A brief overview of gerontechnologies the state of the art is necessary to understand the situation, in 2019, of gerontechnologies as well as the crossroads of options and orientations which currently presents itself and which will be addressed in the third and fourth parts.
The scientific work relating to technological advances is too numerous from the start to be able to give an exhaustive account of it in a few pages. Choices therefore had to be made to keep this report reasonable in size, but a substantial bibliography, although also not exhaustive, refers to numerous articles and reports on the subjects treated.
Rather than a technical diagram (home automation, robotics, sensors, telemetry, actimetry, wireless connection, GPS …), we preferred for this course a diagram linked to basic social and medical needs: isolation, loss of autonomy, loss of the social bond, fall, cognitive disorders, running away and wandering of Alzheimer or related patients, anxiety of the patient, exhaustion of the family caregiver, etc. We have not included in this course the Personal Medical File (and more generally Information Systems for health networks) for several reasons: it is the subject of intense activity for its development and start-up ; it has long been a very complex subject and without convincing experiments, despite the extremely high expectations in gerontology.
This journey will not only be descriptive: the difficulties encountered by projects and the types of failures that threaten them can be mentioned, thus preparing the third part devoted to analyzes of difficulties and proposals.
We would have liked, for each major type of technology convincing by its useful and practical aspects, to be able to answer the sequence of questions: “Is this technology available?” If yes: how, at what price …? If not why ? ” Too many variations, too much diversity and sometimes subtle differences, too many price variations from year to year also make this exercise difficult. But such an exercise is essential and will have to be carried out, in one form or another, if we want to advance in the field of their prescription.
Interest of videophone communication
Technological research and development aimed explicitly at strengthening or restoring a social and medical bond for people with loss of autonomy exists and is developing. Essentially based on innovative designs and uses of the Internet and video telephony, but also home automation and remote assistance, these advances deserve to be placed in the perspective already engaged at ministerial level:
“Much remains to be done in order to strengthen social ties. New technologies will have an essential role in this fight: there is no doubt that they will contribute effectively if the concern for the dignity of the person is kept in view. ”
This positive point of view corroborates the importance of video intercom, at the interface of medicine and social activities:
“This intercommunication must allow: – an instantaneous functional link by call or alert in the event of concern or emergency – a reassuring emotional link to better fight against anxiety, boredom or depression linked to loneliness – a stimulating link for the use of socializing and cultural activities shared even at a distance or in tele-reeducation activities for example. This regular interaction, in particular promoting links between young people and the elderly, contributes to enriching the cultural heritage of each generation and allows the elderly, even those who are dependent, to regain a form of autonomy. ”
Video telephony consists in opening a virtual “window”: in addition to the voice brought by the telephone, there is the face of the other, and the many possibilities that this meeting allows, at a distance certainly, but rich in possibilities still few explored in gerontology: teleconsultation, health check with a nurse or doctor, sharing of useful information, intergenerational meetings, sharing a birthday despite the distance, etc. Being able to “see” the person you are talking to greatly increases the interest and content of the communication, both in medical and social support settings.
Video telephony, now accessible to the greatest number, can it establish, restore or strengthen links between socially isolated people, the sick, families, home help services, natural caregivers, caregivers, doctors, etc. ?
An importance based on the fundamental need to be able to see and speak to each other despite the distances and sometimes the reduced deadlines. The hypothesis of the importance of videophony in the telemedical field is today supported by numerous ad hoc experiments, but not yet used systematically to meet the needs.
An experiment in network geriatric teleconsultation implementing both an organizational model and an innovative videophone technology is underway.
“Some projects consist in having health professionals experiment with an audiovisual tele-consultation device between accommodation establishments for dependent elderly people, on the one hand, and geriatric doctors in hospitals and emergency doctors, ‘somewhere else. A hand-held camera connected to the network of accommodation facilities for dependent elderly people allows nursing staff to show patients via video over a secure network. ”
“The main objective is to avoid a passage to hospital emergencies for vulnerable people and to facilitate access to specialists in a context of quality care. ”
“These projects should enable doctors working in this retirement home, at a distance from a hospital, to access geriatric or specialized skills and to improve their health and social organization. »« Possible openings of the project, it is worth mentioning the monitoring of interventions triggered by “the remote alarm” in the homes of the elderly. ”
The videoconference of gerontological teleconsultation and support for cognitive deficits is developing around the world today. His interest in psychometric assessment and consultation in clinical gerontology has been widely emphasized. Home Hospitalization or home care can make an important contribution, in particular for the care of Alzheimer’s patients.
