Healthy Ageing in Singapore: Opportunities, Challenges and the Way Forward (Social Policy and Development Studies in East Asia) 981990871X, 9789819908714

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SOCIAL POLICY AND DEVELOPMENT STUDIES IN EAST ASIA

Healthy Ageing in Singapore Opportunities, Challenges and the Way Forward Sabrina Ching Yuen Luk

Social Policy and Development Studies in East Asia

Series Editors Joshua Mok, Lingnan University, Hong Kong Jiwei Qian, National University of Singapore, Singapore, Singapore

“Social Policy and Development Studies in East Asia” aims to provide a platform for academics, researchers and policy analysts to contribute their reflections and analysis of how rapid social, economic, cultural, political and even political economy changes would have affected the formulation, implementation and evaluation of social policy responses in handling/managing rapid changes and risk management issues confronting East Asian governments and societies.

Sabrina Ching Yuen Luk

Healthy Ageing in Singapore Opportunities, Challenges and the Way Forward

Sabrina Ching Yuen Luk School of Social Sciences Nanyang Technological University Singapore, Singapore

Social Policy and Development Studies in East Asia ISBN 978-981-99-0871-4 ISBN 978-981-99-0872-1 (eBook) https://doi.org/10.1007/978-981-99-0872-1 © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Palgrave Macmillan imprint is published by the registered company Springer Nature Singapore Pte Ltd. The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore 189721, Singapore

Dedicated to my father (Roger Luk) and my mother (Sandy Chu) for their support and unconditional love. To the memory of my godfather (Wing Lin Leung).

Preface

This book is the result of five years’ hard work. In summer 2017, I relocated to Singapore due to a job opportunity at the Public Policy and Global Affairs (PPGA) Programme, Nanyang Technological University (NTU), Singapore. I decided to write this book because I want to provide a comprehensive picture about healthy ageing in Singapore. Singapore is the world’s second-fastest ageing society. It will become a super-aged society by 2030. The twin challenges of low fertility rate and longer life expectancy have resulted in a shrinking workforce, an increase in old-age dependency ratio and feminization of ageing in the country. Singapore has been a testbed for many schemes, programmes and policies implemented by the government, researchers and community partners to solve the problems caused by population ageing. However, the effectiveness of these schemes, programmes and policies in solving the problems of population ageing varies. Hence, the aim of this book is to provide a comprehensive and updated assessment of healthy ageing in Singapore and discuss the facilitators and barriers to healthy ageing in the country. There is no one-size-fits-all answer to healthy ageing. How an individual, the community and the government understand and interpret the concept of healthy ageing may vary among cities or countries. Besides, how the government in a city or a country develops its healthy ageing framework or implements its healthy ageing strategy very much depends on

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PREFACE

the political, economic, social, cultural and historical context. Nevertheless, achieving healthy ageing should be able to add years to one’s life as well as add life to one’s years. This book covers a lot of hot topics which would interest local and international readers. These hot topics include financial wellness of older adults, ageing in place, music therapy for people with dementia and terminally ill patients, the creation of dementia-friendly communities, technology and the wellness of older adults, Advance Care Planning and digital connection with older adults in the time of the 2019 coronavirus disease (COVID-19). They are examined using both first-hand data collected through semi-structured interviews and secondary data collected through open and authoritative channels. Health financing and long-term care (LTC) financing are key components of healthy ageing. They have been examined in Chapter 2. For readers who are interested in knowing health financing reforms in Singapore in details, you are welcome to read my earlier work titled Health Insurance Reforms in Asia (2014, Hoboken: Taylor and Francis). For readers who are interested in knowing LTC insurance reform in Singapore in details, you are welcome to read my previous work titled Ageing, Long-term Care Insurance and Healthcare Finance in Asia (2020, Abingdon, Oxon; New York, NY: Routledge). For readers who are interested in knowing the Singapore government’s efforts to contain COVID-19, you are welcome to read my work titled Singapore after Lee Kuan Yew (co-authored with Peter Preston) (2020, Milton: Taylor & Francis Group). I hope that this book can provide some valuable insights into some of the key issues of healthy ageing in Singapore. I also hope that readers can find their own way to achieve healthy ageing. Singapore, Singapore Winter 2022

Sabrina Ching Yuen Luk

Acknowledgements

This book is the result of five years’ hard work. I would like to express my deepest gratitude to my parents and elder brother for being the anchors of my soul and the pillars of my strength. This book is a testimony to their unconditional love and support throughout my prolonged pursue of knowledge. I owe a particular debt of gratitude to the informants of this study who generously spent their valuable time and sincerely shared with me their expertise and thoughts but who cannot be named. I would also like to express my gratitude to Miss Saranya Siva and her colleague for their professional advice and assistance in the publication of this book. This book is supported by the Start-Up Grant (SUG) of Nanyang Technological University, Singapore (Grant number: M4082137.SS0.).

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Contents

1

1

Population Ageing in Singapore

2

Financial Well-Being of Older Adults

29

3

Music Therapy for People with Dementia and Terminally Ill Patients

63

4

Technologies and the Wellness of Older Adults

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5

Digital Connection with Older Adults in the Time of COVID-19

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6

Enabling Ageing in Place

147

7

The Creation of Dementia-Friendly Communities

185

8

Advance Care Planning

235

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Afterword: Healthy Ageing in Singapore

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Index

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About the Author

Dr. Sabrina Ching Yuen Luk is Assistant Professor in Public Policy and Global Affairs, School of Social Science, Nanyang Technological University, Singapore. She holds a Ph.D. in Political Science and International Studies from the University of Birmingham. Her research areas include healthy ageing, healthcare and long-term care reforms, smart cities, and crisis leadership and management. She is the leading contributor to the UNESCAP report on Evolution of Science, Technology and Innovation Policies for Sustainable Development: The Experiences of China, Japan, the Republic of Korea and Singapore.

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Abbreviations

AAA AAT ACP AD ADA ADI ADLs AES AHP AI AIC AIP AMD AMTS APRC ARCH Lab ARTISAN ASD AWE B health BFG BP health BPSD CAI CASP-19

Animal-Assisted Activity Animal-Assisted Therapy Advance Care Planning Alzheimer’s Disease Alzheimer’s Disease Association Alzheimer’s Disease International Activities of Daily Living Apparent Emotion Scale Allied Health Profession Artificial Intelligence Agency for Integrated Care Ageing In Place Advance Medical Directive Association for Music Therapy Singapore Asia Pacific Risk Center Action Research for Community Health Aspiration and Resilience Through Intergenerational Storytelling and Art-based Narratives Autism Spectrum Disorder Age Well Everyday Biological Health Best Friends of the Gallery Bio-Psychological Health Behavioural and Psychological Symptoms of Dementia Committee on Ageing Issues 19-item Control, Autonomy, Self-realisation, and Pleasure xv

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ABBREVIATIONS

CB CCs CCS CD CFAA CHAS CIP CMP CMT CNS ComSA@Whampoa COVID-19 CPF CPF LIFE CPR CREST CWA DBS DCM DFCs DOF ECPICC EOL e-payment ETA e-wallet FDWs FinTech FITB FRS FTLD GAB GAI GCOA GDS GP GRC GROs GTPs HALE HDB HMTA

Circuit Breaker Community Clubs Credit Counselling Singapore Community Development City for All Ages Community Health Assist Scheme Customer Investment Profile Commissioner for the Maintenance of Parents Creative Music Therapy Community Networks for Seniors Community for Successful Ageing at Whampoa The 2019 Coronavirus Disease Central Provident Fund CPF Lifelong Income for the Elderly Cardiopulmonary Resuscitation Community Resource Engagement and Support Team Cycling Without Age Development Bank of Singapore Dementia Care Mapping Dementia-Friendly Communities Degrees Of Freedom Elder-Centred Programme of Integrated Comprehensive Care End-Of-Life electronic payment Ecological Theory of Aging electronic wallet Foreign Domestic Workers Financial Technology Fill-In-The-Blank Full Retirement Sum Frontotemporal Lobar Dementia Guided Autobiography Geriatric Anxiety Inventory Global Coalition on Aging Geriatric Depression Scale General Practitioner Group Representation Constituency Grassroots Organizations Go-to Points Healthy Life Expectancy Housing and Development Board Hua Mei Training Academy

ABBREVIATIONS

HPB HSCT IDAPE IHis IMC IMDA IMH IoT I-SING KB KKH KTPH LBD LBS LMICs LTC MAP MCA MCCY ME MIS MOE MOH MOM MP MPA MRT MSCs MSF MT NACFA NAS NDS NEHR NGS NHB NHS NLs NMEC NParks NTU NUHS NUS

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Health Promotion Board Hematopoietic Stem Cell Transplant Interim Disability Assistance Programme for the Elderly Integrated Health Information Systems Inter-Ministerial Committee Infocomm Media Development Authority Institute of Mental Health Internet of Things International-Singapore Intergenerational National Games Kebun Baru Kandang Kerbau Women’s and Children’s Hospital Khoo Teck Puat Hospital Lewy Body Dementia Lease Buyback Scheme Low- and Middle-Income Countries Long-Term Care Music Therapy and Activity Program Ministerial Committee on Ageing Ministry of Culture, Community and Youth Mood and Engagement Minimum Income Standards Ministry of Education Ministry of Health Ministry of Manpower Member of Parliament Maintenance of Parents Act Mass Rapid Transit Multi-Service Centres Ministry of Social and Family Development Music Therapy National Advisory of Council on the Family and the Aged National Archives of Singapore National Dementia Strategy National Electronic Health Record National Gallery Singapore National Heritage Board Nominated Healthcare Spokesperson Neighbourhood Links National Medical Ethics Committee National Park Board Nanyang Technological University National University Health System National University of Singapore

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ABBREVIATIONS

OA OERS OTP P health PA PAM PCMH PHIs PIN PMO POSB PPC PPE PRs PS health PtDD PTSD PWD QoL RA RCs RGB RMBPC ROH ROK RRA S health SA SAC SACH SC health SCOPE Semas SGH SHVC SIJ SING SLEC SLP® SMRT SMS SMU SPD Bank

Ordinary Account Observed Emotion Rating Scale One-Time Password Psychological health People’s Association Patient Activation Measure Person-Centred Medical Home Public Healthcare Institutions Personal Identification Number Prime Minister’s Office Post Office Savings Bank Preferred Plan of Care Personal Protective Equipment Permanent Residents Psycho-Social health Delirium and/or Dementia Post-Traumatic Stress Disorder People With Dementia Quality of Life Retirement Account Residents’ Committees Red, Green and Blue Revised Memory and Behavioral Problems Checklist Remaking Our Heartland Republic of Korea Retirement and Re-employment Act Social health Special Account Senior Activity Centre St Andrew’s Community Hospital Socio-Communal health Self-Care on Health of Older Persons in Singapore Smart Elderly Monitoring and Alert System Singapore General Hospital Smart Health Video Consultation Silver Infocomm Junction Singapore Intergenerational National Games St Luke’s ElderCare Singapore Life Panel® Singapore Mass Rapid Transit Short Message Service Singapore Management University Shanghai Pudong Development Bank

ABBREVIATIONS

SRC SWING TFR THK EIPIC TMV Tricom TTSH UI UN VAA VaD VR VWOs WFMT WKWSCI YCH YCK

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Services Review Committee Sharing Wellness and Initiatives Group Total Fertility Rate Thye Hua Kwan Early Intervention Programme for Infants and Children Therapeutic Music Video Tripartite Committee on Employability of Older Workers Tan Tock Seng Hospital Urinary Incontinence United Nations Vulnerable Adults Act Vascular Dementia Virtual Reality Voluntary Welfare Organizations World Federation of Music Therapy Wee Kim Wee School of Communication and Information Yishun Community Hospital Yio Chu Kang

List of Figures

Fig. 7.1 Fig. 7.2

Fig. 7.3 Fig. 7.4 Fig. 7.5

The use of different colours and familiar cues to provide navigation support for PWD in Nee Soon South The giant blue-colour fish is painted clearly on the side of the housing block in Nee Soon South to help PWD identify the block from afar White rabbit candies are easily recognizable mural to guide PWD home A traiditonal rooster bowl is an easily recognizable mural to guide PWD home A rose vintage thermos flask is an easily recognizable mural to guide PWD home

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209 211 212 213

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List of Tables

Table 7.1 Table 7.2 Table 7.3a Table 7.3b Table 7.4

Dementia Singapore: Training sessions for the general public Dementia Singapore: Training sessions for foreign domestic workers (FDWs) Dementia Singapore: Training sessions for professional caregivers Dementia Singapore: Training sessions for professional caregivers Dementia Singapore: Training sessions for health, social care and home care practitioners

195 196 197 198 199

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CHAPTER 1

Population Ageing in Singapore

Abstract Singapore is the world’s second-fastest ageing society. It will become a super-aged society by 2030. The twin challenges of low fertility rate and longer life expectancy have resulted in a shrinking workforce, an increase in old-age dependency ratio and feminization of ageing in the country. This chapter examines the government’s response to population ageing in Singapore since 1982. The Singapore government adopts the “many helping hands” approach to enable individuals, families and community partners to play their part in supporting and caring for older adults. It also promulgates important legislations to protect the rights of older adults. There is no one-size-fits-all answer to healthy ageing. How an individual, the community and the government understand and interpret the concept of healthy ageing may vary among cities or countries. Besides, how the government in a city or a country develops its healthy ageing framework or implements its healthy ageing strategy very much depends on the political, economic, social, cultural and historical context. Nevertheless, achieving healthy ageing should be able to add years to one’s life as well as add life to one’s years. Keywords Action Plan for Successful Ageing · Healthy ageing · Healthy life expectancy · The “many helping hands” approach · Population ageing · Super-aged society

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 S. Ching Yuen Luk, Healthy Ageing in Singapore, Social Policy and Development Studies in East Asia, https://doi.org/10.1007/978-981-99-0872-1_1

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Introduction Population ageing is a global phenomenon in the twenty-first century (United Nations Population Fund, 2012). ‘People are living longer lives, and both the share and the number of older persons in the total population are growing rapidly’ (United Nations Department of Economic and Social Affairs, Population Division, 2020: 1). ‘In 2018, for the first time in history, persons aged 65 or above outnumbered children under five years of age globally’ (United Nations Population Fund Asia-Pacific Regional Office, 2020: 2). Globally, the number of persons aged 65 years or over was 771 million in 2022, which was three times higher than it was in 1980 (United Nations Department of Economic and Social Affairs, Population Division, 2022: 7). Projections indicate that the older population will ‘reach 994 million by 2030 and 1.6 billion by 2050’ (United Nations Department of Economic and Social Affairs, Population Division, 2022: 7). By 2050, the number of persons aged 65 years or over will be more than double that of children under five years of age globally (United Nations Department of Economic and Social Affairs, Population Division, 2022: 7). Population in the Asia-Pacific region is ageing at an unprecedented speed (United Nations Population Fund Asia-Pacific Regional Office, 2020: 1). The number of persons aged 60 years or over is currently 630 million, which accounts for 60% of the world’s older persons (‘Recognizing Reality of A Rapidly Ageing’, 2022). Projections indicate that the number of persons aged 60 years or over will reach 1.3 billion and one in four people will be over 60 years old by 2050 (Andersson, 2021). Besides, the number of persons aged 80 years or over is projected to reach 258 million in the region by 2050, which accounts for 59% of the world’s older persons aged 80 years or over (United Nations Economic and Social Commission for Asia and the Pacific, 2017: 4). There is no doubt that population ageing is ‘the triumph of public health, medical advancements, and economic and social development over diseases, injuries and early deaths’ (United Nations, Department of Economic and Social Affairs, Population Division, 2019: 3). Nevertheless, population ageing ‘also presents social, economic and cultural challenges to individuals, families, societies and the global community’ (United Nations Population Fund, 2012: 12). It ‘has become a major public policy concern globally, and Singapore is no exception’ (Centre for Liveable Cities, Singapore, 2021: ix).

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Population Ageing in Singapore Singapore is a multi-ethnic and multi-religious state located in Southeast Asia. It is the world’s second-fastest ageing society after the Republic of Korea (ROK) (Geddie, 2019). When Singapore became an independent nation in 1965, it had 49,757 people aged 65 years or over, accounting for 2.65% of the population (Tan, 2015). From 1970 to 1990, the proportion of people aged 65 years or over increased from 3.4 to 6% (Yap & Gee, 2015: 6). In 2000, 7.2% of Singapore’s total population was aged 65 years or over (Yap & Gee, 2015: 6). This indicated that Singapore became an ageing society. From 2010 to 2018, the proportion of people aged 65 years or over increased from 9% (Yap & Gee, 2015: 6) to 13.7% (Singapore Department of Statistics, 2018: 4). In 2019, 14.4% of Singapore’s total population was aged 65 years or over (Asian Development Bank, 2020: 2). This indicated that Singapore became an aged society. In 2020, the proportion of people aged 65 years or over accounted for 15.2% of the total population (Singapore Department of Statistics, 2021a: 5). As of June 2022, 18.4% of Singapore’s total population was aged 65 years or over (National Population and Talent Division et al., 2022: 10). By 2030, Singapore will become a super-aged society with 23.8% of its total population aged 65 years or over (National Population and Talent Division et al., 2022: 10). This means that it will only take 30 years for Singapore to move from an ageing to a super-aged society. The pace of transition to a super-aged society in Singapore is faster than that of China (32 years), Japan (36 years), Germany (76 years) and the United States (86 years) (Tan, 2015). As of June 2022, five areas which had over 20% of resident population aged 65 years or over in Singapore were Ang Mo Kio, Bukit Merah, Kallang, Outram and Rochor (Singapore Department of Statistics, 2022a: 14). Population ageing in Singapore is caused by low fertility rate and longer life expectancy (Scott, 2019; Singapore Department of Statistics, 2022a; Yap & Gee, 2015). In Singapore, the total fertility rate (TFR) which refers to ‘the expected number of births that a group of 1,000 women would have in their lifetimes according to the current age-specific birth rates’ (Mathew & Hamilton, 2019: 2) has been below the replacement level of 2.1 since 1977 (Call et al., 2008: 93). The TFR was 1.82 in 1980, 1.83 in 1990, 1.60 in 2000 and 1.15 in 2010 (Singapore Department of Statistics, 2022a: viii). In 2020, the TFR fell to the historic low of 1.10 because the 2019 coronavirus disease (COVID-19) made some

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Singaporeans delay their marriage and parenthood plans (Chew, 2021; National Population and Talent Division et al., 2021: 15–16; Ong, 2021). It slightly increased to 1.12 in 2021 (Singapore Department of Statistics, 2022a: viii). Causes of low fertility rate in Singapore was due to ‘rising singlehood, later marriages, and married couples having fewer children’ (National Population and Talent Division, Prime Minister’s Office, 2013: 9). According to Census of Population 2020, the proportion of singles increased across age groups, with the increase being the most prominent for the age groups between 25 and 34 years (Singapore Department of Statistics, 2021a: 11). From 2010 to 2020, the proportion of singles among the age group between 25 and 29 years increased from 74.6 to 81.6% for males and from 54.0 to 69.0% for females (Singapore Department of Statistics, 2021a: 11). Similarly, the proportion of singles among the age group between 30 and 34 years increased from 37.1 to 41.9% for males and from 25.1 to 32.8% for females (Singapore Department of Statistics, 2021a: 11). Both males and females in Singapore are marrying later in life. From 1990 to 2020, the median age at first marriage for males increased from 28.7 (National Family Council, 2006) to 30.1 (National Population and Talent Division et al., 2021: 11) while the median age at first marriage for females increased from 25.9 (National Family Council, 2006) to 28.4 (National Population and Talent Division et al., 2021: 11). In Singapore, married couples have fewer children due to late marriage (Ho, 2021), ‘the financial burden and educational stresses of raising children’ (Ho, 2021). From 2010 to 2020, the average number of children born to resident ever-married females decreased from 2.24 per female to 2.04 per female (Singapore Department of Statistics, 2021a: 15). The proportion of ever-married females aged 30–39 years who have never given birth increased from 20.1% in 2010 to 23.8% in 2020 (Singapore Department of Statistics, 2021a: 14). Meanwhile, the proportion of those aged 40–49 years who have never given birth also increased from 9.3% in 2010 to 13.5% in 2020 (Singapore Department of Statistics, 2021a: 14). Life expectancy at birth has increased over the past six decades in Singapore. It was 66 years in 1960 and 1970 (National Population and Talent Division, Prime Minister’s Office, 2013: 10; Scott, 2019: 3). It increased from 72.1 years in 1980 to 78 years in 2000 (Yap & Gee, 2015: 6). From 2010 to 2020, life expectancy at birth increased from 81.7 years to 83.9 years (Singapore Department of Statistics, 2021b: 1). In 2021, life expectancy at birth was 83.5 years (Singapore Department of Statistics, 2022b: 1). Decline in life expectancy was due to higher

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mortality rates arising from COVID-19, which ranked fifth among the top 10 causes of deaths in Singapore in 2021 (Tan, 2022). The World Health Statistics report, which compiled data from 194 countries, ranked Singapore third globally for average life expectancy (83.1 years), behind Japan (83.7 years) and Switzerland (83.4 years) (‘Singapore 3rd in the world’, 2017). In another report titled The Burden of Disease in Singapore 1990 to 2017 , Singapore was ranked first globally for life expectancy at birth (84.8 years) (Epidemiology & Disease Control Division, Ministry of Health, Singapore and Institute for Health Metrics and Evaluation, 2019: 17). In Singapore, the number of centenarians increased from 50 in 1990 (Tai, 2018) to 700 in June 2010 (Ho, 2020), 1,200 in June 2017 (Tai, 2018) and 1,500 in June 2020 (Ho, 2020). This indicated that the number of centenarians in Singapore multiplied 30-fold from 1990 to 2020 (Maulod et al., 2020: 23). Since 1970, life expectancy at birth for both sexes have steadily increased in Singapore. But females have longer life expectancy than males. In 1970, life expectancy at birth was 64.1 years for males and 67.8 years for females (Singapore Department of Statistics, 2022a: viii). Females lived 3.7 years longer than males. In 2020, life expectancy at birth was 81.3 years for males and 85.9 years for females (Singapore Department of Statistics, 2022a: viii). Females lived 4.6 years longer than males. According to World Health Statistics, 2014, Singapore was ranked fourth globally for female life expectancy, after Japan, Spain and Switzerland (‘World Health Statistics, 2014’, 2014). In 2015, Singapore was ranked second globally for female life expectancy (86.1 years), which was behind Japan (86.8 years) (World Health Organization, 2017: 88–90). In 2019, Singapore was ranked fourth globally for female life expectancy (85.5 years), behind Japan (86.9 years), ROK (86.1 years) and Spain (85.7 years) (World Health Organization, 2022: 92–96). In Singapore, females account for a larger proportion of older adults aged 80 years or over. In 2011, about 63% of older adults aged 80 years or over was females (National Population and Talent Division et al., 2021: 10). In 2021, about 62% of older adults aged 80 years or over was females (National Population and Talent Division et al., 2021: 10). Females also account for a larger proportion of centenarians in Singapore. The Census of Population 2010 found that 466 of the 724 centenarians (64%) were females (Ong & Tai, 2011). The twin challenges of low fertility rate and longer life expectancy have resulted in a shrinking workforce, an increase

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in old-age dependency ratio and feminization of ageing in Singapore (Asher & Nandy, 2008). While Singaporeans are living longer, many of them are spending more time in ill health (Lim, 2019). In 1990, life expectancy at birth was 76.1 years in Singapore (Epidemiology & Disease Control Division, Ministry of Health, Singapore and Institute for Health Metrics and Evaluation, 2019: 19). But healthy life expectancy (HALE), which refers to ‘the average number of years that a person at a given age can expect to live an equivalent of full health’ (Lee et al., 2016: S139), was 67.1 years in Singapore in 1990 (Epidemiology & Disease Control Division, Ministry of Health, Singapore and Institute for Health Metrics and Evaluation, 2019: 19). This meant that Singaporeans spent nine years in ill health in 1990. In 2017, life expectancy at birth was 84.8 years while HALE was 74.2 years (Epidemiology & Disease Control Division, Ministry of Health, Singapore and Institute for Health Metrics and Evaluation, 2019: 19). This meant that Singaporeans spent 10.6 years in ill health (Epidemiology & Disease Control Division, Ministry of Health, Singapore and Institute for Health Metrics and Evaluation, 2019: 19). The gap between life expectancy at birth and HALE increased between 1990 and 2017 due to ‘fatal (cardiovascular diseases and cancers) and primarily disabling (musculoskeletal disorders and mental disorders) causes of disease’ (Epidemiology & Disease Control Division, Ministry of Health, Singapore and Institute for Health Metrics and Evaluation, 2019: 22). Spending more time in ill health due to ageing has increased older adults’ demand for healthcare and long-term care (LTC). For example, the average length of stay in public hospitals for those aged 65 years or over was 6.9 days, compared to 3.9 days for those aged below 65 in 2019 (‘Managing Healthcare Cost Increases’, 2020). People spending more time in ill health due to ageing has also increased government spending on healthcare and LTC. Government healthcare expenditure ‘tripled from $3.7 billion in 2010 to $11.3 billion in 2019’ (‘Budget 2022 Speech’, 2022: 66). Ministry of Health (MOH)’s expenditure on LTC sector ‘increased from $296 million to $723 million between 2013 and 2018, or a 20% increase per annum’ (‘Managing Healthcare Cost Increases’, 2020). It is estimated that the government ‘will spend about $27 billion or around 3.5% of GDP by 2030’ (‘Budget 2022 Speech’ 2022: 67) if the current healthcare spending which excludes COVID-19related expenditure ‘continues to increase at a similar rate over the coming decade’ (‘Budget 2022 Speech’, 2022: 66–67). Meanwhile, government

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expenditure on LTC is expected to increase over the coming decade as population continues to age.

Government Responses to Population Ageing in Singapore For the first 17 years since Singapore’s independence in 1965, ‘state resources were primarily channelled towards policies and programs in economic development, housing, education and defence’ (Rappa, 1999: 129). Scant attention was paid to population ageing and the problem of the aged in Singapore (Lee, 1986: 239). Since 1982, however, ‘the issue of a rapidly ageing population had been identified as a part of Singapore’s demographic challenge requiring study in its national agenda’ (Loo, 2017: 3). In June 1982, the Committee on the Problems of the Aged was set up to study the problems of population ageing and their consequences to society and recommend solutions to the problems of population ageing in Singapore (Ministry of Health, 1984: 1). This ‘signified the first serious state effort to address ageing issues’ (Teo et al., 2006: 28). The Committee recommended the adoption of a national policy which could keep older adults physically and mentally fit and active via continued employment, participation in hobbies, family and community activities, maintaining older adults’ financial independence and strengthening the traditional family system and fostering filial piety (Ministry of Health, 1984: 5–19). It said that the family was still the most suitable to support and care for older adults (Ministry of Health, 1984: 16) and recommended the use of a legislation to impose an obligation on children to maintain their parents (Ministry of Health, 1984: 43). From 1988 to 1998, four high-level committees were formed to examine issues related to ageing (Mehta, 2019). The Advisory Council on the Aged was set up in 1988 to ‘review the status of aging in Singapore, especially with regard to programs and service’ (Kong et al., 1996: 533). After completing a review on community-based programmes and services for older adults, the Advisory Council on the Aged recommended the provision of continuing education, cross-generation activities, social activities within elderly peer groups and civic participation to help older adults remain socially active (The Advisory Council on the Aged, 1988: 7). It also recommended the provision of health aide services, an emergency call service, care surveillance/referral service and community care services by the public and voluntary sectors to reduce frail older adults’ needs for

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hospital admissions and more expensive nursing home care (The Advisory Council on the Aged, 1988: 8–10). The National Advisory of Council on the Family and the Aged (NACFA), which incorporated the Committee on the Family and the Committee on the Aged, was set up in 1989 (Yap, 2008: 70). The Committee on the Aged of NACFA ‘monitored the implementation and recommendations made by the Advisory Council on the Aged, identified gaps and proposed solutions in services for older persons’ (Teo et al., 2006: 29). The Inter-Ministerial Committee (IMC) on Health Care for the Elderly was set up in August 1997 to review the healthcare needs of older adults, identify measures to meet their healthcare needs and ensure that healthcare would remain affordable (Ministry of Health, 1999: 7). Its key recommendations included health promotion and disease prevention, regular health screening for older adults, medical students and general physicians to be better trained in geriatric care, government support (e.g. financial assistance, land allocation) for voluntary welfare organizations (VWOs) providing LTC, ensuring the quality of residential and non-residential LTC services, the setting up of a LTC insurance scheme to enable risk pooling (Ministry of Health, 1999: 25–52) and reduce the financial burden of LTC (‘Report of the Inter-Ministerial Committee’, 1999).The IMC on the Ageing Population was set up in 1998 to develop a coordinated national approach to tackle the multi-faceted challenges of ageing population in Singapore (Ministry of Community Development, 1999: 35). It made 78 recommendations on six areas, namely Social Integration of the Elderly, Health Care, Financial Security, Employment and Employability, Housing and Land Use Policies, Cohesion and Conflict in an Ageing Society, to achieve the vision of “Successful Ageing for Singapore” (Ministry of Community Development, 1999: 15–35). It highlighted the fundamental principles of 3Cs which were essential for tackling ageing population: Contributions from Senior Citizens, Care Giving Primarily from Families and Collective Responsibility from All Sectors (i.e. the “Many Helping Hands” approach) (Ministry of Community Development, 1999: 37). In June 1999, the Services Review Committee (SRC), which consisted of representatives from the MOH, National Council of Social Service and People’s Association (PA), was set up to review then existing eldercare service and delivery (Ministry of Community Development & Sports, 2001: 2–3) and ‘develop a blueprint for age-friendly services’ (Yuen et al., 2020: 5). After completing the review, the SRC presented its recommendations in the form of a five-year Eldercare Master Plan (FY2001

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to FY2005) with the aim of achieving “Successful Ageing for Singapore” (Ministry of Community Development & Sports, 2001: 3). In the Eldercare Master Plan, the SRC emphasized the social integration of older adults and recommended the establishment of a two-tier community service delivery system consisting of Multi-Service Centres (MSCs) and Neighbourhood Links (NLs) for a more seamless delivery of services to older adults (Ministry of Community Development & Sports, 2001: 9– 12). Besides, it recommended the introduction of a restructured funding policy which adopted an open tender process to evaluate the economy and efficiency of service providers (i.e. VWOs) and a sliding subsidy scale which provided higher subsidies for the lower income groups to ensure affordability of eldercare services (Ministry of Community Development & Sports, 2001: 13–14). It also recommended the allocation of more resources to develop an active senior volunteer movement, the provision of Case Management Service for frail older adults with complex and multiple needs and the establishment of Carers’ Centres at strategic locations to provide caregivers with information and training to cope with their stress of caregiving (Ministry of Community Development & Sports, 2001: 18–32). In December 2004, the Committee on Ageing Issues (CAI) was set up to ‘provide holistic strategies to achieve the vision of ‘Successful Ageing of Singapore’’ (Yuen et al., 2020: 6). It consisted of ‘a tripartite of people-public–private representatives from health, social, manpower and media sectors’ (Mehta, 2019). It made recommendations on four key areas, namely housing, accessibility, healthcare and eldercare services, and opportunities during old age, in the 2006 Report on the Ageing Population (Ministry of Community Development, Youth and Sports, 2006). On housing, the CAI recommended the provision of elder-friendly housing to enhance the mobility and independence of older adults and monetization of older adults’ housing assets to generate income for expenses in old age (Ministry of Community Development, Youth and Sports, 2006: 16–24). On accessibility, the CAI recommended the creation of barrier-free built environment (e.g. accessible lifts, safe and unhindered travel passage) and transport system (e.g. public buses which were step-free and wheelchair accessible) for older adults (Ministry of Community Development, Youth and Sports, 2006: 26–32). On healthcare and eldercare services, the CAI recommended the adoption of a family-physician-centred approach to manage healthcare needs of older adults and the use of budgetary surplus to top up Medisave accounts

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of less well-off older adults to ensure affordability of healthcare services (Ministry of Community Development, Youth and Sports, 2006: iv). On opportunities during old age, the CAI recommended the provision of funding support from the government to seed more programs and services for older adults (Ministry of Community Development, Youth and Sports, 2006: 60) and the promotion of intergenerational bonding and cohesion to ensure that the family remained the first line of support (Ministry of Community Development, Youth and Sports, 2006: 60). In March 2005, the Tripartite Committee on Employability of Older Workers (Tricom) was set up to ‘recommend measures to enhance the employability of older workers’ (Ministry of Manpower, 2014) and ‘shape the perceptions and mindsets of employers and the public positively towards the employment of older workers’ (Ministry of Manpower, 2014). It consisted of representatives from the government, unions (e.g. National Trades Union Congress) and employer organizations (e.g. Singapore National Employers Federation, Singapore Business Federation) (Ministry of Manpower, 2014). Three key recommendations were made by the Tricom in an interim report submitted to the government (Ministry of Manpower, 2006). First, the Tricom recommended the introduction of the ADVANTAGE!Scheme, which provided funding support of up to S$300,000 per company to motivate employers to recruit and re-employ older workers beyond the age of 62 (Ministry of Manpower, 2006: 17–19). The Scheme covered cost incurred in job redesign, training activities, retention and job replacement services (Ministry of Manpower, 2006: 17). Second, the Tricom recommended that the government consider raising the statutory retirement age beyond 62 years based on the Japanese experience (Ministry of Manpower, 2006: 21–2). Third, the Tricom recommended the setting up of a Tripartite Alliance for Fair Employment Practices to ‘promote mindset change among employers, employees and the general public to adopt positive approaches and practices that are fair and equitable to all workers’ (Ministry of Manpower, 2006: 38). In March 2007, the Ministerial Committee on Ageing (MCA) was set up to ‘coordinate and plan strategies across different government agencies relating to population ageing’ (Ministry of Health, n.d.). It was led by then Minister in the Prime Minister’s Office (PMO) Mr. Lim Boon Heng and consisted of ministers and representatives from MOH, Ministry of Community Development, Youth and Sports, Ministry of National

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Development, Ministry of Trade and Transport and Ministry of Education (Ministry of Community Development, Youth and Sports, 2008). Its vision was to enable older adults to age in place gracefully (Ong, 2014) and ‘continue to enjoy a high quality of life as they age’ (Ong, 2014). In 2011, it started the City for All Ages (CFAA) project which aimed to create a safe, caring and empowering environment for all older adults (Ministry of Health, 2014: 1). The CFAA project brought together grassroots leaders, residents and researchers to assess the needs of older adults living in a community through dialogue sessions, social surveys, health screenings and hardware audits of the flats and built environment (Centre for Liveable Cities, Singapore, 2021: 32; Mehta, 2019). Then, grassroots leaders, residents and researchers ‘work[ed] with public agencies and community partners to customise suitable solutions to meet identified needs’ (Ministry of Health, 2014: 3). For example, Marine Parade, which was the first CFAA pilot case, ‘featured more elderly-friendly fitness corners, larger block numbering, leveled void decks, and a longer “green man time” for traffic light crossings’ (Tao et al., 2021: 1742). At present, there are 16 CFAA communities across Singapore (Ministry of Health 2014: 2). In August 2015, ‘the MCA launched the S$3-billion Action Plan for Successful Ageing’ (Centre for Liveable Cities, Singapore, 2021: 33), which was ‘a national blueprint to enable Singaporeans to age gracefully and confidently’ (‘Strategy to Manage Ageing’, 2021). The Action Plan emerged following a 11-month public consultation involving over 4,000 Singaporeans and grassroot leaders (Ministry of Health, 2016: 10; ‘$3 Billion Action Plan’, 2015). It covered more than 70 initiatives in 12 areas, including employment, health and wellness, healthcare and aged care, housing, transport, public spaces, learning, volunteerism, respect and social inclusion, retirement adequacy, protection for vulnerable seniors and research (Ministry of Health, 2016: 26). The initiatives could be grouped into three levels. At the individual level, Opportunities for All Ages aimed to provide older adults with opportunities to work longer if they wish, pursue lifelong learning, volunteer, adopt healthy living habits, save more money and receive government subsidies or additional cash assistance to help with their healthcare or LTC expenses (Ministry of Health, 2016; Ministry of Health, n.d.). At the community level, Kampong for All Ages aimed to create a caring and cohesive community with intergenerational harmony and protect vulnerable older adults from abuse (Ministry of Health, 2016; Ministry of Health, n.d.). At the

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national level, CFAA aimed to ensure the needed healthcare infrastructure, senior-friendly housing, senior-friendly public transport system and senior-friendly parks are in place (Ministry of Health, 2016: 63–79) to enable older adults to live independently in their communities for as long as possible (Ministry of Health, n.d.). From September to October 2021, the MOH organized the Citizens’ Panel on Contribution with the Ministry of Manpower (MOM) and the Ministry of Culture, Community and Youth (MCCY) to gather 46 Singaporeans of various ages (aged 25 to over 65) and backgrounds virtually over four weekends to discuss ways to enable older adults to contribute their knowledge and expertise at the workplace and in the community (‘Citizens’ Panel on Contribution’, n.d.; Ministry of Health et al., n.d.: 4). The Citizen’ Panel on Contribution was part of the efforts made by the MCA to refresh the existing Action Plan for Successful Ageing (Ministry of Health et al., n.d.: 4). Through the panel sessions, 46 participants who were grouped in four age brackets had chances to understand the current landscape of senior employment and senior volunteerism through first-hand sharing by older adults, guest speakers and resource persons from the private sector, community partners, non-governmental organizations and academia (‘Citizens’ Panel on Contribution’, n.d.; ‘Report on Citizens’ Panel on Contribution’, n.d.; Ministry of Health et al., n.d.: 4–5). Then, they came together to brainstorm and propose innovative ideas to enable older adults to continue contributing in the form of work and volunteerism and age meaningfully (Ministry of Health et al., n.d.: 3). At the final panel session, participants presented the final recommendations to Second Minister for Health and senior government officers from MOH, MOM and MCCY (‘Citizens’ Panel on Contribution’ n.d.; Ministry of Health et al., n.d.: 4). Four of the final recommendations were on senior employment, which included the launch of a social media outreach campaign (#whynot seniors) to shift ageist mindset and redesign jobs for older adults, initiatives to improve age-friendly workplaces, buddy programme at the workplace and the creation of a one-stop hybrid job matching platform for older jobseekers (Ministry of Health et al., n.d.: 7–12). Five of the final recommendations were on senior volunteerism, which included a storytelling program by older adults, a community incubator for volunteer activities which are easily accessible to older adults, the setup of an inclusive intergenerational café where people of various ages can socialise and form interest groups, a platform to link older adults with learners looking for mentors

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and the formation of a befriender network to look out for older adults in the neighbourhood (Ministry of Health et al., n.d.: 13–17). MOH, MOM and MCCY will partner with participants in the Citizens’ Panel to implement some of the recommendations and explore ways to further support each recommendation (Ministry of Health et al., n.d.: 7–18). The Citizens’ Panel is a new mode of engagement adopted by the Singapore government to co-create and co-implement solutions to specific policy problems with citizens based on the principle of deliberation (Soon & Liang, 2021: 5–6). It allows for ‘ideation, consensus building and the testing/refinement of ideas’ (Soon & Liang, 2021: 46). It also enables participants to become ‘more confident about the value of their contributions (internal efficacy)’ (Soon & Liang, 2021: 4) and realize their capacity to do more as citizens (external efficacy) (Soon & Liang, 2021: 4).

Important Legislations Protecting the Rights of Older Adults in Singapore At present, there are three important legislations protecting the rights of older adults in Singapore. First, the Maintenance of Parents Act (MPA), which came into effect in November 1995, allows any Singapore residents who aged 60 years or over and who is unable to maintain himself/herself adequately to apply to the Tribunal for the Maintenance of Parents for an order that his/her children who can financially support him/her but are not doing so pay him/her a monthly allowance, a lump sum or periodical payment for his/her maintenance (‘Maintenance of Parents Act 1995’, 1996; ‘Maintenance of Parents’, 2021). The MPA was amended in 2010 to ‘establish a conciliation-first approach to resolve maintenance disputes’ (‘Review of The Maintenance of Parents Act’, 2022). The conciliation approach led to the annual number of cases of older parents who eventually filed for maintenance orders at the Tribunal decreasing from a three-year average of 170 (from 2008 to 2010) to 86 (from 2011 to 2013) (‘Review of The Maintenance of Parents Act’, 2022). Since 2017, the annual number of cases of older parents who filed for maintenance orders at the Tribunal has remained stable at about 30 cases (‘Review of The Maintenance Of Parents Act’, 2022). In November 2022, the work group for the Maintenance of Parents Act announced four proposed changes to the MPA (Shafeeq & Tan, 2022). These proposed changes included requiring parents who abused, neglected or abandoned their

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children to seek permission from the Tribunal before embarking on the process of conciliation with their children, enabling the Tribunal to dismiss frivolous applications, enabling the Tribunal to introduce nonmonetary orders and giving the Commissioner for the Maintenance of Parents (CMP) the power to contact the children of destitute older parents to attend a mandatory conciliation session with their parents (Shafeeq & Tan, 2022). The MPA ‘is not meant to be a replacement for filial piety’ (Chan, 2004: 552), but ‘to provide a safety net if filial piety fails’ (Chan, 2004: 552) and ‘a viable avenue for assistance’ (Chan, 2004: 575). It ‘underlines the responsibility of the family in providing, at the very least, financial security for their elderly members’ (Thang & Johan, 2018: 139). Second, the Vulnerable Adults Act (VAA), which came into effect in December 2018, is to ‘make provision for the safeguarding of vulnerable adults from abuse, neglect or self-neglect, and to provide for matters connected with that’ (‘Vulnerable Adults Act 2018’). It gives powers to officials from the Ministry of Social and Family Development (MSF) to enter the home of a suspected victim (e.g. older adults, people with disability) to assess his/her well-being and relocate the suspected victim to a place of safety (e.g. shelters, disability homes) if necessary (Rashith, 2018; ‘Protecting Vulnerable Seniors’, n.d.). It is a means only to be used ‘as a last resort in high-risk cases, where family and community interventions may not be effective’ (Rashith, 2018). ‘The VAA seeks to strike a balance between respecting the individual rights of the vulnerable adult and the duty to protect’ (Chan, 2019: 28). It aims to support ‘vulnerable adults to lead lives free from harm’ (Chan, 2019: 28) and is a step toward greater protection for older adults (Moynihan & Yeo, 2018). Third, the Retirement and Re-employment Act (RRA) is to ‘provide for a minimum retirement age for employees, for the re-employment of employees and for matters connected therewith’ (‘Retirement and Reemployment Act 1993’, 1993). Starting from July 2022, the minimum retirement age is 63 years and the re-employment age is 68 years in Singapore (‘Responsible Re-employment’, n.d.). This means that employers are ‘not allowed to dismiss an employee who is younger than the minimum retirement age of 63 years old on the ground of age’ (‘Guide to ReEmployment’, 2022). They ‘must offer, to eligible employees who turn 63, re-employment until the age of 68’ (‘Guide to Re-Employment’, 2022). In fact, ‘older workers are a key part of Singapore’s labour force, with about one in four workers aged 55 and above in 2020’ (Seow,

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2022). In 2021, the employment rate of workers aged 55 to 64 was 69% while the employment rate of workers aged 65–69 was 49% (Tilo, 2022). Nearly all the older employees who accepted re-employment ‘continued on the same job, either on their existing contracts without a specific end date, or a shorter renewable contract’ (‘0110 Written Answer by Minister for Manpower’, 2022). Re-employment helps Singapore mitigate shrinking workforce (Seow, 2022). Besides, it enables older employees to stay active (The Tripartite Workgroup on Older Workers, 2019: 2), to ‘be meaningfully engaged through work’ (The Tripartite Workgroup on Older Workers, 2019: 2) and ‘accumulate more savings to stay financially independent’ (National Trades Union Congress, 2016: 3). It also enables employers to ‘continue to harness the skills and experience of an expanding pool of older workers’ (The Tripartite Workgroup on Older Workers, 2019: 58).

The “Many Helping Hands” Approach The national policy on ageing in Singapore ‘reinforces the state’s position that it does not take sole responsibility for the care of older persons’ (Teo et al., 2006: 30). The adoption of the “many helping hands” approach by the Singapore government reflects its pragmatic style of governance (Teo et al., 2006: 30). The government ‘places the main responsibility of the welfare of its aging population on individuals’ (Thang & Johan, 2018: 147), with the family and the community respectively being the primary and secondary sources of care and support (Thang & Johan, 2018: 138). It advocates self-reliance and self-help (Teo et al., 2006: 30) and holds individuals personally responsible for planning and preparing for old age (Ministry of Community Development, 1999: 37; Rozario & Rosetti, 2012: 645). ‘Each individual should be able to turn to his or her family for physical and emotional support and security’ (Tarmugi, 1995: 3). The idea that family plays a primary role in taking care of older adults ‘is legitimized and socially accepted because of the salience of filial piety in Singapore’ (Rozario & Rosetti, 2012: 646). The government encourages individuals and their families to stand on their own feet (Tarmugi, 1995: 4) because this can ‘preserve their dignity and self-esteem’ (Tarmugi, 1995: 4). The “many helping hands” approach is based on ‘the values of mutual help, reciprocity and giving to society’ (Ang, 2015: 142). The community ‘serves as an intermediary agent between the family and the state’

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(Teo et al., 2006: 30). Its role is to ‘support the family in its caregiving role and to enable the older person to live with his or her family and in the community for as long as possible’ (Ministry of Community Development, 1999: 38). In Singapore, ethnic-based, religious, and secular non-profit VWOs (Thang & Johan, 2018: 138) provide various services to meet the needs of older adults. For example, St Luke’s ElderCare (SLEC) is a Christian, non-profit organization providing a full range of integrated services and programmes (e.g. rehabilitation, dementia day care, dietary counselling, home-based therapy, residential care) for over 5,000 older adults in the country (‘Our Services’ n.d.; ‘St Luke’s ElderCare Ltd’, n.d.). Fei Yue Community Services is a non-profit VWO providing buddying and befriending services for lonely older adults, healthcare support and social care services for frail and home-bound older adults, and counselling and respite services for caregivers of older adults in the country (‘Services’ n.d.). Society for WINGS is a non-profit organization aiming to empower women to age well by staying healthy and socially engaged and remaining financially secure (Society for WINGS, n.d.: 5). It jointly launched a community program called Age Well Everyday (AWE) with the National University Health System (NUHS) to ‘impart mindfulness and healthy nutrition education to elderly people to prevent the onset of dementia’ (Society for WINGS, n.d.: 10). It also offers confinement nanny programme to women who want to develop new skills to earn an income (Society for WINGS, n.d.: 4). The support and care provided by the community helps create social networks and community bonds (Ang, 2015: 142) and improve the quality of life of older adults. The adoption of “many helping hands” approach promotes more sense of responsibility amongst individuals, families and communities in building a caring and supportive society for older adults (Tarmugi, 1995: 4–5). The role of the government ‘has largely been facilitative and residual, supporting voluntary and private sectors by contributing infrastructural and institutional resources’ (Thang & Johan, 2018: 138). For example, the Community Networks for Seniors (CNS) programme, which is overseen by the MOH and Agency for Integrated Care (AIC), brings government agencies and community partners such as VWOs and PA’s grassroots organisations together to engage and support older adults through the “A, B, C” of ageing well: active ageing programmes, befriending, care and support services (‘Active Seniors’, n.d.; Ministry of Finance et al., 2018; ‘Senior’s Wish Comes True’, 2019). The CNS at pilot sites (e.g. Chua Chu Kang, Marine Parade) ‘activated more than 70 Residents’ Committees (RCs) to

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hold regular preventive health and active ageing activities for more than 70,000 seniors’ (Ministry of Finance et al., 2018). This enabled older adults to ‘benefit from more holistic care and support in the community’ (Ministry of Finance et al., 2018).

The Aim of This Book The economic, social and cultural challenges posed by population ageing ‘must be met with thoughtful preparations that centre on the promotion of healthy ageing’ (Bloom, 2022). According to the World Health Organization (2015), healthy ageing is ‘the process of developing and maintaining the functional ability that enables well-being in older age’ (p. 28). There are five key domains of functional ability, including the abilities to meet one’s basic needs (e.g. adequate diet, suitable housing), learn, grow and make decisions (e.g. one’s autonomy, freedom, independence), be mobile (e.g. the completion of daily tasks), build and maintain relationships (e.g. with family, neighbours); and contribute to society (e.g. volunteering, working) (World Health Organization, 2019: 1; 2020: 12). Functional ability combines the intrinsic capacity (i.e. physical and mental capacities) of the individual, the environment a person lives in (i.e. home, communities and the broader society) and how people interact with their environment (World Health Organization, 2015: 28–29; 2019: 1; 2020: 10–12). ‘The optimizing of functional ability requires inputs from multiple sectors and a whole-of-government response to population ageing’ (World Health Organization, 2020: 12). There is no one-size-fits-all answer to healthy ageing. How an individual, the community and the government understand and interpret the concept of healthy ageing may vary among cities or countries. Besides, how the government in a city or a country develops its healthy ageing framework or implements its healthy ageing strategy very much depends on the political, economic, social, cultural and historical context. Nevertheless, achieving healthy ageing should be able to add years to one’s life as well as add life to one’s years. The Singapore government is committed to achieving healthy ageing. It has made unremitting efforts over the past three decades to ‘grasp the opportunity to better unleash the potential of people to contribute as they age’ (Heng, 2022). It adopts the “many helping hands” approach to enable individuals, families and community partners to play their part in supporting and caring for older adults in the country (Ministry

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of Community Development, 1999: 37). Being the world’s secondfastest ageing society, Singapore has been experiencing a lot of economic and social challenges posed by population ageing. A lot of schemes, programmes and policies have been tested and implemented by the government, researchers and community partners to solve the problems caused by population ageing. However, the effectiveness of these schemes, programmes and policies in solving the problems of population ageing vary. Hence, the aim of this study is to provide a comprehensive and updated assessment of healthy ageing in Singapore and discuss the facilitators and barriers to healthy ageing in the country. This study is supported by the Start-Up Grant (SUG) of Nanyang Technological University, Singapore (Grant number: M4082137.SS0.). Data of this study is collected through secondary data and semi-structured interviews. Ethical approval was obtained through the Institutional Review Board of Nanyang Technological University (Ref. No.: IRB-2018–05-047). The remainder of this book is structured as follows: Chapter 2 gives a detailed account of financial well-being of older adults in Singapore. Chapter 3 examines how music therapy as a therapeutic intervention can bring benefits to people with dementia (PWD), terminally ill patients and their caregivers. It also examines ongoing challenges to the development of music therapy in Singapore. Chapter 4 examines the effectiveness of robots, virtual reality (VR), wearable bladder scanner and teleconsultation in improving the wellbeing of older adults in nursing homes. Chapter 5 examines how Facebook, WhatsApp and Zoom were utilized by a social enterprise, a senior activity centre (SAC) and National Gallery Singapore (NGS) to deliver digital knowledge and skills, physical exercise classes and tours of artwork to older adults in the time of COVID-19. Chapter 6 assesses the effectiveness of four community projects in helping older adults age in place. Chapter 7 examines the creation of dementia-friendly communities (DFCs) in Singapore and the challenges to develop and sustain DFCs in the country. Chapter 8 examines Advance Care Planning (ACP) in Singapore. It explains the benefits of ACP and barriers to ACP practices and suggests ways to increase acceptance and implementation of ACP in the country. Chapter 9 is Afterword, which provides an update on policies implemented by the government to achieve active ageing and suggests ways to achieve healthy ageing in Singapore.

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Mehta, K. K. (2019, January 28). Introduction: National engagement with ageing. Retrieved December 4, 2022, from https://www.csc.gov.sg/articles/ positive-ageing-how-can-we-make-it-happen Ministry of Community Development. (1999). Report of the inter-ministerial committee on the ageing population. Retrieved December 4, 2022 from https://eservice.nlb.gov.sg/data2/BookSG/publish/6/64a126a3-8f724e65-aafe-b97626e3fb4d/web/html5/index.html?opf=tablet/BOOKSG. xml&launchlogo=tablet/BOOKSG_BrandingLogo_.png Ministry of Community Development and Sports. (2001). Eldercare Master plan (FY2001 to FY2005). Retrieved December 6, 2022, from https://ese rvice.nlb.gov.sg/data2/BookSG/publish/1/166f6614-9ed2-4278-91ea-4be 86caa64ec/web/html5/index.html?opf=tablet/BOOKSG.xml&launchlogo= tablet/BOOKSG_BrandingLogo_.png Ministry of Community Development, Youth and Sports. (2006). Committee on ageing issues: Report on the ageing population. Retrieved December 6, 2022, from https://eresources.nlb.gov.sg/printheritage/detail/2c0868d2d214-46d4-afd1-e66c8e1659ab.aspx Ministry of Community Development, Youth and Sports. (2008). Good progress made in preparing for an ageing population. Retrieved December 7, 2022, from https://www.nas.gov.sg/archivesonline/data/pdfdoc/200801 15997.htm Ministry of Finance, Ministry of Health, & Ministry of Social and Family Development. (2018, February 19). Integration of health and social services to support seniors. Retrieved December 10, 2022, from https://www.moh. gov.sg/news-highlights/details/integration-of-health-and-social-services-tosupport-seniors Ministry of Health. (1984). Report of the committee on the problems of the aged. Retrieved December 4, 2022, from https://eservice.nlb.gov.sg/data2/Boo kSG/publish/f/f0be2e9a-d4c8-4cea-ad3d-230e5cda4afe/web/html5/index. html?opf=tablet/BOOKSG.xml&launchlogo=tablet/BOOKSG_BrandingL ogo_.png&pn=3 Ministry of Health. (1999). Report of the inter-ministerial committee on health care for the elderly. Ministry of Health. Ministry of Health. (2014). Creating senior-friendly communities: Tips and tools from the City for All Ages project. Retrieved December 7, 2022, from https://www.moh.gov.sg/docs/librariesprovider5/resources-statistics/ educational-resources/moh-cfaa-guidebook-(final).pdf Ministry of Health. (2016). I feel young in my Singapore: Action plan for successful ageing. Retrieved December 7, 2022, from https://www.moh.gov.sg/docs/ librariesprovider3/action-plan/action-plan.pdf

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Ministry of Health. (n.d.). Response to questionnaire. Retrieved December 7, 2022 from https://www.ohchr.org/sites/default/files/Documents/Issues/ OlderPersons/Practices/States/Singapore.pdf Ministry of Health, Ministry of Manpower, & Ministry of Culture, Community and Youth. (n.d.). Government response to recommendations from the Citizens’ Panel on Contribution: As part of the Refresh of the Action Plan for Successful Ageing. Retrieved December 8, 2022, from https://www.moh.gov.sg/docs/ librariesprovider5/default-document-library/govt-response-to-recommendati ons-from-the-citizens-panel.pdf Ministry of Manpower. (2006). Tripartite Committee on Employability of Older Workers: Interim Report. Retrieved December 7, 2022, from https://eresou rces.nlb.gov.sg/printheritage/detail/3a5ed439-6a1f-49e7-80ab-0d63eeedd d6f.aspx Ministry of Manpower. (2014). Tricom recommends promoting the extension of Re- employment Age to 67 by providing incentive support. Retrieved December 7, 2022 from https://snef.org.sg/wp-content/uploads/2016/09/mom_ree mployment-1.pdf Moynihan, N., & Yeo, G. (2018, November 26). What constitutes elderly abuse? Retrieved December 9, 2022, from https://learn.asialawnetwork.com/2018/ 11/26/abuse-elderly-people-singapore/ National Family Council. (2006). State of the family in Singapore. Retrieved December 3, 2022, from https://www.msf.gov.sg/research-and-data/Res earch-and-Statistics/Documents/NFC-StateoftheFamilyReport2006.pdf National Population and Talent Division, Prime Minister’s Office. (2013). A sustainable population for a dynamic Singapore: Population White Paper. Retrieved December 2, 2022, from https://www.strategygroup.gov.sg/ media-centre/population-white-paper-a-sustainable-population-for-a-dyn amic-singapore National Population and Talent Division, Strategy Group, Prime Minister’s Office, Singapore Department of Statistics, Ministry of Home Affairs, Immigration & Checkpoints Authority, & Ministry of Manpower. (2021). Population in brief 2021. Retrieved December 3, 2022, from https://www.popula tion.gov.sg/files/media-centre/publications/population-in-brief-2021.pdf National Population and Talent Division, Strategy Group, Prime Minister’s Office, Singapore Department of Statistics, Ministry of Home Affairs, Immigration & Checkpoints Authority, & Ministry of Manpower. (2022). Population in brief 2022. Retrieved November 30, 2022, from https://www.popula tion.gov.sg/files/media-centre/publications/Population-in-Brief-2022.pdf National Trades Union Congress. (2016). Understanding re-employment. Retrieved December 9, 2022, from https://www.ntuc.org.sg/wps/wcm/ connect/09e9edba-cac1-4094-a047-307481d2c6e5/Reemployment+guideb ook+FINAL2.pdf?MOD=AJPERES

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Ong, C., & Tai, J. (2011, December 18). S’pore’s rising centenarians. The Star. Retrieved December 3, 2022, from https://www.thestar.com.my/news/reg ional/2011/12/18/spores-rising-centenarians/ Ong, J. (2021, September 28). Fewer marriages, births in S’pore last year due to pandemic; Nuptial figures fall to lowest since 1986. The Straits Times. Retrieved December 3, 2022, from https://www.straitstimes.com/singap ore/politics/fewer-marriages-births-in-spore-last-year-due-to-pandemic-nup tial-figures-fall-to Ong, Y. S. (2014). Ageing in place in Singapore. Annual Singapore Conference on Ageing. Retrieved December 7, 2022, from https://www.gs.org.sg/sem inar1-1.htm Rappa, A. L. (1999). The politics of ageing: Perspectives from state and society in Singapore. Southeast Asian Journal of Social Science, 27 (2), 123–138. Rashith, R. (2018, May 18). Law to protect vulnerable adults from abuse and neglect passed. The Straits Times. Retrieved December 9, 2022, from https://www.straitstimes.com/politics/law-to-protect-vulner able-adults-from-abuse-and-neglect-passed Rozario, P. A., & Rosetti, A. L. (2012). “Many Helping Hands”: A review and analysis of long-term care policies, programs, and practices in Singapore. Journal of Gerontological Social Work, 55, 641–658. https://doi.org/ 10.1080/01634372.2012.667524 Scott, A. (2019). A longevity agenda for Singapore. Retrieved December 2, 2022, from https://longevity.stanford.edu/wp-content/uploads/2019/11/ A-Longevity-Agenda-for-Singapore.pdf Seow, J. (2022, February 8). Inclusivity can help S’pore mitigate shrinking workforce, help older workers thrive: Gan Siow Huang. The Straits Times. Retrieved December 10, 2022, from https://www.straitstimes.com/bus iness/economy/inclusive-culture-can-help-older-workers-thrive-and-helpspore-tap-longevity-dividend-gan-siow-huang Shafeeq, S., & Tan, T. (2022, November 16). Abusive parents to get approval before seeking maintenance from children under proposed changes to law. The Straits Times. Retrieved December 9, 2022, from https://www.straitsti mes.com/singapore/changes-to-maintenance-of-parents-act-proposed-to-pro tect-abused-children-and-vulnerable-seniors Singapore Department of Statistics. (2018). Population Trends 2018. Retrieved November 30, 2022, from https://www.singstat.gov.sg/-/media/files/pub lications/population/population2018.pdf Singapore Department of Statistics. (2021a). Singapore Census of Population 2020, statistical release 1: Demographic characteristics, education, language and religion. Retrieved November 30, 2022, from https://www.singstat.gov. sg/-/media/files/publications/cop2020/sr1/cop2020sr1.ashx

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Singapore Department of Statistics. (2021b). Complete life tables for Singapore resident population, 2019–2020. Retrieved December 2, 2022 from https://www.singstat.gov.sg/-/media/files/publications/population/ lifetable19-20.pdf Singapore Department of Statistics. (2022a). Population trends 2022. Retrieved December 2, 2022, from https://www.singstat.gov.sg/-/media/files/public ations/population/population2022.ashx Singapore Department of Statistics. (2022b). Complete life tables for Singapore resident population, 2020–2021. Retrieved December 2, 2022, from https://www.singstat.gov.sg/-/media/files/publications/population/ lifetable20-21.ashx Society for WINGS. (n.d.). WINGS Annual Report 2017/2018. Retrieved December, 10, 2022, from https://www.wings.sg/wp-content/uploads/ 2018/08/WINGS-Annual-Report-FY-2018-Full-K.pdf Soon, C., & Liang, S. J. (2021). Citizen engagement in Singapore: Applications of the Citizens’ Panel. Retrieved December 9, 2022, from https://lkyspp.nus.edu.sg/docs/default-source/ips/ips-reporton-citizen-engagement-in-singapore-applications-of-the-citizens-panel.pdf Tai, J. (2018, February 15). 100 years of Singapore through centenarians’ eyes: Unlocking secrets to longevity. The Straits Times. Retrieved December 3, 2022, from https://www.straitstimes.com/singapore/100-years-of-singap ore-through-centenarians-eyes-unlocking-secrets-to-longevity Tan, T. B. (2015). A super-aged Singapore: Policy implications for a smart nation. Retrieved November 30, 2022, from https://www.rsis.edu.sg/rsispublication/rsis/co15193-a-super-aged-singapore-policy-implications-for-asmart-nation/#.Y4bRy_dByUk Tan, T. (2022, October 10). Life expectancy falls for first time in Singapore’s history in 2021 because of Covid-19. The Straits Times. Retrieved December 2, 2022, from https://www.straitstimes.com/singapore/health/life-expect ancy-falls-for-first-time-in-spores-history-in-2021-because-of-covid-19 Tao, Y., Zhang, W., Gou, Z., Jiang, B., & Qi, Y. (2021). Planning walkable neighborhoods for “aging in place”: Lessons from five aging-friendly districts in Singapore. Sustainability, 13, 1742. https://doi.org/10.3390/su1 3041742 Tarmugi, A. (1995). Statement by Mr. Abdullah Tarmugi, Acting Minister for Community Development, at the World Summit for Social Development. Copenhagen, Denmark, on 10 March 1995 at 5:00 p.m. (Singapore Time). Retrieved December 10, 2022, from https://www.nas.gov.sg/archivesonline/data/pdf doc/at19950310s.pdf Teo, P., Mehta, K., Thang, L. L., & Chan, A. (2006) Ageing in Singapore: Service needs and the state. Routledge.

