PRE2023 1 Group2

Nutrition check and monitoring for the elderly.

Group members

Name	Student ID	Department
YooungGi Park	1534718	Computer Science and Engineering
Zabiollah Amiri	1522175	Electrical Engineering
Thomas Paul Smids	1684329	Computer Science and Engineering
Rune Bal	1755897	Biomedical Engineering

Introduction & Problem Statement

Maintaining a healthy and balanced diet is essential at every stage of life, but it takes on even greater significance as we age. For our elderly population, proper nutrition becomes a vital cornerstone of well-being, impacting both the quality of life and overall health. As we age, our nutritional needs change, and we need to pay special attention to the foods we consume. However even a well-balanced diet can be insufficient in case of improper food intake.

In our elderly population forgetfulness, and diseases like Dementia, especially Alzheimer's can really impact proper food intake. This could for example lead to skipping these essential meals, or conversely eating to much as a consequence of forgetting that one has eaten before.

The device we will be developing will be one that reminds the our elders by monitoring their food intake, when it is necessary to eat, and when this is not the case, ensuring that the individual will eat their meals regularly, ensuring proper food intake.

Requirements

Functional requirements

Several issues that hinder independent eating experience in dementia patients of all levels have been identified through paper research. We came up with functional requirements to encounter some of these difficulties in this section. These functional requirements are characteristics that must be implemented in our product in order for patients/users to effectively use the product and increase the above-mentioned quality of autonomous eating experience.

To begin, it is critical to consider features in terms of user experience, particularly for elderly people with dementia. Functions such as ease of use (simplicity), ease of access, user-friendliness, intuitivity, and safety measures must be the baseline of features to be considered while designing the product.

• Difficulty in proper use of utensils

1. The product should have a grips that is easy to hold
2. The product should have a proper weight
3. The product should have comfortable handles
4. The product should provide clear and intuitive structure.

• Difficulty in scooping the proper amount of food

1. The product should have a different shape for each use purpose? (fork/ spoon/ knife)

• Difficulty in recognizing the total amount of food provided

1. The product should display the total volume of a meal in a clear manner
2. The product should inform the amount of food to be consumed to the user

• Difficulty in maintaining attention while eating

1. The product should include features to minimize distraction in the environment (provide calm and smoothing environment, such as music)
2. The product should provide positive feedback to users during eating for them to staying in focus

• Difficulty in maintaining alertness while eating

1. The product should have activity tracker or camera sensor to detect users movement and alert them when their alertness is declining
2. The product should provide features to engage user with the food in front of them

Further research should be carried out to finalize or improve these guidelines, and surveys or usability testing with users would provide valuable feedback to develop these requirements and create a higher quality product that meets their demands.

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MoSCoW

In this section the requirements of the product will be specified, using the MoSCoW method. Meaning the requirements of our product are sorted into 4 categories: Must have, Should have, Could have and Won't have.

1. Must have

• Retrieve and record data concerning the users food intake.
• Analyze a users intake routine and the quantity of a nutrient intake.
• When an anomaly has been detected alert the user or a responsible person.
• Easy to have on person at all times.

2. Should have

• A long battery life or support for an electronic device with long battery life.
• Have an intuitive alert system.
• If any, have an intuitive UI (User Interface).
• Be physically robust.

3. Could have

• Retrieve data concerning other basic medical information, such as blood pressure, hydration level.
• Report conclusions about the data to a Doctor or responsible person.
• Be able to compare user nutrient intake to their recommended intake.

4. Won't have

• Be able to retrieve data concerning advanced medical information, such as amount of various vitamins or various ions.

The above requirements are not final and can still be changed during the process.

Users

User Profile

In this section, we will provide a detailed profile of the users of the our monitoring device. Understanding needs, and challenges of our target users is essential for designing our device.

1. Demographics

• Age: The typical age range of people with Alzheimer's disease who will use our device varies but is generally older adults. The primary users are typically aged 65 and older.
• Gender: Alzheimer's disease affects both males and females, with no gender-specific considerations impacting device usage.

2. Medical Condition

• Alzheimer's disease: Users of the device are likely to have varying stages and severities of Alzheimer's disease. Some users may be in the early stages, coping with mild cognitive impairment, while others may be in the later stages with severe cognitive handicaps. Common symptoms include memory loss, confusion, disorientation, difficulty with decision-making, and reduced motor functions. Challenges include medication management, food intake, and recognizing the need for medical attention.

