Managing dementia symptoms and needs using technology.

Dementia is a difficult and costly disease to manage. Although caregivers and patients have indicated they need support for activities of daily living and debilitating neuropsychological symptoms, most technology innovations focus on safety and social contact. This feasibility study tested a care technology designed to manage dementia symptoms and everyday routines using common, nonpharmacological interventions. It was implemented in two formal care environments (memory care, assisted living). In Sample 1, independent observers decided which symptoms were present or absent in individual residents pre-intervention and 1 and 2 months during the intervention. In Sample 2, independent observers determined the desired status (goals) for individual residents prior to intervention and evaluated resident status 1 and 2 months into the intervention. The intervention was associated with a reduction in symptoms and progression toward wellness goals, suggesting that nondrug interventions for managing symptoms and daily routines in dementia can be delivered effectively using advanced technology.

Design guidance for video chat system to support social engagement for older adults with and without mild cognitive impairment.

Background: Social engagement technologies offer an opportunity to reduce social isolation. However, there are barriers to adoption among older adults with and without Mild Cognitive Impairment (MCI). Technology designed to meet the needs of those users may improve the acceptability, adoption, and benefits of social engagement technology. Objective: The goal was to assess older adults' needs and preferences for using video chat systems. We used the Technology Acceptance Model as a framework for evaluating and optimizing usability of a web-based video chat system for older adults with and without MCI. Methods: Mixed methods (qualitative and quantitative) were used to achieve this objective. We developed questionnaires and interviews to identify experiences with video chat, and preferences and attitudes towards a web-based video chat system. We conducted heuristic analysis to evaluate and improve the usability of the system. Results: Participants reportedly used video chat less than other social network tools (e.g., Email). They were open to using a web-based video chat system to meet new people of all ages with shared interests. Their favorite topics of conversation were books, health, family, and exercise. Their ideal group size for a video chat session was 3 to 6 people. Overall, participants' attitudes toward the system were positive and they perceived the system as easy to use and useful for social engagement. Their evaluations indicated high usability of the system. However, individuals with MCI might require additional assistance to use the system. Usability issues were identified, such as technical terminology, small font size, and potentially confusing icons that were addressed in the redesign. Conclusion: Older adults, with and without MCI, were interested in using a social engagement technology to interact with previously unfamiliar individuals with shared interests. They provided valuable insights for the design of the systems. Our findings provide guidance for the design of social engagement technologies. Our research approach serves as a case study for the assessment of other technology platforms.

Preserved memory function during bispectral index-guided anesthesia with sevoflurane for major orthopedic surgery.

BACKGROUND: Memory function under anesthesia is undesired but may arise from light hypnosis as well as stress-enhanced learning during surgery. The bispectral index (BIS, Aspect Medical Systems, Norwood, MA) is a monitor of hypnotic state that can help to avoid light hypnosis (i.e., BIS above 60). This study tested the hypothesis that BIS-guided anesthesia maintaining BIS 50-60 reduces the likelihood of memory function under anesthesia. METHODS: After obtaining informed consent, 128 patients scheduled for joint replacement surgery under general anesthesia with sevoflurane were randomly assigned to BIS-guided anesthesia, titrating drugs to BIS 50-60 (BIS group), or a standard practice group in which BIS was recorded but did not guide drug administration. After induction, all patients were repeatedly played a list of 15 words. After recovery from anesthesia, all were interviewed about recall and completed a recognition memory test containing the presented words (targets, 33.3%) and new words (distractors). Preoperatively, patients filled out a stress questionnaire (Spielberger State-Trait Anxiety Inventory). RESULTS: BIS values above 60 were recorded in both groups, but no patient recalled the presented words postoperatively. Only patients in the BIS group selected targets more often than distractors (37.1% vs. 31.5% hit rate, P = 0.001). Target hit rates correlated poorly to stress scores (P > 0.9), but were associated with the amount of fentanyl received preoperatively (P = 0.01) and pain management technique (P < 0.01). CONCLUSIONS: BIS titration to BIS 50-60 does not necessarily curb memory function under anesthesia when BIS values higher than 60 occur. Preoperative analgesia attenuated the likelihood of memory function under anesthesia.

Functional connectivity changes with concentration of sevoflurane anesthesia.

Low-frequency oscillations (<0.08 Hz) have been detected in functional magnetic resonance imaging studies, and appear to be synchronized between functionally related areas. The effect of anesthetic agents on cortical activity is not completely characterized. This study assessed the effect of anesthesia on the temporal relations in activity in the motor cortices. Resting-state magnetic resonance data were acquired on six volunteers under different anesthetic states (using 0.0%, 2.0% and 1.0% stable end-tidal sevoflurane). Across all volunteers, the number of significant voxels (p<2.5 x 10) in the functional connectivity maps was reduced by 78% for light anesthesia and by 98% for deep anesthesia, compared with the awake state. Additionally, significant correlations in the connectivity maps were bilateral in the awake state but unilateral in the light anesthesia state.

