**2. Measurement of decision-making decline in brain-disease related dementia**

Decision-making decline in dementia patients [45] can be measured by using tests for autonomic non-conscious learning and recall expression [46]. The rates of learning and recall are measured from responses to an unconditioned stimulus (US) that is associated with a subsequent aversive conditioned stimulus (CS) [47]. Tests are described abundantly throughout the literature as the basis of cognitive *decisionmaking* [48–50] *evaluation.* The results are matched with the arrival of shortterm neurosynaptic plasticity changes in corresponding neocortical amygdaloidhippocampal-prefrontal cortical networks [51], as demonstrated by fMRI images offered in the Human Connectome Project (HCP) database [52, 53], relative to the disease etiology. XR-investigations are appropriate before stages of profound delirium in advanced dementia [54]. Delirium is defined by the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) to include acute disturbance in attention, awareness, and cognition. The European Delirium Association and American Delirium Society (2014) describe its increased mortality rate [55]. Delirious patients suffer from severe disturbances of the circadian system [56]. And so, XR sessions as described in this chapter offer a diurnal monitoring method to predict the arrival of impaired day-night rhythm in patient dementia-related disease progression, long before stages of delirium have arrived.

Portable virtual reality devices that can simulate 360-degrees of 3D- immersive environments in videogame processing have been used in cognitive decisionmaking diagnostics and therapeutics. They can be scripted with internally-animated virtual cameras and objects, known as *assets* to trigger patient sensorimotor interaction and focus. The engagement parlays into recognition behaviors which can be recorded as data with simultaneous autonomic cardiologic variation measurements as frequently as needed in devices that stream the videogame up to 60 or more frames a second. Also known as serious games or medical virtual reality behavioral tests [54, 57], these videogames require a minimum set of calibration so that the collection of data from the patient (also referred to as the *player*) is medicalmeaningful in investigations of decision-making decline and more.

For example, these include psychiatric considerations for:


persistent on behalf of neurotoxin breakdown and elimination that can last for as many hours as the 36-hour half life of the anesthetic itself [30]. This process is part of inherent mechanisms of survival, regardless the neurotoxic, and it is automatically geared to protect the brain with interleukin-1β (IL-1β), and interleukin-6

*Suggestions for Addressing Clinical and Non-Clinical Issues in Palliative Care*

This is significant considering the fact that, in the Netherlands alone, more than 32,000 killed patients have reportedly also died in conditions of unconsciousness with profound dehydration; and where, at least one pro-euthanization physician promoted the killing of a schizophrenic mentally ill patient to a general public readership with significant reference to the patient's ethnicity and immigrant socioeconomic demeaning reference to drug-addiction [38]. In this chapter, it is particularly relevant to disclose the fact that dementia patients can be proven to be inappropriate for euthanization treatment, both on the basis of their majority highlevel of anti-somnogenic cytokine levels and on the basis of brain survival mechanisms that are successful enough to preserve the brain in the oldest dementia-

Generally speaking, anesthetics bind to gamma-aminobutyric acid (GABA) A subtype receptors of the central nervous system, the post-synaptic NMDA receptors of hippocampal pathways for memory, and the two-pore-domain K+ channels of the central nervous system, depressing signal transmission associated with conscious awareness for a surgical period. Extreme intravenous euthanatic administration does not reach the brain, according to manufacturer related research and instead produces risk of organ-wide tissue damage plius gangrene [30]. This is because the higher dosages trigger instant release of the pro-inflammatory cytokines tumor necrosis factor α (TNFα), interleukin-1β (IL-1β), and interleukin-6 (IL-6) which are powerful repair and survival brain protective cytokines [39, 40]. These cytokines modulate centers of wakefulness regulation located in the hypothalamus, the basal forebrain and the brain stem by influencing substances involved in sleep–wake-behavior such as adenosine, nitric oxide (NO), nuclear

factor-κB (NF-κB), prostaglandin D2 (PGD2), the neurotransmitters γ-

aminobutyric acid (GABA), glutamate and norepinephrine, as well as hormones such as growth hormone-releasing hormone (GHRH) and corticotropin-releasing hormone (CRH). However, several key cytokines including IL-4, IL-13 and TGF-β are anti-somnogenic (wakefulness triggering) [41]. If so, queries against forced euthanization of Alzheimer's disease should include high-risk of patient awakening susceptibility during the process, resulting in opportunity for greater error and

At the time of researching, Dutch physicians reportedly still seem to choose to administer pentobarbital at 9 g/L as the primary euthanatic, which is well above the 0.5 mg/L safe maximum (see online pharmaceutical manufacturing warnings [42, 43]. 71% of patients, dementia and non-dementia, are euthanised at home [30]. Methods of testing brain death and pain detection still include the Bispectral Index monitor (BIS), NeuroSense monitor and Analgesia Nociception Index monitor. There are evidence of pain and suffering, awakening, and discomfort during the euthanization, despite that it is promoted as a dignified pain-free method of termi-

And yet, the law refers to the patient's advance request to receive euthanization

on behalf of preserving self-dignity which is separated from medical

decisionmaking in itself. If so, there is an unchecked expression that could be interpreted as a mandate to destroy dementia-patients who visibly fail to prevent their symptoms from violating rules of local social dignity. If so, then this contradicts the claim of compassionate reasons for euthanization in the law-making.

(IL-6) pleiotropic mechanisms [6, 35–37].

patient suffering (see **Figure 1** below).

nation from irreversible disease conditions [44].

**268**

symptomatic victims.

4.Bioperceptive capacity versus retinal limitations that reduce visual motiondetection and circadian synchronization;

potential model of selected networks with the Human Connectome is shown

*The Need for XR-Measurement of Decision-Making Decline and Conscious-State Transition…*

Currently, no tool exists to measure consciousness or self-consciousness objectively by any machine [65]. In non-communicative patients, its estimation requires the interpretation of motor responsiveness [66]. This response represents active brain processing events in the Primary Motor Cortex (MI, area 4) in the precentral gyrus and the corticospinal tract which has its own relationship to somatotopic organization for specific movement coordination, in general with other sensory processing information via a major thalamic motor nucleus, including its ventral

*Schematic example of a selected nucleic-network XR model using the human connectome project (HCP). HCP hosts detailed neuromorphological fMRI datasets combining networks from dementia and related human and animal pathology treatment records. An assembly of virtual reality (XR) monitoring programmes can be organized to support integration with HCP data collections for dementia patients, focusing on any range of*

in **Figure 2**, below.

*DOI: http://dx.doi.org/10.5772/intechopen.97384*

**Figure 2.**

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*selected neuronal-nucleic networks.*


The reader is encouraged to review a detailed description of how these features may be presented in a Supplementary Materials section titled, *Example XR-setup for Decision-making Decline Monitoring of Dementia Patients.*
