Population ageing is a major and unprecedented 21st-century phenomenon that concerns the whole world. Adopting the World Health Organization guidelines, the Age-It project (https://ageit.eu/wp/), co-funded by the European Union -Next Generation EU Programme, addresses this situation by promoting the adoption of policies and strategies based on the "active and healthy ageing" framework [1]. As part of the Age-It project, Spoke 8 aims to support the needs and strengthen abilities to foster the health of older patients, design and adopt innovative technologies in different life domains and environments, and create a large dataset that can be exploited through AI models to develop personalized interventions.
Spoke 8 also involves small-scale testing of proactive conversational agents that should support patients with cognitive stimulation, reduce feelings of loneliness, help them comply with medical prescriptions, and inform relatives and caregivers about their health status and possible emergencies. This paper, starting with an analysis of related work (Section 2), discusses the requirements that such a conversational agent should meet (Sec. 3), the reasons why it should be deeply rooted in symbiotic AI concepts and the close links with the concept of synesthesia (Sec. 4), a preliminary definition of the system architecture, and some thoughts on implementation aspects (Sec. 5).
Conversational Agents (CAs) dedicated to personalized interventions, particularly in the context of wellness, frequently face the challenge of operating within predefined and limited dialogue patterns and handling circumscribed and anticipated user input [2]. Despite their potential, the use of CAs is still in its early stages, underscoring the urgent need for further research to ensure development that is both safe and effective. It is critical to recognize the inherent limitations in CAs, including the propensity for bias and the dissemination of untrue information, and to consider related ethical issues, particularly privacy concerns. These issues become evident, for example, in the design of conversational companions created to mitigate problems such as loneliness and social isolation, even in response to conditions such as depression, where deeply personal interaction requires careful consideration of ethical implications [3][4].
This focus on the efficacy and safety aspects of interaction marks a shift toward more sophisticated and potentially more invasive forms of care. Li et al. [5] conducted a prospective trial involving 278 patients with osteoarthritis and sarcopenia, observing how the synergistic use of ChatGPT-4 and wearable devices not only facilitated access to care but also significantly improved the quality of rehabilitation care, showing a progression toward more personalized and impactful interventions. This technological advancement, however, brings with it new challenges, as demonstrated by the comparative evaluation of LLM-based chatbots in Alzheimer's recognition [6]. While Bard excelled in disease identification, it showed a tendency to overestimate the presence of disease, unlike GPT-4, which stands out for its accuracy in recognizing cognitively healthy subjects. Overall, to date, it is difficult for a chatbot to reach the levels required for clinical applications, although some preliminary evaluations point to the great potential of CAs in the diagnostic field [7].
Spoke 8 of the Age-It project involves a multicomponent intervention for frail people older than 65 years. The intervention includes moderate-intensity physical activity, personalized nutritional counseling, active aging health education, and social recreational activities (e.g., singing, dancing, music, etc.). After numerous meetings with multidisciplinary experts (physicians, geriatrics, psychologists, computer scientists, data scientists, sociologists, etc.) from January 2023 to January 2024, the project defined small-scale testing of proactive conversational agents capable of:
Collecting patient health status monitoring data (temperature, sleep/wake time, heart rate, blood oxygenation level, etc.) and data related to the performance of Activities of Daily Life (ADLs) (e.g., posture, speed of movement, amount of physical activity, etc.).
Vocally interacting with project participants by providing stimuli on activities to be performed: e.g., adherence to treatment (i.e., taking prescribed medication at the right time), physical exercises, cognitive stimuli, invitation to communicate with friends or family members, etc.
Interacting vocally with the patient's family members or caregivers, informing them in case of an emergency (e.g., patient's illness, abnormal or risky behavior, etc.).
Interacting vocally with medical personnel, summarizing the salient elements related to overall health status (improving, stable, worsening), and reporting specific events (abnormal temperature, poor sleep quality, failure to take medication, falls, etc.) useful for diagnostic evaluation and possible therapeutic upgrade or revision.
