R e v i e w

Gerontechnology in perspective Herman Bouma Emeritus professor Technische Universiteit Eindhoven, the Netherlands E: [email protected]

James L. Fozard School of Aging Studies, University of South Florida, Tampa. FL 33612, USA E: [email protected]

Don G. Bouwhuis Faculty of Technology Innovation Management Technische Universiteit Eindhoven, the Netherlands E: [email protected]

Vappu Taipale October 2007, Vol 6, No 4 Director-General National R&D Centre for Welfare & Health Stakes P.O.Box 220, 00531 Helsinki, Finland E: vappu.taipale @stakes.fi

190 H.Bouma, J.L.Fozard, D.G.Bouwhuis, V.Taipale. Gerontechnology in perspective. Gerontechnology 2007; 6(4):190-216. Gerontechnology is directed at harmoniz- ing two separate developments in present society: the increasing number of older persons, called the ageing society, and the technological innovation of products and services, called the digital era. Harmonization directs technological innova- tion to the ambitions, purposes, and needs of ageing persons. The knowledge ba- sis of gerontechnology is provided by combining insights into processes of ageing individuals and ageing societies on the one hand and insights into new techno- logical options on the other. The combination constitutes the field of gerontech- nology. The present paper reviews a number of developments since the 1990s in the fields of gerontology, technology, and within the interdiscipline of gerontech- nology itself. The cross-fertilization of gerontology and technology leads to a new matrix, in which progress, insights, and methodology specific to gerontechnology can be plotted. A selection of these is made on the grounds of their relevance to gerontechnology, irrespective of their initial scientific label. The review is not specifically directed at products and services suitable for older persons, although a few are mentioned in passing. The present knowledge base in gerontechnology is ready to be utilized for harmonizing demographic and technological develop- ments.

www.gerontechjournal.net Keywords: gerontology, technology, ageing, matrix, review, innovation Gerontechnology studies the interaction simultaneously, their progress is mostly of two dynamic developments in soci- uncoordinated. Until now, technology ety occurring for the first time in history has largely ignored the ageing population and in many countries: (i) the increasing whereas quite a few members of the age- preponderance of older people, due to ing population had neither the desire nor increased longevity combined with a de- the skills to make use of the many new creased birth rate, and (ii) the dynamics facilities. Nevertheless, technology and of technology, globalisation, and the rapid demography are bound to interact. Facili- spread of a multitude of new mass-prod- tation of this uneasy encounter is the core ucts. While the two developments occur of gerontechnology1-3.

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Let us first focus on the ageing popula- embedded logic, globalization in direct tion. In industrial countries, average life communication, mobility, and transport. expectancy has been increasing for over a Recently, the high pace of technological century, leading to a substantial increase change has accelerated further: the inter- in the 65+ population, now standing at net and evolving communication protocols roughly 15%. Together with the decrease invite the creation of ever more sophisti- in the number of children, the percentage cated networked applications7,8, mobile will rise to about 25% in the year 20254. phones with ever more functions, digital The older population will be in far better cameras, satellite TV, and widely available health than a few generations ago: substan- navigation systems; all these emerged in tial numbers will now reach 75-80 years of the last 15 years or so. Developments in age with minor inconveniences only, no- technology exert both positive and nega- tably restrictions in mobility. Governments tive influences on the living environment have recognized the trend toward an age- and on society, and substantial effort is be- ing society, but rather than welcoming and ing directed toward increasing advantages promoting the tremendous opportunities, and reducing dangers. Whatever the ad- including those offered by new technolog- vantages or disadvantages, what is relevant ical applications, the political response is here is that the developments appear to be to concentrate on expected problems such driven by autonomous forces outside the October 2007, Vol 6, No 4 as increased pension burdens and the fi- control of national and international gov- nancing of increased care provisions. This ernments, organizations, and business. may be an unhappy after-effect of the ear- lier prevailing sentiment that equated old The core of gerontechnology is to study 191 age with frailty and withdrawal. It appears the interaction of the two developments. that this erroneous viewpoint persists de- Ageing people are studied from the view- spite the rising influence of ageing people point of their living amidst a dynamic in society in the years to come5. The reality technological society. For them, technol- is that the majority of 65+ people will be ogy is not an end in itself but a means to in good or excellent health, called ‘3rd age’, a better life. Technology is studied from and a far smaller number of older people the viewpoint of its potential to improve in moderate or frail health, called the ‘4th the life of ageing people and to facilitate age’ 6, particularly in the final years of their their participation as full citizens in their life. Demographic projections indicate that own society9-12. in industrialized as well as most industrial- izing societies, both categories will grow Developments since 1990 substantially for many years to come. In The subject matter of technology and age- the 75+ age category there are twice as ing has been on the research agenda for many women as men. This is relevant to quite some time. Before 1990 or so, the attitudes concerning technology innova- combined consideration of technology tions. In most non-industrialized countries and ageing focused largely on ergonomics, www.gerontechjournal.net on the other hand, young people tend to or human factors, for ageing persons and be demographically dominant. on assistive technology for people with physical restrictions13-15. This reflected the Our second focus is technology. Arguably, general feeling at that time that the aged the secular changes in industrial society and the handicapped could be viewed as over the last 150 years have been driven a single category of people dependent on by developments in technology, such as help and care. new products, new services and their in- frastructure, mass production and mass dis- From the early nineties, the scope wid- tribution, new materials and ever present ened substantially, witness the emerging

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concept of successful aging16,17 and the de- chain already well established in business velopment of gerontechnology1,9,18-24. The and industry. original themes stayed in focus, but the goals were set at a higher level. The term The interdisciplinary infrastructure sub- ‘the handicapped’ was replaced by the serving the field has been extended as term: ‘people with a certain restriction’, to well, both as special compartments of indicate that it is not the particular restric- existing organizations in human factors tion that defines preferences, ambitions, and in gerontechnology itself. This is also and identity of a person, whether young reflected in the relevant handbooks27,28. or old25. As for those restrictions, we now A new journal appeared on technology want to concentrate on the extent to which and ageing29. The newly named field these can be levelled or compensated for of gerontechnology gave rise to inter- by specific technologies, just as specta- national congresses: Eindhoven 199119, cles compensate for poor eye sight, for ex- Helsinki 199621, Munich 199922, Miami ample. Ergonomics or human factors for 200230, Nagoya 200531, Pisa 2008; to ageing individuals stayed on as well, but the European projects COST A5 and the got to a higher level of development by educational GENIE project32 followed by recognizing the dynamic and widely vary- a textbook9, to the establishments of the October 2007, Vol ing6, No 4 nature of the ageing process and de- International Society of Gerontechnology veloping methodologies in which ageing in 1997, the quarterly journal Gerontech- persons played an active part. The main nology as from 2001, the gerontechnology achievement of gerontechnology and re- discussion website33, master classes since 192 lated fields such as in human engineering 2006, and many regional initiatives and was the insight that the ageing persons workshops. themselves come first and that their am- bitions and needs should define the R&D System approach and an impact matrix agenda. If they wish to be independent The environment in which the young and and autonomous, let us elaborate what the old live has been immersed in technol- this means for the home environment. If ogy for well over a century. It follows that they wish to communicate, let us see what old people are quite at ease with techno- internet, the web, and the mobile phone logical commodities as such. It is the high can contribute. If they wish to travel, let pace of technological innovations that us work on easy public and private means poses difficulty to many ageing people, of transport and the entire infrastructure who have to adapt to the ever dynamic that comes with it. If they wish to learn environment. To the extent that technol- to use new technology, let us develop ef- ogy is functional to meet human purposes, fective learning methods that will enable the functional result can be portrayed as a them to do so. Technology developments systems outcome, where the system repre- will teach us the domains where innova- sents the total of the human user and his/ www.gerontechjournal.nettive products and services are entering the her technological environment (Figure 1). realm of serious options26. Both the system and the user are dynam- ic: they are in constant change. The term A selection of insights and methods that ‘ageing’ catches the dynamic nature of the have served, and will continue to serve process of getting older. For the ageing such purpose will be reviewed later in this user, these dynamics necessitate, among paper. It will become clear that it is not others, the lifelong learning demanded just research and development (R&D) of by the daily environment. The system products and services that is to change approach pioneered by Chapanis13,34 elu- society, but also design and distribution cidates problems that have to be solved, (D&D), leading to an integrated RDD&D such as the division of control between

