Millions of elderly people live alone, many far from family or others who might watch over them. One option emerging is that of using technology to help someone at a distance tell how things are going, using some sort of passive monitoring system. A passive system does not require the elderly person to do anything to make the system work, as opposed to "active" systems that require the elderly person to take some action, like pushing a button on an emergency response system pendant. Some passive systems put cameras in the older person's home that allow someone somewhere else to see what the camera sees. Others use sensors that can detect motion to alert others if the elderly person is not eating, has not taken their medication, or has fallen. These systems may be used to watch over elderly people who might not realize they need help, like someone with early stage Alzheimers who might forget to eat or take medications. They can also be used to detect falls or other problems as they happen, or to monitor third parties like home health aides and other home help.
Several passive monitoring systems being used in the homes of elderly individuals were described in April 2004 at the annual joint conference of the American Society on Aging and the National Council on Aging, and they illustrate some of potential benefits and potential pitfalls in these systems. Generally the solutions fall into two classes, cameras and sensors, although some systems use both.
Cameras can be used to get a visual picture of how the older person is doing -- to pick up on clues that might not be obvious from a phone call, for instance. Cameras are also used to see if home health aides showed up and treated the elderly person appropriately.
Wired cameras require running wires from the camera to a computer or gateway that will capture pictures, wireless cameras can send information to a wireless access point or computer. Wired cameras are cheaper, but more difficult to install and harder to move. Wireless cameras are more expensive, and may be vulnerable to "hacking" over the Internet if not properly encrypted, but are easy to install and move.
Cameras need power to run and must be located near an electric outlet, limiting their placement options. If the power goes out, the camera will obviously quit working, perhaps just at the time when the elderly person is at most risk.
Some cameras are fixed in place and can only view whatever is in front of them, others can be controlled remotely to scan the room on demand. Those that can scan the room make it possible to see more areas with a single camera, but are more expensive.
Something has to control the cameras. In many cases cameras are controlled by a computer located in the elderly person's home. If the computer loses power, shuts down, gets a virus, or otherwise is put out of commission, the system won't work. The occupant of the home, or perhaps a visitor like a grandchild, could deliberately or accidentally destroy the system by shutting down or changing the configuration of the computer. In some systems the computer is put in an out-of-the-way place like an attic. Other systems bypass a local computer by using a gateway to send pictures directly to a computer located somewhere else, like a central web server.
A system with lots of cameras is more expensive, but make it less likely that something important will happen that the camera cannot "see". A system with numerous cameras leaves the occupant literally living in a fishbowl, a life that few of us would choose for ourselves. Most systems that use cameras try to place them in a few strategic spots that are most likely to allow a remote viewer to know if something is wrong. For instance, one system places a camera in the kitchen and one in front of the occupant's favorite chair. Placement of a camera in a bathroom is a touchy issue, but an important consideration since falls often occur in the bathroom. One system places a camera in the bathroom, but pointed at the floor. The idea is that this placement will protect privacy but make it easy to see if the person has fallen. Other systems avoid cameras in the bathroom entirely.
One issue not well resolved is whether or not the occupant can control the cameras, or turn them off. Privacy concerns would dictate that the occupant should be able to easily turn them on and off, but that would also eliminate the benefit of installing them. If the elderly person falls right after turning off the camera, how would anyone know, and whose responsibility is it? That being the case, is the camera of any benefit anyway? An occupant who most needs to be monitored might be the most likely to turn cameras off -- for instance, someone with Alzheimers might react with paranoia to the cameras and keep them off all the time. In at least one case, an elderly person being monitored by cameras took things into her own hands and cut the wires to the camera.
Systems vary in the way they handle access to the images on the cameras. One system requires users to install proprietary software on their own computers, then dial into a computer in the recipient's home which has been set up to allow access only from specific sources. They tout that as a way to keep "hackers" from seeing the information, but it also ties up a phone line and limits the ways the system can be accessed. With this system, the caregiver cannot access the cameras if they are away from the computer that has the proprietary software installed on it. Most systems upload pictures to a central web site, which can be accessed by anyone with Internet access and the right id and password.
Video files are huge files, and it takes a lot of storage space to archive them. No system is big enough to store all pictures indefinitely, so tradeoffs have to be made on what to keep. No one can possibly look at every picture from every minute of every day, so the possibility exists that important pictures might be destroyed or overlooked.
