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Distributed Mobile Services and Interfaces
for People Suffering from Cognitive Deficits
Sylvain Giroux, Hélène Pigot,
Jean-Pierre Savary
Jean-François Moreau
Département d’informatique
Division R&D CRD
Faculté des sciences
France Telecom,
Université de Sherbrooke
32 rue de la République
2500, boul. Université,
92130 Issy les Moulineaux
Sherbrooke, Qc
France
Canada, J1K 2R1
Phone : (33) 1 45 29 42 47
Fax : (33) 1 45 29 62 90
Phone : (1)-819-821-8000 Ext 2027
Fax : (1)-819-821-8200
e-mail: [email protected]
[email protected]
[email protected]
e-mail: [email protected]
Distributed Mobile Services and Interfaces
for People Suffering from Cognitive Deficits
KEYWORDS
Mobile Services, Cognitive Assistance, Smart Home, Cognitive Deficits, Reminder, Remote
Monitoring, Pervasive Computing, Sensors, Batch Mode, Direct Mode.
INTRODUCTION
The number of people suffering from cognitive impairments (Alzheimer disease, head
injury, schizophrenia...) is growing continually. For one, the ageing of the society plays an
important role in this trend. The always increasing needs for resources generates a huge stress
on human and economical actors. Thus in Canada and United States, as in most western
countries, social and medical policies try to keep at home people suffering from cognitive
deficits [Hareven, 2001]. Progress in cognitive rehabilitation also augments the number of
semi-autonomous people that would be able to stay at home if light assistance is provided. Of
course this results in higher expectations and even more demand on resources. But most of the
time, families have to take responsibility for care without access to appropriate resources.
Too often, this situation then turns to an exhausting weight. Therefore natural and
professional caregivers urge for help.
Recent advances in mobile technology can provide affordable solutions to lessen the burden
and anxiety put on caregivers and to collect reliable information. For many years, numerous
devices have been designed to counterbalance physical and sensory deficits. Nowadays
progress in technology set high hopes for cognitive orthotics that address cognitive decline
[Pollack, 2004, Lange, 2002]. Thanks to their small size and their versatility, mobile devices
can offer a personalized assistance anytime anywhere. Mobile devices then become portable
cognitive prosthesis, for instance acting as pervasive system to remind people Activities of
Daily Living (ADL) to perform when needed. They can also foster sense of security by
keeping people and caregivers directly in touch. In its simplest form a direct call button may
be used to request immediate assistance. Geo referenced data may also be used to detect
crisis of schizophrenia or when a patient suffering from Alzheimer disease is lost [Médical
Intelligence, 2005]. Mobile devices can also provide non intrusive remote supervision by
caregivers. Besides mobile devices can gather ecological data compulsory to adapt or finetune diagnosis and treatments. Nevertheless the design of devices and mobile services must
put a very careful attention to user interfaces used to deliver information. Population suffering
from cognitive deficits has often severe limitations and constraints.
This chapter discusses features and implementation of mobile services for cognitive
assistance and remote supervision. Mobile devices provide practical solutions to the issues
presented above. First we review benefits and limitations of current reminder systems that can
assist patients and/or caregivers. Then we present the needs of the population regarding the
assistance necessary to stay safely at home. The multiple mobile services, designed especially
for that population, are also described. We show how supervision can safely foster autonomy.
Next we describe cognitive assistance to patients and remote supervision by professionals or
relatives, and then we go further and gather ecological data to foster better treatments. Finally
outdoors, safety and security of the patients is relying on geo-localization features.
Implementation specific details are also sketched.
MOBILE PROSTHETIC SYSTEMS
The management of ADL is a central issue for people suffering from cognitive deficits. In the
process of rehabilitation, occupational therapists provide a patient with a paper agenda as a
tool he has to master to manage his life and autonomy. A lot of research projects and
commercial applications also targeted electronic adaptation of specific functionalities of these
agendas. In this section, we review the advantages and limitations of current reminder and / or
agenda systems.
