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Help at Home - Use of assistive technology for older people

Summary

More people are living longer with complex conditions and needs. Technology can help people to stay living well and safely at home as they get older. But technology is changing rapidly and it can be challenging to get the right technology for the right person with the right support. There has been considerable investment recently in developing and evaluating assistive technologies for older people. But this is a relatively new field and there are important gaps in what we know.

This review presents a selection of recent research on assistive technology for older people funded by the National Institute for Health Research (NIHR) and other government funders. This has been selected with help from an expert steering group. In this review we focus on research around the use of technology in the home, remote monitoring systems and designing better environments for older people.

Using technology

We need to understand more about how technology is used by older people in their home. We know that many devices are never used and more are not used fully or as intended. Research helps to understand the reasons for this. Insights include the timing of introducing new technology – often too late, at the point of crisis or advanced illness. The health of older people is often unpredictable and demands of technology may be too much at times. Research also shows real ways in which people use devices and services, including workarounds and adaptations. Under-investment in training to support longer term use of technologies in the home is an issue, and the human element of support is essential. Studies also highlight the need to motivate staff such as community nurses in the benefits of telecare and other initiatives. Based on research, a toolkit has been developed to guide those designing and implementing telecare systems.

Remote monitoring

A number of studies have explored integrated monitoring and response systems to check the health, wellbeing and safety of older people living at home. Some of these are focused on particular groups, like those with dementia. They range from systems using sensors, alarms or wearable technology to cameras, smart televisions and service robots. Some collect data on health status, movement or eating and drinking. Other systems are more interactive. A selection of studies also looks at the use of home technology, from telephone to social networking devices, to combat social isolation in older people. Much of the research to date has focused on developing prototypes and systems. There is little real-life testing or evaluations showing impact on falls, hospital admissions or quality of life.

Designing better environments

Occupational therapists play a crucial role in assessing the home and adapting the environment for older people. Research includes developing smart solutions for bathrooms, where many falls happen. There is also research to inform design of future kitchens to make it easier to cook with limited function. Other studies have focused on the wider neighbourhood, with teams involving clinical and public health researchers working with engineering, housing, architects and urban planning experts. These include better design for those with mobility issues or confusion. There has also been more basic research, for instance on navigation issues for people with dementia, which should inform design of future homes and care homes.

Future directions

This review gives a flavour of recent research which has tested and developed technology to help older people live longer at home. There are challenges in doing this research, from recruiting older people into studies to the rapid pace at which technologies change. Research has focused more on high-end digital technology than evaluation of more basic devices to help toileting, mobility, vision and everyday tasks. In terms of systems and technologies featured in this report, there has been more research effort in developing prototypes than real-world testing in the home. Little is known about actual use of technologies over time and their impact in preventing falls, reducing isolation, or anticipating health crises or emergencies. More research is needed using mixed methods to evaluate technologies in use and share learning across sectors.

Assistive technology

Introduction

Why is assistive technology important for older people?

More people are living longer, but with complex needs which require more health and social care resource. At the same time, people want to stay in their own homes as long as possible. It is in everyone’s interests to find ways to support people living well and independently at home. Assistive technology can play a part in this, helping people to manage complex health conditions and to live with dignity at home while staying connected to others. The right technology solution may also help family carers to support a person’s everyday activities around the house. In this way, it can help to reduce the risk of unplanned hospital admissions or permanent moves into residential care. National strategy underlines the importance for the health and care system as a whole of keeping older people with mild frailty healthy and socially active. Different forms of assistive technology in the home can help in achieving these goals – ageing well in place.

Since 2014, there are also new formal responsibilities for local authorities based on the Care Act in England and the Social Services and Wellbeing (Wales) Act. There is a requirement to provide care and support for those older and disabled people who meet their eligibility criteria, to prevent deterioration and reduce demands on other services. Meeting these needs includes adaptations to the home and provision of technologies.

What is assistive technology?