The requirements thus described were collected in the form of Use Cases and Sequence Diagrams, represented in UML [8], and discussed and fine-tuned with the specialists participating in the project. In Q3 and Q4 2024, to take into account the opinion of direct stakeholders, it is planned to review and extend the requirements together with representatives of associations of patients and family members of frail individuals through focus groups.
Based on the defined requirements and the available scientific literature [9][10], it became apparent that conventional Natural Language Processing (NLP) approaches and current LLMs, taken individually, do not meet the needs summarized in points 1 to 4. For this reason, we defined the architecture described in Fig. 1 that integrates the conversational and reasoning capabilities of an LLM with a Retrieval Augmented Generation (RAG) system capable of storing and subsequently extracting from a vector archive and synthesizing personal information related to a patient's health status and its temporal evolution.
The dialogue between the physician and the patient has been defined as "the most powerful, sensitive, and most versatile instrument available to the physician" [11]. It is fundamental to effective and empathic care; it goes beyond history and diagnosis in that it establishes the rapport and trust necessary to address health needs. Physicians possess considerable skills in history taking and the broader "diagnostic dialogue," but access to these skills remains episodic [12] for reasons that can be mitigated by appropriate usage of AI systems, as discussed in a recent work sponsored by Google Research and Google DeepMind [13]. In the paper, the authors discuss the results of a structured objective clinical examination with validated simulated patients interacting with a conversational AI or primary care physicians via a text interface, finding that AI is superior to primary care physicians in empathy, treatment plan management, and other aspects.
Given the importance that clinicians attribute to aspects such as empathy and trust, it is reasonable to assume that different patients with different diseases and personal histories may produce different mental states and may have different expectations in relation to conversational AI such as the one described. Thus, especially in the hypothesis of Conversational Companions to be placed side by side for long periods of time (months or years) with frail or chronically ill patients, it is reasonable to assume that the adoption of symbiotic AI principles may further enhance the long-term AI-patient relationship by allowing the AI to combine generative capabilities with the ability to make assumptions about the patient's mental state and expectations.
To better understand the profound impact that the concept of symbiosis can have in Conversational Companions in clinical settings, it seems appropriate to retrace the basic steps of its evolution. The concept of symbiosis, proposed by the German botanist and mycologist Anton de Bary in 1878, defines exchange relationships between living organisms, classifying them as forms of mutualism (where both partners benefit from the relationship) or parasitism (where one exploits the other for its own benefit). In his pioneering publication "Cybernetics: Or Control and Communication in the Animal and the Machine" in 1948, Norbert Wiener uses the concept of symbiosis to characterize the integrative relationship between human and machine, emphasizing the profound differences from the more basic and imprecise concepts of use (of machines) or synergy (with machines) and foreshadowing, for machines, the development of "predictive" capabilities with respect to the needs and expectations of the human symbiont. In human subjects, this predictive ability is associated with the concept of "theory of mind" and refers to the ability to attribute mental states to oneself and others, and to understand that others have mental states different from ours.
The theory of mind for Baron-Cohen [14] is a "lens" through which we view the social world, and which allows us to interpret and predict the behavior of others, while for Dennett [15] this allows us to see others not only as physical entities, but as complex beings with desires, beliefs, and intentions.
Returning to Conversational Companions for clinical use, it now appears evident that since they must be equipped with empathic sensitivities, credibility, and the ability to adapt their responses to the mental state of fragile subjects, they must be able to assess the needs, expectations, and mental states of the human symbiont and, specifically, of fragile subjects with potential cognitive problems and problematic emotional states.