Experimentation with a teleservice using a simple telephone to support family caregivers of Alzheimer’s patients revealed a significant clinical effect for three parameters of the caregiver’s health: boredom, anxiety and depression.
Another study highlighted the effectiveness of a technical device coupling a telephone and a computer in a family therapy action: a significant reduction in the caregiver’s state of distress and depression was thus also be clinically demonstrated.
The videophone of social bond
Several countries, notably in Europe, are quite advanced in the use of videophony for the medico-social link, and in particular as a complementary element to the “remote alarm”. It should be noted that what “remote alarm” is known in many countries under the term of “social alarm” (social alarm) or community alarm (community alarm) and fulfills as such a role of support of social bond in which the videophone exchange can be common. For example, in the Netherlands, a video-surveillance telemonitoring service is offered (pilot study) to family carers of Alzheimer’s patients in order to allow them to get away from their patient for a few races or an essential rest. At the request of the caregiver and for a period agreed in advance, a telemonitoring center observes the patient at home using a few cameras and possibly chats with him by videophone. If a problem arises, the center notifies the caregiver or initiates an intervention procedure.
The use of video telephony as an antidote to social isolation is beginning to grow. For example, a very useful use of videophony for social ties has been developed in Canada through the Inter-generation Virtual Village of the international foundation. Intergeneration, the family network or the local network are more and more the subject of videophone research. Innovative Internet relationship solutions are gradually emerging, such as the VISAGE solution.
Finally, video telephony is increasingly used for tele-physical activity sessions such as gymnastics or Tai Chi Chuan for the prevention of falls.
Fall, loss of mobility and activity disorders
After numerous unsuccessful or unsuccessful attempts on the commercial level and like geolocators, increasingly functional fall sensors have emerged in recent years. These devices are all designed to automatically send alerts, by telephone or the Internet, to a monitoring center (or simply a person, on their mobile phone) responsible for applying an emergency rescue procedure. Some also incorporate the actimetry function.
Most often worn on the belt or sewn into a garment, these devices are both very sophisticated technically and increasingly reliable in terms of performance (sensitivity and specificity of detection). Associated with doubt removal devices taking into account the values of other sensors placed at the place of life, these fall or discomfort detectors see their performance increased tenfold; forgetting to wear the sensor by the person at risk is particularly taken into account by these complex devices. A fragile person, whose clinical picture shows a high risk of falling, could thanks to such devices live alone in his home with a relatively high level of security.
Representative of research on the problem of falling, the Parachute project aims to propose a methodology and a technology making it possible to detect in the elderly person at home an evolution towards a risk of falling. Sensors are integrated into usual devices in the home without disturbing the usual environment; their data is used to assess the quality of balance and the quality of walking.
The idea behind this type of device is not to isolate a person in a bubble of sensors, computers and robots that would take care of it at any point, allowing the rest of humans to forget it. On the contrary, it is to allow him to stay as long as possible at home, to postpone as much as possible an unwanted institutionalization, to calm him and his family and to facilitate the action of professionals or caregivers in charge of its maintenance. home. It is therefore a high-tech vision for maximum well-treatment. It is up to all medical and social workers and the family to use such a device for this one and only purpose.
Remote monitoring of biological parameters
Immediately after the emergency of falling or feeling unwell, it is the medium or long-term monitoring of a person’s biological and environmental parameters in their place of life that constitutes a subject of research and development. This is how weight, pulse, EKG, oximetry and many other biological parameters are captured directly on the person or through dedicated objects, analyzed by computers on site or remotely , merged into multivariate analysis models taking into account the entire medical file, and presented on screens for therapeutic monitoring or epidemiological study. More or less complex calculations on these data are aimed at: studying the temporal evolution of these values for therapeutic purposes (chronotherapy, analysis of biological rhythms, trend curves, etc.); automatic identification of data classes (scenarios) and automatic recognition of the occurrence of one of these classes in a continuous flow of sensor data; the study of the phase preceding crisis situations with a view to automatically locating the ‘approach to these situations (identification of a loss of weight or mobility, or a decline in gait insurance); the search for correlates between data from different sensors that can lead to the identification of composite variables useful in medicine; the evaluation of the patient’s functional activity, etc. This is avant-garde research, involving high-level mathematical tools (probabilistic reasoning, Bayesian networks, hidden Markov models, fuzzy logic, etc.) but of which a certain number of by-products could be useful in the short term, either for epidemiological studies of the elderly on his place of life, or for clinical parameters which could be useful to the doctor for daily monitoring of the patient.
Behavior measurement systems
In line with the research previously described, the measurement of behavior constitutes one of the fields of predilection of research. The automatic detection of a slowdown in activity or a deviation from behavior compared to lifestyle habits is a research avenue that has been developing for a few years.
