Developing Technology for People with Dementia

Psychiatric Times

November 2005

Vol. XXII

Issue 13

Home computers, personal organizers, cell phones and microwave ovens are nowcommonplace. We are increasing the use of technology to make our lives easier.Technology also has the potential to offer the same, or even greater, benefitsto people with both physical and cognitive impairments.

People with a diagnosis of dementia experience progressive cognitiveimpairments that typically start with working memory problems but can encompassspeech production, planning, monitoring and visuospatialdifficulties as the condition advances. "Dementia ... makes a personexceptionally dependent on others: not only in the physical sense, but in apsychological sense as well" (Kitwood, 1998).Technology offers potential interventions for people with dementia to maintaintheir independence and maximize their retained abilities for as long aspossible. This includes both practical solutions to managing the activities ofeveryday life and interventions geared to meeting psychological needs.

Recent initiatives such as the ASTRID Project, ENABLE Project and Alzheimer'sAssociation Everyday Technologies for Alzheimer Care (ETAC) highlight thepossibilities offered by technology to address the needs of people withdementia. Currently, developments in dementia are focused on meeting needs inthree broad areas: safety, security and social interaction. Some of theseprojects represent the application of technologies in everyday use in widersociety to dementia care. Other projects are developing technology specificallytailored to the needs of people with dementia. Efficacy, as well as some of theissues raised by these developments, is briefly considered here.

Safety Needs

The most controversial application of technology in dementia care is in theuse of tracking and surveillance equipment. Such technology is increasinglybeing advocated and adopted as a way of keeping peoplewith dementia safe. For example, global positioning systems are advertised onthe Internet as personal locators and tracking devices for people with dementiaand other cognitive impairments. In addition, electronic tagging is being usedin dementia care facilities as an alternative to locked doors and medication tokeep people from becoming lost (Bail, 2003).

Tagging is controversial, not because of the technology per se but due toits association with incarceration and control (Welsh et al., 2003).Specifically, the use of tagging in the criminal justice system as analternative to prison raises issues of how we view people with dementia, theirpersonal autonomy, and their human and civil rights.

Advocates of tagging argue that it reduces caregiver stress and increasesthe freedom of people with dementia to go where they wish (Bail, 2003).However, critics feel that this comes at the expense of the personhood ofpeople with dementia (Hughes and Louwe, 2002).Essentially, because these interventions are technology-led--that is trackingand monitoring technology are available, and people with dementia have beenidentified as a group for whom this technology might be useful--they focus ononly one aspect of having dementia, that of confusion and disorientation due toworking memory problems, rather than addressing the needs of the whole person.As such, any decision to use this technology requires careful cost-benefitanalysis not only for caregivers but also for how it meets the needs of peoplewith dementia.

Security Needs

The majority of older people want to stay in their own homes and people withdementia are no exception. However, the impact of dementia on memory,orientation, planning and monitoring means that people's ability to stay athome is typically called into question. Several major initiatives since 2000have focused on developing technology to respond to specific problems relatingto everyday activities with the aim of helping people enjoy the security oftheir own homes for as long as possible.

The ASTRID Project produced a guide to technology currently available forpeople with dementia plus guidance on the use of technology in response toneeds assessments. The ENABLE Project, by contrast, set out to actually askpeople with dementia in five countries to evaluate a range of devices. Theproject addressed practical issues, such as locating lost items in the home(e.g., keys), as well as meeting the human need to be engaged in satisfyingoccupation and activities. Five items were tested: day and night calendar;do-it-yourself picture gramophone; locator for lost objects; automatic bedroomlight; and programmable telephone with photographs instead of numbers.

The outcome was a set of evaluations of the target devices andrecommendations including implementation of assistive technology (AT) as earlyas possible after diagnosis and recognition of the need for AT to beincorporated into an individual's care package (Gilleard,2004). The United Kingdomtest bed for ENABLE was the Gloucester Smart House (Bath Institute of MedicalEngineering, 2005), a specially equipped house for testing out AT innovations.In a second project, Dementia Voice investigated a further selection of low-keyinterventions for people with dementia in their own homes, including a dooralarm, medication reminder and memory jogger. The evaluations suggested thatpeople with dementia and their family caregivers were able to adapt to all ofthe devices and found them helpful (Cash, 2004).

