Optimizing Voice Controlled Intelligent Personal Assistants for Use by Home-Bound Older Adults

Abstract

Introduction

Social isolation is a major public health concern, as isolated individuals are at increased risk of poor overall health, as well as increased risk of unhealthy behaviors. During the COVID-19 pandemic, social distancing strategies have led to increased rates of loneliness and social isolation. There is a clear need for strategies to mitigate the effects of social isolation and loneliness on the mental and physical health of older adults. In this study, we sought to better understand how Voice Controlled Intelligent Personal Assistants (VIPAs) could be leveraged to reduce loneliness and social isolation among home-bound older adults.

Methods

Patients and geriatric experts were recruited to use VIPA devices (Google Home) in their homes for four weeks and then provide feedback. No prior training was provided. Geriatric experts were recruited via email solicitation from the Northwestern Medicine Geriatrics Clinic, and patients were solicited directly from geriatric primary care physicians. The investigators used qualitative analysis to identify codes and overarching themes.

Results

A total of 288 comments were received from 16 participants. Eight major themes were identified: Administrative, Companionship, Home Control, Education, Emergencies, Entertainment, Health and Well-Being, and Reminders.

Discussion

Results demonstrate that VIPAs can be useful across multiple domains and potentially play a role in providing physical, social, and cognitive stimulation to home-bound older adults. VIPAs have a wide range of functionality, many of which could be implemented to focus on common geriatric syndromes and may ultimately be a tool to help mitigate social isolation and the consequential loneliness.

Introduction

Among older adults in the United States, 17.6% report frequent feelings of loneliness, and up to 50% are at risk of social isolation.¹ Social isolation can lead to poor overall health, cognitive decline, and unhealthy behaviors, such as physical inactivity, poor diet, and psychotropic drug use.^2–3 During the COVID-19 pandemic, social distancing strategies have led to increased rates of loneliness and social isolation.^2,4 Unfortunately, this has had a disproportionate negative impact on older adults, whose social contact can depend on activities taking place outside the home² and has exacerbated the psychological burden on older adults who are home-bound.^5–7

There is a clear need for strategies to mitigate the effects of social isolation and loneliness on the mental and physical health of older adults.^8,9 Studies suggest maintaining a healthy lifestyle and hobbies, virtual social interactions, and mindfulness can be beneficial.¹⁰ Communication technology strategies, such as internet based apps and computers, show promise in reducing social isolation in older adults, but more information is needed regarding the efficacy of different technologies.¹¹ Voice Controlled Intelligent Personal Assistants (VIPAs e.g. Google Home, Amazon Echo) are voice activated smart speakers that are readily available for purchase and affordable, costing as little as $30 per device, and can carry out a variety of different functions. Data on VIPA use by older adults is limited, however we previously demonstrated that older adults are successfully using these devices in their home for a variety of purposes.¹² VIPAs may be particularly useful for home-bound older adults with social isolation, providing functional, cognitive, and social stimulation.¹² In this study, we sought to better understand how VIPAs could be optimized for use among home-bound older adults by convening a multi-disciplinary group of geriatric experts and patients to identify pertinent features and potential barriers to tailor VIPA use to older adults.

Methods

Multi-disciplinary geriatric experts (e.g. social workers, nurses, geriatricians) and patients were recruited from an outpatient academic geriatrics practice. Participants were tasked to use a VIPA device, provided by the study team (Google Home), in their homes for four weeks and provide feedback. In order to better understand challenges that might arise, participants were not given any training prior to device use, and all setup and use occurred through their own manipulation of the device, with a research assistant available for troubleshooting. Eligible participants were over 21 years old (experts) or 65 years old (patients), English-speaking, and able to verbally consent. Participants with cognitive impairment were not included in this study. Geriatric experts were defined as healthcare providers that spend at least two hours a week providing healthcare related clinical services to older adults. After four weeks of use, participants then completed a questionnaire about their experience with the device (see Supplementary Material S1). Qualitative constant comparative and thematic analysis was used to identify codes and overarching themes. Two investigators (KO, SWL) independently analyzed survey results to identify preliminary codes, utilizing Microsoft Excel and Atlas.ti. Data analysis incorporated a deductive approach based on a priori themes from previous works¹² and a data-driven inductive approach for emergent themes. The coders then met to group codes into themes. Disputes were resolved by investigator discussion and review, with a third independent reviewer available if needed to resolve disputes via consensus (SB). This research was approved by the Northwestern University Institutional Review Board, and SRQR standards for reporting qualitative research were followed.¹³

Results:

A total of 288 comments were received from eleven geriatric experts and five patients (Table 1). Eight major themes were identified: Administrative, Companionship, Home Control, Education, Emergencies, Entertainment, Health and Well-Being, and Reminders (Table 2). The frequency of responses for each theme are demonstrated in Figure 1.

