**A Review of Age Friendly Virtual Assistive Technologies and their Effect on Daily Living for Carers and Dependent Adults**

## **Hannah Ramsden Marston 1,\* and Julie Samuels <sup>2</sup>**


Received: 14 February 2019; Accepted: 17 March 2019; Published: 21 March 2019

**Abstract:** Many barriers exist in the lives of older adult's, including health, transport, housing, isolation, disability and access to technology. The appropriate integration of technology within age-friendly communities continues to offer possible solutions to these barriers and challenges. Older adults and disabled people continue to be affected and marginalized due to lack of access to the digital world. Working collaboratively with planners, policy makers and developers, social and living spaces in the future will ensure that residents are equipped to live in an era that continues to be led by, and is dependent upon, access to technology. This review paper uniquely draws together the small volume of literature from the fields of gerontology, gerontechnology, human computer interaction (HCI), and disability. This paper examines the national and international age-friendly frameworks regarding older adults who are carers of dependent people with disabilities.

**Keywords:** ICT; Age in Place; Disability; Smart Technology; Intergenerational Relationships; Connected Health

## **1. Introduction**

The age friendly movement commenced in 2007 when the World Health Organization (WHO) set out its global plan and framework [1] for Age-Friendly Cities. The WHO defines age-friendly as "*policies, services, setting and structure support and able people to age actively*" [1] (p. 5). This programme brought together 33 cities across 22 countries to identify and ascertain what key elements within the urban environment facilitated and supported active and healthy ageing (AHA) [2]. The WHO Global Network of Age-Friendly Cities was established for four reasons:


To date, the global population stands at nearly 7.6 billion people, with 60% of world's population residing in Asia, 17% in Africa, 10% in Europe, and 9% in Latin America and the Caribbean. China and India continue to be the most populous countries, with 19 and 18% respectively [3]. The growth of the population is increasing at a rate of 1.10 per cent per year, slower than the last decade at 1.24 per cent per year. By 2030, the United Nations (UN) estimate the global population will reach 8.6 billion and increase to 9.8 billion by 2050. The global population is estimated to rise to 11.2 billon people by 2100 [3].

The WHO Global Network of Age-Friendly Cities builds on the WHO active ageing framework. Fitzgerald and Caro [4] reported the WHO definition of 'active ageing' as "*the process of optimizing opportunities for health, participation, and security in order to enhance quality of life as people age. It applies to both individuals and population groups*" (p. 12) [5]. More recently, the WHO has replaced the previous policy [5] with the term and notion of 'Healthy Ageing' [6]. The WHO 'Healthy Ageing' policy has been set as a goal to achieve between 2015 and 2030 [6]. The WHO defines Healthy Ageing as "*the process of developing and maintaining the functional ability that enables wellbeing in older age*" [6]. Under this policy, the needs and abilities of an individual are measured through the following criteria:


There are several points which one should consider under this definition, including: the *intrinsic capacity* associated with the mental and physical abilities of an individual (i.e., walking, thinking, seeing and hearing). These can be affected by a disease, injury and age-related conditions. *Environment* includes several factors, including the home, community and society, interwoven in conjunction with relationships, attitudes, values and policies. Health and social care provisions and systems should ideally be interconnected, in a bid to support individuals' *intrinsic capacity* [6]. There are two primary considerations noted by the WHO and their Healthy Ageing framework:


This paper examines the national and international age-friendly frameworks with respect to older adults who are carers for people with disabilities. Within its overview of existing age-friendly frameworks and contemporary evidence, an overview of state-of-the-art technologies is presented, followed by recommendations for expanding this work.

## **2. Background Literature**

## *2.1. Age-Friendly Communities*

Since the turn of the millennium, there have been several age-friendly initiatives building on the WHO Global Age-friendly framework [1]. A review conducted by Steels [7] provides a synopsis of global age-friendly cities and frameworks [2,8–12], illustrating their key features. Fitzgerald and Caro [4] presented several features and elements which they deemed necessary to meet the minimum requirements of an age-friendly city or community. These features include pre-conditions that must be in place before any age-friendly initiative can commence. The preconditions include: the density of population, climate, weather, topographical features (communities residing on hills such as the favelas in Brazil), social and civic organisations, health and social care provision [4]. Within diverse communities, ensuring residents have a variety of mobility options is crucial. This includes ensuring the availability of public transport connections, accessible places to walk, and community transport services (e.g., dial a ride). Within these communities, the requirements of outdoor spaces and buildings to facilitate and enable residents to successfully age in place is central to the success of the environment. Early consultations between residents, planners and developers to identify key challenges and potential barriers are crucial to the achievement of all of the above aims. Barriers and challenges may not be identified, challenged and amended without consultations between the residents, planners and developers. Moreover, community activities require that residents respectfully build up their relationships with one another in conjunction with their friends, family and support networks, ensuring residents are respectful of each other [4]. Several approaches such as focus groups, face-to-face meetings, interviews (e.g., one-to-one or community) or surveys can be conducted to identify needs and requirements from residents. It is important to ensure that all interested parties have the opportunity to communicate and share their expectations and concerns.

Buffel [13] has conducted co-researching and co-production activities as part of the Manchester Age-Friendly strategy (MAS) [2]. A significant element in the success of MAS is the enablement of actors to share their experiences and learn from each other about the needs and requirements of their communities. The concept of an 'Age-Friendly Business' has enabled businesses in the community to make alterations to facilitate ease of access or service by residents [4]. Such alterations or changes include: assisted devices to open doors, increasing the font size on menus, and changing the height and access to toilet dispensers [4]. Already, across America and Ireland businesses have undertaken alterations to provide residents with ease of access to the premises or services. Consequently, many businesses increased their income as a result of word-of-mouth approval in the community [4].

In the UK, the city of Manchester was recognized by the WHO as an age-friendly city-region, chosen as part of the age-friendly initiative programme [14]. McGarry and colleagues [2] provide an overview of the two frameworks and approaches set out by the WHO and MAS [15].

The WHO age-friendly strategy includes eight domains of interest: (1) Outdoor spaces and buildings; (2) housing; (3) transportation; (4) social participation; (5) respect and social inclusion; (6) civic participation and employment; (7) communications and information and (8) community support and health services. Primarily, the MAS 2020 age-friendly strategy [15] focuses on six of the eight domains outlined by the WHO and includes: (1) lifetime neighbourhoods (environment, community safety, housing, transport); (2) cross-cutting themes: improving engagement, improving relationships; (3) cross-cutting themes: promoting equality; (4) income and employment; (5) culture and learning, and (6) healthy ageing, care and support services [2].

To date, age-friendly initiatives have primarily focused on the needs and requirements of existing ageing populations. However, there is little consideration and discussion surrounding the needs of mid-older adults (<~45 years old) who are carers of children/young people and dependent adults with disabilities. Furthermore, what are the implications, based on the national and international age-friendly strategies associated to successfully age in place?

The aim of this paper is to review age-friendly virtual assistants and their effect on carers and dependent adults in contemporary society.

#### *2.2. Methods*

This paper will be underpinned by identity theory posited by Burke & Stets [16]. The notion of identity theory posits persons residing in society the opportunity to reserve a stable environment, irrespective of any slight inconsistencies. This is succeeded by the change in peoples' actions, which in turn results in the perceptions of persons aligned with the standard or ideal self [16], while the balance within one's environment shifts based on the deviation or non-verification of a person's identity; this results in a person's modification of their behaviour.

For those parents, guardians and carers who are residing in disability friendly communities and age-friendly environments, they have the opportunity to continue to live alongside their dependent child. This, in turn, has the potential to alleviate stress, social isolation, loneliness, and promote independence for both carers and dependent adults. Giving dependent adults the opportunity to live semi-independently or fully-independently alongside their parents, guardians and carers will contribute to the creation of and dissemination of good practice.

Age-friendly cities can provide harmonious, supportive, inclusive living and social environments regardless of age, race, gender or disability through face-to-face communications, created and supported by technology. Through a myriad of activities, age-friendly cities can help to identify, and tackle problems experienced by the residents, while providing immediate and on-going support for both the carer and the dependent adult. Conversely, by encouraging the opportunities for social encounters and by building upon the existing age-friendly frameworks, there are potential benefits and improved social cohesion for all residents in the wider community.

#### *2.3. Digital Exclusion*

Automation and accessibility of goods and services (e.g., banking, shopping, health care appointments) are increasing, which is resulting in limited access by some populations. According to the UK Government "*Digital inclusion, or rather, reducing digital exclusion, is about making sure that people have the capability to use the internet to do things that benefit them day to day*" [sic] [17]. Moreover, in the UK Government Digital Inclusion Strategy 2014 policy paper, Francis Maude, Minister for the Cabinet Office, stated, "*We need to equip the whole country with the skills, motivation and trust to go online, be digitally capable and to make the most of the internet*" [17].

A worrying phenomenon relates to the continuation of digital exclusion relating to the "vulnerable and disadvantaged groups in society" [17]. The policy identified five groups within society that are most likely to be digitally excluded:


Within existing debates surrounding digital cities, there are vulnerable members of society who are marginalized and penalized because of limited access to and understanding of the digital world. This in turn, has the potential to be a detrimental factor relating to their health and independence.

The digital divide is still an ongoing topic of discussion, which results in many communities, and individuals not being able to access rudimentary technologies such as a computer and/or access the Internet [18–22]. Ferguson and Damodoran [23] reported how the digital divide primarily focuses on the 'haves' and the 'have nots.' However, it also relates to three points that differentiate those who associated with the digital divide. First, connectivity: this relates to appropriate access to equipment. Second, capability: ensuring everyone has the skills and knowledge to conduct tasks and to retrieve relevant information. Finally, content: the perception of relevant content and the *"motivation from the 'pull' of compelling functionality"* (p. 5) [23].