The devices and interventions evaluated in these projects are all onesintended to support and assist people with dementia while allowing them tomaintain as much autonomy and freedom as possible. However, another stream ofAT is developing that makes use of surveillance technology, and these are opento the same criticisms as electronic tagging. For example, four of the fivegrants awarded by ETAC involved some kind of monitoring or surveillancetechnology (Alzheimer's Association, 2004). Such systems, while reassuringcaregivers by providing a response to safety issues in the home, take awaycontrol from people with dementia and are arguably no longer assistivetechnology.

Psychosocial Needs

The memory problems experienced by people with dementia affect their abilityto participate in social interactions. They find it increasingly difficult tokeep track of conversations and other social activities. However, much of theirlifetime knowledge and skills are relatively intact and can be used as thebasis of engaging activity and to provide conversation topics. Computertechnology offers the potential to circumvent the short-term memory problemsand access these longer-term stores to provide people with increasedopportunities for interaction and meaningful activity. This aspect oftechnological development contains most examples of technology specificallydesigned for people with dementia.

Two examples of such projects are CIRCA and Storytable.The CIRCA project is an interactive multimedia system, using a touch screeninterface and hypermedia links, designed to promote communication betweenpeople with dementia and caregivers. People with dementia are supported andenabled by CIRCA to make choices and to decide topics of conversation (Alm et al., 2004). The touch screen enables them toactively direct the conversation without having to rely on caregivers (Astell et al., 2004) (Figure).In addition, caregivers are relieved of the necessity to keep the conversationgoing and are frequently surprised by the ease with which people with dementiaadapt to the system (Astell et al., 2004).

Storytable was developed to stimulate the memoriesof people with dementia and capture an oral history through the recording oftheir stories and, by doing so, increase interaction and communication betweenresidents in the dementia care homes where it is in use. Storytableis a specially constructed table equipped with two large buttons and threescreens around which up to six people can sit. Patients can play music or videoand television clips and record their thoughts or reminiscences prompted by thestimuli.

By contrast, It's Never 2 Late (IN2L) is acommercial product developed for older people without cognitive impairmentsthat is now being applied to dementia care environments. It was established tohelp older people learn to use computers in a simple, effective and enjoyablemanner. Customized packages are specifically tailored for each older adultfacility that purchases IN2L, and the system has successfully introduced manyolder adults without cognitive impairments to e-mail, the Internet and otheraspects of computing. Preliminary evaluations suggest that people with dementiafind the system as engaging as do people without cognitive impairments, both asa group and an individual activity.

Summary

Technology can benefit people with dementia as much, if not more so, aspeople without cognitive impairments. Several projects illuminate the creativeuse of available technologies to support people in their own homes andfacilitate their independence. In addition, a number of individual projects aredeveloping technology specifically tailored to the needs of people withdementia rather than adapting items in common use. However, applying technologyto meet the needs of people with dementia is not always uncritically positive.As the examples of electronic tagging and other surveillance technologyillustrate, addressing the needs of people with dementia is both a complex andsensitive process.

Dr. Astell is a lecturer in the School of Psychology at St.Andrew's University in Dundee, Scotland. She is also deputy coordinator of the Dundee Alzheimer's Disease Research Centre.

References

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Alzheimer's Association (2004), Alzheimer's Associationand Intel look to everyday technologies to improve care for those withAlzheimer's. Available at: www.alz.org/media/newsreleases/2004/083004_grants.asp.Accessed May 5, 2005.

Astell AJ, Ellis MP, AlmN (2004), Facilitating communication in dementia with multimedia technology.Brain and Language 91(1):80-81.

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Bath Institute of Medical Engineering (2005), Gloucester Smart House. Available at:www.bath.ac.uk/bime/projects.htm. Accessed June 28.

Cash M (2004), At Home with AT (Assistive Technology). Finalreport. Available at: www.dementiavoice.org.uk/Projects/Projects_At_Home.htm.Accessed Aug. 3, 2005.

Gilleard J (2004), Enabling technologies forpeople with dementia. Final report. Available at:www.dementiavoice.org.uk/Projects/Projects_Enable_Project.htm. Accessed Aug. 3,2005.

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