So tomorrow, 2pm PST, I will be interviewed on the VoiceAmerica Network by Dr. Joe Casciani, Ph.D., former President of PLTC, serial entrepreneur in the aging and long-term care space, and generally awesome gentleman and geropsychologist!
A story that I recall reading (or hearing) somewhere ages ago was designed to capture the difference between geriatric medicine and the rest of the medical world, and it goes something like this:
Depending on the procedure, and despite the fact that Medicare has had flat or declining funding formulas for a number of years, we all know that physicians can under Medicare get reimbursed fairly handsomely for conventional medical interventions like general surgery, interventional radiology, et cetera. Specialists like these are not going hungry.
However, geriatric physicians are not whom we look to for invasive, life-saving interventions like what neurosurgeons dispense. Instead, a specialist in Geriatric Medicine (which is a recognized, board-certified medical specialty) will, say, spend 30 minutes in an examination room with an 80 year old, having a discussion about ill-fitting shoes. This is not a sexy discussion to have, and of course is difficult to fit into Medicare billing guidelines for more than a pittance of a payment.
Sometimes significant therapeutic change can happen with better-fitting shoes!
But, that 30-minute discussion about shoes may be what makes a world of difference for that 80 year old in terms of giving them better mobility, less pain, and better safety in their home. It’s incremental, small-scale interventions that can sometimes be what clinches things for this population.
Sexy vs. Incremental Gerontech
So this is what leads me back to my favorite subject. I know that for years, the kinds of discussions I’ve had on my blog and elsewhere about older adults and technology have been somewhat overfocused on ‘sexy’ technology.
My first love – social robotics like Paro, and it’s promise to soothe dementia, cure depression, and even treat dementia in its users. I’ve been enamored with virtual reality (VR), not for it’s purported effectiveness as a tool to treat specific phobias, but instead as a way to give frail, chronically ill older adults the experience of walking again, or visiting faraway lands, as a way to raise their quality of live and treat depression. I’ve preached high-flying approaches to connect long-term care dwelling seniors, and to address fall prevention.
But let’s face it- there’s a couple of things wrong with the idea of hitching our fortunes to the notion there will be some killer technological revolution, some set of “killer apps” that will sweep the country and herald in a new era of technological revolution in older adults.
First, technology adoption and user acceptance is a tricky business, particularly in the case of older adults as end-users. Older adults by definition going to be a generation that’s still to this day somewhat unfamiliar with digital technology (although this familiarity gap is rapidly closing).
Second, there’s an egocentric bias built into technology design that is still a problem – innovative technology is still typically being developed predominantly by twentysomething, upper-middle class Caucasian and Asian males in Silicon Valley – not older adults. As such, it’s difficult (unless designers do a lot of legwork at the outset) for them to make sure their products are designed with older adult endusers in mind. Despite the fact that Facebook is now extremely popular amongst Gen Xers and Baby Boomers (the 40+ crowd), it was initially designed for and by college students and only “seeped into” use later after younger people paved the way and worked out the user experience ‘kinks.’
The Reality (In the Form of some Product Reviews)
Technology *will* be changing the face of aging, but it’s possible change may come gradually. So, as is my habit, here are a few exemplars of “boring” and “incremental” products (much like the 30-minute conversation about shoes I described above – Hat tip to Mark Ray’s excellent article at Nextavenue.org).
Smart refrigerators, anyone?
Samsung Smart Refrigerator
I go to the hardware store with my wife, fairly frequently (she loves home improvement projects). Often when I’m there we pass through the large appliances aisle and (particularly if our kids are with us), we stop at the smart fridges.
Basically these are refrigerators that are tied to the internet. They are typically equipped with a large tablet screen on the outside of the refrigerator, and have cameras and sensors inside that can give real-time information about the contents inside. Of course, you can do fun stuff with the tablet – you can run apps on it and play videos, display a weather feed, etc.
But here’s where it gets really useful. Imagine you have an 80-90+ year old older adult living at home, say, with some impaired mobility and increased fall risk (not at all unusual at that age). Instead of having to go through the trouble of getting up, plodding over to the refrigerator and craning their heads into the refrigerator and digging around to find what they need – they can simply open their app on their phones and look inside? (Note – you can also take a virtual tour of your refrigerators’ contents via the mounted tablet on the outside of these kinds of refrigerators as well).
Combine this feature with the increasingly-common availability of online grocery ordering and delivery, and you have something that could be powerfully useful for older adults looking to “age in place” in their homes. But again – nothing earth-shatteringly revolutionary here. Just a refrigerator that has been outfitted with some additional cameras and sensors, and networked to the internet.
The biggest downside to these so-called smart refrigerators is cost – these are usually the most expensive refrigerators in a typical hardware store lineup.
Samsung Induction Cooktop
I’m not necessarily pushing Samsung products (no conflict of interest here to declare!) but they offer another great example of a simple idea that really can translate into great utility for an older adult who is living at home.
Induction cooktops are basically a system of using electromagnetic charges to heat specially-designed cookware, but that leave the stoves themselves cool to the touch. For older adults in the home the utility is obvious here – if they forget to turn off the stove, there’s limited risk posed after the meal is done. There’s also some additional benefits – induction ranges are around 60% more energy efficient than gas stoves, and they have obvious safety benefits for households with children in the home as well.
Again, similar downsides to smart refrigerators – induction cookware (and the stovetops themselves) are expensive compared to their traditional counterparts. But given the safety aspects, they may be worth the cost!
Again, it doesn’t require complex artificial intelligence algorithms or computer technology to innovate on a simple idea and make it (in some cases) light years better. In a separate article I wrote for Psychologists in Long Term Care a few months ago, I reviewed a couple of aging-related startups. The first was Authored.