There are many different terms to describe technology used to support the care of older people. Common terms include telehealth, digital health and telemedicine, all with particular meanings. Assistive technology covers anything which helps people stay independent, manage their health or compensate for a disability. This includes everyday aids like walking frames or wheelchairs to more advanced digital technology like robots and the internet of things (where everyday household appliances and devices ‘talk to’ each other). Assistive technology is also under the control of those individuals themselves and so does not include implants or other embedded devices. This report, though, does include telecare and telehealth systems, where health professionals may respond at a distance to data collected from sensors, such as motion detectors or wearable devices monitoring heart rate, or to people activating alarms within the home.

What is the purpose of this review?

This review provides a selection of recently published research funded by the NIHR and other government funders related to the use of assistive technology to help older people live independently at home. A number of research projects are highlighted which should be of particular interest to those delivering, planning or using adult health and social care services. These have been identified with input from an expert group of relevant stakeholders listed under Acknowledgements. Our approach to identifying and selecting relevant studies is given in the Search strategies section.

Related links:

You can download a PDF version of this report here.

telehealth

Understanding technology in use

It is well known that much technology to help older people in the home is abandoned or not well used. Some research has suggested that as much as 40% is never used (Federici 2016). Research can help us to understand more about individual preferences and needs and the ways in which devices are integrated (or not) into everyday habits and routines.

Not just the device

We know that making technology useful and ensuring it is used needs an understanding of the individual and the wider context in which services are delivered. This includes the role of the family, the occupational therapist, social worker, community nurse, homecare support or voluntary sector staff working with older adults. Some research studies have looked at how technologies are used – or not used – by older people and the way in which they are supported. Without this understanding, technology will not realise its potential to enable older people to live well for longer at home. 

Older people may have concerns that technology might be used to replace face to face care. This was one finding from an international study in four countries, including the UK, which used citizen panels and observational research to explore ethical and social dimensions of telecare systems for older people. Researchers noted that installation was often wrongly seen as a one-off event, rather than an ongoing process for getting the best out of the technology. Overall, this study found that users of telecare often struggle to understand and engage with the technology in their homes. An important insight was that “telecare does not perform care on its own.” Telecare systems require human input and understanding of the older person and their needs. Most depend on existing networks, including family carers and volunteers. Researchers engaged in this initiative suggested principles for more ethical telecare development. These included greater involvement of service users and carers with on-site evolution and adaptation of technology in the home, rather than one-off installation. (Study 1)

Silver surfers?

The benefits of everyday internet-enabled technology are not shared equally across all age groups. Of the 10% of people in the UK who have never used the internet, four out of five are over 65 years old. But this is changing – for instance, latest figures show that tablet use has increased from 15% in 2016 to 27% in 2018 in the over-75 year age group (Ofcom 2018). Overall though there are risks of digital exclusion for older people and we need to factor this into new developments.

Realities of using technology

Sometimes it is not clear whose job it is to provide ongoing support for older people using technology. A qualitative study of people with dementia, carers and GPs on the use of assistive technology generated some useful insights. Participants were using devices such as GPS tracking systems, community alarms and reminiscence tools. Doctors often did not feel well informed about the availability of technology and noted a lack of clarity about who was responsible for issues like responding to alarms, maintaining systems and training users. The role of the voluntary sector was mentioned, for instance for patients and carers to try out new devices at dementia cafes and peer support groups. (Study 2)

One NIHR study (Study 3) aimed to identify design principles for effective technology solutions in the home. This research combined interviews with technology providers and service staff, together with observational research to understand how people living with multiple illnesses use and experience technology in their everyday lives. This generated useful insights into the nature of living with complex illnesses which may be unpredictable, the demands of using technologies, and the workarounds and pragmatic approaches of individuals to these challenges. Many of the installed assistive technologies did not meet user needs and had been abandoned or disabled. ‘Off the shelf’ devices were rarely useful to the individual, but needed to be adapted or customised – in a process that researchers called ‘bricolage’ – by carers and those who knew their daily routines and limitations. Working together, users and researchers identified some important principles for future telehealth and telecare systems.