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the technology part (automation, robots, ambitions and needs: enhancement and virtual worlds) and the human part (choice satisfaction of life, proactive prevention of options), with the user interface as the of disease and of functional restrictions, technology that makes the human choice compensation and assistance, and fi nally happen. The user interface has input and proper support of necessary formal and output technology functions which com- informal care, including their organiza- plement the respective output and input tion. The fi ve domains of daily life and the by the user, including processing arising four goals to be served by technology to- from the internal states of both technol- gether defi ne an impact matrix, in which ogy and user. Notice that the division of the various technology-defi ned products control and the user interface are just as and services display their function for dynamic as the whole system; that is the ageing people36,37. For each of those, the system itself as well as its parts constantly systems approach helps us to defi ne what changing35. The interaction between age- functional outcome we want, what the ing persons and their technological en- requirements are for the technology, for vironment has several physiological and the user interface, and for the necessary psychological aspects with consequences human learning, given the important no- for the design process11. tion as well as the inescapable fact that the present depends on the past. With the October 2007, Vol 6, No 4 To make this rather abstract general vast array of options offered by embedded scheme concrete, we have fi rst to fi ll in software, technology is made increasingly the functionalities that represent system smart and adaptive so as to relieve users outcomes. So we turn to the main do- of demanding tasks and changing user 193 mains of life in which the technology has control beyond recognition. to function: health and self-esteem; the home environment; mobility and trans- The present paper will review a number of port; information, communication and relevant developments and new insights in governance; work and leisure18,36,37. The gerontechnology as from 1990. The wider main goals that we want to attain with the scope of gerontechnology particularly with technology are the fulfi lment of human respect to serving the ambitions, purposes, and needs of ageing people, furthering their independence and preventing illness- es of old age, has been well documented. De- velopments have hap- pened in many fi elds, not all of which were labelled as gerontech- www.gerontechjournal.net nology. We will take the several gerontolo- gy disciplines studying ageing and the several technology disciplines as a starting point, and their combination will Figure 1. System approach of person, environment, and the user inter- lead to a new matrix face in between. The result of the interaction is displayed as system out- serving as a frame- put. Note the role of time in all three layers, which makes the scheme essentially dynamic. From Fozard35 work for a selection

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of defined progress in the general field of hardening of the eye lens occur somewhat gerontechnology. Since we want to focus later, but nevertheless before the age of 20. on insights and methodology gained, we So ageing effects are not at all restricted to shall not discuss the extensive range of old age, say above 65, where our atten- products and services that are already or tion here is being focused42-48. Sensory as- will soon become available for ageing per- pects are concerned primarily with vision sons, although some of these will be men- and hearing49,50, but also include thermal tioned in passing. comfort51,52 and lighting effects other than on vision such as on mood (for instance, Gerontology ‘seasonal affective disorder’)53. Good ageing can be described as actively selecting among the many opportunities It is well known that daily exercise and/or of later life and consciously living through training will keep the body in good shape. adverse events as these occur. We use the How critical is this factor, what are the in- term ‘good ageing’ rather than ‘successful dividual differences and how can optimum ageing’, as the latter concept carries a his- exercise levels be achieved? Similar ques- tory of interpretation and discussion10,16,17 tions can be asked about physical endur- that we do not need here, although the ance. In the absence of direct disease, can October 2007, Vol elements6, No 4 of independence and autonomy the decline of muscle power and of physical are certainly valuable. Also, we will ab- endurance be fully or largely prevented? In stain from discussing the valuable concept reality, difficulties of movement and of en- of quality of life (QOL)38,39, as this has de- durance rank high among the first restric- 194 veloped mainly for the subject of health, tions experienced by ageing people54,55. which is too restricted for our present purpose. Good ageing rests on the follow- Over the last decade there has been in- ing five individual pillars: healthy nutrition, creasing attention to nutrition, be it for daily physical exercise, regular cognitive increasing healthy nutrients such as un- and mental activities40, maintaining social saturated fatty acids and anti-oxidants, or contacts inside and outside the family, and other nutrients leading to a low choles- keeping an active interest in society. These terol content of the blood for preventing largely correspond to three main academ- vascular and heart disease, or for reduc- ic disciplines that in combination address ing unhealthy nutrients, such as saturated human developments including ageing: fatty acids, which contribute to vascular physiology including nutrition, psychol- disease whereas overweight contributes ogy including social psychology, and so- to diabetes. The list is gradually expanding ciology including demography. To these as more diseases are shown to be influ- we add medicine including rehabilitation enced by certain nutrients. The view that for dealing with restrictions and disease. certain genetic dispositions contribute to The World Health Organization has a pro- the likelihood of certain diseases is gain- www.gerontechjournal.netgramme for healthy and active ageing41. ing influence. Obviously, the prevention of specific diseases of old age and general Physiology of ageing decline must start at an early age, if not How does the human body develop with directly at birth, then certainly well before increasing age? Why does it age at all? the term ‘old age’ is applicable. Such questions are complex and the an- swers are only partly known. However, Psychology of ageing we do know that developments associat- Psychological functions develop with ed with ageing have their origins very ear- age15,27,28,56-58. This is true for basic per- ly in a person’s life, perhaps even at birth, ceptual skills such as vision and hearing, and other adverse developments such as where recognition of the direct environ-