Most of the pictures will show nothing of importance most of the time, and no caregiver will be watching them continuously. Having a camera will allow a remote caregiver to "look in on" their loved one, but will not guarantee they will see something going wrong as it happens. If something does happen, the camera may have captured pictures of it which can be reviewed later, but because of the storage issue mentioned early, this will be useful only if someone checks soon afterward and makes a decision to save the relevant pictures.
Janice Blanchard, MSPH, CSA went into some detail on her concerns about this passive monitoring technology at a workshop in the ASA/NCOA conference, many taken from an article she wrote for the CSA Journal (published by the Society of Certified Senior Advisors, December 2003). She and Harry R. Moody, PhD, who is on the board of Living Independently, debated the pros and cons of the surveillance of seniors using systems like these. Although they disagreed on many issues, both agreed that the primary concern was the potential loss of privacy to the person being monitored if not handled carefully.
Among other things, Blanchard was worried that some systems were installed after getting permission not from the elderly person being monitored, but from adult children. In some cases, she said, no one gave written permission for the installation of the systems. Clearly the person being monitored must give permission unless they are not mentally capable of giving such permission (and you have to wonder whether anyone too impaired to give permission should be living alone in the first place.) She emphasized the need to get written permission to install the system as well as explicit instructions about who pictures and other information can be shared with. In addition, she wants to allow the person being monitored to be able turn the system off themselves at any time, something that is not even possible with some systems.
Other concerns include:
These passive monitoring systems may have merit, but users should be sure to keep the ethical issues under consideration!
A sensor is a very tiny device that can basically do just one thing -- detect if something has touched it, for instance. A sensor in a mat at the side of a bed can detect that someone has stepped on it to get out of bed. A sensor under a bed post could detect if someone is tossing and turning. A sensor on a door could detect if the door had been opened. A sensor under a medicine bottle could detect that someone picked up and put down the bottle. A sensor in a light switch could detect motion in a room. A sensor next to a bathtub, toilet, or washing machine could detect if water has touched it.
A single sensor has some use. It could make a sound if it has been touched, for instance. However, to be really useful, a system of multiple sensors can send information to a central computer, where it can be aggregated into patterns that might describe what is going on in a room or a home. This computer could be in the same home or somewhere else, and could be set up so that someone like a distant caregiver can access it remotely.
It's not hard to understand the interest in sensors. They provide a way to remotely communicate what's going on in a less invasive way than cameras. However, the technology is new and there are many things that need to be ironed out.
Sensors are relatively cheap, and the cost is likely to decline as the market for them increases, so it is possible to use many sensors in a single home. The systems to aggregate and make sense of the information they produce are still very expensive.
Sensors may be powered by either a power cord or a battery. Battery powered sensors obviously can be placed anywhere, but someone will need to be sure the batteries get checked and replaced. Those that use electric power are subject to power outages.
Sensors are usually connected to each other and to a computer wirelessly, so it is not necessary to run wires. The raw data they send is not particularly meaningful in a vaccum, so it is probably less important than with cameras if someone were able to access the data sent over the wireless connection.
A system of dozens of sensors will generate a huge volume of data. Some systems allow the users to see all activity, but it's difficult to look at raw data and tell what activities are ordinary and which ones indicate problems. A key activity of researchers working on these systems is to create a way for the system to "learn" what is normal for the person being monitored. If this can be achieved, the system can be set up to notify caregivers anytime activities vary from their normal patterns. Doing this requires developing and perfecting complex mathmatical algorithms, an imperfect science.
A problem with sensor systems is that they work well when only one person is in the house, but develop problems when there is more than one person there. Guests, and even large dogs can interfere with the operation of the system. For the patterns to make sense, the system has to filter out activity that is not created by the target, and that is hard to do if anyone else is in the house.
The information in this article came from presentations about several systems currently in operation. They include:
http://www.livingindependently.com/
This system was developed by researchers from Drexel University and is now available commercially. The "QuietCare" system uses sensors and no cameras, and caregivers can monitor information from a secure web site. No computer is used in the home of the elderly person, all computing is done on a remote server. The reports show summaries of "activities" colored coded like traffic lights with green, yellow, and red lights to indicate the level of importance of the activity or lack of activity. The caregiver can decide when and how they want to receive alerts for "red light" events -- via phone, cell phone, page, text message, etc.
