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Ageing, Technology and Home Care

Maggie Mort
Christine Milligan
Celia Roberts
et al.

Chapter 1. Healthcare At Home?

New Technologies and Responsibilities Across Diverse European Systems And Cultures. The State of the Art

Texte intégral


1The main objective of this presentation is to pull together findings from research in the social sciences and elsewhere, on how healthcare provision is being shaped by shifts in spatial and technological development, and identify the gendered nature of these shifts. By focusing on the home as a site of care, on new technologies and on the elderly population, the presentation aims to add value firstly, to recent EU FP5 sponsored research into care employment practices and workforce issues (the CARING project) and secondly, to our understanding of technology and independent living in dementia care (the ENABLE project). Issues surrounding the impact of new care technologies on care in the home form a major preoccupation for the EU in the following domains:

  • the context of the ageing population;
  • the clinical, social and technological needs of Accession countries;
  • the need to listen to the voices of patients, carers and user groups;
  • the need to understand the roles of women as carers and employees.

2Social science insights can add considerable value and legitimacy to EU healthcare policy and can help to create systems that enjoy the support of stakeholders. This presentation, combined with the outcomes of the Utrecht conference, is aimed at increasing dialogue between stakeholders involved in the design, delivery and receipt of ‘care in place’. It will provide an essential resource for the EU in helping to avoid expensive and inappropriate development and healthcare systems that do not meet the needs of users and citizens. It will also facilitate the emergence of new questions where there is a need to generate new knowledge and help to develop those research tools and multidisciplinary partnerships most appropriate for their exploration.

3This presentation offers a wide-ranging discussion of key issues raised in both the academic and grey literature in relation to new technologies and responsibilities for health care at home. It focuses specifically on these issues as they relate to older people, highlighting key developments within Europe and beyond. It is not a systematic review, rather it focuses on identifying critical issues arising from the development of these new care technologies in relation to their design and implementation and how this may be [re]shaping not only who cares, but where and how.

4From within Europe, Section 2 (p. 7) sets the scene, by providing a policy overview of pertinent socio-demographic trends such as population ageing and international migration, and considers these in the context of the different care ideologies that prevail throughout Europe. In particular, it questions where care takes place, who takes the greatest responsibility for care and why this should be so. In order to contextualise the policy issues that arise from this discussion, we define both new care technologies and older people.

5Overall Section 3 (p. 21) considers the spectrum of new care technologies that are spread across Europe, and what this means for the care of older citizens across the continent. Four related themes are raised:

6Theme 1: Who benefits from the development of new care technologies?

7Theme 2: How are new care technologies shaping home and work?

8Theme 3: Material, social and affective design issues

9Theme 4: How do new care technologies modify care interactions?

10The conclusion then draws together policy issues and future concerns raised throughout the review, and wich served as a basis for critical discussion between academics, designers, clinicians, carers and end-users about the policy, care and design issues during the Utrecht conference.

11The review is based on existing academic and grey literature. To date there are nearly 200 entries in the accompanying bibliographic database. There is also footnoted, referenced material within this review that, for example, refers to web based literature and discussion sites of pubic/private/ interest groups. Although the time frame for this material covers the period from 2000-2006, some earlier material has been cited and referenced where it helps to put contemporary trends in context (e.g. the 1990s European Union Research and Technological Development Programmes). Much of the literature was retrieved using on-line search databases such as Medline, Metalib and Science Direct. Search terms included the following, usually in combination:

12Technology; older people; gender; home; care; health; care work; men and care; women and care; ageing; elderly; dementia; Alzheimer’s; domotics; ethics; health; telecare; telemedicine; smart homes; ageing/ageing in place; assistive technologies; assistive devices; healthcare technologies; remote care technologies.

13A search of grey literature and web resources was also conducted.


Population ageing and international migration

14The population in virtually all European countries is progressively ageing. Whilst reasons for this may vary substantially from one country to another and from region to region, four intersecting demographic trends have been identified: i) the ‘baby boom’ in the early post war period; ii) the fall in fertility rates from the end of the 1960s; iii) increasing life expectancy; and iv) uncertainties related to the long-term repercussions of net migration from non-European countries (Bettio & Plantenga, 2004; COM 2006). In economic terms, while the size of the working-age population (those between 20 to 64 years of age) will fall in most countries, the old-age dependency ratio (i.e. the ratio of individuals aged 65+ to the working-age population) will nearly double between 2000 and midcentury. For those countries making up the EU, it has been estimated that this means that by 2050, the ratio of working age citizens to citizens aged 65+ will shift from the present ratio of 4:1 to 2:1 (COM 2006). Recent population projections for Europe also indicate that the proportion of the population aged over 60 is set to rise from 15.9 % in 2005 to 27.6 % in 2050 (UN World Population Prospects, 20051).

15Significantly, the European Commission has pointed to the projected rise of the ‘old old’ (those over 80 years of age) where consumption of health services is well above the average. For this age cohort, an increase of 300 % has been forecast for the period 1960-2020 (Banahan 2004). Many older people can, and do, live relatively independent and healthy lives and demographic ageing is also a positive indicator of improved living conditions. However, it must also be recognised that increased life expectancy brings with it a corresponding increase in the risk of developing chronic and debilitating ill-health through, for example, dementia and stroke (Magnusson & al., 2004). In the UK, for example, 14 % of men and 21 % of women in the 75+ age group report problems with self care (National Statistics 2000: 120). There are also concerns about increasing cognitive impairment. Lobo & al., (2000) drew on studies conducted in the 1990s to compare the age- and sex-specific prevalence of dementia, Alzheimer’s Disease (AD), and vascular dementia (VaD) across European population-based studies of persons aged 65 years and older. They found that the prevalence of dementia increased continuously with age, from 0.8 % in the group aged 6569 years, to 28.5 % at age 90 years and older.

16Demographic ageing is already impacting on public finances and has implications for the organisation of care. For example, macroeconomic debate points to the potential for increasing employment ratios, by encouraging higher female participation rates, which may boost output and partly offset the cost of pension systems taken as a share of GDP8 particularly in countries with currently low female participation rates and/or high unemployment rates, such as Italy and Spain (Bettio & Plantenga, 2004). There are also fiscal arguments for postponing retirement as has already happened in the UK.

17The increasing growth of the EU and subsequent national and international migration of older people and care workers raises important issues for care provision. These issues have formed the basis of discussion in a special issue of the journal ‘Ageing & Society’ (2004, vol 24). As Warnes & al. (2004) suggest, older migrants can range from the most socially excluded and deprived to some of the most affluent individuals in our society. These include such diverse groups as: labour migrants who from the 1940s moved within or into Europe and have thus ‘aged in place’. From the 1960s for example, Europe has seen substantial flows of migrants from such places as the Indian sub-continent, Southeast Asia and Turkey, many of whom took on low skilled and low paid manual work. More recently we have seen an expanding group of northern Europeans who, in their 50s or 60s, decide to migrate to southern Europe either permanently or seasonally in their retirement (for further discussion, see Casdo-Diaz & al., 2004 and Section 3 p. 21, below).

  • 2 For an interesting discussion on diversity, mobility, choice, opportunity and risk in terms of Eur (...)
  • 3 Warnes (2002) cites European governments’ refusal to cede to the EU control of social security spe (...)

18Whilst Warnes & al. (2004) caution that there is huge diversity and complexity within and between these groups of older people who migrate across Europe, research into the implications of this migration re-mains scarce2. Nevertheless, they assert that older migrants live in a ‘foreign’ country, and hence experience a cultural ‘otherness’ that presents a number of challenges for them, such as acquiring the host language and becoming familiar with local customs. Similarly, care providers in the host countries are finding themselves having to meet the care needs of older individuals with different cultural backgrounds and expectations. This is exacerbated within some European states where labour immigration and/or the sale of land and property to affluent retirees from 9 other countries are promoted by government. As Warnes & al. (2004) contend, whilst the needs of many of these groups of older migrants are beginning to be recognised, populist reactionary opinion towards illegal migrants, asylum seekers and refugees can mean that European governments do not always deal adequately with their welfare rights.3 So while some of the more affluent older migrants are enterprising, enjoy leisure pursuits and a stable income, as well as maintaining international family relationships, other older migrants will need to be recognised as European citizens or residents that need both income and as well as material, emotional and social care support. Increasing cultural diversity may also present different cultural and economic expectations of care, particularly for example in terms of state, market and/or ‘family’ responsibility for care. This will be discussed in more detail in later sections of this report.

Home care in Europe

  • 4 EUROFAMCARE is an international research project that looks at the services supporting family care (...)

19In Europe, home care is usually provided by a combination of the family or the informal sector (including voluntary or non government organisations); the state or public sector; and the private or market sector. A trans-European study of family carers (Eurofamcare)4 has suggested that the balance of care provision within each European country depends on a number of issues including culture and tradition, health and social policy, national budgets, legal responsibilities, national wealth and demographic trends such as fertility levels and life expectancy, that affect the availability of family care-givers. Following Bettio & Plantenga (2004) we define formal and informal care as follows: ‘

‘Informal care refers to all unregulated, mostly unpaid, activities on behalf of children, elderly relatives, or others. Formal provisions of care can be defined as provisions regulated by law or other contractual arrangement. In principle, these provisions are targeted either to persons who need care (care receivers) or to persons who provide care (care providers or carers).’ (p. 86)

20Who pays for care depends on the degree of formal, state support, either in cash payments and/or in services. Public expenditure on both formal and informal home care of older persons varies across Europe. This includes differences in health care and pensions expenditure, for-mal service provision and instrumental and financial support for family care. Some research also points to within-country variation in older persons’ policies and outcomes. Sweden for example has an established literature that explores variations within and between localities (e.g. Sundstrom & al., 2006). Gori (2000) has discussed regional and within regional variations in Italy, whilst in the UK, devolution in Scotland and Wales and local authorities’ ability to impose user charges for community care services has led to considerable ‘between jurisdiction’ variability in effective access to services (see e.g. Audit Commission 2000; Milligan, 2001).