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ment in its ever changing appearance has events to be remembered at some future to be mastered by making likely selec- time59,61. tions from the available options, followed by decisions as to relevant actions. Inter- Sociology of ageing pretation of the surrounding visual, audi- Sociology deals with group aspects of hu- tory, and haptic environment is a complex man communities rather than with individ- cognitive task in itself. If the environment uals and their interactions. Demographics, is changing, perceptual skills will have to i.e., the present and future age and gender deal with it. The rise of visual and auditory composition of the population as a whole media including virtual reality via so many is basic to gerontechnology, providing in- TV channels, private videos, and internet/ formation on the ageing population itself www applications signifies a changing amidst younger populations4,62. The term general perceptual environment of which ‘generation’ is relevant in defining people the consequences for ageing people are of a certain range of birth years or cohorts still to be assessed. In all cases, percep- who have lived through the same general tion, action, and memory remain closely important events occurring in a certain interwoven43,59. stage of their development. These events may have a negative bearing such as war, The changing environment applies just as scarcity, economic depression, wide- October 2007, Vol 6, No 4 well to language, the primary carrier of hu- spread real or purposely induced fears, man communication. Just as is the case for and political upheaval, or a positive bear- the physical environment, the language en- ing such as peace, general affluence, well- vironment is in continuous flux. These de- being, and political stability63. So, general 195 velopments are now speeding up by mass economics64, and in particular politics65, media and new communication media belong to the sociological scene. Here, such as SMS messaging. Such aspects are the earlier stereotypes of ageing persons addressed by the psychology of language, as frail and socially dependent have only a discipline in its own right, but here men- slowly been eliminated, partly by politi- tioned as part of social psychology60. cally inspired thinking called critical ger- ontology66,67. Apart from the population Another important psychological function as a whole, specific groups are being con- is human memory. Fortunately, there ex- sidered such as in household composition, ists no upper age limit to learning, except education, economics, communication, in case of specific disease. Although ‘for- public transport, paid or voluntary ac- getting’ or ‘access temporarily interrupted’ tivities, computer skills, public provisions, (for example, specific names) is a com- needs, and ambitions68. Epidemiology will mon occurrence in humans, unlearning as be classified here as part of medicine. a controlled process is difficult to achieve. So by necessity newly learned activities So we turn to these disciplines to learn will rest on the basis of earlier learned ac- about the lives of ageing persons: their www.gerontechjournal.net tivities, which therefore may interfere with health, their families, their housing, their the new ones. Relevant distinctions can mobility, their skills, their hobbies, their be made between memory skills that are restrictions, their financial options, their generally steady with rising age, includ- activities, their communications, their ing immediate (sensory) memory, long networks, their interests, their drives, and term memory (‘knowledge’), and episodic the provisions of their communities69. On memory, versus memory skills that tend to each of these aspects, we will have to show a decline with age including (short find out what technologies are or will be- term) working memory, and prospective come available as tools for realizing their or ‘reminder’ memory, which deals with ambitions, meeting their needs, improv-

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ing their health, and otherwise furthering for the handicapped’, it comprises long- their chosen life. An influential theoreti- standing efforts to contribute to the life of cal framework on how ageing people are ageing people. Also, several technologies dealing with changes in their environment have been developed for use by patients has been developed by Baltes and Baltes16, or clients themselves or their relatives, to called a life-span model of selective opti- combat the disease and to compensate re- mization with compensation. strictions. This is true for low vision73, for hard of hearing74, for mobility difficulties Medicine of ageing in walking, equilibrium, or endurance43,55, Since health is such a primary factor of life, for car driving75, for mobility and trans- its absence is of primary concern as well. port76, and to a lesser extent for memo- Geriatrics or geriatric medicine is combat- ry problems and language difficulties in ing the diseases that belong to advanc- communication. ing age. Examples are vascular and heart disease leading to restrictions in endur- Technology ance, joint disease leading to restrictions What types of technologies are or will be- in mobility, general pain that commands come available for reaching the goals of an overdose of self-attention, as does dis- good ageing? For this, we turn to the disci- October 2007, Vol ease6, No 4 in general, eye disease such as cata- plines of technology. ract or age-related retinal macular disease, hearing disease, particularly in the higher Chemistry and biochemistry frequency range, and the generally feared Although often remaining in the back- 196 Alzheimer disease and other dementias. ground, chemistry together with physics Often, different diseases occur together provide the disciplinary base for the rap- requiring the integrated approach specific idly growing spectrum of materials and for geriatricians and general practitioners. products in society. The new materials A great many innovative medical tech- are stronger, lighter, more flexible, and nologies for use by medical professionals integrated with embedded software. Phar- have been developed, particularly in di- maceutical products constitute a special agnostics such as medical imaging and in subset. The rapidly growing insights into surgery such as joint replacements. complex chemical reactions and their catalysts and mastery thereof give rise to Epidemiology covers the overall incidence great expectations about general applica- and prevalence of diseases and how these tions from which older people will benefit change over time and between specified as well. The domain of biochemistry may groups of people or countries70. It is the have an especially important role to play basis for a proper understanding and as- as the impressive progress in understand- sessment of effects of preventive measures ing and mastering genetic and biological in public health. Longitudinal studies in processes potentially leads to a wealth of www.gerontechjournal.netwhich substantial numbers of persons are new applications. It has been suggested being followed individually for many years that biochemistry may be characterized have proven an effective means of identi- as the primary science of the 21st century, fying contributing factors to development holding a similar ranking role to electronic of disease as well as its prevention71,72. and information sciences in the 20th cen- tury77. If so, one may marvel at such pres- An important area of technological ently unforeseen developments. progress is the general field of rehabilita- tion dealing with overcoming restricting Architecture and building effects of disease following surgery or ac- One’s house is the most important place on cidents for instance. Formerly called ‘aids earth. If only for the fact that many ageing

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people spend so much time in and around generation is already taking for granted. their house, building proper houses and The concept of wireless communication making these a healthy, pleasant, and easy derived from remote controls and mobile place to live, is an essential technology, telephony continues to gain ground; how- and this remains true when restrictions oc- ever, wireless power transfer technologies cur common to old or very old age. In case remain around the corner. The older gen- of such restrictions, living independently erations are now gradually following suit, rather than in institutions is an important albeit somewhat hesitantly81. contribution to actual and perceived au- tonomy and is highly valued. This extends In the mean time new applications are ar- to the suitability of the built environment riving at full speed. Particularly since the around the dwelling, that should both be information revolution, ever more types of an agreeable and easy setting, and provide products and services are affected by in- access to essential commodities and serv- tegrated functions and hidden embedded ices. The domain of the house as potent systems software. Ambient intelligence supporter of independent living has also will soon be an omnipresent invisible com- been targeted by communication technol- modity in the human environment, pene- ogy78,79. A subfield of this, related to secu- trating all aspects of life, and also changing rity, safety, and general remote control is the lives of ageing people82,83. The area of October 2007, Vol 6, No 4 called smart housing or domotics80. virtual reality deserves special mention as the boundaries with physical reality are Communication and information getting increasingly blurred. Before long The information revolution in society of this will also apply to direct human com- 197 the second half of the 20th century her- munication, as smart programmes will alded by progress in information science, make virtual communication through pro- electronics, and miniaturization has given grammes including language and speech a decisively new face to the whole soci- technology very realistic. ety, to many subdivisions, and in the final decades to individual citizens. Older seg- Mechatronics and robotics ments of the population have been slow to Mechanical engineering was the over- profit from the many new options in com- arching term applied to this endeavour munication and information handling be- until the information revolution changed cause they were generally unaware of the its appearance into mechatronics and ro- advantages, untrained in the complex user botics. Miniaturization is the key element interfaces, and not targeted in the market- of contribution of these disciplines to in- ing campaigns which were, unfortunately, formation sciences, thereby providing so- dominated by technical details rather than ciety with the means to put on a new face. by useful functionalities. The audio CD Now, invisibly embedded and distributed and the home computer were forerun- logic can be hidden everywhere and in- ners, but it took the infrastructure of the clude sensors and effectors for controlling www.gerontechjournal.net internet and its applications for cheap and the environment and providing a plethora immediate language communication over of choices between automation and user vast distances (e-mail) and for getting use- control. The field has contributed in par- ful information (via search programmes) to ticular to rehabilitation, as the compensa- arrive at the present myriad of applications tion of physical restrictions in activities for collaboration, games, picture exchange, of daily living (ADL) has profited greatly sound access, marketing, and so many from mechatronics and robotics84, and other services producing the recent revo- the science of creating artificial limbs has lution in digital cameras, mobile phones, evolved beyond recognition. and mobile web access, which the young A special domain of application within

