Margaret and Vernon Huffer’s home in the Willamette View retirement community in Portland, Oregon, is under observation. As they go about their daily activities, sensors on the walls, doorways, and appliances gather information about their movements, from how long it takes to walk down the hall to how much they move around the kitchen. Far from being characters in a spy novel though, the Huffers have volunteered to have their movements monitored as part of an innovative research project that could eventually help clinicians better detect early signs of Alzheimer’s disease (AD).
The project, led by scientists at the Oregon Center for Aging and Technology (ORCATECH), part of the Oregon Health & Science University (OHSU), is one of several initiatives funded by the National Institute on Aging (NIA) to explore the use of unobtrusive technology to help diagnose AD or improve care for people with dementia. Much of this research is conducted by or involves OHSU investigators. One initiative, the home-based cognitive assessment project, also involves researchers nationwide.
ORCATECH, a unique academic-industry-community collaboration involving companies such as Intel and SPRY Learning, as well as OHSU scientists and retirement communities, has been supported by NIA since 2004 as an Edward R. Roybal Center for Research on Applied Gerontology. In late 2006, NIA also awarded ORCATECH a 5-year, $7 million Bioengineering Research Partnership grant to study the use of “intelligent systems” to detect aging-related changes that may impair a person’s ability to live independently.
ORCATECH Director Jeffrey Kaye, M.D., explains that around-the-clock, in-home assessment might one day reveal possible signs of cognitive decline, such as changes in walking speed or dressing speed. This would allow clinicians to address emerging problems earlier in the disease process than they can today.
“The traditional model for studying cognitive change is to identify volunteers and follow them over time, using assessment batteries that are most often administered annually,” says Dr. Kaye, who also directs the Layton Aging and Alzheimer’s Disease Center at OHSU, one of the 29 Alzheimer’s Disease Centers supported by NIA. “Typically in our field, we bring people into a clinic once or twice a year, evaluate them, and then they go home. It can take years to map the trajectory of cognitive decline, and the testing is not done in people’s natural environments, so we’re not seeing individuals’ normal daily ups and downs.”
In contrast to this traditional approach, ORCATECH researchers are studying simple, off-the-shelf technology for continuous, “naturalistic,” in-home assessment of people’s activities, to detect subtle changes in movement that may indicate cognitive decline. Previous research has shown that motor-activity changes may arise before memory changes become apparent.
“We recognize that motor changes may be from other causes, but this research will help us understand the relationship between changes in daily activity and memory,” Dr. Kaye explains.
All of the 225 study volunteers, most of whom are 80 years or older or have an octogenarian spouse, live independently in Portland area retirement communities, and meet health and memory criteria. Wireless, infrared motion sensors like those that automatically open grocery store doors have been placed strategically throughout the volunteers’ homes to gather data about changes in their movement over time. Special software also has been installed on each volunteer’s home computer, provided by the project as needed, to capture data about his or her computer use. In addition, each volunteer will undergo standard, annual memory assessments and clinical exams for comparison.
The sensors and computer software collect data about motion, not about what the volunteer is doing. The volunteers are not directly observed, and no video or still photographs are taken, so privacy is largely not a concern.
“We’ve established a living laboratory of homes in the community. We’re using the sensors to study total activity around the home, how long it takes to do activities, where activity occurs, walking speed, and differences in nighttime versus daytime and weekend activity,” says Dr. Kaye.
The computer component measures psychomotor ability and speed in typing or using a mouse. “Once a volunteer is trained to use the computer to a certain level of proficiency, that person becomes his or her own control,” Dr. Kaye explains. “Even if the person is a hunt-and-peck typist, he or she has a usual working speed, and we can collect information about changes in speed over time.”
The 5-year study began in early 2007, so results are not yet available. However, a small pilot study using the same type of sensors showed a clear difference in the walking speeds of people age 65 and older who had mild cognitive impairment (MCI) compared with age-matched cognitively normal people, over time periods averaging 315 days.
“Even with this small sample, we found a consistent pattern—a greater variability in walking speed in the MCI group compared with the control group,” Dr. Kaye reports. “These results are encouraging. They speak to the sensitivity of the system in potentially differentiating groups when monitoring them remotely.”
“This intriguing research takes a fresh perspective on ways to identify early clues pointing to cognitive decline in people at high risk for AD,” says Richard Suzman, Ph.D., director of NIA’s Behavioral and Social Research Program, which has provided significant funding for ORCATECH. “Their research program also is distinctive in that it represents a true partnership of academia, business and industry, and local senior communities.”
Testing home-based cognitive assessment methods
In a related NIA-funded initiative, researchers at 26 academic research institutions nationwide are comparing the use of in-home computer “kiosk” technology with the use of an interactive voice-response system or mail-in questionnaires to assess thinking ability over time. This research, part of the NIA’s multi-center Alzheimer’s Disease Cooperative Study, (ADCS) will ascertain which of those three home-based methods is most efficient and sensitive in measuring cognitive change and how the methods compare with traditional, standardized, in-person assessments.
The investigators plan to apply what they learn to clinical trials studying primary prevention of AD. “Participants in primary prevention trials are those most at risk for dementia—the very elderly who often have physical, social, and health restrictions that make it difficult to participate in clinic-based assessments,” says the project’s principal investigator Mary Sano, Ph.D., director of the Mount Sinai Alzheimer’s Disease Research Center.