Some systems are device specific and are explicitly designed to be used inside the patient
home and then could not help outside [Visions, 2005], [Helal, & al., 2003]. Another category
of systems is designed specifically for mobile devices in such a way that their use is not
restricted to a specific location. These applications are usually running on PDAs or smart
phones to either assist for needs specifically related to mobility [Patterson et al., 2004] or as
general reminder/agenda systems or electronic organizers [Szymkowiak, 2005] [Gorman,
2003] [Haberman, 2005] [Neuropage]. They are usually provided with acoustic alert or
remote communication.
Activity Compass project intends to provide compensatory aid for outdoor courses for patient
suffering from Alzheimer disease [Patterson & al., 2004]. It consists basically of a PDA
equipped with a GPS. Its role is to guide patient towards their destination by a mean of an
arrow indicating the direction to take.
Neuropage is a reminder system that uses radio technology to send reminders of things to do
[Neuropage]. When the message arrives, the pager beeps (or vibrates), one button is pressed
and the message can be read from the screen. Messages can be regular events or single-time
message. Messages are added or removed by contacting Neuropage office by phone, email,
letter, or fax.
The ISAAC system acts as a cognitive prosthesis used by people experiencing dysfunctions
in autonomy due to different kinds of brain injury [Gorman & al., 2003]. It provides a
checklist reminder to execute safely the ADL. Its hierarchical structure permits to navigate
easily throughout the different pieces of advice displayed. Personalization and adaptation of
pieces of advice enable ISAAC to evolve according to the patient cognitive evolution.
Providing a reminder helps the cognitively impaired patient to increase his autonomy. But the
patient himself and his caregiver express needs for safety. Both want to keep in touch and be
confident that activities will be performed in time. So a mean of communication must be
added to the current reminders. In the next section we review the cognitive deficits
encountered and the needs that ensue.
NEEDS OF COGNITIVELY IMPAIRED PEOPLE
Cognitive impairments encountered in schizophrenia, head trauma and during the early
stages of the Alzheimer disease provoke similar losses in autonomy that justify exploring a
common approach to support, assistance and remediation by technology [Pigot, et al., 2005].
Cognitively impaired people present lacks of initiation. For instance, they remain for long
periods without undertaking actions. They all call for frequent reminders to remember what to
do and sometimes how to do. Alzheimer disease strikes elders and one’s situation evolves
from relative autonomy to an unrelenting dependence while trauma injury and schizophrenia
appear most often during adulthood and one’s situation evolves from dependence to relative
autonomy.
Unless severely affected, cognitively impaired people are usually quite autonomous in
performing basic ADL such as eating, dressing, and washing themselves. But they at times
forget to do them and then need continuous recalls in order to initiate ADLs. Taking
medication is a critical issue, as it requires a good short-term memory in order to fulfill the
prescription correctly: which pills, how many and when. Without a reliable short-term
memory, it can be forgotten or taken twice. At home oblivion or bad discernment in the use of
domestic appliances often cause bath and sink flooding, fire, burn, cut... Beside these
hazardous situations, risk of malnutrition, bad hygiene and isolation are also real.
Cognitive impairments experienced at home have also manifest effects outside. Moreover
cognitively impaired people exhibit more difficulties in an unusual context. Oblivion leads to
problems in finding one’s way to a destination, in remembering the shopping list or even the
reason of the trip.
Loss of autonomy requires assistance. Caregivers lavish attention to the patients days and
nights long. Frequent recalls and safety are two factors especially important in the overall
burden coming from constant supervision and assistance. Therefore an electronic companion
could alleviate the “threatening” recalls and improve the relationship. Safety prevents a
caregiver from letting the patient alone.
MOBILE AND PERVASIVE COMPUTING
Although existing services are invaluable for patients and caregivers, overall they suffer from
some drawbacks. These services are not integrated in a common portal. They must run on a
specific patient device. They are either closely linked to a given location or, if they are
location independent, they can not benefit from the casual presence of other devices in the
environment, for instance sensors on the kitchen cupboards.
