Well a number of different

ideas from my work two jobs while

I was writing some poses.

When I thought you were having
various ones how to solve.

OK thanks.

And she we don't know if cloudy is
in labor or not that's so exciting.

But she's not here.

So maybe that maybe that bodes well for
her and

forgive me a little tired I was
at the E.R. I became a caregiver.

Actually this is sort of ironic.

Over Labor Day weekend I went down to
Florida got my mother she called and

said come get me I'm ready which with in
early stage dementia is actually a gift.

It's more typical to take them kicking and
screaming but she called and

said come get me I'm ready.

And went down got her and
she's in the she went to the E.R.

last night which is I'm trying not to
take reflective of my caregiving skills.

It was something else.

So anyway I'm a little tired but I am
from the Atlanta V.A. and that's where my

primary appointment is and I have
a secondary appointment in the division of

geriatrics and you're intelligent Emory
and the Birmingham Atlanta Grech geriatric

research education and Clinical Center and
I do work with Ted Johnson as well as

I do a lot of work with John Stanford
he's co-investigator on the majority

of my projects because he brings in the
environmental piece which is so important.

So I'm just going to be a little
introduction about who we are and

what we do and talk about caregiving
broadly broad strokes and

then give you a brief description
of four studies that we.

It's recently completed or
have going on now and

then throw out some things for
future directions where we're headed and

maybe even give me some input on
some of the things I'll talk about.

So the current mission statement of
the Center of Excellence in which I work

rehabilitation research and development
is to improve the everyday function and

quality of life of aging
veterans with vision loss.

For veterans and
their caregivers and work.

We just wrote essential renewal grants so
instead of being the center of excellence

for aging veterans with vision loss we're
going to be the center of excellence for

visual and neural reply pair or we're
turning into sort of a neuro Center which

is OK because there's still we have
a small group of us that we call ourselves

the center outlier group and that would
be John Sanford myself because we do more

with the whole person rather than a neural
level but we still have our place there.

And so I have the veteran
care giving support studies

lab and here's our staff of course
you can't do anything without

a incredibly wonderful staff and as I said
my CO eyes are mainly John Stanford and

Ted Johnson and Kenneth Hepburn who's in
the division of nursing over at Emory.

And so what we do is we design
implement and evaluate behavioral and

psychoeducational interventions for
caregiving dyads

to help older veterans age and
place key safely within their own homes.

It's a little bit about caregiving that
many of you already familiar with we have

sixty six million caregivers
providing care to an ill or

disabled adult in the United States
close just third of all U.S.

households is involved in caring for
an older person.

And they're carrying on average for
twenty hours per week and

what that equates to is three hundred
fifty billion dollars worth of

unpaid services which is more than
double what we're putting out for

never seeing homes and
home health care combined.

It's a lot more than half of family
caregivers experience clinical depression.

Due to caregiving duties elderly spousal
caregivers have as much as sixty three

percent higher risk of mortality than
non caregivers and caregiving is

multifactorial there's a lot of components
to it and by definition involves a dyad

and this is key because I'm interested
in the diet not just the caregiver but

the care receiver and it's sort of become
trendy to call them Care Partners and

I actually my last Grant used the term
care partner but if you don't hyphenate

it looks like carpenter and
that's a little aggravating and

it's really hard to tell which one you're
talking about which is the care partner I

mean it is that the one providing the care
of the one receiving the care and so

while I would love to
be politically correct.

I went back to caregiver and
care receiver and that's just that's OK.

And so the some of the correlates of
caregiving I put satisfaction first

because.

Caregiving is linked to satisfaction.

A lot of caregivers report increased
affection and being able to be there for

their loved one to be even through
the death process to be able to provide

some nurturing it's also
related to depression and

attenuation of the social network and
a decrease in social activities.

Increased rates of illness burden both
objective and subjective and mortality.

And that's I won't go through the whole
stress help process model but

it's a nice here istic for understanding
the relationship between some of

the stressors that come with caregiving
the primary stressors being the disability

of the care receiver and problem behaviors
especially in dementia care givers and

care receivers and
secondary stressors which result

camp family conflict problems at work
as a result of caregiving duties.

And these primary objective stressors
the relationship between them to health

outcomes are mediated by the caregivers
appraisal of their own demands and

capacities to deal with them.

And so there's a lot of places for

intervention in there which
is what I'm interested in.

