A resident reacts to family photos loaded onto a Connected Living device.
Charles de Vilmorin began developing Linked Senior as he watched his grandmother decline in a nursing home, where he says she often was isolated and her thoughts sometimes discounted because of her Alzheimer's disease diagnosis.
The agonizing personal experience led de Vilmorin to contemplate how technology might create more engaging opportunities for seniors dealing with dementia — the types of patients researchers think can benefit physically and cognitively from meaningful interactions.
Linked Senior uses mobile kiosks to deliver onscreen activities to residents or small groups, and much of the content can be used to create interactive experiences with dementia patients. Other Web-based and software-based applications work across a range of devices — all intended to link users with content ranging from nostalgic television shows to Tai Chi exercises to trivia — and are being incorporated into official activity programs in long-term and memory care centers.
“You really have a more productive team that is providing a better quality of care,” says de Vilmorin, who developed his touch screen friendly software after a career spent at children's toy maker Mattel. “Patients actually come out of their rooms more. They're more socially active.”
Building a strong mind-body connection isn't a new concept, but for years, care for dementia patients has focused on preventing problem behaviors rather than encouraging development. Federal pressure to reduce falls and decrease dependence on antipsychotic medications is forcing facilities to consider new programs that address cognitive deficits. Increasingly, technology-based interventions are being combined with physical activities to strengthen the whole person.
In his newest book, “Dementia Beyond Disease,” internist and geriatrician G. Allen Power, M.D., says the overdependence on antipsychotic medication is a reflection of a culture that defines people with dementia by their weaknesses.
But according to the Alzheimer's Association, it's only during the very severe, final stage of Alzheimer's disease that most patients suffer severe physical setbacks, such as abnormal reflexes, impaired swallowing and the inability to sit without support. Despite a disinclination to participate in activities of daily life, many will engage if given opportunities to do things that are important to them.
“Just because they're cognitively impaired doesn't mean their senses are gone,” says Anna Fisher, Ph.D., director of Quality and Education for Hillcrest Health Services. “You never know what someone is capable of until you try.”
Five years ago, Fisher helped launch a Montessori program for residents and adult day services patients. The weekly program includes about 100 cognitively and physically stimulating activities that residents choose. Some, like a balance beam-like walk, are geared toward developing gross motor skills. Others, such as flower sorting and arranging, encourage fine motor skills.
Power says even those with advanced cognitive changes can experience personal growth in the face of other declining skills if they experience identity, connectedness, security, autonomy, meaning, growth and joy.
“Those aspects of life are as much or more life-giving as any medical therapies we have,” he says.
Many long-term care facilities are looking at technology that enhances therapy and recreational activities.
Some programs can act like new-fangled memory kits, giving residents something to manipulate and reminisce over during troublesome times of day. For instance, when staff at one facility learned the “books” a memory care patient had been asking for were accounting ledgers, Linked Senior created content that would connect him to his former career.
It's Never 2 Late is an interactive system that supports more than 4,000 pieces of content across computers positioned on adjustable, mobile carts.
Established in 1999, the company works with software developers such as TranslaCare's Iconotouch to deliver programs that connect with residents. It's up to residents (and the staff members who know them best) to pick games, songs, exercise classes, puzzles or quizzes that they'll find compelling.
“I'm trying to give the therapist tools to engage your mind, entertain you, get you to interact and facilitate functional movement,” explains Chris Krause, director of the company's therapy business unit. “We can turn the most ridiculous things into physical activities.”
Patients who need to work on balance might be asked to stand and touch a computer screen that's extended overhead. Those who loved driving or tractors can choose to complete a task with a replica steering wheel; bike pedals can be manipulated by hands or feet; and a joystick helps residents work on controlling a power wheelchair.
Making an experience game-like helps users get through physical tasks and may help providers discover new ways to motivate specific patients, says Krause.
A 2010 report from Mather LifeWays found residents of Green House homes who used iN2L at least once a week were significantly more active, more energetic and higher functioning when it came to activities of daily living. They also expressed more positive emotions and demonstrated greater self-efficacy.
iN2L system start-up costs range from $1,700 to $10,000, depending on software, hardware and adaptive equipment. Facilities pay a monthly subscription of about $200 per system, but can have an unlimited number of users on each system.
