Web-Based Cognitive Health Coaching for Elders in a Home Environment
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Transcript of Web-Based Cognitive Health Coaching for Elders in a Home Environment
Web-Based Cognitive Health Coaching for
Elders in a Home Environment Holly Jimison, PhD
Misha Pavel, PhD ORCATECHOregon Center for Aging & Technology
ORCATECH 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
• Verbal Fluency• Word List Learning• Constructional Praxis• Trail Making Test• Symbol Digit Modalities Test• Letter-Number Sequencing• Finger Tap Test
Traditional Cognitive Tests
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
Adaptive Cognitive Computer GamesSpry Learning / OHSU (NIST grant)
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
Word games:• Word length• Word complexity• Speed of word generation• Total number of words
Compare to:• Verbal Fluency
Letter Lotto – Word Game
ORCATECH 11
Letter Generation Rate as a Game Metric
0 10 20 30 40 50 60 70 80 90 1000
50
100
150
200
250
Total Time to Guess Words (Each Game) vs Number Letters Guessed Correctly (User 1020)
# Letters Guessed Correctly
Tim
e (Sec)
Regression Equation: y= 2.31189 x + 13.2406 r = 0.866714
ORCATECH 12
Letter Time vs. Neuropsychological Scores
0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 550
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60
65
70
75
80
85Neuropsych Average Total Fluency vs Letter Generation Time
Letter Generation Time (Sec/Letter)
Ave
rage
Tot
al F
luen
cy (Le
tter + A
nim
al) Fluency vs Letter Generation
y = -4.44616 x + 75.3999 r = -0.343154
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
0 1 2 3 4 5 6 7 8 9 100
0.1
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1Average Frequency of Words Correct by Length
Word Length
Ave
rage
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quen
cy
(Wor
ds G
uess
ed/T
otal
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sibl
e)
ORCATECH 14
Neuropsychological Scores vs. Proportion of Words
30 35 40 45 50 55 60 65 70 7550
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85Neuropsych Average Total Fluency vs Game Difficulty
Game Difficulty
Ave
rage
Tot
al F
luen
cy (Le
tter + A
nim
al)
Fluency vs Game Difficulty
y = 0.522433 x + 40.2374 r = 0.403347 (with outliers)
Outliers
y = 0.687054 x + 31.3083 r = 0.659844 (w/o outliers)
Proportion of Generated Words
Neuropsych Score vs Proportion of Words
ORCATECH 15
Memory games:• Short-term memory• Working memory• Spatial memory• Abstract reasoning
On the Flip Side – Memory Game
ORCATECH 16
• Characterize Memory Capacity as a Function of:– Intervening number of events– Intervening time– Memory load
• Simple Memory Model: Discrete Buffer
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Deterministic Computational Model of Working Memory
Time, Events
ORCATECH 17
Results
0 5 10 150
0.5
1Subject 1020, N = 8687
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bili
ty o
f Co
rre
ct
Intervening Number of Events
0 5 10 15 20 250
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ty o
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rre
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Intervening Time [sec]
ORCATECH 18
Examples of Other Fits
2 4 6 8 10 12 14 160
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1Subject 1021, N = 387
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bili
ty o
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rre
ct
Intervening Number of Events
2 4 6 8 10 12 14 16 18 20 220.2
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rre
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Intervening Time [sec]
0 5 10 150.2
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1Subject 1024, N = 892
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ct
Intervening Number of Events
0 5 10 15 20 250
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ORCATECH 19
Weekly Tracking of Working Memory Buffer Size
10 20 30 40 50 60 70 80 900
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Subject 1021, N = 120M
em
ory
Bu
ffer
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e
Time [Days]
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ativ
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uffe
r S
ize
ORCATECH 20
Estimation of Working Memory Capacity
0 5 10 15 20 250
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fere
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e [#
of It
ems]
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are
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t of
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uffe
r S
ize
ORCATECH 21
Assessment of Neuropsychological Test Scores
60 70 80 90 100 110 120 130 140 150 1600
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TR
AIL
S-B
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res
Predicted Scores from Flipside
Trail-Making Test B R = 0.60
Digit Span R = 0.36
ORCATECH 22
21 Tally (2-D Black Jack)
