Autonomous Management of Agitation in Dementia

1
Autonomous Management of Agitation in Dementia

• Judy Mills, Brandon Knapp, Michael D. Church
• Advisors
• Dr. Imad Elhajj
• Dr. Cheryl Riley-Doucet

2
Presentation Outline

• Background Information on Aging and Dementia
• Project Objectives and Design
• Sensory Stimuli
• Physiological Signal Sensors
• Cost Analysis
• Current Progress and Future Goals

3
Aging and Dementia

• Expected population boom
• Increase from 35 to 72 million between 2010 and
  2030 (26)
• People over the age of 65 are at highest risk for
  developing Alzheimers Disease (26)
• AD is the leading cause of dementia in the
  elderly (26)
• Estimated 4.5 million cases (26)
• Could grow to about 11.3 million to 16 million
  with population boom (26)

4
Aging and Dementia

• Dementia is a growing public health concern (3)
• Affects 8-10 of all people over 65 (26)
• Affects nearly half of all nursing home residents
  (26)
• Can lead to emotional stress and psychiatric
  symptoms of burn-out in caregivers/nurses (20)
• Amplified by short-staffing and lack of
  professionals
• The main behavioral characteristic of dementia is
  agitation (5)

5
Agitation

• Behavioral Response
• Wringing hands
• Vocalizations
• Pacing
• Repetitive actions
• Destructive behaviors
• Hostility
• (5) (14)

• Physiological Response
• Increase heart rate
• Increased skin temperature
• Diaphoresis
• Increased blood pressure
• Increased pulse pressure
• (6) (10)

6
Agitation

• Interrupts care
• Decrease patient quality of life
• Can lead to catastrophic reaction (7)
• Requires nursing time
• Increased cost of care
• Currently measured with documenting surveys to be
  filled out by caregivers or staff (5)
• Documentation requires time
• Subjective

7
Cost Implications

• Staff time expenditure (23)
• Nursing staff spend an average of 23 minutes
  managing each negative behavior related to
  agitation
• Depending on frequency and the number of patients
  staff can spend up to 80 minutes per day for each
  patient in their care
• More efficient methods are needed to reduce cost
  associated with dementia care

8
Methods for Managing Agitation

• Neuroleptic drugs (22)
• Of the 24 of nursing home patients taking these
  medications, 88 are receiving them
  inappropriately
• Hastens cognitive decline
• Reminiscence Therapy
• May be over-stimulating and enhance agitation
• Consumes staff time
• Spinoza Bear (24)
• Limited ability to personalize
• Old technology
• Not Proactive
• Snoezelen Rooms (27)
• Must be set up by caregiver
• Not proactive (patient is already agitated)
• Not personalized for patient

9
Multi-sensory Stimulation

• Has been found to be an effective method for
  calming agitation (27)
• Most effective when personalized (8) (10)
• Enhances alertness (17)
• Decreases anxiety (17)
• Improves quality of life (2)

10
Project Objective

• Develop and prototype an intervention device
• Monitor physiological conditions to detect
  symptoms of agitation in dementia patients
• Provide multi-sensory stimuli in order to reduce
  agitation
• Will be unique because it will be the first to
  detect agitation in a dementia patient and then
  attempt to reduce that agitation

11
Device Benefits

• Reduce time nurse spends managing agitated
  dementia patients
• Reduce health care cost
• Reduce stress on nurses
• Improve quality of patient life
• Reduce use of neuroleptic drugs
• Stimulate happy emotions through memory

12
Device Requirements

• Portable
• Transparent
• Adaptive
• User-friendly
• Easy to interface to the patient
• Patient customizable
• Minimizing cost
• Ensuring safety

13
Challenges

• Quantify and detect agitation before exacerbation
• Choosing physiologic signals to detect and
  analyze
• Choosing appropriate and safe technology
• Choosing appropriate stimuli
• How to administer stimuli
• Controlling stimuli based on sensor feedback

14
Chosen Sensor Technology

• Polar Chest Band Heart Monitor
• Comfortable fit designed for working out
• Sends signal in 3-volt pulses
• Easily interpretted
• RTD Temperature Sensor
• Resistance in relation to temperature
• GSR Skin Conductance Sensor
• Worn on fingers
• Similar to sensor used in lie detection

15
Sensor Technology Available

• BodyMedia SenseWear Armband (15)
• Galvanic skin response, skin temperature,
  two-axis accelerometer, heat flux, and near body
  temperature
• Has been used in order to capture physiological
  responses associated with specific emotions
• Not used in this project because intercepting the
  wireless signal from the armband would have been
  problematic

16
Sensor Technology Available cont.

• Research Group from MIT is developing a system
  called LiveNet.
• Groups goal is to develop monitoring systems for
  proactive health and elder care
• System can monitor a variety of physiological
  signals
• Continuous monitoring to detect subtle changes
• Not commercially available, system is bulky

17
Sensor Technology Available cont.

• UCLA group is developing a system called CustoMed
  (15)
• Revolves around placement of Med nodes
• Med nodes are stand-alone units equipped with
  processing units and batteries that support
  various types of sensors for physiological
  readings
• Med nodes interface with a personal PC that
  collects data and coordinates and controls the
  overall functionality of the system

18
Sensor Technology Available cont.

• CustoMed Applications
• Post knee surgery patient tracking
• Track the angular motion of the knees (flex
  sensors)
• Measure pressure and force under foot (pressure
  sensors)
• Aid Alzheimers patients
• Detect arousal
• Notify staff

