What is gerontechnology? What is the roles for health?The extent of the problems weighing today on the question of the aging of the population and the increase in the number of elderly people losing their autonomy has known for several years a surprising one: that of the extraordinary creativity which is developing in the field of assistive, digital, telemedical, information, communication technologies, biomedical sensors and medical or domestic robotics.
The excitement, intensified since the 1990s, of research and technical inventions in the field of disability / aging today responds to considerable societal pressure for the effective implementation of these inventions.
While there is some interest in these emerging technologies, they are still absent from gerontological care plans. Everyone recognizes that delaying, even if only 6 months, the entry into an institution of an isolated frail elderly person, at risk of falling and experiencing some cognitive impairment, generally represents a considerable gain both for the person concerned and for the economic plan. Such a delay can be obtained thanks to suitable home automation equipment, facilitator of a medico-social assistance device at home.
In addition, the Internet is bringing new uses and new learnings in gerontology (information, health education, attention exercises, inter-generation, etc.) and as such promotes the field of prevention, promoted by law. of public health policy.
It therefore seems useful today, if not urgent, to make an inventory of the inventions available or which will be soon, and areas of gerontology where their use will be beneficial both for the patients, their families, the professionals of health and society as a whole. This inventory must take into account their “added value” in terms of improved care, security, quality of life for those concerned and savings on expenses of all kinds.
This report, produced in a few weeks, does not pretend to provide such an exhaustive inventory (which would be unstable in terms of techniques, given the speed of their evolution). However, it will give public authorities and interested citizens a fairly precise overview not only of the technical solutions available, but also of the levers that it seems necessary to activate for their rational and human consideration in an economy of generalization of the good treatment of the elderly.
It is structured in three main parts, relatively independent of each other to facilitate reading, but in a logical progression:
– The first part is devoted to a global description of the context. Context of needs and constraints linked to the aging of the population but also context linked to the convergence of two fields: that of disability and that of gerontology. This part makes it possible to clarify the interest of the techniques exposed next.
– The second part offers a descriptive tour of technical inventions likely to improve gerontological practices and the daily life of elderly patients and their family carers. It will also describe some avant-garde actions supported in France by important players (General Councils, Regions, etc.). This part constitutes in a way the knowledge base of the following part.
-The third part aims to go beyond the stage of the simple technological window, useful but limited, of the previous part. It addresses the problems encountered today in the social and medical integration of the techniques presented and the associated ethical problems. Is this a lack of adequacy to needs? Of a weakness of the market which would allow their industrial development – we often speak of the “huge market” of the elderly: is it so huge and is it homogeneous -? Lack of recognition by Health Insurance, public authorities, professional organizations, families? Is it a fear of health professionals vis-à-vis a technology that they perceive as threatening for their professions, their jobs? Are these ethical issues, risks to privacy, privacy or medical confidentiality?
We will dwell on this issue of ethics in greater depth, since many other questions depend on its answers. When the world of technology, of a power and omnipresence never reached before, meets that of the suffering or weakened old age and social isolation, the temptation is great to focus on sensor problems, ” ambient intelligence ”or ergonomics of person-system interfaces. These exist, but are the subject of intense study and only need to be resolved by researchers, engineers and industrialists. Ethical issues are more difficult to identify, then to resolve or anticipate. The levers for taking them into account are largely at the political level: health policy, training users and professionals, the culture of integrating the difficult end of life.
– The fourth part is entirely devoted to the recommendations: three short-term and seven longer-term, each of which is preceded by a brief explanation.
A short conclusion followed by the bibliography concludes this report.
What you will learn
Meaning and roles of gerontechnologies
A turning point
The period in which we have entered for a few years is that of integration, a key concept now appearing in first place in the major calls for projects, whether national, European or otherwise, and in numerous writings, reviews conferences and current scientific articles. This integration goal concerns of course the technical plan (complementarity, harmonization and interoperability of the various existing technical devices and associated services), but also and above all the ethical and socio-economic plans.
Three keys to medical and social innovation supported by technological innovation in terms of aging / longevity can thus be identified:
– the key to technical excellence;
– the key to ethical aim;
– the key to socio-economic viability;
It is the harmonization of these three keys that conditions the harmonious and effective integration of these technologies into our society in the field of aging and longevity.
