Detecting and reducing loneliness. Introducing quality communication into lives of elderly

ABSTRACT

Independently living elderly are often subject to deep and long-lasting loneliness. With a steadily aging population and a negative population growth rate by 2040, the current prob­lem of lonely elderly is going to increase simultaneously. A smart home-based system was designed to detect loneli­ness levels and reintroduce quality communication between elderly and their close family members by providing high- level interaction through a multi-modal speech and touch interface including notifications through ambient light pan­els and a home assistant to let elderly users interact with Shu Shi.

An interactive prototype was created for the course Intel­ligent Interactive Systems as part of the Information Stud­ies Master at the University of Amsterdam. The system is designed to detect loneliness based on sound sensors, tem­perature sensors and facial recognition features through the tablet application for the elderly user. Family members can share their mental presence with the elderly in various ways e.g. through sending a commonly shared song to revoke pos­itive memories in the elderly user and reduce the moment of loneliness. There are various types of interpersonal commu­nication such as verbal communication or non-verbal com­munication i.e. body language, eye contact, facial expres­sion, outward appearance. The system focuses on providing asynchronous communication through various state-of-the- art modalities, designed for to meet the requirements of both elderly and family members.

This report covers the introduction and motivation related to the system, the literature review in related works, followed by the interaction and systems design, discussion and future work sections.

KEYWORDS

Intelligent Interactive Systems, Reducing Loneliness, Ambi­ent Lights, Smart Home, Quality Communication, Speech- to-text, Multi-modal systems

1 INTRODUCTION AND MOTIVATION

Loneliness is a frequently observed phenomenon among in­dependently living single elderly people. With the pension age comes a natural decrease in social relationships since the opportunities to meet new acquaintances is not a part of the daily work life any longer. The loneliness patterns are based on various definitions, i.e. a state of social isola­tion and identified through low social interaction and a large gap between the current relationships and the desired rela- tionships[20, 33, 48], We defined loneliness as a feeling of exclusion, feeling of isolation and the tendency towards the absence of friendship.

To decrease the loneliness levels in elderly, certain factors such as quality and frequency of communication with close family members such as children plays an important rule. This type of asynchronous communication helps to increase high-quality communication between two different genera­tions. In other words, an older generation that primarily re­lies on synchronous communication e.g. phone calls and a younger generation, busy working long hours and less flex­ible to answer longer phone calls during the day, therefore prone to using an asynchronous form of communication with their social network through e.g. instant messaging. The con­tribution of Shu Shi offers an enhanced communication tool for family members to provide ad-hoc emotional and social support to their parents within a few clicks, to bridge the gap between their different communication needs, even through­out a busy workday. The system does not imply that users should avoid synchronous forms of communication with their parents but rather offers a momentary solution to conve­niently share their mental presence during the day and ulti­mately decrease loneliness as well as foster life satisfaction and happiness within the growing segment of elderly while supporting independent living [45, 51, 53].

The solution has three overarching design principles; sus­tainable by design, privacy by design and inclusion by de­sign. The first principle concerns the green design that the solution promotes e.g. minimize non-renewable energy con­sumption by aiming to make use of existing hardware in the users’ environment such as tablet devices and WiFi speakers that are already part of the users technology assets. Privacy by design incorporates the inherent protection of user data in the design of the solution, e.g. users don’t have to con­figure privacy settings to ensure their data is not shared with third-party providers but the default data privacy is set to the highest privacy level. The third principle inclusion was created to ensure the interaction design includes colors that are appealing to all genders and not is not built gender­specific to begin with, a crucial step towards diversity and inclusion in user design. Another component that also falls under the inclusion category is the diversity in the digital skill range of elderly users, therefore a range from simple in­teractions with the system to even pro-actively sending over self-recorded material to family members is enabled through the solution.

UY means plant seed in Chinese and Japanese, it serves as a metaphor for transporting communication gently from one place to another, similar to plant seeds carried by the wind to their next place. Also, seeds are something small than grow into a powerful entity such as a plant, this means that the small seeds of communication that are planted ev­eryday through the system can grow into a strong communi­cation and relationship and eventually overcome loneliness. The system is installed in the home of the elderly and allows convenient communication for both generations through vari­ous modalities e.g. speech, touch, light interfaces to facilitate asynchronous, high-level communication with close family members who receive e.g. recorded audio messages from the elderly in transcribed text form on their preferred messen­ger application and hence contribute to building a closer re­lationship through increased quality communication. In the related works section, relevant theories to loneliness and com­munication were identified and analysed for further under­standing of the subject matter.

2 RELATED WORK

This section draws on various fields such as psychology, soci­ology, technology acceptance, use and high-quality commu­nication among elderly.

The causes and consequences of a reduction in social life are explained in detail, leading to a description of loneliness increments and severity levels. Furthermore, asynchronous communication has been defined, followed by the recent de­velopments in user acceptance and technology innovations for elderly to present an overview of currently available in­dustry solutions[l].

2.1 Reduction of Social Life

2.1.1 Causes. From the pension age onward, the social circle of most people starts to reduce naturally since peo­ple above the pension-age have less opportunities to make new acquaintances, previously possible through work con­nections is hence negatively correlated with age[18, 49], As a side factor, the daily routine drastically changes from a full-time active occupation to a lot of free time and only mi­nor personal administration tasks to manage, hence a rather passive role [7, 52], However, as research by Adams proposes, elderly do not necessarily have a desire for novelty and meet­ing new social connections, instead they are looking for cre­ating deeper bonds within existing, reliable relationships [2], Another reason for the decrease in social activities could be the abandonment by family members and a possible abuse of the helplessness of the elderly as seen in a study in Brazil [52], The study concluded that loneliness can be seen in dif­ferent stages of life but is rather prevalent with the elderly age group. Another reason for less contact with family mem­bers could be the urbanization and the children moving to bigger cities for higher-paying jobs to support themselves and reach higher levels of self-actualization to satisfy their social needs[39, 42, 51].

2.1.2 Consequences. If those bonds cannot be formed or are not developing in a positive way, the combination with other age-related factors such as decline in physical strength, health, a growing dependency on relatives in terms of fi­nancial, physical and mental assistance, the loss of spouses as well as the diminishing economical value can create a level of loneliness that leads to outcomes such as depression, poor sleep quality, anxiety, cognitive decline, circumstances that are difficult to reverse for an individual on their own [2, 19, 25].

According to recent academic research papers, one of the positively related consequences of above-mentioned loneli­ness levels across age and nationality is depression [50], In a recent Chinese research study, high levels of loneliness were found to be positively related with high levels of personal dissatisfaction and depression [41], Often times, individuals would pro-actively distance themselves from their social sur­roundings while referring their lack of social interaction as the responsibility of other people in their social circle, a so­cial isolation behaviour can lead to depression and physical diseases [13, 59], Anxiety, a common mental disease is closely related to loneliness and often linked to symptoms such as emotional instability and low social integration [21, 52], Ad­ditional Factors correlated with loneliness among elderly con­cern poor sleep quality as well as cognitive decline [7, 19].

There are various types of cognitive decline, Mild Cogni­tive Impairment (MCI), Alzheimer’s disease and Dementia were found to be the three most widely occurring phenomena among elderly. MCI is the mildest form of CI and can be cat­egorized in between natural aging effects and the affected el­der’s beginning stages of dementia, the estimated number of affected elderly above 65 lies between 10-20 percent. Further­more, it only concerns the cognitive decline, unlike dementia and Alzheimer’s which also impair the elder’s physical and vocal control abilities [43], A research conducted by Baum­gart suggests that loneliness is linked to cognitive decline through the negative behaviours that it introduces into the elder’s life such as a diet high in carbohydrates, trans-fats and sugars, low physical activity and exercise as well as little interaction with regards to cognitive challenge and even al­cohol or substance abuse [8], Consequently, these factors can lead further to poor sleep quality and besides, are all known as contributing factors to cognitive decline[8, 11, 12, 38], In addition, peer-reviewed research in the field of psychoneu­roendocrinology found that loneliness actively increases cor­tisol levels, a physical state that is linked to cognitive decline through the affection of memory-storing neurons in the brain [23, 54], Another loneliness-related research finding by a re­cent study published in the Journals of Gerontology stated that loneliness increases the risk of dementia by 40 percent [55], A clear link between loneliness and severe consequences of cognitive decline can thus be assumed.

Finally, a previously mentioned association with loneliness was made on the sleep deprivation and poor sleep quality topic. Sleep quality was measured in a Turkish study by Tel, to determine the elder’s quality of life. A positive relation between age and poor quality in sleep was found to be sig­nificant, as well as a negative relationship between age and life quality, meaning that an increase in age comes with wors­ened sleep and reduced life quality[56]. An increase in social activities on the other hand, did not result in a better self­recorded sleep quality score on the long-term over a period of five years but rather short-term periods only, according to a recent study by Chen, Lauderdale and Waite[14]. This means that an active social life can be beneficial to good sleep quality and hence less loneliness in elderly, at least on the shorter time-frame[47].

A further consequence of loneliness and the reduction in social life could be personal dissatisfaction among elderly. A recent study by Etxeberria rated the elderly age group on emotional profiles and derived three main categories; the dissatisfied with high negative affect, loneliness and unhap­piness levels, the happy with high levels of life satisfaction and positive affect as well as low levels of loneliness using few passive strategies to regulate emotions and finally the re­silient with moderate levels of emotional affect and a passive coping strategy [24], It was noticeably observed that there was a change with the age group of 85 and above mostly classified as resilient, showing higher levels of negative affect than younger participants[16, 24], Gender categorization and life satisfaction was used in a Korean study, to determine which group would be more inclined to feel lonely, the re­sults showed that the Korean female participants were less susceptible to strong feelings of loneliness because of their natural competence to maintaining close relationships[59]. Overall, it can be concluded that the lack of social relation­ships, decline in physical and cognitive ability as well as poor sleep quality are positively correlated with loneliness [56].

2.1.3 Countermeasures. Factors that counteract negative long-term outcomes such as depression and anxiety are often traced back to solid social foundations and strong family bonds i.e. frequently visiting children and the attendance of social gatherings i.e. weekly leisure club because of the social and emotional support that such connections provide [14, 15, 21, 32, 41, 50], Furthermore, a positive relationship between spiritual or religious contributions and a decrease in loneliness was observed by the Brazilian research study, since elderly ’’were able to cope with the losses imposed by life [...] [by] holding onto a bigger force” [52].

2.2 Levels of Loneliness

Based on the literature review, different levels of loneliness were defined. Social loneliness for instance, concerns an in­dividual that is not part of a social group or network any longer, this can take place in the form of a friend group or social gatherings based on similar interests such as spiritu­ality or other leisure activities [20, 41, 52], A second type is defined as emotional loneliness, the lack of a deep emotional bond with another person in ones social environment[20, 41], This type of emotional bond is not necessarily categorized under romantic relationships but can also take place in close relationships with friends or relatives, as long as they provide feelings of affection and security.

Weiss’ typology concerning social and emotional loneli­ness defines six social provisions, also known as interpersonal needs [57], including attachment and the resulting emotion of safety and security, social integration within a network of shared interests, opportunity for nurturance to mutually exchange the sense of responsibility, reassurance of worth to receive affirmation of ability and skills, reliable alliance to foster the security of a reliable social network and finally guidance by i.e. receiving advice based on previous life expe­rience [20].

Loneliness can induce a state of emotional instability, lack of self-efficacy, purpose and meaning of the elder’s life [8, 26], These research findings let us to assume that decreasing loneliness can play a significant role in increasing the life quality of elderly.

2.3 Asynchronous Communication

To increase the quality of communication and interaction between the elderly user and the child, certain factors were found to be correlated with good communication should be considered for the system. Since most adult children are busy working during the week and have full schedules with week­end activities to attend to, the strong need for asynchronous and yet effective communication, going beyond than chatting services between elderly and their family members exists[51].

With an aged user group, the different needs in commu­nication need to be accommodated due to a natural decline in physical and cognitive states i.e. hearing or vision impair­ment. Yorkston found that vocabulary, grammar knowledge and the ability to repeat remain on a similar level, whereas the "comprehension of utterances” is rather inclined to de­crease with the age [60].

2.4 Current Technology Assistance Solutions for Elderly

A categorization of technical living-assistance was established by Ruijiao Li and his team to further organize ambient- assisted living (AAL) into daily task facilitation, mobility assistance, healthcare and rehabilitation as well as commu­nication, social inclusion[40]. For above described cognitive decline in the form of Alzheimer’s, a number of success­fully implemented technologies are available to assist pa­tients through speech-controlled reminder systems who re­peatedly play reminders via the speakers or digitally con­trolled pill-release boxes to help remind patients to take their medicine at the right time of the day[30].

A study by Shen argued that the use of a smart home­care system for elderly would actively extend the amount of time that elderly can live on their own and thus playing an important role in the future of healthcare as a personalized form of health and care assistance[51]. Options for home-care system include the use of smart sensors installed in every room or a television-operated system to ensure the safety surveillance of the elderly user in the own home[27, 51].

2.5 User Technology Acceptance among Elderly

A survey by Pew Research Center collected data from US- American elderly above the age of 65 and found that 30 percent of the target group participants owned a tablet de­vice, 80 percent had a cellphone, 40 percent a smartphone in use[4]. To test the user acceptance of technology among elderly users in the Netherlands, a study was carried out in the case of a home-care system for elderly and stated that elderly had a generally positive attitude towards adapting the system and learning more about different uses. Elements that would contribute to a user acceptance and adaptation are low-cost efficient systems, the sharing of physical instruc­tions cards for the system and benefits to various stakehold­ers apart from the elderly users [34].

3 INTERACTION DESIGN

The system will be available for elderly tablet users and close family members whom the elderly user would like to interact with on a frequent basis. The tablet is an integral part of the home system, its larger size enables even slightly visually impaired users to make use of the communication service via touch or speech interfaces. It also enables high-level mobility for the user and was deemed suitable for the user group since approximately one third of seniors above 65 already own a tablet based on a 2017 study by Pew Research US [4], While a smartphone version for the app is a possibility for elderly users who are comfortable using a smartphone or don’t own a tablet, this version of the interaction design was directed only towards elderly tablet users due to the large screen size.

3.1 User group persona

Two main user groups were defined to clarify the user needs and requirements within the system, the elderly and the fam­ily member. Split into four separate personas, an overview can be found in Table 1.

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Table 1: System User Persona Table

Based on the elderly user personas, a preference for syn­chronous communication during lonely moments was identi­fied, in contrary to the younger family member who is often restricted to fast-paced, flexible asynchronous communica­tion due to long work hours and full schedules. These two types of communication are not available in current multi­modal communication systems such as the FB Messenger

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Figure 1: Floor plan with Shu Shi System installed

¹ or the WhatsApp Messenger², since they are solely fo­cused on providing either asynchronous communication in the form of messages or synchronous communication through a (video)-call function [58].

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¹ https://www.messenger.com/

² https://www.whatsapp.com/