So why does the V.A.

care which is where I receive the majority
of my funding because overburdened

overstressed caregivers are more likely
to institutionalize their spouse.

And if Kerry if these caregivers
are institutionalizing their spouses

then the V.A. is going to have a whole
lot of veterans in nursing homes that

they're not going to community living
centers excuse me that they're not going

to be able to handle keeping veterans
in the home saves the V.A. money.

This was my research assistant sorry and

happy supported caregivers may keep
the veteran in the home longer.

My goodness.

My.

And it's the right thing to do.

And the great thing is right now the V.A.
purports to support caregivers

with the passing of the veteran caregiver
help I'm going to act that Obama signed.

We have money now to actually help
the caregivers Now a lot of the care.

First in line are the O.A.F.

an O.A.F. veterans and their caregivers
Operation Enduring Freedom and

Operation and Iraqi Freedom for those of
you not familiar with the V.A. acronyms.

So they're first in line and
the chronic older caregivers.

There's some out there too for them but
they are sort of second line but

we're working to change that.

Caregivers of veterans are slightly
different than the caregivers in

the general population.

For example ninety six percent are women
versus sixty five percent nation

wide ninety six percent are spouses or
partners versus six percent

nation nationally we tend to
see daughters sons siblings.

Fifty five percent per report a decrease
in self care activities these might be

O.B.-G.Y.N. visits these might be
showers these might be exercise

seventy five percent report
increases in stress and

anxiety due to caregiving and eighty eight
percent decline in sleep quality which was

important to me because one of
my studies as a sleep study.

So I could use that in my argument.

So some of the studies that we're doing.

I have study in quotes and I'll tell you
that why in a minute this the first one

is telemedicine support for
family caregivers this is also

known as the health buddy study
because we use the health buddy.

The V.A. has a character warden
nation home tele health program.

C C H T which is huge and
they use these help.

Buddies to help veterans with
disease management there's

a module's to choose from all the heavy
hitting diseases congestive heart failure

diabetes etc and the veterans log on to
these little health bodies every day and

they receive education
about their disease and

they report the values you know their
glucose value and nurses back at the V.A.

can read these on a daily basis or I guess
it's there's a twenty four hour lag and

look for flags and
it's been a very effective program.

So we were using the Help buddies for
caregivers and

I had a study in quotes because it
really wasn't a research project it was

a clinical demonstration project
was a little bit different.

You have to frame it a little different
and it was a caregiver pilot to

develop a model telehealth program to help
caregivers and then to evaluate that.

And I came into this
rather late in the game.

And this was for caregivers providing
care to community dwelling veterans over

sixty years of age with one of the chronic
illnesses on the disease modules and

they had to have a touch tone landline
phones so these health bodies are not

good with wireless and more and
more caregivers are going wireless.

And they had a functional
literacy above eighth grade to be

able to interact with the health body and
then of course we needed dyad consent.

Three by three designed three groups
three times baseline three months and

six months usual Care Group which
received absolutely nothing.

The health buddy home monitoring group
which is an instrumental support group and

then the health buddy.

Plus phone friends so
that was instrumental support they got

the education and the monitoring that
they also got emotional support from

these phone friends who they
were encouraged to call.

They didn't call them very often.

One is are in the other
woman is a nurse at the V.A.

who also was a caregiver herself
until her husband passed away.

And so that.

Is to show you sort of the limited utility
of the health but do you have these four

buttons and you can press them
in response to you know choices.

You can't input anything it's not
it's interactive in the way that

you can input that and then twenty four
hours later the nurses will download it.

But there's somewhat limited
utility on these devices.

In the daily content was disease education
management caregiver education and

then these caregiver tips you know go
take a bath talk to a friend and some

trivia which actually ended up driving
them crazy because it was thirty days and

then it would recycle and they've already
heard that I don't want to hear that.

So the results and this is fascinating.

At three months and six months.

We had trends toward
an increase in depression.

We were actually looking for a decrease.

An increase in burden we would
have hoped to see a decrease.

And a decrease in self efficacy for
caregiving and this is the R.I.'s elder

care self efficacy scale we would have
hoped to see an increase in self efficacy.

So why is that.

This is my late friend and colleague
Betty Rose come now and when she was still

alive when I ran these data and
I called her and said OK Sit down.