19
Sensor Acquisition System

• Features
• Microcontroller attached to the heart rate
  monitor chest strap
• Battery pack location can be moved
• RTD temperature sensor can be placed almost
  anywhere on the body
• GSR sensors must be placed around two fingers

20
Chosen Stimuli

• Based on the concepts of Multi-Sensory
  Stimulation (MSS)(12)
• Involves stimulating multiple senses at once
• Non-challenging or stressful stimuli
• Elders with dementia have difficulty processing
  normal stimuli due to neuronal losses (4)
• Music
• Aromatherapy
• Light Stimuli
• Tactile Stimuli

21
Music Therapy

• Memory loss in dementia is associated with recent
  events
• Remote memory relatively intact (1)
• Neural pathways used to recall music are not
  generally affected by dementia (1)
• More therapeutic than spoken words (1)
• Helps elder to retrieve lost memories or feelings

22
Using Preferred Music

• Therapy that uses music the resident prefers is
  more effective (8)
• Decreases agitation fast (9)
• Longer lasting effects (9)
• Sony Psyc Walkman
• Battery powered
• CDs can be changed easily based on patients
  preferences
• Anti-skip capability
• Able to play upside down

23
Aromatherapy

• Has been used in mental health services for years
  (25)
• Studies conducted with lavender and lemon balm
  oil (2) (11)
• Effective for reducing agitation
• Increased quality of life indices
• Found to have no significant side effects
• Aura Cacia Fan Diffuser
• No heat diffusion
• Pads can be changed easily according to patient
  preference
• Battery powered

24
Visual and Tactile Stimulation

• Visual Stimulation
• Colored fiber optic fibers are stimulating with
  bright color and contrast change despite existing
  visual impairment
• LED lighting in many colors and patterns
• Non-abrasive materials
• Non-frightening
• Tactile Stimulation
• Stuffed dolls used in studies to calm agitation
  have reported some success (18)
• Soft, pleasant texture
• Non-frightening shape to avoid inducing
  halucinations

25
Stimuli Delivery System
LED box
Fiber optics
Funnel aroma therapy fan
Battery pack
Fiber optics
Microcontroller
Battery pack
Microcontroller case
Speakers
LED box
CD player
BlueTooth AirCable
Funnel aroma therapy fan
Speakers

• Features
• Microcontroller case contains most of the
  components
• Fiber optic cables can be removed from LED box
• This allows nurses to remove all electronics for
  replacement and cleaning

26
Stimulation Control

• Sharp Change or Relative Threshold
• Sharp Change
• Any combination of two of the following
• 5 beats/minute
• 1 F/ 5 minutes
• 5 consecutive recessive readings in GSR
• Will evolve with further study
• The definition of a sharp change will decrease if
  the threshold for that sensor is reached.

27
Stimulation Control

• Relative Threshold
• Relative to the persons baseline measurement
• Either of the following
• 15 beats
• 1.5 F
• GSR stays the same
• Will evolve with further study
• In place to ensure gradual changes are recognized
  as well

28
Cost Analysis
Components Cost
Microcontroller (2) 118.00
Blue Tooth Air Cables (2) 138.00
Rechargeable Battery Pack (2) 34.00
Galvanic Skin Response 18.00
RTD Temperature Sensor 39.00
Polar Heart Rate Monitor 91.00
Wild Republic 28' Plush Whale 29.94
Sony Psych Walkman 31.79
Sony Desktop Speakers 27.94
Aura Cacia Aromatherapy Diffuser 16.67
Lavender Lemon Essential Oils 8.37
Fiber Optic Strands 37.00
LEDs Parts 27.50
Zipper, thread, Velcro, ect 15.00
Total Cost 632.21
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Total Cost Estimate

• Total Cost 632.21
• When weighed against nursing staff time based on
  study findings
• 26.39 average RN hourly pay 11.12
  average CNA hourly pay
• In an long term care facility where 2 CNAs and 1
  RN are responsible for 22 patients the staff to
  patient ratio is 17.33.
• 7.33 x 80 minutes per day 586.4 minutes or 9.77
  hours.
• ((.33 x 26.39) (.66 x 11.12)) x 9.77 156.61
• This facility spends 156.61 per day or
  57,162.65 per year for the management of
  agitated behaviors.
• The device pays for itself in approximately 4
  days in this situation, or 89 days for one device
  for every patient on the unit.

30
Current Progress

• Literature Review
• Understanding of relevant research
• Familiar with products available
• Prototype Design
• Selection of sensors and stimuli
• Selection of components needed for interfacing
  and control
• All components received
• Further technological refinement of device
  functioning
• wireless transmission of patient data to PC
• System learns patients stimuli preferences
• Construction
• 90-95 completed
• Manuscript
• Completed

31
Plan for Future Work

• Three Phase Project
• 1. Disseminate Research on Device Development
• Submit Abstract to 2007 31st Annual Research
  Conference Midwest Nursing Research Society in
  Omaha, Nebraska, March 23-26
• Submit manuscript for publication in Western
  Journal of Nursing Research.
• Improve device
• Wireless communication to nurse
• Data storage

32
Plan for Future Work

• Pilot MSE Device Functioning
• Obtain IRB approval
• First test on students to determine functionality
• -Stroop test to simulate agitation
• Submit pilot results to Gerontological Society of
  America (GSA) Annual Scientific Meeting Nov.
  2007.

33
Plan for Future Work

• Pilot Effect of MSE Device
• Pilot test device on group of Alzheimer's and
  dementia patients
• Clinical setting
• Observation
• Submit results to GSA Annual Scientific Meeting
  Nov. 2008

34
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