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Dual Taskgames:• Divided attention• Working memory• Spatial memory
ORCATECH 23
Double
Bust
Single
BustAccept
Single
Win
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Win
Bust-Win
highlow
high lowCost
Quality
Evaluation Metrics
ORCATECH 24
Subject ID:1020
Val
ue
of
sub
ject
mo
ve /
valu
e o
f Id
eal m
ove
Response Time per move (sec)
α = 3
in quality function
FAST SLOW
HIGH-QUALITY
LOW-QUALITY
Response Time vs Quality of Move
ORCATECH 25
Reference Players
• Ideal Player- uniform card distribution- look a single move ahead- choose ‘loc*’ where
Valuec(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
Avg
RT
per
mo
ve
Number of Occupied Locations
Number of Occupied Locations
Subject ID 1025
Pro
b S
earc
hing
Occ
Loc
“Serial Processing of locations”
ORCATECH 27
ORCATECH 28
Modeling Subject Reaction Time
ORCATECH 29
Modeling Subject Reaction Time
Subject ID a b T_occ T_emp T_min
1020 10.7166 13.3114 1.2583 0.4043 3.3855
1021 14.1551 1.1685 1.8104 0.2804 1.2226
1022 11.8667 3.534 0.9403 0.9704 2.9144
1023 21.4271 0.9 1.2769 0 2.053
1024 10.8912 37.9464 1.2048 1.6135 0.9237
1025 9.9886 38.4971 1.2840 0.6830 2.9397
1026 18.0063 1.348 0.8088 0.2773 1.1533
1027 18.0757 0.9 0.7120 0.0282 1.6898
1028 13.3458 12.3714 1.1771 0 2.5044
1029 13.7456 1.0617 0.5736 0.8603 2.2749
1030 10.9933 19.787 1.2249 9.9950 7.3894
1032 11.5338 4.6529 1.2456 0.1127 1.176
1033 8.7695 12.867 0.5714 0.0385 2.137
1034 12.8849 21.9481 0.6782 9.9996 2.9198
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
Unforced Bust
Forced Bust-Win
ORCATECH 31
Shape / color games:• Divided attention• Speed / accuracy• Visual search• Planning• Working memory
Pyramid Builder – Color / Shape Matching
ORCATECH 32
Response Time vs. Move Number
• Response time (move duration) Increases with the Complexity of the Game– Average move duration
increases with move number
– Variance increases with move number
0 20 40 60 80 100 120 1400
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Move Number
Res
pons
e T
ime
[Sec
]
File: tst3.mouse
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
0 0.5 1 1.5 2 2.5 3 3.50
0.02
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Response Time[Sec]
Rel
ativ
e F
requ
necy
File: tst2.mouse
ORCATECH 34
Resulting Search Efficiency
0 5 10 15 20 25 302
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e T
imes
[sec
]
Number of Distractors
tst3.move
slope = 24 ms/item
Correlation with
Trail-making B
R = 0.49
ORCATECH 35
Rapid movement games:
• Motor speed• Visual search• Set switching • Speed of processing• Divided attention
Compare to:• Finger Tap Test• Trail Making Test
Scavenger Hunt – Trail Making Test
FreeCell – Solitaire Planning Game
Strategy games:• Planning• Visual search
ORCATECH 37
User Performance Metrics
• Difficultydt = number of moves to solution at time t
• User Performance– Reduction in difficulty
• Outcome of game• Time to completion
11
,t
tD f d d
1t t td d
ORCATECH 38
FreeCell Performance Curve
0 10 20 30 40 50 60 70 80 90 1000
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90S ubjec t nb1.a ls
Eve nts
Diff
icul
ty
Ac tua lExpe c ted
Diff
icul
ty
Number of moves
subject
solver
ORCATECH 39
Performance Scores for Normals vs MCI
0.550.720.27
Mild
Cognitive
Impairment
0.380.120.58Normals
Average
(Individual
SD(Perf))
St Dev
(Individual
Ave(Perf))
Average
(Individual
Ave(Perf))
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
Shared Care Plan(PHR for Chronic Care)
Monitoring ModulesSensors
Health Coaching System
Medication ListElder-Specific HRA
Cognitive Protocols (Spry Games)
Lab Values
Diagnoses
Allergies
HomeCareNurse /Coach
ElderFamily Support
Cognitive Health Coaching Design
ORCATECH 46
Welcome Ellen! Your Cognitive Exercise PlanEllen – 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
View My Action Plan
Detail on Progress Goal 2/day 2/day 2/day 2/day 2/day 2/day 2/day 2/day
FreeCell Hunt LLotto Sp Bee FlipSide Pyr Bldr 21Tally Sudoku
Mon *** ** * ** * ** ***
Tue ** ** **
Wed **** * ** ** ** ** ** ***
Th * * *** ****
Fri ** * *
Sat
Sun ****** * *
Ellen’s Cognitive Exercise Progress
Log Off
Cognitive Coachingfor Better Living
Update My Information
Return to PHMS
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 51
User Model
1. Elder Assessment• Health Risk Appraisal• Health Goals• Motivation• Barriers• Readiness-to-Change• Contact Preferences
•Timing / Media• Social Support Contacts• Data Sharing Preferences• Authentication (pswd?)
Web forms – spread timing
Monitorcontinuous
Elder User Model• Goal (Assume
Cognitive Health)
• Motivations• Barriers• Change State• Contact Prefs• Social Support• Display Prefs
3. Create / UpdateTailored Action Plan
Daily goals & activities
Fam/Fr User Model• Contact Info/Prefs• Data Permission• Authentication (pwd)
Coach User ModelPredefined
2. Family / Friend Assessment
• Contact Preferences•Timing / Media
• Level of commitment• Authentication (pswd?)