Principles for designing telecare systems

Working together, users and researchers identified some important principles for future telehealth and telecare systems which need to be:

  • ANCHORED in a shared understanding of what matters to the user
  • REALISTIC about the natural history of illness
  • CO-CREATIVE, evolving and adapting solutions with users
  • HUMAN, supported through interpersonal relationships and social networks
  • INTEGRATED through attention to mutual awareness and knowledge sharing
  • EVALUATED to drive system learning and future development

(Greenhalgh 2015)

The timing of introducing devices may be important, with many informants in one study seeing it as a ‘last resort’ measure, rather than a preventative measure. This insight emerged from a qualitative research study with older people to understand why individuals might not use devices. (Study 4)

The difficulties of introducing new technologies to people at an advanced stage of impairment or distress has been identified through research. Particular devices like heat extreme and smoke detectors or gas shut-offs helped older people to cook for themselves safely at home. But not all devices were used or useful. A mixed methods study looked at the experiences of 60 frail older people using telecare in two regions over time. The study sites had both developed integrated systems linking elements such as pendant alarms and bed and chair sensors or fall detectors in the home with a community response service. Home care workers and others noted the importance of users having control and choice over the type of technology installed, but this was not always achieved. The qualitative research provided useful insights into how older people experienced the technology. Many telecare systems had been introduced following a crisis like hospitalisation and it took time to realise the benefits. One helpful insight from a human factors perspective was to ask designers of telecare systems, ’Who is this not designed for?’ and ’What do we do when this goes wrong?’ These kinds of questions were often overlooked when investing in and implementing high cost telecare systems. (Study 5)

Beyond installation

Navigating complex partnerships between agencies may be challenging and there is a need for resilience and flexibility in dealing with setbacks and change. These lessons come from 2016 research on the implementation of a large-scale telehealth programme (Study 6). This delivered a range of digital health and wellbeing technology to 169,000 people in four communities across the UK. There were sometimes constraints for commercial providers in maintaining awareness of their brand when technology was adapted and customised for local use. Approaches to product design and marketing were very different in healthcare and in digital technology. There were also often problems of interoperability and information governance in sharing health and other personal information across sectors.

Information and support is often limited for those introducing and implementing telecare systems. One study used research to develop a toolkit with practical guidance for those planning new systems. Past evidence shows that the promise of small-scale telecare pilots are often not realised at scale. This is partly because of local contextual issues which are not properly identified or anticipated. This resource uses the analogy of preparing for a race, frontloading effort in training and preparation work before the system goes live. Piloting and points for reflection are also important. This resource should be useful for managers, practitioners and technical staff. (Study 7)

Get the small things right

"As a patient, I consider that getting user views is crucial in order to find out what the user really wants or needs, and hence what problems the technology is designed to solve."

"The topics selected for research and development are not necessarily those that are important to the user. After I came out of hospital with a broken ankle and couldn’t move around my home easily, I realised the importance of relatively small items, such as cups with spill-proof lids and non-slip mats. Technology is only part of the solution, and the role of occupational therapists is crucial."

“From my experience of diabetes-related technology, if service users do not benefit from the more advanced technology such as user-enabled remote monitoring by clinicians, the service user may decide not to use it and hence the tele-monitored data will not be available to the clinicians. For other tele-monitoring technologies, the user may decide to turn it off, with the same effect.”

Brenda Riley, service user

Services and systems

The level of investment by local authorities in training for telecare assessment and use may be insignificant compared with the large sums spent on telecare devices, and much of it is provided by telecare companies. The duration of this training was also very short. These were amongst the findings of an NIHR-funded national survey of local authority adult social care managers providing telecare services. The most common devices in use were emergency pendants, fall detectors, bed and chair sensors and smoke alarms. Around a quarter of respondents estimated that use of this technology had reduced costs but found it difficult to provide hard evidence of efficiencies. A third of respondents reported that telecare investment was informed by research. Only a quarter had developed telecare strategies for older people with the NHS and other partners. This survey highlights useful ways in which planning could be more joined up and investment focused on areas of need, including staff training and ongoing support for users. (Study 8)

