 |
 |
|
|
|
The cognitive remediation and social reintegration (that is, deinstitutionalization) of patients with severe and persistent mental disorders present challenges that psychiatry has been trying to meet for many years. Nowadays, the unprecedented development in communication and information technologies has redefined the terms of these challenges. Recent studies have attested to the flexibility, effectiveness, and growing affordability of these technologies (1–3). This article 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 terms of means and safety (4,5). At the technical level, adapting these technologies to the conditions specific to schizophrenia poses a priori difficulties that depend on a creative interaction between psychiatrists and technologists. Solutions for disabled persons, with respect to care delivery, workload reduction, and socialization, have become extremely significant and diversified; these include home support video conferencing (6), remote monitoring of medical parameters through sensors (7), teledetection of such critical situations as a fall or malaise (8,9), measures of daily living activities (10,11), and help with daily living tasks (12). However, the introduction of new technologies in the patient– psychiatrist equation raises a series of questions concerning technical interest and feasibility, as well as ethical 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 social 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 for a conceptual shift in the field of psychiatry 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, inclined sidewalks, and wheelchair ramps) and transportation took place. Society must now undertake a similar review aimed at overcoming cognitive disabilities in schizophrenia. This can be achieved by equipping patients’ immediate environment with appropriate technology—the concept behind “smart homes.” We propose to examine the potential contributions new technologies can make in terms of environmental cognitive remediation specific to schizophrenia. We also briefly outline the corresponding socioethical 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.” SchizophreniaDeficits have been observed in individuals with schizophrenia 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 norms in one or more cognitive domains (14,15,18–29). 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 surveillance technologies could exacerbate symptoms. Additionally, schizophrenia patients present several deficits in executive functions and perform significantly worse than normal subjects on tests measuring daily living activities (with strong ecologic validity, such as cooking) (30,31). Course of Cognitive DeficitsFew studies found a gradual deterioration in cognitive functioning in schizophrenia (32,33). Most studies examining the relations among cognitive functions, 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 normal subjects. Similar results were found in longitudinal studies of chronic and first-episode patients (38–40). Further, a review including 15 studies failed to provide evidence that a cognitive deterioration was associated with the diagnosis of schizophrenia (36). It appears that cognitive impairments are relatively stable after disease onset. Impact of Cognitive Deficits on Psychosocial Functioning of Persons With SchizophreniaGreen’s metaanalysis of 16 studies was the first to establish a link between certain cognitive deficits and psychosocial functioning (41). Whereas explicit memory was associated with community integration, interpersonal problem solving, and acquisition of psychosocial skills, working memory was linked to the acquisition of psychosocial skills. Sustained attention was found to be specific to interpersonal problem solving. Green’s second metaanalysis, which included 37 studies, confirmed the previous observations (42). Cognitive deficits seem to predict 40% to 50% of the variance regarding the functioning of a person suffering from schizophrenia in the community (43,44). Accordingly, unemployment 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 functioning, whereas atypical or second-generation neuroleptics (such as risperidone, olanzapine, quetiapine, and clozapine) have a significant impact on cognition (46). The improvement observed at the cognitive level with the use of atypical antipsychotics may be linked to their mechanism of action. Psychosocial RehabilitationIn the field of mental health, it is wise to distinguish between treatment and rehabilitation. Mental health services have traditionally been geared toward the treatment of mental illness. This type of intervention seeks to alleviate or eliminate the symptoms associated 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, psychosocial rehabilitation aims at offering support to mentally ill persons, allowing them to live successfully and satisfactorily in an environment of their choice (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 psychosocial rehabilitation generally accept this definition, the models underlying the different programs offered vary considerably, as does the training of practitioners (51). Numerous programs have been developed under this banner, both in the community and in hospital settings. Initially, psychosocial rehabilitation involves the teaching of skills through psychoeducational 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, psychosocial 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 is then necessary to analyze the requirements of the 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, objects, 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 psychosocial rehabilitation. However, the heterogeneity of the services offered has made it difficult to compare studies with respect to psychosocial rehabilitation (51). Ecologic ValidityCognitive 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 functioning of persons with schizophrenia. However, the evaluation of this dimension in research remains problematic. 