Understanding Aging in the Personal Context
As SmHT become more affordable and diverse, older adults can use these tools to address their unique needs and challenges associated with aging. A critical element in this process involves older adults becoming more aware of the manifestations related to their unique aging-related changes and understanding them in a personal context. The self-awareness of age-related changes and how they impact ADLs is especially important to develop appropriate adaptive strategies to cope with them. SmHT with a specific focus on aging support generate objective physiological, behavioral, and environmental data about older adult users and their home environment. Such data could objectively depict areas impacted by age-related changes within older adults and their living environment and could serve as an insightful resource when making health-related decisions. For example, a sedentary lifestyle is a well-known age-related change prevalent among many older adults. Past research has linked sedentary behaviors with adverse health effects (de Rezende, Lopes, Rey-Lopez, Matsudo, & Luiz, 2014). Assessment of sedentary behaviors has traditionally relied on self-report data. Results from subjective measures may not accurately reflect older adults' actual behaviors and are often uninformative in generating actionable insights for older adults to make positive changes.
SmHT that incorporate on-body sensors and other types of sensing devices with advanced data analytics could objectively and accurately identify ADLs and provide detailed analysis of sedentary lifestyles. Older adults could review their activity data and learn more about the specific context of how sedentary behaviors occur (e.g., time spent sitting watching television, reading books, using a computer) and consider adaptive strategies. In addition, older adults can agree to receive timely reminders to promote physical activity to help them stay active. Table 1 provides some common examples of risk factors associated with aging, the impact of age-related changes, and adaptive strategies using SmHT.
Examples of Adaptive Strategies Using Smart Home Technologies
System designers should also consider how to deliver the data generated by SmHT in easy to understand and intuitive formats. Providing the means for older adults to easily access their data and facilitating insight about individual health status and ADLs is an important element of how SmHT could assist in EWA. Previous studies have shown that older adults are interested in receiving smart home data that help them better understand their health status (Reeder et al., 2013). However, such data that are difficult to access or presented in poorly designed graphs or other data visualization formats will have limited value and may even lead to misinterpretation of data. Therefore, web portals that give continuous access to relevant and useful smart home data must be provided to users. Older adults may want to use interactive data visualizations of their health data and identify longitudinal trends and patterns related to age-related changes. A portal might also use a smart speaker and its embedded AI assistant to allow older adults to dynamically explore their data using natural voice commands. By having access to their detailed health data and behavioral patterns, older adults can make timely adjustments in health behaviors themselves or present the data to health care providers and family caregivers to develop personalized adaptive strategies together, which could be reinforced by the AI assistant.
As SmHT to support aging inevitably collect multitudes of data, it is essential to consider potential negative impacts of data fatigue and context-insensitive alarms (e.g., notifications to exercise when visitors are present, false alarms in fall detection). The risk of context-insensitive alarms may render potentially good solutions ineffective, cause emotional discomfort, and negatively impact long-term adoption of the technology. Therefore, SmHT must be able to integrate with other devices to deliver appropriate notifications. Data analytic algorithms must also preserve a high degree of precision with adequate levels of sensitivity and specificity to minimize the risks of false alarms. Even if started with strong motivation to use smart home data to engage with aging, older adults may quickly find themselves overwhelmed by vast amounts of data and puzzled as to how to access, control, and use the data. To avoid this problem, older adults should be adequately oriented to the smart home environment. This orientation may involve the help of adult family or community members. Nurses or case managers equipped with technological competencies may also assist older adults. Finally, SmHT to support aging should place older adults at the center of design and implementation (Huber & Camp, 2017).
Enhancing Capacity: Agency and the Smart Home
An implicit element of EWA involves the ability of older adults to make decisions based on their needs, preferences, and priorities. Some science and technology researchers note that agency, or the ability to act, is not located solely within an individual (Suchman, 2009). Rather, the ability to act is tied to the social and material resources in one's environment (Suchman, 2009). And one's home and the technologies in it constitute some of these material resources. For example, a smart light that turns on when one is walking to the bathroom at night can be a supportive resource, whereas an individual might not be able to complete that same activity without the light. In this example, one's physical ability to complete a task is tied to the technology in one's home. But SmHT, particularly those supporting aging in place, may also hinder agency. Mort, Roberts, and Callén (2013) argue that aging in place technologies can actually be coercive, potentially hindering people's ability to act according to their preferences. SmHT can be coercive when they are presented as older adults only opportunity to continue living alone (replacing in-person consultation with nurses and other practitioners) or when they intensely monitor people and share private data that invite unwelcome responses or actions from caregivers or family members (Mort et al., 2013).
As research and practice move toward SmHT, near-future dystopian possibilities must be carefully considered: people being compelled to act against their wishes by their home infrastructure (e.g., insurance costs tied to daily exercise, smart refrigerators locking when one has achieved the optimal number of calories). One way of addressing this concern is to ensure that technologies are adaptable and permit non-use (Mort et al., 2013), which requires a range of settings that must be determined in consultation with older adult users. To ensure that older adults play an active role in the use and configuration of these devices, rather than being passive recipients of alerts or directives, an important area in research and practice is supporting digital literacy as technologies evolve.
