>> Hello, I am happy to be with you all. Today I will discuss something that is near and dear to my heart, particularly as it relates to the care of veterans. I receive a salary from the Department of veteran affairs. I have no financial relationship to disclose.
>> We will talk about a variety of potential assistive technologies to develop cognition. This is by no means an inclusive list or discussion of an endorsement of those products.
>> I am hoping we can outline some broad classes of assistive technologies for cognition. Talk about populations who may benefit from CAT  technologies, and start to peek interest about people who might benefit, who may not otherwise have considered. I like to summarize what we know regarding the effectiveness of these technologies. And hopefully spend time talking about how to best train there you for maximum outcome. 
>> Why cognitive assistive technology? What are the goals? Generally, it is to enhance independence in the home and community. Improve quality of life and reduce caregiver burden. Reinforce residual ability and to substitute alternative methods for Completion. -- Tax completion. 
>> Restore function, or take rehabilitative role. 


>> I cannot give a talk about cognitive to -- think about software programs such as brain age Q or velocity, happy neuron, narrow. There are lots of options out there that you might find in a Google search. What I can say, what we know is that the evidence is weak for some of the claims that are made. When you combined CCR  with traditional therapies, however, there has been some evidence to support and improvements in attention and memory for particular patient populations. Also in a case study there has been changes in functional MRI, and improvements in behaviors that were seen -- fMRI . It has demonstrated but limited and positive changes in normal aging adults. The last thing I want to mention about CCR itself, there is likely some  self efficacy are effective benefit from people who stimulate their brain, notice improvement that internal feedback kind of encourages them to do more and stimulates more neurons. The take-home message is not to throw the baby out with the bath water, but to recognize the sub where programs for what they are. 
>> -- Software programs. 
>> Let's talk about some factors to consider when you are considering CCR . We will talk about each three in more detail. 
>> Let's start with the target population. Most people immediately think about those with traumatic brain injury, or cerebral vascular accident as prime targets at appropriate durations -- patients to use [ Indiscernible ]. To encourage you to think about those with right hemisphere disorder, mental illness as well. Patients with dementia, and that pediatric Endo this as well -- end of this as well. Applications that you might be able to use, assistive technologies here also.
>> Another factor to consider are cognitive deficits that you are trying to compensate or rehabilitate. Let's talk about a few of those. The first one is attention. When I think about attention or when I talk about attention, we are being able to sustain attention over time, shifting your attention between things. Dividing your attention, filtering out distractions that may be occurring within the environment.
>> Another example of cognitive deficit is visual processing, or visual spatial processing. You may not recognize words imprints, objects are your position in space. 
>> Memory is self-explanatory. Broadening your thinking about memory to reminiscence are remote memories, perspective memories, remember to do things in the future. 
>> Executive functions, the difference between knowing what to do, and actually doing it, applying those skills. Planning and problem solving, organization are types of cognitive deficits, as well as behavioral and affective changes. I think throughout the course of our time together you are going to realize it is nearly impossible to pull out one of these specific deficits and Sam going to work on this, or I am going to target this with the cognitive assistive technology. You will see overlap among the deficits, and technologies that might help to address the problem. 
>> The other factors that are on the slide, think about target task, whether something specific like note taking, or crosses more domains. You want to think about the availability of the technology it out, whether you can buy off of the shelf, or something that needs to be adapted, or created by a clinician. 
>> When considering your patient or client factors, you need to know how complex of a device is appropriate for them. And which cognitive function you are primarily trying to support.
>> Here are just a few examples of devices that might fit into some groups based on function, and a level of complexity. 
>> I think it is important to note, over the years, cognitive assistive technology has been undergoing a big change. There research center has data from 2017, 95% of Americans own a mobile device. 46% of adults say they could not live without their smart phone. Of which I am certainly one. 
>> I think we need to expand our thinking about the technologies that we are using. 
>> Let's talk a little bit about devices and some of the research and evidence we have for the use of cognitive assistive technologies.
>> Again, I am going to do my best to give us a framework, to think about this, recognizing these things overlap. I think the [ Indiscernible ] colleague today good job of trying to help isolate different groups. We will follow Gillespie framework to talk about different devices. And what the research tells us about the effectiveness. 
>> I need to preface this next part of our talk. There are not very many randomized controlled clinical trials. For cognitive assistive technology, although it is emerging with time you will find that the evidence is based on clinical studies, case studies, small numbers of patients in the studies, and they may have some optimal mythological validity.
>> The next few minutes when we talk about the research, listen with those headphones.
>> Sticking with Gillespie's model, let's talk about what they refer to as alerting devices. Devices focused on trying to improve attention. We want to draw attention to a stimulus that is present in the environment. To break down a couple of ideas, you could think of neglect alert devices. Patients with right hemisphere disorder might neglect their lap arm and leg and left side of the world. There are devices that help call your attention to it.
>> The evidence we have for use of these types of devices, positive outcomes for both mobility and visual search tasks.
>> There are also devices that call attention to goals. The main focus being on reminding you, and your memory, to stop and pay attention to what you are supposed to be doing in the moment. The strongest evidence we have had is tone -- designed to stimulate the nerves to regain leg or hand function due to stroke, multiple sclerosis or other CNS disorders.
>> I like to argue that it might serve to call attention to a neglected limb, when using it toward a functional goal in therapy. Again, I am hopefully getting you to think about blending compensation and restoration together. 
>> There are a couple of wearable devices as well. The Apple watches one example. There is also the watch minder three, designed primarily to target attention and behavioral regulation in ADD and ADHD. It will alert by vibrating on the rest, a short character text message will come across the screen. Some ideas of alert reminding devices. 
>> Another group of devices would be reminding devices. Think about prospective memory or memory for things in the future and planning. The idea is to provide a one-way time-dependent reminder, about something that you need to do that is not right in front of you. 
>> Time management is probably one of the most commonly targeted goals for CAT . For those that are not familiar with neuropage,  it is a simple and it was developed in California. By the engineer of a father with a son with head injury, working with a neuropsychologist to develop a system. It was designed to address every day memory problems, because of organic memory impairment, or impairment with planning and organization. Neuropage is  probably one of the largest most white wine -- widely studied technologies in the literature. Those studies range everywhere from a sample of 12 pediatric adolescence, and the use of neuropage to  randomized controlled trials. Voice recorders with timer functions, text messaging, voice messaging, all of those are effective and bring about positive change. Some studies have next results in terms of the effectiveness. This speaks to the fact that the individuals that we are providing CAT have individual needs . That's makes the research difficult in it of itself. 
>> Another type of reminding device is step-by-step support, to complete a task, whether software or multimedia. Something that talks you through or reminds you of all the steps you need to do to complete a specific task. 
>> We know the use of cognitive assistive technologies to do this, seem to improve the accuracy of step completion, compared to no tech options. Or a low-tech or no tech options. 
>> Here is a simple example of a calendar app that could be found on any smart phone. I think one of the things that people forget, one application that can be readily utilized by our patients, is the alert reminding piece. Remember to make a -- an appointment.
>> Here are some other applications that do very similar things. Reminders, reminding you to do something, scheduling your day. Again, this is not an all inclusive list any means. It is important as we get going, to take into account what your patient has already been using. If anything, and to take the lead from them. 
>> Let's talk about executive functions. Planning, organization, micro prompting, as Gillespie might think about it. I will organize these two organize thoughts or semantic mapping. A lot of times with cognitive deficits have ideas but they cannot figure out how to organize them. Or planning and executing a complex task, such as a trip to Disney or somewhere else. Or school related needs. 
>> There are also applications, the changing face of cognitive assisted technology, there are applications designed to do these things specifically. Talking if you had to make a cup of coffee, or to do your laundry, organize your thoughts and keep your schedule up to date. We can talk in detail about more these applications later. 
>> There are also storing and displaying devices for memory. The main goal is to store and represent episodic memories. Reminiscence. Cameras, multimedia, they have applications out there. This is your photo album with text, but now electronic version. There is limited and period evidence. Most studies are qualitative or single subject designs. I think it is important to know that this is an option, think about a patient with dementia, who cannot remember the trip he took with his family to California. This is a nice way to organize.
>> Here is another example. Ace very creator can be used to either train something that you need your patient to do, or to help them recall, remember and engage about an event in the past. 
>> Another category of cognitive assistive technology are valid to emotional regulation -- devoted. It is to distract the users from something that might be causing them anxiety. Maybe a personal stereo for managing the stress of auditory hallucinations. Or biofeedback in conjunction with traditional cognitive behavioral therapies with psychology, to manage heart rate, anxiety and breathing. There is positive evidence for use of technologies in this way as well. 
>> As a speech pathologist, of course I cannot go without talking about speech generating devices. Which is standard practice for adults with neurodegenerative disease. We highly recommend early referral, regular week evaluations, and continual treatment to ensure the patient's needs are being met throughout the lifespan. 
>> I want to take a moment to talk about how cognitive assisted technologies and traumatic brain injuries, since it is the most studies -- studied as well. And have a interrelate. I would like to point out you cannot separate out these functions. Speech and language are tied to memory and executive functions. 