http://www.shellhomegenie.com
http://www.xanboo.com/
The The Area Office on Aging of Northwestern Ohio and Scripps Gerontology Center SAFE (Safety Assistance for Families of Elders) House Project called the service "virtual respite" and they used equipment manufactured by Xanboo, including a combination of cameras and sensors, with data available on a secure web site, and a system to send alerts to caregivers on their cell phones. This project initially used computers installed in the home of the elderly person to control the cameras and sensors, but they are now eliminating the need for a computer in the care recipient's home. This equipment is currently being marketed as the Shell Home Genie system and is also available directly from Xanboo.
http://www.guardianmedicalmonitoring.com
The Caregiver Respite and Video Monitoring Program is currently being used in Indiana with funds from the Alzheimer's Demonstration Grant using equipment from Guardian Medical Monitoring. This system uses cameras and sensors, along with other medical equipment like medication dispensors. This system is installed on a computer in the recipient's home and caregivers can dial into it to see activity. The equipment company has staff who can monitor the cameras and contact caregivers when necessary.
So what do the targets of all this technology think about it? It depends on their situation and the approach that has been used. In cases where the camera can be turned on or off by the target, or with sensors that don't really "show" anything, there is probably less resistance than there might be to cameras that are always on.
I was particularly interested in hearing what people thought who had cameras trained on them all day long. I was told they were mostly very accepting of it. At first that seems puzzling, but then I realized that the programs that were using always-on cameras were targeting people who were at high risk of institutionalization, many with early stage Alzheimers. In those cases, the cameras were the last barrier between them and a move out of their home to a more supervised setting. Not surprisingly, they felt that staying at home with cameras trained on them was a better option than moving somewhere else. I have to agree that they probably had no less privacy at home with the cameras than they would have had in an institution.
Although the systems seem best suited to people whose health has deterioriated as a way to avoid a move to a more supervised setting, they are not suitable for certain severe situations. Every presentation for every type of system emphasized that their system would not be appropriate for someone who wanders, nor for someone who needs 24 hour a day hands-on care.
So what does this all mean? It may mean that a staged approach could make sense. Someone who needs a little but not a lot of supervision from someone else might benefit from a system that they can control themselves, like personal emergency response systems. As the risk of institutionalization increases, control could shift to someone else. That could involve using sensor systems and/or cameras in a system designed to postpone the need to move for someone who is either opposed to or unable to afford to move to a place where they could be supervised in a more traditional way.
ElderWeb Background
ElderWeb was created by Karen Stevenson, a CPA and a consultant with over 19 years of experience in long term care, finance, and technology. Over its eight years of existence, ElderWeb has grown to include thousands of reviewed links to long term care information, a searchable database of organizations, and an expanding library of articles and reports, news, and events.
This award-winning site is designed to be a research site for both professionals and family members looking for information on eldercare and long term care, and includes links to information on legal, financial, medical, and housing issues, as well as policy, research, and statistics. Thousands of other sites link to ElderWeb, and it has received numerous Web awards and press mentions. ElderWeb has been used extensively by journalists and students doing research, and by professionals looking for Internet resources, as well as by family members looking for help for their elderly relatives.
I first developed the concept and wrote all the code for these pages in 1994, when the browser of choice was Mosaic and I had to hand code everything in HTML. I didn't have any idea at the time how large this project would grow, I just had trouble finding good long term care information on the Web and decided to post the links I found in a Web page for others to use. I had to search hard to find anything on eldercare on the Web in 1994. At that time, most of the sites on these pages did not exist. Many of my early links were text pages in gophers, and the information posted was nothing more than a list of phone numbers to call to get "real" information.
Since then I have completely remodeled the site several times. There is a huge amount of eldercare information now, and it's growing rapidly. Links now take you directly to lengthy articles about eldercare topics, sites where you can search for services by state, county, and even zip code, information about how to apply for Medicaid in various states, and much more. My goal is to include as much direct on-line information as possible, so someone like a worried adult caregiver browsing at 3 AM is not forced to wait until normal business hours to get help. As much as possible, I try to take you directly to online articles, rather than send you to a site's home page where you have to guess where the information might be.
I am revising the site to make it more accessible to handicapped-enabled and text-only browsers. I keep working at new ways to improve the time it takes to load pages, and I'm always trying to make the site easier to navigate. There are no frames on this site, so you can safely bookmark pages and get right back to them, rather than ending up at the home page, as happens with most sites which use frames. When I find articles buried in sites with frames, I have linked you to the unframed page, so you don't have to dig around the site to find it.
I plan to continue to develop and expand ElderWeb. I hope you find it helpful!
Karen Stevenson Brown has presented seminars all over the country on a variety of topics related to eldercare and long term care. Some of these include: