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Technology and long-term care

2013 Vol. 8 No 2 International Federation on Ageing

GLOBAL AGEINGIssues & Action

Global Ageing: Issues & Action is the journal of the International Federation on Ageing (IFA). It is published two times per year.

Guest Editor: Sandra P. HirstDesign: Visual Syntax

Copyright © 2013 by the International Federation on Ageing. All rights reserved. Articles may be reprinted or quoted in whole or in part only with permission.

ISSN 1729-3472, Vol. 8 No2, 2013

Global Ageing welcomes original, unpublished articles. Author’s guide-lines are available from the IFA secre-tariat. Manuscripts, including graphics (tables, figures or photographs), may be submitted at any time via e-mail, unless otherwise agreed. Global Ageing may edit articles accepted for publica-tion. The IFA does not pay authors for articles published. Opinions expressed in Global Ageing do not necessarily reflect the opinions of the IFA.

IFA SECRETARIAT

Jane Barratt, Secretary GeneralGreg Shaw, Director, International & Corporate Relations

International Federation on Ageing351 Christie Street, 1st FloorToronto, ON M6G 3C3 Canada

Tel: 1-416-342-1655Fax: [email protected]

cover image: istockphoto

Table of contents

3 Editorial Board

4 From the Editor sandra p. hirst

6 Leading by example dr jane m. barratt

7 Technology for an active old age andrew sixsmith

10 Assistive technology and the elderly living in long term care: a critique

cyndee seneviratne

17 Personal Emergency Response Services (PERS) in disaster and emergency management

sophia craig-massey

20 Experiment in social innovation in long term care anneke offereins and wil van de laar

23 eNeighbor: A preventive system monitoring residents’ behavior for health services.

robert e. roush

25 Technology: its promise for effective disaster management in long-term care settings

sandra p. hirst

30 With advancements in technology, have societies improved their response to older people in natural disasters?

kelly fitzgerald

editorial board

Articles selected for publication in Global Ageing have been reviewed by members of the Editorial Board; their suggestions and guidance enable the IFA to offer a journal that provides the insights and analyses of experts on policy and practice issues important to those who promote the well-being of older adults throughout the world.

Susan J. Azizconsultant on agingusa

W. Andrew Achenbaumuniversity of houstonusa

Nana Araba Aptashesi universityghana

Laurence G. Branchuniversity of south floridausa

Yitzhak Brickjdc-eshelisrael

Dr Sandra Hirstuniversity of calgarycanada

Ramón M. Gutmannadvisor for aging policy,municipality of buenos airesargentina

Elizabeth Mestheneos50+ hellasgreece

Harry (Rick) Moodyaarpusa

James T. Sykesuniversity of wisconsinusa

4By Sandra P. Hirstguest editor

From the EditorWhat is the contribution of technology to long term care?

Welcome to this issue of Global Ageing! This issue will cover technology in its widest sense and will include a critique of some of the new and emerging technological developments and aids to support the well-being of older adults from a long term care perspective. What is meant by “technology”? Technology is embodied in every device that we use, from the very simple turning on or off of a light switch, to the more complex, for example a tele-vision and its’ remote control. Technologies are simply tools available to assist us with the tasks of daily living.

For most of the 20th century, primarily in developed countries, a major effect of technology has been to extend life expectancy, often as a result of high-technology medi-cine. For the majority of their lives, most older adults live healthy, active, and independent lives. Their interest in technology might be to try use Skype to connect with family or to send a friendly email to a friend. However, not surprisingly with advancing years, health and inde-pendence do decline. The increased need of older adults for technological aids, whether it is a hearing aid or a wheelchair, is a manifestation of their greater dependence.

Technology’s contribution to their independence is its’ ability to compensate for the limitations and disabilities that occur with age. If a piece of technology can help an older adult overcome a disability, then it prevents that disability from becoming a handicap.

It is often the simplest gadgets that provide the great-est benefits. The greatest benefits may not come from the more sophisticated technologies such as a bioelectric limb or robotic nurse, but rather from simple gadgets that make cooking simpler or the bathroom easier to use for an older adult.

Until recent years, “technology” and “long-term care” were not often used in the same sentence. While this maybe a slight exaggeration, one would be hard-pressed to argue against the perception that the long term care industry is a rather late arrival to the introduction and use of technological advancements. However, provider demand, vendor interest, older adult need, and a growing number of technological confident older adults and fam-ily members are triggering an industry response.

As global citizens, we are continually adjusting to the influence of technology, as smart phones, computers, robotics, automated vehicles, and other forms of technol-ogy enter our lives and the lives of older adults. The pace of technological change is fast and ever increasing. It is

ifa global ageing 2013 VOL. 8 No 2 5FrOm the editOr

long term care context. For example, a typical bathroom counter in a facility may not be accessible to everyone, including those of short stature, those who use wheel-chairs, and those who cannot stand for extended periods of time. Applying universal design principles might result in the design of a counter that has multiple heights—the standard height designed for individuals within the aver-age range of height and who use the counter while stand-ing up, and a shorter height for those who are shorter than average, use a wheelchair for mobility, or prefer to interact with facility staff from a seated position.

Making a product or an environment accessible to older adults with disabilities often benefits others. For example, automatic door openers benefit individuals using walkers and wheelchairs, but also help staff members carrying meal trays or holding supplies, as well as family members visiting with gifts.

The second concept is that of “building automation”, such technologies are build into buildings, such as long-term care facilities or seniors centres. They can increase

the independence of older adults and convenience and comfort of the building. For example, they can open and close windows automatically, or help identify callers at the door.

However exciting are the possibilities that technology and technological change offer to the quality of life of older adults, I raise a word of caution. Technology has to be integrated into all services available to older adults and to those who work with them. There is a danger in putting too much faith into technology and forgetting the importance of the human experience.

Sandra P. Hirst RN, PhD, GNC(C)Associate Professor

Director, Brenda Strafford Centre for Excellence in Gerontological Nursing

Faculty of NursingUniversity of Calgary

Calgary, Alberta, Canada

predicted that this rapid pace change will continue well into the future. What does this mean for older adults within the context of long term care, whether that is community, home, or facility based. How will services change? Will they be better, worse, or simply different? What actions should individuals, governments, NGOs, business, and community groups take to promote the effective use of technology to support quality of life for older adults? The answers to such questions are not always clear, but it is certain that rapid change will occur and that it will bring both problems but also opportunities.

There are two concepts that warrant our exploration in attempting to answer these questions. The first is the concept of universal design, the premise of which is to produce things for all people regardless of age, size, shape, need, or ability. In other words, the design of products and environments to be usable by all individuals, to the greatest extent possible, without the need for adaptation or specialized design. Universal design principles can be applied to any product or environment, including the

The greatest benefits may not come from the more sophisticated technologies such as a bioelectric limb or robotic nurse, but rather from simple gadgets that make cooking simpler or the bathroom easier to use for an older adult.

6By Dr Jane M. Barrattsecretary general

Globally we are in the midst of two striking trends in world history namely global ageing and the rapid dif-fusion of advancements in technology.

Imagine life without the evolution of technology. It is one of the few ingredients for survival of mankind living in a fast changing environment.

The development of new technology helps people save lives and extend lives; it helps people work easier and anywhere. It is important in education, travel, health and business and transcends age, culture, race and gender.

Technology as an ‘enabler’ has no bounds – smart homes, robotics, virtual reality and gaming, telemedicine

for clinicians, telemedicine for consumers and social connectedness

Future generations of older people in many countries are expected to have better financial resources and higher levels of education than previous generations. Large purchasing power is expected, alongside their powerful voices of advocacy as consumers and as patients. Fit, active, mobile, safe, connected and self-reliant could define the new generation of older people.

As the proportion of people aged 65 years and over climbs to record highs in many countries, technology companies that fail to take account of the older consumer will be missing a trick; but just because a person is older doesn’t mean they just want a big-buttoned phone.

Organisationally the International Federation on Ageing is at one of the most exciting crossroads in our history. Strategic relationships and partnerships across sectors, disciplines, academia and all levels of govern-ment and industry are connecting experts and expertise regionally and globally to deliver knowledge platforms in Cameroon, Turkey and India in the next year.

We have listened to our members and have joined the digital generation where we can connect with you and respond to your needs and issues quickly and responsibly. Our first issue digital issue of Global Ageing: Issues and Action was made possible through the dedicated work of many people but most importantly the drive and passion of IFA Director Ms Kaye Fallick, in Australia. “Thank you”.

Albert Schweitzer said “Example is not the main thing in influencing others. It is the only thing” - the International Federation on Ageing joins our colleagues in leading by example to protect the rights of older people.