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Thang, L. L., & Johan, S. (2018). Growing old in Singapore: Working of the “Many Helping Hands” policy approach. In T. R. Klassen, M. Higo, N. S. Dhirathiti, & T. W. Devasahayam (Eds.), Ageing in Asia-Pacific interdisciplinary and comparative perspectives (pp. 131–152). Routledge. The Advisory Council on the Aged. (1988). Community-based programmes for the aged. Retrieved December 4, 2022, from https://eservice.nlb.gov.sg/ data2/BookSG/publish/4/4a62da26-e4b9-4fbc-9c7f-cc2a15930358/web/ html5/index.html?opf=tablet/BOOKSG.xml&launchlogo=tablet/BOOKSG_ BrandingLogo_.png&pn=3 The Tripartite Workgroup on Older Workers. (2019). Report of the Tripartite Workgroup on Older Workers: Strengthening support for older workers. Retrieved December 9, 2022, from https://www.mom.gov.sg/-/media/ mom/documents/press-releases/2019/0819-tripartite-workgroup-on-olderworkers-report.pdf Tilo, D. (2022, October 7). MOM reveals Singapore’s re-employment rate. Retrieved December 9, 2022, from https://www.hcamag.com/asia/spe cialisation/diversity-inclusion/mom-reveals-singapores-re-employment-rate/ 423144 United Nations Population Fund. (2012). Ageing in the twenty-first century: A celebration and a challenge. Retrieved December 11, 2022, from https:// www.unfpa.org/sites/default/files/pub-pdf/Ageing%20report.pdf United Nations Population Fund Asia-Pacific Regional Office. (2020). Social policies catalogue on population ageing: A rapid scoping review. Retrieved December 11, 2022, from https://asiapacific.unfpa.org/sites/default/files/ pub-pdf/200930_unfpa_ageing_catalouge_layout-3.pdf United Nations, Department of Economic and Social Affairs, Population Division. (2019). World population ageing 2019: Highlights. Retrieved December 11, 2022, from https://www.un.org/en/development/desa/population/ publications/pdf/ageing/WorldPopulationAgeing2019-Highlights.pdf United Nations Department of Economic and Social Affairs, Population Division. (2020). World population ageing 2020 highlights: Living arrangements of older persons. Retrieved December 11, 2022, from https://www.un.org/dev elopment/desa/pd/sites/www.un.org.development.desa.pd/files/undesa_ pd-2020_world_population_ageing_highlights.pdf United Nations Department of Economic and Social Affairs, Population Division. (2022). World population prospects 2022: Summary of results. Retrieved December 11, 2022, from https://www.un.org/development/desa/pd/ sites/www.un.org.development.desa.pd/files/wpp2022_summary_of_results. pdf United Nations Economic and Social Commission for Asia and the Pacific. (2017). Ageing in Asia and the Pacific: Overview. Retrieved December 11,

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2022, from https://www.unescap.org/resources/ageing-asia-and-pacific-ove rview (accessed 11 December 2022). World Health Organization. (2015). World report on ageing and health. Retrieved December 11, 2022, from https://apps.who.int/iris/bitstream/ handle/10665/186463/9789240694811_eng.pdf World Health Organization. (2017). World health statistics 2017: Monitoring health for the SDGs. Retrieved December 2, 2022, from https://apps.who. int/iris/bitstream/handle/10665/255336/9789241565486-eng.pdf World Health Organization. (2019). Decade of healthy ageing 2020–2030 update 1: March 2019. Retrieved December 11, 2022, from https://www.who.int/ docs/default-source/documents/decade-of-health-ageing/decade-healthyageing-update-march-2019.pdf?sfvrsn=5a6d0e5c_2 World Health Organization. (2020). Decade of healthy ageing: Baseline report. Retrieved December 11, 2022, from https://www.who.int/publications/i/ item/9789240017900 World Health Organization. (2022). World health statistics 2022: Monitoring health for the SDGs. Retrieved December 2, 2022, from https://www.who. int/data/gho/publications/world-health-statistics Yap, M. T. (2008). Singapore’s response to an ageing population. In H. G. Lee (Ed.), Ageing in Southeast and East Asia: Family, social protection, policy challenges (pp. 66–87). Institute of Southeast Asian Studies. Yap, M. T., & Gee, C. (2015). Ageing in Singapore: Social issues and policy challenges. In D. Chan (Ed.), 50 years of social issues in Singapore (pp. 3–30). World Scientific. Yuen, B., Moˇcnik, S., Yu, F. C. H., & Yap, W. (2020). Ageing-friendly neighbourhoods in Singapore, Asia-Pacific, Europe and North America: An annotated bibliography. Springer International Publishing AG.

Websites Active seniors. (n.d.). Retrieved December 10, 2022, from https://www.aic.sg/ caregiving/active-seniors Budget 2022 Speech. (2022). Retrieved December 4, 2022, from https://www. mof.gov.sg/docs/librariesprovider3/budget2022/download/pdf/fy2022_ budget_statement.pdf Citizens’ Panel on Contribution. (n.d.). Retrieved December 8, 2022, from https://www.moh.gov.sg/cpc Guide to re-employment and retirement in Singapore. (n.d.). Retrieved December 9, 2022, from https://singaporelegaladvice.com/law-articles/reemployment-retirement-singapore

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Managing healthcare cost increases. (2020, November 2). Retrieved December 4, 2022, from https://www.moh.gov.sg/news-highlights/details/managing-hea lthcare-cost-increases Maintenance of Parents Act 1995. (1996). Retrieved December 9, 2022, from https://sso.agc.gov.sg/Act/MPA1995 Maintenance of parents: Your child’s duties and how to file. (2021) Retrieved December 9, 2022, from https://singaporelegaladvice.com/law-articles/mai ntenance-of-parents-child-obligations-how-to-file/ Our services. (n.d.). Retrieved December 10, 2022, from https://www.slec.org. sg/our-services/ Protecting vulnerable seniors. (n.d.). Retrieved December 9, 2022, from https:// www.moh.gov.sg/ifeelyoungsg/how-can-we-build-stronger-ties/protectingvulnerable-seniors Recognizing reality of a rapidly ageing Asia-Pacific Region and revitalize the role of older persons in society, urges UN Forum. (2022, July 1). Retrieved December 11, 2022, from https://www.unescap.org/news/recognize-realityrapidly-ageing-asia-pacific-region-and-revitalize-role-older-persons-society “Report of the Inter-Ministerial Committee on the Healthcare Needs of the Elderly”: Minister’s statement. (1999). Retrieved December 7, 2022, from https:// www.sma.org.sg/sma_news/3105n/news/3105n1.html Report on Citizens’ Panel on Contribution. (n.d.). Retrieved December 9, 2022, from https://www.moh.gov.sg/docs/librariesprovider5/cpc/report-on-thecitizens’-panel-on-contribution-2021bcdc27b8158f492592f62a2f68a19bba. pdf Responsible re-employment. (n.d.). Retrieved December 9, 2022, from https:// www.mom.gov.sg/employment-practices/re-employment Retirement and Re-employment Act 1993. (1993). Retrieved December 9, 2022, from https://sso.agc.gov.sg/Act/RRA1993 Review of the Maintenance of Parents Act. (2022). Retrieved December 9, 2022, from https://www.msf.gov.sg/media-room/Pages/Review-of-TheMaintenance-of-Parents-Act.aspx Senior’s wish comes true with help from the community networks for seniors (CNS). (2019). Retrieved December 10, 2022, from https://www.aic-blog.com/sen iors-wish-comes-true-help-community-networks-seniors Services. (n.d.). Retrieved December 10, 2022, from https://fycs.org/seniors/ St Luke’s ElderCare Ltd. (n.d.). Retrieved December 10, 2022, from https:// www.giving.sg/web/slec Singapore 3rd in the world for life expectancy: WHO report. (2017, May 18). TODAY . Retrieved December 2, 2022, from https://www.todayonline.com/ singapore/singapore-3rd-world-life-expectancy-who-report Strategy to manage ageing. (2021). Retrieved December 7, 2022, from https:// www.moh.gov.sg/news-highlights/details/strategy-to-manage-ageing

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World health statistics 2014. (2014). Retrieved December 2, 2022, from https://apps.who.int/mediacentre/news/releases/2014/world-healthstatistics-2014/en/index.html Vulnerable Adults Act 2018. (2018). Retrieved December 9, 2022, from https:// sso.agc.gov.sg/Act/VAA2018 $3 billion Action Plan to enable Singaporeans to age successfully. (2015). Retrieved December 7, 2022, from https://www.moh.gov.sg/news-highlights/details/ 3billion-action-plan-to-enable-singaporeans-to-age-successfully 0110 Written answer by Minister for Manpower Dr Tan See Leng on breakdown of re-employed employees upon reaching statutory retirement age. (2022). Retrieved December 9, 2022, from https://www.mom.gov.sg/newsroom/ parliament-questions-and-replies/2022/0110-written-answer-by-minister-formanpower-dr-tan-see-leng-on-re-employed-employees

CHAPTER 2

Financial Well-Being of Older Adults

Abstract As people live longer, it is more important than ever that they attain financial well-being in old age. But many Singaporeans are financially unprepared for retirement because they lack financial knowledge and skills to help them manage personal finances and accumulate wealth. This increases their risk of having insufficient money to meet their basic monthly expenses, maintain their desired lifestyle or cope with unexpected expenses in old age. Women particularly have lower level of financial literacy than men because they lack opportunities to pursue higher education or do not work. This chapter will examine how financial literacy, the mandatory social security system, personal savings, and health status affect financial well-being of older adults in Singapore. In order to maintain financially well in old age, Singaporeans have to equip themselves with sufficient financial literacy knowledge and skills and have financial planning for retirement when they are young. Keywords CareShield Life · Central Provident Fund · Financial literacy · Financial wellness · Retirement inadequacy · Retirement planning

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 S. Ching Yuen Luk, Healthy Ageing in Singapore, Social Policy and Development Studies in East Asia, https://doi.org/10.1007/978-981-99-0872-1_2

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Introduction Financial well-being ‘is the extent to which a person or family can smoothly manage their current financial obligations and have confidence in their financial future’ (UNSGSA Financial Health Working Group, 2021: 4). It contains four key elements. These include one’s ability to control daily and monthly finances, the ability to absorb financial shocks caused by unforeseen life events, being on track to meet one’s financial goals and having the financial freedom to make the choices which allow enjoyment of life (Consumer Financial Protection Bureau, 2015: 18–20). As people live longer, it is more important than ever that they attain financial well-being in older age. Attaining financial well-being in older age enables people to have a sense of financial security (Miles, 2021), reduce stress related to money (LPL Financial, 2021) and have ‘enough money to support a reasonable standard of living’ (Collard & Hayes, 2014: 7). But longevity pessimism (i.e. underestimating life expectancy) or being not prepared for living a longer life may greatly affect people’s financial well-being in older age (Club Vita, 2022: 4). They would ‘expose themselves to the risks of undersaving, overspending and running out of money in retirement’ (Club Vita, 2022: 4). Such risks may in turn lead to older adults struggling with debt (e.g. credit card debt) or living in poverty (‘Aging With Economic Insecurity’, 2020).

Financial Well-Being of Older Adults in Singapore Several studies have showed that many Singaporeans are financially unprepared for retirement although they have a retirement plan. Singaporeans are good at saving money. But many of them are not good at growing wealth because they lack financial knowledge to do so, do not invest at all, or are financially responsible for both their growing children and ageing parents. Hence, they may be at higher risk of retirement inadequacy. This means that they may not have enough money to meet their basic monthly expenses, maintain their desired lifestyle or cope with unexpected expenses in old age. This section highlights some of the important findings of these studies.

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Standard Chartered Retirement Study 2019 In 2019, a comparative study was conducted by Standard Chartered on retirement aspirations of 1,000 economically active, affluent individuals aged 35–59 in Singapore, Malaysia, China, Hong Kong and Taiwan (200 respondents in each place) (Standard Chartered, 2019). It found that respondents in Singapore, similar to their Asian counterparts, had aspirational retirement plans, but were not financially on track to retire well (‘Almost 80% of Affluent Asians’, 2019; Standard Chartered, 2019). When asked about their ideal retirement lifestyle, respondents in Singapore identified travelling around the world (73%) as their top priority, followed by exercising (64%) and indulging in their hobbies (63%) (‘Almost 80% of Affluent Asians’, 2019; ‘Singapore affluent ahead of’, 2019). The survey found that 74% of respondents in Singapore had started retirement planning, as compared to an overall average of 67% in five places (Standard Chartered, 2019). Despite this, only 43% of respondents in Singapore thought that they were financially on track to achieve their desired retirement lifestyle (Standard Chartered, 2019). They accumulated wealth by investing in stocks, bonds and unit trusts (70%), government retirement savings schemes (47%) and property for rental yields (42%) (‘Singapore affluent ahead of’, 2019). They thought that ‘equip myself with more knowledge by doing more research’ was the best piece of advice they would give to their younger selves to better plan for their retirement (Standard Chartered, 2019). Similar to their Asian counterparts, respondents in Singapore faced challenges to retirement planning. Their top three challenges to retirement planning were insufficient awareness of the investment opportunities which generate sufficient returns (53%), lack of financial knowledge (42%) and unfavourable global financial climate (39%) (‘Almost 80% of Affluent Asians’, 2019; Standard Chartered, 2019). OCBC Financial Wellness Index A comprehensive study conducted by OCBC Bank in 2019 on the financial wellness of 2,000 Singaporeans across the age of 21–65 found that Singaporeans failed to ‘have a good understanding of their overall financial situation and of their projected financial needs when they retire’ (‘Finances of more Singaporeans’, 2020). It found that the average score of Singaporeans for the inaugural OCBC Financial Wellness Index based

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on 26 indicators falling under 10 pillars of financial wellness1 was 63 out of 100 (OCBC Bank, 2019: 14). This indicated that ‘Singaporeans have started taking care of their financial health, but are still behind on most indicators’ (Shiao, 2019). The study found that Singaporeans were good at saving, having medical insurance coverage and sticking to a budget (OCBC Bank, 2019: 15). But they ‘lagged in growing their wealth, and worried about their finances’ (OCBC Bank, 2021: 4). About one-third Singaporeans reported in the study that they did not invest and regarded investing as a form of gambling (OCBC Bank, 2019: 16–17). Women were, by and large, more averse to investing than men (OCBC Bank, 2019: 21; 2021: 4). 39% of women had no investment compared to 31% of men (OCBC Bank, 2019: 21). Besides, the study found that many Singaporeans were financially unprepared for emergencies and retirement. 58% of Singaporeans did not accumulate sufficient money to handle an emergency (OCBC Bank, 2019: 18). 73% of them were not on track with their retirement plans while 65% of them did not accumulate sufficient money to maintain their lifestyle after retirement (OCBC Bank, 2019: 19). For Singaporeans who had to support their growing children and ageing parents at the same time, over half of them were more financially stretched (OCBC Bank, 2019; ‘OCBC Bank launches Singapore’s first’, 2019) while over 30% of them had unsecured debt (OCBC Bank, 2019: 23). In 2021, the annual study conducted by OCBC Bank on the financial wellness of 2,051 Singaporeans across the age of 21 to 65 found that the average score of Singaporeans for the OCBC Financial Wellness Index based on 24 indicators2 falling under 10 pillars of financial wellness was 62 out of 100 (OCBC Bank, 2021: 8). It found that economic uncertainties caused by the 2019 coronavirus disease (COVID-19) pandemic had made Singaporeans adopt better financial habits such as saving more money and having better management of housing loans and unsecured debt (OCBC Bank, 2021: 12). 88% of Singaporeans saved at least 10% of their salary, and Singaporeans on average saved 27% of their salary (OCBC 1 According to OCBC Financial Index 2019 Report, 10 pillars which define one’s financial wellness are: saving habits, regular investing, regular reviews, excessive speculation, spending beyond means, protection from financial emergencies, retirement planning, gambling habit, borrowing money from loved ones and manageable debts (p. 8). 2 10 pillars of financial wellness in both the 2020 and 2021 study were measured against 24 indicators.

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Bank, 2021: 15). Besides, the study found that more Singaporeans had placed emphasis on retirement (‘OCBC Financial Wellness Survey, 2021’, n.d.). 51% of 2,051 Singaporeans listed retirement planning as one of their top priorities, which was 6% higher than that of the 2020 study (OCBC Bank, 2021: 28). In addition, 66% of 2,051 Singaporeans had made a retirement plan, which was 3% higher than that of the 2020 study (OCBC Bank, 2021: 28). For those who had made a retirement plan, however, only 49% of them were on track with their retirement plans (OCBC Bank, 2021: 29). On the other hand, not knowing where to start (31%), not having excess for financial planning (30%) and having no time to do it (29%) were reasons for those who had not made a retirement plan (OCBC Bank, 2021: 28). The study also found that the realities of the COVID-19 pandemic had ‘made Singaporeans more prudent about their dream retirement lifestyles’ (‘The Covid-19 pandemic has’, 2021). Most of Singaporeans (40%) preferred to have a modest retirement lifestyle3 (i.e. live in a HDB, eat at home or food courts, take public transport, no domestic helper) (OCBC Bank, 2021: 30–31). Only 35% of Singaporeans preferred to have a moderate retirement lifestyle (i.e. eat at mid-range restaurants, own a mid-range car, commute via taxi, hire a part-time domestic helper) and 25% of Singaporeans preferred to have an extravagant retirement lifestyle (i.e. live in private property, eat at restaurants, own a high-end car, have a full-time domestic helper, travelling overseas) (OCBC Bank, 2021: 30; ‘OCBC Financial Wellness Survey, 2021’, n.d.). Nevertheless, the majority of Singaporeans were unable to plan the right amount for retirement (‘OCBC Financial Wellness Survey, 2021’, n.d.). Over 80% of Singaporeans in the study were found to underestimate the actual amount of money required for their ideal retirement lifestyles (OCBC Bank, 2021: 32). The shortfall in the actual amount was 31% on average (OCBC Bank, 2021: 32). Endowus: Singapore Retirement Report 2021 In May 2021, Singapore’s first digital wealth advisor Endowus conducted an online survey on Singaporeans’ attitude towards retirement and their 3 According to the 2021 study, a modest retirement lifestyle required SG$2,355 per month (OCBC Bank, 2021: 30). A moderate retirement lifestyle and an extravagant retirement lifestyle required SG$2,970 and SG$5,325 per month (OCBC Bank, 2021: 30).

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use of the Central Provident Fund (CPF) (Endowus, 2021). A total of 1,099 Singaporeans aged 21 or over participated in this survey. The survey found that 45% of respondents had yet to plan for retirement (Endowus, 2021: 10). Hence, many respondents had not prepared adequately for retirement. According to the survey, 39% of respondents lacked confidence in having sufficient money in retirement (Endowus, 2021: 7). This lack of confidence was exacerbated in women, with 44% not being confident (Endowus, 2021: 8). It was also exacerbated in the 35–44 age group, with 49% not being confident because this group of people were financially responsible for both their children and ageing parents (Endowus, 2021: 7). Besides, the survey found that Singaporeans’ intention to use CPF to fund retirement, housing and healthcare was low (53–58%) despite high awareness of using CPF for those purposes (89– 92%) (Endowus, 2021: 9). Notably, only 53% of respondents planned for their retirement with CPF (Endowus, 2021: 9). However, the result varied between income groups. The low-income group (earning S$3,000 and below per month) (41%) were less likely than the high-income group (earning S$6,000 and above per month) (59%) to plan for their retirement with CPF (Endowus, 2021: 13). Underutilizing CPF may consequently limit the ability of the low-income group to meet the threshold of the Full Retirement Sum (FRS), leaving people in this group at greater risk of retirement inadequacy if they did not have additional savings or investments outside of CPF (Endowus, 2021: 13). The survey suggested people in the 35–44 age group and women manage CPF and their finances when they were young to avoid retirement inadequacy (Endowus, 2021: 18). It also suggested improving Singaporeans’ financial literacy on issues relating to specific usage of CPF (e.g. healthcare, housing) so that people could optimize the use of their CPF funds (Endowus, 2021: 18). Great Eastern: The State of Retirement in Singapore (2021) A survey conducted by a leading insurer Great Eastern in 2021 on the state of retirement in Singapore found that 45% of 304 respondents aged over 63 regretted not planning their retirement earlier (Great Eastern, 2021a). A majority of respondents wished they had 60% more money to spend monthly (Great Eastern, 2021a). Respondents who did not have early planning for their retirement and mainly relied on a monthly retirement income of S$1,200 could hardly meet their basic monthly

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expenses (Great Eastern, 2021a). On average, they were only left with S$30 to spend each month and hence they were unable to meet large or unexpected expenses and realize their desired retirement lifestyle (Great Eastern, 2021a). However, respondents who planned for their retirement before 50 years old had an average of S$625 more to spend monthly whereas those who planned for their retirement after 50 years old had an average of S$300 more to spend monthly (Great Eastern, 2021a). The survey found that respondents’ income sources mainly came from ‘past savings (56 per cent), CPF payouts (43 per cent) and allowances from family members (41 per cent)’ (Great Eastern, 2021a). But female respondents (45%) were much more dependent on their family members and children for monthly allowances than male respondents (39%) (Great Eastern, 2021a). This indicated that females did not save enough to support their monthly expenses and were less capable of being financially independent than males in old age.

Factors Affecting Financial Well-Being of Older Adults in Singapore According to the 2017/18 Report on the Household Expenditure Survey, the average monthly household expenditure among households comprising solely non-working older adults aged 65 and above in Singapore ‘increased from $1,660 in 2012/13 to $1,970 in 2017/18, or by 3.5 per cent per annum’ (Singapore Department of Statistics, 2019: 26). Besides, the average monthly household expenditure among households comprising solely non-working older adults aged 65 years or over across all expenditure quintiles has increased over time (Singapore Department of Statistics, 2019: 28). The households in the top 20% expenditure group spent an average of S$4,875 per month in 2017/18, compared to an average of S$3,063 per month in 2007/08 (Singapore Department of Statistics, 2019: 28). Those in the lowest 20% expenditure group spent an average of S$618 per month in 2017/18, compared to an average of S$323 per month in 2007/08 (Singapore Department of Statistics, 2019: 28). These indicated that people must earn and save enough to cope with an increase in the average monthly household expenditure. A study conducted by a team of researcher in Singapore using a consensus-based methodology known as Minimum Income Standards (MIS) found that the household budgets necessary to meet the basic

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needs of older adults were S$1,379 per month for single elderly households, S$1,721 per month for single persons aged 55–64, and S$2,351 per month for coupled elderly households (Ng et al., 2019: 41–42). For older adults who did not have enough money to afford a basic standard of living, they would not ‘have the means to ever retire’ (Ng et al., 2019: 61) or would be ‘permanently dependent on public and informal transfers’ (Ng et al., 2019: 61). This section will examine several key factors affecting financial wellbeing of older adults in Singapore. These factors include financial literacy, the mandatory social security system, personal savings, and health status. Financial Literacy ‘Over the past decades, financial literacy has been increasingly recognised globally as an essential life skill’ (OECD, 2017: 30). Financially literate people are able to make informed financial choices regarding saving, spending, investing, borrowing, debt management and more (Klapper et al., 2015: 4; Lusardi, 2019: 1; O’Neill, 2007). Remund (2010), who explicated the concept of financial literacy by reviewing research studies since 2000, provided a comprehensive definition of financial literacy in his study: Financial literacy is a measure of the degree to which one understands key financial concepts and possesses the ability and confidence to manage personal finances through appropriate, short-term decision-making and sound, long-range financial planning, while mindful of life events and changing economic conditions. (p. 284)

Empirical studies showed that financial literacy can positively and significantly affect financial wellbeing of an individual (Taft et al., 2013: 63; Xue et al., 2020: 4379–4380; Zulfiqar & Bilal, 2016: 94). A study which analyzed dataset from a nationally representative survey called the Singapore Life Panel® (SLP® ) found that wealthier and educated Singaporeans were more financially knowledgeable (Koh et al., 2020: 100179). It found that those who were more financially knowledgeable had ‘higher levels of net wealth, better self-assessed financial preparation for retirement, and more diversified and more complex asset holdings at older ages’ (Koh et al., 2020: 100179). Another study found that more financially literate Singaporeans aged between 50 and 70 years old had greater

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financial security and greater financial well-being than the less financially literate counterparts (Koh & Mitchell, 2019). When they scored one additional correct answer on the financial literacy questions, they had about 3% more net financial wealth (i.e. S$4,850), 2% more non-housing net wealth (i.e. S$9,000) and 14% more total wealth (i.e. S$1,547,000) (Koh & Mitchell, 2019: 18). They also held ‘better diversified portfolios over the life cycle’ (Koh & Mitchell, 2019: 1). Recently, a study has found that more financially literate Singaporeans are more likely to make better financial decisions of timely repaying credit card balances (1.5 percentage point higher), owning stocks and/or mutual funds (8.3 percentage point higher) and following an age-appropriate investment guideline (1.7 percentage point higher) (Fong et al., 2021: 101481). ‘As with many forms of education, the seeds of financial literacy are first planted and nourished at home’ (Roberts, n.d.). Parents play ‘a major role in transmitting financial values, habits and skills to their children’ (OECD, 2017: 3). In primary schools, students are taught basic concepts and core moral values (e.g. thrift, spending within one’s means) during the Form Teacher Guidance Period or when attending Character and Citizenship Education lessons (‘Promoting financial literacy’, 2020). In secondary schools, students are taught simple financial planning, consumer rights and the responsible use of credit (‘Promoting financial literacy’, 2020). At the pre-university level, students obtain financial knowledge in A-Level Economics or through an online learning platform of the Ministry of Education (MOE) called Student Learning Space (‘Promoting financial literacy’, 2020). In 2012, the Citi-SMU Financial Literacy Programme for Young Adults was launched to impart essential financial knowledge and skills to young adults aged 17 and 30 and nurture responsible financial behaviour through lectures and workshop (Singapore Management University, 2019). As Singapore’s first structured financial literacy programme for young adults, the program has trained over 1,200 participants to become financial literacy coaches, who have in turn imparted their financial knowledge to over 76,000 young adults in outreach events (‘Citi Foundation-SMU Financial Literacy Program’, n.d.). Financial knowledge and skills obtained by program participants included financial planning, investment portfolio diversification, financial technology (FinTech) innovation (‘About Train-The-Trainers (TTT) Program’, n.d.), the CPF system, home and car ownership and retirement planning (Quark, 2018). An impact assessment showed that about 60% of program participants demonstrated an increased level of financial

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knowledge after attending the program (Singapore Management University, 2019). Besides, about 29% more participants increased their savings rate, 16% more participants had started investing prudently and 10% more participants had started a regular savings account (Singapore Management University, 2019: 5). For the general public like older adults, they can attend financial education talk modules, workshops or watch online videos offered by Institute for Financial Literacy (‘About Us’, n.d.) and Credit Counselling Singapore (CCS) (‘Financial Literacy and Education’, n.d.). They can also get relevant and practical financial knowledge and resources free of charge on the website of MoneySense (https://www.moneys ense.gov.sg/), which is the national financial education programme in Singapore. People can seek professional advice if they are not financially literate. The survey conducted by Great Eastern in 2021 found that those who planned for retirement with professional advice ‘had on average S$605 extra to spend as they wished’ (Great Eastern, 2021a). This was 1.8 times more than that of those who planned for retirement without professional advice (S$330) (Great Eastern, 2021a). Some older adults like to increase their income through buying investment products. In Singapore, licensed financial advisers under Financial Advisers Act (CAP.110) are required to make recommendations on investment products to a client by collecting and documenting the employment status, financial situation, financial objectives, risk tolerance of the client and other relevant information from the client (Monetary Authority of Singapore, 2011: 11–2). They have to ask a client who like to buy investment insurance products to complete the Financial Needs Analysis Questionnaire (Interview 22SG48). The Questionnaire helps financial advisers understand the client’s financial objectives, investment knowledge and experience, risk appetite, and determine the Customer Investment Profile (CIP) rating (e.g. aggressive, conservative) before recommending suitable investment products to the client (Interview 22SG48). But the client may disregard such recommendations and buy other products based on his/her preference (Interview 22SG48). While investing may not be a bad idea, the client has to taken into account the market conditions and the risk he/she has to bear (Interview 22SG48). For example, a 70-year-old client who was financially literate and was considered as a credited investor chose to buy a vanilla structured product (i.e. a structured deposit) to get a higher return (Interview 22SG48). Structured deposits, however, ‘are riskier than normal fixed deposits’ (‘Making Sense of Structured Deposit’,

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n.d.: 3). Hence, the older client ‘should understand the risks involved and what will happen in a worst-case scenario’ (‘Making Sense of Structured Deposit’, n.d.: 3). On the other hand, some older adults who are risk-averse and have a substantial amount of money just want to go for a fix deposit of S$300,000 or S$400,000 for 9 to 24 months (Interview 22SG48). They want to earn more money within a short period of time because the interest rate is higher (Interview 22SG48). They cannot commit to a 10-year plan because they dislike their money being locked in the bank for too long and they do not think that they would live that long (Interview 22SG48). In sum, financial literacy helps people make savvy financial decisions, improve their financial wellness, achieve financial security later in life and build financial resilience even in the abnormal time such as the COVID-19 pandemic (Mitchell & Lusardi, 2021: 15). Mandatory Social Security System: The Central Provident Fund (CPF) The CPF, which was established in 1955, is the national social security system in Singapore (Chia, 2006; Koh, 2016; Koh & Mitchell, 2019; Luk, 2014: 96). It requires both employers and employees to make mandatory contribution to the CPF every month. Employers must make CPF contributions for their employees who are Singaporean citizens or Singapore Permanent Residents (PRs), working in Singapore under a contract of service and earning total wages of over S$50 per month (‘Who should receive CPF contributions’, n.d.). For employers, their CPF contribution rate is currently set at 17% of monthly salary for workers aged below 55, while contribution rates for workers above 55 range from 7.5 to 14% (‘CPF Overview’, n.d.). For employees, their CPF contribution rate is currently set at 20% of monthly salary for workers aged below 55, while contribution rates for workers above 55 range from 5 to 14% (‘CPF Overview’, n.d.). The salary ceiling for CPF contribution is set at S$6,000 a month (Kok, 2022). Contributions to the CPF are respectively allocated into the Ordinary Account (OA), the Medisave Account and the Special Account (SA) (‘CPF Overview’, n.d.). Allocation of contributions to ‘the three accounts are not uniform, but instead vary with age’ (Koh et al., 2020: 100179). Savings in the OA can be used to purchase homes, pay premiums for insurance, invest in approved stocks and shares, and finance children’s tertiary education (Chia, 2006; Koh et al., 2020). Savings in the Medisave Account can be used to pay selected outpatient treatments (Koh et al., 2020), hospitalization expenses

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and approved medical insurance (‘CPF Overview’, n.d.). The SA ‘holds savings primarily for retirement and these cannot be withdrawn before the age of 55’ (Koh et al., 2020). At the age of 55, a Retirement Account (RA) will be created to hold savings transferred from the OA and SA to form retirement sum to provide a monthly income for CPF members in old age (The Central Provident Fund, n.d.: 2). Home ownership and public housing were two of the important pillars in the nation-building project in Singapore (‘Housing A Nation, Building A City’, n.d.). ‘Home ownership has been linked to national identity’ (Ong & Mokhtar, 2013) and is regarded as a way to generate a sense of belonging, public spiritedness (McCarthy et al., 2002: 202), ‘maintain social stability and promote social mobility’ (‘Housing A Nation, Building A City’, n.d.). To promote home ownership, the government introduced the Public Housing Scheme to help CPF members buy public housing apartments known as Housing and Development Board (HDB) flats and the Residential Properties Scheme to help CPF members buy homes sold by private developers (Koh, 2016: 305). Hence, Singapore has the highest home ownership rate in the world (Chua, 2021). As of 2021, about 89% of people in Singapore owned their homes (‘Households’, n.d.). Nevertheless, CPF members’ excessive pre-retirement withdrawals of CPF savings to buy homes has led to insufficient retirement savings in their CPF accounts (Koh, 2016: 321). This point can be further elaborated by the study of McCarthy et al. (2002), which used a simulation model to evaluate how the interaction of the CPF scheme with the national housing policy shaped asset and saving accumulation patterns of workers in Singapore (p. 198). The study found that the CPF had the potential to render the average workers in Singapore ‘asset rich but cash poor’ in retirement, with about 75% of their retirement assets in housing and only about 20% of liquid assets in the worker’s Ordinary and Special Accounts (McCarthy et al., 2002: 207–209). Annuitizing liquid income would yield a retirement income which could sufficiently cover subsistence, but one which replaced only 28% of pre-retirement earnings (McCarthy et al., 2002: 215). Hence, those ‘accustomed to higher consumption levels while employed might find themselves in a serious cash bind when retired’ (McCarthy et al., 2002: 210). Due to having property assets, older adults who are cash-strapped may not meet the qualifying criteria to receive government assistance (Ong & Mokhtar, 2013). To deal with the cash-strapped situation, older adults can consider monetising their properties through taking up a reverse

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mortgage, subletting, downsizing to a smaller home, or lease and buyback (Koh, 2016: 324–325). A reverse mortgage is a scheme designed to allow homeowners to use their homes as collaterals to obtain loans from a financial institution such as a bank in the form of retirement annuities (Chia, 2006: 31; Koh, 2016: 324). ‘Upon the owner’s death, the home is sold by the financial institution to recover the loan and cumulative interest due’ (Koh, 2016: 324). For example, DBS Bank introduced its new Home Equity Income Loan in August 2021 to allow Singaporeans PRs aged 65–79 to ‘borrow against their fully-paid private residential property to top up their CPF Retirement Sums which will be used for the CPF LIFE scheme’ (‘DBS unveils market-first financing solution’, 2021). This let homeowners ‘receive monthly payouts to supplement their retirement funds for as long as they live’ (‘DBS unveils market-first financing solution’, 2021). As regards subletting, older homeowners can ‘sublet part of their homes to earn rental income’ (Koh, 2016: 324). But it is not favoured by some older homeowners due to their concern about privacy and security (Koh, 2016: 325). Downsizing to a smaller home means ‘paying less for the property and for monthly utilities’ (‘Tips for Downsizing During Retirement’, 2020). The introduction of a Silver Housing Bonus Scheme by the government enables a Singapore Citizen aged 55 or over to receive a cash bonus of up to S$30,000 if he or she sells the existing flat or private home with annual value not exceeding S$13,000 to buy a three-room or small flat from HDB or the resale market (‘Silver Housing Bonus’, n.d.). He or she is required to channel part of the net sale proceeds to his/her RA to boost the lifelong monthly payouts under a national longevity insurance annuity scheme called CPF Lifelong Income for the Elderly (CPF LIFE) (‘What is the Silver Housing Bonus scheme?’, n.d.). But downsizing to a smaller home may lead to older adults having difficulty in adapting to a new living environment if their new homes are in different neighbourhoods (Koh, 2016: 325). The Lease Buyback Scheme (LBS) allows HDB homeowners aged 65 or over to sell a portion of their remaining home’s lease to HDB while continuing to live in their homes (Koh, 2016: 325; ‘Lease Buyback Scheme’, n.d.). They are required to use the proceeds from selling part of the home’s lease top up their CPF RA (‘Lease Buyback Scheme’, n.d.). They can then use the savings in the RA to join CPF LIFE to get monthly income for life (‘Lease Buyback Scheme’, n.d.). But the drawback of the LBS is that older homeowners are not allowed to sublet or sell their homes once they take up the LBS (Ong, n.d.). From 2009 to 2018, only about 3,100 households

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took up the LBS (‘Oral Answer by Ministry of National Development’, 2018). These included ‘830 households in 4-room flats, 2,030 households in 3-room flats, and the remaining 240 households in smaller flats’ (‘Oral Answer by Ministry of National Development’, 2018). Personal Savings Personal savings ‘are obtained by subtracting consumption from disposable income’ (Dagenais, 1992: 687). They can provide a financial “backstop” for life’s uncertainties (e.g. unemployment, disability), which increases one’s feeling of security (O’Neill, 2009). They can also ‘support investments that cost money now but have returns down the road’ (Population Reference Bureau, 2007: 2). Savings can be achieved when one starts setting saving goals (Shruthi & Ramu, 2018: 399), have ‘profitable investment and less consumption of money on unwanted stuffs’ (Shruthi & Ramu, 2018: 399). ‘But decisions about saving are complex, involving consideration of current circumstances and predictions of future conditions’ (Population Reference Bureau, 2007: 1). In Singapore, some young people who do not come from a high-income family would save as much money as possible (‘Gen Z: Things I Wish’, 2020). Some fresh graduates have little savings in the first few months after working because they use most of their salaries to pay off student loans fast to avoid paying the interest (e.g. S$35,000 loan, compound at 5% per annum) (‘Gen Z: Things I Wish’, 2020). Without financial planning, some young working adults are unable to save money at all because they spend more than they earn (‘Gen Z: Things I Wish’, 2020). Some of them are even in debt and have to take up credit lines to pay off their debts (‘Gen Z: Things I Wish’, 2020). Saving money may be difficult for average families with more children because their expenses for raising children are higher (‘Gen Z: Things I Wish’, 2020). ‘The COVID-19 pandemic has hit the Singapore economy hard’ (Seah et al., 2020: 22). Many people have suffered a severe drop in income (Seah et al., 2020: 26) and had less savings (OCBC Bank, 2020). In June 2020, the OCBC Financial Survey Impact Survey for COVID-19 found that 70% of 1,000 working adults aged between 21 and 65 years old earning from S$2,000 a month in Singapore did not have enough savings to sustain themselves for six months if they were to lose their jobs now (OCBC Bank, 2020: 3). Particularly, 18% of them could only sustain themselves for up to one month with their current savings (OCBC Bank,

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2020: 3). Besides, the survey found that 47% of the respondents experienced a reduction in income due to wage cut, having less commission earnings, being forced to take no-pay leave or convert to a part-time job (OCBC Bank, 2020: 4). This may in turn reduce their savings. In the survey, 55% of the respondents reported a reduction in saving, with 22% of them having their savings reduced by more than 20% (OCBC Bank, 2020: 3). For those who had retirement plan, 27% of them had either stopped setting aside funds or reduced funds for retirement (OCBC Bank, 2020: 5). Meanwhile, 32% of the sandwich generation aged between 40 and 54 had stopped setting aside funds or reduced funds for retirement (‘OCBC Financial Impact Survey’, n.d.) because of taking care of their ageing parents and young children at the same time (Lay, 2020). They survey indicated that financial stress caused by COVID-19 appeared to ‘have caused many Singaporeans to shelve or reduce their retirement savings’ (Cua, 2020). Similarly, a survey published by the DBS Bank in August 2020 showed that the COVID-19 pandemic had severely affected the financial wellness of DBS customers in Singapore (Seah et al., 2020). It found that 26% of 1.2 million DBS customers aged between 25 and 70 years old suffered a significant income reduction of more than 10% (Seah et al., 2020: 8). Among these affected customers, about one-third suffered an income reduction of more than 50%, including those who lost their income completely (Seah et al., 2020: 8). Lower-income earners (S$2,999 and below) who were more vulnerable to job losses were particularly worst hit by COVID-19 (Seah et al., 2020: 9). They constituted about 49% of DBS customers suffering income reduction (Seah et al., 2020: 10). Among this group, 51% of them reported an income reduction of more than 50% (Seah et al., 2020: 10). The survey also found that a lot of DBS customers faced the problem of saving inadequacy. A total of 64% of DBS customers suffering a significant income reduction ‘had less than three months of emergency funds’ (Seah et al., 2020: 16), of which 42% had less than one month of emergency funds (Seah et al., 2020: 16). As regards low-income earners, 33% of them had less than three months of emergency funds, of which 22% had less than one month of emergency funds (Seah et al., 2020: 16). With little savings, low-income earners had to ‘heavily reliant on their salaries to meet their monthly cash flow needs’ (Seah et al., 2020: 17). But a significant income reduction had unavoidably inflicted ‘significant stress on the livelihoods of this group of workers and their families’ (Seah et al., 2020: 17). On the other hand, 54% of

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high-income earners (S$10,000 and above) had more than three months of emergency funds (Seah et al., 2020: 31). The survey showed that the COVID-19 pandemic had widened the income gap in Singapore and its financial impact had skewed unfavourably towards lower-income earners (‘DBS on Covid-19’s impact on Singapore’, 2020). In March 2021, another survey published by the DBS Bank found that there was an improvement in the financial wellness of DBS customers in Singapore due to an improvement in the labour market (Seah et al., 2021: 9). From May to December 2020, the percentage of customers suffering a significant income reduction (i.e. more than 10%) decreased from 26% to about 19% (Seah et al., 2021: 9–10). The survey found that lower-income earners (S$2,999 and below) remained the worst hit by COVID-19 and still constituted about 49% of DBS customers suffering income reduction (Seah et al., 2021: 11). From May to December 2020, however, the percentage of lower-income earners having an income reduction of more than 50% decreased from 51 to 42% (Seah et al., 2021: 11). On the other hand, the savings situation of customers suffering a significant income reduction in 2020 appeared to have worsened (Seah et al., 2021: 21). As of December 2020, 47% of customers suffering a significant income reduction had less than one month of emergency funds, which was 5% higher than that of in May 2020 (Seah et al., 2021: 21). The percentage of lower-income earners having less than one month of emergency funds increased from 45% in May 2020 to 51% in December 2020 (Seah et al., 2021: 22). This meant that lower-income earners ‘may have been depleting their savings to sustain their livelihood’ (Seah et al., 2021: 22). ‘It remains to be seen whether the recent deterioration in many Singaporeans’ financial situations is temporary or long lasting’ (Economist Impact, 2021: 10). But the survey suggested people have prudent and rigorous financial planning to better prepare for a sustainable financial future (Seah et al., 2021: 31). The study conducted by Economist Impact (2021) suggested several ways to enhance Singaporeans’ ability to save and invest for their old age. These included raising the public awareness of the need to have longterm financial planning, enabling people to have an easier access to all the information and resources related to financial literacy, and incentivizing older adults to use digital means to manage their finances (Economist Impact, 2021: 10). Other useful suggestions included ‘the importance of having an emergency fund with 6–18 months of reserves, and the need to

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develop a stream of regular, passive income’ (The Economist Intelligence Unit, 2020: 15). Health Status Health status affects financial well-being of older adults. ‘With advancing age comes increases in disease prevalence and greater use of healthcare resources’ (Pfizer Inc., 2007). ‘Functional decline, defined as a deterioration in an individual’s ability to independently and safely perform activities of daily living (ADLs)’ (Van den Berg et al., 2021: 125), is also prevalent among older adults. Poorer physical and functional health would unavoidably lead to higher medical and long-term care (LTC) expenses. In Singapore, people live ‘longer but not necessarily healthier lives’ (The Singapore Ministry of Health and Institute for Health Metrics & Evaluation, 2019: 17). The report entitled The Burden of Disease in Singapore, 1990–2017 found that life expectancy at birth in Singapore increased from 76.1 years in 1990 to 84.8 years in 2017 (The Singapore Ministry of Health and Institute for Health Metrics & Evaluation, 2019: 19). However, healthy life expectancy (HALE) which refers to ‘the average number of years a person can expect to live in full health from any given age’ (The Singapore Ministry of Health and Institute for Health Metrics & Evaluation, 2019: 19) only increased from 67.1 years in 1990 to 74.2 years in 2017 (The Singapore Ministry of Health and Institute for Health Metrics & Evaluation, 2019: 19). That meant the average Singaporeans would spend 10.6 years in poor health (The Singapore Ministry of Health and Institute for Health Metrics & Evaluation, 2019). This was attributed to an ageing population and higher rates of chronic disease and disability among older adults (The Singapore Ministry of Health and Institute for Health Metrics & Evaluation, 2019: 19). In December 2018, a nationally representative survey funded by Singapore’s Ministry of Health (MOH) found that the physical health of older Singaporeans aged 60 or over deteriorated as age increased (Chan et al., 2018). Overall, about 38% of 4,549 respondents rated their health as fair or poor (Chan et al., 2018: 41). This percentage increased with age, reaching about 51% among those aged 80 years or over (Chan et al., 2018: 41). Over 60% of respondents had multiple chronic illnesses, of which about 23% had two chronic illnesses and about 38% had three or more chronic illnesses (Chan et al., 2018: 42). The percentage of respondents with three or more chronic illnesses increased with age,

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reaching about 49% among those aged 80 years or over, and was comparable between males (37.5%) and females (37.8%) (Chan et al., 2018: 42). The top five chronic illnesses among older Singaporeans were high blood pressure (56%), high blood cholesterol (49%), cataract (31%), joint pain, arthritis, rheumatism or nerve pain (29%) and high blood sugar or diabetes (25%) (Chan et al., 2018: 43–49). About 9% of respondents reported experiencing difficulty with at least one ADL, with more females (12.7%) than males (5.3%) experiencing ADL difficulties (Chan et al., 2018: 51). The top three ADL difficulties faced by older Singaporeans were walking around the house (7.5%), standing up from a bed/chair or sitting down on a chair (6.9%) and taking a bath/shower (5.1%) (Chan et al., 2018: 51). As regards healthcare utilization, the most frequent types of health professionals visited by older Singaporeans at least one time three months prior to the survey were a doctor at a polyclinic (42.1%), a private general practitioner (30.5%) and a doctor at a specialist outpatient clinic (24.3%) (Chan et al., 2018: 77). Overall, about 8% of older Singaporeans visited a hospital emergency room within the past 6 months (Chan et al., 2018: 77). This percentage increased with age, reaching 13.5% among those aged 80 years or over (Chan et al., 2018: 77). About 12.5% of older Singaporeans reported being admitted to a public or private hospital in the past 12 months (Chan et al., 2018: 77). This percentage increased with age, reaching 21.3% among those aged 80 years or over, and was higher for males (14.3%) than females (10.7%) (Chan et al., 2018: 77). The survey found that ‘low personal mastery and poor physical health were associated with a higher use of all four considered types of healthcare services’4 (Chan et al., 2018: 92). A report by Marsh & McLennan Companies’ Asia Pacific Risk Center (APRC) estimated that total healthcare costs of older adults in Singapore would increase tenfold over the next 15 years to US$49 billion ($66 billion) annually5 (Huang, 2016; Tai, 2016). This means an average of US$37,427 will be spent on healthcare for every older adult aged 65 or over by 2030 (Huang, 2016; Tai, 2016). A drastic increase in elderly healthcare costs will result in ‘straining government budgets,

4 Four types of healthcare services were primary care outpatient visits, tertiary care outpatient, emergency room visit, and hospital admission (Chan et al., 2018: 81). 5 The report derived elderly healthcare costs by taking into account demographic changes, medical cost inflation and long-term care (LTC) costs (Tai, 2016).

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infrastructure capacity, and personal savings of the elderly and their families’ (Hedrich and Tan n.d.: 2). Regarding personal savings, a study conducted by the Economist Intelligence Unit (2020) found that 78% of 1,219 Singaporean residents cited healthcare as the most important objective for saving for ahead of older age because of their worry about continued inflation of medical costs and the burden of ill health in old age (p. 11). In another study, however, almost half of the healthcare practitioners believed that Singaporeans were ‘unprepared for the health-related expenses of living to 100’ (The Economist Intelligent Unit, 2019: 12). In Singapore, the government introduces several schemes to cover medical expenses of its population, including older adults. Medisave, which is a national compulsory medical savings scheme, covers an individual’s or approved dependents’ inpatient, day surgery and selected outpatient expenses (‘Medisave’, n.d.). It can be used at ‘all public healthcare institutions, approved medical clinics and private hospitals’ (Grey, n.d.). Medisave Withdrawal Limits are ‘carefully set to ensure that Singaporeans have sufficient savings in their MediSave Account for their basic healthcare needs in old age’ (‘Medisave’, n.d.). For example, Medisave Withdrawal Limit for inpatient hospitalization is S$450 per day excluding surgical limits (Grey, n.d.). MediShield Life, which is a compulsory medical insurance scheme, provides universal and lifelong protection for all Singapore Citizens and PRs, including those with preexisting health conditions and the very old (Luk, 2020: 83). It mainly pays for large hospital bills in subsidized wards (i.e. Class B2/Class C ward) and selected costly outpatient treatments (e.g. dialysis) (Luk, 2020: 83; ‘MediShield Life’, n.d.). ‘Patients pay premiums, deductibles, coinsurance, and any costs above the claim limit’ (Lee, 2020). Medifund Silver, which is a medical endowment fund, provides financial assistance for low-income older adults who cannot afford their medical bills even with Medisave deduction, insurance and government subsidies (Luk, 2020: 83–84; Tay, 2021). It ‘ensures that no Singaporean will be denied basic medical care due to the inability to pay’ (Tay, 2021). Pioneer Generation Package, which was launched by the government in 2014, provides

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eligible older adults6 with Medisave top-ups (S$200–900, depending on birth cohort), special premium subsidies (up to 60%) for MediShield Life, and outpatient care subsidies (‘Pioneer Generation Package’, n.d.). Merdeka Generation Package, which was announced in Budget 2019, provides eligible older adults7 with Medisave top-ups (S$200 each year from 2019 to 2023), additional premium subsidies (S$31.5–S$153) for MediShield Life, and outpatient care subsidies (Teng, n.d.). There is also the Community Health Assist Scheme (CHAS) providing subsidies for successful applicants to seek medical and/or dental care at participating General Practitioner (GP) and dental clinics (‘About the Scheme’, n.d.). The CHAS covers chronic illnesses (e.g. flu, fever, urinary tract infection), selected chronic conditions (e.g. hypertension, lipid disorders), dental services (e.g. denture reline/repair, permanent crown, root canal treatment) and some health screening services (e.g. Diabetic Foot Screening) (‘Community Health Assist Scheme (CHAS) Singapore’, n.d.; ‘Managing your chronic conditions using CHAS’, n.d.). Whether the schemes above can sufficiently cover medical expenses of older adults likely varies among individuals. It is because the amount of medical expenses incurred for older adults depends on different factors, including type of illness, severity of illness, length of hospital stay, type of wards, costs for medical tests or X-rays, surgical costs, prescription drug charges and therapy services. Older patients may have to pay out of pocket for expenses not covered by Medisave or MediShield Life. For people who earn lower income, stop working or are unemployed for many years, they may not have enough savings in their Medisave Account to cover their medical expenses in old age. They may have to pay medical expenses on their own or with the help of family members or friends if they are not eligible for receiving any financial assistance such as subsidies from the government. Medisave and MediShield Life can bring peace 6 The Pioneer Generation Package is for living Singapore citizens who were born on or before 31 December 1949 and obtained citizenship on or before 31 December 1986 (‘Pioneer Generation Package’, n.d.). For more details, please visit https://www.moh. gov.sg/cost-financing/healthcare-schemes-subsidies/pioneer-generation-package#:~:text= Where%20can%20I%20receive%20my,Health%20Assist%20Scheme%20(CHAS). 7 The Merdeka Generation Package is for living Singaporean born on or between 1 January 1950 and 31 December 1959 and became a Singapore Citizen on or before 31 December 1996; or for Singaporeans who do not receive the Pioneer Generation Package although they are eligible for the Pioneer Generation Package (Teng, n.d.). For more details, please visit https://www.homage.sg/resources/merdeka-generation/.

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of mind to older patients and their family members if they can cover most of the medical expenses of the patients (Interview 22SG48). For example, a male older adult who suffered a traumatic brain injury had a large hospital bill of over S$86,000 after staying in a subsidized ward for a few months (Interview 22SG48). 79% of his medical expenses was covered by government subsidy, 18% was covered by MediShield Life and about 2.5% was covered by MediSave (Interview 22SG48). The amount of out-of-pocket expenses he had to pay only accounted for about 0.5% of the medical expenses. His daughter said that she and her mother signed a relief because most of the medical expenses of her father was covered by government subsidy and MediShield Life (Interview 22SG48). She praised the current health financing system for providing sufficient financial protection for her father (Interview 22SG48). ‘Diseases, particularly multiple chronic illnesses, are the main cause of old age disability’ (Heikkinen, 2003: 4). People often need LTC when ‘they have a serious, ongoing health condition or disability’ (‘What is Long-term Care?’, n.d.). According to MOH, ‘1 in 2 healthy Singapore residents aged 65 today could become severely disabled in their lifetime’ (ElderShield Review Committee, 2018: 16). While ‘the median duration for severe disability is 4 years, around 3 in 10 could remain in severe disability for 10 years or more’ (Lim, 2021). Prolonged disability will lead to higher LTC costs, which may in turn increase the financial burden of the disabled and their caregivers (Great Eastern, 2021b). LTC costs ‘vary depending on an individual’s needs, desired care arrangements and financing means’ (ElderShield Review Committee, 2018: 49). The LTC study done by Aviva in 2018 found that the average cost of LTC was S$2,324 per month, which included everyday living expenses, aids to help in daily living, medication and therapy, caregiver expenses and miscellaneous expenses (Asia Advisors Network Team, 2020). But many Singaporeans may not be able to afford the LTC costs on their own if they were to become disabled. A study which examined the personal perceptions and attitudes of 2,050 Singaporeans towards LTC and severe disability found that 90% of respondents were worried about how they might finance their LTC needs if they were to become severely disabled (Asia Advisors Network Team, 2020). The cost of LTC (83%) was the top concern of respondents across all age groups, followed by the concern of becoming a burden to their loved ones (80%) (Asia Advisors Network Team, 2020). 69% of respondents were not confident about their ability or their families’ ability to pay for the necessary healthcare if they were

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to become disabled (Asia Advisors Network Team, 2020). About 58% of respondents estimated that the LTC cost would be over S$2,000 per month while only 27% of respondents thought that the LTC cost would be less than S$2,000 per month8 (Asia Advisors Network Team, 2020). In Singapore, the government introduces several schemes to partially cover the LTC expenses of people with severe disability. These schemes include ElderShield, CareShield Life and Medisave Care. ElderShield is a national severe disability insurance scheme introduced by the government in 2002 to provide basic financial protection for Singapore citizens and PRs with severe disability in old age (Luk, 2020: 84; Tan, n.d.). ElderShield 300 provides eligible policyholders with monthly payouts of S$300 for up to five years upon severe disability, whereas ElderShield 400 provides eligible policyholders with monthly payouts of S$400 for up to six years upon severe disability (Luk, 2020: 84). Until 2019, all Singapore citizens and PRs with Medisave Accounts ‘were automatically enrolled in ElderShield at the age of 40, unless they opted out of the scheme’ (‘About ElderShield’, n.d.). On 1 October 2020, the government introduced CareShield Life, which is a national mandatory LTC insurance scheme providing basic financial protection for Singapore citizens and PRs with severe disability (i.e. cannot perform three or more of the six ADLs) (‘CareShield Life’, n.d.). The insured can receive lifetime cash payouts as long as they remain severely disabled (‘FAQ’, n.d.). Their monthly payouts which started at S$600 in 2020 ‘increases annually until age 67 or when a successful claim is made, whichever is earlier’ (‘FAQ’, n.d.). All Singapore citizens and PRs who were born in 1980 or after, or who turn 30, are automatically enrolled in CareShield Life (‘Protect Yourself against Long-term Care Costs’ n.d.). Participation in CareShield Life, however, is optional for those who were born in 1979 or earlier (‘Protect Yourself against Long-term Care Costs’, n.d.). As regards Medisave Care, it was introduced by the government in October 2020 to allow Singapore citizens and PRs aged 30 and above to make monthly cash withdrawals up to S$200 per month from their own or their spouse’s Medisave Account if they are severely disabled (‘Introduction to Medisave Care’, n.d.). Other government schemes which also cover LTC expenses include the Interim Disability Assistance Programme for the Elderly (IDAPE), which provides monthly cash payouts of S$150 to 8 The rest of respondents (15%) were unsure about the LTC costs (Asia Advisors Network Team, 2020).

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S$250 for up to six years for older adults who are not eligible for ElderShield (‘Interim Disability Assistance Programme’, n.d.), and Elderfund, which is a discretionary assistance scheme providing up to S$250 cash per month for severely disabled, lower-income Singaporean citizens aged 30 and above (‘ElderFund’, n.d.). The partial coverage provided by CareShield Life and other government assistance schemes means that people with severe disability still have to rely on other sources to pay for their LTC expenses. These sources can be out-of-pocket spending, voluntary LTC insurance, charitable donations or other private resources (Graham & Bilger, 2017). Since the current schemes provided by the government are mainly targeted at people with severe disability, people with mild or moderate disability have to rely more on private resources to pay for their LTC expenses if they are not eligible for means-tested government subsidies for services. Graham and Bilger (2017) estimated that an older adult aged 65 or over in 2015 paid 40% of the total cost of LTC services out of pocket, with the rest paid by government spending (42%), charitable donations (9%) and LTC insurance (9%) (Graham & Bilger, 2017: 362–363). Older adults unprepared for high out-of-pocket expenses for LTC may experience severe financial difficulties in paying for LTC services and end up having limited or no access to proper and needed LTC services. Some severely disabled older adults have to rely on their grown children to pay for their nursing care costs due to not qualifying for means testing (Interview 21SG43). But this may impose heavy financial burden on their grown children. For example, a severely disabled older adult did not meet the eligibility criteria for government subsidy due to failing the means test (Interview 21SG43). He had to use his own savings and his grown children’s savings to pay for the private nursing home care cost of about S$9,000 every month (Interview 21SG43). He was finally qualified for government subsidy almost two years later when both his savings and his grown children’s savings were totally wiped out (Interview 21SG43). Some grown children whose parents require LTC at the same time may have to make tough decisions about which parent should receive care at a nursing home or at home due to the lack of financial means and/or the ability to take care of both parents at home (Interview 21SG43). Financial well-being of older adults with severe disability may not be affected if they can receive financial support from multiple public and private sources. For example, the cost of nursing home care was about S$2,800 per month for a severely disabled older adult who stayed in a nursing home run by a voluntary welfare

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organization (VWO) (Interview 22SG48). It was covered by meanstested government subsidies (68%), CareShield Life (22%), Medisave Care (7%), charitable donations (2%) and out-of-pocket spending (1%) (Interview 22SG48). This example shows that little out-of-pocket spending is required to pay for the cost of nursing home care (Interview 22SG48) due to substantial financial support from the public sources. Nevertheless, the daughter of the severely disabled older adult said that his father had to wait for a few months before his applications for CareShield Life and Medisave Care were assessed and approved by Agency for Integrated Care (AIC) (Interview 22SG48). During the waiting period, his father still had to pay high out-of-pocket expenses for the nursing home care (Interview 22SG48). Once his applications were successful, payouts were made to his bank account, including payouts from the month the application were submitted (Interview 22SG48).

