Adherence type impacts completion rates of frequent mobile cognitive assessments among older adults with and without cognitive impairment.

Background: Prior to a diagnosis of Alzheimer's disease, many individuals experience cognitive and behavioral fluctuations that are not detected during a single session of traditional neuropsychological assessment. Mobile applications now enable high-frequency cognitive data to be collected remotely, introducing new opportunities and challenges. Emerging evidence suggests cognitively impaired older adults are capable of completing mobile assessments frequently, but no study has observed whether completion rates vary by assessment frequency or adherence type. Methods: Thirty-three older adults were recruited from the Boston University Alzheimer's Disease Research Center (mean age = 73.5 years; 27.3% cognitively impaired; 57.6% female; 81.8% White, 18.2% Black). Participants remotely downloaded and completed the DANA Brain Vital application on their own mobile devices throughout the study. The study schedule included seventeen assessments to be completed over the course of a year. Specific periods during which assessments were expected to be completed were defined as subsegments, while segments consisted of multiple subsegments. The first segment included three subsegments to be completed within one week, the second segment included weekly subsegments and spanned three weeks, and the third and fourth segments included monthly subsegments spanning five and six months, respectively. Three distinct adherence types - subsegment adherence, segment adherence, and cumulative adherence - were examined to determine how completion rates varied depending on assessment frequency and adherence type. Results: Adherence type significantly impacted whether the completion rates declined. When utilizing subsegment adherence, the completion rate significantly declined (p = 0.05) during the fourth segment. However, when considering completion rates from the perspective of segment adherence, a decline in completion rate was not observed. Overall adherence rates increased as adherence parameters were broadened from subsegment adherence (60.6%) to segment adherence (78.8%), to cumulative adherence (90.9%). Conclusions: Older adults, including those with cognitive impairment, are able to complete remote cognitive assessments at a high-frequency, but may not necessarily adhere to prescribed schedules.

Rethinking Human Enhancement as Collective Welfarism.

Human enhancement technologies are opening tremendous opportunities but also challenges to the core of what it means to be human. We argue that the goal of human enhancement should be to enhance quality of life and well-being not only of individuals but also of the communities they inhabit.

Computerized cognitive testing norms in active-duty military personnel: Potential for contamination by psychologically unhealthy individuals.

Normative reference data used for clinical interpretation of neuropsychological testing results are only valid to the extent that the sample they are based on is composed of "normal" individuals. Accordingly, efforts are made to exclude individuals with histories and/or diagnoses that might bias test performance. In this report, we focus on these features in active-duty military personnel because published data on computerized neurocognitive testing norms for this population have not explicitly considered the consequences of neurobehavioral disorders (e.g., PTSD, depression), which are prevalent in this population and known to affect performance on some cognitive assessments. We administered DANA, a mobile, neurocognitive assessment tool, to a large sample of active-duty military personnel and found that scores on self-administered psychological assessments negatively impacted a number of neurocognitive tests. These results suggest that neurobehavioral disorders that are relatively common in this population should be controlled for when establishing normative datasets for neurocognitive outcomes.

Behavioral health characteristics of a technology-enabled sample of Alzheimer's caregivers with high caregiver burden.

BACKGROUND: Caregivers of persons with dementia/Alzheimer's disease (AD) experience considerable physical and psychological burdens associated with their caregiving role. Although mobile technologies have the potential to deliver caregiver supports, it is necessary to demonstrate that caregivers in need of these supports are technology-enabled, that they can be identified and accessed, and that they experience the same unfavorable mental health outcomes characteristic of the broader caregiving population. Our objective was to enroll a cohort of technology-enabled caregivers to determine basic demographic characteristics and assess level of caregiver burden, depression, anxiety, and sleep disturbance as part of a larger project to deliver caregiver support. METHODS: Web-based enrollment and data collection measuring caregiver burden with the Zarit Burden Interview (ZBI), anxiety and depression with the M-3, and sleep disturbance with the PROMIS Sleep Disturbance form. RESULTS: A total of 165 caregivers enrolled via an online portal, all of whom provided care for someone with AD and owned a smart phone. Mean age of this group with 57.9 years, 90.3% was female, 88.5% was White, 51.5% reported providing care for a parent, 9.3% reported providing care for more than 10 years, and 24.8% reported providing more than 100 hours of care each week. Sixty-four percent of caregivers screened positive for both anxiety and depression, and nearly 62% of the sample had moderate or severe caregiver burden. Scores on depression, anxiety, and sleep quality assessments correlated moderately or strongly with caregiver burden. CONCLUSIONS: Dementia caregivers with Internet and smartphone access demonstrate high levels of caregiver burden, depression, and anxiety, and are well-suited to receive caregiver support services delivered via mobile devices that target these issues.

Cognitive Health Assessment and Establishment of a Virtual Cohort of Dementia Caregivers.

BACKGROUND: Many factors impact caregivers' cognitive health and, by extension, their ability to provide care. This study examined the relationship between psychosocial factors and cognitive performance among dementia caregivers and established a virtual cohort of caregivers for future research. METHODS: Data on 527 caregivers were collected via a Web-based survey that assessed cognitive performance. Caregiver data were compared to corresponding data from 527 age-, race-, gender-, and education-matched controls from a normative database. Caregiver self-reported sleep, stress, health, and social support were also assessed. RESULTS: Caregivers performed significantly worse than controls on 3 of 5 cognitive subtests. Stress, sleep, perceived support, self-rated health, years of caregiving, race, and gender were significant predictors of cognitive performance. CONCLUSION: In this sample of dementia caregivers, psychosocial factors interacted in complex ways to impact cognitive performance. Further investigation is needed to better understand how these factors affect cognitive performance among caregivers. This could be accomplished by the establishment of a virtual cohort that facilitates the development of digital tools to support the evaluation and management of caregiver needs in a manner that helps them remain effective in their caregiving roles.

From battlefield to home: a mobile platform for assessing brain health.

Cognitive testing batteries have been used for decades to diagnose deficits associated with conditions such as head injury, age-related cognitive decline, and stroke, and they have also been used extensively for educational evaluation and planning. Cognitive testing is generally office-based, administered by professionals, uses paper and pencil testing modalities, reports results as summary scores, and is a "one shot deal" whose primary objective is to identify the presence and severity of cognitive deficit. This paper explores innovative departures from historical cognitive testing strategies and paradigms. The report explores (I) a shift from disease diagnosis in the office setting to mobile tracking of cognitive health and wellness in any setting; (II) the strength of computer-based cognitive measures and their role in facilitating development of new computational methods; and (III) using cognitive testing to inform on individual-level outcomes over time rather than dichotomous metrics at a single point in time.

The impact of multiple concussions on emotional distress, post-concussive symptoms, and neurocognitive functioning in active duty United States marines independent of combat exposure or emotional distress.

Controversy exists as to whether the lingering effects of concussion on emotional, physical, and cognitive symptoms is because of the effects of brain trauma or purely to emotional factors such as post-traumatic stress disorder or depression. This study examines the independent effects of concussion on persistent symptoms. The Defense Automated Neurobehavioral Assessment, a clinical decision support tool, was used to assess neurobehavioral functioning in 646 United States Marines, all of whom were fit for duty. Marines were assessed for concussion history, post-concussive symptoms, emotional distress, neurocognitive functioning, and deployment history. Results showed that a recent concussion or ever having experienced a concussion was associated with an increase in emotional distress, but not with persistent post-concussive symptoms (PPCS) or neurocognitive functioning. Having had multiple lifetime concussions, however, was associated with greater emotional distress, PPCS, and reduced neurocognitive functioning that needs attention and rapid discrimination, but not for memory-based tasks. These results are independent of deployment history, combat exposure, and symptoms of post-traumatic stress disorder and depression. Results supported earlier findings that a previous concussion is not generally associated with post-concussive symptoms independent of covariates. In contrast with other studies that failed to find a unique contribution for concussion to PPCS, however, evidence of recent and multiple concussion was seen across a range of emotional distress, post-concussive symptoms, and neurocognitive functioning in this study population. Results are discussed in terms of implications for assessing concussion on return from combat.