Attitudes of staff are important to successful implementation. Qualitative research helped to identify some important insights into the views of frontline community nursing staff using telehealth to monitor the health of older people with heart failure and lung disease in four study sites. This study indicated that staff acceptance of telehealth is a slow and fragile process. There was uncertainty about the use of technology and how it might affect the relationship between clinician and patient. Early wins and demonstrated patient benefits appeared essential to ensure buy-in. Further participatory research highlighted the ways in which changes in technology and wider services affected staff motivation and implementation success. (Study 9)

A recent review of evidence on the use of digital technology of all kinds (for remote monitoring, entertainment and care) in care home settings noted the poor quality of research overall. Existing evidence suggests that cost, ease of use and the demands placed on staff could be both barriers and facilitators to supporting use of technology by residents. (Study 10)

We are all potential consumers of technology to help us live at home in old age. One study investigated barriers and enablers to developing a consumer market in assistive technology. It found that public awareness of assistive technology was poor and concluded that the consumer market is not well-developed in the UK. Although there was a willingness to use and buy assistive technology, potential consumers could not find where to go for advice. (Study 11)

remote monitoring

Remote monitoring

How is technology used to monitor the safety and wellbeing of older people in their homes?

The last 20 years has seen a rapid growth in the systems and technologies to monitor people at home. This may include pendant alarms linked to an emergency response centre for people in their own home or in sheltered housing. Other systems are based on collection of vital signs and health markers for those with long-term or complex conditions, with an alert when action is needed by a health professional.

A Social Care Institute for Excellence (SCIE) review of use of video and monitoring technology in health and social care noted that the evidence was limited (SCIE 2008). Available research highlighted potential for staff efficiencies, monitoring large numbers of people through fall sensors and other devices. But there are trade-offs and tensions between privacy and safety which have not always been fully explored. And the impact of using these technologies to help people to live longer at home is poorly evidenced.

Keeping well

There is potential for systems to help people living with chronic or disabling conditions by responding to prompts about deteriorating health or other concerns. An NIHR Cochrane review in 2015 of 41 published studies showed that technology including remote monitoring by health professionals of data like heart rate and blood pressure could reduce deaths and hospital admissions for people with heart failure. (Study 12)

Indeed, the studies focused on remote monitoring indicated a reduction in all types of death of 20% and a reduction in hospitalisation related to heart failure of 29%. This suggests potential gains for people with long-term conditions through tracking changes in health and wellbeing which might need action by a health professional.

A large NIHR trial is looking at whether a tailored telecare package, including sensors or devices like carer alerts, helps people with dementia to remain living in their own homes for longer. The study will test whether people receiving the technology are less likely to move into residential care over a five year period. (Study 13)

Another smaller NIHR study worked closely with older people with heart failure and their families to develop and adapt a monitoring system. This involved sharing data with specialist cardiology teams on medication, blood tests and clinical episodes and was found to be acceptable and practical to patients in their homes. A follow-on trial has tested further whether tailored alerts and personalised feedback to patients improve outcomes. (Study 14)

One important aspect of older people’s wellbeing is what they eat and drink. Poor nutrition and hydration is associated with many risks, from falls to delirium. But it is common for older people, particularly those living alone, to forget to eat or not eat enough. It is estimated that one in ten older people is at risk of malnutrition, particularly those living at home (Age UK 2015). One study validated a touchscreen device for older people who had not used computers before to report regularly what they were eating. This appeared easier and more acceptable than food diaries using pen and paper. Individuals also reported physical activity and mental alertness in this way, without the researcher being present. (Study 15)

Joining up devices around the home

A number of large international research collaborations over the last ten years have developed and tested integrated monitoring and response systems in older people’s homes. These have included use of interconnected home security cameras, tablets, smart televisions, sensors and wearable wristband devices to check activity levels and wellbeing. These have often ended with assessment of prototypes in laboratory conditions. Few studies have taken this further with real-life testing in the home or summative results of impact, such as preventing falls, emergencies or hospital admissions. It can also be hard to locate published and accessible outputs for research projects in this field.