And she said I am and I told her and

she said well we were shooting nets with
elephant gums and that's exactly what

we're doing the assessment battery
was the elephant we had this.

Were well meaning huge so
assessment battery.

How often time.

How often do you have to care for
your husband is that stressful for

you how stressful is it.

How many times a day do you change his
diaper how many times a day do you

wash him how many times a week and

you have no help whatsoever
Are you sure you have no help.

Not even a neighbor and so
what that did even in the control

group because all three groups increased
depression increased burden decreased so

if I could see all three groups.

We increase their awareness and sensor.

To Vittie to their plight.

If you will and then didn't provide them
a strong enough intervention which is

a matter of dosage and intensity that
we all need to pay attention to.

So I'm the only one of the investigator
that wants to write this up but

I think it's important to put out there.

We need to be careful what we're
doing what we're asking of people and

we need to match the intervention to both
the problem and the assessment battery.

I think that that's very
important information and

then we had some ceiling and
floor effects probably.

A lot of these caregivers
weren't actually depressed and

we may have had some be selection bias.

What was interesting.

Another interesting lesson in this
even though we had a fabulous staff.

The veteran caregivers can't separate V.A.
health care from V.A. research.

And so
they perceived dust in some of them.

As Big Brother coming in to pass judgment
on their caregiving abilities and

thought that we might remove
the veterans from the home.

We found them wanting.

And you know how do we get
around that we can talk to.

We're blue in the face.

We can spend extra time trying
to establish rapport but

that that's an issue.

However here we go.

Don't we love satisfaction inventory's
one hundred percent of the caregivers

were very satisfied with the health
buddy would recommend it

to a friend had a better understanding of
their care receivers medical condition.

Found it easier very easy to use and
would likely continue its use.

If they were given that opportunity.

OK let's switch to sleep so because
caregivers don't sleep well I wrote

a grant to look at sleep in veterans and
their family caregivers.

That's also known as sleepy
dyads which stands for the V.A.

loves its acronyms right.

The sleep evaluation and

enhancement psychoeducational intervention
for dyads Maureen helped me come up with

that one weekend I kept saying help me
come up with an acronym I need my acronym.

And so Ted Johnson and
Ken have burn and I have an external

advisory committee Steve Barrett who's
a caregiving research searcher from.

Penn State and then sue McCurry runs
the night aid product project out of.

You watch which studies all timers disease
caregivers and sleep and then John help

me with the environmental stuff I just for
John to everything because he's amusing.

So why sleep in caregiving dads and
why this particular study we have

increased prevalence of sleep problems for
caregivers.

We have an increased prevalence
of sleep problems for

care receivers because they are receiving
care they have many diagnoses which

could disrupt sleep they take
medications that could disrupt sleep.

Better ins have poor sleep and
older adults have poor sleep.

So you put it all together and
these people will have poor sleep and

our need to cure was that we were using
a dyadic approach to sleep measurement

a lot of sleep researchers
study the caregiver or

the care receiver we're studying them
contemporaneously and so we not only

are using the data summaries that are spit
out by that respect or act to graps but

we're going in behind and getting the raw
data and on a second by second basis.

We have thirty points of data and
we can say who wakes up first.

Does the other one wake up is to get
active or move which is a novel way of

looking at and silly fun and we also
have it gives us a lot of data points.

Subjective sleep in journals and
so we're always sorry.

So these are just some data
from the caregiver telehealth

sleep but you project.

Health buddy showing their
burden inventory and

number of night's sleep was restless
from the C E S D and there so

it seems to be a relationship between
restless sleep and subjective burden.

So real quickly some of
the correlates of poor sleep.

Are there implications for

daytime functioning people who don't
sleep well don't function as well

during the day they have poor sleep
hygiene practices sleep hygiene oral

hygiene is how well you take care of your
mouth sleep hygiene is how well you take

care how well you what the effort
you put into your sleeping practice.

Has decreased cognition
memory loss poor judgment

irritability anxiety depression
huge medication mismanagement and

you've got the caregiver who's not
only doing her own medication but

the care receiver's medication to
accidents falls and institutionalization

So it's a it's a problem and
I love this little here a stick.

Put up by Spielman it's a three piece
sleep model that says that sleep.

There are three piece predisposing
precipitating and perpetuating factors.

So we can be predisposed to sleep already
told you that age people who are older

don't sleep as well.

Gender and health status and

then these sleep problems we can have
precipitating factors if I have stress.