In next sections, we present the first steps of an on-going research project at DOMUS
Laboratory. Mobile computing is coupled with pervasive computing [Weiser, 1991]. Mobile
computing will enable patients and caregivers to use services wherever they are. Pervasive
computing will allow them to access services whatever the device is and to benefit from
existing devices, sensors and effectors present in their current environment. This approach
then promotes a tighter integration of devices and services to the environment when possible
while preserving mobility and independence of the patients.
Currently a common portal and many services were implemented and are ready to be
evaluated in situ. Through this portal a patient gets access to services with a simplified
adapted user interface. Caregivers have also access to their counterpart of services but the
interface is more complex. For the moment, devices used are PDAs, but we intend to port
them on e-mate, a platform that renders deployment of services independent of devices they
are deployed on [Giroux & al., 2003]. So phones, laptops, TVs could be used to access
services.
ASSISTANCE AND SUPERVISION SERVICES
A mobile device is designed to offer several services to enhance autonomy, security and
communication to cognitively impaired people and their caregivers. PDAs are linked through
a server. Some are dedicated to patients. Others run applications presenting the caregivers
point of view on information. Patient services fill three functions: a simplified reminder, a
prompter to request immediate assistance, a service to gather ecological information and a
location based health information service [Boulos & Maged, 2003] to help patient in case of
crisis. On the other side, three services are available for the caregiver: monitoring patients’
ADLs, informing system and colleagues of an intervention, and planning patient’ ADLs.
Services also enable patients and caregivers to communicate. The client component running
on a patient’s PDA is kept very simple. The patient benefits on an auto login procedure in
order to reduce the cognitive load.
An Enhanced Agenda as a Mean for Cognitive Assistance
A basic paper agenda is designed to help remembering appointments, to fill a timetable and to
prevent time conflicts. Our aim here is quite different. The agenda acts mainly as a cognitive
prosthesis. Typically the home of a patient suffering from head injury is covered with
numerous notices, for instance written on a post-it. Each one indicates something to do. On
the contrary, the electronic diary can show solely the activities often forgotten, and moreover
just when it is necessary. By default, our prototype displays on the PDA single window the
next three activities to perform in a three hours time bracket (Figure 1). Depending on the
patient’s cognitive abilities the number of activities displayed and the time slot can be easily
reduced or increased. When an activity is performed the patient clicks on it to indicate its
completion to the caregivers. The activities monitored on the agenda are either events
occurring just one time, as appointments, or recurring events as ADLs often forgotten.
Figure 1. Patient agenda.
Keeping in Touch
If help is necessary, the patient clicks on the button “Help” at the bottom of the screen to warn
caregivers. This button is always visible and active. This remote supervision ensures
permanent contact between them. It provides a sense of safety for both patients and
caregivers. Caregivers feel insecure to let patients alone without the opportunity to be
reached. For patients, the phone is often too complicated to use. Carrying everywhere a PDA
offers permanent assistance at a single click.
Monitoring ADL
Previous sections described the patient side of the system. In this section and the next two, we
depict the caregiver view: how ADLs are monitored, how cooperation can be foster between
caregivers and how to manage a patient list of ADLs.
The role of the patient PDA is to foster his autonomy. From time to time, he does not
perform given activities in time which may compromise his ability to stay alone. Equilibrium
must be maintained between a patient intimacy and his safety. For instance, forgetting one
day to take a shower does not justify an immediate intervention. However after several days
without showers, caregivers urge him to do it. On the other side, forgetting once to take
medication could be harmful for the patient’s health. Without a tool that helps to monitor
ADLs, a caregiver surveys constantly the patients asking for the ADLs completion.
(a)
(b)
Figure 2: Caregiver’s ADL monitoring. a) Supervised patients. b) One patient ADLs
The current prototype supports remote supervision of ADLs to perform (Figure 2).