How to integrate these technological innovations into gerontological practices? How to put them at the service of the quality of care and the daily life of elderly patients and that of their families? How to make them play a role of moderator of health expenses? How to make them faithful instruments of a health ethics in France? These are the questions that technologies for autonomy and longevity must answer today, and which now constitute its major challenge, the strictly technical challenge already being largely met and partly won.
Even if essential evolutions remain to be accomplished, the techniques are indeed on our doorstep, either in the form of prototypes, or already marketed or, for some, accessible for free thanks to the use of the Internet which is developing more and more among our elders.
We must distinguish advanced technologies, aimed in particular at facilitating secure and socialized home care, and the simple use of the Internet by people aged 60 and over. The two are in synergy, share issues of accessibility, security, reliability and various protection, and are constantly associated, and rightly so, in public debate. However, this report focuses mainly on the former, that is to say technologies capable of playing a significant role in the socio-health problem of the care of various categories of people with disabilities and in particular the sick or frail elderly.
Numerous experiments in the laboratory or on reduced samples of user populations are followed today by the commercial dissemination of some of the most advanced techniques. A flagship example of this integration movement: the geolocation system for people with cognitive disorders or living in isolation. The prospect of such a device had, in the 1990s, raised many hopes, some severe disappointments because of its unavailability and raised ethical questions. Some fifteen years later, here it is finally available).
However, the few innovations that are making headlines today should not be seen as an illusion: in the medical and social field of caring for the frail or sick elderly, the difficulties are increasing and are only just beginning. Technology is expected to limit its scale.
For several proven and available techniques, it is now urgent to answer the double question: what to choose (depending on the quality and cost of the products) and who will pay?
The first part of the question refers to a challenge, which is not new but remains difficult: that of multiaxial and comparative evaluation of products and services. The second part of the question is not new either, but today requires clarification given both the vagueness around this issue and the growing emergency. Avenues for response exist, for example with the prospect of recognition of a fifth risk or the concept of long-term care insurance which is developing on the side of mutuals. This is to clarify these answers.
It seems to us simply essential to recall very succinctly the “targets” that the technologies which are going to be exposed aim at, both on the pathological level and on that of the social situation of aging. It should also be remembered, so as not to be mistaken about the meaning of this report, that aging is not synonymous with disease and that, on the contrary, life expectancy without disability increases from year to year. But the “demographic tsunami” that we are entering right now will both increase the number of elderly patients and decrease the number of resource people, whether professional or family members. The problems when dependence arises will therefore increase during the next few decades, mobilizing all the forces available to cope with them, certain technical equipment being able to increase these forces.
A worrying reality
The characteristics of pathological aging are linked to the concepts of fragility, vulnerability, precariousness and multi-pathology. If frailty is not a disease, it has nevertheless been studied for several years as a fully-fledged syndrome, predicting the risk of falls, illnesses, hospitalization, institutionalization and mortality. For example, following a large American study carried out by 11 geriatricians and involving 5,317 people aged 65 and over without illness or disability at the start of the study, frailty was defined as the combination of at least three criteria among the following 5: 1) loss of weight, muscle mass, unintentional; 2) decrease in physical strength to grasp something; 3) low endurance and energy, fatigue; 4) slowness; 5) low level of activity or caloric expenditure.
The main functions affected are musculoskeletal, cognitive, respiratory and nutritional functions. The main disorders observed concern: balance and walking (falls), confusion (from simple memory loss to dementia syndrome), incontinence and depressive syndrome.
Quantitatively, a few figures suffice to sum up the challenge of an aging population. Life expectancy at birth has increased by 1 year every 5 years in industrialized countries for about 50 years. The percentage of the population of people over 60 in developed countries in 1950 was 12
%, in 1998 of 19%; in 2035 it should be 28%; globally, this percentage is currently around 10%; it should reach 22% in 2060. In 2015, the percentage of people over the age of 85 will become higher in developing countries than in developed countries. Some countries, such as Japan, will experience a real turnaround: its population will drop, due to the fall in the birth rate, from 127.7 million inhabitants today to 90 million around 2065, for a life expectancy today the highest on the planet (82 years). Still in Japan, but revealing for the whole planet, the average age of consumers should drop from 30 years in 1965 to 50 years in 2027, leading to a severe drop in the active population and a complete change in the rhythms of life and consumption.