>> Younger people tend to compensate post TBI. Very severe impairments can be prosecutors for effective use of cognitive assistive technologies.
>> I will tell you also if you have a focal deficit, or an area of impairment in one specific area of the brain, as opposed to multiple are many areas, you are more likely to have a favorable outcome. 
>> If you had been using compensatory aids prior to the injury, you are more likely to use them after, and have positive effective outcomes. 
>> Let's talk for a minute about TBI and speech generating devices. About 40% of people who do not regain natural speech by the middle of their recovery, think about if you are not familiar with Rancho levels, where they are recovering and they may be educated some agitation and starting to resolve the and starting to follow some commands. The middle stage of recovery, 40% of those people if they are not talking by then, they will likely remain unable to speak to chronic, severe motor speech or language disorders. I think it is important to remember that technology, whatever that might look like for this individual, it should be on the table. 
>> In 2006, a study was done where he talked to patients with TBI and their caregivers. I thought it was very nice to see, 94% of the people from whom they recommended technology, both accept them. Even better yet, after 3 years 81% continue to use their technology.
>> I think if you hear nothing else about this, I would not let severity of the dictate whether or not you should or should not try something allergies. 
>> -- Technologies. 
>> More recently there has been some studies about how language should be organized with TBI. And I think how they organize semantic information in their brain, and the type and the amount of visual information that they need to process, it can have a big impact on the efficiency and the effectiveness of the use of these devices. 
>> I want to say something for that. You can keep them in the back of your mind. If any of your patients may benefit. 
>> Why don't people use CCR ? There are a handful of barriers that are outlined. Everything from funding, to how rapidly technology changes.
>> I would argue one of the biggest and -- and the literature supports, is lack of training with the device being issued. I will take a moment to talk to you now, and the theme for some of the rest of our time together, it will be this training, and how to train technologies. 
>> The difference between systematic instruction, versus a trial and error approach. In brief systematic, considers all of the levels of training and how much cueing is provided. Trial and error is more about self discovery and assumes that learners can learn from there must takes. 
>> -- Learners can learn from their mistakes. 
>> If you have not read optimizing rehabilitation, that is your day job, with your wheelhouse, I recommended.
>> It stands for planning. Adequate and planning needs to happen at the forefront. That there be some systematic organization for the implementation of the technology. And that you are constantly evaluating performance and not just within the session and view. -- P.I.E. . 
>> -- In front of you. 
>> Let's think of this as a four step process. We need to become familiar with the range of CAT tools . It is important also in that planning stage, to conduct individualized needs assessment. Implementing is obviously training the use of the device and ensuring mastery.
>> Evaluating is the effectiveness of the technology prescribed. 
>> When I think about the plan, what is forefront in my head is who is the learner? What is their ability? And what is the technology I am trying to teach? Why did I choose this, where will they need it, when will it be used? And I start my planned that way. 
>> Some nice tools to help you think about planning and to get the information that you might be looking for, are the compensation techniques inventory. Looking at the primary areas of need current and past strategies, and designed to facilitate goalsetting.
>> Matching persons and technology. It looks at the person the environment, technology, and the functional impact. 
>> This is not technology specific, the self-awareness of deficit interview. It gives a nice framework for questioning, questioning your client and/or families. To figure out where the needs are and what their perception of needs are, which directly impacts your choice of technology, to implement technology at all. 
>> Here is a breakdown with more specificity about the difference between systematic instruction and conventional instruction. I think my best example is, you are looking at the slide, how it is compared to a co-treatment session with one of my physical therapist. For example, what often happens, when they are training a transfer and walking with and assisted device, whether a quad cane, is we will go through all the steps, the patient will stand up, we will walk to the end of the game, we will turn around walk back down. And there's nothing wrong with that. However, with cognitive impairment, I think making sure that we can get that set to stand down, and drill and practice that, feeding the cues that we give to effectively making that transfer save, we might stand up and sit down 10 times before we ever walk. That is probably the most concrete example of the difference between systematic instruction, and conventional instruction that I can give you. 
>> Another really important part of systematic instruction, beside the step-by-step models and the fading of cues, is correct practice and distributed practice across environments. I want you to learn this correctly. Training in different environments. That might mean that all we do is practice, walking and unlocking, until you happen and you do not need me to tell you how to do it. 
>> From acquisition and delivery of device and then maintaining use, and instruct will sequence might look something like this -- in structural sequence. 
