A VIRTUAL KITCHEN TO ASSESS THE ACTIVITIES OF

DAILY LIFE IN ALZHEIMER'S DISEASE

Paul Richard

, Lisa Massenot

, Jeremy Besnard

, Emmanuelle Richard

Didier Le Gall

2, 3

and Philippe Allain

2, 3

Laboratoire d'Ingénierie des Systèmes Automatisés (LISA - UPRES EA4094), Université d’Angers, France

Laboratoire de Psychologie (UPRES EA 2646), Université d’Angers, France

Unité de Neuropsychologie, Département de Neurologie, CHU Angers, France

Keywords: Virtual Reality, Virtual Kitchen, Neuropsychological Assessment, Alzheimer’s Disease.

Abstract: This paper presents the EVACOG project that aims to investigate the usefulness of Virtual Environments

(VEs) in cognitive assessment. Our objective is to evaluate the cognitive and/or behavioral abilities of

patients with brain lesions in scenarios implying the planning and the execution of everyday tasks such as

driving a car or preparing a cup of coffee. In this paper we describe a simple and effective VE (a kitchen)

designed to assess patient’s ability to prepare a cup of coffee. We focus on the assessment results obtained

with eight patients with Alzheimer’s disease which were compared to healthy elderly subjects. Participants

were instructed to prepare a cup of coffee in the virtual kitchen. Results revealed significant impairments in

patients with Alzheimer’s disease. Results of this study support the use the virtual kitchen to assess

everyday life activities among persons with Alzheimer’s disease.

1 INTRODUCTION

Lesions of the brain with cognitive and/or behavioral

neuropsychological deficits are one major problem

for patients, their family and the whole society. The

EVACOG project has the ambition to think of the

improvement of the strategies of cognitive diagnosis

and the comprehension of the deficits, among

patients carrying memory disorders and

neuropsychological deficiencies thanks to the use of

Virtual Reality (VR) technologies (Richard et al.,

2006). VR gathers techniques and technologies for

ultimate objective to immerse a human subject in a

Virtual Environment (VE) with which he/she will be

able to communicate via interaction techniques

based on its natural faculties of action, perception

and expression (Fuch et al., 2001; Burdea and

Coiffet, 2003). VEs can play an important role in

reducing the cognitive demands on health care

practitioners by helping them to manage, filter and

analyze multiple sources of information (Riva,

1998). Indeed, with VEs, all the experimental data is

fully controlled, which considerably limits error

making. Moreover, metrics can also be improved

and it becomes possible to analyze parameters

difficult to apprehend in "Paper-pencil" tasks. These

parameters such as latencies, hesitations, strategies,

etc. can be more easily recorded and even

"replayed". This lead to think that it is possible to

discriminate more subtle disorders by using VR

techniques compared to regular techniques. VR

offers many advantages which rest on the

immersive, dynamic, interactive and highly

expressive character of VEs (Riva, Mantovani and

Gaggioli, 2004). VR also authorizes the construction

of very concrete scenarios that allows to "virtually"

confront the brain injured patients with everyday life

situations like crossing a street, driving a car,

preparing a meal, using public transports, shopping,

etc. (Rizzo, 1994). Another advantage of VR lies in

the possibility of adjusting the difficulty level of the

sensorimotor or cognitive tasks simulated, according

to the severity and of the evolution (positive or

negative) of the difficulties of the brain injured

patients. The therapist can also confront the patients

to situations/environments adapted to their sensory

handicaps (hemianopsy), motor (hemiplegia) or

cognitive (syndrome of negligence).

The objective of our work is to evaluate the

cognitive and/or behavioral abilities of patients with

brain lesions in scenarios implying the planning and

the execution of everyday tasks such as driving a car

or preparing a cup of coffee. Experimental VEs

378

Richard P., Massenot L., Besnard J., Richard E., Le Gall D. and Allain P. (2010).

A VIRTUAL KITCHEN TO ASSESS THE ACTIVITIES OF DAILY LIFE IN ALZHEIMER’S DISEASE.