To develop a Conversational Companion for frail individuals that could prospectively include these features, the authors also made use of literature findings related to a specific rare anomaly of the human sensory-cognitive system, termed "mirror-touch synesthesia" and closely related to empathy [16] and hypochondria. In mirror-touch synesthesia, which affects about 1.6% of the population, synesthetes experience tactile sensations on their bodies when they see other people being touched [17]. Incorporating empathy models based on this concept into Conversational Companions for the elderly could significantly enrich the ability of machines to "describe and process" human emotions. Such a conversational clinical AI, by accompanying a specific frail person in his or her daily activities, could over time tune its theory of mind to the characteristics and expectations of the specific frail person with whom it accompanies, potentially enabling more effective and personalized interactions, but a detailed discussion of this is beyond the scope of this paper.
In Fig. 1, the logic schema of the first iteration of the described Conversational Companion for elderly people is depicted. For simplicity, only the patients are indicated on the right side of Fig. 1, but as mentioned in Section 3, the Companion can also alert the patient's relatives/caregivers in case of problems, answer their questions about the patient's health status, and inform physicians about the patient's health/wellness during the relevant time interval.
The main logic blocks represented in the schema are: A proactive agent, based on program-driven and event-driven logic, capable of activating the Conversational Companion when needed, independently from the question-answer mechanism usually adopted by LLMs. The Proactive Agent can also activate/deactivate specific health-monitoring devices, not shown in Fig. 1 for clarity (e.g., wearable wristbands, medical sensors, environmental sensors, etc.), and store monitoring data in the vector store or structured-data store (not shown in the figure).
A Retrieval Augmented Generation (RAG) subsystem, based on the Large Language Model (currently ChatGPT 4), with a purposely-defined logic to generate the embedding associated with each content stored in the Vector Store (currently using the OpenAI embedding model, not represented in Fig. 1), and the Vector Store (currently the Chroma Vector Store). The RAG is responsible for searching, extracting, and transforming into meaningful text messages all contents stored in the vector store or on the Web, when needed.
The "Experts" collection, which is the set of documents, guidelines, best practices, and specific medical prescriptions stored in the Vector DB, describing the multicomponent interventions associated with the specific pathologies of the specific patient. This collection is used by the proactive agent to decide when a specific therapeutic action, cognitive stimulus, or other intervention must be activated.
The "Personal Data" collection, containing the relevant events, health-monitoring data, actions, environmental data, etc., collected by the Proactive Agent and stored in the Vector DB.
A text-to-speech (LabEleven in this version) and a speech-to-text (OpenAI Whisper) system to support natural vocal interaction among the system and the different users (the patient, caregivers, relatives, physicians, etc.).
As of the first quarter of 2024, the system has been implemented in a preliminary version and tested in the laboratory for major functionalities. Due to the limitations of the Chroma Vector Store, the "expert" collection data is only a subset of the data needed for the experimental phase. Additionally, the current implementation is not suitable for experiments with real patients because of the lack of privacy and anonymity inherent in the adoption of ChatGPT 4. However, the system can be used for simulations based on realistic anonymized data downloaded from Physionet and Kaggle, pending a fully private and local version based on LLama 70b and not connected to the Web.
The paper defines the main requirements for a Conversational Companion for elderly and frail patients, to be used in the Age-It PNRR Project -Spoke 8 -Multicomponent Intervention. The system prototype has been designed, implemented, tested, and is currently used with anonymous data for simulation, demonstration, extension, and fine-tuning purposes.
In the next steps, we plan to design and build a more complete implementation of the system and benchmark its "theory of mind" features, aiming for more empathic and effective Conversational Companions for clinical applications. To test the system in the field with real patients, an instance of Llama 70b will be run on a Mac M3 Pro. The system will be connected to a Local Area Network including all needed sensors and devices but not connected to the Internet to preserve the privacy and confidentiality of data collected by the patient. The experiment will undergo the local Ethical Committee for authorization and will implement the prescribed privacy, security, and confidentiality measures.
This publication was partially funded by the European Union -Next Generation EU, in the context of the National Recovery and Resilience Plan, Investment Partenariato Esteso PE8 "Conseguenze e sfide dell'invecchiamento", Project Age-It (Ageing Well in an Ageing Society), CUP: B83C22004800006.