Within the digital divide, digital participation is important for all citizens, be it those who are vulnerable, or who are slow adopters, from the older/elderly person to the wealthiest of individuals. It is important to understand the motivations of digital participation to understand what the barriers are to using technology, and to ensure access and availability is met. Ferguson and Damodoran [24] stated:

"[ . . . ] *widespread digital participation can only come about through the confident and successful take up by older people and others in the digital world and the way that services relevant to their needs are designed and presented*". (p. 5)

The authors believe that by collaborating and communicating with communities at both grassroots networks and with national organisations, there are opportunities to learn and understand the barriers to and enablers of technology faced by older adults and slow adopters. Currently, there is a growth of work in the domains of the digital divide and older adults' engagement. However, there is a paucity of work surrounding those individuals known as 'slow adopters.' This cohort of society are individuals or communities who are not just older people, but who are mid-older and younger people, who may live in social housing; they are people who are unemployed or who are employed on precarious contracts or receive low incomes. They are individuals with disabilities, who reside in different communities both culturally (e.g., traveller) and geographically (e.g., rural), or who are homeless and are moving between towns and cities, or who are moving around different areas within one place, or young people who are not in employment, education or training (NEETs). All of these categories of citizens may have no direct or limited access to public funds [24]. For some citizens, their level of literacy, numeracy and digital literacy skills pose additional barriers to their digital participation.

In January 2019, the NHS (National Health Service) Digital announced the commencement of a project focusing on the use of digital technologies by homeless community outreach workers in Hastings, UK [25]. The project collaborates with several partners including NHS England, NHS Digital, Good Things Foundation and The Seaview project. The aim is to use digital technologies to ensure a suitable approach is conducted by and between support workers/organisations and the homeless community. Physical locations such as libraries can provide public access to rough sleepers who wish to search for specific information (e.g., health and wellbeing centres) on the Internet. However, little work has focused on the barriers and enablers to technology faced by individuals of the homeless communities. Additional issues and challenges can hinder technology use by rough sleepers and include the varying types of data plans, access to charging points for a mobile/smartphone, and possible exclusion from accessing public Wi-Fi. Furthermore, many mobile phone plans require a data contract and bank account, which too could be problematic for rough sleepers who do not have access to this type of information or accounts. There are many reasons why slow adopters and older adults have barriers to adopting and using technology in their lives. This can include embarrassment around their lack of technical knowledge and skills, and the design of technologies, while there could be limited opportunities for learning outside of the workplace [24]. By understanding the needs of marginalized and disadvantaged communities, support and guidance can be offered to ensure individuals within these respective communities can become digital citizens. The UK Government [17] has outlined its digital strategy, although, when it was outlined three years earlier, Adam Hillmore stated:

### *"We should not consider increasing online presence among older people on its own; it is easier to bring people together as a community and to make using the internet part of that"*. (p. 5) [24]

Taking a grassroots approach, as suggested in the quote above should safeguard all voices are heard within respective communities. Ferguson and Damodoran noted that the position of local governments is ideally situated within their communities to take the lead and to facilitate a 'user-driven' approach [24]. Local government is the ideal actor to take the lead role within communities and towns regarding digital participation. Given that local governments own public space and buildings such as libraries, they are ideally placed to input into schools and partnerships. Taking on this role, local governments can encourage their respective networks and partners to become active members across their communities. This, in turn, may link to different initiatives that can also benefit from local government assisting with key issues [26]. Furthermore, understanding the exact needs and requirements of marginalized communities is facilitated by employing a co-design/creation approach rather than a top-down process. Seven needs have been reported by Ferguson and Damodoran [23] based on specific user characteristics:


(7) Offering impartial advices and 'try before you buy' [23,27].

Furthermore, Ferguson and Damodoran argued:

*"The UK Government Digital Strategy (launched 1 March 2017) states that it seeks to simultaneously implement strategies intended to address connectivity issues (with the aim of completing the roll-out of 4G and superfast broadband by 2020) and capability issues (e.g., creating the Digital Training and Support Framework)"*. (p. 6) [26]

Nonetheless, there are concerns that still need to be addressed for rural and marginalized communities, and for those individuals who are slow adopters and older adults. The latter is equally important, because, for many people, they learn how to use technology in the workplace. For those people who have retired and were not exposed to technology, this too will result in limited and low digital participation [26]. Moreover, Ferguson and Damodoran [26], note how evidence indicates *"basic skills training has reached most of those for whom it is appropriate"* (p. 6). However, while basic skills training may benefit some people in society, for those who are slow adopters, it is likely that they have not had the opportunity [26].

Indeed, for many people using technologies to access the digital world, it is an integral part of their daily lives and "*not using the internet is different from 'digital exclusion.' Some non-users have made an informed and reasoned choice to be offline*" (p. 1) [28]. While access to the digital world is available in both public and social spaces, one requires a digital device (i.e., a computer, laptop, smartphone or tablet) to access the Internet, which in turn leads onto other digital worlds. Moreover, the Centre for Ageing Better notes, "*As opposed to digital inclusion operating as a standalone intervention, digital support should be embedded within the delivery model of a range of local community and public services wherever feasible and appropriate*" [28]. With on-going austerity and cuts to public services, it is of paramount importance that local and national governments do not marginalize and penalize vulnerable members of society further.

Mouland, Richardson and Damodoran [28] stated "*Even for those who are engaged with existing technologies, the pace at which technology develops places significant demands on us to learn new behaviors and skills. Those who were raised in a digital world will still hit these obstacles over time and find new technologies harder to adopt—particularly after leaving the workforce*" (p. 6) [28].

#### **3. Technology Solutions**

Phenomenal technology developments have occurred over the last twenty years in the field of enabling industries (i.e., video games, smartphone and small, medium enterprises (SME)) the opportunity to design, develop and enhance solutions to reach a broad spectrum of users in society.

In the proceeding section, the authors will review different technologies, ICTs and contemporary research projects aimed to facilitate and enhance users' accessibility and ease of use, to support successful ageing in place through active and healthy ageing (AHA).

#### *3.1. Overview of Virtual Assistants*

In recent years, we have seen the development of what is been coined as 'personal assistants' or 'virtual assistants,' designed in the form of 'speakers' that can be placed around the house and respond to a voice(s), which in turn executes the command(s). The most commonly known devices are smart speakers/personal assistants such as the Amazon Echo or Alexa [29,30]. There are other devices with similar capabilities known as Google Home and Google Home Mini. Contemporary research has suggested these 'personal assistants' can offer older adults the ability to maintain living independently, and possibly support ageing in place. Indeed, according to the National Institute for Health Research (NIHR), "*A number of studies have explored integrated monitoring and response systems to check the health, wellbeing and safety of older people living at home. Some of these are focused on particular groups, like those with dementia. They range from systems using sensors, alarms or wearable technology to cameras, smart televisions and service robots*" [31] (p. 3).

Therefore, the functionality of these virtual or personal assistants can provide a user with a wealth of information (e.g., weather reports, checking events in a calendar), coupled with the ability to control their heating and lighting on or off via three automation and third-party apps.

Additional features available through the virtual assistants offer users the opportunity to control what music they listen to (via streaming services), set and manage alarms, order food (e.g., Domino's or Pizza Hut) and set reminders (e.g., for medication) [17–23,32–41]. Homes which have 'home automation' virtual assistants have the capacity to interact and connect with several manufacturers, including Philips Hue and Nest [39–41].

Some existing users of Alexa say they feel a strong bond with their virtual assistant and perceive their devices as a member of the family [30,41]. The notion of using Alexa and similar devices or virtual assistants within the home can offer the users or residents a multitude of opportunities to engage and receive information. Whether you are an older adult, a carer or a dependent adult, there are opportunities to age in place by connecting with these types of devices through the primary interaction of voice recognition.

Early adoption of new technology is key. For many people in society, learning how to use a new piece of technology can be worrisome or a steep learning curve [42]. Nevertheless, for some people it is crucial that the technical infrastructure allows several devices to seamlessly operate together, in order to deliver an automated, self-monitoring smart home [43–46].

Li and colleagues [44] proposed the notion of neighbourhoods being connected via wireless sensors, which, if triggered through deviant activity, can be recorded via surveillance cameras, which in turn would inform all residents connected on the smart system. This follows the original conception of the 'Neighbourhood Watch' scheme across the UK, where residents involved in the scheme reported any suspicious behaviour or crime to the police. A 'smart, connected,' age-friendly and disabled-friendly community gives residents the potential to detect problems and protect one another.

#### *3.2. Integrating Virtual Assistants into the Lives of Carers and People with Disabilities*

While research concerning virtual assistants is still in its infancy, these devices have great potential for people with a multitude of disabilities. For example, Hampshire County Council trialled the Amazon Echo to help both the elderly and disabled [47,48] people in their communities. Similarly, Virgin Trains have integrated Alexa to assist disabled passengers [49] with their communication and interactions. Several factors affect dependent adults (e.g., physical, cognitive, speech and visual impairments). These include low self-esteem and confidence and limited social networks, which in turn increase their risk of loneliness, poor health and wellbeing. In some instances, one's disability may fluctuate throughout one's life, and may deteriorate over time. Therefore, the use of virtual assistants (Amazon Echo, Alexa, Google Home and Google Home mini) can offer dependent adult's additional options to communicating with friends and family members, more so than only participating in dialogue when a specific answer is needed.

Devices including Amazon Echo, Alexa, Google Home and Google Home mini provide individuals with disabilities the opportunity to communicate with the device and respond to commands. One example of a disability that may affect an individual's communication (i.e., speech and language) is autism spectrum disorder (ASD). Many individuals who have been diagnosed with ASD require an intervention focusing on the "*aspects involved in producing or understanding speech and language*" [50]. The use of these devices may initially cause frustration for the individual, given the initial inability of the device(s) to decipher speech. However, one of the benefits of virtual assistants is the potential to help improve speech.

An example of this is demonstrated in the written account of Megan D, who reflected on her six-year-old, disabled son, and who used the virtual assistant Alexa. Megan D noted how her son communicates and connects with people through a series of questions that fall into his areas of interest. Regardless of whether the son has asked these questions earlier on in the day or in previous days, the use of Alexa is the primary way for the son to connect and communicate [51]. Since purchasing the

Alexa device, Megan D has observed changes in her son. Typically, through repetition of questions, Megan D's son regularly engages in conversations with the Alexa device. However, it is the virtual assistant's capacity to answer the son's repetitive questions on demand that has improved the quality of life of Megan D and her son. Furthermore, the ability to recognize different voices and language patterns makes this type of virtual assistant an ideal companion for many individuals with ASD.

The use of virtual assistants can be beneficial to individuals who have been diagnosed with a neuro-degenerative condition such as multiple sclerosis (MS). Hampshire County Council, in conjunction with NHS Digital, have launched a scheme which explores the integration of the Alexa device into adult service care plans. For example, Claire Williams, who has been diagnosed with MS, was one of the recipients of these virtual assistants. Williams notes "*I can do loads of things for myself now which when I was first diagnosed with MS seven years ago, I didn't think I'd be able to do.*" Furthermore, Williams has reported positive improvements within her life due to the integration and use of the Alexa virtual assistant. Williams has used the device for many things, including turning on the lights, playing music, reading books and adding items to the shopping list, which is on her husband's phone [52].

Likewise, Bogost shares his experiences of using Alexa with his 82-year-old father, who is legally blind and has been since the age of 18. Bogost notes how the virtual assistant offers a "*hands-free operation for able-bodied folk and new accessibility for those with limited mobility or dexterity*" [53]. Furthermore, Bogost [53] recognises his father's willingness to embrace the new technology, for example, using it playfully by asking the virtual assistant a series of questions he knows it cannot answer.

While we have focused on the use and installation of virtual assistants in the home and an age-friendly environment, there are further opportunities for bringing ageing and disability together. These opportunities do not just safeguard against social disconnectedness, reduce isolation, and improve communication, but also ensure physical and cognitive fitness can be maintained, therefore demonstrating how ICT can help an AHA be achieved. There have been several key pieces of research that have integrated technology investigating both physical and cognitive activities. In the following section, we provide an overview of contemporary research that has the potential to offer older adults, carers and dependent adults the opportunity to engage and interact with the technologies aimed at enhancing AHA and intergenerational relationships.

#### *3.3. Overview of Exergames*

The iStoppFalls (ISF) European Union (EU) Project [54] was an international, multi-centre study, which included a single-blind, two-group randomized control trial (RCT) involving 160 community-dwelling older adults aged 65 years and over [55]. ISF aimed to design and develop information, communication and technology (ICT) based systems using physical activity to reduce the risk of falling by adults aged 65 years and over. Additionally, strength and balance exercises were conducted via user interaction and engagement with three purpose-built exergames. Gschwind and colleagues [55–57] describe the ISF ICT-based system, which was comprised of several types of technologies (Figures 1 and 2). The ISF system offered users a diverse range of interactive approaches (Figure 3), including gesture, a remote control, speech and a tablet device. Participants randomized to the intervention group (IG) had access to the ISF system through several menu options (Figure 4). These included: fitness training, reviewing user performance, meeting point (for example, virtual meeting place for all users), falls and health prevention.

Three purpose-built exergames were designed, developed and implemented into the ISF system. Marston and colleagues [57,58] provide an extensive overview of the purpose-built exergames: the Bumble Bee Park, Hills 'n' Skills and The Bistro exergames (Figure 5). Each exergame incorporated strength and balance exercises from the Otago programme [58], while additional Otago exercises (Figure 6) were integrated into the system under the 'training programme' option. Therefore, users were able to continue building their strength and balance in conjunction with the exergames.

(**4**) tablet.

comfortable-bipedal, semi-tandem, near-tandem and the tandem stance [55–57]. Participants were required to undertake the balance assessments twice for a maximum of 30 seconds each, leading with their preferred foot. Participants were instructed not to change their preference (foot) in between stances and to keep their eyes open. Reaction time was integrated and assessed in the ICT system through hand and foot reaction times for each respective participant. This was calculated by hitting

comfortable-bipedal, semi-tandem, near-tandem and the tandem stance [55–57]. Participants were required to undertake the balance assessments twice for a maximum of 30 seconds each, leading with their preferred foot. Participants were instructed not to change their preference (foot) in between stances and to keep their eyes open. Reaction time was integrated and assessed in the ICT system through hand and foot reaction times for each respective participant. This was calculated by hitting

*Healthcare* **2019**, *7*, x 9 of 22

the green button (when highlighted) on the table or on the floor of the virtual environment [55].

the green button (when highlighted) on the table or on the floor of the virtual environment [55].

The ISF RCT concluded that the ICT-based system did reduce the physiological fall risks of older

The ISF RCT concluded that the ICT-based system did reduce the physiological fall risks of older

adults aged 65 years and over that were living in their own home. Participants assigned to the

adults aged 65 years and over that were living in their own home. Participants assigned to the intervention group showed greater adherence and an improvement in postural sway, step reaction

**Figure 1.** The different technologies integrated into the iStoppFalls ICT-based system. (Permission granted by the Dr Rainer. Wieching—PI, [57].) (**1**) Set top box (iTV), (**2**) mini-PC (exergame), (**3**), Kinect (gesture/voice), (**4**) Senior Mobility Monitor, (**5**) tablet (diary, control). **Figure 1.** The different technologies integrated into the iStoppFalls ICT-based system. (Permission granted by the Dr Rainer. Wieching—PI, [57].) (**1**) Set top box (iTV), (**2**) mini-PC (exergame), (**3**) Kinect (gesture/voice), (**4**) Senior Mobility Monitor, (**5**) tablet (diary, control). granted by the Dr Rainer. Wieching—PI, [57].) (**1**) Set top box (iTV), (**2**) mini-PC (exergame), (**3**), Kinect (gesture/voice), (**4**) Senior Mobility Monitor, (**5**) tablet (diary, control).

**Figure 1.** The different technologies integrated into the iStoppFalls ICT-based system. (Permission

**Figure 2.** The different modes of interaction available to users of the iStoppFalls ICT-based system. (Permission granted by the Dr Rainer Wieching—PI, [57]). (**1**) Remote control, (**2**) gesture, (**3**) voice or **Figure 2.** The different modes of interaction available to users of the iStoppFalls ICT-based system. (Permission granted by the Dr Rainer Wieching—PI, [57]). (**1**) Remote control, (**2**) gesture, (**3**) voice or (**4**) tablet. **Figure 2.** The different modes of interaction available to users of the iStoppFalls ICT-based system. (Permission granted by the Dr Rainer Wieching—PI, [57]). (**1**) Remote control, (**2**) gesture, (**3**) voice or (**4**) tablet.

PI, [57]).

measure displayed user acceptance of the ISF system to be acceptable.

To understand the usability, user experience and acceptance of technologies within the ISF purpose-built system, Vaziri and colleagues [59] deployed the System Usability Scale (SUS) [60], the Physical Activity Enjoyment Scale (PACES) [61] and the Dynamic Acceptance Model for the Reevaluation of Technologies (DART) [62], coupled with interviews and observations of participants. The results showed the ISF ICT-based system to have an overall score of 62 out of 100, indicating

To understand the usability, user experience and acceptance of technologies within the ISF purpose-built system, Vaziri and colleagues [59] deployed the System Usability Scale (SUS) [60], the Physical Activity Enjoyment Scale (PACES) [61] and the Dynamic Acceptance Model for the Reevaluation of Technologies (DART) [62], coupled with interviews and observations of participants. The results showed the ISF ICT-based system to have an overall score of 62 out of 100, indicating

*Healthcare* **2019**, *7*, x 10 of 22

**Figure 3.** The different menu options available to users in the iStoppFalls ICT-based system. (Permission granted by the Dr Rainer Wieching—PI, [57]). (1). Page header. (2) Training: The area of training. The user can exercise or determine their risk of falling. (3) Performance: The user can view their feedback and results. (4) Meeting Point: The user can communicate with other users who use the system. (5) Falls & Health: The area of learning, educational material and information on fall risks in everyday life, and how to reduce this risk. (6) Gesture and Voice Recognition: Two buttons to activate the gesture and/or voice control. (7) Change User: The user can either log out of the program or start with a different user account. (8) Help: The user can find help in this section for the most common problems and how to use the system. **Figure 3.** The different menu options available to users in the iStoppFalls ICT-based system. (Permission granted by the Dr Rainer Wieching—PI, [57]). (1). Page header. (2) Training: The area of training. The user can exercise or determine their risk of falling. (3) Performance: The user can view their feedback and results. (4) Meeting Point: The user can communicate with other users who use the system. (5) Falls & Health: The area of learning, educational material and information on fall risks in everyday life, and how to reduce this risk. (6) Gesture and Voice Recognition: Two buttons to activate the gesture and/or voice control. (7) Change User: The user can either log out of the program or start with a different user account. (8) Help: The user can find help in this section for the most common problems and how to use the system. **Figure 3.** The different menu options available to users in the iStoppFalls ICT-based system. (Permission granted by the Dr Rainer Wieching—PI, [57]). (1). Page header. (2) Training: The area of training. The user can exercise or determine their risk of falling. (3) Performance: The user can view their feedback and results. (4) Meeting Point: The user can communicate with other users who use the system. (5) Falls & Health: The area of learning, educational material and information on fall risks in everyday life, and how to reduce this risk. (6) Gesture and Voice Recognition: Two buttons to activate the gesture and/or voice control. (7) Change User: The user can either log out of the program or start with a different user account. (8) Help: The user can find help in this section for the most common problems and how to use the system.

**Figure 4.** The three purpose-built exergames (a. Hills 'n' Skills, b. The Bistro and c. Bumble Bee Park) integrated into the iStoppFalls ICT-based system. (Permission granted by the Dr Rainer Wieching— **Figure 4.** The three purpose-built exergames (a. Hills 'n' Skills, b. The Bistro and c. Bumble Bee Park) integrated into the iStoppFalls ICT-based system. (Permission granted by the Dr Rainer Wieching— **Figure 4.** The three purpose-built exergames ((**a**) Hills 'n' Skills, (**b**) The Bistro and (**c**) Bumble Bee Park) integrated into the iStoppFalls ICT-based system. (Permission granted by the Dr Rainer Wieching—PI, [57]).

PI, [57]). Fall risk assessment was integrated into the ICT-based system, which enabled users to be initially assessed and included a physical assessment using the purpose-built software, the Microsoft Kinect console and the Senior Mobility Monitor (SMM) developed by Philips Netherlands [55,57]. Four physical assessments were conducted between the user and the integrated sensors which in turn enabled interaction via the user's television. The assessments included several balance tests: comfortable-bipedal, semi-tandem, near-tandem and the tandem stance [55–57]. Participants were required to undertake the balance assessments twice for a maximum of 30 s each, leading with their preferred foot. Participants were instructed not to change their preference (foot) in between stances and to keep their eyes open. Reaction time was integrated and assessed in the ICT system through hand and foot reaction times for each respective participant. This was calculated by hitting the green button (when highlighted) on the table or on the floor of the virtual environment [55].

The ISF RCT concluded that the ICT-based system did reduce the physiological fall risks of older adults aged 65 years and over that were living in their own home. Participants assigned to the intervention group showed greater adherence and an improvement in postural sway, step reaction and executive function [56].

*Healthcare* **2019**, *7*, x 11 of 22

**Figure 5.** The different Otago exercises integrated into the iStoppFalls ICT-based system. (Permission granted by the Dr Rainer Wieching—PI, [57]). (**a**) Knee extension, (**b**) knee flexion, (**c**) leg abduction, (**d**) toe raises, (**e**) calf raises. There is a demonstration via the icon on the bottom right hand side of the screen. On the right side of the screen, the users are able to see themselves on the television screen. The four buttons at the bottom of the screen (pause, instructions, tips, and abort) can be selected by **Figure 5.** The different Otago exercises integrated into the iStoppFalls ICT-based system. (Permission granted by the Dr Rainer Wieching—PI, [57]). (**a**) Knee extension, (**b**) knee flexion, (**c**) leg abduction, (**d**) toe raises, (**e**) calf raises. There is a demonstration via the icon on the bottom right hand side of the screen. On the right side of the screen, the users are able to see themselves on the television screen. The four buttons at the bottom of the screen (pause, instructions, tips, and abort) can be selected by the users to execute the command.

the users to execute the command. *3.4. MobiAssist Project* The MobiAssist project (2015–2018) proceeded the iStoppFalls Project and aimed to explore the social impacts of the ICT-based suite of exergames aimed at people with dementia and their caregivers. Over a period of eight months, researchers used a co-design approach, while observing To understand the usability, user experience and acceptance of technologies within the ISF purpose-built system, Vaziri and colleagues [59] deployed the System Usability Scale (SUS) [60], the Physical Activity Enjoyment Scale (PACES) [61] and the Dynamic Acceptance Model for the Re-evaluation of Technologies (DART) [62], coupled with interviews and observations of participants. The results showed the ISF ICT-based system to have an overall score of 62 out of 100, indicating good usability, with most users enjoying the ISF exergames. The PACES measure and the DART measure displayed user acceptance of the ISF system to be acceptable.

#### the daily lives of informal and professional caregivers of 14 people who had been diagnosed with dementia [63,64]. Conducting a co-design approach enabled the research team to gain insights into *3.4. MobiAssist Project*

*possible*" [64].

the daily routines of the participants' and their caregivers, coupled with biographical backgrounds, memories, social environment and recording their experiences, attitudes and practices of using technology [64]. Participants were aged between 72–89.6 years, comprising six females and eight males [65]. The MobiAssist project (2015–2018) proceeded the iStoppFalls Project and aimed to explore the social impacts of the ICT-based suite of exergames aimed at people with dementia and their caregivers. Over a period of eight months, researchers used a co-design approach, while observing the daily lives of informal and professional caregivers of 14 people who had been diagnosed with dementia [63,64]. Conducting a co-design approach enabled the research team to gain insights into the daily routines

The contents of the MobiAssist system include several digital technologies, software and purpose built exergames (Figure 6) [63,64]. The MobiAssist ICT-based system contains

of the participants' and their caregivers, coupled with biographical backgrounds, memories, social environment and recording their experiences, attitudes and practices of using technology [64]. *Healthcare* **2019**, *7*, x 12 of 22

**Figure 6.** An overview of the MobiAssist ICT-based system and the technological components. (Permission granted by David. Unbehaun [63,64]). **Figure 6.** An overview of the MobiAssist ICT-based system and the technological components. (Permission granted by David. Unbehaun [63,64]).

The MobiAssist project includes a series of strength and balance training exercises (Figure 7) from the Otago Exercise Program (OEP) [66], similar to the ISF ICT-based system [63,64]. The strength training exercises from the OEP enable users to strengthen their upper and lower limb muscles, using knee extensions, knee bends, sideways leg raises, toe-stands, the elbow bends and front raise aimed at the shoulder muscles [63,66]. The exergames aim to enhance and improve the balance and Participants were aged between 72–89.6 years, comprising six females and eight males [65]. The contents of the MobiAssist system include several digital technologies, software and purpose built exergames (Figure 6) [63,64]. The MobiAssist ICT-based system contains exercises and exergames enabling users' performance to be measured and aims to "*counteract the progression of dementia and to help people with dementia to remain as autonomous as possible*" [64].

coordination of the participants [64]. Figure 8 left displays a visual representation of some of the games that are implemented into the MobiAssist project. A brief description of some of the games include: the 'Apple game,' which requires participants to collect virtual apples from a tree and place them into a basket; the 'Mole game,' which requires the participants to hit moles when they pop up from the ground at intermittent times. Participants' engaging with the 'Mole game,' requires the user to move sideways and move forward (take steps) to hit the mole [64]. An additional game (Figure 8, left) is the 'Wheel of Fortune,' which requires the The MobiAssist project includes a series of strength and balance training exercises (Figure 7) from the Otago Exercise Program (OEP) [66], similar to the ISF ICT-based system [63,64]. The strength training exercises from the OEP enable users to strengthen their upper and lower limb muscles, using knee extensions, knee bends, sideways leg raises, toe-stands, the elbow bends and front raise aimed at the shoulder muscles [63,66]. The exergames aim to enhance and improve the balance and coordination of the participants [64]. Figure 8 left displays a visual representation of some of the games that are implemented into the MobiAssist project.

participants to raise their hands and spin the wheel. This game is aimed at problem solving and cognitive tasks such as letter games, mental arithmetic, classification and completion of rhymes, verses and poems or remembering music titles [64]. The second game, displayed in Figure 8, right, is based on folk music, and, while the participant marches on the spot, the music continues to play. However, if the participant stops marching on the spot, the music gradually fades out. If the participant wants to continue listening to the music, they have to restart marching on the spot [64]. MobiAssist project reported several limitations, including the different settings and system issues experienced by participants. For example, there were issues surrounding the Kinect recognition by participants, relatives or caregivers who were standing too close to the camera. There was an in/exclusion criterion to assist with the recruitment of participants and their support network(s). In order to ensure coherent recruitment, process a mediator (care institution) was A brief description of some of the games include: the 'Apple game,' which requires participants to collect virtual apples from a tree and place them into a basket; the 'Mole game,' which requires the participants to hit moles when they pop up from the ground at intermittent times. Participants' engaging with the 'Mole game,' requires the user to move sideways and move forward (take steps) to hit the mole [64]. An additional game (Figure 8, left) is the 'Wheel of Fortune,' which requires the participants to raise their hands and spin the wheel. This game is aimed at problem solving and cognitive tasks such as letter games, mental arithmetic, classification and completion of rhymes, verses and poems or remembering music titles [64]. The second game, displayed in Figure 8, right, is based on folk music, and, while the participant marches on the spot, the music continues to play. However, if the participant stops marching on the spot, the music gradually fades out. If the participant wants to continue listening to the music, they have to restart marching on the spot [64].

involved in the recruitment procedure between the respective participants and the research team. Furthermore, conducting interviews with participants who had been diagnosed with dementia was difficult at times, in particular engaging with the MobiAssist ICT-based system. Therefore, participants were limited in their ability to provide the research team with "*meaningful and informative answers, largely because of the deterioration of their cognitive and communicative resources and capabilities*" [64]. MobiAssist project reported several limitations, including the different settings and system issues experienced by participants. For example, there were issues surrounding the Kinect recognition by participants, relatives or caregivers who were standing too close to the camera. There was an in/exclusion criterion to assist with the recruitment of participants and their support network(s). In order to ensure coherent recruitment, process a mediator (care institution) was involved in the recruitment procedure between the respective participants and the research team. Furthermore, conducting interviews with participants who had been diagnosed with dementia was difficult at times, in particular engaging with the MobiAssist ICT-based system. Therefore, participants were limited in their ability to provide the research team with "*meaningful and informative answers, largely because of the deterioration of their cognitive and communicative resources and capabilities*" [64].

*Healthcare* **2019**, *7*, x 13 of 22

**Figure 7.** Integrated assessments in the MobiAssist ICT-based System. (Permission granted by David. Unbehaun) 65]. **Figure 7.** Integrated assessments in the MobiAssist ICT-based System. (Permission granted by David. Unbehaun) [65].

*Healthcare* **2019**, *7*, x 14 of 22

**Figure 8. (Left)** displays the strength and balance Park, Apple and Mole exergames. (**Right)** displays the Wheel of Fortune and Music/walking on the spot exergames. (Permission granted by David. Unbehaun) [64]. **Figure 8.** (**Left**) displays the strength and balance Park, Apple and Mole exergames. (**Right**) displays the Wheel of Fortune and Music/walking on the spot exergames. (Permission granted by David. Unbehaun) [64].

Both the iStoppFalls and MobiAssist ICT-based systems have the potential to offer carers and dependent adults the opportunity to engage and socially connect with friends, family members and with each other. The technology infrastructure will be a key concern (e.g., cost of Internet connection) for some people, highlighting the very essence of the digital divide. The MobiAssist project shows that there is potential to enhance social interaction and increase empowerment using serious games, and simultaneously build intergenerational relationships between the carer and the individual. For example, the research team concluded that the MobiAssist system has a positive trend to "*support*  Both the iStoppFalls and MobiAssist ICT-based systems have the potential to offer carers and dependent adults the opportunity to engage and socially connect with friends, family members and with each other. The technology infrastructure will be a key concern (e.g., cost of Internet connection) for some people, highlighting the very essence of the digital divide. The MobiAssist project shows that there is potential to enhance social interaction and increase empowerment using serious games, and simultaneously build intergenerational relationships between the carer and the individual. For example, the research team concluded that the MobiAssist system has a positive trend to "*support workflows and thus improve institutionalized quality of care*" [64].

*workflows and thus improve institutionalized quality of care*" [64]. Within an age-friendly environment, older carers and disabled people can connect and share experiences with one another. The technology solutions discussed in the previous section offer users across different age cohorts the motivation and opportunity to interact with both young and older cohorts. This, in turn, has the potential to reduce the risk of social isolation and enhance social Within an age-friendly environment, older carers and disabled people can connect and share experiences with one another. The technology solutions discussed in the previous section offer users across different age cohorts the motivation and opportunity to interact with both young and older cohorts. This, in turn, has the potential to reduce the risk of social isolation and enhance social connectedness, offering enhanced engagement, communication and ensuring the AHA mandate is achieved.

connectedness, offering enhanced engagement, communication and ensuring the AHA mandate is achieved. Conversely, within the home environment and/or community, the notion of ageing-in-place can in some instances require assistance from younger adults of the family or community. Thus, integrating an intergenerational approach within an age-friendly environment has many positive benefits from the perspectives of both younger and older generations. These benefits include learning Conversely, within the home environment and/or community, the notion of ageing-in-place can in some instances require assistance from younger adults of the family or community. Thus, integrating an intergenerational approach within an age-friendly environment has many positive benefits from the perspectives of both younger and older generations. These benefits include learning and sharing knowledge and experiences, caring opportunities for those who have fallen due to short, medium- and long-term illness, enhancing and build upon one's social skills, and enhancing social connectedness,

which created a program located in Illinois, U.S., "*where children adopted from foster care can find permanent homes and develop intergenerational relationships in a specially designed community*" [67] (p. 48).

and sharing knowledge and experiences, caring opportunities for those who have fallen due to short,

which in turn will result in a decrease of social isolation. Steels [7] examines the Generations of Hope Community (GHC) [65], a non-profit organisation and social welfare agency, which created a program located in Illinois, U.S., "*where children adopted from foster care can find permanent homes and develop intergenerational relationships in a specially designed community*" [67] (p. 48).

Hope Meadows is a neighbourhood located two hours outside of Chicago. It became the first community planned by GHC and aimed "*to improve the service delivery and policies of the child welfare system; it ended up helping not only foster and adopted children but senior citizens as well.*" (p.18) [68].

Marc Freedman stated, "*The story of Hope Meadows offers not only a vision for how we can help take care of some of the most vulnerable young people in the society—foster children who essentially have nowhere else to turn—but how we can create neighborhoods that enrich the lives of all ages.*" (2001) [67].

At GHC, there are at least three generations residing in the environment—older adults, families and young people, facilitating a capacity to ensure care and support is available for the residents. By integrating an intergenerational approach into the environment, it can offer different generations of residents living within this type of environment an opportunity to undertake caring responsibilities, whereby the younger residents (e.g., children/teenagers) can understand the ethos of giving and receiving care in the future [68]. Through this social cohesion, each generation facilitates and teaches the others the different complexities, issues, needs and requirements which are significant to them, while learning from one another.

The approach undertaken at GHC enables older adults "*who do not want retirement to mean the end of their productive years, who want it to mean something more than a pension, health care, and a roof over their heads*" [68] (p. 51).

This concept facilitates a myriad of individuals and families to live together in one community, serving a purpose for all residents. Utilizing the theoretical approach of identity theory purported by Burke and Stets [16] in the age-friendly home and framework, it offers the residents the opportunity to take on the role of carer. In particular, Hope Meadows facilitates older residents to re-establish identities and roles previously held in society and their respective communities. For some older residents in Hope Meadows, they have the opportunity to feel needed and/or useful through the eyes of the parents of young children as a knowledgeable friend or community member. In some instances, for the older residents, having the younger residents in the community who may need assistance or care will provide the older person a sense of purpose. This notion also offers co-residents the opportunity to share knowledge and experiences, thus resulting in a learned environment; thus, intergenerational relationships are encouraged and fostered through the differing roles and identities forming and reforming within this age-friendly community.

#### **4. Discussion**

This paper has presented an initial overview of the different types of virtual assistant currently available on the market and how these devices can be integrated into existing age-friendly framework(s), coupled with the integration of technology, which to date has not been a focal point of contemporary age-friendly initiatives. This paper sets the scene for initial discussion combining two popular societal domains that are worth exploring further. This review paper uniquely draws together the small volume of literature from the fields of gerontology, gerontechnology, human computer interaction (HCI) and disability. Furthermore, evidence of worldwide ageing populations and the phenomenal developments of technology, in conjunction with the needs of local and national governments, means that alternative solutions are required to address the concerns of citizens ageing-in-place, be it from the standpoint of an older person or a parent/guardian of a dependent person. This paper contributes to—and is at the intersection of—the fields of gerontology, HCI and disability. Consequently, it offers insights into further discussions in the age-friendly and technology [69] domains.

In the context of older and dependent adults, contemporary evidence illustrates a myriad of opportunities for developers, researchers, health and social care practitioners, older carers and their young dependent children/adults so they can live together, in an environment that is familiar, safe and adaptable to the varying and changing needs of both.

Despite an increase in evidence, there is still a lack of understanding of the barriers and enablers to the take-up of technology by older adults, their support networks and healthcare practitioners. Given the nature of preventative healthcare technology and the potential influences it has in day-to-day activities, there is the self-perception and assumption that technology is not suitable for carers, marginalized and vulnerable communities, dependent adults and children, commonly based on their identification as being frail and/or lacking experience/understanding. Therefore, there is a need to improve understanding of the importance of planning and prevention at an early stage. Moreover, we need to demonstrate and highlight the benefits of technology in one's life, family environment and across communities, who may, in turn, want to use technology to enhance their intergenerational experiences and relationships. The intergenerational exchange of knowledge and experiences can be shared and passed on to younger people. At the same time younger people can facilitate a sense of meaning and purpose for older adults. These shared experiences and community involvement can offer and identify specific meanings to all residents, who may have several identities and roles within the family, community, local area and community groups [16]. Burke and Stets [16] purport that a person's myriad identities are interconnected through their respective behaviour(s), feelings, judgements and sentiments, which are influenced and integrated through identity and society. Identity is associated with one's role in society or community—this could be through their profession, being a member of a community group (e.g., church, organisation) or network. Each identity has its own characteristics and expectations associated with the respective identity, resulting in one's expectations being integral in the transformation of powerful stereotypes [16].

The authors have discussed the use of virtual/personal assistants such as Alexa, Echo and Google Home. This type of technology offers users across society a variety of options and support in their day-to-day tasks. For example, a British man who has cerebral palsy uses his virtual assistant to ensure he is able to get in and out of bed safely [70]. Connecting the virtual assistant to a light bulb in the bedroom and speaking the correct commands (i.e., switch light on/off) can offer a person enhanced safety (reducing the risk of falling) and independence. This type of support or assistance ensures a user who suffers from a disability, chronic health or life-limited condition the dignity, power and control over his or her own life. While it is still necessary for carers and support networks to assist individuals with deliberating conditions, virtual and personal assistants seem to offer users greater control.

Ferguson and Damodoran [23,24,26] have discussed and highlighted the needs and requirements of grassroots networks surrounding the issues and concerns of the digital divide, while offering and proposing solutions to local and national governments. Several recommendations include taking a 'user pull' approach rather than a top-down approach, to enhance and offer greater opportunities to communities and marginalized communities. The suggested 'user pull' approach encompasses 15 characteristics, including individuals who are community-based and trusted, drop-in sessions, user centred practice enabling individuals to choose and set their own learning pathways, no demands or assessments placed on the individual(s), and peer-to-peer learning. While fostering this type of physical space, additional benefits are offered to users, including flexibility, which in turn enables users to try new technologies without experiencing pressure from others (for example, sales/retail assistants). Furthermore, by offering a safe, approachable, flexible and peer-to-peer learning space, users' fears and anxieties regarding learning new technologies are reduced. Similarly, this type of physical space is paramount for individuals in the homeless community who wish to seek health information and advice [25].

Using and engaging with a virtual assistant may facilitate the dependent adult to have an identity and role within their environment, where previously this may not have been the case or may have been very limited. From the standpoint of the carer, this may provide a greater sense of freedom, knowing this virtual assistant has the capabilities to offer their dependent adult or child more confidence to conduct different activities. Moreover, the use and deployment of smart home devices, wearable

devices and communication tools such as virtual assistants can offer ageing carers and dependent adults the option to monitor their daily activities, their wellbeing and their quality of life. Additionally, this form of technology can offer inter-generational support, resulting in the perception of the role and identity of a person to be positive, an authority figure role within the family, peer group(s) or community group(s) as a tech-savvy dyad [16]. However, little is known about the use and impact of technologies and the positive benefits of deploying virtual assistants into the lives of ageing carers and dependent adults on a day-to-day basis. This is also the case with the age-friendly framework, and in ascertaining whether one or both actors can age-in-place in their respective communities when faced with the barriers and enablers of being digitally connected or disconnected.

#### **5. Recommendations and Thoughts**

Future work should incorporate technology being tested and used in real-life settings, with dependent adults, their carers and support networks. Additional investigations should seek to include health practitioners to examine their perspectives and impact of virtual assistants within their role(s) and identity within the community.

Concomitantly, the cost-effectiveness of virtual assistants and associated technologies needs to be explored and taken in to account. This would not solely relate to purchasing of technology, but also the integration of technology into new construction projects (e.g., housing) and infrastructure [17,28]. Contemporary research and policy briefings show few or no evidence-based recommendations associated with the cost of installing the Internet, and this should be evaluated for both short-term and long-term adherence, focusing on a cost–benefit analysis to ascertain whether the cost implications outweigh the benefits of integrating the technology into the lives of older adults. For some actors, there is a perception that a piece of technology is a luxury or an unnecessary bill, which in turn may outweigh the benefits and take-up. For users on a low income, whose income may already be stretched, the added necessity of an Internet bill may not be an incentive or motivation to invest, regardless of the potential benefits.

Greater exploration is needed to examine the barriers and enablers of technology associated with existing carers and people diagnosed with diverse disabilities. This work has the potential to ascertain the impact that such technology has or may have on successful ageing and ageing-in-place. Therefore, conducting this examination would reveal myriad perceptions and impacts associated with technology, home automation and the issues associated with this integration and use.

Across the healthcare sector, services are aiming to be more cost-effective, and technology has the potential to offer alternative solutions (e.g., Skype consultations/appointments). However, the paucity of evidence from the standpoint of the health practitioner demonstrates the need for this area to be explored. Coupled with health provisions, it is necessary to ensure local and national policymakers are informed of contemporary evidence to safeguard and ensure that community and national infrastructure is available to deliver digital solutions to all members of society. It is particularly important for networks and communities at a grassroots level to have an input and voice. Previously, policy briefings have been given at the Northern Irish Assembly [71,72] in Belfast that demonstrate how contemporary research can be used to inform policymakers and community actors who can make a difference at the local government level, and who represent their respective communities.

In the context of age-friendly environments, the GHC Hope Meadows environment illustrates the positivity and benefits of intergenerational residents residing in one environment. Therefore, the use and deployment of smart home devices, wearable devices, and communication tools offer residents in this type of environment or their respective digital eco-system the option to monitor their health and wellbeing, their daily activities, and also that of their neighbours.

Contemporary evidence and work surrounding age-friendly frameworks has made great strides [69], yet, there is still a paucity of work on understanding of the impact technology can have on the physical space of a home, shared community or outdoor space. Future work should consider exploring the age-friendly agenda in conjunction with technology, taking on board the suggestions posed by Ferguson and Damodoran [23,24,26] to take a 'user pull' approach, furthering previous initiatives and ensuring local governments can support volunteers through the provision of physical space, advice and need in order to support those who are vulnerable, slow adopters or who are homeless.

#### **6. Conclusions**

This review paper is significant because it draws on the work from the fields of gerontology, HCI and age-friendly framework(s). Based on the evidence, there is a paucity of current debates focusing attention on the power technology can have within and across age-friendly cities and communities. This is particularly the case for those individuals who are carers in later life to dependent adults.

Furthermore, this paper brings together a myriad of domains to discuss contemporary issues surrounding individuals and communities of the 21st century society. While there are phenomenal technological developments occurring through artificial intelligence (AI), interaction (e.g., gesture, voice) and engagement, it cannot be ignored that there are still concerns surrounding access and digital participation.

To alleviate and close the gap of the digital divide requires substantial work relating to and focusing on communication and co-production from all directions of society. This would require groups including local and national governments, education providers, charities, architects, construction, families, and generational cohorts and businesses to collaborate together and move this agenda forward. Circulating strategies are not productive when the needs of the most vulnerable or marginalized communities are not met. Ensuring the infrastructure of a city/town or country is accessible to those wealthiest as well as those who are in marginalized communities is key. Exploring and identifying issues surrounding infrastructure could be useful, such as offering free Wi-Fi on public transport (e.g., train service), and public spaces which in turn allow individuals such as rough sleepers to access an Internet connection while also facilitating them to search specific information (e.g., health). The UK has experienced 10 years of austerity, witnessed across varying regions up and down the country, that has left the neediest and most vulnerable in extremely difficult circumstances. Businesses—be they large or small—have a social responsibility to assist and support local and national initiatives and communities. This too is the responsibility of county councils and government(s).

All proposed recommendations and future proposals should work towards the culmination of industry, community networks, health practitioners, families, and policymakers to learn and share knowledge, experience, and share 'lessons learned.' More importantly, all actors playing a role and part in decision making need to listen to the voices of those directly affected, while also identifying the needs of the people at all socio-economic levels of society.

The work presented in this paper contributes to the fields of gerontology, gerontechnology, (HCI) and disability, based on the debates associated with the integration of new technologies into the home and/or physical space used by citizens in society with/out a myriad of disabilities.

There is the potential for virtual/personal assistants to positively impact the lives of carers of dependent adults, children and adults with chronic health and neuro-degenerative conditions. Conducting a co-production approach with a multitude of actors has the potential to move age-friendly framework(s) forward. Taking this kind of approach will ensure all voices are heard, especially the voices of those who will be residing in these environments or cities, by those actors who will primarily be responsible for making the final decision(s).

**Author Contributions:** Both authors contributed equally to writing the manuscript, proof reading and final revisions prior to submission.

**Funding:** This research received no external funding.

**Conflicts of Interest:** The authors declare no conflict of interest.

## **References**


© 2019 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).

## *Article* **Making Homes More Dementia-Friendly through the Use of Aids and Adaptations**

#### **Simon Evans \* , Sarah Waller, Jennifer Bray and Teresa Atkinson**

Association for Dementia Studies, St John's Campus, University of Worcester, Worcester WR26AJ, UK; s.waller@worc.ac.uk (S.W.); j.bray@worc.ac.uk (J.B.); t.atkinson@worc.ac.uk (T.A.)

**\*** Correspondence: simon.evans@worc.ac.uk

Received: 25 February 2019; Accepted: 14 March 2019; Published: 16 March 2019

**Abstract:** The majority of people with dementia live in their own homes, often supported by a family member. While this is the preferred option for most, they often face multiple challenges due to a deterioration in their physical and cognitive abilities. This paper reports on a pilot study that aimed to explore the impacts of aids and adaptations on the wellbeing of people with dementia and their families living at home. Quantitative data were collected using established measures of wellbeing at baseline, 3 months and 9 months. In-depth case studies were carried out with a sample of participants. Findings from the pilot suggest that relatively inexpensive aids can contribute towards the maintenance of wellbeing for people with dementia in domestic settings. The project also increased the skills and confidence of professionals involved in the project and strengthened partnerships between the collaborating organisations across health, housing and social care. Providing aids that can help people with dementia to remain living at home with a good quality of life, often with the support of a family member, is an important element in the development of age-friendly communities.

**Keywords:** dementia-friendly environments; aids and adaptations; loneliness; domestic settings

#### **1. Introduction**

The profile of ageing is changing. In 2017, the global population over the age of 60 numbered 962 million, rising from 382 million in 1980. The number of adults over the age of 80 has tripled and older adults are set to outnumber young people under 10 years old by 2030 [1]. In the UK, health and social care services are supporting increasing numbers of people over the age of 65. This trend is set to continue in coming years, with over half of local authorities expecting to see 25% of their population to be over the age of 65 by 2036 [2]. Ninety-six percent of older people live in mainstream, un-adapted housing as owner occupiers [3]. However, this is a population which is paving the way for change. The growing number of older people represent an influential body who voice higher expectations for living in communities which are more responsive to their needs and 'age-friendly', yet 'the places in which older people experience ageing have often proved to be hostile and challenging environments' [4]. One response to population ageing at international and national levels is the development of age-friendly communities, based on the premise that 'physical and social environments are key determinants of whether people can remain healthy, independent and autonomous long into their old age' [5].

Ageing is often accompanied by challenges to physical and cognitive wellbeing. In recent years the UK government has prioritised an agenda to support people to live well with dementia [6], including an aspiration for communities to become dementia-friendly [7]. There are currently an estimated 850,000 people living with dementia in the UK, a figure which is projected to increase to over 1 million by 2025 [8]. This picture is replicated globally where the number of people living with dementia is estimated to be in the region of 36 million, doubling by 2030 and projected to be

more than tripled by 2050 [9]. Dementia is a complex and multi-faceted condition which impacts each individual differently, resulting in a range of symptoms which can limit a person's ability to function independently. Memory loss is a common symptom of dementia, but the condition brings other challenges, such as compromised visual and spatial awareness, difficulty with object recognition, challenges in seeing colour and colour contrast, greater need for increased light levels and challenges with orientation to space and time.

For people with long-term degenerative conditions such as dementia, living well in their own homes can be a challenge and moving to long-term care is often seen as the only option. However, the projected increase in this population places substantial financial burdens on society, so that the traditional expectation of supporting people in long-term residential settings is no longer viable. Additionally, with greater diversity within the housing and care markets, residential care is now just one option alongside a range of models including sheltered housing, extra care housing and remaining in one's own home with additional support.

There is growing evidence to suggest the importance of the physical environment in enabling older people to attain their full potential [10], sometimes known as 'ageing in place'. This is also recognised within established theoretical approaches such as the environmental press model, which focuses on the fit between the environment and an individual's physical and cognitive capacities [11]. Eighty-five percent of people in the UK say they would prefer to remain living in their own homes if they received a diagnosis of dementia [12]. An estimated two thirds of people with dementia live in their own homes, and of this population one third live alone and one third live in housing with care [8]. This brings with it additional difficulties including a greater risk of social isolation and loneliness. Research conducted in the UK by the Alzheimer's Society found that 62% of people with dementia who live alone felt lonely, compared to 38% of all people with dementia [13].

For people living with dementia, the symptoms they experience can have a significant impact on their confidence and ability to continue to lead an independent and full life, yet remaining in a familiar environment with the right assistance can often be beneficial. Based on data from the English Housing Survey [14], there are at least 475,000 households in England lived in by adults aged over 65 with a disability or long-term limiting illness, many of whom report that they lack the home adaptations they need [15].

There is good evidence that minor aids and adaptations can improve a range of outcomes for older people and help them remain at home for longer. In addition to increased levels of confidence and autonomy, aids and adaptations can reduce hospital admissions for avoidable conditions such as falls and urinary tract infections, which remain some of the most common reasons for hospital admissions among the elderly [16]. However, there is little evidence in relation to the value of aids for people living with dementia in their own homes [15]. This paper adds to the body of knowledge in understanding the importance of aids and adaptations in the home from a UK perspective. It demonstrates that for people with dementia at the early stages of their journey, minor aids and adaptations can have significant benefit for helping to improve quality of life and supporting living well at home.

'People with a dementia have the right to live life . . . as they did before their diagnosis . . . to live in their home, in the neighbourhood they know and perhaps surrounded by friends and caring neighbours' [17].

#### **2. Materials and Methods**

A study providing aids and adaptations to people living with dementia in their own homes was piloted in Worcestershire, a county in the West Midlands region of the UK, for a 12 month period during 2017–2018. Worcestershire has approximately 588,000 residents with 3.9% having a diagnosis of dementia, a figure which is slightly lower than the national average. Known as the Dementia Dwelling Grant (DDG), the pilot study built on an existing service through which people with a dementia diagnosis were allocated a dementia advisor (DA). Assessment for the DDG was carried out by the DAs, an approach that it was hoped would minimise disruption and anxiety for the people living with dementia and their families. While dementia is associated with older age, it was felt that the potential benefits of the DDG should be made available to anyone referred to the DA service, regardless of their age. The DDG was not means-tested and was available to people with a clinical diagnosis of dementia who were living at home.

The DDG pilot did not provide a monetary grant but instead offered a range of small-scale aids and home adaptations that were believed to benefit people living with dementia, and that were not available through other programs. Where necessary, these were delivered and installed by the established handyperson service. The list of aids and adaptations was informed by research and best practice in dementia-friendly design. It included items for use around the home including key locators and clocks, and those for specific areas, such as touch bedside lights and bath mats.

A research team at the University of Worcester was commissioned to carry out an evaluation of the pilot, with the broad aim of exploring the impacts of the aids and adaptations that were provided on the wellbeing of recipients. Two paper-based forms were developed by the research team in consultation with the local authority administering the project, to capture information from people living with dementia who consented to participate in the study. The first, an assessment form, captured basic demographic data as well as information on which aids and adaptations were to be provided with the grant. The second form comprised a series of validated measures to assess aspects of the grant recipients' health and wellbeing. This form was completed as part of the baseline assessment and repeated after three and nine months to capture the impact of the DDG intervention over time. The measures were taken from the UK Office for National Statistics 'People, Population and Community' (UKPPC) survey [18] and the Short Warwick Edinburgh Mental Wellbeing Scale (SWEMWBS) [19]. General wellbeing was measured using four questions that assess quality of life on a scale from 0 (not at all) to 10 (completely). The SWEMWBS tool asks respondents to describe their experience over the past two weeks in relation to seven statements on a five-point scale from 'none of the time' to 'all of the time'. In addition to the individual statements, composite SWEMWBS scores can be generated on a scale from 7 to 35, with higher scores indicating greater mental wellbeing.

The information captured by the assessment form was analysed to provide descriptive statistics about the evaluation participants, while the validated measures in the evaluation form were analysed according to the relevant process for each individual measure. Where possible, findings were compared between baseline, 3 month follow up and 9 month follow up to investigate the longer-term experiences and impacts of the aids and adaptations for intervention participants. The results were analysed to see if any significant changes had taken place between the different time points, and any significance will be highlighted in the results. In the absence of a control group, comparator data were obtained from the UK Office of National Statistics to enable the DDG information to be viewed within a wider context.

In addition, a purposeful sample of 15–20% of grant recipients who had completed a three-month evaluation were chosen as case studies. The sample aimed to mirror the wider group of DDG recipients by including participants with a variety of dementia diagnoses, ages, living situations, and types of aids required. The case studies used semi-structured interviews conducted in a person's home to explore which aids and adaptations had been of most benefit, and if any additional aids or adaptations would be useful and might be made available and included in future grants. Finally, towards the end of the pilot, research interviews were carried out with key project stakeholders to discuss how the project was developed and implemented and to explore the main benefits, facilitators and barriers. The interviews with grant recipients and project stakeholders were transcribed and analysed for key themes.

#### **3. Results**

#### *3.1. Participants and Interventions*

In this pilot project, 510 people were assessed for the DDG by the dementia advisors. Of these, 382 (75%) received a DDG, with 101 (26%) of these consenting to be part of the full evaluation. The majority of referrals (60%) came from the Early Intervention Dementia Service, with 14% unknown, and 13% from the Community Mental Health Team. The remainder were from families, self-referral and family doctors. The age range of those receiving a DDG was 36 to 98 years with an average (mean) of 80 years old. Fifty-five percent were female and 97% were White British. This profile closely reflects the local population. Sixty-two percent of DDG recipients were married, with the majority of the remainder being widowed.

Although those consenting to be evaluation participants were slightly younger than those who did not give consent (mean age 78 compared to 81), their overall demographics were very similar to the whole group of DDG recipients. Among the evaluation participants, Alzheimer's disease was the most common dementia diagnosis (40%) followed by vascular dementia (22%) and mixed dementia (21%). Fifty-four percent had at least one other medical condition, with arthritis, diabetes, mobility issues, frailty and heart conditions being the most common. Ninety-five percent had at least one carer, with 80% living with their carer. This person was most commonly a partner or spouse, followed by a son or daughter. Eighty-six percent of the evaluation cohort were owner occupiers, with 64% living in a house and 23% in a bungalow.

Ages of the 13 case study participants ranged from 55 to 92 years, with an average of 80. Nine were female and four were male. Five had Alzheimer's disease, four had mixed dementia, two had vascular dementia, one had Lewy-bodies and one had fronto-temporal dementia. Ten case study participants lived with their spouse with three recipients living alone supported by carers or family.

All individuals in the evaluation cohort requested at least one item; 12 items were the maximum requested by an individual. The five most popular items requested were a dementia clock (two types were offered: a day/night clock and a digital 12/24 h clock), noticeboard/white board, touch-activated beside light, key locator and memo minder. The average number of items required by customers was five (four different types of item) at a cost of £138. This cost does not include additional costs, such as the time of a dementia advisor to undertake the assessment or the time of the handyperson to deliver and install items.

#### *3.2. The Wellbeing of Participants*

General wellbeing was measured at baseline, at 3 months and at 9 months as shown in Table 1. Comparator data from the UKPPC survey [19] show slightly lower levels of general wellbeing for DDG participants at baseline than for the wider population in relation to items 1 to 3. Scores for item 4 indicate levels of anxiety that are considerably higher than those for the wider population.

**Table 1.** General wellbeing scores for intervention participants and the UK population. Percentages for items 1, 2 and 3 refer to respondents who scored 9 or 10 on a scale from 0 (not at all) to 10 (completely). Percentages for item 4 refer to respondents who scored 1 or 2 on the same scale. DDG: Dementia Dwelling Grant.


Two further items taken from the UKPPC survey were used to measure satisfaction with health and satisfaction with accommodation, using a seven-point scale from 'completely dissatisfied' to 'completely satisfied'. The findings shown in Table 2 indicate higher levels of satisfaction with their health and accommodation for those receiving the intervention than for the wider UK population.

The final measure of general wellbeing asked participants to answer the question 'How often do you feel lonely' on a five-point scale from 'often/always' to 'never'. A high proportion (14.8%) responded 'often/always' compared with 4.1% of the wider UK population.

Mental wellbeing was measured using SWEMWBS [19]. Responses were largely positive for each item as shown in Figure 1, with the majority of respondents selecting at least 'some of the time'. Composite SWEMWBS scores were generated for the 77 participants who responded to at least five of the seven items and so would have a valid score. This gave a mean score of 23.6 for the DDG group compared with 24.6 for the wider population. *Healthcare* **2019**, *7*, x 5 of 11 Mental wellbeing was measured using SWEMWBS [19]. Responses were largely positive for each item as shown in Figure 1, with the majority of respondents selecting at least 'some of the time'. Composite SWEMWBS scores were generated for the 77 participants who responded to at least five of the seven items and so would have a valid score. This gave a mean score of 23.6 for the DDG group

**Table 2.** Satisfaction scores for intervention participants and the UK population. Percentages for each question refer to respondents indicating any level of satisfaction on the scale. compared with 24.6 for the wider population. **Table 2.** Satisfaction scores for intervention participants and the UK population. Percentages for each


**Figure 1.** Baseline participant scores for mental wellbeing based on the Short Warwick Edinburgh Mental Wellbeing Scale. **Figure 1.** Baseline participant scores for mental wellbeing based on the Short Warwick Edinburgh Mental Wellbeing Scale.

Due to the timings of the baseline assessments and the ongoing nature of referrals to the DA service, it was only possible to carry out 80 of the 3 month follow up assessments during the evaluation, with 73 participants still living at home and being able to complete the assessment process. Mean scores for satisfaction with life, feeling worthwhile and happiness had improved slightly for the 73 participants, while remaining lower than the national average. Similarly, anxiety levels decreased for the participants but were still substantially higher than the wider population. At three months there was little or no change in 'satisfaction with health' and 'satisfaction with accommodation' compared to baseline. There was also no significant change in the composite SWEMWBS scores, although they had declined slightly. However, there was a reduction in levels of loneliness, with 10.6% of respondents reporting that they felt lonely 'often' or 'always' compared with 14.9% at baseline. This improvement was not statistically significant. Due to the timings of the baseline assessments and the ongoing nature of referrals to the DA service, it was only possible to carry out 80 of the 3 month follow up assessments during the evaluation, with 73 participants still living at home and being able to complete the assessment process. Mean scores for satisfaction with life, feeling worthwhile and happiness had improved slightly for the 73 participants, while remaining lower than the national average. Similarly, anxiety levels decreased for the participants but were still substantially higher than the wider population. At three months there was little or no change in 'satisfaction with health' and 'satisfaction with accommodation' compared to baseline. There was also no significant change in the composite SWEMWBS scores, although they had declined slightly. However, there was a reduction in levels of loneliness, with 10.6% of respondents reporting that they felt lonely 'often' or 'always' compared with 14.9% at baseline. This improvement was not statistically significant.

Nine-month assessments were completed with 36 participants, with the reduction in numbers again being closely linked to the timing of the baseline assessment in relation to the lifetime of the study. In terms of general wellbeing, there was a slight decline in the mean response for 'satisfaction Nine-month assessments were completed with 36 participants, with the reduction in numbers again being closely linked to the timing of the baseline assessment in relation to the lifetime of the study. In terms of general wellbeing, there was a slight decline in the mean response for 'satisfaction

with life' and 'feeling worthwhile' between baseline and 9 months, and a slight improvement for 'anxiety', while 'happiness' was unchanged, as shown in Table 3. The reduction in loneliness that

'often', 'always' or 'some of the time'.

with life' and 'feeling worthwhile' between baseline and 9 months, and a slight improvement for 'anxiety', while 'happiness' was unchanged, as shown in Table 3. The reduction in loneliness that was seen at 3 months continued at 9 months, with fewer participants reporting that they were lonely 'often', 'always' or 'some of the time'.


