Keywords

1 Introduction

According to world population reports, in 2015, it was estimated that there were 46.8 million people with dementia. In developed regions, dementia rates for people over the age of 60 were reported between 4 and 6%. This number increases to 20–33% in people over 85. Estimates suggest that the number of people diagnosed with dementia continues to grow at a rate of 4.6 million people annually, reaching 131.5 million people in 2050 [14, 15].

There are 4.62 million people with dementia over the age of 65 in Japan today, but it is estimated that they will be over 7 million people in the 2030s, approaching 25% of the population over the age of 65. The increased number of people diagnosed with dementia is a major social problem that will only grow more serious in the future, as life expectancies continue to rise [16].

Due to the damage to higher brain functions such as memory, orientation, knowledge, action, cognition, language, emotion, and personality, people with dementia become antagonistic towards situations in which they’ve placed themselves. Dementia can be induced by a variety of causes. Its pathology and symptoms are very diverse. Symptoms can be divided into core symptoms and peripheral symptoms. The core symptoms include memory impairment, executive function disorder, apraxia, aphasia, and agnosia. Patients with dementia may exhibit execution dysfunction, difficulty in initiating action, reduction of spontaneity, behavioral conversion dysfunction, impulsive behaviors, and disinhibition. Apraxia is a degradation of motor skills or coordination without any link to sensory impairment. Patients may be unable to put on clothes or use tools properly. Agnosia is an inability to recognize objects through use of the senses, including physical landmarks or other visual stimuli, as in visuospatial agnosia. It may also apply to sounds. “Peripheral symptoms” refers to various behavioral disorders and psychiatric symptoms that appear to be affected by the patient’s environment and physical condition. This category includes delusions, hallucinations, anxiety, impatience, depression, wandering, aggressive behavior, sleep disorders, eating disorders, including binge eating and pica, and resistance to care, among others.

The Symptoms of “BPSD”. The Behavioral and Psychological Symptoms of Dementia, or BPSD, are the “core symptoms” of dementia. It occurs in conjunction with memory loss, psychiatric symptoms, and a decline in comprehension ability, and was previously referred to as “problematic behavior” or “nuisance behavior”. The symptoms are divided into behavioral and psychological symptoms, with more symptoms appearing as the dementia progresses from mild to moderate. Behavioral symptoms may include violence, verbal abuse, wandering, rejection, and unsanitary acts. As the manifestation of symptoms differs from person to person, all symptoms may not always appear. These symptoms appear frequently as dementia progresses from mild to moderate, leading to a rapid decrease in quality of life accordingly [17,18,19,20]. It is known that a person, when ignored by others, causes various negative reactions and enhances aggressive behavior and Self-destructive behavior [1,2,3].

The same goes for the elderly people with dementia who have these symptoms, therefore, depending on the care may cause fear and confusion for elderly people with dementia [4].

At the same time, care for the elderly with dementia has a great mental and physical burden on caregivers. For this reason, the turnover rate has increased and it has become difficult to provide adequate care [5,6,7,8].

At the same time, the caregiver requires more time and effort than necessary to care for the elderly with dementia, care for the elderly with dementia has a great mental and physical burden on caregivers. For this reason, the turnover rate has increased and it has become difficult to provide adequate care.

For these problems, as one of the dementia care is gaining attention Humanitide [4, 10].

1.1 What is Humanitide

Humanitide is a dementia care technique created by Yves Ginest and Rosette Mallescotti [11].

Humanitide is a care technique based on comprehensive communication based on perception, sensation, and language, for people who need care, not only for people with dementia and the elderly people. The caregiver always cares for the care receiver by acting on the human characteristics of seeing, speaking, touching, and standing. It is important to keep sending the message “I care about you” to those who need care. It allows people to feel that they are the only beings and that they are respected. Humanitide is the philosophy that respects and communicates the humanity of those who need care and consists of more than 150 practical techniques based on it [4, 10, 21,22,23].

1.2 Purpose

So, our research focus on “see”, one of the basic skills.

Although, Gaze is one of the important skill in Humaniude. While the difference of the mutual gaze behavior between caregivers and receivers are already reported [24] (Fig. 1), gaze behaviors of the care receivers were not well studied (Fig. 2).

Fig. 1.
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Mutual gaze

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Fig. 2.
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Left: Line of sight from care receiver to caregiver Right: Line of sight from caregiver to care receiver

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A person’s gaze is generally directed to an object of interest or attention. The gaze is extremely useful information for estimating the mind of another person [11, 12].

Therefore, We let a caregiver wear the first person camera, and four types of “seeing” behavior patterns during the oral care (caregiver → caregiver, caregiver ← caregiver, mutual gaze, none) are measured. We compared the differences be-tween humanity experts and beginners.

We examined whether there was a large difference in the frequency and time of gaze matching between novice and expert of Humanitude. The act of matching the sight of eyes is an act of not ignoring the other person [1,2,3], indicating an interest in the care receiver, and it is considered that for the care receiver, the anxiety and fear during care are reduced.

2 Experiment

In actual nursing scene at a hospital in Fukuoka, we used three care categories and four types of gaze patterns to measure gaze trends of caregiver and care receiver during oral care.

2.1 Data Collection

We compared the differences between Humanitude experts and Novice. The number of collaborators is 22 nurses (21 Humanitude novice, 1 expert), and the care receiver is 9 elderly people with dementia who are hospitalized.

A total of 29 sessions were given for about 5 min of care per session.

2.2 Classification of Care Categories

Classify the acquired oral care data into 3 categories before care, during care and after care. The three categories were classified under the following conditions (Fig. 3) (Table 1).