AltitudeOmics: Decreased reaction time after high altitude cognitive testing is a sensitive metric of hypoxic impairment.

Humans experiencing hypoxic conditions exhibit multiple signs of cognitive impairment, and high altitude expeditions may be undermined by abrupt degradation in mental performance. Therefore, the development of psychometric tools to quickly and accurately assess cognitive impairment is of great importance in aiding medical decision-making in the field, particularly in situations where symptoms may not be readily recognized. The present study used the Defense Automated Neurobehavioral Assessment (DANA), a ruggedized and portable neurocognitive assessment tool, to examine cognitive function in healthy human volunteers at sea level, immediately after ascending to an elevation over 5000 m, and following 16 days of acclimatization to this high altitude. The DANA battery begins with a simple reaction time test (SRT1) which is followed by a 20-min series of complex cognitive tests and ends with a second test of simple reaction time (SRT2). Tabulating the performance scores from these two tests allows the calculation of an SRT change score (dSRT=SRT1-SRT2) that reflects the potential effect of mental effort spent during the 20-min testing session. We found that dSRT, but not direct SRT in comparison to sea-level baseline performance, is highly sensitive to acute altitude-related performance deficits and the remission of impairment following successful acclimatization. Our results suggest that dSRT is a potentially useful analytical method to enhance the sensitivity of neurocognitive assessment.

AltitudeOmics: the integrative physiology of human acclimatization to hypobaric hypoxia and its retention upon reascent.

An understanding of human responses to hypoxia is important for the health of millions of people worldwide who visit, live, or work in the hypoxic environment encountered at high altitudes. In spite of dozens of studies over the last 100 years, the basic mechanisms controlling acclimatization to hypoxia remain largely unknown. The AltitudeOmics project aimed to bridge this gap. Our goals were 1) to describe a phenotype for successful acclimatization and assess its retention and 2) use these findings as a foundation for companion mechanistic studies. Our approach was to characterize acclimatization by measuring changes in arterial oxygenation and hemoglobin concentration [Hb], acute mountain sickness (AMS), cognitive function, and exercise performance in 21 subjects as they acclimatized to 5260 m over 16 days. We then focused on the retention of acclimatization by having subjects reascend to 5260 m after either 7 (n = 14) or 21 (n = 7) days at 1525 m. At 16 days at 5260 m we observed: 1) increases in arterial oxygenation and [Hb] (compared to acute hypoxia: PaO2 rose 9±4 mmHg to 45±4 while PaCO2 dropped a further 6±3 mmHg to 21±3, and [Hb] rose 1.8±0.7 g/dL to 16±2 g/dL; 2) no AMS; 3) improved cognitive function; and 4) improved exercise performance by 8±8% (all changes p<0.01). Upon reascent, we observed retention of arterial oxygenation but not [Hb], protection from AMS, retention of exercise performance, less retention of cognitive function; and noted that some of these effects lasted for 21 days. Taken together, these findings reveal new information about retention of acclimatization, and can be used as a physiological foundation to explore the molecular mechanisms of acclimatization and its retention.

Prevention of surgical skill decay.

The U.S. military medical community spends a great deal of time and resources training its personnel to provide them with the knowledge and skills necessary to perform life-saving tasks, both on the battlefield and at home. However, personnel may fail to retain specialized knowledge and skills if they are not applied during the typical periods of nonuse within the military deployment cycle, and retention of critical knowledge and skills is crucial to the successful care of warfighters. For example, we researched the skill and knowledge loss associated with specialized surgical skills such as those required to perform laparoscopic surgery (LS) procedures. These skills are subject to decay when military surgeons perform combat casualty care during their deployment instead of LS. This article describes our preliminary research identifying critical LS skills, as well as their acquisition and decay rates. It introduces models that identify critical skills related to laparoscopy, and proposes objective metrics for measuring these critical skills. This research will provide insight into best practices for (1) training skills that are durable and resistant to skill decay, (2) assessing these skills over time, and (3) introducing effective refresher training at appropriate intervals to maintain skill proficiency.

