Designing A Better Visit Touch Screen App for people living with dementia and their visitors

The interactive touchscreen iPad app A Better Visit (games and activities) was co-created with older adults living with moderate and advanced dementia and their visitors in residential care settings.

Dementia Australia has collaborated with Lifeview Residential Care and Swinburne University of Technology to develop the new free, tablet app A Better Visit to support families and carers to improve communication and interaction with people living with dementia in residential care or in the community.

Phase 3: Results and evaluation A Better Visit bundles together eight mini-games, including picture guessing, dance hall tic-tac-toe, skill-based games of bowls, fishing and gyroscopic marble maze, as well as creative activities where users trace lines of colour, clean windows to reveal destinations or colour scenes to play animations.

Our data showed us which of the activities were played most by individual residents over the months, hence providing a good indication of preferred game styles and level of difficulty. The total suite of games also offered a wide range of activities, including both competitive and collaborative, art and music exploration and skill-based activities. This information can also be used to inform other activities.

Introduction ConclusionDesign phases

Presenter Maree McCabe, CEO, Dementia Australia

Researchers Sonja Pedell1, Stu Favilla1, Andrew Murphy1, Jeanie Beh1 and Tanya Petrovich2

1Swinburne University of Technology 2Dementia Australia

Project Partners Dementia Australia, Lifeview Residential Care and Swinburne University of Technology

Background

Phase 1: Understanding user needsIn designing the app, consideration was given to factors such as:

1 Social connection and personhood

• positive social experiences facilitated through meaningful touchscreen technology interactions may lead to benefits for self-esteem, identity and connectedness

• active communication and meaningful activities need to be informed by interests and aspirations to increase quality of life and a sense of personhood

• the need to cater for different people who may be available to share these interactions without just focusing on staff and carers

2 Exploring interests

We specifically wanted to learn about the interests of the residents – in many cases about the hobbies or activities they had pursued in earlier years. Our rationale was that the iPad apps should not cater primarily for people with dementia, but for people with certain interests who also live with dementia. At the same time, we considered it to be relevant to also address the interests of the visitors.

Early interviews with staff and visitors of all three facilities established that a good visit is defined through interaction and communication.

One staff member elaborated on the quality of interaction:

“So having a good visit is being there in that moment and not about what has happened before or what is happening tomorrow […] so having something, a common ground, something that is not reflecting: ‘this is what happened in the past, or this is what’s happening now’. So, taking away all of that and just having that moment; there and then”.

A bad visit was defined as spending time without interaction. Often, family members are reluctant to visit, coming in and leaving quickly, because the family member in residence no longer recognises them. They do not know what to do and often underestimate what the person living with dementia is able to do. They don’t know how to connect and so they leave, having had little or even no engagement.

Another staff member said:

“A not so good visit that I’ve seen, and it mainly occurs in the evening, is a resident and a family member sitting there and watching TV. The resident is nodding off and the family member is just sitting there, sort of not really knowing what to do or what to say.”

The application aims to assist everyone and promote a better visit.

RecommendationsAs a result of this project, we offer the following recommendations on co-creating for interpersonal interactions for dementia:

• always design for two people

• find the right activity at the right time

• play as much as possible together

• be flexible and explorative

• engage in conversations

• encourage active engagement versus passive consumption

User feedbackThe feedback received has been overwhelmingly positive and through anecdotes, it seems to be achieving its goal of enhancing social interaction and encouraging active engagement. One person said:

“I have downloaded this app for my husband. It is easy to use for seniors who are not super techno capable, provides opportunities for conversations and positive interactions. It has given me a platform to share some activities, have a few laughs and wonderful to see his old competitive spirit return with the bowls. The music selection was great for our age group as he sang along with some of the music. Keep up this great initiative”

Another person said:

“Thanks, this is so innovative and thoughtful for loved ones with dementia, a real conversation-starter and easy to interact with. Thank you.”

Currently the apps are still undergoing their final evaluation phase.

Touchscreen and tablet technologies have been playing a valuable role in dementia care for over a decade, being more accessible than conventional computers1,2. Like cinema, theatre, music or books, digital interactions can be persuasive and expressive with the power to change attitudes3. Digital media influence and change us, contributing to the type of person each of us becomes3.

