People in the developed countries are living longer with advances in medical science. The life expectancy, today, is much longer than it was in the previous generations. With the baby boomer generation now reaching the age of 65 years and people living longer as compared to the olden days, the population worldwide of those aged over 65 years is increasing day by day or is set to increase substantially in the coming decades ahead. With an increased life expectancy, there is also a rise in chronic diseases. Worldwide, over 22 million people die from chronic diseases every year (Free 2). Optimal treatment of such diseases requires the involvement of patients themselves in managing their disease. They can do this by monitoring their own disease conditions.
Quality of life is also very important to all; and is also to the elderly, their families, and their treating physicians. Older people, if suffering from any chronic disease, will generally have a poorer quality of life; therefore, more assistance is necessary in activities of daily living to help maintain their quality of life or at least improve upon it. Besides, chronic diseases are a significant cost to the healthcare industry. Nearly three quarters of medical expenditures take place on this small number of chronic illnesses that mainly include the cardiovascular diseases, diabetes, and cancers (West, 2013 p.9). There seemed to be a tremendous necessity for such chronic diseases to be controlled and monitored by patients themselves; and this has resulted in the increased use of medical devices, mostly in the home.
A medical device is, simply defined as any item, used to diagnose, treat, or prevent a disease, injury, or any other condition. The device can range from items as simple as a tongue depressor to more complex devices, such as ventilators (Swayze 2). Many healthcare professionals are also encouraging the use of mobile devices that monitor patient symptoms and provide timely advice on treatment and drug therapy because they have the potential to control costs, reduce errors, and improve upon the patients’ experiences (West, 2013 p.9). Today, increasing number of elderly people are using medical devices at home; and are also using mobile devices that assist them in keeping up with their health. We will review the literature on what impact such devices have on the healthcare of such elderly people who use them in their daily life.
Body of literature
The hospital and the clinical environment is standardized and regulated, but the home environment is unpredictable and uncontrolled (Bitterman 39). Studies have investigated the user friendliness of devices such as home ventilators, long term oxygen therapy, antibiotic intravenous therapy, peritoneal dialysis, and peritoneal hemodialysis when used at home by the patients themselves.
The home environment is particularly important to the elderly since they are associated with a deep emotional attachment with their home (O’Bryant 349). It is believed that clinical interventions at home might have a different effect on the natural characteristics of the home; and create ambiguities between ‘home’ and ‘institution,’ that may wipe away any positive notions that older people might have for their home (Thomson 2). The older people might feel as if their home has become an institution/ hospital. Another fact is that older people have their spouses or other family members living with them, who will also have similar kind of attachment towards their home. Thus, the presence of medical equipment at home, and the possibility that they may have to interact with the device or help the elderly patient with treatment, may have an effect on their own roles and identity, within that environment (Thomson 2).
A recent study of twelve older people aged 65 and above adopted a qualitative study design; and interviewed the study participants and their partners. The older people used medical devices in their homes (Table 1) (Thomson 2). Braun and Clarke’s systematic approach to thematic analysis was used to identify, analyze, and report the themes within the interview data (Thomson 3). Two themes were constructed after the analysis was done that described how medical devices used at homes present certain challenges to the elderly, and their spouses, and other family members. The themes were constructed around the idea, in how the device is adopted, and the personal adjustments that they are required to make because of the presence of the devices at home. The first theme of ‘self-esteem’ highlighted the psychological impact of the device on the elderly users; while the second theme of ‘social device' highlighted the social impact of these devices on the user and the people around them. The authors concluded that the use of devices at home had both a positive and negative psychosocial impact on the users’ lives (Thomson 6).
In the first theme of self -esteem, there was a real sense of helplessness when participants agreed that there is no real alternative to having these medical devices in their lives. In this study, participants using the device monitored their condition and used the results to modify their behavior. This theme also described examples of the ability of older participants to derogate others, and point out that other people with similar conditions and using similar devices were doing less well or using their devices incorrectly (Thomson 6). As was described in the social device theme, the use of device impacted the lives of elderly users’ partners and wider social circle. Though the device was used by the elderly in the shared bedroom, the role of husband/wife remained intact. The reason for this is not clear, but could be the result of the device acting to supplement informal care and promote independence. There were still other emotional consequences of the use of such devices on their partners. While one husband reported a certain amount of embarrassment when he was out with his wife and while she was using the medical device, another user reported that the very act of using the device in front of her spouse caused the husband to become angry and irritated. However, the study also showed that devices can also become a part of social interaction with the grandchildren (Thomson 7).
In general, participants communicated overall positive feelings about their devices and the impact the device had on their everyday personal and social lives. The users also, by themselves, expressed an overall feeling of satisfaction; and were often not able to think of ways to improve the device (Thomson 7).
One medical device that is widely used and has now become the standard in postoperative pain control is the patient-controlled analgesia (PCA) (Licht 307). PCA devices enable patients to receive prompt pain relief, and allow their doctors to understand how much pain medication will be administered with each request. The devices have adjustable lockout intervals, and can be programmed to deliver a continuous infusion of medication through different routes (Licht 308). By administering the pain killer drug, only when the patient is sufficiently alert and cognitively intact to push a button, they are also believed to reduce the chance of opioid-related complications (Licht 308). Some research has shown that elderly adults can use the device themselves and are very much satisfied with its use. Some other research has also noted that even though there is a relatively small decrease in pain scores with PCA, the patient’s preference for the device is still high; and the research has suggested that the underlying cause may be a sense of increased autonomy, rather than simply improved analgesia (Licht 311).
In different studies by Langer, 1976; Ogden, 2009; and Huang 2009, being given a choice to use medical devices at home was associated with a feeling of alertness, well-being, and enhanced device attractiveness. However, the physical presence of the device at home was something most users were uncomfortable with, especially with respect to the size of the device and the noise it made (Fig 1) (Langer 191; Ogden 34; Huang 713). Altering the home was a difficult transition for many users. Some users had some amount of negativity towards the devices because their partners had to share the same room without directly benefiting from the device; yet, in general, participants expressed positive feelings about their device (Langer 191; Ogden 34; Huang 713). As shown by Calnan (2003), older people more likely express greater satisfaction with medical devices and healthcare as such, compared with younger populations (Calnan 125).
Fig 1: When the device is at home.
Medical devices can sometimes cause or contribute to some kind of adverse events, such as ‘burns’ from devices like for e.g., defibrillator pads (Swayze 3). Older patients need to be hospitalized for various health–related reasons. Generally technological devices used in hospitals, such as specialty beds, infusion pumps, and monitoring devices certainly improve patient outcomes, but there are reports of such devices having contributed to injuries and deaths (Swayze 3). Sometimes, patients have received too little or too much fluid and medications when intravenous infusion pumps did not deliver the appropriate dosage, while sometimes they have been given inappropriate or unnecessary interventions due to inaccurate data displayed on blood pressure monitoring screens (Swayze 3).
Health care personnel are needed to encourage and support the patients to adopt a healthy behavior and to self-manage chronic diseases. However, sometimes the amount of information, encouragement, and support that can be given to these patients during consultations is limited, may be due to time or any other factor (Free 2). Here is where mobile technologies come into picture - mobile health devices for patients have been designed to increase healthy behavior or improve disease management e.g., increasing adherence to prescribed medication, improving management of diabetes or asthma, or delivering therapeutic interventions (Free 2). Mobile technology is helping with managing chronic diseases, empowering the elderly, sending reminders to people to take medication at the correct time, extending service to underserved or rural areas, improving health outcomes of such chronic diseases, as well as improving on medical system efficiency (West, 2012 p.1). Mobile technologies keep the patient out of doctors’ clinics or hospitals for routine care; and thereby help to reduce the health care costs. Such technologies include devices such as personal digital assistants (PDAs) and PDA phones (e.g., BlackBerry, Palm Pilot), enterprise digital assistants (EDAs); smartphones (e.g., iPhone); portable media players (i.e., MP3-players, MP4-players, e.g., ipod); handheld and ultra-portable computers such as tablet PCs (e.g., iPad), handheld video-game consoles (e.g., PlayStation Portable [PSP]); and Smartbooks (Free 2). These devices have functions ranging from mobile cellular communication using text messages (SMS), to sending photos and videos (MMS), to telephone and World Wide Web access to multi-media playback, and software application support (Free 2). A recently published systematic review assessed the effectiveness of mobile technology interventions delivered to patients, and suggested that there is evidence of a certain benefit of such devices in the life of the user, particularly the elderly (Free 1).
