12-Week Cognitive Fitness Training Curriculum
Project Lead: Todd Tran
Host Institution: Women’s College Hospital, Toronto, ON
Quality of life and functional independence are important factors among the older adult population in retirement. One of the most significant barriers to these factors is the normal age-related decline in cognitive functioning, which the 12-Week Cognitive Fitness Training Curriculum addresses. Hosted by Women’s College Hospital in Toronto, the Curriculum incorporates both Mindfulness-Based Interventions and Psycho-Educational Interventions, such as sleep hygiene, diet, exercise, and relaxation techniques. In terms of targeted segment, the Curriculum targets adults over the age of 65 with mild cognitive impairment, as well as those with regular cognitive function who would like to preserve their memory and prevent the onset of Mild Cognitive Impairments and/or Alzheimer’s Disease and related dementias. A prototype of the 12-Week Cognitive Fitness Curriculum has been developed by the project team, consisting of six occupational therapists. As a Spark Program Project, the Curriculum will be tested on the patient population at Women’s College Hospital in efforts to evaluate its effectiveness.
A Mobile Application for Direct Behavioural Observation in Dementia
Project Lead: Dr. Andrea Iaboni
Host Institution: Toronto Rehab Institute, Toronto, ON
People with dementia often exhibit responsive behaviours, such as agitation, wandering, and aggression that can be difficult to manage. These behaviours can increase the cost of care, as well as negatively impact an individual’s independence, quality of life, and safety. In order for clinicians to identify and develop effective strategies for managing responsive behaviours there is a need for clear and accurate information, specifically regarding patterns and context. However, there are challenges associated with obtaining clear and accurate information. For example, most reports of responsive behaviours are made post-incident, relying on memory or second-hand information, which can decrease the accuracy of the information and lead to inappropriate treatment. To address this challenge, Dr. Iaboni’s team has developed a prototype mobile application that allows caregivers to record details of client behaviour in real-time, using a proven framework for directly observing and analyzing responsive behaviours. The application summarizes data in an easy-to-read report. As a Spark Project, Dr. Iaboni is focused on enhancing the usability of the prototype, both in terms of data capture and reporting.
Avoiding Hospitalizations for Long-Term Care Residents: the PREVIEW-ED© eTool
Project Lead: Catherine Kohm
Host Institution: Fraser Health Authority, Surrey, BC
Care Aides and Personal Support Workers comprise more than 70 percent of the staffing in long-term care (LTC) homes and are ideally positioned to notice subtle nuances in the health status of a resident. PREVIEW-ED© is a tool that helps staff in LTC detect early health decline among residents related to four conditions: pneumonia, urinary tract infections, dehydration and congestive heart failure (CHF). It measures the signs, symptoms, and severity of nine indicators using a simple scale to score each indicator, generating an aggregate score to quantify changes that have occurred. This project will involve the design, development and beta testing of an electronic version of the PREVIEW-ED© tool.
Comprehensive Geriatric Management of LTC Residents w/ BPSD
Project Lead: Sheelagh Willett
Host Institution: William Osler Health System, Brampton, ON
The senior population in the Central West Local Health Integration Network (LHIN) is expected to increase by 64 percent by the year 2021. Furthermore, 62 percent of residents in long-term care suffer from Alzheimer’s or other forms of dementia (Ontario Long Term Care Association, 2016). This project, hosted by William Olser Health System, seeks to improve the delivery of high-quality health care for seniors who exhibit behavioural and psychological symptoms of dementia in long-term care (LTC). Specifically, the project will create a structured approach to managing a variety of intertwined stakeholders, as well as assist with process management to create a care delivery process that involves comprehensive geriatric assessment and management. This project addresses the unmet needs of optimal behavioural management of LTC residents in the Central West LHIN with behavioural and psychological symptoms of dementia.
Cover and Comfort Wrap
Project Lead: Kimberley Smith (Clinical Lead)
Host Institution: Providence Health Care, Vancouver, BC
Whether provided in a hospital, long-term care or home setting, activities of personal hygiene and bathing are some of the most intimate that a person with dementia requires assistance with. Moreover, these activities are also one of the highest risk activities for a person with dementia and their caregiver(s).
