“<scp>iADL</scp>”: The New IADL?

My mother called again. “My password isn't working… Something is wrong with my computer!” It was the third time that month. Though a member of the “Greatest Generation,” my mother was not a “digital native.” She was an early adopter of technology and viewed it as essential to being independent and up-to-date. She was capable of using her computer, the internet, and its various applications. As her mobility and physical independence declined, her digital footprint grew. We effectively kept in touch through email as her hearing impairment made telephone calls a challenge. My mother was highly intelligent, was accomplished, and valued her independence keenly. At the age of 18 years, she graduated Phi Beta Kappa from New York University and completed the first of two graduate degrees, a Master of Public Administration, the following year. By this time, around the end of World War II, she achieved a level of independence that she intended to retain. During the 1960s, when my brothers and I were still young, she completed a second master's degree in education and briefly taught social studies. My mother then embarked on a successful and lucrative career as an executive recruiter, specializing in placing electronic data processing auditors. Her coworkers regarded her with awe both for her professionalism and her work in a technical area. Perhaps her work in this field foreshadowed her later competence with the computer, acquired in her 70s. After my father's death, my mother continued to regularly use email, pay bills, manage her bank account, check stocks, read the newspaper and, when she stopped driving, use an online grocery delivery service. When my mother was in her 80s, she called several times for assistance in resetting her passwords. It was clear that she had forgotten the passwords, but it was not immediately clear to me that this might be the first sign of cognitive impairment. She retained her intellectual capacity and independence, as was evident by the opinions offered in her emails. She appeared able to manage her affairs as far as we were able to discern. Calls for assistance now included help to fix her desktop, which periodically became disorganized and the home screen unrecognizable. Following numerous trips to her home several hours away to reset her desktop and passwords, I began to think that she might be experiencing early signs of dementia. My brother installed an application on his computer that allowed him to remotely manage my mother's computer. Rather than traveling, he could fix her desktop and reset her passwords with a few keystrokes from the comfort of his home. We had a brief reprieve. She was still able to use email, check her stocks, read the news, and order groceries, which was now essential. As time passed, her emails became less frequent and the content diminished. When we visited her, we noticed that she seemed to be accumulating the same food and products repeatedly in her refrigerator and cupboard. It took us some time to realize that she was having increasing difficulty ordering groceries online. She was able to access the website but seemed to forget how to edit her previous order. Normally, one would edit this list to create a new order. Rather than deleting items she did not require, and adding new items that she did, she would simply click the button to repeat the purchase. During my visits, I would make a list of groceries she needed and make a trip to the supermarket. This was a temporizing measure as I did not visit frequently enough to keep up with her shopping requirements. My brother, using his remote access to her computer, subsequently started to monitor and edit her grocery cart. We knew this plan was failing, but my mother insisted on maintaining her independence in her home, refusing to move or allow an aide to assist. She seemingly retained both her competence in making this decision and her authority over my brothers and me, at least for a brief period. Eventually, after several falls and subsequent hospitalizations, my mother could no longer use the computer at all. She now required a 24-hour home health aide to assist her with activities of daily living. She would repeatedly fire her home aides and, in the interim between home aides, would subsist on yogurt, which she had in ample supply. Eventually, she completely lost the ability to live alone, requiring nursing home placement, and spent the last 18 months of her life in a lovely facility not far from my home. Use of the computer, smart phone, and other digital tools has become more central in life and can provide access to the world beyond for homebound older adults. These devices also require sustained cognitive ability to use them to provide that access and to maintain one's independence at home. My mother was probably somewhat unusual in her ability to manage a personal computer early and to use it to keep others at bay. Fortunately, she was not making dozens of stock trades, ordering endless merchandise or, worse, falling victim to nefarious hackers by providing her passwords or personal information. She was spared having to decide whether to compromise her privacy and allow us to monitor her digital footprint to preserve her financial, personal, and physical security. Undoubtedly, this is a quandary many in this and future generations will face as they retire, age, and struggle to maintain their autonomy, analogous to the decision to surrender the car keys. In retrospect, I wonder whether I had stumbled on the 21st century version of unpaid bills, lost keys, or the misplaced purse: early, yet easily overlooked, signs of cognitive impairment. My mother's computer skills or cyber-skills, her “iADLs,” if you will, provided a lifeline to prolonged independence, but also provided the first clue to its loss.