SmartHome for Ambient Assisted Living

Reuven Granot

Holon Institute of Technology and Perlis Ltd

rgranot@perlis-aal.com

AbstractThe immediate consequence of radical improvements in medical treatment of the world population is a significant growth in the elderly population and their standard of life. As aging is directly related to degrees in elderly peoples’ abilities to take care of themselves, care giving services suffer from a tremendous overload, which can be balanced only by enabling “aging at home”. This goal demands the development of really practical smart homes (SmartHomes), designed to support the needs of individuals, mostly isolated individuals. Robotic and communication technologies enable today the transformation of our homes into an intelligent environment, which can monitor our behaviors, while we age. SmartHomes are equipped with sensors, actuators, and/or biomedical monitors. This paper describes the implementation of a selection of various available and future technologies for Aging in Place.

IntroductionOver the last century there have been radical improvements in medicine. The immediate consequence of this fact is the extension of lifespan for humans especially in the developed countries. The elderly population is expected to grow dramatically while in some places it might even double over a decade. For example, in the US alone, the older population (persons 65 years or older) numbered 39.6 million in 2009. They represented 12.9% of the U.S. population. By 2030, there will be about 72.1 million older persons, more than twice their number in 2000. People 65+ represented 12.4% of the population in the year 2000, but are expected to grow to be 19% of the population by 2030 (1). These data show that the elderly population is not only expected to grow, but will grow faster than the rest of the population. This puts an economical threat on younger generations, who will have to work harder than usual, only to pay for the legally contracted rights of previous generations’ commitments.

This blessed effect together with the transformation of our planet into a "Global Village", where young people frequently change their residency, has a less pleasant consequence that elderly people can rely less on their families on the day to day basis.

These improvements in medicine although extending the lifespan, are not capable to restore old people's health, so they have to rely on medications and Emergency Medical Services(2). About

7% of elderly people are recognized as eligible to be housed in Nursing Homes or

The trend in population distribution over age (vertical axis) and women (left) vs. men

(right).

The trend in population distribution over age (vertical axis) and women (left) vs. men

(right).

receive similar treatment in their homes, but only about 4% could find a bed in 2006. About 1.5 million Americans live in nursing homes and about 22% of the 5.3 million people 85 or older had a nursing home stay in 2006 (3). Since it is not possible to double the number of Nursing Homes over the next decade, as is needed, actions must be taken to improve efficiencies in Nursing Home operation and at the same time develop technologies to enable elderly people to stay at their homes in Ambient Assisted Living (AAL) environments.

Heath Care expenditure.The problem of the increasing burden of chronic disease and the ageing population on health care expenditure is acknowledged worldwide. In 2004, the United States spent $1.9 trillion, or 16 percent of its gross domestic product (GDP), on health care. This averages out to about $6,280 for each man, woman, and child(4).

However, actual spending is distributed unevenly across individuals, different segments of the population, specific diseases, and consumers. For example, analysis of health care spending shows that(5): 5% of the population accounts for almost half (49 percent) of total health care expenses; patients with multiple chronic conditions cost up to seven times as much as patients with only one chronic condition.

In response to the high costs of health care, much focus has been placed on appropriate technologies for supporting ageing-in-place and for promoting self-care. Instead of hospitalization or institutionalization, the elderly and disabled can be assisted in their own environment 24h a day with numerous 'smart' devices.

Types of living environments.Living environment is a general word used to indicate place of residence, or “home”. Housing provides for basic human needs, such as food, clothing and shelter. At the end of life, independence, autonomy, and safety are especially relevant. Older adults strive to maintain their independence and autonomy in a safe living environment.

There are several residential options for elderly people, depending on their health situation and relative independence in performing basic activities. The most independent will continue their way of living at their regular accommodation. Even these people need some health care assistance, mostly to remind them about life saving activities and detect changes in their behavior.

The less independent have two options, assisted living, and nursing homes. According to a survey done in 2000, approximately 95 percent of adults aged 65 and older reside in private households(6). This data also point out that the number of elders who maintain a private household declines across age groups. In addition, the proportion of elders who live alone increases across successive age groups and varies markedly by sex. Among those aged 85+, the majority of women live alone(7).

Given the preference of older adults to “age in place,” private homes will remain an important housing option in the future, particularly for the young-old, and will be important targets for increased technology to help elders remain there.