The Cover and Comfort Wrap (CCW) is a real-world solution, developed by direct health care providers. It is an opportunity to create a new approach to care that improves the quality of life for people experiencing the behavioral and psychological symptoms related to dementia, as well as their families and care providers. During a bath or shower, the CCW is worn and positioned on the body for secure coverage, preserving the person’s privacy and facilitating the care provider’s health and safety. This Spark project will involve refining the design of the existing proof-of-principle prototype to develop a working prototype of the CCW. Once the working prototype is developed, staff will be trained in the use of the CCW, and it will be tested in a pilot research study in a tertiary mental health wetting.
Dementia Talk App
Project Lead: Einat Danieli
Host Institution: Sinai Health System, Toronto, ON
With Canada’s aging population and increasing number of dementia cases, caregivers are in need of practical and effective solutions to guide them in managing care. Many caregivers encounter difficulties with respect to tracking and communicating the challenges they face to care providers and /or their family doctor, contributing further to the sense of loneliness that is often associated with caregiving. Dementia Talk App is an award-winning smartphone application designed to empower dementia caregivers in tracking and managing challenging behaviours and in enhancing their communication with other care providers in the circle of care. Funded in part by a grant from the Canadian Internet Registration Authority’s Community Investment Program, this project will further develop the application through the addition of a new suite of features and format compatibilities. Furthermore, the project will also involve beta testing of the application in a clinical setting.
Polypharmacy Management and Reduction: Developing a process
Project Lead: Jennifer Donovan
Host Institution: York Care Centre, North York, ON
With the growing prevalence of polypharmacy (patients taking 5+ medications) in long-term care, there is an increasing need for the optimization of medication assessment and review. Using York Care Centre for analysis, this project will seek to identify appropriate criteria for medication management and reduction, with the ultimate goal of developing a mobile application to be used by clinicians and caregivers.
GeriMedRisk: A pilot study on a scalable geriatric pharmacology consultation service to prevent adverse drug events among seniors
Project Lead: Dr. Joanne Ho
Host Institution: Schlegel Villages, Waterloo, ON
GeriMedRisk is an interdisciplinary, technology-based geriatric pharmacology consultation service. To be specific, clinicians across the Waterloo-Wellington region will have access to nurses, pharmacists, physicians specializing in geriatric medicine, clinical pharmacology and geriatric psychiatry by telephone or Ontario Telemedicine Network e-consult during business hours. This is an important service because it helps to optimize the patient’s medications, cognition, mobility, function and mental health. These benefits lead to other positive impacts, such as decreasing drug-related cognitive impairment, falls and hospital visits among seniors in all clinical settings. In the project’s inaugural 12 months, the feasibility and efficacy of GeriMedRisk will be evaluated in various clinical settings, including long-term care, primary care and mental health in Waterloo-Wellington region. Specifically, the Spark program will fund GeriMedRisk’s randomized feasibility trial in the long-term-care setting.
iGeriCare: Online resources on dementia from your geriatrician
Project Lead: Dr. Richard Sztramko
Host Institution: GERAS Centre at St. Peter’s Hospital, Hamilton Health Sciences, Hamilton, ON
A diagnosis of dementia is a stressful experience. Persons newly diagnosed with dementia and their families are provided with an overwhelming amount of information during this period. Providing a platform where these groups can access information at their own pace can reduce stress and increase retention and understanding of key information. iGeriCare aims to, with the input of geriatricians, clinical staff, patients, and families, create an online information platform whereby physicians can ‘prescribe’ modules on relevant topics to patients and their families. Amongst other activities, this project will involve the development of 10 eLearning modules and complimentary materials, a social forum for users, and the implementation of a full-scale pilot test of the technology.
illuminAID: Lighting for fall prevention
Project Lead: Pauline Yee (Clinical Lead)
Host Institution: Providence Health Care, Vancouver, BC
The increased likelihood of falling in individuals with dementia can partially be attributed to challenges related to sensory input and interpretation of the environment. For example, older adults can take longer to adapt to sudden changes in light and often have an increased sensitivity to glare, causing illusions and misperceptions. Building off of a proof-of-concept study, the goal of this project is to design a working prototype of a lighting system for residential care homes that considers the experience of an individual with dementia. Testing of the prototype will take place in a care home, leading to further refinement of the prototype, with increased autonomy of the user as the main objective.