Among studies which included some element of real-life testing was an integrated monitoring and communication system in demonstrator sites in the UK, Greece and Israel. There were interesting differences in laboratory and home settings – for instance, smart watches which needed charging every day were not always worn by older people at home. In both settings, smart televisions appeared unobtrusive and well accepted, but active use of the health portal through the television declined in the home without the support of a facilitator. Further work is needed to build on these preliminary findings reported piecemeal in 2015. (Study 16)

An earlier EU project reporting in 2011 combined home security, personal and environmental monitoring and communication. This was developed with older and disabled people and tested in laboratories and through a trial which included 62 users, 45 carers and 14 staff delivering home and residential care. (Study 17)

Another UK study which did real-life testing assessed a remote monitoring system in a sheltered housing complex in London (Study 18). This combined sensors to response systems with health care professionals, social workers, friends and family. It picked up problems from information collected by sensors, such as people spending an unusual length of time in the bathroom.

Other studies have included some feedback loops to develop and adapt the prototype. A large EU assistive technology project focused on the need for remote monitoring systems to be tailored to individual needs and to allow some control for the user. This included for instance decisions about number of reminders and when to escalate concern if medication was forgotten. Another feature which was adapted during development was to make the user interface more like a television remote with numbers instead of icons, as this made it easier to use. (Study 19)

Similar adaptation was seen in another study of older people connecting wearable sensors, devices in the home and mobile phones to care workers. During the study, touchscreens were made bigger so that they were easier for older people to use. Emerging findings from early prototype testing suggested good usability (Study 20).

Using robots to support care

An interesting development is the use of robots to support older people. Many of these projects are at ‘proof of concept’ or early stage research. One project looked at a wide range of uses for people with early stage dementia, including playing music, contacting friends and family, reminders of medication,tracking individuals’ movements and linking to smart devices in the home. (Study 21)

A similar project is designing robots to help older people to stand up from a chair or bed, move around and carry objects in the kitchen and elsewhere. The robot would respond to voice commands and interact with other devices and sensors in the house. Friends and family could also be kept informed of individuals’ health status and wellbeing. (Study 22)

One large research programme is focused particularly on the interactions between older people and robots in the home. Researchers are looking at how elderly people, or their carers or relatives, can make robots learn and respond to activities and sensors. (Study 23)

Keeping safe

A number of projects have focused on the particular needs of people with dementia. This includes the challenge of keeping people safe who may be confused but able to move around.

One study addressed the problem of older people with early stage dementia waking at night and being confused and disorientated. Having tracked typical patterns and risks working with people with dementia and carers in their homes, the researchers developed some prototypes. This included use of software, bed sensors and cues for light, music and other technology which could provide reassurance or alerts for response services. (Study 24)

One qualitative study of people with dementia and carers explored the acceptability of GPS tracker devices as part of a wider study to develop a new safe walking device. GPS trackers can be used to enable people with dementia to keep active by walking, without risk of wandering or getting lost and keeping others informed of their whereabouts. Although small in scale, this part of the research suggested positive support for such devices, with little concern about the ethical issues or stigma of ‘tagging’. However, there were practical suggestions about the design, including the need to be discreet, easy to operate and charge. (Study 25)

Looking at wearable technology, another project on remote monitoring brought together different disciplines to design a prototype for smart clothing for older people walking outdoors. The research team included experts in textiles, design, electronics and care of older people. The clothes included electronic tags and sensors of heart rates and activity levels. (Study 26)

The majority of people with mild to moderate dementia are looked after by family carers. One interactive system was directed to carers of people with dementia. This consisted of a smart television, with information and advice on everyday caring challenges, social networking platform with other carers and remote monitoring, with the carer uploading information which might trigger intervention by the health team. Initial findings from the small study suggested improvements in carer quality of life for those using the system, but no significant reduction in demands on carers. This was tested in a small pilot trial involving thirty carers in three pilot sites across Europe, including the UK. (Study 27)