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this field is transport. In particular in many well-to-do, as a group controlling the li- types of public and private vehicles with on’s share of private capital. As soon as their extensive infrastructure a high de- the ageing populations are targeted as a gree of innovation is evident. Driven by worth-while market segment, a whole the need for safety and comfort of users, range of new products and services can cars have been forerunners in applying be expected. In industrial countries, the automation while leaving the driver in the older segment of the population combines drivers seat75. Tinker76 has provided an in- a critical attitude and diverse interests for sightful paper on the importance of mobil- new functionalities with an overall suf- ity and transport of ageing people and on ficient purchasing power. New skills and the many problems encountered. management focus may be necessary for successfully addressing the ageing popula- Design and ergonomics tion91. There are clear signs that industrial Design is the core of products and serv- forerunners are now working towards this ices. It is not just concerned with outward goal82,92. appearance, but involves the integrated aspects of materials, production, function- Cross-fertilization matrix ality, user control, maintainability, and ap- The combined disciplines of ageing and of October 2007, Vol pearance6, No 4 85. The user interface is the part technology lead to a matrix of disciplines, that enables user control and can be con- the cells of which provide the positions sidered the heart of the functionality as ex- where the actual new insights and innova- perienced by the user. The general aspects tions for ageing people can be visualized 198 of products related to the user are dealt (Table 1). Of course nothing is static with- with by ergonomics, human factors, or hu- in such a matrix: it simply shows where man engineering. This field is long known knowledge, insights, and methods are to to provide essential expertise in the devel- be found or developed necessary for the opment of products and services for age- task at hand. The matrix may also serve ing users86-90. The valuable concept of in- as a tool to select the professional skill clusive design, also called universal design and methodology necessary for choos- or design for all, originates from the design ing and working toward useful technology discipline and will be elaborated later. Un- products and services for the target group fortunately for ageing people or consumers, of ageing people, and to develop proper in real practice ergonomics has often been training schemes for the intended users. disregarded in product development for reasons of legacy problems, professional We will now consider a selection of ma- ignorance or unwise cost reduction. trix entries, i.e., relevant developments for gerontechnology, in a coarse time frame Business management with intervals of 5 or 10 years, and starting Management science has established itself around 1990. Some of these stem directly www.gerontechjournal.netas an indispensable enabling discipline to from research, development, and design bring the fruits of technology to the glo- in the field of gerontechnology; others bal market place, and ensuring that the have originated elsewhere. The common products, services, and infrastructures feature is their great potential for contrib- are realized. The proper organization of uting to a good life of the ageing popu- innovation, production, distribution, and lation. Each of the cells of the interdisci- marketing is a major feat of recent global plinary matrix may reflect existing and economies. In product innovation, the new insights, methods, and activities. The younger population has received most selection of content for the matrix cells of attention so far. It may have escaped chosen in Table 1 may change or increase attention that many ageing people are over time, reflecting new insights gained

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and methods developed. Below, we will a low or moderate general education are explain our selection criteria. The indicat- at a disadvantage as compared to people ed years provide a rough estimate of the with a higher general education. Since time when relevant gains in insight and the level of general education has risen methods were obtained. over the last century, many ageing peo- ple have not been in a position to receive Understanding ageing users higher education. This contributes to the Situated learning (1990+) generation effect: it is not just age itself [One matrix cell: Psychology & Informa- that may stand in the way but also the en- tion / Communication] vironment, education, and training of the Teaching yourself user skills from a book- generation to which one belongs and the let, by attending a theoretical class, or by type of skills acquired during one’s child- following ‘directions for use’ appears far hood, adolescence, adulthood, and older from effective93. Situated learning94 re- age. The general sociological concept of fers to learning neither in a classroom nor ‘generation’ thus may get applied to the from ‘directions for use’, but by getting common technological environment dur- automatic guidance in the actual situation ing the formative years. This is the general that one wants to control (learning by do- background of the notion of ‘technology ing). This appears to be more motivating generation’98. October 2007, Vol 6, No 4 and also more useful, since one feels in control from the very start of the applica- Research has shown that in consumer tion process. Wizards and situated com- goods the type of user interface used puter prompts are special case examples before the age of 30 or so, either of the 199 of this approach. The design of such situ- mechanical or the electrical type, remains ated learning systems is a demanding task present in one’s mind and habits and may and has to be based on validated experi- interfere with using later types of user in- mental findings. Animation may present a terface such as menu-driven ones99,100. method that resembles or emulates situ- The concept of ‘user interface genera- ated learning95-97. tion’ also indicates that the difficulties of ageing persons to deal with new control Technology generation (2000+) concepts are unlikely to disappear in the [Three matrix cells: Sociology & Informa- future when most ageing people will have tion/Communication, Mechatronics / Ro- had extensive experience with menu in- botics, Ergonomics/Design] terfaces, for example in their jobs. It is The prime time to development of gen- the dynamics of technology innovation eral physical, mental, and social skills is that will continue to cause difficulties for roughly up until the age of 30 (formative people of generations that have learned to period); more complex skills -including control the former type of user interface. social ones- can be acquired later when The system concept referred to earlier is demands of the working and living en- well suited to cover this type of difficulty. www.gerontechjournal.net vironment specifically require them. Whereas young people may learn new Apart from the user interface, there will be skills easily, old people must learn them other aspects of technology that may show while disregarding earlier mastered skills generation effects such as the functionali- that cannot easily be unlearned. There- ties of telephone, radio and television, the fore, ageing people are at a disadvantage internet, and mobile phones. The general when dealing with new technology, par- term ’technology generation’ is then the ticularly if they have not had the opportu- guiding concept covering ‘user interface nity to learn such new skills in the context generations’, ‘functionality generations’, of their daily work and life. People with and other effects still to be found101.

