With the number of Americans age 65 years or older expected to reach 78 million by 2035, the Cizik School of Nursing at UTHealth Houston has made exploring ways to enhance the lives of senior citizens a priority.
Two faculty members in the Department of Research – Seema Aggarwal, PhD, RN, AGNP-C, assistant professor and PARTNERS Research Scholar, and Carina Katigbak, PhD, RN, ANP-BC, FAH, associate professor – each recently received a $40,000 Aging in Place Research Award. These grants go to interprofessional teams conducting research in the nursing school's Smart Apartment, a laboratory for testing age-appropriate technologies to help older adults live safely and independently. Funding comes from the Maria C. and Christopher Pappas Distinguished Chair in Nursing Endowment, which is held by Associate Dean for Research Constance Johnson, PhD, RN, FAAN, and the UTHealth Houston Consortium on Aging.
In addition, Katigbak received an $30,000 grant from the Center for Clinical and Translations Sciences (CCTS) for a separate study related to how older adults and their caregivers perceive technology.
Using virtual gaming to improve the lives of stroke survivors
Aggarwal got the idea for her project, "The Feasibility, Usability, and Acceptability of Using the Oculus Virtual Gaming Reality in Stroke Survivors for Upper Extremity and Cognitive Rehabilitation,” from her teenage son.
"My son kept asking me to play a game with him on his virtual reality gaming system. I resisted but eventually relented. After playing it for just a few minutes, I began to wonder how patients recovering from a stroke might benefit from games that simulate real-life activities," said Aggarwal.
She will test the effectiveness of a consumer-level virtual reality (VR) system as an economical option for providing outpatient stroke rehabilitation, particularly for patients who live in rural areas or who lack transportation or adequate insurance.
VR gaming is not a new approach in helping stroke survivors. It has been shown to improve functional outcomes in clinical settings. Headsets are immersive and highly interactive; however, most of the equipment previously used in research is expensive - $1,000 at a minimum – with required computer and fixed wall sensors.
"Consumer-level VR gaming systems can cost as little as $400, making them an accessible option for patients needing therapy that can be done in their homes. In addition, it may be more effective than telerehabilitation, which is less interactive. While appropriate in some settings, telerehabilitation can lead to a lack of motivation and patient satisfaction over time," said Aggarwal.
More than half patients who experience stroke develop arm weakness and cognitive impairments within the first six months of injury, and one in five develop dementia. Because of this, stroke survivors require both upper extremity and cognitive therapies to prevent deformative joints and cognitive decline.
Aggarwal will specifically study using the Oculus VR system to deliver remote upper extremity and cognitive rehabilitation. Patients will be immersed in a 3D gaming environment simulating daily activities that combine motor and cognitive rehabilitation, known as "dual tasking." Dual tasking encourages neuro-stimulation and interaction between multiple brain regions, which is thought to promote neuroplasticity, the brain's ability to develop neuronal connections, which may lead to improved functional recovery.
The study's primary goal is to test the feasibility, usability, and acceptability of the system to administer cognitive and extremity rehabilitation six months to a year post-stroke for patients who have mild to moderate impairment.
"The Smart Apartment is the perfect place to conduct this research as it's a laboratory to pilot technology," said Aggarwal.
The project's secondary goal is to qualitatively explore the impact of engaging caregivers in supporting the patient's rehabilitation and the effect of this engagement on the stroke survivor and caregiver relationship through structured interviews.
Helping stroke survivors and their families is a topic that hits home for Aggarwal. Her father experienced a stroke in 1992 and recovered with fewer motor and cognitive deficits than other patients who experienced a similar stroke.
"My dad had access to the right type of rehabilitation and care, which is why he had a good outcome. But, unfortunately, many other patients are not that lucky, which is why I'm so passionate about finding an accessible, affordable way for stroke patients to receive the therapy they need," she said.
Katigbak is one of Aggarwal’s co-investigators on the study along with Mary Russell, DO, and Sean Savitz, MD, of McGovern Medical School; Jiang Xiaoqian, PhD, of UTHealth School of Biomedical Informatics; and Heather Smith, SLP, and Emily Stevens, OT, of UT Physicians.
Measuring heart rate as an indicator of stress in caregivers
Katigbak is using her Aging-in-Place grant for her project "Care Matters: Using Ecological Momentary Assessment & Heart Rate Variability Monitoring to Identify the Timing and Experience of Caregivers' Stress."
"Chronic stress can negatively impact caregivers’ overall physical and mental health," said Katigbak. " It is recognized as one of the most severe risk factors for cardiovascular disease, which is a leading cause of death among caregivers of homebound older adults."
She added that research surrounding chronic stress or stress reactivity – how people emotionally and physically respond to stressors – has typically only been measured in controlled laboratory settings.
"While this information provides some valuable insight, it does not accurately reflect the stress activity of daily life and that of people in their natural surroundings," said Katigbak.
Caregivers participating in Katigbak's study will wear small, unobtrusive sensors that provide automated electrocardiography (ECG) analysis and will be asked to answer a series of survey questions via phone app throughout the day for seven days. Combining both types of data may provide Katigbak and her team with information on how a caregiver's physical surroundings and daily activities might contribute to their overall stress.
The team will use the Smart Apartment at the Cizik School of Nursing to orient participants in the study so they feel comfortable doing so in their own environments.
"The results of this study are pivotal to connecting care priorities of older adults and their families and promoting aging in place. In addition, the data we collect may help us develop tailored technology-driven interventions for caregivers, so we are well-positioned to address consequences of chronic stress," said Katigbak.
Co-investigators on the project are Sahiti Myneni, PhD, of the UTHealth Houston School of Biomedical Informatics; and Jessica Lee, MD, of McGovern Medical School. The group is also collaborating with Harris Health LBJ House Call program.
Exploring how technology can support aging in place
Katigbak’s CCTS study, "In Tandem: Exploring Homebound Older Adults' and Caregivers' Perspectives on Technology to Support Caregiving and Aging in Place," will take a deep dive into how homebound older adults and caregivers perceive technology. Specifically, her research will examine any barriers to usage and how technology may enhance the quality of life for homebound older adults and help caregivers carry out their various roles and responsibilities.
"Homebound older adults and their caregivers face multiple challenges to meet various emotional and informational needs," said Katigbak. "In recent years, numerous health-related technologies have emerged – ones that promote behaviors such as physical activity, stress management, and nutritional tracking, which may be beneficial to this population; however, little is known about how the homebound and caregivers embrace these tools."
Katigbak and her team will work collaboratively with CarePartners, a Houston-based organization that provides support, education, resources, and respite care to family caregivers, to understand how technology may improve health outcomes for homebound older adults and their caregivers. Through a series of focus groups and individual in-depth interviews with a cross-section of participants, including older homebound adults, their caregivers, community stakeholders, and clinicians, they hope to derive a clear picture of how technology can help throughout the aging-in-place process.
"The work we will do through this study is critical to developing accessible and sustainable theory-driven, interventions to address caregiver and homebound older adults' needs in real-time," said Katigbak. "We look forward to the findings of our research, which may help senior citizens as they age and ease some of the burdens of caregivers."
Collaborating with Katigbak on the CCTS project are Lee; Padmavathy Ramaswamy, PhD, of Cizik School of Nursing; and Kathrin Milbury, PhD, of MD Anderson Cancer Center.
Laura Frnka Davis