Staying in touch

Social isolation and loneliness pose real risks to health. This is particularly true for older people. Technology can play a part in supporting social contact – seen in some of these integrated monitoring schemes which allow older people to stay in touch with family and friends. One large NIHR study is testing a web-based social networking tool. This is supported by trained facilitators who help people identified as being at risk of loneliness to map their existing social networks and identify interests and preferences. Facilitators then use online resources to match individuals to relevant activities and community groups in their area. The ambitious trial should deliver useful evidence for those planning services. (Study 28)

But these schemes can be difficult to deliver. Another NIHR study wanted to test a telephone befriending scheme for older people delivered by trained volunteers. This involved one to one telephone calls followed by group telephone sessions with peers. The pilot study never moved on to a full trial, as the voluntary organisations failed to recruit enough volunteers. (Study 29)

Technology can also be used to stimulate and encourage mental wellbeing, as well as make connections with others. One study in care homes had small groups of residents with a facilitator using technology to access photographs, videos and music by a touchscreen. Results from a before-after test suggested improvements in memory and quality of life which were sustained over some months. These promising results need further testing. (Study 30)

“While technology will never replace the human touch of caring, enhancing care through new technologies can offer real benefits to older people and their families. We need the right research to know which technologies for which people will really help them stay well at home.” Alice Roe, Professionals & Practice Programme Officer – Age UK

A recent international review looked at various technologies to encourage social interaction in care homes. What evidence there was suggested that interventions to bring residents together and digital aids or companions like robotic pets appeared to have a positive effect on loneliness and social isolation. But there was no evidence to suggest these might be better than other non-technological solutions to make people feel more connected (Study 10).

There is more interest now in the role of technology in helping to reduce loneliness and social isolation as well as improve the health of older people. This is currently under-used. A recent survey (Study 8) found that almost no local authorities were using telecare to address loneliness in older people. Future systems and services are likely to give social wellbeing as much importance as health outcomes in assessing the impact of particular initiatives to support ageing well at home.

designing better environments

Designing better environments

Local authorities are required to make reasonable adjustments to homes to help older and disabled people to live independently. The role of the occupational therapist is critical, assessing the individual and the home to see what changes and assistive technology might help. There are different kinds of adaptations that can be made to help older or disabled people live at home. These include a range of equipment from simple aids to help with everyday living tasks to more complex adaptations, such as wet rooms and domestic lifts. There are also changes which can be made to streets and neighbourhoods to make them safer for older people or those with dementia and other conditions. A number of research projects in the last ten years have explored different ways in which homes and neighbourhoods can be made more age-friendly through good design.

“This review will help occupational therapists understand recent research which has tested and developed technology to help older people live longer at home. It is important to realise that you don’t have to be a specialist in the field to incorporate everyday technology into practice. To support health and care needs, occupational therapists should ask technology related questions within the assessment process such as; “Have I asked my service user if they use technology at home? Would they be interested in using technology to help or support them?” in order to realise the full potential that digital technologies may offer and match the right technology to the needs of the person.”

Dr Gillian Ward, Research and Development Manager, Royal College of Occupational Therapists

Bathroom

Problems with bathing and toileting present major challenges for many frail older people. It is also the place where many falls happen. One project reporting in 2011 worked with older people (and using older aged researchers to capture views and experiences of older people) to develop a prototype Future Bathroom. This involved a ‘living lab’ to study how older people get in and out of baths and showers, then developing and testing solutions. This included flexible equipment and adaptations, as needs and abilities change over time. (Study 31)

Bathing adaptations are one of the most common demands for equipment. There are often long waiting times to assess and meet these needs. To date, there has been no good evidence on the effect of bathing adaptations on function, health and wellbeing of older people and the impact of delays. One NIHR study is testing the feasibility of a trial to compare the effects after three and six months of people getting immediate adaptations with those waiting. (Study 32)

“I was interested in reading about the research on changing kitchens and bathrooms with special devices. But it made me think – why not make all designs disabled user friendly, so no adaptations are needed!”

