Ashok Bharucha

Intelligent assistive technology applications to dementia care: current capabilities, limitations, and future challenges.

The number of older Americans afflicted by Alzheimer disease and related dementias will triple to 13 million persons by 2050, thus greatly increasing healthcare needs. An approach to this emerging crisis is the development and deployment of intelligent assistive technologies that compensate for the specific physical and cognitive deficits of older adults with dementia, and thereby also reduce caregiver burden. The authors conducted an extensive search of the computer science, engineering, and medical databases to review intelligent cognitive devices, physiologic and environmental sensors, and advanced integrated sensor networks that may find future applications in dementia care. Review of the extant literature reveals an overwhelming focus on the physical disability of younger persons with typically nonprogressive anoxic and traumatic brain injuries, with few clinical studies specifically involving persons with dementia. A discussion of the specific capabilities, strengths, and limitations of each technology is followed by an overview of research methodological challenges that must be addressed to achieve measurable progress to meet the healthcare needs of an aging America.

Predictors of nursing facility admission: a 12-year epidemiological study in the United States

Objectives: To identify predictors of institutionalization in a community‐based cohort of older adults.

Resident-to-Resident Aggression in Long-Term Care Facilities: Insights from Focus Groups of Nursing Home Residents and Staff

OBJECTIVES: To more fully characterize the spectrum of resident‐to‐resident aggression (RRA).

Motivations for Physician-assisted Suicide

AbstractOBJECTIVE: To obtain detailed narrative accounts of patients’ motivations for pursuing physician-assisted suicide (PAS). DESIGN: Longitudinal case studies. PARTICIPANTS: Sixty individuals discussed 35 cases. Participants were recruited through advocacy organizations that counsel individuals interested in PAS, as well as hospices and grief counselors. SETTING: Participants’ homes. MEASUREMENTS AND RESULTS: We conducted a content analysis of 159 semistructured interviews with patients and their family members, and family members of deceased patients, to characterize the issues associated with pursuit of PAS. Most patients deliberated about PAS over considerable lengths of time with repeated assessments of the benefits and burdens of their current experience. Most patients were motivated to engage in PAS due to illness-related experiences (e.g., fatigue, functional losses), a loss of their sense of self, and fears about the future. None of the patients were acutely depressed when planning PAS. CONCLUSIONS: Patients in this study engaged in PAS after a deliberative and thoughtful process. These motivating issues point to the importance of a broad approach in responding to a patient’s request for PAS. The factors that motivate PAS can serve as an outline of issues to explore with patients about the far-reaching effects of illness, including the quality of the dying experience. The factors also identify challenges for quality palliative care: assessing patients holistically, conducting repeated assessments of patients’ concerns over time, and tailoring care accordingly.

Time course of response to antidepressants in late-life major depression: Therapeutic implications

In the treatment of depression, there is considerable interest in the time course of response and, in particular, the speed with which individuals recover from depressive episodes. Examination of the time course and speed of response is critical for assessing the usefulness of specific treatments. However, while this issue has received attention in mid-life adult populations, it has received little consideration in the context of late-life major depression. The synthesis of empirical reports indicates that, while older adults with depression seem to respond with the same speed as mid-life adults, several factors have consistently been associated with reduced speed of response to antidepressant treatment, including greater severity of depressive symptoms and co-occurring anxiety symptoms. Limited evidence suggests that sleep impairment and genetic factors (e.g. presence of the s allele of the serotonin transporter gene promoter region) may also be associated with reduced speed of response. Some factors have consistently been found to be unrelated to speed of response (demographic characteristics, nonpsychiatric physical illnesses) whereas other factors have only mixed evidence supporting any effect (psychosocial and other clinical factors). While there is little work available to date, some evidence suggests that time course and speed of response affect longer-term outcomes of depression pharmacotherapy; thus, older adults with more rapid versus slower patterns of response may differ in the types of maintenance treatment needed to avert additional depressive episodes.None of potential strategies for accelerating speed of response have been clearly shown to be effective in late-life depression. Future treatment studies for late-life depression should routinely consider not only overall efficacy of a given pharmacotherapy (i.e. total rate of response), but time course and speed of response. To this end, new investigations must be designed to overcome the methodological limitations of prior studies that have examined time course and they should include a range of potential covariates and outcomes of between-patient differences in speed of response. Better understanding of factors related to such differences may suggest new intervention strategies to accelerate response.

Dining activity analysis using a hidden Markov model

We describe an algorithm for dining activity analysis in a nursing home. Based on several features, including motion vectors and distance between moving regions in the subspace of an individual person, a hidden Markov model is proposed to characterize different stages in dining activities with certain temporal order. Using HMM model, we are able to identify the start (and ending) of individual dining events with high accuracy and low false positive rate. This approach could be successful in assisting caregivers in assessments of residents activity levels over time.

Prevalence of Behavioral Symptoms: Comparison of the Minimum Data Set Assessments with Research Instruments

OBJECTIVE To examine the total and domain-specific prevalence of verbally and physically abusive, socially inappropriate, and care-resistive behaviors according to the Minimum Data Set (MDS) compared with research instruments in nursing home residents with severe dementia. DESIGN, SETTING, AND METHODS As part of a longitudinal observational study, MDS behavioral symptoms data were compared with corresponding items from the Ryden Aggression Scale and the Cohen-Mansfield Agitation Inventory for 15 nursing home residents with severe dementia. McNemars test was used to compare the difference in the proportion of subjects who experienced any symptoms, as well as specific symptoms in several domains, according to the MDS and the research instruments. Additionally, temporal fluctuations in behavioral symptoms were descriptively and graphically summarized. RESULTS The MDS significantly underestimated both the total proportion of subjects experiencing any behavioral symptoms (P = .016), as well as the proportion of subjects experiencing verbally abusive symptoms (P < .002), physically abusive symptoms (P = .008), or socially inappropriate behaviors (P = .016) compared with corresponding items from the research instruments. Moreover, these behaviors exhibited considerable temporal instability, suggesting that the systematic daily collection of measures of behavioral disturbances is imperative during the week in which the MDS assessment is to be completed. DISCUSSION Albeit from a small study sample, our findings call into question the validity of the MDS behavioral symptom items as they are currently recorded, and suggest that a simple intervention of twice daily completion of a behavioral symptoms checklist containing the MDS items during the week of the assessment may significantly improve the accuracy of the recorded data.

Intelligent Video Monitoring to Improve Safety of Older Persons

This paper presents the application of computer vision and machine learning technologies to a clinical task of paramount importance, improving safety of older persons. We propose an intelligent monitoring system equipped with a camera network and an automatic elopement detection algorithm to reduce the risks of un-witnessed elopements from a dementia unit in order to avoid their potential catastrophic consequences. The camera network employs 23 cameras to record daily activities in our test bed, which includes 15 residents, 4 registered and licensed practical nurses and a number of certified nursing assistants. An elopement detector is then built by using computer vision algorithms and a machine learning algorithm to automatically detect elopements and alert caregivers. The experiments demonstrate that the proposed system leverages the advantages of monitoring from multiple cameras and is able to detect elopements with almost 100% accuracy.

The pursuit of physician-assisted suicide: role of psychiatric factors.

Physician-assisted suicide (PAS) has attracted considerable professional attention in recent years in the end-of-life care debate. The role of depression and other psychiatric illnesses on the patients pursuit of PAS is unclear. As part of a qualitative study exploring the motivations, deliberations, and complications experienced by persons with incurable diseases who were actively seeking PAS, we conducted semistructured interviews that were reviewed for psychiatric content. In total, 159 interviews were conducted with 60 participants concerning 12 prospective cases (12 patients and 20 family members) and 23 retrospective cases (28 family members), with more than 3600 pages of transcripts. Depressive symptoms, when present, were not described by the subjects and/or their family members to be an influential factor in their pursuit of PAS; no subject appeared or was described to suffer from depression-related decisional incapacity. Findings from this study, albeit from a small and self-selected sample, highlight not only the importance of avoiding a reductionistic understanding of the role of psychiatric illnesses in contributing to serious pursuit of PAS, but also the pressing need for scientifically rigorous studies of PAS in samples representative of the larger population.

Treatment considerations for anxiety in the elderly.

Anxiety is common in the elderly and can present as a primary anxiety disorder or as a symptom of another disorder. Generalized anxiety disorder, in particular, is a common syndrome in late life. Anxiety symptoms are also common features of late-life depression and dementia. Treatment of anxiety in elderly persons has typically involved the use of benzodiazepines, which are often effective but problematic because they are associated with increased risk of cognitive impairment, falls, and fractures. Based on their safety and efficacy, antidepressants, particularly serotonergic medications, are considered first-line treatment for most anxiety disorders as well as anxiety symptoms of major depressive disorder. Psychotherapy, particularly cognitive-behavioral therapy, may be effective in these disorders as well; research is underway to adapt this therapy to the needs of elderly persons. Anxiety symptoms in dementia are poorly understood but may respond to atypical antipsychotics, serotonergic antidepressants, or mood stabilizers. Overall, the research in late-life anxiety has not caught up to the literature in late-life depression and, for the most part, treatment recommendations must be extrapolated from studies in young adults.