Using Nvidia`s SHIELD to help with Dementia Terminal Agitation
By Mark Poppin
Terminal agitation is a syndrome often observed in patients during their last days of life. It is a type of delirium that refers to multiple signs of central nervous system irritability that may include restlessness, agitation, distressed babbling or singing, twitching, jerking and/or recurrent fits which generally result in the sufferer's inability to sleep. A lack of sleep coupled with continual movements may exhaust the patient and the caregivers. This sometimes agitated final stage, is often medically managed by strong drugs such as Atavan or morphine. The agitation is ugly and it takes a toll on the patient and the caregiver. Although managing agitation is extremely challenging, this editor as primary caregiver, has found that using Nvidia's SHIELD is very helpful.
From researching, this editor learned that it is absolutely crucial to the hospice patient's comfort that the caregivers and medical professionals remove any underlying causes of distress before declaring, "terminal agitation". In the case of my mother, even 1 ml of morphine every hour could not alleviate her distress because of an overlooked urinary tract infection. Once the infection was treated, the agitation stopped.
Generally, with terminal agitation, often no underlying causes can be found, or else it may be emotional with no resolution. Often a popular temporary medical solution is to give the patient enough drugs to manage their agitation; sometimes with a goal to put the patient into unconsciousness. During the day, familiar music, television, conversation, massage, or other activities may distract the dementia patient, but in the evening, the dreaded "Sundowner's" syndrome often occurs when the agitation may be multiplied many times.
At a point nearing terminal agitation, the patient may not be able to concentrate or focus on anything but their own internal distress, and there are few distractions to ease their discomfort and resulting agitation. For weeks, this was the case in this editor's household until SHIELD arrived.
SHIELD is Nvidia's Android console which is an amazing device that can play PC games streamed in full HD from a GeForce-equipped PC over a user's network or the Internet, using the SHIELD's built-in Wi-Fi, XBox-like controller, and 'retina-display' for a totally in-your-face quality mobile gaming experience.
Let's give our reader some background of how SHIELD came to be used to ease agitation in this one particular case for an older person who has never cared for video games. For many years, television and movies were the preferred choice for entertainment and distraction. As my mother's cognitive abilities diminished and her dementia deepened, the television set was moved closer and closer to her. Eventually, the TV no longer served to distract her daily as evening approached, and something more engaging was needed - SHIELD.
Nvidia's GTC ... SHIELD, "Video Games and the Future of Cognitive Enhancement."
SHIELD was a gift from Nvidia to each of the 3,000 attendees at Nvidia's GPU Technology Conference (GTC 2014). This is the same conference where this editor sat paying rapt attention to Thursday's keynote given by Dr. Adam Gazzaley, director of Neuroscience Imaging Center at the University of California, San Francisco, "Video Games and the Future of Cognitive Enhancement."
As some of us suspected, it appears that playing video games may improve cognition for all of us, and even help those with some cognitive impairment. Dr. Gazzaley pointed out that the current system for managing cognitive impairment is a disaster and a shame on 21st century medicine. This is something that we personally can attest to in my mother's particular case as she has been diagnosed with dementia for nearly 15 years, and has spent her last 4 years bed-bound, in hospice at home. There really are very few medicines that are useful for her, and after time, she has suffered severe reactions to many of them, including getting Tardive Dyskinesia.
In attempting to alleviate the symptoms of dementia, we have also used alternative therapies, including nutritional supplements, music of her generation, massage, movies, and homeopathic remedies to ease pain. Carefully researched nutritional supplements may have been helpful and they have included St. John's Wort, GABA, L-Theanine, Taurine, branch chained amino acids, Vitamin B complex, and fresh juices including ginger. However, ultimately dementia cannot be held back and it steadily progresses as the patient's condition deteriorates.
