New PCAST Report on Independence, Technology & Connection in Older Age

Yet another major report was released this month: “Report to the President: Independence, Technology, and Connection in Older Age,” from the President’s Council of Advisors on Science and Technology (PCAST).

PCAST convened a blue-ribbon working group for this report, which included several prominent experts who have done terrific work in improving the health and wellbeing of older adults.

So I was a bit surprised to find myself a bit disappointed by the report and the recommendations. Every now and then I read something that leaves me thinking “Wow, this really clarifies what’s happening, what’s important, and points towards solutions that are viable and likely to improve the problems we face.”

This report did not leave me with that feeling. But perhaps it will do more for you? In this post I’ll summarize some key highlights from the report, and then I’ll share a few thoughts on what I’m hoping to see in future expert reports.

How PCAST framed its report

PCAST identified four areas of change in aging, which offer opportunities for technology to help:

• hearing loss
• loss of social engagement and connectivity
• cognitive change
• physical change

They released a report in October of 2015 on technologies for hearing assistance, so this month’s report addresses the other three issues, based on PCAST’s investigation of “technologies that promote individuals’ continued independence and productivity as these changes happen.”

Specifically, PCAST “sought to identify technologies and policies that will maximize the independence, productivity, and engagement of Americans in their later years,” with an emphasis on “technologies important to the key areas, rather than specific diseases and situations,” and “technologies that could have an effect broadly and in the near future.”

In conducting their study, PCAST uncovered the following “cross-cutting themes:”

• “Older adults in the U.S. are heterogeneous,” and vary greatly in terms of background, socioeconomic status, physical and cognitive functioning, living environment, as well as in terms of access to and facility with newer technologies.
• “Internet connectivity plays a foundational role” in enabling options, but many older adults have limited access to broadband or may not feel comfortable/adept in using Internet-associated technologies
•  A “growing role of monitoring within homes and communities has been facilitated by new devices and fast Internet connections…can be used to great benefit for reminders, predictions and possible prevention of events such as falls, threats to financial security, identification of problems with normal activities of daily living, or discovering vulnerable people in emergencies.”
• A “need for more interdisciplinary and translational research into technologies that can support an aging population. Such research areas include home robotics, advanced mobility technologies and next-generation technologies for wheelchairs, communication technologies (especially during emergencies), cognitive training and coaching, and home monitoring technologies.”
• The “importance of standards, as effective use of many technologies is stymied by limited standards…technologies need to be interoperable in order to exchange information.”

PCAST’s recommendations:

The three key areas of the study and the cross-cutting themes led PCAST to four cross-cutting recommendations, plus an additional eight recommendations. I will paraphrase them here but be sure to read the executive summary for additional details, including which agencies PCAST suggests involving.

Recommendations:

