Environmental Cognitive Remediation in ...

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Environmental Cognitive Remediation in Schizophrenia: Ethical Implications of "Smart Home" Technology Emmanuel Stip, MD, MSc, C S P Q ' , Vincent Rialle,

Objective: In light of the advent of new technologies, we proposed to reexamine certain challenges posed by cognitive remediation and social reintcgration (that is, deinstitutionalization) of patients with severe and persistent mental disorders. Method: We reviewed literature on cognition, remediation, smart homes, as well as on objects and utilities, using medical and computer science electronic library and Internet searches. Results: These technologies provide solutions for disabled persons with respect to care delivery, workload reduction, and socialization. Examples include home support, video conferencing, remote monitoring of medical parameters through sensors, teledetection of critical situations (for example, a fall or malaise), measures of daily living activities, and help with tasks of daily living. One of the key eoneepts unifying all these technologies is the health-smart home. We present the notion of the heallh-smart home in general and then examine it more specifically in relation to schizophrenia. Conclusion: Management of people with schizophrenia with cognitive deficits who are being rehabilitated in the community can be improved with the use of technology; however, such technology has ethical ramifications. (Can J Psyehiatry 2005;50:2H 1-291)

Clinical Implications • Cognitive deficits in schizophrenia can lead lo the introduction and maintenance of a true handieap. • New technologies, applied to the field of health, could serve as a cognitive prosthesis. • Smart homes are an illustration of a possible environmental modifieation that would facilitate rehabililation and community adaptation. Limitations • Altering the environment in a fashion suitable for persons with cognitive handicaps is not a common approach. • There are significant ethical concerns related to smart homes, including issues of individual freedom, personal autonomy, infoiTned consent, and confidentiality. • There is limited literature evaluating the outcome and impact on the quality of life of persons using smart equipment.

Key Words: schizophrenia, dementia, cognilion. menial disorder, rehahililation. cybernetics, ethics, smart home, cognitive remediation he eognitive remediation and soeial reintegration (that is,

dented development in communication and information tech-

dcinstitutionalization) of patients with severe and pcrsistent mental disorders present challenges that psyehiatry has been trying to meet for many years. Nowadays, the unprece-

nologies has redefined the terms of these challenges. Recent studies have attested to the flexibility, effectiveness, and growingaffordabilityofthese technologies (1-3). This article

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aims to demonstrate the potential these technologies may have with respect to research and the efforts made by psychiatric institutions that provide cognitive remediation to persons with schizophrenia. Our second objective is to start a debate on an unresolved matter: what are the ethical implications of new technologies in teaching cognitive skills and monitoring safety in schizophrenia patients? Community care today has. in many respects, become a necessity., provided that acceptable conditions of safety and autonomy are met. A lower birth rate and a higher life expectancy together go a long way toward explaining the growing need for medical care for dependent seniors. As the number of dependent seniors increases, so do economic and sociomedical issues (for example, overloaded health facilities, higher health costs, desire for quality of life [QoL], and quality care). When a senior person is no longer capable of independent living, home living has always been the preferred choice over institutionalization. The advent of innovative technologies has today revived issues related to community care in tenns of means and safety (4,5). At the teehnical level, adapting these technologies to the eonditions specific to schizophrenia poses a priori difficulties that depend on a creative interaction between psychiatrists and technologists. Solulions for disabled persons, with respect to care delivery, workload reduction, and socialization, have become extremely significant and diversified; these include home support video confereneing (6), remote monitoring of medical parameters through sensors (7), teledeteetion of such critical situations as a fall or malaise (8,9), measures of daily living activities! 10,1 I), and help with daily living tasks (12). However, the introduction of new technologies in the patientpsychiatrist equation raises a series of questions concerning technical interest and feasibility, as well as ethieal and legal questions. These technologies are also likely to bring about significant changes in how institutions and sociomedical organizations function. Consequently, it has become imperative to begin medical and social debate on the use of these technologies with psychiatric patients. The lack of significant improvement in the cognitive sphere brings us to consider the notion of cognitive disability. Unlike elderly subjects afflicted by a degenerative dementia, young persons affected by a mental disorder that causes a cognitive disability see their soeial insertion, academic performance, and employability compromised. Society must recognize this disability and consider the possibility of modifying patients' environments to remedy the situation. This recognition calls fora conceptual shift in the field of psyehiatry toward adapting the environment to the disability. This was done in the industrialized world 30 years ago, with respect to motor disabilities, when the modification of living environments (for example, lower kitchens, wider bathrooms, inelined 282