Virtual Reality Training Program: A home-based, innovative solution for improving cognitive and physical function
Project Lead: Dr. Hillel Finestone
Host Institution: Bruyère Continuing Care, Ottawa, ON
In efforts to improve the experience of aging at home, an innovative home-based virtual reality (VR) exercise program has been developed. VR training uses computer software to track the user’s movements, allowing the user to interact with a game or activity presented on a TV screen. Activities will focus on balance (e.g. sitting, standing, stepping), arm and leg exercises (e.g. arm circles, knee extensions), gentle aerobic conditioning (e.g. marching on the spot), and cognition (e.g. matching, sequencing, attention). For example, many of the physical games have cognitive and perceptual components (e.g. attention, hand-eye coordination, reaction time). VR is an enjoyable and interactive experience; it may encourage individuals with Mild Cognitive Impairment (MCI) to exercise more consistently and at a higher intensity. This project will test the feasibility of the VR program and assess its potential for maintaining and improving the physical and cognitive function of users. To be specific, after 6 weeks of home-based VR, participants and their study partners will be interviewed for their opinions on the program. Participants’ use of the VR system and any adverse events will be tracked, and physical and cognitive testing will be performed.
Integrated Care Pathway (ICP): Improving care for neuropsychiatric symptoms of dementia
Project Lead: Sanjeev Kumar
Host Institution: Centre for Addiction and Mental Health, Toronto, ON
Neuropsychiatric symptoms of dementia (NPS) affect up to 80 percent of patients with Alzheimer’s Disease (AD). These symptoms include aggression, agitation, anxiety, depression, hallucinations, and delusions. Among these symptoms, aggression and agitation are most burdensome for patients, families, caregivers, and the healthcare system. The Geriatric Psychiatry Division at the Centre for Addiction and Mental Health has developed and implemented an Integrated Care Pathway (ICP) to evaluate and treat aggression and agitation associated with NPS in AD. Dr. Kumar’s team will adapt and implement the ICP to a community long-term care facility in Toronto in anticipation that this will result in better clinical outcomes, more appropriate use of treatments, better patient experience, and better health economics for patients with NPS of dementia.
Intelligent Mobile and Web-Based Alerts Application: Detecting and preventing falls in the long-term care setting
Project Lead: Teresa Lee
Host Institution: Bruyère Continuing Care, Ottawa, ON
Most off-the-shelf fall detection products require seniors to access mechanical devices (buttons) or wear sensors. While these devices alert caregivers to a fall when the resident is capable of activating them, they do not work when the resident is incapacitated. Furthermore, these devices do not provide evidence as to what caused the fall. Therefore, this project will be testing a commercially available solution that utilizes built-in cameras in smartphones and tablets to capture important health data for a caregiver. The application allows caregivers to view video capture of the events leading up to and including the fall itself. This application will be tested in a long-term care (LTC) setting, in efforts to determine its accuracy and potential to inform clinical practice regarding fall reduction and injury prevention in this population.
Bed/Chair Alarm Removal for Falls Prevention
Project Lead: Tammy Retalic
Host Institution: Hebrew Rehabilitation Center, Boston, MA
In 2013, Hebrew Senior Life (HSL) became the leading long-term care facility in Massachusetts to eliminate alarms. While 30 to 40 percent of patients had bed alarms, chair alarms, or both, few patients had alarms (as requested by their families) at present. Instead, HSL focuses falls prevention efforts on purposeful rounding, using the framework of the “4 Ps”, which include pain, position, personal care, and possessions. Preliminary implementation of this project at HSL has resulted in a significant decline in patient falls and injury rates from falls. This Spark Project replicates HSL’s model of removing alarms in different contexts and settings, and implementing purposeful rounding as the primary fall prevention effort, in order to reduce falls and improve outcomes for the seniors, particularly those with dementia.
Making Therapeutic Recreation Available to Seniors through a Multi-Media Interactive Model
Project Lead: Lacey Sheng
Host Institution: The Perley and Rideau Veterans’ Health Centre, Ottawa, ON
The benefit of recreational therapy is widely recognized and used under multiple health conditions. However, the lack of access in the community remains a challenge for seniors, particularly seniors living in their homes. This team intends to build a self-sustained online resource hub and platform for recreation in the community. The users of this platform will benefit from multiple resources that are produced by the state-of-the-art recreation and creative arts service at the Perley and Rideau Veterans’ Health Centre. This project intends to build, market, and launch an online resource hub with original content and measure its impact in the community.