In Proceedings of the International Conference on Computer Graphics Theory and Applications, pages 378-383

DOI: 10.5220/0002867603780383

 SciTePress

designed within the framework of the EVACOG

project have been integrated in both a human-scale

immersive VR platform and a desk-top VR set-up.

These VEs are the following: a virtual “Tower of

London”, a virtual city, a virtual supermarket, and

some virtual kitchens. In this paper we present the

last virtual kitchen that allows the user to make a

cup of coffee and focus on the assessment results

obtained in patients with Alzheimer’s disease.

The remainder of the paper is organized as

follows: In section 2, we look at the related work.

Then, in section 3, the VIREPSE platform is

described together with some experimental VEs.

Section 4 is dedicated to the description of the

virtual kitchen and the interaction techniques. In

section 5, the experimental study is presented along

with the results analysis. The paper ends by a

conclusion and gives some tracks for future work.

2 RELATED WORK

VR techniques have been used in cognitive

neuropsychology for more than ten years. A

relatively exhaustive state of the art was carried out

by Rizzo et al. and Pugnetti et al. worked out a test

of VR taking again the problems of the evaluation of

the executive processes of generation of concept and

mental flexibility (Rizzo et al., 2004; Pugnetti et al.,

2004). Indeed, the Virtual Wisconsin test simulated

a building environment in which the subjects had to

make use of environmental cues to choose the doors

to be opened in order to evolve/move through the

structure. The choice of the doors to be opened

varied according to several criteria. As in the

"Paper-pencil" version, the criterion selection

making it possible to cross the doors was modified

after a predetermined number of successes. The user

was forced to adopt another strategy to go further

while seeking the relevant cues in the environment.

The virtual Wisconsin test was more often

overdrawn than the "Paper-pencil" version.

In a study by Brooks et al., a patient with

amnesia was trained in route finding around a

hospital rehabilitation unit using a detailed

computer-generated VE based on the real unit. Prior

to the training, she was unable to perform 10 simple

routes around the real unit, all involving locations

which she visited regularly. She was tested at

weekly intervals on these same 10 routes around the

real unit during the course of the study. Her first

course of training involved practising two of the 10

routes in the VE for 15 minutes each weekday. After

three weeks' training, she successfully performed

these two routes in the real unit and she retained her

knowledge of these routes for the remainder of the

study, despite not receiving any further training on

these routes. For her second course of training, two

more of the original 10 routes were chosen, one of

which she practised in the VE and one in the real

unit. Within two weeks, she had learned the route

practised in the VE, but not the route practised in the

real unit, and she also retained her knowledge of this

route (Brooks et al., 1999). More recently,

applications more particularly dedicated to the study

and the treatment of social phobia or behavioral

impairments were also successfully developed (Riva

et al., 2003; Klinger et al., 2006).

3 THE VIRTUAL KITCHEN

Our objective is to evaluate the cognitive and/or

behavioral abilities of patients with acquired brain

injuries in scenarios involving action planning

and/or problem solving and the execution of

everyday tasks. The virtual kitchen described in this

section allows the patients to prepare a cup of coffee

using a virtual coffee machine. Different interaction

techniques and kitchen configuration have been

implemented. All actions of the patient in the virtual

kitchen are recorded in real-time and are proposed to

the therapist in excel files for further analysis. These

actions include both the objects involved in the task

and the distractor objects that could not be moved

but can be selected.

3.1 Experimental Configurations

Four different configurations of the kitchen are

proposed: (1) a basic configuration (Fig. 1), (2) a

basic configuration with distractor objects (Fig. 2),

(3) a complex configuration (Fig. 3), and a complex

configuration with distractor objects (Fig. 4). In the

basic configuration, objects of interest are arranged

on the table from left to right in the order of use in

the task. In the basic configuration with distractors,

objects are also arranged in the order, but distractor

objects that are visually and/or semantically similar

to target objects (e.g., water pot, a box of chocolate,

etc.) are also placed on the table.

In the complex configuration, objects are put

away from each other (for example, the milk is

placed away from the cup). In the complex

configuration with distractor objects, interacting

objects are put away from each other and distractor

objects are displayed.

