Suggestion category: Low-cost innovations to improve AD/ADRD care.
Reason for entry: While the "ideas" site is for RFIs about the best ways to structure and frame the NIA's Eureka grant, this "application-like" idea attempts to motivate the NIA to focus the grant on gaps in assistive technology which make care giving challenging and unnecessarily costly. Drug therapies and more recently Internet-based information systems and brain exercise devices and programs have taken the lion's share of grant funds. This entry (idea) attempts to show the need for the Eureka prize to focus more on "hardware" and improving the inadequate assistive tools and safe patient handling technologies that nurses must rely on to care for dementia patients.
As a former nursing aide and nursing advocate, I can state that the care of later stage dementia patients is frustrating, labor-intensive, and prone to adverse events primarily because of inadequate assistive technology. Activities of daily living (ADLs) require the use of "patient lifts" for fully or maximally dependent patients in the highly repetitive and costly care-taking activities of bed transfer, toileting, showering, and pericare.
For instance the cost of 56 transfers per dependent patient per week for toileting (to and from commode x 4 daily visits x 7 days) uses up enormous nursing resources and results in many nursing back injuries (and added Workers Comp costs). About 39% of the cost of long term care is nursing labor costs and ADLs for the most dependent patients (i.e., dementia patients) consume a significant portion of this money. Since there is no effective medical treatment for dementia at present, research organizations such as the NIA need to acknowledge the limitations of current drug-related efforts and begin to shift some resources to efforts to improve the methods of patient care.
There is a coming wave of new dementia patients but the NIH does not appear to be addressing this critical need for better devices. Patient care and ADLs need to become much easier, safer, and less labor-intensive than they are today if Medicaid is to remain solvent (http://www.alz.org predicts dementia care will cost a staggering $1200B annually by 2050).
As an assistive technology engineer and the PI for a recent NICHD-TREAT grant who interviewed dozens of nurses, caretakers, and healthcare administrators on this subject, I concluded that this issue is critical to confronting the challenge of dementia care. Research to improve medical devices for Safe Patient Handling (lifts are an antiquated 60-year old technology with numerous limitations) is needed.
When a dementia patient is forced into long term care because they are too difficult to care for in the home, the costs range from $65K annually in Arkansas to $125K in New York.
These costs quickly consume the savings of the patient and their family. The caregiver's burden is often increased substantially as this financial stress increases and they approach bankruptcy. Medicaid leaves families with less than $20K assets in most states before it begins paying for long term care.
Two of the central reasons that dementia patients are forced into nursing homes is that they 1) become bedfast and lose mobility or 2) wander and cannot be guided to (or will not reliably sit on) commodes or toilets. Both situations generally require the use adult briefs. When a patient is confused and cannot consistently follow the caregiver's directions, they cannot be transferred to the wheelchair, commode, or shower without assistive technology (a transfer chair or patient lift). Manual lifting of patients requiring multiple caregivers is usually not possible in home care.
Patients who wear briefs need to be changed every two to three hours leading to increased caregiver stress, and home caregivers often cannot cope with this responsibility.. Assistive devices that permit quick, safe patient transfer to commodes are important in reducing incontinence and the need for patient briefs so patients can remain at home. But such devices are not available at present, Thus long term care becomes the only option.
However even caregivers who are willing to change patient's briefs find that this is a painful, slow process since the patient in a wheelchair must first be transferred from the wheelchair to the bed, rolled, cleaned, and new briefs applied. Then the patient must transferred back to the wheelchair. Here a well-designed device would permit the patient to be changed while remaining in a mobile chair saving a great deal of caregiver effort. But again, inexpensive devices that allow this labor-saving option do not exist.
The issues associated with bed confinement are difficulties with incontinence (changing briefs or diapers, clothes, and sheets) along with UTIs, decubitus ulcers, kidney infections, contractures, poor circulation, blood clots, hypostatic pneumonia, and depression. Bed confinement and its resultant medical and patient care problems is often the central thing that forces dementia patients into costly nursing homes.
So the central questions become:
1) How do later stage dementia home care patients become bedfast, immobile, or incontinent (from lacking quick, safe access to commodes/toilets)?
2) What can be done to avoid this?
The answer to the first question is:
Current assistive technologies are inadequate for home use, and improved assistive technologies need to be developed that are faster, safer, usable by a single-caregiver, less painful for patients, and less prone to adverse events (i.e., patient falls, caregiver back injuries).
Existing transfer or repositioning chairs are too expensive costing $5,000-$15,000. They are therefore rarely used in the home and do not aid in showering and toileting. Patient lifts or hoists (a 1955 design and a direct copy of existing automotive engine hoists) require two trained caregivers, considerable space to use, smooth floors, and a large storage space. Patients can also be dropped if the device tips over during use or the sling chosen is the wrong size or type, or wrongly positioned under the patient. Though Medicaid will pay for rental of these devices, they are also rarely used in home-care.
A central concern of the NIA should therefore be how to support improved assistive technologies to reduce bed confinement and facilitate ADLs in the home. This will allow dementia patients to stay in home-care longer and help their families avoid financial stress. However better assistive devices that make transfer, showering, and toileting faster, safer and easier are needed for BOTH home and institutional use.
If dementia care costs $250B annually currently, it is surprising that there is virtually no NIH support for R&D in this area (based on an extensive search of the NIH's Reporter database).
The EZCareChair ( http://www.ezcarechair.com ) is a prototype multi-purpose bed- transfer, mobility, showering, toileting, and peri-care device. It is a single-operator, no-lift, cost-effective transfer and mobility device for both home and facility use. It is less invasive than sling lifts because lateral stretcher-based transfer does not bend and compress the patient during transfer. Because there is no hoisting and minimal disturbance, confused, disorientated and frail (i.e., dementia) patients are less likely to act out reducing patient and caregiver injuries. The patient is supported at all times during transfer from beds, to commodes, and to showers greatly reducing the potential for patient falls. The devices is very efficient allowing for 2 minute bed transfer, 60-90 second commode transfer, and 30 second shower transfer which will reduce the cost of caring for highly dependent patients (compared to both manual lifting transfer and mechanized patient transfer methods).
There are a series of videos on the "EZCareChair" YouTube channel showing the way the device works. The prototype device currently needs further risk analysis, bench/FEA testing, and testing in a pilot project in a rehab or long term care medical environment. Funding is required to move the device from a prototype to a product.
Note: The picture gives a good representation of what caregivers do tens of thousands of times a day in the US to transfer dependent patients using what the American Nurses Association and OSHA consider the "state-of-the-art" assistive device (the patient hoist or floor sling lift).