Connected Living offers similar services across its Web-based tablet and kiosk system. CEO and Co-founder Sarah Hoit says employee training is essential for real connections.
Her company offers more than 150 courses for staff — CNAs, activity directors, therapists — who might be called upon to guide residents through touch screen experiences.
Meeting the mind
“It's about training. It's about content. It's about finding people where they're at,” Hoit says, noting that about 35% of her systems are in memory care centers, with another 40% in assisted living communities.
Using a tablet to share video from a grandchild's hockey game or developing an application that ties in to a resident's childhood home on Cape Cod may provide a motivating spark, Hoit says.
Connected Living's service can be used on personally owned tablets or added to those already owned by the facility. They're in 30 states and working to close the digital divide by partnering with publicly supported senior housing in Atlanta and Washington, D.C.
The rapid spread of wireless technology and new, pre-wired long-term care buildings has made connecting online even more appealing.
Ryan Ries, inventor of Iconotouch, developed it for patients with acquired speech deficiencies but quickly saw its potential to help with memory care. He developed the Web-based system so that it could be used on personal devices across multiple browsers and service providers. He wanted to avoid high, up-front equipment costs for communities, which aren't reimbursed for shared software even when using it exclusively for therapy.
Ries says if the system helps address sundowning behaviors or gets one patient off of antipsychotic medications, most will be able to swallow the monthly facility fees.
“If you can get somebody to use this to communicate, that's good,” says Ries, who has a background in neurobiology and linguistics. “You're also working on hand-eye coordination, you're working on motor skills and the rapidity of responses when seeing a prompt.”
Kathy Laurenhue launched a line of downloadable brain-building activities called Wiser Now and also develops content for iN2L. She says increasing brain activity can help dementia patients remain resilient when they begin to decline.
“If one pathway gets damaged, being able to take a detour is so helpful,” she says.
Laurenhue favors brain-body games like “Imaginary Balls,” in which one to 10 residents sit in a circle and pretend to throw each other various objects like footballs or drink pitchers. Imagination triggers new connections. She says even if residents don't remember exactly what they've learned, they may associate a positive feeling with the experience, and that makes them more willing to engage in the future.
Coordinated care best
There isn't a strict consensus yet on the advantages brain games can provide. But at a time when consumers are increasingly comfortable with technology, flashy electronic programs hold enormous promise.
“There's an opportunity to take some of these technologies to the next level, but we need evidence-based parameters,” says Linda Riccio, an occupational therapist who provides dementia care consulting.
Riccio has teamed up with St. Paul Hermitage and researchers from nearby Indiana University to study how regular use of iN2L affects cognitive impairment and fall reduction efforts. They'll be studying how often patients need to use the applications and how therapists can effectively add stretches and other exercises to the mix.
Anecdotally, Riccio says seniors with cognitive deficits can make gains, but she adds that CNAs and activity aides must know how to find and use key content — not rely on the 12 easiest applications as a one-size-fits-all solution. They also can't put tablets in residents' hands and leave them isolated in their rooms.
Part of the problem addressing the needs of the cognitively impaired, Riccio says, is frequent staff turnover. Many people can get better with therapy if they build a bond with their caregiver, but if that caregiver goes, so does the rapport and the knowledge collected.
Senior Helpers creates activity programs for homebound dementia patients (and some in skilled nursing facilities) by determining their rating on the “Senior Gems” scale developed by dementia expert Teepa Snow.
“This helps us identify their basic needs, but we also understand the importance of activities,” says Vice President of Training Christina Chartrand. “No matter what an individual's diagnosis, they need to wake up in the morning and feel like they have a purpose.”
For geriatric psychologist and retired administrator Mary Harroun, engaging seniors in meaningful activities begins with walking. She believes wheelchairs weaken residents and make them dependent on caregivers.
Harroun developed the GROW Program, a muscle-strengthening effort to get even cognitively impaired residents up and moving. It has been implemented at only one facility, but Harroun would like to see it and more restorative care mandated by the Centers for Medicaid & Medicare Services.
“To me, if one is ambulatory, more food is going to be ingested, regular sleep patterns are going to be realized, muscle mass will not decrease,” Harroun says. “The biggest thing is that stronger residents do not fall due to muscle weakness.”