>> You might have a checklist with all steps to learn technologies. You want to fade the support of learning, you want to increase their engagement by having dialogue about what is beneficial, what are barriers, and to elicit input. And plan for your technology to be abandoned. As we know, that happens. Stay ahead of the game. 
>> Evaluation can occur in multiple ways, whether within the session, the ability to generalize use of technology to another in fireman, the impact on daily lives, those are ways to think about it. Here are some tools that may help. We have the quest, 12 item outcome measure assesses to have user satisfaction with both focus on device and services. 
>> Another one is, again this is not an all inclusive list something to about. The psychosocial impact of the is did devices -- assisted device. The goal is to have effects on well-being, and quality of life. 
>> I want to transition and talk to you about what this looks like in real time. The first case is Erin. Asko ering. He is a 20-year-old S/B blast exposure, he has PTSD, anxiety, history of alcohol use. He has mild attentional Lakshman Tatian's on neuropsych testing that likely are responsible for all of his functional complaints regarding memory and organization. 
>> Here is the planning part. Collaboration between the speech pathology service, for whom he was also working, and veteran himself to outline the barriers. Together we established goals. If you recall he has PTSD and anxiety disorder gone for psychotherapy. He is having difficulty remembering and applying what he is learning from that valuable session in real time.
>> We also established a goal to organize daily act cavities to reduce his frustration and anxiety. Ultimately the goal was to return to school. 
>> After meeting with him and doing the needs assessment, figuring out the goals, we decided to implement assistive technologies for attention and organization. We used a tablet device in conjunction with the smart phone. And some additional study skill training. More traditional therapy I spoke of earlier. 
>> I would say, that's probably took a more trial and error approach to his rehabilitation. We trained one application at a time. I also encourage him to explore and do some self discovery outside of the session itself. I had an understanding of his baseline impairment, which were only mild. And likely exacerbated by other things such as is PTSD and anxiety. 
>> We put three applications in place. He embraced it beautifully. He immediately saw the benefit and the effectiveness of the application and use them in the way I did not anticipate. I will tell you that in a second. 
>> Let's look at some of the applications that we used. One was inspiration maps. That is the semantic mapping thought organization map. There are more than this one. The beauty of this application, is you can get all of your thoughts out and you can connect them. You can color code, import photos, and audio. Maybe you are not a math person, but with a touch of a button it turns into a linear outline.
>> I think this could be a very powerful tool. And the way I was thinking Erin might use this to brainstorm for writing papers in school. He is the to find himself an apartment. And also the school. 
>> Erin told us he had to get exciting about organizing his day, and getting task completed. And feeling like he could manage all of the things that he had to do. We chose to use this application to do that very thing. Give him a daily to do list, that can -- communicated with the calendar which he was familiar. Just one idea. 
>> Finally, we chose the application notability for notetaking. You can import PDF, do audio recordings. This is just one tool. We talked about a live scribe pen that would be task specific. And we decided to just go with what made the most sense to him. This is working beautifully for him. I am happy to tell you currently he is in school and doing well. 
>> Let's switch gears and talk about someone else. Sam, a 64-year-old male who was status post right hemisphere stroke. Has left hemiparesis, dysarthria and dysphasia. He has a history of an old stroke in the frontal parietal region as strokes in the palms. I will let you take a look at some of the other non-cognitive assistive technologies that we were using as a team with him.
>> Our big concerns related to balance transfers. On cognitive testing he demonstrated mild impairments, visual-spatial skills, only memory was a strength for San. What we were saying, was this great disparity between the testing, and his actual performance. Difficulty during functional tasks and daily activities. Especially when there was a lot going on. 
>> The big problem for us, we saw him for inpatient rehabilitation. I am tying back to thinking about using cognitive assistive technologies, yes for compensation, but also for restoration and rehabilitation. Having difficulty retaining and executing sequences for transfers. He had reduced insight into his impairment, which is not uncommon. He had inattention to the left side and during functional activities. 
>> This is a joint PT/OT speech collaboration. Obviously with the veteran as well. We have seen him individually for treatment, and report our heads together. His goal is to return to independent living. We made a list that he would be able to do in order to do safely. 
>> Here is where the assistive technologies for cognition come into play for San. We put things in place for attention multi step sequences. Using that notion of systematic instruction in the back of my head. We used a very simple alert reminding device on his arm. To increase his awareness and use. In Sam's case we did not need anything big and fancy. When he felt that multiple alarm watch vibrate on his arm, he knew what he was supposed to do. Stretch out his fingers, we had it set for mealtimes to engage the arm. For support and to eat. We also put in place the use of a tablet to help train the multi step commands. In his case we use can plan. I will show you a screenshot. We did multiple discrete trials for execution of those complex sequences, and we used the cognitive assistive technology to train the nursing staff, the family, so he is systematically, consistently having the same instruction, in a multimedia reference points, if you will. 
