Public Defense: Torhild Holthe

This PhD study is part of the Assisted Living Project (2015-2019) and explores assistive technology as a complex intervention to facilitate occupation and participation in everyday life among home-dwelling older adults, both with and without mild cognitive impairment and dementia (MCI/D). The demographic changes with bigger cohorts in the oldest age groups challenge the future healthcare services.

Assistive technology refers to devices or systems whose purpose is to maintain or improve an individual’s functioning and independence, to facilitate occupation and participation, and to enhance overall well-being, and is perceived as means for independent living, to improve the quality of healthcare services and to avoid costs.

In the past decade, several research projects have aimed to support older adults at home, facilitate their independent living and safety, provide cognitive stimulation and entertainment, and contribute to their ageing in place. Despite many examples of technological failures, false alarms and a lack of infrastructure robustness a general optimism about technology is evident.

Access to assistive technology may foster or hinder participation in meaningful occupation in older home-dwelling citizens. Implementation of assistive technology is seen as a complex intervention. The Medical Research Council (MRC) framework was used in this PhD study to explore this complexity and develop new knowledge.

Occupational science emphasises human occupation as important for health and well-being and provides a theory for understanding human occupation through the life course as a dynamic and transactional process; i.e. a dynamic on-going interaction between human, occupation and objects within a specific context. This thesis is based on four studies; a systematic literature review (Paper I), a study of health care workers’ experiences of using assistive technology with care recipients with MCI/D (Paper II), a technology feasibility study (Paper III), and a user inclusion study on technology development (Paper IV).

Study I

Study I found that a wide variety of assistive technologies was used to support home-dwelling older adults and their family caregivers.

The types of technologies can be categorised into four groups; for

1. safe walking indoors and outdoors
2. safe living
3. independent living
4. entertainment and social communication.

Users; i.e. persons with MCI/D, family caregivers, staff or other older adults were involved in different research occupations such as focus groups, workshops, technology trials and interviews. A major finding was that user inclusion was both necessary and important to learn about the design features required to enhance usability and acceptability.

Surprisingly, less than half the studies reported on citizens with MCI/D’s experiences of technology use regarding quality of life, occupational performance, or human dignity. Rather family caregivers and staff were asked about feasibility and technical functionality.

Study II

Study II explored how community healthcare workers talked about and worked with assistive technology for care recipients with MCI/D. Twenty-four healthcare workers with different professional backgrounds took part in focus group discussions about technology to support people with MCI/D at home.

We found that the participants’ knowledge and practice of technology varied. Some regarded technology as efficient services provision, such as physical training programmes to several patients at the same time, and remote monitoring of patients via screens. Others feared that technology might increase loneliness and confusion in the care recipients and was motivated only by economic reasons.

Technology did not appear to be in the repertoire of healthcare workers’ clinical practice due to low knowledge of and competence in technology, and lack of management. This study demonstrated that home-dwelling older citizens with MCI/D who are deprived access to supportive assistive technology may experience occupational injustice.

Study III

Study III described the feasibility of the implementation of environmental sensors in one of eight apartments, in order to learn about the strengths and weaknesses of the implementation process and of the technology.

This process evaluation drew on the Medical Research Council (MRC) framework. A major finding was that a feasibility study was important for identifying strengths and weaknesses of the intervention, critical evaluation of the research plan to facilitate implementation in the other apartments.

Study IV

Study IV sought to investigate how eight older adults in an assisted living facility evaluated user inclusion in a 3-year technology development project. Individual structured interviews, dialogue cafés, interventions with environmental sensors, follow-up home visits and a final focus group discussion constituted sites for development of knowledge.

The older adults with and without documented MCI/D could nevertheless meaningfully contribute with opinions about needs and preferences. One major finding was that they wanted to contribute with their opinions. User inclusion of older citizens in research projects may contribute to extended knowledge about user needs and technology requirements, as well as user inclusion processes.

Applying a critical occupational perspective raised awareness regarding sociocultural assumptions about older adults in assisted living facilities, which may reinforce ageist and ableist stereotypes, as well as promote occupational injustice.