Conclusion To conclude, it is important for Singaporeans to have financial planning for retirement when they are young. They have to equip themselves with sufficient financial literacy knowledge and skills to help them manage personal finances and accumulate wealth. They also have to lead a healthy lifestyle and take steps to prevent chronic illnesses (Ng et al., 2019: 38) so that they can stay healthy, remain independent and avoid high medical and LTC expenses in old age. They can do so by eating a healthy and balanced diet, exercising regularly, getting good-quality sleep and going for regular health screenings (Ng et al., 2019: 38).

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About Train-the-trainers (TTT) program. (n.d.). Retrieved June 24, 2022, from https://skbi.smu.edu.sg/cfs/program/about-ttt-program#ttt-curriculum About us. (n.d.). Retrieved June 24, 2022, from https://ifl.org.sg/about-us/ Aging with economic insecurity: Resources for older Americans. (2020). Retrieved June 15, 2022, from https://msw.usc.edu/mswusc-blog/the-aging-poorhow-social-workers-can-help/ Almost 80% of affluent Asians see travel as ideal retirement lifestyle. (2019). Retrieved June 20, 2022, from https://www.sc.com/en/media/press-rel ease/almost-80-of-affluent-asians-see-travel-as-ideal-retirement-lifestyle/ CareShield Life. (n.d.). Retrieved July 2, 2022, from https://www.aic.sg/financ ial-assistance/careshield-life Citi Foundation-SMU financial literacy program for young adults. (n.d.). Retrieved June 23, 2022, from: https://skbi.smu.edu.sg/cfs Community Health Assist Scheme (CHAS) Singapore. (n.d.). Retrieved July 6, 2022, from https://www.healthhub.sg/a-z/costs-and-financing/4/chas (accessed 6 July 2022). CPF overview. (n.d.). Retrieved June 28, 2022, from https://www.cpf.gov.sg/ member/cpf-overview DBS unveils market-first financing solution for seniors with private residential properties. (2021). Retrieved June 29, 2022, from https://www.dbs.com/ newsroom/DBS_unveils_market_first_financing_solution_for_seniors_with_ private_residential_properties DBS on Covid-19’s impact on Singapore residents’ financial health: More help needed for lower income group. (2020). Retrieved June 30, 2022, from https://www.dbs.com/newsroom/DBS_on_Covid_19_s_impact_on_Sin gapore_residents__financial_health__more_help_needed_for_lower_income_ group Elderfund. (n.d.). Retrieved July 2, 2022, from https://www.aic.sg/financial-ass istance/elderfund FAQ . (n.d.). Retrieved July 2, 2022, from https://www.cpf.gov.sg/member/ faq/healthcare-financing/careshield-life/what-is-careshield-life Finances of more Singaporeans hit by COVID-19: OCBC survey. (2020). Retrieved June 19, 2022, from https://sg.finance.yahoo.com/news/singaporeans-fin ances-hit-by-covid-19-ocbc-survey-100641622.html Financial literacy and education. (n.d.). Retrieved June 24, 2022, from https:// ccs.org.sg/education/ Gen Z: Things I wish my peers knew about financial literacy. (2020). Retrieved June 30, 2022, from https://www.moneysense.gov.sg/articles/2020/3/gai ning-financial-literacy-early Households. (n.d.). Retrieved June 28, 2022, from https://www.singstat.gov.sg/ find-data/search-by-theme/households/households/latest-data

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Housing A Nation, Building A City. (n.d.). Retrieved June 28, 2022, from https://www.psd.gov.sg/heartofpublicservice/our-institutions/housing-a-nat ion-building-a-city/ Interim Disability Assistance Programme for the Elderly (IDAPE). (n.d.). Retrieved July 2, 2022, from https://www.aic.sg/financial-assistance/int erim-disability-assistance-programme-elderly Introduction to Medisave Care. (n.d.). Retrieved July 2, 2022, from https:// www.aic.sg/financial-assistance/medisave-care Lease Buyback Scheme. (n.d.). Retrieved June 29, 2022, from https://www.hdb. gov.sg/residential/living-in-an-hdb-flat/for-our-seniors/monetising-yourflat-for-retirement/lease-buyback-scheme Making sense of structured deposit. (n.d.). Retrieved June 24, 2022, from https:// www.citibank.com.sg/global_docs/prod/id/structured_deposits.pdf Managing your chronic conditions using CHAS. (n.d.). Retrieved July 6, 2022, from https://www.chas.sg/managing-your-chronic-conditions-using-chas Medisave. (n.d.). Retrieved July 2, 2022, from https://www.moh.gov.sg/costfinancing/healthcare-schemes-subsidies/medisave#:~:text=meet%20healthc are%20needs.-,MediSave%20is%20a%20national%20medical%20savings%20s cheme%20that%20helps%20individuals,healthcare%20needs%20in%20old% 20age. MediShield Life. (n.d.). Retrieved July 2, 2022, from https://www.healthhub. sg/a-z/costs-and-financing/6/medishield-life OCBC Bank launches Singapore’s first Financial Wellness Index. (2019). Retrieved June 19, 2022, from https://www.ocbc.com/group/media/release/2019/ ocbc_financial_wellness_index (accessed 19 June 2022). OCBC Financial Wellness Survey 2021 vs 2020: What have Singaporeans learned in the past year. (n.d.). Retrieved June 19, 2022, from https://www.moneyl ine.sg/ocbc-financial-wellness-survey-2021-vs-2020-what-have-singaporeanslearned-in-the-past-year/ OCBC Financial Impact Survey for COVID-19: Timely tips to move forward. (n.d.). Retrieved June 30, 2022, from https://www.ocbc.com/group/cov id19-support/survey.html Oral answer by Ministry of National Development on Lease Buyback Scheme. (2018). Retrieved June 29, 2022, from https://www.mnd.gov.sg/new sroom/parliament-matters/q-as/view/oral-answer-by-ministry-of-nationaldevelopment-on-lease-buyback-scheme Pioneer Generation Package. (n.d.). Retrieved July 2, 2022, from https:// www.moh.gov.sg/cost-financing/healthcare-schemes-subsidies/pioneer-gen eration-package#:~:text=Where%20can%20I%20receive%20my,Health%20A ssist%20Scheme%20(CHAS).

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Promoting Financial Literacy among School Students. (2020). Retrieved June 23, 2022, from https://www.moe.gov.sg/news/parliamentary-replies/202 00106-promoting-financial-literacy-among-school-students Protect yourself against long-term care costs with CareShield Life. (n.d.). Retrieved July 2, 2022, from https://www.cpf.gov.sg/member/healthcare-financing/ careshield-life Silver Housing Bonus. (n.d.). Retrieved June 29, 2022, from https://www.hdb. gov.sg/residential/living-in-an-hdb-flat/for-our-seniors/monetising-yourflat-for-retirement/silver-housing-bonus Singapore affluent ahead of North Asian counterparts in retirement planning. (2019). Retrieved June 21, 2022, from https://av.sc.com/sg/content/docs/ sg-standard-chartered-north-asian-counterparts.pdf The Covid-19 pandemic has made many Singaporeans adopt better financial habits. (2021). Retrieved June 19, 2022, from https://www.ocbc.com/ group/media/release/2021/ocbc-fwi.page? Tips for Downsizing During Retirement. (2020). Retrieved June 29, 2022, from https://storefriendly.com.sg/tips-for-downsizing-during-retire ment-self-storage-singapore/ What is the Silver Housing Bonus scheme? (n.d.). Retrieved June 29, 2022, from https://www.cpf.gov.sg/member/faq/retirement-income/monthly-pay outs/what-is-the-silver-housing-bonus-scheme What is long-term care? (n.d.). Retrieved July 3, 2022, from https://www.nia. nih.gov/health/what-long-term-care Who should receive CPF contributions (n.d.). Retrieved July 1, 2022, from https://www.cpf.gov.sg/employer/employer-obligations/who-shouldreceive-cpf-contributions

Interview Interview 21SG43, a medical social worker, December 2021. Interview 22SG48, a banker, May 2022.

CHAPTER 3

Music Therapy for People with Dementia and Terminally Ill Patients

Abstract This chapter will examine the development of music therapy (MT) in Singapore. It will examine the meaningful role of music therapist and how MT as a therapeutic intervention can bring benefits to people with dementia (PWD), terminally ill patients and their caregivers. It will examine ongoing challenges to the development of MT in the country. To facilitate the development of MT in Singapore, the professional status of music therapists should be raised through amending the Allied Health Professions Act 2011. This in turn helps increase public acceptance toward MT and make the availability of government subsidy for defraying the cost of MT possible. With the consent of patients and their caregivers, MT service providers can videotape the journey of patients receiving MT or create short videos which enable patients receiving music therapy to share their stories of receiving MT and how they and their caregivers benefit from MT. Storytelling can be a useful communication tool because it helps the audience understand the situation of the patients, educate and inspire the audience, and forges a deeper emotional connection with the audience. It is hoped that more older adults can benefit from MT in future. Keywords Allied health profession · Empowerment · Music therapy · People with dementia · Songwriting · Terminally ill patients

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 S. Ching Yuen Luk, Healthy Ageing in Singapore, Social Policy and Development Studies in East Asia, https://doi.org/10.1007/978-981-99-0872-1_3

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Introduction Music therapy (MT) is a non-pharmacological therapy (Svansdottir & Snaedal, 2006: 614). It is ‘the use of music and/or its musical elements (sound, rhythm, melody and harmony) by a qualified music therapist’ (The World Federation of Music Therapy, 1996) to ‘accomplish individualized goals within a therapeutic relationship’ (de Witte et al., 2020) and address the physical, mental, emotional, cognitive and social needs of an individual or a group (The World Federation of Music Therapy, 1996). A qualified music therapist, ‘observing with a clinical eye, will identify existing problems, and understand how those problems can be treated with specific applications of music elements’ (Berger, 2009). MT can be active or passive (Aalbers et al., 2019; Agres et al., 2021; de Witte et al., 2020). In an active MT intervention, a client who is supervised by a trained music therapist is involved in creating the musical experience through selecting music, writing lyrics, singing or playing musical instruments (Lynch et al., 2021; McPherson et al., 2019; Tsoi et al., 2018). In a passive MT intervention, a client ‘takes in live or recorded music as a listener and responds in some manner, whether internally (e.g. imaging or relaxing) or externally (e.g. drawing or discussing)’ (Gardstrom & Hiller, 2010: 147). Musical skill is not required for a client to benefit from MT (Owens, 2014: 2). ‘Currently, practice models of music therapy are mainly based on a humanistic, psychodynamic, or developmental theory’ (Li et al., 2020: 1112). This chapter will examine the development of MT in Singapore. It will examine the meaningful role of music therapist and how MT as a therapeutic intervention can bring benefits to people with dementia (PWD), terminally ill patients and their caregivers. It will examine ongoing challenges to the development of MT in the country.

The Development of Music Therapy in Singapore In Singapore, ‘music therapy is still “fairly novel”’ (Tham, 2020) due to ‘the perception that music is abstract and that only the musically inclined can attend music therapy sessions’ (Tham, 2020). Music therapist ‘is a relatively little-known occupation’ (Tham, 2020) although pre-independence Singapore in 1963 had its first music therapist, Louise Cheng, who completed her study in MT in Kansas University, the United States (‘History of Music Therapy in Singapore’, n.d.; Tham, 2020). ‘Due

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to the lack of local university-level training to date, the music therapists in Singapore have all graduated from accredited programs overseas’ (Kwan et al., 2014: 28). The bachelor’s or master’s degree programme music therapists go through cover ‘music foundations, music therapy foundations and clinical foundations such as psychology, anatomy and counselling’ (Gan, 2022). Music therapists have the ability to ‘perform an assessment of the patient, determine baseline functional and psychoemotional levels, come up with goals and objectives, and customise a treatment plan’ (Tham, 2020). In September 2007, the Association for Music Therapy Singapore (AMTS) was established with 11 founding members (‘Music Therapy Milestones in Singapore’, n.d.). It was a professional society aiming to ‘promote public awareness about music therapy as an international healthcare profession’ (Kwan et al., 2014: 25). It was ‘the first music therapy association in Southeast Asia’ (Ng, 2015: 163). It became a member of the World Federation of Music Therapy (WFMT) in 2011 (‘History of Music Therapy in Singapore’, n.d.). In 2017, AMTS had over 30 professional members (‘Music Therapy Milestones in Singapore’, n.d.). MT services were first made available to children with special needs (Kwan et al., 2014: 26). ‘The goal was educational rather than for healing’ (Assissi Hospice Community Engagement Team, 2017: 14). MT services were later made available to patients in different hospitals. For example, Ksdang Kerbau Women’s and Children’s Hospital (KKH) provided MT services for hospitalised children in 2007 and hospitalised women with cancer in 2009 (‘History of Music Therapy in Singapore’, n.d.). At present, there are several local hospitals providing MT services for patients. They include KKH, Singapore General Hospital (SGH), Khoo Teck Puat Hospital (KTPH), St Andrew’s Community Hospital (SACH), Yishun Community Hospital (Dementia ward), Ren Ci Hospital and St Luke’s Hospital (‘History of Music Therapy in Singapore’, n.d.; ‘Music and Creative Therapy Unit’, n.d.; Tan et al., 2014; Tham, 2020). Besides, MT services are available at Institute of Mental Health (IMH) (The Association for Music Therapy Singapore, 2021), Dover Park Hospice, Assisi Hospice, St. Joseph’s Nursing home (‘History of Music Therapy in Singapore’, n.d.) and Apex Harmony Lodge, which is Singapore’s first home for PWD (Neo, 2016). MT services are also available at Voluntary Welfare Organizations (VWOs), including Thye Hua Kwan Early Intervention Programme for Infants and Children (THK EIPIC) centres, THK

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Children’s Therapy Centre, St. Andrew’s Autism Centre, Singapore Association for Mental Health, Rainbow Centre Yishun Park School, Rainbow Centre Margaret Drive School and Asian Welfare Women’s Association School (‘Music Therapy in Singapore’, n.d.). But there are ‘only 36 accredited music therapists in Singapore’ (Gan, 2022).

Literature Review Overseas studies found that MT can bring positive effects to children with autism spectrum disorder (ASD), patients with mental illnesses and patients with cancer. MT can improve mood, sensory perception, behavior (Shi et al., 2016), communication skills and social interaction of children with ASD (Geretsegger et al., 2014). It has proven to be an effective treatment for various forms of psychiatric disorders, which included depression, anxiety, post-traumatic stress disorder (PTSD), schizophrenia and personality disorders (Krauss, 2019: 62–71). As ‘an established adjuvant to standard cancer care’ (Popkin, 2016), MT had positive effects on ‘psychological well-being, quality of life and physical symptom distress in different phases of oncological treatment’ (Köhler et al., 2020). It was found to be more effective for decreasing the score of pain, anxiety and depression of patients with cancer (Li et al., 2020). A study found that a therapeutic music video (TMV) intervention delivered by a consistent board-certified music therapist significantly improved courageous coping (confrontive/optimistic/supportant coping), social integration (i.e. perceived social support from healthcare providers, friends and family) and family environment (e.g. family cohesion/family adaptability/family strength) for adolescents and young adults undergoing hematopoietic stem cell transplant (HSCT) (Robb et al., 2014). Besides, overseas studies found that MT can bring positive effects to PWD and their caregivers. A systematic review of 82 studies on the effects of MT of PWD suggested significant improvements in verbal fluency and significant reductions in apathy and behavioural and psychological symptoms of dementia (BPSDs) including anxiety and depression (Lam et al., 2020). A study found that implementing classical Turkish music therapy at home could bring the blood pressure of PWD under control and decrease the care burden of their caregivers (Ugur et al., 2019). Another study found that a community-based MT support group in the United States was found to relieve some of the strain on caregivers of people with Alzheimer’s disease (AD) through increasing meaningful

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interactions and having a deeper connection with their loved one with dementia and gaining greater emotional support from peers and professionals (Rio, 2018). A position paper, adapted from the keynote lecture given at Cambridge University in 2018, concluded that MT interventions were needed at all stages for PWD, their caregivers and companions (Odell-Miller, 2021) and ‘should be defined as central pathways of care’ (Odell-Miller, 2021: 7). Overseas studies also found that MT can bring positive impact to terminally ill patients. A study found that MT ‘improved subjective assessment of relaxation and well-being in terminally ill patients receiving palliative care’ (Warth et al., 2005: 791) and significantly reduced the fatigue score on the quality-of-life scale (Warth et al., 2005: 788). The study of Gutgsell et al. (2013) found that a single MT session which incorporated therapist-guided autogenic muscle relaxation and live music using the ocean drum and the harp significantly reduce the functional pain score of hospitalized palliative care patients (Gutgsell et al., 2013: 827). The study of Porter et al. (2017) found that MT could provide palliative care patients with ‘physical, psychological, emotional, expressive, existential and social support’ (p. 70). A study which reviewed 11 empirical study on the use of MT for terminally ill patients found that MT could help patients relieve pain, improve their mood, increase their spiritual wellness, enhance their quality of life and bring physical comfort and relaxation to them (Hilliard, 2005). Similarly, a meta-analysis study found that MT could significantly relieve pain, improve psychological symptoms, quality of life and emotional function of terminally ill patients (Gao et al., 2019: 324–328). In Singapore, there is a lack of study on MT. The first known journal article on MT in Singapore was authored by Louise Cheng (1989) (‘Music Therapy Milestones in Singapore’, n.d.), who examined the impact of MT on a brain-damaged teenager. The study of Cheng (1989) found that the use of different unpitched instruments and the ORFF pitched instruments in gradual stages by the teenager helped her achieve sensorimotor, psychological, cognitive and musical goals (p. 81). The first MT study on dementia in Singapore was published in 2010 (‘Music Therapy Milestones in Singapore’, n.d.). The study examined the impact of a weekly structured group music therapy and activity program (MAP) on depressive and behavioral symptoms in persons with moderate dementia using the Revised Memory and Behavioral Problems Checklist (RMBPC) and the modified Apparent Emotion Scale (AES) (Han

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et al., 2010: 541–542). It found that a weekly session of MAP over eight weeks significantly improved depressive and behavioral symptoms in persons with moderate dementia (Han et al., 2010: 543). However, ‘AES scores showed a nonsignificant trend towards improvement’ (Han et al., 2010: 540). A review of literature review for the past 10 years has shown that there were only few local studies on MT in Singapore. But these local studies have shown that MT can bring positive impact to older patients with delirium and/or dementia (PtDD), patients with persistent pain, terminally ill patients and children undergoing cancer treatment. The study of Cheong et al. (2016) found that the Nordoff-Robbins creative music therapy (CMT) programme including music improvisation could improve mood (i.e. pleasure and general alertness) and engagement (i.e. constructive and passive engagement) in older PtDD in an acute care hospital setting in Singapore (pp. 272–273). It suggested CMT could be incorporated in the daily care of PtDD or other areas of care such as nursing and physical rehabilitation to improve their cooperation and compliance (Cheong et al., 2016: 273–274). The study of Kwan and Seah (2013) examined the impact of MT on patients with persistent pain in an acute hospital in Singapore. It found that MT could ‘address pain arising from a variety of diagnosis’ (Kwan & Seah, 2013: 155) and ‘enabled some patients to regain a level of control’ (Kwan & Seah, 2013: 157). It suggested MT serve as ‘an allied health adjunct to standard medical treatment for pain’ (Kwan & Seah, 2013: 151). They study of Leow et al. (2010) examined five terminally ill patients’ experiences with MT, their expectation of and feelings about MT in an inpatient hospice in Singapore. It found that MT could improve patients’ mood (i.e. happiness and liveliness) and distract them from their physical illnesses (Leow et al., 2010: 346), ‘bring comfort to them by giving them peace, relaxation, and motivation to live’ (Leow et al., 2010: 347), enabled them to ‘reminisce and reflect on the past’ (Leow et al., 2010: 347) and provide enjoyment for them (Leow et al., 2010: 347). The study of Wong et al. (2021) found that MT was an accessible and effective intervention in supporting the mood and morale of children undergoing cancer treatment in Singapore (p. 1761). It suggested MT to be ‘considered as an integral part of holistic paediatric cancer care’ (Wong et al., 2021: 1761). In order to fill the research gap, the author will use two local case studies to examine how MT brings benefits to PWD, terminally ill patients and their caregivers. Through these two case studies, the author hopes

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that policy makers and the general public can have a better understanding of what MT is, the meaningful role of music therapists and ongoing challenges to the development of MT in Singapore.

Music Therapy for People with Dementia In Singapore, an organization offered MT with eight to ten sessions to a group of eight people with mild and moderate dementia in a café setting (Interview 19SG28). The duration of each session was one hour. Music ‘acts as the tool for communication between therapist and patient, and enables rapport building’ (Leow et al., 2010: 347). At the beginning of the session, a music therapist sang a hello song to PWD while simultaneously playing the guitar (Interview 19SG28). She incorporated the names of all the group members into the lyrics (Interview 19SG28). She greeted and smiled at each group member when singing the hello song. Singing the hello song could ‘promote and validate the individuality of each person in the group, whether cognitive understanding levels are high or low’ (Moss et al., 2021). It could make group members ‘feel welcome and comfortable’ (Moss et al., 2021) and promote social connection by reminding group members of each other’s names. Sometimes the music therapist may hold the hands of group members to make them feel valued and loved (Interview 19SG28). The remainder of the session was devoted to singing Chinese or English songs to be familiar to group members or playing musical instruments (Interview 19SG28). When conducting MT sessions, the music therapist adopted an empowerment model (Interview 19SG28), which focuses on ‘the client’s strengths and potentials and emphasizes the importance of collaborations and equality in the relationship between therapist and client’ (Rolvsjord, 2004: 99). Empowerment is a perspective supporting the idea that ‘people are competent and have equal value’ (Rolvsjord, 2004: 102) and stressing the importance of ‘self-determination and participation in decision-making processes in general’ (Rolvsjord, 2004: 104). It is ‘a process connected to participatory activities’ (Rolvsjord, 2004: 102) and collaborations which are based upon respect, mutual trust, cooperation and shared responsibility (Rolvsjord, 2004: 102). It ‘assists in self-validation and growth’ (Daveson, 2001: 36) and leads to one moving from ‘a state of powerlessness to one of motivation’ (Daveson, 2001: 29). Motivation in turn increases clients’ endurance and their treatment compliance (Interview 19SG28). During each session, the music therapist

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empowered PWD by offering them opportunities for choice (Interview 19SG28). For example, PWD were given a basket of musical instruments to choose from to create music (Interview 19SG28). They were also given a song choice, which allowed PWD to select songs that they liked to sing in MT sessions (Interview 19SG28). The music therapist offered PWD a sense of control by asking them questions such as ‘Which songs do you think we should be singing next?’ (Interview 19SG28). Getting frequent feedback from PWD about the MT sessions (e.g. ‘Do you enjoy playing the drums more or do you prefer singing more?’ ) and having random chit chat with PWD enabled the music therapist to understand the preferences and needs of PWD and facilitate client-centred care (Interview 19SG28). Besides, the music therapist adopted a flexible approach when it came to the structure and the content of the sessions. Since she played live music with participants, she had the flexibility to change the lyrics or the speed of the songs to respond to the mood, needs and requests of participants (Interview 19SG28). She was always prepared for any last-minute changes in session plan (Interview 19SG28). For example, if PWD told the music therapist that they wanted to play drums instead of singing, the music therapist would implement the change immediately (Interview 19SG28). Such change could be quite different from the initial session plan. Hence, the music therapist thought that every MT session was a learning experience for her (Interview 19SG28). ‘The relationship between music and memory is powerful’ (Jenkins, 2014). Music can evoke pleasant or unpleasant memories, which in turn affects the emotion of PWD (Interview 19SG28). It is important for a music therapist to know ways to provide emotional support for PWD whose response to music or songs is negative. ‘For those with dementia, singing may encourage reminiscence and discussions of the past’ (Vink et al., 2003: 3). Take a famous Chinese lullaby called Shi Shang Zhi You Mama Hao (Only Mom is the Best in the World in English) as an example. While this Chinese lullaby was a favourite song for most of the PWD in the MT session, it negatively affected the emotion of a female participant (Interview 19SG28). The female participant felt down after singing this lullaby because the lullaby triggered bad childhood memories of being abused by her mother (Interview 19SG28). For this reason, the music therapist had to use some counselling techniques to help the female participant find closure from the past and redirect her feelings in more positive directions (Interview 19SG28).

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Every member joining the group MT session was considered unique. He/she faced different issues. As such the goal set by the music therapist for each member was different (Interview 19SG28). A goal is defined as ‘the ultimate attainment of change or betterment of a presenting issue and its cause(s) over the long term (overall design) - the end of the road’ (Berger, 2009). For PWD, there are a wide variety of goals (e.g. increasing social interaction, connecting with family, having non-verbal expression) that can profoundly affect their quality of life (Adout, 2017). A goal is set based on the needs of a person with dementia or how the music therapist wants to treat the problem faced by the person with dementia. For example, a female group member who had anxiety had to stick to her husband all the time and did not allow her husband to leave her side (Interview 19SG28). The goal set by the music therapist for this female group member was having her to attend the whole MT session without leaving in the middle of the way to look for her husband (Interview 19SG28). While the music therapist used music to draw the attention of this female group member, she also used some persuasion techniques to convince the female group member not to stick to her husband during the session (Interview 19SG28). Since all the participants in the MT session were women, she told the female group member that this was a ladies-only club which did not allow her husband to sit with her (Interview 19SG28). Whether this persuasion technique worked or not really depended on the level of trust the participant had in the music therapist (Interview 19SG28). In this situation, the female group member trusted and listened to what the music therapist said (Interview 19SG28). After attending several sessions, the female group member did not easily get anxious. Her husband could sit behind in the café and observe her from afar (Interview 19SG28). This example showed that MT was a goal-directed process in which the music therapist helped the participant restore or improve a state of well-being (Cheong et al., 2016: 269). The objective and the content of MT sessions vary among people with different stage of dementia. If MT sessions were conducted for people with mild dementia, the music therapist aimed to use music to preserve the cognitive abilities of people with mild dementia as much as possible (Interview 19SG28). She would encourage participants to engage with their short-term and immediate memories during sessions (Interview 19SG28). She asked participants to memorize a song and get them to recall lyrics (Interview 19SG28). She may sing one line of a song and

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then asked participants if they knew which singer sang this song (Interview 19SG28). If MT sessions were conducted for people with moderate dementia, the music therapist aimed to use music to manage BPSD such as agitation of PWD and preserve their long-term memory through reminiscence (Interview 19SG28). During the sessions, the music therapist engaged participants to share what songs they listened to when they were young (Interview 19SG28). For example, if participants sang one of Teresa Teng’s songs during the session, the music therapist would ask them to name one more song sung by Teresa Teng (Interview 19SG28). If MT sessions were conducted for people with advanced dementia, the music therapist aimed to use music to provide comfort, a sense of safety and a sense of containment to participants (Interview 19SG28). During the sessions, the music therapist and participants hummed familiar songs (e.g. a lullaby, children songs), which could be quite soothing for participants (Interview 19SG28). The music therapist may not even play any musical instruments to avoid overstimulation (Interview 19SG28). She and participants would just sing acapella or sing short excerpts of songs (Interview 19SG28). Letting PWD have a sense of safety and a sense of containment was to bring them orientation to time or space through music (Interview 19SG28). For example, the music therapist and participants may sing Jingle Bell in December to let participants know that Christmas was coming (Interview 19SG28). The outbreak of the 2019 coronavirus disease (COVID-19) in Singapore led to group MT sessions moving online (Interview 21SG38). Participants had to adjust to a new routine of joining the sessions through Zoom or Microsoft Teams (Interview 21SG38). Besides, they had to get used to having social interaction with their peers and the music therapist over a digital media (Interview 21SG38). Their entire interactions came through a screen (Interview 21SG38). When participants looked at each other, their focal points were on the screen (Interview 21SG38). There were two advantages of moving group MT sessions online. Firstly, it could reduce the music therapist’s and participants’ risks of exposure to the virus. Secondly, it could save transportation cost (Interview 21SG38). Before the outbreak of COVID-19, caregivers had to bring participants to the café to attend group MT sessions (Interview 21SG38). When group MT sessions were offered to participants online, participants could attend the sessions in the comfort of their homes. All they needed was to ensure that there was a stable Internet connection at home, a usable digital device

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(e.g. mobile phones, tablets, computers) to access the sessions and technical assistance (e.g. connect HDMI cable to a computer) from domestic helpers or their family members when necessary (Interview 21SG38). To avoid participants from having screen fatigue, the duration of the online session was shortened to 30 minutes (Interview 21SG38). When running the online sessions, the music therapist selected the right lighting setup to help her look her best on screen. She shared songs with participants directly through Zoom (Interview 21SG38). She used interactive aids to show lyrics to participants and other props to make the sessions more engaging (Interview 21SG38). MT sessions bring benefits to PWD in several ways. Short-term memory loss leads to PWD experiencing greater difficulty in learning new things (Botek, n.d.; ‘The Importance of a Daily Routine’, 2022). Hence, PWD usually find comfort in routines (Interview 19SG28). The predictability of a routine can decrease anxiety of PWD, make them feel confident (Heerema, 2020), keep them oriented and prevent distraction and frustration (Botek, n.d.). However, PWD who joined group MT sessions were more willing to attempt new activities and were less afraid of changes because they were encouraged by the music therapist to try new activities such as playing drums (Interview 19SG28). MT sessions help alleviate sundowning symptoms of PWD so that PWD would not be so agitated when evening came (Interview 19SG28). PWD often felt happier and more settled after attending MT sessions (Interview 19SG28). Some of them would even share what they did in MT sessions with their family members (Interview 19SG28). Their caregivers told the music therapist that the quality of life of PWD was improved after attending MT sessions (Interview 19SG28).

Music Therapy for Terminally Ill Patients In Singapore, a community hospital offered individual MT sessions to terminally ill patients to improve their quality of life by alleviating pain, providing psychosocial support, achieving communication needs and supporting meaning making (Interview 21SG38). Terminally ill patients who received MT sessions had no major hearing loss and were able to use minimal responses such as eye blinking and hand movements (Interview 21SG38). Before the outbreak of COVID-19, terminally ill patients received an individual MT session twice a week (Interview 21SG38). Each session lasted for 45 minutes to an hour (Interview 21SG38). In the

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time of COVID-19, a hybrid mode was adopted to deliver individual MT sessions to terminally ill patients (Interview 21SG38). Two out of 10 sessions would be conducted in person while the rest of the sessions would be conducted online (Interview 21SG38). If this was an in-person session at the hospital, a music therapist had to put on Personal Protective Equipment (PPE) (e.g. gloves and mask) to meet a patient (Interview 21SG38). If this was an online session, the music therapist would share songs and lyrics with a patient remotely over Zoom (Interview 21SG38). But it required staff at the hospital to provide technical assistance to ensure that there was Internet connection and proper Zoom setup (Interview 21SG38). Patients may need to wear headphone in order to hear what the music therapist said or the music clearly (Interview 21SG38). Sometimes family members and friends of a terminally ill patient were invited to join online sessions if the patient wanted them to listen to a song he or she created for them (Interview 21SG38). Using a hybrid mode to deliver MT made physical encounters between the music therapist and terminally ill patients more precious and meaningful (Interview 21SG38). A personalized approach was adopted by the music therapist when she offered individual MT for terminally ill patients. Patients may have song choice, singing, music listening, music-prompted reminiscence, songwriting or other MT activities in the sessions, depending on their psychosocial needs and preferences (Interview 21SG38). Take a male terminally ill patient as an example. The patient was an entrepreneur. One of the MT activities he had was selecting a song which defined him and represented his life journey (Interview 21SG38). He selected Frank Sinatra’s classic song My Way (Interview 21SG38). He had a strong attachment to this song (Interview 21SG38). He used to sing this song every day (Interview 21SG38). The song became more significant for him as he grew older because the lyrics of the song could reflect his real-life journey as an entrepreneur (Interview 21SG38). The song was about how a man overcame challenges in life with courage and persistence and lived a life that was full and on his own terms (i.e. the lyric ‘I did it my way’). It could resonate with the patient. The music therapist would let the patient listen to this song to enable him to reminisce and recount good memories (Interview 21SG38). She would also sing this song and few other songs he liked to motivate him, comfort him and alleviate his pain (Interview 21SG38). My Way was played at his funeral for family members to remember him and honour him (Interview 21SG38). It became a very

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special thing for his family members to hold on to (Interview 21SG38) and enabled his family members to feel connected to him again when he passed away. Music could be ‘used to represent thoughts and feelings that may be difficult to express verbally’ (‘Music Therapy and Palliative Care’, n.d.). It was particularly useful to help very stoic and reserved patients open up, express their feelings to family members and facilitate conversation with them (Interview 21SG38). If the MT activity was about song selection, the music therapist would start by using a list of questions to guide a terminally ill patient to select a song he or she liked (Interview 21SG38). These questions included ‘What is significant to you?’, ‘Is there anything you want to say to your favourite child?’, ‘Is there something you would like to say to your family?’, ‘Is there a song you think your son may like?’ and ‘What are your hopes and wishes?’ (Interview 21SG38). Through this process, the music therapist helped patients open up gradually, talking about their childhood or their past and their feelings related to the song (Interview 21SG38). Besides, she engaged them in creative expression, and most importantly, helped them have meaning making (Interview 21SG38). Most of the time having good lyrics or a nice tune was not how a song was selected by a patient as his or her favourite song (Interview 21SG38). Instead, it was because how the song helped a patient get through tough times, the emotional story behind it or how it helped a patient deliver some important messages to his or her family members (Interview 21SG38). For example, a male patient hoped to use a Hokkien song Ai Phing Tsiah Yei Yen (No Pain No Gain in English) to tell his family members to continue to give their best to the family business (Interview 21SG38). The song helped him say things he always wanted to say but was never able to say it verbally (Interview 21SG38). MT ‘provides a means by which a patient’s family can engage with a loved one who is in the hospital’ (Rafieyan & Ries, 2007: 51). Family members may be invited by a music therapist to attend MT sessions. But some family members volunteered to attend the sessions (Interview 21SG38). Through attending the sessions, family members get to know the patient in a better way. For example, grandchildren of a male terminally ill patient had no idea why their grandfather liked to listen to a particular song 10 times a day (Interview 21SG38). With the help of the music therapist, they realized that listening to that particular song enabled their grandfather to relive his youth (Interview 21SG38). That song was like a time machine transporting their grandfather back to a

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particular point in time. It helped ‘induce emotions and activate associated memories’ (Loukas et al., 2022: 674). Attending the sessions made the grandchildren realize that there was so much more they had to know about their grandfather before he passed away (Interview 21SG38). When they attended the session, they would sit with their grandfather and had more spontaneous interactions with him (Interview 21SG38). They made priceless memories with their grandfather (Interview 21SG38) and had more opportunities for intergenerational bonding. For terminally ill patients, ‘songwriting provides possibilities for life review and for creating legacies for those significant family and friends who will be left behind’ (Baker, 2015a: 18). Besides, it can support and facilitate relation completion (Interview 21SG38). Relationship completion refers to five sentiments which ‘permit relationships to reach completion once they are expressed’ (Clements-Cortes, 2011: 32). These sentiments are ‘I love you’, ‘Thank you’, ‘Forgive me’, ‘I forgive you’ and ‘Good-bye’ (Clements-Cortes, 2011: 32; Gordon & ClementsCortes, 2013). Songwriting enables patients to ‘address relationship issues’ (Baker, 2015a: 17). Songs are created to help patients externalize their internal feeling and emotions (Baker, 2015a: 17) and send messages of love, thankfulness, forgiveness or goodbye to people who matter to them. Songwriting also enables patients to ‘craft a song that has personal meaning and simultaneously leads them through a journal of personal discovery’ (Cugnetto, 2016). It helps patient ‘construct a sense of self and identity’ (Baker, 2015a: 17), ‘experience mastery, self-esteem, and self-confidence’ (Baker, 2015a: 17), ‘promote the exploration of meaning and hope, and address existential and spiritual needs during the process of dying’ (Heath & Lings, 2012: 110). As a therapeutic intervention (Heath & Lings, 2012: 110), songwriting is the process of creating lyrics and music within the client-therapist relationship to address the specific needs (e.g. communication, psychosocial, cognitive, emotional) of a client (Baker, 2015a: 14; 2015b: 124; Wigram & Baker, 2005: 16). The songwriting process has to be facilitated by the music therapist to ensure that the composition (i.e. the song) ‘can be felt as owned by the client and expressive of his or her personal needs, feelings and thoughts’ (Wigram & Baker, 2005: 14). ‘Clients facing death will often find the process revealing and transformational’ (Heath & Lings, 2012: 110). Different methods or techniques can be utilized by a music therapist to stimulate lyric generation (Baker et al., 2009: 35). Brainstorming,

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fill-in-the-blank techniques, the use of open-ended and closed questions are frequently endorsed techniques (Baker et al., 2009: 40–42). Brainstorming is used to encourage patients to ‘contribute ideas and communicate feelings around a pre-determined theme’ (Baker et al., 2009: 35). Fill-in-the-blank (FITB) techniques substitutes only certain key words or lyrics of an original song for patient-generated words or lyrics (Silverman, 2022: 278). The music therapist engages a patient in a therapeutic process (Baker, 2015a: 99) which may bring the patient’s ‘emotions, memories, and thoughts that were hidden in the unconscious or pre-conscious into conscious awareness’ (Baker, 2015a: 107). These ‘are then translated into new key words and inserted into the spaces’ (Baker, 2015a: 99). ‘The harmonies, melodies, and many of the original lyrics remained unchanged, providing a high degree of structure’ (Silverman, 2022: 278). ‘Open-ended questions delve beyond yes or no inquiries’ (Knapp, 2015). They are storytelling questions which often start with what, when, where and how (Walter, 2017). They inspire patients to communicate their feelings, experiences and ideas with the therapist (OptimistMinds, 2022) and prompt storytelling (Knapp, 2015). A multitude of replies and reactions elicited by open questions helps the therapist understand the patient in a better way and provides the patient with proper guidance (OptimistMinds, 2022). Close-ended questions usually are single answer questions which provide a therapist with necessary information with a client (Walter, 2017). They are ‘typically shorter and more concentrated, making them easier to respond’ (OptimistMinds, 2022). Meanwhile, the adoption of a pre-defined song structure, improvised music and pre-composed melodies or parts of melodies are common techniques used by a music therapist to the creation of music (Baker et al., 2009: 42). Individual factors, including a patient’s level of arousal (i.e. high, low or fluctuating), physical wellness, cognitive factors (e.g. an injured temporal lobe), emotional wellbeing and perception of his or her songwriting or music performance skills, determine a patient’s level of participation in the songwriting process and how effective the songwriting process is for him or her (Baker, 2015a: 53–66). The music therapist interviewed said that she used different methods to assist terminally ill patients to create a song which was personally meaningful for them. The template she created contained several ‘wh-’ questions (e.g. ‘What do I want to say?’, ‘Who would I say it to?’) to guide patients to have self-reflection, develop and expand their ideas (Interview 21SG38). The answers given by patients to these questions usually

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contained useful information or key words which could be used for songwriting. For some patients, they were scared of the idea of songwriting (Interview 21SG38). This was because they may have ‘little or no musical experience or skills’ (Heath & Lings, 2012: 110). To help patients overcome the fear of songwriting, the music therapist would ask patients to choose some ready-made lines which appealed to them most and then she would put these lines in a songwriting template (Interview 21SG38). Interestingly, choosing some ready-made lines helped lead patients slowly to the process of song creation (Interview 21SG38). When patients met the music therapist in the following week, they wanted to have certain key words or lines of the song replaced (Interview 21SG38). For example, a patient wanted to change the Chinese words of didi (younger brother in English) and meimei (younger sister in English) to qin ai de (my dear in English) (Interview 21SG38). By the end of the entire process which usually took two to three months, most of the patients had already created their own songs by changing almost every single word, every phrase and even melody (Interview 21SG38). A possible explanation for this was that ‘songs take time to create and therefore allow for prolonged engagement with issues’ (Baker, 2015a: 19). The songwriting process allowed patients to ‘process and reprocess issues across several sessions’ (Baker, 2015a: 19). This enables patients to ‘expand their awareness and understanding of the issues over time and to “sit with” their feelings and experiences’ (Baker, 2015a: 19). Hence, they had clearer and better ideas about the choices of lyrics or melody that were personally meaningful for them. Most frequently, songs which were created within therapy ‘were recorded and shared with family and friends’ (Baker et al., 2009: 37). Songs created by patients allow their family members and friends to know a very different side of them (Interview 21SG38) and had a deepened understanding of them (Baker, 2015a: 22). Take a female older patient as an example. At the beginning of the songwriting process, she had no idea about what she wanted to say to her family members (Interview 21SG38). She was only able to realize that she wanted to create a Thank You song after following the music therapist’s suggestion of eliminating lyrics and lines which were not applicable to her in a sample template (Interview 21SG38). Once her idea of creating a Thank You song was clear, the patient added her own words to the song (Interview 21SG38). Through the song, she wanted to send her best wishes to her siblings (Interview 21SG38). She wanted them to have healthy diet and live a happy and meaningful life every day (Interview 21SG38). Her siblings were surprised

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that she was able to write a song and express so much in a song although she lacked education (Interview 21SG38). In sum, songwriting enables terminally ill patients to experience ‘the self-exploration process and the subsequent transformation of their thoughts, feelings, experiences, and stories into meaningful lyric’ (Baker, 2015a: 108).

Ongoing Challenges to the Development of Music Therapy in Singapore In Singapore, there are some ongoing challenges to the development of MT. First, the professional status of music therapists is underrecognized because MT is not included as part of the allied health profession (AHP) under Allied Health Professions Act 2011. Allied health professional refers to a healthcare professional who is not part of the medical, nursing or dental profession (‘What Is Allied Health?’, n.d.). He or she is trained to diagnose, treat and prevent a range of conditions and illness and provide therapeutic and direct health services to improve the physical and mental health of patients (‘Allied Health’, n.d.; ‘What Is Allied Health?’, n.d.). In Singapore, allied health professionals whose qualifications are recognized under the First Schedule of the Allied Health Professions Act 2011 include audiologist, clinical psychologist, dietitian, occupational therapist, physiotherapist, podiatrist/orthotist, radiation therapist, radiographer and speech therapist (‘Allied Health Professions Act 2011’, 2011). Underrecognition of professional status of music therapists creates a hurdle in attracting talents. Second, government subsidy is unavailable to help patients defray the costs of receiving MT (‘Helping Patients Heal’, 2021) due to the lack of formal recognition of MT as one of the “core” allied healthcare therapies (e.g. physiotherapy) by the government (Tan et al., 2014: 32). Patients requiring MT have to pay the fees of MT on their own unless they can obtain financial support through other channels. For example, the Music and Creative Therapy Unit at SGH aimed to raise S$200,000 through a year-long fundraising campaign on Giving.sg (https://www.giving.sg/) to support patients who could not afford MT (‘Helping Patients Heal’, 2021). But it only raised about 3% of the fundraising target (‘Helping Patients Heal’, 2021). Patients who cannot afford MT may have limited or no access to MT if there is insufficient financial support. Third, MT ‘still needs acceptance from patients and family members’ (Assissi Hospice Community Engagement Team, 2017: 15). People treat

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MT as a form of entertainment and regard music therapist as a musician (Assissi Hospice Community Engagement Team, 2017: 15) who entertains patients or ‘teaches’ patients to sing or play songs (Tan et al., 2014: 32). Many of them are not aware of the therapeutic benefits of MT. Besides, they may not know that music therapists ‘are also clinically trained to individualize music selections and interventions based on the client’s cultural, emotional, psychological, and spiritual background’ (“Music Therapy: An Interview With’, 2015). More work has to be done in the country to increase public awareness of MT and public acceptance toward it.

Conclusion To conclude, MT ‘has been proven effective for people of all ages and abilities, including the senior population, who are in need of emotional security and well being’ (‘Music Therapy for the Elderly’, n.d.). It is high time the government aligned the Allied Health Professions Act 2011 with international practices by including MT as part of the AHP. This helps raise the professional status of music therapists, which may in turn help increase public acceptance toward MT. This may also make the availability of government subsidy for defraying the cost of MT possible. Hospitals and other MT service providers can help raise public acceptance toward music therapy by creating or using an online platform (e.g. website or YouTube channel) to showcase videos which contain the stories, personal reflections and experiences of patients receiving MT sessions. With the consent of patients and their caregivers, MT service providers can videotape the journey of patients receiving MT or create short videos which enable patients receiving music therapy to share their stories of receiving MT and how they and their caregivers benefit from MT. Storytelling can be a useful communication tool because it helps the audience understand the situation of the patients, educate and inspire the audience, and forges a deeper emotional connection with the audience. It is hoped that more older adults can benefit from MT in future.

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music therapy for cancer in the inpatient setting: A qualitative analysis. Journal of Pain and Symptom Management, 62(1), 58–65. https://doi.org/10.1016/ j.jpainsymman.2020.11.014 Moss, H., Lee, S., Clifford, A. M., Bhriain, O. N., & O’Neill, D. (2021). Together in song: Designing a singing for health group intervention for older people living in the community. Nordic Journal of Music Therapy, 31, 413–430. https://doi.org/10.1080/08098131.2021.2004613 McPherson, T., Berger, D., Alagapan, S., & Fröhlich, F. (2019). Active and passive rhythmic music therapy interventions differentially modulate sympathetic autonomic nervous system activity. Journal of Music Therapy, 56(3), 240–264. https://pubmed.ncbi.nlm.nih.gov/31175814/ Neo, X. (2016, December 8). Giving them a sense of purpose. The Straits Times. Retrieved May 31, 2022, from http://www.lienfoundation.org/sites/ default/files/2016_08_12%20-%20ST%5EST%20-%20FIRST%20-%20B8% 20,%20B9.pdf Ng, W. F. (2015). Being human: Music therapy. In R. Lee (Ed.), Art hats in renaissance city: Reflections & aspirations of four generations of art personalities (pp. 162–169). World Scientific Publishing Co., Pte. Ltd. Odell-Miller, H. (2021). Embedding music and music therapy in care pathways for people with dementia in the 21st century—A position paper. Music & Science, 4, 1–10. https://doi.org/10.1177/205920432110204 OptimistMinds. (2022). 3 benefits of open-ended questions in counselling. Retrieved May 29, 2022, from https://optimistminds.com/benefits-of-openended-questions-in-counselling/ Owens, M. L. (2014). Remembering through music: Music therapy and dementia. Age in Action, 29(3), 1–5. Popkin, K. (2016, September 25). The role of music therapy in cancer care. Retrieved May 14, 2022, from https://ascopost.com/issues/september-252016/the-role-of-music-therapy-in-cancer-care/ Porter, S., McConnell, T., Clarke, M., Kirkwood, J., Hughes, N., GrahamWisener, L., Regan, J., McKeown, M., McGrillen, K., & Reid, J. (2017). A critical realist evaluation of a music therapy intervention in palliative care. BMC Palliative Care, 16(1), 70. Rafieyan, R., & Ries, R. (2007). A description of the use of music therapy in consultation-liaison psychiatry. Psychiatry (Edgmont), 4(1), 47–52. https:// www.ncbi.nlm.nih.gov/pmc/articles/PMC2922391/ Rio, R. (2018). A community-based music therapy support group for people with Alzheimer’s Disease and their caregivers: A sustainable partnership model. Frontiers in Medicine, 5, 293. https://pubmed.ncbi.nlm.nih.gov/30460236/ Robb, S. L., Burns, D. S., Stegenga, K. A., Haut, P. R., Monahan, P. O., Meza, J., Stump, T. E., Cherven, B. O., Docherty, S. L., Hendricks-Ferguson, V. L., Kintner, E. K., Haight, A. E., Wall, D. A., & Haase, J. E. (2014). Randomized

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clinical trial of therapeutic music video intervention for resilience outcomes in adolescents/young adults undergoing hematopoietic stem cell transplant: A report from the Children’s Oncology Group. Cancer, 120, 909–917. https:// pubmed.ncbi.nlm.nih.gov/24469862/ Rolvsjord, R. (2004). Therapy as empowerment: Clinical and political implications of empowerment philosophy in mental health practices of music therapy. Nordic Journal of Music Therapy, 13(2), 99–111. https://doi.org/10.1080/ 08098130409478107 Shi, Z., Lin, G., & Xie, Q. (2016). Effects of music therapy on mood, language, behavior, and social skills in children with autism: A meta-analysis. Chinese Nursing Research, 3(3), 137–141. https://doi.org/10.1016/j.cnre. 2016.06.018 Silverman, M. J. (2022). Music therapy in mental health for illness management and recovery (2nd ed.). Oxford University Press. Svansdottir, H. B., & Snaedal, J. (2006). Music therapy in moderate and severe dementia of Alzheimer’s type: A case-control study. International Psychogeriatrics, 18(4), 613–621. https://pubmed.ncbi.nlm.nih.gov/16618375/ Tan, L. P. P., Spears, A. M., Kwan, M., & Chiang, H. L. C. (2014). Music therapy at SingHealth. Music & Medicine, 6(1), 31–39. Tham, P. (2020). The (therapeutic) sound of music. Retrieved May 31, 2022, from https://read-a.com/the-therapeutic-sound-of-music/ The Association for Music Therapy Singapore. (2021). 2021 music therapy times. Retrieved May 31, 2022, from http://musictherapy.org.sg/wp-content/upl oads/2021/10/Music-Therapy-Times-2021.pdf The World Federation of Music Therapy. (1996). Definition of music therapy. Retrieved May 11, 2022, from https://www.wfmt.info/Musictherapyworld/ modules/wfmt/w_definition.htm Tsoi, K. K. F., Chan, J. Y. C., Ng, Y.-M., Lee, M. M. Y., Kwok, T. C. Y., & Wong, S. Y. S. (2018). Receptive music therapy is more effective than interactive music therapy to relieve behavioral and psychological symptoms of dementia: A systematic review and meta-analysis. JAMDA, 19, 568–576. https://pubmed.ncbi.nlm.nih.gov/29396186/ Ugur, H. G., Orak, O. S., Yaman Aktas, Y., Enginyurt, Ö., & Saglambilen, O. (2019). Effects of music therapy on the care burden of in-home caregivers and physiological parameters of their in-home dementia patients: A randomized controlled trial. Complementary Medicine Research, 26(1), 22–30. https:// pubmed.ncbi.nlm.nih.gov/30497077/ Vink, A. C., Bruinsma, M. S., & Scholten, R. J. P. M. (2003). Music therapy for people with dementia (Review). Retrieved May 22, 2022, from https://www. cochranelibrary.com/

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Walter, I. R. (2017, July 11). The art and science of therapy as craft, Part 2: Crafting questions. Retrieved May 29, 2022, from https://familytherap ybasics.com/blog/2017/7/10/the-art-and-science-of-therapy-crafting-que stions Wigram, T., & Baker, F. (2005). Introduction: Songwriting as therapy. In F. Baker & T. Wigram (Eds.), Songwriting: Methods, techniques and clinical applications for music therapy clinicians, educators and students (pp. 11–23). Jessica Kingsley. Wong, K. C., Tan, B. W. Z., Tong, J. W. K., & Chan, M. Y. (2021). The role of music therapy for children undergoing cancer treatment in Singapore. Healthcare, 9, 1761. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC870 2053/ Warth, M., Keßler, J., Hillecke, T. K., & Bardenheuer, H. J. (2005). Music therapy in palliative care: A randomized controlled trial to evaluate effects on relaxation. Deutsches Ärzteblatt International, 112(46), 788–794. https:// pubmed.ncbi.nlm.nih.gov/26806566/

Websites Allied Health. (n.d.). Retrieved July 11, 2022, from https://www.healthdirect. gov.au/allied-health Allied Health Professions Act 2011. (2011). Retrieved July 11, 2022, from https://sso.agc.gov.sg/Acts-Supp/1-2011/Published?DocDate=20110211& ProvIds=P1I-#pr1Helping patients heal and regain their lives with music. (2021, March 29). Retrieved July 12, 2022, from https://www.singhealth.com.sg/rhs/news/giv ing-philanthropy/Helping-patients-heal-and-regain-their-lives-with-music History of music therapy in Singapore. (n.d.). Retrieved May 31, 2022, from http://musictherapy.org.sg/wp-content/uploads/2018/01/Music-TherapyTimeline-Poster.pdf Music therapy: An interview with Emily Cornish & Linda McNair. (2015, December 17). Retrieved July 12, 2022, from https://bethesdahealth.org/ blog/2015/12/17/music-therapy-an-interview-with-emily-cornish-lindamcnair/ Music and Creative Therapy Unit. (n.d.). Retrieved May 31, 2022, from https://www.sgh.com.sg/patient-care/specialties-services/Music-andCreative-Therapy-Unit Music therapy and palliative care. (n.d.). Retrieved May 25, 2022, from https:// www.mtabc.com/what-is-music-therapy/how-does-music-therapy-work/pal liative-care/ Music therapy for the elderly. (n.d.). Retrieved July 12, 2022, from https://www. completecare.ca/blog/elderly-care/music-therapy-elderly/

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Music therapy in Singapore. (n.d.). Retrieved June 1, 2022, from https://singap oremusictherapy.wordpress.com/music-therapy-in-singapore/ Music therapy milestones in Singapore. (n.d.). Retrieved May 31, 2022, from http://musictherapy.org.sg/milestones-in-singapore/ The importance of a daily routine for dementia patients. (2022, January 11). Retrieved May 22, 2022, from https://www.whereyoulivematters.org/import ance-of-routines-for-dementia/ What is allied health? (n.d.). Retrieved June 3, 2022, from https://ahpa.com. au/what-is-allied-health/

Interviews Interview 19SG28, a music therapist, November 2019. Interview 21SG38, a music therapist, November 2021.

CHAPTER 4

Technologies and the Wellness of Older Adults

Abstract This chapter will examine whether technologies can improve the wellbeing of older adults in nursing homes, day care centres and public hospitals and bring benefits to carers through five examples: NAO (i.e. a humanoid robot), PARO (i.e. a seal-type mental commitment robot), Virtual Reality (VR) Googles and Immersive VR Rooms, DFree® (i.e. wearable bladder scanner) and Smart Health Video Consultation (SHVC). Technologies, if used properly, can improve the quality of life and the quality of care of older adults and relieve the burden on care workers. They will not replace care workers. Instead, they complement care workers and free them up to do more meaningful tasks (e.g. care tasks). It is expected that the scale and the pace of using health information technologies, monitoring technologies, assistive technologies and robotics increase in the LTC sector in future due to manpower shortage and the increase in the number of older adults in Singapore. Factors such as awareness, acceptance, ease of use, trust, knowledge and perceived risk will affect technology adoption. It is important to strike a balance between technology and human touch. Implementing technology with a human touch can make older adults feel loved, valued and cared for. Keywords DFree® · Human touch · NAO · PARO · Teleconsultation · Virtual reality

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 S. Ching Yuen Luk, Healthy Ageing in Singapore, Social Policy and Development Studies in East Asia, https://doi.org/10.1007/978-981-99-0872-1_4

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Introduction Technologies have been deployed by nursing homes and other long-term care (LTC) facilities to provide fun and engaging activities for older residents, improve their quality of life (Cavenett et al., 2018), improve the quality and efficiency of care (Hamann & Bezboruah, 2020: 2250) and ‘productively relieve staff from non-essential tasks’ (Tak et al., 2010: 68). They include assistive technologies and robotics (Franke et al., 2021), health information technologies (e.g. electronic care records) (Bail et al., 2022; Ko et al., 2018), monitoring technologies (e.g. wearable locationtracking devices, bed-monitoring systems) (Hall et al., 2017: 60) and other technologies such as artificial intelligence (AI) (Loveys et al., 2022) and the Internet of Things (IoT) (Zhao et al., 2022). In Singapore, ‘a growing number of technological solutions are being introduced to tackle the challenges of ageing’ (Goonawardene et al., 2018: 4). This chapter will examine whether technologies can improve the wellbeing of older adults in nursing homes, day care centres and public hospitals and bring benefits to carers through five examples: NAO (i.e. a humanoid robot), PARO (i.e. a seal-type mental commitment robot), Virtual Reality (VR) Googles and Immersive VR Rooms, DFree® (i.e. wearable bladder scanner) and Smart Health Video Consultation (SHVC).

NAO: A Humanoid Robot A humanoid robot ‘is an actuated human-size biped robot with a torso, arms, and a head, designed to achieve some of human capabilities’ (Yoshida, 2019). NAO is an autonomous, programmable humanoid robot manufactured by a French company called Aldebaran Robotics (AssadUz-Zaman et al., 2019: 3; Gouaillier et al., 2009: 774), which was renamed to SoftBank Robotics Europe (Tao, 2016). It is small and lightweight (Gouaillier et al., 2009; Gouda & Gomaa, 2014). It is 58 centimeters tall and weighed 4.5 kilograms. It has ‘no sharp edges, only smooth, rounded surfaces’ (Gelin, 2019: 149). ‘For the first time the robot needs to be configured for internet connection and later it can connect to internet autonomously using ethernet port and Wi-Fi’ (Ramkumar et al., 2019: 1598). NAO can allow ‘autonomous operation and remote control’ (Amirova et al., 2021). It ‘is equipped with rechargeable battery powers that work only 60 minutes in active use and 90 minutes in regular use’ (Baothman, 2021).

