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Automatic detection of confusion in elderly users of a web-based health instruction video.

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.


MATERIALS AND 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.