Dr Jane M. BarrattSecretary General

International Federation on Ageing351 Christie St

Toronto, ON. M6G3C3Canada

Leading by example

7By Andrew Sixsmith

Technology for an active old age

A globally aging population demands innovative approaches to ensure seniors can live and age well. In particular there is a need to move from health and social agendas that emphasise dependency in later life to ones that promote active aging. This idea of active ageing focuses on how people can continue to participate fully in society and to avoid the isolation and physical and mental decline that often undermines independence and quality of life.

My own research explores how new technology can help older people to remain connected and active. I often illustrate my talks with a front page headline from the local paper from my home town of Liverpool in England which read “Pat Lay Dead for Six Weeks”. Pat, a 72-year old lady, had died alone and undiscovered at Christmastime in her home just a few days after she had been visited by a social worker. No-one could quite understand how such a terrible thing could happen. Was it the fault of the local health and social services? Was it because she was neglected by her family? Was it because Pat was a loner who wanted to live quietly and privately at home? Or is

ifa global ageing 2013 VOL. 8 No 2 8

“Seniors, especially the boomer generation, are currently the fastest growing demographic for social media and internet usage in general, challenging the stereotype that they are technophobic.”

techNOLOgy FOr aN actiVe OLd age

one case, the system noticed that a man who had previ-ously been quite active had stopped leaving his home. At the same time his sister, who usually helped him with simple tasks of living, had stopped coming to visit him. When we investigated the situation, we found that he had stopped walking due to swollen feet and that his sister could not come to visit because she had to look after her husband who had become seriously ill. We arranged for

podiatry treatment and for visits from a community care worker. This is a clear example of how technology might be able keep people stay connected with those who can help. Being able to intervene at an early stage avoided an inevitable hospital or nursing home admission, options that are both expensive and hugely impactful on the inde-pendence of seniors.

There are privacy concerns and technology should not be seen as a substitute for human contact. However, research shows that many people would be happy with the support of technology if it meant they were able to stay living at home. At the moment Canada lags behind much of the rest of the world in both technology research and development and in using available technology to help and support seniors living at home. Moreover, the very people who might benefit most from using technol-ogy appear to be the ones who are least likely to be able access it. A “grey digital divide” exists, where many older people have been left behind by the technological revolu-tion due to lack of knowledge and skills or plain old lack of money. A more active role by government is needed to encourage and support older people to participate in the digital economy for the mutual benefit of both society and industry.

Andrew Sixsmith PhDProfessor and Director, Gerontology Research Centre

Simon Fraser University Harbour Centre515 West Hastings Street

Vancouver, British Columbia

it that modern society has lost its sense of community? Whatever the cause, these stories occur with monotonous frequency. The week after I moved to Vancouver to take up my post as Director of the SFU’s Gerontology Research Centre, I read a story in the Vancouver Sun about a woman in Prince George who had slipped in her bath and had laid waiting for help for 16 hours. On this occasion a local health worker eventually found her and she survived the ordeal, but I was struck by the similarities of the stories. These were two very different places that shared a com-mon problem: neither seemed capable of supporting the people who need help most, especially those who are frail, in poor health and who are socially isolated.

Modern information and communication technologies, such as broadband internet and mobile phones have a huge potential to enhance the independence and social partici-pation of isolated seniors. Seniors, especially the boomer generation, are currently the fastest growing demographic for social media and internet usage in general, challenging the stereotype that they are technophobic. There is also a lot of private and public sector money being spent in developing technologies to help people remain active and independent. For example, people can be helped by simple prompts and encouragement via a phone or internet to carry out tasks such as taking medication or following exercise routines. “Brain-training” computer games may also be useful in preserving the cognitive abilities of people with dementia. Doctors are increasingly able to monitor chronic health conditions at home without the need for hospital visits. A recent research project I looked at how sensors, such as infrared movement detectors, installed in a person’s home could help them stay connected with families and health workers. The system builds up a pro-file of the person’s daily pattern of activity and then sends an alert to a caregiver if there is significant deviation. In

The International Federation on Ageing (IFA) and TURYAK Seniors Council Association is proud to be partners in this inaugural event which aims to deliver a series of

transformative policy and practice conversations about the social and economic opportunities that population ageing brings to the regions of the Middle East, Northern Africa,

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Full Papers and Abstracts – Deadline May 31, 2013Full papers are peer reviewed by an International Jury, eligible to

$13,000 worth of fi nancial awards, and a publication in a special edition of the IFA journal, Global Ageing

CONGReSSExperts, charismatic and challenging are characteristics that personify many of the speakers confi rmed for the Foundational Plenary Panels:

1. National Leaders Panel: Ageing in the New World2. World Bank Panel: The Economies of Ageing3. Mayoral Panel: Age-Friendly Cities the Key to Sustainability and Livability4. Evidence to Action Panel: When Rubber Hits the Road – Visualizing the Demographic Picture5. Game Changers in Policy Development Panel: The New Normal and What it Means to Age6. Aged Care Panel: Revolutionizing Client-Centered Aged Care7. United Nations Panel: Beyond 20158. Global Business (CEO) Panel: Visionaries in Business and the Business of Ageing

eXPO 50+ iSTANBulThe Wow International Convention Center will feature advances in technology, assistive devices, and innovative designs catered for a changing population profi le. With over 400+ exhibitors, and over 10,000 visitors, Expo 50+ Istanbul will spark a new wave of innovation and design across the many aspects of the life course. Register at www.expo-50.com.

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10By Cydnee Seneviratne

Assistive technology and the elderly living in long term care settings

According to the World Health Organization (2012), one in four people worldwide will be over the age of 60 by 2050. Similarly, the Canadian elderly population will surpass children aged < 14 years between 2015 and 2021 (Statistics Canada, 2010). The increase in numbers is of interest because approximately 35% of older adults in Canada aged 65- 85 years and over currently reside in long term settings and require individualized care (Statistics Canada, 2006). Such an increase may impact the amount of personalized time health care professionals can dedicate to residents living in long term care. Thus, how, when, and in what circumstance do health care professionals use assistive technology with and for elderly residents has become an important issue in long term care settings.

Assistive technology and the elderly living in long term care: a critique

ifa global ageing 2013 VOL. 8 No 2 11assistive technology and the elderly living in long term care: a critique

The use of technology and assistive technology to enhance care and improve quality of life has been pro-moted as critical for older adults in acute and community settings (Courtney, Demiris, Rantz, & Skubic, 2008; De Craen, Westendorp, Willems, Buskens, & Gussekloo, 2006; Gosman-Hedstrom, Claesson, & Blomstand, 2002; Hoenig, Taylor, & Sloan, 2003; Miskelly, 2001; Sheehan, 2011; Zwijsen, Neimeijer, & Hertogh, 2011). Health care professionals use assistive technology such as automatic guidance lights, wheelchairs, mechanical transfer devices, etc. to provide optimal care for their elderly patients. However, limited research exists that explores whether technology and/or assistive technology enhance care pro-vided in long term care settings or whether they replace personalized care. The purpose of this discussion paper is to critique and extend the current literature related to the use of technology and assistive technology to improve care in long term care settings. Implications related to future research possibilities will be discussed.

Literature critique

MethodsWhen we began this critique we asked the question: Are care practices provided in long term care settings optimal for the elderly population or does technology replace interactions with their registered nurse, nursing atten-dant, or care aide? We examined each article using the following sub questions: is assistive technology beneficial, is it used as a primary or complementary care method, and how does the impact of health care professionals play a role? We included published papers in peer reviewed journals for the preceding 15 year period. The following on-line databases were searched: CINAHL, PubMed, and Google Scholar. Key words used in our search included:

assistive technology, assistive devices, technology and the elderly, technology and long term care. Using these key words, our search generated 84 papers relevant to assistive technology and long term care. Thereafter, we identified seven papers that specifically met our inclusion criteria of: written in English, published between the years 1997 and December 2012, and relevance to assis-tive technology use as a supplement to care provided by health care professionals in long term care (See table 1).

Findings/critiqueOf the seven papers identified for critique three were research articles and four were discussion papers. For their pilot study, Trefler, Fitzgerald, Hobson, Bursick, and Joseph (2004) examined the effects of individualized wheelchair systems on mobility, forward and lateral reach, quality of life, and satisfaction with use of technology for residents in long term care. The researchers recruited 60 participants into the study of whom were measured three times congruent with a semi crossover design. Participants were measured using their existing wheelchairs, after participants were prescribed individualized wheelchair systems, and then three months thereafter for follow-up. Trefler et al. (2004) found that an individually prescribed wheelchair system can be beneficial for residents in long term care. Mobility, reach, quality of life and satisfaction with use of assistive technology was enhanced. Although Trifler et al. (2004) found prescribed wheelchairs systems are of benefit, the authors failed to account for the pos-sible impact that health care providers may have had on satisfaction by the residents using the technology. The authors assumed that the caregivers were not a variable, but how the nurse or care attendant worked with and believed in the effectiveness of technology could also have impacted overall resident satisfaction.

