Exploring the effects of aging on mobility Anna de Jonge, Robin Karels, John Faria, Riccardo Sarijoen, Ryan Brand,

and Maarten Langbroek

Faculty of Industrial Design, Technical University of Delft, the Netherlands
Abstract: The authors of this report believe that insufficient attention has been given to the effect that early aging can have on mobility. This paper reports on research preformed to explore the aggravations elderly may encounter as a result of their age. After studying literature and consulting an expert on this topic, interviews were conducted to test our presumptions. Specifically, active elderly aged 60-75 were interviewed while going out in an urban environment. The specificity of the subject is based upon research that was done as part of a larger project with the goal of designing an elderly mobility product for 2019. The frequency, with which elderly go out, remains high, even after retirement. Maintaining a high level of physical activity prolongs the onset of age-relate loss in function. The common assumption that cognitive ability deteriorates with age is largely incorrect; where anxiety is kept at bay, elderlycomprehension is near to middle-aged levels. Keywords: Age, elderly mobility, urban environment

Introduction Mobility can present unique challenges when considered in the context of aging. Individual and cultural habits, relating to how people move, are based largely on the abilities and limitations of a young and able body. Adapting such habits, to those limitations associated with aging, can present unique challenges. This paper seeks to understand some of the specific aging processes which may inhibit mobility. Physiologically, what processes does the human body undergo as a result of aging? In practical terms, how do these processes affect normal function and how can these changes be expected to affect personal movement routines? The term personal movement will also be explored, as it relates to a specified target user, which has been defined according to the following pillars: 1. The Clients Vision This vision is to provide mobility products that are both visible and appropriate for use in an urban environment.

2. Authors Target User The authors of this report believe that insufficient attention has been given to the effect that early aging can have on mobility. Such effects may present themselves more so as aggravations than limitations; as such, they likely do not prevent or deter mobility, but rather make it more difficult than was previous for an individual. As such, this paper endeavours to explore how early stages of aging can affect freedom of movement. In order to do this effectively, a target user has been defined as being 60-75 years of age, and in normal health. To adequately bridge the gap between the physiological effects of aging, and their consequences, as they relate to freedom of movement, this paper will endeavour to answer the questions: 1. How does the target user typically move themselves (and their personal articles) and for what purposes? 2. What are the early stages of physical aging? 3. What effect will these physical changes have on mobility habits? Presumptions It is presumed that urban movement will typically not involve automobiles, but rather will exploit public transportation such as subway systems, trains, buses, and even air travel. It is also presumed that urban travel will involve the transportation of light personal items, such as daily shopping and personal articles required for a day away from home. The authors make the following presumptions regarding the physiological effects of aging and how they may compromise freedom of mobility: 1. Sensory (hearing, sight, sense of balance, etc.) will degrade with age and is expected to have a negative effect on mobility. 2. Joint and muscular impairment will make movement more difficult, especially where

steps or inclines must be navigated. Lifting objects will also become problematic. 3. Endurance will decrease with age. This will result in the need for more frequent breaks and will restrict an individual with regards to their total range in terms of walking, cycling, etc. 4. Memory loss may occur in various degrees, causing difficulty where information such as directions must be recalled. 5. Because our target group is still highly active and in good health, the aforementioned physiological changes, are assumed to present themselves as aggravations, as they relate to freedom of movement, and will not prevent or cause deterrence from partaking in activities where mobility is part-in-parcel.

Materials and Methods A literature search was conducted in order to understand what physiological changes result as a consequence of normal aging. The search was conducted by searching the internet for academic papers that focused on the declining capabilities that occur with age. The objective of this investigation was broken down into three main categories: 1. Exploration of elderly mobility patterns (modes and purposes) 2. Understanding the aging process as it relates to: a. Sight b. Stamina/endurance (respiratory/circulation) c. Musculoskeletal changes d. Neuroanotomical changes

3. Understanding, in practical terms, what affect the aforementioned aging processes will have for an individual. 4. Assessing how the affected functions will influence or cause limitation to mobility by

investigating elderly mobility habits. In order to support our literature findings, an expert interview was conducted. Hanneke Hoos is a physiotherapist specializing in elderly rehabilitation. Her participation was solicited in order to gain insight into the physical and psychological problems facing elderly as they relate to mobility. Our expectation was that Hoos expertise would focus mostly on the most aggressive stages of physical impairment, since they are most likely to require the assistance of a physiotherapist. Such individuals those whose condition is debilitating to their freedom of movement are not within our target group. Hoos input, however, was considered valuable as it would give practical indication as to the physical impairments that cause the greatest impact to freedom of movement. The rational was that, by identifying which physical impairments most affected mobility during the debilitating phases of aging, our understanding of which physiological functions cause aggravation or discomfort would be bettered. A semi-structured interview was devised in order to gain insight per the aforementioned objectives. Our presumptions were mentioned during the interview. The goal was to evoke reactions as to their validity. The expert interview with Hoos lasted approximately 45 minutes in duration. A series of semi-structured interviews were compiled. The objective for this interview series was to gain insight into the mobility patterns of the target group as they relate to the urban environment (previously defined). A second objective was to draw parallels between those factors considered by participant to be aggravations whilst moving, and the agerelated, physiological changes covered in the literature search. The term aggravations was used so to keep consistent with presumption No. 5. An objective of the interview was to encourage participants to reveal aggravations that relate to (a) their own physiological condition and (b) the environment within which they commonly mobile. The approximate

length of each interview was 30 minutes - in this time the participant was presented with four broad-reaching questions. The question topics covered were, in order of presentation: Routines / Activity Types / Frequency / Motivation Travel Items / Carrying and Packing Strategies Aggravations: Physiological / Environmental New and Unfamiliar Urban Settings Fourteen participants were selected, for their compatibility with the defined target group. Of this total, 13 participants were recruited at the Army Museum of Delft, The Netherlands. The nationality of all participants was Dutch; however they were from varied regions throughout the country. The museum was determined to be an appropriate location from which suitable participants could be recruited because (a) those in attendance were considered to be engaging in the type of urban outing that represented the habits of our target group (b) It could be expected that attendees were not in a particular rush, and thus would likely give-forth the time required to properly complete the interview (c) The location was easily accessible to the authors. The fourteenth participant was selected on account of her residency in downtown Amsterdam. It was assumed that her experience in a major cosmopolitan setting would lend particular insight into mobility habits where there exists a diverse public transport system and high population density. All interviews were conducted by a single interviewer, in order to provide consistency in procedure. Furthermore, all interviews were conducted in Dutch so that participants had the greatest opportunity to express themselves.

Results Literature Search The Causes of Aging There exist two popular explanations as to the cause of physical aging, also known as senescence. The first argues that the process is programmed by genes. The second argues that cells suffer cumulative damage from free radicals, toxins produced by their own internal chemical reactions (Kroemer, pp.127). Regardless the cause, life expectancy plays a significant role in how aging affects us. In historical terms, human life expectancy has increased radically within a very short timeframe (see Figure 1).

Figure 1: Average Human life Expectancy (Kroemer, pp.127)

Where, in past eras, the physical consequences of aging would have been experienced by few and in relatively moderate forms. Todays life expectancy data suggests that the effects of aging are experienced by the majority of people and to degrees that were uncommon only a short time ago.

Musculoskeletal Changes Biological Changes A reduction in total bone mass, combined with changes in mineral content, contribute to agerelated osteoporosis (Kroemer, pp.132). Women and inactive people constitute highest-risk demographics. A healthy, high-calcium diet and regular exercise can partly counteract these developments (Kroemer , pp.132). Thinning of joint linings, the reduction in synovial and loss of elasticity are the causes of arthritis (Kroemer, pp.132) Practical Consequences Degenerative arthritis is associated with pain, often debilitating, and is the most-cited cause for limitations in daily activities (Kroemer, pp.132)

Respiration and Circulation Changes Biological Changes The respiratory systems capacity to move air reduces significantly with age, in part because the muscles in the chest diaphragm loose ability to produce space in the chest cavity. Alveoli inside the lungs lose their ability to exchange oxygen for carbon dioxide (Kroemver, pp.132). Practical Consequences Despite the reduced capacity of the respiratory system, a test conducted using a crosssectional sample of +1600 men, aged 25-70 years, revealed that their physical capacity for work was more closely correlated with changes in body composition (mostly body fat content) and exercise habits than with age (Kroemver, pp.135).

