title: Automatic detection of confusion in elderly users of a web-based health instruction video.
abstract: BACKGROUND
  Because of cognitive limitations and lower health literacy, many elderly patients have difficulty understanding verbal medical instructions. Automatic detection of facial movements provides a nonintrusive basis for building technological tools supporting confusion detection in healthcare delivery applications on the Internet.
  
  
  METHODS
  Twenty-four elderly participants (70-90 years old) were recorded while watching Web-based health instruction videos involving easy and complex medical terminology. Relevant fragments of the participants' facial expressions were rated by 40 medical students for perceived level of confusion and analyzed with automatic software for facial movement recognition.
  
  
  RESULTS
  A computer classification of the automatically detected facial features performed more accurately and with a higher sensitivity than the human observers (automatic detection and classification, 64% accuracy, 0.64 sensitivity; human observers, 41% accuracy, 0.43 sensitivity). A drill-down analysis of cues to confusion indicated the importance of the eye and eyebrow region.
  
  
  CONCLUSIONS
  Confusion caused by misunderstanding of medical terminology is signaled by facial cues that can be automatically detected with currently available facial expression detection technology. The findings are relevant for the development of Web-based services for healthcare consumers.
authors.affiliation: Department of Communication and Information Sciences, Tilburg University, Tilburg, The Netherlands.
authors.forename: Marie
authors.initials: M
authors.lastname: Postma-Nilsenová
authors.affiliation: Department of Communication and Information Sciences, Tilburg University, Tilburg, The Netherlands.
authors.forename: Eric
authors.initials: E
authors.lastname: Postma
authors.affiliation: Department of Communication and Information Sciences, Tilburg University, Tilburg, The Netherlands.
authors.forename: Kiek
authors.initials: K
authors.lastname: Tates
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005149:Facial Expression; D005260:Female; D005853:Geriatrics; D006266:Health Education; D006801:Humans; D020407:Internet; D008297:Male; D009426:Netherlands; D019370:Observation; D017216:Telemedicine; D014584:User-Computer Interface; D014741:Video Recording; D055815:Young Adult
keywords: geriatrics; home health; telemedicine