Web form
4. Tailored Feedback & Recommendations
Based on Spry GamesBased on meeting other goals
Sleep behaviorsDietExercise …
5. Generic News and Articles of Interest
Standard Web content
ORCATECH 52
Architecture for Tailored Messaging
Elder Assessment
MonitoringSensorsComputer InteractionsSelf Report
Elder DBUser ModelRaw dataUser State
State DependentActive Methods
(Coaching Protocols)
Update Action Plan
Elder’s Technology Interface(computer, cell phone, exercise watch)
Content DatabasePreconfigured MessagesTutorialsGeneral ContentDefinitions
Summary ReportsPrioritized Alerts
Recommended Messaging
Health CoachTechnology(computer, cell phone)
Tailored Content Delivery• reminders• encouragement• tailored feedback/education• prompt for assessment
Shared Care Plan
ORCATECH 53
Welcome Ellen! Your Cognitive Exercise PlanEllen – 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
View My Action Plan
Detail on Progress Goal 2/day 2/day 2/day 2/day 2/day 2/day 2/day 2/day
FreeCell Hunt LLotto Sp Bee FlipSide Pyr Bldr 21Tally Sudoku
Mon *** ** * ** * ** ***
Tue ** ** **
Wed **** * ** ** ** ** ** ***
Th * * *** ****
Fri ** * *
Sat
Sun ****** * *
Ellen’s Cognitive Exercise Progress
Log Off
Cognitive Coachingfor Better Living
Update My Information
Return to PHMS
ORCATECH 54
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 55
Summary
• Scalable approach to delivering health care to the home– Extends outreach of lower cost professionals– Can involve family members– Timely and continuous– Home health management is key to caring for chronic conditions
• Cognitive monitoring and potential remediation– Most important aspect of health– Keeps people independent – (better quality of life & lower costs)
• Cognitive Health Coaching System– Serves as a framework for testing the best delivery of cognitive
interventions
ORCATECH 56
Acknowledgements
• ORCATECH – NIA funding• Intel funding for initial FreeCell Cognitive Monitoring• NIST Funding for Spry Learning Cognitive Computer
Games• Health Coaching funding to OHSU from Intel as part of
the Behavioral Intervention & Assessment Commons
More info: [email protected]
ORCATECH 57
Representative FreeCell Performance DataMCI Subject and Healthy SubjectOver Time
MCI Subject FreeCell Efficiency Over Time
-1.5
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Healthy Elder FreeCell Efficiency Over Time
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Subject with Mild Cognitive Impairment Cognitively Health Subject
ORCATECH 58
Median Login Inter-keystroke IntervalsM
illis
eco
nd
s
Date
Subject with mild cognitive impairment
Two cognitively healthy elders
ORCATECH 59
Framework for Data and Inferences
• Data– Movements – trajectory and speed
– Selection of objects – ID and response time
– Placement of objects – position and speed
• Interpretation– Characterization of movements
– Inference of tactics
– Inference of strategy
– Inference of abilities
Raw Data
TacticsStrategies
State Estimation
ORCATECH 60
– Average move duration increases with move number
– Variance increases with move number
0 20 40 60 80 100 120 1400
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Move Number
Res
pons
e T
ime
[Sec
]
File: tst3.mouse
Duration of Move ↑ with Complexity of Game
ORCATECH 61
– Multimodal Trajectory of a mouse movement on a single move.
– The size of the disks indicates the dwell time at a that location
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Move number 53
Mouse Move: Trajectory and Dwell Time
ORCATECH 62
Background on Shared Care Plan
• Personal Health Record specifically designed for people with multiple chronic conditions
• Marc Pierson, MD – Whatcom County, Washington• Pursuing Perfection Project funded by Robert Wood Johnson
Foundation• Further refinement of the application was made possible
through grants from the Agency for Healthcare Research and Quality (AHRQ), the Foundation for eHealth Initiative (HRSA OAT), and PeaceHealth
• Commercial version called PHMS from the Congral Company – Nic Ivancic
ORCATECH 63
Project Team Members
• Holly Jimison – PI• Misha Pavel – Co-PI• Nicole Larimer – Senior Research Associate• Michael Shapiro – Graduate Research Assistant • Bobby Hagerty – Health Educator / OHSU Brain Institute• Nic Ivancic – Programmer, Congral Company• Lori Nichols - Consultant
– Director, Whatcom Health Information Network– Shared Care Plan Personal Health Record
• Marc Pierson – Consultant• Spry Learning Company
ORCATECH 64
Correlation Amongst Standard Test (Animal and Letter Fluency)
• What is the inherent variability within animal and letter fluency?
• Within users averaged over baseline, 3 month, and 6 month test period
• R^2~=.46
• Used sum of animal and letter score as total verbal fluency
0 5 10 15 20 25 30 350
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10
15
20
25
30
35Average Animals vs Average Letter Fluency (C,F,L)
Animal Fluency
Lette
r Flu
ency
Average Animal vs Average Letter
y = 0.36845 x + 7.78601
R2=0.354482 (with outliers)Outliers
y = 0.378927 x + 7.89503
R2=0.464943 (w/o outliers)
ORCATECH 65
Newly Developed Cognitive Computer GamesSpry Learning / OHSU (NIST grant)