Web-Based Cognitive Health Coaching for Elders in a Home Environment

1. Web-Based Cognitive Health Coaching for Elders in a Home Environment Holly Jimison, PhD Misha Pavel, PhD ORCATECH Oregon Center for Aging & Technology

2. What Can Be Done about Cognitive Decline? • Good news • Neural plasticity at all ages • New drugs to delay cognitive decline • Potentially good news • Monitoring computer interactions may detect decline earlier • Development of cognitive exercises to delay decline and possibly remediate ORCATECH

3. Project Objectives • Develop & test computer games for continuous cognitive monitoring of elders in a home environment • Sufficiently enjoyable to play frequently • Embedded assessment algorithms • Dynamic user models • Develop & test a cognitive health coaching system that provides opportunities for cognitive skill building • Assess cognitive deficits • Provide tailored cognitive exercises • Interactive cognitive health coaching ORCATECH

4. Problems with Current Cognitive AssessmentMethods • Assessments done only after concern on the part of the patient or caregiver – usually late • Repeated assessments infrequent – yearly at best • Large day-to-day variability in cognitive performance with onset of dementia • Unwanted variability in assessments due to education, language, motivation, etc. ORCATECH

5. Traditional Cognitive Tests • Verbal Fluency • Word List Learning • Constructional Praxis • Trail Making Test • Symbol Digit Modalities Test • Letter-Number Sequencing • Finger Tap Test ORCATECH

6. Adaptive Cognitive Computer Games • 30 users (all cognitively healthy) • Average age 81.5 yrs (standard dev= 6.04 yrs) • 13% male, 87% female • 9 Interactive games developed with Spry Learning as part of NIST grant • Being evaluated in local elders’ residences • Neuropsychological data was collected at baseline, 3 month, 6 month, and at a planned 1 year period ORCATECH

7. Elders’ Use of Computers • Growth in computer use by elders rose 47% since 2000 – fastest growing group • 70% use email • 59% Web browsing • 35% play computer games (similar to general population rate of 39%) ORCATECH

8. In-Home Monitoring of Computer Interactions • Frequent data  trend detection • Individual as their own control • Less influenced by • Educational background • Language • Cultural differences • Dynamic algorithms to model user performance • Inexpensive  screening, coaching ORCATECH

9. Game Data Analysis and Interpretation • Objective: Develop metrics that reflect cognitive capability and function of the players For Each Game • Ideal Player:Develop framework capturing the information processing resources and capabilities required by an ideal player • Cognitive Models and Limits:Describe ways that a human player may differ from an ideal one • Specific Metrics:Characterize the required cognitive processes by a small set of parameters ORCATECH

10. Letter Lotto – Word Game • Word games: • Word length • Word complexity • Speed of word generation • Total number of words • Compare to: • Verbal Fluency ORCATECH

11. Letter Generation Rate as a Game Metric ORCATECH

12. Letter Time vs. Neuropsychological Scores ORCATECH

13. Frequency Generation of Words by Length • Shorter words are guessed more frequently than longer ones • Exception is 7 letter word • Try harder because it’s the goal • Have to use all letters • Hence not necessarily most difficult ORCATECH

14. Neuropsychological Scores vs. Proportion of Words Neuropsych Score vs Proportion of Words ORCATECH Proportion of Generated Words

15. On the Flip Side – Memory Game • Memory games: • Short-term memory • Working memory • Spatial memory • Abstract reasoning ORCATECH

16. Deterministic Computational Model of Working Memory • Characterize Memory Capacity as a Function of: • Intervening number of events • Intervening time • Memory load • Simple Memory Model: Discrete Buffer Time, Events B A C D A E B C F B G H D G E I B A C D D E B B F F G H D D D B A C C D E E B E F G H H H B A B C D D E D E F G F F B C D D E F E E ORCATECH