Neuroanotomical Changes Biological Changes Evidence suggests that a decline in intelligence and creativity begins in the late 30s and early 40s (Haigh, pp.13). The cells which make up neurons, called soma, disappear with age. When this atrophy of the soma occurs in the basal ganglia the result has a negative effect on such functions as, planning, initiation, timing, and learning of complex motions (Kroemver, pp.133). Practical Consequences Generally speaking it is difficult to accurately deduce the practical impact of those changes to the brain described above. For example, tasks one has knowledge of are less likely to cause mental difficulties than something completely new at the age of 60 (Haigh, pp.13). Where information was acquired over a long period of time, the results will be more favourable than when mental tasks are based on momentary analysis of new information (Haigh, pp.13). As a consequence, increasing age has a negative effect on a persons capacity for rapid information processing; speed and accuracy of logical and arithmetical reasoning; and spatial ability (Haigh, pp.13). It is worth remembering that the changes described above hold relatively little bearing for our target group, as fewer than 5% of those aged 65 to 75 show symptoms of dementia. Given enough time and an environment that keeps anxiety at bay, most healthy older people score about as well as young or middle aged adults on tests of mental performance (Koemver, pp.134).

Changes to Sight Biological Changes The ability to respond to ambient light conditions is controlled by the pupil. Its ability to change size is highest during early teenage years, and thereafter, diminishes with age (Haigh, pp.9). Accommodation is defined as the eyes ability to adjust focus to objects near and far. The near-point of focus typically reduces from age eight. By 55 years, the rate of reduction levels-off, after losing approximately 55% (Haigh, pp10). Contrast ability enables a person to recognise outlines between light and dark spaces. Sensitivity to Contrast begins to diminish by age 20, however the main decline begins around 40 to 50 (Haigh, pp.10). Glare is the result of gel deposits that clump together with age. These clumps reflect light within the vitreous humor, giving the illusion of a veil of light (Koemver, pp.137) Practical Consequences As a result of deterioration in acuity and contrast sensitivity, there is greater need for light. The average 60-year-old eye requires three times as much light as a 20-year-old eye to see the same object (Haigh, pp.9). A natural conclusion would be that more light can equalize the effects of age, however an increase in illumination can improve performance only up to the point at which glare begins to decrease performance (Haigh, pp.10)

Typical Movements of the Elderly Perry Hanson conducted a study on the mobility habit of elderly. He monitored 300 households in the city of Uppsala, Sweden for a 35 day period. Hanson defined a trip as any series of movements that began and terminated at the home-place, and could thus consist of multiple stops. He defines elderly as 67 years and older. Hanson makes two significant discoveries: Firstly he recognizes a striking difference in the importance of pedestrian and bus travel among the elderly, while non-elderly rely more

on automobiles (Figure 2).

Figure 2: Modal Choice and Distance (Hanson, pp.117)

Secondly, Hanson investigates the reasons for elderly travel:

Car (Passenge r) E N/E 17.7 18.5 7.8 25.8 22.5 25.4 100

Walk Bike Bus Activity type E N/E E N/E E N/E Shopping 49.7 44.3 24.8 23.5 37.9 26.4 Personal Business 17.6 18.7 14.8 10.2 16.6 12.9 8.9 9.9 8.4 Social 11.6 11.6 16.5 7.9 22.6 17 25.8 18.1 40.3 Work 7.7 17.6 30 53.6 11.3 38.7 16.4 32.8 15.5 Recreation 13.3 7.8 13.9 4.7 11.5 5.1 15.8 13.3 18.1 Figure pp.118) Total 3: Percentage of movement for 100 mode, according to purpose (Hanson,100 100 100 100 each 100 100 100 100

Car (Driver) E N/E 33.1 26

From his findings, Hanson observed that, when work is omitted, there is remarkable similarity in the two groups' use of the walking, bus, and car (driver) mode to the four remaining trip purposes (Hanson, pp.119). In conclusion, Hanson argues that The elderly visit non-work activity sites as frequently as do the non-elderly using similar methods. The only purpose for which the elderly make significantly fewer stops is work (Hanson, pp.113). The Intuit report for 2020 predicts, however, that The majority of baby-boomers will work beyond the traditional retirement age... [and in 2020] younger baby-boomers, aged 5565, will start more small businesses than any other demographic (Intuit 2020 Report, pp.8).

Interview results Routines / Activity Types / Frequency / Motivation Only two of the fourteen interviewees mentioned a decline in their mobility. The rest said it has not changed for the past few years. According to four of the participants, the frequency of going out increased once they retired (I think we do more nowadays). One participant claimed a reduction in trips out of the house. Common motivations for going out were visiting family, doing groceries, shopping, city trips and hiking or cycling. Groceries were mostly done by foot or by bicycle. Shopping was done in bigger cities (urban environment). Interviewees who used a car and those who used public transport were divided quite evenly. Some preferred public transport (...I usually go to the Hague by public transport since parking is undoable), others went by car (if I have to haul a lot).

