Best practices for implementing a technology-based intervention protocol: Participant and researcher considerations

Technology-based interventions present a promising approach to support health and wellness for older adults with a range of cognitive abilities. Technology can enhance access to interventions and support scaling of programs to reach more people. However, the use of technology for intervention delivery requires particular attention to users' needs and preferences and ensuring the materials are adaptable and supportive of a diverse range of technology proficiency levels. We share best practices based on lessons learned from the deployment of a randomized controlled trial (RCT) wherein we delivered an 8-week social engagement intervention through a video technology platform called OneClick for older adults with varying cognitive abilities. We developed a set of best practices and guidelines informed by the lessons learned through this RCT implementation. Technology-based interventions require attention to the application (e.g., video calls), system requirements (e.g., system memory, broadband internet), training (e.g., adaptability based on user competency), and support (e.g., handouts, live contact). These best practices relate to user needs; training design; personnel responsibility; structuring delivery and content; and evaluating success. These research-based best practices can guide the design, development, and implementation of technology-based interventions to support older adults with varying cognitive abilities.

Everyday Challenges for Individuals Aging With Vision Impairment: Technology Implications

BACKGROUND AND OBJECTIVES

There are growing numbers of older adults with long-term vision impairment who are likely to experience everyday activity challenges from their impairment in conjunction with age-related changes. Technology has potential to support activity engagement. To develop effective technologies and interventions, we need to understand the context of activity challenges and identify unmet support needs.

RESEARCH DESIGN AND METHODS

The Aging Concerns, Challenges, and Everyday Solution Strategies (ACCESS) study is a mixed-method approach to explore everyday challenges of people aging with long-term disabilities. Participants included 60 adults aging with long-term vision impairment (63% female; M age = 67, SD = 4.6) who completed in-depth, structured interviews exploring the nature of everyday challenges and their unmet support needs for activity engagement. We conducted a content analysis using a deductive and inductive approach to build a detailed coding scheme of challenge codes and subcodes.

RESULTS

The analyses provided detailed insights about the nature of challenges people aging with vision impairment experience when performing specific instrumental activities of daily living (IADLs) in the context of home maintenance, transportation, shopping/finance, and managing health. Vision-related challenges and participation restrictions were identified for several activities that require reading, navigation, and identification (e.g., shopping, medication management, public transportation). Emergent challenge themes for performing IADLs included personal limitations (e.g., physical, cognitive, financial) and environmental barriers (e.g., accessibility, technology, transportation).

DISCUSSION AND IMPLICATIONS

Contextual examples of IADL challenges among individuals aging with vision impairment highlight opportunities for technology design and innovation to support participation in everyday activities.

Immersive participatory design of assistive robots to support older adults

Assistive robots have the potential to support independence, enhance safety, and lower healthcare costs for older adults, as well as alleviate the demands of their care partners. However, ensuring that these robots will effectively and reliably address end-user needs in the long term requires user-specific design factors to be considered during the robot development process. To identify these design factors, we embedded Stretch, a mobile manipulator created by Hello Robot Inc., in the home of an older adult with motor impairments and his care partner for four weeks to support them with everyday activities. An occupational therapist and a robotics engineer lived with them during this period, employing an immersive participatory design approach to co-design and customise the robot with them. We highlight the benefits of this immersive participatory design experience and provide insights into robot design that can be applied broadly to other assistive technologies.

How should artificial intelligence be used in Australian health care? Recommendations from a citizens' jury

OBJECTIVE

To support a diverse sample of Australians to make recommendations about the use of artificial intelligence (AI) technology in health care.

STUDY DESIGN

Citizens' jury, deliberating the question: "Under which circumstances, if any, should artificial intelligence be used in Australian health systems to detect or diagnose disease?"

SETTING, PARTICIPANTS

Thirty Australian adults recruited by Sortition Foundation using random invitation and stratified selection to reflect population proportions by gender, age, ancestry, highest level of education, and residential location (state/territory; urban, regional, rural). The jury process took 18 days (16 March - 2 April 2023): fifteen days online and three days face-to-face in Sydney, where the jurors, both in small groups and together, were informed about and discussed the question, and developed recommendations with reasons. Jurors received extensive information: a printed handbook, online documents, and recorded presentations by four expert speakers. Jurors asked questions and received answers from the experts during the online period of the process, and during the first day of the face-to-face meeting.

MAIN OUTCOME MEASURES

Jury recommendations, with reasons.

RESULTS

The jurors recommended an overarching, independently governed charter and framework for health care AI. The other nine recommendation categories concerned balancing benefits and harms; fairness and bias; patients' rights and choices; clinical governance and training; technical governance and standards; data governance and use; open source software; AI evaluation and assessment; and education and communication.

CONCLUSIONS

The deliberative process supported a nationally representative sample of citizens to construct recommendations about how AI in health care should be developed, used, and governed. Recommendations derived using such methods could guide clinicians, policy makers, AI researchers and developers, and health service users to develop approaches that ensure trustworthy and responsible use of this technology.

Cost-Related Non-Adherence to Prescribed Medicines: What Are Physicians' Moral Duties?

As the price of pharmaceuticals and biologicals rises so does the number of patients who cannot afford them. In this article, we argue that physicians have a moral duty to help patients access affordable medicines. We offer three grounds to support our argument: (i) the aim of prescribing is to improve health and well-being which can only be realized with secure access to treatment; (ii) there is no morally significant difference between medicines being unavailable and medicines being unaffordable, so the steps physicians are willing to take in the first case should extend to the second; and (iii) as the primary stakeholder with a duty to put the individual patient's interests first, the medical professional has a duty to address cost-barriers to patient care. In articulating this duty, we take account of important epistemic and control conditions that must be met for the attribution of this duty to be justified.

Understanding Wheelchair Use in Older Adults From the National Health and Aging Trends Study

OBJECTIVE

To identify the trends of wheelchair use and physical characteristics among older people who used wheelchairs relative to those who did not.

DESIGN

Cohort and survey.

SETTING

General community.

PARTICIPANTS

7026 participants (N=7026) were selected from the 2011 cohort of the National Health and Aging Trends Study (NHATS), which is made up of Medicare beneficiaries over the age of 65. Repeated observations among participants in the 2011 cohort were analyzed in the 4 following rounds: 2013 (N=4454), 2015 (N=3327), 2017 (N=2623), and 2019 (N=2091). Participants were divided into 2 groups: those who used and did not use wheelchairs.