>> We evaluated this case multiple environments. We enlisted, most certainly, family and nursing staff. 
>> Here is a quick screen shot of the milk I mediate step-by-step -- multimedia step-by-step training. He can see all of the photos to get himself ready. This training allowed him to internalize those steps. We were able to fade the cues. I am happy to say Sam ended up returning to independent living, and he's doing well. 
>> The last case I want to talk about today, it is dog. He is a 30-year-old veteran -- who sustained a catastrophic injury. While he was deployed. He is now years status post injury. He has severe TBI, bilateral above-the-knee applications, bilateral strokes. Shunted hydrocephalus, right hemiparesis and neglect, and left hemi lists Miss -- [ Indiscernible ] he has severe apraxia, aphasia, nonverbal. Functional communication limited to facial expression and eye movements for those who know him very well. 
>> With someone with such severe impairments, where do you begin? I will argue, that it is the attention. At least to bring about some functional change.
>> This is another case where we have all been working with this pattern as an outpatient. Separately, and came together collaboratively. 
>> We implemented assistive technologies for attention and communication and cotreatment. That is where we started to see some significant change and improvement. 
>> From a speech pathology standpoint, what does this look like? I wanted to improve attention, with the use of a speech generating device, as CCR . We need to get him to pay attention to an entire visual field, so that theoretically he could use it for functional communication down the road. We systematically increased how complex the tasks were, and his ability to resist distractions in his strong visual field of the left.
>> And then transitional to functionally relevant page set targets for communication. Controlling the mistakes as they go. 
>> Here are some screenshots of clinician generated [ Indiscernible ] myself. Page sets that's worked on retraining his visual attention and his intention to the right side of the world. Using a tool that might not otherwise be considered for it.
>> And cotreatment, PT and OT worked on improved functional use of upper extremities. Increased awareness and use of muscles on the neglect side and the core. Increasing the time that he had his prosthetics on. Our goals were to reduce caregiver burden, and maintained current function. The Mac
>> I was looking to get Kerry over to the right attention training and more functional application of the communication device. We have used all types of technologies From a baseball cap that locked at the left side to constrain attention to the right up to a high tech AAC device to work on retraining attention. 
>> Here is what I can tell you in this case. We have seen improved attention to the right side beyond the device self. To novel situations and the environment. He is starting to use the device indicate preference, he is wearing the biomass. -- BioNess . He pays attention to it when he feels changes to the program. It stimulates [ Indiscernible ]. We have seen active muscle contraction on the right side, it has been neglected when he is focused -- when the attention is on point we have seen functional improvements and change. 
>> That brings me to my point of using both technology to compensate for, but to also restore function. I think that is a real thing that we should think about when doing this as professionals. 
>> In the cases that I have reviewed with you, I hope that I have tooted the horn enough for consideration of systematic instruction, something that should be in your repertoire port training cognitive assistive technologies.
>> We have evidence in the literature to support this notion. There was a randomized controlled clinical trial, for patients with acquired brain injury, and they can. Systematic instruction with conventional structure, for teaching use of PDA.
>> Where there was no difference on the post test measures of accuracy and fluency of use of the device, those who underwent systematic instruction had better generalization to novel environments. Had more powerful and effective outcomes of the 30 day follow-up. 
>> The candidacy themes for considering systematic instruction. Please remember, there is nothing wrong with conventional instruction, nothing wrong with learning from your mistakes.
>> I think it is important to recognize that if you are prescribing cognitive assistive technologies, there is likely something that is not completely intact regarding cognition. The level of impairment, the disease characteristics, those things need to be at the forefront of your brain. How am I going to teach the use of this device?
>> The task you are trying to accomplish, and how complex your technology can be, and the personnel variables, those internal things. What expectations do your patients have? How motivated are they and what is their support system?
>> In summary, there are a wide range of cognitive assistive technologies available to us. I hope that I have made the case, cognitive assistive technologies may be appropriate for people you may have not otherwise considered.
>> I think it is powerful when you combine technologies with traditional therapies, for this particular population. I would like you to consider utilizing systematic instruction more often when you are prescribing cognitive assistive technologies. 
>> Collaboration with the team members to work toward a common goal. And a part of your team is your patient, and it is paramount. If there is not proper evaluation and training, the technologies that you are trying to implement for your patient will not succeed. 
>> I thank you for your time. 
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