This is a company that’s leading the charge to make “adaptive apparel” fashionable and mainstream, as opposed to relegated to a niche market marketed in occupational therapy circles and via long-term-care industry catalogs. “Adaptive clothing,” as a quick reminder, refers to clothing that has been engineered to improve usability for people with functional and/or cognitive issues. For example – older adults with arthritis may have a great deal of difficulty with traditional buttons, but would benefit greatly from using snaps or Velcro. Older adults with dementia who may become agitated when a shirt is pulled over their heads, or may become combative when it’s buttoned from the front, may benefit from a shirt that opens from the back.
For Authored, though, it’s than just adding snaps, buttonhooks, and Velcro to clothes and calling it a day – Authored has taken pains to re-engineer adaptive clothing from the ground up. From their website: “We have reduced or eliminated irritating seams, used premium and durable fabrics and positioned closures to reduce discomfort while improving accessibility.” They’ve also made sure that their clothes look fashionable, and not ‘fuddy duddy.’
I *like* focusing on what Authored has done because they’re as much about innovation in usability as they are in terms of innovation in aesthetics and style – and I feel like the media attention Authored has gotten thus far (e.g., they’ve been featured on the BBC as well as last year’s Aging 2.0 conference in SF) has probably helped to make companies like Tommy Hilfiger, Target, and Zappos begin innovating their own lines of “adaptive clothing.”
Much like what Authored has done for adaptive clothing, Eatwell has been doing the same for adaptive flatware and dinnerware:
And again – these kind of adaptations can be critical for older adults who have arthritis, or cognitive impairment that may be affecting their perceptual abilities or otherwise. Adaptive tableware has been something utilized by Occupational Therapy for a very long time – and when employed properly, it’s an intervention that can, in the main, extend the amount of time an older adult or person with disabilities can eat independently.
What makes Eatwell’s products different than their competitors is again, they reengineered adaptive tableware from the ground up, utilizing evidence-based research down to the correct color contrasts to employ in their tableware in order to maximize meal percentages eaten by their test subjects. Much like adaptive clothing, adaptive tableware will be a growing sector of the retail market in coming years – it will soon be a much more mainstream product!
Moral of the Story
So sure, artificial intelligence, machine learning, wearables, mobile apps, etc., etc. – these will all have a place in the gerontechnology landscape as the population ages. But we need to keep an eye out for the “incrememntal tech” that will change the world and make the greying of the population a little easier as we progress into the brave new world that’s out there!
I’ve written a lot about the growing influence of technology on the world that older adults occupy, from the world of cute and fuzzy robots, to smart homes and smart nursing homes, and consumer applications of artificial intelligence (think Amazon Alexa and Apple’s Siri technology).
I’ve written about how the fastest-growing adopters of information technology (internet use) are older adults, and in some areas, older adults (particularly the baby boomers) match or eclipse the degree of adoption and use of certain classes of information technology at this point, specifically health-related technology.
One thing I haven’t written about is the so-called “emerging asset class” of cryptocurrencies – the most well-known of which at this point is Bitcoin.
I ran across article the other day, on the crypto-centric news site NewsBTC. Title of the article: “Nearly All American Seniors Don’t Know or Want Bitcoin: But It’s Not a Concern.” They reference a survey, apparently conducted by the “Gold IRA Guide,” located here, that lines up some pretty compelling statistics about how older adults (defined as people 50 years and older) seem to have a pretty dim view of this “emerging asset class.”
I have an uncle, who has been active on Facebook (and Twitter, I believe) for a number of years, who has occasionally posted about cryptocurrencies, and says he suspects that Bitcoin is either a “Ponzi scheme” or a “solution in search of a problem.” Either way, he’s not interested. Then there’s Warren Buffet – one of the most well-known and successful older adults out there, who has famously referred to Bitcoin as “rat poison squared.”
Neither my uncle nor Warren Buffet seem to be particularly out of step with the results of this survey (from https://goldiraguide.org/new-survey-reveals-american-retirees-currently-have-a-negative-outlook-on-bitcoin/):
(Photo by David Crowder from goldiraguide.org)
Big takeaways from this very interesting survey. Over half (56%) of all older adults surveyed have heard of Bitcoin but are “not interested” in it. About 1/3 (32.9%) don’t even know what Bitcoin or cryptocurrencies are. A much, much smaller percentage (3%) own some, and similarly negligible percentages are interested but either don’t know how to invest, or are just “keeping an eye on it” for now.
So, there’s a few things going on here to keep in mind. First, by their nature, older adults are a risk-averse group when it comes to managing their finances. They’re more likely than not to be on fixed incomes, and they’re more likely to be retired and naturally be geared towards wealth preservation and be avoidant of excessive risk in their retirement portfolio. Also, keep in mind – this survey was conducted deep in the Bitcoin bear market of 2018, after Bitcoin and the larger cryptocurrency market had lost around 75% of its market value, and all but the most optimistic of cryptocurrency supporters had thrown in the towel.
What is Bitcoin? Briefly, Bitcoin is the first example of purely peer-to-peer currency. There will only ever be 21 million Bitcoins in existence (making it noninflationary), and it requires no central issuing authority (like the Federal Reserve). Bitcoin itself is only 10 years old, having been borne of the 2008 “Great Recession” and subsequent Federal Reserve money-printing binges (QE1-QE3) that followed.
It’s also the first example of true digital scarcity that I’m aware of. You see, one of the features of computers and technology, as well as the internet, is that it’s trivially easy to copy things, like music (MP3s) or books, or websites, etc.
Bitcoin is the first completely digital entity that is uncopiable and un-counterfitable. That’s what makes it unique and valuable, and due to the fact that it can be sent peer-to-peer, avoids third-parties (like Visa or PayPal, who charge transaction fees) and also avoids censorship or confiscation, such as if the government decided to seize your funds, or if a bank decided to close your account.