A total of 600 community-dwelling, cognitively healthy volunteers over age 75 will be randomly assigned to the three cognitive assessment methods and further randomized to be assessed annually, 3 times a year, or monthly over a 4-year period. All three methods gather the same data about several domains known to be important in early detection of cognitive decline:
- language skills,
- attention and concentration, activities of daily living,
- quality of life,
- health care and resource use, and
- changes in “global” well-being as measured by self-rating of health, cognition, and mood.
The stand-alone computer kiosk was developed by ORCATECH researchers at the OHSU Center for Spoken Language and Understanding. It combines a touch-screen computer monitor with a telephone handset. At designated times, the kiosk “wakes up” and a pre-recorded video of a friendly interviewer appears on the screen to walk the user through a series of questions, in a manner similar to that used during in-person assessment. The virtual interviewer cues the volunteer to answer a battery of questions by speaking into the telephone handset or touching the computer screen.
The second method, the inter-active voice-response system, prompts the volunteer to answer questions verbally using technology like that used to make airline or train reservations. The third method involves filling out and mailing in paper forms and completing a validated cognitive assessment by telephone.
“This research is looking at questions such as how likely people are to complete the questions by using each assessment method, which method is the most efficient, and how sensitive each method is,” says Dr. Sano.
“This project will provide evidence that we hope can be used to increase participation in trials and reduce the expense and burden of traditional, in-person assessment,” says Marcelle Morrison-Bogorad, Ph.D., director of NIA’s Neuroscience and Neuropsychology of Aging Program, which sponsors the ADCS.
Although the nationwide project only recently began, an earlier ADCS pilot study showed that the in-home computer kiosk is both usable and acceptable to older adults. “At first, there was a little bit of skepticism about installing the kiosk, and people were worried about the size of the kiosk when it was delivered in a large box,” Dr. Sano reflects. After it was installed and they learned to use the technology, however, the participants became enthusiastic and excited about the project.
Assessing change through medication compliance
NIA-funded researchers also are studying the use of a high-tech pill box called the MedTracker as a tool to measure cognitive change. The device, developed by ORCATECH researchers, is a typical daily pill dispenser mounted on wireless electronics that record the time of day the user opens one of the pill compartments and when the person refills the compartments.
“Medication taking is one of the most important instrumental activities of daily living, and lack of adherence to medication regimens is one of the main reasons people are admitted to nursing homes,” says Dr. Kaye. “Even a minor impairment in cognitive function can affect a person’s ability to adhere to a medication regimen.”
In a pilot project led by Tamara Hayes, Ph.D., assistant professor of biomedical engineering at OHSU, 38 octogenarians without MCI used the MedTracker pill box to dispense a low-dose vitamin C tablet twice a day at a time of their choosing.
“What they found was very interesting.” Dr. Kaye says. “When they looked at this normal group, those who scored on the lower end of normal functioning were only able to adhere correctly to the medication regimen 30 percent of the time, and the others adhered about 78 percent of the time.” The pilot study, he explains, demonstrated that even minor impairment in cognitive function can be detected and may affect a person’s ability to adhere to a regimen.
“We think this bodes well for the use of these kinds of unobtrusive devices to detect when important changes begin to occur,” Dr. Kaye says.
For more information
Oregon Center for Aging and Technology: www.orcatech.org 
Home-Based Assessment for Prevention of Alzheimer’s Disease Project: www.nia.nih.gov/alzheimers/clinical-trials 
To learn more
- Hayes TL, et al. An electronic pillbox for continuous monitoring of medication adherence. Proceedings of the 27th Annual International Conference of the IEEE Engineering In Medicine and Biology Society. Conf Proc IEEE Eng Med Biol Soc. 2006;1:6400-3.
- Hayes TL, Kaye J, Pavel M. A novel marker of mild cognitive impairment. Proceedings of the 10th International Conference on Alzheimer’s Disease and Related Disorders. Alzheimer’s & Dementia: The Journal of the Alzheimer’s Association. 2006;2(3):S302.
- Hayes TL, Pavel M, Kaye JA. Continuous health assessment using in-home sensors. Presented at the 2007 Festival of International Conferences on Caregiving, Disability, Aging, and Technology (www.ficcdat.ca ).
- Kaye J, et al. Deploying wide-scale in-home assessment technology. Presented at the 2007 Festival of International Conferences on Caregiving, Disability, Aging, and Technology (www.ficcdat.ca ).
- Pavel M, et al. Unobtrusive assessment of mobility. Proceedings of the 28th Annual International Conference of the IEEE Engineering In Medicine and Biology Society. Conf Proc IEEE Eng Med Biol Soc. 2006;1:6277-80.
From the ADEAR Center: Caregiver Guide: Tips for AD Caregivers. Copies may be ordered by calling the ADEAR Center at 1-800-438-4380.
From the NIA Information Center: So Far Away: Twenty Questions for Long-Distance Caregivers. Copies may be ordered by calling the NIA Information Center at 1-800-222-2225 or online from: www.nia.nih.gov/health .