Fig. 3.
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A: Before Care, B: During Care, C: After Care

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Table 1. Conditions for care classification
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2.3 Gaze Pattern Classification

The conditions for classifying caregivers and care receivers movements of gaze patterns will be described. The movements of gaze patterns were classified into four types.

  1. (a)

    shows when the mutual gaze. The face of the elderly is located in the center of the frame and the gaze are looking at the camera.

  2. (b)

    shows the time when the care receiver is looking but the caregiver is not looking.

  3. (c)

    shows the time when the caregiver is looking but care receiver is not looking.

    Even if the face of the care receiver is in the center of the frame, when he gaze of care receiver is not looking at the camera, it is considered that only the caregiver is looking.

  4. (d)

    shows the time when neither is seen.

    Details are shown in Fig. 4. In the figure, “G” is the caregiver and “R” is the care receiver.

    Fig. 4.
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    Four gaze-behavioral patterns

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3 Result

We used three care categories and four types of gaze patterns to measure gaze trends of caregiver and care receiver during oral care.

The time it takes for Novices and expert to take oral care is shown in Fig. 5.

Fig. 5.
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The time it takes for Novices and expert to take oral care

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The horizontal axis shows the time taken for Whole care, Before care, During care, and After care. The vertical axis represents care time. Significant differences were found throughout time, Before and After care.

On the other hand, there was no significant difference in time During care between the Novice and the expert. Experts spend about 40% of the time Before Care and After Care. On the other hand, novice accounts for only about 20% of the total time.

We used three care categories and four types of gaze patterns to measure gaze trends of caregiver and care receiver during oral care. Figure 6 shows the results.

Fig. 6.
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Gaze behavior analysis results

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The three care receiver shows as A, B, and C

Figure 6 shows the results of Humanitude experts and two novice (1 and 2) for each care receiver. The horizontal axis represents the number of frames, and the vertical axis represents each care. R represents a care Receiver and G represents a caregiver. In general, it can be seen that the expert spent a lot of time mutual gaze and the caregiver is seeing care receiver in one session. However, there is almost no difference in the time during care for both expert and novice.

On the other hand, when comparing the gazing time before and after care, it can be seen that the expert spends a certain amount of time, while the novice hardly spends time before and after care. Especially After Care, it was found that Novice hardly saw the care receiver.

During care, the expert has a short time when the caregiver and the care receiver do not look each other, whereas the novice does not look each other for a long time.

The situation that only the care receiver sees was rarely seen by the expert.

Figure 7, 8, and 9 show the ratio of Mutual Gaze. The horizontal axis represents three stages, and the vertical axis represents the ratio. Figure 7, 8, and 9 show care receivers A, B, and C, respectively.

Fig. 7.
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Percent of mutual gaze (Care Receiver A)

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Fig. 8.
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Percent of mutual gaze (Care Receiver B)

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Fig. 9.
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Percent of mutual gaze (Care Receiver C)

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Ratio of mutual gaze = Mutual Gaze/caregiver’s gaze + care receiver’s gaze

Expert was found to have a high percentage of mutual gazes overall.

There was a large difference in gaze ratio between the expert and the novice Before Care and After Care, but the most significant difference was After Care.

After Care, the two novices accounted for less than 20%, while the expert accounted for a very high percentage of 40–80%.

4 Conclusion

In this study, a first-person camera was worn by a caregiver, and four types of gaze patterns in three stages during oral care were measured (care receiver → caregiver, care receiver ← caregiver, mutual gaze, none). We compared the differences between Expert and Novice in Humanitide.

In one session of care, we measured that divided into three stages: Before Care, During Care, and After Care. As a result, it was found that expert spend more time in one session than novices, but there is no significant difference in the time “During Care”. It is considered that there was no difference in the time required for care because the procedure of oral care was decided. On the other hand, significant differences are found in, the duration of Before Care and After care between novices and experts (Experts > Novices).

There are five steps that are important for practice in Humanitide. Humanitide has the first step, “preparing to meet”, and the last step, “promise of resumption”. These are items that are not related to direct care but are very important when interacting with people. This is an item that is difficult to practice in a nursing care setting that is usually pressed for time.

Expert perform these two steps, and they spend a certain amount of time Before Care and After Care.

However, novice do not perform this step and immediately perform oral care. It is thought that there was a big difference in time of After Care and Before Care.

The number of mutual gaze between the experts and novices (Experts > Novices).

Considering that the time of Mutual Gaze is longer for the expert than for the novice, it is considered that when the care receiver makes eye contact, the expert notices the care receiver’s eye contact and looks at the cared receiver. In this way, it was found that, although both expert and novice intend to see the cared During Care, the novice often do not.

Moreover the ratio of None is smaller in the expert.

The duration of R → G is smaller in the expert, which means the care receivers are less ignored in expert’s sessions.

Prior literature is known that a person, when ignored by others, causes various negative reactions. Elderly people may feel anxious or fearful about being cared for, in addition if they are ignored by nurses, they may feel more anxious or fearful. Also, I think that it is important for nurses to be aware of elderly gaze, because the act of turning their gaze to the other party may not only be looking but also complaining.

Therefore, the act of “see” is a necessary act for care, and from the contents of the analysis video, taking into account that there were few actions to refuse care that the elderly are removing the expert’s hand or turning their face away from the expert during care, the act of “see” was found to be important for care.

5 Future Works

In order to verify whether the same can be said for other cares, we will measure movement of gaze trends in other cares. In addition, even in the same “gaze”, the reaction of pleasant or unpleasant is different, so we believe that it is necessary to measure pleasant or unpleasant with physiological data.