G6(4)Review-Bouma-v2.indd 199 18-10-2007 16:15:29 Gerontechnology ); gy erontolo g , and , Care management innovation Technology acceptance Persuasive technology Targeted marketing Targeted marketing Care management innovation Business management

rocesses ( rocesses p

g ein g Individual differences User participation design Inclusive Standardisation User participation design Inclusive Standardisation Technology (user generation interface) Self medication Telecare Individual differences Ergonomics Ergonomics Design s of a of s p rou g line p cell. All are detailed in the text. the in detailed are All cell. October 2007, Vol 6, No 4 Biorobotics Biorobotics sharing Resource (man-vehicle) Technology generation (protocols) Biorobotics sharing Resource (man-vehicle) Mechatronics Mechatronics Robotics contain a selection of concepts, insights concepts, of selection a contain

200 Technology generation generation Telecare Situated learning Temporal discount & benefits Technology acceptance Persuasive technology Domotics tools Navigation Perceptual implants (signal processing) Modelling restrictions Telecare Technology Technology (protocols) Information Information Communication these belong to more than one than more to belong these . The four rows indicate the main disci main the indicate rows four The . gy of innovative technology. The matrix cells cells matrix The technology. innovative of Experimental houses Healthy indoor environment Experimental houses Domotics Healthy indoor environment Architecture Architecture Building erontechnolo g gerontechnology. Some of Some gerontechnology. www.gerontechjournal.net Chemistry Chemistry Biochemistry Preventive nutrition drugs Preventive Perceptual implants (materials)

Physiology Nutrition Psychology psychology Social Sociology Demography Medicine Rehabilitation

Gerontology

the six columns the main discipline groups groups discipline main the columns six the to relevant are that methodology Table 1. Cross-fertilization matrix of matrix Cross-fertilization 1. Table

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Temporal discounting and benefi ts (2000+) this reason, the user interface for ageing [One matrix cell: Psychology & Informa- people should be designed to be as easy tion / Communication] as possible. The basic paradigm for temporal discount is that future rewards are less valuable than Nevertheless, an easy interface is not suf- immediate rewards. As a consequence the fi cient for ageing people to accept new value of a certain reward decreases with technology that may be of great function- future time. The effect can be measured al benefi t to them. It appears that people experimentally by equalizing the value of need clearly discern the benefi ts of a new a future higher reward with an immedi- product before they want to try, use, let ate lower reward. For ageing people, this alone accept it. The greater the perceived temporal discounting has an extra dimen- benefi t, the less important the quality of sion because they take into account the the user interface becomes102. expected though unknown number of re- maining years of their life. Therefore, age- Experimental houses (2000+) ing people with poor health apply higher [Two matrix cells: Physiology, Psychology temporal discounting than healthy people & Architecture/Building] of the same age (Figure 2). This is perfect- Demonstration or model houses are in ly logical behaviour. In practice it means standard use for a long time, but ‘houses October 2007, Vol 6, No 4 that expectations on the total effort neces- of the future’ too have been around for sary for learning a new task now should a while, usually showing fantasies of the be balanced against expected rewards present rather than previews of the fu- of actually using the acquired skill in the ture. In certain countries sample houses 201 future102-104. Therefore, ageing persons have been produced for public visits that may be perfectly rational when they have are meant to offer realistic views of feasi- reservations about technological innova- ble new features including ways to make tions: the future benefi t of the promised provisions for physical restrictions, also functionality has to be compared with im- taking into account their cost effective- mediate cost, be it fi nancial cost or effort ness. However, new types of experimen- for mastering the user interface. If only for tal houses have been conceptualized and realized which are not in- tended as a blueprint of the future but as an experimental R&D tool for fi nding out what type of housing and useful provisions would attract the elderly105-107. This seems to have accelerated the mass realization of certain internal and external features of hous- www.gerontechjournal.net es, since their potential value can be assessed beforehand. If combined with carefully considered inclusive design, many older people may want to use these experimentally Figure 2. Temporal discount functions of favourite and sec- identifi ed useful features, all ond best holidays (upper and lower lines respectively) for the more if they are properly a high rate (upper fi gure) and a low rate (lower fi gure) dis- normalized, mass-produced, count group. Response strength of attractiveness in logits. From Melenhorst103 and widely distributed.

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Designing for ageing users eral scenarios have been described such Individual differences (1990+) as focus groups and drama sessions117-122. [Two matrix cells: Physiology, Psychology Secondly, choice options or adaptation to & Ergonomics/Design] individual preferences and differences are Individual differences generally increase valuable113,123. In general, these aspects with age because of different life experi- have been incorporated in the concept of ences and life situations of individuals. inclusive design. This makes that each adult human is a unique person with individual ambitions Take memory aids for example. Although and needs. The increase in individual diaries and calendars are classical mem- differences with ageing concerns a great ory aids, their equivalents in the informa- many physical, mental, and social factors tion age like palm tops and address and including ones that have negative conno- telephone lists on computer, have not yet tations such as a low income, a narrow been able to fully replace them, certainly job experience, loneliness108, or a certain not for the older segment of the popula- chronic disease. As to the latter, Alzheim- tion. This is partly due to inadequately de- er’s disease and other types of dementia signed user interfaces, but more basically are relevant examples109-111, as are visual this may be due to insufficient research in October 2007, Vol and6, No 4 auditory restrictions50,112,113. In mac- what added practical benefit ageing peo- ro-descriptions such extensive individual ple could get from such aids. All technical differences are sometimes disregarded, options are available, but a lack of really for example in anthropomorphic, demo- appropriate functionalities (such as useful 202 graphic, or epidemiological data. In using reminders), as well as an overdose of less such data for the design of products or useful functions, are witness to the lack of services, this can easily be misleading. The insight into memory restrictions in daily so-called ‘average fallacy’ in ergonomics life of ageing people. is that almost nobody exists who is aver- age on all counts. The greater the number Inclusive design (2000+) of dimensions taken into consideration, [Two matrix cells: Physiology, Psychology the fewer the number of people who can & Ergonomics/Design] be classified as average. For example, if New technology, certainly in consumer on each dimension 67% of the population products, has usually been targeted at the is considered ‘average’, this percentage young generation who are supposed to shrinks to 9% if six independent dimen- be receptive, dynamic, and perhaps less sions are being considered together. The critical in accepting new products as com- general message is that the spread and the pared to ageing adults. Often the designers lower and upper limits of the particular were young as well, designing for people target group are at least as important as their own age and for their own genera- grand averages. tion, which they understood so well from www.gerontechjournal.net within. Advertising for new technologies User participation (1990+) openly breath this atmosphere of youthful [Two matrix cells: Physiology, Psychology enthusiasm, thus excluding ageing con- & Ergonomics/Design] sumers implicitly and perhaps not always Given that there are many unknowns unintentionally. This is augmenting gener- about ageing people and that both indi- ational differences at the disadvantage of vidual differences and cultural differences older generations. may be substantial114-116, several recom- mendations can be made. Firstly, ageing The remedy for this has been called univer- people of the target group should partici- sal design124,125, design for all, or, the name pate in the design process for which sev- preferred here: inclusive design89,126-133.

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al point of view, applying a relevant selec- tion of the extensive body of methods and insights in design is a must128,136,137, how- ever, not always receiving the required at- tention (Figure 3).