You know so the stress of providing
care during the day for the caregiver or

some conflict or anxiety depression
that can precipitate a bad sleep night.

But then the that can be
perpetuated by the poor sleep

hygiene practices sort of compensate for
having a bad night of sleep.

I'll drink a lot of caffeine the next
day and I have some alcohol at night and

we just get into a vicious cycle
put that together for the dyads and

each each cycle for the caregiver and

the Cure receiver are interacting
in a dynamic fashion together.

And so where we're intervening is
at the level of precipitating and

perpetuating factors.

It's three phase studies of the V.A.
funded this for five and

a half years and Phase one was just
a nice little cross sectional study and

I did that to buy myself
some time frankly.

But I said we had to explore
the phenomenon before we could intervene

that made sense right.

When that happens and
we had proposed an end of thirty and

the staff were so good that they
knocked them off in no time at all so

went back to the I.R.B. doubled the
recruitment and said OK no no we're doing

sixty and so we've got sixty two and
I was actually we went back and

doubled the recruitment because I was
looking for more dimension dyads and

then we ended up with very few
dimentia diodes Unfortunately so.

Phase one is the cross-sectional study
phase two is when we're actually doing

interventions and phase three we
do the revised intervention and so

we need caregivers and veterans over sixty
and they have to meet the criteria for

caregiving and post baseline.

So after we put the active refer
the actor graphs on them for a week.

If they have a movement related
disorder or sleep apnea.

They're excluded.

If they can't tolerate the active
graphy they're excluded and

people with dementia don't often Telerate
the wristwatch it's uncomfortable for

them and if they have good sleep criteria
which is generally described as either.

Above eighty percent sleep efficiency
as determined by the actor graph and

we're looking at subjective
reports as well.

So these are the best actor graphs that's
our center statistician who who doubles

as a model for us from time to time
they've been accelerometer in them and

they capture movement and
then based on an algorithm.

The movement they capture
movement they capture light and

based on that it determine
sleep wake throughout the day.

These are some standard sleep
parameters sleep efficiency total

sleep time wakes after sleep onset
sleep latency and the number of sleep.

Epix or bouts and the duration
of those and also why is this.

My goodness.
OK.

They're very proud of the journals
we have these journals.

And it's a lot of information that
they actually fill out for us and

we had incredibly good come in here and
compliance with these as well as another

subjective measure is the Pittsburgh
sleep quality index and the a worth

sleeping on a scale huge assessment
battery again and we just say that.

Watch out for
those huge assessment batteries.

But we're going to have a very robust
intervention to compensate for that.

So we have some Phase one preliminary
results from the cross-sectional

study with the baseline interviews and
the seven day sleep obsessed.

Assessments using active Graphy.

We completed with sixty to

mean age of caregiver sixty seven of
carry servers receivers seventy three.

They're all female thirty
one percent Caucasian

fairly well educated and
actually not too bad income either.

They've been providing care.

The majority of them for
over two years over forty hours a week.

They're not necessarily preoccupied
with caregiving demands all the time.

This may be a select sample and

I only have eighteen percent to mention
which is I had wanted more and in

the two other studies we had we had over
fifty percent dementia and I think that's

because we weren't giving them anything
in this particular the cross-sectional

study there was nothing to make
them say yeah sure I'll do this.

This is asking them to do
a whole lot of work and

not offering them anything in return.

Other than forty dollars per interview.

So this to me is a little bit
disappointing because the key thing from

the slide I want you to get is eighty and
eighty three.

They're all sleeping well OK so
I wrote this sixty five and

a half your grant saying caregivers
of veterans don't sleep well.

And I may be in trouble.

So these are what the actor
grams look like and

this is the veteran caregiver
together they're the caregivers

the star the veterans the flag and
we give them these what did we call them.

These individualized sleep
in Alice's profile reports.

And what this shows is the little green
is rest or latency the blue is sleep.

The yellow spikes are white light and
the blacks like this bikes are activity so

what we would see here is she probably
got up to go to the bathroom right before

six or at six am and turned on
the light that made him wake up to.

He didn't get up.

So we get those for some.

Nights in a row for each of the diodes and
we give them them the those as well as

we interpret them for them and
then based on that and

the journals and all the other measures
we do we design an intervention.

We're not doing this in
the cross-sectional study they didn't get

anything other than our good wishes.