Travel Items / Carrying and Packing Strategies If a bicycle was used as transportation for doing groceries, bicycle bags were often attached to the luggage carrier. When going out, most interviewees brought some food and drinks in a bag or backpack and, depending on weather, a jacket, umbrella or raincoat. Apart from those obvious things not much was needed. Three of the interviewees were accustomed to bringing a map of their destination. One interviewee had a small dog with her. Where dogs are not permitted it was a problem to find someone to look after it. The target group used cell phones, and many were familiar with smart phones and tablets some brought their smart devices with them. Three interviewees stated that they had difficulty with transporting heavy objects. When moving wheeled suitcases over the street or sidewalk, the small plastic wheels were

reported to get stuck or caused the suitcase to fall. Only one interviewee mentioned that she had considered buying a shopping trolley.

Aggravations: Physiological / Environmental Three interviewees, of whom two have had surgery, said they had problems with walking. Because of aging, their body has trouble to overcome obstacles like uneven surfaces and curbs and stairs. Two interviewees mentioned their decreasing eyesight as a possible problem. Because of this it was harder to spot obstacles. Also signs with a lot of text were difficult to read. Three other participants claimed to have no physiological problems, but still mentioned uneven surfaces as an aggravation (One could easily trip over a pavement stone while not paying attention), especially in Delft where curbs are more frequent. Eight interviewees mentioned other people as being their biggest aggravation. More specifically, six cited the unsocial behavior of youth as an annoyance. Not offering a place in public transport and loudly calling with their cell phone were examples.

New and Unfamiliar Urban Settings Navigation through an unfamiliar city was mentioned as an aggravation by two interviewees. Delft was mentioned as being a particularly hard city to find your way around. To prepare for a trip, nine interviewees checked the Internet first. The Internet was often used to find info on routes, prices, facilities, weather, etc. I never go somewhere unprepared We usually sit down the day before and think of stuff we can and want to do.

Discussion Overall mobility Within urban environment, interviewees often go by foot or bicycle; most claim that their frequency of going out has increased or remained level since retirement. Hansons research stands to report this, as the diminished importance of the work trip accounts for lower level of trip-frequency among elderly. This is a significant finding, because, the Baby-boomer generations (which will reach our target group in 2019) is predicted to break previous trends with respect to retirement (Intuit 2020 Report, pp.8). The result could be unprecedented employment and entrepreneurship for elderly, which could see overall gap (in trips made between young and old) narrow.

Physiological aggravations Kroemers research revealed that the physical capacity to for work is more related to exercise habits than age. Thus, as long as elderly stay active, their physical capabilities will not suffer so severely from aging. This nullifies our initial presumption (No.3 in the introduction) linking endurance directly linked to age. From Kroemvers emphasis - that exercise as a key variable in the severity of age-related issues - we can conclude that any Bugaboo device should serve not to insulate the user from physical activity, but rather, should give assistance only to those activities which exceed the capabilities of the user. Unnecessary support, could unintentionally initiate a downward spiral leading towards immobility. Although our target group is very mobile, they tend to plan ahead prior to making a trip: eight of the fourteen interviewees check the Internet before going on a trip. For them, it is important to sit down and gather information about their destination and route. This shows that our target group likes to be prepared so to minimize stress from travel. Here, we can draw a parallel here between our interview results and literature findings: Older people have

more difficulty in doing two things at once (Haigh, pp.13). Furthermore, changes to the basal ganglia, as we have learned, cause a negative effect on the capacity for, planning, initiation, and timing. Perhaps it is these neurological changes, as they occur in older people that give impetus to their need for thorough planning a coping mechanism adopted in order to avoid those neurological activities for which they experience difficulty. A common assumption is that elderly have trouble with new products and technology (Ostlund, 2004), since their use is typically associated with requirements for learning complex interfaces. Presumption No.4 in the introduction of this paper is consistent with this common assumption. Thus, it is interesting to learn that the majority of interviewees checked the Internet before going on a trip; many used navigation systems in their car; and all used cellphones. One interviewee even showed his Apple iPad I check everything on this: I cant do without it. Further evidence against our original presumption can be seen in Kroemers conclusion that those experiencing early aging may not learn as rapidly as at younger ages, but one can still learn and remember nearly as well (Kroemer, pp.134). Such a discovery shows our presumption, regarding deterioration of cognitive ability, to be largely incorrect and suggests that implantation of software-based technology into our design may not intimidate our target-group as first assumed. Acceptance of new technology among the 2019-generation of elderly (the babyboomers) might be even greater. As noted by Haigh, mental abilities are related, in large part, to the nature for which a users knowledge for a given task has been acquired. Since Babyboomers are understood to have significantly more exposure to software-related technologies, their inclination for smart solutions may be greater than previous generations.