21A common element in the care provision for older people in Europe is a shift from care provision within largely institutional settings to the home or domestic care services (OECD 1996). The extent to which this has occurred varies across the European Union, mirroring cultural attitudes towards family responsibilities to care-giving, residential care and parent-child co-residence (Grundy & Henretta, 2006; Tomassini & al., 2003).

22Long established research into older adults’ use of formal and informal care, particularly social care (e.g. help with household tasks and personal care) has demonstrated that those who have few financial resources, who live alone and are in poor health will have the greatest need for assistance (see for example Arber & Ginn, 1993; Larsson & Silverstein, 2004). Wolf & Ballal (2006) contend that of the different forms of services provided to older people, such as health care, income support and social care, the latter is most open to provision by market as well as non-market means. Whether formally or informally provided, social care often encompasses ‘hands on’ care wherein the identity of the care provider becomes a significant part of the care relationship. Care, however comprises two main components – the physical entity of caring and the affective (or emotional) entity of caring (Graham, 1991; Milligan, 2003, 2006). Himmelweit (1999) and others assert that increased levels of stress associated with family care is likely to derive, at least in part, from the close emotional bonds between the care provider and care recipient (Amirkhanyan & Wolf, 2003). Recipients’ affective responses to care have critical implications for the use of new care technologies as will be discussed in later sections of this review.

23Researchers examining home care provision for older people across Europe highlight the difficulties of collecting and collating data. Cross national comparisons may be hampered by unavailability of comparable indicators (for example formal and informal help may have different cultural connotations) (Broese van Groenou & al., 2006); conceptual ambiguity; differences in institutional and legal frameworks and a focus on national strategies that tends to obscure the roles played by smaller, but important, care providers such as voluntary organisations, churches, private charities, or companies (Anttonen & Sipilä, 1996; Bettio &Plantenga, 2004; Johansson & Moss, 2004). Moreover many of the analyses encompass both young and old dependent people.

24That said, several international networks have been formed, some encompassing new data collection (e.g. Survey of Health, Ageing, and Retirement in Europe: ‘SHARE’) and others that are supported by transnational agencies such as the European Union. Glaser (2004) has recently published an inventory of 12 of these projects all of which report on the living conditions of elderly people in Europe. One such network is the ‘Family Support for Older people: Determinants and Consequences’ (FAMSUP), a European and US partnership that is investigating the nature and determinants of support for older people across Europe such as household composition and care provision (Glaser & al., 2006; Wolf & Ballal, 2006).

25A number of European studies compare different models of community or home care (e.g. Anttonen & Sipilä, 1996; Bettio & Plantenga, 2004; Carpenter & al., 2004). The ‘Aged in Home Care’ (AdHoc) study (Carpenter & al, 2004) was designed to compare outcomes of different models of community care using a structured comparison of services and a comprehensive standardised assessment instrument across 11 European countries. A random sample of 4,500 people aged 65 years and older and already receiving home care services within selected urban areas in each country were included in the study. Key findings suggest that in southern Europe, marital and living status reflect close family relationships, while in Nordic countries, five times as many older people live alone. In France and Italy those receiving home care tended to have very high physical and cognitive impairment compared to those in Northern Europe, who had comparatively little impairment in ‘activities of daily living’ (ADL) and cognitive function. The study concluded that across Europe, formal care for people with similar dependency varies widely with very little formal care in Italy and more than double the average across all levels of dependency in the UK. Other studies support these findings (see for example, Daly & Lewis, 2000; Pacolet & al., 1999; Rostgaard & Fridberg, 1998).

26However in Esping-Andersen’s (1999) work on the role of families in the provision of welfare, it was argued that the differences between southern Europe and the rest of continental Europe are not large enough to distinguish a separate Mediterranean regime. Lopes (2004) examining trends in living conditions and living arrangements amongst older people in Portugal, contends that younger cohorts of females have increasing levels of participation in the labour market and that national surveys on values suggest that this younger generation is drawn to values of self-fulfilment and individual economic independence. Lopes (2004) thus questions whether this will create tensions between developing a professional life and caring for older family members. Moreover a study by Glaser, Tomassini & Grundy (2004) explored the north-south divide in various dimensions associated with support for older people. They concluded that when a wide range of measures associated with different dimensions of support for older people is considered, more complex variations in patterns of support for older people are found among European countries. Hence a north-south divide is too simplistic. Johansson (2004) suggests that older people’s preferences to remain in their own homes alongside the need to contain costs means that in Sweden, a country where the state has traditionally been the main provider of care, there has been a ‘rediscovery of family care’.

27Finally and from within an expanding Europe, the recent EUROFAM (see footnote 1) study which investigated family care in 6 European countries and drew on the expertise of 17 further European countries, asserts that former Communist regimes are gradually being reconstructed with home care being provided by a plurality of partners from private sector, non government organizations, local authority and state care providers.

Who cares: home care and gender

  • 5 European Community Household Panel (ECHP). The ECHP is a longitudinal panel covering the EU popula (...)

28National data and European statistics show that care for older adults is primarily a female responsibility (Fagan & Burchell, 2002; Jönsson, 2003) and that gender inequality and the gendered nature of the labour market in employment policies (Rubery & al., 1999) compounds this situation. For example, using European Community Household Panel (ECHP)5 microdata on the volume, character, and intra-household distribution of informal care provisions, and across pre-accession EU countries, Bettio & Plantenga (2004) denote a strong link between care systems and the female labour market. In this study care work includes caring for children and elderly persons. As well as identifying clusters of care models across Europe, Bettio & Plantenga (2004: 104) also ranked European countries on two indicators: the proportion of the female population (25-59) that because of care work, is inactive in the labour market; and the share of the female working population (25-59) employed on a part-time basis for reasons of care. Their findings suggest that within identified countries where care has been identified as largely a family responsibility, (e.g. Italy, Greece, and Spain):

‘… options for reconciling work and women’s care tasks are relatively scarce, costly, or perceived as offering inferior-quality care, with the result that many women take responsibility for housework and/or care work instead of seeking paid work.’

29By contrast, countries with established and affordable formal care services such as Portugal, France, Finland, and Denmark

‘… score relatively low with regard to women choosing non-activity and part-time work for reasons of care. These scores match the previous finding that these countries are relatively ‘‘light’’ users of informal care, overall.’

30Finally those countries that present more of a mix of formal and informal care such as Austria, Belgium, Germany, the Netherlands, and the UK:

‘… combine a medium score on ‘‘non-activity’’ with an above-average score on part-time work, suggesting that, in their cases, the care regime is complemented by a working-time regime geared toward individual arrangements.’ (Bettio & Plantenga 2004: 104)

31The authors of this study also point out that barriers to women’s employment are likely to increase the risk of poverty within families, and a low level of economic activity is likely to correspond to a much higher risk of poverty at an older age. Women tend to outlive men and marry men that are older than themselves. In older age, women are thus likely to be widowed with minimum resources, partly attributable to their high participation in informal care. Moreover current demographic trends in the western world imply that a new multigenerational kinship pattern is emerging: it is not unusual for three or more generations to coexist at any given point in time, while each generation has fewer members (Jönsson, 2003). More women and men can expect to experience the ‘middle-generation squeeze’, when they are required to care for both their grandchildren and their frail elderly parents. The ‘sandwich generation’ concept (Grundy & Henretta, 2006) of parents raising dependent children while also having parents in need of support, is said to be a result of some women childbearing in later years; younger generations spending more years in education and training and, therefore, remaining dependent for longer upon their parents, and as noted above, the growing numbers of ‘old old’. (Jönsson, 2003).

  • 6 The Framework Programme 5 project funded by the European Commission (HPSE-CT-1999- 00031), and ent (...)

32Research also points to caring becoming increasingly differentiated between women. For example, in a Framework Programme 5 project6 Jönsson (2003) illustrated how the roles played by the state, the market, the family and civil society in family welfare vary across Europe. This work also sought to ascertain the perceptions that European families have of intergenerational relations and their expectations of policy actors. Echoing much of the discussion on clusters of care models above, Jönsson (2003) found that in southern European countries, welleducated women with high incomes and in secure employment can buy care for children and elderly relatives.

33Moreover this domestic labour is often undertaken by less educated and low-paid women in their home country or from other parts of the world (Hochschild, 2001, cited in Jönsson, 2003). Families with lower income levels continue to rely on female relatives, friends or neighbours. The Lisbon Agenda recognises that the ageing population of Europe will create more demand for these workers in the future (Connolly, 2005). By contrast in Scandinavia where public provision of care is long established, Jönsson (2003) found that whilst women take on practical and emotional caring task for older family members, these were seen as additional to public services. She further suggests that women’s increased labour market participation and changing family forms are resulting in greater involvement of men in care for children and elderly parents. However, cross comparative European research investigating men’s involvement in formal care appears scarce.