Defense Automated Neurobehavioral Assessment (DANA)-psychometric properties of a new field-deployable neurocognitive assessment tool.

The Defense Automated Neurobehavioral Assessment (DANA) is a new neurocognitive assessment tool that includes a library of standardized cognitive and psychological assessments, with three versions that range from a brief 5-minute screen to a 45-minute complete assessment. DANA is written using the Android open-source operating system and is suitable for multiple mobile platforms. This article presents testing of DANA by 224 active duty U.S. service members in five operationally relevant environments (desert, jungle, mountain, arctic, and shipboard). DANA was found to be a reliable instrument and compared favorably to other computer-based neurocognitive assessments. Implications for using DANA in far-forward military settings are discussed.

Feasibility of gestural feedback treatment for upper extremity movement in children with cerebral palsy.

External feedback of performance is an important component of therapy, especially for children with impairments due to cerebral palsy because they lack intrinsic experience of "good movements" to compare effort and determine performance outcomes. A robotic therapy system was developed to provide feedback for specific upper extremity movements (gestures) which are therapeutically desirable. The purpose of this study was to compare changes in forearm supination/pronation or wrist extension/flexion motion following conventional therapy and gestural robotic feedback therapy intervention. Six subjects with cerebral palsy (ages 5-18, GMFCS level IV--three subjects, level III--one subject, and level I--two subjects) participated in a blinded crossover design study of conventional and robotic feedback therapy targeting either forearm supination or wrist extension. Functional upper extremity motion at baseline and following conventional and robotic feedback therapy interventions were obtained using a motion capture system by personnel blinded to the intervention order. All activities were approved by IRB. Use of the robotic feedback system did result in slightly increased movement in the targeted gesture without change in untargeted motions. Data also suggest a decrease in both agonist and antagonist motion following conventional therapy intervention. Results suggest improved motion when robotic feedback therapy intervention precedes conventional therapy intervention. Robotic feedback therapy is no different than conventional therapy to improve supination or wrist extension function in upper extremity impairments of children with cerebral palsy when changes were considered as aggregate data. In this very small group of diverse patients, individual subject results suggested that intervention order could be responsible for obscuring differences due to intervention type. Outcomes from several individual subjects suggest that results could be different given a more homogeneous group of subjects which future studies should be considered to ultimately determine efficacy of the robotic feedback therapy. Future studies should also address efficacy in other neuromuscular patient populations.

Distance and Size Perception in Astronauts during Long-Duration Spaceflight.

Exposure to microgravity during spaceflight is known to elicit orientation illusions, errors in sensory localization, postural imbalance, changes in vestibulo-spinal and vestibulo-ocular reflexes, and space motion sickness. The objective of this experiment was to investigate whether an alteration in cognitive visual-spatial processing, such as the perception of distance and size of objects, is also taking place during prolonged exposure to microgravity. Our results show that astronauts on board the International Space Station exhibit biases in the perception of their environment. Objects' heights and depths were perceived as taller and shallower, respectively, and distances were generally underestimated in orbit compared to Earth. These changes may occur because the perspective cues for depth are less salient in microgravity or the eye-height scaling of size is different when an observer is not standing on the ground. This finding has operational implications for human space exploration missions.

Geometric illusions in astronauts during long-duration spaceflight.