1. Integrate federal action
   • Create a one-year Task Force of the National Science and Technology Council that will identify technologies vital to an aging population, focused on enhancing work between agencies.
   • Support a standing private/public Council, with private-sector leaders from industry, academia, and advocacy organizations to advise on sector-wide ways to advance technology in the service of improving quality of life for older people.
2. Engagement and Social Connectivity
   • Create a national plan to ensure all older people have broadband Internet access.
   • Support training centers in accessible distance for all older people.
3. Monitoring Technology for Frail and Vulnerable Elders
   • Develop guidelines for marketing and instructional materials to ensure that consumers understand the operational requirements, benefits, and risks of various monitoring technologies.
   • Develop guidance to identify privacy and security risks in a way that does not pose undue barriers to innovation and adoption.
4. Research is Needed to Spur Further Innovation
   • Support interdisciplinary and translational research including robotics, advanced mobility technologies, communications technology with special emphasis on emergency situations, cognitive training, and home monitoring.
5. Education and Training in Online Technologies
   • Support ongoing reauthorization of the Older Americans Act and build on the provisions in Section 415 to ensure access to online services and protection from scams and fraud, tailored to the learning needs of older adults.
   • Expand Senior Corps to include older people with literacy and skills in technology use.
6. Emergency Response and Communications
   • Advance national strategies to create effective communications systems that reach isolated and vulnerable older people.
   • Promote more rapid interoperability of medical information to ensure timely access whenever and wherever a patient may appear.
   • Advance policies that make medical device interfaces more consistent and interoperable to ensure timely access to people who depend on these devices.
7. Financial Services
   • Encourage the banking and financial services sector to offer monitoring services to protect assets from fraud and exploitation.
   • Ensure that reports of suspicious activity are reported to relevant adult protective services agencies.
8. Cognitive Training
   • Continue to enforce regulatory review and guidelines for commercial cognitive training products.
9. Improve Regulation and Payment to Reflect Innovation in Telehealth
   • Accelerate reciprocal state licensure policies.
   • Use the full capacity of the Innovation Center to advance payment policies that support innovation in telehealth.
10. Home Design to Sustain Independence
    • Streamline and strengthen regulations and payment policies that govern home accessibility standards in order to promote uniform standards allowing efficient use and changes in technological support systems.
11. Improving Product Design for Older Adults’ Needs
    • The Consumer Product Safety Commission (CPSC) should work with AARP and other relevant groups to accelerate better design guidelines for senior-friendly packaging, especially of technology and essential products like food and medical supplies.
12. Future Role of Assistive and Robotic Technologies
    • Examine current payment policies and implement changes that allow people to buy higher-functioning [wheelchairs and other mobility-necessary technologies] with some Government support.
    • A multiagency and industry task force led by VHA, DOD, DARPA, and HHS should recommend a ten-year roadmap for improving wheelchair functional capabilities.

Some thoughts on the PCAST report

My main thought, when I first read the executive summary, was that this report is very focused on technology and doesn’t have nearly enough emphasis on identifying the most important aging problems, and prioritizing the problems.

For instance, the purpose of the study was “to identify technologies and policies that will maximize the independence, productivity, and engagement of Americans in their later years.”

But there is no obvious list of the most important threats to independence, productivity and engagement, other than the three rather broad and vague key changes that affect older adults (loss of social engagement, cognitive changes, physical changes).

This seems to me a serious flaw. If we are to realize the potential of technology to improve the lives of aging Americans, it seems crucial that we provide more direction on what exactly are the key threats and problems that we want technology to help us avert or mitigate.

For instance, if I think about recurring problems that I see interfering with older adults having the best possible health, happiness, function, and well-being, here are few that come to mind:

• Difficulty managing IADLs. Transportation is a biggie and can be due to either cognitive or non-cognitive (e.g. vision, arthritis, general problems with ambulation) causes. Developing dementia pretty reliably affects all IADLs and means that an older person needs to rely on people (family, paid caregivers, other services) to provide IADL support in the home. Moving to assisted-living can meet many IADL needs.

• Difficulty managing ADLs. Your neighbors in a naturally occurring retirement community can help you with groceries and transport, but once you have ADL problems, the need for caregiving assistance really moves into another level altogether. I suspect that difficulty managing ADL needs is a big reason that people move to a residential facility or possibly even a nursing home. (Do people move to nursing homes because they need more monitoring — as this report asserts — and this could be alleviated by technology and sensors in the home? I am skeptical of this claim.)

• Problems related to safety or disruption. Here I am thinking of problems like the dementia patient who wanders, or keeps calling the police. Or I think of older adults who have falls and need help getting up, either because they live alone or because their elderly spouse can’t get them up. Many older adults also experience safety issues related to taking their medications.

• Problems accessing high-quality primary care grounded in geriatrics. This is more than not getting telehealth services because of lack of broadband or interstate licensing issues. This is not being able to access medical care that is coordinated, comprehensive, works with patient’s care circle, is tailored to the person’s preferences and values and health situation, and integrates with other long-term care supports and services. Instant iPad access to an internist on HealthTap is not going to fix this problem. The Hartford Foundation recently published an issue brief on primary care for older adults, which lists barriers and opportunities in this arena. Technology could and should be part of this.

• Inadequate support for the involvement of family caregivers and for the family caregivers themselves. Family caregivers have a lot to do, and need all kinds of help in doing it. Products and systems need to be designed to facilitate their involvement and to make it easier for them to do what needs doing.