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 of the laboratory method, fail to grasp the concrete reality of patients’ daily lives. In addition, most of the research into patients’ QoL is conducted in relation to the long-term effects of treatment with a certain type of neuroleptic, without focusing more deeply on the different underlying aspects of daily dysfunctioning. 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 executive 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 uniformly in all patients presenting with a negative symptomatology is more likely to fail than identifying and compensating for cognitive difficulties that are discerned more specifically. That is, recognizing and measuring particular configurations of signs of frontal dysfunctioning would lead to a better individualization of treatment plans and a more precise evaluation of therapeutic progress. To compare the executive dysfunctioning 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 formal 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 (30,31). It is important not to lose sight of the fact that each symptom represents but one visible sign of an affliction that is never entirely observable and that a good neuropsychological 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 interaction 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 research to ensure the development of theoretical models that not only account for the experimental data but that also share a correspondence with the situations normally encountered by patients. Adopting an ecologic approach in the study of their cognitive deficits would make it easier to apply experimental results to clinical practice. Cognitive RehabilitationThe literature regarding cognitive rehabilitation distinguishes 3 types of interventions: first, interventions aimed at improving cognitive impairments; 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 cognitive approach aimed at improving individuals’ cognitive functions involves the use of specific exercises for expanding attentional 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 cognitive training on targeted functions has been widely investigated, results remain inconsistent (58). Certain studies observed an improvement in cognitive 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 psychosocial skills and other requisites for employment (56). Certain programs begin by offering training geared to basic cognitive functions before presenting laboratory exercises that allow participants to gradually learn problem-solving methods through role-playing. It is assumed that the improvement in cognitive deficits will allow the individual to more effectively integrate skills taught. This combination 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 account specific cognitive deficits, fostering a higher awareness of deficits and the use of environmental aids such as memory joggers and electronic signals and alarms. These environmental methods are geared to foster the appearance 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 each 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 with clear cognitive benefits, the effect size of treatments’ effectiveness is still overly small. Typical neuroleptics, such as haloperidol, have little impact on a person’s cognitive functioning, whereas atypical antipsychotics are now recognized for their significant impact in this regard. Improvements noted at the cognitive level, following use of such atypical antipsychotics as risperidone, olanzapine, quetiapine, and clozapine, could be linked to the mechanisms specific to this new generation of drugs (46). Aside from medication, current research recommends combining a pharmacologic approach with rehabilitation to obtain the greatest possible impact on a person’s cognitive and functional ability (51,65–67). Smart Homes and Smart ObjectsThese measures deploy a broad array of high technologies, including 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 complementary 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 maintenance to various teleservices that help keep home-living, disabled persons in contact with different types of interveners, such as home support workers, physicians, social workers, other persons with disabilities, and associations.
Background and State of the Art One of the recent technological responses to home support needs has taken the form of health-smart homes (1–3,12,68–74) and adapted smart objects, such as telephones (75). Related research has examined specific medical fields, such as respiratory medicine (asthma) (76), cardiology (7), and gerontology (77), or has sought a general model capable of being adapted to a wide variety of applications (78). Numerous scientific and technological projects in the area of home support for frail persons have been undertaken in France and elsewhere in the past 15 years. Recently there has been a noticeable surge in the number of smart home projects, which is no doubt related to the development of ubiquitous computing and smart objects. Begun in the 1980s, research into the interior design and outfitting of living environments with electronic, computerized, and robotic instruments has progressed considerably in the 1990s. Various model homes have been developed in the past decade for demonstration and research purposes. Figure 1 shows an example of a smart home floor plan. The first appeared in the early 1990s, when Celler and colleagues (79,80) tested whether it was possible to evaluate the functionality of seniors at home in a noninvasive manner using a network of sensors dispersed throughout the natural living environment and connected to a remote data processing centre. The Japanese, too, have been quick to appreciate the potential use of domotics technology, as evidenced in particular by 2 projects, namely, the Smart House in Tokushima (72) and the Welfare Techno House (WTH) in Tokyo (81). In Toulouse, France, the PROSAFE (Systems of Surveillance of Elderly Persons) project has sought to describe the nighttime activity of dependent elderly patients in their hospital rooms (82,83). Two other projects—the AID House (84) in Edinburgh, UK, and Smartbo (69) in Stockholm, Sweden—were geared toward the use of automatic devices to ensure the greatest autonomy possible for persons with disabilities or with restricted mobility (for example, the use of remote controls to open and close doors and curtains, to flush toilets, to switch lights on and off, and to adjust heating). Also, the Smart Model House (72) in Eindhoven, Netherlands, was designed according to 71 criteria set by the Dutch Senior Citizens Label system to ensure an optimal QoL at home. Figure 1 Model smart home
More recently, research projects have been undertaken in the field of medical robotics and artificial intelligence. These are aimed at developing systems for supporting tasks that have certain risks, such as forgetting a pot on a burner when one’s attention is distracted. Domotics automatically lights a room upon a user’s approach and allows for the remote control of “white goods” (that is, appliances) and “brown goods” (for example, televisions, videoplayers, doors, and windows). Robotics offers automated guides for the visually impaired, articulated arms for paraplegics (85), and tongue-activated switch systems (86). Finally, the existing domotics technology used to serve the needs of disabled persons or dependent seniors (for example, communication by videophone and voice-controlled telephone) can also be employed to keep persons in touch with their familial, medical, and social environments (see http://www.autonomic-expo.com/ and http://195.101.157.190/gerontexpo/pub/2003/). Functions A smart home can have numerous functions, depending on the medical and social ends they are meant to serve and the population being targeted, which can be extremely diverse (for example, at-risk pregnant women, heart patients, persons with asthma, dependent seniors, or schizophrenia patients). Moreover, although the term “living environment” essentially designates the home, it should be considered in its broader ecologic sense, which extends to the neighborhood and to the urban or rural area where persons circulate, conduct their business, and engage in activities. Generally speaking, these functions can be grouped into 4 major categories: data collection, data analysis, intervention, and evaluation. Data Collection Data collection concerns the gathering of 3 sorts of data: physiological and actimetric (that is, a person’s state of health), georeferential (that is, a person’s location), and environ-mental (that is, the state of a living environment). This data collection is performed by various means, including various sensors and, if need be, microphones and cameras in certain cases. Where schizophrenia patients are concerned, it would be useful also to gather electrophysiological data on their cognitive anomalies and brain activations. Certain sensors are currently being developed to this end. Presence detectors placed throughout the home can provide data on a person’s mobility and movements within and between rooms, to analyze their coherence. Data on abnormal movements, such as akathisia, agitation, and amotivation can be obtained through actimetric sensors (8). The incidence of deficit-related risks (for example, leaving a stove burner on and flooding a bathroom) can be evaluated by domotics systems consisting of sensors and switches fitted in household appliances. Data Analysis Data transmitted by sensors can be analyzed for the immediate purpose of detecting critical situations or for the longer-term purpose of understanding the pathology in question. There are several data-analysis techniques. Some seek to recognize preestablished sensor reading scenarios (for example, pollakiuria, insomnia, and constipation), while others profile the patient’s behaviour (that is, the normal state and deviations from the norm) with a view to gaining a better understanding of cognitive phenomena or to triggering an alarm in the event of a sharp deviation. Intervention The living environment can intervene to provide support with specific tasks, to