sidewalks, and wheelehair ramps) and transportation took place. Society must now undertake a similar review aimed at overeoming cognitive disabilities in schizophrenia. This ean be achieved by equipping patients' immediate environment with appropriate technology—the concept behind "smart homes," We propose to examine the potential contributions new technologies ean make in terms of environmental cognitive remediation specific to sehizophrenia. We also briefly outline the corresponding soeioethical issues. Because the technical dimension is extremely vast, we approach it more specifically through the notion of the smart home and the use of certain "smart objects."

Schizophrenia Deficits have been observed in individuals with sehizophrenia in practically every cognitive domain (13-15). Although some studies show that 27% have normal cognition (16,17), most studies show that 85% of schizophrenia patients perform below established nonns in one or more eognitive domains (14,15,lS-29). The resulting disabilities in higher mental functions often have a major impact on patients' ability to function in society. It is important to bear in mind that schizophrenia causes distortion of reality in the form of delusions of persecution and psychosensorial phenomena (19). Thus surveillanee technologies could exacerbate symptoms. Additionally, schizophrenia patients present several deficits in executive functions and perform signifieantly worse than normal subjeets on tests measuring daily living activities (with strong eeologie validity, sueh as cooking) (30,31).

Course of Cognitive Deficits Few studies found a gradual deterioration in cognitive functioning in sehizophrenia (32,33). Most studies examining the relations among cognitive funetions, illness duration, and age could not confirm these results (13,26,27,34-37). Indeed, subjects with schizophrenia demonstrate performance stability on various cognitive tests, when compared with nonnal subjects. Similar results were found in longitudinal studies of chronic and first-episode patients (38^0). Further, a review including 15 studies failed to provide evidence that a cognitive deterioration was associated with the diagnosis of sehizophrenia (36). If appears that cognitive impairments are relatively stable after disease onset.

Impact of Cognitive Deficits on Psychosocial Functioning of Persons With Schizophrenia Green's metaanalysisof 16 studies was the first to establish a link between certain eognitive defieits and psychosoeial functioning (41). Whereas explicit memory was associated with community integration, interpersonal problem solving, and • Can J Psychiatry, Voi 50, No 5. April 2005

Environmental Cognitive Remediation in Schizophrenia: Ethical Implications of "Smart Home" Technology

acquisition of psyehosocial skills, working memory was linked to the acquisition of psyehosocial skills. Sustained attention was found to be specific to interpersonal problem solving. Green's seeond metaanalysis, which included 37 studies, confinned the previous observations (42). Cognitive deficits seem to predict 40% to 50% ofthe variance regarding the funetioning of a person suffering from schizophrenia in the community (43,44). Accordingly, unemploymenl rates among schizophrenia patients are reported to be as high as 70% to 80% (45). These rates are higher in industrialized countries, owing to job complexity. Conventional or first-generation neuroleptics (for example, haloperidol) have little impact on cognitive funetioning, whereas atypieal or second-generation neuroleptics (such as risperidonc, olanzapine. quetiapine, and elozapine) have a signifieant impact on cognition (46). The improvement observed at the cognitive level with the use of atypical antipsychotics may be linked to their mechanism of aetion.