“...assistive devices do not substitute the personal care provided to the elderly living in long term care.”


Agree, Freedman, Cornman, Wolf, and Marcotte (2005) also explored the use of assistive technology in long term care. The researchers focused on whether or not assistive devices took the place of care provided by health care professionals. Using United States National Health Survey Disability data drawn from phase 2 (1994-1995), Agree et al. (2005) analyzed a national sample of elderly who have difficulties in activities of daily living. Findings indicated that assistive devices do not substitute the personal care provided to the elderly living in long

term care. Rather, assistive devices complement nurses and/or nursing attendant care. The researchers also found if the individual required institutionalized care due to severe disability then assistive devices were required daily. They also cautioned the use of assistive technology as a means to decrease overall cost for institutions serving the elderly. Nevertheless, in addition to using outdated data (survey data was collected in 1994-1995) the authors did not address whether daily assistive technology in long term care may be over used in long term care.

The final research study conducted by Al-Oraibi, Fordham and Lambert (2012), used a retrospective case control design to conduct a managerial audit of the incidence of resident falls before and after installation of assistive devices in two care homes in Norfolk, England. The types of assistive devices that were installed were: pull cord, pendent alarm, passive infra-red movement sensor, flood detector, falls detector, urethra sensor, pres-sure pad/mat for bed and chair, speech unit, and control/response software on the central computer. Al-Oraibi, Fordham and Lambert (2012) found that a total of 314 falls were reported in both care homes: 202 before and 112 after installation of assistive devices. They concluded that falls were significantly reduced (p= 0.0015) after the installation of assistive devices in both care homes. The authors identified study limitations including a small sample size (2 care homes) and limited follow up periods indicating poor generalizability, inconsistent evaluation time periods, and requirement of further detailed stud-ies of individual resident use of assistive technology, cost analysis, and care giver training. However, in addition to these stated limitations, the authors did not include or account for the possible ways personalized care provided by health care professionals complementary to assisted technology professionals impacts fall reduction.

The four discussion papers focused on the ways assis-tive technology may improve the care of residents living in long term care. Nelson et al. (2004) explored how new technology such as: hip protectors, wheelchair/scooter safety features, intelligent walkers, fall alarms etc. to prevent falls; novel and height adjustable hospital bed designs, bedside floor mats to address bed-rail entrap-ment; mechanical floor based and ceiling mounted lifts, friction reducing devices to reduce care giver injury; and wandering monitors, can improve patient and caregiver

assistive technology and the elderly living in long term care: a critique


TABle 1. Identified papers for critique

Author Design Focus Critique

Agree, Freedman, Cornman, Wolf, & Marcotte (2005)

National Survey Analysis Supplementn=4006

Analysis of national sample of older persons with difficulty in activities of daily living.(1994-1995 US National Health Interview Survey (NHIS) Disability)

• Found that assistive devices do not substitute personal care, rather complement.• Also found that if the individual required institutionalized care due to severe disability, assistive

devices were required daily.• Did not address the question of whether assistive technology is over used in long term care.• Sample not recent data.

Al-Oraibi, Fordham & Lambert (2012)

Retrospective case-control study- Data collected from routinely collected incident report forms from 2 care homes.

Managerial audit of two care homes in Norfolk, UK. Examined the incidence of falls before and after assistive technology systems were installed

• In both care homes a total of 314 falls reported (202 before, 112 after), thus reduction of falls after installation of assistive devices (p = 0.0015).

• Importance of personalized care provided by health care professionals not addressed in relation to fall incidence.

• Did not mention health care provider impact on fall reduction.

Long (2012) Discussion Paper Using data from interviews conducted in 2003-2007, discusses interdependence on assistive devices in long term care by elderly in Japan.

• State that interviews point to acceptance of assistive technology to avoid over-dependence on caregivers.

• Offered more research is required to explore issues related to over-dependence belief related to state definition of who is elderly

• Did not fully explore the notion of care giver interaction and whether such interaction could address the issue of overdependence.

Nelson et al. (2004) Discussion Paper Discussed the importance of assistive technology to enhance care provided in long term care settings. Offered pictorials of best practice and suggested nurses would benefit from exposure to assistive technologies to improve safety

• Authors did not indicate the need to explore research related to the importance of the care giver as a supplement to assistive technology

• Focused on ways front line nurses can test equipment rather than evaluate the need for such assistive technologies.

Sheehan (2011) Report/Discussion Paper Report of current assistive devices available in long term care centers

• Clear bias on need for assistive devices.• Did not offer suggestions regarding how assistive devices improve interactions between

residents and health care providers.• Research possibilities not offered.

Tak, Benefield, & Freeney Mahoney, (2010)

Discussion Paper Discussion of important uses of technology and assistive technology in long term care settings

• Discuss that to staff shortages, an increase in baby boomers, and voices from business and government, technology must be an important consideration for care of the elderly.

• Offered both research ideas and novel possibilities for technology in long term care, including a robot named RoBear in the care of Dementia residents.

• Focus only on how technology needs to be used in long term care not on whether we ‘should’ use technology as a replacement for care providers.

• Did not include a discussion of how care providers play a role in improving care in a technological age.

• Ethical dimension was not considered.

Trefler, Fitzgerald, Hobson, Bursick, & Joseph (2004)

Pilot study: semi cross over design n=30

Examined the use of assistive technology (wheelchair systems intervention) by elderly residents

• Found that individually fitted wheelchair systems are beneficial.• Benefits included: increase in independent mobility, functional reach, feeling of well-being, and

satisfaction with technology.• Did not explore the impact of the care giver as a variable to buy-in by residence to use the

assistive technology. Was there an impact?



safety. The authors offered that it was important that care givers are forefront in the testing and selection of assistive devices in order to maximize the use and benefits of the technology. In spite of this, the authors did not extend their discussion to include how nurses and care aids may also be complementary to assistive devices. It would be interesting to understand the authors perspec-tive on whether an increase in personal interaction (i.e.: an increase in staffing) might improve issues related to injury and safety in long term care settings. In addition, rather than indicating the need to explore research related to Nelson et al. (2004) suggested cost analysis research would be important to explore.

Similarly, in the second discussion paper, Sheehan (2011) reported that communication and assistive technology is the wave of the future for residents living in long term

care. The following communication and assistive tech-nologies were showcased: intuitive computer interfaces, wireless data communication/networks, electronic health record systems electronic records sharing, telemedicine/telehealth, behavioural/activity monitoring systems, fall prevention/detection systems, tracking/wander manage-ment systems, medication adherence systems. Given this report was from a management industry guide for long term care it is understandable that a clear bias related to the need and important of communication and assistive devices in long term care settings. Sheehan (2011) stated the importance that caregivers are knowledgeable and use communication and assistive technology in order to improve the care of the elderly. However, the author did not offer any suggestions regarding how such technologies may enhance and improve interactions between residents and health care providers. In addition, the report did not include current research evidence.

In the third discussion paper, Long (2012) suggested that an interdependence may exist between Japan’s elderly and use of assistive devices in long term care. To conduct this discussion, Long (2012) used specific quotes related to assistive device use from interview findings from a 2003-2007 study of elder care under Japan’s long term care insurance program. She argued that partici-pants typically chose to use assistive technology to avoid over-dependence on caregivers in order to support the current long term care system belief that over-dependence is burdens the health system. It was important to the participants to use assistive devices if their health had begun to decline rather than not use them and become burdensome. The acceptance to use assistive technology helped participants (patients and family) to not depend on the care providers. Long (2012) indicated that given the push to support the concept of the ‘good’ old person

who minimizes dependency it is no surprise that a greater demand for assistive technology in long term care setting. She argued that more research is required to explore issues related to this over-dependence belief related to the state definition of the elderly resident in Japan. Although, the author clearly articulated a sociological issue it would also have benefited the paper to highlight in what ways caregivers could support resident to not feel that they are a burden on the health system.

Finally, Tak, Benefield and Feeney Mahoney (2010) discussed the plethora of possibilities for the use of technology and assistive technology in long term care. The authors argued that because of the increase in the numbers of elderly (baby boomers) in the United States and the strong voices from business, government, and health care consumers, it is imperative to improve and optimize the care of elderly. In addition to suggesting research possibilities related to efficacy of technologies used in long term care and improved quality of life as a result of technology use by the elderly, Tak, Benefield and Feeney Mahoney (2010) also offer suggestions for novel technology use in long term care. One example is the use of robotic care providers (named RoBear) with Dementia residents. Notwithstanding the importance of finding novel solutions to provide optimal care for residents in long term care, the authors neglect to ask the question: should technology replace the care of our elderly popu-lation to decrease health care costs? Furthermore, the authors could have explored the possible ethical issue to uphold personalized human interactions with our elderly population perhaps is just as important as decreasing health care costs. It would have enhanced the discussion if the authors included ways in which nurses and care aides could also optimize care in addition to assistive technology.