Kate Brown, service user

Kitchen

Another critical space in the home is the kitchen. Making it easier for older people to cook and prepare food is important to maintaining independence. One study used observational and qualitative research with 48 older people to understand how they used space in their kitchen and what could be improved. Researchers identified problems with vision and lighting, including difficulties in reading controls on ovens or food packaging instructions. Surfaces and appliances were often at the wrong height and cupboards were difficult to access. People with arthritis and other conditions had limited strength and dexterity to open jars or lift heavy dishes. There were other challenges around the space and layout of typical kitchens, especially for those with limited mobility or using wheelchairs. Researchers looked at ways the traditional ‘cooking triangle’ (pattern of moving between sink, fridge and cooker) could be adapted for older people with limited function. As a result of this research, solutions for adaptations and for newbuild kitchens suitable for older people have been shared with users, designers and manufacturers. (Study 33)

Outside the home

Other research has looked outside the home to the neighbourhood and wider environment. One study looked at older people’s experience of mobility and challenges in the built environment. This focused on particular transition points, including when people stopped driving or lost sight or hearing. Research projects included tracking accessibility for mobility scooters and the implications for town planners, and use of a prototype app to customise walking routes for people with particular mobility challenges. (Study 34)

It is important to start with the needs and experiences of older people in their community. Qualitative research with older people experiencing confusion and memory loss identified some of the activities people found most enjoyable and which technologies might be helpful to adapt the environment to these needs. (Study 35).

Indeed, some projects are using researchers from fields like neurosciences to understand better how people with dementia navigate spaces inside and outside the home. This includes use of visual cues to help people reach the right door or room. (Study 36) This early research could lead to useful insights on technologies and design features for adapting homes and care homes for people with advancing dementia. (Study 37)

Another project looked at the building and technology design of care homes to maximise independence and social interaction for residents. The research involved architects as well as experts in design, ergonomics, ageing and engineering. Outputs included software to help architects involve residents in designing and planning homes and prototype systems, including monitoring technologies and sensors. (Study 38) In Sheffield, a similar mix of architects, urban planners, landscape designers and public health researchers worked with older people and housing and care staff to look at ways of adapting or designing housing and neighbourhoods to maximise mobility. Outputs varied from prototypes for new build houses to neighbourhood renewal schemes. (Study 39)

A similar tool was developed in 2010 to help architects to make building modifications or design new homes to meet the needs of older people. This is intended for extra care housing, sheltered housing and adaptations of regular houses. (Study 40)

Future direction

Future directions

What do we know already?

This review has highlighted some recent UK-based research on aspects of assistive technology for older people. This is a field of rapid growth with developments worldwide. We have emphasised some of the learning on using and implementing devices and technology systems and their place in keeping older people safe and well at home.

The state of knowledge is emerging in this field. To date, one of the largest research investments has been in the large-scale trial starting around ten years ago of a telehealth and telecare scheme in three demonstrator sites across the UK. There were different strands of work in this complex programme of evaluation. Early results suggested some impact for those with chronic disease in reducing the number of deaths and hospital admissions (Steventon 2012) but, overall, the telecare initiative did not appear effective (Steventon 2013) or cost-effective. (Henderson 2014).

These kinds of large evaluations have been useful in managing expectations about expected efficiencies or immediate improvements. It is often said that technology is not a ‘silver bullet’ for addressing complex problems. It also highlights the need for a range of research approaches to understand how best to realise the gains of technology to improve everyday life for older people. Trials are largely designed to answer simple questions - ‘ does it work?’, ‘does x work better than y?’ In this field, a range of approaches is needed to understand not just the impact on particular outcomes, but also how technologies are used and the ways in which they might lead to improvements for individuals in particular contexts. Even simple technologies should be considered as complex interventions. Research to date underlines the limitations of a ‘plug and play’ mindset when implementing technology systems for older people.

