Brain Computer Interfaces for Improving the Quality of Life of ...

Brain computer interface (BCI) technology is now being incorporated into the treatment of many patients suffering from cognitive or physical ... Articles IoanOpris UniversityofMiami,UnitedStates ChristophGuger g.tecmedicalengineeringGmbH,Austria YuZhang LehighUniversity,UnitedStates Theeditorandreviewers'affiliationsarethelatestprovidedontheirLoopresearchprofilesandmaynotreflecttheirsituationatthetimeofreview. Abstract Introduction Methods HowCanBCIApplicationsImprovetheQualityofElderlyLiving? Conclusion AuthorContributions Funding ConflictofInterest Footnotes References SuggestaResearchTopic> DownloadArticle DownloadPDF ReadCube EPUB XML(NLM) Supplementary Material Exportcitation EndNote ReferenceManager SimpleTEXTfile BibTex totalviews ViewArticleImpact SuggestaResearchTopic> SHAREON OpenSupplementalData MINIREVIEWarticle Front.Neurosci.,30June2020 |https://doi.org/10.3389/fnins.2020.00692 BrainComputerInterfacesforImprovingtheQualityofLifeofOlderAdultsandElderlyPatients AbdelkaderNasreddineBelkacem1*,NurainiJamil2,JasonA.Palmer3,SofiaOuhbi2andChaoChen4 1DepartmentofComputerandNetworkEngineering,CollegeofInformationTechnology,UnitedArabEmiratesUniversity,AlAin,UnitedArabEmirates 2DepartmentofComputerScienceandSoftwareEngineering,CollegeofInformationTechnology,UnitedArabEmiratesUniversity,AlAin,UnitedArabEmirates 3DepartmentofNeurologicalDiagnosisandRestoration,OsakaUniversity,Suita,Japan 4KeyLaboratoryofComplexSystemControlTheoryandApplication,TianjinUniversityofTechnology,Tianjin,China Allpeopleexperienceaging,andtherelatedphysicalandhealthchanges,includingchangesinmemoryandbrainfunction.Thesechangesmaybecomedebilitatingleadingtoanincreaseindependenceaspeoplegetolder.Manyexternalaidsandtoolshavebeendevelopedtoallowolderadultsandelderlypatientstocontinuetolivenormalandcomfortablelives.Thismini-reviewdescribessomeoftherecentstudiesoncognitivedeclineandmotorcontrolimpairmentwiththegoalofadvancingnon-invasivebraincomputerinterface(BCI)technologiestoimprovehealthandwellnessofolderadultsandelderlypatients.First,wedescribethestateoftheartincognitiveprostheticsforpsychiatricdiseases.Then,wedescribethestateoftheartofpossibleassistiveBCIapplicationsforcontrollinganexoskeleton,awheelchairandsmarthomeforelderlypeoplewithmotorcontrolimpairments.Thebasicage-relatedbrainandbodychanges,theeffectsofageoncognitiveandmotorabilities,andseveralBCIparadigmswithtypicaltasksandoutcomesarethoroughlydescribed.WealsodiscusslikelyfuturetrendsandtechnologiestoassisthealthyolderadultsandelderlypatientsusinginnovativeBCIapplicationswithminimaltechnicaloversight. Introduction Aginghasitseffectsonhumanbodyandbrain,especiallyinthemolecules,cells,vasculature,grossmorphology,andcognition.Thisbiologicalagingbecomesdisabilityanddependenceastimegoesby.Manyresearchershavebeensuggestingtransdisciplinaryapproachestoaddresstheproblemofaginganditseffectsonactivitiesofdailyliving.Healthyolderadultsandelderlypatientsmayhavedifficultiesincommunicating,concentrating,memorizing,talking,walking,ormaintainingbalance.Thesedeficitsmayleadtoinabilitytocommunicatewiththeirfamily,climbstairs,memorizenewinformation,ordrivesafely.Theagingprocessdoesnotaffectpeopleuniformly,butmostelderlyneedtouseassistivetechnologiestobetterperformdaily-lifeactivitiesifonlytheneedforhandrailsorcanestogetupsteps.Unfortunately,theydonotreceivethesupporttheyneed,becausethecostofcaringforthemrunsintothebillionsofdollars.Braincomputerinterface(BCI)technologyisnowbeingincorporatedintothetreatmentofmanypatientssufferingfromcognitiveorphysicalimpairments.Thistechnologyoffersthepromiseofgreatlyenhancingthesepatients’qualityoflifebyconsiderablyimprovingtheirpersonalautonomyandmobility.BCIcanbeusedasanassistive,adaptive,andrehabilitativetechnologytomonitorthebrainactivityandtranslatespecificsignalfeaturesthatreflecttheelderly’sintentintocommandsthatoperateanydevice.BCIsystemscouldbeusefulforelderlypeopleinmanywayssuchas:(1)trainingtheirmotor/cognitiveabilitiesforpreventingtheagingeffects,(2)controllinghomeappliances,(3)communicatingwithothersduringdailyactivities,and(4)controllinganexoskeletontoenhancethestrengthofthebody’sjoints.Thepurposeofthismini-reviewistosurveysomeexampleswhereBCIscanbefeasibleandusefulmedicalandnon-medicalapplicationsforhealthyolderadultsandelderlypatientsusingnon-invasivemeasurementssuchaselectroencephalogram(EEG)toimprovetheirqualityoflife. Thetopicisintroducedfurtherinthefollowingsubsections.Insubsection“Age-relatedChanges,”age-relatedbrainandbodychangesarereviewed.Insubsection“Braincomputerinterfacetechnology,”theprincipleandparadigmofseveraltypesofBCIarereviewed.Insubsection“Agingandcognitiveabilities,”theimpactofagingoncognitiveabilitiesisdiscussed.Finally,commonhealthconditionsassociatedwithagingsuchasmotorcontrolimpairmentsaregiveninsubsection“Agingandmotorcontrolimpairments.” Age-RelatedChanges