Psyehosocial Rehabilitation hi the field of mental health, it is wise to distinguish between treatment and rehabilitation. Mental health serviees have traditionally been geared toward the treatment of mental illness. This type of intervention seeks to alleviate or eliminate the symptoms assoeiated with a diagnosis. Interventions aim to minimize the impact of illness on functioning (47), and they constitute the preliminary stage in a mentally ill person's engagement in rehabilitation. Conversely, psyehosocial rehabilitation aims at offering support to mentally ill persons, allowing them to live sueeessfully and satisfaetorily in an environment oftheir ehoice (47) with minimal intervention (48,49). This approach seeks first and foremost to help persons with mental illness develop the skills necessary for community integration and to subsequently establish a network of support and strategies to compensate for impaired skills (50). Although the various proponents of psyehosocial rehabilita(ion generally accept this definition, the models underlying the different programs offered vary eonsiderably, as does the training of practitioners (51). Numerous programs have been developed under this banner, both in the eommunity and in hospital settings. Initially, psyehosocial rehabilitation involves the teaching of skills through psyehoeducational methods, lab work, and the use of daily living and psychosocial-skills training groups (52). Unfortunately, individuals have trouble generalizing the skills outside the laboratory setting (53). Today, psychosoeial rehabilitation comprises training aimed at acquiring the skills related to real life settings. This entails determining whether it is preferable to develop a skill or, rather, to implement compensatory measures and use a support network (47), It i.s then necessary to analyze the Can J Psychiatry. Vol 50, No 5, April 2005

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requirements ofthe person's life setting, identify the level of performance required for the person to function within the setting with the least possible intervention, and evaluate the person's skills in his or her natural environment. The support network is then identified, and its implementation is facilitated, whether this consists of arranging individuals, objeets, or activities (49,54). In the past 20 years, various programs have been proposed and implemented in the US and Canada, all of which claim to be defined according to the principles of psyehosocial rehabilitation. However, the heterogeneity of the services offered has made it diffieult to compare studies with respect to psyehosocial rehabilitation (51).

Ecologie Validity Cognitive theories as a whole seem to concur that hypofrontality of negative schizophrenia translates into difficulties in organizing one's actions and carrying out a predetermined plan. These difficulties have direct repercussions on the daily funetioning of persons with schizophrenia. However, the evaluation of this dimension in research remains prohlematic. Whether it is estimated as a function of subjective satisfaction with daily functioning, gainful employment, or functional autonomy, the results obtained never directly quantify the extent and efficiency of their daily tasks. Indeed, this type of data is often derived from questionnaires, which, being tools ofthe laboratory method, fail to grasp the concrete reality ofpatients'daily lives. In addition, most ofthe research into patients' QoL is conducted in relation to the long-term effeetsoftreatment with a certain typeof neuroleptic. without foeusing more deeply on the differeni underlying aspects of daily dysfLincliontng. Social skills are the only aspect of daily dysfunctioning studied to date under truly ecologic conditions, through role-playing that aims to evaluate the capacity for interpersonal problem solving (55). Organizational problems occurring in daily living activities have yet to be investigated in a natural environment. It cannot be assumed that the effective treatment of symptoms is a guarantee for proper community functioning or that skills evaluated by means of exeeutive function tests reflect those needed for daily independent living. The identification of distinct sets of executive deficits in schizophrenia could contribute to the establishment of rehabilitation programs better suited to individual needs. Treating frontal dysfunctioning unifonnly in all patients presenting with a negative symptomatology is more likely to fail than identifying and eompensating for cognitive difficulties that arc discerned more speeifieally. That is, recognizing and measuring particular configurations of signs of frontal dysfunetioning would lead to a better individualization of treatment plans and a more precise evaluation of therapeutie progress.

