response-cuing • Activity tracking for status monitoring • Task sampling for status monitoring • Health maintenance • Cognitive support in ADL’s • Enhanced communication with the outside • Access to information and stimulation

18. Note: this need is not limited to elders. This is universal assistive technology. For example: • Application of mass-market technologies such as PDA’s and GPS • Purpose-designed software and human interfaces* for prompting during home-based ADL’s, e.g. cooking: “cognitive orthoses” • Integrated smart home solutions, e.g. networking contents-monitoring refrigerator with shopping service; or digital voice prompts about safety issues such as door locking or remembering to shut off the stove *Elliot Cole, Institute for Cognitive Prosthetics

19. Sixth application … • Emergency detection and response-cuing • Activity tracking for status monitoring • Task sampling for status monitoring • Health maintenance • Cognitive support in ADL’s • Enhanced communication with the outside • Access to information and stimulation

20. For example: • Phone • Email, instant messaging, … • Cell-phone-based short text message service • Televisits with remote family (via H.324 videophones; H.323 Internet-based standard; or coming 3G video cell phones) • Special-interest chat rooms, blogs, … • On-line photo albums • Web-based advocacy and politics • Amazon.com etc. Note: Evidence is convincing that old age itself is not a barrier to use of sophisticated IT. The habits, expectations, experience and attitudes of this particular generation of elders can be.

21. Seventh application … • Emergency detection and response-cuing • Activity tracking for status monitoring • Task sampling for status monitoring • Health maintenance • Cognitive support in ADL’s • Enhanced communication to the outside • Access to information and stimulation ARMCHAIR TRAVEL.COM

22. For example: • Unlimited access to all interest areas via specialty Web sites • Virtual travel • On-line news and other publications • Health information Web sites • Internet-based music browsing and downloading

23. More notes: • The majority of the products noted here are sold to the mass market. Elders are themselves a huge and growing market; but many of these IT app’s or their core technologies suit virtually the entire population. • In telehealth, communication and cognitive support, mass-market convergence products can become specialty tools -- 3G video smart phones, for example, for telehealth.

24. New Yorker Cartoon by Gregory Swissmemory USB by Victorinox