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NAO ‘is made up of a distinct composition of hardware and software’ (Ramkumar et al., 2019: 1598). NAOqi is the main software that runs on NAO (‘NAOqi Framework’, n.d.) and controls its actuators and sensors (Ramkumar et al., 2019: 1598). NAO has 25 degrees of freedom (DOF), 11 DOF for the lower part (i.e. legs and pelvis) and 14 DOF for the upper part (i.e. head, arms and trunk) (Gouaillier et al., 2009: 770). This enables NAO to perform simple human motions such as walking forward and backward, standing up and sitting down, kicking a ball and waving hand (Assad-Uz-Zaman et al., 2021: 226; Gouda & Gomaa, 2014: 404; Vital et al., 2013). NAO can ‘walk on a variety of floor surfaces, such as carpeted, tiled, and wooden floors’ (‘NAO Humanoid Robot Motion’, n.d.). Its walking speed is similar to that of a 2-year-old child, which is about 0.6 km/h (Gouaillier et al., 2009: 770). NAO has ‘a fall manager mechanism which is responsible to protect it in case it falls’ (Chartomatsidis et al., 2016: 30). It also has a fall recovery mechanism which enables it to stand up on its own after a fall (‘Nao’, n.d.). NAO can learn, recognize and track images and faces with the help of two cameras located on its forehead and at mouth level (‘NAO Humanoid Robot Vision’, n.d.; Ramkumar et al., 2019: 1598). Besides, it can perceive the environment where it interacts with the help of nine tactile sensors, eight pressure sensors and two ultrasonic sensors (OchoaZezzatti et al., 2021: 224). NAO can also interact with people (‘NAO Humanoid Robot Audio’, n.d.). It uses ‘four microphones to track sounds, and its voice recognition and text-to-speech capabilities allow it to communicate in 8 languages’ (‘NAO Humanoid Robot Audio’, n.d.). It ‘can respond to queries with the help of microphones and loudspeakers around its head’ (Ramkumar et al., 2019: 1598). It ‘can perform acoustic and physical expression of emotions’ (Amirova et al., 2021). The voice of NAO is ‘the voice of a machine but with a fluidity that makes it very comfortable to listen to’ (Gelin, 2019: 156). Additionally, the child-like appearance and non-judgemental characteristics of NAO make it more appealing (Amirova et al., 2021). Full-colour red, green and blue (RGB) LEDs are installed around the eyes, on the chest and on the feet of NAO while 16 step blue LEDs are installed around its ears and the head tactile sensor (‘H21—LEDs’, n.d.). ‘The colour and the strength of LEDs can be adjusted through the functions called the advanced language’ (Zhang & Xiao, 2020: 116). NAO can serve as a conversational companion, a storyteller, a language tutor in autism therapy, a facilitator in speech therapy, a mediator,

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a presenter, an assistant (Amirova et al., 2021) and ‘peers for selfdisclosure among people with visual impairments and intellectual disabilities’ (Amirova et al., 2021). Since 2015, ‘the use of NAO has expanded stably in healthcare, autism therapy, and education’ (Amirova et al., 2021). Currently, over 13,000 NAO robots are used in more than 70 countries worldwide (Amirova et al., 2021). In Singapore, a 6-week research was carried out in two day care centres in 2017 to see if NAO could bring any benefits to older adults and address staffing shortages at the centres (Interview 18SG01). One of the day care centres used NAO to interact with healthy older adults (Interview 18SG01). Another day care centre used NAO to interact with healthy older adults as well as older adults with dementia (Interview 18SG01). NAO was given a Chinese name (Interview 18SG01). It was called ‘Ah De’ at the day care centres (Interview 18SG01). The Chinese name helped older adults remember the robot more easily and make the robot more approachable. Besides, NAO could speak Mandarin (e.g. “Hi!”, “Good morning!” and “How are you?” in Chinese) (Interview 18SG01). With the help of software developers, two NAO robots were programmed to do three things: perform a variety of exercises, singing and playing games (Interview 18SG01). Being an exercise coach, NAO demonstrated, guided and motivated older adults to perform physical exercises such as stretching their legs (Interview 18SG01). As an entertainer, NAO could sing popular Hokkien songs from Chinese television series (Interview 18SG01). As a game facilitator, NAO used questions in Chinese (e.g. “Can you guess what food this is ?”) and prompting (i.e. subtle indicators such as the twisting of the robot and light from its eyes) to help older adults identify Singapore’s signature dishes (e.g. chilli crab) or food shown in the pictures (Interview 18SG01; Interview 22SG46). It would say out encouraging phrases (e.g. “Very good!”, “That’s great!” in Chinese) when older adults got their answers right during the game (Interview 22SG46). When playing a sound association game, NAO would perform animal behaviour and sounds (e.g. a dog, a cat, an elephant) and made older adults guess what animal it was pretending to be (Interview 22SG46). When NAO was interacting with older adults, however, human facilitators (i.e. care team staff and volunteers) were still required to be on-site (Interview 18SG01). They helped ensure that the robot functioned well (Interview 18SG01). Besides, they carried out supervision to ensure that older adults did not fall or older adults with dementia did not get distracted and start walking around

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(Interview 18SG01). They also observed the facial expressions of older adults to see if older adults felt gloomy and helped encourage older adults to play games with NAO (Interview 18SG01). General responses from healthy older adults and older adults with dementia to NAO were positive (Interview 18SG01). They felt very happy when interacting with NAO (Interview 18SG01). They liked to lift and carry NAO because they thought that NAO was cute and was like a little boy (Interview 18SG01). However, some older adults lost interest in NAO after a while, especially those with dementia, because the robot was not as lively as a real person (Interview 22SG46). Hence, there was a concern if older adults who visited the day care centres all the time would get bored of NAO in the long run (Interview 18SG01). In order to keep older adults engaged, NAO needs to be programmed in a way that older adults can associate the robot as something local instead of being something entirely foreign (Interview 22SG46). For example, older adults’ familiarity with the robot would increase if the robot can be programmed to speak local dialect phrases, or even Singlish (Interview 22SG46). Besides, some incentives such as snacks, freebies and tissue paper packs can be used to keep older adults engaged in games (Interview 22SG46). This human–robot interaction research also found that the duration of playing the games between old adults with dementia and those without dementia differed more significantly than expected (Interview 22SG46). It mainly depended on how familiar older adults were with the item (e.g. food), their memories and association with the item (Interview 22SG46). Regarding familiarity with the food, for example, some older adults could clearly differentiate the Singapore chilli crab dish compared to a bowl of chicken curry (Interview 22SG46). For some older adults, however, they really could not tell the difference between chilli crab and chicken curry because they had never eaten the food before (Interview 22SG46). As regards participants’ memories, older adults with dementia tended to lose motivation to play the games when they found it hard to recall the food or animals (Interview 22SG46). Hence, ‘indirect hints and prompts from the sideline were needed to encourage them to participate’ (Interview 22SG46). Meanwhile, lower literacy level posted problems when the game required older adults to read words and associate them to the item (i.e. the game about identifying food) (Interview 22SG46). This created pressure for older adults with lower literacy level to be engaged in games (Interview 22SG46).

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Most of the care staff and therapists who worked in these two day care centres were Singaporeans aged between 26 and 55 (Interview 22SG46). They felt overwhelmed by their responsibilities (Interview 22SG46). They were always alert and watchful of every movement made by older adults while taking note of their special needs (Interview 22SG46). More often than not, they had to perform multiple tasks at the same time (Interview 22SG46). Apart from frequently assisting older adults to walk, get exercise or get to the toilet, care staff also had to carry out specific tasks individually, which included schedule planning, conducting a group programme, facilitating activities, mending pantry duties and a number of other operational matters (Interview 22SG46). However, their help for older adults was not strictly of a physical nature (Interview 22SG46). Rather, care staff often provided important cognitive help, guidance and motivation, in addition to valuable social interaction with older adults (Interview 22SG46). Hence, care staff and therapists hoped that NAO could assist in carrying out some activities (e.g. cognitive exercises, singing, games, and narrating in dialect) (Interview 22SG46) so that their workload could be alleviated. After seeing how NAO could be programmed to do different activities, care staff at the day care centres thought that there was potential in having humanoid robots as part of the care team down the road (Interview 22SG46). For example, the technology in assistive robots could be leveraged for navigation, localization and mapping, and specifically focus on developing new algorithmic approaches to track people, predict the behaviour of older adults, and react appropriately (Interview 22SG46). In fact, overseas studies show that humanoid robots have been used in care of older adults, which include supporting their everyday life (e.g. provide medication reminders), providing interactions (e.g. read news headlines, play music), facilitating physical training (e.g. a walking trainer for older adults), and facilitating cognitive training (e.g. play memory games) (Andtfolk et al., 2022: 522–524). Since humanoid robots have ‘advanced sensing and motor capabilities, they may be well suited to performing caring tasks’ (Andtfolk et al., 2022: 518). Hence, general responses from care staff to NAO were positive (Interview 22SG46). In October 2018, a pilot Robot Therapy programme using NAO was introduced to Yishun Community Hospital (YCH) in Singapore (‘The Future Is Nao’, 2021). NAO was programmed to speak both Mandarin and English, ‘perform three sets of neck and upper limbs exercises’ (‘The Future Is Nao’, 2021) and perform a Tai Chi routine for the purposes

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of social interaction and entertainment (‘The Future Is Nao’, 2021). Staff were trained to know the steps to operate and maintain NAO (Tan et al., n.d.). A total of 48 older patients from a dementia ward were chosen to receive NAO robot therapy sessions because they experienced behavioural and psychological symptoms of dementia (BPSD) (e.g. anxiety, agitation, depression, delusions) (Cerejeira et al., 2012), thereby requiring more attention and care (‘The Future Is Nao’, 2021). Every robot therapy session which lasted for about 15 minutes had an average of four participants (‘The Future Is Nao’, 2021). Participants were supervised by a Registered Nurse during the session (‘The Future Is Nao’, 2021). ‘At least four sessions were conducted each month’ (‘The Future Is Nao’, 2021). The Observed Emotion Rating Scale (OERS), which measured the intensity or duration of two positive emotions (e.g. pleasure and general alertness) and three negative emotions (e.g. anger, anxiety, sadness) of participants (Perugia et al., 2018; Phillips et al., 2010; Taani & Kovach, 2022), was used to evaluate the effectiveness of the Robot Therapy programme (‘The Future Is Nao’, 2021). Staff were trained to use the OERS (Tan et al., n.d.). The result of the pilot Robot Therapy programme showed that having NAO robot therapy sessions could increase the pleasure rating of older participants by 25% and the general alertness rating by 46% while decreasing the anger rating by 4.2% and the anxiety/fear rating by 6.3% (Tan et al., n.d.; ‘The Future Is Nao’, 2021). However, there was no difference in the sadness rating before and after the introduction of the Robot Therapy programme (Tan et al., n.d.). Based on staff observation, the introduction of the Robot Therapy programme could quickly engage older patients with dementia in activities (Tan et al., n.d.). The overall engagement rate reached over 76% (Tan et al., n.d.; ‘The Future Is Nao’, 2021). The introduction of the Robot Therapy programme could also save time, manpower and costs (Tan et al., n.d.; ‘The Future Is Nao’, 2021). Before introducing the Robot Therapy programme, each conventional activity session lasted for 180 minutes and required four Registered Nurses to be present during the session (Tan et al., n.d.). After introducing the Robot Therapy programme, however, each NAO robot therapy session only lasted for 15 minutes and required one Registered Nurse to be present during the session (Tan et al., n.d.). Hence, 165 minutes (i.e. 2.75 hours) were saved per session and a total of 660 minutes (i.e. 11 hours) were saved per month (Tan et al., n.d.). Time

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could be freed up for other care tasks (Tan et al., n.d.). As regards manpower, three registered nurses were saved per session and 12 registered nurses were saved per month (Tan et al., n.d.). This resulted in saving the total man-hour costs of SG$4,775 per month (Tan et al., n.d.; ‘The Future Is Nao’, 2021).

PARO: A Seal-Type Mental Commitment Robot PARO is an award-winning mental commitment robot created by Professor Takanori Shibata at the Tokyo Institute of Technology (Vaswani, 2020) to provide psychological (e.g. comfort), physiological (e.g. promotion of brain activity), and social benefits (e.g. improvement in communication) (Shibata, 2011: 361; Shibata & Wada, 2011: 384; Wada & Inoue, 2010: 2) for people with dementia (PWD), cancer patients (Vaswani, 2020), medium or long-term hospitalized patients at pediatric hospitals, and children with autism or Down’s syndrome (Shibata, 2012: 2532). It is an animal type robot giving mental values such as relaxation and pleasure to human beings (Shibata, 2004: 1753; 2012: 2529; Shibata et al., 2001: 1053; Shibata & Wada, 2011: 381). It is ‘roughly the shape, size and weight of a baby harp seal’ (Vaswani, 2020). Its ‘artificial soft white fur imitates the white coat exhibited by baby harp seals for the first three weeks after birth’ (Wada & Inoue, 2010: 3). ‘Its length is approximately 55 cm and its weight is 2.7 kg, similar to that of a human baby’ (Shibata, 2012: 2529–2530). The key characteristic of PARO is its cuteness (Calo et al., 2011: 20; Shibata, 2004: 1755). Hence, PARO can be widely accepted by users regardless of religious and cultural differences (Shibata, 2011: 357; Shibata & Wada, 2011: 382). PARO can respond to its environment and users’ interaction with it (Calo et al., 2011: 20) because it ‘is equipped with an array of sensory capabilities’ (Shibata et al., 2021: 11502). It ‘has two light sensors providing simple stereo vision, three microphones for speech recognition and sound localization’ (Shibata, 2012: 2530), temperature sensors maintaining a constant warm body temperature (Shibata, 2011: 357), ‘two whisker-type tactile sensors, a whole body tactile sensor’ (Shibata, 2012: 2530) and ‘postural sensors that allow PARO to know the position in which it is being held’ (Shibata et al., 2021: 11502). It ‘has seven degrees of freedom that allow for a variety of movements’ (Shibata et al., 2021: 11502). These include ‘vertical and horizontal neck movements, front and rear paddle movements, and independent movement of

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each eyelid, which is important for creating facial expressions’ (Shibata, 2004: 1754). PARO can move silently (Shibata, 2012: 2530) and respond by ‘nodding its head, moving its arms, blinking its eyes, or producing the sounds of “ee-ying” when a person is speaking to or touching it’ (Koh & Kang, 2018: 301). It can ‘handle relatively strong forces inflicted by an interacting human’ (Shibata et al., 2021: 11502). ‘PARO is run by hierarchical intelligent control’ (Shibata et al., 2021: 11502) and has reinforcement learning functions (Shibata, 2012: 2530). It can ‘learn to recognize its given name’ (Wada & Inoue, 2010: 3) and ‘adapt its personality and behaviors through interaction with the owner’ (Shibata et al., 2021: 11502). It has positive value on preferable stimulation (e.g. gentle touches, nice words) and negative value on undesirable stimulation (e.g. beaten) (Calo et al., 2011: 21; Shibata et al., 2001: 1055; Wada et al., 2003: 273). PARO has ‘its own diurnal rhythm (morning, daytime, and night) to perform various activities during its interaction with people’ (Shibata & Wada, 2011: 382). For example, it ‘has some spontaneous desires such as sleep based on the rhythm’ (Wada et al., 2003: 274). PARO is ‘functionally designed to be soft and evoke a feeling of warmth’ (Shibata & Wada, 2011: 382). It is easy to use. No specialized knowledge or skills is required to operate PARO (Shibata & Wada, 2011: 381). It ‘has only one switch for power on/off’ (Shibata, 2012: 2530). ‘Its battery lasts about one and a half hours and can be recharged by inserting a pacifier-shaped charger into Paro’s mouth, as if one were feeding it’ (Wada & Inoue, 2010: 3). Besides, PARO is safe to use. The artificial fur of PARO is hypoallergenic (Calo et al., 2011: 21), antibacterial, dirt-resistant (Shibata, 2012: 2530; Shibata & Wada, 2011: 382) and ‘anti-alopecia to allow it to be used in medical and nursing facilities’ (Wada & Inoue, 2010: 3). PARO contains an electromagnetic shield in its internal circuit to prevent any ill effect on pacemakers (Shibata, 2011: 358). The drop test, withstand voltage test, 100,000 times stroking test and a seven-year clinical test confirmed that PARO is very safe and highly durable (Shibata, 2011: 358; Shibata & Wada, 2011: 382). PARO ‘was built by Sankyo Aluminum Industry’ (Shibata et al., 2001: 1054) and is designed ‘to have a product lifespan of over 10 years’ (Shibata et al., 2021: 11502). It is currently in its ninth generation after many prototypes and clinical trials (Shibata et al., 2021: 11502). It ‘was commercialized in Japan in 2005’ (Shibata et al., 2021: 11502) and is sold for approximately US$6,000 (Calo et al., 2011: 20). PARO is used as a substitution for animals in animal-assisted therapy (AAT) and

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animal-assisted activity (AAA) (Shibata & Wada, 2011: 381) because it can eliminate potential safety, health and hygiene risks, including allergy, scratches, bites, insect infestation (e.g. fleas) and zoonoses (Shibata, 2012: 2528; Wada et al., 2004: 1781; Wada & Inoue, 2010: 2). It is also used as a biofeedback therapy to ‘stimulate brain activities of the human’ (Shibata, 2012: 2529) and improve the emotional well-being of users (Vaswani, 2020). It ‘can stimulate the human by its weight, texture, temperature, and vibration’ (Shibata, 2012: 2529) and helps alleviate users’ stress, loneliness, anxiety, depression and pain without medication (Vaswani, 2020). By July 2021, about 7,000 PARO had been used in over 30 countries (e.g. Japan, America, Denmark, Italy and Sweden) (Shibata & Wada, 2011: 382; Shibata et al., 2021: 11502). In Singapore, a nursing home received funding from Agency for Integrated Care (AIC) to buy one PARO to carry out a trial in a dementia care unit to see if PARO could bring any benefits to residents with dementia (Interview 21SG44). Residents who liked to interact with pets, were not bed bound and had no skin conditions could join PARO sessions (Interview 21SG44). The trial lasted for a few years. The result showed that PARO only appeared to benefit residents with mild or moderate dementia, especially those who were females (Interview 21SG44). The PARO session was carried out every day at the initial stage (Interview 22SG45). Each session was participated by two to four older residents with dementia based on older residents’ profile and needs (Interview 22SG45). Subsequently, each session was participated by one or two older resident(s) with dementia (Interview 22SG45). The cumulative number of older residents who played with PARO was estimated at about 10 (Interview 22SG45). In order to help older residents get ready to accept PARO, the care staff first played with PARO in front of the older residents (Interview 22SG45). Then, she carried PARO to the older residents and stimulated PARO to have some movements, blink its eyes or produce some sounds to gain the older residents’ attention (Interview 22SG45). She would ask the older residents to look at the eyes of PARO and encourage older residents to touch PARO by saying how cute PARO was and how soft its fur was (Interview 22SG45). If an older resident expressed his/her desire to touch PARO, the care staff would slowly hold the older resident’s hand to let her/him touch PARO (Interview 22SG45). Once the older resident came into physical contact with PARO, they would start talking to PARO (Interview 22SG45). In the PARO session, some residents would interact

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with PARO for 15–20 minutes while some residents would interact with PARO for more than half an hour (Interview 21SG44). If an older resident wanted to play longer with PARO, the care staff would facilitate the session (Interview 22SG45). If the meal time or tea break time was due, the care staff would let the older resident play a slightly longer time and later bring the food or drinks to older residents (Interview 22SG45). When it was not in use, PARO would be kept in the cabinet in the dementia care unit (Interview 22SG45). Residents in general enjoyed the moment they had when they interacted with PARO (Interview 21SG44). They talked to PARO as if they were talking to a baby (Interview 21SG44). For example, some residents would ask PARO to go to sleep (Interview 21SG44). Some residents would laugh when they played with PARO (Interview 21SG44). ‘PARO acts as a social mediator, providing a common topic for the elderly and encouraging them to communicate with each other’ (Shibata, 2011: 362). Older residents would talk to each other using short and simple sentences such as ‘PARO is cute!’, ‘PARO is happy!’ and ‘PARO is sleepy’ (Interview 22SG45). Older residents’ interaction with PARO helps ‘grease the gears of social interaction’ (Calo et al., 2011: 22). Besides, those who liked to play with PARO, especially female older residents, had a sense of attachment to PARO (Interview 22SG45). In general, PARO could promote older residents’ psychological wellness, reduce their anxiety and stress, and help them keep calm and stay happy (Interview 22SG45). Eventually, PARO was helpful to reduce some of the older residents’ violent or aggressive behaviours such as shouting (Interview 22SG45). However, some older residents lost their interests in interacting with PARO although staff at the nursing home encouraged them to do so (Interview 21SG44). The main reason was that a baby seal was an unfamiliar animal to residents (Interview 21SG44). According to Professor Shibata, ‘the design team intentionally chose an unfamiliar animal’ (Calo et al., 2011: 21) for wider acceptance of PARO. His study found that the seal robot ‘was more acceptable than robots of familiar animals because most people had minimal knowledge of seals’ (Shibata, 2012: 2530), and ‘hence were unable to compare the seal robot with their knowledge of seals (Shibata & Wada, 2011: 382). If the team used a familiar animal, people ‘would have noticed that the robot failed to perfectly imitate the actual motions of the animal’ (Calo et al., 2011: 21). However, the use of an unfamiliar animal as a robot became the main reason why older

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residents in the Singapore’s nursing home were not interested in interacting with PARO. A baby seal is not common or popular in Singapore (Interview 21SG44). Older residents said that PARO was cute, but it was unrecognizable to them (Interview 21SG44). Hence, some residents made a request of having a robot dog or a robot cat to play with (Interview 21SG44). Staff at the nursing home found that older residents still needed to have human touch although they played with PARO (Interview 21SG44). In general, PARO was not welcomed by male residents (Interview 21SG44). Instead, male residents were more interested in having gardening therapy and hand massage therapy (Interview 21SG44). Gardening therapy was quite useful for residents in the dementia care units (Interview 21SG44). If the weather was good, residents could enjoy a morning tea break, do physical exercises and sing songs in the garden (Interview 21SG44). Although residents with dementia may not recognize the flowers they saw, they would still talk to each other about which flowers looked nice (Interview 21SG44). Some male residents with dementia enjoyed having a hand massage therapy if they did not want to talk to other people but simply wanted to enjoy the silent moment (Interview 21SG44). Hand massage or therapeutic touch is part of Namaste Care (Interview 21SG44), which ‘seeks to engage people via their senses, especially through the power of “loving touch”, to improve quality of life’ (Soliman & Hirst, 2015). Touch is, after all, ‘a fundamental means of human communication and humans need touch as a part of our lifelong need to be cared for, nurtured, valued and loved’ (Agency for Integrated Care, n.d.). Residents with dementia enjoyed the human touch and felt relaxed when they smelled the aroma during the hand massage session (Interview 21SG44). Staff at the nursing home found that the frequency and duration of screaming reduced after residents with dementia received hand massage therapy (Interview 21SG44).

Virtual Reality (VR) Googles and Immersive VR Rooms Virtual reality (VR) refers to the use of computer hardware and software to create a simulated environment with objects and events that appear to be real (Weiss et al., 2006). A user has to place a thick pair of special goggles, also known as a VR headset, over his/her eyes (Dredge, 2016; ‘Virtual Reality: Another World Within Sight’, n.d.) in order to fully

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immerse himself/herself in the virtual environment (Barnard, 2021), ‘creating a realistic experience in the simulation’ (Barnard, 2021).‘Immersion, presence, and interactivity are regarded as the core characteristics of VR technologies’ (Radianti et al., 2020). VR has been proven valuable in education (McGovern et al., 2020; Tai & Chen, 2021) and clinical treatment (Vincent et al., 2021). Besides, it has been proven effective in reducing subjective stress (Beverly et al., 2022), improving rehabilitation outcomes (Asadzadeh et al., 2021; Feng et al., 2019), supporting active ageing (Syed-Abdu et al., 2019) and playing a positive role in attitude and behaviour management during the 2019 coronavirus disease (COVID19) pandemic isolation (Yang et al., 2022: 179). It also shows potential to promote wellbeing in people with dementia (PWD) (Appel et al., 2021), increase physical movement of older adults living in long-term care homes, distract them from the chronic pain, enhance their emotional (e.g. happiness, relaxation) and cognitive well-being (e.g. bring back old memories) and increase their social interactions (Chaze et al., 2022). In Singapore, a social enterprise called Mind Palace (www.mindpa lacevr.org) used VR as a form of reminiscence therapy to help PWD in nursing homes remember familiar places and faces from their past (Ghosh, 2021). Reminiscence therapy is a non-pharmacological intervention aiming to stimulate one’s memories and the discussion of past activities, experience and events, usually with the aid of tangible prompts such as photos, familiar items from the past and music (Tominari et al., 2021; Woods et al. 2018). ‘Technology makes the accessibility and storage of material (memories) to reminisce convenient and VR allows an environment to connect with these easily’ (Lodha et al., 2020). In the VR reminiscence therapy sessions, Mind Palace immersed older PWD into well-trodden neighbourhoods or places they were unable to visit on their own through watching 360-degree video footages automatically played by an application customized by a technology artist of Mind Palace on the Oculus headset (Cheah, 2019; Ghosh, 2021). Mind Palace had filmed over 10 videos with different themes (e.g. animals, old and popular places in Singapore) (Interview 19SG25). Each video footage lasted for three to four minutes (Interview 19SG25). It was scripted entirely by the team of Mind Palace (Cheah, 2019). The video tour could bring older PWD to a kampong (i.e. a village, which is the oldest settlement in Singapore) (Interview 19SG25), Singapore’s popular places such as Haw Par Villa (i.e. an 8.5-hectare Asian cultural park and Hell’s Museum), Chinatown, Gardens by the Bay and Jewel at Changi Airport, or overseas places such

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as the Great Wall of China (Interview 19SG25). When older PWD were watching the videos, they would be asked about what they saw or where they were (Interview 19SG25). This helped initiate conversations (Ghosh, 2021) and ‘trigger memories that may be attached to sensory cues like sounds and colors’ (Ghosh, 2021). One example was that occupational therapists were surprised to see that a male older PWD who had difficulty speaking could suddenly read out the street names clearly when he was having a VR walking tour of Chinatown (Interview 19SG25). Another example was that a female PWD who had difficulty speaking pointed to a stuffed panda toy she carried with her when she was asked about what she saw in the video which showed the view of a panda farm in China (Interview 19SG25). According to the occupational therapist, panda was her favourite animal (Interview 19SG25). Nevertheless, animal footage was not suitable for older adults who were very scared of animals (Interview 19SG25). For example, some older adults were scared to be bitten by camels when the immersive effects of VR made them feel like they were standing right beside the camels (Interview 19SG25). Recognizing that reminiscence therapy engaged the senses (i.e. sight, sound, touch, smell) to elicit memories (Gillies et al., 2013), the technology artist of Mind Palace also incorporated environmental scents into one of the VR reminiscence therapy sessions (Ghosh, 2021). Since older adults in the nursing home liked chicken, the technology artist went to Chinatown personally to film Chef Chan Hon Meng, who ran Singapore’s ex-Michelin-starred street hawker stall called Hawker Chan (Ghosh, 2021; Mehta, 2019). He asked Chef Chan to look into the camera directly (Mehta, 2019) and talk to the camera as if he was speaking to older residents at the nursing home while preparing his famous soya sauce chicken rice (Ghosh, 2021; Tee, 2021). For example, Chef Chan held up a piece of chicken and said that only older adults would get to eat the drumstick (Mehta, 2019). This made older adults feel very personal, as if Chef Chan was making chicken rice for them (Ghosh, 2021). While older adults were watching this video footage, they could smell the chicken rice too (Ghosh, 2021). Once they finished watching the video footage and took off the headsets, they were surprised to find a box of chicken rice in front of them (Ghosh, 2021). The technology artist found that older residents with dementia still remembered him a week after the chicken rice session and wanted to know if food would be served in the next VR reminiscence therapy session (Ghosh, 2021).

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During the COVID-19 pandemic, ‘nursing homes became out of bounds to visitors and volunteers to protect their vulnerable elderly residents’ (Tan, 2021). For this reason, Mind Palace collaborated with Cycling Without Age (CWA) Singapore, which was a registered charity, to produce VR trishaw rides for older residents in nursing homes (Tan, 2021). Once older adults put on a VR headset, they could relax and enjoy the views of Gardens by the Bay, Admiralty Park or Bishan Park in the comfort of the nursing home without getting tired or having to worry about any mobility challenges (Balasubramanian, 2020). The immersive effect brought by VR made older adults feel like ‘they were actually riding the trishaw’ (Tan, 2021). A survey done by CWA Singapore found that the virtual trishaw tour of Singapore could increase older participants’ happiness by 34% (Balasubramanian, 2020). It also made older participants talk more, more excited and more appreciative of the opportunity to engage with VR (Balasubramanian, 2020). The VR experiences created by Mind Palace could help older residents in nursing homes and older PWD ‘relieve their sense of social isolation and keep them engaged from the comfort and safety of their chairs’ (Tee, 2021). Such experiences also helped calm older adults, reduce their stress, helped them remember things better and provide ‘escapism’ for older residents who may feel cooped up at nursing homes (Ghosh, 2021). For healthy older adults and those without dementia, having a VR experience was more for fun, exploration and discovery (Interview 19SG25). Nevertheless, Mind Palace encountered a hygiene issue with the VR headsets (Interview 19SG25). The headsets had to be shared among older residents and they were getting gross and smelly (Ghosh, 2021). All sorts of hygiene methods tried by Mind Palace, including washing the foam pads on the headsets (Ghosh, 2021), the use of disinfectant sprays (Interview 19SG25), and putting a hygiene mask on the older user first before putting on the headset (Ghosh, 2021; Interview 19SG25), were unable to completely cope with the issue. Another issue was that the straps on the headsets were too tight for some older users, which led to leaving a red mark on their faces (Interview 19SG25). Hence, some older users found it more comfortable with holding the VR headsets near their faces (Interview 19SG25). This could help older users get some arm exercises (Interview 19SG25). In 2020, the introduction of an immersive VR room by Mind Palace became an alternative to wearable VR headsets (‘Virtual Reality for Dementia’, n.d.). Mind Palace built its first immersive VR room in

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the NTUC Health Senior Day Centre (Geylang East) (‘NTUC Health Reimagines Care for Seniors’, 2021). An immersive VR room is a room where healthy older adults, those with mobility issue or PWD can watch 360-degree videos that are projected directly onto the wall (Interview 19SG25). It is set on an interchangeable background panoramic view of Singapore’s iconic attractions (e.g. Gardens by the Bay, the Marina Bay Sands, Jewel), cultural and heritage sites (e.g. Haw Par Villa, kampungs) (Yap, 2021) as well as foreign landscapes such as Penang, Hong Kong (‘Future Ready’, n.d.) and the Great Wall of China (Tee, 2021). During this activity, older adults ‘get to tour the venue as if they are onsite, with a virtual tour guide explaining the background of the attraction’ (Yap, 2021). The immersive VR room experience enables older adults to have outdoor experiences such as ‘taking a stroll through Haw Par Villa’ (‘NTUC Health Reimagines Care for Seniors’, 2021), diving underwater with turtles (‘Future Ready’, n.d.) and ‘going on a bobsled ride through an icy tundra without leaving a room’ (‘NTUC Health Reimagines Care for Seniors’, 2021). It provides an interesting way for older adults to ‘discover new places and reminisce about old places’ (‘NTUC Health Reimagines Care for Seniors’, 2021). The immersive VR room helps trigger the memories of older adults, improve the social bonding between care staff and older adults (Yap, 2021) and increase the social interaction among older adults through sharing their life experiences with each other (‘NTUC Health Reimagines Care for Seniors’, 2021). For example, a male older adult shared the memories of a temple he visited previously during an immersive VR room experience session featuring Perak, Malaysia (‘Future Ready’, n.d.). Another example was that a male older adult with moderate dementia shared the kampung life he experienced in the past after having an immersive VR room experience session featuring olden-day kampungs (‘NTUC Health Reimagines Care for Seniors’, 2021). The immersive VR room experience also helps improve the emotional wellness of PWD. For example, reminiscing about old places through the immersive VR room helped an easily agitated and irritable male person with moderate dementia become calmer (‘NTUC Health Reimagines Care for Seniors’, 2021). The immersive VR room has become even more useful when the outbreak of COVID-19 called for social distancing and the use of contactless technologies (Ghosh, 2021). Meanwhile, basic games such as jogging on a race track (Yap, 2021) or ‘finishing a marathon run’ (Yap, 2021) were also built into the immersive

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VR room to encourage older adults to do more physical exercises (Ghosh, 2021). These games help improve the physical health of older adults and keep them energized (Yap, 2021). Besides, they encourage friendship and increase social interactions among older adults because older adults would cheer one another when playing the games (‘NTUC Health Reimagines Care for Seniors’, 2021). A study conducted by NTUC Health found that older adults were positive about their immersive VR room experience and ‘demonstrated higher levels of interest and attentiveness’ (‘NTUC Health Reimagines Care for Seniors’, 2021). Older adults thought that activities in the immersive VR room was fun and they were eager to join these activities every day (‘NTUC Health Reimagines Care for Seniors’, 2021). The immersive VR room experience is expected to be rolled out progressively in other NTUC Health Senior Day Care Centres in Singapore (‘NTUC Health Reimagines Care for Seniors’, 2021). Other permanent immersive VR rooms can be found at other eldercare facilities, including Ling Kwang Home, Society for the Aged Sick and Kwong Wai Shiu Hospital (‘Virtual Reality for Dementia’, n.d.).

DFree® : Wearable Bladder Scanner Urinary incontinence (UI) which is defined as the involuntary loss of urine is highly prevalent among older adults aged 60 years or over (World Health Organization, 2017: 1) due to age-related changes to the genitourinary system (Davis et al., 2020: 57). These changes may include increased residual urine volume, increased involuntary bladder muscle contractions, decreased bladder capacity, decreased pelvic floor muscle strength, prostate enlargement, and decreased estrogen levels (Batmani et al., 2021: 212; Davis et al., 2020: 57). UI can lead to urinary tract infections, sleep disturbances, a decrease in physical activities, social withdrawal and isolation, a sense of shame, psychological problems (e.g. depression, lower levels of self-esteem), a reduced quality of life (Batmani et al., 2021: 212; Lee et al., 2021: 9054; Sahin-Onat et al., 2014: 89), and greater caregiver burden (Tamanini et al., 2011). In many cases, UI ‘can be treated, better managed and even cured’ (‘Urinary Incontinence’, n.d.). However, it is underreported due to humiliation, stress (‘Spotlight On: DFree’, n.d.), ‘embarrassment, stigma, or acceptance as normal’ (O’Reilly et al., 2018). DFree® , which stands for “diaper-free”, is the first non-invasive, wearable health device designed by engineering startup called Triple W for

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people with UI to monitor bladder fullness (Business Insider South Africa, 2019; ‘Spotlight On: DFree’, n.d.; ‘Triple W Partners with Pisces Healthcare Solutions’, 2019). There are two types of DFree devices on market: DFree® Personal and DFree® Professional (‘Spotlight On: DFree’, n.d.). The former is ‘designed for use by individuals and family care providers’ (‘Spotlight On: DFree’, n.d.) while the latter is designed for use by inhome care agencies, nursing homes, and hospitals (‘Spotlight On: DFree’, n.d.). DFree® contains two connected pieces, which are the main unit (i.e. the transmitter) and a sensor (Gebhart, 2019). The size of the transmitter is 3.27 inches (Width) × 3.15 inches (Length) × 1.3 inches (Height) and weighs 2.56 ounces (DFree, n.d.). The size of the sensor is 2.13 inches (Width) × 1.38 inches (Length) × 0.48 inches (Height) and weighs 0.64 ounces (DFree, n.d.). DFree® ‘has a built-in lithium-ion rechargeable battery’ (PRNewswire, 2018) which would last ‘approximately 24 hours under normal usage and can be fully charged in four hours’ (PRNewswire, 2018). The transmitter device can be clipped to a user’s belt or fit in his/her pocket while putting the smaller sensor about 0.5 inches above their pubis bone with medical tape after applying ultrasound gel (Anderton, 2019; DFree, n.d.; Gebhart, 2019; PRNewswire, 2018). ‘Bladder indicator light will change color when the sensor is placed in the right location’ (DFree, n.d.). The device uses safe ultrasound technology to detect the changing size of the user’s bladder as he/she accumulates urine (Business Insider South Africa, 2019; Gebhart, 2019; Stolyar, 2019; ‘Triple W Partners with Pisces Healthcare Solutions’, 2019). DFree® Personal syncs with the companion application on the user’s smartphone or tablet so that notifications would be sent to the user when it is time to go to the toilet (‘How It Works’, n.d.; ‘Triple W Partners with Pisces Healthcare Solutions’, 2019). The application ‘can be customized to send notifications when the bladder is filled to a specific capacity’ (Stolyar, 2019). It ‘displays the volume in numbers from 0, being completely empty, to 10, being the fullest’ (Business Insider South Africa, 2019). This ensures that users have sufficient time to go to the toilet (Business Insider South Africa, 2019). As regards DFree® Professional, it connects to the Wi-Fi base station that is placed in a patient’s or a resident’s room to upload the bladder data to the cloud, which enables remote monitoring by professional caregivers in real time (‘DFree Professional Health Tech’, 2018; ‘DFree Professional Launches’, 2018; PRNewswire, 2019). The DFree® Professional companion application or the web dashboard can

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track bladder activities of multiple patients/residents on a single screen (PRNewswire, 2019). Advance notifications would be sent to a professional caregiver’s smartphone, tablet, desktop or laptop computer via the application or the web dashboard (PRNewswire, 2019) so that he/she can prioritize assistance for an individual patient’s or resident’s toilet break needs (‘DFree Professional Health Tech’, 2018) and has ample time to help patients/residents get to the toilet (‘DFree Professional Health Tech’, 2018; ‘DFree® Pro’, n.d.; ‘Meet DFree® ’, n.d.; ‘Spotlight On: DFree’, n.d.). The data collected by the application would be ‘analyzed using a patented algorithm to predict urination timing’ (‘Spotlight On: DFree’, n.d.). DFree® aims to support daily toileting (DFree, n.d.) and help users ‘prevent accidental urinary leaks’ (‘Triple W Partners with Pisces Healthcare Solutions’, 2019). This in turn helps maintain the dignity of users (Kyodo News, 2020), enables them to live a more active and independent daily life (‘Triple W Develops DFree’, 2021), ‘have a safe and cost-effective alternative to diapers and medications’ (‘Triple W Develops DFree’, 2021) and mitigate caregiver burden (‘Triple W Partners with Pisces Healthcare Solutions’, 2019). But DFree® costs US$500, which is rather expensive (Anderton, 2019; Gebhart, 2019). Alternatively, it can be rented for US$40 per month (Anderton, 2019; Gebhart, 2019). Since 2017, DFree® has been used in more than 500 elder care facilities in Japan and Europe (PRNewswire, 2018). In Singapore, a nursing home carried out a trial to see if DFree® could help monitor bladder fullness of residents who could not recognize or communicate that they needed to go to the toilet (Interview 21SG44). The aim was to use DFree® to predict urination timing of the residents so that caregivers could help residents get to the toilet in time (Interview 21SG44). However, there were three main issues facing the nursing home when it introduced DFree® to residents. First, placing the sensor of DFree® on the lower abdomen to monitor the change in bladder size made residents felt uncomfortable and strange (Interview 21SG44) because the lower abdomen area was a sensitive area. Since the nursing home was not an air-conditioned space, wearing DFree® made some residents feel very itchy and hot, thereby removing DFree® by themselves (Interview 21SG44). In the beginning, nursing home staff were able to convince some residents to wear DFree® (Interview 21SG44). But most of the residents refused to wear DFree® at a later stage because of the uncomfortable feeling (Interview 21SG44). Residents’ acceptance of the

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device may increase if there was an improved design of DFree® , which no longer required the use of medical tape to place and secure the sensor on the lower abdomen (Interview 21SG44). Second, there was the connection issue (Interview 21SG44). DFree® connected to the Wi-Fi base station that was placed in a resident’s room to upload the bladder data to the cloud. However, the wireless range of the Wi-Fi base station was just 10 metres (Interview 21SG44). Once the residents with DFree® left their rooms, the connection between the Wi-Fi base station and DFree® would be lost (Interview 21SG44). Hence, the bladder data sent to the cloud was not completed and hence nursing home staff was not able to track bladder fullness of some residents. Residents liked to move around a lot because the nursing home was quite big (Interview 21SG44). Sometimes DFree® would be dropped on the floor when residents moved around.1 Besides, nursing home staff also encouraged residents to move around instead of staying in bed all day (Interview 21SG44). Hence, it would be difficult for nursing home staff to ask residents to stay in their rooms simply because of the need to collect their bladder data (Interview 21SG44). Meanwhile, due to the layout of the nursing home, certain areas could not be covered by Wi-Fi properly or unstable Wi-Fi often occurred in the nursing home (Interview 21SG44). This would also affect the collection of bladder data as well as the transfer of bladder data to the cloud. Third, some residents made the request of going to the toilet although the bladder data showed that the resident’s urine volume had yet to reach a level for toilet visit.2 Under this circumstance, nursing home staff still needed to help these residents get to the toilet because they could not argue with the residents or disregard the toilet rights of residents.3

1 This point was mentioned by the same professional caregiver who accepted to be interviewed in this study in a discussion session of a three-hour seminar on digital health on 4 October 2021. The seminar was run by the author of this study. 2 This point was mentioned by the same professional caregiver who accepted to be interviewed in this study in a discussion session of a three-hour seminar on digital health on 4 October 2021. The seminar was run by the author of this study. 3 This point was mentioned by the same professional caregiver who accepted to be interviewed in this study in a discussion session of a three-hour seminar on digital health on 4 October 2021. The seminar was run by the author of this study.

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Smart Health Video Consultation ‘Teleconsultation refers to the electronic communication between a clinician and patient for the purpose of diagnostic or therapeutic advice’ (‘Teleconsultation: Enhancing Interactions’, n.d.). It can be done through a phone call or video call (‘Teleconsult’, n.d.). In April 2017, Smart Health Video Consultation (SHVC) was introduced to several public hospitals in Singapore to enable patients to remotely consult healthcare professionals via a synchronous video call (‘Healthcare Consultations Move Online’, 2017). One of the public hospitals used SHVC to provide remote consultation for older residents with mental illness in over 20 nursing homes (Interview 19SG15). In order to be eligible for teleconsultation, older residents must first have a face-to-face consultation with the doctor (Interview 19SG15). This helped the doctor build relationship with older residents (Interview 19SG15). The follow-up consultations could then be done via the synchronous video call (Interview 19SG15). But the public hospital had the annual practice of making one of the follow-up consultations a face-to-face consultation so that older residents could do a physical examination (Interview 19SG15). To make video consultations possible, the operation team from the public hospital first went to nursing homes to get a bandwidth check (Interview 19SG15). Screen freeze or latency in the connection could be avoided if there was the right Internet speed for video conferencing (Bell, 2021). Teleconsultation was carried out in a room of a nursing home (Interview 19SG15) to ensure that the privacy of older residents was protected (Interview 19SG15). Staff in nursing homes used a laptop with a webcam to connect the doctor in the public hospital over the Internet (Interview 19SG15). ‘Each private virtual consultation session uses end-to-end encryption and is protected with security measures and proven technologies, such as two-factor authentication’ (‘Healthcare Consultations Move Online’, 2017). All the video consultations were not recorded (Interview 19SG15). When an older resident sat down in front of the web camera, he/she would see the doctor in the screen (Interview 19SG15). Staff who cared for the older resident would also be present during the virtual consultation session (Interview 19SG15). The SHVC used high-resolution live video streams to enable the doctor to have real-time visual patient assessment (Interview 19SG15). A bill would be sent to the nursing home after the video consultation (Interview 19SG15). A courier

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would be sent by the public hospital to deliver medication to nursing homes (Interview 19SG15). There are several advantages of using SHVC. First, the use of SHVC helps save time and money (Interview 19SG15). Before the launch of SHVC, staff at the nursing home had to book a private ambulance and then accompany the older resident to the public hospital to have a faceto-face consultation (Interview 19SG15). A family member of the older resident may have to take leave to accompany the older resident to the public hospital to have a face-to-face consultation if the nursing home was short of staff (Interview 19SG15). The use of a private non-emergency ambulance to have a one-way trip to the hospital for an appointment may cost at least S$60 or S$80 (Interview 19SG15). A visit to the public hospital for a scheduled appointment would take about three hours (Interview 19SG15). The use of SHVC helps save medical transport fees and the time spent on commuting, waiting for consultation and collecting medication at the public hospital (Interview 19SG15). A half-day video consultation in the morning enabled the doctor to consult with 20 older residents (Interview 19SG15). Second, the use of SHVC can avoid patient no-shows at scheduled appointments (Interview 19SG15). Patient noshows occurred when the nursing home was short of staff and could not find a care worker to accompany the older resident to the public hospital to have a face-to-face consultation (Interview 19SG15). They also occurred when a private ambulance was not available (Interview 19SG15). Patient no-shows cause ‘a minimized access for other patients’ (Marbouh et al., 2020: 510) and waste human resources (Marbouh et al., 2020: 509). After the launch of video consultation, the public hospital would send a patient list to the nursing home one day before teleconsultation to confirm which older residents could attend the consultation (Interview 19SG15). This enables the doctor to clearly know which older residents he/she would consult with the next day (Interview 19SG15). Third, the use of SHVC enables the doctor to have direction communication with care workers who take care of older residents (Interview 19SG15). Due to manpower shortage, nursing homes usually sent a junior staff who was not directly involved in the care of the older resident to accompany the older resident to the public hospital for a scheduled appointment (Interview 19SG15). This led to the accompanying staff failing to answer the doctor’s enquiries on the older resident’s situation after taking medications (Interview 19SG15). Meanwhile, some older residents were unable to articulate or clearly express themselves due to

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intellectual disability or their inability to talk (Interview 19SG15). Hence, the doctor had to spend more time to assess the older resident during the face-to-face consultation (Interview 19SG15). He/she had to ask the accompanying staff to pass the meeting note which contained some key points of information (e.g. medication, therapy) or instructions jotted down by the doctor to the care worker who was directly involved in the care of the older resident (Interview 19SG15). But whether the meeting note could be handed over to the right care worker at the nursing home was unknown (Interview 19SG15). Whether the accompanying staff could properly communicate with the care worker who took care of the older resident was also unknown (Interview 19SG15). With SHVC, the care worker who was directly involved in the care of the older resident would be present in the teleconsultation session (Interview 19SG15). This enables the doctor to communicate with the care worker directly and more effectively (Interview 19SG15). The care worker could provide real-time feedback to the doctor regarding the well-being of the older residents being cared for (Interview 19SG15). For example, the care worker let the doctor know that the older resident who took medications had been talking to himself more (Interview 19SG15). This may help the doctor do a faster and more accurate patient assessment (Interview 19SG15). Fourth, the use of SHVC enables continuity of care because it was the same doctor consulting with the older resident (Interview 19SG15). This helps make the older resident more open to tell the doctor about his/her symptoms or let the doctor provide better medical treatment for the older resident (Interview 19SG15). In sum, the SHVC improve the whole process of care for older residents with mental illness at nursing homes (Interview 19SG15).

Conclusion Technologies, if used properly, can improve the quality of life and the quality of care of older adults and relieve the burden on care workers. They will not replace care workers. Instead, they complement care workers and free them up to do more meaningful tasks (e.g. care tasks). It is expected that the scale and the pace of using health information technologies, monitoring technologies, assistive technologies, robotics and other technologies will increase in the LTC sector in future due to manpower shortage and the increase in the number of older adults in Singapore. Factors such as awareness, acceptance, ease of use, trust,

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knowledge and perceived risk will affect technology adoption. It is important to strike a balance between technology and human touch. Implementing technology with a human touch can make older adults feel loved, valued and cared for.

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Yang, J., Menhas, R., Dai, J., Younas, T., Anwar, U., Iqbal, W., Laar, R. A., & Saeed, M. M. (2022). Virtual reality fitness (VRF) for behavior management during the COVID-19 pandemic: A mediation analysis approach. Psychology Research and Behavior Management, 15, 171–182. https://pubmed.ncbi.nlm. nih.gov/35082540/ Yap, E. (2021, March 8). Keeping seniors engaged. Retrieved April 4, 2022, from https://projectcare.co/keeping-seniors-engaged/ Yoshida, E. (2019). Robots that look like humans: A brief look into humanoid robotics. Mètode Science Studies Journal, 9, 143–151. https://doi.org/10. 7203/metode.9.11405 Zhang, J., & Xiao, N. (2020). Capsule network-based facial expression recognition method for a humanoid robot. In V. Jain, S. Patnaik, F. P. Vl˘adicescu and I. K. Sethi (Eds.), Recent trends in intelligent computing, communication and devices: Proceedings of ICCD 2018 (pp. 113–121). Springer. Zhao, Y., Rokhani, F. Z., Sazlina, S.-G., Devaraj, N. K., Su, J., & Chew, B.H. (2022). Defining the concepts of a smart nursing home and its potential technology utilities that integrate medical services and are acceptable to stakeholders: A scoping review. BMC Geriatrics, 22, 787. https://doi.org/10. 1186/s12877-022-03424-6

Websites DFree. (n.d.). Retrieved February 14, 2022, from https://www.healthproductsf oryou.com/ProdImages/CommonFile/dfree-professional-product-brochure. pdf DFree® Pro. (n.d.). Retrieved February 16, 2022, from https://www.dropbox. com/s/a8dcygf0e828no9/DFree_Brochure_Professional_8-2019_4pg.pdf? dl=0 DFree professional health tech wearable device for incontinence launches in U.S. for senior care facilities. (2018). Retrieved February 16, 2022, from https://www.dfreeus.biz/press-releases/dfree-professional-health-techwearable-device-for-incontinence-launches-in-u-s-for-senior-care-facilities DFree Professional launches for patient care facilities. (2018). Retrieved February 16, 2022, from https://rehabpub.com/conditions/dfree-professio nal-launches-patient-care-facilities/ Future ready: NTUC Health goes digital. (n.d.). Retrieved April 4, 2022, from https://www.sncf.coop/component/tags/tag/ntuc-health H21—LEDs. (n.d.). Retrieved February 21, 2022, from http://doc.aldebaran. com/1-14/family/nao_h21/leds_h21.html Healthcare consultations move online in Singapore’s first national implementation of Smart Health Video Consultation for Healthcare. (2017). Retrieved

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December 17, 2022, from https://www.ihis.com.sg/Latest_News/Media_ Releases/Pages/Healthcare-Consultations-Move-Online-in-Singapore%E2% 80%99s-First-National-Implementation-of-VC.aspx How it works. (n.d.). Retrieved February 14, 2022, from https://www.dfreeus. biz/how-it-works Meet DFree®. (n.d.). Retrieved February 16, 2022, from https://www.dfreeus. biz/dfree Nao. (n.d.). Retrieved February 21, 2022, from https://robots.ieee.org/robots/ nao/ NAO humanoid robot audio. (n.d.). Retrieved February 21, 2022, from https:// www.robotcenter.co.uk/pages/nao-humanoid-robot-audio NAO humanoid robot motion. (n.d.). Retrieved February 21, 2022, from https://www.robotcenter.co.uk/pages/nao-humanoid-robot-motion NAO humanoid robot vision. (n.d.). Retrieved February 21, 2022, from https:// www.robotcenter.co.uk/pages/nao-humanoid-robot-vision NAOqi framework. (n.d.). Retrieved February 21, 2022, from http://doc.ald ebaran.com/1-14/dev/naoqi/index.html NTUC Health reimagines care for seniors through immersive room experiences and more. (2021). Retrieved April 4, 2022, from https://aic-mosaic.sg/2021/ 01/26/how-ntuc-health-reimagine-care-seniors-singapore/ Spotlight on: DFree. (n.d.). Retrieved February 16, 2022, from https://www. nafc.org/featured-product-partner-dfree Teleconsult. (n.d.). Retrieved December 17, 2022, from https://www.nuh.com. sg/patients-visitors/Pages/Teleconsult.aspx Teleconsultation: Enhancing interactions between clinicians and patients. (n.d.). Retrieved December 17, 2022, from https://cis.unimelb.edu.au/hci/pro jects/teleconsultation The future is Nao: Is robot therapy the next big thing for seniors’ rehab? (2021). Retrieved February 18, 2022, from https://aic-mosaic.sg/2021/04/07/ robot-therapy-nao-future-rehabilitation-yishun-community-hospital/ Triple W develops DFree, the first wearable device to predict when you need to go to the bathroom. (2021). Retrieved February 14, 2022, from https://www.superbcrew.com/triple-w-develops-dfree-the-firstwearable-device-to-predict-when-you-need-to-go-to-the-bathroom/ Triple W partners with Pisces Healthcare Solutions to provide first wearable device for urinary incontinence to veterans. (2019). Retrieved February 14, 2022, from https://www.prweb.com/releases/triple_w_partners_with_pis ces_healthcare_solutions_to_provide_first_wearable_device_for_urinary_inco ntinence_to_veterans/prweb16751771.htm Virtual reality: Another world within sight. (n.d.) Retrieved March 1, 2022, from https://www.iberdrola.com/innovation/virtual-reality

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Virtual reality for dementia. (n.d.). Retrieved April 2, 2022, from http://www. mindpalacevr.org/ Urinary incontinence. (n.d.). Retrieved February 16, 2022, from https://www. continence.org.au/types-incontinence/urinary-incontinence

Interview Interview 18SG01, a researcher in a university, June 2018. Interview 19SG15, Chief Operating Officer in a public hospital, January 2019. Interview 19SG25, a technology artist, October 2019. Interview 21SG44, a professional caregiver in a nursing home, December 2021. Interview 22SG45, a follow-up interview with the professional caregiver in a nursing home, February 2022. Interview 22SG46, a follow-up interview with the researcher in a university, February 2022.

CHAPTER 5

Digital Connection with Older Adults in the Time of COVID-19

Abstract The outbreak of the 2019 coronavirus disease (COVID-19) has infected a lot of Singaporeans and caused major disruptions to everyday life. It has accelerated people’s adoption of digital devices to work, play, and stay connected with friends when they have to stay at home to reduce their exposure to the virus. This chapter will examine how Facebook, WhatsApp and Zoom were utilized by a social enterprise, a senior activity centre (SAC) and National Gallery Singapore (NGS) to deliver digital knowledge and skills, physical exercise classes and tours of artwork to older adults in the time of COVID-19. Looking forward, more older adults can learn and acquire sufficient digital literacy skills to use social media, mobile applications and other digital devices. This enables them to stay relevant and live a more independent and fulfilling life. Keywords People with dementia · Senior activity centre · The 2019 coronavirus disease · Virtual tour · Xiohoo · Zoom

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 S. Ching Yuen Luk, Healthy Ageing in Singapore, Social Policy and Development Studies in East Asia, https://doi.org/10.1007/978-981-99-0872-1_5

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Introduction The 2019 coronavirus disease (COVID-19) is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) (Vodnar et al., 2020). It first emerged in Wuhan City, in the Hubei Province in China in late December 2019 and became a pandemic on March 11 2020 (Luk & Preston, 2021: 106). As of December 26, 2022, over 657 million confirmed cases and over 6.6 million deaths have been reported globally (‘COVID-19 Dashboard’ 2022). ‘The COVID19 outbreak in Singapore began on January 23, 2020, when the Ministry of Health (MOH) confirmed the first imported case from Wuhan’ (Luk & Preston, 2021: 107). As of December 26, 2022, over 2.1 million confirmed cases and 1,711 deaths were reported in Singapore (‘COVID-19 Situation at a Glance’ n.d.). In order to limit the exposure of residents to COVID-19, the Singapore government put in place partial lockdown and strict safe distancing measures (Luk & Preston, 2021: 122). Schools and most workplaces were closed. Singapore residents had to stay at home and went out only for essential activities such as buying food and doing physical exercise (Yong, 2020). This led to people spending more time online— whether for school, work or social interaction (Organisation for Economic Co-operation and Development, 2020: 5). This chapter examines how Facebook, WhatsApp and Zoom were utilized by a social enterprise, a senior activity centre (SAC) and National Gallery Singapore (NGS) to deliver digital knowledge and skills, physical exercise classes and tours of artwork to older adults in the time of COVID-19.

XIOHOO: Empowering Older Adults with Digital Knowledge and Skills Established in 2018, Xiohoo is a social enterprise appointed by Infocomm Media Development Authority (IMDA) as a Silver Infocomm Junction (SIJ) (i.e. a senior-friendly infocomm learning hub) (‘Silver Infocomm Junctions’, 2020) to offer useful and affordable technology training classes for older adults in Singapore (Interview 19SG18). Its name comes from a phonetical word ‘xiang zhu’ in Teochew dialect (Yap, 2018), which means ‘to help each other’ (Ang, 2020; Interview 19SG18). It provides a wide range of courses for older adults to increase their digital literacy. These include courses on smartphone/tablet usage, the use of

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communication applications (e.g. WhatsApp, WeChat) and productivity applications (e.g. Google Drive, Google Maps), video conference (e.g. Zoom), digital entertainment (e.g. YouTube, meWatch), mobile photography and videography, video and digital photo editing, online shopping and selling, electronic payment (e-payment), cybersecurity, government digital services and applications (‘Courses for Seniors’ n.d.). All the courses provided by Xiohoo are bilingual, using both Mandarin and English as the language of instruction (Interview 19SG18). Each course lasts for 2.5 to 3 hours (‘Courses for Seniors’ n.d.). The fee of each course is SG$50. However, older participants who are Singapore citizens or Permanent Residents (PRs) aged 50 or over are eligible for course subsidies (‘Course in April, 2022’ n.d.). Xiohoo sometimes provide free training programs for older participants when it collaborates with organizations which usually subsidize trainer fees and venue costs (Interview 19SG18). Older participants are required to bring their smartphones to class to have hands-on learning. They would receive a soft copy of PowerPoint slides of the course for reference (Interview 19SG18) and obtain a question-and-answer service after class to query and troubleshoot anywhere, anytime (Yap, 2018). Older adults want to learn about technology (Interview 19SG18). But they would usually forget what they have learned after class (Interview 19SG18). Hence, the provision of the question-and-answer service aims to provide older adults with more guidance after class so that what they have learnt from the class will not be wasted (Interview 19SG18). The service allows older adults to ‘use the peer-to-peer app to ask IT experts for help, or use features like “Screen Calling” to obtain face-to-face support’ (Yap, 2018). Older adults can also use WhatsApp to contact trainers if they have any questions (Interview 19SG18). During the classes, trainers would make learning engaging and easier for older adults. One way to do it is to communicate with older adults in the way they like it (Interview 19SG18). For example, older adults like to call Google Photos ‘feng shan’ in Mandarin, which means ‘a fan’ in English because the icon for Google Photos looks like a fan (Interview 19SG18). Recognizing that older adults do not understand what a hamburger menu is, trainers would call the hamburger menu ‘three lines’ because the icon for the hamburger menu consists of three parallel horizontal lines (Interview 19SG18). The use of lingo can help older adults

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remember and understand some of the features of mobile applications more easily (Interview 19SG18). Trainers have helped older adults become more tech-savvy. Many older adults bring their friends to join the classes (Interview 19SG18). They can also make new friends when attending classes (Interview 19SG18). They are able to apply the knowledge and skills acquired from courses in everyday lives in many ways. Those who have attended a course on WhatsApp know how to stay connected with their friends and family (Interview 19SG18), use WhatsApp to add contacts, create group chats, make voice calls and video calls (‘Courses for Seniors’ n.d.) and ‘send messages, images and files’ (‘Courses for Seniors’ n.d.). The use of WhatsApp enables older adults to interact with other people more easily, which helps reduce social isolation (Yap, 2018). Most of the older adults who have attended a course on Facebook do not like to share things about them on Facebook (Interview 19SG18). One possible explanation for this is their concern about privacy. But older adults like to use Facebook to follow some pages or read news to see what is going on (Interview 19SG18). Older adults who have attended a course on mobile videography learn how to record their own videos (Interview 19SG18). For example, a grandmother learnt to create an educational video to teach her grandchildren to count numbers (Interview 19SG18). Those who have attended the ‘Get Creative’ class learn how to create images with motivational messages on their own and add emojis to pictures (Interview 19SG18). For older adults who have attended a course on e-payment, some of them can make payments with their smartphones in daily life without the need to carry cash or count the correct change that is given to them (Yap, 2018). However, some older adults are still reluctant to use epayment because of two main reasons. First, they worry about whether their money will disappear in a digital setting (Interview 19SG18). When using e-payment, older adults cannot see or touch currency notes (Interview 19SG18) because electronic money is not physically tangible like cash. This makes them feel uncomfortable with e-payment. They worry that they may lose money due to security vulnerabilities in e-payment systems (Interview 19SG18). Hence, the trainer would reassure older adults that e-payment is safe because there are security measures such as a one-time password (OTP), short message service (SMS) and Personal Identification Number (PIN) putting in place to ensure the safety of online transactions (Interview 19SG18). He suggested older adults open

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a new bank account solely used for online transactions and maintain a minimum balance inside it if they want to use e-payment but have security concerns over it (Interview 19SG18). Second, there is the issue of ease of use (Interview 19SG18). Some older adults think that e-payment is not user-friendly because it involves more steps than exchange of cash (Interview 19SG18). For example, an older adult can only use electronic wallet (e-wallet) unless he/she has already gone through the steps of having a bank account, registering for and activating Internet banking, and transferring money from his/her bank account to his/her e-wallet (Interview 19SG18). Having too many e-wallets in the market also make it difficult for older adults to choose the right e-wallet because they need time to find out the differences between these e-wallets (Interview 19SG18). While e-wallets in general offer a fast, easy and secure payment experience (Hartung, 2020), some e-wallets bring extra benefits to consumers because they let consumers ‘receive offers, rewards, and discounts’ (Hartung, 2020). Besides, some of them contain integrated features such as splitting bills with friends, food ordering and restaurant reservations (Hartung, 2020). These bring convenience and better user experience to consumers. The outbreak of COVID-19 in Singapore led to the country entering the period of Circuit Breaker (CB) (7 April 2020–1 June 2020) to reduce the transmission of the virus. During the CB period, there was ‘a ban on dining in at eateries, curbs on people leaving their homes except for essential reasons and the closure of workplaces and schools’ (Goh, 2021). It also led to the suspension of all classroom courses offered by Xiohoo (Ang, 2020). In order to keep older adults physically and mentally active, Xiohoo stepped up to connect and engage with older adults through Facebook and WhatsApp (Ang, 2020). It moved classes online so that older adults could ‘continue learning at home by watching Xiohoo TV on Facebook and browsing through teaching materials shared via WhatsApp’ (Ang, 2020). Through Xiohoo TV, older adults could learn about useful icons and functions found in WhatsApp, Facebook, YouTube, Zoom, Google Maps, Google Photos and Google Translate. For example, Episode 3 of Xiohoo TV taught older adults to use WhatsApps to make voice call, video call and group video call (Xiohoo, 2020a, April 17) while Episode of 7 taught older adults how to use PayNow and PayLah! to make digital payment for various products and services, transfer money to their friends and top up their e-wallet (Xiohoo, 2020b, May 18). In Episode 17, older adults learnt to use ‘My Location’, ‘Directions’ and ‘Map Filter Options’ in Google Maps to find their current location, plan their trips and get different transport routes (Xiohoo, 2020c, July 27). In

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Episode 19, older adults learnt to use ‘raise hand’ and ‘clap hands’ icons to communicate with the speaker on Zoom (Xiohoo, 2020d, August 10). The introduction of online classes helped Xiohoo reach out to more older adults (Ang, 2020) and led to ‘active participation on the Facebook page’ (Ang, 2020). When Xiohoo resumes physical classes, it continues to help older adults become tech-savvy and make use of different digital devices and online platforms to keep up to date with the latest policies related to COVID19 (Ang, 2021). From October to December 2021, Xiohoo offered eight sessions sponsored by Shanghai Pudong Development Bank (SPD Bank), Singapore Branch, to a group of older adults aged 50 years old or over (Ang, 2021). Through the sessions, older adults learnt to use Singpass (i.e. the digital identify of Singapore residents to access public and private sector services online), banking and e-payment applications, TraceTogether (i.e. digital contact tracing device) and TikTok and protect themselves from online scams (Ang, 2021). Staff from SPD Bank also volunteered to answer questions raised by older participants and clarify their doubts throughout the duration of the course (Ang, 2021). They also provided useful advice for older adults about ways to use various digital services securely (Ang, 2021). In sum, Xiohoo helps older adults become digitally confident and empowers them with digital knowledge and skills to stay connected with their friends and family, obtain services and useful information and live an independent and meaning life.