prevent dangerous situations, to remind the person to take medication, and so on. With regard to cognitive remediation, devices must be user-friendly to compensate for memory or planning deficits and poor symptom management. Evaluation A smart living environment must make it possible to validate measures ecologically to account for daily functioning more accurately and to study the relation between functioning and cognitive performance. Evaluation is meant to validate or invalidate concepts and hypotheses underlying research programs. This evaluation covers various dimensions, the predominant ones being medical (that is, the impact of the support provided by technical devices on the patient’s rehabilitation), technological (that is, sturdiness, sensitivity, and specificity of devices), economic (that is, industrial feasibility of certain prototype devices and economic viability of new practices), and socioethical and legal (that is, the respect of privacy and of medical confidentiality and the legalization of innovative practices). LimitationsParanoid Delusions The distortion of reality is one of the syndromic dimensions of schizophrenia. This dimension can be responsible for paranoid ideation and psychosensorial phenomena such as hallucinations. This means that patients may already believe that hidden microphones and cameras are present in their immediate living environment for the purpose of influencing and persecuting them. Consequently, the technological devices installed in a smart home could easily fuel delusions and further undermine an already tenuous grip on reality. Notwithstanding the equipment’s virtues with respect to cognitive impairments, the risk exists that patients’ psychotic delusions may already contain elements of thought and behaviour control by an outside force. The big challenge here is to achieve a balance: to improve outside cognitive support without aggravating or inducing delusions. Ethics The development and application of the technologies described above raise several questions regarding respect for the dignity and privacy of disabled persons, their safety outside the hospital setting, and the quality of telemedical care. These issues concern us all as citizens and cobuilders of society. Because they specifically touch on our life and evolution, these questions, in our view, fall directly within the field of bioethics. Although they have already been the focus of extensive reflections regarding their general aspects (87–90), the application of these technologies to persons with persistent and severe mental disorders adds a specific dimension to the debate. On one hand, what are the anticipated risks, and how can they be taken into account at the conceptual stage of such an application? This question falls within the domain of normative ethics, the aim of which is to initiate a public debate on the potential risks and consequences of such an application and to lay ground for new laws, if need be. Conversely, what are the potential positive aspects of these new technologies? What practices do these technologies permit that were not possible before? What benefits can we expect for disabled persons and for their extended families? What social changes to our relation toward severe and persistent disabilities are at issue? These are some of the questions that proactive ethics must raise in the clearly asserted aim of making social gains. Regarding normative ethics, the types of problems raised are threefold: 1. Privacy: What do we make of privacy, a fundamental tenet of the universal declaration of human and civil rights? How do we ensure respect for privacy while monitoring a person’s physiological and activities of daily living data at a distance? Who will ensure proper practice in the area of telemedicine? 2. Responsibility: How will responsibility be shared when it extends beyond the traditional and clear-cut concept of medical responsibility as defined under the medical code of ethics? The patient is no longer treated solely by the medical corps, is not confined to the hospital, lives in a neighbourhood and in an apartment that he or she may leave and return to, just like anybody else. Thus the patient gains in sociality, which is the aim of deinstitutionalization; technologies are what make this possible. However, how much power do these technologies actually have? How much should we allow this return to social life to hinge on technology? What measures of support, what new services, and what new organization must be set up? 3. Dependence: Do we not risk creating a new dependence on technical devices that will regulate our lives in a manner yet difficult to fathom. How can we clearly identify and manage a dependence on new technical means that are often extremely complex and that can break down in a multitude of ways, however low the risk of this happening? What role must the human element play in this system? Needless to say, the technology will have to be maintained or serviced. Who will see to this? Will home support workers be called on to ensure that both the technological environment and the dependent person are functioning properly? In our culture, too much technology immediately evokes a nightmarish vision stigmatized by utterances such as the following: The touch pads and screens of artificial intelligence are called on at every turn to assist the physician; soon they will replace