34Bettio & Plantenga’s (2004) study suggests that across the EU preaccession countries, three times as many women as men devote a substantial part of their time to care work. They also note national differences with the gender gap being particularly high in Portugal and 16 Greece in comparison to Denmark and Finland where the gender balance of care is more equal. The EUROFAM study (see footnote 1) also reported the predominance of female carers, whether as child, sister, spouse or friend / neighbour. Here two thirds of care was seen to be provided by women, albeit with substantial national variation. However the EUROFAM study did note that where older people provide care to each other, there is no evident gender gap. For example, Switzerland and Poland reported equal proportions of male family carers in the 50+ age groups while the UK reported no gender differences amongst co-resident carers.

35Johannson & Moss (2004) also report on care work in Europe with older persons as part of the EU funded research study ‘Care Work in Europe: Current Understandings and Future Directions’ (Moss & Cameron, 2002). Drawing on interviews with practitioners, local and national (or regional) policy makers and trainers, the study compared residential and domiciliary services for elderly people across Sweden, England and Spain (in particular, Catalonia).The researchers note that in all three countries, the workforce was ‘overwhelmingly female’ with an average age around 40 and salaries were low, the highest being in Sweden. In England and Spain most care work is undertaken by the private sector, compared to the public sector in Sweden. The researchers contended that few men work in elder care and those that do, often enter after a major life change provokes a career change.

36In addition to cross-national studies there are a number of national studies that consider gender differences in care-giving. One longitudinal study in Norway on the primary care-giving activities of adult children to a parent aged 80 and over found few gendered differences in care giving activities, and suggested that the potential for sons to give informal care to parents is underestimated in modern societies (Romoren, 2003). In their study of spouse carers over the age of 75 in the UK however, Bywaters and Harris (1998) found that female carers were less likely than their male counterparts to be offered the support of public services despite the fact that women often took on a heavier caring role than men. Though caring for spouses or other close family members with a lower dependency need overall, they found that male carers received a higher level of public support services – particularly in terms of day and respite care and most homecare tasks with the exception of personal care. Hence, it is worth noting that while we may be underestimating the potential for addressing the gender balance in family care-giving, there may still be gender biases in professional responses to male and female care givers.

New care technologies: ageing and home care

37Assistive Technology (AT) includes a broad spectrum of ‘support’. Within the literature, it encompasses ‘devices’ and ‘systems’ that ‘allows an individual to perform a task they would otherwise be unable to do or increases the ease and safety with which the task can be performed’ (Cowan & Turner-Smith, 1999). These range from ‘… video-monitoring, remote health monitoring, electronic sensors and equipment such as fall detectors, door monitors, bed alerts, pressure mats and smoke and heat alarms (Miskelly, 2001: 455 ), and includes ‘… the burgeoning variety of devices associated with ‘smart’ and ‘telecare’’ (Tinker & al., 2004: 2). Of smart homes, Tinker & al (2004: 5) say:

‘A Smart Home contains devices that interact and which are monitored by a central computer. These may include sensor-activated devices (intelligent gas or hot-water taps, infra-red-controlled lights, etc), time-of-day-dependent lighting and heating sequences, alarm systems, telecare (including community alarm services), or telemedicine systems.’

38Information and Communication Technologies (ICT), Electronic Assistive Technologies (EAT), and Environmental Control Systems (ECS) (see Tinker & al., 2003b) are also associated with ‘smart’ technologies.

39(Koch, 2006) makes a useful distinction between telemedicine and telehealth, the former having been utilised for a number of years and largely indicating the management of disease and medical conditions; the latter more recent term, denoting a shift towards health promotion and disease prevention. Eysenbach (2001, cited in Koch 2006) introduces ehealth as both ‘health services and information delivered through the internet and related technologies and as a commitment to using ICT to deliver healthcare’. Home based ehealth, telehomecare or home ehealth thus came into use (Koch, 2006).

40Demiris & al. (2004) moves the discussion forward with the use of the concept: home based ehealth to include telehomecare and smart homes, the latter encapsulating non-obtrusive disease prevention and monitoring at home, the former describing how technology can improve existing home care services. In their study investigating AT and housing adaptation, Tinker & al. (2004) distinguish between portable AT (e.g. alarms, monitors, detectors) and fixed AT that may require housing adaptation, and discuss cost implications. They also suggest that new developments in wireless networks and mobile phones have created a consumer platform for smart home technology. Such wireless networks may replace existing wired home technology, be less costly and more flexible to install and cheaper to maintain. Moreover familiar consumer technology such as mobile phones may be easier to use for a new generation of older people and their families.

41This review focuses on the emergence of new care technologies for supporting, delivering and/or maintaining older peoples’ healthcare at home. It focuses on care that is ICT aided and, whilst acknowledging their usefulness, excludes assistive devices such as hoists, canes and rails.

Older/elderly/old old persons and new care technologies

42Much of the new care technologies’ related literature uses a number of interchangeable terms when describing older people: elderly, frail elderly, older persons, elders, senior citizens, aged persons. Retirement is no longer an automatic entry point into old age. For example in the UK some physically active professionals may choose to retire at 50 and there is national and regional recognition of the need to influence policy and decision makers on the opportunities presented by those aged over 507. Conversely centenarians are the fastest growing section of the UK 19 population and some continue with paid employment into their 80s (Lyall, 2007). Some of the literature discusses ‘active ageing’, a term adopted by the World Health Organisation to connote continuing participation in social, economic, cultural, spiritual and civic affairs, not just to be physically active or able to do paid work.8

  • 9 ENABLE project: an EU funded project (2001-4) that sought to facilitate independent living of peop (...)

43The literature outlines the challenges to older peoples’ ability to access and use ICT based technology. These include: low ownership of a computer and the access difficulties of older housebound persons (see for example, Irizzary & al., 2002). For current cohorts that are dealing with a technology that became available relatively late in their lives access to new technology is compounded by the challenges of learning new skills, in later in life, and with the possible physical, sensory and cognitive limitations that can accompany advancing age (Goodman & Lundell, 2005). Conditions such as dementia and diabetes are more common in older people; these can present particular challenges to care and aging in place (see Alm & al., 2004; reports of the EU ENABLE project9: Holthe & al., 2004; Jones, 2004; Macijauskien & Budraitiene, 2004; Topo & al., 2004a; Topo & al., 2004b).

44Despite this, Magnusson & al (2004) highlight a number of European and international studies that point to older people’s ability to adapt to new technology, providing they receive appropriate training (see for example Czaja & Sharit, 1998; Demiris & al, 2004) and the technology is useful in their everyday lives (e.g. banking, shopping, leisure activities, communication with friends and relatives). Billip (2001) also noted that computer usage had the potential to reduce depression and increase self-esteem amongst ‘vulnerable’ older people. However Billip’s (2001) study found that this only happened when a trainer spent weekly sessions with the individual. This suggests that regular human interaction may have resulted in mood improvement as much as computer technology training. Moreover, there are current disparities in terms of the extent of information society development with ICT services for older persons with such services being far more widespread in Scandinavian countries than in Southern European countries (Cabrera & Rodriguez, 2005).

  • 10 Ambient Intelligence refers to intelligent, intuitive interfaces embedded in everyday objects that (...)

45Finally when defining older people in relation to home care and new care technologies, whilst there is a tendency in the literature to focus on the frail elderly. However it should also be noted that the growth of older populations across Europe is accompanied by increased mobility and differential wealth acquisition, with some older adults having a substantial disposable income. Cabrera & Rodriquez (2005: 275) in their critique of the role of ambient intelligence (AmI)10 in supporting an ageing population, describe a 2020 future scenario, in which retirees from Northern Europe are increasingly settling in milder climates in the Mediterranean where differential European care models prevail. One consequence they suggest is that the growing number of Scandinavian retirees moving to southern Europe, may act to influence regional policies in the south. These migrants might also increase demand for customised care, such as eHealth services like telemedicine and telecare services offered either by local or remote providers.


46In western economies, new and emerging care technologies are the visible, material signs of attempts to solve the range of perceived health and social care related challenges that have been discussed above. Given the current and projected growth of those in the older age groups and policies aimed at ‘ageing in place’, many of these technologies are targeted at supporting the care needs (or perceived needs) of older people, particularly ‘frail’ older people, within the domestic environment. A spectrum of care technologies exists or is being developed to address these needs. While we acknowledge the importance and ubiquity of assistive devices (such as hoists, canes and rails), our focus here has been on new and emerging care technologies many of which employ information and communication technologies (ICTs). The ‘state of the art’ indicates four themes of importance to care policy and implementation. Overarching all four themes, however, is the question of how the spectrum of these new care technologies is spread across Europe, and what this means for the care of older citizens across the continent.

47Theme 1: Who benefits from the development of new care technologies?

48Theme 2: How are new care technologies shaping home and work?

49Theme 3: Material, social and affective design issues

50Theme 4: How new care technologies modify care interactions?

Who benefits from the development of new care technologies?

51In an early study exploring using technology to adapt the home environment to the needs of older people with Alzheimer’s disease, Colombo & al. (1998) spoke of a ‘triangle of care’ wherein care intervention is seen as a negotiation between the expressed needs of informal and formal carers and the ‘patient’. This captures two issues that are beginning to be problematised in the home care technologies’ literature. One is whose needs do such technologies aim to address, how and why? The other is, as a home ‘user’, how is the older person, configured?

Whose needs are being met – older persons

52For some older people expressing need may be complex. As briefly introduced in Section 2 (p. 7), not only are we seeing an ageing population but European estimates indicate that within the next fifty years we will see a doubling of the numbers of people with dementia. In their study of the efficacy, use and acceptance of enabling technological systems and devices for people with dementia that are living at home, the ENABLE project sought to include people with dementia across five European countries so that ‘users’ perception of new care technology, its ‘user friendliness’, perceived benefits and overall ability to improve quality of life could be assessed in their study alongside the evaluation of carers. This was no easy task, given that dementias are types of brain disorder characterised by reduced memory and ability to learn and reason as well as progressive loss of cognitive functioning. This has profound implications for the ability to maintain relationships or to handle different tasks and activities (Jones, 2004). Despite the challenges the ENABLE study designed appropriate data collection tools so that ‘users’ as well as carers were included in the study.