Zoom: The Use of Video Conferencing Application to Move Physical Exercise Classes Online In Singapore, senior activity centres (SACs) which are drop-in centres located in Housing and Development Board (HDB) rental blocks provide social and recreational activities (e.g. art and craft, karaoke, physical exercises), befriending programmes (e.g. home visits) and support services (e.g. information and referral to care services) for older adults so that the latter can age in place within their communities (Grey n.d.-a; ‘Senior Activity Centre’ n.d.; ‘Senior Activity Centres in Singapore’ n.d.). Although all older adults are welcome to visit SACs, older adults served in SACs are mostly those who have low incomes, live alone, physically vulnerable due to health issues or are at risk of social isolation (Grey n.d.-a).

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Before the outbreak of COVID-19, a SAC offered aerobics and resistance band exercise classes every week to older adults (Interview 20SG32) to help them counteract and prevent diseases, build strong bones, reduce the risk of falls and improve mental health and overall quality of life (Grey n.d.-b). Older adults who were constricted to a wheelchair could also visit the SAC to do exercises with proper guidance from a fitness instructor (Interview 20SG32). The fitness instructor in the SAC would play upbeat music or songs to get older adults motivated while exercising (Interview 20SG32). This is because upbeat music can function as a stimulant which increases arousal (Karageorghis & Terry, 2012: 18). In fact, music and exercise are an effective pairing (Jabr, 2013). Music has an ergogenic (i.e. work enhancing) effect which can increase exercise participants’ work capacity and delay their fatigue (Karageorghis et al., 2010: 551). It can result in ‘higher-than-expected levels of endurance, power, productivity, or strength’ (Karageorghis et al., 2010: 551). Besides, music ‘can function as a metronome’ (Jabr, 2013). It enables exercise participants to maintain a steady pace and help their bodies use energy more efficiently when moving rhythmically to a beat (Jabr, 2013). Exercises that are repetitive in nature ‘lend themselves particularly well to musical accompaniment’ (Terry & Karageorghis, 2006: 4). Music can also elevate exercise participants’ mood (e.g. excitement, happiness, vigour) (Karageorghis & Terry, 2012: 18) and make exercises more fun and enjoyable (Ferreira, 2017). Apart from music, the fitness instructor would motivate older adults by teaching them to do some easy-to-follow dance moves while exercising (Interview 20SG32). For example, she would tell older adults to ‘Act like a monkey!’ when teaching them to do some dance moves (Interview 20SG32). She would also mimic monkey sound ‘ooh ooh aah aah’ so that older adults would laugh and find the exercise more interesting (Interview 20SG32). Games was another way to motivate older adults while exercising. For example, hula hoop pass required older adults to pass the hula hoop around the circle without anyone letting go of their groupmates’ hands (Interview 20SG32). This game got older adults thinking ways to coordinate their body movements (Interview 20SG32) and could promote teambuilding, teamwork and good communication. Older adults could be incentivized further when there was score calculation and the fitness instructor also participated in the games (Interview 20SG32). Starting from March 2020, however, the spread of COVID-19 among older adults led to the government suspending all senior-centric courses and activities in SACs, community clubs (CCs), residents’ committees

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(RCs), Active Ageing Hubs, ActiveSG sport centres and Community Resource Engagement and Support Team (CREST) centres (‘Additional Precautionary Measures to Protect Our Seniors’, 2020). There was evidence of COVID-19 transmission among older adults participating in singing classes and other group activities such as line-dancing and qigong because some older adults who were unwell had continued to participate in these activities in different CCs and RCs (‘Additional Precautionary Measures to Protect Our Seniors’, 2020). Hence, the suspension of all senior-centric courses and activities became a precautionary measure to protect older adults against COVID-19. Older adults, especially those with hypertension or pre-existing heart conditions, were more vulnerable to COVID-19 infection due to lower immunity and reduced physiological reserves (‘COVID-19: Seniors more vulnerable’, 2020). As of 19 March, 2020, around 25 percent of confirmed cases in Singapore were older adults aged 60 and above (‘Taking care of our seniors’, 2020). As of 14 April, 2020, 9 out of 10 deaths due to COVID-19 infection were older adults aged 65 years and above (‘COVID-19 Advisory for the Older Person’, 2020). In order to reduce older adult’s risk of exposure to COVID-19, health minister urged older adults to stay indoors for their safety and not to meet family members they did not live with (Wong & Tai, 2020). The suspension of all senior-centric activities and the stay-home measures led to the lack of social interaction and disruption to usual routines for many older adults (Tai, 2020). These in turn affected the social and mental wellness of older adults (Centre for Research on Successful Ageing, 2020; Tai, 2020). A local survey which examined the wellbeing of about 7,500 older Singaporeans aged 55 to 75 in the time of COVID-19 found that overall life satisfaction of respondents decreased by 3.8 percent in April 2020 and 4.0 percent in May 2020, as compared to January 2020 (Centre for Research on Successful Ageing, 2020: 8). Besides, it found that respondents who lived alone experienced a larger increase in feelings of socially isolation in April 2020 than those who did not live alone (Centre for Research on Successful Ageing, 2020: 10). The survey also found that over one-third of respondents ‘were very or extremely worried about the health of their loved ones’ (Centre for Research on Successful Ageing, 2020: 12) while 29 percent of respondents ‘were worried about the availability of medical treatment if they contracted COVID-19’ (Centre for Research on Successful Ageing, 2020: 12). In another study, the findings showed that the mental health of

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community-dwelling older adults in Singapore deteriorated during the period of CB (Yu & Mahendran, 2021). Paired-samples t-tests revealed a significant increase in the Geriatric Depression Scale (GDS) score (t = 10.61, p ≤ 0.001, cohen’s d = 0.52) and the Geriatric Anxiety Inventory (GAI) score (t = 2.30, p = 0.022, cohen’s d = 0.11), both of which corresponded to worse outcomes (Yu & Mahendran, 2021). Meanwhile, paired-samples t-tests revealed a significant decrease in the friendship scale score which measured social isolation (t = 5.14, p ≤ 0.001, cohen’s d = 0.25), corresponding to worse outcomes (Yu & Mahendran, 2021). Hence, ensuring that older adults remained socially connected and had adequate social support were found to be critical in improving the mental health of older adults (Centre for Research on Successful Ageing, 2021: 20). During the period of CB, the fitness instructor in the SAC prerecorded physical exercise videos and then sent the videos to older adults she coached via WhatsApp (Interview 20SG32). Older adults could follow the videos to do exercises (Interview 20SG32). But there was the lack of interactions (Interview 20SG32). Meanwhile, the fitness instructor used WhatsApp group video calls to stay connected with about 50 older adults she coached and provide emotional support for them (Interview 20SG32). The group video calls she set up could support eight persons at a time (Interview 20SG32). To make the 8-person video calls possible, the fitness instructor gave necessary technical guidance to older adults to help them update WhatsApp to the latest version on their phones (Interview 20SG32). She usually made the WhatsApp group video calls from 2:00 p.m. to 5:00 p.m. every day because most of the older adults were available during this period of time (Interview 20SG32). Through the group video calls, the fitness instructor and older adults greeted each other and had casual communication (Interview 20SG32). They were excited and happy to talk about what they did that day (e.g. having indoor cycling workout, planting flowers at home) (Interview 20SG32). The use of WhatsApp group video calls during the period of CB helped ‘compensate for the lack of face-to-face interactions and to fight social isolation and psychological distress’ (Costa et al., 2022). It enabled users to ‘experience co-presence and proximity with others’ (Costa et al., 2022) and ‘maintain a sense of togetherness across distance’ (Costa et al., 2022). In early June 2020, SACs and CREST centres were allowed to resume activities which could be done individually (e.g. gardening, reading) (Koh, 2020). But limits were set on activity durations and number of

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participants allowed to minimize social interactions (Koh, 2020). Starting from 9 September, 2020, SACs and other eldercare facilities were allowed to resume small group activities of up to five people (Chong, 2020). These small group activities included board games and exercise classes (Chong, 2020). For SACs, they used Zoom to provide live exercise classes (Interview 20SG32). The fitness instructor could stay at home and use Zoom to coach older adults who came to different SACs and those who stayed at home to do resistance band exercises (Interview 20SG32). Since social distancing measures were put in place at each SAC, five adults who came to the centre to watch the Zoom live exercise session had to wear face masks and were told to seat on a chair to do physical exercises (Interview 20SG32). This meant that the fitness instructor could only teach simple exercises that did not involve dance moves or require standing (Interview 20SG32). For older adults who stayed at home, they received necessary technical guidance from staff at SACs to use Zoom (Interview 20SG32). They did not have to wear face masks and could choose to stand up while exercising (Interview 20SG32). But some of them may watch the live sessions on a smaller device such as their mobile phones. Hence, the fitness instructor had to check on older adults regularly to ensure that they could see her do exercise clearly. The advantage of conducting Zoom live exercise sessions is that the fitness instructor could reach a wider audience (Interview 20SG32). She could overcome geographical boundaries and meet many older adults in other SACs via Zoom (Interview 20SG32). She could still play music on Zoom live exercise sessions (Interview 20SG32). When hosting exercise session over Zoom, she could see if older adults were performing exercises correctly (Interview 20SG32). She would correct the postures of older adults by verbalizing what should be done (Interview 20SG32). For example, she would use analogy and say ‘must be straight like a ruler’ to remind older adults to hold up their hands straight or keep their wrist straight (Interview 20SG32). She would also say ‘must hit that tree’ or ‘must chop down the tree’ if she wanted older adults to put forth their strength to do physical exercises (Interview 20SG32). Sometimes she would even call out the names of older adults whom she knew to correct their postures (Interview 20SG32). Since she muted older participants to block out unwanted background noises, she found that she lacked interactions with older adults (Interview 20SG32). Hence, she would make funny faces over Zoom to make older adults laugh or say words of encouragement

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such as ‘Come on! You can do it!’ to motivate older adults to do exercises (Interview 20SG32). In sum, conducting live exercise sessions over Zoom helped older adults ‘get back on their fitness routines’ (Narayanan, 2020) and stay physically active (Narayanan, 2020).

Art with You: From Virtual Tours to On-Site Tours of Artwork for People with Dementia NGS is a visual arts institution overseeing the largest public collection of modern art from Southeast Asia (‘The Art and Soul of Southeast Asia’ n.d.). It collaborated with Dementia Singapore, which is a leading nonprofit organization in dementia care, to develop a program called Art with You (Lee, 2021). The program aims to foster meaningful and positive engagement for people with dementia (PWD) and their caregivers through art (‘Art with You’ n.d.; Lee, 2021). It consists of a welcome session, chit-chat for reality orientation, a tour of artwork and a handson art making session (Interview 22SG47). It is available in English or Mandarin (Interview 22SG47). Most of the PWD joining Art with You were about 80 years old and were in the early stage or middle stage of dementia (Interview 21SG40). Because of the COVID-19 pandemic, Art with You was introduced in three stages. In the first stage, the program was conducted virtually via Zoom (Interview 21SG40). The duration of the program was about 1 to 1.5 hours (Interview 22SG47). PWD received technical assistance from their family members or caregivers (e.g. domestic helpers) to join the guided tours of artwork in the comfort of their homes (Interview 21SG40). The tour of artwork was led by a museum docent from NGS (Interview 21SG40). Each tour had four PWD (Interview 21SG40). Most of the PWD were accompanied by a family member (e.g. spouse or child) or a domestic helper (Interview 22SG47). But family members and domestic helper would not appear in the screen (Interview 22SG47). On the day of the virtual tour, two staff from Dementia Singapore would provide phone answering services to family members or caregivers of PWD experiencing technical issues with Zoom (e.g. being logged out of Zoom) (Interview 21SG40). The virtual tour only showed one painting to PWD (Interview 21SG40). After joining the virtual tour, PWD had the hands-on art making session conducted by staff from Dementia Singapore (Interview 21SG42; Interview 22SG47). PWD would use the art materials sent to their homes earlier to have some

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hands-on art making activities (Interview 21SG40). The same group of PWD attended four different Art with You sessions in different weeks, which gave PWD opportunities to meet different museum docents, explore different artworks and have different art-making activities (Interview 22SG47). Staff from Dementia Singapore carried out Dementia Care Mapping (DCM) (Interview 22SG47), which is an intensive observational tool designed to evaluate the quality and effectiveness of care from the perspective of PWD (Schaap et al., 2021: 150–151). They also used a Mood and Engagement (ME) value to measure the wellbeing of PWD (Interview 22SG47). In the second stage, Art with You was conducted virtually via Zoom in day care centres (Interview 21SG40). PWD were gathered in a room to join the virtual tour of artwork remotely conducted by a museum docent (Interview 21SG40; Interview 21SG42; Interview 22SG47). But they sat around in a square setting to maintain social distance (Interview 21SG40). They could first see the painting in a big screen (Interview 21SG40; Interview 21SG42). Then, the museum docent used a gadget to zoom into different portions of the painting and discussed the painting with PWD (Interview 22SG47). The virtual tour was followed by an on-site art-making session conducted by staff from Dementia Singapore (Interview 22SG47). In the third stage, the program was conducted physically at NGS to allow different groups of PWD from the day care centre to see artworks in the galleries and have hands-on art making activities (Interview 22SG49). NGS is accessible to PWD requiring a wheelchair in mobility (Interview 22SG49). All levels can be accessed by lifts. There are accessible toilets near lift lobbies (Interview 22SG49). The tour of artworks for PWD is held in the morning on weekday to avoid crowds (Interview 22SG49). Every time, a museum docent would lead a group of four PWD to DBS Singapore Gallery to see and discuss some paintings (Interview 22SG49). PWD were accompanied by their family caregivers (Interview 22SG49). They were also accompanied by a manager and an assistant from the day care centre because centre staff were familiar with the behaviours and liking of PWD (Interview 22SG49). A staff from Dementia Singapore would be present to assess the mood and engagement of PWD during the tour (Interview 22SG49). Best Friends of the Gallery (BFG), who were volunteers of NGS, were also present to guide and assist PWD (Interview 22SG49). Each group of PWD attended three different Art with You sessions in different weeks (Interview 22SG49). Each session has

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a different theme. The themes include food, stories and places (Interview 22SG49). The duration of the tour of artworks would last for 45 to 60 minutes (Interview 22SG49). The tour is followed by a 15-minute refreshment break (Interview 22SG49). Then, PWD would attend a 30minute hands-on art making session conducted by the museum docent (Interview 22SG49). In the session, PWD and their caregivers made their own postcards using the materials (e.g. stickers, pictures) available (Interview 22SG49). When they finished making the postcards, they were asked by the museum docent to share about whom they would like to give this postcard to and why, the design of the postcard and the story behind it (Interview 22SG49). This helped the museum docent know PWD better, tiggered the conversation and interactions among PWD and between PWD and their caregivers (Interview 22SG49). Preparation work had to be carried out for the tours of artworks (Interview 21SG40). For the virtual tour, NGS and Dementia Singapore jointly decided on the theme of a tour of artwork (Interview 21SG42). Then, they chose three paintings which could match with the theme (Interview 21SG42; Interview 22SG47). These paintings were from the collection of NGS (Interview 22SG47). Among these three paintings, a museum docent could choose one painting that he/she would like to show to PWD in the tour (Interview 22SG47). Once the painting was chosen, the museum docent would study the background of the painting (Interview 21SG42). Besides, he/she spent time finding photographs which would be used to supplement the painting and trigger memories in PWD (Interview 21SG40; Interview 21SG42). These photographs came from the National Archives of Singapore (NAS) and other social media (Interview 21SG40; Interview 22SG47). The museum docent would also read the background information (e.g. race, education level, former occupation) of PWD so that he/she could know PWD better and know how to ask questions which could lead to PWD sharing memories of their past experiences while looking at the painting (Interview 21SG40; Interview 22SG47). He/she aimed to let PWD go on a reminiscence journey during the tour of artwork while appreciating art. Take the virtual tour of Market at Marmot (1940; Oil on board, 220 × 254 cm) as an example. Market at Marmot was created by a French traveller artist called Louis Rollet. It depicted a market scene in an Eastern Cambodian district sharing a border with Vietnam (Interview 21SG42). People in the painting had tawny skin and placid facial expressions. Some

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of them were street vendors, selling vegetables, fresh fruits (e.g. watermelon), fish and live poultry (e.g. ducks). Some of them were customers. The left-hand side of the painting depicted a man walking with a wooden carrying pole over one shoulder to transport produce. Dried sausages, dried salted fish and dried salted meats were seen hanging on a tree. The right-hand side of the painting depicted two ladies looking at the vegetables, fruits and poultry. Both of them were wearing áo dài (i.e. the traditional dress of Vietnam). One of them wore nón lá (i.e. Vietnamese conical hat). In the centre of the painting, there was a young lady balancing a rattan tray of herbs and spices on her head. Standing next to her was another young lady who wore Cambodian krama (i.e. traditional checkered scarf) on her head. She was holding a basket with two hands. When preparing for the virtual tour Market at Marmot for PWD who stayed at home, the museum docent had to think of the best way to break the electronic version of the entire painting apart into different portions and then position each portion of the painting on the PowerPoint slide properly (Interview 21SG42). This was because she recognized that PWD had a short attention span and could only focus on one thing at a time (Interview 21SG42). For each portion of the painting, the museum docent prepared for some questions to ask participants on the day of the virtual tour to spark conversation and connection (Interview 21SG42). When it came to the day of the virtual tour, the museum docent would first introduce the artwork to PWD by telling them about the title of the artwork, the artist’s name, the background information of the artist, the date of the artwork, the size of the artwork and the medium of the artwork (Interview 21SG42). She also used to a map to tell PWD about the location of the market (Interview 21SG42). Since the artwork depicted a market scene, the museum docent asked PWD about what they would see or feel if they were in the market (Interview 21SG42). PWD were able to tell the museum docent that the market was a very noisy place where many people would bargain for better prices and people could hear animal sounds (e.g. ducks quack) (Interview 21SG42). To spark conversation, the museum docent complimented the artwork with photos of wet markets in Singapore in the 1950s and 1960s and asked PWD to share their past experience of buying food in wet markets (Interview 21SG40). Then, the museum docent proceeded to direct the focus of PWD to a particular portion of the painting and relate that portion of the painting to someone or something that could trigger the memories of PWD or spark

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conversation among PWD. For example, the museum docent related a man in the painting to a Tok Tok man in the old days of Singapore (Interview 21SG42). A Tok Tok man was a mobile noodle hawker knocking on a bamboo slab with a stick to alert customers of his presence (Lee, 2016; ‘Fatty’s Wanton Mee’, 2019). Using the stick to knock on the bamboo slab ‘emitted a very distinctive “tok tok” sound—hence, giving the Tok Tok Man his name’ (Lee, 2016). Customers staying in a twoto three-storeys high shophouse would lower a basket which contained a coin and an empty bowl to buy noodles from the Tok Tok Man on the street (Interview 21SG40). Once the Tok Tok Man received the payment and put a bowl of noodle into the basket, the customer would pull up the basket to collect the bowl of noodle (Interview 21SG40). When the museum docent directed the focus of PWD to the man in the painting by saying, ‘Oh! This is the Tok Tok Man!’, some of the PWD could related to it as well (Interview 21SG42). PWD told the museum docent that the Tok Tok Man would made different sound tones and beats to indicate different noodles sold by him (Interview 21SG40; Interview 21SG42). ‘Wanton noodles had a straight beat while fishball noodles had a more staccato sound, alternating between high and low pitch’ (Lee, 2016). After PWD shared their memories about the Tok Tok man, the museum docent moved on to bring the attention of PWD to two young ladies in the centre of the painting (Interview 21SG42). She would ask PWD if they could spot a lady balancing a rattan tray of herbs and spices on her head and then talk about all the herbs and spices that were available in the market (Interview 21SG42). This led to an older participant who was over 80 years of age talking about how he used blue ginger to make Teochew braised duck to celebrate the Chinese New Year (Interview 21SG42) and other participants talking about how they made shrimp paste (i.e. a fermented condiment) and used it in some dishes (Interview 21SG40; Interview 21SG42). Many PWD actively engaged in the conversation about local food in Singapore when they looked at the painting (Interview 21SG42). They talked about the best place to buy the food they liked (Interview 21SG42). The conversation about food was then followed by a conversation about costumes when the museum docent directed the focus of PWD to the ladies wearing áo dài in the painting (Interview 21SG42). PWD were asked by the museum docent to make a guess if the ladies were Chinese, Vietnamese or Cambodian (Interview 21SG40). The museum docent encouraged PWD to share their views by saying that there were no right or wrong answers (Interview 21SG40).

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She invited PWD to give her information based on what they saw and how they interpreted the artwork (Interview 21SG40). The virtual tour of Market at Marmot was followed by an art session. In the art session, a sensory stimulation activity was carried out (Interview 22SG47). PWD learnt to use spices and herbs to make scented sachets which could be given to someone they love or used as a room/cupboard refresher (Interview 21SG42; Interview 22SG47). During the virtual tour of artwork, the role of a museum docent was not about giving all the information of the artwork to PWD (Interview 21SG42). Instead, it was about facilitating conversation among PWD, triggering their memories of their past life experiences through artwork (Interview 21SG42), facilitating meaningful social interaction between PWD and other people and making them feel good when experiencing art (Interview 21SG40). Most of the PWD joining the virtual tour had very rich memories and they were able to tell the museum docent about how Singapore was like in the past, how they grew up in the country and places they had visited (Interview 21SG42). Some of the family caregivers of PWD were surprised and touched to know that their father or mother could still remember those days when their sons and daughters were very young (Interview 21SG40). For example, a female participant with dementia remembered how her four children used to play hideand-seek with other children in a kampong (i.e. a house built on stilts in the coastal water) when the museum docent showed a picture of a kampong scene during the virtual tour of Life by the River (1975; Oil on canvas) (Interview 21SG40), an artwork portraying ‘a typical, local scene of village life in the 1970s near the Pasir Panjang area, located at the western part of Singapore’ (‘Life by the River’ n.d.). Although she may not remember the names of her children, she remembered the number of children she had and which child was a boy or a girl (Interview 21SG40). She told the museum docent that ‘my number two boy will always hide behind his sister’ (Interview 21SG40). She also told the museum docent that people living in kampongs would go to the beach to dig up clams and crabs for their dinner when the tide got low (Interview 21SG40). This made the museum docent realized that she could learn a lot from PWD when the latter shared their past life experiences with her (Interview 21SG40). When the program was conducted physically in NGS, the museum docent first greeted PWD by briefly introducing the historical facts about NGS and its beautiful architecture (e.g. a giant glass roof which allowed

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natural light to flood in) to them (Interview 22SG49). During the tour of artworks, the museum docent would bring PWD, their caregivers and the centre staff to see and discuss three paintings. She would ask PWD some questions related to the paintings to spark conversation and connection (Interview 22SG49). Take the tour of artworks under the theme of places as an example. One of the paintings seen by PWD was Artist and Model (1954; Oil on canvas), which was created by a famous Singaporean artist called Liu Kang (Interview 22SG49). It depicts an artist sketching a woman. When PWD were looking at the painting, the museum docent asked them the following questions: ‘What do you see?’, ‘Is the man painting the woman indoors or outdoors?’, ‘What do you think of the relationship of these two people?’, ‘Can you describe the dressing of the woman?’, and ‘Do you like the man or the woman in the painting?’. PWD were able to tell the museum docent that the person was painting the woman outdoors because they could see clouds and mountains in the painting (Interview 22SG49). They thought that the woman was a host, using a red-colour European teapot to serve tea to the man (Interview 22SG49). They said that the woman was an Indonesian because of wearing sarong (Interview 22SG49). Some of them said that they liked the woman in the painting because there were beautiful flowers on her head (Interview 22SG49). Since the painting was created in 1954, the museum docent asked PWD how old they were and what they were doing in 1954 (Interview 22SG49). PWD were able to tell the museum docent that they were young and were working in 1954 (Interview 22SG49). Another painting seen by PWD was Hokkien Street (1947; Watercolour on paper), which was created by a Singaporean artist called Leng Joon Wong (Interview 22SG49). It depicts the street food scene with a popular prawn noodle stall in Singapore in the 1960s and 1970s (Interview 22SG49). In order to trigger conversation, the museum docent asked PWD about what they could hear, smell or feel if they were present in the prawn noodle stall (Interview 22SG49). Some PWD told the museum docent that they could hear people shouting when ordering a bowl of noodles and smell prawn stock (Interview 22SG49). They said that it was a hot and sweaty place (Interview 22SG49). In order to facilitate the conversation and social interactions, the museum docent also invited caregivers of PWD, centre staff and BFG to join the discussion with PWD (Interview 22SG49). She noticed that PWD in general were happy during the physical tour (Interview 22SG49). This was probably because of the pleasant

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environment (e.g. an ample open space) of NGS and the opportunity to interact with different people (Interview 22SG49). It is important for museum docents to receive communication skills training and dementia care education so that they can meet the specific communicative needs of PWD (Eggenberger et al., 2013: 345–346). Before the launch of Art with You, all museum docents attended training sessions (e.g. Interacting Effectively with Persons with Dementia) to get a basic understanding of dementia and acquire the skills to communicate with PWD (Interview 21SG40; Interview 22SG47). They were also invited by Dementia Singapore to attend other online programs to observe the behaviors of PWD (Interview 22SG47). During the tours, the museum docent used simple language and very short sentences to communicate with PWD (Interview 21SG40). She would always give a positive stroke to PWD answering her questions or sharing their thoughts with her (Interview 21SG40). She made PWD felt happy and valued by saying ‘Yes, you are right!’ (Interview 21SG40), ‘Oh! That’s great!’ or ‘Thanks for sharing!’ (Interview 21SG42). Her experience shows that having communication strategies (e.g. short and simple sentences), the use of good manners and embracing a respectful attitude when communicating with PWD (Alsawy et al., 2017; Stanyon et al., 2016) are conducive to increasing conversations and positive interactions in PWD (Alsawy et al., 2017: 1786), affirming the personhood of PWD and empowering them to continue in communication (Stanyon et al., 2016: 168).

Conclusion To conclude, COVID-19 has caused ‘major disruptions to everyday life, altering the way people live, work, study, and interact’ (Giuntella et al., 2021: e2016632118). It has accelerated digital adoption in daily life. ‘The increasing use of technology to work, play, and stay connected have shaped new digital habits’ (Moneta & Sinclair, 2020). Older adults in Singapore obtained digital knowledge and skills through Facebook and WhatsApp in the time of COVID-19. They also used Zoom to attend physical exercise classes offered by SACs and tours of painting offered by NGS. Looking forward, more older adults can learn and acquire sufficient digital literacy skills to use social media, mobile applications and other digital devices. This enables them to stay relevant and live a more independent and fulfilling life.

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Narayanan, J. (2020, September 22). From live sessions to workout videos: Senior citizens take the e-route to stay fit amid pandemic. The Indian Express. Retrieved April 29, 2022, from https://indianexpress.com/article/ lifestyle/fitness/senior-citizens-elderly-pandemic-fitness-online-classes-wor kout-videos-6586823/ OECD (2020). Digital transformation in the age of COVID-19: Building resilience and bridging divides. Retrieved December 26, 2022, from https:// www.oecd.org/digital/digital-economy-outlook-covid.pdf Schaap, F. D., Dijkstra, G. J., Reijneveld, S. A., & Finnema, E. J. (2021). Use of dementia care mapping in the care for older people with intellectual disabilities: A mixed-method study. Journal of Applied Research in Intellectual Disabilities, 34(1), 149–163. https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC7818226/ Stanyon, M. R., Griffiths, A., Thomas, S. A., & Gordon, A. L. (2016). The facilitators of communication with people with dementia in a care setting: An interview study with healthcare workers. Age and Ageing, 45(1), 164–170. https://pubmed.ncbi.nlm.nih.gov/26764403/ Tai, J. (2020, April 11) Coronavirus: Elderly hit hard by social isolation amid Circuit Breaker measures. The Straits Times. Retrieved April 24, 2022, from https://www.straitstimes.com/singapore/health/elderly-hithard-by-social-isolation-amid-circuit-breaker-measures Terry, P.C., & Karageorghis, C. I. (2006). Psychophysical effects of music in sport and exercise: An update on theory, research and application. Retrieved April 19, 2022, from https://www.piuvivi.com/docs/effetti-musica-sulla-psiche.pdf Vodnar, D-C, Mitrea, L., Teleky, B-E, Szabo, K., Calinoiu, L. F., Nemes, S-A, & Martau, G-A (2020). Coronavirus disease (COVID-19) caused by (SARSCoV-2) infections: A real challenge for human gut microbiota. Frontiers in Cellular and Infection Microbiology, 10, 575559. https://pubmed.ncbi.nlm. nih.gov/33363049/ Wong, L., & Tai, J. (2020, May 3) Coronavirus: Elderly must continue to be extra cautious, not time yet to relax. The Straits Times. Retrieved April 23, 2022, from https://www.straitstimes.com/singapore/elderly-must-continueto-be-extra-cautious-not-time-yet-to-relax Xiohoo (2020a, April 17). XIOHOO TV Guess Episode 3. Facebook. Retrieved April 15, 2022, from https://www.facebook.com/xiohoo Xiohoo (2020b, May 18). XIOHOO TV Guess Episode 7 . Facebook. Retrieved April 15, 2022, from https://www.facebook.com/xiohoo Xiohoo (2020c, July 27). XIOHOO TV Guess Episode 17 . Facebook. Retrieved April 15, 2022, from https://www.facebook.com/xiohoo Xiohoo (2020d, August 10). XIOHOO TV Guess Episode 19. Facebook. Retrieved April 15, 2022, from https://www.facebook.com/xiohoo

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Yap, E. (2018, November 1). Beyond classroom learning. Retrieved April 9, 2022, from https://www.agelessonline.net/beyond-classroom-learning/ Yong, C. (2020, April 5) Coronavirus: Residents urged to stay home and comply with ‘Circuit Breaker’ measures. The Straits Times. Retrieved December 26, 2022, from https://www.straitstimes.com/singapore/coronavirus-residentsurged-to-stay-home-and-comply-with-circuit-breaker-measures Yu, J., & Mahendran, R. (2021). COVID-19 lockdown has altered the dynamics between affective symptoms and social isolation among older adults: Results from a longitudinal network analysis. Scientific Reports, 11, 14739. https:// pubmed.ncbi.nlm.nih.gov/34282245/

Websites Additional precautionary measures to protect our seniors. (2020). Retrieved April 23, 2022, from https://www.moh.gov.sg/news-highlights/details/additi onal-precautionary-measures-to-protect-our-seniors#:~:text=All%20senior% 2Dcentric%20activities%20conducted,Board%20and%20ActiveSG%20sport% 20centres. Art with You. (n.d.). Online. Retrieved May 2, 2022, from https://www.nation algallery.sg/art-with-you Courses for seniors. (n.d.). Retrieved April 9, 2022, from https://xiohoo.com/ courses/digital-courses-for-seniors.html Course in April 2022. (n.d.). Retrieved April 9, 2022, from https://xiohoo. com/courses/XIOHOO-TECH-CLASS-SENIORS-SINGAPORE.pdf COVID-19 advisory for the older person. (2020). Retrieved April 23, 2022, from https://www.mhpa.org.sg/index.php/our-activities/articles/131-covid19advisory-olderperson COVID-19: Seniors more vulnerable likely due to lower immunity. (2020). Retrieved April 23, 2022, from https://sph.nus.edu.sg/2020/03/covid-19seniors-more-vulnerable-likely-due-to-lower-immunity/ COVID-19 dashboard. (2022). Retrieved December 26, 2022, from https://cor onavirus.jhu.edu/map.html COVID-19 situation at a glance. (n.d.). Retrieved December 26, 2022, from https://www.moh.gov.sg/ Fatty’s wanton mee: Remember the Tok Tok Mee man? (2019). Retrieved May 7, 2022, from http://ieatishootipost.sg/fattys-wanton-mee-tock-tock-mee/ Life by the River. (n.d.). Retrieved May 7, 2022, from https://artsandculture. google.com/asset/life-by-the-river-liu-kang/cwFRYfjRcs5sWA?hl=en Senior activity centre. (n.d.). Retrieved April 18, 2022, from https://www.aic. sg/care-services/senior-activity-centre

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Senior activity centres in Singapore. (n.d.). Retrieved April 18, 2022, from https://www.healthhub.sg/a-z/medical-and-care-facilities/8/senior_act ivity_centre Silver Infocomm Junctions. (2020). Retrieved April 9, 2022, from https://www. imda.gov.sg/en/seniorsgodigital/Stories/Silver-Infocomm-Junctions Taking care of our seniors amidst COVID-19. (2020). Retrieved April 23, 2022, from https://www.gov.sg/article/taking-care-of-our-seniors-amidst-covid-19 The art and soul of Southeast Asia. (n.d.). Retrieved May 2, 2022, from https:// www.nationalgallery.sg/about

Interviews Interview Interview Interview Interview Interview Interview

19SG18, 20SG32, 21SG40, 21SG42, 22SG47, 22SG49,

a a a a a a

trainer from Xiohoo, July 2019. fitness instructor, October 2020. museum docent, November 2021. museum docent, November 2021. museum docent, May 2022. museum docent, June 2022.

CHAPTER 6

Enabling Ageing in Place

Abstract This chapter will examine how four community projects enable ageing in place (AIP) in Singapore. They include the establishment of SilveCove Senior Wellness Centre, Community for Successful Ageing at Whampao (ComSA@Whampoa), exergaming competitions for older adults, and Project ARTISAN (Aspiration and Resilience Through Intergenerational Storytelling and Art-based Narratives). The SilverCOVE project showed that the involvement of older adults in the design process of SilverCOVE could encourage shared responsibility, foster community engagement, and create a sense of ownership among older residents. ComSA@Whampoa empowered older residents to take charge of their own health, built community capacity through knowledge transmission and fostered a sense of purpose among older residents. Exergaming competitions for older adults could increase social interactions and engagement among older adults, promote intergenerational bonding and gave older adults a sense of accomplishment. Project ARTISAN could enhance older adults’ life satisfaction, resilience and their interactions with other older adults, empower them to learn new things, help them develop a growth mindset, and create stronger intergenerational relationships. It is hoped that the number and scale of community projects will increase so that more older adults can grow old healthily, independently and gracefully in their communities in future.

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 S. Ching Yuen Luk, Healthy Ageing in Singapore, Social Policy and Development Studies in East Asia, https://doi.org/10.1007/978-981-99-0872-1_6

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Keywords Ageing in place · Communities · ComSA@Whampoa · Exergaming · Project ARTISAN · SilveCove Senior Wellness Centre

Introduction In Singapore, ageing in place (AIP) is an important policy goal for the government and the wishes of most older adults. The government adopts AIP as the key principle in housing and land use policies to enable older adults to grow old in their home and community with minimal disruption or change to their lives and activities (Goh, 2006). Facilitating older adults to age in a familiar environment empowers them and helps them maintain their connection to social support (Centre for Liveable Cities, 2019: 39). On the other hand, living in nursing homes can be costly and reduce the autonomy and independence of older adults (Centre for Liveable Cities, 2019: 39). Many people have a stigmatized perception of nursing homes being a dreadful place with poor living conditions and quality of care (Tan, n.d.). Children are considered unfilial for sending their older parents to nursing homes (Tan, n.d.). Since the family is emphasized by the government as the first line of care and support (‘Speech by Mr Tan Chuan-Jin’, 2015), nursing homes have been viewed unfavourably by people as “the refuge of last resort” (Basu, 2016: 25) and are meant to provide long-term care (LTC) for older adults who have no family support and need assistance with most activities of daily living (ADLs) (Heng, 2021). Indeed, the trend of AIP has become more and more popular among older adults in the country. The Sample Household Survey conducted by the Housing and Development Board (HDB) in 2018 showed that 85.9% of elderly residents aged 65 years old or over intended to age in their existing flats, which was 5.7% higher than that in 2013 (Housing and Development Board, 2021: 169). 70.3% of future elderly residents aged between 55 and 64 years old also intended to age in their existing flats, which was 9.4% higher than that in 2013 (Housing and Development Board, 2021: 169). Ageing in the existing flat was favoured by both elderly residents and future elderly residents because they found the existing flat comfortable, had an emotional attachment to it or they wanted their flat to be inherited by their children (Housing and Development Board, 2021: 169). Both elderly residents (46.2%) and future

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elderly residents (41.2%) thought that living in their current home with family members or domestic helpers as caregivers was an ideal living arrangement for an elderly resident requiring assistance with daily living (Housing and Development Board, 2021: 183). However, about 42% of elderly residents and about 51% of future elderly residents were willing to live in assisted living facilities because they wanted to ‘have access to professional medical and nursing care’ (Housing and Development Board, 2021: 184). The survey result indicated that most of the elderly residents ‘showed a strong preference to age in place’ (Housing and Development Board, 2021: 188).

A Multidimensional Concept of Ageing in Place AIP ‘is centrally concerned with the fit between people and their environments, as well as an ongoing process of deciding about staying or moving’ (Forsyth & Molinsky, 2021: 193). The people-environment fit can be explained by the ecological theory of aging (ETA) developed by Lawton (1977), which ‘suggests that behavior is a function of the competence of the individual and the environmental press of the situation’ (p. 8). The environmental docility hypothesis in the ETA ‘posits that high competence is associated with relative independence from the effects of environment’ (Wong & Peacock, 1994: 64), whereas low competence resulted from poor physical health, mental health problems or age-related sensory losses (Lawton, 1977: 8) ‘is associated with increased vulnerability of the environmental press’ (Wong & Peacock, 1994: 64). The competencepress imbalance caused by either an individual’s exposure to a higher level of environmental pressure or a decrease in the level of competence may elicit maladaptive behaviour or negative emotional state (Lawton, 1977: 8; Wong & Peacock, 1994: 64). From a relational perspective, peopleenvironment fit ‘is not static, given that both communities and older people change’ (Van Dijk et al., 2015: 1776). Places can be ‘dynamic and constantly evolving entities which have positive and negative consequences for the people located within them’ (Cummins et al., 2007: 1833). Older adults’ decision to stay in their current residence or move to another place can be affected by personal factors (e.g. health, selfcare ability, loneliness, income) and external factors (e.g. social network, availability of necessary services, housing market) (Forsyth & Molinsky, 2021: 183–184; Iecovich, 2014: 22). Over the past decade, AIP policies ‘have been adopted internationally as a response to population aging’

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(Lewis & Buffel, 2020: 100870). In many countries, AIP ‘has become a central part of policy and advocacy discussions’ (Forsyth & Molinsky, 2021: 185). Facilitating AIP through the promotion of active and healthy ageing at local level has been considered as one of the top 10 priority actions by the United Nations (UN) to maximize the opportunities of ageing populations (The United Nations Population Fund, 2012: 15). Nevertheless, the meaning of AIP ‘differs depending on the context and users of the term’ (Forsyth & Molinsky, 2021: 181). Although most discussions on AIP focuses on home (Wiles et al., 2012: 358), there is growing recognition that ‘beyond the home, neighbourhoods and communities are crucial factors in people’s ability to stay put’ (Wiles et al., 2012: 358). Besides, ‘a critical approach to understanding place suggests it is much more than simply a physical setting’ (Wiles et al., 2017: 28). The discussion of AIP would be more meaningful if one can understand that the term place has four dimensions which are interrelated: physical, social, emotional/psychological, and cultural (Iecovich, 2014: 22). The physical dimension refers to places (e.g. home, neighbourhood) which can be seen or touched (Iecovich, 2014: 22). The social dimension refers to older adults’ relationships with other people and the ways in which they remain connected to other people (Iecovich, 2014: 22). For example, the study of Wiles et al. (2012) found that friendship in the community was an important resource for older adults in New Zealand to age well because there would be ‘a safety net of people who “look out for you” and would come if something was wrong’ (p. 362). The study of Kim (2020), which examined how the AIP ideology was implemented in Saku City, Japan, found that rural older adults solved difficulties in their daily lives and eased their loneliness through having tea with neighbours at least once a week (p. 155). The emotional/psychological dimension refers to ‘a sense of belonging and attachment’ (Iecovich, 2014: 22). Attachment to place refers to ‘the affective, positive bonds between individuals and their homes, neighbourhoods, and communities; often involving feelings of pride, safety, familiarity, belongingness, and satisfaction with place’ (Wiles et al., 2017: 28). Many older adults become attached to their places of life during life time (Arani et al., 2022: 104), ‘although the degree of attachment may vary depending on the individual’s time, place, and personality situation’ (Arani et al., 2022: 104). For example, the study of Wiles et al. (2017) found that when it came to attachment to place, the majority of older adults aged between 80 and 90 years old in New Zealand liked

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their homes and had positive feelings of connection to their immediate neighbourhoods, communities, nature and the outdoors (pp. 34–35). Nevertheless, ‘attachment to place may present greater problems for more vulnerable groups of people or those living in changing or undesirable neighbourhoods’ (Wiles et al., 2017: 28). Older adults with deteriorating health conditions or those who become disabled may have strong emotional attachment to their homes with design unfit for their physical and functional needs. Their level of independence may decrease while their risk of injury may increase if they continue to stay in their homes. Meanwhile, homeless older adults may never have an attachment to a specific house or flat whereas older adults facing family break-up may have to deal with the loss of such an attachment (Means, 2007: 80). The cultural dimension ‘has to do with older people’s values, beliefs, ethnicity, and symbolic meanings’ (Iecovich, 2014: 22). Significant places can reflect an individual’s evolving identity, provide opportunities for introspection and reflection, serve as markers in life’s journey and act as bridges to the past (Manzo, 2005: 74–75). Many places become significant or meaningful ‘through the steady accretion of experiences in them’ (Manzo, 2005: 81). For example, many older adults considered a home as ‘a crucial piece of one’s self-identity’ (Gonyea, 2006: 559) and ‘a highly cherished symbol of their independence and dignity’ (Gonyea, 2006: 559). They study of Kim (2020) found that many rural older adults in Saku City, Japan ‘were living with the old objects that had belonged to their children, who had moved out, and those that had belonged to their deceased spouses’ (p. 154). While they lived alone in a house, they thought that their home was ‘a place full of memories of living with their children who had needed their care’ (p. 154). It was ‘also a place where, despite the change in form of existence, the spirits of their family members remain for them to care for’ (Kim, 2020: 154). Experiences in place can evoke positive feelings (e.g. love, comfort), negative feelings (e.g. hatred, anger, resentment) or ambivalent feelings (Manzo, 2005: 75). Hence, ‘it is the experience-in-place, rather than the places themselves that are meaningful’ (Manzo, 2005: 75).

Community Projects to Enable Ageing in Place The concept of AIP needs ‘to be contextualized in order to capture how each place and community interprets and deals with ageing locally’ (Chong, 2016: 56). This section will examine four community projects

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to see how they enable AIP in Singapore. These projects were (1) the establishment of SilveCove Senior Wellness Centre, (2) Community for Successful Ageing at Whampao (ComSA@Whampoa), (3) exergaming competitions for older adults, and (4) Project ARTISAN (Aspiration and Resilience Through Intergenerational Storytelling and Art-based Narratives). SilveCove Senior Wellness Centre: A Case Study in Participatory Design ‘Design is about addressing challenges’ (Ferguson & Candy, 2014: 1) and ‘imagining how things could be better in the future’ (Ferguson & Candy, 2014: 1). Participatory design which originated in Scandinavia refers to a democratic and inclusive design process (Cozza et al., 2020: 272; Holter, 2022: 277–278) directly involving future users of a design in the co-design of artefacts, products, tools, environments that shape their lives, businesses and so on (Robertson & Simonsen, 2012: 3; 2013: 2; Van der Velden & Mortberg, 2015: 41). Genuine participation is the core of participatory design (Robertson & Simonsen, 2013: 5). It is about involvement where future users of a design feel a strong sense of intrinsic motivation (i.e. internal drive sustained by an inherent satisfaction of the activity itself or other internal awards), experience a strong sense of participation self-efficacy (i.e. expectations of personal mastery), and share positive group affect (i.e. trust, group cohesiveness, and having ‘wefeelings’) (Segalowitz & Chamorro-Koc, 2018: 206–208). It removes the dichotomy between expert and non-expert to enable future users who are experts of their own lived experiences to become part of the design team (Rice, 2018: 239) and be involved in ‘decision making about what it is going to be developed and how’ (Galleguillos & Co¸skun, 2020: 142). In the participatory design process, ‘designers act as facilitators or visual translators for people who may not be skilled or confident in idea expression’ (‘Participatory Design’, n.d.). They help clarify any doubts participants may have, generate participants’ ideas through brainstorming, and prompt participants who become stuck at any point with open-ended questions (Wong et al., 2018: 155). For example, designers use the 5 Whys Technique (e.g. ‘Why do you need this?’, ‘Why is it important to you?’) to help them get to the root of a problem faced by future users of a design (Interview 19SG26). The pragmatic rationale for genuine participation in participatory design emphasizes the need for designers

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and future users of a design to learn from each other (Robertson & Simonsen, 2013: 6). Mutual learning enables designers and future users of a design to ‘gradually learn about the corresponding experiences of each other’ (Fischer et al., 2021: 66) and ‘spur knowledge transfer between both groups’ (Fischer et al., 2021: 66). It is supported by the use of design-by-doing methods such as mock-ups and prototypes to enable future users of a design to ‘experience something of how emerging designs may effect their everyday activities’ (Robertson et al., 2014: 25), enhance future users’ engagement in the process (Robertson & Simonsen, 2013: 6), develop a shared understanding between designers and users (Robertson & Simonsen, 2013: 6) and build consensus through effective communication and face-to-face interaction. Participatory design helps empower future users of a design to express their ideas and needs, equip them with skills to address future design challenges (Ferguson & Candy, 2014: 4), and increase their feeling of ‘psychological ownership’ towards the end product (Van Rijn & Stappers 2008). It can also generate outcomes which ‘are more likely to be accepted and sustained’ (Robertson & Simonsen, 2012: 6) or more creative outcomes enjoyed by most of the people (Interview 19SG26). In Singapore, SilverCOVE Senior Wellness Centre (hereafter SilverCOVE) is a case study in participatory design (Chong, 2016; Chong et al., 2017). Its designs, programmes and service model were results of the participatory approach initiated by designers from a design consultancy called COLOURS: Collectively Ours together with the service provider called NTUC Health (Chong, 2016: 61). SiloverCOVE aims to support older residents living in the new serviced apartments at Block 180A and Block 180B Marsiling Road and the wider community with a range of facilities (e.g. gym equipment), services (e.g. Traditional Chinese Medicine services, nursing service, dental care, organic food and grocery purchase) and social activities (e.g. inter-generational bonding activities, learning activities) (‘A Cove for Seniors’, 2016; ‘NTUC Health’s First Senior Wellness Centre’, 2016). For older residents living in Block 180A and Block 180B, they paid S$10 annually to use the facilities and join the activities at SilverCOVE (Ong, 2016a). For older residents living outside the blocks, they paid S$300 annually to become the members of SilverCOVE (Ong, 2016a). Older residents living in the new serviced apartments were invited by NTUC Health to attend a participatory workshop prior to the commencement of the design of SilverCOVE (Chong, 2016: 61). The

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workshop was held at the actual site of SilverCOVE to allow older residents to ‘physically feel and visualize how this place could be’ (Chong, 2016: 61) and give them ‘a sense of what could or could not be done within the space, thereby managing expectations’ (Chong, 2016: 61). A total of 30 older residents attended the workshop (Ong, 2016b). They were very excited and actively gave input on design preferences, spatial requirements and programmes for SilverCOVE through site walkabouts, visual activities, interviews and group discussions (Chong, 2016: 61; Yabuka & Peh, 2016: 37). They used yellow Post-it Notes to indicate their likes and red Post-it Notes to indicate their dislikes of designs for SilverCOVE during the workshop (Ong, 2016b). Many of them wanted SilverCOVE to have a garden (Zhuang, 2016: 13) and enough space for small group activities (e.g. cooking, doing handicraft) (Chong, 2016: 61). Some of them wanted SilverCOVE to have quiet corners for reading books, newspapers or tablets (Yabuka & Peh, 2016: 37). All the input given by older residents, together with service provider requirements, were conducive to informing and shaping the design (Chong et al., 2017: 167). After grouping older residents’ desires, suggestions and preferences into different categories, designers came up with the final design of SilverCOVE which could meet the needs of older residents (Chong, 2016: 61): ‘a changeable space with a feeling of openness to provide a variety of programs’ (Chong, 2016: 61) and empower older residents to ‘choose what they want to do in each space’ (Chong et al., 2017: 167). This results in the creation of an airy, bright and open atmosphere in SilverCOVE by drawing in natural and daylight ventilation (Chong, 2016: 62). Rattan chairs which give people a sense of nostalgia and bring a homely ambience to the space are used throughout the centre to encourage residents and visitors to gather around and talk to each other (Tan, 2016a, 2016b). The introduction of a modular room concept to the design of SilverCOVE with the use of sliding partitions, mobile furniture and moveable display shelves allows most of the spaces to be flexible and changeable to accommodate various programmes and activities (e.g. doing exercise, singing karaoke, playing cards, holding talks) (Chong, 2016: 62; Chong et al., 2017: 167; Yabuka, 2017: 59). With the help from the National Park Board (NParks) (Yabuka, 2017: 59), designers transformed the outer wall of SilverCOVE into a vertical garden (Ong, 2016b; Zhuang, 2016: 13). This empowers ‘residents to grow their own herbs and plants, thereby promoting green, active and healthy

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living’ (Chong, 2016: 62). Besides, a new form of ‘Kampung spirit’ is inculcated when residents help each other out with watering the plants and adding fertilisers to the soil (‘NTUC Health’s First Senior Wellness Centre’, 2016; Tan, 2016a). The vertical garden has also become a place for residents to greet and meet each other (Chong, 2016: 63). At SilverCOVE, there is a reading corner with books regularly supplied by the National Library Board (‘NTUC Health’s First Senior Wellness Centre’, 2016). The reading corner is bright, cozy and naturally ventilated, opening up to the view of the vertical garden (Tan, 2016a, 2016b; ‘NTUC Health’s First Senior Wellness Centre’, 2016). All these could not have been achieved by the traditional design model ‘which seldom empowers and enables end users to create what they want and need’ (Wong et al., 2018: 146). Joining different programmes at SilverCOVE enabled older adults to pick up new hobbies (e.g.crocheting) and make new friends in the neighbourhood (‘NTUC Health’s First Senior Wellness Centre’, 2016). Some older adults said that their physical health and cognitive function had improved after joining the exercise programmes at SilverCOVE (‘NTUC Health’s First Senior Wellness Centre’, 2016). A post-occupancy survey found that the adoption of a participatory approach to the design of SilverCOVE helped ‘foster a sense of ownership among the residents’ (Chong et al., 2017: 167). Nine out of 11 residents who attended the participatory workshop thought that they contributed to the design of SilverCOVE (Yabuka & Peh, 2016: 37) and seven of them ‘offered to help out more in future’ (Yabuka & Peh, 2016: 37). Almost all the residents in the survey liked ‘the openness of the environment, the variety of spaces and the facilities provided’ (Yabuka & Peh, 2016: 37). In April 2016, SilverCOVE won Best Silver Architecture (Community Spaces) and Best Approach to Support Ageing-in-place in the 4th Asia Pacific Eldercare Innovation Awards (‘2016 Awards Categories Finalists’, 2016; Ong, 2016b). It ‘has since become a precedent for public place design in future senior resident buildings’ (Chong et al., 2017: 167). Indeed, participatory design can bring several benefits to designers, end users and the wider community if it is adopted properly and successfully. Designing together helps break down barriers amongst participants who barely know one another (Zhuang, 2016: 13) and generate better design which incorporates the perspectives of end users and other professionals (Wong et al., 2018: 153). By involving in the design process, end users have ‘a sense of mission and good team spirit in creating a

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better design’ (Wong et al., 2018: 156). They become ‘more aware of the challenges of the design and are thus less critical and more appreciative of the final design’ (Wong et al., 2018: 155). Besides, a sense of pride and ownership over the final design (Rohaidi, 2017) result in end users sustaining the final design in the long run. The case study of SilverCOVE shows that ‘participatory design invites community engagement and responsibility’ (‘The Architecture of Community’, n.d.). ‘By centering the community at the heart of the design process, participatory design, can foster community ownership and pride’ (‘The Architecture of Community’, n.d.). Nevertheless, there are several critical factors affecting the successful adoption of participatory design in a community. First, both the government and designers have to be opened to the idea of participatory design and have the courage and willingness to test this new idea (Interview 18HK01). Participatory design may not be cost-effective (Interview 18HK01). Besides, it requires more time for designers to come up with the final design because of engaging end users and other stakeholders in the design process (Interview 18HK01; Interview 19SG26). ‘Designers always want to be in control’ (Yabuka, 2017: 59). But the adoption of participatory design requires designers to ‘release some of this control to the user’ (Yabuka, 2017: 59). Second, it is important to help end users overcome their psychological barrier which potentially prevents them from expressing their design ideas (Interview 18HK01). Many end users think that they are not talented or creative enough to become designers (Interview 18HK01). But the case study of SilverCOVE and overseas experience show that end users can be designers if they are given proper guidance, training and exposure (Wong et al., 2018: 155; Interview 19SG26). For example, an architect in Hong Kong named a participatory design workshop by calling it ‘An exploratory journey of elderly friendly public space’ (Interview 18HK01). This was because directly calling the workshop a participatory design workshop may make older adults think that the workshop was too professional or serious to join (Interview 18HK01). Calling the workshop ‘An exploratory journey of elderly friendly public space’ helped make older adults think that the workshop was like a leisure event (Interview 18HK01). Hence, older adults were more willing to join the workshop and felt comfortable with expressing their design ideas through the use of pens, tracing paper or interesting ways such as LEGO (Interview 18HK01). Participatory design workshop can also be organized in the form of a funfair containing games

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with design elements to collect different design ideas from participants (Interview 18HK01). Third, ‘participatory design will only truly flourish when people become more tolerant, respectful and responsible for their own words or actions’ (Yabuka & Peh, 2016: 37). In Asian society, people are looking for the exact mindset because most of them are trained to say ‘yes’ or ‘no’ or use the “I’m right; you’re wrong” mindset to handle disagreements (Interview 18HK01). But there is no right or wrong answer when it comes to design (Interview 18HK01). After all, design is about finding some useful solutions to address a problem and meet the needs of users (Interview 18HK01). Designers have to keep abreast of the times to come up with new solutions that can address new problems or the changing needs of users (Interview 18HK01). Design requires people to have an everchanging mindset in order to cope with new challenges (Interview 18HK01). Fourth, participatory design ‘is a process of enlightenment and can foster cultural exchange among participants’ (Wong et al., 2018: 155). In places where there are different ethnicities, designers need to provide accessible materials in different languages to ensure inclusive participation is achieved (Zhuang, 2016: 13). ComSA@Whampoa: Community for Successful Ageing In Singapore, Whampoa was ‘a very old, underserved and isolated community with significantly insufficient community health and social services as well as transportation connectivity’ (Tsao, 2013: 8). More than a third of its 33,000 residents were over 50 years old (Basu, 2015). About 3,600 residents crossed the age of 65 (Basu, 2015). In 2012, Whampoa was chosen as one of the pilot sites for the City for All Ages (CFAA) project (‘Speech by Mr. Gan Kim Yong’, 2017), which aimed to create a safe, caring and empowering environment to support older adults to age gracefully in place (Ministry of Health, n.d.: 1). In 2013, it became a site for the launch of a ground-breaking programme called Community for Successful Ageing at Whampao (ComSA@Whampoa) by Tsao Foundation (Peh, 2021), a non-profit organization specializing in ageing issues (Basu, 2015). ComSA@Whampoa was a S$5 million initiative adopting a ground-up, community-wide approach (Peh, 2019) to ‘create an integrated system of holistic programmes and services with the aim to promote health and well-being over the life course and to enable ageing in place’ (Harding & Lee, 2017: 123). It consisted of three

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components: primary care and care management, community development and infrastructure development (Harding & Lee, 2017: 123). This part will only focus on the first two components because the component related to infrastructure development ‘is still in the pipeline’ (Harding & Lee, 2017: 124). For primary care and care management, there was the establishment of Hua Mei Clinic based on the concept of Person-Centred Medical Home (PCMH) to provide comprehensive geriatric assessment (Peh, 2019), medical care, counselling services, health education and/or home-based care management services for Whampoa residents aged 40 or over with complex medical and psychosocial needs (Lim et al., 2021; ‘Integrated Care System’, n.d.). ‘As the PCMH model aimed to have relationshipbased care, care managers and healthcare providers sought to reach consensus with patients and their caregivers and family on individualised care plans’ (Sum et al., 2021: 435). A survey with 165 participants who received the PCMH intervention in Whampoa found that there was a significant impact of the PCMH on Pleasure domain (β = 0.62, p = 0.03) of the 19-item Control, Autonomy, Self-realisation, and Pleasure (CASP19) at 6 months post-enrolment, compared to baseline (Sum et al., 2021: 435). It also found an improved patient activation with the proportion of participants in the higher Patient Activation Measure (PAM) Level 3 (i.e. Taking action) increased by 23.4% and Level 4 (i.e. Maintaining behaviours and pushing further) increased by 16.7%, from 3 to 6 months post-enrolment into the PCMH (Sum et al., 2021: 435). The shift in proportion of participants from lower to higher PAM levels ‘may reflect the change from being passive recipients of care, to having more proactive engagement in recommended health behaviours’ (Sum et al., 2021: 435). In April 2013, there was the implementation of Hua Mei ElderCentred Programme of Integrated Comprehensive Care (ECPICC) (‘Centre-based Comprehensive Care’, n.d.). Hua Mei ECPICC is a day club program (six hours a day) enabling frail older adults aged 60 or over with multiple, chronic medical conditions and limited family support to engage in social and recreational activities and receive a package of services (e.g. medical and nursing care, physiotherapy, counselling service, homehelp, 24-hour medical emergency coverage) customised to their physical, emotional and social needs (‘Centre-based Comprehensive Care’, n.d.). Meals and transport service are included in the programme (‘Centrebased Comprehensive Care’, n.d.; ‘Integrated Care System’, n.d.). Also,

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partnership has been built between the ComSA team and the care team of Tan Tock Seng Hospital (TTSH) since November 2018 to allow the ComSA team to be updated when its clients ‘visit the TTSH Emergency Department, are admitted to the wards, and upon discharge’ (‘Integrated Health and Social Care Network’, 2019). It allows both teams to provide early interventions or targeted care for individuals after hospital discharge and timely support for their caregivers so that unplanned readmissions can potentially decrease (‘Integrated Health and Social Care Network’, 2019; Wong, 2019). As regards community development (CD), it aims to promote selfcare among older adults, build community capacity and promote positive image of older adults (Interview 19SG30). It targets six dimensions of health of older adults, including Biological (B) health, Bio-Psychological (BP) health, Psychological (P) health, Psycho-Social (PS) health, Social (S) health and Socio-Communal (SC) health (Aw et al., 2019a). One of the important CD programmes implemented by Tsao Foundation is the Self-Care on Health of Older Persons in Singapore (SCOPE). The SCOPE is jointly funded by the Ministry of Health (MOH) and the Ministry of Education (MOE) to ‘test and evaluate the efficacy of self-care approach in maintaining health, controlling chronic disease and improving functional status and quality of life of older persons’ (‘Project SCOPE’, n.d.). It targets B and BP health of older adults through 16 weeks of lessons (a two-hour session every week) about the meaning of ageing well and self-care practices (e.g. chronic disease management, healthy diet, physical exercise, stress reduction techniques) (Aw et al., 2019a, 2019b, 2020). The Sharing Wellness and Initiatives Group (SWING) is another important CD programme targeting S and SC health of older adults in terms of civic engagement and social support (Aw et al., 2019b). It offers an eight-week participatory workshop to older adults to understand their role in the community (‘Sharing Wellness and Initiatives Group (SWING)’, n.d.), ‘foster critical community assessment and thinking on community solutions’ (Aw et al., 2019b: 263). It allows older adults to work with like-minded residents to promote wellness in the community (Harding & Lee, 2017: 126–127). Guided Autobiography (GAB) is an eight-week CD programme targeting P and PS health of older adults (Aw et al., 2019a). It enables older participants to share life stories in a group and listen to the story of others under the guidance of a trained instructor (Birren, 2006; Cheong, n.d.). It also offers a chance for older participants to ‘explore their lives moving

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forward, with new directions, meaning and optimism’ (‘Guided Autobiography Group (GAB) Programme’, n.d.). At the end of the programme, older participants ‘are encouraged to organize their life stories in the form of an autobiography, as a personal legacy for their family and friends’ (Cheong, n.d.). When implementing the CD programmes, Tsao Foundation works in partnership with the People’s Association (PA), a statutory board having a network of over 2,000 grassroots organizations (GROs) and over 100 Community Clubs (CCs) in the country (‘About Us’, n.d.). The support from GROs and their help to introduce Tsao Foundation to residents in Whampoa help Tsao Foundation gain legitimacy to be in the community and implement the CD programmes (Interview 19SG30). Tsao Foundation invites older residents in Whampoa to join the CD programmes through flyers, banners, community sign-up booths and presentations with community partners (Aw et al., 2019a: 254). The PA conducts outreach for participant enrolment and provides space and operational support to run the classes (Aw et al., 2019b). Program activities are run at 13 community sites, including a CC, nine resident centres and three other community organizations (Aw et al., 2019b). They are delivered face-to-face by volunteer trainers who were coached by master trainers from Tsao Foundation (Aw et al., 2019b: 263). The CD programmes can benefit older participants in several ways. The SCOPE empowers older participants to take charge of their own health and build community capacity by sharing self-care knowledge and practices with their peers, family members, friends and other people in the community (Harding & Lee, 2017: 126). It helps boost the self-esteem and self-worth of older participants. Hence, older participants feel more confident about pursuing the life they truly want and actively engaging with the community (Interview 19SG30). This helps promote a positive image of older adults. The SWING gives older adults a sense of purpose by enabling them to see the potential in themselves and realize that they can also have a positive impact on CD (Interview 19SG30). It leads to older adults having a strong sense of community. Older adults become more observant of the community and more forthcoming when engaging GROs (Interview 19SG30). They have learnt to see the good in others and build trusting relationship with other people in the community (Interview 19SG30). This helps promote a positive image of older adults and the community goal of successful ageing (Interview 19SG30).