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To compare the executive dysfijnctioning of schizophrenia patients against their capacity for daily living, it is necessary to observe patients in a natural context where they are called on to use the same functions that appear impaired In fonnal testing. Such studies have already been conducted on patients with frontal brain lesions and are only now beginning to be implemented in the field of schizophrenia; it is to this end that the "cooking test" was developed in Montreal (30,3!), It is important not lo lose sight of the faet that each symptom represents but one visible sign of an aftlietion that is never entirely obscn'able and that a good neuropsyehologieal functioning test measures only a limited number of functions, ideally, only one. However, most daily activities require the combined effort of various cognitive functions and involve frequent changes in tasks that entail multiple interruptions and readjustments. Finally, it is possible that the interaetion of symptoms and executive deficits finds a different expression in the laboratory than in the natural environment. All these questions must be answered by future researeh to ensure the development of theoretical models that not only account for the experimental data but that also share a correspondence with the situations nomially encountered by patients. Adopting an ecologie approach in the study of their cognitive deficits would make it easier to apply experimental results to clinical practice.

Cognitive Rehabilitation The literature regarding cognitive rehabilitation distinguishes 3 types of interventions: first, interventions aimed at improving cognitive impaimients; second, teaching compensatory intervention strategy when impairments fail or cease to improve; and third, the possibility of modifying certain environmental elements to circumvent deficits (17,18,56,57) The eognitive approaeh aimed at improving individuals' cognitive functions involves the use of specific exercises for expanding attentionai capacity or memory, for example, repeating selected exercises many times weekly while gradually increasing their level of difficulty. Various computer programs have been developed to provide this type of intervention. Although the impact of systematic eognitive training on targeted functions has been widely investigated, results remain inconsistent (58). Certain studies observed an improvement in eognitive functions following sustained training, but the capacity to generalize these gains was not established (17,20,22,59), Consequently, it is recommended that this form of cognitive training be used in conjunction with cognitive-behavioural interventions to maximize the learning of psyehosoeial skills and other requisites for employment (56). Certain programs begin by offering training geared to basic cognitive functions before presenting laboratory exercises

that allow panicipants to gradually learn problem-solving methods through role-playing. It is assumed that the improvement in eognitive deficits will allow the individual to more effectively integrate skills taught. This eombination of cognitive training and cognitive-behavioural methods seems to yield good results relative to personal functioning and integration at work (17,55,60). The compensatory methods taught subsequently take into aeeount specific eognitive deficits, fostering a higher awareness of deficits and the use of environmental aids such as memory joggers and electronic signals and alanns. These environmental methods are geared to foster the appearanee of desired behaviours (61-64). However, since none of these interventions have been demonstrated to be definitively beneficial, they are generally combined to meet the needs of eaeh individual and are used as a function of the person's response to the intervention (18). Despite advances in the development of less deleterious antipsychotics w ith clear cognitive benefits, the effect size of treatments' effectiveness is still overly small. Typical neuroieptics, sueh as haloperidol, have little impaet on a person's cognitive functioning, whereas atypical antipsychotics are now reeognized for their significant Impaet in this regard. Improvements noted at the cognitive level, following use of such atypical antipsychoties as risperidone, olanzapine, quetiapine. and elozapine, eould be linked to the mechanisms specific to this new generation ofdrugs (46), Aside from medication, eurrent research recommends combining a phannacologie approach with rehabilitation to obtain the greatest possible impaet on a person's cognitive and functional ability (51,65-67),

Smart Homes and Smart Objects These measures deploy a broad array of high technologies, ineluding smart sensors (physiological, actimetric, and environmental), smart clothes integrating fabrics and sensors, wire and wireless networks, home robotics and activators, distributed artificial intelligence, and ubiquitous computing (Table 1). The development and diffusion of these technologies have increased considerably over the past few years (1). However, maximum efficacy lies in combining eomplcmentary technologies to produce tools that provide new responses to medicosocial needs. Finally, all these technologies do not suffice in and of themselves; seldom can they be divorced from the notion of service. The services that are complementary or indispensable to the use of these technologies range from simple maintenanee to various teleserviees that help keep home-living, disabled persons in contaet with different types of interveners, such as home support workers, physicians, soeial workers, other persons with disabilities, and associations.

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