Table 1:

Demographic Data for Participants

	Number of respondents
Gender
Male	2
Female	14
Ethnicity
White	12
Asian	2
Hispanic/Latino/Latina	1
Refused/Not sure	1
Age Range
21–34	4
35–49	4
50–64	1
65–79	4
80+	2
Refused/Not sure	1
Education Level
High School	1
College	3
Post-Graduate	12
Years Caring for Older Adults	Mean 12.6 years (range 2–40 years)

Table 2:

Themes and representative quotes

Main Theme	Quote
Administrative	“Shopping - can order groceries, other products and may receive an alert when has arrived/been delivered”
Companionship	“And just having VIPA speak to them does give them a sense they are not alone”
Home Control	“Skill blueprints - ability to create personalized skills and set Alexa to say something predetermined / customization of answers”
Education	“Getting definitions of word and meaning of phrases, like ‘how to pull the wool over your eyes’”
Emergencies	“Being able to make calls - please call my daughter, doctor, pharmacy, 911, could all be programmed. don’t have to worry about finding in cell phone and especially for patients with low vision or limited dexterity in hands”
Entertainment	“Jokes and trivia can also provide entertainment”
Health and Well-Being	“I knew there were some fitness/wellness apps, so I asked about headspace meditation”
Reminders	“Calendar sync and reminders of social events, plans, birthdays, etc.”

Figure 1:

Frequency of Theme References

Theme 1: Entertainment

Entertainment was mentioned by most participants as a beneficial function of the VIPA devices. One expert suggested that listening to music can “boost mood and trigger nostalgia” (Expert 8) and “can be particularly uplifting especially when (it’s) related to a time period or something that is important to the person…” (Expert 4). Participants mentioned using the VIPA for listening to music, podcasts, and stories; playing games and trivia; and looking up entertaining information, taking quizzes, and listening to jokes.

Theme 2: Reminders

Another prevalent theme was reminders. Specifically, participants mentioned setting calendar-linked reminders for social events, plans, and birthdays, or using the VIPA to check the date, time, or weather. Others mentioned using the device to set timers to take medications, exercise, nap, or wake up. As one expert said, “Having a routine is important for the older adult…the ability to set up the day to keep that senior moving is excellent.” (Expert 10).

Theme 3: Education

Another theme was the potential for using the VIPA device for educational purposes. Participants reported using the device’s search tool to answer simple questions, help look up “definitions of words and meanings of phrases…” (Patient 13), and look up recipes.

Theme 4: Companionship

Companionship also emerged as a potential benefit of the VIPA device. Participants highlighted the VIPA’s capabilities for phone calls to family members and loved ones. One expert said, “The ability to call people with just using the voice is a great idea for increasing socialization. Since the older adult does not have to navigate using their phone…older adults who have issues with sight or touch could still socialize” (Expert 11). Another participant said, “I could see myself using this to call…contacts when I don’t have my hands available…” (Patient 17). Finally, some participants suggested that simply hearing the VIPA’s voice at home might be comforting: “just having the VIPA speak to them does give them a sense they are not alone” (Expert 4).

Theme 5: Home Control

Many participants noted the VIPA’s capability to assist with control of the home. This was discussed in reference to automation of the home with voice activation, creation of personalized skills, and interaction with other smart devices. For instance, one participant endorsed using the voice control feature to find television programs or control the volume (Patient 14). One expert said, “Many seniors have arthritis and the device can turn lights on and off and adjust the thermostat” (Expert 10). Participants noted that utilizing certain VIPA features could help older adults maintain their independence and potentially “remain more safely at home” (Expert 10).

Theme 6: Emergency Communication

Emergency communication appeared as another important feature of the VIPA devices. One participant said, “Being able to call 911 hands-free would be a terrific function” (Patient 17). Another participant highlighted that “the ability to easily call without having to pick up the phone and look up the number” (Expert 2) would be enormously beneficial when a user needs to call for help. One participant emphasized the VIPA’s ability to program numbers ahead of time so that users “don’t have to worry about finding it in the cell phone, especially for patients with low vision or limited dexterity in their hands” (Expert 4).

