GeriTech

In Search of Technology that Improves Geriatric Care

quantified self

Sleep, Stress, and Sustaining Behavior Change

If you are interested in the non-pharmacological treatment of insomnia, an interesting item ran in the NY Times this week: “How Exercise Can Help Us Sleep Better.”

This particularly caught my eye for a few reasons. The main one is that sleep problems are a common complaint among older adults. And exercise is something that I’ve often recommended as part of an approach to improving sleep, whether the patient was a sixty-some year old caregiver, or a more elderly person with dementia.
Plus, as I’ve mentioned in a prior post, I myself have had frequent struggles with insomnia, and have sometimes applied to patients what I’ve learned from myself.
The thing is, it didn’t really seem that I slept much better on days when I got more exercise. Still, I’ve continued to recommend exercise to caregivers and frailer elders alike, given how beneficial exercise is over all. (It’s linked to better strength, better function, better mood, better health outcomes, better glucose control, etc.)
Do most of them manage to increase their exercise? Well, no. At least, not as far as I could tell, and determining how much people’s exercise levels have changed is a challenge because so far, I’ve mostly had to rely on people’s self-report, during a visit. (I’m still waiting to have a patient or caregiver use a Fitbit or other activity tracker.)
And does exercise in fact improve sleep? The Times article describes a fascinating new research study addressing this topic. 

A clinical study of sleep and exercise

To summarize: the study randomized 11 sedentary women (avg age 61 years old) with insomnia to a program of exercise 3x/wk versus no change. 
After four months, the women who were exercising regularly did have better sleep, and were sleeping on average 45-60 minutes longer every night.
But here’s the kicker: it took literally months of exercising before sleep got better. And on a day-to-day basis, most participants did not sleep better on days when they exercised. 
According to the Times article (the study’s author was interviewed), this is at odds with most research & the experience of many people, which is that exercise = better sleep that night.
However, Dr. Baron, the study’s lead author, notes that many studies of how exercise affects sleep used people who didn’t have insomnia at baseline. She goes on to explain that people with insomnia may be “neurologically different,” and have a “hyper-arousal of the stress system.” But if they maintain an exercise program, after a few months they do start to sleep better, which Dr. Baron attributes to a dampening of the stress response.
The study also found that participants exercised less on days after sleeping poorly, so in the short-term it seemed that sleep had more of an effect on exercise than vice-versa. 
The Times article concludes with Dr. Baron advising readers with chronic insomnia to start exercising regularly if they aren’t already doing so, but to bear in mind that improvements in sleep probably won’t be immediate and could very well take months.

Implications for the practice of geriatrics and general medicine

Would one find similar results if one studied a group of 85 year old women with poor sleep? And what if they had dementia? No one knows, and it’s quite possible that the results would be different since both aging and cognitive impairment are known to modify sleep patterns.
Still, these results are very important to the practice of geriatrics, because the study group sounded very similar to a population that we often work with: family caregivers.
Chronically stressed? Not enough time to exercise? Can’t sleep well at night?
Sound like anyone you know? Actually, it sounds a bit like me and other working mothers who have too much on their plate, but it also sounds like the women I see bringing their elderly loved ones to see the doctor, frazzled by the strains of worrying about a parent and taking on more and more caregiving duties.
And, the chronic stress of family caregivers is a very serious public health problem. It affects the health, wellbeing, and even workplace productivity of the caregivers themselves. Plus it often has a direct bearing on the health and wellbeing of the elderly person being cared for.
In general, stress is a huge and thorny problem in healthcare and for society. As a physician, I’ve often diagnosed stress as an important contributor to some significant health problem we’re trying to manage. But it’s very difficult to help people reduce their stress.
This study sheds some light on why: reducing one’s internal reactivity to stress takes time. A behavior change meant to reduce stress may need to be sustained for months. 
This is a tough challenge for all involved. Tired and stressed caregivers want relief now, and don’t have a lot of energy and bandwidth to stick with a behavior change for months. Clinicians want to help (and if they’ve kept up with best practices, want to help the patient minimize the use of pills for sleep or anxiety), but it’s hard to find a way to get patients to sustain behavior changes.

What tech solutions might help?