INTERVENTIONS

Not applicable.

MAIN OUTCOMES MEASURES

Physical characteristics, including pain, strength limitation, balance problems, mobility disability, as well as the frequency of going outside.

RESULTS

The number of older adults who use wheelchairs had increased significantly from 4.7 per 100 people in 2011 to 7.1 in 2019 (P<.001). The logistic regression analysis indicated that participants who reported less frequently going out were at least 4.27 times more likely to be wheelchair users than non-wheelchair users (P<.01). Participants who reported health and physical problems were at least 2.48 times more likely to be wheelchair users than non-wheelchair users from 2011 to 2017 (P<.0001). Balance or coordination problems increased (24%-38%) significantly among non-wheelchair users from 2011 to 2019 (all P<.05).

CONCLUSIONS

Current wheelchair users reported more physical difficulties and were much less likely to go outside. This lower outdoor mobility could be due to physical difficulties or potential barriers in physical and socio-cultural environments. In addition, older adults who do not use wheelchairs showed increasing physical problems over time (including balance or coordination problems). Clinicians should consider older wheelchair users' health and physical limitations when prescribing wheelchairs.

Developing a Healthcare Technology Acceptance Model (H-TAM) for Older Adults with Hypertension

Older adults with a chronic health condition (e.g., hypertension) use various self-management methods. Healthcare technologies have the potential to support health self-management. However, it is necessary to understand the acceptance of these technologies as a precursor to older adults' adoption and integration into their health plan. Our focus was on the factors older adults with hypertension initially consider when introduced to three new healthcare technologies that might support their health self-management. We compared their considerations for a blood pressure monitor, an electronic pillbox, and a multifunction robot to simulate incrementally more complex technologies. Twenty-three participants (aged 65-84) completed four questionnaires and a semi-structured interview. The interview transcripts were analyzed using a thematic analysis approach. We identified the factors that were frequently mentioned among the participants for each of the three healthcare technologies. The factors that older adults initially considered were familiarity, perceived benefits, perceived ease of use, perceived need for oneself, relative advantage, complexity, and perceived need for others. Upon further reflection, participants considered advice acceptance, compatibility, convenience, facilitating conditions, perceived usefulness, privacy, subjective norm, and trust. We integrated the factors that older adults considered into the Healthcare Technology Acceptance Model (H-TAM), which elucidates the complexity of healthcare technology acceptance and provides guidance for future explorations.

Practical, epistemic and normative implications of algorithmic bias in healthcare artificial intelligence: a qualitative study of multidisciplinary expert perspectives

BACKGROUND

There is a growing concern about artificial intelligence (AI) applications in healthcare that can disadvantage already under-represented and marginalised groups (eg, based on gender or race).

OBJECTIVES

Our objectives are to canvas the range of strategies stakeholders endorse in attempting to mitigate algorithmic bias, and to consider the ethical question of responsibility for algorithmic bias.

METHODOLOGY

The study involves in-depth, semistructured interviews with healthcare workers, screening programme managers, consumer health representatives, regulators, data scientists and developers.

RESULTS

Findings reveal considerable divergent views on three key issues. First, views on whether bias is a problem in healthcare AI varied, with most participants agreeing bias is a problem (which we call the bias-critical view), a small number believing the opposite (the bias-denial view), and some arguing that the benefits of AI outweigh any harms or wrongs arising from the bias problem (the bias-apologist view). Second, there was a disagreement on the strategies to mitigate bias, and who is responsible for such strategies. Finally, there were divergent views on whether to include or exclude sociocultural identifiers (eg, race, ethnicity or gender-diverse identities) in the development of AI as a way to mitigate bias.

CONCLUSION/SIGNIFICANCE

Based on the views of participants, we set out responses that stakeholders might pursue, including greater interdisciplinary collaboration, tailored stakeholder engagement activities, empirical studies to understand algorithmic bias and strategies to modify dominant approaches in AI development such as the use of participatory methods, and increased diversity and inclusion in research teams and research participant recruitment and selection.

Utopia versus dystopia: Professional perspectives on the impact of healthcare artificial intelligence on clinical roles and skills

BACKGROUND

Alongside the promise of improving clinical work, advances in healthcare artificial intelligence (AI) raise concerns about the risk of deskilling clinicians. This purpose of this study is to examine the issue of deskilling from the perspective of diverse group of professional stakeholders with knowledge and/or experiences in the development, deployment and regulation of healthcare AI.

METHODS

We conducted qualitative, semi-structured interviews with 72 professionals with AI expertise and/or professional or clinical expertise who were involved in development, deployment and/or regulation of healthcare AI. Data analysis using combined constructivist grounded theory and framework approach was performed concurrently with data collection.

FINDINGS

Our analysis showed participants had diverse views on three contentious issues regarding AI and deskilling. The first involved competing views about the proper extent of AI-enabled automation in healthcare work, and which clinical tasks should or should not be automated. We identified a cluster of characteristics of tasks that were considered more suitable for automation. The second involved expectations about the impact of AI on clinical skills, and whether AI-enabled automation would lead to worse or better quality of healthcare. The third tension implicitly contrasted two models of healthcare work: a human-centric model and a technology-centric model. These models assumed different values and priorities for healthcare work and its relationship to AI-enabled automation.

CONCLUSION

Our study shows that a diverse group of professional stakeholders involved in healthcare AI development, acquisition, deployment and regulation are attentive to the potential impact of healthcare AI on clinical skills, but have different views about the nature and valence (positive or negative) of this impact. Detailed engagement with different types of professional stakeholders allowed us to identify relevant concepts and values that could guide decisions about AI algorithm development and deployment.

Australian women's judgements about using artificial intelligence to read mammograms in breast cancer screening

Objective

Mammographic screening for breast cancer is an early use case for artificial intelligence (AI) in healthcare. This is an active area of research, mostly focused on the development and evaluation of individual algorithms. A growing normative literature argues that AI systems should reflect human values, but it is unclear what this requires in specific AI implementation scenarios. Our objective was to understand women's values regarding the use of AI to read mammograms in breast cancer screening.

Methods

We ran eight online discussion groups with a total of 50 women, focused on their expectations and normative judgements regarding the use of AI in breast screening.

Results

Although women were positive about the potential of breast screening AI, they argued strongly that humans must remain as central actors in breast screening systems and consistently expressed high expectations of the performance of breast screening AI. Women expected clear lines of responsibility for decision-making, to be able to contest decisions, and for AI to perform equally well for all programme participants. Women often imagined both that AI might replace radiographers and that AI implementation might allow more women to be screened: screening programmes will need to communicate carefully about these issues.

Conclusions

To meet women's expectations, screening programmes should delay implementation until there is strong evidence that the use of AI systems improves screening performance, should ensure that human expertise and responsibility remain central in screening programmes, and should avoid using AI in ways that exacerbate inequities.

Designing Feedback Visualizations for Anti-Hypertensive Medication Adherence for Older Adults

Adhering to anti-hypertensive medications contributes to control of blood pressure and improved health outcomes. However, adherence rates among older adults are low. Patient monitoring of medication taking helps increase adherence and technology has great potential to support self-monitoring, in part by providing visual feedback about medication taking performance. However, little attention has been paid to designing feedback visualizations in medication-monitoring technology for older adults. In this research, we identified guidelines for designing understandable and effective adherence visualizations for older adults from existing theories and literature. With the guidelines in mind, we designed, refined, and evaluated visualizations that provided adherence feedback for a smartphone application with 17 older participants. Based on theory and evidence, we identified design guidelines for feedback visualizations. These guidelines can support design of useful feedback visualizations that may improve medication adherence among older adults.

Older Adults and Smart Technology: Facilitators and Barriers to Use

Smart technologies (e.g., smartphones, smart security technologies, digital home assistants) have advanced over the years and will continue to do so. There are various benefits to using these technologies in one's life, such as an increase in productivity through automation and self-monitoring one's health. Older adults particularly may benefit from smart technologies to support their everyday activities and compensate for age related changes. In this study, we explored the experiences and attitudes of eighty older adults including those who had prior experience and those who had never used (or perhaps never heard of) smart technologies through an online survey. We assessed their general opinions toward using smart technology and explored what facilitated or hindered their use. Older adults rated the facilitators to use for each smart technology differently, with few commonalities between the order of the most agreed upon facilitators. However, older adults' opinions were consistent across each technology about their ignorance of technological features and cost of the smart technology, which could be potential barriers to use. Among those who had never used one of the smart technologies, privacy was the most commonly endorsed concern. The results from this study support the understanding of key considerations when developing and deploying smart technologies for older adults.

Maximizing the Benefits of Participatory Design for Human-Robot Interaction Research With Older Adults

OBJECTIVE

We reviewed human-robot interaction (HRI) participatory design (PD) research with older adults. The goal was to identify methods used, determine their value for design of robots with older adults, and provide guidance for best practices.

BACKGROUND

Assistive robots may promote aging-in-place and quality of life for older adults. However, the robots must be designed to meet older adults' specific needs and preferences. PD and other user-centered methods may be used to engage older adults in the robot development process to accommodate their needs and preferences and to assure usability of emergent assistive robots.

METHOD

This targeted review of HRI PD studies with older adults draws on a detailed review of 26 articles. Our assessment focused on the HRI methods and their utility for use with older adults who have a range of needs and capabilities.

RESULTS

Our review highlighted the importance of using mixed methods and including multiple stakeholders throughout the design process. These approaches can encourage mutual learning (to improve design by developers and to increase acceptance by users). We identified key phases used in HRI PD workshops (e.g., initial interview phase, series of focus groups phase, and presentation phase). These approaches can provide inspiration for future efforts.

CONCLUSION

HRI PD strategies can support designers in developing assistive robots that meet older adults' needs, capabilities, and preferences to promote acceptance. More HRI research is needed to understand potential implications for aging-in-place. PD methods provide a promising approach.

An Integrative Framework to Guide Social Engagement Interventions and Technology Design for Persons With Mild Cognitive Impairment

Social isolation and loneliness in older adults are associated with poor health outcomes and have been linked to an increased risk of cognitive impairment and incident dementia. Social engagement has been identified as a key factor in promoting positive health behaviors and quality of life and preventing social isolation and loneliness. Studies involving cognitively healthy older adults have shown the protective effects of both in-person and technology-based social engagement. However, the benefits of social engagement for people who are already at-risk of developing dementia, namely those with mild cognitive impairment (MCI), have yet to be elucidated. We present a narrative review of the literature, summarizing the research on social engagement in MCI. First, we identified social networks (quality, size, frequency, and closeness) and social activities (frequency, format, purpose, type, and content) as two overarching dimensions of an integrative framework for social engagement derived from literature examining typical cognitive aging. We then used this framework as a lens to examine studies of social engagement in MCI to explore (i) the relationship between in-person and technology-based social engagement and cognitive, emotional, and physical health, and (ii) interventions that target social engagement including technology-based approaches. Overall, we found that persons with MCI (PwMCI) may have different levels of social engagement than those experiencing typical cognitive aging. Moreover, in-person social engagement can have a positive impact on cognitive, emotional, and physical health for PwMCI. With respect to activity and network dimensions in our framework, we found that cognitive health has been more widely examined in PwMCI relative to physical and emotional health. Very few intervention studies have targeted social engagement, but both in-person and technology-based interventions appear to have promising health and well-being outcomes. Our multidimensional framework of social engagement provides guidance for research on characterizing the protective benefits of social engagement for PwMCI and informs the development of novel interventions including technology-based approaches.

Understanding Health Self-Management Challenges and Needs for Older Adults with and without Mobility and Sensory Disabilities

Health self-management could be challenging for older adults with disabilities and technology has great potential to support them for managing health activities. Assessing users' needs is a significant technique to develop useful technologies. However, studies overwhelmingly collected and analyzed qualitative data in smaller samples or quantitative data in populations with single type of disability. This study aimed to analyze a national level dataset to assess the frequency of and challenges with managing health activities in older population with and without disabilities and identify potential support solutions to provide guidance for technology interventions. In this study, 4,541 older adults from the National Health and Aging Trends Study were grouped into five sub-groups (non-disability, mobility, vision, hearing, multiple disability). The findings indicated lower participation in wellness activities (e.g., exercise) than disease management activities (e.g., taking medicines, going to medical appointment). Around one tenth of older adults reported difficulty with tracking medicines and 23.4%-64.3% of respondents reported being accompanied during medical appointments. Managing health activities was more challenging for older adults with mobility and multiple disabilities. They were more likely to have difficulties and receive assistance with managing these activities, including accessing online health information. In conclusion, needs of older adults to manage health varied across activities and for people with different types of disabilities. We provide direction for person-centered and tailored interventions to respond to these needs.

Developing an Instructional Suite for the Amazon Echo to Support Novice Older Adults' Use

Digital home assistants (e.g., Amazon Echo) hold great potential to support older adults across a wide range of abilities to improve or maintain their quality of life. However, these devices and other related environmental control applications are not equipped with sufficient support for successful technology adoption among older adults. Without useful and usable information for guidance during the initial and continued use of these technologies (i.e., facilitating conditions), older adults may not sufficiently learn how to best utilize them, which is a primary barrier to technology adoption among this population. Our goal was to iteratively develop and test an instructional suite to support set up and use of an Amazon Echo Show and related connected technologies by older adults. Our human factors approach provides a roadmap to inform future instructional development for older adults to learn smart and connected technologies.

Ethical Guidance for Hard Decisions: A Critical Review of Early International COVID-19 ICU Triage Guidelines

This article provides a critical comparative analysis of the substantive and procedural values and ethical concepts articulated in guidelines for allocating scarce resources in the COVID-19 pandemic. We identified 21 local and national guidelines written in English, Spanish, German and French; applicable to specific and identifiable jurisdictions; and providing guidance to clinicians for decision making when allocating critical care resources during the COVID-19 pandemic. US guidelines were not included, as these had recently been reviewed elsewhere. Information was extracted from each guideline on: 1) the development process; 2) the presence and nature of ethical, medical and social criteria for allocating critical care resources; and 3) the membership of and decision-making procedure of any triage committees. Results of our analysis show the majority appealed primarily to consequentialist reasoning in making allocation decisions, tempered by a largely pluralistic approach to other substantive and procedural values and ethical concepts. Medical and social criteria included medical need, co-morbidities, prognosis, age, disability and other factors, with a focus on seemingly objective medical criteria. There was little or no guidance on how to reconcile competing criteria, and little attention to internal contradictions within individual guidelines. Our analysis reveals the challenges in developing sound ethical guidance for allocating scarce medical resources, highlighting problems in operationalising ethical concepts and principles, divergence between guidelines, unresolved contradictions within the same guideline, and use of naïve objectivism in employing widely used medical criteria for allocating ICU resources.

Social Support, Isolation, Loneliness, and Health Among Older Adults in the PRISM Randomized Controlled Trial

Objectives: Social isolation and loneliness are serious public health issues given the association with negative physical, mental; and cognitive health outcomes and increased risk for mortality. Due to changes in life circumstances many aging adults are socially isolated and experience loneliness. We examined the relationships among four correlated but distinct constructs: social network size, social support, social isolation, and loneliness as they relate to indices of health and wellbeing among diverse subpopulations of older adults. Guided by WHO's International Classification of Functioning, Disability and Health (ICF) we also examined factors that predict loneliness and social isolation. Methods: Analyses of baseline data from sample of older adults who participated in an intervention trial that examined the beneficial effects of a software system designed to support access to resources and information, and social connectivity. Participants included 300 individuals aged 65-98, who lived alone, were primarily of lower socio-economic status and ethnically diverse. Participants completed a demographics questionnaire, self-report measures of health, depression, social network size, social support, and loneliness. Results: Loneliness was strongly associated with depression and self-ratings of health. In turn, greater social isolation and less social support were associated with greater loneliness. Social isolation was associated with depression and lower self-ratings of health. The association between social isolation and health was mediated by loneliness. Individuals in the older cohorts (80+) reported less social support. With respect to loneliness, having a smaller social network, more functional limitations, and limitations in engaging meaningful activities was associated with higher levels of loneliness and greater social isolation. Conclusion: The findings underscore the importance of social connectively to wellbeing for older adults and suggest that those in the older cohorts, who have a small social network, and with greater physical and functional impairments may be particularly vulnerable to being socially isolated and lonely. The findings provide guidance for future interventions. In this regard, we discuss how Information and Communication Technologies (ICTs) may be used to promote social connectivity and engagement. Strategies to make the usability and availability of these applications for aging adults are highlighted.

Insights on an automated fall detection device designed for older adult wheelchair and scooter users: A qualitative study

BACKGROUND

Falls are a concern for older adults who use wheelchairs and scooters. Many wheelchair and scooter users require assistance to recover from a fall and often lie on the ground waiting for assistance for 10 min or more. An automated fall detection device may facilitate communication with care partners and expedite recovery; however, there is limited research on the specifications and features of an automated fall detection device preferred by older adults who use wheelchair and scooter.

OBJECTIVE

To examine the desired specifications, perceived ease of use and perceived usefulness of an automated fall detection device desired by older adults who use a wheelchair or scooter through semi-structured interviews.

METHODS

Fifteen full-time wheelchair and scooter users (9 females; age: 68 ± 5 years) were interviewed from July to November 2020. Interviews were transcribed, coded, and analyzed.

RESULTS

Preferred features include wireless charging, a watch form, ability to change the individual who is contacted in the event of a fall, and the ability to disable a notification in the event of a false alarm. Participants felt that an automated fall detection device would be useful and easy to use.

CONCLUSIONS

Older adults who use a wheelchair or scooter indicated the need for an automated fall detection device to facilitate recovery from a fall. Participants reported challenges with previous fall detection devices and the need for specific design requirements to facilitate ongoing use. Participants' insights inform the design of a fall detection device to maximize usability and prevent technology abandonment.

Evaluation of artificial intelligence clinical applications: Detailed case analyses show value of healthcare ethics approach in identifying patient care issues

This paper is one of the first to analyse the ethical implications of specific healthcare artificial intelligence (AI) applications, and the first to provide a detailed analysis of AI-based systems for clinical decision support. AI is increasingly being deployed across multiple domains. In response, a plethora of ethical guidelines and principles for general AI use have been published, with some convergence about which ethical concepts are relevant to this new technology. However, few of these frameworks are healthcare-specific, and there has been limited examination of actual AI applications in healthcare. Our ethical evaluation identifies context- and case-specific healthcare ethical issues for two applications, and investigates the extent to which the general ethical principles for AI-assisted healthcare expressed in existing frameworks capture what is most ethically relevant from the perspective of healthcare ethics. We provide a detailed description and analysis of two AI-based systems for clinical decision support (Painchek^® and IDx-DR). Our results identify ethical challenges associated with potentially deceptive promissory claims, lack of patient and public involvement in healthcare AI development and deployment, and lack of attention to the impact of AIs on healthcare relationships. Our analysis also highlights the close connection between evaluation and technical development and reporting. Critical appraisal frameworks for healthcare AIs should include explicit ethical evaluation with benchmarks. However, each application will require scrutiny across the AI life-cycle to identify ethical issues specific to healthcare. This level of analysis requires more attention to detail than is suggested by current ethical guidance or frameworks.

Transportation challenges for persons aging with mobility disability: Qualitative insights and policy implications

BACKGROUND

Persons aging with mobility disability (PAwMD) experience transportation barriers, which can hinder their ability to fully participate in society. Despite a vast infrastructure of federal laws and programs designed to ensure access to transportation, PAwMD remain a transportation-disadvantaged population.

OBJECTIVES

This paper presents detailed insights on transportation challenges experienced by PAwMD along with recent Federal programmatic initiatives designed to enhance access and mobility for transportation for older adults and people with disabilities. To identify policy gaps and opportunities to improve transportation services, we compared individual-level challenges from PAwMD to national survey data about barriers associated with delivering transportation services at state and local levels.

METHODS

To assess individual-level transportation challenges, we conducted in-depth, structured interviews with sixty older adult participants with self-identified mobility disabilities for at least 10 years. We also conducted a content analysis of end-user transportation challenges and agency-level transportation coordination barriers to identify correspondences.

RESULTS

Participants reported challenges utilizing public and private modes of transportation, related to availability; accessibility; safety; advanced planning; as well as societal attitudes. Barriers to the availability, delivery, and coordination of access and mobility services are linked directly or indirectly to the PAwMD reports of experiencing a shortage of accessible transportation options.

CONCLUSIONS

Findings highlight the complexity of federal transportation policies and programmatic initiatives designed to support older adults and people with disabilities, which contribute to implementation barriers and transportation challenges. Results highlight the importance of integrating end-user and state and local provider input into transportation policy development and program implementation.

Activism and Bioethics: Taking a Stand on Things That Matter

The question of whether activism should be overtly embraced as part of the bioethicist's role deserves serious consideration. Like others, we agree that bioethics is inescapably partisan; bioethical deliberation is based on trying to determine morally relevant features of situations and morally justifiable outcomes. Where disagreement arises is over the degree to which bioethicists should be activists. Meyers argues for a somewhat circumscribed role, limited to action on ethically concerning institutional matters, for those who are financially independent of the institutions. We take a broader view, arguing that some issues are so morally egregious that there is a duty to take a stand against them, even if the prospects of success are dim. There is a need for further debate, sharing of experiences, and analysis of case studies, to support bioethicists who take a stand.

Modeling Task Scheduling Decisions of Emergency Department Physicians

OBJECTIVE

This study evaluated task-scheduling decisions in the context of emergency departments by comparing patterns of emergency physicians' task-scheduling models across levels of experience.

BACKGROUND

Task attributes (priority, difficulty, salience, and engagement) influence task-scheduling decisions. However, it is unclear how attributes interact to affect decisions, especially in complex contexts. An existing model of task scheduling, strategic task overload management-no priority (STOM-NP), found that an equal weighting of attributes can predict task-scheduling behavior. Alternatively, mathematical modeling estimated that priority alone could make similar predictions as STOM-NP in a parsimonious manner. Experience level may also influence scheduling decisions.

METHOD

An experimental design methodology shortened a judgment analysis approach to compare a priori task-scheduling decision strategies. Emergency physicians with two levels of experience rank-ordered 10 sets of 3 tasks varying on 4 task attributes in this complex environment.

RESULTS

Bayesian statistics were used to identify best-fit decision strategies. STOM-NP and priority-only provided the best model fits. STOM-NP fit the lower-experienced physicians best, whereas priority-only-using only one cue-fit the higher-experienced physicians best.

CONCLUSION

Models of decision strategies for task-scheduling decisions were extended to complex environments. Experts' level of experience influenced task-scheduling decisions, where the scheduling decisions of more-experienced experts was consistent with a more frugal decision process. Findings have implications for training and evaluation.

APPLICATION

We assessed models of cues that influence task-scheduling decisions, including a parsimonious model for task priority only. We provided a sample approach for shortening methods for understanding decisions.

A Framework for Design of Conversational Agents to Support Health Self-Care for Older Adults

OBJECTIVE

We examined the potential of conversational agents (CAs) to support older adults' self-care related to chronic illness in light of lessons learned from decades of pedagogical agent research, which investigates the impact and efficacy of CAs for a wide range of learners.

BACKGROUND

The role of CAs in education (i.e., pedagogical agents) has been long studied, but their potential for supporting self-care has received less attention, especially for older adults.

METHODS

We reviewed work on pedagogical agents and considered how it informs the design of CAs for older adults. We propose a framework for designing CAs to support older adult self-care, which organizes a review of work in this area and integration with the pedagogical agent literature.

RESULTS

Our review of the pedagogical agent literature revealed an evolution from teaching machines to interactive, social systems that influence student motivational as well as learning outcomes. To integrate this review with work on CAs and self-care, we developed a framework that specifies how self-care goals evolve with stages of an illness, communication goals that support self-care at each stage, patient needs, and requirements for CAs to support these needs. The review identified an agenda for future research on CA functions and features that help older adults accept need for self-care, establish self-care, and sustain self-care over time.

CONCLUSIONS

Integrating insights from the pedagogical agent literature with research on developing CAs for self-care defines an agenda for developing and evaluating CAs to help older adults manage illness.

Acute effects of aerobic exercise and relaxation training on fatigue in breast cancer survivors: A feasibility trial

OBJECTIVE

This three-armed randomized controlled feasibility trial tested the acceptability and acute effects of aerobic exercise and technology-guided mindfulness training (relative to standalone interventions) on cancer-related fatigue among breast cancer survivors (BCS).

METHODS

BCS recruited from Central Illinois completed pre- and post-testing using established measures and were randomized to one of three groups (combined aerobic exercise with guided-mindfulness relaxation, aerobic exercise only, and relaxation only), conducted in three 90 min sessions over the course of 7 days in a fitness room and research office on a university campus.

RESULTS

We enrolled 40 BCS (M_age = 57.33 ± 8.75), M_BMI = 27.38 ± 5.27, M_fatigue = 4.56 ± 1.81 as measured by the Piper Fatigue Scale. More favorable post-intervention evaluations were reported by the combined group, compared to aerobic exercise or relaxation only (p < 0.05). Reductions in fatigue favoring the combined group (p = 0.05) showed a modest effect size (Cohen's d = 0.91) compared to aerobic exercise only.

CONCLUSIONS

These findings provide preliminary evidence for the feasibility of combining evidence-based techniques to address fatigue among BCS. The combined approach, incorporating mobile health technology, presents an efficacious and well-received design. If replicated in longer trials, the approach could provide a promising opportunity to deliver broad-reaching interventions for improved outcomes in BCS. Preregistered-ClinicalTrials NCT03702712.

Against the use and publication of contemporary unethical research: the case of Chinese transplant research

Recent calls for retraction of a large body of Chinese transplant research and of Dr Jiankui He's gene editing research has led to renewed interest in the question of publication, retraction and use of unethical biomedical research. In Part 1 of this paper, we briefly review the now well-established consequentialist and deontological arguments for and against the use of unethical research. We argue that, while there are potentially compelling justifications for use under some circumstances, these justifications fail when unethical practices are ongoing-as in the case of research involving transplantations in which organs have been procured unethically from executed prisoners. Use of such research displays a lack of respect and concern for the victims and undermines efforts to deter unethical practices. Such use also creates moral taint and renders those who use the research complicit in continuing harm. In Part 2, we distinguish three dimensions of 'non-use' of unethical research: non-use of published unethical research, non-publication, and retraction and argue that all three types of non-use should be upheld in the case of Chinese transplant research. Publishers have responsibilities to not publish contemporary unethical biomedical research, and where this has occurred, to retract publications. Failure to retract the papers implicitly condones the research, while uptake of the research through citations rewards researchers and ongoing circulation of the data in the literature facilitates subsequent use by researchers, policymakers and clinicians.

Revisiting the equity debate in COVID-19: ICU is no panacea

Throughout March and April 2020, debate raged about how best to allocate limited intensive care unit (ICU) resources in the face of a growing COVID-19 pandemic. The debate was dominated by utility-based arguments for saving the most lives or life-years. These arguments were tempered by equity-based concerns that triage based solely on prognosis would exacerbate existing health inequities, leaving disadvantaged patients worse off. Central to this debate was the assumption that ICU admission is a valuable but scarce resource in the pandemic context.In this paper, we argue that the concern about achieving equity in ICU triage is problematic for two reasons. First, ICU can be futile and prolong or exacerbate suffering rather than ameliorate it. This may be especially true in patients with COVID-19 with emerging data showing that most who receive access to a ventilator will still die. There is no value in admitting patients with poor prognostic indicators to ICU to meet an equity target when intensive critical care is contrary to their best interests. Second, the focus on ICU admission shifts focus away from important aspects of COVID-19 care where there is greater opportunity for mitigating suffering and enhancing equitable care.We propose that the focus on equity concerns during the pandemic should broaden to include providing all people who need it with access to the highest possible standard of end-of-life care. This requires attention to culturally safe care in the following interlinked areas: palliative care, communication and decision support and advanced care planning.

Design guidance for video chat system to support social engagement for older adults with and without mild cognitive impairment

Background

Social engagement technologies offer an opportunity to reduce social isolation. However, there are barriers to adoption among older adults with and without Mild Cognitive Impairment (MCI). Technology designed to meet the needs of those users may improve the acceptability, adoption, and benefits of social engagement technology.

Objective

The goal was to assess older adults' needs and preferences for using video chat systems. We used the Technology Acceptance Model as a framework for evaluating and optimizing usability of a web-based video chat system for older adults with and without MCI.

Methods

Mixed methods (qualitative and quantitative) were used to achieve this objective. We developed questionnaires and interviews to identify experiences with video chat, and preferences and attitudes towards a web-based video chat system. We conducted heuristic analysis to evaluate and improve the usability of the system.

Results

Participants reportedly used video chat less than other social network tools (e.g., Email). They were open to using a web-based video chat system to meet new people of all ages with shared interests. Their favorite topics of conversation were books, health, family, and exercise. Their ideal group size for a video chat session was 3 to 6 people. Overall, participants' attitudes toward the system were positive and they perceived the system as easy to use and useful for social engagement. Their evaluations indicated high usability of the system. However, individuals with MCI might require additional assistance to use the system. Usability issues were identified, such as technical terminology, small font size, and potentially confusing icons that were addressed in the redesign.

Conclusion

Older adults, with and without MCI, were interested in using a social engagement technology to interact with previously unfamiliar individuals with shared interests. They provided valuable insights for the design of the systems. Our findings provide guidance for the design of social engagement technologies. Our research approach serves as a case study for the assessment of other technology platforms.

Defining Aging in Place: The Intersectionality of Space, Person, and Time

Aging in place (AIP) is a term that is commonly used and defined in a plethora of ways. Multiple disciplines take a different stance on the definition of AIP, and its definition has evolved over time. Such diverse ways to define AIP could be a barrier to reach a shared expectation among multiple stakeholders when formulating research studies, making policy decisions, developing care plans, or designing technology tools to support older adults. We conducted a scoping review for the term AIP to understand specifically how it has been defined across time and disciplines. We collected exemplary definitions of AIP from 7 databases that represent different fields of study; namely, AgeLine, Anthropology Plus, Art and Architecture Source, CINAHL, PsycINFO, PubMed, and SocINDEX. We conducted a thematic analysis to identify the common concepts that emerged across the definitions identified in the scoping review. We developed 3 main categories from the themes: space, person, and time to illustrate the root of meaning across the definitions. Intersectionality across the categories yielded a comprehensive understanding of AIP, which does not constrain its definition to a place-related phenomenon. We propose that AIP be defined as "One's journey to maintain independence in one's place of residence as well as to participate in one's community." With this shared understanding of the term AIP, policymakers, researchers, technology designers, and caregivers can better support those who aim to age in the place of their choice.

Aging Concerns, Challenges, and Everyday Solution Strategies (ACCESS) for adults aging with a long-term mobility disability

BACKGROUND

There are growing numbers of adults aging with long-term mobility disabilities. Very little is known about the challenges this population experiences with everyday activities, and such challenges are likely to be greater and more complex than those of older adults who experience mobility declines later in life.

OBJECTIVES

The current manuscript presents in-depth insights on the specific activity challenges experienced by older adults with long-term mobility disabilities, and the response strategies they employ to overcome those challenges.

METHODS

In-depth, structured interviews designed to assess challenges and response strategies for a range of daily activities were conducted with sixty older adult participants (ages 60-79) who self-identified as having a mobility disability for a minimum of 10 years. A coding scheme was developed to classify emerging themes. We identify the most common challenges and responses reported across all 6 broad categories as well as for a single activity category as an exemplar of an in-depth activity analysis.

RESULTS

A needs taxonomy revealed challenges and response themes in relation to the most difficult activities identified by the participants. Frequently reported challenges included physical limitations and accessibility challenges. Common response strategies (e.g., utilizing tools or technologies, obtaining assistance from others, or modifying the approach to the task) were successfully mapped onto the Selection, Optimization, and Compensation model.

CONCLUSIONS

Findings reveal the unique challenges individuals face when engaging in everyday activities, and the potential of affordable and effective supports to promote aging-in-place, functional independence, and community engagement for adults aging with long-term mobility disability.

The TechSAge Minimum Battery: A multidimensional and holistic assessment of individuals aging with long-term disabilities

BACKGROUND

People with disabilities acquired in early to mid-life are living longer, contributing to growing numbers of older adults who are aging with disability, an understudied population likely to be underserved.

OBJECTIVES

This paper demonstrates the usefulness of the TechSAge Minimum Battery as a holistic assessment of health for people aging with disabilities.

METHODS

Survey data of socio-demographic and health characteristics were collected from 176 older adults with long-term vision, hearing, and/or mobility disabilities. A series of descriptive and bivariate analyses were conducted to illustrate the heterogeneity of the sample. An in-depth analysis of the subsample with vision difficulty was conducted to highlight the tool's value in assessing detailed contextual information for a specific disability.

RESULTS

Prevalence of health conditions (M = 4.1; SD = 2.5), prescription medications (M = 4.1; SD = 3.9), and serious functional difficulties (M = 1.6; SD = 0.85) indicated a fair degree of comorbidity, but with considerable variation in number and type among individuals. Subjective health ratings were high overall, but lower scores were correlated with additional comorbidities (r = -0.31-0.40, p =<.001). Analyses of the subsample with vision difficulty demonstrated heterogeneity in functional capacity, degree of impairment, duration, and use of supportive aids.

CONCLUSIONS

Findings highlighted the heterogeneity among people aging with disability and demonstrated the importance of capturing multi-dimensional factors inclusive of an individual's capacity, context, and personal factors, which the Minimum Battery provides in an integrated assessment. Potential healthcare applications of the tool are discussed with implications for bridging aging and disability services.

Depressive Symptoms as a Predictor of Memory Complaints in the PRISM Sample

Objectives

The current study investigated baseline and longitudinal relationships between memory complaints, depressive symptoms, and cognition in older adults.

Method

Using the sample from the Personal Reminder Information and Social Management trial, we generated path models predicting self-rated memory complaints measured by the Memory Functioning Questionnaire (MFQ).

Results

Our baseline models showed that more depressive symptoms were associated with reporting more frequent forgetting incidents and a greater decline in memory function. The baseline models also revealed that higher scores in a latent cognitive function were associated with reporting a greater decline in memory functioning and a greater use of mnemonics. However, cognitive predictors did not mediate the baseline associations between the MFQ measures and depressive symptoms. Further, these predictors were not able to directly predict the 12-month MFQ measures over and above the baseline effects. Including personality traits (neuroticism and conscientiousness) did not significantly affect the models.

Discussion

Our results suggest that memory complaints about frequency of forgetting can be the most reliable indicator of depression risk among the four factors in the MFQ. We discuss theoretical implications for longitudinal relationships between memory complaints, depressive symptoms, and cognitive function in older adults.

EXPLORING VIDEO CHAT FOR SOCIAL ENGAGEMENT IN OLDER ADULTS WITH AND WITHOUT COGNITIVE IMPAIRMENT

Social engagement technologies have the potential to benefit health and quality of life in older adults with and without mild cognitive impairment (MCI). However, technologies are rarely designed to accommodate the interests, capabilities, and limitations of these populations. In the current study, we focused on examining the potential of video chat to socially engage older adults with and without MCI by providing opportunities to link people with shared interests. Eight cognitively normal older adults (Mage: 73.3 years) and five with MCI (Mage: 70.0 years) completed a four-week experiential field trial using a novel online video chat platform called OneClick. System Usability Scale scores at both pre- and post-assessment revealed that OneClick was easy to use for older adults with and without MCI, however individuals with MCI experienced more technical issues and required additional assistance to use the system. Pre- to post- comparisons of questionnaire data revealed positive changes for the Quality of Life, Friendship/Social Isolation, and Loneliness scales in both groups. Of the 13 participants, five cognitively normal and four individuals with MCI reported that they would be interested in continuing to use the video chat system at home to connect with family and friends or to discuss topics of mutual interests. Overall, all participants enjoyed using the video chat system as a means for social engagement and showed trends for social health and quality of life benefits. This field trial illustrates the potential for video chat to provide social engagement opportunities for older adults with and without cognitive impairment.

UNDERSTANDING ACCEPTANCE OF HEALTHCARE TECHNOLOGY BY OLDER ADULTS: IMPLICATIONS FOR ADOPTION

Healthcare Technology (HCT) can support older adults as it is not uncommon for them to be managing one or more chronic diseases at a time. Thus, understanding older adults’ willingness to use HCTs can guide introduction of new technologies to help with their health management. The purpose of the research is to understand what influential factors emerged when older adults considered using new HCTs and how well current models of technology acceptance represented these factors. Twenty-three older adults (age 65-84) with hypertension completed a semi-structured interview to gain insight into these factors. During the interview, participants were first presented with a scenario to imagine and one of three HCTs (blood pressure monitor, electronic pillbox, and multifunctional healthcare robot) to consider. The qualitative coding identified: (a) facilitators: perceived advantages, easy to use, familiar, useful, and advice acceptance from a healthcare provider; (b) barriers: good for others, not good for me, disadvantages, and unfamiliar; and (c) transition factors that can lead to acceptance: with advice acceptance from a healthcare provider. These findings provide recommendations which can inform dissemination of new HCTs. Recommendations include: highlight the facilitators when introducing new HCT, understand the barriers and transition factors to give support where needed, and include the care network (i.e., people knowledgeable about the HTC and health conditions) to recommend the technology.