him. Disembodied and virtualized, the patient is fast becoming a database manageable at a distance. Under the guidance of the physician-data manager, the notion of the patient may be gone, making way for the user/manager-of-his-own-health. Welcome to the brave new world of medicine—a world of robots and computers (personal communication, V Rialle, April 2002). This negative vision is offset by a more humanist outlook, such as that proposed by Serres: “The sciences and the technical disciplines are simply following humanism by the book: You want to make man? Here’s how. And now, humanists, unveil your plan, for the time has come to execute it” (91, p 58) Temporary SolutionOne aim of this article is to bring forth a discussion involving colleague psychiatrists and ethicists regarding a complicated issue. It seems preferable in psychiatry to substitute the term “patient,” which is passive, to “user,” which is more active, suggesting one who can express his or her needs (92). Technological intrusion could be limited while the “presence” of the equipment is preserved, for example, by integrating it into the interior and exterior designs of building. Similarily, as much technological control as possible should be given to the user (for example, control of transmitted information and time of transmission, choice of disconnecting the system, and choice of using the camera, except in particular cases). In addition, the frequency and duration of interaction with technology can be considered. Finally, it is necessary to consider the rewards brought by the use of these technologies: access to complementary services and conselling, social contact, distant access to bookshops and other on-line shopping, banking services, and distant learning. Further, it is worth mentioning that today there exist specific standards for health technologies. The American congress in particular recommended such standards (93) in the US (94). The increasing use of advanced technologies should gradually erase reservations about them and thus allow them to become an element of everyday life like the telephone, television, and microwave. Another concern is the risk of overtechnicalization of health care and human involvement. A simple question can lead us in the right direction: What happens in the event of power failure, as experienced in Quebec in 1998? Will dependent schizophrenia patients in turn become dependent on electronics? Is one likely to create a dependence on technologies that is more serious than a dependence on other people? Deeper analysis has to be conducted and will be the topic of another research article on issues of individual freedoms, civil rights, personal autonomy, informed consent, confidentiality, and the ethics of reality shows. ConclusionThis article introduces the concept of the smart home and how it can be applied to remediation in schizophrenia. Another future objective is to illustrate that it could be a new way to collect data in a real-world environment. As we have seen, the complexity of digital technologies renders the matter of responsibility more complex. However, does the tool not merely extend the physician’s capacities and broaden medical resources? Above all, digital technology expands the capacities of society as a whole—in particular, the capacity to allow its more dependent members, such as schizophrenia patients, to lead a happier life. Funding and SupportThe University of Montreal Eli Lilly Schizophrenia Chair supported this work. AcknowledgementsWe thank the General Consulate of France in Quebec City (the French Ministry of Foreign Affairs) and the Conseil Régional Rhône-Alpes for their support in this research. We also thank Professor C Hervé (Director of the LEM, University Paris V), Dr P Rumeau (Hospital Center of Toulouse), Professor H Pigot, and Professor S Giroux (University of Sherbrooke) for their methodological advice References1. Haigh, KZ, Yanco HA. Automation as caregiver: a survey of issues and technologies. In: AAAI 2002 Workshop on Automation as Caregiver: The role of intelligent technology in elder care; Edmonton (AB). p 39–53. 2. Rialle V, DuchLne F, Noury N, Bajolle L, Demongeot J. Health ‘smart’ home: information technology for patients at home. Telemed J E Health 2002;8:395–409. 3. Tang P, Venables T. ‘Smart’ homes and telecare for independent living. J Telemed Telecare 2000;6:8–14. 4. Rialle V, Noury N, Bajolle L, Lamy JB, Virone G, DuchLne F, and others. Le concept d’Habitat Intelligent pour la Santé: considérations techniques et scientifiques pour un service médico-social. Revue de Gériatrie 2003;28:403–16. 5. Rialle V, Noury N, Demongeot J. L’habitat médicalisé de demain: premiers pas et résultats d’une étude prospective B Grenoble. In: Grant AM, Fortin JP, Mathieu L, editors. Actes des 9e Journées Francophones d’Informatique Médicale (JFIM). Sherbooke (QC): Soqibs; 2003. p 35–45. 6. Bernard MM , Fruhwirth M. Customized tele-health video conferencing systems for use by home bound seniors: four years of retrospect. E-Health 2002 Conference: Emerging Trends in Care Delivery and Technologies 2002. Available: http://www.pace2000.org/abstracts/e-HEALTH_1.html. Accessed 2005 March 10. 7. Roth A, Carthy Z, Benedek M. Telemedicine in emergency home care—the ‘Shahal’ experience. J Telemed Telecare 1997;3(Suppl 1):58–60. 