A global survey of 114 nations undertaken by the WHO in 2011 found that mHealth initiatives (Graph 1) have been established in many countries, but there is variation in adoption levels. The most common mHealth activity was the creation of call centers to respond to patient queries.
Graph 1: Graph showing mHealth activities across globe
It is clear that mobile health has expanded in activity as well as number, and is projected to become a multibillion dollar industry by 2017. According to a report from PwC, yearly revenues of the mHealth industry are projected to reach to $23 billion worldwide that includes the largest share of $6.9 billion in Europe, followed by $6.5 billion in USA (West, 2012 p.12).
Complex mobile health applications help an elderly patient in areas such as monitoring of critical health indicators. Such devices enable easy to use access to tools like calorie counters, prescription reminders, medical references, appointment notices, and physician or hospital locators (West, 2013 p.1).
One of the biggest problems with elderly patients is that they do not remember to take their prescription drugs. It is understood that only 50 percent of patients take their medication as prescribed. Either they forget to take the drug, or they do not take it on time, or do not take a dosage set by their physician (west, 2012 p.5). This means that complete benefit of prescription drugs is not achieved; and this happens due to human error. This costs the healthcare systems billions of dollars in negative health outcomes; however, now things are changing with such mobile technology having the potential to help everyone. Patients can get personal reminders via e-mail, automated phone calls, or text messages; and be constantly in touch with healthcare (West, 2012 p.5).
Applications such as the iWander app for Android devices are increasingly being used by Alzheimer’s disease or dementia patients. The app makes use of the GPS function of smart phones to track where the patient is (Errol 1). If the dementia patient travels away from their home or other known or unknown locations, it triggers a signal to the person’s family to check on their status and through geo-location coordinates, the person can easily be located and traced (Errol 1).
Another device is an inhaler with an asthma sensor built into it. The function the sensor performs is of tracking environmental conditions that pose possible dangers to asthma sufferers. By doing this, and also by keeping a track of how often the person is taking medicine, the device helps to manage asthma. The patient’s doctor is also kept informed about disease condition and its management (West 2013 p.3).
In Japan, the Wireless Health Care@Home program allows patients living in remote areas to send critical health information to their doctors via a wireless network. This way, they receive a timely treatment (West 2013 p.5).
A Brookings Institution analysis undertaken by economist Robert Litan found that remote monitoring technologies could save as much as $197 billion over the next 25 years in the US alone (Litan 1). He found that cost savings were especially prevalent in the chronic disease areas of cardiovascular diseases and diabetes, pulmonary disease, and skin ulcers. With around-the-clock monitoring and electronic data transition to care-givers, remote devices help in speeding up the treatment of patients who require medical intervention. Instead of having to wait for a patient to discover that there is a problem, such monitors identify deteriorating conditions in real time; and alert the physicians about the deteriorating condition of the patient (Litan 1).
In diabetic care, it is very important that patients monitor their blood glucose levels and gear their insulin intake to proper levels. In the past days, patients had to visit a doctor’s laboratory, take a blood test, and wait for the results to be delivered. Certainly, this process was time-consuming, expensive, and even inconvenient for the patient as well as his family. Having to get regular tests for diabetes and other conditions is one of the factors that drive up medical costs; however, it is now possible to use remote monitoring devices at home that record the blood glucose levels instantaneously and electronically send them to the appropriate health care provider (West, 2012 p.3). Diabetic patients use something known as “Gluco Phones” that monitor and transmit blood glucose information to their caregivers, while also reminding patients when they need to undertake glucose tests (West, 2012 p.3). This puts the patient in charge of their own test-taking and monitoring; and keeps them out of their doctor’s offices until they really need more detailed care. It is estimated that over 11 million Americans use home monitors for their glucose (West, 2012 p.3).