Engaging with digital gaming in a group setting can elevate social interaction organically through discussion about the technology itself as it used or by the application presenting topics of conversation either implicitly or explicitly4.

Touch screen technology can be used to support reminiscence, aid recall, increase interpersonal interactions, promote intergenerational relationships, improve staff and resident relationships and enhance quality of life.

We propose that touch tablets offer interactions supported by film, photo-media, animation and music, each with the potential to stimulate minds and stir memories, stories and conversations.

With all of this in mind, the app aims to:

• create positive social interactions and benefit people with dementia

• promote active engagement (as opposed to passive consumption e.g. TV), emphasising creativity, skills and participation while being easy to use.

Project

We recruited 18 residents living with dementia and their main visitors (often partners, children and carers) from three separate residential care centres.

Many of the participants had no previous technology experience and a range of conditions, including loss of touch and tactile sensitivity, restricted vision, aphasia and shortened attention spans. Hence, a wide range of interaction solutions needed to be found to accommodate these challenges to achieve an enjoyable and social experience.

The project consisted of three phases:

1 Understanding the needs of both residents and visitors during a visit

2 Systematic co-development and investigation of interactions

3 Iterative evaluations

Phase 2: Co-development and investigation of interactionsIn order to strike a balance between preferences, non-patronising content and layout and to promote personhood, two design approaches were adopted – interest-based design and co-creative design.

1 Interest-based design approach

For a person with dementia to successfully participate with an application or technology-supported activity, it is important to find one that works for them7. Leng et al.8 argues that activities should reflect a person’s past experiences, interests and remaining capabilities to facilitate engagement in meaningful activities, but also to promote wellbeing. Older adults take up touchscreen technology more easily and are more interested in technology learning when it supports their pre-existing interests9.

Leahey and Singleton7 suggested that playing games together or observing may provide carers with insight into an individual’s cues, interests and abilities and potentially lead to discovery of new suitable activities.

To facilitate interest-based design, initial field trips were spent getting to know the participants living with dementia and their loved ones. This was an essential and important step in our research process, taking several weeks to establish trust and good rapport.

2 Co-creative design approach

To address the needs and interests of people living with dementia, it is equally important to include them in the design process of new technologies. Co-design is a design process that gives unique insight into user needs, preferences and ideas. Effectively, the role of the user transcends that of “user as subject” and becomes one of partnership with the designer10, pp.1. This also avoids “doing things to people with dementia rather than with them” and eroding their ability to do things themselves11, pp.15.

Tsekleves et al.12 argues that for people with advanced dementia involved in design, the term co-creation is more suitable than co-design; nonetheless, all authors agree that the strong involvement is both possible and necessary to create products that are meaningful and useful for people living with dementia13, 14, 15.

Ease of use

The ability of people with dementia to interact and engage with technology, regardless of being unfamiliar with it, often surprises persons with dementia and carers alike 4, 16. When the touchscreen game is simple, straightforward and casual and only minimal instruction is required, people living with dementia can successfully play17 and derive enjoyment from the act of learning technologies4.

However, touchscreen tablet games can also be the cause of negative reactions when they do not fit the users’ preferences or capabilities or if the game is considered too childish.18 This highlights the importance of finding the right balance of challenge and frustration16.

Technology challenges and solutions

• Loss of connectivity For button pushing and simple switch interactions, we found an excellent and robust solution setting our software interactions to register touch-offs rather than touch-ons.

• Accidental touches Accidental touches may unexpectedly and critically interrupt play. To limit accidental interaction with navigation, a single menu button was placed in the top corner of the screen and the app restricted to landscape only.

The apps were found to facilitate equal engagement and mutual social interaction with the visitors and residential staff. They provided new social opportunities with volunteers, or other people unknown to the older adults.

We evaluated the games over a period of six months, remotely logging play sessions from multiple iPads used by 24 residents across four Lifeview locations to gain insight into favoured games, frequency and duration of play. To track individual play sessions, we implemented a login screen within the app to record the participant’s name and who was playing with them. Evaluating game data is challenging. Time on task is not an effective measure of engagement and other interaction measures suggested by Yasini & Marchand19, including the number of games launched, success rate and scoring, are neither suited to studying dementia users nor social interactions.