All of that aside, cryptocurrencies are a very risky asset class. Despite the aforementioned bear market, since its inception, it’s gone from being worth around .008-.08 cents to being around $5,300 dollars today. While that’s an impressive run, it’s undeniable that Bitcoin has experienced sickening volatility compared to other assets, which has made it an investment only for those with the most iron of constitutions.
I have a confession to make. I own some cryptocurrencies. Mostly Bitcoin, but also several “altcoins.” I bought my first Bitcoins in 2011 – and then sold some and spent the rest a year or two later, which I kick myself about to this day. Since then, I’ve bought back in (and turned a decent profit at the end of the bull market of 2017), and right now my crypto portfolio stands at around a little less than 1% of my net worth, with most of my net worth otherwise being tied up in real estate, as well as a 403B and IRA stock portfolio.
Interestingly, I know of a lot of millennials (e.g., those in their 30s or younger at this point) who have an almost mirror-image view of cryptocurrencies compared to the older adults reported on in this survey, with a number of them with exposure in the double-digit percentages and upwards in their investment portfolios – with many of them reporting they trust cryptocurrencies more than the stock market. While I don’t advise this approach, given the cohort that millennials hail from, and their generational experiences (they essentially came of age during the Great Recession), it’s understandable they have the view they do of “traditional” investment vehicles, and that they embrace high-tech innovations like cryptos.
Here’s what I think – I think that much like any new technological advance or innovation, it takes time for older adults to “catch up.” We’ve seen this with information technology as well, although in the case of internet use, the “youngest-old” (baby boomers, mostly) they’ve basically already caught up in terms of their comfort and usage rates. Cryptocurrency is a bit different though – it’s bleeding-edge fintech,it’s both financial innovation and technological innovation, of a kind we’ve never seen before.
So, not only will Bitcoin and cryptocurrency have to scale the obstacles that technological innovations normally have to in order to be adopted by older cohorts (e.g., generation effects), it will have to also be accepted as a much surer thing, as opposed to the way it seems to most older adults today – a speculative vehicle that’s not much better than throwing it all on black in Vegas. In other words, it will have to truly demonstrate that it’s a store of value, in the same vein as gold and silver.
Likewise, as my uncle has told me, it will have to probably at some point show that it’s a solution that actually addresses an identifiable problem.
However, given the sheer scale of the US Federal Governments’ money printing (QE1-QE3), and the incomprehensible degree of US sovereign debt (21 trillion and counting), I’m guessing we won’t have that long to wait….
About five years ago, I noted a big event – after years of debate, the “big APA” folks (e.g., the American Psychiatric Association) had proposed that “dementia” be from heretoforward renamed as “major neurocognitive disorder.” In the article, I noted that there were some good reasons for proposing this change. For one thing, “dementia,” like “senility,” has some negative etymological baggage:
“the origin of the word ‘dementia’…. (is) a bit harsh as well, from the perspective of those who carry the diagnosis… ‘dementia’ originates from the latin term demens literally ‘mad, raving.’”
So, five years out – has this changing of the terminology cause any big changes in the field? It’s worthwhile looking at exactly why the “big APA” decided to make this this change in the first place.
From the DSM-5 online:
“Dementia is subsumed under the newly named entity major neurocognitive disorder, although the term dementia is not precluded from use in the etiological subtypes in which that term is standard….. The term dementia is retained in DSM-5 for continuity and may be used in settings where physicians and patients are accustomed to this term. Although dementia is the customary term for disorders like the degenerative dementias that usually affect older adults, the term neurocognitive disorder is widely used and often preferred for conditions affecting younger individuals, such as impairment secondary to traumatic brain injury or HIV infection.”
So, what it appears the “big APA” folks are saying is that they want us to stop using “dementia” when we’re talking about some disease entities where the term may be in less “standard” use – but if practitioners wish to keep using the term dementia as they always have, well, they can.
Where may the term be in less “standard use”? Well, given the association of the word “dementia” with older adults, nursing homes, and the aged, it seems pretty fair to say that “dementia” means “old people” to most. In practice, it’s worth noting that in my tiny corner of the geropsychology world, “dementia” continues to be the standard term. This may be for a number of reasons: for one thing, “major neurocognitive disorder” is well, rather wordy. Also, family members and consumers are not aware of the term. They typically have heard of “Alzheimer’s,” and may be aware of the term “dementia” (and at times, often ask “is dementia different than Alzheimer’s”)?
Moreover, it’s not particularly clear that the term “major neurocognitive disorder” has quite seeped into the public consciousness yet. Out of curiousity, I did a quick “Google Trends” dive, looking to compare the terms “major neurocognitive disorder” and “dementia.” Suffice it to say – while searches for the term “major neurocognitive disorder” are on the rise, it seems pretty clear the latter term has gained comparatively zero traction.
Searches for the term “dementia” appear to have over forty-plus times the
average volume, and continue to rise year upon year. It’s worth noting the same is true for searches within Google Scholar – which is a pretty good proxy for search use amongst academics and clinicians – a search for articles between the years 2015-2019 for the term “neurocognitive disorder” yielded just under eight thousand hits. “Dementia,” in contrast, yielded over a quarter million. Clearly, dementia wins.
This probably reflects a few things. One – the term “dementia” is entrenched as the “standard” term. Two, it probably reflects that the clinical wordiness of the new moniker is too unwieldy for consumers, and probably for clinicians and academics as well.
Would the world of dementia care be different if somehow we all got on board and dropped the use of the term “dementia” outright? Would this translate into more humane and person-centered care for persons with dementia / major neurocognitive disorder? At this point, we don’t know, because five years out from the APA’s grand semantic shift, “dementia” continues to rule the diagnostic roost.
I’ve been wanting to write this article for a long time. I’ve been working in geropsychology and the long-term care (LTC) industry for the last 14+ years. I’ve worked mostly in the area of skilled nursing (what most people know of as nursing homes), as a consultant and staff member. Skilled nursing facilities are where people, typically OA (OA), live and receive medically necessary professional services from nurses and other allied health professionals to provide them assistance with activities of daily living.