Mindfulness Interventions for Caregivers of Patients with Dementia
Project Lead: Deana Huntsbarger
Host Institution: Kawartha Regional Memory Clinic, Peterborough, ON
Caregivers for persons with dementia can face several challenges. Unfortunately, there can be limited resources available to help caregiver’s cope with these challenges. Deana’s team has been studying mindfulness-based strategies designed specifically for caregivers of individuals with dementia. This project, involving mindfulness-based strategies, will pilot three 8-week in-clinic sessions of mindfulness training techniques to caregivers of patients at Kawartha Regional Memory Clinic to evaluate the techniques’ impact on stress, anxiety, and burden.
Learning the Ropes for Living with MCI: Optimizing health outcomes for older adults at risk of dementia
Project Lead: Dr. Kelly Murphy
Host Institution: Baycrest Health Sciences, Toronto, ON
1 in 10 Canadian seniors experience an identifiable cognitive decline, labeled Mild Cognitive Impairment (MCI), which can be representative of future dementia risk. Pharmacological intervention for MCI has not been shown to be effective. However, behavioural interventions focusing on cognitive strategies and lifestyles have shown promise. For example, Dr. Murphy’s team has developed an intervention program called ‘Learning the Ropes for Living with MCI that has demonstrated clinical efficacy. This project will aim to increase the scalability and adoption of the program by making it available online, delivering ‘Train the Trainer’ workshops, establishing a business plan, and publishing program materials.
Play Intervention for Dementia (PID): A caregiver’s resource
Project Lead: William Leung
Host Institution: Yee Hong Centre for Geriatric Care, Toronto, ON
With a growing population of senior citizens, and a remaining desire for care to continue in the home setting, equipping caregivers with resources is empowering and essential. Play Intervention for Dementia (PID) is an intervention tool that has demonstrated positive engagement, synchronization, and stimulation from seniors who have participated through the program offering at Yee Hong Centre for Geriatric Care. This project aims to increase the accessibility and functionality of PID by running training sessions for caregivers, developing and distributing promotional content, and developing an educational video component.
Positive Risk Management
Project Lead: Dr. Linda Lee
Host Institution: Centre for Family Medicine, Kitchener, ON
The disease process in dementia affects behaviour, mood, physical and social functioning, often resulting in significant impairments in the ability to perform at work, maintain social relationships, and complete daily activities of living. To meet the urgent need for a feasible, effective tool that guides the assessment and management of risks associated with living with dementia, the CFFM Primary Care Collaborative Memory Clinic (PCCMC) have developed and piloted a person-centered “risk enablement” framework based on research evidence and best practices. This PCCMC Person-Centered Risk Assessment tool is a pro-active approach that allows older adults living with dementia to retain as much control over their lives as possible by identifying risky situations and developing systems to manage risk. This project aims to evaluate and refine this Person-Centered Risk Assessment tool. Once refined, this tool can help other primary care settings with better assessment and management of high-risk situations associated with older adults living dementia, with the aim of avoiding crises pro-actively and allowing these persons and their care partners to live in the community with the best quality of life for as long as possible.
Prescribing Virtual Reality
Project Lead: Dr. Howard Abrams
Host Institution: OpenLab, UHN, Toronto, ON
Persons with dementia often experience stress, anxiety, and wandering behaviours, which can interfere with their ability to live in the setting of their choice. Dr. Howard Abrams is evaluating the use of Virtual Reality technology, which exposes persons with dementia to simulated natural environments, in efforts to decrease this stress, anxiety, and desire to wander. This project is a collaboration between the University Health Network’s Openlab and Kensington Health’s Long-Term Care facility, Kensington Gardens.
Preventing Emergency Department Visits by Identifying People with Unrecognized Dementia
Project Lead: Dr. Jacques Lee
Host Institution: Sunnybrook Research Institute, Toronto, ON
Patients with dementia are frequently discharged from the ER without diagnosing the fact that they have an underlying cognitive impairment. This greatly increases the chance of a return visit. Ideally, all older adults visiting the ER for dementia would be screened. However, due to time and resource constraints, this is not feasible. Dr. Lee and his team have developed a prototype application that employs “serious gaming” techniques on a tablet computer that allows patients to perform a self-assessment that accurately indicates a dementia diagnosis to clinicians. This Spark project will focus on refining and expanding the functionality of the application, as well as test its effectiveness to reduce crowding in ERs through the avoidance of unnecessary repeat visits from patients with dementia.