“...communication and assistive technology is the wave of the future for residents living in long term care.”


DiscussionThe use of assistive technology in long term care has not been clearly researched or discussed in relation to long term care. This gap is concerning given technological advances in robotics as a possibility for use with the elderly in com-munity settings (Carelli, Gaggioli, Pioggia, De Rossi, & Riva, 2009). It is clear that assistive technology plays an important role in the care of the elderly. However, it is not clear how or if health care professionals will/can comple-ment assistive technology nor is it clear if the elderly would be accepting of such changes to their care.

Although assistive technology should and could make an important contribution to the safety, security, indepen-dence, and quality of life for the elderly in these settings, there are some limitations to their use. As mentioned previously, it is not clear if the elderly will accept such changes. Some older adults view technology as estheti-cally unpleasant to the eye, or the sound of a running wheelchair motor as intrusive (Aminzadeh & Edwards, 1998). In addition, since many staff in long term care set-tings in Canada have a diverse ethnic background, their level of understanding of technology is not know.

Consequently, to facilitate the appropriate use of tech-nological devices in long term care settings, administrators and educators need to assess staff attitudes towards their use and their training needs in regards to the introduction of new technology into the facility in general or its use by a resident in particular. Based upon the knowledge gained through these assessments, educational sessions can be designed and implemented.

The use of any new or emerging technology into long term care settings also requires an examination of reimbursement. For instance, reimbursement policies for health promotive technologies devices need to be expanded to include aids that promote quality of life,

such as electronic wheelchairs and GPS monitoring footwear. Some equipment is relatively inexpensive, such as alarm systems, while others (e.g. video monitoring) is quite expensive.

Research possibilitiesAs stated earlier in this paper, we asked following ques-tion while conducting this critique: Are care practices provided in long term care settings optimal for the elderly population or does technology replace interactions with their registered nurse, nursing attendant, or care aide? As we reviewed and critiqued each article it became clear that we need to understand how health care providers define their role related to use of assistive technology in long term care settings. Such an inquiry requires a two step process. Step one will be to conduct an ethnographic study in a long term care centre to explore the cultural underpinnings related to the perceptions of technology held by nurses and other health professionals. Through interviews and participant observation individual per-ceptions and cultural norms can be highlighted with the intent to define roles related to technology and provided by nurses and like professionals for and with the elderly.

Our next step would be to conduct a survey of profes-sionals working in Canadian long term care settings to understand what they believe is most important about complementary practice that includes technology more than just wheelchairs, bed sensors, lighted floors, etc. The intent of the survey would be to examine the needs of those working in long term care to ensure optimal care for the elderly in relation to technology.

Education and practice possibilitiesResearch should inform practice. As the previous section indicates recent developments in technology are the sub-ject of some investigation destined to make an important contribution to the quality of life for older adults, residing in long term care facilities. Electronic sensors to registered falls or risks of elopement, bed alerts, pressure mats, even smoke and heat sensors, can improve the safety of the elderly in long term care settings.

ConclusionAlbert Einstein said, ‘It has become appallingly obvious that our technology has exceeded our humanity’. The ways in which health care professionals use assistive tech-nology with and for elderly patients is an important issue in long term care settings. Although current literature is limited, it is apparent that assistive technology comple-ments the care provided to the elderly by nurses and care aides, and other health care workers. Future research should explore whether technology and health care pro-fessions can be complementary, and whether health care professionals perceive their work with the elderly in long term care as a dying art that could potentially be replaced by technology.

Cydnee Seneviratne RN, PhDFaculty of Nursing, University of Calgary




referencesAgree, E.M., Freedman, V.A., Cornman, J.C., Wolf, D.A., & Marcotte, J.E. (2005). Reconsidering substi-

tution in long-term care: When does assistive technology take the place of personal care? Journal of Gerontology, 60B, S272-S280.

Al-Oraibi, S. Fordham, R., & Lambert, R. (2012). Impact and economic assessment of assistive technol-ogy in care homes Norfolk, UK. Journal of Assistive Technologies, 6, 192-201.

Aminzadeh, F., & Edwards, N. (1998). Exploring seniors’ views on the use of assistive devices in fall prevention. Public Health Nursing, 15, 297-304.

Carelli, L., Gaggioli, A., Pioggia, G., De Rossi, F., & Riva, G. (2009). Affective robot for elderly assistance. Studies in Health Technology and Informatics, 144, 44-49.

Courtney, K.L., Demiris, G., rantz, M., & Skubic, M. (2008). Needing smart home technologies: the perspectives of older adults in continuing care retirement communities. Informatics in Primary Care, 16, 195-2001.

De Craen, A.J. M., Westendorp, R.G.J., Willems, C.G., Buskens, I.C.M., & Gussekloo, J. (2006). Assistive devices and community-based services among 85-year-old community-dwelling elderly in The Netherlands: Ownership, use, and need for intervention. Disability and Rehabilitation: Assistive Technology, 3, 199-203.

Gosman-Hedstrom, G., Claesson, L., & Blomstand, C. (2002). Assistive devices in elderly people after stroke: A longitudinal, randomized study – the Goteborg 70+ stroke study. Scandinavian Journal of Occupational Therapy, 9, 109-118

Hoenig, H., Taylor, D.H, & Sloan, F.A. (2003). Does assistive technology substitute for personal assistance among the disabled elderly? American Journal of Public Health, 93, 330-337.

Long, S.O. (2012). Bodies, technologies, and aging in Japan: Thinking about old people and their silver products. Journal of Cross Cultural Gerontology, 27, 119-137.

Miskelly, F. G. (2001). Assistive technology in elderly care. Age and Aging, 30, 455-458.Nelson, A., Powell-Cope, G., Gavin-Dreschnack, D., Quigley, P., Bulat, T., Baptiste, A.S., Applegarth, S.

& Friedman, Y. (2004). Technology to promote safe mobility in the elderly. Nursing Clinics of North America, 39, 649-671.

Sheehan, P. (2011). Technology takes off in long-term care. Long-Term Living: For the Continuing Care Professional, 60(7), 66-70.

Statistics Canada (2006). A Portrait of seniors in Canada. Retrieved January 2, 2013 from http://www.statcan.gc.ca/pub/89-519-x/89-519-x2006001-eng.pdf.

Statistics Canada (2010). Population Projections for Canada, Provinces and Territories 2009-2036. Retrieved January 2, 2013 from http://www.statcan.gc.ca/pub/91-520-x/91-520-x2010001-eng.pdf.

Tak, S.H., Benefield, L.E, & Feeney Mahoney, D. (2010). Technology for long-term care. Research in Gerontological Nursing, 3(1), 61-72.

Trefler, E., Fitzgerald, S.G. Hobson, D.A., Bursick, T., & Joseph, R. (2004). Outcomes of wheelchair systems intervention with residents in long term care. Assistive Technology, 16, 18-27.

World Health Organization (2012). Connecting and Caring: Innovations for Healthy Aging. Bulletin of the World Health Organization. Retrieved November 4, 2012 from http://www.who.int/bulletin/volumes/90/3/12-020312/en/index.html.

Zwijsen, S.A, Niemeijer, A.R., & Hertogh C.M.P.M. (2011). Ethics of using assistive technologyin the care for community-dwelling elderly people: An overview of the literature. Aging and Mental Health, 15, 419-427.


17By Sophia Craig-Massey

The increased vulnerability of the elderly to disasters is well documented in disaster management literature (Bourque, Siegel, Kano & Wood, 2007; Fernandez et al., 2002), as are the numerous unique impacts of natural disasters on the elderly population. Bourque et al. (2007) and Fernandez et al. (2002) argued that the increased number of seniors choosing to live independently, added to the private sector’s expanded role in emergency man-agement, necessitate thoughtful and strategic emergency management for this important vulnerable group.

Articulated in this paper is how technological advance-ments in personal emergency response services (PERS) influence and shape the practice of disaster and emergency management. Firstly, I will describe the technologies used in PERS, their limitations, and new advancements to improve these assistive technologies. Secondly, I will describe the role of PERS in disaster and emergency

Personal Emergency Response Services (PERS) in disaster and emergency management

ifa global ageing 2013 VOL. 8 No 2 18personal emergency response services (pers) in disaster and emergency management

management (DEM). Finally, I will show how the increas-ing role of PERS in emergency management improves an important vulnerable population’s ability to access emer-gency response services quickly and effectively.

Private emergency response companies are becoming increasingly popular with elderly individuals wishing to live independently in their own homes. For a monthly cost, these companies provide personal emergency response services (PERS) to seniors, many of whom expe-rience chronic health problems, such as difficulty with mobility, and/or are fearful of needing emergency help and being unable to summon it (Fallis et al., 2007). Fallis et al. (2007) described PERS clientele: “PERS services, although used by many individuals with chronic condi-tions and disabilities, are primarily utilized by the well elderly as a means to safe, secure, independent living and to get help in a timely manner when necessary. Further, these services are marketed as providing reassurance and respite to families and caregivers” (p.3).