53Cortés & al. (2003) in their discussion of new care technology design for older persons, give a helpful overview of sophisticated monitoring technologies such as sensors that track individuals’ daily ‘habits’ including eating, drinking and sleeping as well as cognitive aids such as reminders and task instructions (when cooking for example). Blythe & al. (2005) assert that such subtle monitoring technologies may not only track changes in behaviour over a period of time (for example, gradual increased restlessness noted by less time spent in bed) but may also be more acceptable to an older person as they are less obtrusive than for example, the wearing of a fall detector. However, this throws into question a whole range of issues such as: who takes responsibility for installing the new care technology; who maintains it; who manages it; who interprets and evaluates automated inferences from such sensors; who acts upon such information; what of informed consent, responsibility and liability? There are many players in the new care technology arena, including designers, engineers, builders, manufacturers, care providers and users. In their work on smart homes and affective computing, both Wu & Miller (2005) and Lundell & Morris (2006) highlight concerns about who has access to ICT based data gathered by these technologies, how it is being used, and the extent to which it affects the roles and relationships between service recipients, family carers and health professionals. Blythe & al. (2005: 683) illustrate the complexity of responsibility for and effective management of new care technologies:

‘Imagine a scenario where a daughter can text a request for information about the status of her ageing mother who is slightly demented and who has a history of leaving the house at inappropriate times. [...] Now let us say that the message sent back to the daughter’s mobile phone is ‘Mrs Jones has been in bed since 10.30, you will be sent another text if she leaves the bed for more than 20 min before 7.00 am.’ If the data this inference was drawn from was faulty and the mother was actually in a confused state on a busy road the manufacturer of the equipment or the provider of the service could be in trouble. To cover themselves the manufacturer could guard the inference with some sort of probability ‘Our data indicate that there is a 95 % probability that Mrs Jones has been in bed since.’ But this may make the system less attractive. Medical instruments do not normally give this kind of information.’

Whose needs are being met – Formal carers

54As Mort & al. (2003) and others point out, within telemedicine research, ‘users’ are sometimes assumed to be the doctors or nurses, rather than the person receiving care. Blythe & al’s (2005) study considers how a professional ‘duty of care’ might underpin the use of care technologies, who chooses such technology and how it is appropriated. Whilst every effort may be made to include older persons in decisions about AT, particularly in their own home, notions of vulnerability and frailty may lead to a medical perspective of risk with older persons being labelled as non-compliant and/or in denial (for example if they choose not to wear an alarm pendant or ‘deny’ that a tendency to fall presents a risk to personal safety. McCreadie & Tinker (2005) suggest that the development of home telecare can be read as having more to do with ‘risk avoidance’, a key concern of the health professsional, than with improved quality of life for the service user.

55Furthermore research indicates that older people very often delay seeking care support, preferring to ‘soldier on’ with pain or discomfort, accepting that these are part of their everyday life (Milligan & al., 2005). If they are asked to monitor and report on their physical condition, such expectations may need to be challenged. New care technologies may produce new anxieties and stresses for both older persons and carers (Mahoney & al., 2003).

Whose needs are being met – Informal carers

  • 11 This was part of the ACTION research project (Assisting Carers using Telematic Interventions to me (...)

56Looking to family carers, albeit contextualised from within differential care models, there is growing research interest in how new care technologies might support the informal carer. For example, Chambers & Connor (2002) considered a software application, including a carer self-assessment instrument, designed to provide both family and professional carers with information in order to assess how the family carers were coping with their care-giving role. Czaja & Rubert (2002) explored how ‘online discussion’ groups and resource guides for caregivers might help them meet the challenges of care giving and thus improve their quality of life. In a Swedish study11 Magnusson & al. (2005a) explored the perceived benefits of, and barriers to, information technology as a means of supporting family carers of older people in order to care more effectively and to work in partnership with professionals. In a review of ICT support for frail older people living at home and their family carers, Magnusson & al. (2004) also suggested that a number of US based telecare support models are aimed at family members who are caring for older persons with stroke or dementia rather than the older person themselves.

57A UK study investigated a television link system that can be activated when the older person does not answer the phone after a specified number of rings. The caller could manipulate the camera to see if the older person ‘is in trouble’ (Winchester, 2002: 34). The researcher concluded that both older person and informal carer liked the technology. The older person expressed feeling less isolated, whilst relatives contended that it reduced worry. However, whilst such technology may reduce anxiety for informal carers, Tinker & al. (2000: 118) warned that reduction in human contact could result if technical devices became the normal response to the need for help.

58However technological care support designed with informal carers in mind may also offer the potential for the development of caregiver virtual support networks and links to professional carers that could reduce carers’ social isolation, increasing their confidence and generally improving the quality of life for both carer and ‘cared for’. However given that informal care is still a predominantly female responsibility across many European countries and that some European governments are responding to demographic ageing by encouraging higher female participation in the workplace, technological ‘surveillance’ and ‘virtual communities’ infrastructure could result in women being called upon to both carry out paid work outside of the home and meet informal caring needs inside the home. The argument of course would extend to male carers.

As a home ‘user’, how is the older person, configured?

59As to the issue of how the older person is configured in relation to new care technologies and home care, lay stereotypes of old age and senility coupled with the evidence that the prevalence of dementia increases with age, could further reinforce a viewpoint of a vulnerable, ‘frail’ and confused older user of new care technology. Tinker & al. (2004) in their study on the feasibility, acceptability, costs and outcomes of introducing AT into existing homes of older persons, contended that whilst intellectual functioning in old age is a major concern, physical and sensory impairment is more common. They cited evidence from the ‘Health Survey for England’ (Hirani & Malbut, 2003) which shows that within the population of those over 80 years, 45 % have difficulty walking 200 metres, 34 % with climbing 12 stairs, 16 % with getting in and out of chairs and 23 % with picking up shoes. Finding out how individuals cope with such difficulties, how for example they cope with picking up their shoes, has design implications for new care technologies.

60Wu & Miller (2005: 897) describe a smart home field test wherein focus group discussions with older persons and their adult children caregivers, elicited their social, emotional and practical responses to smart home technology:

‘Elders have difficulties using the typical interaction devices employed in smart home designs (i.e. touch screens, computer interfaces, telephone interfaces, and even panic buttons) because of both physical and psychological barriers. Perhaps more importantly, current smart home systems do not provide the emotional support needed by independent elders. The study revealed that elders would appreciate greater interactivity with a smart home system, especially in entertainment and social aspects, but industry has thus far taken an approach similar to the traditional medical profession – where the patient is observed rather than acts as an active participant in the selection of treatments.’

61Wu & Miller (2005) contend that direct communication with the older person might be the best method to gather information about his/her well being, but they acknowledge that voice recognition capabilities and the ability to extract computer-usable information from casual conversations are not readily available. Research into relational agents, computational artefacts designed to build and maintain long term social emotional relationships with users suggest that these are readily accepted and liked (Bickmore & al., 2005). Wu & Miller (2005) also found that older persons wanted to understand the underlying mechanisms of the smart home technology and would vary their routines, ‘subvert the system’, to see what would happen. Wu & Miller (2005) also note that the local adaptation of technology often continues to provide the cognitive activities it was designed for, albeit in different ways. Whilst the researchers accept that participants in this type of reach may be naturally curious and not necessarily indicative of the general public, Dickinson & al. (2003) assert that older people, particularly those labelled frail or vulnerable may feel a distinct lack of authority and control. They are ‘guided’ by carers and others.

62Dickinson & al. (2003) cite the work of social historian Scott (1990) to suggest that for those whose lives are controlled by others, ‘resistance’ takes shape in small acts of ‘disobedience’, thus challenging the control of those who seek to ‘dominate’ them. Whilst this may seem extreme in the context of older people, AT and home care, it highlights the need for sensitive ‘in-situ’ research into the ‘felt’ and expressed needs for and understanding of, assistive technologies. ‘Felt’ needs are often tied to emotions which in turn may be triggered by interactions with familiar people and objects, as the research by Lundell & Morris (2004) demonstrates.

63As to ‘listening to old people’ and giving them ‘information and opportunities about AT’, so that they can make informed choices, (Magnusson & Hanson, 2005b) contend that the current generation of older people are not able to exert the same economic pressure as customers and shareholders of private sector organisations. The UK Audit Commission (2004)12 refers to the need for a national forum that would bring together key stakeholders to develop a clear strategic direction for AT projects, products and services that support independence for older and disabled people.

64In situations where the ‘care triangle’ includes informal and formal carers, configuring the older user as a ‘patient’, albeit cared for at home, may lead to medically orientated monitoring and prompting of physical and cognitive ‘health’, rather than designing socially and emotionally sensitive technology that ‘adds to’ and improves, older persons and carers’ quality of life. Indeed Castollo & al. (2004) in their conference paper introducing the concept of a ‘telecare time bank virtual community’ suggest that new care technologies need to work with older persons so that they continue to be involved in and be part of society and feel useful. Using the time bank concept: people ‘deposit’ time they are willing to contribute to the community by giving practical help and support; in exchange they are able to ‘withdraw’ their time when they need something done to themselves by others. With the support of ICT technology, a coordinator of a telecare timebank brings together a number of mobile and stationary TeleCARE agents, for example: care centres, relatives, older person. A ‘member’ may request a service, which is matched to potential providers who may then bank the time taken to meet the request. The researchers acknowledge that there are challenges such as integrating new technology with existing and familiar technology such as TV sets and other home appliances. We would question how the ‘bank’ is to be managed and by whom. Critically, however, Castollo & al. (2004) also observe that what is needed is a cultural shift in attitude toward elderly care particularly amongst key service providers and institutions. Whilst older people may need a variety of support, creating new care technologies that give them both autonomy in terms of when and how they need such support and crucially, an opportunity to reciprocate and thus share their valuable experiences with other ‘community’ members, is likely to support positive attitudes towards ageing.