The use of such devices by occupational therapists and social workers has even been tested in some countries. This path is enriched by the constant improvement in the performance of sensors, not only of fall but also of actimetry, of presence in various places of an apartment or its surroundings, detectors for gripping objects of daily life and various biological data sensors (scales, cardiometers, blood pressure monitors, etc.).
Many behavior measurement and automated remote assistance systems have emerged in recent years. For France, we can cite the PROSAFE system developed by the LAAS laboratory in Toulouse, the AILISA system tested in two hospitals (Toulouse University Hospital and Charles-Foix Hospital) and two apartments with a home for the elderly, and the GUARDIAN system that characterizes different types of behavioral disorders among the elderly with Alzheimer’s disease. Several authors have studied the nocturnal movements of patients with dementia. Cries are also studied: demented screamers subject those around them to stress that overcomes the need to stop the cry before seeking its meaning; a system for analyzing the duration of cries and agitations of a demented patient has also been proposed to allow the doctor to give meaning to these cries and to take them into account without being overrun by the emotional factor.
These systems remain largely in the field of research. However, simplified versions would be useful today in nursing homes. For example, it would be useful for the doctor to be able to have a summary of nocturnal activity each morning with histogram of the level of agitation of a patient suffering from cognitive disorders and unable to express himself other than by gestures, agitation or shouts . Such a device, used in hospitals for strictly medical purposes, would have no other purpose than to refine the treatment, thus promoting the ideal of quality care for the patient. Being designed for much more ambitious objectives, the larger systems mentioned above are capable of producing such highly targeted objects, the usefulness of which is recognized by geriatricians and caregivers. This simple example of the morning summary of night activity levels shows the interest of this type of device, but also the difficulty of our research valorization system to extract subsets directly useful for the patient, and by therefore likely to find a market. The problem here is not that of research, that of medicine, or even that of industry: it is between the three and can only be solved by bringing these universes together. The reconciliation tools exist (incubators, competitiveness clusters, etc.), but they must be strengthened.
The walkers (or walking frames) are in their elementary version of the sort of canes with four feet, with or without casters, allowing a person suffering from walking disorders but having sufficient muscular resources to move on his legs. Researchers have spent the past fifteen years exploring the concept of walkers with “smart” capabilities such as collision avoidance or choosing the optimal route in the event of an obstacle.
In France, the most promising high-tech walker project is led by the Paris Robotics Laboratory. It is the MONIMAD walker, made up of movable handles to stand up from a seated posture, then walk around an apartment or a service. Equipped with a mobile monitoring system for monitoring falls and physiological parameters, it is defined as follows:
“Monimad has motorized wheels, and above all” intelligent “handles capable of analyzing in real time the pushing force produced by the person. Depending on the pressure exerted, Monimad advances, brakes or stops. The smart handles can also detect situations of imbalance, allowing Monimad to stabilize the patient to avoid falling, a source of frequent trauma in the elderly. In addition, ultrasonic sensors placed at the front of the robot make it possible to avoid any obstacles that may arise nearby, and thus guide the patient in an environment that he does not know perfectly. ”
Cognitive impairment due to neurological conditions (Alzheimer’s type dementia, schizophrenia, head trauma, etc.) hamper activities of daily living, in particular the ability to take care of oneself, and severely harm social and interpersonal relationships. It has been shown in psychiatry that the more patients suffer from serious executive disorders, the lower the commitment to their treatment. Even at a moderate stage, these disorders (forgetfulness, confusion) constitute in the elderly an important factor of social isolation, morbidity and mortality, and are a significant predictor of
Alzheimer’s disease . Ranging from simple memory loss to dementia syndrome, these disorders have been mobilizing for fifteen years, and especially today, a major effort in technological research.
Remediation of memory disorders and executive functioning
For about two decades, technological research has included in its objectives the “remediation” of memory disorders and executive functioning. As early as 1994 for example Hersh et al. propose NeuroPage, a reminder system for taking medication worn by the patient and emitting a specific sound signal each time a medication must be taken or information must be given. This first device will be followed by several others, similar in principle of transmitting information to a receiver worn by the patient or installed close at hand at his home. The current boom in multifunctional mobile phones and Personal Digital Assistants is particularly stimulating the development and testing of this type of device. In addition, high-level technological research is taking place today, notably in cognitive science, to prepare the ground for future cognitive orthoses.
Cognitive stimulation systems
Numerous works in computer-assisted cognitive stimulation are organized around the concepts of neuroplasticity and cognitive reserve. These notions of neurology define the brain’s ability to modify itself both in its structures and in its functioning, throughout life, in the event of lesions or under the effect of adapted stimulations.
Several systems have emerged in the field of stimulation of memory functions for the purpose of rehabilitation or slowing down the degradation process. In France, studies of cognitive stimulation software are taking place as part of the national project, notably based on the work of Jocelyne De Rotrou and her colleagues at Broca hospital (Paris), on improving the management of Alzheimer’s disease through cognitive stimulation. It should also be noted that this is a large multidisciplinary project intended to test and evaluate in situ a set of technologies useful for patients with cognitive disorders, their family carers and all medical and social professionals.
There is also the HAPPY neuron website from Scientific Brain Training, which offers a program of around fifty exercises divided into five cognitive domains: memory, attention, language, executive functions, visuospatial.
“Unlike laboratory exercises intended for training an ultra-specific cognitive subsystem (…), our exercises are fun and educational, and although each of them is characterized by a cognitive dominant, several cognitive sectors are actually trained simultaneously. »Reports Dr Croisile, neurologist at the Hospices Civils de Lyon and contributor to this site with colleagues and students from Lyon. Another system, SmartBrain, distributed by a specialized structure, the ACE Fundation of the Catalan Institute of Applied Neurosciences (Fundacio ACE. Catala Institute of Applied Neurosciences) also offers a number of exercises on a CD-ROM.
Fugue and wandering
As a direct result of cognitive loss, running away is an important source of accidents and death. It consists of the patient leaving his place of residence without any caregiver or caregiver being able to notice it. It is particularly dangerous for people suffering from memory loss, confusion or disorientation. The risk of running away greatly increases the caregiver’s stress. The fugue can mobilize heavy human and technical resources (gendarmerie, fire brigade, etc.).
Technical aids capable of preventing runaway or of limiting its effects when it occurs are nowadays more and more accessible, from the “door contact” which transmits to the responsible person a signal each time a door is crossed, until the more sophisticated solution of the geolocator mentioned previously (bracelet or beacon anti-disappearance). Based on different technical possibilities that are often combined (GPS satellites, mobile phone, radiodetermination, etc.), geographic location systems are most often in the form of a box attached to the belt (anti-disappearance beacon) or a kind of watch (anti-disappearance bracelet). These objects can transmit radio signals on a particular frequency, which are received by a receiving system capable of calculating the geographical position of emission to within a few meters; provided of course that the signals have not encountered any obstacle to their transmission. This type of device, very sophisticated on the technical level, owes its development a lot to the automotive (road guidance) and leisure (guidance or tracking hikers) sectors.
For some systems, the natural caregiver or the professional in charge of it reports the patient’s flight from a remote assistance center, which itself detects and directs help to the lost patient. Other devices can implement a simplified and direct service between the caregiver and the carrier: in the event of a runaway, the caregiver directly questions the anti-runaway beacon by telephone, which returns the last known position via a speech synthesis explaining the geographic address, which also makes it possible to see the patient’s position on a map accessible on the Internet.
Although commercially available, these devices are still little known. They could nevertheless in the near future allow to increase the space of freedom of the patients: instead of being “cordoned off” in a restricted area they could have access to a wider space without excessive fear that it ” escapes ”. It would certainly decrease the caregiver’s stress. Their wide dissemination should make it possible to conduct analyzes of medico-social impact and cost / service ratio rendered in various countries and social contexts. The completely free nature of their current use.
Very simple: an automatic lamp
Anxiety is the manifestation of Alzheimer’s disease that most affects the patient. The technological contribution in this area can range from the simplest to the most sophisticated. In terms of simplicity, we can cite the bedside lamp which lights up itself when the evening light declines: some Alzheimer patients are taken, at dusk, a strong anxiety called “anxiety of the end of the day “. This anxiety subsides appreciably or disappears when the light increases. The disease deprives the patient of the faculty to understand that it is enough to activate the switch of his bedside lamp. A lamp controlled by a luxmeter which could maintain a sufficient level of lighting; the patient could benefit, but also the overworked caregiver or caregiver temporarily absent. This type of simple device does not exist in commercial form.
At the most complicated: a robotic animal
The complex technique seems to be more likely to prevail: a “therapeutic robot cat” for “Alzheimer” patients has been tested in the United States. It is in fact a robot sold in the general public trade and presented in the form of a new therapeutic instrument. A statistical analysis of the data from this experiment, which related to the decrease in agitation and the increase in the patient’s pleasure or interest, enabled the authors to affirm that a significant step towards “robotherapy” had been crossed.