Personal emergency response systems (PERS) are a form of assistive technology designed for the elderly and disabled to support independent living by enabling quick access to assistance in an emergency (Lewin & Miguel, 2008). Other forms of assistive technologies, including computers, cellphones, traditional phones, personal digital assistants, home automation systems and home health monitoring systems, are also available to the inde-pendently-living elderly, but are not normally considered part of PERS package (Mann & Ferreira de Mello, 2010).

Typical PERS technologies can include a combination of a portable/wearable ‘help button’ device that is acti-vated by the wearer to call the emergency responder for assistance and/or a wireless communicator that enables communication between the subscriber and the emer-gency responder. Access to assistance for clients occurs

at the press of a button that alerts a 24-hour monitoring centre. The monitoring centre immediately follows up with the subscriber, and if needed, with one of the sub-scriber’s designated responders (family, friend, neighbour) or emergency services.

Improvements in PERS technology support the elderly and disabled to live independently by reducing mortality rates, hospital utilization and health-related expendi-tures (Lewin & Miguel, 2008). In addition, PERS users indicated they were satisfied with their ability to access emergency assistance more quickly, live independently longer, and perform everyday activities with greater confidence (Lewin & Miguel, 2008). A common theme identified by many PERS researchers was clients’ decrease in anxiety, contributing to a greater sense of confidence in living alone (Dibner, 1981; Fallis et al., 2007; Sherwood & Morris, 1981). Overwhelmingly, PERS is considered to be a very successful emergency response program and is recommended by advocates for the elderly as a means of living independently.

Despite high client satisfaction rates with traditional (call button) PERS systems, drawbacks to this technology exist. Since PERS subscribers pay monthly costs to the service providers, elderly and disabled individuals who are unable to afford costs will be excluded from this service. Many older adults feel stigmatized by having to wear the call button activator, which places the burden on the subscriber to wear the device at all times and press the but-ton when an emergency occurs (i.e., the subscriber must be conscious and physically capable). Finally, some older adults are hesitant to press the button when an emergency does occur because they either downplay the severity of the situation or are wary of being transferred to a long-term care facility (Young et al., 2009).

“Despite high client satisfaction rates with traditional PERS systems, drawbacks to this technology exist.”


(and effective) services for their clients (Fernandez et al., 2002). The availability of new technology could enable PERS to interface more effectively with the wider DEM system if DMs encourage collaboration with these private companies.

Importantly, the most vulnerable elderly individuals are often not those who subscribe to PERS. Such individuals lack the financial means to pay for the service, and often suffer from hearing loss or confusion. These individuals are forced to rely on traditional methods of summoning emergency response, such as via the telephone. If a large-scale disaster were to occur, it is likely that these individu-als would be assisted much later than those using PERS, further exacerbating their vulnerable status.

The role of PERS in disaster and emergency manage-ment is becoming increasingly important as more and more seniors rely on the emergency response capacity of these services. As technology improves, so does the ability of PERS providers to serve its elderly and disabled cli-ents. DMs will need to factor in the growing role of these technologies when planning for and managing DEM programs. DMs will need to ensure coordination and collaboration between PERS companies and the wider disaster management system.

Sophia Craig-MasseyMasters of Disaster and Emergency

Management Program at Royal Roads University in British Columbia

Formerly, country director for the British medical NGO Merlin

allowing for a greater variation in accent recognition, as well as speech to text capability. New generation ASR are able to provide a “simple, intuitive, and unobtrusive method of interacting directly with the PERS, giving the user more control by enabling him/her to choose the appropriate response to the detected alarm, such as dismissing a false alarm, connecting directly with a fam-ily member, or connecting with a call centre operator” (Young et al., 2009, p. 3). Finally, microphone sensitivity has been improved to enable communication from greater distances through the household. These technologies can improve PERS response rates, lower emergency responder costs, and free subscribers from the requirements to wear push button alarms.

The assisted living technologies used by PERS enable greater access to and information about an important vulnerable population during emergencies. Using the electronic case files of subscribers, emergency responders can provide better care while involving family members when appropriate. The technology enables the elderly and disabled to access medical emergency response quickly, easily and at a relatively low cost. Finally, as technological advances occur, greater opportunities are available to expand emergency response services beyond the traditional medical emergency responses offered by PERS (Leung et al., 2009).

Despite the many advantages of PERS, potential drawbacks could negatively impact holistic DEM. The PERS industry is unregulated and is only responsible for maintaining standards of service as set out contractually with its clients. There are no legal requirements for PERS companies to formally collaborate with established emer-gency management systems or to expand their services to include other facets of emergency management (mitiga-tion and preparedness), which could lead to more holistic

Traditional PERS technology lacks the ability to dia-logue with clients to gather information on the subscriber’s condition. False alarms caused by accidental button acti-vation are a significant problem and can account for as many as 85% of call-centre calls (Young et al., 2009, p.2). False alarms where first responders are sent to the home may further burden limited emergency resources and delay emergency responders from attending to true emergencies.

In order to address the limitations of the push-button communication system of traditional PERS, new tech-nologies are being designed to incorporate intelligent ‘home health monitoring systems’ with PERS (Young et al., 2009). New technologies include a combination of sensors, personal monitoring devices, and microphones which identify emergency situations and transmit infor-mation to caregivers and medical professionals regarding the emergency status of subscribers (Young et al., 2009). Young et al. (2009) described new advancements in PERS technology: “One novel technique developed employs computer vision technology (e.g., image capture via video camera) and artificial intelligence (AI) algorithms to track an image of a room and determine if the occupant has fallen. Alternatively, [other researchers] used arrays of infrared sensors to produce thermal images of an occu-pant” (p.3).

Another potential advancement that may soon improve the usability and efficiency of PERS is automatic speech recognition (ASR), which is comprised of a microphone array and speech recognition software to enable commu-nication and dialogue with an interfacing PERS. The use of an automated dialogue-based PERS has the potential to provide users with more autonomy in decisions regard-ing their own health as well as more privacy in their own homes (Young et al., 2009). New advancements in ASR technology have achieved improvements in accuracy,

personal emergency response services (pers) in disaster and emergency management

20

Experiment in social innovation in long term care

The Dutch national association for long term care, ActiZ, has initiated an Experiment of Social Innovation for long term care to develop a new innovative organiza-tional design that is intended to improve the quality of care, work and efficiency. BrabantZorg, a large care provider in the South of the Netherlands, is the pilot organization for the experiment. In the new organizational design, ICT and technology play an important role. It is used to increase efficiency in administration, but also contributes to facilitate and organize the informal care and social networks of patients. Remarkably, the implementation of technology is the result of the employees’ and clients’ need for technological solutions, and was not a strategic decision by the management. The result of the experiment will be a general methodology that should enable other care providers to initiate a similar innovation process in their own organization.

The project consisted of three pilots of three different nursing homes. The employees described their dreams for their own nursing home and have been provided complete

By Anneke Offereins and Wil van de Laar

ifa global ageing 2013 VOL. 8 No 2 21experiment in social innovation in long term care

autonomy to develop and implement their innovative ideas. They have worked on these designs together with the patients and their families. The new care concepts and organizational designs developed by the three teams are each different according to their dreams, and focused on different aspects of long term care. For instance, one of the designs is focused on team design (autonomous teams), whereas another team has developed the concept of family participation in dementia care. In all dreams, the client forms the central position, yet the pilot teams have different perspectives in order to realize them.

IntroductionIn The Netherlands, the healthcare demand is increasing rapidly due to the ageing of the population and technologi-cal developments. As result, there is a tight labour market and healthcare costs are rising. Subsequently, the quality of care is put under pressure. In the last few years, the health-care processes have been split up to a large extent and standardized in order to decrease costs. There are many managerial organizational levels which increases the need for coordination and control. Patients see many different faces on a daily basis, resulting in an impersonal relation-ship with professionals. Care professionals experience high working pressure and don’t feel professional autonomy to do their work. This leads to stress and demotivation. These developments often form the most important reason for care providers to improve and innovate. In addition, for BrabantZorg, the major stimulus for the experiment is the client’s request for more demand-driven care and personal attention from the employees. This resulted from an inter-nal inquiry among clients in 2011.

Employees, staff members and patients have rearranged the care in three different nursing homes. It concerned the delivered care, but the residential conditions as well.

Everything was evaluated from the perspective of the patients and their family.

The main goals of the experiment were:1. Development and implementation of a new orga-

nizational model for care that results in a proven improvement of quality of care, labor and (business) operations; and

2. Methodology for social innovation based on the knowledge and experience from the experiment for other care organizations.