The burden of care for people with disabilities by the younger generations will increase accordingly: according to the US Department of Commerce, the parent support ratio, that is to say the number of people over 85 for every 100 people aged 50 to 64 was 10 to 25 in 1998 in developed countries; in 2025, it should be 25 in the United States, 31 in France, 35 in Sweden and 42 in Japan.
Social ties are the key to aging both in optimal security and in harmony with other generations. The isolation and desocialization of older people is the primary source of distress, leading to a great number of critical situations or psychological suffering in the last years of life.
The fall, by its dramatic consequences (rupture of the neck of the femur, hospitalization, institutionalization …) is one of the main plagues to which biological aging exposes the elderly. Retirement homes are particularly vulnerable to falls from their residents. Morbidity and mortality rates due to a fall are highly correlated with the speed of intervention by the emergency services.
The prevalence of Alzheimer’s disease and related diseases, estimated between 25% and 48% in people over the age of 85, increases severely with age. The most common symptoms are memory loss, speech impairment, reasoning and judgment impairment, learning impairment, very high susceptibility to stress, fear and anxiety. Radical behavior modification (running away, irrational decisions, silence, apathy …) and almost complete loss of autonomy result from this disease. Despite these dramatic events, a growing number of moderately ill people live alone, resulting in a high number of accidents and deaths without care. The life expectancy of an Alzheimer’s patient after a fall with fractured femoral neck and operation is 3 months. Caregivers (spouse, child, parent, friend, etc.) are severely affected by this disease: threatened by exhaustion, spouses, themselves elderly, Alzheimer’s patients or relatives have an excess mortality of 63% compared to mortality spouses of the same age with no particular charges. 50% of primary caregivers living under the same roof as the patient have proven depression. With the increase in lifespan and the subsequent increase in the number of elderly people in the population, the number of patients is expected to double by 2030 and triple by 2060. If current trends continue this increase will not be proportional to the complete population: the prevalence, from 15 per 1000 inhabitants currently, will drop to 30 per 1000 around 2050. These figures clearly make this disease one of the major challenges in our society.
One principle of this report was to take Alzheimer’s disease or related disorders as one of the bases for reflection in gerontechnology. This principle consists in starting from the most difficult problem, but also the most common on the medical and social planes, to go towards the simplest, fragility. As we will see, various techniques, thought based on cognitive disorders (memory loss, disorientation, etc.) appear to be particularly appreciated by people who do not have this type of disorder, like the television remote control or of the video recorder, originally designed for people with physical disabilities and quickly became of general public use. It should also be remembered that Alzheimer’s disease takes two victims, the patient and his caregiver, and that therefore the sick-caregiver couple represents a real concentrate of medical and social problems associated with people of the 3rd and 4th age. The reflection carried out in this study, the various techniques which are analyzed there and the solutions envisaged, thus concerns more or less all the elderly / disabled people, even all citizens interested in these techniques.
Disability technologies and gerontechnology: a convergence
One of the striking contrasts that the evolution of our society offers us is the one that has arisen between the difficult situations experienced by people with loss of autonomy – chronically ill, elderly or disabled – and their carers on the other hand, these technologies, often qualified as new or emerging, whose potential in terms of simplification and lightening of the tasks of daily life seem considerable.
At the international level, assistive technologies are promoted by a large community of researchers who have their cooperation networks and their international congresses.
The world of disability technologies pre-exists that of the more recent, though increasingly active, technologies dedicated to the 3rd and 4th ages. These technologies are now brought together under the term of “gerontechnology”, a term from northern Europe and popularized in the late 1990s. As its name suggests, the field of gerontechnology is located at the crossroads of gerontology and technology: sciences of aging including biology, psychology, sociology and medicine for one; research, development and modeling of innovations or improvements in techniques, products and services for others (physical, chemical, civil, mechanical, electrical, industrial, IT, and communication engineering).