8. Noury N. A smart sensor for the remote follow-up of activity and fall detection of the elderly. Proceedings of the IEEE-MMB 2002 May 2–4; NEw York: IEEE; 2002. p 314–7 9. Williams G, Doughty K, Bradley DA. A system approach to achieving CarerNet—an integrated and intelligent telecare system. IEEE Transaction on Information Technology in Biomedicine 1998;2:1–9. 10. Van Someren EJW. Actigraphic monitoring of movement and rest-activity rhythms in aging. IEEE Transaction on Rehabilitation Engineering 1997;5:394–8. 11. Virone G, Noury N, Demongeot J. A system for automatic measurement of circadian activity deviations in telemedicine. IEEE Transactions on Biomedical Engineering 2002;49:1463–9. 12. Giroux S, Pigot H, Mayers A, Lefebvre B, Rialle V, Noury N. Smart house for frail and cognitive impaired elders. First international workshop on ubiquitous computing for cognitive aids; 2002 Sept 29. Available: http://www.cs.washington.edu/homes/kautz/ubicog. Accessed 2005 March 10. 13. Mohamed S, Paulsen JS, O’Leary D, Arndt S, Andreason, N. Generalized cognitive deficits in schizophrenia. Arch Gen Psychiatry 1999;56:749–54. 14. Heinrichs RW, Zakzanis KK. Neurocognitive deficit in schizophrenia: a quantitative review of the evidence. Neuropsychology 1998;12:426–45. 15. Lussier I, Stip E. Memory and attention deficits in drug naive patients with schizophrenia. Schizophr Res 2001;48:45–55. 16. Palmer BW, Heaton RK, Paulsen JS, Kuck J, Braff D, Harris MJ. Is it possible to be schizophrenic yet neuropsychologically normal? Neuropsychology 1997;11:437–46. 17. Spaulding WD, Reed D, Sullivan M, Richardson C, Weiler M. Effects of cognitive treatment in psychiatric rehabilitation. Schizophr Bull 1999;25:657–76. 18. Wykes T, van der Gaag M. Is it time to develop a new cognitive therapy for psychosis-cognitive remediation therapy (CRT)? Clin Psychol Rev 2001;21:1227–56. 19. Stip E. Schizophrenia. In: Marquard-Botez T, editor. Clinical neuropsychology and behavioral neurology. Paris:Masson. Forthcoming. 20. Velligan DI, Bow-Thomas CC. Executive function in schizophrenia. Semin Clin Neuropsychiatry 1999;4(1):24–33. 21. Saykin AJ, Gur RC, Gur RE, Mozley DP. Neuropsychological function in schizophrenia: selective impairments in memory and learning. Arch Gen Psychiatry 1991;48:618–24. 22. Wykes T, Reeder C, Corner J, Williams C, Everitt, B. The effects of neurocognitive remediation on executive processing in patients with schizophrenia. Schizophr Bull 1999;25:291–307. 23. Woodward T, Whitman J, Arbuthnott K, Krageli T, Lyons J, Stip E. Visual search irregularities in schizophrenia depend on display size switching. Cognitive Neuropsychiatry 2005;10:137–52. 24. Lecours AR, Vanier-Clement M. Schizophasia and jargonaphasia. A comparative descrition with comments on Chaika’s and Fromkin’s respective looks at “schizophrenic” language. Brain Lang 1976;3:516–65. 25. Rossi A, Arduini L, Daneluzzo E, Bustini M, Prosperini P, Stratta P. Cognitive function in euthymic bipolar patients, stabilized schizophrenic patients, and healthy controls. J Psychiatr Res 2000;34:333–9. 26. Townsend LA, Malla AK, Norman RMG. Cognitive functioning in stabilized first-episode psychosis patients. Psychiatry Res 2001;104:119–31. 27. Gold S, Arndt S, Nopoulos P, O’Leary DS, Andreasen NC. Longitudinal study of cognitive function in forst-episode and recent-onset schizophrenia. Am J Psychiatry 1999;156:1342–8. 28. Gold JM, Harvey PD. Cognitive deficits in schizophrenia. Psychiatr Clin North Am 1993;16:295–312. 29. Katz N, Hartman-Maeir A. Occupational performance and metacognition. Can J Occup Ther 1997;64:53–62. 30. Semkovska M, Stip E, Godbout L, Paquet F, Bedard MA. Behavioral disorganization in schizophrenia during a daily activity: the kitchen behavioral scoring scale. Brain Cogn 2002;48:546–53. 31. Semkovska M, Bédard MA, Godbout L, Limoge F, Stip E. Assessment of executive dysfunction during activities of daily living in schizophrenia. Schizophre Res 2004;69:289–300. 32. Davidson M, Haroutunian V. Cognitive impairment in geriatric schizophrenic patients. In: Bloom FE, Kupfer D, editors. Psychopharmacology: the fourth generation of progress. New York: Raven Press Ltd; 1995. p 1447–549. 33. O’Donnell BF, Faux SF, McCarley RW, Kimble MO, Salisburry DF, Nestor PG, and others. Increased rate of P300 latency prolongation with age in schizophrenia. Arch Gen Psychiatry 1995;52:544–9. 34. Heaton RK, Gladsjo JA, Palmer BW, Kuck J, Marcotte TD, Jeste DV. Stability and course of neuropsychological deficits in schizophrenia. Arch Gen Psychiatry 2001;58:24–32. 35. Eyler Zorrila LT, Heaton RK, McAdams LA, Zisook S, Harris JM, Jeste DV. Cross-sectional study of older out patients with schizophrenia and healthy comparison subjects: no differences in age-related cognitive decline. Am J Psychiatry 2000;157:1324–6. 36. Rund BR. A review of longitudinal studies of cognitive functions in schizophrenia patients. Schizophr Bull 1998;24:425–35. 37. Sweeney JA, Haas GL, Keilp JG, Long M. Evaluation of the stability of neuropsychological functioning after acute episodes of schizophrenia: one-year follow-up study. Psychiatry Res 1991;38:63–76. 38. Nopoulos P, Flashman L, Flaum M, Arndt S, Andreasen N. Stability of cognitive functioning early in the course of schizophrenia. Schizophr Res 1994;14:29–37. 39. Hoff AL, Sakuma M, Wieneke M, Horon R, Krishner M, DeLisi LE. Longitudinal neuropsychological follow-up study of patients with first-episode schizophrenia. Am J Psychiatry 1999;156:1336–41. 