OK So turning to the other two
studies this is caregiver assist and

caregiver assist two or squared which is
caregiving assessment of skill sets and

individualized support
through training and C.G.

assist to or
squared is through tele training.

So C.G. is this was a pilot
project funded by R. and D.

a feasibility study which were supporting
the caregivers through a comprehensive

needs assessment provision of assistive
technology which is dirt in the form

of durable medical equipment grab bars
three in one commodes Super Bowls.

Key training on the assistive technology.

Why are we doing that.

OK These activities of daily living are a
basic need for the use of these caregiving

dyads and often times you get
discharged from the V.A. and unless you

have an if you have any amputation they
may give you some assistive technology.

If you're just aging into increasing
levels of disability your doctor

has no way of knowing how
well you're getting around.

If you need a raise commode
if you need grab bars and

they don't ask this routinely.

You know how are you doing your
daily activities of daily living.

Do you need any help
you need new equipment.

And so they strategize some of the most
resourceful ways to transfer which

are often times very unsafe and it results
in injury or excess disability and

this use of the equipment
if if it doesn't fit.

Well wrong way.

My.
Because if they do oftentimes

that they do give you certain equipment
they don't match it to the characteristics

of the dyad the needs the preferences or
the environmental features of the home.

So the objectives were to field test the
measurement battery and the intervention

and this in this pilot study were also
comparing to needs assessment procedures

which was caregiver resort self
report needs over the phone and then.

Observation based through the O.T.S.
and Petey's.

To see if we could possibly
use one over the other

two by two group by time we had two phone
interviews by the project coordinators and

then we had three home visits by the O.T.
and the P.T. team.

The first one was a blinded baseline
assessment to look at features of

the environment and observation of four
functional tasks of getting on and

off the bed in and out of the bed on and
off the toilet in and out of the shower

and the third the second visit was
to prescribe assistive technology so

look at what they had meet
with the dyad say OK I

really think you'd benefit
from a Super Bowl no many

diets don't want a Super Bowl in
the middle of their living room.

So we needed to have the buy in of
the diet and then returned to train and

reinforce on the on the intervention.

And these are caregivers veterans.

A.T.L. dependent and dependent in
transfer or positional change.

We ended up with one thousand
in the intervention and

one thousand in the control.

Hundred percent female
predominantly Caucasian.

Seventy three percent providing care for
two or more years.

And so
see fifty four percent with dementia and

I was hoping to get that in
the sleep study and we didn't.

But this one here was so easy to recruit
for here's what we're going to do.

We'd like to come see how you do
activities of daily living have an O.T.

observe you and if you if she feels
that you need more equipment we're going

to provide that equipment to you and

then train you on the use of the the
equipment would you like to sign up.

Heck yes and it won't be any cost to you
and will pay you for the interviews.

So this was really.

To recruit for.

And so the percentage of dyads
requiring this is fifty percent or

greater assistance on these tasks and
you can see the caregiver

is in blue they were under
estimating on every task except for

bathing bathing was the most the most
problematic task which is not unusual.

Once again the safety
concerns how concerned.

How concerned are you about safety drying.

Getting in and
out of bed dressing toileting bathing.

Yet how satisfied are you with
your level of skill both the P.T.

ots and the caregivers are saying well
they have some skill in this area yet.

They replaced a lot of equipment.

So that the most frequently
prescribed eighty were grab bars and

three in one commodes and a lot of
devices received more than one device so

they would receive multiple grab
bars that make sense right.

And there's a guy with a Superpole.

So some of the issues we
encountered on this was are P.T.S.

and O.T.'s were not researchers they
were clinicians and they clinicians

must there are research clinicians
don't always act like researchers and

so they didn't adhere to the protocol
the way we wanted them to and

they took a more holistic approach and
we actually contaminated

our own intervention because they
would email or call and say OK I'm

up in Buford and there's this house
trailer and there's holes in the floor and

they lost their water and
she can't afford insurer and what do I do.

Well let's call the social worker.

So then OK what does that
do to all of our outcomes.

You know but
what are you going to do what can you do.

So and it also had little
effect on the caregiver.

Perceptions of safety of dependency
of satisfaction with skill level.

And once again we got to
trends toward depression and

burden but there's a huge need as
identified but the clinical experts.

So what we take away from this is OK
the O.T. and P.T. showed improvement

on you know they were at a level seven and
now they're at a level four.