Methods

The start: Dreams for the futureAs a start, the teams had inspiring sessions where new ideas were born from different perspectives. Employees were able to share their dreams about the best care and living conditions for clients, and how to cooperate and learn as professionals. Each team made a rough sketch for a new care model based on their dreams. The new models were presented to and discussed with clients and their families. They were asked to express their wishes for change, related to the new care, living conditions and daily activities. The models were extended and adapted accordingly.

In the newly designed care models, clients and family are positioned in the center of attention. They determine what kind of care is given and also how, and all along, the family members are participating in the daily care in the nursing home. For example, one of the starting points was the notion that the client is literally at home in the nursing home, and that family should be able to visit the client easily. Just like they did when the clients still lived at their own homes. Families should be able to comfortably chat or help with some small tasks. Employees are expected

“...the family is engaged and involved even before the client comes to live in the nursing home.”


to work as if the client is at home (the employees are the ‘guests’; clients don’t live at the employees’ ‘workplace’). In addition, the family is engaged and involved even before the client comes to live in the nursing home. A digital community is considered to support involvement of family and clients.

Design of the new organizational modelFollowing the rough sketches, concrete steps were taken towards the building of a new model of care, with an associated work organization. Some examples of these concrete steps were:•The composition of smaller teams with more self-

management, concerning a smaller group of clients; managers will have a coaching role;

•Stimulating the participation and control of the client and his or her family by family gatherings, in which the employees have an important role;

•To set up a digital family network, which, in a very practical way, allows them to organize their involve-ment and participation themselves;

•An easy way of administration that provides the client more insight into reporting. In the preliminary phase, this was developed by means of making notes on paper; now teams are using iPads that they carry with them to the clients’ rooms.

Implementation of the new organizational modelIn early 2012, the actual implementation of the new care models in daily practice started. The employees started their new way of working in small-scale teams. With some “trial and error” they gradually started to enjoy their autonomy while at work, all in consultation with the client and family. Employees and managers are, now,

increasingly growing in their new roles. The use of more digital solutions, such as the limited reporting and admin-istration, are being implemented step by step.

In the summer of 2012, the experiment was com-pleted. However, the growth process and development of the teams and their innovations will not stop and will be continued by the teams themselves. The team manager will play an important role in supporting and coaching the teams in this process.

FindingsThe results of the experiment will be available in 2013. The preliminary outcomes of the experiment have been presented by Wil van de Laar, Manager of BrabantZorg, on September 24, 2012, in the AAL Forum workshop ‘Navigating between active ageing and frailty’.

ConclusionThe experiment was finished in the summer of 2012. The results of the measurement will be available in 2013. This experiment of social innovation is unique in that the innovation is initiated and developed from bottom upward, by the employees themselves. Managers, Board and back-office are required to react on the change pro-cess started from the work floor, and need to reflect upon their roles and adapt it in order to facilitate the process. The project combines organizational design with change and implementation. This feature makes the experiment a unique and valuable experience to learn from.

Dr Anneke OffereinsResearcher,

The University of Applied Science of UtrechtOnderzoeker Kenniscentrum Sociale Innovatie

HU Hogeschool Utrecht Heidelberglaan 7, 3584 CS Utrecht

Kamer 4.025 Postbus 85397, 3508 AJUtrecht

Dr Wil van de laarManager BrabantZorg

Onderzoeker Kenniscentrum Sociale Innovatie HU Hogeschool Utrecht Heidelberglaan 7, 3584 CS

Utrecht Kamer 4.025

Postbus 85397, 3508 AJUtrecht

experiment in social innovation in long term care

23

Over the past fifteen years, there has been much interest in research in personal emergency response services, especially when indicated by health or social cir-cumstances (Roush, & Teasdale, 1997) and on technol-ogy assisting elders to live independently in their places of residence as long as possible (Glascokc & Kutzik, 2006). Remote monitoring systems have led to fewer and shorter hospital days and to lower overall costs (Barrett, 2007). First generation electronic activities of daily living report-ing systems (e-ADLRS) were developed to gather data unobtrusively on the well-being of elders living alone and to send reports to clients.

A second-generation e-ADLRS that has been devel-oped by Healthsense builds on these experiences and brings a broader range of services to users than before. Developed with a peer reviewed grant from the United States National Initiative of Health, Healthsense has now entered into studies in selected sites.

eNeighbor: A preventive system monitoring residents’ behavior for health services

By Robert E. Roush

FiGuRe 1. Schema of sensor placement in a typical apartment in the study site

ashlar village - smart apartment sensor placements

ifa global ageing 2013 VOL. 8 No 2 24eneighbor: a preventive system monitoring residents’ behavior for health services.

From a technical description perspective, eNeighbor employs strategically placed sensors to monitor residents daily activities: e.g. tilt sensors on medicine boxes moni-tor medication usage, motion detectors on walls detect movements within rooms, contact sensors on kitchen cupboards and refrigerator doors monitor whether the resident is eating regularly, toilet usage is also monitored; pressure sensors on beds detect when residents get in or out of bed; and home-or-away sensors detect when a resident leaves or returns (figure 1).

Using algorithms to predict residents’ behavior based on their individual habits, the technology’s operating sys-tem analyzes correlated data from the sensors and issues an alert when results indicate help is needed. The effi-cacy of eNeighbor is being tested in a two-year study at Quinnipiac University to determine whether 34 monitor-ing long term care residents remain independent longer, delay hospital and nursing home admission, and attend

better to their own basic needs than a comparable group of 34 nonusers (Albert J. Sensor technology, 2009). A related study on eNeighbor revealed that users and their caregivers held a higher sense of security with the system in place than nonusers (Leiland, 2009).

Robert e. Roush, ed.D., M.P.H. Director, Texas Consortium Geriatric Education Center;

Associate Professor, Geriatrics Section, Department of Medicine

The Roy M and Phyllis Gough Huffington Center on Aging

Baylor College of Medicine

referencesAlbert J.Sensor technology studied at Connecticut retirement commu-

nity. (2009). Future Age. Retrieved from http://www.leadingage.org/article.aspx?1d=6750%20

Barrett, L. L. (2007). Healthy2Home. AARP Knowledge Management. http:// assets.aarp.org/rgcenter/il/healthy_home.pdf

Glascock, A. P. & Kutzik, D M. (2006). The impact of behavioral monitoring technology on the provision of health care in the home. Journal of Universal Computer Science, 12, 59-79.

Leiland, J. (2009). Sensors help keep the elderly safe, and at home. Retrieved from www.nytimes.com/2009/02/13/us/13senior.html?_=1&emc=eta1

Rousch, R. E., & Teasdale, T.A. (1997). IAGG, Gerotechnology, Journal of Applied Gerontology, 16, 355-366.

“Remote monitoring systems have led to fewer and shorter hospital days and to lower overall costs”

25

Long term care settings present distinct challenges both during and after manmade and natural disasters, because their residents have serious physical and/ or cognitive impairments and rely on health care staff for support with activities of daily living and require 24-hour nursing supervision.

In Canada, the frailty and medical complexity of facil-ity residents is very different from what it was a decade or two ago. Residents are admitted when they are closer to the end of life. They are more functionally dependent and require greater assistance with activities of daily living (Frohlich et al., 2006; McGregor et al., 2010; Smith et al., 2009). Many have a confirmed diagnosis of Alzheimer’s or a related dementia. The effects of Hurricane Katrina in the United States in 2005, demonstrated the vulnerability of older residents during and after disasters. Evidence

Technology: its promise for effective disaster management in long-term care settings

By Sandra P. Hirst

ifa global ageing 2013 VOL. 8 No 2 26technology: its promise for effective disaster management in long-term care settings

suggests that long term care settings receive substantially less support from response agencies during disasters (Brown et al., 2007; Dosa et al., 2007; Hyer et al., 2006; Laditka et al., 2008).

Until relatively recently, “technology” and “long term care” were not often used in the same sentence. While this may be a slight exaggeration, one would be hard-pressed to argue against the perception that the long term care industry is a late adaptor of technological advance-ments. However, provider demand, vendor interest and an increasing number of both natural and manmade disasters are changing all that.

Needs of long term care settings during disastersIdentified in the literature are a number of common prob-lems faced by long term care settings during disasters: inability to track and monitor older residents; loss of power for brief or sustained periods of time; lack of suffi-cient and appropriate transportation available for evacu-ation of residents; disruption of communication systems with breakdowns in telephone and cellular services; lack of food, water, medications, oxygen equipment, and other medical and general supplies; lack of sufficient numbers of staff, and lack of adequately prepared staff (Deeg et al., 2005; Dosa et al., 2007; Laditka et al., 2008; Saliba et al., 2004).