Humandevelopmentencompassesmultiplephases,includingbaby,toddler,teenager,adult,andoldage.Throughouttheagingprocess,someofthemostprofoundchangesinvolvebraincognition.Cognitionisanessentialaspectofhumaninformationprocessing.Accordingtosocialdevelopmentperspectives,aperson’sbrainwillbegintodeclinegraduallyastheindividualreachesmiddleadulthoodandwillcontinuetodeclinethroughouttheagingprocess(Peters,2006).Recallingmemoriesandlearningnewskillsbecomemoredifficultandcantakealongertime.Bothdeclarativememoryandproceduralmemorycanbeaffected.Liferoutinesstoredindeclarativememorywillslowlychangeandbeforgottenduetoaging.ThiscanbemostpronouncedinAlzheimer’sdisease.Deteriorationinproceduralmemorycanmakeitverydifficulttolearnnewskillssuchasanewlanguage(Quametal.,2018).Lifestylechangesasaresultoftheagingprocesswilloftenaffectbothelderlypersonsandtheirfamilymembers.Healthyelderlypeopleoftenreportadeclineinmemorythatcausesthemtoexperiencedepressionandanxiety(Hertzogetal.,2000).Aspeopleage,theymayalsohavedifficultypayingattentiontomultipletasks.Forexample,atatrafficlight,theprocessingoftheinformationaboutthelightchangingcandistractfromprocessingofothersurroundings,andthuscanleadtoroadaccidents. Additionally,thebrainparenchymawillshrinkandchangealongwiththeadjustmentincognitiveability.Brainshrinkageappearsespeciallysignificantinmedialtemporallobestructuresandtertiaryassociationcortices(i.e.,regionsthatareparticularlyimportantforsupportofage-sensitivecognitivefunctions).Incontrast,sensorycorticalregions(i.e.,thevisualcortex)evidencelesserage-relatedchange(Perssonetal.,2016).Thisshrinkingwillaffectmemoryandmentalsharpness.Whenapersongetsolder,thebrainshrinksnaturally.Changesinthebrainstructurecanreducethecommunicationbetweenneuronsinsomepartsofthebrain.Bloodflowtothebrainwillalsodecrease.Changesmayalsotakeplaceintheneurotransmittersystem,whichcancausedepressionandothermooddisorders(Nutt,2008). Ashumansage,theriskfactorsforbraindiseasessuchasAlzheimer’s,dementia,heartattack,depression,andobesityincrease.Allofthesediseasescancontributetodamagetobrainstructureanddecreasedbrainfunction(UylingsandDeBrabander,2002),leadingtoreducedcognitiveandmemoryfunction.Theseprogressionscaninfluencethecapacitytoencodenewdataintomemoryandretrievedataalreadyinmemory.Healthylifestyle,includingphysical,andmentalexercise,mightbeoneofthewaystopreventchanges. Agingaffectsmorethanjustthebrain.Musclescommonlystarttolosethefunctionandbecomeslowandweak(sarcopenia;Ryalletal.,2008).Strengthgraduallydecreases(frailty)andcontributestowardthelimitationofphysicalactivitysuchasrunning,hikingandgeneralsocialwellbeing(Friedetal.,2001).Furthermore,neurodegenerativediseasesasParkinson’sbecomeariskforpeopleoverage60.Themotorsystemaffectedbythedegenerativeimpairmentofthecentralnervoussystemcancauselimbtremor,posturalinstabilityandstiffness(Willis,2013).PhysicalconditioningandtheuseofadvancedtechnologiessuchasBCItoassistmobilityandperformanceoffinemotorcontrolcangreatlyimprovethequalityoflifefortheelderly. BrainComputerInterfaceTechnology