40. Heaton R, Paulsen J, McAdams LA, Kuck J, Zisook S, Braff D, and others. Neuropsychological deficits in schizophrenia: relationship to age, chronicity, and dementia. Arch Gen Psychiatry 1994;51:469–76. 41. Green, MF. What are the functional consequences of neurocognitive deficits in schizophrenia? Am J Psychiatry 1996;153:321–9. 42. Green MF, Kern RS, Braff DL, Mintz J. Neurocognitive Deficits and functional outcome in schizophrenia: are we measuring the “right stuff”? Schizophr Bull 2000;26:119–36. 43. Velligan DI, Bow-Thomas CC, Mahurin RK, Miller AL, Halgunseth LC. Do specific neurocognitive deficits predict specific domains of community function in schizophrenia? J Nerv Ment Dis 2000;188:518–24. 44. Lecomte Y. The contribution of a modified transactional model to the adaptation of schizophrenics living in the city of Montreal. Schizophr Res 2005;72:279-81. 45. Mulkern VM, Manderscheid RW. Characteristics of community support program clients in 1980 and 1984. Hosp Community Psychiatry 1989;40:165–72. 46. Stip E, Chouinard S, Boulay LJ. On the trail of a cognitive enhancer for the treatment of schizophrenia. Prog Neuropsychopharmacol Biol Psychiatry 2005;29(2):219–32. 47. Vallée C. La réadaptation psycho-sociale et ses impacts cliniques sur la pratique de l’ergothérapie. Revue Québécoise d’Ergothérapie 1997;6(3):114–9. 48. Anthony WA, Cohen M, Farkas M. Psychiatric rehabilitation. Boston: Center for Psychiatric Rehabilitation; 1990. 49. Anthony WA. Integrating psychiatric rehabilitation into managed care. Psychiatr Rehabil J 1996;20(2):39–44. 50. Anthony WA, Liberman RP. The practice of psychiatric rehabilitation: historical, conceptual, and research base. Schizophr Bull 1986;2:542–59. 51. Bond GR, Meyer PS. The role of medications in the employment of people with schizophrenia. J Rehabil 1999;64(4):9–16. 52. Liberman RP, Mueser KT, Wallace CJ, Jacobs HE, Eckman T, Massel HK. Training skills in the psychiatrically disabled: learning coping and competence. Schizophr Bull 1986;12:631–47. 53. Corrigan PW, Basit A. Generalization of social skills training for persons with severe mental illness. Cognitive and Behavioral Practice 1997;4:191–206. 54. Vallée C. Journée de formation sur l’approche de la réadaptation psychosociale. Organisés par le Service d’ergothérapie du CHUM. Montreal (QC): Organisés par le Service d’ergothérapie du CHUM; 2001. 55. Liberman RP, Green MF. whither cognitive-behavioral therapy for schizophrenia? Schizophr Bull 1992;18(1):27–35. 56. Twamley EW, Jeste DV, Bellack AS. A review of cognitive training in schizophrenia. Schizophr Bull 2003;29:359–82. 57. Bellack AS, Gold J, Buchanan RW. Cognitive rehabilitation for schizophrenia: problems, prospects, and strategies. Schizophre Bull 1999;25:257–74. 58. Suslow T, Schonauer K, Arolt V. Attention training in the cognitive rehabilitation of schizophrenic patients: a review of efficacy studies. Acta Psychiatr Scand 2001;103:15–23. 59. Jaeger J, Douglas E. Neuropsychiatric rehabilitation for persistent mental illness. Psychiatr Q 1992;63:71–94. 60. Roder V, Zorn P, Müller D, Brenner HD. Improving recreational, residential and vocational outcomes for patients with schizophrenia. Psychiatr Ser 2001;52:1439–41. 61. Cook JA, Razzano L. Vocational rehabilitation for persons with schizophrenia: recent research and implications for practice. Schizophr Bull 2000;26:87–103. 62. Velligan DI, Bow-Thomas CC. Two case studies of cognitive adaptation training for outpatients with schizophrenia. Psychiatr Serv 2000;51:25–9. 63. Velligan DI, Bow-Thomas CC, Huntzinger C, Ritch J, Ledbetter N, Prihoda TJ, and others. Randomized controlled trial of the use of compensatory strategies to enhance adaptive functioning in outpatients with schizophrenia. Am J Psychiatry 2000;157:1317–23. 64. Katz N, Hadas N. Cognitive rehabilitation: occupational therapy models for intervention in psychiatry. Psychiatr Rehabil J 1995;19(2):29–36. 65. Noordsy DL, O’Keefe C. Effectiveness of combining atypical antipsychotics and psychosocial rehabilitation in a community mental health center setting. J Clin Psychiatry 1999;60(Suppl 19):47–53. 66. Green MF, Nuechterlein KH. Should schizophrenia be treated as a neurocognitive disorder? Schizophr Bull 1999;25:309–18. 67. Mojtabai R, Nicholson RA, Carpenter BN. Role of psychosocial treatments in management of schizophrenia: a meta-analytic review of controlled outcome studies. Schizophr Bull 1998;24;569–87. 68. Chan M, Hariton C, Ringeard P, Campo E. Smart home automation system for the elderly and the disabled. IEEE International Conference on Systems, Man, and Cybernetics; 1995 Oct 22–25; Vancouver. New York: IEEE; 1995. p 1586–9. 69. Elger G, Furugren B. “SmartBo”—an ICT and computer-based demonstration home for disabled people. Proceedings of the 3rd TIDE Congress: Technology for Inclusive Design and Equality Improving the Quality of Life for the European Citizen; 1998 June 23–25; Helsinki (Finland). Available: http://www.stakes.fi/tidecong/content.html. Accessed 2005 March 10. 70. Mynatt ED, Rogers WA. Developing technology to support the functional independence of older adults. Aging International 2002;27:24–41. 71. Noury N, Virone G, Barralon P, Yé J, Rialle V, Demongeot J. New trends in Health Smart Homes. Paper presented at the Healthcom Workshop; 2003 June 6–7; Santa Monica (CA). 72. Sueda O, Ide M, Honma A, Yamagushi M. Smart House in Tokushima. 