Over this time, I’ve learned a few things. Skilled nursing care, at least as it’s practiced in the United States (but this is largely true across the industrialized world) is highly regulated, very labor intensive, and because of these two reasons – is very expensive. Caring for medically complex and frail, chronically ill, primarily older adults (OA) involves a lot of monitoring and supervision, along with the physically demanding tasks of caring for their bodily needs.
Back to the issue of cost – according to recent statistics, the average monthly cost of a stay in long-term care in the United States is over eight thousand dollars per month ($8,121 to be exact). While that number is obviously high, it’s sobering to recognize that the cost is 13% higher than it was just 5 years ago (citation here).
Setting the stage – Recapping the “Demographic Tsunami”
And these trends aren’t going to be slowing down anytime soon. As I’ve written here, and here, and a number of other places, the US and the rest of the industrialized world is currently poised to be swept away by a “demographic tsunami.” This refers to the fact that from the year 2000 to 2050, the world’s population who is 60 years or older will approximately double from about 12% to 22%. The number of “oldest old” (those over age 80), will quadruple.
Moreover, there’s strong data suggesting that there are, and will continue to be growing and severe shortage of healthcare professionals out there to meet the needs of OA (both in long term care and otherwise). In my own particular field, geropsychology, the shortages are already severe and are projected to continue to grow. The story is not much different for the fields of geriatric medicine or geriatric nursing – even the front-lines of LTC, the people who do the real demanding, physically laborious work of caring for elders, the nursing assistants – even this field is experiencing growing shortages.
There’s a number of reasons why this is. One, reimbursement. Geriatric medicine is a field with one of the lowest reimbursement rates of any medical specialty, so, in response, it’s a very poorly sought-out specialty for the hordes of newly-minted physicians who want nothing more than to pay off their increasingly-herculean student loans and to start providing a good living to their families (and who can fault them for that?). Geriatric nursing isn’t much different, and in the case of nursing assistants, hourly wages of 10$ per hour in very demanding conditions provides a poor retention incentive.
So why is this such a problem?
So far, it’s fair to say that the rapidly growing cost of nursing home care and elder homecare and facility care in the United States and industrialized countries is not stopping. While our current generation of 65-year-olds and older are (arguably) the healthiest they’ve been in a long time, the fact is – when people get old, they are at far greater risk of developing a whole host of problems that often require significant and at times, round-the-clock care. For example:
- Dementia – I never fail to mention this one. The #1 risk factor for developing dementia (such as Alzheimer’s disease), is advanced age – and, dementia is endemic in LTC facilities (at the VA nursing home I am employed at in my day job, around 70% of my population have dementia, which is roughly in line with US averages).
- Falls and ambulation problems – chronically ill OA are more likely to lose the ability to walk as they get older. Musculoskeletal issues (like degenerative joint disease), deconditioning and muscle wasting, dementia, and other issues can often render OA wheelchair bound or worse. Sometimes they are unable to transfer from wheelchair to bed or toilet without assistance, or require lifts to be moved. Sometimes they are even unable to turn themselves in bed. Also – closely related to the issue of ambulation is falls – older people are much more prone to injuring themselves during a fall, and of falling more frequently. This is due to issues like cognitive impairment and poor judgment (due to the aforementioned issues with dementia).
- Incontinence – another major issue is lack of control of one’s bowels or bladder. Again, medical conditions like dementia, spinal cord injury, or other neurological problems can put chronically ill OA at risk for this. Obviously, incontinence, when combined with other issues, can require care as incontinence briefs need to be regularly changed so as to prevent other issues.
- Difficult-to-heal, or nonhealing wounds – often the above issues of problems with ambulation, incontinence, or frequent falls often put chronically ill OA at risk for developing wounds that are often very difficult to heal. Often this is because they are less likely to move when they are in bed or in a chair (leading to pressure sores), or they can bang or scrape themselves during a fall. Due to thin skin and reduced ability to heal (often because of poor circulation, diabetes, etc.), their wounds take a very long time to heal, and without constant care, can at times become infected.
And this isn’t even scratching the surface. As you can see, chronically ill OA require significant amounts of monitoring and care by professionals in order to just exist, and without it, they can rapidly become acutely ill and require much more expensive care (such as in an emergency room).
So what’s the solution?
There’s been much discussion about solutions over the years, from making OA healthier, to strengthening home and family caregiving options, to training more doctors, nurses, and psychologists to help OA living in nursing homes, as well as improving existing models of care.
It’s also worth mentioning that with all the hullabaloo of the so-called “Affordable Care Act,” AKA Obamacare, there has been virtually no attention paid to reforming the broken state of LTC funding in the United States (I’ll quickly get off that soapbox!).
So what if there was some other solution? We all know, as is was said here by venture capital investor Shourjya Sanyai, that the “rapid(ly) aging demographic will directly affect social, economic and health outcomes for these growing economies. Particularly healthcare delivery pathways need to be readjusted, keeping in mind the prevalence of chronic diseases, comorbidities and polypharmacy requirements of the elderly and geriatric patients.”
Sanyai goes on: “Given the situation, healthcare providers are starting to offload certain parts of the care-pathways to artificial intelligence (AI) based automatization. AI can now be found in every step of the care-pathway, starting from intelligent tracking of biometric information to early diagnosis of diseases.”
So what is AI?
Artificial Intelligence and Machine Learning – Definitions, and the Example of Alexa
The definition of artificial intelligence, as found via Google: “the theory and development of computer systems able to perform tasks that normally require human intelligence, such as visual perception, speech recognition, decision-making, and translation between languages.” Note that artificial intelligence (or AI, as it’s frequently called) is frequently combined with smart machine learning algorithms – which thereby assure a system that can do specialized cognitive tasks and also learn from experience as it does it’s work.