Standardisation (2000+) [Two matrix cells: Physiology, Psychology & Ergonomics/Design] The great value for the ageing user of nor- Figure 3. Ten barriers to inclusive design in malization and standardisation in related companies with their estimated importance; products from different sources is obvi- A= lack of internal support; B= requiring cul- ous138. The main relevant base document tural change; C= lack of knowledge; D= lack of 139 business case; E= lack of time/budget; F= too is ISO/IEC Guide 71 which needs to be diffi cult; G= compromises aesthetics; H= not translated into more concrete design rules perceived end user need; J= stigma; K= unach- (Figure 4). The importance of standardisa- 136 ievable. From Goodman et al tion in general becomes clear from a great many products in which this is already The concept is that if a design is directed applied such as in car control, and in a October 2007, Vol 6, No 4 toward users with lower skills, those with negative sense from products where this higher skills can also easily use it. The has not yet been achieved such as in early concept has been developed at the Royal domotics. Many new products teach us College of Arts in London133,134 and ex- that in practice it can take several years or 203 tended elsewhere, such as in the EU fund- more before normalization is actually im- ed GENIE project32,36,135. Inclusive design plemented. Since the learning of new skills cannot really be for everyone: there will becomes more diffi cult in old age, lack of be limits in perceptual, motor, and mental normalisation is detrimental particularly skills beyond which the design cannot be for ageing people. Also, deliberate efforts used without help of others. Therefore the to unlearn certain skills are bound to fail choice of skills included requires an ex- as more often than not the extra attention plicit answer, to be corroborated by the in- paid to unlearning in fact makes the pres- volvement of a carefully selected group of ence of that old skill more apparent than users to be included127. From a profession- ever. New types of products should not try to distinguish themselves by a new type of in- terface unless the latter is substan- tially easier to use than alternative www.gerontechjournal.net solutions. Stand- ardisation should be based not just on the technol- ogy but on prop- er insights and experiments on Figure 4. ISO-IEC Guide 71 is concerned with the needs of older persons. the broad target Technical guidelines translate Guide 71 into practical design fi elds. From groups of users 138 Sagawa as well140.

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Convincing ageing users effectiveness seem crucial, these should Technology acceptance (2000+) include the explicit endorsement of their [Two matrix cells: Social Psychology & peers, or even be demonstrated by them. Information/Communication, Business Management] Persuasive technology (2005+) The problem of non-acceptance of new [Two matrix cells: Social Psychology & technology specially designed for in- Information/Communication, Business creased usefulness neither by older peo- Man­gement] ple, nor by youngsters has given rise to In contrast to functionality, motivation theories of acceptance. An influential is a somewhat underestimated aspect of one is the Technology Acceptance Mod- ageing persons’ appreciation (positive or el (TAM)141. It states that the behavioural negative) of certain products or services. intention to use a product is determined Persuasive technology144 tries to lower the by its perceived usefulness and its ease psychological barrier by providing intrin- of use. Both of these are subjective con- sic motivation. The intervention can be structs, and may deviate considerably realized in several ways such as by situ- from more objective measures of useful- ated advice or immediate rewards. Social ness and usability. In that sense the model connectiveness is one of the areas of ap- October 2007, Vol is6, No a4 somewhat indirect measure of the ten- plication, for example by stimulating inter- dency for real technology adoption. Nev- generational contact and by telegames. ertheless, perceived usefulness has been Perceived benefit must be the real drive consistently found to relate strongly to for ageing people79. The boundary be- 204 usage intentions142,143 (Figure 5). The au- tween overt and hidden persuaders needs thors reported four longitudinal studies in to be monitored to avoid unrealistic ex- which they further explored which factors pectations or actual disappointments145. contributed to perceived usefulness and to perceived ease of use. Social influence Targeted marketing (2005+) appears to be a major factor, described as [Two matrix cells: Social Psychology, Soci- the person’s perception of what people ology & Business management] important to him feel he should do, or not This is an area eagerly awaiting develop- do. On the cognitive side, prospective us- ment91. Tools for marketing for specific ers should have a clear perception as to age groups are well established, especially what the product can do for them, and those aimed at young people. Targeting how well and effectively it will function. ageing consumers is more complicated So while demonstrations of comparative because of the many specifics, most of which have been outlined in the earlier sections on inclusive de- Cognitive Social norms appraisal of sign, technology acceptance, and & habits effectiveness persuasive technology. As to fi- www.gerontechjournal.net nancial aspects, a substantial part of private capital is controlled by Perceived ageing people, but at the same usefulness time ageing people constitute a Behavioural Actual substantial part of the society’s intention to use use poor, thus generally suggesting that there are large individual dif- Perceived ease of use ferences in this market. The rising use of internet/www applications Figure 5. Diagram of the Technology Acceptance by ageing people offers an extra Model after Davis141 and Venkatesh et al.143 opportunity for interacting with

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them. Areas where ageing people have their input from devices such as humidity already been discovered by marketers are and carbon dioxide sensors and provid- banking and travel. ing output to effectors controlling natural and forced ventilation149-151. Remarkably, Prevention battery operated effectors for opening Preventive nutrition and drugs (2000+) windows with wireless control are not yet [Two matrix cells: Nutrition, Medicine & mass-produced, since these would make Biochemistry] dynamic control of air composition in One way to remain in good health is each separate room possible. This would healthy nutrition, exemplified by the be helpful for all ageing persons, and in saying: ‘an apple a day keeps the doctor particular for people with lung diseases away’. Over the last decade the value of such as emphysema. In fact, most present these good eating habits has been increas- ‘air conditioning’ systems are crude tem- ingly recognized. In particular the need perature conditioners only. to maintain a diet that includes the types of food that contribute to health or, con- Domotics (2000+) versely, a diet that excludes foods that con- [Two matrix cells: Psychology & Architec- tribute to disease. An interesting example ture/Building, Information/Communica- of this knowledge is the use of so-called tion] October 2007, Vol 6, No 4 anti-oxidants such as certain vitamins and Domotics can be defined as the semi-au- traces of metals such as zinc. The idea is tomatic handling of house functions such that the ageing body is less able to neu- as security, safety, alarms, indoor climate, tralize the oxidants that are accompanying and the concomitant user control. Basi- 205 energy processes in the body146,147. It turns cally, domotics uses proper sensors and out that indeed quite a few diseases of old effectors combined with embedded soft- age can be connected with this type of ware and distributed intelligence. Domot- process. Of late, even age-related macular ics has gradually grown in significance and disease (AMD), that used to be classified many partial solutions are on the market80. as incurable, has been shown to develop However, network standardisation includ- more slowly in response to a proper diet ing the selection of protocols (for instance established years earlier148. New insights internet protocol IP) and the characteristic in genetic factors related to the presence of the user interface is still far from real- or absence of protection for specific dis- ized. Also certain elements are not yet eases can be expected to lead to more widely available such as the standard ef- effective individual preventive measures fectors for opening and closing windows, such as specific diagnostics and drugs. mentioned earlier, that are integrated into the automatic air quality control systems Healthy indoor environments (2010+?) in separate rooms including the kitchen. [Two matrix cells: Physiology, Medicine & This hampers application on a large scale; Building] standardisation and mass-production are www.gerontechjournal.net A healthy indoor environment is being necessary to bring costs down and induce threatened by a number of invisible dan- general acceptance within the population. gers such as insufficient ventilation, exces- Domotics also seems to suffer from insuffi- sive humidity in the kitchen, and mites in cient understanding of actual practice. Ex- textiles. The situation has recently wors- periments are needed to identify which of ened due to a reduction in the number of the many possible functions deliver added air vents to improve energy efficiency. It value and deserve to be implemented on is wholly within the reach of present-day a large scale. The field is maturing slowly technology to avoid such unhealthy situ- but progress may be expected in the next ations by using control systems that get decade.