Braincomputerinterfaceisoneofthemostpromisingandincreasinglypopulartechnologiesforassistingandimprovingcommunication/controlformotorparalysis(e.g.,paraplegiaorquadriplegia)duetostroke,spinalcordinjury,cerebralpalsy,andamyotrophiclateralsclerosis(ALS).Eye-trackingtechnologyalsoallowsparalyzedpeopletocontrolexternaldevicesbutithasmanydrawbacksduetothewayofmeasuringtheeyemovementsviacamerasorusingattachedelectrodeonfacesuchaselectrooculography(EOG)signals.BCIessentiallyinvolvestranslatinghumanbrainactivityintoexternalactionbysendingneuralcommandstoexternaldevices(Belkacemetal.,2015a,2018;Gaoetal.,2017;Chenetal.,2020;Shaoetal.,2020).Although,themostcommonuseofBCIistohelpdisabledpeoplewithdisordersinthemotorsystem,itmightbeveryusefultoolforimprovingthequalityoflifeofhealthypeople,particularlytheelderly.Assistive,adaptive,andrehabilitativeBCIapplicationsforolderadultsandelderlypatientsshouldbedevelopedtoassistwiththeirdomesticchores,enhancerelationshipswiththeirfamiliesandimprovetheircognitiveandmotorabilities.BCItechnologyhasclinicalandnon-clinicalapplicationsinmanyareas,includingmedicine,entertainment,education,andpsychologytosolvemanyhealthissuessuchascognitivedeficits,slownessinprocessingspeed,impairedmemoryandmovementcapabilitydeclineamongelderlypeople.Theseissuescanaffectthequalityofelderlylifeandmayhaveadverseeffectsonmentalhealth.Tohelpolderpeoplemaintainahealthy,goodqualityoflifeandsenseofwellbeing,manyBCIapplicationshavebeendevelopedinthepastdecade. TherearetwotypesofBCIbasedontheelectrodesusedformeasuringthebrainactivity:non-invasiveBCIwheretheelectrodesareplacedonthescalp(e.g.,EEGbasedBCI),andinvasiveBraincomputerinterfacewheretheelectrodesaredirectlyattachedonhumanbrain[e.g.,BCIbasedonelectrocorticography(ECoG),orintracranialelectroencephalography(iEEG)]. BraincomputerinterfacesusingEEGtechnologyhavebeenwidelyusedtoestablishportablesynchronousandasynchronouscontrolandcommunication.Non-invasiveEEG-basedBCIscanbeclassifiedas“evoked”or“spontaneous.”AnevokedBCIexploitsastrongcharacteristicoftheEEG,theso-calledevokedpotential,whichreflectstheimmediateautomaticresponsesofthebraintosomeexternalstimuli.SpontaneousBCIsarebasedontheanalysisofEEGphenomenaassociatedwithvariousaspectsofbrainfunctionrelatedtomentaltaskscarriedoutbytheBCIuserattheirownwill.TheseBCIshavebeendevelopedbasedonsomebrainfeaturessuchasevokedpotentials[e.g.,P300andsteady-statevisualevokedpotential(SSVEP)]orbasedonslowpotentialshiftsandvariationsofrhythmicactivity[e.g.,motorimagery(MI)]. TobuildaBCIsystem,fiveorsixcomponentsaregenerallyneeded:signalacquisitionduringaspecificexperimentalparadigm,preprocessing,featureextraction(e.g.,P300amplitude,SSVEP,oralpha/betabands),classification(detection),translationoftheclassificationresulttocommands(BCIapplications),anduserfeedback.Forquickandaccurateprocessingandanalysisofbraindata,researchershavedevelopedmanyopensourcesoftwarepackagesandtoolboxessuchasBCI20001,EEGLab2,FieldTrip3,andBrainstorm4.Thesesoftwarepackagesarebasedonadvancedsignalandimageprocessingmethodsandartificialintelligenceprogramsforperformingsensororsourcelevelanalyses(Belkacemetal.,2015b,2020;Dongetal.,2017). However,manycriticalissuesarefacedinthedevelopmentofaready-to-useBCIproduct.Thesecriticalissuesincludelowclassificationaccuracy,smallnumberofdegreesoffreedom,andlongtrainingtimetolearnhowtoperfectlyoperateaBCI.Therefore,researchershavebeentryingtoimprovetheperformanceoftheexistingBCIsbydevelopingahybridBCI(hBCI)thatcombinesatleasttwoBCImodalities(e.g.,P300withSSVEPorP300withMI).ThehBCIcombinesdifferentapproachestoutilizetheadvantagesofmultipleBCImodalities.Itcanbealsoacombinationofbrainactivitywithnon-brainactivity,andvariousotherpsychologicalsignalswereshowntobeapromisingoptionofhBCIdevelopment(Schereretal.,2007;Choietal.,2016).Thus,theinputsignalscanconsistofthecombinationoftwobraincharacteristicsusingEEGsignals,orEEGwitheyemovements(EOG),muscleactivity(electromyography,EMG),orwithheartsignal(ECGorEKG).However,P300-basedBCIs(e.g.,avisual/auditory/tactileP300Speller)arethemostpopularBCIsystemsduetotheirhighclassificationaccuracyandspeed,orinformationtransferrate(ITR). Inaddition,aclosed-loopBCIsystemusingvisualandproprioceptivefeedbackwithreal-timemodulationandcommunicationcanbeusednotonlyforinteractingwiththeexternalenvironment,butalsoasabiofeedbackplatformtoenhancethecognitiveabilitiesofelderlypatientsandprovidebettertherapeuticeffects.Thisclosed-loopinteractionbetweentheparticipant’sbrainresponsesandthestimuliisthoughttoinducecerebralplasticityandtherebyfacilitaterehabilitation. OneofthegreatestchallengesinBCItechnologyisthedevelopmentoflessinvasiveornon-invasivetechnologiesforparalyzedpatients.Usingnon-invasivedevicescangreatlyreducetheboththetotalcostofsurgicaloperationandthephysicalharmtothepatient.However,non-invasivemethodscanleadtoweakersignalsandalowsignal-to-noiseratio(SNR)withlesssourceprecisionandlowerspatialresolution.ThesedrawbackscanbepartiallyovercomewithadvancedmethodssuchasdeeplearningtodecodeandextractmorerelevantsourceinformationfromtheEEGsignal(NagelandSpüler,2019). Electroencephalogram-basedBCItechnologyhasmanyimportantapplicationsinthemedicalandpsychologyfieldsnotonlyformotorcontrolimpairments.Onepromisingapplicationforelderlypatientsisthedevelopmentofautomaticsystemstodetecttheinfluencesonthebrainsignalrelatedthesmokingandalcoholabuseusingresting-stateEEG(Mumtazetal.,2017;Suetal.,2017).BCIhasalsobeenfoundtobehelpfulinidentifyingdeficitsandimprovingsocialskillsinpatientswithautismthroughtheuseofBCI-assistedsocialgames(Amaraletal.,2018).Otherresearchhasfocusedonsystemstotestmemorycapacityandcognitivelevel(Burkeetal.,2015;Buchetal.,2018). AgingandCognitiveAbilities Oldageisakeyriskfactorformanymajormedicalhealthproblems,notleastneurodegenerativediseaseanddementia.Infact,anumberofneurologicalandpsychiatricdiseases(e.g.,schizophrenia,depression,epilepsy,HIVinfection,andtraumaticbraininjury)havebeenproposedtoresultinprematureoracceleratedaging,basedonclinicalobservationsandbehavioralorbiologicalresearch(Coleetal.,2019).Invasivetechniques(e.g.,deepbrainstimulation)andnon-invasivemeasurements[e.g.,EEGandfunctionalmagneticresonanceimaging(fMRI)]havebeenusedtotreatand/orunderstandthepathophysiologyofschizophrenia,depression,andepilepsyusingspecifiedregionsofinterest(ROIs),quantitativeEEG(brainmapping),orEEGrhythms(e.g.,delta,theta,alpha,beta,andgammabands).However,oneofthemostcommonaging-relatedhealthissuesaftercardiovascularconditionsisdementia,whichmaybecausedbydiseasessuchasAlzheimer’s,Lewybodydisease,vasculardementiaandfrontotemporaldementia.Patientswithdementiamaylosetheabilitytothinkclearly,learnandremember.WefocusinthefollowingparagraphsonmemoryimpairmentsandhowBCItechnologycanprevent,reduce,orsolvethem. Memoryisstoredinthehumanbraintokeepinformationandpreviousexperiencesavailableforrecallwheneverneeded.Memoryhelpspeopletolearnfrompastexperiences,andassistsinacquiringnewskillsandlearningnewinformation.Fromaneurologicalandpsychologicalperspective,humanmemoryinvolvesgroupingandcommunicationbetweenneuronsinthehumanbrain.Humanmemoryisnotlocatedinonlyoneareaofthehumanbrain,butratherinvolvesthecooperationofseveralareas.Memoryandlearningarestronglyrelatedintermsharingalmostthesamebrainareas,butintermofbrainmechanismandprocessarestrictlydistinctfromoneandanother.Memoryitselfisconsecutivefromretrievingtheknowledgeandadjustwithourbehaviorbutlearningistheprocesswhentheneuronsareworkinguptogaintheknowledgeandinformation. Ingeneral,humanmemoryisdividedintoshort-termmemoryandlong-termmemory.Short-termmemory,alsoknownasworkingmemory,istemporarystoragethatcanholdasmalleramountofmemorythatcanbeaccessedimmediately.Forexample,rememberingaphonenumberthatwasjustmentioned,orasecurenumberfromthebankforthetransactioninvolvesshort-termmemory.Informationcanberetrievedafteronlyafewsecondsinourshort-termmemory.Incontrast,long-termmemorylastsoveranextendedperiodoftime,andcanstoreamuchlargeramountofinformation(Konkleetal.,2010).Workingmemorycanbetransferredtolong-termmemorythroughrehearsalandstrengthening. Humanmemorycanstarttodegradefromage20.Memorylosscanbeoneoftheworstfactorsassociatedwiththeagingprocess.Theriskofdevelopingmemory-relateddiseaseslikedementiaandAlzheimer’sproportionallyincreasewithage.Olderpeopletendtohavedifficultyrememberingorrecognizingobjectsinthesamegroupandsemanticcategory(Pansuwanetal.,2020).Forexample,differenttypesofanimal-likehamstersordogsinthesameclasscancauseconfusionandincorrectrecognition.Asthebrainages,someregionsbecomeslowerduetodecreasedbloodflow.Additionally,neurotransmittersarealsoreducedandaffecttheabilitytounderstandtheenvironmentandaccessmemory. Braincomputerinterfacetechnologycouldbeonepotentialtoolforrestoringlearningandimprovingmemory,attention,andconsciousnessforcognitivelyimpairedelderlypatients(Buchetal.,2018).Forinstance,non-invasiveBCIshavebeenbeusedforrestoringmemoryandplanningusingelectromagneticstimulationandbiofeedbackthatmodulateactivityinapatient’sbrainaspartofarehabilitationprogram.Inaddition,BCIshavebeenusedtoenhanceepisodicmemoryinhumanparticipantswhereneuraloscillationsinthethetaandalphabandswereusedtopredictthefuturesuccessofmemoryencoding.Electrophysiologicalsignalsmayalsobecausallylinkedtoaspecificbehavioralcondition,andcontingentstimuluspresentationhasthepotentialtomodulatehumanmemoryencoding(Burkeetal.,2015).Moreover,BCIcouldprovideapowerfulapproachforfutureapplicationsincognitiveprosthetics(e.g.,promisestoimprovelearningandmemoryforpatientswithcognitiveimpairment,whichneedadeepunderstandingoftheneuralmechanismsunderlyingthesecognitiveprocesses). AgingandMotorControlImpairments