Rural Support for Care Partners for People with Dementia
Project Lead: Paul Yost
Host Institution: Alzheimer Society London and Middlesex, London, ON
Caregivers living in rural setting soften have difficulty accessing support services. Moreover, when these services are available, caregivers find it difficult to attend because they are unable to arrange care for their partner with dementia. These caregivers are at high risk for illness, isolation, and burnout. The Alzheimer Society of London and Middlesex (ASLM) would like to address this problem by partnering with rural community agencies to provide a support group for caregivers, while also offering a concurrent Social Recreation program for the person with dementia. ASLM will work with each agency to plan the concurrent sessions, and train volunteers to deliver programming for persons with dementia.
SOS: A gamified app to improve early detection of acute deterioration associated with unnecessary emergency hospitalization in the frail elderly
Project Lead: Dr. Raquel Meyer
Host Institution: Baycrest Health Sciences, Toronto, ON
Acute changes in condition in the frail elderly are clinically important deviations which, without timely intervention, may lead to significant deterioration or death. Nearly 33 percent of frail elderly admitted to hospital from long-term care are admitted unnecessarily (Canadian Institute for Health Information, 2014). In long-term care, 62 percent of residents experience dementia (Canadian Institute for Health Information, 2015) and are increasingly unable to communicate their symptoms or changes in health status. This requires healthcare providers to be skilled in observing and responding to the early, subtle, and atypical signs and symptoms of acute deterioration in the frail elderly. The purpose of the SOS Gamified App is to increase accessibility, retention, and application of geriatric specialty knowledge for healthcare providers caring for the frail elderly at risk of acute deterioration, in order to prevent unnecessary hospital emergency room visits for this vulnerable population. The application entails a continuing learning product that provides instant feedback to the user that is highly accessible and available 24/7 online. The application enables staff managers and student educators to monitor learning outcomes and to tailor future learning to address identified performance gaps. This project aims to transition a previously developed and tested beta version of a product into a commercially available product.
Stronger at Home
Project Lead: Abby Malott
Host Institution: Stonebridge Community Services, Tillsonburg, ON
Regular physical activity targeted towards balance, mobility and strength training has been shown to significantly reduce falls. In addition, research indicates that regular exercise improves brain health and cognitive functioning. Stronger at Home, a volunteer-based in-home exercise program, aims to reduce the number of falls, as well as emergency room visits by targeting isolated individuals who are at risk for, or who are living with, dementia. This project will develop and implement a virtual exercise program that is user-friendly and accessible for isolated and vulnerable seniors living in Tillsonburg.
The Fountain of Health Initiative: A clinical tools & app feasibility study
Project Lead: Dr. Keri-Leigh Cassidy
Host Institution: Nova Scotia Health Authority, Halifax, NS
The current medical model focuses on pathology in aging, rather than on health promotion. Furthermore, practitioners who include health promotion lack tools to support a systematic approach. The purpose of The Fountain of Health Initiative for Optimal Aging (FoH), one of the first educational initiatives of its kind in the world, is to translate the current science on healthy aging, well-being, and resilience, into practical tools for use by clinicians and the public to improve health outcomes.In this project, paper-based and online FoH Initiative Clinical Tools will be disseminated to at least 50 healthcare providers, who will use the tools with patients to assess the feasibility of FoH in changing clinicians’ practice, patients’ health behaviours, and improving cognitive fitness.
TheLaser Walk: Improving mobility and preventing falls using visual cueing
Project Lead: Vepeson Wijeyakulasingam
Host Institution: Assistive Technology Clinic, Toronto, ON
The ability to walk is negatively impacted in many older adults with Parkinson’s disease, cognitive impairment, and other neurological conditions. This can manifest into symptoms such as shuffling, unstable gait, and freezing of gait (FOG), which can compromise balance and lead to falls and injury. With the goal of facilitating safe and independent mobility, The Laser Walk is a laser module mounted to a senior’s existing mobility aid that projects a line in the user’s pathThis Spark project will focus on refining and testing an existing laser unit prototype that can be mounted on a wide variety of assistive devices, easily seen in a variety of environments, and easy-to-use, durable, and energy efficient.