You know we're not going
to get somebody completely

independent you know who's an amputee.

But we decrease the level of dependency
on the caregiver in some cases

we had this one instance
where the veteran had

been using a day to clean up
after toileting and he fell

into the marble bath tub that humid
Toma so she had been cleaning him up and

we installed some grab bars in
the three and one commode and

he was once again independently toileting
that's a good thing you know but

how do you measure dignity there's not
really a good dignity measure out there.

We had these this other couple that
at first glance we thought they had

fold down the rails but they were
loose and improperly installed and so

she had bruises up and down her arm and
had been dropping him.

So we installed proper bed rails transfer
disk on the floor he was an amputee

Superpole And so
he could get out of bed and

into his wheelchair in the morning we'll
into the other room and watch T.V.

and she could stay in bed for
another hour.

That's huge.

Another hour.

So we wrote America review and
that's the C.G. assist to which got funded

we're just waiting for them to release
funds from the federal government and so

this time instead of just looking
at women spousal caregivers

we're taking all caregivers because we had
to turn away people we felt really bad.

And all eighty L's were
partnering with prosthetics and

social work and there wasn't a T
two objective assessment for

the O.T. We added that I'm really
interested in outcomes for the dyad.

In C.G. assist we just looked
at outcomes for the caregiver.

But these veterans many of
them were completely cognizant

of the burden they were
placing on their care.

Caregivers and they wanted to be
independent and so I want to measure.

You know the effects of the intervention
on the care receivers of well and

key a delayed intervention group.

It's unethical to not have an intervention
group after you assess these people and

uncover a need and so we have a delayed
intervention group and then the tele arm

which John Sandford really wanted to throw
in and so we did and so the tele arm.

Why the tele are OK because
tele rehab increases A.D.L.

of efficacy and
newly prescribed wheelchair users.

And that was a tell rehab project
from a few years ago we did.

And we've got we did find out the tele
education is feasible with and

enjoyed by caregivers so
in the Tele arm we will have

a new device that I'll tell you about
in a minute we wrote a grant for and so

rather than sending the P.T.
into the home.

We can send a research assistant which is
a lot more cost effective and she'll set

up this device the to tell us therapist
will be sitting at home dictating what's

going on and doing the training that
way and we'll see what works with that.

That's a very complex timeline this is
going to be a nightmare to staff but

we're having research
visits at three points in

time the telephone interviews
just they don't cut it.

You know I question the the Lydian
reliability of the data we got on

the phone interviews and so we're sending
a research team into the house at three

points in team time to do face to face
interviews and it'll be a team of two so

that one person can be with the care
receiver while the interviewers

are at the caregiver and then we
send an assistant technology expert

to the home to do the actual
intervention either.

By tele rehab or in person and
so the supplemental.

Ameriquest a couple months
ago I was in Tucson Arizona

at a yoga meditation workshop because
I had to learn how to do that so

that we could train
the caregivers in the sleep study.

So it was very important that the V.A.
send me there right.

And I got an email saying
that there was some funds for

supplemental Quitman if you need
something throw something together so

I did and I asked for these B.L.
health care devices.

And we've told the V.A. that we were going
to use them and we are to monitor measure

and manage so we're going to monitor on
a daily basis instead of using pen and

paper diaries and journals which
can people spill coffee on them.

People sit down and fill them out
all at one time people lose them.

So we'll have these journals and so
we can monitor daily activities falls

injuries medication inherence a whole
lot of things and I can use them for

my sleep studies and we're going
to be able to measure better and

caregiver capacity and performance and
then use them to manage on a daily basis

to deliver our interventions and
the reason we choose chose this B.-L.

health care device out of Boston was
because it was touch screen which was

attractive to me it was much more
interactive than the health buddy.

It was five compliant meaning we can
adjust the font we can have audio

capability to.

Better adhere to some of the sensory and
cognitive limitations of our subjects' has

Tell a video conferencing capability so
we can have instantaneous communication.

Real time data collection the data
get collected on this device and

shot back behind the V.A.
fire wall which is real nice and

we can have preprogramed messaging and
reminders on it for medication or for

whatever we're doing in our intervention
and then it also comes with all these

peripherals and we did get quite
a few of those of interest to

me as the pulse oximeter as I use that to
screen out sleep apnea or sleep study.

And bundled into that request.