Ambient Assisted Living (AAL) environments.Assisted living housing is characterized as a housing-and-services setting where older adults with disabilities can live in private, disability-adapted houses and apartments and receive services tailored to their needs. They carry out daily

activities; while receiving assistance in health and activity monitoring, enhanced safety and security, as well as getting access to medical and emergency systems. This concept is a broad term that encompasses a variety of licensed care facilities, such as residential care facilities, personal care homes, adult foster homes, or small group homes. These facilities take many forms but most commonly consist of self-contained, private-occupancy apartments in a range of sizes, styles, and amenities. AL homes typically provides access to services such as medical and nursing care, monitoring of residents (including monitoring of medications, medical conditions, falls, and so forth), meal services, and housekeeping. AL also provides residents with a range of structured activities (such as exercise or reading groups), transportation (to stores and healthcare providers), and social activities (e.g., holiday parties, informal contact with neighbors and friends). For that reason we use the term of Ambient AL, to emphasize the broad aspect of the term.

SmartHomes – a Holistic solution.A "smart home" is a residential setting which employs cutting-edge technologies to offer a holistic solution for domestic safety, security, and comfort. Equipped with a set of sensors and automated devices specifically designed for care delivery, remote monitoring, and early detection of problems or emergency cases, the SmartHome improves quality of life. Information and Communication Technologies (ICTs) are utilized to allow individuals to live independently in their preferred environment. These systems are patient-centered rather than institution-centered as they are designed to address the needs of individuals, their families and caregivers rather than these of health care facilities.

The concept of the SmartHome is a promising and cost-effective way of improving home care for the elderly and the disabled in a non-obtrusive way, allowing greater independence, maintaining good health and preventing social isolation. The benefits of SmartHomes range from gate/door access, to health monitoring.

Technological developments related to living environments.Independent living, AAL, and nursing homes are often viewed on a continuum. The most healthy, most independent elders live at home; the most frail, most dependent elders live in nursing homes. Over the past decade or so, continuing care retirement communities have been developed to capitalize on this continuum of care model. These retirement communities typically have independent living apartments or houses, assisted living facilities, and a nursing home on the same grounds. This model may be very successful today, but cannot be transferred to serve the entire elderly population.

In the near future, people living in independent private homes will receive emergency help based on monitoring alerts from the AAL facilities and move there when the frequency of these alerts is almost daily. Some elders may move into a retirement community in anticipation of age-related declines. For the vast majority, however, the move from a private dwelling into an alternative living environment is the consequence of some event, such as a serious fall, illness, death of spouse, or gradually declining health or cognition that necessitates increased healthcare and services. Thus, they move to a living environment that provides them with services because they need to. Besides, as only about 5% of the elderly population live in AAL environment, it is not possible to consider this type of accommodation as a solution for the entire community. However, equipping AAL facilities with monitoring technologies may accelerate development of products for independent living and help to build the market. While independent living monitoring solutions require

attention from family, friends, and neighbors or need a contract with care giver centers placed in vicinity, the AAL facilities are already delivering this service.

The technology to be considered belongs to one of the following categories: (a) assistive devices that compensate for motor, sensory, or cognitive difficulties; (b) monitoring and response systems, both for emergency response to crisis situations and for early warning for less critical and emerging problems; and (c) social communication aids.

Age-related changes in motor movement include slowing, inability to make continuous motions, and lack of or variable coordination (8,9). Sensory difficulties are also common, and much is known about changes in vision and hearing (10,11). These devices include powered wheelchairs, stair climbers, or provide assistance like grab bars, magnifiers, hearing aids, etc. At least the intelligent powered wheelchair serves as goal for many robotic projects. The developed robotic devices are still too expensive to be widely used as real consumer products(12). At the Georgia Institute of Technology, computer vision researchers have prototyped the Gesture Pendant as a wearable device to control a variety of home appliances through simple hand gestures(13).

Technologies for cognitive aging include devices to help overcome decline in attributes such as the capacity of working memory, on-line reasoning, and the ability to attend to more than one source of information. Other abilities remain largely intact, such as recall of rehearsed material, vocabulary and reading, and ability to focus on a single source of information.

An example of such a device is SimpleMed(14) a smart and simple home medication alert and tracking system. It is a smart box, developed to help manage the medication to be taken, which alerts if the medication was not taken in time, and continues to send alerts if necessary using an automatic phone system to call family members or special care alert service to announce about the problem.

