NeuroRehabilitation 28 (2011) 249260 DOI 10.

3233/NRE-2011-0653 IOS Press

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Smart home technology for safety and functional independence: The UK experience
Guy Dewsburya, and Jeremy Linskellb
a b

Florence Nightingale School of Nursing and Midwifery, Kings College London, UK NHS TORT Centre, Ninewells Hospital, Dundee, UK

Abstract. This paper proposes that people with neurological conditions can be successfully supported by smart homes only when their needs and aspirations of the technological interventions are fully understood and integrated in the design. A neurological condition can and does provide a clue to the nished technological design but this alone fails to personalise the system and stands to be rejected by the person who requires the technology. This paper explores the underlying issues of the complexity of this design process when designing for people with neurological conditions, and advances a matrix to facilitate the assessment process to maintain a person-centred design of any system. Keywords: Smart Home, technology, United Kingdom

1. Smart homes and disabled people The notion of a smart home is not new, and the use of smart home technology has been used for many years to support people in their own homes to lead more independent lives [19,20,29]. We consider the main smart houses in the UK. Before undertaking this task it is important that we address the question of what a smart house is. A smart house is a house that has smart devices in it. Smart devices are devices that can be programmed so that they can determine their status in relation to other devices. They can share any information that is available within the system and the sophistication of individual devices determines how many layers of functionality they can each engage in simultaneously. For example a presence detector, which is a sophisticated security sensor, can provide automated control of heating and lighting independently of each other, whilst simultaneously offering a security function and acting as part of a lifestyle monitoring system. The ability to easily and independently alter the relationships between devices and access all available information within the system offers exciting

possibilities for providing managed and interactive environments. This paper will discuss both the localised and global advantages of utilising such technology to support individuals with neurological conditions. 2. Smart homes and neurological conditions Gentry [26] broadly covers many of the key aspects of smart home technology in an excellent overview of the subject area. This paper and those by Rogoante et al. [46] and Rosen [47] on Telerehabilitation provide excellent overviews of the differing relationships between technology and people with neurological conditions. There is considerable material on the application of smart home technology that incorporates many aspects of the use of technology that can be applied to people with neurological conditions [2,4,9,11,23,29 31,37,41,51,54] but little real evidence of the application of smart home technology to support neurological conditions specically. To this end, we will concentrate on the UK aspects of smart homes and their importance for people with neurological conditions. 3. Smart homes in the UK

author: Guy Dewsbury, Florence Nightingale School of Nursing and Midwifery, Kings College, London, UK. E-mail: guy.dewsbury@kcl.ac.uk.

Corresponding

In the UK, the Assistive Interactive Dwelling (AID) house in Edinburgh was probably the earliest attempt to

ISSN 1053-8135/11/$27.50 2011 IOS Press and the authors. All rights reserved

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apply smart home technology to support independent living [25]. The site functioned primarily as a demonstration facility [6] but the design team were subsequently commissioned to create a Dementia smart at in Paisley. The layout was designed and generally remodelled to meet the needs of people with dementia, which included the sympathetic design of doorways, bathroom and gardens and it incorporated technology, similar in conguration to the AID House. Glasgow City Council wanted the at to be able to accommodate a wider range of disabilities and it was used by a young adult with acquired brain injury. Members of the same design team were also commissioned to design a system for people with learning disabilities and challenging behaviour. This consisted of three properties; one residential home for four people and two units, each providing ten supported living accommodations. The Commissioners introduction to smart home technology had come via a visit to the CUSTODIAN smart at in Dundee (see below). The other smart house system that was developed alongside the AID House had limited success as a demonstrator and was decommissioned but the design team were invited to collaborate with the University of Portsmouth [8] and John Grooms Housing Association on a project where six out of 500 social housing units were to have smart systems installed, with 3 wheelchair accessible units of the ground oor and three preparatory cabled units on the 1st oor. After some modications, following the ofcial launch, some technology was used by the residents of all three ground oor units. Also the same design team were approached to install systems into two bungalows in Wigton, although only one was eventually commissioned. It was initially used by an elderly couple and was then occupied by a physically disabled young adult. In 1999 the Bath Institute of Medical Engineering (BIME), in conjunction with Dementia Voice and Housing21, formed a consortium to develop the Gloucester Smart House, which was launched in June 2000 [44]. It was designed as demonstrator to show how smart technology can be applied sympathetically and as a test bed for disability-specic devices. BIME designed a number of devices, intended to support a dementia sufferer. These included: A bath monitor A cooker monitor A voice feedback system Following the success of the Smart House in Gloucester, Housing21 agreed to the installation of two

real-life installations, one in Bristol and one in London, within extra care sheltered housing schemes. The Gloucester smart house closed in 2004 when the work began on the Bristol at. A detailed evaluation of the use of the London at has been performed with very positive results, which indicated that key aspects of the individuals lifestyle had been either retained or improved with the support of the technology [45]. The Bristol at operated in a similar manner to the London at and although it never fullled its function as an intermediate care facility, it is currently being used by one long-term tenant with dementia. Hereward College is a further education college based in Coventry that has specialist facilities to cater for students with impairments on a residential or day only basis. The College has been incorporating technology within their residential blocks since 2001, on an assessed need basis, with funding from the Learning and Skills Council [7]. There are now 24 smart house rooms at the College and it has recently installed an iCue system into a cottage within its grounds in order to provide intelligent management of a communal kitchen area for a range of residents with cognitive impairment. iCue, which is a proprietary system built on the experience gained within the Millennium Homes/Foresight initiative described below, has also been implemented in a number of technology demonstrator sites within England recently, including the iHouse, with a number of scenarios to support cognitive and sensory impairment programmed in for illustration. The Millennium Homes project led by Brunel University was funded to develop caring technology for the elderly [21]. A demonstrator/evaluation cottage was followed by the Caring Home Project that consisted of twelve silent homes in Greenwich, which were further described as caring not smart. However this project led to the technology, known as Insight, being implemented in a Supported Living Scheme, Southwark, London. A review in 2005 reported positive view from residents and carers. There was also a private purchase of a system for an individual, post-stroke. In 1999 The Manchester Methodist Housing Association (MMHA), in collaboration with Bolton Council, undertook two smart house projects, as part of a regeneration project. The Cedar Foundation in collaboration with Habinteg Housing Association currently has three active smart facilities. Their rst development was in Belfast, which was opened in 2003 [27], which consists of two blocks, each with four apartments on two levels. The four ground oor apartments are fully accessible for

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wheelchair users and three of the upper ats are designed for able-bodied individuals with brain injury or sensory impairment. The ground oor apartments offer a full range of automation and safety monitoring. The three upper apartments offer safety monitoring and have preparatory cabling for full automation. An evaluation of the development, from a user perspective, was published. Two further projects followed in 2007. The developments offer a full range of automation and safety features and are intended for a mixed population of wheelchair users, brain injury and sensory impairment. The outcome of both developments are documented in a report that provides insights into the value of smart technologies for these client groups in facilitating and developing supported living [39]. Reference has been made to the CUSTODIAN project (http://www.scotmark.eca.ac.uk/research/58. pdf), which was an EU-funded project from within the TIDE programme that developed and evaluated a user-friendly interface for designing smart home systems [12]. Health and Social Services within Dundee, Scotland participated within the project and as a result Dundee received a demonstration smart home, which was used to develop interest in the technology from local housing and care providers. A smart home system was also provided to an individual with acquired brain injury in her own home, which was the rst recorded real-life implementation of smart home technology to meet a specied, neurological need [17,19,20]. This individual continued to benet from the technology for a number of years and the demonstrator site provided the impetus for developing the smart Transitional Living Unit (TLU), which itself led to an number of signicant further smart home developments and implementations. These have included three supported living developments for fteen individuals with complex needs and challenging behaviour, which had all previously been considered unsuitable for community-based living; a custom designed new house for a tetraplegic teenager to meet her long term needs; and, a signicant number of properties within Dundee City were installed with preparatory cabling for future smart home implementation. The smart TLU was a fully adapted at developed jointly by The Centre for Brain Injury (CBIR) and Dundee City Council as a Transitional Living Unit (TLU) to support the rehabilitation and preparation for discharge of in-patients of the CBIR. Both partners subsequently supported and funded the implementation of an extensive smart house system within the TLU to broaden the applicability of the TLU to in-patients of

the CBIR and explore its potential to support rehabilitation [35]. The complexities associated with managing and supporting hospital in-patients on non-NHS property limited the ability to fully explore these issues fully and the facility has recently passed into the control of Dundee City Social Work Department, via the Dundee Telecare Project, who intend to use it as a demonstrator and training facility as well as an assessment facility for young adults with a range of disabilities. A fully adapted smart house system has also been installed in a cottage in Clackmannanshire that is intended both for respite and assessment, for those with physical and learning disability. A number of privately funded installations have occurred on an ad hoc basis and these include: a custom-built house for a tetraplegic individual a custom-built house for an individual with paraplegia a young adult with acquired brain injury a custom-built extension to a house for 2 autistic siblings a woman with dementia whose carer was her husband There have been on-going ad hoc smart home implementations within the UK that have continued at a slow but steady rate over the last decade. Most of the projects described have some relevance to neurological conditions, covering a range of physical, sensory and cognitive impairments. A lack of detailed reporting, however, has limited the level and quality of knowledge available for strengthening the on-going developments

4. Neurological conditions and smart homes In England, smart homes were rejected in favour of less complex systems through the introduction of the Governments 2006 Preventative Technology Grant (PTG) which provided money to all English local authorities for telecare services. As has been widely reported the uptake of telecare by local authorities was patchy and no overall standards were embodied in their services [42]. Difculties aside, the PTG and its more formally structured counterpart in Scotland, the National Telecare Development Programme, allowed local authorities to embrace the use of technology to support people. The focus was supporting older people but many authorities took the opportunity to see how telecare could be used to support people with other conditions. Telecare manufac-

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turers recognised this and developed some conditionspecic sensors to support these efforts (most notably the epilepsy sensors). The extensive roll out of telecare has allowed many observations to be made regarding the application of monitoring and alerting technologies and these will be considered in this next section, juxtaposed against the more complex solutions that smart home technology can offer. These observations are learned from the personal and practical experiences of the authors who were both directly involved in the design of technology systems to support people; Guy Dewsbury was a primary researcher on CUSTODIAN and was Telecare coordinator for a large London Borough and has over fteen years experience of designing technology to support people including the design of 54 residences for autistic adults in Scotland, whilst Jeremy Linskell has fteen years experience in assessing for and providing Electronic Assistive Technology (EAT) and has designed and implemented a number of smart house systems to support individuals with complex needs, which commenced with participation in the aforementioned CUSOTODIAN project [16]. The authors therefore have considerable combined experience on practical perspectives as well as both authors working in the eld academically for over fteen years. Telecare deployment can be considered in a number of ways. One of the more popular is to consider the product output through things such as the post installation questionnaire [5] which locates the system from the perspective of its effectiveness. Within telecare there are a range of devices that are commonly used, namely Pendant alarms; fall detectors; bed occupancy sensors; pull cords; movement sensors; Smoke/heat/ood detectors/carbon monoxide monitors; automated lighting; location sensors; activity sensors; well being monitors; medication reminder systems. Pendant alarms are simple buttons usually worn around the neck which when pressed cause the dispersed alarm unit, to dial out to a remote call centre. Pendants can have different properties and assessment for a pendant must ensure that the person has the capacity and dexterity to actually use it. It is also important that the dial tones from the dispersed unit can be turned off so these do not trigger other side effects such as seizures or confusion but doing so can remove the ability to cancel the alert. Pull chords are another method of actively triggering an alert call and these must again be congured around the individuals needs and abilities. The exibility of smart technology would provide

a system in which activation, feedback of activation and method(s) of cancellation were fully congurable, within the living space, to meet the individuals cognitive, sensory and physical abilities, which may change signicantly over time. There are a range of devices, relating directly to personal safety or status that can trigger alerts. Fall detectors are client-borne devices that can be worn in a number of ways and depending on the sophistication of the sensing technology have differing levels of accuracy and reliability. Importantly they rely on being worn at all times and this may be inconvenient or impractical of some occasions, some of which can be ameliorated. For example failure to don the device at bedtimes can be augmented with the use of bed occupancy sensors, which would not necessarily cover day time bathroom usage for instance, so such activities may require more sophisticated methods of monitoring than simple sensors. But even apparently straight forward usage would benet from intelligent information processing in order to support decision-making. The individual with Parkinsons Disease who has tripped and cannot rise due to bradykinesia may self-manage with the support of automated cueing, whilst the individual with the early stages of MND who has fallen and cannot press a pendant or rise because of reduced upper limb function will need assistance, and a confused older person may be lying in distress for days and never consider pressing a pendant for help. Aside from these issues it is preferable to consider more intelligent technology predicting possible falls and supporting the individual in preventing such situations. Occupancy sensors have already been referred to, but are not always appropriate or sufcient. An example might be identifying when an individual with Huntingons chorea has moved themselves into a compromised position on their bed, as a result of their writhing movements, and additionally proactively managing fall prevention might involve predicting when someone is about to leave their chair or bed. Safety sensors such as heat or gas detectors have legal requirements to provide loud audible warnings, which may cause problems for some individuals, so using such devices within a predictive protocol, to prevent the situation arising, would be benecial. This acknowledgement of potentially harmful situations with interactive response scenarios, which can be backed up by remote alerting if necessary, offers signicant exibility for supporting people with cognitive disabilities. Epilepsy sensors can detect the shake of the tonic phase of a seizure and some can also detect the limp-

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ness of the clonic phase. Many epilepsy monitors are rudimentary, consisting of simple vibrations sensors, which are difcult to tune to the individuals needs, whilst sophisticated devices, based on pressure sensitive lm that can analyse many aspects of a beds occupancy and others that utilise a combination of sensor inputs to analyse bed activity. Movement sensors have changed little in the last ten years and are often still big clunky things that glow when activity is sensed and even when the glow is switched off, they can produce adverse reactions from confused people. There are a number of software suites that use the information from these devices to produce logs of a persons activity patterns over a day. Some of these systems are very useful if used correctly but it is difcult to not infer things from the evidence they provide, and it is in fact now clear that much additional contextual information is required to support such usage [28]. Automation of functions such as lighting,doors, windows and curtains offers signicant benets for individuals with physical disabilities, but automation provided via standalone sensors may prove limiting, by taking the locus of control away from the individual. An individual may have some physical skills that they wish to maintain, or which may vary signicantly over the day, so having variable and transferrable methods of control would be benecial. Additionally automation may not always be required or appropriate and the ability to selectively disable automation may be of great benet, for doorways in conned areas for instance. The use of technological interventions for cognition is now well established [36] and a range of technologies from pagers [53] to PDAs [10] are regularly being used in rehabilitation and to promote independence, especially for those with Acquired Brain Injury. These devices provide a range of supports to assist in structuring daily life, performing tasks and general orientation and there is also emerging evidence on the benets of this approach for carers [51]. It is clear that safety and general monitoring capabilities as well as simple, automated prompting could be benecial for such individuals, but it is the potential interactivity of a pervasive smart technology that offers exciting possibilities to provide context-specic feedback for many aspects of daily life. With the recent appearance of many interfaces and gateways between smart home systems and smart phones, the potential to implement this is available, and the ability to overlay this interactivity onto existing technological methodologies for cognitive support, offers new possibilities in terms of enhanc-

ing independence for individuals with acquired brain injury. Smart house technology, with its ability to utilise all information within the system in a exible manner provides a number of advantages over an environment supported by arrays of discrete devices alone. These include the ability to selectively enable automation; the ability discern levels of alert; the ability to combine multiple alerts for a more textured monitoring conguration; and, the ability to combine monitoring and alerting to provide an interactive environment. In such an environment, where there is no inherent differentiation between information streams, and how they might be used, a more person-centred approach is required for indentifying the appropriateness of the system. This requirement is compounded by the challenging nature of integrating the more personal and social aspects of the technology, as will be discussed in the next section.

5. The Neurological Dependability Assessment Matrix (NDAM) Putting the person into the assessment is a key factor in ensuring a person-technology-t exists. Getting the correct technological response for a persons needs, experiences and wishes are critical. The authors advance a matrix that is based on their research experience in the area for use in the technological assessment of people with neurological conditions. The important feature of the (NDAM) matrix is that it looks at the persons needs, wishes and experiences as a method of informing the assessment process. Therefore, it allows the person to be more than their medical condition. Experience with working with people with a wide range of neurological conditions dictate that no two people experience their condition in the same way and that life patterns can contribute to the relief or cause of further episodes of a condition. The matrix does not mean that the condition is not important, rather that it is the outward expression of how the condition is experienced and the resulting needs and wishes that are most important. For example, two people with the same brain injury will experience their injury in completely different ways. A condition such as Apraxia, which is characterised by an inability to carry out learned purposeful movements, can be experienced differently by each person with the condition and their subsequent needs might be ignored in the assessment for a potential technological solution. Similarly two people with Parkinsons, displaying similar

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Fig. 1. The Neurological Dependability Assessment Matrix (NDAM).

levels of impairment and problems with initiation, may respond to completely different sets of cues. Post installation techniques [5] and methods that focus on the technology or the outcome without considering the whole person are fraught with danger as technology mismatch can lead to technology rejection or non-compliance. It is with these caveats that we introduce the Neurological Dependability Assessment

Matrix (NDAM) (Fig. 1) which builds on the work of [14,15,18,49] who developed a model, a method and a tool namely Dependability Model of Domestic Systems (DMDS), a Method of Dependable Domestic Systems (MDDS) and Dependability Telecare Assessment tool (DTA). The model (Fig. 2) uses the ideas behind dependability within computer systems as originated by [33] and [3] and adapts them to a social context

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Fig. 2. The Dependability Model Domestic Systems (DMDS).

of designing assistive technology systems for disabled people. The main points of this model is that it breaks the social and technical aspects of designing technology systems for older or disabled people down into bite size pieces and therefore allows the assessor to consider a range of both social and technical issues that are addressed in the subsequent Method of Dependable Domestic Systems (MDDS). MDDS provides a number of checklist questions for each box in gure one and a range of suggested questions. Essentially DMDS and MDDS promotes that the technology system needs to be Fit For Purpose in that it does what it is supposed to do. It also is required to be Trustworthy, such that the user will place trust and condence in the system. The system is also required to be Acceptable to the user in a number of ways and nally the system should be able to be modied and adapted. MDDS follows the order of the DMDS dia-

gram (Fig. 2). The grouping of the items is a useful way of trying to encapsulate a number of key dimensions into a small number of pointers. Not all of the items in MDDS will be applicable to all AT devices or systems. MDDS users have to decide the level of dependability and criticality (how critical the system is in relation to the user) of the system based on their professional expertise. This alters depending on the type of system under consideration. Systems that support life and with which failure could have catastrophic reactions might require all the dependability aspects to be considered, but in most cases this will not be the case. As the system increases in criticality, the more elements within the system are required to ensure that the system functions dependably. The table serves an illustrative purpose only to demonstrate the increase in dependability issues per system complexity. It is ac-

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Fig. 3. The Relationship between Dependability features and Assistive Technology Outcomes.

knowledged that some apparently simple systems might have a number of dependability issues that are required to be considered. As the criticality of the system increases, more aspects are required to be considered. The professional through close contact with the user best determines the criticality of the system. Often the persons needs are so evident that the criticality of the system ts obviously into one of the categories above (Fig. 3). MDDS and DMDS gave rise to the Dependability Telecare Assessment tool (Fig. 4)(http://thetelecareblog. blogspot.com) which was developed specically to assist System Integrators in the in their assessment process. This tool has the many of the same elements of the DMDS diagram but also comprises elements such as portability, comfort.

6. The application of NDAM NDAM is a qualitative matrix that does not answer questions, rather it provides them. The utility of the matrix is that when someone with neurological difculties is being considered for technology the dependability attributes serve as a simple interrogative guide to the assessor to determine if the best solution is being addressed. Through the use of the matrix it is envisaged that this will result in value for money as appropriate investments in technology, planning and manpower (by taking into account the subjects personal preferences/requirements). NDAM assists the designer of the smart home by assisting the interrogation of the system from the user perspective.

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Fig. 4. The Dependability Telecare Assessment tool (DTA).

7. Example of NDAM in action A mother in her mid 30s with Multiple Sclerosis lives with her 2 children aged 9 and 13. She lives in a wheelchair adapted house. She has good use of her arms and can self transfer although she is suffering increasing periods of weakness, and has fallen on occasions when transferring. She has become slightly forgetful and gets frustrated at her increasing difculties with performing unfamiliar, but seemingly simple tasks. She has support from social services but her oldest child provides a substantial amount of her informal care. She is ercely independent and is determined to continue to care for her children independently. NDAM allows the designer/reviewer to consider the mothers actual needs against current provision and consider the options for systems that can supplement the mothers abilities by producing prompts and monitoring her activities to ensure the family is safe. The aspects of tness for purpose, trustworthiness, acceptability and adaptability focus the designer on the whole system including the family in the needs and wants based assessment for technological support. It is the personalisation and person-t to technology that the success of failure of an installation can be judged. NDAM can facilitate better personalisation of technology and personalised assessments; it adds the person and the technology into the equation.

8. An appraisal of NDAM NDAM is founded on well established roots but has not ofcially been evaluated at this stage. What is evident is that is has been used, and like its predecessors, MDDS, DMDS and DTA have demonstrated, there is a great need to have something that provides questions rather than answers. NDAM and smart homes are where the real evidence can be uncovered. The use of NDAM in the design of smart homes for people with neurological conditions will enable bespoke solutions that reect and meet the needs of the potential occupants. NDAM focuses the designer on the needs of the occupant as well as the technology and serves as an integrator between the two, mediating the challenges of any new and bespoke design. This nurturing element of a design can mean that a person is in reality disabled rather than enabled through the over protective and over prescribing assessor. Technology should mitigate against but not remove elements of everyday living such as danger, doing things for oneself that one can do etc. A core essential philosophy that underlies NDAM is the rationale that people must be encouraged to do for themselves what they can actually do. NDAM personalises the design and ensures that the expectations are actually met and that a rational design is achieved which mixes automation, monitoring, undertaking core tasks with facilitating the person to achieve their own goals.

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In the world of smart homes and assistive technology where there are many outcome focused methods such as PIADS [32,34]; LIFE-H [43]; Assistive Technology Outcome Measure (ATOM) [22], OTFACT [48]; IPPA: Individually Prioritised Problem Assessment [52]; it is important that there is a qualitative technique of assisting the assessment process which NDAM provides. NDAM complements these other methods and supports the development of questions; it provides no answers but the questions are often the most important element of an initial design. Failing to ask a signicant question can be the difference between an enabling and disabling design.

9. The clinical applications of NDAM NDAM provides a way of visualizing the core issues faced by smart home providers and users, thus answering Gentrys plea for a mechanism in place to promote collaboration among stakeholders [26, p. 215]. The matrix provides a template for discussions and a platform for all concerned parties to illuminate and justify their concerns. It facilitates the designers/technologists by providing a simple method of demonstrating their worth and most importantly, it provides a traceable audit trail of the key decisions that were reached in the discussion. The different elements in each dependability area provide a point of interrogation that should be discussed with all stakeholders including the person with the neurological condition. Finally, through using NDAM the end user is provided with a voice, and a way of articulating their needs to providers and to have those needs and desires respected. NDAM is not envisioned as a complete answer to all questions; rather, it is a model that encourages clinicians to consider the person, their environment, their needs and the technological limitations that might apply in a particular situation. A key benet of NDAM is that through discussing the various elements and needs of a person, a high-end solution may be reframed as a low-end solution (instead of a sensor alerting someone a simple bell might do the trick).

tions means that the design of a smart home or smart space cannot be guessed at but has to precisely meet the needs and wishes of the person who will be using the technologies. The paper has argued that although there are many outcome measures applied to assistive technology and assisted living, there are currently few tools to assist the smart home designer. The paper then advances the Neurological Dependability Assessment Matrix (NDAM) as a qualitative assistance for the smart home designer to ensure that there is a technological-t and that the needs and wishes of the person requiring the smart home are not overshadowed by complicated and often redundant technologies which could disable rather than enable the person with the neurological condition.

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