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iPad Project

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on 10 March 2014

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Transcript of iPad Project

Introduction
Dementia is a growing problem in the United States
Behavioral and psychiatric symptoms of dementia (BPSD)
Pharmacologic interventions (antipsychotics) shown to be relatively unsafe and with poor efficacy
Need for non-pharmacologic interventions






Case/Feasibility Studies:
Goal of iPad use with patients at SBH
iPad as a tool for redirection
Personalizing iPad use to the patient based on interests and abilities:
Pandora, TalkingTom2, & Pottery
Individualizing iPad use through patient interactions, patient histories and suggestions from the interdisciplinary treatment team
iPad Study Patients
Next
Customization of iPad use to type of impairments
Understand human-device interaction:
deconstruction of cognitive processes used for apps
Feasibility study:
increasing sample size
decreasing confounders
Simulated Presence
M
Demographics:
82 y.o. Caucasian woman
Dementia NOS, Psychosis NOS
MoCA: 8/30
Behavioral and physical Concerns:
sundowning, agitation, perseveration, labile mood
high fall risk
M & the iPad:
iPad introduction
redirectable with iPad
Assessment of iPad interactions:
not independent
interaction with iPad and staff
memory of "amazing dog" app
iPads for Controling Behavior & Symptoms in Older Psychiatric Patients
Dementia & Associated Symptoms
iPad Use With Patients
I.
Protocol Development:
Macular degeneration and other vision impairments in pts (Such as our patient, I.=>anti-glare screen protector)
hearing impairments (speakers)
Understanding the appropriate use of the ipad for the purposes of the study:
i.e. appropriate to use in patients with chronic anxiety in acute anxiety spell?
Introducing the iPad to patients on admission
Fine-Tuning the Process
By Jennifer Gahan and Elizabeth Ryer
M Graph
The iPad Project
Study design: Open study design, in order to assess feasibility in a wide range of clinical presentations, and to generate hypotheses.
-case studies vs. feasibility study

Variables to measure and compare:
PRN Medication Administration
Behavioral changes before & after intervention
Case/Feasibility Studies:
General Study Design
Non-Pharmacological
Interventions for BPSD: Categories
Sensory
Stimulation-Oriented
Cognitive-Oriented
Emotion-Oriented
Behavioral
or Environmental-Oriented
i.e. Simulated presence therapy: audio recordings of a patient's family
i.e. Decreasing patient density in special care units
Teaching Points Learned Study So Far
iPad
Nurse #2
Nurse #1
Research Assistant
Social Interaction:
I. Graph
I. is a 91-year-old Caucasian female who presented to the Senior Behavioral Health unit with severe dementia (likely AD)
MoCA=8/25
Cognitive and visual impairments=>severe dementia
Preferred apps: Amazing Dog, Soilitaire, Pandora
Polypharmacy=>gabapentin=>sedation and confusion. Risperidone=>parkinsonianism
Co-morbidities: UTI and Psychosis NOS
A Case Study
Controls:
Other controls to consider for future studies: age, gender, severity of dementia, time of day/year, degree of impairment, highest level of education obtained, time iPad used, app used etc.
New Format:
Old Format:
Accounting for degree of staff interaction: how do we measure it?
Multi-Sensory Stimulation (MSS)
Amazing Dogs
iPad project at the Senior Behavioral Health (SBH) unit at UCSD Medical Center, Hillcrest

iPads are both stimulation- and cognitive-oriented non-pharmacological strategies to treat BPSD

Prior studies support the use of technology in improving symptoms in dementia patients

Benefits of using iPads:
customization to cognitive and physical impairments
broad spectrum of options