Figure 1 shows one participant’s preferences, mapped in a spider diagram, highlighting an interest in collaborative play over competitive or skill-based interactions. Across all residents, the easy-to-use creative games were the most popular ones.

References1. Tyack, C., and Camic, P. M. (2017). “Touchscreen Interventions and the Well-Being of People with Dementia and Caregivers: a Systematic Review”. International Psychogeriatrics, vol.29, no.8, pp.1261–80. doi:10.1017/S1041610217000667.

2. Upton, D., Upton, P., Jones, T., Jutlla, K., Brooker, D., and Grove, H. (2011). Evaluation of the impact of touch screen technology on people with dementia and their carers within care home settings. UK: University of Worcester.

3. Bogost, I., Wright, W. (2003). Purposes of persuasion. Chapter 11, pp.317-340.

4. Cutler, C., Hicks, B., Innes, A. (2015). Does digital gaming enable healthy aging for community-dwelling people with dementia? Games and Culture, vol.11, no.1-2, pp.104-129. DOI: 10.1177/1555412015600580

5. Ryan, E. B., Byrne, K., Spykerman, H., Orange, J. B. (2005). Evidencing Kitwood’s personhood strategies: Conversation as care in dementia. Palgrave Macmillan. Alzheimer Talk, Text and Context, pp.18-36.

6. Craig, C. (2017). Journeying through dementia: an occupational approach to supported self management.

7. Leahey, A., Singleton, J. F. (2011). Utilizing therapeutic recreation to empower persons with Alzheimer’s in a day center: A case report. Therapeutic Recreation Journal, vol.45, no.2, pp.135-146.

8. Leng, F.Y., Yeo, D., George, S., Barr, C. (2013). Comparison of iPad applications with traditional activities using person-centred care approach: Impact on well-being for persons with dementia. Dementia, vol.13, no.2, pp.265-273

9. Beh, J., Pedell, S. (2017). When interest pays off: The relationship between motivation, well-being and learning of technologies by older adults. Design 4 Health, pp.27-30.

10. Sanders, E & Stappers, P. (2008). ‘Co-creation and the New Landscapes of Design’. CoDesign, vol. 4, no. 1, 5-18.

11. Astell, A. (2006). Technology and personhood in dementia care. Quality in Ageing – Policy, practice and research, vol.7, no.1, pp.15-25. https://doi.org /10.1108/14717794200600004

12. Tsekleves, E., Bingley, A. F., Escalamte, M. A. L., Gradinar, A. (2018). Engaging people with dementia in designing playful and creative practices: Co-design or co-creation? Dementia, vol.0, no.0, pp.1-17. DOI: 10.1177/1471301218791692

13. Rodgers, P. A. (2018). Co-designing with people living with dementia. International Journal of CoCreation in Design and the Arts, vol.14, no.3, pp.188-202. DOI: 10.1080/15710882.2017.1282527

14. Treadaway, C., Fennell, J., Prytherch, D., Kenning, G., Walters, A. (2016). Desiging for wellbeing in late stage dementia. The Context of Medical Humanities.

15. Wintermans, M. C., Brankaert, R. G. A., Lu, Y. (2017). Together we do not forget co-designing with people living with dementia towards a design for social inclusion. Design Management Academy Conference.

16. Kong, A. P.H. (2015). Conducting cognitive exercise for early dementia with the use of apps on iPads. Communication Disorders Quarterly, vol.36, no.2, pp.102-106. DOI: 10.1177/1525740114544026

17. Joddrell, P., Astell, A. J. (2016). Studies involving people with dementia and touchscreen technology: A literature review. JMIR Rehabilitation and Assistive Technologies, vol.3, iss.2, e10. doi:10.2196/rehab.5788

18. Groenewoud, H., Schikhof, Y., Astell, A. J., Goumans, M., de Lange, J. (2014). iPad happy games for people with dementia as pleasant and meaningful activities. Dementia Care Practice: E-Interventions for Training and Care.

19. Yasini, M., Marchand, G. (2016). Adoption and use of a mobile health application in older adults for cognitive stimulation. Transforming Healthcare with the Internet of Things. Proceedings of the EFMI Special Topic Conference April 2016, UK doi:10.3233/978-1-61499-633-0-13

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