Cognitive Capacity. In considering one's ability to act according to his/her preferences, it becomes important to discuss cognitive capacity. Although many older adults do not experience cognitive impairment such as dementia, it is a condition that becomes more prevalent as people age (Plassman et al., 2007). A diagnosis of dementia is no longer viewed as the end to one's ability to make decisions (Kelly & Innes, 2013). Thus, consideration should be given to supporting people at varying levels of cognitive abilities to evaluate tradeoffs and make decisions. This support includes big picture decisions such as health care priorities and end-of-life considerations, but also the mundane day-to-day choices, such as when to go to bed. When thinking about capacity to make decisions, legal capacity, which includes the ability to understand and appreciate the consequences of one's actions, should be considered. According to some frameworks, capacity is not something that someone globally “has” or “does not have,” but is something that should be evaluated on a case-by-case basis (e.g., capacity to consent to treatment) (Appelbaum, 2007). Capacity, like agency, is tied to the socio-material environment—someone may have less capacity when there are many distractions present or when questions are delivered in dense language or jargon. In some countries, individuals who assess capacity (i.e., physicians, nurses, social workers, occupational therapists, health care assistants, support staff) are required to optimize the environment accordingly for people with dementia, yet it is not currently clear how technological platforms can support these efforts (Batchelor, Bobrowicz, Mackenzie, & Milne, 2012).
Smart homes have the potential to serve as environments that enhance, or support, cognitive capacity. First, seeing cognitive capacity as something that fluctuates over time, particularly for persons with dementia (e.g., sun-downing), a smart home could learn the times when someone has the most capacity and present decisions to them at that time. This approach could draw on the algorithms and sensors being developed to detect decline and orient outcomes toward supporting action by people with dementia rather than primarily as information to be used by others. A second approach could be to use prompting to support action. Past research shows that with support and prompting, people with dementia can do more than their scores on dementia rating instruments may indicate (Perry, Galloway, Bottorff, & Nixon, 2005). A smart home might draw on advances in machine learning to provide prompts (e.g., steps to complete making tea) or even remote communication that supports a simulated presence, such as social VR where a family member might guide someone through an everyday routine.
Addressing Risks. When discussing any kind of digital networked technology, it is essential to consider the potential for scams and security risks. Elder abuse includes exploitation, including financial exploitation. Older adults are targeted for exploitation and scams, yet elder abuse is a significantly under-addressed area (Daly, 2011). Being a victim of these crimes impedes one's ability to engage with aging in many ways: it reduces one's resources and may cause others to step in and begin to make decisions on the behalf of an individual. SmHT might play a role in preventing some of these crimes. For example, showing someone who is at the door or inviting family members who may have input into older adults' decisions (Rowles & High, 1996) to have more insight into what is happening in an older adult's life may provide preventive measures or the ability to step in to avoid what seems to be a scam. At the same time, SmHT must not invite potential for security risk. Many smart devices on the market are “hackable” on the device level and through higher-level security breaches, where many individuals' private data are stolen. Further, data collected by these devices may not be protected by HIPAA, and companies might share or sell the data with other parties. Even when medical data are protected, it might be shared with insurance companies without older adults' awareness. Devices used by older adults, and particularly those marketed to them, should be held to a high standard of security as well as transparency.
As another factor to consider, elder abuse is not only perpetrated by strangers, but also by family members and caregivers (Daly, 2011). Therefore, how SmHT might inadvertently provide opportunities for abuse must be considered: for example, extreme monitoring or even executing domestic violence enabled through technology (e.g., stalking via GPS) has been noted with other populations (Freed et al., 2017). There should be ways that inappropriate use of SmHT can be tracked, documented, and prosecuted when officials become concerned about possible abuse.
Engaging With Higher Level Needs in Aging
Technologies designed for aging often focus on physical and cognitive factors, such as detecting acute events (e.g., falls). However, “higher level needs,” such as self-esteem and self-actualization, are rarely addressed in technology design. These needs, which include factors such as confidence, achievement, and respect, as well as morality, creativity, and acceptance, respectively, may be unmet in many existing technologies and thereby explain some older adults' lack of adoption of technology (Thielke et al., 2012). Beyond technology design, these needs are often neglected in ways of conceptualizing older adulthood and definitions of successful aging (McCarthy, Ling, & Carini, 2013). EWA to its fullest extent means that higher purposes should be considered and supported (Carnevali, 2019). What might it mean for a smart home to support higher purpose?
For many, engaging with a higher purpose is centered around religion. In beginning to attend to religion with technology, the diversity of religions and factions that older adults practice is one important component of the heterogeneity of the population of which to take note. Considering religion in the design of smart homes might involve smart homes that support the observation of Sabbath directives, the telepresence of church services for those who face mobility restrictions, include Buddhist soundscapes, and take into account dietary needs around Ramadan for smart refrigerators.
For others, higher purpose may be about contributing to one's community or to society more broadly. Volunteering is something that benefits older adults who engage in it (Morrow-Howell, Hinterlong, Rozario, & Tang, 2003) and the community around them. Some may gain a sense of contribution from continuing to work full or part time. Gig (i.e., temporary) and crowd-work may open new opportunities for people to work from home (Brewer, Ringel Morris, & Piper, 2016) should that be their preference. Finally, opportunities to engage in life-long learning are essential for continued work and may be a way people find meaning. To support volunteering, paid employment, and lifelong learning as fundamental components of EWA, a smart home would need to consider making space for work and learning, including workplace technology, such as remote communication and collaboration technologies, as well as opportunities to access information and online courses.