How are new care technologies shaping home and work?

How are new care technologies reshaping the experience of home?

65Social policy across Europe supports ‘ageing in place’, that is, enabling people to remain longer in their own homes whilst at the same time acknowledging the challenges of potential disability and ill health. ‘Ageing in place’ should also consider how care technologies are shaping both ‘the home’ and older people’s identity within the home. Some researchers have drawn attention to the ways in which policies focused on ageing in place, can create changes in how people use their homes and create shifting power relationships within the home, between service recipients, health professionals and family carers (Milligan 2000, 2003; Twigg, 2000). Willems (2006) also notes that technologies used at home can affect the nature of home, until it is almost unrecognisable. However within Europe, response to AT is varied. For example Tinker & al. (2004) contend that within the UK, AT has been a low priority in health and social care strategies, whereas the same research team Tinker & al. (2003) suggest that within the Netherlands, the creative use of AT is well established and moreover, there is a network of older people, interested in AT, who give advice to policy makers.

66Within the UK, an extensive study questioned the feasibility, acceptability, costs and outcomes of introducing assistive technology into the existing homes of older people (Lansley & al., 2004; McCreadie & Tinker, 2005; Tinker & al., 2003a; Tinker & Lansley, 2005; Tinker & al., 2004). There was also some collaboration with the Netherlands (Tinker & al., 2003b). The study used Cowan & Turner Smith’s (1999) broad definition of AT including ICT based care technology. The focus was on the social rented housing sector as this has a disproportionate number of registered disabled older persons (Grundy & al., 1999). The study started from the premise that home contributes to a person’s sense of identity and their perceptions of how to remain independent and in control. This is why a person may wish to remain in the same property, even if the environment poses particular challenges for declining functional capacity. The study included 67 respondents, aged between 70 to 97 and who were recent recipients of AT from the housing providers. Most lived on their own but were in touch with family members who largely provided care. Formal support was rare. The use of AT for practical assistance included mobility, bathing and toileting, safety and security, door entry phones, remote controls for electrical equipment and lever taps.

67Overall findings from this study suggest that older people seem to know what they want but are less clear about what AT has to offer them; there is also some concern about ongoing reliability of that which is installed. Providers and assessors need to be clear about what is on offer and there is still a tendency to take a ‘medical needs approach’ rather than a user centred view of need as discussed in earlier sections.

68Milligan (2005) has suggested that for frail older people and their carers, the affective experience of home can be as important as the physical structure. Enabling older people to respond to the use of new health care technologies in the home, requires policy makers to recognise that design needs to take into account the ways that technologies may shape the physical and affective aspects of the home. Heywood (2004) cites a range of literature which points to the detrimental impact upon health when professionals involved in the delivery of adaptations, fail to consider psychological factors and the meaning of home to recipients. As Heywood (2004) says, when unwelcome adaptations are installed in the home, recipients can feel helpless and disempowered.

69UTOPIA (Usable Technology for Older People, Inclusive and Appropriate)13 is a Scottish project that is exploring appropriate ways of extending the benefits of technology to older people (Dickinson & al., 2003). They suggest that in-home interviews and observations allow for useful data gathering about older persons’ practical and emotional understanding of technology. For example they describe visiting older persons’ homes wherein TVs and computers were covered with cloths when not in use, perhaps denoting that technology was not viewed as part of everyday life.

70Dickinson & al. (2003) also assert that being in a person’s home meant that familiar objects could act as triggers for discussion. For example one interviewee described her difficulty with ‘getting down to the controls’ on the video player and seemed dismissive of the remote control, ‘oh yes, it’s over there’, whereas another interviewee had a number of remote controls arranged in a ‘hub’ around her armchair. In another instance, an interviewee used her walking stick to retrieve her mobile phone, which she had dropped and which she hit several times before retrieving it. As Dickinson & al. (2003) note, this is likely to be an established coping strategy, not discussed, and yet has design implications in that such a phone would need to be sturdy enough to survive such treatment.

71The ethnographic work of Lundell & Morris (2004) working for INTEL14 in the US also stresses the importance of gathering ‘in-situ’ information. Their ethnographic research involved extensive fieldwork with older people, some of whom who had cognitive impairment, in order to understand how people manage their daily lives, how they deal with critical incidents, and the nature of their existing coping strategies and how might such coping strategies inform new care technologies. In other words, Lundell & Morris (2004: 2) suggest:

‘[Rather than using] the laboratory ‘home’ as the dedicated research site in which prototype technologies are implemented and later evaluated by bringing in people from the community […] we have focused on conducting more extensive research to uncover hidden needs and values, generating many different concepts and testing these concepts using interaction scenarios.’

72The starting point is thus to fit technology around potential users’ existing lives rather than the other way round. For example their research found that many older people like to pursue games and puzzles ‘to keep the mind active’, but for some, ‘getting started’ proved problematic. Photos and memorabilia of key events, tended to be displayed in areas of the house where visitors would circulate. Many participants were prescribed daily medication and struggled to remember to take it. Whilst for some, the coping strategy involved leaving the medication in a single location, for others, medication was distributed in ‘key places’, such as that to be taken with food, placed in the kitchen. Calendars and strategically placed notes and prompts were also in evidence. Such observations suggested that older people’s requirements are not just surface needs to do with safety and security, with remembering to take medication or to eat lunch. Rather such needs and how they are felt are embedded in a lifelong sense of individual and social identity.

73From interviews and detailed observations Lundell & Morris (2004) developed a number of potential solutions which attempted to address such embedded needs. Critically and in order to enable potential older users to think through the usefulness of such solutions, Lundell & Morris (2004) used drama to act out how a solution grounded in technology, might work within the emotional, social and environmental context of their own homes.

Experience of home in relation to gender, class, ethnicity

74Social context is also crucial to understanding experiences of home in relation to critical aspects of identity such as gender, class, and ethnicity. For example, an interesting aspect of Tinker & al’s (2004) work is its focus on social housing. The design literature, much of it US based and seemingly consumer oriented, does not appear to question how class and ethnicity based assumptions are made about the kinds of houses that the technologies will be placed in: assumptions based on both the material layouts and sizes of homes, and on the social experience of home. Linked to this is the issue of how cultural difference will affect the implementation of care technologies across Europe. As previously discussed ‘home’ and ‘care’ ideologies are different across Europe but research focusing on social variables such as class and ethnicity seems sparse.

75From within the US, research has noted gender and ethno-racial differences in the ownership and use of new care technology. For example a review by (Rintala, 2002) found that out of 15 studies investigating gender differences, 7 concluded that women were more likely to own or use various devices, 3 found mixed results for gender differences depending on age of respondent or type of device, and 5 found no gender differences. Out of 9 studies examining the relationship between race-ethnicity (African, American, White, Hispanic) and ownership and use of assistive equipment found that African American respondents owned or used fewer assistive devices than did White respondents, 1 found that Hispanic respondents were less likely to have one type of device than were White respondents, and 5 found no differences based on race-ethnicity. In one study, African American respondents were less satisfied with owned devices than were White respondents, and in the other there was no difference in satisfaction based on race or ethnicity. Although inconclusive such research does raise important issues. However as to its transferability to European culture Magnusson & al. (2004) suggest that there are cost considerations with regard to the time and skills needed to carry out cultural adaptation and testing with users (Tetley & Hanson, 2000).

Variable Access across the EU

76That said there is policy analysis of European healthcare systems which in turn questions notions of equal access to new care technologies. For example, an e-report: ‘Science and Technology Road mapping: implications for e Health (Boden & de Costa15 ) by The European Commission’s Institute for Prospective Technological Studies, uses Science and Technological ‘road mapping’ to consider how emerging information and communication technologies can meet the challenges faced by European healthcare systems dealing with an ageing population, the enlargement of European Union and growing healthcare budget constraints. Roadmaps bring together various stakeholder perspectives in order to develop an overview of potential future developments of a technological field or industry.

77‘The Healthcare Technologies Roadmap (HCTRM) Effective Delivery of Healthcare in the Context of an Ageing Society,’ (Braun & al., 2003) examined emerging technologies; ‘Ambient Intelligence in Everyday Life’ (AmI@Life) (Friedewald & Costa, 2003), the health application area. The HCTRM roadmap asserts that across European healthcare systems, a major challenge is to achieve a balance between equal access to health, financially sustainable healthcare systems and high quality health care. Braun & al. (2003: 9) also contend that whilst in principle healthcare technologies are available for everyone throughout Europe, there remain: ‘huge differences in the provision of innovative healthcare technologies between the various European countries depending on the national health delivery system.’ Moreover the roadmap suggests that self care and self responsibility are being promoted, particularly as limits to what can be financed collectively are being acknowledged. As the authors note: ‘If the patient is not able to afford the treatment or is not able to assess the treatment’s benefits correctly, then the diffusion of innovative healthcare technologies will be hampered…’ (Braun & al., 2003: 9).