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Compensating restrictions Perceptual implants (cochlear 2000+, Biorobotics 2005+ vestibular 2010+?, visual 2010+?) [One matrix cell: Physiology & Robotics] [Two matrix cells: Rehabilitation & Chem- The field of robots for direct use by age- istry, Information/Communication] ing people is still in its infancy, robots Cochlear implants have been developed being considered as automatons with a in the nineties primarily for deaf children. degree of automobility and adaptivity to Sound is picked up by a microphone, ana- the environment. Daily-task robots on lyzed, and transmitted to an electrical the market include vacuum cleaners that stimulation unit with thin electrodes very navigate through rooms and grass-mow- near the cochlear nerve. Although normal ers finding their own way across the lawn. hearing cannot be restored, the additional Both these devices perform similar physi- hearing function has proved to be very cal tasks. Quite different is the ‘robot-pet’ effective. The success has inspired ear that may help to satisfy the need for per- surgeons to apply the same technique to sonal affection without the difficulties in- certain types of deafness in ageing peo- volved in handling live animals8 (Figure ple, again with reasonable degrees of im- 6). It seems likely that robots will perform proved hearing functions74. Perhaps, the a more general semi-automatic control technique might also become applicable October 2007, Vol 6,function No 4 in the environment, responding in cases of vestibular deficiencies. to the user’s handling preferences with different types of adaptive programmes For vision, the situation is more difficult if from which the user can choose as he/she only because the optic nerve carries a mil- 206 likes by giving instructions to the device. lion fibres as compared to about 30.000 The notion of manifold ‘butlers’ that has for the auditory nerve. Nevertheless, ef- been proposed for household machinery forts have long been directed at realizing in general83 seems particularly suited for the goal of restoring at least minimal vision personal robots that not only perform a for blind people with residual retinal func- required task but also induce positive feel- tion. The recent advance of image sensors, ings in the user because the required task exemplified in digital cameras, as well as is carried out in the desired way. This re- implanted electrodes has given rise to new quires an interface that mimics aspects of efforts using visual implants from which the communication between humans152. It also ageing people may benefit. For all goes without saying that biorobotics is of types of perceptual implant, the problems the utmost importance for compensating that have to be solved must begin with physical restrictions84. medical and sensor technology. Basically there are two types of visual prostheses, those functioning in the retina, and those stimulating the visual brain areas. The reti- nal implants are also of two types, epireti- www.gerontechjournal.net nal and subretinal, where the subretinal systems essentially mimic the role of the cones. The number of light sensitive cells is still very limited, in the order of 5x5, but new developments suggest a potential lay- out of 60x60. Power delivery to systems in the moving eyeball is an acute problem. It is sometimes supplied by a wireless coil or by means of thin flat cables hugging the eyeball153. Epiretinal systems are mounted Figure 6. The adaptive robotic harp seal Paro8 on top of the retinal layers and stimulate

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the underlying ganglion cells, but need an in practice: hard of hearing, low vision, external camera that may be mounted ei- low endurance, and memory difficulties. ther in a pair of spectacles, or even in the But it remains to be seen to what extent eye lens itself. Many engineering problems this accords with real restrictions. Mod- will have to be solved before such systems elling the restrictions is a possible way can be successfully employed. of objectively comparing subjective and actual restrictions. The reliability of this Pioneering work by stimulating the visual methodology depends on the validity of cortex directly has been done by Brind- the theoretical and experimental basis of ley and Lewin154. Their subjects reported such modelling. Good results have been seeing phosphenes, small bright dots that obtained for modelling colour anomalies behaved in a regular manner as a result of (colour weaknesses) for which suitable stimulation. Later, microelectrodes were theories exist. The models permit calcu- actually inserted in the visual cortex which lation and presentation to persons with obtained a resolution five times higher155. normal colour vision what actual colour All mentioned systems require complex differences persons with different types of surgery, either in the eyeball or on the colour anomalies can see or distinguish. brain tissue; transcranial magnetic stimu- Recently, the method has also been ap- lation (TMS) is a non-invasive and pain- plied to modelling low vision of different October 2007, Vol 6, No 4 less method that can modify or modulate types157 (Figure 7). This software has been neural activity. For these systems also an made freely available and permits design- external camera is needed. It should be ers and architects to get a far better idea of realized that these methods currently of- the consequences of their designs for peo- 207 fer a visual resolution of no higher than ple who have to live with such restrictions. 0.05 of decimal acuity (20/400) but mostly The methodology lends itself to a much much lower. Nevertheless, for some peo- wider range of restrictions in perception. ple this will provide a considerable im- It would be interesting to find out if this provement of their visual capabilities. The method can also be extended toward a se- image that people see is not at all a simile lection of age-related restrictions in motor of the natural scene around them, and far and psychological functions. less so in the case of visual cortex stimula- tion that lacks the pre-processing of the Navigation tools (2000+) retina and the lateral geniculate nucleus. [One matrix cell: Psychology & Informa- As the external cameras move in conjunc- tion / Communication] tion with the head, or with the eyeball Navigation tools are a recent accessory itself, subjects can recognize movement to cars. Automatic adaptation to current relatively fast, and -after some training- road and traffic situations can reasonably also approaching and receding objects. be expected to expand gradually and this Nevertheless, the follow-up with training may be of great help to ageing people as for interpreting the artificially created sen- well. Cycling could follow suit (2005+), al- www.gerontechjournal.net sations in terms of the outer world has to though a number of difficulties still need be carefully prepared and carried through, be overcome. For pedestrians, particularly for which a suitable theoretical framework in cities, a suitable and robust navigation will have to be developed156. tool is urgently needed. Such a system would help people with mobility restric- Modelling restrictions (2000+) tions to find the shortest route and people [One matrix cell: Rehabilitation & Informa- with visual restrictions to navigate inde- tion / Communication] pendently. In fact all older and younger It seems intuitively obvious what a partic- people could then find their way in poorly ular physical or mental restriction means known environments. In order to reach

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Figure 7. Modelling low vision. The effect of applying a local blur linked to local contrast: (a) original image; (b) a measure of local contrast determining the amount of blur via the contrast sensitivity function; (c) the result of the local blur transformation. From Hogervorst et al.157