Motorcontrolisacomplexsystemthatincludesthebrain,muscleandlimb(Rosenbaum,2009).Cooperationbetweenphysicalandphysiologicalsystemsmakesitpossibleforthehumanbodytomove.Physicalmovementsincludewalking,running,grabbingorexercising.Physiologicalcontrolmechanismsincludecholesterollevels,bloodpressureandequilibrium.Allofthesecanbedestroyedduetoagingfactors,accidents,ordiseaseandtheytypicallydonothealnaturally. Agingtendstonaturallyreducemotorskillsandphysiologicalenergylevels.Hence,itcanreducethespeedofhumanmovementssuchaswalking(Wertetal.,2010).Theelderlycanexerciseandpracticetoimprovemuscleandmotorskills(Kleim,2011),however,excessivetrainingandpracticecanberiskyforolderpeopleandmightcontributetootherinjuryordisease.EmergingtechnologiesusingBCIcancontributetokeepinghealthyelderlyfit.ElderlypeoplewhoneedassistanceorrehabilitationcancontinuetheirordinaryliferoutinesusingaBCIsystem(seeFigure1).Inthefollowing,wenotethreepossibleEEG-basedBCIsforage-relatedmotorcontrolimpairments:controllinganexoskeleton,wheelchair,andsmarthomeappliances(includingdroneandsmartcleaningand/orassistiverobotstoperformphysicaltasksforthewell-beingoftheelderly). FIGURE1 Figure1.PossibleassistiveapplicationsofEEG-basedBCIfordecreasingdebilitatinganddependenceofelderly(e.g.,controllingawheelchair,exoskeleton“softExosuits,”drone,assistiverobot,andsmarthomeappliances). Roboticexoskeletonshavebeendevelopedtoincreasejointstrengthandtoreducetheeffectofcarryingaheavyload.Anexoskeletoncanenableasoldiertoliftaheavyobject,orassistafirefighterwhohastowearheavyequipment.Atthesametime,exoskeletonscanbeaccessoriestoassistelderlypeopleorpeoplewithmotorimpairmentsinperformingtheirdailyactivities.Therearevarioustypesofexoskeletonsforusebyelderlypeople,suchaslowerlimbExosuits(Shoreetal.,2020),ankle-footexoskeletontoassistinplantarflexionwhilewalking(Galleetal.,2017),roboticexoskeletontofacilitatethemovementofshoulderandelbow(Tangetal.,2019),andupperlimbexoskeletonforhandgraspingandmotion(Chauhanetal.,2019). Awheelchairisaverycommondeviceusedbyhealthyanddisabledelderlytomovefromoneplacetoanotherwithoutexternalaid.Theneedforawheelchaircanbecausedbylossofmusclestrength,ordiseaseslikeALS,arthritisorParkinson’s.Oftenpatientsrequireacaretakertohelpthemmoveandperformtheirdailyroutine.However,sometimesacaretakerisnotavailable.Inthiscase,someextendedfunctionsareavailableforwheelchairusebyelderlypeople.Theautomatedwheelchairisoneeasywayfortheelderlytonavigateinthehome(Brandtetal.,2004).Theelderlycanalsomovefromoneroomtoanotherroombywheelchairwithvoicecontrolincombinationwiththenavigationassistanceprovidedby“Smartwheelchairs,”whichusesensorstoidentifyandavoidobstaclesinthewheelchair’spath(Megalingametal.,2011).Finally,anintelligentwheelchairsuchasRoboChair,withaheadgesture-basedinterface,canbeusedformobilitywithlittleeffort(Grayetal.,2007). Ontheotherhand,thehomecanbeadangerousplace,especiallyforolderpeoplewholivealoneandhavehealthproblems,astheymaybepronetofallingorotheraccidents.Smarthometechnologiesarethusimportantsolutionstoenableseniorstolivemoresafelyintheirownhomes.Theuseofintelligenthomesbytheelderlyincreasestheirindependenceandimprovestheirhealth(SapciandSapci,2019).Forexample,eHomeSeniorsfocusesontheobjectiveofdetectingtheelderlywhofallinthehome(Riquelmeetal.,2019).Also,Kernetal.(2019)developedMyLittleSmartPersonalAssistantforelderlypeopletointeractwithavocalassistantthatprovidesthemedicalservices.Finally,Shangetal.