Caregivers then know when an ADL is completed without bothering residents. On his mobile
device, a caregiver can monitor every patient under his responsibility. On his patients list,
colored icons indicate the status of current ADLs for each patient: green if all is OK, yellow if
the patient is near to forgot to perform an ADL and red if time planned for the ADL is over
(Figure 2a). For each patient, a caregiver can know: which activities are under monitoring
(Figure 2.b) and the time of completion of a given ADL. The same color code prevails.
Coordination between Caregivers
Since many caregivers can be in charge of a patient, coordination is important. Several
caregivers can take care of many patients. When a patient does not perform a task in time, all
responsible caregivers are informed. It is then essential to coordinate their actions, for
instance in order to avoid all of them going to see the patient. As soon as a caregiver notifies
his intervention to the system, this information is sent to all the mobile devices owned by the
other caregivers. Caregivers can also exchange responsibility of patients, for instance when a
working shift occurs.
Implementation section explains in more details how the information is updated on each PDA.
Planning ADL
In addition to ADL monitoring, caregivers must have also simple means to update and change
rapidly the ADLs and events that have to be monitored. Like a usual organizer, the caregiver
mobile device enables to register an activity occasionally or on a periodic basis ranging from
hours to months (Figure 3a). The caregiver has to specify duration and completion time and
for how long the activity has to be monitored (Figure 3b). This last information is particularly
suitable during the rehabilitation period or to update a medication prescription that is
regularly changed by the physician.
(a)
(b)
Figure 3: Planning activity. a) Activity period basis. b) Time activity information.
Ecological Data: Gathering Information for Better Treatments
Collecting ecological information may be of tremendous value for delivering better
treatments. For instance to control the schizophrenic symptoms, a physician prescribes
neuroleptics which induce severe side effects [Shriqui and Nasrallah, 1995]. The physician
has then to adjust medication during years to limit side effects and to avoid the recurrence of
hallucinations. He needs valid information about the patient feelings.
On his mobile device, the patient can notify symptoms (or other information) as soon as he
feels them (Figure 4). An intensity scale permits him to estimate the level of severity. The
PDA is also equipped with a GPS to register automatically date, time and position. These georeferenced data are sent to the server on a batch mode. Data can be analyzed later to improve
diagnosis and treatments.
Figure 4: Patient symptoms
IMPLEMENTATION
The basis of the implementation is a client-server architecture (Figure 5). Patients and
supervisors use iPAQs to connect to the server through wireless networks. The system is
available both indoors and outdoors. Indoors, the wireless connections to the server use IEEE
802.11b,g. Outdoors, the wireless connection is made through a Sierra Aircard. Each PDA
connects to the server through TCP sockets. The server allocates a different thread to each
connection. If the connection is lost, the mobile device tries to restore it. The PDAs and the
server exchange serialized objects through sockets. Outdoors, a GPS gives the patient
location. To ensure rapid communication the traffic is kept low. When a patient confirms an
ADL has been done or when a caregiver let know about his intervention, a message is sent to
the server. The server first updates the database, and then sends a message to each PDA to
inform a change happens. At that moment, some PDAs may want to display the information
under change. They request all the information needed to update their screen displayed.
Figure 5: Connection infrastructure.
Different types of communication are used between the PDAs and the server. Inside, when the
connection is established the transmission is in direct mode. Outside or when the connection
is out, the communication is in batch mode. Messages are saved in a queue waiting till a
connection becomes available. Finally a configuration file is used to personalize the
application: auto-login, font, font size, message strings, icons, and number of activities
displayed.
The implementation is in standard Java (J2SE) for the server part. PersonalJava is used for the
client part on PDAs. On the PDAs, user interfaces were implemented with SWT. On the
PDAs, the virtual machine was J9 for PocketPC. The system was tested on HP iPAQ 4155
and HP iPAQ 1945 running Microsoft PocketPC OS.
DISCUSSION
Specific needs are addressed by our system for cognitively impaired people in order to foster
their autonomy. Functions of an electronic agenda are redesigned to limit cognitive load,
especially the burden put on memory. Presently only the patient name is displayed. We are
evaluating the relevance of adding other information such as the patient address and caregiver
phone number. It may be helpful when a patient is lost but it could raise the cognitive load by
requiring one more screen.