In our previous studies, we have shown that the occurrence of geometric illusions was reduced in vestibular patients who presented signs of otolith disorders and when healthy observers were tilted relative to gravity. We hypothesized that the alteration in the gravitational (otolith) input was responsible for this change, presumably because of a connection between vestibular and visual-spatial cognitive functions. In this study, we repeated similar experiments in astronauts during long-duration spaceflight. In agreement with the data of otolithic patients, the inverted-T geometric illusion was less present in the astronauts in 0 g than in 1g. In addition, the vertical length of drawings made by astronauts in orbit was shorter than that on the ground. This result is also comparable with the otolithic patients who perceived the vertical length of line drawings to be smaller than healthy individuals. We conclude that the impairment in the processing of gravitational input in long-duration astronauts affects their mental representation of the vertical dimension similar to the otolithic patients. The astronauts, however, recover to baseline levels within 1 week after returning to Earth.

Assessment of laparoscopic surgical skill acquisition and retention.

Currently, a need exists for a more comprehensive understanding of the nature of laparoscopic surgical skill acquisition and decay; novel, objective metrics with which to assess these skills over time; and simulation-based training that supports rapid acquisition, longitudinal retention, and targeted retraining for sustainment of these critical and perishable skills. This pilot study examined traditional metrics of laparoscopic surgical skills training, as well as a novel motion tracking metric using an instrumented glove. Data were compared for PreTest, PostTest following training to specified proficiency levels, and ReTest following an 8-10 week retention period, as well as comparison to expert performance. Despite a small number of complete data sets (n=5 novice, n=1 expert), these preliminary results demonstrate a lack of sensitivity of the current manual skills assessment metrics and demonstrate initial technical feasibility for the development of novel objective metrics based on instrumented glove motion tracking data.

Development of an interactive upper extremity gestural robotic feedback system: from bench to reality.

Development of an interactive system to treat patients with movement impairments of the upper extremity is described. Gestures and movement of patients as instructed by therapists are detected by accelerometers and feedback is provided directly to the patient via a robot.

Therapeutic robotics for children with disabilities: a case study.

The advancement of technology is having a profound effect on enhancing the lives of children with disabilities. As advances in biomedical technology allow research breakthroughs to continue at a steady pace, more and more is being discovered about the nature of different disorders in children. At the same time, partly due to the continuing rapid rate of advancement (and societal acceptance) of robotics technology, researchers, educators, and therapists are exploring the idea that robots might be used as an effective therapeutic and educational tool. Over the past nine years, AnthroTronix has collaborated extensively with therapists, educators, researchers, parents, and children to uncover the therapeutic and educational benefits of including robotics as part of rehabilitation curriculum for children. As a central part of this effort, the company has worked with its colleagues to develop and refine the CosmoBot system, an interactive robotic toolkit designed to enhance therapy, education, and play for children with disabilities.

Secure telemonitoring system for delivering telerehabilitation therapy to enhance children's communication function to home.

A secure telemonitoring system was developed to transform CosmoBot system, a stand-alone speech-language therapy software, into a telerehabilitation system. The CosmoBot system is a motivating, computer-based play character designed to enhance children's communication skills and stimulate verbal interaction during the remediation of speech and language disorders. The CosmoBot system consists of the Mission Control human interface device and Cosmo's Play and Learn software featuring a robot character named Cosmo that targets educational goals for children aged 3-5 years. The secure telemonitoring infrastructure links a distant speech-language therapist and child/parents at home or school settings. The result is a telerehabilitation system that allows a speech-language therapist to monitor children's activities at home while providing feedback and therapy materials remotely. We have developed the means for telerehabilitation of communication skills that can be implemented in children's home settings. The architecture allows the therapist to remotely monitor the children after completion of the therapy session and to provide feedback for the following session.

Design evolution of an interactive robot for therapy.

This paper describes a project using telecommunication and robotics to develop a system that addresses developmental goals for children with disabilities. A user-centered design was employed to meet the needs of the end users: children with disabilities, therapists, educators, and parents. The design team developed the prototype robot system for therapy, education, and play. The robot system is an adaptable, programmable robot, designed to address a wide range of disabilities, interests, and developmental goals. The production design will include data collection and remote monitoring capabilities. The steps leading to the prototype and its evaluation are described, including identification of user needs and system requirements to satisfy these needs.