17. Results ORCATECH

18. Examples of Other Fits ORCATECH

19. Weekly Tracking of Working Memory Buffer Size Relative Buffer Size ORCATECH

20. Estimation of Working Memory Capacity Square Root of Buffer Size ORCATECH

21. Assessment of Neuropsychological Test Scores Trail-Making Test B R = 0.60 Digit Span R = 0.36 ORCATECH

22. 0 0 8 18 0 0 19 21 Tally (2-D Black Jack) • Dual Task • games: • Divided attention • Working memory • Spatial memory ORCATECH

23. Evaluation Metrics high Cost low low Quality high ORCATECH

24. Response Time vs Quality of Move Subject ID:1020 HIGH-QUALITY LOW-QUALITY Value of subject move / value of Ideal move α = 3 in quality function FAST SLOW Response Time per move (sec) ORCATECH

25. Reference Players • Ideal Player- uniform card distribution- look a single move ahead- choose ‘loc*’ whereValuec(loc*)= min(Valuec(loci)), i = 1 … # empty loc Valueq(loc*)= max(Valueq(loci)), i = 1 … # empty loc • Chance Player- place card randomly- all locations are equally likely ORCATECH

26. Modeling Subject Reaction Time a= 9.9886 b= 38.4971 To= 1.284 s Te= 0.683 s RTmin= 2.9397 s Prob Searching Occ Loc Number of Occupied Locations Subject ID 1025 Avg RT per move “Serial Processing of locations” Number of Occupied Locations ORCATECH

27. ORCATECH

28. Modeling Subject Reaction Time ORCATECH

29. Modeling Subject Reaction Time Took more time looking at… Model shows these subjects don’t spend time searching empty locations ORCATECH

30. Cost and Benefits of Divided Attention Forced Bust-Win Unforced Bust Forced Bust ORCATECH

31. Pyramid Builder – Color / Shape Matching • Shape / color games: • Divided attention • Speed / accuracy • Visual search • Planning • Working memory ORCATECH

32. Response Time vs. Move Number File: tst3.mouse 8 • Response time (move duration) Increases with the Complexity of the Game • Average move duration increases with move number • Variance increases with move number 7 6 5 Response Time [Sec] 4 3 2 1 0 0 20 40 60 80 100 120 140 Move Number ORCATECH

33. Example: Response Time Distribution(Data from a Single Game) Multimodal distribution suggests • Fast responses to known or easy decision • Medium requiring some search and decision • Long – pondering and planning of execution ORCATECH

34. Resulting Search Efficiency Correlation with Trail-making B R = 0.49 ORCATECH

35. Scavenger Hunt – Trail Making Test • Rapid movement games: • Motor speed • Visual search • Set switching • Speed of processing • Divided attention • Compare to: • Finger Tap Test • Trail Making Test ORCATECH

36. Strategy games: • Planning • Visual search FreeCell – Solitaire Planning Game

37. User Performance Metrics • Difficulty dt = number of moves to solution at time t • User Performance • Reduction in difficulty • Outcome of game • Time to completion ORCATECH

38. FreeCell Performance Curve ORCATECH

39. Average (Individual Ave(Perf)) St Dev (Individual Ave(Perf)) Average (Individual SD(Perf)) Normals 0.58 0.12 0.38 Mild Cognitive Impairment 0.27 0.72 0.55 Performance Scores for Normals vs MCI ORCATECH

40. Benefits of Cognitive Computer Games Improvements over standard techniques: • Daily monitoring (not yearly, after-the-fact) • Individual as their own control • Adaptive measurement – more sensitive measure • Understanding of variability, trend detection • Unobtrusive, more representative performance • Potential for remediation ORCATECH

41. Cognitive Health Coaching Project Objectives Remote Cognitive Health Coaching to the Home • Provide tailored cognitive exercises & advice with tailored feedback • General coaching protocols based on principles of health behavior change • Using health behavior change techniques (motivational interviewing) • Tailored action plans • Automated feedback • Facilitate care manager and caregiver communications • Extend the outreach of health coaches • Tailored messaging / automated dynamic protocols • Incorporate patient and family members into the care team ORCATECH