Moreover, one of the nice things about today is that AI and machine learning is a concept that’s rapidly seeping into the consciousness of consumers worldwide:
Figure 1. Amazon Echo (http://www.bestaiassistant.com/google-home/amazon-echo-vs-google).
Amazon probably has done more to make the concept of AI (and it’s capabilities) obvious to the masses with the introduction of the Amazon Echo device, which is the most well-known vehicle for its so-called Alexa AI technology. What does the Echo do? One of the things we like most about the Echo in our family (we have several) is that it takes rote tasks and automates them.
For example, we have most of the lightbulbs in our house now controlled by Alexa – instead of having to get up and flip a switch, we say “Echo, turn off bedroom lights,” etc. We’ve also hooked it to our music streaming service, so if we want to hear a song, we say “Echo, play (insert favorite song),” and off it goes – this is as opposed to fiddling with our phones, or a CD player, or whatnot.
There’s more – Alexa will now be doing double-duty as a burglar alarm! One of the newer “skills” that Alexa has been enabled with is something called “Guard Mode” – whereby if a user leaves their home, they can say “Alexa, I’m leaving,” and Alexa will listen for the sound of glass breaking and alert the user. So – Alexa is also a smart monitoring system – while you can still purchase an analog burglar alarm system monitored by “24/7 security personnel” (which is expensive and requires people on duty to constantly monitor your home), you don’t have to – because AI (in the form of Alexa), will do it for you.
AI and Machine Learning in Healthcare
So let’s go full-circle back to LTC. Why would be interested in it?
First, remember all the examples I listed above, regarding the kinds of problems regularly addressed by nursing staff in LTC facilities (e.g., dementia, falls, wounds, incontinence, ambulation and movement issues). What they all have in common is that in order to address them in the LTC environment, they require a significant amount of personnel to perform rote tasks relating to monitoring and rounding. I would suggest that a very significant number of these tasks currently performed by nursing staff could be offloaded to so-called “smart systems.”
Smart Device Assisted Living and Monitoring. What happens when an older adult with dementia tries to leave their nursing home (trying to “go home”)? The current standard approach to “wandering” is to attach “wander guards” to residents at risk, which, when residents cross a perimeter, will alert staff and allow them to redirect them back into the facility. The downside of this is that often these alarms don’t help to locate residents (it just alerts them that the perimeter has been breached), nor does it distinguish between those who legitimately are trying to escape, versus those who merely accidentally trip the alarm when they are merely, say, rolling outside to get a breath of fresh air.
Or how about when an older adult is bedbound, is at high risk for nonhealing wounds, but due to neurological impairment fails to turn themselves? The current standard of care is for nursing staff to regularly “turn” residents (say, on an hourly or per-shift basis). However, this requires that nursing staff, who are often busy, overworked, tired (and human) to remember to remember – moreover, it’s often possible that these residents may be still turning on their own and don’t need this extra intervention.
AI is tailor-made for the situation I sketched out above, in the case of “turning” residents. You can apply a wrist-mounted (or bed-mounted) sensor to a resident and monitor their movements. If a resident has not turned after a certain amount of time, you can have the AI system alert staff proactively, essentially telling them, “hey, Mr. Jones hasn’t turned in a while – can you go help him?” This prevents staff from having to round unnecessarily on residents who are not at risk for wounds and who are turning in bed, and also relieves nursing staff from having to “remember to remember.” One of the companies mentioned in this article are already developing an AI system to address this very issue.
Wrist-actuated actigraphy (such as what you see with Fitbits, and Apple Watches), combined with AI, is also potentially ideal for replacing the old “wanderguard” system – I am familiar with a company called Carepredict, who is essentially doing just this – they have facility residents wear their own proprietary wristbands which detect a resident’s movements within the unit (as well as level of activity). The system is designed to provide “early warnings” to staff when a resident’s behaviors deviate from their established norms – and can precisely locate a resident when they are trying to escape (this is also something AICare is also trying to do).
Not only that, Carepredict claims they can provide “early warning” for staff to let them know if a resident is becoming depressed (say, if they begin to isolate in their rooms when their previous pattern was to be out and about regularly), or if they have stopped eating.
Fall Detection and Prevention. How are falls currently addressed by nursing staff?
Figure 2. Bed / chair alarm pressure pad (courtesy of Alimed, Inc).
Currently, it’s the ol’ analog pressure-pad system. In other words, residents identified as being high fall risk are issued pressure pads placed on their beds or chairs, and if a resident gets up from their bed or chair, the alarm sets off a loud racket, and nursing staff come running. The downside of the current system are manifold – one, it has a significant number of false positives – residents who merely move in their chair or bed (something we *want* them to do, actually) set the alarms off. Second, the noise is annoying to residents, and for those with dementia, can serve to agitate them further – thereby inadvertently raising their fall risk. Third – it leads to “alarm fatigue” in staff (due to the frequent false positives) – staff sometimes don’t respond to the alarms because they know they are often wrong. Despite all of this, residents continue to fall at high rates, staff often find a resident on the floor and are left to question these frequently-memory-impaired residents and otherwise piece together what happened, and then institute fall prevention measures after the fact.
Enter Safely-You, a company I’ve been very excited about (although note they’re not the only market participants in this space). Instead of pressure pads, they offer a camera placed in a resident’s room, typically at bedside (since this is where most falls occur) and the camera then continuously monitors the resident, constantly capturing video of the resident.
However, there is never more than 10 minutes of video saved in the systems’ buffer at any one time, and video is only ever permanently saved if a fall is detected. The AI and machine learning built into the system detects falls at apparently a 94% level of accuracy, and immediately alert staff when a fall occurs. Staff are immediately able to review the video and institute fall prevention recommendations based on exactly what they see the resident do (as opposed to what they imagine happened).