Reluctant acceptance of xenotransplantation in kidney patients on the waiting list for transplantation.

Previous research has shown contradictory results regarding the acceptance of xenotransplantation (XT) by kidney patients. This variance in attitude towards XT could be explained by differences in knowledge of XT, the availability of alternative treatment options, specific beliefs and cognitions of the patient, and differences in the health status of the patients. We studied 61 patients in this contention in the Netherlands waiting for a kidney transplant. All took part in in-depth interviews and filled out questionnaires on two occasions, once before and once after an information brochure on XT had been read. We found that a better health status is correlated with a greater acceptance of XT, but only before information was given. After information had been given, the acceptance of XT decreased significantly. However, if XT is the only possibility in a life-threatening situation, almost all patients are willing to accept XT, except for a small group (approximately 10-15%) with fundamental religious and/or spiritual objections against such treatment. When alternative treatment options such as a human cadaver donor, a living related donor or commercial donor are offered, the majority of patients would prefer those to XT. The main reason for reluctance is uncertainty about the risks of XT to personal health. Because alternatives are currently available, we expect that XT will become more popular only if future results of this procedure have proved to be comparable to transplantation with a human donor kidney.

Personalized technology to support older adults with and without cognitive impairment living at home.

Although persons with dementia (PWD) and their family caregivers need in-home support for common neuropsychiatric symptoms (NPS), few if any assistive technologies are available to help manage NPS. This implementation study tested the feasibility and adoption of a touch screen technology, the Companion, which delivers psychosocial, nondrug interventions to PWD in their home to address individual NPS and needs. Interventions were personalized and delivered in home for a minimum of 3 weeks. Postintervention measures indicated the technology was easy to use, significantly facilitated meaningful and positive engagement, and simplified caregivers' daily lives. Although intervention goals were met, caregivers had high expectations of their loved one's ability to regain independence. Care recipients used the system independently but were limited by cognitive and physical impairments. We conclude the Companion can help manage NPS and offer caregiver respite at home. These data provide important guidance for design and deployment of care technology for the home.

Altered local coherence in the default mode network due to sevoflurane anesthesia.

Recently we introduced a robust measure, integrated local correlation (ILC), of local connectivity in the brain using fMRI data which reflects the temporal correlation of brain activity in every voxel neighborhood. The current work studies ILC in fMRI data obtained in the absence and presence of sevoflurane anesthesia (0%, 2%, and 1% end-tidal concentration, respectively) administered to healthy volunteers. ILC was determined specifically in regions of the default mode network (DMN) to address local changes in each state. In addition, a potential confound in analyses based on correlations due to signal-to-noise variations was addressed by wavelet denoising. This accommodated decreases in signal power commonly seen during anesthesia without artificially reducing derived correlations. Results showed that ILC was significantly reduced in the entire DMN during 2% sevoflurane yet recovered in the posterior and anterior cingulate cortices as well as inferior parietal cortex during 1% sevoflurane. By contrast, ILC remained attenuated prefrontally in the 1% condition, which indicates uncoupling of the frontal areas of DMN during light anesthesia. These results confirm widespread anesthetic-induced cortical suppression but also demonstrate that the local connectivity of the prefrontal cortex is rapidly reduced by sevoflurane. It remains to be seen whether these alterations arise locally as a direct consequence of anesthetic action on local neurons or are driven by distant changes in oscillations and activity elsewhere in the brain.

No evidence of memory function during anesthesia with propofol or isoflurane with close control of hypnotic state.

BACKGROUND: The authors previously demonstrated memory function during apparently adequate general anesthesia in trauma patients. Hypnotic state fluctuations, stress, and variable amnesic qualities of commonly used anesthetics could account for this effect. METHODS: The authors replicated the trauma investigation in 90 elective surgical patients to enable anesthetic titration to a bispectral index value of 50-55 during auditory presentation of word stimuli. Patients were randomly assigned to maintenance with propofol (n = 48) or isoflurane (n = 42). Before surgery, state anxiety and trait anxiety were assessed using self-report measures. Postoperative memory assessment relied on the process dissociation procedure using a word stem completion task. RESULTS: There were no differences between groups for relevant demographic, preoperative, or supplemental drug variables. Ninety-eight percent of words were presented within a bispectral index range of 40-60, with values averaging 48.8 (SD = 5.7) during word presentation. Neither the process dissociation procedure nor standard measures of conscious recall and recognition memory showed evidence of explicit or implicit memory. Preoperative stress levels did not correlate with postoperative memory test scores in either study group. CONCLUSIONS: In contrast to the results of their previous study, the authors found no evidence of memory function with close control of hypnotic state. This suggests that hypnotic state fluctuations are important to memory activation under anesthesia. Other variables may contribute to preserved memory function as well. Propofol and isoflurane block memory equally well during adequate anesthesia.

Attenuated brain response to auditory word stimulation with sevoflurane: a functional magnetic resonance imaging study in humans.