October 2007, Vol this6, No 4 goal, a number of difficulties will have added. This development makes it much to be overcome such as permanent avail- easier for ageing people to continue cy- ability of navigational signals in densely cling, for daily purposes such as shopping, built environments and increased display but also for exercise and leisure. Since 208 adaptability to indicate the presence of bicycles need a certain speed for a sta- permanent and temporary obstacles. For ble equilibrium, the auxiliary motor also the user interface, a number of problems contributes to safety. The advanced equi- will have to be solved such as the format librium technology developed for a fully of instructions by the user and the differ- automated scooter might be partly useful ent types of detailed feedback of the rec- for bicycles as well (equilibrium sharing). ommended routes158,159. It is perhaps somewhat far-fetched to think about a similar power sharing for walking, Resource sharing (2000+) i.e. the technological equivalent of a sup- [One matrix cell: Physiology, Rehabilita- portive human arm rather than the low- tion & Mechatronics] tech walker. The smart walker was per- Hybrid power systems in cars are gaining haps a forerunner of this technology161. ground for reasons of energy efficiency. For a different purpose and using different Care support technology, hybrid cycling is on the rise160. Self-medication (2010+?) Here, the power is being supplied partly [One matrix cell: Medicine & Ergonomics/ by the cycling person and partly by a si- Design] www.gerontechjournal.netlent electrical motor. What is interesting is Correct adherence to a self administered that the motor is only supplemental, i.e., it medical drug regime may present a real is active only in combination with actual problem even if the patient is fully coop- cycling by the person and adds a certain erative. Automatic memory aids can be percentage of power only. The added combined with a system that provides the electrical power can be adjusted so as to right drugs at the right time162. This will be address adverse environmental circum- an improvement over the current prevail- stances such as a head wind and cycling ing situation where patients are effectively up a slope. Present rechargeable battery left to sort it out themselves. However, the technologies are sufficiently powerful for problem is complicated if accidental or about 100 km if no excessive weight is deliberate underdose and overdose are

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to be excluded. Conceivably, microtags a diabetes pen, the frequency or time of could be developed that would enable di- which may be dependent on weight, glu- rect remote registration of the real intake cose level, or blood pressure. Instructions of medication163. on how to handle the various devices can be provided by specialized nurses, who Telecare (2000 +) see the patients perform the measure- [Three matrix cells: Physiology, Medicine ments on their monitor, or they can dem- &, Information/Communication, Ergonom- onstrate how to do it. While this seems an ics/ Design] efficient procedure with a potentially wide Although telemedicine is perhaps best application, there are many problems that considered an issue of medicine, telecare still need to be solved. These problems re- is certainly within the scope of gerontech- side on a number of levels that call for a nology. A striking example is the use of much more integrated design process of video links in telecare provision. Initially such complex systems. Glucose level, for there was scepticism due to concerns over example, is measured by taking a drop of the issue of privacy protection, since the blood from a small cut with a sharp tip older person had no control over who that is to be removed from its sterile pack- was watching her or him. But carefully de- aging. Especially patients with bad eye- signed experiments dealing with this issue sight, which is common in diabetes, have October 2007, Vol 6, No 4 have made clear that video links are per- trouble doing this, and frequently patients fectly acceptable for clients provided that are not able to draw blood successfully. its actual use is for strict necessities only The various measurements have to be reg- and the clients are fully informed about istered in a computer system that engages 209 the technology and when it is actually ap- in a dialogue with the user which can pro- plied164,165. For specific services this condi- duce either incomprehensible statements tion is automatically fulfilled, for instance (‘invalid measurement: negative weight’) in the form of the so-called ‘good morn- or clearly untrue statements (‘no patient ing’ service where clients are contacted by data’) when all data have been filled in. videophone every day at a fixed time to enquire after their health status or special Any setback of this kind that reduces the demands. The ‘good morning’ service is patient to forced helplessness diminishes considered to be a close substitute of a real the trust in and acceptance of such sys- conversation; while it is explicitly stated tems to a considerable degree, even if the that the call service is available on a 24/7 occurrence of such messages is relatively basis, clients practically refrain from mak- rare. This is not a biochemical or medi- ing calls after five o’clock in the afternoon cal problem but a typical design prob- or before nine in the morning, which they lem, where it is imperative that the design feel to be ‘impractical’ or ‘impolite’ for the should concentrate on robustness, intui- call desk. Such measures are not just cost- tion, and reliability as the most basic re- effective, but offer options for increased quirements of the product. Even the most www.gerontechjournal.net communication that can be exploited on simple and intuitive interface is pointless if a large scale. Telecare is now entering a the system itself is unreliable. new period for both professional care and for informal care provided by family mem- Care management innovation (2005+) bers, friends or neighbours. [One matrix cell: Medicine/Rehabilitation & Business Management] In a number of locations in Europe, video The goal of care management is high qual- communication is used for telemedicine; ity care, i.e., well timed, friendly, and ef- diabetes medication being the most com- fectively geared towards the needs of the mon. Patients self-administer glucose with individual patient. Efficiency is another

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important consideration. There are in- that are changing many aspects of present creasing options for tele-tools such as pas- society at a high pace beyond recognition. sive and active alarms, self-measurements We are also living in an unprecedented era and semi-automatic communication of where absolute numbers and percentages physiological variables, and video-com- of older persons are increasing at a marked munication, involving telecare166,167. Also rate. The technological revolution has put tele-instruction may be utilized far more the growing generations of older persons than is presently the case. Together with at a disadvantage if only because their life- navigation tools167 this is bound to influ- long experiences have been shaped by ence the organization of care. The bound- their experiences in earlier technological aries between professional care, informal environments. However, it appears quite care, and self-care are increasingly fluid feasible to bridge the gap between ageing due to the influence of the many new op- people and their present environment if tions offered by technology. The dynam- only efforts are focussed toward that goal. ics will draw on the innovative capacity of care management. The knowledge base for informing such ac- tions is the combination of the disciplines To elaborate: it is hugely underestimated of ageing (gerontology) and the disciplines October 2007, Vol what6, No 4 the transition to more automated care of technology. In the second half of the and self-care will mean for care providers. 20th century efforts were initially directed As a rule, care providers financially do not at two important fields: ergonomics or hu- have the investment capacity to change man factors for ageing persons and aids 210 the care process, as well as the fact that for the handicapped. From the nineties, they will have to care for both those cli- the knowledge base has been expanded ents that need traditional physical care and as other ambitions and needs of ageing those for which a telecare system has to be persons have been taken into account as maintained. Also the national or regional well. This is the field of gerontechnology, financing schemes of the care providers bringing gerontology and technology to- may not allow changes or diversification, gether for the purpose of a good life for or make those difficult. As a sobering ageing persons, most of whom can be in- thought, it should be kept in mind that in dependent and integrated in society. most European research projects on tel- ecare and telemedicine the actual cost of Seventeen years of gerontechnology have care provision has been much higher than produced many new insights as to op- those of providing traditional care. None, portunities and obstacles or challenges in or very few of the telemedicine projects bringing the fruits of technology innova- can currently run in a cost-effective way, tion to the large and growing older seg- compared to traditional care. This means ment of the population. In this paper a that much research and development number of recent insights and methods www.gerontechjournal.net(R&D) is needed, not only on cost-effec- are being reviewed that are ready to be tiveness and functional effectiveness of utilized in products and services con- telecare, but also on care models that can tributing directly to a good life of ageing be sustained against the background of the persons. Given that gerontechnology is existing legal and financial framework or/ interdisciplinary by nature, a cross-ferti- and are so convincing that even the legisla- lization matrix between gerontological tors are forced to embrace innovation. disciplines and technological disciplines can serve as a mapping device. Increased Conclusion efforts in gerontechnology are necessary We are living in an era of unprecedented to keep pace with the rate of technologi- exciting progress in technological options cal innovation against the background of

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prevailing cultural attitudes in the various the global nature of technology and the ageing societies. relatively low cost of digital communica- This review is directed at developments in tion and services makes its findings rel- industrial and industrializing societies but evant for other societies as well.

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