Virtual Companions. This is a subject near and dear to my heart (see here, here, and here). Let’s go back to the example of Amazon’s Alexa (and it’s various competitors – like the Google Home or the Apple Homepod) – these digital assistants are useful, but they aren’t exactly companionable – more just disembodied and mildly robotic voices that do what you tell them (although Alexa can tell jokes, or sing songs for you if you ask it).
One of the other “rote” tasks in nursing (hate to put it that way) revolves around the insubstantial yet extremely important task of providing companionship to residents. The hug, the touch on the shoulder, the listening intently to the older adult as they tell a story – these are all vital to the health of OA but due to the abovementioned issue of staffing and sky-high demand for long-term care services, nursing staff are much less able to provide this service to their clients.
So, how about this?
Figure 3. Paro robot doing its thing. Courtesy of the Toronto Star.
Above is the Paro robot – a robotic companion that uses its built-in machine learning algorithms to learn the name users give it, and to respond preferentially to being stroked, and to avoid being hit or dropped. Moreover, it’s adorable – and research tends to suggest that it delivers beneficial affects to the users (which includes calming dementia patients), by stimulating oxytocin production. Oxytocin, of course is the feel-good chemical that parents get when bonding to their children or when new mothers first nurse their babies.
Other Applications for AI and Machine Learning in Facility and Home Care?
This kind of technology has applications that literally are only limited by imagination and a few smart programmers. A worthy mention is the company Winterlight Labs, which has a proprietary assessment tool which claims to assess for the presence of dementia via speech-sample assessment of patients to a degree heretofore impossible using standard, human-administered cognitive tools. This kind of innovation has the potential to put geriatric neuropsychologists out of business!! (Well – maybe not quite yet).
Also an honorable mention goes to CareAngel – they have a system whereby the digital assistant (like Alexa) calls OA and simply asks them how they are doing (they call these “care touches,”) and then has an actual conversation with them. For example, if the older adult says “terrible, I’m in a lot of pain,” then the system asks them additional questions (like what level their pain is, where it’s located, etc). and then depending on their answers, summons a live care provider.
The bottom line is that AI and machine learning are poised to revolutionize the care of OA both within and outside the LTC industry. This revolution will result in a lowering of costs, mostly in the form of less staff required for routine, rote monitoring and rounding of residents, but also – in the form of less costly trips to the emergency room or ICU due to real or even misclassified falls, as well as infections and injuries. It may even result in less need for humans to provide companionship to residents, as we might be able to offload some of that work to social robots and digital companions (as creepy, and potentially ethically questionable as that may be to some).
Nursing homes and OA care are going to see skyrocketing demand over the coming years. In order for our nation to not get completely swamped by the sheer weight of the cost and labor of caring for our most needy and vulnerable citizens, we’ll need to find ways to innovate our way out of this. The AI and machine learning revolution may in fact help us to do just that!
My first foray into Youtubing. Focusing on gerontech and AI / machine learning and how it may apply to the aging and long-term care space.
Movie Review Time!
It’s been awhile. So, I think it’s time to go full circle and return with another movie review. If you, dear reader, recall – that was in fact how this blog was started in the first place, with my review of “Robot and Frank” with Frank Langella. The movie in that case was reviewed because I considered it both a whimsical and touching exploration of the stresses of dementia caregiving. Today I’ll be talking about “A Man Called Ove,” a Swedish-language film, from a 2012 book of the same name by Swedish author Fredrik Backman. In this case, I think it’s an incisive exploration of a somewhat different topic that’s relevant to aging – that of loss and of older adult suicide.
(Warning – spoilers ahead!)
The movie opens with the 59-year-old Ove (played by the Swedish actor Rolf Lassgård), arguing and being unpleasant and angry with a cashier at a grocery store, over a coupon to pay for flower arrangements for his late wife’s gravesite, who died six months previous to the movie’s opening. The movie, which is billed as a comedy-drama, gets a lot of laughs through Ove’s over-the-top negativistic behavior, where he variously threatens to kick and turn barking dogs into “purses” (if I remember correctly), calls at least two dozen different characters in the movies “idiots!” and at one point gets into a physical altercation with a clown at a children’s hospital.
Ove’s woes and losses are many over his 59 years – he is depicted in the opening scenes of the movie as losing his job, and also has apparently recently lost his best friend to dementia (or, at least, a severely disabling neurodegenerative illness that has rendered him largely unable to communicate). The movie depicts Ove as responding to this by becoming chronically suicidal, and throughout the movie he attempts to kill himself via multiple methods, such as hanging, carbon monoxide poisoning, and via a shotgun – and ultimately failing due to interruptions from nosy neighbors as well as the sheer difficulty of the task itself – apparently suicide is not so easy. (He comments at one point at his dead wife’s gravesite that killing oneself is actually rather difficult)!
A Man Called Ove – A Prototype of the High Suicide Risk Individual?
Some brief facts for you, at least as they regard the United States:
- A completed suicide happens ever y thirteen minutes.
- Our suicide rate is the highest it’s been in approximately 28 years.
- Older adults are disproportionately represented in older adult suicides, with white males being disproportionately represented.
“A Man Called Ove,” in my view, almost-perfectly movie illustrates the prototypical high-risk individual for suicide.
In the movie, Ove becomes suicidal ostensibly so he can join his wife, Sonja, as he has supposedly promised her. However, it becomes clear that what may be driving Ove is he has been suffering the ‘death by a thousand cuts,’ multiple losses over time – his wife, his job, his child, his friend, as well as his treasured position as the leader of his small homeowners association.
This theme – that of multiple losses in an older white male leading to increased suicide risk – it is a distressingly familiar one. Aside from adding in alcohol abuse and medical / functional losses (e.g., such as loss of eyesight, or ability to walk), Ove hits just about every risk factor for older adult suicide I am aware of, at least as far as North Americans are concerned (I suspect that there may be some similarities with our Swedish counterparts).