Other systems on the shelf today, track position of the person with cognitive decline to ensure being restricted to some well defined area or use GPS technology to find him/her in case of emergency (HomeFree wireless resident monitoring solution(15) ). Aerotel Medical Systems(16) provide for example telemedicine and digital monitoring devices that transfer over the telephone, wireless network or Internet vital medical or lifestyle data.

However, the current technological solutions are still mostly isolated solutions and require strong collaboration from the resident. A real SmartHome solution for elderly people, one which can let them age in place, or stay at AAL facilities with reliable, invisible and inexpensive supervision, is still to come. Such a system has to overcome technological challenges, but the solutions are just around the corner.

ChallengesThe world is becoming more and more health conscious. Society, health policy and patients' needs are all changing dramatically. The challenges society is currently facing are related to the increase in the aging population, changes in lifestyle, the need for healthcare cost containment and the need for improvement and monitoring of healthcare quality.

1. Preventive Medicine requires Monitoring.

The emphasis is put on prevention rather than on treatment. This solution moves the care giving activity from points of care to the physical residence of the population. The health givers are now expected to be aware of coming threats, even before the person is aware of any behavioral or medical failure.

A relatively simple method is to detect all movements in house and associate the sensed movements to some behavior to be monitored, like: waking up, using bathroom, preparing and eating meal, watching TV in living room, leaving house or returning home and more. Alerts to check about happening in house should be sent to a close relative or service center, when major changes in the tracked behavior are detected. The system has to differentiate between a falling event and just staying longer in some place, like bathroom. The challenge is related to development of multi- sensor systems with advanced analysis and decision making algorithms.

The new possibilities for home care and ambulatory monitoring are provided at 4 levels: (a) Micro-sensors: offer the possibility of small size, intelligent, active devices, working with low energy, wireless and non-invasive or minimally-invasive; (b) Wrist devices: may combine sensors, with display and wireless transmission in a single box; (c) Health smart clothes: make contact with 90 % of the skin and offer many possibilities for the location of sensors; (d) Health smart homes: integrate the information to provide a holistic distant visualization of the patient's living conditions to avoid hospitalization.

2. AAL requires an unobtrusive solution.

Elderly residents, who live in the SmartHome define themselves as independent people, who can take care of themselves. They are not hospitalized and a solution which fits their needs must be a long term solution. In other words, the technology to support the needs of the elderly should only assist them and not make them dependent on its performance. The technology is also associated with an invisible interaction among people and computer-based services taking placed, which should be there to help when needed and “absent” most other times. Elderly people, like young ones, expect to continue their private and independent life in an environment which is transparent, follows ethical and privacy acceptance rules and does not spy on residents’ activities, except to the minimum agreed upon. Visiting a medical doctor is at some limit also crossing personal privacy. People require medical intervention because they realize that this action is vital for them and compromise on their privacy in order to receive the required care. The same attitude holds toward the intelligent monitoring systems installed in a SmartHome. People will interact with these services through intelligent and intuitive interfaces embedded in these objects and devices, which in turn will be sensitive to what people need. The level of monitoring must be dynamically adapted to the needs of the resident in order to enable care givers interaction in case of real alerts. For the same reason, the false alarm rate of mart home alert systems must be maintained as low as possible; else the residents will force them out.

3. RepresentationBut home environments are challenging as they’re different to represent. For autonomous systems, each home is completely different. It is not possible to use a standard representation of home environment as it is unstructured and dynamic. Even if the description of walls is static, current changes in furniture, carpets and similar house hold items make the environment for the autonomous system (robot) semi structured. This environment is also dynamic as people, pets and some devices are moving inside the environment.

Dynamic and unstructured and even semi-structured environments are still challenging robotic applications. Current technology enables use of simple machines like the Roomba(17), autonomous vacuum cleaner, which uses a simple reactive architecture to perform a basic task of moving around.

The other challenge relates to the fact there are not only elderly people in a home. If we wish to monitor the resident’s moving behaviors, we must discriminate between the resident to be monitored and other people, who may live in the house, including even an elderly spouse.