What do we still need to know?

We have not carried out a systematic analysis of gaps in research. However, our expert group has identified some important areas of uncertainty. We need more high quality evaluations of impact and outcomes in using technology in the home. This report has shown much descriptive and developmental work to produce prototypes with lab-style testing. More work is needed to provide summative assessments of technology in use.

Much of the evidence to date has been informed by technology ‘push’, rather than the ‘pull’ of user need. Future research has to involve older people and carers in the design and testing of solutions and in prioritising the problems to be addressed. Future research should see solutions which are co-designed by those with lived experience of the challenges of ageing at home.

A priority for future development is collaborations between researchers, users and industry to see how everyday technology – from smartphones to virtual assistants, like Amazon Echo – can be adapted for the needs of older and disabled people. Given the common issue of an ageing population, there is an urgent need for large technology providers to address issues of disability and ageing.

The needs and abilities of carers will be different from the individuals they look after at home. Research to develop and test bespoke technology for carers is needed. This might include technologies to reduce isolation for carers, building on more general evidence such as an NIHR trial of support for dementia carers. (Livingston 2014)

In terms of future research, the World Health Organisation set an agenda in 2017 for future global research on assistive technology. There were two important guiding principles. One was that research should be user-driven. But secondly, a social or environmental approach, rather than a medical model, is appropriate to understand individual needs and use of technology. This means that researchers would need to consider the acceptability and appropriateness of technologies for the individual and their social contexts. It also has implications for the range of methods needed to develop and evaluate these technologies.

Research is also needed which addresses the ethical and moral issues around use of assistive technology. This is a dimension that should be considered in designing all studies in this area, as well as a research topic in its own right.

This review has highlighted a number of recent studies from an emerging and relatively new field of knowledge. We still do not know enough about the extent to which the right technologies can help older people to stay living longer safely and well at home. This review has underlined the importance of understanding the needs and experiences of older people and providing ongoing support from trained staff to make the most of technologies in their everyday lives.

This is an emerging and important field, which will be strengthened in coming years. NIHR has a role to play in this, not only through national programmes to deliver relevant research to health, social care and public health services but also through a dedicated stream to bring researchers and industry together to develop useful new technologies (i4i). NIHR is supporting a number of calls relating to new research on digital technologies to improve health and care. This is just one of many opportunities for new research in this area. In March 2018, the government announced £300 million as part of its Industrial Strategy Challenge Fund to address the challenges of healthy ageing in the UK. This is an area of rapid growth, where high quality interdisciplinary teams are needed to develop workable solutions to help us all to live at home as well as possible as we get older.

Questions arising from this evidence

Questions for commissioners of assistive technologies

  • How can technology help us to support older people living with complex conditions at home? What benefits can we realistically expect?
  • What assistive technology could we consider here, for instance remote monitoring and support for older people with heart failure?
  • Have our technology solutions involved service users in their testing and design?
  • How are these initiatives being monitored and evaluated?
  • Have our staff had the right training to match technology to individual needs and to support their ongoing use in the home?
  • What housing and neighbourhood designs do we need to create an ageing-friendly environment?

Questions for health and care professionals working with older people

  • Have I received training to assess the needs and abilities of older people and the technologies that could help?
  • How do I keep up to date with new technology?
  • Have I asked my service users what technology they use at home and what for?

Questions for older people and carers

  • What tasks and activities around the home do I find difficult?
  • Which matter most to me?
  • What devices or technologies might help?
  • What support would I need to feel confident in using this every day?
  • Who can I call if I need more help?

Disclaimer: This independent report by the NIHR Dissemination Centre presents a synthesis of NIHR and other research. The views and opinions expressed by the authors in this publication are those of the authors and do not necessarily reflect those of the NIHS, the NIHR or the Department of Health and Social Care. Where verbatim quotes are included in this publication, the view and opinions expressed are those of the names individuals and do not necessarily reflect those of the NHS, the NIHR of the Department of Health and Social Care.

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