Hiding (sometimes very well!) underneath the curmudgeonly, depressive exterior of Ove there is a man with an almost-boundless capacity for love and attachment, as well as a man of many talents – a man with the ability to repair just about anything (cars, radiators, dishwashers), perform acts of heroism (saves the life of a man from an oncoming train, ironically as he is trying to commit suicide himself), and shows surprising acts of tenderness and caring, such as sheltering a young, newly-outed gay man who has recently been thrown out of his home.
What saves Ove, in the end, is finding connection with others. Some of the nosy neighbors include an Iranian-born pregnant wife and her bumbling husband, whom for some reason fail to be repelled and are instead charmed by Ove’s nonstop cantankerousness. Over time, he becomes part of their family and he finds within himself a reason to live. He finds connection, and he finds life.
Overall, while superficially this may look like another movie milking the “grumpy old man” shtick seen in popular culture that has in my mind bordered at times on outright ageism, I was charmed by this movie; in how it carefully and bitter-sweetly took it’s time with the character development of the protagonist, who over a series of flashbacks is depicted as coming of age and marrying the love of his life while at the same time enduring terrible, traumatic loss and yet soldiers on.
The movie ends fittingly and in a way that made my heart ache and yet practically sing at the same time – Ove died because of (no irony here!) an enlarged heart, and with a funeral service packed with well-wishers, friends, and loved ones. Ove dies – because his heart is too big.
So, as a long term care psychologist, I like to tell students and staff that I am really generally quite useless on my own in such a large, chaotic care environment like a long-term-care facility. Ironic, of course, because that’s the traditional model of provision in community nursing homes, right? The psychologist scurries in, sees patients in his caseload, he / she barely has time to talk to nursing staff, the psychologist scrawls some notes in the chart, and scurries out. This basically the traditional “collaborative care” consultancy model that I operated under when I worked my first year doing nursing home consulting post-licensure.
This traditional service delivery model (again, which is basically the rule in community skilled nursing facilities) is a direct result of the way we fund the services of psychologists in nursing homes – e.g., fee-for-service via Medicare, and overwhelmingly reimbursing for direct care services only (e.g., where the psychologist is interacting directly with the patient).
Moreover, this type of service delivery model – via economics – completely disincentivizes and discourages long-term-care psychologists from doing the most valuable kind of work they have in their arsenal, which is making close, collaborative partnerships with interprofessional care staff. Psychologists do all sorts of work with staff, formal and informal, which Medicare doesn’t (as far as I’m aware) reimburse for. In terms of informal, indirect services – we do “curbside consulting,” which is what I call those informal, friendly chats at nursing stations or in breakrooms where nurses, usually in the midst of chatting about unrelated issues (what they did for the weekend, etc.) they say “oh, by the way Doctor, can I talk to you about….” (insert behavior issue here).
In terms of the more formal work psychologists do? We do in-service trainings for nursing staff (I’ve taught classes for nursing CE credits, in fact). We are resources for mental health education for staff. One service which I find very enjoyable to deliver is the STAR-VA behavior management intervention, which deliberately makes sure to include Social Work, Recreation Therapy, physician staff, and nursing – because, bottom line, psychologists are generally fairly ineffective on their own. I attend care planning meetings where I assist and consult with nursing staff in developing care plans… and then there’s all the other stuff too! (Attending nursing reports, attending administrative meetings, etc etc etc).
So, what’s the moral of this post? At least as far as I can tell (because I don’t think Medicare’s approach to reimbursing psychologists for their work has changed much over the last few years since I worked as a private consultant), Medicare doesn’t pay psychologists do the most effective work they can do. Under Medicare, geropsychologists don’t tend to do their best work (unless they’re unusually creative and charitable, perhaps?).
I’m lucky though – I get a salary for what I do here at the VA (and I get paid reasonably well). So, I get paid just as much for seeing a patient for 1:1 therapy (which I do here and there) as I do for working with staff to brainstorm a difficult behavior management issue. I’ve seen how ineffective it is to operate as a Medicare-reimbursed psychologist in community nursing homes (it’s like sticking your fingers in the proverbial dyke, really), and I’ve also experienced first hand how much more effective I can be in my job as a collocated, salaried provider. Obviously you know what my preference is.
Behavior Management in Dementia and Linda Teri’s STAR program
So I think at this time I’m going to get briefly away from my current fixation on gerontechnology and gadgets and instead focus on something that’s been happening at my day job at the VA. Over at my job site we’ve instituted something called the “STAR-VA” program, which is based pretty closely on Linda Teri’s STAR and STAR-C programs (btw, STAR stands for Staff Training in Assisted living Residences).
Dr. Linda Teri’s STAR program has been trialed extensively at assisted living facilities (ALFs, as they say in the biz), nursing homes and also with family caregivers (the STAR-C program) and has been found to yield exceptionally good results. As I indicated above, it has now been ‘ported’ to the VA and although the data is somewhat preliminary, it appears that STAR-VA is an extremely effective non-pharmacological approach.
What is the STAR program? Well, you can find out by purchasing a kit over at http://depts.washington.edu/adrcweb/STAR.shtml. Or, you can get hired by the VA as a nurse or psychologist, work for a VA Community Living Center (CLC, which is VA-speak for what we all know of as skilled nursing facilities, or nursing homes), and get trained in STAR-VA by their ongoing VA Central Office (VACO) training program. Or – you can listen to my very brief overview and commentary here (although that doesn’t substitute for the above – but will give you a sense of things). I have received the STAR-VA intensive training myself, as have my colleagues at the VA facility where I am employed.
Very briefly, the STAR program is designed to address what is an endemic problem in nursing homes and ALFs, specifically what is called “behavioral and psychological symptoms of dementia” (or BPSD for short) as the technical term currently in vogue, but also often called things like “agitation” or “behavior problems.”