BACKGROUND: Functional magnetic resonance imaging offers a compelling, new perspective on altered brain function but is sparsely used in studies of anesthetic effect. To examine effects on verbal memory encoding, the authors imaged human brain response to auditory word stimulation using functional magnetic resonance imaging at different concentrations of an agent not previously studied, and tested memory after recovery. METHODS: Six male volunteers were studied breathing 0.0, 2.0, and 1.0% end-tidal sevoflurane (awake, deep, and light states, respectively) via laryngeal mask. In each condition, they heard 15 two-syllable English nouns via closed headphones. Each word was repeated 15 times (1/s), followed by 15 s of rest. Blood oxygenation level-dependent brain activations during blocks of stimulation versus rest were assessed with a 3-T Siemens Trio scanner and a 20-voxel spatial extent threshold. Memory was tested approximately 1.5 h after recovery with an auditory recognition task (chance performance = 33% correct). RESULTS: Scans showed widespread activations (P < 0.005, uncorrected) in the awake state, including bilateral superior temporal, frontal, and parietal cortex, right occipital cortex, bilateral thalamus, striatum, hippocampus, and cerebellum; more limited activations in the light state (bilateral superior temporal gyrus, right thalamus, bilateral parietal cortex, left frontal cortex, and right occipital cortex); and no significant auditory-related activation in the deep state. During recognition testing, subjects correctly selected 77 +/- 12% of words presented while they were awake as "old," versus 32 +/- 15 and 42 +/- 8% (P < 0.01) correct for the light and deep stages, respectively. CONCLUSIONS: Sevoflurane induces dose-dependent suppression of auditory blood oxygenation level-dependent signals, which likely limits the ability of words to be processed during anesthesia and compromises memory.

Awareness: Monitoring versus remembering what happened.

BACKGROUND: Awareness during anesthesia is foremost assessed with postoperative interviews, which may underestimate its incidence. On-line monitors such as the Bispectral Index and patient response to verbal command are not necessarily commonly used. This study investigated response to command during deep sedation (Bispectral Index 60-70) and the ability of prevailing monitoring techniques to indicate awareness and predict recall. METHODS: The authors systematically assessed the response to command using the isolated forearm technique while monitoring electroencephalographic and hemodynamic variables. Fifty-six elective surgical patients were repeatedly given verbal instructions to squeeze the observer's hand during target-controlled infusion with propofol and alfentanil. After recovery, conscious recall was assessed with a short structured interview. RESULTS: Overall, 1,082 commands were given. No response was observed to 887 (82%) commands, an equivocal response was observed to 56 (5%) commands, and an unequivocal response was observed to 139 (13%) commands. Of the 37 patients (66%) with an unequivocal response to command ("awareness"), nine (25%) reported conscious recall after recovery. Their reports provided valuable insights as to how awareness may be adequately addressed. Hemodynamic variables poorly predicted awareness, whereas parameters derived from the encephalogram, especially the Bispectral Index, were highly significant predictors (P < 0.0001). Electroencephalographic parameters did not discriminate between patients with or without conscious recall, whereas heart rate and responsiveness to command did. CONCLUSIONS: The incidence of awareness is underestimated when conscious recall is taken as evidence. Awareness can be monitored on-line with behavioral and modern neurophysiologic measures. Providing feedback during intra-anesthetic awareness helps patients to cope with a potentially stressful situation.

Memory function during propofol and alfentanil anesthesia: predictive value of individual differences.

BACKGROUND: Conscious recall and implicit memory have been shown to depend on hypnotic state as measured by electroencephalographic (EEG) bispectral index (BIS). A third expression of memory (unconscious-controlled memory) was recently observed after moderate to light sedation (BIS, 70-80). The present study investigated memory function during deep sedation (BIS, 60-70). As memory effects are small, the authors studied potential predictors of individual differences in memory performance. METHODS: Memory function and speed of information processing were assessed in 56 outpatients before surgery. During propofol anesthesia supplemented with alfentanil, patients heard a series of words while anesthesia was titrated to BIS, 60-70. In between words, response to command was assessed using the Isolated Forearm Technique. The authors tested memory with a word stem completion task and process dissociation procedure to distinguish explicit from implicit effects. RESULTS: Mean (+/- SD) BIS during word presentation was 64.0 +/- 3. Patients with conscious recall of verbal commands (n = 9) did not recall or recognize presented words. Even so, the process dissociation procedure revealed evidence of memory by a significantly higher hit rate in the inclusion condition (0.26) than in the exclusion condition (0.12). Patients without conscious recall showed no evidence of memory for presented words. Hit scores correlated significantly with scores in the preoperative memory test (r = 0.35). CONCLUSIONS: The authors found evidence of weak explicit memory function during anesthesia titrated to BIS, 60-70. The observations strongly suggest that postoperative memory relates to awareness during anesthesia, but the nature of this relation remains unclear. Memory seems more likely in patients with good preoperative memory performance.