We also asked for some zoom tablets and
videography equipment.

Which will enable us to videotape our own
intervention modules and then deliver

them on the device and the Xoom tablets
offer us portability of course and

we can once again individualized
the content on the screens and

have preprogrammed data collection forms
and cat ECT is going to use these for

medication management intervention.

So Future Directions are going to
use these devices as I said for

the sleepy diets intervention which is
more is a multi component intervention.

It's non pharmacological we did we just
finished last year a couple of sleep

studies over it.

Emory one was and I try.

We just about crawled in
bed with these people.

We took over their care.

Twenty four seven.

We kept them awake and engaged during
the day because people in nursing homes

often times why they don't sleep at night
is because they're sleeping in the chair

during the day we offered activities
one on one Activities twice a day and

group activities twice a day right.

And we took over their nighttime care.

So rather than going into the room
turning on the light at two am and

ripping down the diaper.

We did we gently checked and if if there
was no need to do that we didn't do it and

we used flashlights we tuck them in bed at
night with a head massage scented lotion

if they wanted nice music sleepytime tea.

We woke them up gently and
it had absolutely no effect on sleep.

So the argument there was OK It's
because it's an institution and

there were too many environmental
factors we couldn't control.

So we'll be able to control them in the
home environment and I'm hoping we will.

We're using an adaptive prescription
approach which is individualized to

the needs and
preferences of the dyad and thereby N.

and we're doing some behavioral
psychoeducational strategies and

it will all be delivered on
the the health b l healthcare device.

And so here sir.

Of the intervention components
that we're going to look at and

not everybody will get all of these
because we know that you know it.

So if it's not broke don't fix it.

Don't include caregivers in
a depression study if they're

not depressed because it's just going
to screw up the rest of your results.

So we can individual lives
from a menu of items.

What each care giver and care receiver
dyad receive on a daily basis.

So they'll use their television
a which is much more user friendly and

it's more novel and fun for
them which will increase adherence and

compliance even though we had
excellent compliance amazed.

Programmable content and fonts and

audio capability and instant access
to the data for us which is good

because if we see OK two days have gone by
and caregiver A has not done her journal.

We can call or we can program
a message if she doesn't turn it off.

So here's our say it so
they'll see in the morning good morning.

Please fill out your Monday morning
journal they can call they can indicate if

they want to be called and will tell them
when we're going to call them back and

they can indicate if they want
to be leave a message to us.

And one will respond.

And then it will go into one of
the modules so every single day.

We're going to have you know cyber
host for that familiarity and

then they'll have a thank you
from the project coordinator and

then one of these things so it may be a
medical tip of the day or week here's some

of the medical conditions that interfere
with sleep it could be nutrition.

You know here are some
nutritional tips for sleep.

OK And finally.

So our rehabilitation research and

development center of
excellence was up for renewal.

We have to renew every five years that
we're becoming a center for visual and

neural rehabilitation and
we submitted with that.

Three areas with three projects each and
so my area was the tele health corps.

And we have three projects that will
be doing with telemedicine The first is

a balance and mobility training for
older adults Courtney Hall who is just.

Added to go to the Mountain Home V.A.
was going to lead that but

now either Madeleine Hackney or
someone else will.

And that's delivering the false proof
intervention via the tele health devices

second ones met ex
medication management for

veterans and their care partners and
then the third group.

We're going to deliver this specifically
with dementia dyads will deliver C.G.

assist John and I.

And so anyway.

Thank you thank you and I would love to
have any feedback from you guys on my

negative results for the burden of
depression or suggestions for any of these

projects going forward that are just
we're just getting ready to start up.

Yes.

It's four G..

And actually the B.L.

healthcare devices those so
we had to negotiate in the contract and

build into the V.A. supplemental equipment
crest we've crossed air time and

time to the configuration of the V.A.

server behind the fire wall
I mean it's as you can guess

really challenging to work
with the privacy officers and

information security officers at the V.A.
to adhere to all everything they want to

see

her leave.

You know.

So we'll build that into and that's

all we know yeah we're keeping detailed
cost cost for a cost analysis.

Afterwards we have a we have to document
all the costs for the staff and

the the technology.

And that's huge.

And it seems well with the way things
are moving right now in the V.A.

and funding you write a grant which may.

It will receive approval for
funding but it.

It may be a year and a half to two years
from that the drafting of the grant to

the actual funding and things can change a
whole lot in two years or a one six months

so that

you

know.