Gerontechnology has today gained wide international recognition. An International Society of Gerontechnology (International Society of Gerontechnology, ISG, www.gerontechnology.org) was born in 1996, which publishes an international scientific journal: Gerontechnology.
When talking about illness or frailty in the elderly, gerontechnology is above all a problem of gerontology. When it comes to designing or adapting techniques according to needs and functional and cognitive characteristics, it is a problem of applied science and multidisciplinary engineering. Finally, when it comes to the social integration of these technologies, it is essentially a problem of industrialization and health economics.
More recently, the report “Home Health Technologies: Opportunities and Challenges”, conducts an in-depth analysis of the market potential in the health sector, excluding the social field but while emphasizing its major importance. Although reduced to the single field of disabilities covered by social security at home, this study sheds light on this area, still imprecise and uncertain, of the market for medical technologies for the home. Another study commissioned by the Technologies Group of the Ministry of Industry seeks to determine how to better understand user expectations to enlighten industrialists on potential markets.
Finally, a report from the European Commission is particularly worth reading: “User Needs in ICT Research for Independent Living, with a Focus on Health Aspects”.
Complementarity and convergence
These two fields – disability and gerontology – come from different communities formed around significantly different needs: those of people of all ages with disabilities for one, those of the frail elderly, sick or losing autonomy for the other. That of the elderly with loss of autonomy also has its own developments, such as for example the charter of rights and freedoms of the dependent elderly person. These fields of disability and gerontology are in no way opposed: we proposed the following classification of technical aids for people with disabilities:
– Help with hygiene and personal care (toilet, toilet disposal, dressing, etc.).
– Mobility aid (transfer, positioning, gripping and handling, internal or external movements, transport for purchases, shopping, work, etc.).
– Help with rest and home support.
– Help with sensory functions (sight, hearing, speech, voice …).
– Communication support (oral, written, etc.).
– Help with household tasks (food, meal preparation, cleaning, etc.).
– Helps with body integrity and aesthetics.
– Helping consistency (protection and security, ability to live in a group, etc.).
– Help with learning, culture and leisure (training, working, fun activities …).
Without being limited to it, gerontechnologies can largely refer to it. In addition, it was proposed to “differentiate between” medical “technical aids (for treatment, treatment aid and prevention), and” social “technical aids (for life support):
The “social” technical aid for life support is intended for:
– a physical, sensory, mental, psychic or mixed impairment of origin
constitutional or acquired but also to a deficiency with sequelae due to chronicity
of a disease,
– a consolidated statement. They respond to:
– a definitive nature of the impairment,
– tertiary prevention with a palliative aim.
On the basis of these criteria, it is possible to propose a simplification of the LPP by keeping only the products which meet:
– a notion of treatment, care,
– a temporary character of the person’s state,
– a compulsory medical and surgical procedure,
– primary, secondary and tertiary prevention for curative purposes.
This distinction directly concerns gerontechnologies, which constitute only part of the technologies for disability and autonomy.
In technology, as in other fields, it is often the case that what is needed in one of these need areas may be useful in the other. A fall detector for the elderly living alone can be useful for a younger person with a disability. On the other hand, a geolocator (bracelet or anti-disappearance beacon) allowing to find a person suffering from Alzheimer’s disease who has run away is more specific to this type of pathology, while being able to prove to be practical for a person moving in wheelchair and wishing to be geolocated in the event of difficulties during its movements. Communities of researchers in these two fields coexist widely, especially within the framework of national structures and international. Disability technologies and gerontechnologies are also associated with telemedicine, of which they share many concepts (tele-assistance, telemetry, telediagnosis, etc.).
Internet: a powerful vector of innovation
“24% of elderly people believe that the Internet represents a good vector of sociability, 29% believe that the use of computers can make their daily lives easier, and 40% recognize both their interest in distraction or in training ” With its immense possibilities and its increasing availability anywhere in the world, at constantly decreasing costs, the Internet plays and will play a catalytic role for a long time “new working age” and intergeneration.
For all these reasons, we will not describe the Internet as a technology specifically useful for longevity, knowing that it is becoming an element of daily life like the telephone or public transport. However, we will describe the efforts still necessary to make it more accessible, and some experiences that go in this direction.