Environmental aggravations

Many environmental aggravations cited by our participants can be linked directly to the physiological state of the subject: if curbs are an aggravation, this is likely because of problems lifting or moving a leg. Interestingly, only three of the six interviewees who mentioned uneven surfaces as an aggravation, acknowledged any troubles walking. Of course, some environmental aggravations are simply not age-related. The streets in the city of Delft are a fine example of an urban environment having lots of obstacles. Uneven sidewalks with different uneven pavements, curbs, narrow alleys, many cyclists and lots of building sites causing traffic diversions. These are obstacles for everyone, but especially for aging people. They have to be taken into account when designing a mobility product. Hoos names crowds and hurrying people on the street as a problem for elderly when going out. Similarly, interviewees mentioned their annoyance towards crowds especially youth. Perhaps what is seen by the participant as an environmental aggravation can, in fact, be traced back to a physiological root-cause. For example, when an older person describes their frustration for younger passengers who do not offer their seat on a full bus, can a physical aggravation be extrapolated from this scenario? We might infer that the interviewees comment insinuates that their endurance is not as good as the younger person sitting in the seat. They feel that they need the rest more. When the younger passenger, from the previous example, is categorized as being the aggravation, it is hard to identify opportunities for our future product. Perhaps the product could evoke others to pay more attention to elderly? By stripping the problem down to its physiological root-cause, however (endurance for standing), solutions become more clear. Maybe Bugaboos future mobility product should serve as a rest station, thereby alleviating the users reliance on publicly provided support?

Transportation of goods

Our interviews suggest that cars are a popular mode of transportation among elderly travelers, as they can be well adapted with high seats, cruise control and navigation systems. Hansons research, however, suggests that the elderly give greater importance to public modes of transportation. He cites Uppsalas off-peak incentive scheme (a common tool used by many municipalities) as a contributing cause for this. Furthermore, elderly are more likely to be located in the city centres than in the suburbs (Hanson, pp.110). With more cities banning cars from their centres (or considering such action), the reliance of the elderly upon public transport is set to increase. Especially when objects like suitcases or bought goods have to be carried along. Carrying groceries can be problematic for our target group. Evidence from literature, regarding respiratory and muscular aging, stands to support this.

Recommendations Older people, even those with early symptoms of aging, are affected by physical limitations that previously did not exist. Research shows that the decline of many functions begins very early and is extremely gradual. This gives explanation for the lack of recognition shown by our interviewees towards their own limitations. Indeed they are at worst aggravations, and so our final presumption, that early reductions in functionality are no deterrence to mobility, is correct. When and how these limitations transcend from aggravation to disability, is greatly related to an individuals health and diet, often more so than to a persons age. The ability of an individual to prolong the effects of aging is an unexpected discovery and nullifies certain presumption regarding capacity for work and cognitive ability. Perhaps then, a suitable goal for any new elderly-mobility product should be a design that encourages some degree of physical effort from the user. The key then would be to administer assistance only when and where the users strength and endurance might otherwise be exceeded.

Research indicates that public transport will continue to serve the elderly more, as municipal policy strives improve sustainability through public transport incentives and penalties for automobile use. Hansons report gives useful insight into how the elderly choose to travel, and for what purpose. Valuable research for the future might explore, in greater depth, the reasons why certain modes of transportation are selected by elderly. If the availability of particular modes were affected by policy, what impact might this have on the distribution of travel-modes, as they relate to a given purpose? Perhaps, such research could be useful in order to anticipate how sustainable policy and market demand will shape our cities for 2019.

References Haigh, R. (1993). The Aging Process: A Challenge for Design, Applied Ergonomics Vol.24 No1 (pp.9-14). Hanson, P. (2011). The Activity Patterns of Elderly Households, Geografiska Annaler. Series B, Human Geography, Vol. 59, No. 2 (1977), pp. 109-124 Kroemer, K. H. E. (2006). Extraordinary Ergonomics (Chapter 6) (1st ed.), London, UK: Taylor & Francis Group. stlund B. (2004), Social Science Research on Technology and the Elderly Does it Exist?, Science Studies, Vol. 17 No. 2, 4462 -Unknown author- (2010), Intuit 2020 Report: Twenty Trends that will Shape the Next Decade, Intuit