• Difficulty finding affordable housing and caregiving options to meet the needs of aging adults. Whether it’s making modifications to the home or moving somewhere else, the expenses involved are often a serious issue for families. Same for getting help from someone.

• Overall complexity in everything related to health and aging, which makes it hard for people to find suitable help. There is an awful lot of complexity in everything, whether it’s picking a Medicare Part D plan, or considering long-term care insurance, or finding good in-home care, or even following up on the chronic care plan the doctor recommended. This is a real burden for older adults and their families, and also means people often don’t take action because figuring out what to do is so arduous.

I could come up with more, but I’ll stop there for now. Also as I think about these problems, I wonder:

• What are the main drivers of people moving in facilities? Into nursing homes? How can you get technology to prevent or mitigate those?
• What would be a useful way to sub-divide our population of older adults, in order to problem-solve and find tech solutions more effectively? And within those groups, what do the older adults themselves most want us to work on and help them with? Where is their voice in this process?

And here’s another issue: although I agree that social connectivity and engagement are extremely important issues for older adults, they become particularly challenging when people have developed cognitive or physical limitations. But in this report, the social connectivity chapter does not say much about this. This I feel is a fairly common problem in aging reports, which is that there is a tendency to mix together the problems and needs of people with and without substantial functional limitations. Obviously, there is a lot of overlap in the issues; whether you have dementia or not, access to broadband is important, as is access to suitable training. But having notable cognitive impairment will drastically affect the way one can take advantage of a helpful technology, as well as what one needs from technology.

For instance, if you have moderate dementia, then you shouldn’t be driving and you probably can’t take public transportation by yourself, which has a huge impact on your social options…or your ability to use Facebook to connect with old friends.

In short, this report doesn’t resonate with me because I don’t feel it speaks very well to the problems that I see older adults struggling with the most.

This is not to say that the recommendations are not worthwhile. I especially like the idea of extending broadband access and technology training to all older adults, as well as the recommendations relating to protecting the finances of older adults.

But I am skeptical of the emphasis on monitoring technology for frail and vulnerable elders. Monitoring has a mixed track record and as noted in this excellent review article on aging and technology, it is one thing to identify risks and much harder to meaningfully intervene.

The other recommendations strike me as okay. Some seem a bit ponderous and bureaucratic, but of course we need more government coordination and research. Some recommendations seem oddly narrow (e.g. regulatory review for cognitive training products). Some seem necessary but not nearly sufficient for what I see as the related problems of aging (e.g. telehealth regulations, home design standards).

Two ideas to advance our use of technology to improving the aging experience

Here are two ideas I found myself wondering about as I read the PCAST report.

First: what is working in other countries? Clearly, different countries have different types of infrastructure and systems, so what works in one place is not going to necessarily work here. But the problems that aging people experience — especially the ones that force people to move or drive family caregivers crazy — are likely similar in other developed countries. Hence, we should be able to learn from what other countries have tried and studied.

In keeping with my preference for “name the important problem then name options for addressing,” it would be great to see a report that could tell us all what solutions have helped in other countries. Bonus if there is any evidence of benefit; we need to move beyond “this has potential” and focus on this “this worked this well under these (real-world, hopefully )circumstances.”

Second: how about picking a smaller community and using all the tech and innovation you can, to see how well you can ameliorate the aging issues? A naturally occurring retirement community or an existing “Village” would be a good place to start.

After all, if you can’t get tech to make a meaningful difference in outcomes there, then where?? Assisted-living would be another good place to try piloting some of this, although of course many older adults hope to avoid assisted living and instead “age-in-place”. More complicated would be to pilot a whole program of innovations to support aging adults in a city (come on, Louisville!) or some kind of municipal entity, but it certainly would be interesting and I imagine we’d learn quite a lot.

In closing, I’ll say that I’m glad PCAST felt it necessary to address aging. But I think we need more, in order to move along more effectively towards a tech-enabled future in which older adults live a better late life.

As I’ve said, I feel we need a better delineation of the key problems that worsen the independence and wellbeing of aging adults. (And of their families!)

What do you think is needed? And what do you suggest, in order to more quickly develop technology solutions that will help many older adults ?