Theme 7: Administrative Support

The VIPA’s ability to provide administrative support was mentioned by several participants. These administrative capabilities included assistance with medication refills, shopping and deliveries, and getting directions and transportation schedules. One participant “asked about a bus route in the city” (Patient 28) and another shared that it was useful that users “can order groceries and other products…” (Expert 4).

Theme 8: Health and Wellbeing

The potential utility of VIPA devices in promoting health and wellbeing was another theme, for instance via fitness, relaxation, meditation, and religion applications. One participant suggested playing sleep sounds to enhance relaxation (Expert 5) or using a feature for mindfulness and meditation activities (Patient 28). Some participants mentioned using specific applications for meditation, mindfulness, or help with anxiety.

Challenges

All participants identified challenges that older adults might have with VIPA devices. The challenges involved difficulty setting up the device, learning the proper wording to control the device, and being overwhelmed by the vast number of features available. One older adult’s daughter said, “I think it would be sitting here un-set up if I hadn’t come over” (Patient 15). One expert said, “If they are not familiar with the settings on their phones and/or their internet settings in their homes, it will require assistance…” (Expert 6).

Multiple participants also discussed the learning curve involved in phrasing commands and questions properly for the VIPA. For instance, one participant said, “I had to think through the way to word things to make it work…but once you catch onto it, it’s pretty easy” (Patient 16). Participants also endorsed having challenges with the physical buttons, needing to troubleshoot when it disconnected from Wi-Fi, needing help creating and linking the device with pertinent accounts, and having difficulty accessing the plug when physical limitations are involved.

Finally, a common response was that participants felt overwhelmed by the number of available features. One participant said, “exploring the range of what it offers and being able to use all the possible options challenged me” (Patient 17). Similarly, an expert reported, “I found it a bit overwhelming; it’s like being a child in a candy store” (Expert 10).

Discussion

The results of this study demonstrate that VIPAs do have the potential to be useful across multiple domains, play a role in providing physical, social and cognitive stimulation to home-bound older adults, and to potentially allow older adults to remain safely in their home settings. VIPAs have a wide range of functionality, much of which could be leveraged to focus on common geriatric syndromes and may ultimately be a tool to help mitigate social isolation and the consequential loneliness. Without specific instruction, older adults were able to successfully use the devices, and three of the five older adults rated it as very easy to use. Importantly, both older adults and geriatric experts identified challenges that could be addressed to make these devices more accessible.

Many of the reported challenges surrounded basic set up and use of the device. The instruction manual included with the device provides minimal information and many participants pointed to this as a barrier or suggested that having another person available to help with setup or troubleshooting might be useful. The voice activation feature is another challenge that several participants cited, including being able to speak loudly enough to trigger the device or understanding how to appropriately phrase commands or question. Providing more information to users about how to navigate these issues may make the device more accessible to older adults. Finally, many participants cited functionality issues with the device. Some cited the overwhelming number of functions as an issue and others cited difficulty even understanding the full array of available functions. Providing more information to users about what the device can do, with a specific focus on functions that could target physical, social and cognitive stimulation, could increase acceptability and benefit of the device.

There are several limitations of the study. Firstly, the sample size is small with only 16 total participants. That said, thematic saturation was reached during qualitative evaluation. Secondly, no instruction or setup information was provided to participants. While this was intentional in order to better understand challenges and inform creation of an accompanying instruction booklet, added information may have been gleaned if participants better understood device functionality. Finally, there were limitations to the demographic sample. All geriatric experts were pooled from one academic practice and there was limited gender and ethnic distribution of patients which may limit generalizability. Further work could aim to reproduce these findings with a larger, more diverse sample size.

Ultimately, further research is necessary to determine how to best implement VIPAs in the home setting. There are myriad of disease-specific implications that could be studied, as well as collaboration with device manufacturers to address challenges and create devices targeted towards older adults. Caregivers are also essential for the wellbeing of home-bound older adults and may be a future target for VIPA use. Next steps include leveraging this data to create a companion booklet to facilitate VIPA use among older adults, as well as formal evaluation of whether implementation reduces symptoms of loneliness and isolation.

Supplementary Material

supinfo

Supplementary Material S1: Survey Questions for Study Participants

Key points:

1. Voice controlled Intelligent Personal Assistants are readily available and easy to use devices that can be implemented in the home setting.

2. Voice Controlled Intelligent Personal Assistants could potentially play a role in providing physical, social, and cognitive stimulation to home-bound older adults.

3. Voice Controlled Intelligent Personal Assistants may potentially be a tool to help mitigate social isolation and loneliness.