4. Fault tolerant and small false alert rates.Sensors and other devices used by the SmartHome system have to function continuously to rely on their alert capabilities. If the alert decision sends an unexpected high false alert rate it will lose owners’ trust. The same if batteries have to be frequently replaced or the system fails and need technicians’ support. There are several commercial off the shelf (COTS) falling alert devices, which if worn on the body of the resident will send alerts based on accelerometers signals. Most of these devices fail to distinguish between a fast movement and a falling event. Some others are still under development.

5. System Integration.The devices operate in a network connected to a remote data collection and processing centre. The remote centre autonomously diagnoses the ongoing situation and initiates assistance procedures as required.

All devices and other computer and communication subsystems have to interoperate smoothly in order to achieve the required system integration. Since devices and sensors are manufactured by numerous companies, and their number is expected to grow, only standard interface devices should be considered. Unfortunately, this does not really solve the problem because many accepted standards in the relevant field are already in use. As each sensor provider supports its specific network, even networks which are standards compliant require an overall integrated monitoring system to alert the staff of deterioration in any individual's health condition. Nevertheless, this integration is known to be a hard task, it is expected by the elderly that for their lifetime, the addition of new devices or improved versions of existing devices in the SmartHome system must be a painless procedure.

There are multiple layers of Interoperability: (a) Protocol Interoperability (exchange bits & bytes over the network); (b) Functional Interoperability (exchange messages and data); (c) Semantic Interoperability (provide common understanding of the exchanged data); (d) User Perceived Interoperability (components of the system provide expected services).

A multiple of relevant standards exist for AAL: Cable Networks (i.e. Ethernet -32 variants); Point-to-Point (i.e. DisplayPort, DVI, FireWire, USB); Field Buses(i.e. BACnet, BatiBus, EHS); Wireless Network( i.e. WLAN, ZigBee, Z-Wave,Bluetooth,DECT, HomeRF); Network Protocols( i.e. BitTorrent, HTTP, SMTP, SNMP,IPP, IMAP, FTP, NFS); Medical( i.e. aECG, CCD, CCR, CDA,DICOM, EDF, EDIFACT, ECG, xDT, OPS, UCUM, UMLS); Runtime( i.e. OSGi, .NET, SOA,URC, ).

As each sensor provider supports its specific network, even networks which are standards compliant require an overall monitoring system to alert the staff of deterioration in any individual's health condition.

Our goal at Perlis(18) is to provide a service which is able to bring fault tolerant sensory and biometric data gathering, saving and retrieval; to prioritize alerts and deliver actionable items delivered to personal mobile devices of the relevant staff. The Holistic assessments are based on cross-referenced information gathered from multiple disparate sensors.

6. Robotic and sensor network technologies.

The requirements presented above result in a need to use multiple sensors, forming some type of network, and then analyze the measured information to autonomously reach the conclusion if any alert has or has not been initiated. The autonomous activities are usually related to robotic technologies, which in the last decades continue to get recognized as trusted technologies we may rely on.

Autonomous machines, called robots are expected to replace people in care giving or other support tasks. As this is an expectation of the crowd, it should be stated that introduction of robots to serve aging population is very challenging. The Japan Times reported that in March 2009, the Japanese government affirmed its commitment to developing robotic technology that will assist seniors in the country, promising the delivery of robot nurses within five years. However, seniors’ reaction was that most elderly people are not interested in robots. They see robots as overly-complicated and unpractical. They want to be able to get around their house, take a bath, get to the toilet and that‘s about it. European researchers are working to deliver comprehensive monitoring systems that do not compromise an older person’s privacy or dignity; makes aging adults who live alone feel safe but not watched.

7. The expected health care revolution is related to socio-technological challenges.

Just as advances in science and technology converged to spawn invention of the health clinic several centuries ago, contemporary developments in these same arenas may herald the birth of a new era in which healthcare is increasingly based in the home and community, enabled by a range of pervasive, embedded computing and communications technologies. This evolutionary, if not revolutionary shift from clinic-centric to community-centric healthcare will likely coincide with revised notions of healthy aging. Traditionally associated with regular visits to the doctor to keep body parts and functions in working order, healthy aging may evolve into a more

holistic process through which optimal function and life quality are achieved using an array of health-related technologies that augment human interaction and support.

More is known about technical challenges to build the hardware, software and integrated solutions to enable safe monitoring of individuals, than how the individuals will receive the change. And how do we expand the repertoire of available technologies to include devices that are more personal and embedded in our home environment as opposed to having to travel elsewhere for care? The way the technology will be implemented and accepted will have a social as well as technological aspect of our daily life(19).