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Meanwhile, GAB is ‘a powerful catalyst for improved self-esteem, selfconfidence and communication within communities and within families’ (‘What is Guided Autobiography?’, n.d.). It leads to ‘an increased awareness and appreciation of having lived through so much’ (Birren, 2006) and ‘attachments and friendships among group members’ (Birren, 2006). A local study by Aw et al (2019a) found that the CD programmes could improve different dimensions of health and quality of life (QoL) of older adults. Its analysis on a baseline survey completed by Whampoa residents who joined the CD programmes found that BP self-perceptions of ageing promoted by SCOPE and P life satisfaction promoted by GAB were most strongly associated with QoL of older adults (Aw et al., 2019a: 254). It suggested organizations facing the problem of limited resources prioritize the implementation of CD programs which target BP self-perception of ageing and P life satisfaction (Aw et al., 2019a: 254). The achievements made by the CD programmes rely on strong support from key community stakeholders (Harding & Lee, 2017: 129–130), including the PA (Aw et al., 2019b), City for All Ages at Whampoa, the Whampoa Constituency Office and residents in Whampoa (Harding & Lee, 2017: 127–128). Tsao Foundation has always been transparent (Interview 19SG30) and update key community stakeholders through regular meetings and informal conversations (Harding & Lee, 2017: 128). This helps build rapport and trust with key community stakeholders and obtain buy-in from them (Harding & Lee, 2017: 130). Meanwhile, strong rapport with the community and cohesion within partner organizations help persuade volunteers and participants to be committed to the CD programmes (Aw et al., 2019b: 263). Centre managers who are favoured and trusted by older adults can effectively advocate for the CD programmes and boost program participation (Aw et al., 2019b: 263). Their presence helps ‘extend trust to trainers, boosting trainers’ confidence and ability to build rapport with participants’ (Aw et al., 2019b: 263). Effective coordination and resource allocation can be achieved when there is alignment of partners’ interests and ways to manage conflict and turf issues and overcome partners’ KPI-centric organizational culture (Aw et al., 2019b: 263). The development of a comprehensive monitoring systems to appraise the benefits of the CD programs helps sustain partners’ commitment to the programs (Aw et al., 2019b: 263) and ‘foster a spirit of learning and experimentation’ (Aw et al., 2019b: 263).

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From SING to I-SING: Exergaming Competitions for Older Adults ‘Games are gaining popularity as a tool for health prevention and education’ (Brox & Hernández, n.d.). Exergaming, ‘which is a portmanteau word of “exercise” and “gaming”’ (Tanaka et al., 2012: 69), are video games requiring ‘physical exertion or movements that are more than sedentary activities’ (Oh & Yang, 2010: 10) and including ‘strength, balance, and flexibility activities’ (Oh & Yang, 2010: 10). When playing an exergame, users ‘perform actions similar to those in actual sports, providing an immersive feeling as if they were actually playing the sport’ (Kim et al., 2022). There are different types of exergames. These include sports games (e.g. bowling, boxing, tennis, golf), instructionbased exercise (e.g. aerobics, Tai-Chi, dance, yoga) and flexibility and coordination games (e.g. balance board, penguin slide) (Byrne & Kim, 2019: 468). Exergaming ‘generally relies on participant involvement with interactive technology’ (Exergaming, n.d.). Exergame systems such as Xbox Kinect allow users to ‘interact with the system freely, with sensors detecting the user’s gestures and body movement’ (Tsai et al., 2020: 964). Other exergame systems such as Nintendo Wii allow users to ‘interact with a hardware device that communicates with the system’s software’ (Tsai et al., 2020: 964). A study found that exergaming could produce improvements in ambulation ability, balance, and confidence of older adults identified to be at risk for falling (Clark & Kraemer, 2009). Other studies found that exergaming could improve older adults’ physical function (e.g. arm-lift and sit-to-stand repetitions, balance and mobility) (Agmon et al., 2011; Albores et al., 2013; Chao et al., 2015; Jorgensen et al., 2013; Pacheco et al., 2020; Williams et al., 2011), cognitive performance (Amjad et al., 2019; Liao et al., 2021; Rosenberg et al., 2010), social interaction (Agmon et al., 2011; Chao et al., 2015; Chu et al., 2021; Keogh et al., 2014; Wollersheim et al., 2010) and reduce their depressive symptoms (Chao et al., 2015; Heinbach et al., 2021; Rosenberg et al., 2010). In Singapore, exergaming competitions for older adults were implemented by a team from Wee Kim Wee School of Communication and Information (WKWSCI), Nanyang Technological University (NTU), to motivate older adults to do physical exercise and make physical exercise a habit (Interview 18SG08). Singapore Intergenerational National Games (SING), which was the first exergaming competition for older adults, was held on 6 May 2016. A total of 122 older adults from 10 Senior Activity

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Centres (SACs) participated in this competition (Wee Kim Wee School of Communication and Information, n.d.). The second exergaming competition for older adults was held on 1 December 2017. A total of 317 older adults from 16 SACs participated in this competition (Wee Kim Wee School of Communication and Information, n.d.). InternationalSingapore Intergenerational National Games (I-SING), which was the third exergaming for older adults, was held on 30 November 2018. It was an international event joined by local and foreign older adults. A total of 317 older adults from 16 SACs in Singapore and 117 older adults from Japan, Taiwan, France and Finland participated in this competition (Wee Kim Wee School of Communication and Information, n.d.). Before entering the exergaming competition, older adults would receive exergame training in participating SACs (Interview 20SG33). Training sessions were conducted by university students from NTU (Interview 20SG33). These students knew how to communicate with older adults using Mandarin, Chinese dialects, English or other languages (e.g. Indian, Malay) (Interview 20SG33). They offered one-on-one coaching to older participants (Tang, 2016). Older participants who received exergame training had to be 65 years old or over and be able to stand and walk on their own safely (Interview 20SG33). Those who were wheelchair bounded were not selected (Interview 20SG33). Older participants received the training sessions twice a week, for a total of six weeks (Interview 20SG33). The duration of each training session was 20–30 minutes (Interview 20SG33). In each training session, an older participant was paired with another older participant from the same SAC or a student volunteer to play two to three exergames. Through training, older participants learnt how to perform the right movements and score points during exergaming (Interview 20SG33). After the training sessions, older participants who would like to enter the competition had to compete with other older participants from the same SAC over three rounds of exergames. Winners who were selected from participating SACs would qualify for the finals (Interview 18SG08). The champion in the finals would win a trophy (Interview 18SG08). Kinect, which was the off-the-shelf exergame, was used in the exergaming competitions in 2016 and 2017 (Interview 20SG33). In 2016, older participants played the bowling exergame, Fruit Ninja and ‘the fish cracking the tank’ game (Interview 20SG33). Fruit Ninja, which required players to ‘use arm and hand movements to swing virtual swords to slice fruit’ (Huang, 2020: 145), was a popular exergame among older

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adults. In 2017, older participants played the new Fruit Ninja game, the ball game, the water racing game and the rock climbing game (Interview 20SG33). In 2018, I-SING introduced exergames which were developed by the team from WKWSCI and game designers from the polytechnics (Interview 20SG33) because of two main reasons. First, many off-theshelf exergames which were fun games were not designed for older adults (Interview 20SG33). They were not elderly friendly enough for older adults to play (Interview 20SG33). Exergames which were introduced in I-SING were designed especially for older adults to provide the best gaming experience for them (Interview 20SG33). They were designed with full consideration of older adults’ physical conditions, safety requirements (Li et al., 2021: 469) and ‘suitable difficulty that only requires simple movements to accomplish’ (Li et al., 2017: 372). These could motivate older adults to keep playing while preventing them from having negative emotions such as anxiety and frustration or having injuries during game performance (Li et al., 2017: 372). Besides, the themes of the exergames were those older adults felt familiar to, could relate with (Tang, 2016) or had cultural or educational benefits (Li et al., 2017: 372). This would ‘increase the motivation of older adults to play exergames and encourage them to play for a longer run’ (Li et al., 2017: 372). For example, ‘The China Town Race’, which was developed by the team from WKWSCI and game designers, was an interesting game related to the cultural context of Singapore (Li et al., 2017: 372; Interview 20SG33). Older adults were familiar with Chinatown because it is a cultural heritage area in Singapore (Li et al., 2017: 372). When playing ‘The China Town Race’, older participants had to ‘lean the body to the left or right to move and avoid the fences and people walking by’ (Li et al., 2021: 469). They also had to ‘use their hands to collect coins and lanterns to increase the final game score’ (Li et al., 2021: 469). Other exergames introduced in I-SING included the ‘Apple Frenzy’ game (i.e. grab the good apples only) and the ‘Punch Punch’ game (i.e. punch the wooden dummy while avoid being hit by it). Second, developing their own exergames allowed the team from WKWSCI to use their system to quickly tabulate, record and track all the scores of older participants in the competition (Interview 20SG33). It was more convenient and enabled overseas participants to join the competition as long as their equipment was connected to the Internet (Interview 20SG33). On the competition day, shuttle buses brought finalists, other older adults and managers from participating SACs to the competition venue

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(Interview 20SG33). Before the competition began, older adults could go to game booths which were set up outside the competition hall to play games individually and have fun. Once older adults entered the competition hall, they took a seat to wait for the competition to begin. Each of them would receive a goodie bag (Interview 20SG33). The goodie bag was a thank you gift containing a bottle of water, milk, crackers, healthy snacks, fruit (e.g. apples), pocket tissues and small gifts (Interview 20SG33). Prior to the start of the competition, a facilitator of the exergame competition went on stage to greet all the finalists, older adults and other guests. He/she warmed up the audience and let the audience get excited. Then, he/she gave the audience the full agenda for the competition, talked about the competition rules and introduced the finalists. Finalists played three games in the competition. During the competition, finalists stood in front of the television screen to play exergames and score points. Older adults who were spectators at the competition supported and motivated the finalists to perform better by cheering, applauding and whistling. They took photos of the competition scenarios and took photos with each other. Some of them also used mobile phones to take videos of the exergame competition. Each game result and the final result of the finalists were shown on the screen. The champion would go on stage to receive the trophy. When the competition was over, shuttle buses would bring older adults back to SACs. Exergaming can bring several benefits to older adults. First, exergaming increased social interactions and engagement among older adults (Interview 20SG33). Playing exergames offered opportunities for older adults to engage with other older adults whom they had not interacted with previously. Older adults engaged with their counterparts when they talked about how to play exergames and compared their scores with each other (Interview 18SG08; Interview 20SG33). When joining the exergaming competitions, older adults had opportunities to meet and compete with other older adults from different SACs. For older adults who were spectators at exergame competitions, they applauded and shouted their cheers and positive remarks to the finalists. Hence, exergaming enabled older adults to ‘enlarge their social network and form new friendships’ (Xu, Li et al., 2016: 390), which may reduce their feelings of loneliness (Xu, Li et al., 2016). Since older adults bonded with their peers in the training sessions and in the competitions, they became closer and more friendly to each other after the exergaming competitions

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were over. Their level of sociability had increased significantly (Li et al., 2018). Second, exergaming promoted intergenerational bonding. University students who were volunteers went to SACs to teach older adults to play exergames (Interview 20SG33). The presence of university students energized older adults (Interview 20SG33). Older adults talked to university students not only about exergames, but also other things like hobbies (Interview 20SG33). When they were paired with university students to play exergames in the training sessions, they cooperated with university students and both parties shared ‘a common goal of obtaining good in-game performance’ (Xu, Li et al., 2016: 390). For these reasons, exergaming enabled older adults and university students to learn from each other and know each other better. It promoted a positive intergenerational perception between older adults and university students (Interview 20SG33), helped ‘bridge the generation gap’ (Li et al., 2021: 467), provided older adults with ‘richer opportunities for interaction and communication, which lead to a greater impact of exergame playing on psychosocial well-being’ (Xu, Li et al., 2016: 394). Third, exergaming offered opportunities for older adults to expose to technology or activities they were unfamiliar with (Interview 20SG33). Learning how to play exergames gave older adults a sense of accomplishment, helped them develop a positive self-image, boosted their confidence and self-esteem (Interview 18SG08) and reduced alienation. All these intangible benefits helped older adults feel good about themselves and age well (Interview 18SG08). Winning a trophy provided recognition of the hard work and the effort the champion had made in the exergaming competition (Interview 18SG08). Besides, playing exergames could become an interesting topic to spark conversation among older adults and between older adults and their family members, grandchildren or friends. Fourth, exergaming ‘is a fun, engaging, and interactive form of exercising that may help overcome some of the traditional exercise barriers’ (Pacheco et al., 2020: 163). Older adults’ interaction with the game scenario during exergames stimulated their cognitive, psychological, sensorial, and motor functions (Pacheco et al., 2020: 163). ‘As exergames combine game enjoyment with exercise activities’ (Xu, Theng et al., 2016: 2966), they ‘can be used as an enabler to stimulate the elderly’s exercise participation and fundamentally improve the elderly’s health conditions’ (Xu, Theng et al., 2016: 2966). In fact, some of the older

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adults continued to play exergames in their own time at SACs even after the exergaming competitions were over (Interview 20SG33). It shows that exergames may stimulate older adults’ exercise intentions (Xu, Theng et al., 2016: 2966), which in turn may help older adults stay healthy and keep fit. Besides, exergaming ‘can bring out a competitive team spirit’ (Ikeda, 2010) among older adults. Awareness of a competitive challenge or the presence of competitive information can increase older adults’ intrinsic motivation to exercise via exergames (Li et al., 2021). There are several factors critical to the successful implementation of exergaming in SACs or exergaming competitions in the community. First, there should be sufficient exergame equipment. Second, new and interesting exergames have to be introduced to keep the interest of older adults over longer periods of time (Interview 20SG33). Some useful guidelines should be adopted when designing exergames for older adults (Li et al., 2017; Planinc et al., 2013). These include ‘mind the physical conditions of older adults’, ‘use a suitable topic’, ‘use appropriate gestures’, ‘use a clear user interface’, ‘adjust the difficulty’ and ‘give visual and auditive feedback’ (Planinc et al., 2013). A participatory approach can be adopted to invite older adults to provide inputs during the game design process so that their preferred gameplay experience can be understood by the design team. This helps enhance older adults’ acceptance of exergames. Third, most of the SACs are packed with a lot of activities such as dancing and arts and craft activities. Exergaming has to fit into the schedule of SACs (Interview 20SG33). Fourth, offering exergame training to older adults and organizing exergaming competitions are labour-intensive activities (Interview 18SG08; Interview 20SG33). SACs encountering insufficient staff may have difficulty in running an exergame program or competition on their own. They may rely on assistance of volunteers. Fifth, there should be sufficient financial support if the exergaming program is turned into a community or social program with more participants and is held regularly. Institutions such as the People’s Association (PA) and Sport Singapore may have the capacity to take over the exergaming program (Interview 20SG33) so that exergaming can reach out to more older adults in the country. Sixth, older adults’ awareness, acceptance and adoption also affect the introduction of exergaming in SACs or in the community. It would be good to see that exergaming can become part of the lifestyle of older adults and keep older adults active (Tang, 2016). Exergaming ‘should not, and cannot replace traditional physical exercise’ (Benzing & Schmidt, 2018: 422). But ‘an increase in screen time has

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to be monitored carefully in order to prevent potential negative effects’ (Benzing & Schmidt, 2018: 422). Project ARTISAN: Participatory Art and Heritage-Based Interventions Project ARTISAN (Aspiration and Resilience Through Intergenerational Storytelling and Art-based Narratives) was a 5-week, 15-hour program aiming to alleviate loneliness and build resilience and social connectedness among older adults and young people through an integrative intervention framework consisting of guided museum tours, collaborative art making, storytelling, reflective writing and group sharing (Interview 20SG34; Interview 20SG35). It was developed by the Action Research for Community Health (ARCH Lab), NTU in collaboration with the National Arts Council and the National Museum of Singapore (‘ARTISAN: Fostering Aspirations’, n.d.). Intervention contents of Project ARTISAN (e.g. weekly themes, art activities) ‘were jointly developed by community partners, museum representatives, artists, and the research team’ (Ho et al., 2021: 730709). They were later refined based on older adults’ feedback collected from an open forum held at a community centre (Interview 20SG34). The finalized Project ARTISAN was introduced in the early summer of 2018 (ARTISAN: Fostering Aspirations and Resilience, n.d.). An intergenerational, group-based approach was adopted in Project ARTISAN (Interview 20SG34; Interview 20SG35). Older adults who participated in Project ARTISAN aged 65 or over, could speak English or Mandarin, were relatively mobile and had no major mental health conditions (Interview 20SG34). They came from the Ang Mo Kio and Yishun communities (Interview 20SG35). Young people who participated in Project ARTISAN aged between 18 and 35, could speak English or Mandarin and had no major mental health conditions (Interview 20SG35). They came from NTU and other polytechnics in Singapore (i.e. Ngee Ann Polytechnic, Nanyang Polytechnic) (Interview 20SG34; Interview 20SG35). Each group in Project ARTISAN consisted of five to six dyads (Interview 20SG34). Each dyad consisted of an older adult and a young person (Interview 20SG34). The matched dyads had to engage in all the activities in Project ARTISAN together (Interview 20SG35). Project ARTISAN consisted of five weekly themes (Interview 20SG34; Interview 20SG35). They were ‘(1) Discovering our National Heritage,

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(2) Strengthening Social Bonds, (3) Overcoming Adversities and Resilience, (4) Building our Dreams and Aspirations, (5) Sharing our Stories and Legacies’ (Ho et al., 2021: 730709). An ARTISAN session which lasted for about three hours (i.e. from 10 a.m. to 1 p.m.) was held at the National Museum of Singapore in the first four weeks of the intervention (Interview 20SG35). It consisted of a 45-minute guided tour by a museum docent on three selected heritage artifacts, a 90-minute art making and storytelling segment facilitated by artists or art therapists, a short break and a 30-minute guided reflective writing and group sharing segment (Ho et al., 2021; Interview 20SG34; Interview 20SG35). It was delivered bilingually in both Mandarin and English (Interview 20SG34). The first four weeks of the intervention needed further elaboration. The three selected heritage artifacts shown to participants during every guided tour matched with a weekly theme. For example, the docent helped participants discover the national heritage of Singapore by showing them artifacts which told stories of national traditions and pastime with food and play (Ho et al., 2021: 730709). As regards the art making and storytelling segment, dyads were encouraged to share their personal stories related to the weekly theme and then used an art medium to create an art piece based on the theme with their partners (Ho et al., 2021: 730709). For example, in week one, dyads used air-dry clay to make food (e.g. a traditional dessert called Kuih) or toys they grew up with (Interview 20SG35). In Week 2, the theme was about social bonds. Participants were asked to bring a photo which served as a conversation starter to talk about their loved ones and what type of leisure activities they had with their loved ones (Interview 20SG35). Then, they were given canvases and acrylic to create an art piece which symbolized unity (Ho et al., 2021: 730709). In Week 3, participants were encouraged to ‘share their personal stories of overcoming adversities’ (Ho et al., 2021: 730709). They were asked if there were any difficult incidents which they experienced growing up and what they learned from these incidents (Interview 20SG35). Then, they used beads to make bracelets or necklaces which symbolized personal resilience (Ho et al., 2021: 730709; Interview 20SG35). Some participants talked about what each bead meant to them while some used the beads to talk about their past or current journey (Interview 20SG35). In Week 4, participants were encouraged to share their hopes and dreams for Singapore (Interview 20SG35) and then used recycled materials to create an art piece which symbolized their future aspirations for Singapore (Ho et al., 2021:

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730709). This required them to think out of the box and think of something larger than themselves (Interview 20SG35). A two-level art piece was created by some participants to express land scarcity in Singapore and the need to develop underground spaces in the country (Interview 20SG35). Another art piece created by other participants was about people using flying cars in Singapore (Interview 20SG35). For the guided reflective writing and group sharing segment, a handout containing some guiding questions (e.g. What is this art piece about? Do you have a name for it? What is the story behind it?) was distributed to participants to help them reflect on their experience in each ARTISAN session (Interview 20SG35). Participants wrote down a short paragraph which described the artwork and then shared it with group members (Interview 20SG35). Some young participants helped older adults write down their stories (Interview 20SG34). Some dyads came up with a shared writing and a shared reflection together (Interview 20SG35). The fifth and final ARTISAN session was held in a void deck (Interview 20SG34), which was an open space ‘located on the ground floor of Housing and Development Board (HDB) blocks of flats’ (Koh, 2015). It started with a 60-minute creative writing segment to let older adults and young people reflect on ‘the experiences from the previous 4 weeks as well as all the art pieces that were created’ (Ho et al., 2021: 730709). Then, there was an exhibition showcasing the artworks made by older adults and young people and their creative writing (Ho et al., 2021: 730709). It enabled older adults and young people to share the artworks they created with their family members, friends and neighbours (Interview 20SG34). The exhibition was followed by a 60-minute group sharing and debrief segment, which let older adults and young people celebrate their achievements and share words of gratitude and wisdom to their partner and the rest of the group (Ho et al., 2021: 730709). After the completion of Project ARTISAN, the art pieces were shown in two art exhibitions in the National Museum of Singapore (Interview 20SG35). One of the exhibitions was for Singapore’s National Day while another exhibition was for Grandparents’ Day (Interview 20SG35). Project ARTISAN brought several benefits to older participants. First, between-group linear mixed model analyses show that older adults in the intervention group experienced enhanced life satisfaction (3.14 vs. 3.54; 95% CI: 0.12 to 0.94, p = 0.011, d = 0.48) as compared to those in the controlled group (Ho et al., 2021: 730709). Besides, within-group linear mixed model analyses showed that at 5-weeks follow-up, older adults in

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the intervention group experienced enhanced resilience (5.04 vs. 5.65; 95% CI: 0.19 to 1.04, p = 0.005, d = 0.80) and significant reduction in loneliness (1.97 vs. 1.75; 95% CI: −0.44 to −0.02, p = 0.034, d = 0.83) as compared to baseline (Ho et al., 2021: 730709). Second, Project ARTISAN could empower older adults. It made older adults realize that they could still learn new things like art and in fact, they could do much more than what they thought they could (Interview 20SG35). After the completion of Project ARTISAN, some older adults attended art classes at community centres to sustain their interest (Interview 20SG35). Third, Project ARTISAN led to a change in mindset among older adults (Interview 20SG35). Before joining Project ARTISAN, older adults had a fixed mindset, thinking that they were too old to do anything and art was something for young people only (Interview 20SG35). They were intimidated by art (Interview 20SG34). After joining Project ARTISAN, older adults had a growth mindset, leading them to believe that they could still learn new things in old age (Interview 20SG35). They ‘developed a greater level of confidence and mastery’ (Ho et al., 2021: 730709). Besides, they became more open to new experience and were more willing to try new things in life (Interview 20SG35). Fourth, Project ARTISAN gave older adults a sense of purpose. Some older adults said that joining Project ARTISAN made them realize that they were not obsolete (Interview 20SG35). It was because they could share their personal stories and their wisdoms with young people who appreciated their sharing and reciprocated (Interview 20SG35). Young people found that what they learnt from their history lessons was now brought to life by older adults who shared their personal stories and lived experiences with young people (Interview 20SG35). This helped young people learn, understand and appreciate the past in a better way (Interview 20SG35). Fifth, Project ARTISAN helped remove age stereotypes about older adults and age stereotypes about young people (Interview 20SG35). Since young people and older adults had to engage in all the activities in Project ARTISAN together, they had chances to talk to each other and learn from each other (Interview 20SG35). Through interaction, both older adults and young people had more positive views on each other. A young participant said that older adults were easy to get along with when she got to know them (Ho et al., 2021: 730709). An older participant said that it was fun talking to university students and he felt young again (Ho et al., 2021: 730709). Sixth, Project ARTISAN helped build social bonds between older adults and young people (Interview 20SG35). Both older

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adults and young people shared their personal stories with each other and became friends (Interview 20SG35). After the completion of Project ARTISAN, young people and older adults exchanged phone numbers to keep in touch and met outside of the programme (e.g. had tea together) (Interview 20SG35). Older adults in Project ARTISAN had better social connection with young people and vice versa. Seventh, older adults also had better social connections with other older adults (Interview 20SG35). When joining Project ARTISAN, older adults had chances to meet and interact with other older adults (Interview 20SG35). When Project ARTISAN was over, some older adults were quite close with other older adults and felt like family (Interview 20SG35). They visited each other’s house and played Bingo together (Interview 20SG35). Meanwhile, young participants in the intervention group experienced significant increase in quality of life, life satisfaction and self-reported national identity upon the completion of Project ARTISAN (Ho et al., 2021: 730709). The success of Project ARTISAN relied on the assistance and support from key stakeholders (Interview 20SG34; Interview 20SG35). The National Arts Council funded Project ARTISAN (Interview 20SG34). The National Museum of Singapore provided the intellectual art input (Interview 20SG34). It helped the ARCH Lab identify the art space and artifacts which could be used for Project ARTISAN (Interview 20SG34; Interview 20SG35). Besides, it worked with docents to come up with the guided tours and write the scripts for the guided tours (Interview 20SG34). TOUCH Community Services helped recruit older adults from the community to join Project ARTISAN (Interview 20SG34) and book the venue for the final ARTISAN session and the exhibition to be held in the void deck (Interview 20SG35). Involving key stakeholders in the development and implementation of the project design could get a stronger buy-in from key stakeholders and led key stakeholders have a stronger sense of ownership towards Project ARTISAN (Interview 20SG34). This would encourage and motivate key stakeholders to sustain Project ARTISAN beyond its completion (Interview 20SG34). Nevertheless, having leadership and sufficient resources were also important to sustain the project and extend its reach to more older adults (Interview 20SG34). When implementing Project ARTISAN, there was the creation of a non-judgemental environment for older adults to feel safe to express themselves (Interview 20SG34). Having good facilitation enabled older adults to know that art was not judged by the way it looked (Interview 20SG34). Art was not about aesthetic beauty but

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about the way older adults expressed themselves (Interview 20SG34). It was used in Project ARTISAN to ask older adults about their lives and their stories in a manner that older adults felt heard and respected (Interview 20SG35). ‘The sense of achievement gained from creating an art piece can even inject a dose of confidence, lift mood and improve participants’ self esteem’ (Nanyang Technological University, MSc in Applied Gerontology, 2020).

Conclusion To conclude, the four community projects introduced in Singapore show that AIP can be achieved in different ways. The SilverCOVE project showed that the involvement of older adults in the design process of SilverCOVE could encourage shared responsibility, foster community engagement, and create a sense of ownership among older residents. ComSA@Whampoa empowered older residents to take charge of their own health, built community capacity through knowledge transmission, fostered a sense of purpose and a sense of community among older residents and promoted a positive image of older adults in the community through an integrated system of holistic programmes and services. Exergaming competitions for older adults could increase social interactions and engagement among older adults, promote intergenerational bonding, stimulate older adults’ exercise intentions, gave older adults a sense of accomplishment and reduce alienation. Project ARTISAN showed that an integrative art and heritage-based interventions could enhance older adults’ life satisfaction, resilience and their interactions with other older adults, empower them to learn new things, help them develop a growth mindset, and create stronger intergenerational relationships. It is hoped that assistance and support from multiple stakeholders can lead to an increase in the number and scale of community projects so that more older adults can grow old healthily, independently and gracefully in their communities.

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Community Engagement Event (ICE): Diabetes in an Ageing Population: The Way Forward. Wiles, J. L., Leibing, A., Guberman, N., Reeve, J., & Allen, R. E. S. (2012). The meaning of “aging in place” to older people. The Gerontologist, 52(3), 357–366. https://doi.org/10.1093/geront/gnr098 Wiles, J. L., Rolleston, A., Pillai, A., Broad, J., Teh, R., Gott, M., & Kerse, N. (2017). Attachment to place in advanced age: A study of the LiLACS NZ Cohort. Social Science & Medicine, 185, 27–37. https://doi.org/10.1016/j. socscimed.2017.05.006 Williams, B., Doherty, N. L., Bender, A., Mattox, H., & Tibbs, J. R. (2011). The effect of Nintendo Wii on balance: A pilot study supporting the use of the Wii in occupational therapy for the well elderly. Occupational Therapy in Health Care, 25, 131–139. https://doi.org/10.3109/07380577.2011.560627 Wollersheim, D., Merkes, M., Shields, N., Liamputtong, P., Wallis, L., Reynolds, F., & Koh, L. (2010). Physical and psychosocial effects of Wii video game use among older women. International Journal of Emerging Technologies and Society, 8, 85–98. Wong, L. (2019, July 27). Tan Tock Seng Hospital marks 175th anniversary by stepping up efforts to provide community eldercare. The Straits Times. Retrieved July 27, 2022, from https://www.straitstimes.com/singapore/ tan-tock-seng-hospital-marks-175th-anniversary-by-stepping-up-efforts-to-pro vide-community Wong, P. T. P., & Peacock, E. J. (1994). Environment, stress and aging. In A. H. Rose (Ed.), Human stress and the environment (pp. 59–84). Gordon and Breach Science Publishers. Wong, R. K. M., Ho, C. M. C., & Chan, G. W. L. (2018). A participatory design experience with older people: Case study of participatory design in the HKSKH Tseung Kwan O aged care complex project. In K. H. Chong & M. Cho (Eds.), Creative ageing cities: Place design with older people in Asian cities (pp. 145–158). Routledge. Xu, X., Theng, Y. L., Li, J., & Pham, T. P. (2016). Investigating effects of exergames on exercise intentions among young-old and old-old. Paper presented at the Proceedings of the 2016 CHI Conference Extended Abstracts on Human Factors in Computing Systems, Santa Clara, CA, pp. 2961–2968. Retrieved October 22, 2022, from https://doi.org/10.1145/2851581.289 2296 Xu, X., Li, J., Pham, T. P., Salmon, C. T., & Theng, Y.-L. (2016). Improving psychosocial well-being of older adults through exergaming: The moderation effects of intergenerational communication and age cohorts. Games for Health Journal: Research, Development, and Clinical Applications, 5(6), 389–397. https://doi.org/10.1089/g4h.2016.0060

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Yabuka, N. (2017). Preparing for a senior’s city. CUBES, 83, 57–61. Retrieved July 23, 2022, from https://www.col-ours.com/_files/ugd/57552f_3a4b0f 179e634f0eb7e1a67bef1cc5f6.pdf Yabuka, N., & Peh, S. (2016). Crowdsourcing design. CUBES, 79, 36–37. Retrieved July 23, 2022, from https://www.col-ours.com/_files/ugd/575 52f_5e70107707f943a0a8a6eb527744a165.pdf Zhuang, J. (2016). Creative hacks to public spaces. Skyline, 5, 10–13. Retrieved July 23, 2022, from https://www.col-ours.com/_files/ugd/57552f_31addc b069c944718e947fd7f6d04854.pdf

Websites About us. (n.d.). Retrieved July 30, 2022, from https://www.pa.gov.sg/about-us A cove for seniors to age in place healthily and happily. (2016). Retrieved July 23, 2022, from https://www.moh.gov.sg/ifeelyoungsg/our-stories/how-can-iage-in-place/receive-better-care/a-cove-for-seniors-to-age-in-place-healthilyand-happily ARTISAN: Fostering aspirations and resilience through intergenerational storytelling and art-based narratives. (n.d.). Retrieved October 29, 2022, from https://blogs.ntu.edu.sg/arch/2018/07/27/artisan/ Centre-based comprehensive care. (n.d.). Retrieved July 27, 2022, from https:// tsaofoundation.org/towards-successful-ageing/hmcsa/centre-based-compre hensive-care Exergaming. (n.d.). Retrieved October 22, 2022, from https://reference.jrank. org/fitness/Exergaming.html. Accessed 22 October 2022. Guided autobiography group (GAB) programme. (n.d.). Retrieved July 29, 2022, from https://tsaofoundation.org/towards-successful-ageing/comsa/ community-development/gab Integrated care system. (n.d.). Retrieved July 27, 2022, from https://tsaofound ation.org/towards-successful-ageing/comsa/integrated-care-system Integrated health and social care network to build health with residents in central Singapore. (2019). Retrieved July 27, 2022, from https://www.ttsh.com. sg/About-TTSH/TTSH-News/Pages/Integrated-health-and-social-care-net work-to-Build-Health-with-residents-in-Central-Singapore.aspx NTUC Health’s first senior wellness centre brings together partners with services to enable successful aging in place. (2016). Retrieved July 23, 2022, from https://assets-prod.ntuchealth.sg/nh/Documents/Press-Rel ease/Media-Release-SilverCOVE-Official-Opening-Web.pdf Participatory Design. (n.d.). Retrieved July 23, 2022, from https://www.wicked problems.com/4_participatory_design.php

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Project SCOPE. (n.d.). Retrieved July 29, 2022, from https://tsaofoundation. org/towards-successful-ageing/comsa/community-development/projectscope Sharing Wellness and Initiatives Group (SWING). (n.d.). Retrieved July 29, 2022, from https://tsaofoundation.org/towards-successful-ageing/comsa/ community-development/swing Speech by Mr Tan Chuan-Jin at social service partners conference 2015. (2015). Retrieved July 15, 2022, from https://www.msf.gov.sg/media-room/Pages/ Speech-by-Mr-Tan-Chuan-Speech-by-Mr-Tan-Chuan-Jin-at-Social-ServicePartners-Conference-2015.aspx Speech by Mr. Gan Kim Yong, Minister for Health at the re-opening of Whampoa CC and opening of ComSAcentre. (2017). Retrieved July 27, 2022, from https://www.singaporenewstribe.com/speech-by-mrgan-kimyong-minister-for-health-at-the-re-opening-of-whampoa-cc-and-opening-ofcomsacentre/ The architecture of community: How participatory design builds connection. (n.d.). Retrieved July 24, 2022, from https://www.thinkwood.com/blog/the-archit ecture-of-community-how-participatory-design-builds-connection What is guided autobiography? (n.d.). Retrieved August 4, 2022, from https:// guidedautobiography.com/guided-autobiography 2016 awards categories finalists. (2016). Retrieved July 24, 2022, from https:// na.eventscloud.com/ehome/apacawards2016/categories/

Interviews Interview Interview Interview Interview Interview Interview Interview

18HK01, an architect, July 2018. 18SG08, a scholar, August 2018. 19SG26, Professor of Architecture, November 2019. 19SG30, staff from the Tsao Foundation, December 2019. 20SG33, a researcher, October 2020. 20SG34, a scholar, November 2020. 20SG35, a researcher, November 2020.

CHAPTER 7

The Creation of Dementia-Friendly Communities

Abstract In Singapore, the number of people with dementia (PWD) has increased over the past 10 years. This chapter will examine what dementia is, the dementia landscape in Singapore and how dementia-friendly communities (DFCs) are created in the country. Four key components of DFCs, including dementia awareness, Go-to Points (GTPs), technology and infrastructure, will be examined in details. Challenges to develop and sustain DFCs will also be examined. In order to sustain DFCs in Singapore, it is necessary for the government to develop and implement a national dementia policy which includes the creation of DFCs. This can help stakeholders and community partners have better ideas about the key elements of DFCs, infrastructure, systems, services and resources available for creating DFCs, and the core areas for action. A social model of disability should continue to be adopted to create and sustain DFCs in Singapore. Besides, more public awareness campaigns should be held to destigmatize dementia in the country. It is hoped that Singapore will become a dementia-friendly country in future. Keywords Dementia · Dementia awareness · Dementia friendly communities · Dementia friends · Go-to Points · Social model of disability

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 S. Ching Yuen Luk, Healthy Ageing in Singapore, Social Policy and Development Studies in East Asia, https://doi.org/10.1007/978-981-99-0872-1_7

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Introduction ‘Dementia is a leading cause of disability and dependency globally’ (World Health Organization, 2021: 1). In Singapore, the number of people with dementia (PWD) has increased over the past 10 years. This chapter will examine what dementia is, the dementia landscape in Singapore and how dementia-friendly communities (DFCs) are created in the country. DFCs are created based on the social model of disability. They consist of four key components, including dementia awareness, Go-to Points (GTPs), technology and infrastructure. This chapter will examine four key components of DFCs in details. Then, it will examine challenges to develop and sustain DFCs in Singapore and critical factors for developing and sustaining DFCs in the country.

What is Dementia? Dementia refers to a syndrome characterized by a progressive decline in cognitive ability (Molinari & Volicer, 2010), including memory, thinking, language, learning capacity, comprehension, and judgement (World Health Organization, 2020). It progresses through three stages: early, middle and late (Alzheimer’s Society, 2020). These stages are sometimes referred to as ‘mild, moderate and severe, because this describes how much the symptoms affect a person’ (Alzheimer’s Society, 2020: 3). ‘[T]he early stage of dementia is often overlooked’ (World Health Organization, 2020) because a person can continue to function in most daily activities with a mild and often unrecognized memory lapses and a mild decline in thinking ability (Valcour & Blanchette, 2002: 20). Symptoms becomes more apparent when a person progresses to the middle stage of dementia. There is increased memory loss and confusion. A person in the middle stage of dementia has difficulty in recognizing family or close friends and may confuse them with strangers (Alzheimer’s Society, 2020: 10). Behavioural issues such as repeated questioning, getting lost in familiar surroundings and wandering may arise (Valcour & Blanchette, 2002: 20; World Health Organization, 2020). Psychotic symptoms such as delusions, paranoia, and hallucinations may also occur (Alzheimer’s Society, 2020: 10–11; Valcour & Blanchette, 2002: 20). The late stage of dementia is ‘a state of profound physical and cognitive disability’ (Mitchell, 2021). A person in the late stage of dementia needs high levels of care and support due to experiencing severe memory loss,

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loss of speech, immobility, and losing control of his or her bladder (The Alzheimer Society, of Ireland 2015: 1–2). He or she may experience behavioural changes, including increased agitation, aggression (e.g. shouting, screaming, physical or verbal abuse) (‘Coping with dementia behaviour changes’ n.d.), repetitive movements, delusions, hallucinations, restlessness, and sundowning (also known as late-day confusion) (‘Changes of behaviour in the later stages’ n.d.). Such behavioural changes ‘may be partly due to the progress of dementia and partly due to distress’ (Alzheimer’s Society, 2013: 5). They may increase caregiver burden. Particularly, physical aggression against caregivers in home environment (e.g. shoving, hitting, kicking, being struck by flying objects) may severely affect personal safety and wellbeing of caregivers and eventually lead to caregivers’ decision to place a person with dementia in a nursing home (Cahill & Shapiro, 2008). Dementia can result from a variety of diseases or brain injuries such as a stroke (World Health Organization, 2020). Alzheimer’s disease (AD), which is a neurodegenerative disorder, is the most prevalent cause of dementia (van der Flier & Scheltens, 2005). It accounts for an estimated 60 to 80% of dementia cases (The Alzheimer’s Association, 2020: 393). Vascular dementia (VaD), which results from reduced blood flow to brain tissues, is the second most prevalent cause of dementia (van der Flier & Scheltens, 2005) and accounts for about 20% of all cases (Jørgensen et al., 2020). Other common causes of dementia include frontotemporal lobar dementia (FTLD) and Lewy body dementia (LBD) (van der Flier & Scheltens, 2005). FTLDs, which is an early-onset dementia, results from progressive nerve cell loss in the frontal and temporal lobes of the brain (‘Frontotemporal dementia’ n.d.). Meanwhile, LBDs results from an abnormal accumulation of the misfolded alpha-synuclein protein in the brain (Cummings, 2004). But a recent study has found that 12 risk factors can be modified over a lifetime to prevent or delay about 40% of worldwide dementia cases (Livingston et al., 2020). These modifiable risk factors include physical inactivity, obesity, smoking, excessive alcohol consumption, hypertension, depression, diabetes, head injury, hearing impairment, less education, infrequent social contact and air pollution (Livingston et al., 2020: 414). Globally, the number of PWD has significantly increased over time. It rose from 24.3 million in 2001 (Ferri et al., 2005) to over 55 million in 2020 (Alzheimer’s Disease International n.d.). At present, about 60% of the dementia cases are found in low- and middle-income countries

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(LMICs) (World Health Organization, 2020) where dementia ‘has been relatively under-prioritized’ (Prince et al., 2008: 332) and is stigmatized due to the lack of understanding of dementia (Prince et al., 2008: 337). The number of PWD globally is estimated to reach 82 million by 2030 (The Economist, 2020) and over 152 million by 2050 due to population ageing (The Alzheimer’s Association International Conference, 2021). As the number of PWD increases, the cost of dementia care also increases. From 2010 to 2015, the global cost of dementia increased from US$ 604 billion to US$ 818 billion, representing an increase of 35.4% (Alzheimer’s Disease International, 2015: 58). While direct medical cost accounted for 19.5% of the global cost of dementia, direct social sector costs and informal care costs respectively accounted for 40.1% and 40.4% (Alzheimer’s Disease International, 2015: 62). In 2030, the cost of dementia ‘is estimated to increase to US$2 trillion, a total that could undermine social and economic development globally’ (Dua et al., 2017). Dementia has become a global health challenge that can no longer be ignored (World Health Organization, 2012).

Dementia Landscape in Singapore In Singapore, one in every 10 older adults aged 60 years and above has dementia, according to a national study led by Institute of Mental Health (IMH) (Subramaniam et al., 2015; Vaingankar, 2015: 6). Various factors are associated with a higher risk of dementia in the country, including older age, a history of stroke, low education level, homemaker and retired status (Subramaniam et al., 2015; Vaingankar, 2015). The national study found that the likelihood of dementia for older adults aged 75–84 years and 85 years and over were respectively about 4 times and 18 times higher than that of those aged 60–74 years (Subramaniam et al., 2015: 1133– 4). While dementia is not a normal part of ageing (Irwin et al., 2018), ageing is the greatest risk factor for dementia (Alzheimer’s Society, 2021). This is because ‘dementia can take a long time to develop’ (Alzheimer’s Society, 2021: 5). Older adults are likely to be coping with health conditions such as high blood pressure that can increase their risk of dementia (Alzheimer’s Society, 2021: 5). Stroke interrupts blood supply to the brain, resulting in brain injury. A history of stoke would increase dementia risk by about 70% (University of Exeter, 2018). Education is ‘widely regarded as a factor that promotes cognitive reserve’ (Mungas et al., 2018: 142). ‘Cognitive reserve refers to resilience to cognitive decline

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resulting from brain injury’ (Mungas et al., 2018: 148). Individuals with higher education level have greater cognitive reserve to withstand agerelated brain changes than those with lower education levels (Stern, 2013; Subramaniam et al., 2015). This is because their cognitive networks are more flexible and efficient (Almeida-Meza et al., 2021: 243). Hence, individuals with lower education level have higher risk of dementia. In Singapore, the risk of dementia was 25.6 times higher for homemakers and 30.3 times higher for retirees than for workers (Subramaniam et al., 2015: 1134). Participation in the paid labor force helps protect later-life memory decline (Mayeda et al., 2020: e3078) because of ‘cognitive stimulation, social engagement or financial security’ (The Fisher Center for Alzheimer’s Research Foundation, 2020). People without participating in the paid labor force (e.g. homemakers) experienced faster later-life memory decline, thereby having higher risk of dementia (Mayeda et al., 2020). ‘Working tends to keep people physically active, socially connected and mentally challenged’ (Marchione, 2013). Retirement would reduce mental stimulation (Dufouil et al., 2014: 354) due to reducing the use of a range of mental skills (e.g. organizational, problem-solving, communication skills) (Alzheimer’s Society, 2021). This leads to retirees having higher risk of dementia. Locally, the number of PWD increased from 28,000 in 2012 (Tai, 2015) to about 40,000 in 2015 (Boh, 2016) and about 82,000 in 2018 (Rashith, 2019). Such number is projected to reach more than 130,000 by 2030 (Rashith, 2018) and 187,000 by 2050 (SPD, 2018). A significant rise in the number of PWD is set to increase the cost of dementia in the country. The first local study which provided a comprehensive estimate of the societal cost of dementia based on a nationally representative sample found that dementia cost ‘more than two times as much as heart problems, stroke, diabetes, and depression’ (Abdin et al., 2016: 447). The annual total societal cost of dementia in Singapore among older adults aged 60 years and over was S$532 million (US$409 million) in 2013 (Abdin et al., 2016: 444). The total societal cost of dementia was ‘split unequally between healthcare and social care costs’ (Abdin et al., 2016: 447), with social care cost accounting for 76% of the total societal cost of dementia (Abdin et al., 2016: 447). The cost of unpaid care was higher than that of paid care, accounting for 60% of social care costs (Abdin et al., 2016: 447). In the same year, the annual cost of dementia per person was S$10,245 (US$7,881), which was within the range of worldwide estimated cost of dementia (US$6,827-US$32,869) (Abdin et al.,

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2016: 447) and was ‘lower than the mean world-wide cost of dementia (US$16,986)’ (Abdin et al., 2016: 447). ‘The costs of hospital admissions were the largest cost drivers in those with dementia (S$7,178)’ (Abdin et al., 2016: 444). A study by Woo et al. (2017a) quantified the monetary cost of family caregiving for 51 older adults with different severity of dementia. It found that the monetary mean annual cost of dementia care was about S$70,185 (Woo et al., 2017a: 61). Of this, about S$44,531 (63.45%) was attributable to informal cost (i.e. the time and the salary foregone by caregivers) and about S$25,654 (36.55%) was attributable to formal cost (e.g. medical costs, transportation costs, charges for day care centres, charges for full-time residential care facilities) (Woo et al., 2017a: 61). Besides, the study found that the median annual costs of informal care increased with severity of dementia (Mild: S$13,847.68; Moderate: S$38,607.84; Severe: SG$47,251.30) (Woo et al., 2017a: 63). It also found that the costs for those who did not have domestic helpers was approximately more than double the costs for those with domestic helpers (Woo et al., 2017a: 62–4). For example, the median total annual cost of informal care of people with serve dementia was about S$83,674 if they had no domestic helpers and S$37,287 if they had domestic helpers. (Woo et al., 2017a: 62). This meant that cost saving could occur when the family employed live-in domestic helpers and informal caregivers remained in the workforce (Woo et al., 2017a: 64). Another study estimated that the total annual net informal cost of care for PWD in Singapore was S$1.76 billion in 2015 and was projected to almost triple to S$4.02 billion by 2030 (Woo et al., 2017b: 101). Besides, it estimated that the net informal care cost of dementia was about S$39,053 per person per year and increased with severity (Woo et al., 2017b: 100). The net informal care cost of dementia was about S$8,371 for people with mild dementia, about S$33,131 for people with moderate dementia and about S$41,774 for people with severe dementia (Woo et al., 2017b: 100). The mean annual informal cost of care for PWD (S$44,530.55) was eight times higher than that of care for people without dementia (S$5,477.03) (Woo et al., 2017b). The existing studies above show that the informal cost of dementia care is very high. Informal caregivers of PWD have to bear huge financial burden, especially when they take care of people with severe dementia. ‘Dementia care is difficult’ (World Health Organization, 2015: 2) It ‘is associated with long care hours and physically demanding caregiving’ (Brodaty & Donkin, 2009: 218). ‘Many informal carers who have to

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juggle professional and care responsibilities decide to leave paid employment due to the stress deriving from work and care’ (United Nations Economic Commission for Europe, 2019: 8).‘Support is needed to enable informal caregivers to continue in their role for as long as possible’ (World Health Organization, 2015: 1). Inadequate support can lead to informal caregivers facing the risk of social isolation, ill-health and poverty (United Nations Economic Commission for Europe, 2019: 6).

The Creation of Dementia-Friendly Communities (DFCs): Adopting a Social Model of Disability In Singapore, the creation of DFCs began in 2016 when Khoo Teck Puat Hospital (KTPH) and the Lien Foundation, which is a philanthropic organisation, launched the “Forget Us Not” initiative to raise awareness of dementia, destigmatize dementia and increase public acceptance of PWD (Lien Foundation, 2016). DFCs can be geographically defined as regions, countries, municipalities, cities, towns, or villages (Williamson, 2016: 13) where PWD and their caregivers ‘are empowered, supported and included in society, understand their rights and recognise their full potential’ (Alzheimer’s Disease International, 2016: 10). In 2016, the first DFC in Singapore was created in Yishun where about 10% of residents were aged 65 or over and the community resources such as a geriatric centre at KTPH were available to support PWD (Tai, 2016a). At present, there are eight DFCs in the country. They include Bedok, Bukit Batok East, Fengshan, Hong Kah North, Macpherson, Queenstown, Woodlands, and Yishun (About Dementia Friends, n.d.). They have more older estates and higher proportion of older adults in their population (Interview 19SG21). All the DFCs are supported by multiple stakeholders, including Dementia Singapore, Brahm Centre, Centre For Seniors, Pharmaceutical Society of Singapore, schools, grassroots organisations, faith-based organisations, family service centres, community care sector partners (e.g. day care centres), volunteers and staff of business entities (‘Launching more Dementia-Friendly Communities in Singapore’, 2016). A social model of disability is adopted to create DFCs in Singapore. From a social model perspective, there is ‘a relatively sharp distinction between impairment and disability’ (Goering, 2015: 135). Impairment refers to the functional limitation within an individual caused by physical, cognitive, sensory, or intellectual impairment (All-Party Parliamentary

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Group on Dementia, 2019; Anastasiou & Kauffman, 2013; Barnes, 1999). Disability, by contrast, refers to limited opportunities or the loss of opportunities to participate in the normal life of the community on an equal level with other people because of physical (e.g. stairs, ramps), social (e.g. education, employment), institutional (e.g. restrictive laws, lack of enforcement for disability inclusion policies) and attitudinal (e.g. discrimination, hostility) barriers (Anastasiou & Kauffman, 2013: 442; Centers for Disease Control and Prevention n.d.; Goering, 2015: 135; Governance and Social Development Resource Centre n.d.). From a social model perspective, disability is caused by an oppressive and unaccommodating society rather than by a person’s impairment (Hogan, 2019). It is ‘a social creation which causes the impairment to be a problem’ (Bunbury, 2019: 30). Disability ‘is socially constructed through the failure or unwillingness to create ability among people who do not fit the physical and mental profile of “paradigm” citizens’ (Wendell, 1996: 41). Deviate from the dominant norm, people with impairment are ‘evaluated and labelled through a process of power which then serves to separate them from mainstream society, education, work or social interaction’ (Owens, 2015: 386). For these reasons, the social model advocates for the removal of the disabling barriers produced by hegemonic institutional and social structure in an attempt to address issues of discrimination, oppression and marginalization of disabled people (Bunbury, 2019; Terzi, 2004). It ‘argues for the full inclusion of disabled people in society and for their complete acceptance as citizens with equal entitlements, rights and responsibilities’ (Terzi, 2004: 144–5). The social model of disability was ‘developed in reaction to the limitations of the medical model of disability’ (Retief & Letšosa, 2018: a4738), which characterizes disability as ‘a medical problem that resides in the individual’ (Retief & Letšosa, 2018: a4738), regards people with disability as ‘passive objects of intervention, treatment, and rehabilitation’ (Oliver, 1990: 5), and reinforces the sick and dependency roles of people with disability (Bunbury, 2019: 28). Seeing dementia as a disability through the social model perspective helps recognize and promote the disability rights of PWD and identifies areas where adaptations have to be made for PWD so as to maximize their wellbeing, capacities, independence, choice and control. Applying the social model of disability to the creation of DFCs is to maintain personhood of PWD, improve their quality of life and foster social inclusion of PWD through de-stigmatisation, increasing public awareness and understanding of dementia, increasing meaningful engagement for PWD,

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delivering services that can meet the specific needs of PWD, having legal or other measures in place to empower PWD to protect their rights (Alzheimer’s Disease International, 2016: 7–11), and improving the physical environment to keep PWD safe and give them a choice of spaces for activities and social interaction (Edgerton & Richie, 2010).

Key Components of DFCs in Singapore There is no single model or template for creating DFCs (Williamson, 2016: 9). ‘Communities are diverse’ (Williamson, 2016: 5). Hence, ways in which DFCs are created differ, depending upon political, economic, social, cultural, demographic and geographical factors (Williamson, 2016). But equality, respect, autonomy, empowerment, participation, and social acceptance are some of the essential attributes of ‘dementia friendly’ (Alzheimer’s Disease International, 2016: 9; Lin, 2017: 146–7). In Singapore, DFCs contain four key components: (1) dementia awareness, (2) Go-to Points (GTPs), (3) technology and (4) infrastructure (‘Dementia-friendly communities’ n.d.). Dementia Awareness A lack of awareness and understanding of dementia result in a number of misperceptions about dementia and a perpetuation of stigma (World Health Organization, 2012: 83). Stigma ‘refers to problems of knowledge (ignorance), attitudes (prejudice) and behaviour (discrimination)’ (Thornicroft et al., 2007: 192). It ‘is a mark or sign of disgrace usually eliciting negative attitudes to its bearer’ (Thornicroft et al., 2007: 192) due to ‘believed or actual individual characteristics, beliefs or behaviours that are against norms, be they economic, political, cultural or social’ (Lauber, 2008: 10). Stigma associated with dementia negatively affects PWD and their family caregivers (World Health Organization, 2012: 83). PWD who face stigma have lower self-esteem, feel anxious, develop a sense of shame, and fear the judgement of other people (Urbanska ´ et al., 2015: 225). They may isolate themselves, delay seeking a diagnosis and help (World Health Organization, 2012: 82) and have poorer quality of life (Rewerska-Ju´sko & Rejdak, 2020: 1343). Their family caregivers who deal with the stigma may feel embarrassed, anxious (Urbanska ´ et al., 2015: 225), ‘guilt and a sense of failure’ (Urbanska ´ et al., 2015: 227). Raising public awareness and understanding of dementia helps counter

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stigma (World Health Organization, 2012: 84), increases help-seeking and help-giving (World Health Organization, 2012: 88), leads to ‘more acceptance and greater inclusion within the community and, importantly, a more proactive community that is aware of potential risks to developing dementia’ (World Health Organization, 2012: 86). In Singapore, the provision of dementia care training is one of the most important ways to raise public awareness and understanding of dementia. In 2016, KTPH offered training sessions to different organizations, businesses, schools, retailers and the general public as part of the “Forget Us Not” initiative to raise awareness of dementia (Tang, 2016). It trained ‘organisation staff to be more dementia-friendly through customised, face-to-face sessions that involve hands-on activities, such as role-playing’ (Tang, 2016). Dementia Singapore, formerly known as Alzheimer’s Disease Association (ADA), is a leading non-profit organization in dementia care. It offers dementia awareness and care training courses, from beginner to advanced level, to the general public (see Table 7.1), foreign domestic workers (FDWs) (see Table 7.2), professional caregivers (see Table 7.3a, Table 7.3b), health, social care and home care practitioners (see Table 7.4). Other dementia training providers include Agency for Integrated Care (AIC), Temasek Polytechnic, Ren Ci Learning Academy, Hua Mei Training Academy (HMTA), and St. Luke’s Elder Care. AIC offers an online course on dementia awareness to the general public and caregivers (‘E-Learning on Dementia and Mental Health’ n.d.). A three-hour workshop which shares a more in-depth case study and involves hands-on activities such as role playing is also offered by AIC to Family Service Centres or mental health organizations which deal with PWD regularly (Interview 19SG21). Temasek Polytechnic offers a 1-day course to individuals to understand dementia and learn some reminiscence activities when interacting with PWD (‘Introduction to Dementia and Reminiscence Workshop’ n.d.). Ren Ci Learning Academy offers a foundational course on dementia to healthcare workers and volunteers who want to gain basic knowledge of dementia and understand older PWD (Ren Ci Learning Academy, 2019). HMTA offers a 5-day training programme on clinical dementia care to professional care staff (e.g. nurses, occupational therapists, social workers, counsellors) (Hua Mei Training Academy n.d.). St. Luke’s Elder Care offers basic and intermediate level courses on dementia to community care staff caring for PWD (‘Care of Client with Dementia (Basic)’ n.d.; ‘Care of Client with Dementia (Intermediate)’ n.d.).