In fact, the use of artificial animals as a substitute for real animals in therapy or as a remedy for the patient’s anxiety may only be in its infancy, given a potentially large demand:
Unfortunately, for many good or bad reasons, many elderly people in general, Alzheimer in particular, can no longer keep their pet, either because at home they can no longer provide for their daily life, or because the host institution refuses animals. So why not this little marvel of technology, certainly not as rich as a real dog, but much more reactive than a soft toy, to give birth and be reborn emotions without which there is no more quality of life?
This is how various robot animals are experienced. In addition to the cat previously presented, we can also cite the small dog AIBO, capable of responding to oral stimuli and experimented with patients suffering from severe dementia: at the start of the experiment, the patients recognized that it was indeed a robot, but after being dressed, the robot appeared to them like a real dog or a child. Let’s finish this short series with the Paro baby seal robot developed by the Japanese National Institute of Advanced Industrial Science and Technology: equipped with light, sound and pressure sensors, it moves the head and limbs according to the stimuli received. Tested with the residents of a Japanese retirement home, it has led, according to the experimenters, to a significant and lasting improvement in their psychological state.
Robotics is not limited to pets seen previously; on the contrary, it is extremely varied. There is in particular a walking assistance robotics, a housework assistance robotics and a very futuristic robotics aiming at the realization of humanoid robots:
– Walking assist robotics seeks to promote and secure the walking of a person who has become unable to walk without help. The Paris Robotics Laboratory, for example, is developing the MONIMAD “intelligent walker”.
– The very classic robotics for housework seeks to automate tedious tasks such as cleaning floors or assisting with culinary tasks. In terms of remote assistance, we are seeing automatic systems capable of triggering alarms. For example, a Japanese firm offers a “smart kettle” dubbed
“I-pot”: which sends a message to a correspondent each time it is used, indicating that the person is using their kettle. This device allows a family member to know if his parent is active through a gesture of daily life consisting in preparing his tea.
– Humanoid robotics, largely inspired by science fiction, seeks to create robots in human form capable of performing domestic or care tasks. The idea of creating robots capable of serving humans and performing in their place all kinds of strenuous, repetitive or dangerous tasks, in other words technological versions of the slave, occupies a major place in the aims of technoscience current. The idea is not new. Their use for the elderly is therefore not surprising and has been envisaged for several years by roboticists. Almost always humanoid in shape, these robots are presented as a companion solution aimed at “human relationships” or as a complement or substitute for nursing staff. In fact, this type of robotics seeks its justifications through two hypotheses:
– A hypothesis according to which our society, reluctant for various reasons to accompany the elderly in their daily life, could offer them as last resort human-shaped devices to keep them company and be at their service to perform various tasks. According to this hypothesis, for lack of humans we should be content with robots, or even prefer these robots because tireless, always present, superiorly intelligent, always calm and kind, with a
“algorithmic” compassion, that is, mimicked by a computer program. In the extremist conception, the robot becomes the very destiny of humanity.
– Another hypothesis that we will no longer have enough nurses and nursing assistants to take care of people in specialized establishments. The robots will then have to take over.
If Japan has championed this Android robotics, Europe is not to be outdone with notably the IWARD project intended to produce “nursing robots” which in a few years should be introduced in hospitals.
This type of robotics is of course the one that poses by far the most ethical problems.
Some major initiatives in the field of Alzheimer’s disease
ENABLE (www.enableproject.org), also from European funding and still active. This project has intensively studied the potential of a number of technologies adapted to improving daily life and reducing the burden on the caregiver: programmable telephone with large keys, automatic closing of the bathtub tap, automatic pill organizer, automatic calendar indicating the days and nights, a ‘Do-it-yourself-Picture gramophone’: memory aid, etc.). This project continues today by making these technologies available to the general public (on their website). Like its predecessors, this project also gives a large place to the ethical analysis of the uses of these technologies. It complements the other projects with its pragmatic dimension of technical evaluation and dissemination of this aid, which is still often difficult to obtain.
REACH (Resources for Enhancing Alzheimer’s Caregiver Health,), is a North American project for multi-site and large-scale evaluation of various actions including technological aids to help caregivers in their care tasks and alleviate their burden. In particular, he highlighted a significant reduction in depressive symptoms by implementing remote telephone-based therapeutic interventions.
“Ambient Assisted Living”. Among the most promising projects are the European projects:
– COGKNOW (www.cogknow.eu), dedicated to people with cognitive impairments.
– SOPRANO (Service Orientated Programmable Smart Environments for Older European, www.tunstall.co.uk) dedicated to all kinds of services aimed at improving the quality of life of elderly people across Europe.
– OLDES (www.oldes.eu) aimed at developing a user-friendly, accessible and ready-to-use technological platform for remote assistance and telecomputing, for an affordable subscription price.