It’s not hard to envision how technology solutions might help. For those caregivers who have a smartphone or can access technology, it should be possible to
  • Log sleep and exercise. Ideally, with as little hassle as possible. Collecting this data can be helpful to clinician and caregiver when they meet to follow-up on a plan to increase exercise, decrease stress, and improve sleep. 
    • In some cases following data in real-time might help people maintain a behavior or technique (such as in biofeedback). 
    • Whether caregivers would find it helpful on a daily basis to see how much they’d slept every night is unclear to me; it could potentially be stressful to not see sleep improving as quickly as one wants it to.
  • Provide reminders and support to help caregivers maintain the exercise habit. There must be some way to leverage technology to help caregivers (or any patient/person) maintain an exercise habit, but I’m not sure which would work the best for the caregivers I work with. 
    • In fact, the multiple options available (there are so many apps/services available to help people meet fitness goals!) is a problem: making a choice is difficult!
    • Caregivers and patients would probably appreciate and value a recommendation from clinicians, but it might be hard for clinicians to make a recommendation unless it’s a product the clinician has already tried for him/herself.
      • We may also see companies aggressively market themselves to doctors, in hopes that their fitness app will be “prescribed.” I have mixed feelings about this since historically when business markets to doctors, the patients are not always well-served by the results.

In search of tech tools to try

Ok, so now let’s play a fun game called “Help-a-Doc.”
I am willing to try an app or service in the next few months to log my own sleep and exercise, and also to help me start and maintain a 3x/wk exercise habit. (And let’s see if it improves my sleep, which could stand to get better.)
If you have a recommendation to meet any of the needs above (sleep tracking, exercise tracking, and behavior change support), please post in the comments below, or drop me a line.
I’d like to eventually have some specific tools to suggest to caregivers and other non-frail adults who are struggling with sleep, exercise, and stress.

Pew Publishes Report on Family Caregivers

I’ve been a fan of Pew’s reports on health and the Internet for quite some time, but now I’m a superfan.

Just today, Pew has published a health report focusing on caregivers: Family Caregivers Are Wired for Health. Based on survey data collected in Aug-Sept of 2012 from 3014 adults, Pew found that 39% of respondents were caring for an adult or child with significant health issues.

The whole report is interesting, but here are some particular findings that caught my eye:

  • Pew’s survey found that 30% of adults were caregivers in 2010, compared to 39% now. 
    • This strikes me as a big jump; I’d love to eventually learn more about just what went into this increase. (Is an aging population and increased chronic disease burden enough to explain such a jump in 2 years?)
  • 86% of caregivers have Internet access; of those, 84% went online to research health topics. In comparison, 64% of non-caregivers with Internet access went online to research health topics.
    • I’m not surprised that caregivers are doing more research; families often seem more worried to me than patients do.
  • 39% of caregivers are helping to manage medications. 
    • The report doesn’t say how many medications they have to manage. But if you have someone else involved in your care, I’m guessing it’s a lot of medications. I’d love to eventually find out how many meds caregivers deal with on average.
  • Caregivers are more likely than non-caregivers to tap both online and offline information sources, such as clinicians, friends/family, or patient communities. Pew reports that “thirteen percent of caregivers were in contact with a clinician both online and offline, compared with 5% of non-caregivers.”
    • This is good, 13% of caregivers with access to clinical help online and offline. But we need to make it better.
  • One in three caregivers tracks a health indicator for a loved one. Of these, 44% track in their heads, 43% use paper, and 8% use an app.
    • As a clinician, I often rely on caregivers to give me the information I need to help address their loved one’s symptom. We definitely need to make it easier for them to track on paper or electronically, as this supports better clinical collaboration between patient, caregiver, and clinician. 
  • 41% of the caregivers who track end up sharing the tracked information with another person. More than half of the caregivers who track report sharing the data with a health professional.
    • This is good and I hope to see these numbers go up over the coming years. 

Unfortunately, although the demographics of the caregiver respondents are laid out, the main report doesn’t list the demographics of the care recipients. So, I don’t know just what proportion of these respondents are caring for elderly people, but presumably many respondents are caring for someone aged 65+.

All in all, this is a fascinating report and hopefully will generate some much needed attention to the need to educate and support caregivers.

If this topic is of interest to you, I’d also urge you to read Susannah Fox’s related blog post at e-patients.net, which is here. In it, she remarks

“Let’s stop there and consider: we have a large and growing group of people who are trying to conduct on-the-job training for themselves using the internet. They are more likely than other adults to have internet access and a mobile device. Many of them act like the kid who sits in the front row of every class, taking copious notes, clapping erasers for the teacher (anyone younger than 40, ask an older friend to explain). And yet if this report could be seen as a report card for how we as an online community are serving them, frankly it’s a D+.”

I myself am not sure just what grade I’d give the online community and digital health community when it comes to supporting caregivers…

But I think we can all agree that caregivers are very important, especially to those of who serve the elderly. Caregivers certainly need better support, education, and tools. This report should help spur additional attention to this essential issue.

Nice work, Pew!

Practical and Prosaic Data Needed by This Doctor

Since deciding to delve into the world of healthcare technology and innovation, I’ve repeatedly come across the term “Big Data,” which many claim will be transforming healthcare. As best I can tell, in healthcare terms, Big Data seems to refer to two overlapping ideas. One is that healthcare systems are currently collecting reams of health data, and by analyzing this data, we can identify patterns and signals that we can take action on. The other is that individuals can turn into personal repositories of big data, by frequently measuring various biometric and other parameters (i.e. personal tracking, which leads to the “quantified self”), and then this data can be analyzed and acted upon by the person and healthcare providers.

