Social Science Perspective

Introduction

An ecosystemic perspective is particularly useful when a study crosses disciplinary boundaries or attempts to draw upon disparate research traditions. In order to study the effective application or utility of computer based technology for enhancing capacity in the elderly to remain at home, knowledge in several areas of the behavioral and social sciences provides a needed foundation. Foremost, the significance of control for the elderly will be reviewed as a critical element of empowerment. In order to assist the elderly in engaging comfortably with new technology, it is essential to enhance their sense of agency and control and thus promote empowerment. The impact of the home environment on elderly individuals is another key issue to be examined, especially if introduced technology will need to be adapted to that environment. It is also essential to understand the potential of technology to provide cognitive stimulation to the elderly. What then is the impact of such stimulation on depression or other mental health risks? Can it modify self care patterns? We will also examine the unique cognitive and learning issues for older adults in mastering new technology and will attend, as well, to the ethical issues related to the introduction of different types of technology.

Ecosystemic Perspective

The ecosystemic perspective is presented first in that it provides a broad framework that encompasses all other areas we plan to discuss. It views complex environments as composed of numerous interacting parts (socio-cultural, interpersonal, physical/structural, psychological, institutional and biological elements) that fit together to form a larger whole (Bronfenbrenner, 1979). Ecosystemic theory is at the heart of theory for the practice of social work which seeks to understand human behavior within its numerous social contexts. The theory examines the interrelatedness and interdependence of parts of a living system and assumes that changes in one part of a system will influence the whole. More recently, ecosystemic theory has emphasized that social systems are not static but responsive to new information and evolve over time (Hoffman, 1984).

Ecosystemic theory is grounded in systems theory in the behavioral sciences and has been framed even more broadly in natural science as well. Within social science and social work practice, the theory has focused on interactions between people and their environments. Social work in particular has emphasized the need to identify the environmental supports which enhance human development and to locate and remove barriers to positive, healthy development. The ecosystemic framework seeks to understand how and how well people adapt to the challenges of their environments (their own natural capacities, the built environment and social environments); in order for effective adaptation to take place, adequate resources and opportunities need to be available. Yet, people are seen as interacting dynamically and co-constructively with their environments (Saleebey, 2001), a recursive process in which there is mutual shaping of and by the environment (Kondrat, 2002).

An ecosystems perspective is critically important to this study because the elderly face the challenge of continual adaptation to changing physical and cognitive capacities as well as constant changes in social relationships and support. Changes in any functional domain may require numerous adjustments, shifting the “fit” between person and environment. For the elderly, especially those who have lost some aspect of their former capacities, individual autonomy is less realistic than at other developmental phases of life because of need for supports from the various systems on which they depend. In order to maintain capacity, many elderly individuals need to be situated within a network (family, formal caregiving, informal supports, assistive supports, community) of interdependent parts. Change in any part of the system can have a ripple effect; therefore, a change in personal capacity or in the system of social support can influence the ecological balance of the entire network. And if changes involve deterioration in capacity, stressors in all parts of the system can be anticipated which will then need to be addressed in order to preserve or improve capacity of the elder.

Empowerment

The ecosystems theoretical base in social work has generated interest in understanding and promoting social processes which lead to the empowerment of clients; this emphasis is grounded in the assumption that individuals can influence as well as adapt to their environment.. Empowerment is thus a key goal of ecosystemic study and practice with a focus on identification of those interventions that enhance capacity and thus generate cascading effects of improved functioning in different domains of life. Empowerment requires identification of cultural, institutional and interpersonal dynamics which diminish the experience of self efficacy or accomplishment in others. One important cultural dynamic identified in the gerontological literature as contributing to disempowerment is “declinism”, the tendency for cultural values, media images, and professional discourses to focus exclusively on the loss of capacity in the elderly (Thomas, 2004). “Declinism” has shaped the traditions of gerontological research as well; such research has tended to focus on the comparison of physical and cognitive capacities of younger and older adults. “Declinism” has been counterbalanced more recently by an interest in the development of capacities unique to old age. However, concern about the excessive romanticism of some of this “successful aging” literature (Holstein & Minkler, 2003) has led current gerontology to a more balanced interest in recognition of both the increased risk to well-being for the elderly and the particular strengths which can be developed at this stage of the life cycle. Such a perspective is congruent with empowerment theory that attempts to mediate the impact of cultural representations and professional discourses which contribute to societal expectations for decline in the elderly.

Importance for the Elderly of Control over Life Circumstances

An important element of empowerment, especially for elderly individuals, is the freedom to maintain control over as many aspects of one’s life as possible. People are defined as having control when they can bring about a desired outcome through their own actions (Seligman, 1975). A group of classic studies in the gerontology literature have indicated strongly that the degree of control individuals experience over life circumstance influences their health status, utilization of medical care, activity levels, mental health, feelings of well being and mortality rates (Mirotznik & Ruskin, 1984; Seligman, 1975; Abramson, Seligman & Teasdale, 1978; Langer & Rodin, 1976; Langer, 1983; Janis & Mann, 1977). These studies also pointed out that modest interventions to enhance perceived control had significant impact on individual well-being and physical status as well as reducing mortality rates. More recently, Smith et al., (2000) found that, although age indirectly affected interpersonal agency (obtaining positive ends through interactions with others) and personal agency (achieving desired outcomes on one’s own behalf), perceived primary control (agency of both types) balanced the impact of physical deterioration on quality of life and sense of personal efficacy.

Solie notes that the need for control is the key motivator behind most actions taken by elderly individuals on a daily basis and is a major influence on their judgment and self-management (Solie, 2004). The pervasiveness of loss is also a major motivator in efforts to hang on to what remain. He comments that the social and psychological impact of the often overlapping losses of health, strength, peer group and independence are so major that the efforts to preserve what is left may be the essential theme of life. Sometimes all that is left is the ability to say no (Solie, 2004).

Given the significance of control for the elderly, an empowerment approach is inherently a collaborative one that forms partnerships with the elderly and is responsive to their definitions of the problems to be addressed. Since collaboration is a critical element of empowerment, this study will emphasize methodology that engages the elderly and key related constituent groups such as caregivers and service providers in contributing to the design of future efforts to provide them with assistive technology (Andersen, 1991; Mishler, 1986). This approach to research is described by Bray, et al (2000) as collaborative inquiry or participatory action research where the subjects become co-investigators and share the experience of trying to understand the subject under study. Continual efforts to examine underlying assumptions through mutual critical reflection are a key element to this approach as well and assure the researchers that their research is finely tuned to the everyday experiences and perspectives of the “subjects.”

Mental Health Risks for Depression in the Elderly

In the popular imagination, growing old is often associated with greater vulnerability to depression. Research into the epidemiology of depression shows a more complex picture. The elderly do not appear to experience more Major Depressive Disorder (the most serious form of depression) than younger adults. There is some evidence however of increased vulnerability to mild to moderate depressive affect and cognition connected with greater frequency of experiences of loss, physical illness and social isolation (Zarit & Zarit, 1998). Depressed mood connected with these sources can lead to troubling symptoms of personal neglect and inadequate self care. It can be treated or even prevented by a combination of medications, interpersonal support, and environmental modification. This study seeks to examine how to introduce technology into the life space of the elderly to enhance communication with caregivers and significant others and to provide environmental supports to prevent and/or reduce depressive mood and its symptoms. Mental health interventions with depressed elderly tend to be oriented to the present and problem-solving, with a focus on “changing habitual action that have contributed to depression and replacing them with more adaptive behaviors” (Zarit & Zarit, p. 212). The technological innovations presented here may serve to reduce depression risk as a result of increased stimulation of cognition, reduction of social isolation, improvement in self care and greater sense of self efficacy.

Environmental Gerontology

Many of the questions pursued by this study can be informed by the long-standing research tradition of environmental gerontology which examines the impact of physical, social, organizational and cultural environments on aging processes and outcomes (Lawton, 1977; Wahl & Weisman, 2003). This research has focused particularly on the significance of the physical, home environment, with a recent interest in exploring “the inner life processes associated with aging at home or the internal socio-physical environment of homes and support of everyday competencies in that setting” (Gitlin, 2003, p. 628). Environmental gerontology research is concerned with three different functions of the home environment: the “maintenance” function (role of stability and predictability), the “stimulation” function (departure from the usual through novel stimuli), and the “support” function (potential to compensate for reduced capacity) (Wahl & Weisman, 2003). This study introduces technology which enhances stimulation and provides support while ensuring that maintenance and stability are protected.

Cognitive and Learning Issues of the Elderly in Using New Technology

A review of the past six years of research reports in The Gerontologist and reports of presentations at the 2003 International Conference on Aging, Disability, and Independence reveals that there have been numerous studies about the introduction and effectiveness of computerized assistive devices in the homes of the elderly and/or disabled. Many of these studies show positive results for both the elderly and their caregivers (Agree and Freedman, 2003; Mahoney, Tarlow and Jones, 2003; Sweeney & Chiriboga, 2003; Eisdorfer et al, 2003). However, it is not clear the extent to which this research formulated intervention strategies that took the special cognitive and learning issues of the older population into account. As Benke (2003) notes, “many practitioners concentrate on the technology rather than the human application/integration of the devices.” This study will address the realities of “usability” (Neilson, 1993; Traskback, 2003) by directly incorporating the perspectives and reality of the elderly through engaging them in the research and technology adaptation process. In order to do so, it is important to first understand the impact of aging on cognition and learning.

Much research into the psychology of aging has focused on cognitive changes, particularly cognitive decline. This area of study is recently producing a more nuanced and complex account of the influence of aging on cognition. It is now recognized that accumulated knowledge, or “crystallized intelligence”, including verbal ability and vocabulary, remain relatively stable across the life span. The process of learning, or “fluid intelligence”, including working memory, does undergo decline with age. Both speed of processing and “effortful” processing (controlled processing of information leading to problem solving) decline (Brown & Park, 2003; Park, 2000) Such impairments adversely affect the ability of many elderly people to retain and integrate new information, including medical feedback (Brown & Park, 2003). This results in more cautious behavior in response to novelty and necessitates a longer time frame to process information (Restak, 2001). However, slowing down is not the same as diminished capacity, and the capacity of normal elderly people to maintain intact or even superior performance on ordinary tasks remains stable (Park, 2000). No doubt, the introduction of new technology to this population will pose unique problems. However, it has been established that part of that disadvantage can be offset by training. (Zarit & Zarit, 1998).

Additional challenges are posed by the shift from doing to reflecting that characterizes individuals at this developmental phase of life. Solie (2004) notes that elements of life review (or making sense of the past) routinely get incorporated into the everyday activities of the elderly. Such a focus would likely have implications for any efforts to introduce new technology to the elderly. Their pace of learning and need to reflect on the past may not be congruent with those in their environment who are intent on engaging them in learning something new. So it is clear that while the elderly have the capacity and inclination for continued learning, approaches to teaching them will need to be adapted to their learning styles. This study will be distinct from many of the current studies examining the utilization of technology by the elderly (Agree and Freedman, 2003; Mahoney, Tarlow and Jones, 2003; Sweeney & Chiriboga, 2003; Eisdorfer et al, 2003) in that the elderly will be essential members of the research team. Therefore, the methods used in introducing technology to their environments will be developed collaboratively and thus are likely to result in approaches that will be effective and well-accepted by the elderly.

Ethical Considerations

The use of assistive technology in the homes of the elderly raises many ethical issues that have yet to be widely addressed, given the newness of such efforts. Bickmore & Pickard (2004) express concern that relational agents could be used to replace rather than facilitate or enhance social networks. They also raise the concern that once such technology is established in the home of an elderly individual, it could potentially be abused by marketers targeting the frail or vulnerable. They wonder about the impact of machines that “pretend to care” on those with whom they engage. The potential then exists for misuse of the trust in the agent to ends that serve someone else’s agenda for that person (Bickmore & Picard, 2004). Other concerns emerge as well. If “smart rooms” are in place, can the data from observation of the elderly person be imparted without his or her permission? Words like monitoring and surveillance, frequently encountered in security applications based on visual (or other) sensors seem to underscore the likelihood that data generated by the technology could be used by caregivers to undermine the freedom of elderly individuals to make decisions about their own lives. Given what is known about the importance of control over aspects of their lives for the well-being and even health of the elderly, any approach to technology that minimizes or undercuts a sense of control has the potential to do serious damage. It also may not be safe to assume that family members or other caregivers always have benign intentions in light of increasing rates of elder abuse.