Monitoring System classificationSeveral questions must be answered based on the gathered experience, like what information is being recorded or transmitted - medical information (e.g., heart rate, respiration, blood pressure, medication compliance), movement data (e.g., restlessness in bed, gait patterns), or simply awareness information (e.g., a video transmission to a relative). Next, over what period of time are data analyzed? The capture of information can be for instantaneous purposes only or over a period of time for trend analysis, as you would expect for vital signs in a telemedicine application or in medication monitoring for compliance in a home or assisted living environment. Or, how is information reported to relevant individuals? Medical alert systems provide a phone call to a response agency. What is the role of the older person in using the technology? Does the monitoring require any instrumentation or active cooperation on the part of the individual being monitored? For example, do they have to wear an infrared badge for a positioning system, or is it passive, with the environment instrumented to measure a naturally occurring phenomenon using devices such as a motion detector or face recognition system?

Computer Science research needs to transform raw sensor data into useful, meaningful information.The users of the SmartHome for elderly aging in place are not interested in the raw data gathered. They want to know about the more general feature and trends of the measured data; i.e. not about insignificant values of tenant’s daily weight, but rather that over the past month the tenant has become more agitated while sleeping, tripled the number of times he gets up to go to bathroom at night, lost significant weight, or feeling irritated that “Big Brother” is watching, and as a consequence unplugged some sensors from the network.

The computing technologies to create reliable trending, often from unreliable and “noisy” sensor data will have to be quite advanced to deal with the complex rhythms of home life, which are often much less controlled and routine than in nursing homes or hospitals. Multiple approaches to classic artificial intelligence problems are likely to be needed for different purposes in the system: dynamic Bayesian networks and other statistical approaches, hierarchical approaches, and learning-based systems that may be comparing a current activity or behavior to a decade′s worth of prior data. Experts in information fusion and sensor networks will have to work hand in hand with medical experts of all kinds (gerontologists, biochemists, psychologists, etc.) to identify classes of activities that need to be tracked and the sensor approaches that can even begin to provide the raw data to such an inference system.

Summary and ConclusionsOver the next few decades, the aging population will face numerous changes and challenges. Many of these will involve changes in health and functioning and will impact where older adults live. The vast majority of elderly people will live at home, often with the assistance of family, friends, and professional home-care services to assist them as their functional abilities decline. This assistance will be based or backed-up by effective monitoring and response from care giving centers, located in the neighborhood and which will respond on autonomously detected alerts, before real emergencies occurs.

In the coming decades, as the baby boomer generation ages, we can expect to see an even greater demand for technology. These systems are patient-centered rather than institution-centered. The technology required to age in place will first be implemented at AAL facilities, since these facilities are better prepared to familiarize with it.

SmartHome systems may be the expected solution for elderly residences because they are able to personalize the information and enable reversing the current care procedures: instead of calling the caregivers when a person feels health degradation or in an emergency situation, the intelligent decision making sub-system calls attention of the caregivers much earlier or efficiently than it is done today.

Technology can facilitate the safety and security of older adults, who may be able to delay or avoid moving from their home to alternative living environments and may maximize their ability to live independently. Specifically, technology applied across living environments can provide cognitive assistance, monitoring, and social communication, thus optimizing “home” for many older adults as they age.

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http://www.youtube.com/watch?v=3xXhnJuPlV4 b. YouTube - Toyota wheelchair robot http://www.youtube.com/watch?

v=cnRg4SjhHxs c. Robot wheelchair finds its own way

http://web.mit.edu/newsoffice/2008/wheelchair-0919.html d. d. Stair Climbing Robot Wheelchair - The iBot Mobility

http://www.trendhunter.com/trends/stair-climbing-robot-wheelchair-the-ibot-mobility-system

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14. SimpleMed, Vaica Medical, Tel Aviv, Israel, http://www.vaicamedical.com/ 15. HomeFree, Tel Aviv, Israel, http://www.homefreesys.com/ 16. Aerotel Medical Systems, Holon, Israel, http://www.aerotel.com/en/ 17. Roomba from iRobot

http://homesupport.irobot.com/cgi-bin/irobot_homesupport.cfg/php/enduser/home.php 18. www.perlis-aal.com19. Eric Dishman, Judith Matthews, and Jacqueline Dunbar-Jacob; “Chapter 7: Everyday

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