**Table 3.** Mean general wellbeing scores for intervention participants at baseline, 3 months and 9 months.

Overall there was a slight decline in terms of composite wellbeing scores from baseline to 9 months. Participants also reported greater satisfaction with their accommodation, with 94% being 'completely satisfied' at nine months compared with 71% at baseline. Levels of satisfaction with health and accommodation remained higher than the UK average at 9 months. The data only allowed calculation of a composite SWEMWBS score for ten participants at the 9 month follow up. For these, the average score increased marginally from the 3 month figure, while remaining slightly below the UK average. As for the 3 month assessments, no statistically significant changes were seen at the 9 month follow up.

#### *3.3. Case Study Themes*

While participants were on the whole very pleased with the aids they had received, they appeared to have had little involvement in choosing them. Most had products chosen for them either by the dementia advisor or by their spouse. The items reported as being of most use were whiteboards, lights/lamps and clocks. Whiteboards were most commonly fitted in the kitchen area and used to remind participants about appointments and events, although some were kept in the lounge to remind them of immediate tasks. One participant described how she used the whiteboard to plan her week and maximise her independence:

"I write everything on there. I put everything that we are going to do through the week. I write it all down so that I don't have to keep saying 'what are we doing' all the time. When we have done something, I immediately rub it off because I know that's done. And it makes me think as well, I like that." (Marjorie).

Her husband added that initially she was writing everything haphazardly on the board and it became confusing for her. He divided the board into days of the week and found that this provided an excellent way to enable Marjorie to note, and anticipate, events for the forthcoming week.

Several participants found lights and touch lamps to be the most beneficial aids. Some had chosen battery operated as opposed to plug in lights; some had chosen motion sensitive lights whereas others could be switched on and off manually. The lights appear to have helped with orientation, preventing injury and maintaining continence:

"The best thing for me is the light, we've got it on top of the landing and it comes on by movement so in the middle of the night when either of us goes to the loo, it comes on. We sleep with our bedroom door open and I've only got to move my blanket and it comes on." (Peggy).

"Before we had them, I meant to switch on the switch by the door, but I missed it and I cut my finger all down there because there was no light." (Joan).

Several participants were provided with multiple aids through the grant program. For example, Nancy and her daughter who was her main carer had chosen a GPS tracker, a large button telephone, a memo-minder, a touch lamp, a red toilet seat, a white board, a key locator and new signage. She particularly liked the big button telephone, which allows speed dialling by using large buttons at the top of the display:

"We haven't put pictures on it . . . we have just put (son's name) press to call and (daughter's name) press to call. I think it's good to put 'press to call' rather than just a photograph because if it's just a face you don't know that's going to call."

However, Nancy viewed the new signage as intrusive and unnecessary:

"No, I don't like that . . . because I don't need a blooming thing like that . . . I just go out of there and into there."

Other participants also described the limitations of specific aids that were provided. For example, Florence's husband talked about the memo-minder that was fitted adjacent to the front door and played a message to remind his wife to close the door properly or to take her keys if she left the house. He felt that the device was 'too sensitive' and had become a nuisance:

"I've recorded various messages. The one at the moment says 'Florence, don't forget to close the door properly' because sometimes she doesn't latch it properly and lock it, 'and if you go out, don't forget your key'. Now that's been on but it did get on our nerves a bit so what we've started to do is for me to only switch it on when I go out and I don't go out that often, just one night a week when I play squash, and I like to switch it on then but sometimes I forget and that's the disadvantage of that method . . . it's easy to go out and forget to switch it on. It could be useful but if you open the door to anyone it goes off."

Other problems that were reported included someone who found it difficult to understand the digital clock when it was set to 24 h time mode. They had been unable to find out how to change the function and settings of the clock.

#### *3.4. Stakeholder Perspectives*

Stakeholders identified a wide range of benefits arising from the DDG pilot. For example, the aids provided were thought to offer crucial support after a diagnosis of dementia, as well as a way to promote continued independence:

"You've got to keep them using it, you've got to keep them stimulated. And some of this equipment does just that, they can tell their own time, they can tell what time of the day and night it is you know? They can see where they're going, they can look in a drawer, and know that it's the right one, because it's got a label on. Okay it's got a label on, but so what? At least it means that they're not going into the wrong drawer, becoming frustrated, and then giving up."

The benefits for family carers of someone living at home with dementia were perceived to be equally important:

"I think if we can benefit the carer and make life better, easier for the carer as well, to be able to care for that person, and stay well themselves, then yeah, absolutely, I don't think we should distinguish between the two, as such."

Additional benefits were thought to arise from the highly collaborative nature of the pilot, putting the partners in a good position to deliver future initiatives:

"Partnership working as well, has been really beneficial between obviously, the University, but also with Worcester City Council, and with Care and Repair (the local home improvement service), and our knowledge, as well, has increased in terms of what people need and want, to be able to manage their dementia, to be able to live at home as well."

Finally, there were seen to be substantial benefits for some of the professionals involved in implementing the grant, in terms of their skills and confidence levels:

"The more they (handyperson staff) went into people, they'd always visited people with dementia, 'cause they had mobility issues as well, but they actually hadn't thought about it from the dementia person's point of view, whereas actually fitting equipment and showing people how to work it, they got more of a feel for it, and their experience, and they became obviously more sensitive to the issues, and could also raise other issues that they were worried about."

The flexibility that was allowed in terms of the list of aids and adaptations on offer was seen as an important feature of the grant:

"I think, as a regular list, this one is fine, then we just say to people, if there's something outside the box, you let us know, and we will review, and if it's okay, and comes from a reputable source, we'll probably buy it, to be honest with you."

Similarly, the lack of means-testing was viewed by all stakeholders interviewed as a key factor in the success of the pilot, largely due to the additional burden that means-testing would place on people with dementia and their families:

"And yes, it means that we get stuff to people quicker, and they benefit from it quicker as well. It doesn't matter whether you've got the money or not, if you haven't got the capacity, and you've got a carer who's stretched to the limit, they really aren't going to go out and source these things, and bother with them. So, they will go without them. And, at that point in time, that person then will deteriorate and lose their independence, and I think, for the small cost that it is, because it's not a massive amount of cost, means-testing would be too much trouble, in reality."

#### **4. Discussion**

Findings from the pilot study reported in this paper suggest that relatively inexpensive aids were associated with increased overall wellbeing for people living with dementia in their own homes three months after receiving them. This should be considered in the context of an intervention group who were living with dementia and whose quality of life might be expected to be deteriorate over a period of nine months. Levels of wellbeing for pilot study participants were lower than that for the wider population, particularly in relation to loneliness, which again is not unexpected given the widely reported challenges of living with dementia. However, it was more difficult to account for the fact that levels of satisfaction with both health and accommodation were higher at baseline for participants than for the wider population.

Of particular note is the reduction in levels of loneliness amongst the people using the aids, which has been recognised as an important issue for older people generally [4] and those living with dementia in particular [13]. The picture was more mixed at nine months, with a slight deterioration in satisfaction with life and feeling worthwhile but an improvement in terms of anxiety and overall mental wellbeing. This may reflect the complexities of health and wellbeing for participants. For example, levels of co-morbidity were over 50%, which indicates the high levels of frailty experienced by people living with dementia. It also raises the possibility that the benefits reported from having the aids related not just to their dementia, but also to other conditions such arthritis, diabetes and heart conditions. In addition, it is important to note that most participants received several aids, with one person having 12, which raises the possibility different aids may be having different impacts for specific individuals. While this pilot study identified specific aids as being of most value to participants (dementia clock, notice board or white board, touch beside light, key safe), more research is required to explore the impacts of such items individually and in combination. The findings also demonstrate the key role played by family carers, usually a spouse, in supporting people with dementia in their own homes. This highlights the importance of providing aids, and other services, that can protect their wellbeing and enable them to continue in their role.

The case study findings draw on the experiences of those receiving the aids to highlight the impact they had on quality of life for people with dementia and their families. For example, the use of a whiteboard for planning weekly activities and tasks brought major benefits for one person with dementia and her husband. Similarly, touch-activated bedside lights made it easier for participants to get up at night and make their way to the bathroom. However, several participants experienced challenges when using the aids provided. One family carer described having to turn off the memo minder because it had an over-sensitive activation mechanism, while one person with dementia found the 24 h clock to be confusing. One unanticipated theme that emerged from this pilot study was the benefits experienced by the professionals involved, particularly increases in knowledge and confidence for working with people with dementia.

Learning from the pilot study has informed the following key recommendations:


#### **5. Conclusions**

In conclusion, the findings from the pilot study reported in this paper indicate that relatively small and inexpensive aids and equipment can make a positive difference to the lives of people living with dementia in their own homes. The benefits spanned three main areas: promoting independence and quality of life for people with dementia and their family carers; increasing the skills and confidence of professionals involved in the project; and strengthening partnerships between the collaborating organisations across health, housing and social care. During the pilot study, five aids were reported to be the most beneficial: dementia clock, noticeboard/white board, touch-activated beside light, key locator and memo minder. While people earlier in their dementia 'journey' have the opportunity to become more familiar with the equipment, this should not prevent people with more advanced dementia from benefitting, particularly when a carer or family member can also become familiar with the items and their potential use. Providing aids that can help people with dementia to remain living at home with a good quality of life, often with the support of a family member, should be considered as an important element in the development of age-friendly communities [5]. Following the positive findings from this evaluation, the grant scheme is continuing to be offered to people with a diagnosis of dementia living at home across Worcestershire.

**Author Contributions:** S.E., S.W., J.B. and T.A. contributed towards conceptualisation, methodology, investigation, original draft preparation, review and editing. S.E. and S.W. contributed towards project administration and funding acquisition.

**Funding:** This research was funded by the six district councils in Worcestershire: Bromsgrove, Malvern Hills, Redditch, Worcester, Wychavon and Wyre Forest.

**Acknowledgments:** The authors are grateful to the people with dementia and their families who agreed to take part in the research. We would also like to thank the staff at Worcester City Council and Age UK Hereford and Worcester including the Dementia Advisors, without whom the evaluation would not have been possible.

**Conflicts of Interest:** The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results.

#### **References**


© 2019 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).