SMART HOME TECHNOLOGY FOR OLDER ADULTS WITH MOBILITY DISABILITIES: POTENTIAL AND CHALLENGES

Recently, there has been a significant expansion in the number of smart and connected technologies for assisting individuals with a variety of tasks within the home. Examples include digital home assistants (e.g., Amazon Echo), smart lights, smart plugs, robotic vacuums, as well as a multitude of other devices. Such technologies hold the potential to support independence for older adults with long-term mobility disabilities, as they may experience challenges engaging in daily activities. The aim of the current study was to utilize a comprehensive approach with an interdisciplinary team to improve understanding of how to integrate smart technology into older adults’ homes. We focused on identifying functionality that would be useful to them, understanding their perceptions, and developing instructional support. We conducted interviews among older adults with, and without, long-term mobility disabilities to better understand their attitudes towards digital assistants, identify needs for instructional support, and test the usability of our instructional protocol. The overall goal of this research is to improve understanding of older adults’ perceptions of these technologies and identify usability challenges within the home. The instructional protocol offers support by reducing the identified barriers to initial adoption and continued use to promote aging-in-place and improving overall quality of life for older adults with long-term mobility disabilities.

IDENTIFYING COMMUNITY PARTICIPATION CHALLENGES FOR ADULTS AGING WITH MOBILITY AND VISION DISABILITIES

There are growing numbers of older adults with mobility and vision disabilities acquired in early to mid-life who are a part of a population described as “aging with disability”. For these individuals, the addition of normative age-related declines (e.g., vision loss, arthritis) on top of a long-term disability can create extensive barriers to community participation. We present findings on activity challenges with community participation among older adults with long-term vision and mobility disabilities (N=120) from the Aging Concerns, Challenges, and Everyday Solution Strategies (ACCESS) interview study. Results provide detailed insights on the specific task-based challenges experienced when engaging in one’s community (e.g., going to entertainment events, doing activities with a group or organization, and participating in religious services and activities) as well as the solutions and strategies employed to overcome those challenges. Findings provide guidance for the design of supportive technologies that promote participation and independence for this understudied population.

A New Approach to Defining Disease

In this paper, we examine recent critiques of the debate about defining disease, which claim that its use of conceptual analysis embeds the problematic assumption that the concept is classically structured. These critiques suggest, instead, developing plural stipulative definitions. Although we substantially agree with these critiques, we resist their implication that no general definition of "disease" is possible. We offer an alternative, inductive argument that disease cannot be classically defined and that the best explanation for this is that the concept is structured as a cluster. We further argue that we do not need to reject the possibility of defining the general concept "disease" to legitimate developing stipulative definitions of disease that are relative to particular purposes. A cluster definition of disease is compatible with contextually motivated definitions, which may be considered précisifications of the more general cluster concept.

Effects of Extended Use of an Age-friendly Computer System on Assessments of Computer Proficiency, Attitudes, and Usability by Older Non--Computer Users

This study examined the impact of use of a computer software application designed specifically for older people known as PRISM—a Personal Reminder Information and Social Management system—which was installed on a computer that was placed in the homes of adults aged 65 to 98 years, who were at risk for social isolation and had minimal or no computer skills and no computers in their homes. Participants received face-to-face training on the system in their homes over several days and a variety of measures were collected at baseline and at 12 months. A growth mixture model applied to participants’ usage of the system over the course of 12 months revealed two distinct subpopulations of users—less-frequent users and more-frequent users—who after one year of exposure to the system differed in computer proficiency, attitudes toward computers, and ratings of system usability. These two groups did not differ on computer proficiency and computer attitude measures at baseline. The more-frequent user group, however, had significantly higher fluid cognitive abilities. Additional analytical models were used to further examine the relationships among the study measures. The implications of the findings are discussed in terms of the importance of usability for promoting initial engagement with a system and that increased engagement with the system can instill beliefs in these older adults that they can successfully transition to other computer-based technologies and applications. The results also underscore the importance of the user-centered design approach and designing highly usable systems for older adults with low technology proficiency.

Understanding the use and non-use of social communication technologies by older adults: A qualitative test and extension of the UTAUT model

Technology has the ability to foster social engagement, but a sizable divide exists between older and younger adults in the use of social communication technologies. The goal of the current study was to gain a better understanding of older adults' perspectives on social communication technologies, including those with higher adoption rates such as email and those with lower adoption rates such as social networking sites (e.g., Facebook, Instagram). Semi-structured group interviews were conducted with either users or non-users of social networking sites to gain insight into issues of adoption and non-adoption of social communication technologies. The Unified Theory of Acceptance and Use of Technology model (UTAUT) was adapted and used to categorize the interview content. We found support for a benefit-driven account of social communication technology acceptance and usage, with participants most frequently discussing the degree social communication technologies would or would not help them attain gains in social connectedness, entertainment, and/or information sharing. However, the UTAUT was not sufficient in fully capturing the group-interview content, with additional categories being necessary. For instance, trust in social networking sites (privacy and security concerns) was frequently discussed by both users and non-users. The current results broaden theories of technology acceptance by identifying facilitators and barriers to technology use in the older adult population.

Perceptions of Digital Assistants From Early Adopters Aged 55+

Voice-activated digital assistants have the potential to assist adults aging-in-place with a variety of everyday tasks and leisure activities. To understand this potential, semi-structured interviews were conducted to explore perceptions and attitudes from current adult users based on the models of the unified theory of acceptance and use of technology model. Several model factors were identified as influential in the initial and continued use of the digital assistants. Results indicate the need for an effective instructional protocol to promote successful interactions during the learning phase and for continued engagement with novel abilities of the digital assistants.

Supporting trust in home healthcare providers: insights into the care recipients' perspective

Successful care in home health for older adults is heavily dependent on the relationships between care recipients and care providers. A key component of that relationship is trust. To investigate trust in this context, we explored what older care recipients perceive as supporting trust in home care providers. Participants discussed three main categories that support trust in a care provider: professional skills (e.g., safety), personal traits (e.g., honesty), and communication (e.g., content). Insights from the care recipients' perspective are utilized to provide training recommendations for developing trust. For example, care providers should complete tasks in the care recipients' preferred manner.

Mobile Health Apps: Improving Usability for Older Adult Users

With smartphone use among older populations on the rise, older adults have increased access to health-focused mobile apps. Despite their potential benefits for managing health, currently no guidelines exist for designing these apps specifically for older adult users. We evaluated the usability of one medication management app and two congestive heart failure management apps using cognitive walkthroughs, heuristic analysis, and user testing. We identified design issues that may affect usability for older users, including poor navigation, small button sizes, and inadequate data visualizations. We provide guidelines for developers of health apps to facilitate use by older adults.