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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

New Yorker Cartoon by Gregory Swissmemory USB by Victorinox