(2019)designedasystemtoidentifyandobservebehaviortosupporthomecareforelderlypeoplewholivealoneinahouse. Methods Inthismini-review,theauthorsconductedaliteraturesearchofavailablesourcesdescribingissuesrelatingtoelderlywithBCI,EEG,cognitiveaging,andmotorcontrolimpairments.RecentresearchstudieswereselectedbasedonresearchtopicsfoundingloballyacknowledgeddatabasessuchasWebofScience,PubMed,Springer,IEEEXplore,andScopus.Searcheswererestrictedtorecentoriginalideaspublishedinnreputablejournalsinthepast10years.PapersthatwerenotEnglish,grayliterature,bookchapters,conferenceproceedingsandopinionspieceswerenotincluded.TheinclusioncriteriawereappliedfortheBCIapplicationsthatcanhelptheagingpeoplebyreviewingtitlesandabstractsbasedonkeywords.Weexcludedmanyresearchpapersformanyreasonssuchasredundancy,titleandabstractareunrelatedtotheresearchtopic,orifwecouldnotfindanyoccurrenceofatleastelderly(orolderadults,elderlypatients,etc.)withonekeyword(BCI,EEG,cognitiveaging,motorimpairment,exoskeleton,wheelchair,smarthomecontrol,freecommunication,disordersofconsciousness,rehabilitation,andneurofeedback,etc.).DuethelimitedavailableBCIarticlesthatusedtheelderlypeopleassubjectsorparticipants,somepotentialBCIstudydesignswereconsideredforinclusion.Thus,somestudieswereincludedwithnon-elderlyparticipantsiftheiroutcomesseemtobehelpfulandusefulforhealthierelderlyliving.Theselectedarticleswereclassifiedaccordingtotheirrelevancy(seeTable1).Theinformationprovidedintheselectedrecentstudies(e.g.,ageoftheparticipants,invasiveornon-invasivemeasurements,experimentalparadigm,thepurposeoftheoriginalstudy,theimpactofthepaper’soutcomesonelderlylivingsuchasengineeringapplications,andscientificfindings)werecarefullyevaluatedanddiscussedinthefollowingsection. TABLE1 Table1.SomeinterestingexamplesofrelatedworkforBCIapplicationsforelderlypeople. HowCanBCIApplicationsImprovetheQualityofElderlyLiving? Withtherapidlyincreasingpopulationofelderlypeople(Coimbraetal.,2010),therehasbeenmuchinterestinresearchinvolvingtheuseofBCIstoimprove,repairorenhancelostcognitiveormotorfunction.Table1showsselectedstudiesthatrepresentdifferentusesofBCItoimprovethequalityoflifeoftheelderly,includingimprovedcognitivefunction,especiallymemory,controlofsmarthomes,andlimbsupportformovement.Wepresenttheparticipants,theBCIparadigmsthatwereimplementedinthepapers,thetargetortaskthattheparticipantswereinstructedtocomplete,andtheresultfromtheexperiments. Toaddressaging-relatedcognitiveimpairments,Leeetal.(2013),andGomez-Pilaretal.(2016)studythecognitivecapabilitiesofelderlypeoplerelatedtomemory.BothofthestudiesshowthatBCIandcognitivetestscanimprovememoryabilityamongtheelderly.IntheLeeetal.(2013)experiment,participantshavetoplayacardmatchinggametotesttheirmemoryability.Atthesametime,theyneedtofocusongivingacommandtocloseandopenthecard.IntheGomez-Pilaretal.(2016)experiment,participantshavefivetasks:(i)learningtoimaginethehandmovement,(ii)movingthecursoronthescreen,(iii)movingthecursortowardthecorrecttarget,(iv)avoidinganobstacleforpersonwalkinginthescreen,and(v)identifyingtheimagefromapreviouslydisplayedgroupthatmatchesanewlydisplayedimage. Furthermore,deliriumandconfusionalstatesarecommonmentaldisorders,whichcanleadtoadisorderofconsciousness(DOC)amongolderadultsinvolvinglackofenvironmentalawareness.EEG-basedBCIparadigmshavemanyadvantagesinthisproblemdomain.Xiaoetal.(2018)developedaBCIsystemtoassistthevisualfixationofelderlypatientswithDOCtoevaluatethevisualpartofthecomarecoveryscale-revised(CRS-R).Panetal.(2018)usedBCItodetecttheemotionforDOCsincetheyareunabletoaffordthemotorrespondedtodisplaythefeelings.Someoftheelderlyfacedifficultyincommunicatingtheirneeds.Hence,thefreecommunicationcanbeatoolforthemtosupporttheconversation(Rentonetal.,2019).Asageisthemostsignificantriskfactorinstroke,rehabilitationcanhelpforrestoringtheabilityforthemotorfunctions.Predictionandmonitoringofspecificbiomarkersofthemotorfunctionarebeinginvestigatedtopersonalizetherehabilitationprogram(Maneetal.,2019).Strokeisalsoassociatedwithmentalfatigue,andmemoryissues.Foongetal.(2019)studiedthecorrelationsofmentalfatigueduringtheBCIwhileperformingtheupperlimbstrokerehabilitation. Regardingaging-relatedmotorcontrolimpairments,BCI-assistedwheelchairtechnologyisoneofthepromisingdevelopmentsforrehabilitationandtheelderlywithmuscleandseveremotordisabilities.Herwegetal.(2016)haveshownwithtenhealthyelderlyparticipantstheabilitytotraintheusertocontrolthewheelchairusingEEGandthetactileevent-relatedpotential(ERP).Eachparticipantdidfivesessionswithamaximumofthreesessionsperweek.Thetrainingtaskinvolvedcontrolofavirtualwheelchairusing14commandsinvirtualenvironments.90%accuracywasachievedforthenavigationtasks.Fortheoptionalorbonustasks,theefficiencywasmorethan95%.Kaufmannetal.