The Road to Connection: Combined model of caregiver support and arts engagement for care recipients
Project Lead: Renee Climans
Host Institution: Baycrest Health Sciences, Toronto, ON
A support gap has been identified for both care recipients and caregivers. For example, caregivers often experience exhaustion and loneliness and lack opportunity for human connection with trained social work facilitators and other caregivers who are experiencing similar situations. This project weaves together three evidence-based interventions into a combined model that provides an emotionally-focused psychosocial group intervention for spouses (caregivers), as well as a group that incorporates arts-based and cognitive interventions for their partners (care recipients). The ultimate goal of this program is to decrease the burden experienced by family caregivers, increase the quality of life for both the caregiver and care recipient, and decrease premature institutionalization of care recipients. Offering this innovative program will increase knowledge of evidence-based targeted interventions for people with dementia.
Toolkit for Assessing Human Balance and Mobility
Project Lead: Dr. McIlroy
Host Institution: Grand River Hospital, Kitchener, ON
Clinically assessing balance is critical to care planning, avoiding injury, and maintaining independence. Currently, the best techniques to measure balance and mobility require significant financial investment, which very few can afford. Therefore, a low-cost, easy-to-use, and accurate point-of-care tool to assess balance is needed, which Dr. McIlroy’s toolkit aims to address. Using a tablet and wearable technologies, the toolkit samples and synchronizes data from multiple (inexpensive) wearable devices and generates a patient assessment, as well as possible actions to improve the health of the patient. The tool is usable by family physicians, physiotherapists or similar healthcare professionals, who provide assessments of balance in rural, urban and remote community healthcare settings. The goal of this project is to test the efficacy of the toolkit in a normal clinical setting: Grand River Hospital’s Freeport Campus in the rehabilitation clinic.
Toronto HEARS: A community-based hearing program for at-risk seniors
Project Lead: Marilyn Reed
Host Institution: Baycrest Health Sciences, Toronto, ON
Hearing loss, prevalent among older adults, is associated with a decline in cognitive, physical and mental health. Despite this, the hearing loss goes largely untreated due to the stigma and challenges associated with accessing current models of hearing health care. In this way, new approaches are needed to overcome these barriers and address this major public health concern. The primary objective of this project is to deliver and test the feasibility of a tailored education and counseling program, combined with an accessible and affordable hearing device. This project, based on Access HEARS and developed by a team of ENTs and audiologists at Johns Hopkins University, addresses the concern of untreated hearing loss among older adults. The program will be delivered to approximately 100 clients, who reside in community centers in low-income areas in Toronto. It is expected that this program will result in improved communication, social engagement and health-related quality of life for those participating in the project.
Using Home Visits by Community Paramedics to Reduce Ambulance and Emergency Room Use by Older Adults with Dementia
Project Lead: Ryan Sneath
Host Institution: Winnipeg Fire Paramedic Service, Winnipeg, MB
Overcrowding in Emergency Departments (EDs) is a recognized problem across Canada. An important subset of ED visitors arrive by ambulance, leading to additional delays for paramedics who must remain with patients until space is available in the hospital. To investigate this problem, the Emergency Paramedics In the Community (EPIC) program identifies patients at risk of harm or frequent Emergency Medical Services (EMS) use based on a range of factors such as living conditions, lack of social supports, and cognitive impairments (among others). EPIC medics maintain contact with patients in the program and their circle of care, providing medical care in their home to identify unmet needs that would otherwise trigger calls to 911. This project will improve on the current model of care delivery by refining medics’ ability to independently identify patients with dementia and refer them to the appropriate resources. The goal is to improve identification of older adults with dementia and collaborate more effectively with other allied agencies to meet the unique needs of each patient in a timely manner.
Virtual Calm: Using VR videos to reduce dementia distress
Project Lead: S. McKay
Host Institution: VHA Home HealthCare, Toronto, ON
Evidence suggests that persons with dementia can benefit from watching 3D videos of serene environments. Specifically, this has been demonstrated to be a potentially effective non-pharmacological tool that could be made available to manage the neuropsychiatric symptoms of dementia. The goal of this project is to better understand the potential of 3D virtual reality scenarios as a tool to manage neuropsychiatric symptoms such as aggression, agitation, and apathy.