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Table 7.1 Dementia Singapore: Training sessions for the general public Course title

Dementia awareness workshop

Facilitate meaningful interaction with persons with dementia

Course duration Course outline

3 hours [1] Myths and facts of dementia [2] Recognise the signs and symptoms of dementia [3] Effects and challenges when communicating with persons with dementia [4] Assisting persons with dementia [5] KIND gestures and CARE approach [6] Know the community resources for dementia

Fees

SG$80.25 [inclusive of Goods and Services Tax (GST)] SG$20.25 (inclusive of GST) [For recipients of National Silver Academy (NSA)* subsidy]

8 hours [1] Signs, symptoms and causes of dementia [2] Impact of dementia on the person and caregivers [3] Introduction to Person-Centred Care [4] Impact of dementia on communication [5] Effective communication strategies [6] Facilitate meaningful interaction through conversation SG$214.00 (inclusive of GST) SG$54 (inclusive of GST) (For recipients of NSA subsidy)

Source Dementia Singapore https://dementia.org.sg/academy/awareness/ Dementia Singapore https://dementia.org.sg/academy/interaction/ *NSA subsidy is only applicable for Singaporeans and Permanent Resident (PR) aged 50 and above

The practical knowledge and skills learnt from the dementia awareness and care training courses enables participants to recognise and assist PWD in various community care settings (e.g. home care, day care, residential care) (Alzheimer’s Disease Association, 2021a; ‘Dementia Awareness Workshop’ n.d.), communicate and interact with PWD effectively, provide person-centred care for PWD (Alzheimer’s Disease Association, 2021a), and refer PWD to community resources for support (‘Dementia Awareness Workshop’ n.d.). In 2016, more than 10,000 people in Singapore received dementia awareness training (Tai, 2016b). These included local grassroots leaders, front-line staff from transport companies, banks, retailers and public organizations (e.g. National Library Board, Bedok Police Division), church members and school students (Tai, 2016b). A local grassroots leader made use of the skills he learnt from the dementia awareness training to calm residents with dementia down when they got lost and helped them reunite with their families (Tai, 2016b). A

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Table 7.2 Dementia Singapore: Training sessions for foreign domestic workers (FDWs) Course title

Essentials of dementia care (Core module)

Meaningful activities (Elective module)

Course duration Course outline

8 hours [1] Identify signs and symptoms of dementia [2] How dementia causes changes in the behaviour of a person and ways to manage these behaviours [3] Effective communication techniques English, Malay and Burmese SG$180 [before the Caregivers Training Grant (CTG)] A minimum co-payment of SG$10* (after CTG)

3 hours Identify and conduct suitable activities for persons with dementia (PWD)

Medium of instruction Fees

English, Malay and Burmese SG$90 (before CTG) A minimum co-payment of SG$10 (after CTG)

Source Dementia Singapore https://dementia.org.sg/academy/fdw/ Dementia Singapore https://dementia.org.sg/academy/fdw/#elective *Subjected to eligibility and the remaining amount of the care recipient’s CTG

Singapore Mass Rapid Transit (SMRT) service ambassador found the dementia awareness training useful because it enabled her to identify older commuters with dementia in the midst of a chaotic peak-hour crowd (Tai, 2016b). She could help a regular older commuter with dementia by reassuring him that he was on the right platform and alerting a fellow passenger to keep a look out for him to ensure that he alighted at the right Mass Rapid Transit (MRT) station (Tai, 2016b). In December 2019, all 12,000 staff from Development Bank of Singapore (DBS) and Post Office Savings Bank (POSB) completed AIC’s Dementia Awareness (Foundation) e-learning course (DBS, 2019), which carried ‘a compulsory passing score of 80 per cent’ (Iskandar, 2020). The course equipped bank staff with skills to recognize, serve and communicate with customers with dementia and protect customers with dementia who may be at higher risk of financial abuse (Choy, 2019). In October 2017, Kim San Leng Food Centre in Bishan became Singapore’s first dementia-friendly food centre having trained stallholders to identify and help customers with dementia (Toh, 2017). It displays specially designed decals on dining

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Table 7.3a Dementia Singapore: Training sessions for professional caregivers Certification programme

Support Persons Living with Dementia

Certificate in Foundations of Person-Centred Dementia Care

Duration

4 days (classroom training) 6.5 hours (self-paced e-learning) Professional staff (i.e. nurses, allied health professionals, social workers, counsellors) who are involved in developing care plans or planning activity programmes for people with dementia (PWD) Module 1: Apply Person-Centred Care Module 2: Provide Activities to Maximise Autonomy and Promote Wellbeing Module 3: Develop and Implement Techniques which Minimise the Impact of Changed Behaviour

4 days

Who should attend

Content

Assessment

Fees

Written assignments PowerPoint presentation for practical performance Oral questioning SG$1,348.20 (inclusive of GST) Prevailing course fee subsidy: 90% for Singaporeans or Permanent Residents (PRs) 45% for Work Permit Holders working in eligible community care organisations

Front-line care staff and volunteers

Module 1: Nature and Impact of Dementia Module 2: Person-Centred Care Module 3: Behavioural Communication Module 4: Purposeful and Meaningful Engagement Module 5: Palliative Care Approach A quiz A written assessment Role-playing Oral questioning SG$941.60 (inclusive of GST) Prevailing course fee subsidy: 90% for Singaporeans or Permanent Residents (PRs) 45% for Work Pass Holders working in eligible community care organisations

Source Dementia Singapore https://dementia.org.sg/academy/support/ Dementia Singapore https://dementia.org.sg/academy/certificate-pcdc/

tables to educate diners on how to identify PWD and their behaviours (Lim, 2017). Simulation is another important way to raise public awareness and understanding of dementia. It is a technique to ‘replace or amplify real experiences with guided experiences, often immersive in nature, that

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Table 7.3b Dementia Singapore: Training sessions for professional caregivers Certification programme

Implement Namaste Care (Intermediate)

Duration

6 hours (self-paced e-learning) 12 hours (classroom training) Nurses, allied health professionals, social workers, programme coordinators/executives E-learning: [1] Person-centred care and behaviour of concerns [2] Enriching Lives [3] Reflect and recap on Namaste Care Classroom training: [1] Introduction and application of Namaste Care in care settings [2] Develop Namaste Care Implementation Plan SG$449.40 (Inclusive of GST) Prevailing course fee subsidy: 90% for Singaporeans or Permanent Residents (PRs) 45% for Work Permit Holders working in eligible community care organisations

Who should attend Content

Assessment

Source Dementia Singapore https://dementia.org.sg/academy/namaste/

evoke or replicate substantial aspects of the real world in a fully interactive fashion’ (Gaba, 2004: i2). Overseas studies found that dementia simulation allows people to experience for themselves the physical and mental challenges PWD face (Kimzey et al., 2021). This enables reflective learning to occur, which forms a richer understanding of PWD (Slater et al., 2019: e12243). Dementia simulation can also enhance people’s sensitivity to the need of PWD (Meyer et al., 2022) and their empathy for PWD (Adefila et al., 2016; Kimzey et al., 2021; Meyer et al., 2022; Slater et al., 2019). In Singapore, an event held in Nee Soon South used simulation to increase participants’ empathy towards PWD (Cheow, 2017). The simulation challenged about 100 participants to perform daily tasks such as counting money or buttoning a shirt by asking them to wear special googles which replicated peripheral vision loss and gloves which mimicked reductions in tactile sensation (Cheow, 2017). It allowed participants to walk in the shoes of PWD, better understand the obstacles encountered by PWD in daily life and think of ways to improve the lives of PWD.

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Table 7.4 Dementia Singapore: Training sessions for health, social care and home care practitioners Course title

Dementia Care Mapping (DCM™) for Realising Person-centred Care

Duration Who should attend

4 days Health and social care practitioners

Outline

Fees

Dementia Care Mapping (DCM™) for Supported Living

1 day Home Care Practitioners who are involved in guiding home care staff (Pre-requisite: DCM™ for Realising Person-centred Care) [1] Theory and DCM Coding [1] Introduce good practice principles for briefing sessions [2] Application of learning [3] Analyse data and data [2] Distinguish coding interpretation differences between DCM™ and DCM™-SL [4] Report results and how to apply the learning [3] Data analysis using tracker graphs [4] Action planning SG$2,022.30 (inclusive of GST) SG$513.60 (inclusive of GST) Prevailing course fee subsidy: Prevailing course fee subsidy: 90% for Singaporeans or 90% for Singaporeans or Permanent Residents (PRs) Permanent Residents (PRs) 45% for Work Permit Holders 45% for Work Permit Holders working in eligible community working in eligible community care organisations care organisations

Source Dementia Singapore https://dementia.org.sg/academy/dcm/ Dementia Singapore https://dementia.org.sg/academy/dcm-sl/

Immersive virtual reality (VR) simulation has been used by Dementia Singapore since March 2019 in a dementia care workshop called Enabling EDIE™ (Educational Dementia Immersive Experience). VR immerses users into ‘an interactive, simulated visual and audio environment generated by computer technology’ (Lee et al., 2020: 251). The immersive environment enables users to ‘feel a sense of ‘presence’ or connection with a virtual scene’ (Hicks et al., 2021: 3), ‘interact and play with virtual objects’ (Lee et al., 2020: 251), and ‘associate themselves with a persona that is not their own’ (Hicks et al., 2021: 3). The Enabling EDIE™ workshop conducted by Dementia Singapore was developed by Dementia Australia in 2016 and ‘is Dementia Australia’s fastest selling workshop for dementia care education to the aged care sector’ (McKeown, 2021). It is ‘a mobile headset virtual reality experience that enables participants

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to see the world through the eyes of a person living with dementia’ (‘EDIE launched in Singapore’, 2019). Participants experience waking up as Edie, a 65-year-old man with dementia who needs to go to the bathroom in the middle of the night (Nott, 2018). They go through scenarios of finding their way to the bathroom before and after improvements were made to the home (Choo F., 2019). Through the three-hour workshop, participants in Singapore can better understand the visual and perception challenges faced by PWD (e.g. seeing ominous shadows or moving patterns on the floor) (Choo C., 2019; Choo F., 2019; Taylor, 2019), empathize with PWD (Alzheimer’s Disease Association, 2021b: 19; Choo C., 2019; Choo F., 2019; Taylor, 2019), be more patient with and considerate of PWD (Taylor, 2019), learn how to develop a support plan that can improve the quality of life for PWD (‘Enabling EDIE™’ n.d.) and enable them to continue to live independently in their own homes (Taylor, 2019). Having exhibitions, road shows, public forums, annual event and health communication campaigns are other ways to raise public awareness and understanding of dementia in Singapore. For example, the Enabling Festival is an annual community festival leveraging a combination of art (e.g. music, dance, and performance) and science with interactive talks and panel discussions with industry experts, medical professionals and caregivers of PWD to raise public awareness of dementia, facilitate discussions about dementia, find innovative ways to enable, engage and empower PWD, and strengthen the sense of community amongst caregivers of PWD (Enable Asia, 2020; Media OutReach Newswire, 2021; ‘The Virtual Enabling Festival 2020’ n.d.; ‘The Enabling Festival, 2021’ n.d). It was a three-day event before the 2019 coronavirus disease (COVID-19) pandemic. It went virtual during the COVID-19 pandemic to reach a wider audience. It was a three-week long festival in 2020 and a two-week long festival in 2021. Another example is Walk 2 Remember, which was launched in 2019 and was Singapore’s first non-profit health communications campaign encouraging intergenerational walking habits amongst Singaporean adults to reduce the risk or progression of dementia and foster stronger familial ties (Channel NewsAsia, 2019; ‘Walk 2 Remember’ n.d.). It was led by four final-year students from Nanyang Technological University (Channel NewsAsia, 2019). The campaign included a walkathon, a panel discussion about dementia and caregiving, interactive informational booths, games, lucky draws, a morning Tai Chi session and mass workout (Channel NewsAsia,

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2019; ‘Walk 2 Remember’ n.d.). In 2019, more than 400 members of the public and a total of 15 organizations participated in this walkathon (Channel NewsAsia, 2019; ‘Walk 2 Remember’ n.d.). When Dementia Singapore launched the Walk2Remember event in 2020 and 2021, the event became a 21-day virtual steps challenge for participants to show their support for PWD in Singapore (Alzheimer’s Disease Association, 2020). Participants could choose to complete 20,000 steps, 50,000 steps, 100,000 steps or 200,000 steps over the course of 21 days (i.e. from 1 to 21st September) (Alzheimer’s Disease Association, 2020; ‘Dementia Singapore Walk2Remember 2021’ n.d.). The number of steps each participant took every day was recorded by a virtual race application he/she downloaded on his/her mobile phones and culminated on 21st September, which is World Alzheimer’s Day (Alzheimer’s Disease Association, 2020; ‘Dementia Singapore Walk2Remember 2021’ n.d.). In 2020, the Walk2Remember event had a total of 3,399 participants and 430,530,202 steps were recorded (‘ADA Walk2Remember, 2020’ n.d.). In 2021, the Walk2Remember event had a total of 6,351 participants and 913,556,902 steps were recorded (‘Dementia Singapore Walk2Remember 2021’ n.d.). At present, a wide range of dementia resources, useful information on dementia and practical dementia care tips are available online free of charge. This is very convenient for people to learn about dementia anywhere, any time. For example, DementiaHub.SG (https://www.dem entiahub.sg/) is Singapore’s first one-stop portal providing the most comprehensive, relevant and up-to-date information and resources on dementia (‘DementiaHub.SG’ n.d.). The website of Forget Us Not (https://forgetusnot.sg/videos.html) contains bite-sized videos which come with practical tips and personal stories by and for caregivers on how best to support PWD (‘Videos’ n.d.). The electronic version of LIEN Dementia Handbook is a practical guide to equip people with knowledge and tips on how to recognise and help PWD (Forget Us Not n.d.). Those interested in learning more about dementia, PWD, caregivers of PWD and care professionals can visit the websites of Lien Foundation (https://www.lienfoundation.org/), AIC (https://www.aic.sg/), Dementia Singapore (https://dementia.org.sg/), Enable Asia (https:// www.enableasia.org/) or DementiaHubSG to obtain relevant information they need.

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Go-to Points (GTPs) Wandering or frequently getting lost in both familiar and unfamiliar surroundings is common among PWD due to reduced spatial navigation abilities (Verghese et al., 2017; Vlˇcek & Laczó, 2014), reduced visual-perceptual ability or reduced topographical memory (White & Montgomery, 2015: 224). This would expose PWD to potential dangers such as falling and traffic accidents (Petonito et al., 2013: 18), which jeopardizes their safety and autonomy (Cushman et al., 2008). To PWD who get lost, it may be an unpleasant experience to be sent to a police station and kept there until they reunite with their family members (Yap, 2017). For this reason, over 400 dementia Go-to Points (GTPs) are set up in Singapore to assist PWD who get lost and are unable to find their way home. They include senior activity centres, community clubs, active aging hubs, nursing homes, dementia day care centres, community health centres, MRT stations, bus interchanges, and Guardian (i.e. health and beauty chain). Most of them are at convenient locations. Their staff have received dementia awareness training and can handle follow-up cases (Interview 19SG21). Members of the public can bring PWD who get lost to their nearest GTPs (‘Go-To Points across Singapore’ n.d.). They can search for the nearest GTPs online (https://dementiafriendly.sg/Home/GoToPoints). Once they bring PWD to GTPs, trained staff at GTPs would calm PWD down and assist in identifying and contacting their family members (Chan & Tan, 2019: 93). Sree Narayana Mission Nursing Home in Yishun is Singapore’s first nursing home to become a dementia GTP (Yap, 2017). It is also Singapore’s first GTP that is open 24 hours a day, seven days a week (Hong, 2017a). Its nursing team has 108 trained staff to help PWD who got lost contact their family members and attend to their immediate needs such as the provision of food or a bed to rest on (Wong, 2017). All GTPs also serve as community resource centres which allow the general public, PWD and their caregivers to ‘get information about dementia, attend classes and be linked with relevant services’ (Hong, 2017b). For examples, leaders at GTPs can link PWD and their caregivers to Community Resource, Engagement and Support Teams (CREST) (‘Launching more Dementia-Friendly Communities in Singapore’ 2016).

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Technology Caregivers of PWD report higher levels of psychological distress and stress and lower levels of physical health, subjective wellbeing and self-efficacy than other types of caregivers (Brodaty & Donkin, 2009: 219). This is because ‘irreversible and progressive impairments in cognition, behavioral function and activities of daily living (ADL)’ (Tsai et al., 2021: 59) result in increased dependence of PWD on caregivers for assistance and longer durations of care (Chan et al., 2021; Pihet & Kipfer, 2018). But ‘family caregivers may not have the necessary skills and experience to handle caregiving responsibilities’ (Basnyat & Chang, 2017: 1171). In Singapore, caregivers of PWD ‘are usually middle-aged and mostly children followed by spouses’ (Seow & Yap, 2013: 27). Over 50% of them are assisted by foreign domestic helpers to provide physical support (e.g. feeding PWD, bringing PWD to the toilet, taking PWD out) (Basnyat & Chang, 2017: 1175), ‘emotional and mental relief, and the opportunity to return to normal routine’ (Basnyat & Chang, 2017: 1175). In recent years, technology has been used to support PWD and their caregivers in Singapore. In October 2018, a free-to-download mobile application called Dementia Friends was launched to empower caregivers of PWD and users with knowledge, resource and support they need to better care for PWD (‘App-ed help for people with dementia’ n.d.). It was financially supported by Tote Board (Interview 19SG21), which is a statutory board of the Ministry of Finance, and was jointly developed by AIC, Nanyang Polytechnic, and Integrated Health Information Systems (IHis), which is a multi-award-winning technology agency for the public health sector in Singapore (‘Integrated Health Information Systems’ n.d.). It is a one-stop platform enabling users to easily access information and resources on dementia and caregiving (e.g. tips for managing wandering behaviour of PWD, a caregiver’s guide to avoid burnout), receive updates on upcoming events on dementia and caregiving (e.g. community mental wellness support, mood and memory screening, mental health talk), find out what support services are available for PWD and their caregivers, and most importantly, report missing PWD and respond to missing PWD alerts (‘App-ed help for people with dementia’ n.d.; ‘Development of the Dementia Friends Mobile Application’, 2018). It is a race against time to find missing PWD safe and return them home (Edinburgh Evening News, 2019). Missing PWD may not recognize the body’s signals (e.g. dehydration, pain, hunger) to stop and can

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walk farther than their physical condition may indicate because of experiencing sensory and neurological impairments (International Association of Chiefs of Police, 2010). The traditional ways used by caregivers when their family member with dementia goes missing are searches on foot, posting an appeal on Facebook or other social media platforms, or filing a missing persons report at a local police station (Interview 19SG21). Local news report show that it would take 12 hours (Yee, 2020) or four days to find missing PWD and return them home (Qing, 2020; Tan, 2020). The Dementia Friends mobile application helps facilitate an immediate missing PWD search. When a PWD goes missing, his/her caregiver can use the ‘Finding My Loved One’ tab of the Dementia Friends mobile application to send an alert. The alert contains the following information: the missing PWD’s photo, name, age, gender, description of clothing, physical appearance (e.g. height, hair colour, mole), places frequently visited by the missing PWD, date, time, and/or place that the missing PWD is last seen at, and relationship to one that sends the alert (Agency for Integrated Care, n.d.). The Dementia Friends mobile application users who have signed up as a Dementia Friend would receive the alert on their mobile phones to help look out for the missing PWD (Interview 19SG21). They can use the feature embedded within the Dementia Friends mobile application to report a sighting once they see a person matching the description of a missing PWD (Interview 19SG21). They can give consent to share their mobile phone number with the caregiver so that the latter can contact them directly (Interview 19SG21; Agency for Integrated Care, n.d.). Then, they can choose to stay with the missing PWD until the latter reunites with his/her caregiver, bring the missing PWD to the nearest GTP, or call for an ambulance if the missing PWD requires medical attention (Agency for Integrated Care, n.d.). Dementia Friends mobile application users would receive a notification once the missing PWD has been found and the case has been closed (Agency for Integrated Care, n.d.). A local newspaper reported that the use of the Dementia Friends mobile application helped find a missing PWD less than 10 hours and the caregiver of the missing PWD praised that the mobile application was ‘a really good initiative’ (Tan, 2019). Meanwhile, a case worker of PWD said in an interview that the best case he had come across was finding a missing PWD within two hours through the use of the Dementia Friends mobile application (Interview 19SG21). In October 2018, more than 1,500 people downloaded the Dementia Friends mobile application (Koh, 2018). As of May 2019, the Dementia Friends mobile

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application assisted over 80 PWD to reunite with their families (Chan & Tan, 2019: 95). As of 28 December 2022, a total of 12,645 people downloaded the Dementia Friends mobile application and assisted 411 PWD to reunite with their families (‘About Dementia Friends’ n.d.). Another free-to-download mobile application called My House of Memories, which was launched in late September 2020, allows PWD and their caregivers to explore over 100 objects from the 1930s to the 1990s (‘House of Memories’ n.d.; Menon, 2020) and access useful resources (e.g. memory activity guide, useful contacts). It was developed based on the knowledge and expertise provided by National Museums Liverpool and was jointly funded by National Heritage Board (NHB) and the British Council in Singapore (Neo, 2019). ‘Working on the premise that objects can elicit deeply held memories’ (Neo, 2019), the application features a curated selection of widely recognized objects (e.g. the first black-and-white television set in Singapore in 1964) from Singapore’s National Collection and Dementia Singapore (‘‘My House of Memories’ Singapore App’ n.d.; Menon, 2020). In selecting these objects, NHB and the AIC jointly organised community consultation sessions with over 40 older adults from NTUC Health (Inside Recent, 2020), which is Singapore’s largest home personal care, senior day care and nursing home care providers (‘Who We Are’ n.d.). The application contains multimedia features (Menon, 2020). The objects are brought to life with images, sounds and informative descriptions (‘House of Memories’ n.d.). They are grouped into six categories comprising “Growing Up”, “Household Items”, “Food and Drinks”, “Lifestyle”, “Jobs”, and “Festivals and Special Occasions” (‘‘My House of Memories’ Singapore App’ n.d.). Every object is like a memory trivia game (Neo, 2019). It features a hint that directs PWD to think about the memory associated with it (Neo, 2019). This helps stimulate conversation and interactions between PWD and their caregivers (Neo, 2019). The application also contains some userfriendly and personalization features. The simple touch screen control enables PWD to easily explore the objects by themselves (Menon, 2020; ‘My House of Memories’ n.d.). Users can save their favourite objects to a digital memory box, a digital memory tree, or memory timelines, and come back to their favourite objects whenever they want (‘My House of Memories’ n.d.). They can also create personal albums by simply taking photos of people, objects or places, and upload them to the application for easy retrieval (‘House of Memories’ n.d.; ‘‘My House of Memories’ Singapore App’ n.d.). Older adults which used the mobile application

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praised that looking at the images of objects helped them recollect the past, lifted their spirits and made them happy (Inside Menon, 2020; Recent, 2020). The “360° Virtual Reality Dementia-Friendly HDB Home Design Guide” (https://aic.buzz/DFhome), which is an online resource jointly developed by AIC and Dementia Singapore, provides caregivers with helpful tips to make their homes more friendly for PWD so that PWD can stay in the comfort of their homes for as long as possible. It is an interactive platform allowing users to click on the pins in the floor plan to navigate different rooms (e.g. bedroom, bathroom, living room kitchen), with 360º views of each room, to find out how simple home modifications can accommodate the changing needs of PWD, improve their safety and their quality of life. For example, adding signage on doors helped PWD identify their bedrooms easily and adding labels to containers helped PWD find their favourite biscuits (‘360 Degree Virtual Reality Dementia-Friendly HDB Home Design Guide’ 2021). Besides, users can zoom in and out the rooms by scrolling their mouse wheel up or down. They can also click on the “thumb up” icon to view the positive living environment for PWD or the “thumb down” icon to view the negative living environment for PWD (‘360 Degree Virtual Reality Dementia-Friendly HDB Home Design Guide’ 2021). Since its launch in August 2021, the Guide has been accessed by more than 1,500 people (Ang, 2021). A caregiver who followed the Guide to modify her home praised that the Guide was extremely useful, easy to navigate and simple to understand because it is in Singapore context (‘360 Degree Virtual Reality Dementia-Friendly HDB Home Design Guide’ 2021). Only simple home improvements could help her dad in his daily activities and make him feel happier (‘360 Degree Virtual Reality Dementia-Friendly HDB Home Design Guide’ 2021). Infrastructure A dementia-supportive built space helps PWD remain active, confident and socially included in their familiar environment for as long as possible (Kuliga et al., 2021: 1084), ‘while requiring less caregiver support when navigating their community’ (Kuliga et al., 2021: 1084). It must be tailored specifically to the needs and perspective of PWD through supportive orientation cues and appropriate dementia-sensitive levels of stimulation (Kuliga et al., 2021: 1084). For example, an exploratory study

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with people living with mild-to-moderate dementia in Seattle, the United States finds that visual distinctiveness (i.e. unique form, bright colour, distinct material quality, appropriate scale, clear and distinct signage) and meaningfulness (i.e. connection to personal interest, emotional resonance, well-defined purpose) of outdoor landmarks can support community navigation for PWD (Seetharaman et al., 2021). Its findings ‘suggest that outdoor landmarks should be designed for maximum legibility and noticeability, as well as familiarity, recognizability, and memorability’ (Seetharaman et al., 2021: 1192). In Singapore, supportive orientation cues have been introduced to a total of 21 Housing and Development Board (HDB) blocks in Nee Soon South and Chong Pang to help PWD identify their surroundings more easily and improve their wayfinding performance (Qi, 2021). They include easily recognisable colours, graphical directional signage and large block numbers (Qi, 2021). Colour recognition is ‘well-preserved among older adults even up to 95 and older, despite age-related vision changes’ (Davis & Therrien, 2012: 144). The combination of colour and familiar cues (i.e. objects that are well known) can enhance place learning condition for PWD (Davis & Therrien, 2012: 144). In Nee Soon South and Chong Pang, different colours are used to ‘demarcate different zones in the neighbourhood’ (‘Written Answer by Ministry of National Development’ 2021). HDB blocks are painted with red, blue or green colour for easy identification (Kurohi, 2019; Qi, 2021; Teo, 2021). ‘On top of colour codes, each zone also corresponds to a different icon, such as rubber trees, fish, and pineapples, which are historically significant to Nee Soon’ (Qi, 2021) (See Fig. 7.1). Red blocks are linked to a pineapple icon, whereas blue blocks and green blocks are respectively linked to a fish and a rubber tree icon (Chua n.d.) (See Fig. 7.2). These three icons help PWD recollect the past because Nee Soon used to be a fishing village and its land was used for rubber and pineapple plantations (Interview 19SG29). They also foster a sense of identity among residents. Meanwhile, block numbers which are in large font size are painted clearly on the side of the housing blocks and the pillars to help PWD identify the blocks from afar (Chua n.d.; Teo, 2021; ‘Written Answer by Ministry of National Development’ 2021). There are also signages to nearby key amenities (e.g. coffeeshops, supermarket, community centre, neighbourhood police centre, car park), which help PWD locate their destination more easily (Qi, 2021; Teo, 2021). All these supportive orientation cues

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are salient cues that can stand out from the surroundings, grab the attention of PWD (Davis & Weisbeck, 2016: 37) and improve the spatial awareness of PWD. Besides, they can enhance memory of PWD by ‘providing environmental support for encoding and retrieval so that there is less demand on processing resources’ (Davis & Weisbeck, 2016: 37). As a result, PWD can maintain their out-of-home mobility (Seetharaman et al., 2021: 1193) and ‘achieve higher wayfinding function, which can result in more independence, less anxiety, and a sense of environmental knowing’ (Davis & Weisbeck, 2016: 38). The successful transformation of HDB blocks in Nee Soon South and Chong Pang into a dementiasupportive built space relies on the support from Ms Lee Bee Wah, who was former Member of Parliament (MP) for Nee Soon Group Representation Constituency (GRC) as well as the collaboration between Nee Soon Town Council, Nee Soon South Grassroots Organisations, KTPH, AIC and GoodLife!@Yishun centre (Kurohi, 2019). In 2020, the Wayfinding Project was carried out in HDB blocks of Kebun Baru (KB) located at Ang Mo Kio Avenue 3 and 4 to help PWD

Fig. 7.1 The use of different colours and familiar cues to provide navigation support for PWD in Nee Soon South

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Fig. 7.2 The giant blue-colour fish is painted clearly on the side of the housing block in Nee Soon South to help PWD identify the block from afar

recognize their surroundings (Danao, 2021) and find their way home with hand-painted, eye-catching murals (Kebun Baru Citizens Consultative Committee n.d.; Teo n.d.; ‘Kueh and Colour Help Elderly’ 2021). It was initiated by Dementia Singapore in 2019 after the need to improve wayfinding in the KB neighbourhood was highlighted by PWD and their caregivers during a ground-sensing survey (Low et al., 2020: 2). KB is ‘a residential district in the north-eastern part of Singapore’ (Low et al., 2020: 2). It has 6,871 older adults aged 65 years or over, which accounts for 20% of the population in KB (Kebun Baru Citizens Consultative Committee n.d.). The ground-sensing survey found that a lack of familiar landmarks or visible signage within the KB community made it hard for PWD to ‘navigate their way through the blocks as the pillars and walls at the void decks look similar’ (Low et al., 2020: 7). Void decks are open spaces on the ground floor of HDB blocks for residents to get together with friends (National Heritage Board, 2013). They also serve as a shelter on rainy days (Tan, 2016). But some older adults or PWD would become

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confused and get lost at void decks (Leong, 2021). They need other residents’ help to find their way home (Leong, 2021). In order to provide better navigation support for PWD, Mr. Henry Kwek, who was MP for Kebun Baru Constituency, had a closed-door dialogue session with PWD and their caregivers (Low et al., 2020: 11). The dialogue led to the introduction of the Wayfinding Project, which aimed to use easily recognisable murals as visual markers to guide PWD home (Kwa, 2021). The walls of HDB blocks are embellished with murals which feature delicacies and familiar, retro household items including White Rabbit candies (See Fig. 7.3), satay, Ang Ku Kueh (i.e. red tortoise cakes), kuih lapis (i.e. nine-layer steamed rice cake), a bowl of glutinous rice ball, a kopitiam-style coffee cup, a traditional rooster bowl (See Fig. 7.4), a Peranakan-style tiffin carrier and a rose vintage thermos flask (See Fig. 7.5). These murals were designed in consultation with PWD who were aware of their own cognitive abilities and needs (Kebun Baru Citizens Consultative Committee n.d.). The type of murals appropriate for painting, the size of the mural, the location of the murals, the number of colours used in the murals, and the size of block numbers were all taken into consideration when carrying out the project (Kebun Baru Citizens Consultative Committee n.d.; Low et al., 2020: 11; Teo, 2020). Familiarity, in terms of meaning to PWD and the ability to easily identify cues, has been shown to help PWD in wayfinding (Davis & Weisbeck, 2016: 43). Household items in the old days and delicacies in Singapore were chosen as murals for painting because they are easily recognisable and help evoke memories (Teo, 2020). PWD may not remember their block number (Leong, 2021). But they can associate murals with where home may be, thereby helping them with wayfinding (Leong, 2021). For example, rooster bowls were commonly used to serve rice and noodle dishes in the old days because ‘the rooster motif signifies the meaning of hard work, a fighting spirit, and a flourishing family’ (Tay, 2021). Ang Ku Kueh, which is a red-colour, oval-shaped Chinese pastry with a distinctive design that resembles a tortoise shell, are offered on many occasions such as the Chinese New Year because they signify auspiciousness, longevity and happiness (Cao n.d.). Mr Anjang Rosli, who was a PWD involved in the Wayfinding Project, said in an interview that the ‘White Rabbit candy’ mural brought back his childhood memories (‘Finding My Way Home’, 2021). The candies were his daily companion when he had to walk over long distances from school to home (‘Finding My Way Home’, 2021). Murals are large in size so that they can be easily identified by PWD and

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Fig. 7.3 White rabbit candies are easily recognizable mural to guide PWD home

clearly seen from afar (Kwa, 2021). Regarding the location of the murals, murals are not painted on every wall at void decks because this would confuse PWD (Leong, 2021). Instead, they are in a navigationally relevant location where PWD need to make a decision (Wiener & Pazzaglia, 2021: 718). They are strategically painted at key points with block numbers so that they can be easily noticed by PWD (Finding My Way Home’, 2021; Kwa, 2021). ‘This has the potential to reduce spatial anxiety in people with orientation problems as well as facilitating navigation’ (Wiener & Pazzaglia, 2021: 718). Colour ‘is a strong cue property for the identification and memory of environments’ (Davis & Weisbeck, 2016: 43). Nevertheless, the colour of each mural is kept to a maximum of three colours because too many colours may overwhelm PWD (‘Finding My Way Home’, 2021). ‘This also explains the rationale for the comparatively smaller-sized numerals for the block numbers to avoid competing for attention with the murals’ (‘Finding My Way Home’, 2021).

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Fig. 7.4 A traiditonal rooster bowl is an easily recognizable mural to guide PWD home

As of April 2021, a total of 37 murals were painted across 10 housing blocks (‘Finding My Way Home’, 2021). The successful transformation of the KB community into an inclusive, dementia-friendly place through mural paintings relies on the team effort by the Nee Soon Town Council, Kebun Baru grassroots, community volunteers, artists, students from Tembusu College, the National University of Singapore (NUS), residents of KB and PWD (‘Building an inclusive and dementia-friendly Kebun Baru’ 2020). PWD felt empowered when they participated in the Wayfinding Project as co-planners and decision makers (‘Finding My Way Home’, 2021). They thought that their voices were valued and had huge sense of achievement after the project was completed (‘Finding My Way Home’, 2021). A dementia-friendly project will also be carried out in Yio Chu Kang (YCK), which ‘is a sub-urban area in the northeast of Singapore’ (‘Rediscover Singapore Yio Chu Kang’ n.d.). YCK has 44% of older residents aged 50 or over and a higher proportion of PWD (Ang, 2021). It will incorporate dementia-friendly features in its entire neighbourhood by

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Fig. 7.5 A rose vintage thermos flask is an easily recognizable mural to guide PWD home

2025 (Ang, 2021). These features will include colour zoning of HDB blocks to help PWD with wayfinding and bigger block numbers to be painted on the flats (Ang, 2021). Meanwhile, YCK will enhance its infrastructure (e.g. sheltered walkways, anti-slip tiles, and assistive grab bars on slopes) to ensure the safety of people using mobility devices and improve their accessibility in public spaces (Ang, 2021).

Challenges to Develop and Sustain DFCs in Singapore There have been ongoing efforts to create inclusive DFCs in Singapore. However, both local and international surveys show that more work needs to be done to overcome challenges to developing and sustaining DFCs in the country. The results of Singapore’s First National Survey on Dementia (http://www.screeningstatistics.com/alzheimers/), which was conducted by the Singapore Management University (SMU) and Dementia Singapore in 2019, indicate that more efforts have to be made

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to overcome the stigma of dementia and raise public awareness and understanding of dementia. The survey had 5,679 participants, including 32 PWD, 1,156 caregivers and 4,491 ordinary people with no connection to dementia (Choo D., 2019; Rashith, 2019). It found that those who had no connection to dementia had the strongest stigmatizing attitudes toward dementia, whereas 50% of PWD felt ‘ashamed of their condition, citing stigma as the main reason’ (Rashith, 2019). According to the Survey, 72% of PWD felt rejected and lonelier than before while about 50% of them felt that they could not be open with others regarding their condition (‘3 in 4 Persons with Dementia feel ashamed’ 2019; Remember.For.Me.’ n.d.). About 56% of PWD thought that people treated them as less competent while about 37.5% of them thought that they were less competent than they did before having dementia (‘Remember.For.Me.’ n.d.). As regards caregivers, almost 30% of them felt embarrassed when caring for PWD in public (Rashith, 2019). About 56% of ordinary people rate themselves low in dementia knowledge due to no outreach or education (‘Remember.For.Me.’ n.d.). 44% of ordinary people surveyed felt frustrated with not knowing how to help PWD (Choo D., 2019) while only about 20% of them felt confident in interacting with PWD (‘Remember.For.Me.’ n.d.). But almost 80% of ordinary people surveyed agreed that they could do more to improve the lives of PWD (‘Remember.For.Me.’ n.d.). In 2020, an international survey which examined the readiness and ability of 30 cities to develop and adopt innovations in the treatment, prevention, risk reduction, and care of dementia ‘yielded mixed results for Singapore’ (The Global Coalition on Aging et al., 2020a). Known as Dementia Innovation Readiness Index 2020: 30 Global Cities, this international survey was jointly conducted by the Global Coalition on Aging (GCOA), Britain’s Alzheimer’s Disease International (ADI) and Singapore’s Lien Foundation (The Global Coalition on Aging et al., 2020a, 2020b). It evaluated 30 cities’ performance based on ‘26 weighted indicators across five categories: Strategy and Commitment, Early Detection and Diagnosis, Access to Care, Community Support, and Business Environment (The Global Coalition on Aging et al., 2020b: 51). Rated on a 0–10 scale, the top three performing cities were London (8.4), Glasgow (7.8), and Manchester (7.7) (The Global Coalition on Aging et al., 2020b: 10). Tokyo, which ranked 7th in the survey, was the best performer of 10 Asian cities evaluated (The Global Coalition on Aging et al., 2020a). It was followed by Seoul (7.1), Taipei (6.8) and Singapore

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(6.8), which ranked 11th, 15th and 16th respectively (The Global Coalition on Aging et al., 2020b: 10). The survey ‘found that, overall, cities are failing to support innovation in dementia comprehensively, though bright spots exist’ (The Global Coalition on Aging et al., 2020c). Singapore scored higher in the categories of Strategy and Commitment (8.8), Business Environment (7.2) and Community Support (7.1) (The Global Coalition on Aging et al., 2020a). There was solid government leadership on dementia and funding for dementia care in the country (The Global Coalition on Aging et al., 2020a: 3). The business environment was good, with strong intellectual property protection, strong universityindustry collaboration in reach and development, and healthy presence of top 500 health institutions for research and innovation (The Global Coalition on Aging et al., 2020a). Regarding community support, Singapore was praised for the integration of once-discrete dementia care services to form larger community networks (e.g. Tsao Foundation, KTPH), which provided a more seamless continuum of care and support for PWD (The Global Coalition on Aging et al., 2020b: 41). However, Singapore scored lower in the categories of Access to Care (6.9) and Early Detection and Diagnosis (5.1) (The Global Coalition on Aging et al., 2020a, 2020b). This was due to the absence of reliable, publicly available diagnosis rate, the relative inability of general physicians to detect and treat dementia, and stigma which prevented older adults and their caregivers from coming forward for dementia diagnosis (The Global Coalition on Aging et al., 2020a). The survey provides insights into areas Singapore needs to work on (The Global Coalition on Aging et al., 2020a: 2).

Critical Factors for Developing and Sustaining Dementia-Friendly Communities in Singapore ‘The risk of developing dementia increases exponentially with age’ (Wittenberg et al., 2019: 1). The number of PWD is expected to rise significantly as the population continues to age rapidly in Singapore. The creation of DFCs in Singapore is a real positive move to enabling PWD and their caregivers to ‘live well and receive the care and support they need to fulfil their potential with dignity, respect, autonomy and equality’ (World Health Organization, 2017: 4). But there are several critical factors for the government and other stakeholders to consider if they want to further develop DFCs and make them sustainable in the long run.

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First, a national dementia policy which includes the creation of DFCs has to be developed and implemented. The National Dementia Strategy (NDS), which was developed by Ministry of Health (MOH) in 2009 and updated in 2017, mainly focuses on increasing awareness of dementia, promoting early detection of dementia, and guiding MOH and public healthcare institutions (PHIs) in the development and implementation of services to care for PWD (‘Dementia Plans & Subsidy Support for Dementia Care’, 2020). Nevertheless, NDS ‘is not publicly available’ (L.E.K. Consulting, 2022: 5). It is necessary to implement a more comprehensive national dementia policy which ‘systematically address(es) dementia, from prevention, diagnosis, and treatment, to care and supportive services’ (Sun et al., 2020: e2). Such national dementia policy is indicative of the government’s sustained commitment to dementia (Sun et al., 2020: e2) and provides ‘a template for unifying efforts and driving progress’ (Sun et al., 2020: e2). The creation of DFCs began as a bottom-up movement in Singapore. The government can incorporate the creation of DFCs to the national dementia policy so that stakeholders and community partners have better ideas about the key elements of DFCs, infrastructure, systems, services and resources available for creating DFCs, and the core areas for action. Second, there should be an active inclusion and involvement of PWD and their caregivers (Alzheimer’s Disease International, 2016: 10; Williamson, 2016: 46). Knowledge shared by people with lived experience is conducive to developing a DFC which can really meet their needs and challenge stereotypes. Developing and sustaining DFCs by actively involving PWD can ‘instill a sense of value and autonomy for people living with dementia’ (Hung et al., 2021: 4), empower them, and give them ‘the sense of respect, dignity and purpose they seek’ (Alzheimer’s Disease International, 2016: 10). Third, more public awareness campaigns should be held to destigmatize dementia. They should be able to ‘foster an accurate understanding of dementia’ (World Health Organization, 2017: 14), educate people about the human rights of PWD (World Health Organization, 2017: 14), get the general public talking more comfortably about dementia (‘Antistigma campaign “Let’s Talk About Dementia”’ n.d.), and encourage people to find out more about dementia and seek help and advice for it (‘Anti-stigma campaign “Let’s Talk About Dementia”’ n.d.). They should involve key stakeholders (e.g. PWD, caregivers, health professionals) to identify issues that are important to them (World Health Organization

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and Alzheimer’s Disease International 2012: 85) and should be carried out in four official languages (i.e. English, Mandarin Chinese, Malay, and Tamil) to reach out to ethnically diverse population in the country. Key messages delivered by the campaigns should be simple, clear and easy to understand (World Health Organization and Alzheimer’s Disease International 2012: 85). Take the dementia awareness campaign in the United Kingdom as an example. The key message of, ‘I have dementia, I also have a life,’ sought to ‘normalise dementia and challenge the misconception that people with dementia are not able to enjoy life’ (Phillipson et al., 2019: 2681). The public awareness campaigns ‘should also be conducted on a long-term, routine basis to have a sustainable impact’ (World Health Organization and Alzheimer’s Disease International 2012: 86).

Conclusion To conclude, it is necessary to develop and implement a national dementia policy which includes the creation of DFCs. The creation of DFCs should become part of the national dementia policy so that stakeholders and community partners have better ideas about the key elements of DFCs, infrastructure, systems, services and resources available for creating DFCs, and the core areas for action. A social model of disability should continue to be adopted to create and sustain DFCs in Singapore. Besides, more public awareness campaigns should be held to destigmatize dementia in the country. Looking forward, Singapore will become a dementiafriendly country, supporting every person with dementia to ‘achieve the best quality of life reasonably possible’ (Alzheimer’s Disease International, 2016: 4).

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Verghese, J., Lipton, R., & Ayers, E. (2017). Spatial navigation and risk of cognitive impairment: Prospective cohort study. Alzheimer’s & Dementia, 13(9), 985–892. Vlˇcek, K., & Laczó, J. (2014). Neural correlates of spatial navigation changes in mild cognitive impairment and Alzheimer’s disease. Frontiers in Behavioral Neuroscience, 8, 89. https://doi.org/10.3389/fnbeh.2014.00089 Wendell, S. (1996). The rejected body: Feminist philosophical reflections on disability. Routledge. Wiener, J. M., & Pazzaglia, F. (2021). Ageing- and dementia-friendly design: Theory and evidence from cognitive psychology, neuropsychology and environmental psychology can contribute to design guidelines that minimise spatial disorientation. Cognitive Processing, 22, 715–730. https://doi.org/10. 1007/s10339-021-01031-8 Williamson, T. (2016). Mapping dementia-friendly communities across Europe: A study Commissioned by the European Foundations’ Initiative on Dementia (EFID). Retrieved January 3, 2022, from https://www.dataplan.info/img_ upload/5c84ed46aa0abfec4ac40610dde11285/mapping_dfcs_across_eur ope_final_v2.pdf Wittenberg, R., Hu, B., Barraza-Araiza, L., & Rehill, A. (2019). Projections of older people with dementia and costs of dementia care in the United Kingdom, 2019–2040. Retrieved January 3, 2022, from https://www.alzhei mers.org.uk/sites/default/files/2019-11/cpec_report_november_2019.pdf White, E. B., & Montgomery, P. (2015). Dementia, walking outdoors and getting lost: Incidence, risk factors and consequences from dementia-related police missing-person reports. Aging & Mental Health, 19(3), 224–230. Wong, P. T. (2017, September 11). Yishun Nursing Home first 24/7 Go-to Point for dementia patients. TODAY. Retrieved December 15, 2021, from https://www.todayonline.com/singapore/yishun-nursing-homefirst-247-go-point-dementia-patients (accessed 15 December 2021). Woo, L. L., Thompson, C. L., & Magadi, H. (2017a). Monetary cost of family caregiving for people with dementia in Singapore. Archives of Gerontology and Geriatrics, 71, 59–65. https://doi.org/10.1016/j.archger.2017.03.006 Woo, L. L., Thompson, C. L., & Dong, Y. H. (2017b). Net informal costs of dementia in Singapore. Journal of Clinical Gerontology & Geriatrics, 8(3), 98–101. World Health Organization (2012). Dementia: A public health priority. Retrieved August 21, 2021, from https://apps.who.int/iris/handle/10665/75263 World Health Organization (2015). Supporting informal caregivers of people living with dementia. Retrieved October 30, 2021, from https://www.who. int/mental_health/neurology/dementia/dementia_thematicbrief_informal_c are.pdf

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World Health Organization (2017). Global Action Plan on the Public Health Response to Dementia 2017–2025. Retrieved January 1, 2022, from https://apps.who.int/iris/bitstream/handle/10665/259615/978924 1513487-eng.pdf?sequence=1 World Health Organization (2020). Dementia. Retrieved August 16, 2021, from https://www.who.int/news-room/fact-sheets/detail/dementia World Health Organization (2021). Global status report on the public health response to dementia. Retrieved August 16, 2021, from https://www.who. int/publications/i/item/9789240033245 World Health Organization, & Alzheimer’s Disease International (2012). Dementia: A public health priority. Retrieved January 3, 2022, from https:// www.who.int/publications/i/item/dementia-a-public-health-priority Yap, E. (2017.) First nursing home becomes a Go-To Point. Retrieved December 15, 2021, from https://www.agelessonline.net/first-nursing-home-becomesa-go-to-point/ Yee, J. (2020, July 17). Elderly lady with dementia missing since 8am on 17 Jul, found after 12 hours. MSNews. Retrieved December 18, 2021, from https:// mustsharenews.com/elderly-lady-dementia-missing/

[b] Websites About Dementia Friends. (n.d.). Retrieved December 28, 2022, from https:// dementiafriendly.sg/ ADA Walk2Remember 2020b. (n.d.). Retrieved December 12, 2022, from https://web.42race.com/race-bundle/adawalk2remember Anti-stigma campaign ‘Let’s talk about dementia’ marks beginning of World Alzheimer’s Month in the Americas. (n.d.). Retrieved January 3, 2022, from https://www3.paho.org/hq/index.php?option=com_content&view=article& id=15390:anti-stigma-campaign-let-s-talk-about-dementia-marks-beginningof-world-alzheimer-s-month-in-the-americas&Itemid=1926&lang=en App-ed help for people with dementia and their caregivers. (n.d.). Retrieved December 17, 2022, from https://www.moh.gov.sg/ifeelyoungsg/our-sto ries/how-can-we-build-stronger-ties/care-for-a-senior/app-ed-help-for-peo ple-with-dementia-and-their-caregivers Building an inclusive and dementia-friendly Kebun Baru. (2020). Retrieved December 30, 2022, from https://dementia.org.sg/2020/04/20/buildingan-inclusive-dementia-friendly-kebun-baru/ Care of Client with Dementia (Basic). (n.d.). Retrieved December 4, 2021, from https://www.slec.org.sg/learning-hub-course/care-of-client-with-dem entia-basic/

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Care of Client with Dementia (Intermediate). (n.d.). Retrieved December 4, 2021, from https://www.slec.org.sg/learning-hub-course/care-of-clientwith-dementia-intermediate-3/ Changes of behaviour in the later stages. (n.d.). Retrieved August 17, 2021, from https://www.alzheimers.org.uk/about-dementia/symptoms-anddiagnosis/how-dementia-progresses/changes-in-behaviour-later-stages Coping with dementia behaviour changes. (n.d.). Retrieved August 17, 2021, from https://www.nhs.uk/conditions/dementia/behaviour/ DementiaHub.SG. (n.d.). Retrieved December 15, 2021, from https://dem entia.org.sg/hub/ Dementia Awareness Workshop. (n.d.). Retrieved December 2, 2021, from https://dementia.org.sg/academy/awareness/ Dementia-friendly communities. (n.d.). Retrieved November 23, 2021, from https://www.aic.sg/body-mind/dementia-friendly-community Dementia plans and subsidy support for dementia care. (2020). Retrieved January 3, 2021, from https://www.moh.gov.sg/news-highlights/details/dementiaplans-and-subsidy-support-for-dementia-care Development of the Dementia Friends mobile application. (2018). Retrieved December 17, 2021, from https://www.moh.gov.sg/news-highlights/det ails/development-of-the-dementia-friends-mobile-application Dementia Singapore Walk2Remember 2021. (n.d.). Retrieved December 12, 2021, from https://web.42race.com/race-bundle/dementiasgwalk2rem ember E-Learning on dementia and mental health. (n.d.). Retrieved December 4, 2021, from https://www.aic.sg/body-mind/mental-health-elearning EDIE launched in Singapore. (2019). Retrieved December 9, 2021, from https://www.dementia.org.au/about-us/news-and-stories/news/edielaunched-singapore Enabling EDIE™. (n.d.). Retrieved December 9, 2021, from https://dementia. org.sg/academy/edie/ Finding my way home. (2021). Retrieved December 27, 2021, from https:// dementia.org.sg/2021/06/22/finding-my-way-home/ Frontotemporal dementia. (n.d.). Retrieved August 21, 2021, from https:// www.hopkinsmedicine.org/health/conditions-and-diseases/dementia/fronto temporal-dementia Go-To Points across Singapore. (n.d.). Retrieved December 15, 2021, from https://dementiafriendly.sg/Home/GoToPoints ‘House of Memories’. (n.d.). Retrieved December 24, 2021, from https:// www.nhb.gov.sg/what-we-do/our-work/community-engagement/silverhubs/house-of-memories

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Integrated Health Information Systems. (n.d.). Retrieved December 17, 2021, from https://www.imda.gov.sg/imtalent/programmes/TeSA-Mid-Car eer/IHIS Introduction to dementia and reminiscence workshop—“Think-Feel-Do” approach. (n.d.). Retrieved December 4, 2021, from https://www.tp.edu. sg/schools-and-courses/adult-learners/all-courses/short-courses/introduct ion-to-dementia-reminiscence-workshop-think-feel-do-approach.html Kueh and colour help elderly find their way home. (2021). Retrieved December 27, 2021, from https://www.campus.sg/kueh-and-colour-help-elderly-findtheir-way-home-campus-sg/ Launching more dementia-friendly communities in Singapore. (2016). Retrieved January 3, 2021, from https://partners.aic.sg/sites/aicassets/AssetGallery/ Press%20Release/Press%20Release%20-%20Launching%20more%20Deme ntia-Friendly%20Communities%20in%20%20Singapore.pdf My House of Memories. (n.d.). Retrieved December 24, 2021, from https:// play.google.com/store/apps/details?id=com.nml.myhouseofmemories&hl= en_SG&gl=US ‘My House of Memories’ Singapore App. (n.d.). Retrieved December 24, 2021a, from https://www.britishcouncil.sg/programmes/arts/inclusive_arts/housememories-singapore-app Rediscover Singapore Yio Chu Kang. (n.d.). Retrieved December 31, 2021, from https://www.edgeprop.sg/rediscover/yio-chu-kang Remember.For.Me. (n.d.). Retrieved December 31, 2021, from http://www.scr eeningstatistics.com/alzheimers/ The Enabling Festival 2021. (n.d.). Retrieved December 31, 2021, from https://give.asia/campaign/enabling-festival-dementia/ The Virtual Enabling Festival 2020. (n.d.). Retrieved December 14, 2021, from https://www.raise.sg/events-menu/event/event/215-the-virtual-enablingfestival-2020.html Videos. (n.d.). Retrieved December 15, 2021b, from https://forgetusnot.sg/vid eos.html Walk 2 Remember. (n.d.). Retrieved December 11, 2021, from https://blogs. ntu.edu.sg/colab4good/2019/05/31/walk-2-remember/ Who we are. (n.d.). Retrieved December 24, 2021, from https://ntuchealth.sg/ about-us Written answer by Ministry of National Development on whether the Ministry will add dementia-friendly features like those piloted in Nee Soon, to other old estates and incorporate such designs in HDB’s future BTO housing

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projects (2021). Retrieved December 25, 2021, from https://www.mnd.gov. sg/newsroom/parliament-matters/q-as/view/written-answer-by-ministry-ofnational-development-on-whether-the-ministry-will-add-dementia-friendlyfeatures-like-those-piloted-in-nee-soon-to-other-old-estates-and-incorporatesuch-designs-in-hdb’s-future-bto-housing-projects 360 degree virtual reality dementia-friendly HDB home design guide. (2021). Retrieved December 31, 2021, from https://www.youtube.com/watch?v= DbceY0oXcJ8 3 in 4 persons with dementia feel ashamed and rejected, Singapore’s first national survey on dementia finds (2021). Retrieved December 31, 2021, from https://news.smu.edu.sg/news/2019/04/29/3-4-persons-dem entia-feel-ashamed-and-rejected-singapores-first-national-survey

[c] Interviews Interview 19SG21, a case worker of people with dementia, October 2019. Interview 19SG29, a grassroot leader in Singapore, November 2019.

CHAPTER 8

Advance Care Planning

Abstract Advance Care Planning (ACP) is a process supporting an individual at any state of health in discussing his/her life goals, care preferences and preferred place of death with his/her family members and healthcare professionals. This chapter will examine ACP in Singapore. It will examine benefits of ACP and barriers to ACP practice and suggest ways to increase the acceptance and implementation of ACP in the country. The implementation of ACP can achieve patient autonomy, avoid unwarranted suffering and enable patients to die with dignity. Death aversion, family dynamics, collusion, the lack of health literacy, treating physicians’ refusal to endorse the ACP document are barriers to the acceptance, discussion and implementation of ACP. It is important for the government to enhance public acceptance of ACP and facilitate the implementation of ACP through normalizing conversations about death and dying, reinterpreting the concept of filial piety to develop culturally appropriate campaigns for ACP, upstreaming the ACP discussion into usual health promotion activities, offering life education to students, adopting a multipronged approach to tackle collusion and adopting an interprofessional approach to ACP. Keywords Advance care planning · ACP coordinator · Collusion · End-of-life · Filial piety · Self-determination

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 S. Ching Yuen Luk, Healthy Ageing in Singapore, Social Policy and Development Studies in East Asia, https://doi.org/10.1007/978-981-99-0872-1_8

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Introduction Advance care planning (ACP) refers to a voluntary process whereby a patient who still has decision-making capacity (NHS Improving Quality, 2014; Pealrman et al., n.d.; Interview 19SG19) discusses and documents his/her wishes with regards to the care and treatment actions necessary to meet his/her care needs and care goals and preferred place of dying and death in advance with his/her family carers and healthcare professionals (NHS Improving Quality, 2014; Ng, 2009: 93–5). ‘The process, when accomplished comprehensively, involves four steps’ (Pealrman et al., n.d.): (1) one’s reflection on what is important to him/her, (2) talking about one’s wishes and care preferences with his/her Nominated Healthcare Spokesperson (NHS), (3) documenting one’s ACP and (4) reviewing and updating one’s ACP as needed to ensure currency and consistency with his/her personal goals and care preferences (Pealrman et al., n.d.; Queensland Government n.d.; The Agency for Integrated Care n.d.; ‘Simple Steps for ACP’ n.d.). The ACP process ‘often works best when discussion initially focusses on a patient’s goals, values, and beliefs, rather than on particular treatments, interventions, or outcomes’ (Mullick & Martin, 2018: 29). ACP ‘might be an opportunistic one-off conversation’ (Thomas, 2018: 5) or an ongoing conversation over time within a trusted relationship (Thomas, 2018: 5). But either way it is an important conversation opening up ‘a space in which the various possibilities and scenarios can be discussed within the wider context of a person’s life’ (Thomas, 2018: 5). It allows a patient to ‘prepare for the eventuality of debility and death and to some extent retain control over this part of his/her life’ (Ng, 2009: 94). At the same time, it is a guide for healthcare professionals (Interview 19SG19) to better meet the care needs of a patient after understanding the patient’s treatment and care goals (Queensland Government n.d.). It also enables family carers to ‘have less distress in making decisions when they know the patient’s wishes and preferences’ (Ng, 2009: 94). The goal of ACP ‘is to try to engage in conversations more proactively rather than just reacting to changes in health conditions’ (Prince-Paul & DiFranco, 2017: 18). ACP ‘is as much about life as it is about death’ (Thomas, 2018: 4). It aims to provide ‘good quality person centred care towards the end of life’ (NHS Improving Quality 2014: 6) and enable one to ‘die with dignity in the place and the manner of their choosing’ (Thomas, 2018: 4). ACP

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‘is based on fundamental principles of self-determination, dignity and the avoidance of suffering’ (‘Advance Care Planning’ n.d.). It ensures that patients’ wishes are ‘known, honoured and respected’ (Thomas, 2018: 5) in case they lack capacity to make independent decisions (Ng, 2009: 94) or ‘to consent to actions connected with health and social care provision’ (NHS Improving Quality 2014: 17). It helps patients live their lives ‘more in tune with their wishes and preferences in the time remaining to them, and help to bring their lives to a fitting and respectful conclusion’ (Thomas, 2018: 14). ACP ‘may be instigated by either the individual or a care provider at any time, not necessarily in the context of illness progression’ (NHS Improving Quality 2014: 25). In fact, ACP ‘is suitable for everyone, in any state of health or illness’ (Tan Tock Seng Hospital Advance Care Planning Team n.d.: 9). But a significant change in one’s health status (e.g. a new diagnosis of chronic progressive and terminal illness) (Pealrman et al. n.d.), experiencing a life-changing event (e.g. death of spouse) (Thomas, 2018: 8) or ‘an anticipated deterioration that may result in a future loss of mental capacity’ (Mullick & Martin, 2018: 29) can be triggers for ACP conversations (Thomas, 2018: 8). This chapter will examine ACP in Singapore, different types of ACP, benefits of ACP and barriers to ACP practice.