(2014)alsoproposedaBCIsystemusingEEGandERPtocontrolawheelchair.There,theparticipantsneededtonavigatethewheelchairtofourdifferentcheckpointsinsidethebuilding.Theprimarytargetusersarepeoplewithneurodegenerativedisease. ThewearablekneeexoskeletonhasbeenproposedandtestedbyVilla-Parraetal.(2015)withfourmainhealthysubjectsusingEEGandEMGsignals.Theprimarypurposeofthedeviceistoimproveandrehabilitatethegait,andrestorethefunctionformusculardisabilitiesrelatedtokneemotionlikestandingupandsittingdown.Eventhoughtheparticipantsintheexperimentwerenotelderly,thisequipmentcanalsobeusedforseniors,especiallythosewithmuscleproblems.Ontheotherhand,Leeetal.(2017)developedthelowerlimbexoskeletonusingtheEEGsignal,withtheintentionofofferingmorefunctionalitythanatraditionalwheelchair.Theyusedhealthyparticipantsasaproofofconceptfortheirwork,withthetargetusersbeingpeoplewithlimitedornoresidualmotorcontrol.Thisexoskeletoncanalsobeusedforelderlypeoplewithmotordifficulties.Theresultshowedallthesubjectssuccessfullyperformedthemaintaskforthethreedifferentdirections:walkfront,turnleftandturnright. StateoftheartsmarthometechnologiesforelderlypeopleusingBCIhavebeenproposedbyJafrietal.(2019)andChaietal.(2020).BothoftheexperimentsofJafriandChaiwereconductedtotestthefeasibilityofthesmarthomedesigns.Althoughtheresultofattentionlevelfortheyoungermalereachedattentionlevel74.78within26.20swhichwasquickerthanyoungerfemaleandolderpeople,theaddedvalueforthisexperimentistheelderlypeoplestillcancontrolthefunctioninasmarthomeusingseveralBCIexperimentalparadigms(Jafrietal.,2019).Oneofthesmarthomeservicesisdialingthethreeemergencynumbersspeciallydesignedforolderpeopleinhands-freemodeusingEMGandSSVEP(Chaietal.,2020). AnotherimportantunresolvedissueinvolvesthechallengesinclinicalapplicationsofBCIswitholderindividualswhohaveswallowingdisorders(e.g.,ALSpatientswithprogressivedysphagia),orspinalcordinjury[e.g.,afterspinalshockendsspasticactivitymaydevelopinthedetrusormusclerestrictingthebladdercapacitytostoreurineandresultinginincontinence(Rupp,2014)].Moreover,invasiveBCIsthatrequireimplantationofthedevicemightbeaseriousethicalissue.Therefore,non-invasiveEEG-basedBCIsandhBCIsappeartobethemostpromisingtechnologies.However,hBCIhasshownadvantagesinvariousapplicationsasitcombinesthestrengthsofdifferentBCIparadigms(e.g.,highaccuracy,minimaldailysetup,rapidresponsetimes,andmulti-functionality).hBCIcouldfurtherhelpimprovethequalityoflifeofolderadultsandelderlypatientsthroughthedevelopmentofmultifunctionalandmultidimensionalinterfaces.Auditory,visualortactileBCIsmaynotabletosatisfytherequirementsofreal-lifeactivities,andmaynotbesuitableintermsofcomfortforallelderlypeopleduetothepotentialdeficitsinhearing,vision,andsensationassociatedwithaging.Forexample,visualstimuliusingP300-basedBCI,orSSVEP-basedBCImaycauseeyefatigue(e.g.,imminentretinalfatigue)duetotheprolongedvisualfixation,ormayevenharmelderlypeoplewhocannotcontroltheirgaze(unattainablevolitionalmovements),orhaveweakvision.Thesestimulimayalsoinduceepilepticseizuresinsomepatients.Inaddition,agingaffectstheintegrationoftemporalrateofauditoryflutter(amplitudemodulation)presentedwithvisualflicker(Brooksetal.,2015).Theseage-relatedchangesinauditoryandvisualinteractionsintemporalrateperceptionmayaffectP300-basedBCIperformances.However,addingadditionalnon-brainsignalsorcombiningmorethantwoBCImodalitiesmaycompensatetheage-relatedchanges.BCIbasedoncontrollingasmarthomeoranautonomouswheelchairrequiresmultipledegreesoffreedomandfastintentiondetection,makingsolelyEEG-basedmultipledevicesorwheelchaircontrolachallenge.hBCIsmayoffermoreeffectivecontrolforelderlypeople,especiallybyofferingmultiplecommandsandaccuratestopinemergencycases.Inaddition,directtactilestimulationmayimproveshort-termandlong-termmemoryinelderlypatientsdiagnosedwithAlzheimer’sdisease.Theseimprovementsmayleadtoimprovedpsychologicalwell-being,andincreasedsocializationandparticipationindailyactivities(WituckiandTwibell,1997;Herwegetal.,2016). TherapidgrowthinneuroinformaticsandrelatedintelligentalgorithmsmayalsoadvanceEEGanalysesandhelptoimprovetheperformanceofexistingBCIsfortheusageathomebyreducingthetimeforthecalibrationphaseandincreasingclassificationaccuracyandITR.Withthisgoalinmind,researchershavebeenusingsomecommonmethodsforreducingthenumberofEEGchannels,removingartifactsusingonlinesourceseparation,distinguishingbetweenneuralactivationpatternsusingmachine-learningalgorithms,andunderstandingbrainmechanismsusingadvancedbrainnetworkanalyses.Forexample,SparseBayesianLearning(Zhangetal.,2015)hasbeenusedtopredictsubject’sbehaviorsorcognitivestatesfromhisbrainactivitieswithasmallnumberofsamplesofhighdimensionaldata(Sparseestimationtoolbox:https://bicr.atr.jp/cbi/sparse_estimation/index.html).Deeplearningalgorithms(TabarandHalici,2016;Schwemmeretal.,2018)havealsobeenusedtoextractusefulfeaturerepresentationsfromrawdataandachieveahighEEGclassificationaccuracy.Inaddition,theGrangercausalitymethodshavebeenusedtoassessbrainconnectivity(Chenetal.,2019). DevelopingEEG-basedgamecontrolmayalsohelpelderlypeopletoimprovetheircapacityofmultitaskingtocarryoutthetasksineverydaylife.Thiscapacitycanfacilitatethecontrolofsmarthomeappliances,droneswarms,and/orassistiverobots.Neurofeedback(biofeedbackforthebrain)canbeanadditionaloptiontoenhancecognitiveperformanceofelderlypeople(Jirayucharoensaketal.,2019).Thelastchallengeisthedevelopmentofhardwareandsoftwaresolutionsforhome-basedapplicationsthatcanbeusedbyhealthyolderadultsandelderlypatientswithminimaltechnicaloversight,althoughtherearealreadymanyuser-friendly,wearable,portable,andwirelessEEGequipmentinthemarketsuchasrecoveriX,mindBEAGLE,UnicornSpeller(g.tecmedicalengineering,Graz,Austria). Conclusion Thismini-reviewhaspresentedseveralpotentialBCIapplications(e.g.,cognitiveandmotorprosthetics)toassisttheolderadultsandelderlypatientsusingnon-invasivemeasurement.Avarietyofexternalaidsandneurofeedbacktestsareavailable,andhavebeenshowntobeusefultoanddesiredbyolderpeople,healthcarepersons,caretakersandfamilymembers.Interactivegamingtestscanmonitorandimprovethecognitiveabilityofagedpeople.Thecurrentwheelchairandexoskeletontechnologieshavebeendevelopedtosupportelderpeopleandallowthemtocarryontheirdailyroutinesandatthesametime,toproviderehabilitationofdeterioratedmuscleandmotorfunction.Smarthomeenvironmentscanassisttheelderlyinlivingindependentlyandfeelingsafeintheirownhomes.WehopethatthetechnologiesreviewedinthisarticlewillfurtherstimulatethedesignofnewtechnologiesanddevicesbasedonBCIforseniorcitizens.BCItechnologyhasalreadyshownpromisingresultsinprovidingassistanceinbothcognitiveandphysicalsupportandrehabilitation,andwelookforwardtofutureinnovationinthisimportantareaofresearchthataffectsallofuseventually. AuthorContributions Allauthorswereinvolvedinthewritingandeditingofthemanuscript,specificauthorcontributionswere:ABoverallconceptualdesignforreview,supervisorofNJ–advisinginwritingandfiguredesign.AB,NJ,andSOcontributedtoselectingthearticles,analyzingresults,writing,andeditingofthemanuscript.JPandCCcontributedtowritingandeditingofthemanuscript. Funding ABacknowledgessupportfromtheUnitedArabEmiratesUniversity(Start-upgrantG00003270“31T130”). ConflictofInterest Theauthorsdeclarethattheresearchwasconductedintheabsenceofanycommercialorfinancialrelationshipsthatcouldbeconstruedasapotentialconflictofinterest. 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GoogleScholar Keywords:braincomputerinterface,EEG,cognitiveaging,motorimpairment,olderadults,elderlypatients Citation:BelkacemAN,JamilN,PalmerJA,OuhbiSandChenC(2020)BrainComputerInterfacesforImprovingtheQualityofLifeofOlderAdultsandElderlyPatients.Front.Neurosci.14:692.doi:10.3389/fnins.2020.00692 Received:13February2020;Accepted:08June2020;Published:30June2020. Editedby: IoanOpris,UniversityofMiami,UnitedStates Reviewedby: ChristophGuger,g.tecmedicalengineeringGmbH,Austria YuZhang,StanfordUniversity,UnitedStates Copyright©2020Belkacem,Jamil,Palmer,OuhbiandChen.Thisisanopen-accessarticledistributedunderthetermsoftheCreativeCommonsAttributionLicense(CCBY).Theuse,distributionorreproductioninotherforumsispermitted,providedtheoriginalauthor(s)andthecopyrightowner(s)arecreditedandthattheoriginalpublicationinthisjournaliscited,inaccordancewithacceptedacademicpractice.Nouse,distributionorreproductionispermittedwhichdoesnotcomplywiththeseterms. *Correspondence:AbdelkaderNasreddineBelkacem,[email protected];[email protected] COMMENTARY ORIGINALARTICLE Peoplealsolookedat SuggestaResearchTopic>