Short term recovery to a disaster restores vital services and systems to long term care settings. This may include temporary food, water and shelter for older residents, assuring they have medical care and prescribed medica-tions, and/or restoring electrical services through emer-gency generators. Sustained power outages can impact an older resident’s life support equipment, such as an electric wheelchair, or disrupt the elevators, which may

prevent effective evacuation of residents from a facility. The effects of the disaster may remain, but the immediate threats can be halted, and both basic services and vital needs restored. Long-term recovery restores all services to normal or enhanced levels. It can take several years. These challenges and the recovery period are the impetus for the development and use of technology within these same settings. Yet, substantive work remains to be done in this area.

Challenges and opportunities for technology within long term care settingsThere are challenges that face those of us who work in and have a commitment to those older adults who live in long term care settings, if we wish to integrate technology into these settings.

Lack of technological sophistication Currently reported health care and social service data does not include information on technology support that is presently available in long term care settings. The lack of province by province (or territory) data prevents the investi-gation of national trends concerning usage of technology in general, and in disaster response management in particular. This information is essential as the building blocks for the use of technology to support older adults before, during, and after disaster situations. Findings from a number of studies about technology used in long term care settings indicate that few technology systems are being used in these settings. In addition, they identify that computer use in long term care settings is often limited to administrative business applications (Alexander, 2008). Yet, findings also suggest that there are a growing number of long term care

settings that are using sophisticated technologies to sup-port resident care management, but few within the context of disaster response.

This has practical implications for disaster manage-ment. Administrative staff remain either unaware of or are perhaps resistant to new technologies that could enhance the mandate of their settings. This lack of awareness can be attributed, perhaps to a lack of knowledge of technol-ogy and its potential benefits. In addition, administrators who have had previous problems using technology are uncertain about whether these technologies are right for them, and with misconceptions about their own need for this technology, they are likely to be resistant to trying new high-tech devices within their sites (Yu et al., 2009). The complexity of simplifying technology use to cater to a broad spectrum of users, and their varied levels of

“Until relatively recently, “technology” and “long term care” were not often used in the same sentence.”


information about an older resident, at the required time, and displayed logically. Maintaining treatment for com-mon conditions such as arthritis, cardiovascular disease, diabetes, cancer and other diseases is often dependent upon consistency and timely access to health care, and upon documented medical treatment routines. When disasters compromise health resources, staff may find it difficult to manage the older resident’s condition. Information sharing between first responders and monitoring agencies can be difficult, due in large part to a strong reliance on paper

Tracking, monitoring, and meeting the needs of older residentsOlder residents potentially experience disruptions in both quality of life and medical care for preexisting conditions during disaster situations. Past disasters in the United States have demonstrated a lack of a centralized medical record tracking system for evacuees, delaying the provi-sion of health services for frail older residents (Hyer et al., 2006). During a disaster, it is essential to have the right

competence and comfort with the technology, is an ongo-ing challenge.

Disaster personnel need detailed information concern-ing pipelines, building layout, electrical distribution, sewer systems of the long term care facility, and other key structural components. Given this specific requirement, responders must gain access to a number of depart-ment managers, their unique maps, and facility-specific data. Most disasters do not provide time to gather these resources. This results in responders having to guess, or make decisions without adequate information. This costs time, money, and perhaps lives. The use of a geographic mapping system could map out the long term care facility in terms of structure, equipment and so forth. Disaster management staff could use this system to accelerate restoration of needed services.

There is a dearth of outcome studies demonstrating the value of technologies, especially with regard to their cost-effectiveness and efficiency in general, and in long term care settings in particular. Research is needed to quantify the value that disaster technology can hold for older residents and settings. The few studies conducted have been on a small scale, leaving researchers question-ing whether larger-scale studies would produce similar results. Without such evidence, administrators are unable to reach a consensus on the value of disaster management technologies within their settings.

Administrators of long term care settings will be hesi-tant to invest in operational processes that make the most of disaster technologies, unless they have financial or other incentives (for e.g. legal, mandated by health authorities) to do so. Technology costs, including the cost of the devices and the infrastructure needed to support them. In health-care, technology is often cited as the reason for increased costs of delivering services (Kern & Jaron 2003).

technology: its promise for effective disaster management in long-term care settings


based systems or on a computer system where data is not accessible outside the facility.

Developing a cost-effective package of monitoring communications technology that will allow superior communication and treatment response, is essential. This might include advanced GPS vehicle locating, which can be incorporated to track (in real time) the location of transportation vehicles. It would permit monitoring of the location of residents and a response to any situa-tion that might arise during their transportation to other settings. Requirements for the success of this technology include the interconnectivity between different informa-tion systems to guarantee completeness and continuity of information between long term care settings, transfer locations, and care documentation systems. This will mean revisiting existing governmental legislation to ensure that they permit electronic access and sharing of information, and improving interconnectivity between all types of technologies that will be found in long term care settings in the future.

Meeting communication and information needsEstablishing reliable communication networks is essential for effective disaster management. A global position-ing system (GPS) can be located within long term care settings, which in response to a disaster, can be used to identify the type and amount of damage. GPS can display (through the primary database) overall current damage assessment as it is conducted, and the geographic area near the long term care facility. Laptop computers can update the primary database from remote locations.

The GPS can provide one of the primary components for computer facilitated dispatch/ response systems. Response units based at fixed locations can be selected

and routed for disaster response to the long term care facility. The closest (quickest) response units can be selected, routed, and dispatched to a disaster once the location is known. Depending on the disaster, a GPS can provide detailed information before the first units arrive. For example, during a long term care facility fire, it is possible to identify the closest hydrants, electrical panels, hazardous materials, and floor plan of the facility enroute to the disaster site.

A challenge for long term settings before or during a disaster is contacting staff and family members due to the limited number of phone lines or cell phones. Family members, who are often concerned about the safety of their older member, will attempt to contact the facility. How will technology address the need for communication when the usual lines of communication are not operating, or a request has been issued to avoid phones? Improved interconnectivity between social networks and home-based technologies (such as cell phones, email) helps staff reach out faster to inform families of disasters, and this is one outcome of technology.

Moving forward to address these challengesThe degree to which technology is ready for adoption within long term care settings is open to discussion. The following suggestions are proposed for further explora-tion by disaster management personnel and long term care setting administrators. To make technology useful for and usable by these settings creates challenges and opportunities for key stakeholders including: the research and design community, facility administration and staff, and older residents, and their families.

Designers of technology support need to work closely with facility administrators throughout the design process

“During a disaster, it is essential to have the right information about an older resident, at the required time...”



in order to learn their preferences, the capabilities of the facility’s structure in relation to technology adoption, and how products and services can be designed to promote their use, specific to disaster management. Learning from their feedback would not only improve the design of the technologies, but also enhance the processes of technical support.

Technology researchers need to carry out adequately scaled demonstration projects that incorporate health economics and policy perspectives. As Wells (2003) stated, “In the past, the majority of health care interven-tions have not been evaluated from an economic perspec-tive” (p.22). Vigorous studies are needed to quantify the value of these technologies towards reducing the impact of disasters within long term care settings, and to encour-age their widespread and effective use. Independence from technology manufacturers should be emphasized to add to the credibility of research findings. Identifying and learning from the “best practices” selected from among already ongoing efforts, as well as the need to continue to plan and execute additional outcome-oriented field pilots and larger-scale demonstration projects, is recommended.

There is a role for public policy to raise awareness about existing disaster management technologies and their value to long term care settings and older residents. Governments might convene a meeting of technology companies, consumers, and administrators, to define the challenges facing the use of disaster-specific technologies in long term care settings and to develop recommenda-tions to address these issues. Raising awareness about effective disaster management technologies for long term care settings can also be done through a variety of credible influence channels, including adult children, physicians and other health care professionals, and gerontological associations, such as the International Federation on

Ageing. No single organization can by itself fully inte-grate disaster management technology into long term care settings.

As a consensus builds concerning the need to protect older adults during disaster situations, advocates, legisla-tors, and policy makers will require a greater understand-ing of technology and its application possibilities within the context of long term care settings. Efforts to develop a set of best practice guidelines that enable health informa-tion exchange by linking data from different care related systems, must be accelerated to enhance efficiency of care, as well as the safety of older residents. Such guidelines will need to recognize the diversity of long term care set-tings, in terms of their organizational structure, funding models, and staff requirements to name but a few factors.

Enhanced technical support that is accessible and suit-able for facility administration to promote the use of the technology is needed. On-line and hands-on training for staff, and opportunities to experience the technology in the field, are suggested. Staff is more likely to accept technol-ogy if they receive hands-on and on-going training, as well as responsive and easy-to-access technical support.

In spite of the emergence of technology, its use within long term care settings has not to date been adequately addressed. From sophisticated safety and disaster response assessment capacities, to advanced communica-tion technologies with the ability to account for large scale populations to networks of responders, the interface of technology and long term care settings has the potential to meet the health and safety needs of older residents. A proactive, realistic, and comprehensive approach is needed to respond to disaster management within the context of long term care settings.

