Seniors at the controls

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Seniors may not be known as gamers, but researchers at Sunnybrook are hoping to change that with an app that will allow them to achieve something more important than a high score – reducing the incidence of delirium.

Using a digital version of the popular whack-a-mole carnival game, participants are measured on how fast they use their fingers to tap certain furry critters – and avoid tapping others – on a tablet screen.

"In the current prototype, we have a 'go or no-go' task, where the player tries to hit targets that pop up – for example, raccoons, but not the butterflies," says Dr. Jacques Lee, a scientist at Sunnybrook Research Institute and a physician in the hospital's Emergency Department.

According to Dr. Lee, measuring changes in patients' reaction times to the game-based activities could be a potential predictor of delirium onset.

"We want to find out how long it takes people to do this, if they find it easy to complete and how many errors are made."

Delirium, characterized by acute confusion and inability to concentrate, is a common occurrence in seniors, especially in an emergency department setting and regardless of the reason that sent them there.

Delirium is a serious condition that may persist for weeks or months and is associated with several negative outcomes, including risk of death, complications after surgery, and problems with memory.

"The key is prevention," according to Dr. Lee. "Once an older person becomes delirious, it's difficult to treat or reverse."

Working with Mark Chignell, a professor of mechanical and industrial engineering at the University of Toronto, Dr. Lee is conducting two innovative studies aimed at better predicting the onset of delirium in seniors in the emergency room, so health-care teams can prevent it.

They're using video-game-like technology in both research projects.

"The primary objective," explains Dr. Lee, "is that by better understanding the early course of delirium, we hope to design targeted interventions to prevent it and the many life-altering complications that can follow an episode."

Informed consent is obtained from elderly patients who fit the profile of someone who might be susceptible to delirium, and then they are asked if they would like to participate in the studies, which use tablet-based apps that measure reaction time and act as potential delirium-screening tools.

Many more versions of the game could be created – say, a timed bingo game – but Dr. Lee also notes that this is just another tool to spot the early signs of delirium. "A lot of clinical experience, judgment and training [are] required to make the diagnosis, [which uses] the standard Confusion Assessment Method (CAM) test."

The CAM test is a brief, standardized and evidence-based clinical tool that allows health-care professionals who are not trained in psychiatry to quickly diagnose the presence or absence of delirium. The test is considered by many to be the gold standard of delirium detection in both clinical and research settings.

The research is funded by the Canadian Frailty Network (CFN) – a cross-Canada alliance of 45 universities, hospitals and research institutes. CFN supports original research and trains the next generation of health-care professionals and scientists to improve health outcomes for older Canadians across all settings of care.

Delirium can be challenging for health-care providers to diagnose, says Dr. Barbara Liu, executive director of Sunnybrook's Regional Geriatric Program of Toronto, as well as director of the geriatric medicine postgraduate program at the University of Toronto. A proper diagnosis of delirium requires knowledge of the patient's baseline or usual cognitive status and there may not be a person available who can provide that background information when the patient is admitted to hospital.

"When delirium occurs in the context of underlying dementia, it can sometimes be challenging for clinicians to tease out whether the patient's level of confusion is different from their baseline," Dr. Liu explains.

"Delirium can also present in different ways – the hypoactive [less than normally active] form of delirium may be missed by clinicians when the patient is drowsy and quiet. And delirium, by definition, is fluctuating, so the diagnosis needs to reflect the patient's symptoms over a period of time. [The patient] may seem fine at one point during the day, but later be more confused."

So if you see a senior playing a video game at the hospital, it may not be just for fun, it could be part of research to improve future health outcomes for an aging population.

DELIRIUM VS. DEMENTIA: WHAT'S THE DIFFERENCE?

Illustration by Kevin Hand

Onset
The onset of delirium occurs within a short time, while dementia usually begins with relatively minor symptoms that gradually worsen over time.

Attention
The ability to stay focused or maintain attention is significantly impaired with delirium. A person in the early stages of dementia remains generally alert.

Fluctuation
The appearance of delirium symptoms can fluctuate significantly and frequently throughout the day. While people with dementia have better and worse times of day, their memory and thinking skills stay at a fairly constant level during the course of a day.

Delirium is frequently overlooked or underdiagnosed. •

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