  • 16 The Lisbon European Council of 2000 and the e-Europe Action Plan describe the Commission as being (...)

78The HCTRM roadmap which includes genetic and medical, as well as ICT healthcare technologies, seems to emphasise medicalised notions of care with for example ‘users’ defined as ‘patients’. However, the AmI@Life (Friedewald & Da Costa, 2003: 9-10) roadmap considers the development of Ambient Intelligence (AmI) from a quality of life perspective: ‘technology should be designed for the people rather than making people adapt to the technology’ and the authors stress that: ‘universal access is […] not limited to access to infrastructures. It includes access to services and applications as well as access to the necessary resources to make use of AmI in the home/everyday environment.’ The authors also note a policy concern with inclusiveness16, it should not only be designed for the urban, highly educated and mobile techno-freaks, but also for low-tech, ubiquitous use in the lives of most people to improve their everyday life.’ (Friedewald & Da Costa, 2003: 10). There is also emphasis on the social context of the home:

‘Home is a sanctuary, so technology and technological devices integrated to the house should not dominate the overall function of housing. The technology should enhance the quality of life of residents, not only by facilitating their daily activities, but also supporting their socialisation. Another major challenge for ambient intelligence is how to make technology learn about the people and their identity: habits, preferences, behavioural patterns etc. and how to apply such knowledge in varying contexts. Such situational awareness should be promoted simultaneously securing a sufficient degree of privacy and prevention against misuse.’ (Friedewald & Da Costa 2003: 28).

79Friedewald & Da Costa (2003) cite Castells (1996: p. 397-398) ‘home centeredness’ as a critical societal trend. As well as people increasingly working and managing services from their home, it is also perceived as a ‘safe’ place for relaxation, communication, care, entertainment and rest. As (Friedewald & Da Costa 2003: 28) caution:

Applications of ambient intelligence in housing should not automate the ‘home to the utmost. If initiative or physical movement is no longer needed, the ‘passivating’ implications for the elderly, especially, might prove deteriorating to one’s physical and mental health. Moreover, if the prices of ambient intelligence are high, there is also a risk of excluding average people. The ultimate challenge is to promote ambient intelligence in balance with producing a high quality technological system of ‘housingaids’ and providing enough safety, stimulation and socialisation.’

80And finally:

‘Skeptical views of the role of technology as overlooking the needs of humans quite rightly emphasise that Home is not a Machine – Home is for People. Home is not an array of technological tools that only help the residents lead and survive everyday life. Home is for humans, whose quality of life is expected to improve via technology and ambient intelligence. Home is an emotionally charged and personally furnished cradle of living – physical space as much as a socio-cultural context and a state of mind.’ (Friedewald & Da Costa 2003: 18-19)

81We caution against eulogising the ‘safety’ and sanctity of the home, particularly in the light of elder abuse and pragmatically, in view of Tinker & al’s (2004) research on the suitability of existing housing stock for adaptation to the installation and maintenance of new care technologies. However it is important to consider the scope of such new technologies for changing the experience of home, not only for older people but for societies as a whole. Future generations of older people are more likely to have experienced technological innovation shaping both home and work environments. The challenge is to promote cost effecttive, user friendly technology that responds to users’ needs and remains sensitive to the socio-cultural context of ‘home’.

Changing modes of care work and gender

82Section 2 (p. 14) outlined how care seems to fall on women, in particular women in middle age and older, how caring is becoming increasingly differentiated between women and the section also noted the paucity of European cross comparative research on male carers. This sub-theme theme considers how new and emerging technologies may change patterns of care work, both formal and informal and questions the gendered nature of such work. The division of labour in the health field is still notably gendered with women typically clustered at the lower ends of labour hierarchies (for an interesting discussion across Europe, see Blättel-Mink & Kuhlmann 2003). These cascades have implications for who cares for older people in Europe.

83‘Teleclinics’ or ‘call centres’, shift work activities in a kind of ‘downwards’ cascade: from doctors to nurses (Starren & al., 2005; Martin & Coyle, 2006; Engstrom & al., 2005); from nurses to call centre staff (Soopramanien & al., 2005); from clinicians to patients (Oudshoorn 2006). Emerging research in this area indicates that these shifts in work also create new responsibilities: call centre staff have to make decisions about the responses of older people to automated calls (Lopez & Domenech, 2006); patients have to decide when to take medical measurements (Oudshoorn, 2006); and nursing and other clinical staff have to learn to make medical assessments via videoconferencing (Laflamme & al., 2005; Mahoney & al., 2001) An example from the Netherlands is the Camcare experiment, in which district nurses maintain a frequent contact with elderly patients through a web-cam, a combination of television, web and telephone technology (the patient sees the nurse on her TV, the nurse uses the moveable webcam to follow the patient and zoom in on wounds, bandages, etc; appointments are made by telephone). These changes in work release time for some groups and allocate new activities to others (a redistribution which may, or may not be burdensome).

Material, social and affective design issues

  • 17 See The MobiHealth Project, EC IST Programme 2001-6.
  • 18 EC, Applications relating to health. Fifth research and development programme 1998–2002, IST. Dire (...)

84A review of the literature suggests that the design of new care technologies has tended to focus on medical and/or practical needs of older people and/or their carers (Blythe & al., 2005; Curry & al, 2002 for a review of technologies used in the English context; Wu & Miller, 2005). It could also be said that a focus on management and monitoring of disease may have emerged from established use of telemedicine and telehealth, as outlined in section 3 (p. 22) For example Magnusson & al. (2004) discuss models such as the HealthBuddy system, initially introduced in the US and tested in Europe (EC 2003), that enable health workers to remotely monitor patients with advanced chronic illnesses such as chronic heart disease, chronic obstructive pulmonary diseases, diabetes and hypertension. EU funded projects such as Doc@Home (Vijk, 2002) and MobiHealth system project17 developed and tested ‘value-added’ tele-health services that claim to give patients full mobility whilst undergoing health monitoring. The EU’s 5th framework funding of telehealth applications within the Information Societies programme, targeted persons with chronic illness living at home and focused on the effectiveness of a variety of electronic health record systems as well as electronic recording of the delivery of home care services.18

85There is however a growing recognition of the need to focus on the social and/or affective needs of older people. For example, much current technology, usually involving sensors, alarms and web-based or telephone links, remind older people to take medication, to eat, or to close their doors and windows, for example. They alert carers when the older person deviates from his/her daily routine and/or fails to respond to automated reminders to follow this routine. The focus, then, is on averting health risks rather than enhancing the lives of older people. Blythe & al (2005: 673) interviewed medical and care professionals and older people in order to explore how such monitoring is perceived in practice. They suggest that:

‘Quite frail older people are given the confidence to live independently through telecare devices that automatically call for help should they fall or experience some other domestic emergency. Technology can assist with activities of daily living by compensating for problems of mobility, manual dexterity, also for sensory and cognitive deficits. [...] There is also much current interest in reminder and advice systems for people with cognitive problems.’

  • 19 Blythe & al. (2005) give examples: a bed occupancy sensor, for example that retrieves information (...)

86Whilst monitoring might mitigate hazards and help may be summoned, this is nevertheless reactive, not preventive. Sophisticated sensors are beginning to address this concern19 although Blythe & al. (2005) do acknowledge that knowing that help will come in the event of a fall for example, can instil confidence in both the client and their relatives.

87Blythe & al’s (2005: 678) study also explored tensions between medicalised notions of risk and client’s sense of autonomy. A quote from an Occupational Therapist illustrates:

‘We do ask them to take rugs out of the way, and move furniture. Especially, if you’re using a hoist, you need space. But again, quite often the customer doesn’t want that and you’re in their own home so you can make suggestions but you can’t say ‘this is what you will do!’

88McCreadie & Tinker, (2005) also found that acceptability of care technology raises complex issues to do with ‘felt’ as well as pragmatic need. The researchers used in-depth interviewing with 67 people aged over 70 to find out about their use, experience and acceptance of a wide range of what they term, assistive technologies, using the Cowan & Turner-Smith (1999) definition as outlined in section 2 (p. 18) Critically the researchers found that the interviewees willingness to accept care technologies depended upon their perceived need and whether they felt that the technology would support or undermine their sense of personal identity. Echoing the above discussion, whilst pendant social alarms may be designed to be worn at all times, the user may rely on ‘felt’ rather than pragmatic need:

‘Yes I haven’t got it round my neck now. It’s in the bedroom. I don’t go outside in the garden without it… I don’t feel too bad today but if I don’t feel so good I put it on (Mrs Irving aged 84 years)’ (McCreadie & Tinker, 2005: 102)

89Research is also considering the social needs of older people, most of this is within the US (Wu & Miller, 2005; Morris & al., 2004; Morris & al., 2003; Morris, 2005; Lundell & Morris, 2004) but some is emerging from Europe (Camarinha-Matos & H, 2004; Castolo & al., 2004; Cabrera & Rodriquez 2005; Pereira & Lindstrom, 1994; Storetmann & Erket, 1999 cited in Magnusson & al., 2004) and some trans-European partnership AT projects also focus on the social context.

90Camarinha-Matos & Afsarmanes (2004: 2) in their conference paper on ‘collaborative, virtual elderly support communities’ and from a European perspective assert:

‘Loneliness is one of the most serious problems affecting the elderly population. Development of applications to enrich the elderly’s social life and avoid problems of loneliness is of great importance. Fieldwork data (Pascual, 2002) show that today the elderly hardly participate in activities relating with others, and 16 % of them express dissatisfaction with their social lives. According to family members, 28 % of the elderly have little or no contact with other people.’

91The authors propose using technological infrastructures, to connect key players: care centres / day centres, health care institutions, social security institutions as well as social care assistants, health care professionals, and older people, and their relatives. Camarinha-Matos & Afsarmanes (2004: 1) suggest:

‘When based on computer networks and adequate supporting tools, the collaboration among the care institutions may evolve towards operating as a long term virtual organization and the various involved actors become part of a virtual community (VC).’

  • 20 Video telephony describes person to person communication that uses voice and visual connections.

92However the need for ‘real time’, human contact may be very strong. Morris & al. (2003) for example, found that older people with varying states of cognitive decline felt very strongly about loneliness and the need to maintain social ties (see also Morris, 2003; Morris & al, 2004). They argue that meeting these social needs is central to older people’s health status. If virtual care communities result in a reduction of ‘real time’ home visits from clinicians and carers, it is important to consider the extent to which this might impact on older people’s mental wellbeing. Magnusson et al (2004) cite video telephony20 projects in Germany and Portugal (Pereira & Lindstrom, 1994; Storetmann & Erket, 1999) that focused on providing ‘virtual’ psychological support and physical therapy to older people living alone and housebound. The projects concluded that video-telephony reduced social isolation and improved well-being amongst participants. However Magnusson & al. (2004) con-tend that there is conflicting evidence that suggests that ‘virtual’ home visits are experienced as substantially different to ‘real’ visits (Whitten & Collins, 1998) and that some older people with visual and hearing impairment may find ‘virtual’ communication a particular problem (Johnson-Mekota & al., 2001).

93That said, work in robotics technology suggests that lonely, isolated, older people living on their own, respond well to robots. ‘Paro’ a robotic seal, designed in Japan. is said to be the World’s first therapeutic, robotic pet21 Magnusson & al. (2004) cite ‘RoboCare’ a project in Italy that is working with cognitive robotics, artificial intelligence and software technology to develop an ‘in-home’ personal assistant to help older and disabled people with complex tasks in a range of care settings. The researchers stress that robotic devices can meet psychological as well as functional needs of users (Leone & Nardi, 2003) Further work in the US is looking at the potential of a robotic ‘pet’ to act as a companion for isolated and lonely older people (see for example Libin & Libin 2003, cited in Magnusson & al. 2004).

94Cortés & al. (2003) who suggest that traditionally, technology has focused on supporting, extending or improving human physical capabilities and powers of reasoning and tended to ignore the affective domain. However and more recently, ‘affective computing’ aims to bring emotions into computing and artefacts and thus endow them with capabilities such as responding to, facilitating, influencing and expressing. Integrating affective computing and assistive technology may improve the emotional state of the user by, for example, responding appropriately to loneliness, anxiety, frustration and by trying to elicit positive reactions.

95However, Cabrera & Rodriquez (2005: 275) describe innovative work emerging from Japan, a country with the largest research programme of robotics, work that suggests that robots can be ‘sociable’. However the authors question if human-robot relationships can ever be an alternative to human-human relationships. Overall whilst new technological infrastructures can be part of a new concept of virtual integrated care systems, such as that proposed by Camarinha-Matos & Afsarmanes (2004), and research and new technological innovation is beginning to acknowledge complexity of need, technology may not entirely substitute for embodied human communication and interaction.

How do new care technologies modify care interactions?

Changing experiences and definitions of care and social contact

96As stated above, new technologies need to take seriously older people’s ongoing and ever-changing needs for meaningful human interactions. Spending time with older people in varying stages of ‘cognitive decline’ and their carers, Morris found that older people felt very strongly about loneliness and the need to maintain social ties and wanted to feel that they could still contribute to the wellbeing of others (Morris & al 2003; Morris 2003; Morris & al, 2004). Older people did not want to be ‘stuck’ with a narrow range of others, but to maintain a diverse and extensive social network. They also desired reciprocity in social interactions: ‘most participants expressed a strong desire for reciprocal relationships in which they help or in some way have an impact on others’ (Morris & al, 2004: 1152). Meeting these social needs was central to older people’s health status – people cannot be well unless they have meaningful and satisfying social networks. Indeed, ‘The experiences of giving to and having an impact on others could be as important for health as receiving support’ (Morris, 2003: 30).

97New care technologies inevitably challenge existing definitions of ‘good’ care. Their use highlights concerns about conflicts between their potential benefits and declining social contact, raising issues of social isolation and mental well-being (Agree, 2005; Glascock & Kutzik, 2006; Mort & Finch 2005; Finch & Mort 2005). Existing research shows that social and caring relationships change through the use of new care technologies, although these tend to report from short trials with small numbers of participants. Some trial participants (older people, carers and service providers) fear a diminution in social contact and some studies find that people seriously resented new ‘relationships with machines’ (Wu & Miller 2005).

What new ethical and legal problems arise in relation to new care technologies and the data arising from their implementation?

98There is a potential for care technologies to be seen as a shift towards an increased ‘statization’, involving surveillance and monitoring of older people (Tracy & al, 2004; Hanson & Clarke 2000). It has also been argued that call centre based homecare for older people are extitutional technologies, in that they seek to control (rather than actively discipline) patients and users (Domenech & Tirado 1997; Domenech & al 2006; Tirado & Domenech 2001; Lopez 2006) in contexts which are processes and programmes rather than buildings or enclosures. This raises serious ethical and legal questions about informed consent and data ownership, particularly in the case of older people with cognitive decline or dementia (Wu & Miller, 2005; Bjørneby & al 1999; Colombo & al 1998; Czaja, 2002; Magnusson & Hanson 2003; Mort & Finch 2005). It also raises serious questions about how monitoring technologies change older people’s experiences of privacy at home.

99The new care technologies literature raises a number of ethical and legal issues in relation to supporting older persons in their own homes and particularly for those with dementia (Wu & Miller, 2005; Bjørneby & al., 1999; Colombo & al., 1998; Czaja & Rubert, 2002; Magnusson & Hanson, 2003). Magnusson & Hanson (2003) cite Hanson & al’s (1998) caution that regarding older people and their family carers as a ‘special group’ might be viewed as patronising. However Magnusson & Hanson (2003) suggest that negative stereotyping of older people and the invisibility of informal carers may mean that ethical considerations are overlooked. As Magnusson & al. (2004) note, key concerns are to do with the use of monitoring or surveillance devices particularly in relation to informed consent and personal integrity. The European projects, Technology, Ethics and Dementia (Bjorneby & al., 1999) and the ASTRID project have produced useful guides22.

100In the EU-funded, ‘Assisting Carers using Telematics Interventions to meet Older Persons’ Needs’ (ACTION) project, ethical guidelines were produced and used as a awareness raising tool within the multidisciplinary project team (Magnusson & Hanson, 2003). The ACTION project aimed to support frail older people and their family carers in their own homes across England, Northern Ireland, the Republic of Ireland, Sweden and Portugal via the use of user-friendly information and communication technology. Autonomy, independence, quality of life, beneficence, non-maleficence and justice were key ethical concerns, as well as issues to do with the implementation of the technology: security, privacy and confidentiality, increased expectations, and withdrawal of the service. Telecare and smart home ‘solutions’ are sociotechnical innovations in health care in people’s homes that carry the potential to reorder care practices and relationships. Though there will be some specificities, partly to do with the different technologies (and elements and combinations thereof), partly to do with the different contexts and care systems in which the new technologies and care arrangements are being realized, the general and common questions thrown up by these developments will be the same. These questions revolve around issues of how the new sociotechnical arrangements work and change care practices, how they define good care, how they redistribute tasks and responsibilities, and where the pitfalls and promises are for caring and being cared for at home. (Willems 2004; 2006; Finch, Mort, Mair, May. 2008)

101Within the ACTION project issues of confidentiality and privacy were directly related to the technology installed, in this case a videophone:

102Several ACTION families commented that they felt that people could see into their home, as highlighted by a family carer in England when she first had ACTION installed in her home:

‘I was worried for the privacy of our home… that’s with the camera.’ (Hanson & Clarke, 2000, cited in Magnusson & Hanson 2003:.436)
‘[…] after an initial period, most families became accustomed to using he videophone and their initial anxieties wore off as they enjoyed using it to communicate with other families in the project. For example, a family carer in Portugal argued:
‘The thing that really interests my mother is the videophone my mother talks with other families in the project and it’s company for her. She likes it very much.’ (Magnusson & al., 2000)

103Issues of privacy and confidentiality are of particular concern in terms of communication and information exchange about the ‘cared for’ among health and social care providers and family carers. In Canada, Tracy & al. (2004) conducted a series of interviews with professional care providers, persons with early-stage dementia, and their family caregivers, in order to explore the practical, ethical, and legal issues surrounding personal health information exchange. Their findings suggest that professionals valued disclosure both to colleagues and family caregivers and this was justified as being ‘in the patients’ best interests’. Whilst patients also valued inter-professional exchange, they wished to exert strong control over disclosure to family members. By contrast family caregivers valued being kept informed of the patient’s condition, even without the latter’s consent. Magnusson & Hanson (2003) discussed issues of privacy in the context of ‘unjustified paternalism’ (Beauchamp & Childress, 2001). More cross comparative research is needed but in relation to informal care across Europe it is unclear whether familial ‘unjust paternalism’ is felt or expressed differently, depending on a particular country’s care ideology. In other words, in Southern European countries where in general, informal care prevails over formal care, would older people feel as strongly about disclosure to family members as those in Nordic countries that have a care model more wedded to formal care?