42. Overview of Methods • Needs Assessment • Interviews & focus groups with patients, family caregivers, home health workers, clinicians, nurse care managers, payers • Interview researchers/experts with an interest in deploying and evaluating a health intervention in a home environment • Clinical / Behavioral Protocol Development (Cognitive) • Design Specifications • System Development • Implementation / Usability Testing / Stakeholder Feedback • Test in Homes of Elders ORCATECH

43. Elder Focus Group Findings • “Brain before body” • Most had multiple chronic diseases, but were not as interested in working on the “medical” aspects of health • Highest priorities were quality-of-life and independence • Advice for others • Considered depression and socialization to be the big problems for their age group • Many elders recognized a downward spiral in older people who became increasingly embarrassed about their abilities and appearance, so that they tended to avoid leaving their room or socializing. ORCATECH

44. Expert Interviews • Researchers • Government • Legislators, policy makers • Industry • Health record developers, interoperability specialists, disease management system vendors • Elder Care Professionals • Geriatricians, home health nurses, senior activity coordinators, health coaches • Cognitive Health Intervention Experts (continuing) ORCATECH

45. HomeCare Nurse / Coach Family Support Elder Cognitive Health Coaching Design Elder-Specific HRA Medication List Allergies Health Coaching System Shared Care Plan (PHR for Chronic Care) Diagnoses Lab Values Cognitive Protocols (Spry Games) Monitoring Modules Sensors ORCATECH

46. Welcome Ellen! Your Cognitive Exercise Plan Cognitive Coaching for Better Living Ellen – Last week you did a great job with the number of FreeCell and Sudoku exercises played. This week, in addition let’s try adding some verbal exercises, such as the Spelling Bee game featured below. Click here for more information on the importance of verbal exercise. Reply to Coach Previous Messages Update My Information View My Action Plan Ellen’s Cognitive Exercise Progress Detail on Progress Return to PHMS Log Off ORCATECH

47. Review of Methods • Needs Assessment • Interview researchers/experts with an interest in deploying and evaluating a health intervention in a home environment • Interviews & focus groups with patients, family caregivers, home health workers, clinicians, nurse care managers, payers • Clinical / Behavioral Protocol Development (Cognitive) • Design Specifications • Implementation / Usability Testing / Stakeholder Feedback • Test in Homes of Elders ORCATECH

48. Components of Cognitive Health Coaching • Adaptive Computer Games - Cognitive Exercise • NIST grant with Spry Learning • Adaptive cognitive games • Embedded cognitive assessment algorithms • Suite of 9 games measuring various aspects of cognition • Health Advice Related to Cognition • Physical exercise • Social Interactions • Nutrition • Sleep • Novelty exercises • Mood management (depression advice, humor) ORCATECH

49. Sample Message – Novelty Exercises Non-routine actions and thoughts encourage the growth of new connections in the brain. This week let’s work on novelty exercises that can exercise your brain. Here are some examples to choose from: □ Turn your desk clock or an illustrated calendar upside down. □ Go to a new park, or a new store. □ Try brushing your teeth with your non-dominant hand. □ Distinguish coins using only your sense of touch. □ Turn the volume off on television and invent the dialog based on what you see the characters doing. □ Find a magazine you normally wouldn't choose, and read it for a while. ORCATECH

50. Sample Message – Novelty Exercises ◙ Turn your desk clock & calendar upside down. When you look at a familiar image right side up, your left brain quickly labels it and diverts your attention to other things. When the picture is upside down, the quick-labeling strategy doesn't work and your right-brain kicks in, trying to interpret the shapes, color and relationships of a puzzling picture. This week, place at least one clock and your calendar upside down. Practice using them this way and see how it feels. Do you get better over time? Next week we’ll try something new. ORCATECH