3. Cognitive Abilities

• Cognitive impairment: The extent of cognitive impairment in our user group can range from mild to severe. Many users will experience difficulty in understanding and operating complex devices. Therefore the device should be simple, work with clear visual cues, and need minimal user input so that the device can be used effectively.
• Memory loss: Memory loss is a common symptom of Alzheimer's disease. Users may have difficulty recalling recent events, which can impact their ability to remember device usage instructions and data generated by the device.

4. Caregiver

• Involvement of caregivers: Caregivers play a vital role in assisting users with Alzheimer's disease. They may be responsible for device setup, maintenance, and interpretation of data. The device should have features that facilitate caregiver involvement while respecting the user's privacy.
• Caregiver characteristics: Caregivers may have varying levels of experience and qualifications. Some may be family members, while others may be healthcare professionals. Designing the device to support different caregiver backgrounds and abilities is important.

5. Daily Activities

• Daily Routine: Users often follow predictable routines, and the device should easily integrate into their daily activities. This may include reminders for meals, medication, and other daily tasks.

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First conceptual design

- Smart spoon (weight-track, alert)

State of the art

State of the art:

1.    Smart plate:

-       Focusses on weight loss

-       Consist of a plate with different boxes with separate scales. An app that you need to take photo’s of your food with. And an AI that coaches you.

-       Principle:

o  Take photo of your food on the plate

o  AI recognizes what is on your plate

o  Scales detect how much

o  Calculate the calories and macronutrients for you

o  AI gives advise on what and how much to eat

-       https://www.getsmartplate.com/

2.    Non technology dinnerware

-       Adaptive plates (deep ones, heating, suction cup, spill proof bowls)

-       Adaptive utensils (big grip, non-slip surface, different design, special attachments)

-       Adaptive cups

-       https://www.healthproductsforyou.com/c-plates-and-bowls.html

3.    SpoonTEK

-       Enhances flavor

-       How does it work?

o   SpoonTEK generates a mild electric current to stimulate the tongue and alter taste. You cannot feel it but you do taste it.

-       https://spoontek.com/

4.    Liftware

-       Smart spoon for hand tremors

-       2 different levels

o  Reduce spilling from shaking

o  Reduce spilling from tuning, twisting and shaking

-       https://www.liftware.com/

Approach / Planning

Every monday at 9:30 a tutoring session will take place. After that an in-person meeting will take place. If the need arises for anymore meetings, they will be scheduled. Further communication will be done through a whatsapp group.

Week	Task	Associated Milestone
1	Planning
1	Literature Research	Phase 1
2	Continue Research	Phase 1
3	State of the art, Functional requirements	Phase 1.2, 2.1, 2.2

Milestones

Phase 1 Subject Research

1. Find Subject
2. Literature studies
   • Identify problem and objective of the project
   • Who are the users?
   • What do they want? require?
8. Survey
   • Discover a more in depth individual user needs.

Phase 2 Design

1. Conceptual design
   • Come up with multiple designs for the subject, identify strength and weakness of each design, and analyze key aspects for the product.
2. Requirements review
   • Identify functional/non-functional requirements.
     • Identify MSCW(MoSCow method).
     • Be more specific for software design.
       • ex) “The device should ring when the signal is on within x seconds”.
   • Identify technical requirements
     • Identify which skills will be required
       1. Programming language.
       2. Soldering …
     • Required resources
       • What we need to actually build the product.
3. Final design concept
   • Based on findings from the requirement review, we create final design concept for the next phase.

Phase 3 Build and implementation

1. Concept drawing or First design using CAD
2. Software design
   • Based on Requirement review from Phase 2.
3. Hardware design
   • Based on Final design concept.

Phase 4 First prototype, test and evaluation

1. Finish first prototype
2. Testing
   • Test individual components.
   • Test software and hardware combined.
3. Evaluate results
   • Check the quality of the product.
   • See if there is improvements that can be made within the given time.

Phase 5 Final Documentation

1. Final presentation/ video/ discussion

Article summary

Natural history of hyperphagia and other eating changes in dementia

The text discusses various dietary changes and challenges experienced by individuals with Alzheimer's or dementia. These changes include alterations in eating habits, malnutrition, dehydration, and a range of eating behavior disorders. Some individuals may show a decrease or increase in the amount eaten, changes in eating habits, food choice preferences (particularly for sweet foods), and even hyperphagia (excessive eating). Hyperphagia can lead to issues such as weight gain, eating dangerous foods, and constant food seeking. The article highlights the significance of these eating abnormalities, which can be a significant source of stress for caregivers and may lead to the need for institutional care. Weight loss is also a common concern among individuals with dementia and is associated with protein-energy malnutrition, increased mortality risk, morbidity, and a poor quality of life. Weight loss can start early in the disease's course and is related to cognitive decline. Additionally, the text mentions that certain factors, such as the severity of the disease and the emotional and material burden on family caregivers, can predict aversive eating behaviors in Alzheimer's disease. Sweet food preference and hyperphagia have been reported in a subset of patients with Alzheimer's disease.

Weight Loss and Nutritional Considerations in Alzheimer Disease

This paper discusses some of the current methods of feeding assistance for people with Alzheimer's disease. These are: Caregiver Assistance: Caregivers can provide assistance during mealtime, such as sitting and chatting with the patient, giving specific instructions, and offering encouragement. In later stages, patients may have coordination difficulties, so serving finger foods can make eating easier. This approach has been shown to increase food intake. Texture Modification: As patients deteriorate, some may become intolerant of certain textures, so menu items may need to be prepared in softer or pureed forms to facilitate consumption. Meal Environment: Simplifying the mealtime environment, such as improving lighting, serving meals on individual plates, and scheduling nursing staff to assist during mealtimes, can improve food consumption and nutritional status. Nutritional Supplementation: This includes providing frequent snacks, fortified foods, and liquid supplements. Studies have shown that protein-energy supplementation can lead to weight gain and reduced mortality in undernourished individuals. Pharmacologic Agents: Some medications have been used to improve appetite or cause weight gain in patients with weight loss. However, their use is limited due to side effects, and further study is needed before clinical recommendations can be made. Tube Feeding: In cases where other interventions fail and patients have severe dementia, tube feeding may be considered. However, there is limited evidence to support its benefits, and it may increase the risk of infection and aspiration pneumonia.

Assessment of Perceived Attractiveness, Usability, and Societal Impact of a Multimodal Robotic Assistant for Aging Patients With Memory Impairments

This study aims to assess the clinical application of a robotic assistant for patients with mild cognitive impairments (MCI) and Alzheimer's Disease. Testing was conducted with the prototype version of the Robotic Assistant for MCI Patients at Home (RAMCIP) in a controlled environment, involving 18 elderly participants (10 healthy and 8 with MCI). Participants performed various tasks facilitated by RAMCIP, such as medication intake, hazard prevention, and social interaction. No significant differences were observed between the groups in terms of perceived attractiveness, usability, or social impact, with high assessments for attractiveness and social impact but neutral feedback on usability due to the limited interaction time. The study emphasizes the increasing need for support for the aging population, particularly those experiencing memory impairments. It highlights the potential role of robotic assistants in aiding caregivers and enhancing the independence and security of elderly individuals. The research methodology follows a user-centric approach, involving medical professionals, caregivers, and end-users in the evaluation process. The robot's design and functionalities have been adjusted based on user feedback. The RAMCIP prototype offers support in various aspects, including reacting to potential hazards, assisting with cooking, monitoring medication intake, providing cognitive stimulation, and maintaining social connections through multimodal communication. The study focuses on assessing the acceptability, usability, and social impact of the RAMCIP prototype among users. Standardized questionnaires and surveys are used for evaluation, with positive results in terms of acceptance and social impact, but neutral opinions on usability. In summary, this study evaluates the clinical application of a robotic assistant for individuals with cognitive impairments, emphasizing user perception and social impact, and aims to improve the robot's usability and acceptance among the target population.

The efficacy of cognitive prosthetic technology for people with memory impairments: A systematic review and meta-analysis

The purpose of this paper was to provide a detailed review of the quality of studies that have investigated memory orthotic technology with people with memory problems and to relate these findings to the different categories of technology. Studies testing cognitive orthotic devices with adults with any brain injury, trauma or neurological/degenerative disease. The NeuroPage has been highlighted in previous reviews as being the technology with the most evidence for its efficacy. Combining portable and non-portable PDA’s has excellent prospects for patients with memory impairment due to surgeries. However, in the case of degenerate diseases, such as Alzheimer’s, the benefits have still to be researched. Furthermore Future research should aim to establish whether or not there is a benefit to using technology instead of non-technological reminders, such as calendars.

Easily accessible and cheap smartphones are also a promising development in supporting patient with memory impairment. Touchscreen makes it more accessible for elderly users instead of a device with buttons. Also smartphones or portable tablets have the advantage that they are highly adaptable to personal preferences. On the other hand, using a smartphone or tablet device as a reminder may be less effective because of the number of different functions it provides and because they will not always be within the vicinity of the user.

Micro-prompting devices another promising development in memory impairment help. The details of the devices is not discussed in the paper (find other source for micro prompting devices in SCED studies). While prospective prompting devices and micro-prompting devices differ in the type of memory performance they are designed to aid, these findings suggest that if applied correctly both could be useful for memory impaired patients.

Eating Behavior in Aging and Dementia: The Need for a Comprehensive Assessment

• Eating behavior changes with aging, influenced by physiological, psychological process, and social factors.
• These changes encompass food choice, eating habits, and dietary intake.
• Dietary behavior, such as the Mediterranean diet, can impact the risk of age-related pathologies like dementia.
• Dementia can be associated with significant eating behavior modifications, including weight loss and dietary changes.
• Screening tools like the Mini Nutritional Assessment (MNA) and Simplified Nutritional Appetite Questionnaire (SNAQ) help assess eating behavior in aging individuals, while tools like the Eating Behavior Scale (EBS) and Cambridge Behavioral Inventory (CBI) are useful in identifying symptoms of dementia.
• Management of eating behavior in aging and dementia involves a combination of strategies, including dietary adjustments, environmental modifications, and caregiver support.
• Alzheimer's disease, which accounts for 60% of all cases of dementia, introduces the problem of over and under eating. Due to the forgetfulness that comes with it.
• As this disease progresses dysfunctions like swallowing tend to worsen. This together with general changes, can make nutritional intake quite the challenge
• Right now is combatted by caregivers or the patients will have to be in a nursery home, improving regularity.
• Weight loss has always been a main symptom of Alzheimer's.

Eating habits and behaviors of older people: Where are we now and where should we go?

• Eating habits influenced by social and psychological changes. Financial, loneliness, depression
• Macronutrients: protein, carbohydrates, lipids
• Many older adults avoid consuming animal protein because they find it difficult to chew and swallow, because of the age-related decline in their sense of smell and taste, or because of health concerns about their intake of cholesterol and saturated fat.
• Animal sources provide on average 60% of their total protein intake, the greatest part of that being in a meal
• Reviews suggest that older people should consume 25–30 g of high-quality protein at each meal in order to achieve the maximum anabolic response
• Older people are more prone to vitamin B12 deficiency due to insufficient intake of animal foods, such as meat, which are good sources of B12. Results from a recent review estimated that 16% and 19% of older men and women respectively have intakes below the average requirement of the vitamin, with mean daily intakes of 6.4 and 5.1 micrograms respectively
• Author suggested a couple diet programs such as DASH, MIND, Okinawa diet to tackle these issues.

Changes in appetite, food preference, and eating habits in frontotemporal dementia and Alzheimer’s disease

• Frontotemporal dementia (FTD) is characterized by progressive focal atrophy in the frontal or anterior temporal lobes and is associated with various non-Alzheimer pathologies.
• FTD can manifest with predominantly frontal involvement, known as frontal variant FTD (fv-FTD), leading to behavioral changes such as loss of insight, impulsivity, mood changes, and altered eating behaviors.
• Research comparing FTD subgroups and Alzheimer's disease in terms of eating behavior changes has been limited but is crucial for both clinical and theoretical understanding.
• This study used a caregiver questionnaire to investigate eating behavior changes in FTD and Alzheimer's disease, aiming to determine their frequency, sequence of development, and variations among FTD subtypes.
• Results showed that eating behavior changes were more common in both FTD subgroups compared to Alzheimer's disease, with alterations in appetite and food preferences being significant features in FTD, while Alzheimer's disease mainly exhibited loss of appetite.

An open-ended question: Alzheimer’s disease and involuntary weight loss: which comes first?

• Involuntary weight loss (IWL) and malnutrition have been observed in Alzheimer's disease (AD) patients for many years.
• Clinically relevant IWL is typically defined as a loss of at least 5% of usual body weight over 6-12 months.
• IWL can result from various factors, including disturbances in calorie intake, absorption, utilization, and loss.
• Malnutrition in the elderly, including AD patients, is considered a geriatric syndrome with multiple contributing factors.
• Early evaluation of IWL in elderly patients is crucial to prevent malnutrition, which can lead to complications.
• Nutritional status and dementia are interconnected, with IWL being common in AD cases.
• The relationship between AD and IWL is complex and may involve bidirectional causality.
• AD-related brain changes can impact food intake regulation, leading to IWL.
• IWL may precede the clinical onset of AD and contribute to its progression.
• Strategies for preventing IWL in AD patients include nutritional assessment, caregiver support, and oral nutritional supplementation.

Eating disorders in the elderly

The article looks at eating disorders in people above 50.

• Eating disorders in elderly are a serious concern.
• 88% of the cases were female.
• 80% of the cases were anorexic.
• Depression is seen a lot of times in combination with eating disorders.
• Only 42% were treated successfully and 21% died with their disorder as cause.

Factors affecting independence in eating among elderly with Alzheimer's disease

The article uses regression techniques to research the factors that affect people with Alzheimer disease the most in eating independently.

• The beginning of a meal was an important difficulty.
• It is of importance to find ways to help people with Alzheimer Disease to begin eating, if they want to remain independent.

Eating disorders in elderly: Clinical implications

The article stresses the importance of taking eating disorders seriously in the elderly population.

• Psychological & Social Factors play a sizable role.
• There are several Psychiatric aspects to eating disorders in elderly.

Treatment of eating disorders in older people: a systematic review

The article looks systematically at the treatment of elderly with eating disorders.

• The majority of cases is female (85%)
• 84.6% ate was identified with anorexia nervosa.
• 95% were treated, where 52% were treated with a hospital-based treatment.
• 80% improved during treatment, but the other 20% relapsed or died.
• Hard to make conclusions as results were very different.

Eating Behaviors and Dietary Changes in Patients With Dementia

• Malnutrition or undernourishment resulting from insufficient food intake is reported in up to 85% of nursing home residents
• Changes in eating in dementia include a decrease or increase in amount eaten (with or without weight changes), a change in eating habits (for instance, a change in the frequency of eating, playing with food, and improper or no use of utensils), a change in food choice (most commonly a predilection toward sweet foods), and pica (persistent ingestion of non-nutritive substances).
• A peculiar change is represented by hyperphagia that can be a serious aspect for several reasons, for example, weight gain, eating dangerous foods, and continual searching for food.
• The caregivers indicated that “forgetting” was the first and most common eating characteristic exhibited by the patients, which contributed to overeating.
• Mentions a few types of dementia, with a good visualization, showing the different symptoms come with different forms of dementia.
• As with many areas of intimate care, such as bathing and attending to toilet needs, there is relatively little research on individualized interventions about eating in persons with dementia, particularly when it is carried out at home.

Feeding and dementia: a systematic literature review

• This paper discusses what is already known about this topic
  • Older people with dementia experience difficulty with feeding.
  • Feeding difficulty is associated with decline in cognitive function and with physical decline.
  • There is a lack of research into interventions aimed at helping older people with dementia to feed.
• What this paper adds
  • Intervention studies of feeding and dementia lack statistical power.
  • There are no standardized interventions or outcomes across intervention studies of feeding and dementia.
  • Studies of interventions to alleviate feeding difficulty in dementia do not account adequately for confounding factors.
• Tldr; It is basically an entire document discussing the interventions that have been researched.
  • However these "interventions" are more so techniques than technology, but because they do help with feeding for the elderly with forms of dementia, it still falls inside the scope of our research.
• A newer more modern version of this is also made, as can be seen in: "Effectiveness of interventions on feeding difficulties among people with dementia: A systematic review and meta-analysis"

Exploring perception of eating with dementia: Findings from a massive open online course

• Basically a nice paper to get some insight to what elderly with dementia think of the help that is provided already. This data is from an online course called Understanding Dementia, filled in by participants mostly over the age of 50, and also caregivers.
• This paper finds out how and what the elderly think about the current perceptions of the care given/received when eating.
• So not really relevant to coming up with the idea of an intervention itself, but it does add insight in how they think about the care right now, and give some USErs restraints.

Personal Efforts

Week 1

Name	Time Spent	Breakdown
YooungGi Park	8.5h	lecture, group meeting, subject research, wiki edit(Milestones)
Zabiollah Amiri
Thomas Paul Smids

Week 2

Name	Time Spent	Breakdown
YooungGi Park	9	Tutor, group meeting, 4 article research & summary, first conceptual design
Zabiollah Amiri		Group meeting, 5 articles summarized, first conceptual design
Thomas Paul Smids

Week 3

Name	Time Spent	Breakdown
YooungGi Park	7.5	Tutor, group meeting, research on problems for early dementia patients and eating disorder, functional requirements
Zabiollah Amiri		Group meeting, 5 articles summarized, first conceptual design
Thomas Paul Smids