All well and good, but as with many exciting healthcare tech ideas, I find myself wondering:

“How is this going to help me get the data that I’ve been struggling to get?”

After all, my work requires me to obtain and process a lot of data, namely data regarding a person’s behavior, symptoms, and abilities, and how all of these have changed over time.


Will the Big Data movement help doctors like me?

Here’s a little story to illustrate my data needs in practical terms. Not too long ago, I went on a housecall to see a very elderly man with mild dementia, who lives in a small residential board and care (B&C) facility. The staff there had called the patient’s durable power of attorney (DPOA), saying that the patient, who we’ll call Mr. A., had recently become agitated at night. A urine test had been negative for infection. The B&C staff was wondering if a sedative or other prescription might be indicated. The DPOA had visited the patient and did think he looked less energetic than usual.

“Doctor, what do you think is going on, and what should we do?”

(Actually, people usually just ask the second part of the question, but good medical practice dictates that a clinician should first form a theory of what might be going on, before deciding what to do.)

As many dementia caregivers can tell you, this is a common scenario, and doctors are commonly asked to weigh in and make things better.

The catch is that, to sort out this common situation, one needs data on what has happened. In particular, I needed to know:

  • When exactly did this problem start? Did it start suddenly, or did it come on progressively?
  • Was there an inciting event that can be identified?
  • Is Mr. A distressed at night every night, or just now and then? If now and then, can we identify other factors that fit with the pattern (bowel movements, use of certain medication, etc)?
  • How is his current strength and energy level different from his baseline?

I went to visit the gentleman in question, whom I had never met before. He was very charming and pleasant, but also hard of hearing, and with poor short-term memory. His physical examination did not reveal any obvious cause for the recent concerns. Unsurprisingly, Mr. A. was not able to provide me with the historical data that I needed to make sense of the situation.

So I interviewed the patient’s primary caregiver at the B&C. But here too, the data was hard to obtain. The staffer is Filipino, and although his English seemed ok, he seemed to have difficulty understanding my questions on how Mr. A. seems different now compared to a few weeks ago. He was also inconsistent in his reports of how often specifying how often Mr. A has been having nighttime confusion.

Finally, the caregiver went to find his log book. This facility does not log every resident’s behavior on a daily basis, just “as needed.” We found two entries noting nighttime confusion, the last being a week prior. I left, still uncertain as to just how Mr. A. had changed compared to a month ago. I had just spent over 30 minutes trying to ferret out the data I need for my medical decision-making, and still was not sure I had accurate information to work with.

Given the shortage of geriatricians such as myself, it would obviously be very helpful if technology innovations resulted in my quickly being able access accurate data on a patient’s behaviors and symptoms.

So, will the Big Data movement help a doctor like me? I would say this depends on two key factors:

  • Will emerging technologies facilitate the collection of data relevant to geriatricians? Let’s face it, I don’t currently feel a burning need for a “small, wearable sensor that can capture and transmit blood chemistry data continuously.” What I need is something that reliably logs behaviors and symptoms, as well as medication use. [Update 10/17/12: Since yesterday Sano Intelligence, whose site my link points to, has removed the basic info on their blood chemistry sensor. But I am including a screenshot of the cached site below.]
  • Will Big Data shower doctors with information before we are equipped to triage and act on it? It sounds terrific to send more data to doctors, but we’re currently already suffering from information overload. (I wrote about the trouble with apps sending data to doctors last week.) We first need to develop systems that allow us to act effectively on the information we already have.

The truth is, although I think Big Data offers a lot of potential for population health management, I’m a little worried about how it might play out regarding the care of individual geriatric patients. Each elderly person could certainly generate a significant stream of physiologic, behavioral, and symptomatic data. But often collecting more data from frail elderly patients results in more healthcare, much of which ends up being of uncertain benefit. (Example: more scans usually turns into more things to work up and investigate.)

However, here’s an approach that sounds more manageable to me: a system that would allow doctors such as myself to specify the data to be collected, and that would make this data collection manageable and accurate for patient and caregiver.

In other words, instead of bombarding me with data and telling me to help the patient, what if the patient, the system, and I all first agreed on what information would be useful to gather, and then I received it?

Could I get a nightly confusion monitor for Mr. A please, along with an accurate log of his pain and constipation complaints, a record of medications taken including as-needed medications and over-the-counter drugs, and a daily measure of his physical energy, so I can study his trends and patterns? Please?

10/17/12: Here’s a screenshot of Sano Intelligence’s homepage as it was on 10/10/12, with a little description of the kind of data they could be providing: