Care and PreventionResearch Programme >

Disabling or Enabling Technology? Ethical and Practical Concerns of Assistive and Surveillance Technologies in Formal Dementia Care

Alzheimer Europe Conference, 30th of May 2009

Alistair Niemeijer, M.A., Department Of Nursing Home Medicine, VU

University Medical Center, Amsterdam

ageing population- dementia on the rise..

changing demographic: emergence of technological solutions

• ‘Demographic Time Bomb’ (Alisky 2006)

• ‘Care Vacuum’ (Agree et al 2005, Astell 2006)

• Technology to the rescue!

• Use of technology in relation people with dementia provokes conflicting reactions (Cash 2003)

assistive and surveillance technology in dementia care

• vast variety of technological interventions in dementia care:

wandering detection (bracelets, chips); leefcirkels transl.: ‘living circles’; alarm systems, active/passive (movement detection, infrared devices) automation of domestic environment (automatic lighting, temperature, tv, domestic appliances); speaking/listening/video connections; camera surveillance

• distinction between assistive and surveillance technologies

assistive technolgies offer assistance and support, enabling certain degree of independence over day to day activities

surveillance technologies aim to safeguard and protect & can serve as alternative to (other) forms of restraint

• assistive technology enables; surveillance technology controls?? (Astel 2006)

‘Wondering about the wanderers…’

• this form of (wandering) technology has sparked off considerable ethical debate

• stigmatises, removes personhood, infringes human rights of privacy and dignity (Cahil 2003, Astell 2006)

• ‘tagging should be reserved for criminals!’ (O’Neill 2003)

could lead to a more secure environment; decrease caregiver burden

isn’t policy of incarceration worse? (Bail 2003, Welsh et al 2003)

literature review

• still unclear what ethical and practical implications would be in an intramural care setting..

• Main aim of the review:

‘..to explore what is known on effectiveness and acceptability of assistive and surveillance technologies in the intramural care for people with dementia and intellectual disabilities.’

• Insight in these issues serves multiple purposes:

can technology serve as viable alternative to freedom restriction?

setting forth the state of the ethical debate might contribute to development of clear(er) policies

method and procedure

• 6 literature databases were searched: Embase.com PsycInfo Cinahl INSPEC ETHXweb

• Both controlled terms and free text terms were used 1st category: captured all forms of dementia 2nd category: terms related to assistive or surveillance technology 3rd category: terms related to (potential) outcome/influence last category: included all articles in Dutch/German/French/English

• Inclusion criteria were set broadly

Table 1. Central themes and subthemes on assistive and surveillance technologies in the formal care for people with dementia or intellectual disabilities as covered in the literature

System/Institution Patient

Reliability/efficacy

Care relation Rights of patient

Functional efficacy Duty of care vs autonomy Freedom & autonomy

Safety/risks Replace care (giver) Dignity /stigma

Caregiver burden Person centred care Privacy

reliability/efficacy

• functional efficacy

few (n=6) studies

practical problems

• safety/risks

Only 2 RCT’s

False sense of security

• caregiver burden

Too much emphasis?

System/ Institutio

n Patient

Reliability Efficacy

Care relation

Rights of patient

Functional efficacy

Duty of care vs autonomy

Freedom & autonomy

Safety/risksReplace care

(giver)Dignity /stigma

Caregiver burden

Person centred care Privacy

Care relation

• duty of care vs autonomy

carers exhibited lesser tolerance of risk due to fear of litigation (Robinson et al 2007b)

clear risk policy is needed (Bewley 1998)

• replace care(giver)

use of technology might lead to degrading of skills (Cassidy 1994, Counsel&Care 1993)

use of technology is in itself demanding? (Lauriks et al 2008, Thompson 1998)

• person centred care

technology should be catered to the individual

System/ Institutio

n

Patient

Reliability Efficacy

Care relation

Rights of patient

Functional efficacy

Duty of care vs autonomy

Freedom & autonomy

Safety/risks Replace care (giver)

Dignity /stigma

Caregiver burden

Person centred care

Privacy

Rights of the patient

• freedom and autonomy

issue of autonomy problematic

informed consent; wide consultation

• privacy

‘Big Brother effect’ (Casas et al 2006)

• dignity/stigma

‘safer walking technology’

System/ Institutio

n

Patient

Reliability Efficacy

Care relation

Rights of

patient

Functional efficacy

Duty of care vs autonomy

Freedom & autonomy

Safety/risks Replace care (giver)

Dignity /stigma

Caregiver burden

Person centred care Privacy

Discussion

• Hardly any RCT research

• No ethical consensus has yet been reached, underlining the need for clear(er) policies

• But for a few key articles, majority of articles lack in depth analysis

• Difference UK and US

‘mechanical acceptance’ (Eltis 2005)

Discussion

• Lack of patient perspective

• Empirical ethical research is lacking

Limitations of this review

Appropriate terminology?