No I don't think that consumers
would ever actually go for this.

I think the V. V.
I would have to provide it.

So if we come along with something that
you know has proven efficacy then the V.A.

would have to provide it is care
as part of standard of care even

with my healthy vet which is just
nice program that's trying to

service a surprise atory of all
the veterans' health care information and

education information and
they can renew their their meds on it.

We only have eighteen percent of
the Atlanta better ins and rolled on that.

So is it eight percent eight percent.

Well

you

know I was talking to
a doc in Homebase primary

care there was a patient centered care
proposal request that came out and I said.

I just wrote a grant
over Fourth of July and

I wasn't ready if I was you know
if I was up for another one and

I said you have any ideas what would you
want you know in Homebase primary care.

And she said what I would love
is a device that primary care.

They are seen once a year by a nurse
practitioner and twice a year by an R.N..

And so and then P.R.N. and the P.R. ends
are getting expensive having nurses from

the V.A. go to you know Gainesville Buford
wherever they're going and

so she said if you could have
one of your telehealth devices.

Show me the purple year and which was the
thing that week or you know how somebody

have somebody cough or show me the wound
and I wouldn't have to be sending out

a nurse to travel and you know pay her for
all that that would be huge.

So you know we may do that but

then do you really have this device
be in in the person's home for

all that time to pay for all that air time
how cost effective is that we don't know.

We're working on our parking.

Yeah.

And it does.

What we have community living centers they
used to be called nursing homes now but

the culture strange They're there with
the eagle's nest at the Atlanta V.A.

and we have some contract
homes as well and

a huge facility going in Carrollton which
will be based on the green house model.

Dr House's been working with them and
it'll be saying to you.

Hey.

Well yes.

I think given the three to six months we
wouldn't we wouldn't see that happen and

given such a short time frame.

What would be great is if
I could go back to them.

Now you know another six months
down the line to see what happened.

It's just it's I really think it's and
we did look at it by dementia status and

non dementia status by duration of
caregiving but it's a small sample too so

we couldn't slice and
dice it as much as I would like to.

You

know that wasn't assessed which is
why we've got we've got that of.

The about you.

Ation of the assessment battery
into the next two studies but

things are aging in place lady.

Positively.

Yeah positively and

a great

rest

as well.

Please.

OK.

No that's OK I wasn't clear there it is it
is the stellar stroke teller rehab model

that you were involved in so it for the.

There's that in person traditional
group and for the tele group.

It will be a C.N.A. or an R A going
out with the equipment she won't leave

it in the House and
the therapist sitting back.

You know in the office or
wherever she is your your other point

we are building into I'm building into
everything I do now measures on awareness

of access to and utilization of community
and V.A. resources that's huge.

And that could be a study in and
of itself.

I'm sliding into everything I'm doing but
I really think it warrants a whole study

on awareness access and
utilization you know for

resources because people have
no idea what's available to them

right now.

You know.

Right right right where

when actually I was on the Internet.

The other day.
Massachusetts has an.

Excellent caregiver resource repository.

It's I love their website.

It's very straightforward GA We're not so
great.

Yet and so I mean I think I
think we need to design much.

So

you're designing a website that's
kind of cool laid all this in

YEAH

Water.

YEAH

YEAH.

Right.

By what

they said we're going to live and
so they say by

the words already like my wife

will and I wrote this letter.

This looks like you not only ready for
anything that comes down the pipe but

you're decreasing the probability of
accidents and injuries involved work and

just say OK you heard folks say.

So you know what that they say

yeah you're right but
they're really trying to say

OK but I live in a house that doesn't
have a master on the main and

I'm thinking about putting one in for my
mother my mother now my mother was an R.N.

up until fourteen months ago she was
working as an R.N. and on a dementia in it

and so what is very interesting is she
was up close and personal with the whole

dimension trajectory she knows
exactly what she's looking at.

And so she is very unusual in that
case where she would say come get me

I'm right here.

I'm.

I don't know

why you're your role

very well yeah yeah

yeah yeah yeah yeah yeah you're

right or yeah right.

And it's a marketing issue you know we
have to market this information and

how do we do that we had
a November's national carrier.

Then we had a fair last year or
a whole month of activities planned.

And we had very poor
attendance we had a lot.

We had staff there but
not a lot of caregivers.