Talking Tom 2
The Pottery App
Introduction to iPad
Patient population
Tracking PRN Administration
agitation includes the following: restlessness, impulsivity, disruptiveness, irritability, anxiousness, pacing, yelling out, or difficulty redirecting.
Acknowledgments
Conclusions
Safely & effectivley use iPad with this population
no throwing/droping iPads
Diagnosis & presentation may effect ability to use iPad
delirum
stage of dementia, degree of cognitive impairment
Supplemental Hardware
Improvement in memory
A Possible Confounder
Thank you to Dr. Vahia, Omid Salaami, Dr. Jeste, Michelle Black, Dr. Sewell, SBH staff, M-STREAM
Antipsychotic Medications
Used in the elderly for delirium, dementia, or a primary psychotic disorder
Delirium: for agitation and confusion (Haloperidol, perhaps olanzipine)
Dementia (AD): for psychosis and agitation (large-scale trials for haldol, risperidone, olanzipine, quietapine, aripiprazole)
Considerations for the elderly: AE's, drug metabolism, comorbidities=> haldol and tardive dyskinesia in elderly, atypicals and orthostatic hypotension (concomitant meds)
Atypicals: diabetes and hyperlipidemia ('pines), increased risk of stroke (olanzipine/risperadone), QTc prolongation (ziprasidone)
Antipsychotic Medications: AE's
Haloperidol: EPS (mostly Parkinsonism and akathasia)
Clozipine: agranulocytosis, anticholingergic delirium, sedation, postural hypotension
Risperidone (effective for schizophrenia in elderly, agitation/psychosis seen in AD): metabolized by liver, excreted by kidney (watch out for liver/kidney disease)=> EPS & orthostatic hypotension (high doses); recent study=> stroke and TIA's
Antipsychotic Medications: AE's
Olanzapine: In elderly=> schizoprenia and agitation/psychosis in AD. AE's: Sedation, weight gain, hyperlipidemia, orthostatic hypotension, cerebrovascular accidents in dementia patients
Quietapine: for behavioral disturbances in AD and psychosis. AE's: sedation, orthostatic hypotension (less than other antipsychotics) and syncope
Ziprasidone: Qtc prolongation (avoid concomitant use of loop/thiazide diuretics and antiarrhythmics)
Aripiprazole: tx behavioral disturbances (psychosis and agitation) in AD=> sedation at high doses
Citations
Salzman C, Jeste DV, Meyer RE, Cohen-Mansfield J, Cummings J, Grossberg GT, Jarvik L, Kraemer HC, Lebowitz BD, Maslow K, Pollock BG, Raskind M, Schultz SK, Wang P, Zito JM, Zubenko GS. Elderly patients with dementia-related symptoms of severe agitation and aggression: consensus statement on treatment options, clinical trials methodology, and policy. J Clin Psychiatry. 2008 Jun;69(6):889-98. Review. PubMed PMID: 18494535; PubMed Central PMCID: PMC2674239.



Galante E, Venturini G, Fiaccadori C. Computer-based cognitive intervention for dementia: preliminary results of a randomized clinical trial. G Ital Med Lav Ergon. 2007 Jul-Sep;29(3 Suppl B):B26-32.
Kverno KS, Black BS, Nolan MT, Rabins PV. Research on treating neuropsychiatric symptoms of advanced dementia with non-pharmacological strategies, 1998-2008: a systematic literature review. Int Psychogeriatr. 2009 Oct;21(5):825-43. doi: 10.1017/S1041610209990196. Epub 2009 Jul 9. Review. PubMed PMID: 19586562; PubMed Central PMCID: PMC3058045.
Acevedo A, Loewenstein DA. Nonpharmacological cognitive interventions in aging and dementia. J Geriatr Psychiatry Neurol. 2007 Dec;20(4):239-49. Review. PubMed PMID: 18004010.
Jokel R, Rochon E, Anderson ND. Errorless learning of computer-generated words in a patient with semantic dementia. Neuropsychol Rehabil. 2010 Jan;20(1):16-41. doi: 10.1080/09602010902879859
Van Weert, van Dulman, Spreeuwenberg, Ribbe, and Bensing. "Behavioral and mood effects of Snoezelen integrated into 24-hour dementia care." J Am Geriatr Soc. 2005 Jan;53(1):24-33.
Schwab W, Messinger-Rapport B, Franco K. Psychiatric symptoms of dementia: Treatable, but no silver bullet. Cleve Clin J Med. 2009 Mar;76(3):167-74. doi: 10.3949/ccjm.76a.07270. Review. PubMed PMID: 19258463.
Citations, Cont'd
Folsom, David; Nyak, Gauri and Dilip V. Jeste. Antipsychotic Medications and the Elderly. Psychiatry Weekly August 2013
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