According to Dr. Gazzaley, brain plasticity is the key to improving cognition. We need targeted treatment that is personalized, multi-modial, and closed loop - something where today's medicine falls completely flat. Tests have shown that a person's multi-tasking performance peaks in their early twenties and then falls off slowly as the 60s are approached. However, with training by using a particular video game, an older person's cognitive performance, as demonstrated by measured frontline Theta, can improve to perform at age 60 even better than at the peak of a 23 year old.
What is noticeable is that video games can help improve multi-tasking performance, and with training and with the right kind of game, an older person can improve cognition. And when a video game is made specifically for improving cognition, it can be important therapy. Actual brain wave measurements can be made during gameplay to chart progress and to provide feedback.
The first video game specifically designed for cognitive enhancement is Neuroracer. After a few years, a second mobile game was created with better and more immersive graphics. They both give rewards when specific criteria are met, and the player levels up as a reward as he gets better at it.
The keynote finished up with a realtime demonstration using Mickey Hart of the Grateful Dead. He used the Oculus Rift while wearing electrodes attached to his scalp as he drummed and played a interactive game. All the while his brainwaves were being measured and visualized with the "Glass Brain" for all to see. Much credit goes to the Nvidia for making this keynote address possible.
More information can be found at:
The Keynote may be found in its entirety on Nvidia's GTC site. The video is of Thursday's main presentation. It is highly recommended and a major highlight of GTC 2014 and should be viewed by everyone, no matter their age.
Clearly, it is way too late for my mother to benefit from playing video games as her coordination and most of her verbal skills have been lost because she has been bed-bound for years. And because of her deteriorating condition, she has lost interest in music, and television no longer interests her when the dreaded evening (and "Sundowner's") approaches. It means that something more engrossing is required to capture and hold her attention. And it has turned out that streaming and playing PC video games on SHIELD is the kind of intimate experience that has allowed her to sleep again for seven nights in a row - and counting! This is something that was considered impossible a week ago when this experiment began. But first, let's look at SHIELD and see what it is capable of.
SHIELD is a hand-held game console with a five-inch display using Nvidia's fastest Tegra 4 processor, 2GB of RAM and 16GB of storage with further expansion available through microSD. SHIELD is also an Android device that functions as a tablet with the very latest Android OS. It syncs easily with your PC and you can use it to check your email, surf the web, and do just about anything but take pictures with it. The price is $199 at Newegg and at other retailers.
SHIELD uses a console-grade controller coupled with a five-inch high-definition, 720p multi-touch HD retinal display. SHIELD's Tegra 4 processor features 4 ARM Cortex-A15 processor cores and 72 graphics cores. It uses Android's latest operating system, and it supports 802.11n WiFi, Bluetooth, and GPS, together with a HDMI output so you can also play games on your TV in full HD. You can also use a Bluetooth keyboard and mouse for gaming with it if you prefer. SHIELD is very versatile!
SHIELD is an amazing new open platform gaming portable which is the best way to play Android games, working with both Tegra-optimized and regular Android games - as well as with Android apps. Google Play has many games available for Android games and some of them have been optimized specifically for SHIELD.
Nvidia has many recommended titles at Tegra Zone which link directly to SHIELD at the press of a button, many of which have been optimized for the SHIELD controller to make 720p handheld gaming a reality. SHIELD comes with Sonic 4 Episode II, and Expendable: Rearmed preloaded. Unfortunately, none of these games held the slightest bit of interest for my mother as her agitation increased.
SHIELD owners can also download Half-Life 2 from Google Play, in addition to Portal. Half-Life 2 is the winner of over 50 Game of the Year awards, multiple Game of the Decade awards, and the highest rated PC game in history. It's now available from Google Play for SHIELD for $9.99. Each of these games requires a download of about 2GB each. To the right is a screen capture from SHIELD of Half-Life 2 at it's native 1280×720 resolution.
Nvidia is working hard to build a thriving ecosystem of games on the Android platform. Half-Life 2 and Portal join more than 300 SHIELD-supported Android games now available. Since we received a SHIELD from Nvidia at the GTC in March, we have been exploring our first console since Sega Genesis, over 35 years ago. Although SHIELD is also our first Android device, we found using it to be quite intuitive. We are also quite impressed with Android gaming on SHIELD and find the controller to be intuitive and precise. And since attending the GTC keynote on video games and cognition, we were also looking for a way to integrate video games into my mother's daily routine before bedtime so as to capture her attention and perhaps to decrease her agitation.
Although there is a bit of aliasing and the frame rate drops at times, the experience of playing HalfLife 2 on a handheld console is recreated faithfully from the PC version, helped by the SHIELD's precise controls. Although, this editor is a Half-Life fan and thoroughly enjoyed replaying the game on SHIELD, his mother did not like the game one bit.
The next step was to try streaming the SHIELD supported PC games to SHIELD to see if AAA games held any interest. SHIELD works with Nvidia's GeForce GRID game streaming service serving from San Jose, California.
If your ISP and home Wi-Fi network connections are fast enough, you can stream games directly from Nvidia's GRID cloud. This editor has a fast enough connection, but the ping over satellite is higher than 800ms, making the GRID streamed games an unsatisfactory slideshow.
Streaming PC games to SHIELD
Fortunately, the very best feature of SHIELD in this editor's opinion, is its ability to stream PC games, at full HD and with full details and maximum anti-liaising supported by the host PC's GeForce over Wi-Fi, directly to SHIELD.
Amazingly, picking a $65 N-900 Netgear router, allowed us to stream without lag from the GTX 780 Ti equipped PC in the house, directly to the SHIELD in the apartment next door. Best of all, Nvidia has made it easy to setup this streaming with GeForce Experience, making the installation, launching and playing of supported PC games, a breeze!
Streaming BioShock from a GeForce-equipped PC
Shield is amazing. The streaming technology works very well streaming from the PC to SHIELD (and it could also be played on my mother's little "big screen" TV via HDMI, but we want SHIELD's in-your-face shared gaming experience).
Occasionally, there is a tiny bit of lag, as there is quite a bit of physical distance between the PC and the SHIELD, and a 5GHz signal doesn't seem to carry as well as 2.4GHz. Well, streaming was working well and I took my SHIELD over to my mother's apartment to see if an experiment using PC gaming on SHIELD might work to calm her agitation.
My idea was to take SHIELD over to my clearly suffering mother and play a game right in front of her face. BioShock was the first choice as she loves the old music from that era. Well, she was instantly captivated by the introduction and apparently by the fact that it was interactive and that my own play could affect what she was seeing. She loved the old music when we got to Columbia and for one half hour, she payed rapt attention to the screen. Soon she calmed down and her tics and twitching stopped. Before long, it became obvious that she was getting tired and had difficulty keeping her eyes open. Within an hour she was asleep - without any extra drugs. In fact, morphine has been discontinued for the past week, and she requires less than 1/2 of her former dosage of Atavan.
In game SHIELD screenshot of BioShock
Interestingly, she has responded well to other games, especially to GRID 2, Metro Last Light, and to many others. Since she doesn't like some games, like Half-Life 2 and Borderlands, it is easy to tell and a game can be exited and another started within a few seconds.
This experiment has lead to a week of much less agitation coupled with much more quality sleep that has brought relief to both the dementia patient and to this caregiver. Playing video games with my mother watching is also a very special shared experience, since she cannot really communicate verbally.
This personal experience is not intended to diagnose any disease nor offer any recommendation for treating dementia patients. Each person is an individual and what works for one may not be helpful, or even harmful, for another. However, just as playing familiar and favorite music has been found to be calming to many people suffering with dementia, perhaps video games may also improve the quality of life.
We are grateful to Nvidia for inviting us to their GTC where we learned about possibly improving cognition with video gaming, and for giving us the SHIELD which has given us a wonderful respite from dementia's agitation for over a week.