A representative kind of behavior that the STAR program is designed to address is a problem that’s consistent and chronic (as opposed to a one-off behavior), takes place at reasonably consistent times, and isn’t the result of an unstable underlying medical condition (e.g., such as what you might see in a delirium). A prototypical behavior is “resistiveness to care,” such as when nursing staff (typically nursing assistants) are cleaning a patient, e.g., “ADL care.”
Imagine that you’re a patient in a hospital and you have trouble walking, controlling your bowels and bladder, and require assistance to keep yourself clean and toileted. Now imagine that you require assistance from other adults (nurses) to clean you every time you have a bowel movement or need to pee. Imagine how difficult (e.g., embarrassing, anxiety-provoking, and even somewhat demoralizing) that might be!
Now imagine what would happen if you were in the same situation, and you had *dementia.* Imagine you didn’t know where you were, and how you got there. Imagine that you’re lying in a bed, confused, and all of a sudden strangers come into the room and start squawking at you and saying unintelligible things, and start pulling off your pants and grabbing at your private area.
What would *you* do?
In many cases, these patients become aggressive, will yell, scream, physically resist, and at times try to hit nursing staff. Staff will respond by trying to reason or sweet-talk the patient. They may give “time outs” (leaving the room and coming back later, hopefully when the patient has calmed down). They may medicate the patient with pain pills and/or psychiatric medications. Also, in this situation I’ve seen nursing make use of multiple staff members (ostensibly to protect the staff giving the care from physical injury). Very frequently, these interventions either don’t work or make the problem behavior worse.
How do psychologists help with these problem behaviors in dementia?
In community nursing homes, where psychologists are typically reimbursed by Medicare, and the traditional “roving consultant” model applies, psychologists are restricted to being reimbursed for largely what is direct care services only. That is, they are reimbursed for seeing patients on a 1:1 basis for psychotherapy or to provide psychological assessment. Although there is a category of “behavior management” services that psychologists can be reimbursed for, it still requires the psychologist to be seeing the patient and only reimburses for 2-3 sessions at most.
This is not a very effective model for delivering effective behavior management approaches in residential care facilities where dementia is frequently a presenting issue.
We are not hamstrung by fee-for-service restrictions on care at the VA, which is fortunate, because I know as a geropsychologist with a decade’s experience in this field that the best way to address behavior problems in dementia requires approaches that embody the following:
- The approach must be staff-driven. At best you’ll likely only have one psychologist available for an entire nursing home or ALF, who is only there part of the day or week. Therefore, all staff must be prepared and empowered to offer effective behavior management techniques on a 24/7 basis.
- The approach must be interdisciplinary. Behavior problems are not just a “psychology problem” or a “nursing problem.” Older adult residents at ALFs or nursing homes interact with a wide variety of staff from janitors to food service to physicians and et cetera. Behavior management is a team effort!
- The approach requires an intense focus on staff education and even a “cultural shift” in how dementia patients are looked at and cared for. Dementia is a disease unlike any other because it affects how patients see and understand the world and interact with others, it affects everything. It has no cure. There is no effective treatment that can restore people to normal functioning. It requires lifetime management for the sufferer. In order to provide the most compassionate and effective care, staff need to understand, appreciate, and as best as possible, empathize with the plight of these patients.
So, given the above, what is does the STAR approach entail? The STAR program has within it four distinct elements which embody key principles and approaches:
- The ABCs of Problem Behaviors. This of course refers to the old “Antecedents, Behaviors, Consequences” model of looking at behavior problems in dementia (this is also a model that behavior analysts use to address behavior issues with developmentally disabled individuals, as an aside). An example of a simple “ABC card” is here. In working through this ABC model, where staff carefully define the behavior problem, look at the Who, What, When and Where of a behavior, and look for its triggers and consequences, staff can then find ways to alter the contingencies that may be maintaining the behavior issue, and ultimately, change it. In encourages staff to look at behavior problems in dementia as a “detective work” problem (since dementia patients typically can’t tell you what the problem is).
- Increasing pleasant events. As I’ve worked on the STAR-VA program, I have found that this is a critically important piece – namely, that behavior problems in dementia patients becomes much less likely when they are regularly exposed to personally meaningful pleasant activities. In an unrelated aside, interestingly, a tried-and-true method for treating depression in intact adults was pioneered by psychologist Peter Lewinsohn, so-called “pleasant events therapy.” In the same way that systematically increasing exposure to pleasant events can result in remission of depressive symptoms, it can also result in decreases in behavior problems in dementia – almost as if these behavior problems are how dementia patients tend to express their distress!!
- Promoting effective communication skills. Dementia patients have problems with language. They may have trouble expressing themselves verbally, or understanding language, or both. That means for staff to stand the best chances of having themselves and their intentions understood, they need to communicate with their patients differently. They need to SLOW DOWN when they speak. Speak clearly and in short, simple sentences. They need to pay attention to their nonverbals – because with dementia patients, it matters as much (and frequently more) in terms of how you say things as much as what you’re saying.
- Realistic expectations. Of the four STAR principles, this one is probably the most purely educational in nature, and in my opinion, one of the most critically important. For caregivers to be in the position to interact calmly and compassionately (and therefore, the most effectively) with residents who have dementia, they will need to have the most accurate understanding possible of what exactly is the matter with their patients. What is a sign that a staff member does NOT have a realistic or accurate picture of a dementia patient? When a caregiver says, “oh, they have selective memory.” Or “they are doing it on purpose.” Or “they know what they are doing.” Obviously, these are not helpful ways to look at our dementia patients. Realistically, when dementia patients act out, forget things, and perhaps are even aggressive or combative, we know it’s because their brains are sick and not working properly. If we understand things thusly, then we are much more likely to react calmly and compassionately to them then to take it personally.
In future posts, I’d like to talk more about the STAR program components in detail.