A study of a physical activity (PA) program in the UK found that mobile feedback coupled with wrist-worn accelerometers that monitor PA yielded overall positive results. Those getting virtual interventions with the devices showed an increase of 2 hours and 18 minutes per week in PA and lost 2.18 percent more body fat as compared to the control group (West, 2012 p.6).
Another type of medical devices are used to assist an elderly in daily life. According to Edwards (1998), use of assistive devices in everyday life can potentially compensate for disability and reduce handicap, thus increasing a patient’s independence and improving their overall quality of life (p. 463). Assistive devices are mechanical devices that are designed specifically for people with disabilities and help them to do what they want to do (Brooks 1417). Devices such as wheel chairs, crutches, walking sticks, walking frames, raised lavatory seats, hearing aids, spectacles, stair rails, etc. are normally used by the elderly to ease out the everyday life. Some studies have shown that such devices allow the user to carry out certain amount of physical activity every day; and allow the task to be more efficiently performed. A research by Resnik (2006) has shown that elderly people who live alone generally substitute human assistance with assistive devices (p. 106). Devices such as bathing devices are used at an early stage in old age, while toileting devices are needed at a later stage. This probably is due to increasing chronic health problems and weakness in the body strength as one ages (Resnik 107). Overall, such assistive devices are a great help especially to the aging population. A research by Haggblom – Kronlof and Sonn (2007) has shown that the most common reason why elderly use assistive devices is that they feel more secure and confident while using the device (p. 335). The same research cited several other reasons for their usefulness. These were ‘less effort’ and ‘absolute necessity to use’. While using the devices, on a personal aspect, the users felt more normal, pleasant, safe and secure, but there were also some who were unsatisfied towards the device and expressed unpleasant feelings towards its use (Haggblom – Kronlof 341). The users regarded the assistive devices as impractical and inappropriate when the device did not adapt to various environments. Some users expressed assistive devices as more cumbersome. In terms of social aspects, users of assistive devices believed that it is embarrassing to use the device in public (Haggblom – Kronlof 342). Overall, this study showed that most of the old users did not use assistive devices for activities of daily living (Haggblom – Kronlof 335). Though, most of the users regarded such devices as a positive experience, when it came to using outdoors or publicly, they were not comfortable. This study gives a good insight into older people’s experience with assistive devices (Haggblom – Kronlof 335).
Today, several disease conditions are positively impacted by the use of such devices. Assistive devices like walkers are often useful for people with claudication, congestive heart failure, or respiratory disease who often need to stop ambulating and sit down to rest (Bradley 10). Another device known as the Activa® Parkinson's Control System, is a totally implanted brain stimulator to reduce the symptoms associated with advanced Parkinson's disease that are not adequately controlled with medications. It improves some of the symptoms associated with the disease (FDA, 2013 p. 1). One more device that has proved to be of great use particularly to the elderly cardiovascular disease patient is the pacemaker that is used to treat arrhythmias or irregular heartbeats.
In summary, we can see that medical devices bring a great comfort to the elderly user and are also well-accepted by a majority of users, but some challenges are faced by this group. The challenges mostly include the social aspects in that there seems to be an effect on their self-esteem. Once an elderly starts using a device at home, it does have implications on the home he/she lives and the people they share the home with. Some users are not comfortable with the size of the devices, while some are not comfortable with the noise it makes. Yet, there is an overall satisfaction because it gives the elderly a sense of well- being, comfort, and a sense of security. Devices like mobile medical technologies have eased the life of the user in urban as well as the rural setting of most of the countries. It has made keeping a track of the disease so easy that the elderly users can virtually relax and let the technology do everything for them - be it a reminder to take a drug, or a calorie counter, or appointment notices, or even physician or hospital locators. Such devices can actually control costs and improve the patient’s quality of life. Medical devices are becoming an essential tool in everyday life of an elderly; and with such devices and technologies around, one can even have an option of living well without human assistance or support.
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