Advance Care Planning in Singapore In Singapore, ACP was first piloted in Tan Tock Seng Hospital (TTSH) in 2009 (Ng et al., 2017: 84) to help terminally ill, non-cancer patients (e.g. those with advanced heart failure) explore their preferences ‘with regards to resuscitation status, place where they would like to be cared for and place of death’ (Ng, 2009: 98). Healthcare professionals in TTSH were trained by the faculty of Respecting Choices® from Wisconsin, the United States, to facilitate and implement ACP (Tan Tock Seng Hospital Advance Care Planning Team n.d.: 10). In September 2009, a pilot program called Project CARE (Care At the end of life for Residents in the homes for Elderly) was initiated and led by TTSH in collaboration with the Ministry of Health (MOH), the Agency of Integrated Care (AIC) and Dover Park Hospice to promote ACP in seven nursing homes managed by voluntary welfare organizations (VWOs) (Ng et al., 2011: 97). These nursing homes included All Saints Home (Hougang), Lions Home for the Elders (Bishan), NTUC Health Nursing Home (Geylang East), Ren Ci Nursing Home (Ang Mo Kio), Saint Theresa’s Home, Society for the

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Aged Sick and Thong Teck Home for Senior Citizens (‘Project Care’ n.d.). The Project CARE team which consisted of doctors, nurses and a medical social worker (‘Project CARE’ n.d.) ‘screened all residents in the nursing homes to identify those with a prognosis of 1 year or less’ (Raj, 2013: 13). It engaged in an ACP discussion with end-of-life (EOL) residents who wanted to receive palliative care and their family members (Leong n.d.; Raj, 2013). ‘Residents who chose to receive comfort or limited additional intervention in the nursing home came under the care of the Project CARE team’ (Raj, 2013: 13). As of January 2019, 478 residents had enrolled in Project CARE, of which 345 had passed away (National Healthcare Group, 2019: 93). ‘91.6 per cent of these 345 residents had their ACP wishes fulfilled regarding their preferred place of death’ (National Healthcare Group, 2019: 93). In 2011, a national ACP programme was introduced to public hospitals and community care providers by the AIC (TODAY, 2015), which was an independent corporate entity set up by the MOH to oversee and facilitate nation-wide efforts in care integration for older adults in Singapore (‘Agency for Integrated Care Pte. Ltd.’ n.d.). The nationwide ACP programme is branded Living Matters® (Chung, 2018: 251) and is based on Respecting Choices® , an evidence-based model of ACP (Niranjan et al., 2018) originated from Gundersen Health System, Wisconsin, the United States to normalize EOL communication (Chung, 2018: 251; MacKenzie et al., 2017: 897). Living Matters® underwent ‘several iterations with adaptations made largely to language and nuances to better suit the understanding of Singapore residents as well as conform to healthcare contexts’ (Chung, 2018: 251). It aims to encourage patients to articulate their treatment preferences in accordance with their values, beliefs and personal goals of care through a series of open and honest conversations with their family carers and healthcare professionals (Chong et al., 2018; Ho et al., 2021; Lall et al., 2021). ‘Each ACP session may last between 30 minutes to 1.5 hours, and more than one may be needed’ (‘ACP Frequently Asked Questions’ n.d.). ‘At the conclusion of an ACP conversation, patients are asked to sign an official ACP document that details their specific care preferences’ (Ho et al., 2021: 83). Signed ACP documents ‘are further endorsed by patients’ primary physician’ (Ho et al., 2021: 83) and entered into the national ACP information technology system for guiding future healthcare professionals involved in care of the patients during the final phases of life (Chung, 2018: 252; Ho et al., 2021: 84; Lall et al., 2021). The ACP information technology system

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‘captures key decisions on care options, and catalogues conversation transcripts and other supporting documents into a single record’ (Chan, 2019: 900). Starting from April 2017, ACP has become available ‘at the point of care through the National Electronic Health Record (NEHR), which holds together the patient’s key health information captured from the public healthcare system’ (Chung, 2018: 252). ACP can be reviewed and updated when the patient’s medical condition, wishes and preferences change (Tan Tock Seng Hospital Advance Care Planning Team n.d.: 26). Patients who choose not to sign the official ACP document can ‘simply employ the knowledge obtained through the conversations as their own preference of care in the future’ (Ho et al., 2021: 83). They may designate their family carers or their close friends who attended the ACP conversations to be their proxy decision makers (i.e. NHS) to communicate their treatment preferences with the medical team should they become too ill to do so (Lall et al., 2021; Lall et al., 2022; ‘Simple Steps for ACP’ n.d.). The National Medical Ethics Committee (NMEC) ‘identified individual autonomy as the primary principle guiding ACP in Singapore’ (Chan, 2019: 901). From 2011 to 2016, a total of S$18.1 million was spent on developing ACP capacity within and across the public healthcare system in Singapore (Chung, 2018: 251). The largest portion of the money was spent on recruiting and training ACP facilitators (S$12.4 million) (Chung, 2018: 251). The rest of the money was spent on building and strengthening systems (e.g. the national ACP information technology system) to support ACP implementation (S$5.4 million) and increasing awareness of ACP and its importance among healthcare providers (S$0.4 million) (Chung, 2018: 251). ACP is now available in public hospitals (e.g. Alexandra Hospital, Changi General Hospital), polyclinics (e.g. SingHealth Polyclinics), community facilitators (e.g. Fei Yue Senior Activity Centre, Brahm Centre, Wellness Kampung) (‘ACP Directory’ n.d.) and some nursing homes (Chia, 2016; Ng et al., 2011). Substantial flexibility is given to each hospital to adapt the ACP program to its own context (Tan et al., 2019: 1283). Public hospitals such as Changi General Hospital, Ng Teng Fong General Hospital and Khoo Teck Phuat Hospital have an ACP office to facilitate the completion of ACP for patients and conduct ACPadvocacy trainings (Interview 19SG19). ACP advocates are trained to identify patients who are suitable for doing ACP and then refer the patients to ACP facilitators (Interview 19SG19). There are 1,500 trained

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and certified ACP facilitators in public hospitals and 500 trained and certified ACP facilitators in community-based health and social care services (Chung, 2018: 252). These facilitators are ‘doctors, nurses, counsellors, medical social workers and administrative personnel—most of whom are based in public hospitals’ (TODAY, 2015). They were trained to understand how the ACP framework works and develop communication and facilitation skills to guide patients and their family carers through the ACP process (TODAY, 2015). In April 2015, Licensing Terms and Conditions on Enhanced Nursing Home Standards introduced by the MOH included ACP as one of the conditions for retaining a nursing home’s licence (Ministry of Health 2015: 7). In some nursing homes, ACP is introduced by social workers or Care Concierge to older adults and their family members during the pre-admission counselling sessions (Interview 21SG44). The ACP discussion usually is a face-to-face meeting guided by an ACP facilitator with a patient and his/her family carer (Alexandra Hospital, 2021). But tele-ACP which carries out the ACP discussion over a video conferencing platform is also available in some community facilitators (e.g. Brahm Centre, Fei Yue Community Services) (‘ACP Directory’ n.d.). A local study found that having a serious life-threatening illness (83.7%), knowing more about ACP (76.8%) and being of an older age (74.6%) were significant factors increasing one’s willingness to have an ACP discussion (Ng et al., 2017: 87–8). From 2011 to May 2015, 2,026 ACP discussions took place in Singapore (TODAY, 2015). From 2011 to 2021, over 27,000 ACP were lodged in the country (Ong, 2021).

Three Types of Advance Care Planning in Singapore There are three types of ACP in Singapore: General ACP, Disease Specific ACP and Preferred Plan of Care (PPC) (Menon, 2017; Tan Tock Seng Hospital Advance Care Planning Team n.d.: 6). The type of ACP best suited for one’s needs depends on his/her health conditions (‘How to Make An Advance Care Plan’ n.d.). General ACP is for healthy individuals and people with early chronic illnesses (Ho et al., 2021: 83). Disease Specific ACP is for ‘patients with progressive, life limiting illness with frequent complications’ (Tan Tock Seng Hospital Advance Care Planning Team n.d.: 6). PPC is for patients ‘suffering from life-limiting illnesses with a prognosis of less than 12 months’ (Ho et al., 2021: 83). One

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can decide to do a different type of ACP when his/her health condition changes (Interview 19SG19). All three types of ACP involve the appointment of up to two NHS by a patient/an ACP enrollee (‘Advance Care Planning in Singapore’ 2019; ‘FAQ on ACP’ n.d.). The role of a NHS is to speak for the patient when the patient no longer has the mental capacity to make decisions or communicate his/her wishes to others (‘Advance Care Planning in Singapore’ 2019; ‘FAQ on ACP’ n.d.; Interview 21SG39). The NHS should be 21 years old and above and can either be the patient’s family member or close friend (‘Advance Care Planning in Singapore’ 2019; ‘FAQ on ACP’ n.d.). He/she should understand the patient well, can respect the patient’s care wishes in making decisions and can make decisions under stressful situations (‘Advance Care Planning in Singapore’ 2019). For General ACP, the discussion focuses on the goal of care should an individual becomes severely mentally impaired with low chance of recovery, comfort care and life sustaining care (‘Advance Care Planning in Singapore’ 2019). For Disease Specific ACP, the discussion focuses on specific disease-related care and treatment preference in three clinical scenarios (e.g. serious complications with low chance of survival) (‘Advance Care Planning in Singapore’ 2019). For PPC, the discussion focuses on care options on Cardiopulmonary resuscitation (CPR), the intensity of medical interventions if one suffers a potentially life-threatening crisis (e.g. full treatment, comfort measures, limited additional interventions), preferred place of care and preferred place of death (Ho et al., 2021: 83; ‘Advance Care Planning in Singapore’ 2019; Interview 21SG39). PPC is usually facilitated by doctors, nurses or social workers who have a very good knowledge of geriatric or palliative care (Interview 19SG19). ‘ACP is not a legal document; therefore, there is no need for the presence of lawyers for its discussion or documentation’ (How & Koh, 2015: 20). It is different from Advance Medical Directive (AMD), which is a legal document an individual signs in advance to inform the doctor treating him/her the personal decision to stop any extraordinary lifesustaining treatment to be used to prolong his/her life if he/she becomes terminally ill and unconscious (‘Advance Medical Directive’ n.d.). The AMD status of a patient ‘is kept strictly confidential’ (Tan, 2021). Doctors and nurses are not allowed to ask if a patient has made an AMD (‘Advance Medical Directive’ n.d.). However, the attending doctor can check with the Registrar of Advance Medical Directives on whether a patient has made an AMD if he/she recognises that the patient is terminally ill and

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loses capacity to make decisions (‘Advance Medical Directive’ n.d.). ‘Both ACP and AMD are not mutually exclusive’ (‘Advance Care Planning in Singapore’ 2019). Anyone can make an ACP as well as AMD (Tan Tock Seng Hospital Advance Care Planning Team n.d.: 32).

Benefits of ACP and Barriers to ACP Practice ‘ACP is a welcome initiative and an important addition to Singapore’s palliative care ecosystem’ (Ho et al., 2021: 89). It offers doctors an opportunity to develop empathy and rapport with patients (Lall et al., 2022: 1722) and helps them know what best to do for patients (Interview 19SG19). It enables doctors to incorporate patients’ wishes into the care plan and deliver care which is congruent with patients’ values (Interview 19SG19). Hence, the delivery of person-centred care to patients can be achieved (Interview 19SG19). Besides, ACP can prevent family members of patients from carrying the psychological burden of witnessing patients’ unnecessary suffering and painful death (Lall et al., 2021: e0252598) and making significant decisions on treatment with little knowledge of what the patients would have wanted (Lall et al., 2021: e0252598). Being a pilot ACP program implemented in nursing homes in Singapore, Project CARE resulted in enabling residents to have ‘lower odds of being hospitalised, fewer hospitalisations, shorter cumulative length of hospital stay, and lower healthcare costs’ (Raj, 2013: 13). Besides, families which were surveyed one to three months after the demise of the residents ‘felt more satisfied in their ability to manage residents’ medication and condition at the time of death’ (Raj, 2013: 13). A local study which ascertained the extent of concordance between stated preferences and EOL care of 1,731 deceased individuals who completed their ACP found that 98% of individuals who opted to receive comfort measures met their preference (Tan et al., 2018: 663). Besides, 65% of individuals who opted to be cared for at home received care at home at 14 days before death (Tan et al., 2018: 663). ‘The percentage of concordance with hospital care ranged from 68% at 14 days before death to 90% at 90 days before death’ (Tan et al., 2018: 663). And 50% of the individuals died at their preferred place of death (Tan et al., 2018: 663). The study indicated that ACP helped many individuals receive care which was consistent with their expressed preferences, reflecting respect for patient autonomy and preserving one’s dignity.

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In reality, however, the implementation of ACP is less than ideal in Singapore due to several reasons (Interview 20SG34). First, death aversion is prevalent in the country (Ho et al., 2021: 85). ‘Many Singaporeans remain superstitious and regard death as an inauspicious and taboo subject’ (Lim, 2021). They fear about death and avoid having ‘dielogues’ with family members (Interview 20SG34). A local survey which examined over 1,000 Singaporeans’ death attitudes and perception of hospice palliative care in Singapore found that Chinese respondents (47%) and those aged 60 or over were less likely to have talked about death and dying because they did not know how to broach the topic (Lien Foundation, 2014: 33). 36% of the respondents felt comfortable with talking about their own death while only 20% of the respondents were comfortable with talking about death with someone who was terminally ill (Lien Foundation, 2014: 35). Medical cost (88%), being a burden to family and friends (87%) and the well-being of their family after death (80%) were respondents’ top fears about death (Lien Foundation, 2014: 40). Such fears ‘were pronounced amongst the Chinese, especially those who are older’ (Lien Foundation, 2014: 41). As a result, many Singaporeans defer the conversation about death and dying until an acute medical event occurs (Arivalagan & Gee, 2019: 24; Wales & Rajendran, 2016: 11), ‘by which time many options are precluded and intense negative emotions dominate the dialogue’ (Wales & Rajendran, 2016: 11). Many people have an impression that ACP is to discuss how a person is going to die (Interview 21SG44). In particular, older adults in Singapore were ‘resistant to concepts underlying ACP as they believed that any mention of death could hasten their demise’ (Lall et al., 2021: e0252598). Local people’s serious misconception of ACP prevented them from engaging in ACP conversations (Interview 21SG44). For example, when a healthy male older adult wanted to tell his children and grandchildren about the photo he had chosen for his funeral, his wife scolded him because she said that talking about death during Chinese New Year would bring bad luck to the family (Interview 21SG44). But the male older adult thought that Chinese New Year was a good opportunity to have ‘dielogues’ with his family members because everyone came back home to have reunion dinner (Interview 21SG44). He just wanted his children and grandchildren to know that he was showered with love and he hoped that his funeral planning could be respected by family members (Interview 21SG44). It took him some time to convince his wife to engage in ‘dielogues’ with him and open up to share her feelings and thoughts with him

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(Interview 21SG44). Being able to have open conversations with loved ones and planning for one’s death (Kang, 2021) can in fact ‘prevent a lingering sense of regret and “unfinished business” in life’ (Kang, 2021). However, a death-avoidant culture in Singapore inhibits older adults from having ‘human connectedness, finding meaning in suffering and building legacy’ (Lin, 2018: 46). Second, ACP discussion cannot be started or completed due to family dynamics (Interview 19SG19). It ‘would cause conflict within the family’ (Bernard et al., 2020: 94). For example, adult children of a terminally ill patient may disagree with one another about an appropriate course of care the patient should receive (Interview 21SG44). Younger sons of a terminally ill patient are not comfortable with discussing ACP with their terminally ill father/mother or making decision for their terminally ill father/mother because they are afraid of being blamed by older siblings (Interview 21SG44) or the eldest sibling who ‘often plays a hosting role related to items about parents’ disease, funeral, and so on’ (Wang et al., 2020: 638). Some family members refuse to be involved in the ACP discussion or to become the NHS because they do not want to bear the responsibility of making decision for the terminally ill patients in the later stage (Interview 21SG44). Medical professionals or social workers sometimes have to first find out who the dominant figure is in the family and then introduce ACP to the dominant figure (Interview 21SG44). If the dominant figure refuses to be involved in the ACP discussion with the terminally ill patient, medical professionals or social workers would suggest the dominant figure at least understand the needs of the patient and think about how the patient prefers to be taken care of and what is best for the patient (Interview 21SG44). Third, a meaningful ACP discussion cannot occur due to collusion (Interview 19SG19), which ‘refers to a secret agreement made between clinicians and family members to hide the diagnosis of a serious or lifethreatening illness from the patient’ (Low et al., 2009: 11). In Singapore, clinicians ‘tend to approach family members first with the bad news, leaving up to family members the decision of whether to disclose the diagnosis to the patient’ (Low et al., 2009: 14). ‘Arguably, competent elderly patients are infantilized if they are treated in this way’ (Krishna & Menon, 2014: 543,228). Family members ‘usually choose collusion over disclosure’ (Low et al., 2009: 14) because of their worry that disclosure may cause the patient to have psychologic pain, lose hope or feel depressed (Low et al., 2009: 11) or hasten ‘the progression of the illness and death’

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(Low et al., 2009: 11). Besides, they want to ‘maintain their filial obligations to care for their family members which are rooted in social and local cultural beliefs’ (Krishna & Menon, 2014: 543,228). They ‘must maintain hope and never give up on the patient’ (Krishna & Menon, 2014: 543,228). Out of love, they keep the patient in the dark about their health condition (Lim, 2021). Hence, it is hard to talk about ACP if the patient is unaware of his/her health condition (Interview 19SG19). While some doctors in Singapore think that patients have the right to know about the diagnosis, patients’ family members intervene and insist the patients should not know about it (Lim, 2021). This leads to family members making decisions which ‘may not necessarily be in the best interests of the patient’ (Lim, 2021) and such decisions may become a huge burden for family members (Lim, 2021). Fourth, many older adults lack confidence in making care or treatment decisions because they think that they are incapable of doing so (Interview 20SG34). Health literacy which is ‘fundamental for patient’s understanding of health information, adherence to treatment, and participation in making treatment options and informed decisions’ (How, 2011: 119) is lower among older adults in Singapore (Koh, 2017). Hence, older adults usually rely on their adult children or medical professionals to make important care decisions for them (Interview 20SG34). Fundamentally, ACP aims to empower patients to ‘have a say about their current and future treatment’ (Detering et al., 2010: c1345) when they still have the mental capacity to do so. In reality, however, older adults’ dependency on their adult children or medical professionals to make important care decisions for them ‘contradicts the aspiring ACP philosophies of patient autonomy and self-determination’ (Ho et al., 2021: 86). Meanwhile, a local study found that almost 60% of healthcare professionals ‘would abide by the wishes of the family over the previously expressed wishes of the patient’ (Foo et al., 2013: 355) in a situation where the patient loses mental capacity and his/her previously expressed wishes and the family’s wishes were conflicting (Foo et al., 2013: 357). This means that ‘patient autonomy is lost when the patient loses mental capacity’ (Foo et al., 2013: 355) due to a ‘‘familial determination’’ decision-making model occupying a central role within the decision-making process (Foo et al., 2013: 357). Confucianism and the concept of ‘filial piety’ lead to patient autonomy being subordinate to physician authority and family values (Cheng et al., 2020: 977).

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Fifth, some treating physicians refuse to endorse the ACP document because they think that some trained ACP coordinators cannot be trusted and are not qualified enough to carry out a proper ACP discussion with patients (Interview 20SG34). They think that some ACP coordinators are just university graduates without receiving any medical training (Interview 20SG34). Without medical training, these ACP coordinators may ‘feel inadequate to explain complex medical procedures’ (Ho et al., 2021: 87) and fail to address some of the unrealistic expectations from patients. Some terminally ill patients may have an inaccurate or unrealistic understanding of the nature of their potential or likely future (Land et al., 2019: 670). Doctors with knowledge and experience about EOL ‘may want to question ACPs that include invasive interventions such as resuscitation or chemotherapy when there is little chance of benefit’ (Land et al., 2019: 671). This can lead to tensions between endorsing patients’ plans and addressing how realistic these plans are (Land et al., 2019: 670). Working to ensure patients’ plans are realistic ‘can risk putting patients under undue pressure to commit to something they do not want’ (Land et al., 2019: 671), undermine their autonomy and jeopardize doctor-patient relationship (Land et al., 2019: 670). While some treating physicians do not trust that ACP coordinators can carry out a proper ACP discussion with patients, they do not want to have ACP discussions with patients (Interview 20SG34). This is due to many feasibility challenges they counter, including added workload (Ho et al., 2021: 87), ‘language barriers with ethnically diverse patients, and the tedious and time-consuming task of ACP paper documentation’ (Ho et al., 2021: 87). Singapore’s biomedical model which focuses predominantly on saving and sustaining life is another reason for doctor’s reluctance in engaging patients in ACP conversations (Ho et al., 2021: 89–90).

Ways to Increase the Acceptance and Implementation of ACP People ‘will age and die; there is a finitude of living’ (Prince-Paul & DiFranco, 2017: 18). They can be more comfortable having ACP discussions with family members only if conversations about death and dying can be normalized (Boundris, 2015). In recent years, the Death Positivity Movement has been growing in western countries to break the culture of silence around death through ‘discussions, gatherings, art, innovation and scholarship’ (‘Death Positive Movement’ n.d.). ‘Death cafés are among

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the earliest pieces of the death positive movement’ (Gooden, 2020) to provide accessible, confidential and respectful spaces for people, often strangers, to gather over drinks and cakes (‘What Is Death Café?’ n.d.) to discuss ‘the logistics, services, and finances of attending to death, medical care at end of life’ (Fong, 2017: 2), ‘experiences of grief’ (‘The Death Positive Movement’ 2015) and ‘if a good death can be had’ (Fong, 2017: 2). In Singapore, Health Minister Ong Ye Kung said at the 7th Singapore Palliative Care Conference that the sensitive issue of death should be discussed more openly and honestly in order to bridge the mismatch of expectations and desires between a dying patient, his/her loved ones and healthcare professionals (Ong, 2021). Open and honest conversations about death and dying not only ‘empower people to take charge of their own death’ (Meade, 2014), but also ‘greatly improve the chances of getting the death they want’ (Meade, 2014). Various efforts have been made by different parties to normalize conversations about death and dying in Singapore (Ong, 2021). For example, Both Sides, Now: Living with Dying is an inter-disciplinary community arts project aiming to engage the general public in ‘discussing issues of living life, death and dying’ (Wales & Rajendran, 2016: 12) and raising public consciousness about ACP (Wales & Rajendran, 2016: 12). In 2019, the project ‘engaged over 12,000 individuals and trained over 300 volunteers in Advanced Care Planning advocacy’ (Ong, 2021). Launched by Singapore Hospice Council, “Live Well. Leave Well” is a campaign encouraging people to openly talk about what matters to them near the EOL and make plan in advance (‘About the Campaign’ n.d.). It portrays that discussing EOL care ‘is an act of love’ (‘Singapore Hospice Council spot’ 2018). Project Happy Apples is a project initiated by medical students to raise public awareness about palliative care in Singapore (‘Project Happy Apples’ n.d.). Dying To Talk is another project initiated by university students in Singapore to encourage people to discuss death with their family members over dinner at home (Toh, 2020). Giving the rapidly aging population in Singapore, it is of great importance to encourage people to have open and honest conversations about death and dying, which may in turn increase public acceptance of ACP. The government can consider upstreaming the ACP discussion into usual health promotion activities (Prince-Paul & DiFranco, 2017: 18) so that people ‘will have the courage to confront the reality of mortality’ (Prince-Paul & DiFranco, 2017: 18).

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A local study suggests the concept of filial piety can be reinterpreted to develop culturally appropriate campaigns for ACP (Lall et al., 2021). The fulfilment of filial piety by adult children or younger relatives can be understood as endorsing parents’ or older relatives’ treatment preferences instead of prolonging their lives and sufferings through unnecessary treatment (Lall et al., 2021). This may help increase public acceptance of ACP, especially among ethically Chinese populations in Singapore (Lall et al., 2021: e0252598). Education reform can be implemented by bringing life education to schools and universities in Singapore. The development of life education ‘is as important as the relevant social policies and medical services’ (‘In Focus: A Matter of Life’ 2020). Life education enables students to ‘explore the true meaning and nature of the wisdom, caring, and practice of life’ (Phan et al., 2020: 580,186). Besides, it empowers students to ‘confront and face death with sense of dignity, serenity, and respect’ (Phan et al., 2020: 580,186) and ‘overcome death-related matters (e.g., sorrow)’ (Phan et al., 2020: 580,186). It enhances students’ death literacy by equipping them with ‘a set of knowledge and skills that make it possible to gain access to understand and act upon end-of-life and death care options’ (Noonan et al., 2016: 32). The government can learn from the experience of Taiwan, which promulgates the Curriculum Guidelines of Life Education, implements life education at schools at different levels and cultivates qualified teachers for life education (Chen & Lee, 2021: 131). Teaching methods of life education can include experiential learning, narratives and stories (Interview 20SG34), instructional media (e.g. interactive video) and role-playing (Shih, 2020: 1248–9). The government can adapt the concept of life education to ‘the local setting not only at a conceptual level but also at an operational level’ (Lin and Lee, 2021: 68). This can enhance the acceptance of life education among students, their parents and teachers. It is challenging to reduce the incidence of collusion (Krishna & Menon, 2014: 543,228). The solution to collusion requires the adoption of a multipronged approach, which consists of ‘creating awareness among patients, family, and clinicians of the problems with collusion from the standpoint of each group’ (Low et al., 2009: 11), explaining the burden of collusion to family members in a compassionate and empathetic way (Low et al., 2009: 14), informing family members of the patient’s wish to know the truth (Low et al., 2009: 14), equipping healthcare professionals and family members with the techniques for breaking bad news

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in a sensitive and respectful manner (Krishna & Menon, 2014: 543,228; Low et al., 2009: 13–4) and providing continual care and support for the patient and his/her family members (Low et al., 2009: 13). Doctors’ refusal to endorse the ACP document attributes to their ‘own reservations on the efficacy of ACP conversations’ (Lall et al., 2022: 1723). Their distrust of non-medically trained ACP coordinators posed an obstacle to ACP implementation. To solve this problem, it is important to develop ‘standardized competency guidelines for interprofessional collaboration in ACP as an important first step in reducing confusion among roles and other challenges in facilitating ACP’ (Kwak et al., 2022: 321). Members of interprofessional care teams can include physicians, nurses, physician assistants, social workers and psychologists (Kwak et al., 2022: 328). An interprofessional approach to ACP can ‘give a holistic delivery of care’ (Ng et al., 2011: 102) because it utilizes ‘unique scopes of practice and skillsets among team members from diverse professional backgrounds with specific training’ (Kwak et al., 2022: 328). For example, a doctor can provide medical advice (Ng et al., 2011: 102) and ‘guide patients toward palliative care’ (Lall et al., 2022: 1719). A nurse can help explain the diagnosis to patients and their families in lay man’s terms and offer psychological comfort to patients and their families (Lall et al., 2022: 1719). A social worker can ‘facilitate discussion about the values and preferences of patients and families, who also must be included as integral members in each ACP discussion’ (Kwak et al., 2022: 329). The interprofessional collaboration requires ‘an open, receptive professional culture’ (Kwak et al., 2022: 329). It also requires ‘clear policies, procedures, and protocols with suitable information structures, as well as time, space, and resources to support communication and care planning’ (Kwak et al., 2022: 329).

Conclusion To conclude, ACP is a process supporting an individual at any state of health in discussing his/her life goals, care preferences and preferred place of death with his/her family members and healthcare professionals. The implementation of ACP can achieve patient autonomy, avoid unwarranted suffering and enable patients to die with dignity. Death aversion, family dynamics, collusion, the lack of health literacy, treating physicians’ refusal to endorse the ACP document are barriers to the acceptance, discussion and implementation of ACP. It is important for the government

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to enhance public acceptance of ACP and facilitate the implementation of ACP through normalizing conversations about death and dying, reinterpreting the concept of filial piety to develop culturally appropriate campaigns for ACP (Lall et al., 2021), upstreaming the ACP discussion into usual health promotion activities (Prince-Paul & DiFranco, 2017: 18), offering life education to students, adopting a multipronged approach to tackle collusion and adopting an interprofessional approach to ACP. Looking forward, comfort, dignity and solace can be brought to the majority of dying in the country (Ong, 2021).

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The Agency for Integrated Care (n.d.). Advance care planning booklet: Plan for your health and personal care. Retrieved November 16, 2022, from https://www.aic.sg/resources/Documents/Brochures/ACP%20Publica tions/Workbook/ACP%20Workbook-EN.pdf Thomas, K. (2018). Overview and introduction to Advance Care Planning. In K. Thomas, B. Lobo, & K. Detering (Eds.), Advance care planning in end of life care (2nd ed., pp. 3–16). Oxford University Press. TODAY (2015, May 30) THE BIG READ: As population ages, more are confronting the last taboo’ TODAY . Retrieved November 16, 2022, from https://www.todayonline.com/singapore/big-read-populationages-more-are-confronting-last-taboo Wales, P., & Rajendran, C. (2016). Both sides, now: Living with dying. Retrieved November 26, 2022, from https://artswok.org/wp/wp-content/uploads/ 2017/09/Both-Sides-Now-Report-2016.pdf Wang, W., Liu, X., Dong, Y., Bai, Y., Wang, S., & Zhang, L. (2020). Son preference, eldest son preference, and educational attainment: Evidence from Chinese families. Journal of Family Issues, 41(5), 636–666. https://doi.org/ 10.1177/0192513X19874091

Websites About the campaign. (n.d.). Retrieved November 28, 2022, from https://singap orehospice.org.sg/livewell-leavewell/ Advance Care Planning. (n.d.). Retrieved November 16, 2022, from https:// www.racgp.org.au/running-a-practice/practice-resources/practice-tools/adv ance-care-planning Advance Care Planning in Singapore: Why and how to get started. (2019). Retrieved November 17, 2022, from https://singaporelegaladvice.com/lawarticles/advance-care-planning-singapore-get-started/ Advance Medical Directive. (n.d.). Retrieved November 17, 2022, from https:// www.moh.gov.sg/policies-and-legislation/advance-medical-directive Agency for Integrated Care Pte. Ltd. (n.d.). Retrieved November 13, 2022, from https://www.mycareersfuture.gov.sg/companies/agency-integr ated-care-200915135W ACP directory. (n.d.). Retrieved November 13, 2022, from ACP frequently asked questions. (n.d.). Retrieved November 17, 2022, from Death positive movement. (n.d.). Retrieved November 28, 2022, from https:// www.orderofthegooddeath.com/death-positive-movement/ FAQ on ACP. (n.d.). Retrieved November 17, 2022, from https://www.aic. sg/care-services/faqs-on-acp#:~:text=Who%20can%20I%20appoint%20as,or% 20to%20communicate%20your%20wishes.

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How to make an Advance Care Plan. (n.d.). Retrieved November 17, 2022, from https://www.beforebeyond.page/post/how-to-make-an-advance-careplan-acp In focus: A matter of life and death Interview with Dr. William Ng. (2020). Retrieved November 28, 2022, from https://rel.hkbu.edu.hk/news/infocus-a-matter-of-life-and-death-interview-with-dr-william-ng Project CARE. (n.d.). Retrieved November 16, 2022, from https://www.ttsh. com.sg/Community-Health/Central-Health-Stories/Pages/Project-CARE. aspx Project Happy Apples. (n.d.). Retrieved November 28, 2022, from https://pro jecthappyapples.wordpress.com/about/ Simple steps for ACP. (n.d.). Retrieved November 16, 2022, from https://www. aic.sg/care-services/simple-steps-for-acp Singapore Hospice Council spot shows discussing end-of-life care as an act of love. (2018). Retrieved November 28, 2022, from https://www.marketing-intera ctive.com/singapore-hospice-council-spot-shows-discussing-end-of-life-careas-an-act-of-love The death positive movement: What is it? (2015). Retrieved November 28, 2022, from https://www.talkdeath.com/the-death-positive-movement/ What is death cafe? (n.d.). Retrieved November 28, 2022, from https://deathc afe.com/what/

Interviews Interview Interview Interview Interview

19SG19, 20SG34, 21SG39, 21SG44,

Advance Care Planning Coordinator, July 2019. a scholar, November 2020. community care doctor, November 2021. a professional caregiver in a nursing home, December 2021.

CHAPTER 9

Afterword: Healthy Ageing in Singapore

Abstract There is no one-size-fits-all answer to successful ageing or healthy ageing. How an individual, the community members and the government understand and interpret the concept of successful ageing or healthy ageing may vary among cities or countries. Besides, how the government in a city or a country develops its successful ageing or healthy ageing framework very much depends on the political, economic, social, cultural and historical context. Nevertheless, achieving successful ageing or healthy ageing should be able to add years to one’s life as well as add life to one’s years. This chapter provides an update on policies implemented by the government to achieve active ageing and suggests ways to achieve healthy ageing in Singapore. Keywords Ageism · geing in place · Destigmatize dementia · Healthier SG · Healthy longevity · Kampung admiralty

Singapore has been experiencing population ageing over the past four decades. It is the world’s second-fastest ageing society (Geddie, 2019) and will become a super-aged society by 2030 (National Population and Talent Division et al., 2022: 10). The rapid ageing of populations has posed several challenges on the Singapore government, including © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 S. Ching Yuen Luk, Healthy Ageing in Singapore, Social Policy and Development Studies in East Asia, https://doi.org/10.1007/978-981-99-0872-1_9

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a shrinking workforce, an increase in old-age dependency ratio, feminization of ageing (Asher & Nandy, 2008) and an increasing demand for healthcare, long-term care (LTC) and age-friendly housing. How to address the challenges of population ageing effectively and help people remain healthy, active and independent as they age are growing concerns for the government. Since the early 1980s, the government has set up different high-level committees to study the problems of population ageing and recommend solutions to such problems. It sees ageing in a more positive light through the discourse of ‘successful ageing’ with older adults continuously making important contributions to society as they age (Wong, 2013: 81). The anti-welfare policies of the state led to the government’s emphasis on older adults being independent and self-reliant and the family being the ‘first line of support’ (Wong, 2013: 92). The adoption of the ‘many helping hands’ approach promotes the active involvement of non-state actors to meet the needs of older adults (Ang, 2017: 135) so that the government can ‘undertake a philanthropic approach to its social welfare function’ (Ang, 2017: 135). At the time of writing, the government is refreshing the Action Plan for Successful Ageing with a special focus on 3Cs: Care, Contribution and Connectedness (Ministry of Health et al., n.d.: 3). For care, the government aims to empower older adults to take charge of their physical and mental health through active ageing programmes and preventive healthcare (Ministry of Health et al., n.d.: 3). For Contribution, the government aims to enable older adults to continuously contribute their knowledge and expertise through senior employment, volunteerism and enhanced learning (Ministry of Health et al., n.d.: 3). For Connectedness, the government aims to support older adults to age in place and stay connected with their loved ones and society through digital platforms and support networks (Ministry of Health et al., n.d.: 3). Achieving successful ageing is not the sole responsibility of the government. Instead, it requires the engagement of every Singaporean to build an inclusive society where chronological age does not define who we are or determine how well we live (Ministry of Health et al., n.d.: 3; Cox, 2019). It also requires the government and people in the community to ‘turn ageing into a positive force’ (‘Prolonging Healthspan by Delaying Ageing’ 2022) so that people will not fear getting older or losing their worth when they grow old.

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There is no one-size-fits-all answer to successful ageing or healthy ageing. How an individual, the community members and the government understand and interpret the concept of successful ageing or healthy ageing may vary among cities or countries. Besides, how the government in a city or a country develops its successful ageing or healthy ageing framework very much depends on the political, economic, social, cultural and historical context. Nevertheless, achieving successful ageing or healthy ageing should be able to add years to one’s life as well as add life to one’s years. ‘Older adults are a heterogeneous population’ (Jaul & Barron, 2021: 513,557). They can be divided into eight categories: the active/healthy older adults, the at-risk ones, the lonely and frail, the disabled, the needy (i.e. economically less well-off older adults), older caregivers, older adults with dementia (Interview 18SG02) and those with illnesses. They have different types of needs and ways to help them remain healthy are different. For example, at-risk older adults may fall at home or may not have the right amenities at home (Interview 18SG02). They are susceptible to trips and falls, thereby requiring extra care (Interview 18SG02). They need to have strength training exercises (Ng, 2014) and fall prevention tips to stay healthy. For the lonely and frail, regular home visits by volunteers are one of the important ways to make them feel socially connected (Ng, 2014; Interview 18SG02). For older caregivers, they may ‘become a high-risk group for physical and mental health morbidity and even mortality’ (Amar et al., 2022: 1034). They need respite care and counselling support to stay physically and mentally healthy. In Singapore, some areas which have over 20 percentage of resident population aged 65 years or over will have to provide more elderly-friendly infrastructure and build a stronger network to support older residents to age in place. Given that Singapore will become a super-aged society, the government can consider mobilizing grassroots advisors, grassroots leaders and grassroots volunteers to conduct a needs survey in their areas to understand what the care and support needs of older adults and their caregivers are. Based on the survey results, grassroots advisors and grassroots leaders can work with community partners (e.g. healthcare service providers) and socially responsible companies to provide proper care and support for older adults and their caregivers (Interview 18SG02). Unremitting efforts have to be made by the government, employers, community members and individuals to combat ageism, which refers to

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‘the stereotypes (how we think), prejudice (how we feel) and discrimination (how we act) directed towards people on the basis of their age’ (World Health Organization, 2021: xv). Ageism in the workplace is still prevalent in Singapore. A survey conducted by the global payroll and human resources leader ADP found that 17% of employees in Singapore experienced age discrimination in their workplace, which was higher than the Asia–Pacific region average of 12% (‘HR Briefing: Ageism’ n.d.). It found that employees aged over 55 and those aged between 18 and 24 were most likely to experience age discrimination (‘HR Briefing: Ageism’ n.d.). But 60% of employees did not know who to contact if they encountered discrimination and 69% of employees lacked confidence in raising the issue (Kang, 2020). Another survey conducted by the Ministry of Manpower (MOM) found that age discrimination was found to be the most common form of workplace discrimination and it was experienced by employees who were in their 40 s and over (Chea, 2022: 5). ‘On the whole, the instances of discrimination were mostly related to career development, salary, and promotion’ (Chea, 2022: 5). Similarly, the survey conducted by Randstad Singapore found that 57% of employees felt that they had fewer training and development opportunities as they grew older (Randstad Singapore, 2020). It also found that 31% of employees aged 18 to 34 avoided communicating with mature employees aged 55 years or over (Randstad Singapore, 2020). To combat ageism in the workplace, employers can enforce non-discriminatory human resources policies (Randstad Singapore, 2020) and create an intergenerational mentoring program to encourage cross-generational exchanges (Gurchiek, 2020). They can also build multigenerational work teams to allow for a wider range of education and experience (Gonzalez, 2022), ‘better problemsolving capabilities and more innovative thinking’ (Rubenstein, 2022). Meanwhile, the study of Burnes et al. (2019) found that combined interventions with education and intergenerational contact worked best at reducing ageist attitudes in society. ‘Educational activities help enhance empathy, dispel misconceptions about different age groups and reduce prejudice and discrimination by providing accurate information and counter-stereotypical examples’ (World Health Organization, 2021: xvii). As regards intergenerational contact, it can ‘reduce intergroup prejudice and stereotypes’ (World Health Organization, 2021: xvii). The government can consider providing such interventions for students and older adults with the assistance and support from schools, universities, voluntary welfare organizations (VWOs) and grassroot organizations.

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Ageing healthily requires people to remain physically, mentally, cognitively and socially well. They have to make a conscious effort to have a balanced diet, regular physical activity, an adequate amount of good quality sleep and regular socialization with family and friends. But adopting and maintaining healthy behaviours requires motivation and determination. The launch of Healthy 365 mobile application by the Health Promotion Board (HPB) is one of the interesting ways to motivate local people to adopt and maintain healthy behaviours. Users are encouraged to sign up for in-app challenges (e.g. The Eat, Drink, Shop Healthy Challenge) and health programmes to earn digital stamps and Healthpoints which can be redeemed for food and beverages and shopping digital vouchers (‘Eat, Drink, Shop Healthy Challenge’ n.d.; ‘Healthy 365’ n.d.). Called Healthier SG, the new healthcare reform plan shows the government’s determination to better care for an ageing population and tackle the rising impact of chronic disease through a shift in focus from reactive curative care to proactive preventive care and empowering residents to take responsibility for their own health (Ministry of Health, 2022: 12). Residents will be encouraged to enrol with a family doctor of their choice to develop a personalized health plan (e.g. regular health screening, lifestyle adjustments) and receive continuity of care (Ministry of Health, 2022: 7–8). Meanwhile, community partners and various agencies (e.g. People’s Association, Sports SG) will be rallied to support residents in leading healthier lifestyles and adhering to their health plans through enhancing the accessibility of suitable healthy living programmes and activities such as aerobics, cooking classes and community gardening (Ministry of Health, 2022: 46–51). Making Healthier SG work requires changes in people’s mindset about the healthcare system and collective efforts made by the government, residents, family doctors and community partners in the long term (Ong, 2022). The initial results of a healthier population will not be seen until eight to 10 years later (‘White Paper on Healthier SG’ 2022). But the government is heading in the right direction for healthy longevity. As people live longer, it is more important than ever that they attain financial well-being in old age. But many Singaporeans are financially unprepared for retirement because they lack financial knowledge and skills to help them manage personal finances and accumulate wealth. This increases their risk of having insufficient money to meet their basic monthly expenses, maintain their desired lifestyle or cope with unexpected expenses in old age. Women particularly have lower level of financial

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literacy than men because they lack opportunities to pursue higher education or do not work, according to Professor Benedict Koh from Singapore Management University (Singapore Management University, 2020). The MoneySense National Financial Capability Survey 2021 found that 4 in 10 respondents did not understand financial concepts (e.g. simple and compound interest, risk diversification) and over half of the respondents had not developed a plan for retirement savings (‘MoneySense Campaign to empower Singaporeans’ 2022). Hence, a two-month campaign was launched by MoneySense in autumn 2022 to increase Singaporean’s financial literacy through one-to-one financial health clinics, complimentary retirement planning workshops and MoneySense’s digital financial planning service (‘MoneySense Campaign to empower Singaporeans’ 2022). Nevertheless, a better way for the government to enhance the level of financial literacy of Singaporeans in the long run will be formally introducing financial literacy programmes to the school or university curriculum (Singapore Management University, 2020). Afterall, financial literacy ‘is a core life skill for participating in modern society’ (OECD n.d.). It has a positive effect on the quality of retirement-related decisions (Prast & van Soest, 2016: 118). Ageing in place has been adopted by the government as the key principle in housing and land use policies to enable older adults to grow old in their home and community with minimal disruption or change to their lives and activities (Goh, 2006). The government has used many innovative methods to help older adults age in place. Starting from 2007, some of the Housing and Development Board (HDB) towns and estates have been rejuvenated through the Remaking Our Heartland (ROH) programme to ensure their vibrancy and sustainability (‘Written answer by Ministry of National Development’ 2022). ‘Bukit Merah, Queenstown, Choa Chu Kang, and Ang Mo Kio will be the next HDB towns to undergo the fourth series of ROH’ (‘About the Remaking Our Heartland programme’ n.d.). An online survey, online focus group discussions and physical engagement have been used by HDB to collect residents’ ideas to rejuvenate their towns (‘Written answer by Ministry of National Development’ 2022). Through public engagement, the authority can better understand what improvements made in HDB towns would benefit residents most (‘Written answer by Ministry of National Development’ 2022) and empower residents to take greater ownership of their towns. Officially opened in May 2018, the 11-storey Kampung Admiralty is Singapore’s first retirement community integrating studio apartments for older adults

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with a wide range of healthcare, communal, social, retail and commercial facilities (‘Kampung Admiralty’ n.d.). It is also ‘the first Housing Board project to co-locate childcare and senior centres in one integrated development, aimed at encouraging inter-generational bonding’ (Seow, 2018a). Yew Tee Integrated Development, another integrated development with housing for older adults, is expected to be completed in 2027 (Ng, 2021). Heartbeat@Bedok is an integrated community hub bringing retailers, the public library, sports centre, community club, senior care centre and polyclinic under one roof in Singapore (Seow, 2018b). It ‘offers greater convenience to residents’ (People’s Association, 2018) and better serves their needs (People’s Association, 2018). Community partners and researchers have also used creative methods to help older adults grow old in their communities. The case study on SilveCove Senior Wellness Centre shows that the involvement of older adults in the design process of the centre could encourage shared responsibility, foster community engagement, and create a sense of ownership among older residents. Community for Successful Ageing at Whampao (ComSA@Whampoa) empowered older residents to take charge of their own health, built community capacity through knowledge transmission, fostered a sense of purpose and a sense of community among older residents and promoted a positive image of older adults in the community through an integrated system of holistic programmes and services. Exergaming competitions for older adults (i.e. SING, I-SING) could increase social interactions and engagement among older adults, promote intergenerational bonding, stimulate older adults’ exercise intentions, gave older adults a sense of accomplishment and reduce alienation. Project ARTISAN (Aspiration and Resilience Through Intergenerational Storytelling and Art-based Narratives) showed that an integrative art and heritage-based interventions could enhance older adults’ life satisfaction, resilience and their interactions with other older adults, empower them to learn new things, help them develop a growth mindset, and create stronger intergenerational relationships. It is hoped that the number and scale of similar community projects can increase in future so that more older adults can grow old healthily, independently and gracefully in their communities. But the problem encountered by some community partners or researchers is the lack of money to increase the scale of the projects or continue the projects. Some projects that were supported by research grants had produced positive impact on the physical, mental and social wellness of older adults and the results had been published in high-impact

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academic journals. Unfortunately, they were not able to move to the next stage by being tested in more communities due to the lack of money, manpower and participants. In fact, some projects which produced positive results have the potential to benefit more older adults and their caregivers if they get sufficient support from funders, community organizations and government agencies. They have the potential to turn into a nationwide project or even become part of the ageing policy in future if their positive results were recognized and valued by the government. It is worth exploring the possibility of turning some research projects which produced positive results into a nationwide project. But a platform has to be created to allow researchers and representatives from multiple government agencies to discuss such possibilities. A significant rise in the number of people with dementia (PWD) is set to increase the cost of dementia in Singapore. It is necessary to develop and implement a national dementia policy which ‘systematically address(es) dementia, from prevention, diagnosis, and treatment, to care and supportive services’ (Sun et al., 2020: e2). Such national dementia policy helps provide ‘a template for unifying efforts and driving progress’ (Sun et al., 2020: e2). How to help PWD age in place will be an important task for multiple stakeholders. The creation of dementia-friendly communities (DFCs) began as a bottom-up movement in Singapore. The creation of DFCs should become part of the national dementia policy so that stakeholders and community partners have better ideas about the key elements of DFCs, infrastructure, systems, services and resources available for creating DFCs, and the core areas for action. A social model of disability should continue to be adopted to create and sustain DFCs in Singapore. Besides, more public awareness campaigns should be held to destigmatize dementia. They should be ‘conducted on a long-term, routine basis to have a sustainable impact’ (World Health Organization and Alzheimer’s Disease International 2012: 86). Technologies, if used properly, can improve the physical, mental, cognitive and social wellness of healthy older adults and older adults in public hospitals, day care centres, nursing homes, and other long-term care (LTC) facilities. They can improve the quality of life and the quality of care of older adults and relieve the burden on formal and informal caregivers. Singapore, which is a smart nation, has been a testbed for various digital technologies, including artificial intelligence (AI), robotics, sensors, autonomous vehicles, additive manufacturing and virtual reality (VR) (Luk & Preston, 2021). Local people use HealthHub, which is

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Singapore’s first one-stop online portal, to obtain health information and services (e.g. health screening records, manage medical appointments) (Luk & Preston, 2021: 95). They use mobile applications and wearable devices to track their health and fitness. Some nursing homes, day care centres and public hospitals piloted the use of robots, VR reminiscence therapy and teleconsultation to improve the quality of care of older adults. Telerehabilitation and Smart Elderly Monitoring and Alert System (Semas) have also been tested to see their effectiveness in improving the health and quality of life of older adults in Singapore. Zoom has been used by senior activity centres to offer online physical exercise classes to older adults and by National Gallery Singapore to offer virtual tour of paintings to PWD in the time of the 2019 coronavirus diseases (COVID19) pandemic. The use of technologies to deliver care and improve the wellbeing of older adults is expected to become more popular in the coming five to 10 years in Singapore. In the next phrase of smart nation development, the government can consider ways to harness digital technologies to tackle manpower shortage in the LTC sector and improve the quality of life of older adults. Meanwhile, it is important to bridge digital divide among older adults through Digital Clinics and other training programmes. Local people should be trained to have good cyber hygiene to stay safe online. It is also important for the government to strengthen its cybersecurity capacity and fight misinformation online. ‘The ethical use of digital technologies should be promoted so that human and machines can co-exist in harmony’ (Luk & Preston, 2021: 105). Technology, if used properly, can complement care workers and free them up to do more meaningful tasks (e.g. care tasks). Implementing technology with a human touch can definitely make older adults feel loved, valued and cared for. To conclude, collective efforts have been made by the government, community partners and other stakeholders to create a supportive environment to enable residents to age healthily, independently and gracefully. It is hope that residents can make conscious efforts to adopt and maintain healthy behaviours and live a meaningful life in old age.

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Websites About the Remaking Our Heartland programme. (n.d.). Retrieved December 21, 2022, from https://www20.hdb.gov.sg/fi10/fi10349p.nsf/hdbroh/index. html Eat, drink, shop healthy challenge. (n.d.) Retrieved December 21, 2022, from https://www.healthhub.sg/programmes/136/eat-drink-shop-healthy-challe nge?utm_source=google&utm_medium=sem&utm_campaign=fy22-edsh-ao& utm_content=campaignRSA Healthy 365. (n.d.). Retrieved December 21, 2022, from https://hpb.gov.sg/ healthy-living/healthy-365 HR briefing: Ageism still rocking Singapore workplaces. (n.d.). Retrieved December 21, 2022, from https://sbr.com.sg/hr-education/in-focus/hr-bri efing-ageism-still-rocking-singapore-workplaces Kampung Admiralty. (n.d.). Retrieved December 23, 2022, from https://www. hdb.gov.sg/residential/where2shop/explore/woodlands/kampung-admiralty MoneySense campaign to empower Singaporeans with knowledge and skills on financial and retirement planning (2022). Retrieved December 23, 2022, from https://www.mom.gov.sg/newsroom/press-releases/2022/0914-mon eysense-campaign-to-empower-singaporeans-with-knowledge-and-skills-on-fin ancial-and Prolonging healthspan by delaying ageing—NUHS opens Singapore’s first centre for healthy longevity to increase healthy lifespan of Singapore population by five more

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disease-free years (2022). Retrieved December 19, 2022, from https://www. nuhs.edu.sg/sites/nuhs/NUHS%20Assets/News%20Documents/NUHS% 20Corp/Media%20Releases/2022/Media%20Release-NUHS%20opens%20S ingapore%E2%80%99s%20first%20Centre%20for%20Healthy%20Longevity.pdf World Health Organization (2021). Global report on ageism. Retrieved December 21, 2022, from https://www.who.int/teams/social-determinants-of-health/ demographic-change-and-healthy-ageing/combatting-ageism/global-reporton-ageism White paper on healthier SG. (2022). Retrieved December 23, 2022, from https://www.moh.gov.sg/news-highlights/details/white-paper-on-hea lthier-sg Written answer by ministry of national development on update on HDB’s remaking our heartland programme. (2022). Retrieved December 20, 2022, from

Interviews Interview 18SG02, a professor in a university, June 2018.

Index

A Action Plan for Successful Ageing, 11, 12, 258 activities of daily living (ADLs), 45, 46, 50, 148, 203 Advance Care Planning (ACP), 18, 236–250 aged society, 3 ageing in place (AIP), 148–152, 157, 173, 262 ageing society, 3, 8, 18, 257 ageism, 259, 260 Agency for Integrated Care (AIC), 16, 52, 98, 100, 194, 196, 201, 203–206, 208, 236–238 allied health profession (AHP), 79, 80 artificial intelligence (AI), 90, 264 Art with You, 133, 134, 140 Association for Music Therapy Singapore (AMTS), 65 C CareShield Life, 50–52

centenarians, 5 Central Provident Fund (CPF), 34, 35, 37, 39–41 Circuit Breaker (CB), 127, 131 City for All Ages (CFAA), 11, 12, 157, 161 community, 2, 7, 9, 11, 12, 14–18, 73, 148, 150, 151, 153, 155–161, 167, 168, 171–173, 191, 192, 194, 195, 200, 202, 203, 205–207, 209, 212, 215–217, 238–240, 247, 258, 259, 261–265 community clubs (CCs), 129, 130, 160, 202, 263 Community for Successful Ageing at Whampao (ComSA@Whampoa), 152, 157, 173, 263 Community Health Assist Scheme (CHAS), 48 COVID-19, 3, 5, 6, 18, 32, 33, 39, 42–44, 72–74, 101, 103, 104,

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 S. Ching Yuen Luk, Healthy Ageing in Singapore, Social Policy and Development Studies in East Asia, https://doi.org/10.1007/978-981-99-0872-1

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272

INDEX

124, 127–130, 133, 140, 200, 265

D Death cafés, 246, 247 Death Positivity Movement, 246 Dementia Care Mapping (DCM), 134 dementia-friendly communities (DFCs), 18, 186, 191–193, 202, 213, 215–217, 264 Dementia Friends, 191, 203–205 Dementia Innovation Readiness Index, 214 destigmatize, 191, 216, 217, 264 DFree® , 90, 105–108 digital literacy, 124, 140

E ElderShield, 50, 51 end-of-life (EOL), 238, 242, 246–248 exergaming, 152, 162, 163, 165–167, 173, 263

F Facebook, 18, 124, 126–128, 140, 204 financial literacy, 34, 36, 37, 39, 44, 52, 262 financial well-being, 18, 30, 36, 37, 45, 51, 261 Frontotemporal Lobar Dementia (FTLD), 187

G Go-to Points (GTPs), 186, 193, 202, 204 Guided Autobiography (GAB), 159, 161

H Healthier SG, 261 Health Promotion Board (HPB), 261 Healthy 365, 261 healthy ageing, 17, 18, 150, 259 healthy life expectancy (HALE), 6, 45 Heartbeat@Bedok, 263 Housing and Development Board (HDB), 33, 40, 41, 128, 148, 149, 170, 206–210, 213, 262

I Immersive VR Rooms, 90, 103–105 Infocomm Media Development Authority (IMDA), 124 Institute of Mental Health (IMH), 65, 188 Integrated Health Information Systems (IHis), 203 Inter-Ministerial Committee (IMC), 8 International-Singapore Intergenerational National Games (I-SING), 163, 164, 263 Internet of Things (IoT), 90

K Kebun Baru (KB), 208, 209, 212 Khoo Teck Puat Hospital (KTPH), 65, 191, 194, 208, 215 Ksdang Kerbau Women’s and Children’s Hospital (KKH), 65

L Lease Buyback Scheme (LBS), 41, 42 Lewy body dementia (LBD), 187 life expectancy, 3–6, 30, 45 long-term care (LTC), 6, 45, 46, 49, 90, 101, 148, 258, 264

INDEX

M Maintenance of Parents Act (MPA), 13, 14 “Many helping hand” approach, 8, 15–17 Market at Marmot , 135, 136, 138 Medisave, 9, 47–49 Medisave Care, 50, 52 Member of Parliament (MP), 208, 210 Mind Palace, 101–103 Ministerial Committee on Ageing (MCA), 10–12 Ministry of Culture, Community and Youth (MCCY), 12, 13 Ministry of Education (MOE), 11, 37, 159 Ministry of Health (MOH), 5–8, 10–13, 16, 45, 49, 124, 157, 159, 216, 237, 238, 240, 258, 261 Ministry of Manpower (MOM), 10, 12, 13, 260 Ministry of Social and Family Development (MSF), 14 music therapist, 64–66, 69–80 music therapy (MT), 18, 64–75, 79, 80 My House of Memories, 205 N Nanyang Technological University (NTU), 18, 162, 163, 168, 173, 200 NAO, 90–95 National Advisory of Council on the Family and the Aged (NACFA), 8 National Electronic Health Record (NEHR), 239 National Gallery Singapore (NGS), 18, 124, 133–135, 138, 140, 265 National Park Board (NParks), 154

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National University Health System (NUHS), 16 National University of Singapore (NUS), 212 Nee Soon South, 198, 207, 208 Nominated Healthcare Spokesperson (NHS), 236, 237, 239, 241, 244 non-pharmacological therapy, 64

O OCBC Financial Wellness Index, 31, 32 out-of-pocket, 49, 51, 52

P PARO, 90, 96–100 People’s Association (PA), 8, 160, 167, 261, 263 people with dementia (PWD), 18, 64–73, 96, 101–104, 133–140, 186–195, 197, 198, 200–217, 264, 265 Permanent Residents (PRs), 39, 41, 47, 50, 125 Personal Protective Equipment (PEE), 74 population ageing, 2, 3, 7, 10, 17, 18, 188, 257, 258 Preferred Plan of Care (PPC), 240, 241 Prime Minister’s Office (PMO), 4, 10 Project ARTISAN, 152, 168, 170–173, 263 Project Happy Apples, 247

Q quality of life (QoL), 11, 16, 66, 67, 71, 73, 90, 100, 105, 111, 129, 159, 161, 172, 192, 193, 200, 206, 217, 264, 265

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INDEX

R Remaking Our Heartland (ROH), 262 reminiscence therapy, 101, 102, 265 Residents’ Committees (RCs), 16, 129, 130 Retirement and Re-employment Act (RRA), 14 robot, 18, 90, 92–96, 99, 100, 265 S senior activity centre (SAC), 18, 124, 128, 129, 131, 132, 140, 163–167, 202, 239, 265 SilveCove Senior Wellness Centre, 152, 263 Singapore General Hospital (SGH), 65, 79 Singapore Intergenerational National Games (SING), 162, 263 Smart Health Video Consultation (SHVC), 90, 109–111 smart nation, 264, 265 social model of disability, 186, 191, 192, 217, 264 St Luke’s ElderCare (SLEC), 16 successful ageing, 160, 258, 259 super-aged society, 3, 257, 259 T Tan Tock Seng Hospital (TTSH), 159, 237 teleconsultation, 18, 109–111, 265 terminally ill patients, 18, 64, 67, 68, 73–77, 79, 244, 246 total fertility rate (TFR), 3

U Urinary Incontinence (UI), 105, 106

V Vascular dementia (VaD), 187 Video conferencing, 109, 240 virtual reality (VR), 18, 90, 100–103, 105, 199, 264, 265 void decks, 11, 170, 172, 209–211 voluntary welfare organizations (VWOs), 8, 9, 16, 52, 65, 237, 260 Vulnerable Adults Act (VAA), 14

W Wayfinding Project, 208, 210, 212 wearable bladder scanner, 18, 90 Wee Kim Wee School of Communication and Information (WKWSCI), 162–164 WhatsApp, 18, 124–127, 131, 140

X Xiohoo, 124, 125, 127, 128

Y Yishun Community Hospital (YCH), 65, 94

Z Zoom, 18, 72–74, 124, 125, 127, 128, 132–134, 140, 206, 265