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379

Figure 1: Snapshot of the basic virtual kitchen

configuration: the virtual objects are arranged in the order

that they should be used.

Figure 2: Snapshot of the basic kitchen configuration with

distractor objects (chocolate boxe, fork, and bottle of

wine).

Figure 3: Snapshot of the complex configuration of the

kitchen: interacting virtual objects are put away from each

other.

Figure 4: Snapshot of the complex configuration of the

kitchen with additional distractor objects.

3.2 Interaction Techniques

In order to accomplish the task (to prepare a cup of

coffee), the users have to select and move some

virtual objects. To this aim two interaction

techniques have been developed. The first one is

based on the computer mouse, while the second uses

a data glove (http://www.5DT.com) along with a

Patriot

3D tracking device (http://www.polhemus-

corp.com). In the first interaction technique, the user

move the computer mouse in the horizontal plane

(real table) while in the second one, the user moves

his/her hand in the vertical plane. In both cases, the

user controls only the vertical and horizontal

position of the manipulated objects. The objects are

automatically rotated or moved in depth in order to

help the patient, to avoid sensory-motor coordination

difficulties, and to get rid of the depth perception

problem. Selection is done by putting the 2D cursor

on an object and by clicking of the left button (first

technique) or by closing the hand (second

technique).

4 EXPERIMENTAL STUDY

Everyday activities are familiar tasks that require

multiple cognitive processes, such as serial ordering

of tasks steps, object selection, and so on, to achieve

practical goals such as preparing a cup of coffee.

However, among individuals with brain damage or

disease, errors are frequent and may preclude

achievement of the task’s goal (Buxbaum, Schwartz

and Montgomery, 1998; Humphreys and Forde,

1998; Schwartz et al., 1998, 1999). Everyday action

errors are also a serious concern in dementia

(Giovannetti, Libon, Buxbaum and Schwartz, 2002).

In fact, everyday action impairment is one of the

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380

diagnostic criteria of Alzheimer’s disease and is

associated with numerous serious consequences.

The aim of this study was to examine the value of

the previously described virtual kitchen to detect

disturbances in activities of daily life in

Alzheilmer’s disease through the task of preparing a

cup of coffee with a coffee machine.

Figure 5: Subject performing the task in the more complex

configuration.

4.1 Task

Due to the reduced number of participants and to the

fact that patients with Alzheimer’s disease were

early in the course of the disease, we decided to use

the more complex condition (Fig. 4). Participants

were instructed to perform the following steps using

the virtual kitchen:

- Open the coffee machine drawer (1)

- Put the filter inside the machine (2)

- Put the coffee powder on the filter (3)

- Close the coffee machine drawer (4)

- Open the machine water recipient (5)

- Put some water in the coffee machine (6)

- Put the coffee recipient on the machine (7)

- Turn on the coffee machine (8)

- Wait until the coffee is done (9)

- Put the coffee in the cup (10)

- Put back the coffee recipient (11)

- Put a piece of sugar in the coffee cup (12)

- Put some milk in the coffee’s cup (13)

Sounds events were integrated in order to foster

the sense of presence in the VE when participants

were performing the task. A subject performing the

task is shown in Fig. 5.

4.2 Method

Sixteen subjects participated in the experiment.

Eight patients (5 females and

3 males) diagnosed

with probable or possible Alzheimer’s disease

(McKhann et al., 1984). Participants met the

following inclusion criteria: (a) Mini Mental Status

Exam (MMSE, Folstein, Folstein and McHugh,

1975) comprised between 20 and 26/30, (b) no

evidence of psychiatric or medical history (focal

lesions or cerebrovascular accidents, medication

damaging cognition and memory), (c) no vision

problems. The average age of the patients was 84.8

(+/- 4.4) years. Their average education level was

8.4 (+/ 1.8) years of study since the first grade. Their

mean MMSE score was 22.7 (+/-1.5). Eight healthy

elderly subjects (5 females and 3 males) without

previous medical or psychiatric disorders and

without visual problems were used as controls. Their

mean age was 78.5 (+/- 4.6) years. They have been

educated on average 10.1 (+/- 2.9) years since the

first grade. Their average MMSE score was 28.1 (+/-

1.3).