The help function is germane to a panic button provided by various companies. A panic
button is generally linked to a remote controller that intervenes when the button is pressed.
The use of such panic systems remains generally difficult especially for elders suffering
Alzheimer disease. First, we hope that providing on the PDA a help button they use
frequently is more likely to be used in case of emergency. Secondly, making explicit the help
button on the PDA by an icon or by writing the function is a guarantee they could understand
its use.
Providing geo-referenced data is another critical issue. Knowing a patient position may be
worthful and even vital in many situations and for a range of purposes:

to send directly somebody at the patient location if he is in crisis or in danger;

to forbid specific zones;

to detect crisis states by analyzing paths and detecting pathologic patterns of
movement of patients suffering from schizophrenia;

to predict the goal of a patient combining path history and analysis.
When a patient is outdoors, a GPS connected to his PDA get his position. This position is sent
at predefined time interval to the server. Path analysis can then be performed. Currently client
and server components are under development to specify and manage forbidden zones.
Mobile services are actually designed to offer the activities monitoring by professional
caregivers. Families need too a similar system to be informed of difficulties. They feel
insecure to let alone the patient. They could exploit geo-referenced data in the timetable
information to know if it is conform to the one expected. For instance a patient suffering from
schizophrenia shows disorganization symptoms before experiencing a new crisis. Sending no
information about the activity performed is a premonitory sign. Applying it to the Alzheimer
disease may help to detect falls or other health problems.
CONCLUSION
In this chapter, we presented a client-server based mobile system for patients suffering from
cognitive deficits and their caregivers. Users will use mobile devices. They help especially to
remember the activities a patient have to perform. We adapted traditional agenda to decrease
the cognitive prerequisites and to provide a permanent communication between a patient and
his caregiver. All along the development process attention was paid on the real needs
expressed by patients and caregivers. A sociological questionnaire and study had established
previously the needs among patients suffering Alzheimer disease, head injury and
schizophrenia [Pigot, & al, 2005]. Periodic meetings with caregivers have ensured conformity
of the design of services to the needs expressed. Finally a clinical validation is under process
among people suffering from schizophrenia.
Future works will integrate mobile services to a helpful environment designed for people
suffering from cognitive impairments in the spirit of pervasive computing. For instance
instead of asking a patient to notify when an activity is completed, the environment will be
able to recognize the activities performed by means of sensors [Pigot, 2004]. The home will
adapt itself to alleviate autonomy, remembering when necessary what needs to be done and
how to do it. Such smart homes are an answer to the growing demand of cognitively impaired
people to stay safely at home.
INDEX
Mobile Services : Mobile services refer to the software applications available on portable
devices such as PDA or smart phone.
Cognitive Assistance : It is the assistance provided by the environment to compensate the
cognitive deficits.
Cognitive Deficits : They are the deficits encountered by a person following a brain lesion.
The memory losses and the lacks of planning, initiation and attention are examples of
cognitive deficits.
Smart Home : The smart home are the home equipped with sensors and effectors that could
react according to the inhabitant actions. The smart home could warn persons outside by the
remote monitoring or give advices to the inhabitant.
Remote Monitoring : see smart home.
Reminder : a reminder is a prosthestics aid which displays the common agenda functions and
information on memories or advices to be followed.
Pervasive Computing : Pervasive computing is the next generation computing environments
with information and communication technology everywhere, for everyone, at all times.
Sensors : the sensors are electrical devices that gather information on the state of the
environment and on the localization and the activities performed by the inhabitant. For
instance some sensors detect the presence of the inhabited or which door is open.
Direct Mode : The direct mode indicates the transmission mode where the data are sent to the
receptor immediatly after the transmittor command.
Batch Mode : The batch mode indicates the transmission mode where the data are sent to the
receptor a moment after the transmittor command.
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