104Thus new care technologies carry the potential to intervene in relationships previously thought to be private. In a trial conducted by Morris (2005), adult sons and daughters had access to graphic representations of their parents’ social behaviour, that detailed whom they had spoken to during the day. This access had implications for the sons’ and daughters’ relationships with their parents and also with their own siblings and friends. Technologies such as these can stimulate helpful discussions in families or between older people and their carers about unequal or problematic caring roles (see also Wu & Miller, 2005), but they also raise ethical questions about everyday interactions, privacy and consent. These issues of privacy are closely connected to Theme 2’s concerns about changing definitions of the home.

105Rauhala & Topo, (2003: 205) suggest that sound ethical conduct may also need to include the ‘reality’ of trying to achieve certain standards. They use an analogy between clinical medical research and enabling technology research to suggest:

‘Similarities between clinical medical research and development of enabling technology research and development are that trial participation does not equal benefit to participants, informed consent can be problematic, participants may incur costs, participation can be risky, situation of participants after the trial is uncertain, the privacy of participant data is of central importance, user groups with special needs as participants are involved, raising unfounded expectations is a concern, and that ethics committees are relevant in designing studies.’

106The ‘privacy of participant data’ has particular significance for new care technologies. Many of these technologies involve understanding the ‘normal’ routine of the older person and using alarms to monitor any deviation from this routine. Information about the daily activities of older people is collected, aggregated and stored in databases, and could be very valuable to a range of designers and marketers of relevant products, raising ethical and legal questions about consent and data ownership. Moreover and as discussed and illustrated in Section 3 (p. 37) collecting, interpreting and acting upon such data raises critical design issues to do with reliability, responsibility and informed consent (see in particular, the reference to Blythe & al., 2005). This also raises questions about the need to move new care technologies from a medically focused, safety and functioning orientation to a user centred focus on quality of life as also discussed in Section 3 (p. 37).

107While research has shown that assistive and telecare technologies can enable older people to remain in their own homes and/or avoid hospital admission, accountability for its provision, management and maintenance remains unclear. Lansley (2001: 439) in his editorial on ‘the promise and challenge of AT to older people’ asserts:

‘The cost of installation, issues of who should pay, disruption caused when installing larger items of assistive technology, the cost of maintenance and the risks arising from failure of equipment create a very difficult prospect for a housing provider contemplating the wider use of assistive technology with older tenants.’

108Whilst Lansley (2001) is particularly focusing on social housing issues, there are concerns about lack of economic evaluation, lack of agreed technical standards, and unclear funding responsibilities from the provider side and issues to do with access, provision, cost and impacts, from the user side (Blythe & al., 2005; Brownsell & al., 2001; Miskelly, 2001).

109Health Technology Assessment (HTA) is defined as ‘the systematic study of the consequences of the introduction or continued use of the technology in a particular context, with the explicit objective to arrive at a judgment of the value or merit of the technology.’ (Van der Wilt & al, 2000: 103). Ideally ‘assessment’ would include social, ethical and affective issues. However Van der Wilt & al. (2000) suggest that methodology remains under developed with few mechanisms in place to take actions based on such evaluations. However:

‘If health technology assessment, aims to enhance the accountability of the decision making process regarding funding and use of health technology, it is a major challenge to assessors of health technologies to deal adequately with existing value pluralism. In this respect interactive evaluation may have something to offer. ’

110Johri & Lehoux, (2003a: 179) stress that:

‘Health technology assessment (HTA) can be used both to promote
access to safe, efficacious, and cost-effective technologies, and to
discourage access to undesirable ones.’

111New care technologies can improve quality of life but research suggests that such technology needs to ‘assist’ not take over and that older people need to be involved in their design. This is a critical issue. Safety may be a key concern of some authorities with a statutory requirement to provide medical and social care. Some relatives who are acting as informal carers, may feel that they have a ‘right’ to access personal and medical information about the ‘cared for’. For the older person however, particularly in an endeavour to secure privacy and freedom, they may have a very different perception of ‘safety’ (Blythe & al 2005). Such different positions raise difficult moral issues such as safety, access, cost and efficacy versus user centred focus on quality of life and ultimately, concerns about responsibility and accountability.


112Two key issues emphasise the importance of understanding the impact of new care technologies for older people within and across the European Union. Firstly, there is little doubt that the countries that comprise both the EU and accession countries are undergoing a fundamental shift in the make up of their populations. This is marked by a significant growth in the dependency ratio as the population ages and birth rates decline. Whilst not all older people require care, it is nevertheless true that increasing age brings with it an increased likelihood that some formal or informal care support will be required. Secondly, EU countries have witnessed a general shift away from policies designed to deliver care for older people within institutional settings (such as hospitals, residential care and nursing homes) to care policies designed to support ‘aging in place. Here, new care technologies come into their own. From the relatively low-tech assistive technologies such as grab rails, hoists, monitors and alarms, to the more subtle but highly sophisticated technologies such as tracking sensors and emotion-technologies these technologies offer the potential to maintain or increase care support for older people living at home, whilst minimising state intrusion into the private sphere of the home.

113We cannot, however, accept the development and adoption of these new care technologies uncritically. As the sections above have clearly outlined there are major social and ethical questions that need to be addressed and resolved.

  1. Critical to this debate is how these new care technologies are designed, who is involved in the design process and who they are being designed for. Who gains and who loses as a consequence of their development and implementation?
  2. To what extent are these new care technologies re-shaping the nature and experience of care? For example, are the older people empowered and enabled by theses technologies, or are the concerns of medicine and risk avoidance being prioritised over social needs and the potential for increasing the social isolation of frail older people?
  3. To what extent are these new care technologies creating a shift in who cares and the nature of that care work? Will this increase or decrease the gendered nature of care work? What will be the role of the private sector in the new forms of care work that emerge from this process?
  4. How are these new care technologies acting to shape/reshape where that care takes place? Remote care technologies do have implications for where formal care takes place. Monitoring and surveillance technologies may have the potential to increase the ‘statization’ of the home, raises ethical and legal issues about who has access to the data generated. However, hand such systems may offer opportunities for frail older people to ‘reclaim’ the homespace from more intrusive forms of (face to face) personal care.
  5. How will the different models of care that exist across Europe engage with these new care technologies? Might this offer opportunities to increase the porosity of boundaries across member states, or is it likely to increase the spatial inequity of care across the EU? To what extent is this bring further complicated by internal migration and differences in cultural expectations of who should provide care and where care should be provided?

114While the studies referred to in this report provide some partial answers to these questions, there is a clear need for dialogue around these issues to be extended beyond the confines of academic research in ways that will bring together not just the academic community but also new care technology designers, clinicians, care providers, policy makers, family carers and of course older people from across Europe. These issues formed the foundation of a dialogue that took place in Utrecht in September 2007.


1 See:

2 For an interesting discussion on diversity, mobility, choice, opportunity and risk in terms of European integration see the work of the Futures project (

3 Warnes (2002) cites European governments’ refusal to cede to the EU control of social security spending as set out in the European Charter of Fundamental Rights.

4 EUROFAMCARE is an international research project that looks at the services supporting family carers of older persons across Europe and funded within the 5th Framework Programme of the European Community. Please see:

5 European Community Household Panel (ECHP). The ECHP is a longitudinal panel covering the EU population, which commenced in 1994 and follows up its sample members annually.

6 The Framework Programme 5 project funded by the European Commission (HPSE-CT-1999- 00031), and entitled ‘Improving Policy Responses and Outcomes to Socio-Economic Challenges: Changing Family Structures, Policy and Practice’

7 For example 5050 vision is a Northwest of England forum on ageing: see; In 1998, Age Concern, England launched Debate of the Age’, a comprehensive national programme that raise awareness of the ageing population and considers how policies and provision might need to change See

8 For further discussion see:

9 ENABLE project: an EU funded project (2001-4) that sought to facilitate independent living of people with dementia, through access to enabling technology and devices. England, Lithuania, Ireland, Finland, and Norway were the participating countries.

10 Ambient Intelligence refers to intelligent, intuitive interfaces embedded in everyday objects that can detect and respond to individual’s changing needs

11 This was part of the ACTION research project (Assisting Carers using Telematic Interventions to meet older person's Needs). This was a 36-month EU-funded project (1997–99) which examined the use of user-friendly information and communication technology to support frail older people and their family carers in their own homes across England, Northern Ireland, the Republic of Ireland, Sweden and Portugal.

12 For further details please see:

13 See:

14 For further information see:

15 See:

16 The Lisbon European Council of 2000 and the e-Europe Action Plan describe the Commission as being committed to ensure European leadership in generic and applied knowledge society technologies, to improve European competitiveness and to enable all European citizens to benefit from the knowledge society. The European knowledge based society also needs to be a socially inclusive one.

17 See The MobiHealth Project, EC IST Programme 2001-6.

18 EC, Applications relating to health. Fifth research and development programme 1998–2002, IST. Directorate C4eHealth. Luxembourg: Office for Official Publications of the European Communities, 2003.

19 Blythe & al. (2005) give examples: a bed occupancy sensor, for example that retrieves information from a clock and a pressure pad and can infer that a client has got out of bed at a time when they are normally sleeping. It can be used to switch on lights guiding them to the bathroom (preventing falls) and raising an alarm via the carephone if they are not back in bed within a previously set duration (reacting to a potential fall). Also a ‘wandering client’ for people in the early stages of dementia that combines data from movement detectors and a clock to infer that the client is about to leave the house at an inappropriate time. A warning message, perhaps recorded by a relative, can be played as a way of trying to alert the client.

20 Video telephony describes person to person communication that uses voice and visual connections.

21 See

22 For further information see:

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