Search strategy

Conclusions

• Study offers overview and elucidation of ethical debate and points to omissions

• The thematic overview this study provides can contribute to the much described call for developing clearer policies

• More research is needed, in particular taking into account the client perspective

• Review is part of larger research project

Staff & Partners

Alistair Niemeijer M.A., Department of Nursing Home Medicine/ Institute for Research in Extramural Medicine, VU University Medical Centre, Amsterdam 

In collaboration with:

C.M.P.M Hertogh, MD, PhD, Project Supervisor Department of Nursing Home Medicine/ Institute for Research in Extramural Medicine, VU University Medical Centre, Amsterdam

B.J.M. Frederiks, PhD, Department of Public and Occupational Health/Institute for Research in Extramural Medicine, VU University Medical Centre, Amsterdam

Prof. J. Legemaate, PhD, Department of Public and Occupational Health/Institute for Research in Extramural Medicine, VU University Medical Centre, Amsterdam

Prof. J.A. Eefsting, MD, PhD, Department of Nursing Home Medicine, Institute for Research in Extramural Medicine, VU University Medical Centre, Amsterdam 

This research project is funded by the following organisations: RVVZ, Nuts Ohra, ActiZ, ‘Vereniging Gehandicaptenzorg Nederland’, ‘Het Zonnehuis’, ‘Stichting Regionale Zorgverlening Zeeland’

Thank you!

• Thank you for your attention!

For more information please contact me at: a.niemeijer@vumc.nl

Example searchstrategy (PsycINFO)

• Database(s):

• PsycINFO

• Thesaurusterminologie: Mental Retardation and Dementia met NT’s includes all intended terms

• PATIENT:

• P

• DE=("mental retardation" or "anencephaly" or "borderline mental retardation" or "crying cat syndrome" or "downs syndrome" or "home reared mentally retarded" or "institutionalized mentally retarded" or "mild mental retardation" or "moderate mental retardation" or "profound mental retardation" or "psychosocial mental retardation" or "severe mental retardation" or "tay sachs disease" or "dementia" or "aids dementia complex" or "dementia with lewy bodies" or "presenile dementia" or "alzheimers disease" or "creutzfeldt jakob syndrome" or "picks disease" or "senile dementia" or "senile psychosis" or "vascular dementia") OR kw=dement* OR kw=alzheimer disease OR kw=alzheimers disease OR ((ti=cogniti* OR ti=intellectual) AND (ti=impair* OR ti=dysfunction* OR ti=disabilit* OR ti=disabled OR ti=disorder*)) OR ((ab=cogniti* OR ab=intellectual) AND (ab=impair* OR ab=dysfunction* OR ab=disabilit* OR ab=disabled OR ab=disorder*))

• INTERVENTION

• I

• Kw=domotic* OR kw=robotic* OR DE=robotics OR de=computer applications OR DE=computer peripheral devices OR kw=ict service OR kw=ict services OR de=information technology OR de=assistive technology OR de=apparatus OR de=telemedicine OR kw=electronic* OR kw=eas system OR kw=eas systems OR kw=non pharmacological OR kw=sensor OR kw=sensors OR kw=surveillance device OR kw=surveillance system OR kw=surveillance technology OR kw=assistive technology OR kw=gps OR de="automated information processing" or DE="automated information coding" or DE="automated information retrieval" or DE="computer searching" or DE="automated information storage" OR DE="information technology"

• AIM/GOAL

• O

• Kw=Wandering OR ti=safety OR de="accident prevention" OR kw=security OR kw=patient coding OR de=monitoring OR kw=walking OR de="motor performance" OR kw=coercion OR kw=confinement OR kw=constriction* OR kw=constraint* OR kw=curtailment OR ti=control OR kw=freedom OR kw=immobili?ation OR kw=limitation* OR kw=restraint* OR ti=restrict* OR kw=autonomy OR ti=independen* OR kw=liberty OR kw=privacy OR kw=self determination OR kw=self reliance OR kw=self rule OR kw=self sufficient OR kw=self sufficiency OR kw=ambulatory OR kw=mobility OR kw=domestic OR kw=home OR de=tracking OR kw=tracking OR kw=tagging OR de=fear OR de=anxiety OR DE="computer anxiety" or de="performance anxiety" or de="social anxiety" OR DE=needs or de="health service needs" or de="psychological needs" OR de="well being" OR DE="risk management" OR DE="quality of life" OR DE="home environment"

• Total search in scheme: P AND I AND O > 246 hits (20080121)

robotics

safety security restrain restrict

sensor assistive technology

ab= cognitive ti= dysfunctionDE= dementia