5th European Conference for the Advancement of Assistive Technology; 1999 Nov 1–4; Dusseldorf (Germany). 73. Van Berlo A. A “smart” model house as research and demonstration tool for telematics development. Paper presented at the Proceeding of 3rd TIDE Congress: Technology for Inclusive Design and Equality Improving the Quality of Life for the European Citizen; 1998 June 23–25; Helsinki (Finland). Available: http://www.stakes.fi/tidecong/content.html. Accessed 2005 March 10. 74. Wild C, Kirshner A. Safety-alarm systems, technical aids and smart homes. Knegsel (The Netherlands): Akontes Publishing; 1994. 75. Mann W, Helal S. Smart phones for the elders: boosting the intelligence of smart homes. automation as caregiver: a survey of issues and technologies. Edmonton (AB): AAAI Press; 2002. p 74–9. 76. Finkelstein J, O’Connor G, Friedman RH. Development and implementation of the home asthma telemonitoring (HAT) system to facilitate asthma self-care. MEDINFO, London: IOS Press; 2001. 77. Chan M, Bocquet H, Campo E, Val T, EstPve D, Pous J. Multisensor system and artificial intelligence in housing for the elderly and the disabled. Proceedings of the 2nd International Conference on Gerontotechnology, a sustainable investment in the future; 1998 Oct 15–17; Helsinki (Finland): IOS Press; 1998. p 148–9. 78. Williams G, Doughty K, Bradley DA. A system approach to achieving CarerNet—an integrated and intelligent telecare system. IEEE transaction on information technology in biomedicine 1998;2:1–9. 79. Celler BG, Hesketh T, Earnshaw W, Ilsar E. Remote monitoring of the elderly at home: preliminary results of a pilot project at the University of New South Wales. Biomedical Engineering, Applications, Basis and Communications 1997;9:134–40. 80. Celler BG, Hesketh T, Earnshaw W, Ilsar E. An instrumentation system for the remote monitoring of changes in functional health status of the elderly at home. Proceedings of the 16th Annual International Conference IEEE Engineering in Medicine and Biology Society; 1994 Nov 3–6; Baltimore (MD). 81. Suzuki R, Ogawa M, Tobimatsu Y, Iwaya T. Time-course action analysis of daily life investigations in the welfare techno house in Mizusawa. Telemed J E-Health, 2001;7:249–59. 82. Chan M, Campo E, Laval E, Esteve D. Validation of a remote monitoring system for the elderly: application to mobility measurements. Technol Health Care 2002;10:391–9. 83. Steenkeste F, Bocquet H, Chan M, Campo E. La mise en place d’une technologie pour observer le comportement nocturne des personnes âgées en institution. ITBM-RBM 2001;22(1):25–30. 84. Bonner SG. Assisted interactive dwelling HOUSE. Proceedings of the 3rd TIDE Congress: Technology for Inclusive Design and Equality Improving the Quality of Life for the European Citizen; 1998 June 23–25. Available: http://www.stakes.fi/tidecong.content.html. Accessed 2005 March 10. 85. Mokhtari M, Didi N, Grandjean B, Roby-Brami A, Laffont I. Man/Machine interaction when using an arm robot by people with disability. Paper presented at the Technology for Inclusive Design and Equality Improving the Quality of Life for the European Citizen Proceedings of the 3rd TIDE Congress; 1998 June 23–25. Available: http://www.stakes.fi/tidecong/content.html. Accessed 2005 March 10. 86. Noualhat L. La langue du médecin, guide de la chirurgie de demain. Libération 003;18:20. 87. Rialle V. La santé par des capteurs au domicile: entre “meilleur des mondes” et opportunités de solidarités nouvelles: réflexions pour une éthique des technologies médicales au domicile du patient. Cahiers du groupe Sujet, Théorie et Praxis, Paris: Maison des Sciences de l’Homme; 2002. Available: http://www.lutecium.fr/stp/meilleur.html. Accessed 2005 March 10. 88. Rialle V. Introduction B quelques questions d’ordre éthique concernant la télé-surveillance médicale au domicile de la personne. In: Hervé C, et al., editors. Éthique médicale, bioéthique et normativité. Paris: Edition Dalloz; 2003. p 59–81. 89. Bjorneby S, Van Berlo A, (editors). Ethical Issues in Use of Technology for Dementia Care. Knegsel: Akontes Publishing; 1997. 90. Rialle V, Rumeau P, Hervé C. Éléments pour une méthodologie d’analyse éthique des technologies d’aide au maintien B domicile de personnes en perte d’autonomie. In:. Agostinelli, editor. L’éthique des situations de communication numérique. Paris: SL’Harmattan; 2005. Forthcoming. 91. Serres M. Hominescence. Paris: Le Pommier; 2001. p 58. 92. Fisk MJ. Telecare equipment in the home. Issues of intrusiveness and control. J Telemed Telecare 1997;3(Suppl 1):30–2. 93. Ofice of Technology Assessment. Identifying health technologies that work: searching for evidence. Washington (DC): US Government Printing Office; 1994. 94. Kane RL. Medicine in cyberspace [editorial]; J Am Geriatr Soc 1996;44:1477–8. Author(s)Manuscript received May 2004, revised, and accepted August 2004. 1. Eli Lilly Chair of Schizophrenia Research, Centre de Recherche Fernand Seguin, Hôpital Louis-H Lafontaine, Hôpital Sacre Cœur, Université de Montréal, Montreal, Quebec. 2. Senior Lecturer Laboratoire TIMC-IMAG UMR CNRS 5525, Grenoble, and Laboratoire d’Ethique Médicale, Université Paris V, France. Address for correspondence: Dr E Stip, Université de Montréal, Centre de recherche Fernand Seguin, Hôpital Louis-H Lafontaine, 7331, rue Hochelaga, Montreal QC H1N 3V2 e-mail: emmanuel.stip@umontreal.ca
1 | 2
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||