Assessing Technology Use as an Activity of Daily Living: You Don’t Know What You Don’t Ask About

Author: Jared F. Benge, Ph.D., ABPP

Overview:

The impact of cognitive problems on day-to-day activities is critical for most diagnoses neuropsychologists make, including major vs. mild neurocognitive disorder, MCI vs. dementia, or gauging the functional impact of psychiatric disorders. Increasingly, technology permeates HOW we perform daily functions. For example, for many individuals bill pay is now more often done via autopay than writing checks, paper maps are replaced with GPS, and communication is facilitated by text and smartphones as opposed to mailing letters or dialing phone numbers by memory.

Despite the many ways technology impacts daily activities, many existing tools for measuring instrumental activities of daily living (iADL) were either made well before the modern internet era (i.e. the Lawton and Brody ADL measures, made in 1968) or rely on outdated stimuli without consideration of computerized methods for acquiring information (i.e. the Instrumental Living Scales and use of a mock phonebook to find a phone number).

For practicing clinicians and researchers, there are starting to be more tools that may help get at these activities, as well as things to try in clinic which we outline below.

Things to Ask About and Observe:

1. Make a habit of inquiring about technology use as a part of your evaluations, just like most of us do with activities such as managing finances, driving, and managing medications. Useful prompts might include:
   
   1. Can the patient use a smartphone to send text messages or check emails? Can they make a call?
   2. How are bills getting managed? If they are online and something came up unexpectedly, could the patient operate the website to make any corrections or contact customer support?
   3. Has the patient fallen victim to email or other financial scams or released details of personal information online?
   4. If there are problems with a given technology, is it due to the person never having learned the task, or loss of a new skill?  Are they having problems learning new tech?
2. Observe technology use as a part of behavioral observations. This might give useful information about clinically relevant technology based cognitive prosthetics. Useful prompts might include:
   1. Does the patient use a digital or written calendar and/or to-do list? Can your recommendations be personalized to use the technologies the patient is already using?
   2. Asking a patient to enter a date or to-do (especially a follow up appointment) on a smartphone calendar. Check for errors, opportunities to set the alarm louder or different, or share a digital calendar/to-do list with a loved one to add notifications. See if there are errors that can be addressed (i.e. adding a short cut; clicking ‘stay logged in” so app does not close out, etc.).
   3. Ask about or observe inputting directions into mapping programs? Can common locations be saved to allow quicker access?

Questionnaires to Try:

1. The Amsterdam iADL measure is a freely available (for non-commercial use) psychometrically rigorous iADL measure. It is available at: https://www.alzheimercentrum.nl/professionals/amsterdam-iadl/. The short form includes questions about several household technologies, cell phone use, online banking, ATM, PIN codes, computer use, email, print documents, GPS use, and other electronic devices. A longer version contains more such items.
2. The everyday technology use questionnaire was developed in Europe as well and inquires about a range of daily technologies. https://ki.se/en/nvs/everyday-technology-use-questionnaire-etuq
3. Items designed to incorporate with Functional Activities Questionnaire (FAQ) and include technology related tasks such as using credit cards and online bill pay are under development at the University of Texas at Austin and are available from the author upon request https://sites.utexas.edu/techanslab/.

What’s in the pipeline?

Many test publishers are aware of these limitations and are updating their measures: more will follow!

Increasingly, passive sensory technologies are used both in the home and on smartphones to help track ADLs. For example, sensors in the phone can monitor kitchen performance and movement in the home, GPS can track driving characteristics, and smartphone usage is being explored as a “digital biomarker.”

Where to Read More:

Jutten, R. J., Peeters, C. F. W., Leijdesdorff, S. M. J., Visser, P. J., Maier, A. B., Terwee, C. B., Scheltens, P., & Sikkes, S. A. M. (2017). Detecting functional decline from normal aging to dementia: Development and validation of a short version of the Amsterdam IADL Questionnaire. Alzheimer’s & dementia (Amsterdam, Netherlands), 8, 26–35. https://doi.org/10.1016/j.dadm.2017.03.002

Malinowsky, C., Kottorp, A., Wallin, A., Nordlund, A., Björklund, E., Melin, I., Pernevik, A., Rosenberg, L., & Nygård, L. (2017). Differences in the use of everyday technology among persons with MCI, SCI, and older adults without known cognitive impairment. International psychogeriatrics, 29(7), 1193–1200. https://doi.org/10.1017/S1041610217000643

Disclosures:

Dr. Benge studies technology use in activities of daily living, with funding from the Alzheimer’s Association on tech ADL item development (items linked above) and NIH for smartphone detection of activities of daily living.