Figure 6: Snapshot of the virtual environment used to

familiarize the subjects with the computer mouse

(translation and stacking of three spheres on the blue

cube).

Before starting the task, participants were given

two training session. The first concerned the use of

the mouse. Participants

were asked to manipulate

objects with the movement

of the mouse. The

interactive training simulation is illustrated in Fig.6.

The second training session was designed to

familiarize the participants with the use of the virtual

coffee machine (Fig. 7a and 7b).

4.3 Data Collection

Task completion time was recorded for each patient

with Alzheimer’s disease and each control subject.

The number of errors made (that correspond to the

number of task steps uncompleted or competed with

sequencing problems) was also measured. These

A VIRTUAL KITCHEN TO ASSESS THE ACTIVITIES OF DAILY LIFE IN ALZHEIMER'S DISEASE

381

data were automatically recorded throughout the

experiment with all user action involving the virtual

object including the distractor ones).

(a)

(b)

Figure 7: Snapshot of the virtual environment used to

familiarize the subject with the use of the virtual coffee

machine: placing the filter in the machine (a), and placing

the pot (b).

4.4 Results

The analysis of completion time revealed a

significant difference between control subjects and

patients with Alzheimer’s disease (U=0.0, z = -3.36,

p = 0.0008). Indeed, patients take longer than control

subjects to perform the task (Tab. 1). Similarly, the

statistical study of errors committed revealed a

significant difference between the two groups

(U=6.0, z = -2.73, p = 0.006). The average number

of errors was higher in patients with Alzheimer’s

disease (Tab. 1). A qualitative analysis of the type of

errors made by control subjects and patients with

Alzheimer’s disease allowed highlighting that the

most common errors committed were the following:

not put the filter inside the machine, not close the

coffee machine drawer, not put the coffee recipient

on the machine before turning the coffee machine

and not put the coffee recipient on the machine. This

pattern of performance indicates that subjects mainly

committed omission errors. After the virtual

assessment, each subject was asked to answer a

questionnaire of presence to assess their sense of

immersion in the VE and to identify any

shortcomings in the use of the platform.

All participants have found congruence between

the objects, the sounds, the colours and the actions in

the virtual environment and real situations. All

subjects told us that using the mouse and the coffee

machine was difficult and that the training session

was important. Finally, no subjects experienced

problems of cybersickness.

Table 1: Mean (standard deviation) virtual test scores for

controls and patients with Alzheimer’s disease on the

virtual task.

Controls

Patients

Completion time (Sec.)

277.6

(std 41.4)

780.8

(std 104,8)

Number of errors

0.2

(std 0.4)

2.0

(std 1.2)

5 CONCLUSIONS AND

PERSPECTIVE

In this paper, we have presented the EVACOG

project that aims to contribute to the development of

evaluation tools for the assessment of cognitive

and/or behavioral dysfunctions resulting from

lesions of the central nervous system. We focused on

the virtual kitchen developed to investigate the

abilities of patients with Alzheimer’s disease to

prepare a cup of coffee with a coffee machine. This

preliminary work confirms that such a simple VE

allows detecting disturbances in activities of daily

living in Alzheimer’s disease. In future work, we

will add these few preliminary data with greater

groups of control subjects and patients with

Alzheimer's disease. We will confront our data with

those obtained from evaluating the same activities in

real context and from autonomy scales completed by

relatives of the patients in order to ensure the good

ecological value of the virtual coffee task. We will

also develop other spots in our virtual kitchen to

expand our studies of autonomy in everyday life

activities in patients with dementia or other

neuropsychological problems. Beyond these

prospects, we will study the way in which VEs are

perceived by the patients. Indeed, as "realistic" as

can be these environments, they are only

representations of the reality. Which relations the

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patients can build between these representations and

their daily environment? The development of the use

of VEs at ends of diagnosis or rehabilitation also

depends on the answers which one will be able to

bring to such questions (Le Gall and Allain, 2001;

Le Gall et al., 2008).

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