There is a word of caution to be added. With the intro-duction of technology into long term care settings, there

needs to be evaluation of its effectiveness. Evaluation is an investment in the facility’s ability to make sound operational decisions.

So in revisiting the commentary above, technology holds promise for effective disaster management in long term care facilities. The responsibility lies with us to examine how we can keep this promise.

Sandra P. Hirst RN, PhD, GNC(C)Associate Professor

Director, Brenda Strafford Centre for Excellence in Gerontological Nursing

Faculty of NursingUniversity of Calgary



30By Kelly Fitzgerald

With advancements in technology, have societies improved their response to older people in natural disasters?

It seems that you cannot go for more than a few days without learning about new earthquakes, landslides, floods, and other natural disasters around the globe. Disasters are not new to us and some would argue they are beginning to increase in numbers and sizes. Others would argue that things have not changed dramatically and that the media has helped to promote the devastating effects of disasters in a way that have brought disasters to the forefront of peoples’ minds. The financial impact of disasters has also significantly increased because of highly developed communities in disaster prone areas such as beaches. Regardless which side of the argument you sit on, disasters appear to not have a major impact on the way societies prepare and respond to older adults in disasters.

ifa global ageing 2013 VOL. 8 No 2 31with advancements in technology, have societies improved their response to older people in natural disasters?

To use a very recent example, although Hurricane Sandy was quite devastating to the northeast region of the United States, it did not present any new information on how older people fare during disasters. The following are a few simple examples of how societies have not improved in their disaster response to older adults.

Often you see mass destruction of lower income devel-opments along coasts affected by major disasters such as hurricanes and tsunamis. Haiti, countries bordered by the Indian Ocean, and the United States Gulf Coast were some recent key examples. More recently, Hurricane Sandy affected a diverse population of both higher and lower income communities. The coasts of New Jersey, New York, and Connecticut, all of which have densely populated areas, are often associated with higher income residents. With higher income comes access to potentially more post-disaster resources such as improved communi-cations and technology. So if this is the case, then why

were so many older people adversely affected by Hurricane Sandy in this region alone?

According to an early report by the Huffington Post, over a dozen older people perished in Hurricane Sandy (Neumeister, 2012). The article speculated that some older people did not leave their homes because they were tired or in poor health, while others could not because they relied on assistive devices such as wheelchairs. The ones of high concern were those who died for unnecessary reasons such as power cuts that left oxygen machines, used in indi-vidual homes, without electricity. With the advancement of technology and all the lessons learned from other major disasters such as the Indian Ocean Tsunami and Hurricane Katrina, why are older people still dying because of basic technology failures? This is especially disconcerting when technologically advanced societies with a large proportion of older adults, such as Japan, are significantly impacted by massive disasters such as the 2011 earthquake and tsunami.

Three weeks after Hurricane Sandy and the subsequent snow storm that followed, there were reports of poor and older people still without power. High rises were commonly found in the affected areas. This means that older residents, who did not have power, were potentially unable to leave their apartments if they resided on higher floors. This is not a new phenomenon. For example, similar stories surfaced following the 2004 multiple hur-ricanes in Florida. Elevators cannot run without electric-ity, leaving residents with disabilities stranded in their homes – or away from their homes. Why has technology not advanced enough to ensure continuous access to homes post-disaster?

Although humans can survive for long periods with-out running water, they cannot survive without water. Societies that rely on running water often do not have

access to other water resources, like wells, when running water supplies are cut off. Bottled water is an option – until bottled water supplies are diminished. Recall the older person living on the twentieth floor of a high rise building without a functioning elevator? Now imagine how that older person will manage to carry multiple bottles of water or one heavy bottle of water up to his or her apartment. Disaster response groups know that water is an essential resource that disaster victims often require. Therefore you will see water distribution areas pop up in disaster areas. The problem, though, is that older people may not be able to physically access those distribution sites. Even if they do, will they be able to carry the bottles home or even simply open the bottles? Why have technol-ogy and disaster services not advanced enough to ensure access to clean water post-disaster?

All of the above questions are posed to illustrate some simple issues that basic advancements in technology might be able to improve upon disaster response while meeting the needs of older adults in disasters. Often the needs of older adults do not differ from anyone else – for example access to water. What does differ is that older people may not be able to actually use that resource because of physical or mental changes that are associated with aging. Simple solutions could be developed to improve disaster response for older adults. For example, if water bottles are provided, a small hand-sized rubber mat could be made available to help grip the top of the bottle when the person tries to open it. Creative solutions such as this do not cost a lot of money and can sometimes be found in random disaster response activities. So why do we still keep making the same mistakes?

Reviewing the disaster literature starting from the 1950’s, advancement in disaster preparedness and response for older adults has been slow (Fitzgerald, 2008).

“...of high concern were those who died for unnecessary reasons such as power cuts that left oxygen machines...without electricity.”


Although the study of how disasters affect people (in general) has grown, research on how disasters impact the older population has been underdeveloped and relatively small (Ngo, 2001). Events like Hurricane Katrina did help to improve some disaster response activities. For example, SWiFT, a rapid health assessment tool that can help triage older adults in shelters was developed and tested (Mixson, 2007). Unfortunately seven years later, research, what little there is, still shows that older adults have not significantly changed their responses to disasters and that disasters impact older adults in a similar way as they did decades before. Recent news articles following Hurricane Sandy provided evidence of this. However, we will not know the true impact of Hurricane Sandy on the older population for some time. Therefore there is still hope that evidence will appear to show that response to older adults has improved.

The final point of this paper is to emphasize the fact that while disasters can affect all ages, older, vulnerable adults can be disproportionally affected by disasters. Societies have still not advanced as far as they could when it comes to disaster preparedness and response to older adults. It is encouraging to learn that on a global level, the United Nations 2015 Millennium Development Goals (MDGs) include targets such as “In cooperation with the private sector, make available benefits of new technologies, espe-cially information and communications” (United Nations, 2012). An improvement in technology not only could benefit communities and governments as they share infor-mation on how to prepare and respond to older adults in disasters, it also provides the opportunity for older adults to access critical information. Another MDG target, “Integrate the principles of sustainable development into country policies and programmes and reverse the loss of environmental resources”, highlights the need to address

climate change (United Nations, 2012). Climate change, some would argue, has a significant effect on the number and size of disasters. According to the United Nation’s report The Millennium Development Goals Report 2010, “Investments in disaster risk reduction can yield long-term benefits, including progress on the MDGs.” The United Nation’s MDGs illustrate the need to look at this problem on a global level. Unfortunately, why is it taking so long for local communities, especially among developed nations, to understand the inherent need and to actually improve disaster preparedness and response for older people? Technological advancements happen every day. It is time to focus some of that advancement on pre-paring for disasters and responding to the needs of older disaster victims. Natural disasters are not decreasing, but the older population is increasing. The need is there. Therefore it’s time to re-focus resources and consider improving disaster management for the older population.

Alternatively, maybe the problem is that societies rely too heavily on high level organizations to develop strate-gies for technological advancement. Many societies have become so dependent on technology to forge advance-ments, that often simple human power at the grassroots level is forgotten as an excellent resource. ake for example older people. Wisdom and experience could be argued as a far more advanced tool compared to technological devices. Older adults are a massive resource that commu-nities could tap as they look to improve disaster prepared-ness and response. Some communities are beginning to do just this. Instead of waiting for technology to advance enough to ensure the safety of older adults in disasters, societies should consider utilizing the precious resource that so many communities will have an abundance of over the next several decades – older people.

Kelly Fitzgerald, PhDSenior Scientist & Affiliated Gerontology Faculty

Western Kentucky University, United [email protected]

andGuest Scientist

University of Zurich, [email protected]

referencesFitzgerald, K. (2008). Evaluation of the Preparedness of

Massachusetts Nursing Homes to Respond to Catastrophic Natural or Human-Made Disasters. (Doctoral Dissertation). University of Massachusetts Boston, Boston.

Mixson, P. (2007). From Houston--the SWiFT tool and recommen-dations for best practices. Victimization of the Elderly & Disabled, 9(6), 81, 90-83.

Neumeister, L. (2012, November 28). Hurricane Sandy Deaths: Storm was Cruel to New York’s Elderly. Huffington Post. Retrieved from: http://www.huffingtonpost.com/2012/11/03/hurricane-sandy-deaths-storm-new-york_n_2068812.html

Ngo, E. (2001). When disasters and age collide: Reviewing vulner-ability of the elderly. Natural Hazards Review, 2(2), 80-89.

United Nations. (2010). The Millennium Development Goals Report 2010. New York: United Nations.

United Nations. (2012, November 28). We Can End Poverty 2015 UN Millennium Development Goals. Retrieved from: http://www.un.org/millenniumgoals/global.shtml

with advancements in technology, have societies improved their response to older people in natural disasters?

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