Nursing home residents desire activity. Approximately 90% of residents consider engaging in favorite activities as either important (30%) or very important (60%), according to a recent Minimum Data Set report (Centers for Medicare & Medicaid Services [CMS], 2014). However, nursing home residents with dementia experience limited engagement in enriching activities. Their cognitive and functional limitations, coupled with an institutionalized living environment, often lead to low levels of engagement. Nursing home residents spend the majority of their time unoccupied and rarely initiate activity engagement (Kolanowski & Litaker, 2006). In a large-scale study, residents spent 17 hours per day in bed (Bates-Jensen et al., 2004). Low levels of activity engagement precipitate behavioral symptoms, depression, sleep disorders, and poor well-being in nursing home residents (Cadieux, Garcia, & Patrick, 2013; Genoe & Dupuis, 2014; O’Neil et al., 2011; Richards, Beck, O’Sullivan, & Shue, 2005).
Provision of ongoing and sufficient activity programs has been emphasized in the activity regulations and guidelines issued by the U.S. Department of Health and Human Services (USDHHS) CMS (Allen, 2010). Nevertheless, given the variability of cognitive and functional impairment and individual preferences, the “one size fits all” approach does not work, and activities must be individualized to an individual’s abilities and interests. In fact, approximately 78% of nursing home residents do not attend most group activities organized by nursing homes (CMS, 2012); instead, more than 90% of residents prefer to do an activity in their own room.
Recent advances in computer technologies offer a new means to expand activities that residents can enjoy in their own rooms (Bouwhuis, 2006; Gamberini et al., 2006; Tak, Beck, & McMahon, 2007; van Rijn, van Hoof, & Stappers, 2010). Computer activities can be therapeutic because of visual and auditory stimulation, interactivity, multiple repetitions on demand, and easy modifications in speed and level of cognitive challenge (Alm et al., 2009; Astell et al., 2009; Riley, Alm, & Newell, 2009). Literature suggests that computer activities may improve cognitive abilities, such as attention, eye–hand/body coordination, executive function, and information-processing skills (Anguera et al., 2013; Fenney & Lee, 2010; Gamberini et al., 2006; Tun & Lachman, 2010; Zelinski & Reyes, 2009).
Growing evidence indicates that nursing home residents with dementia enjoy computer activities (Fenney & Lee, 2010; Tak, Beck, & Hong, 2013; van Rijn et al., 2010). However, cognitive or physical impairments are identified as major barriers to a continual use of computers in the population (Astell et al., 2009; Bouwhuis, 2006; Tak et al., 2013). It is estimated that 41% of nursing home residents have moderate to severe cognitive impairment, whereas 27% experienced mild cognitive impairment (Alzheimer’s Association, 2013). Only 1.6% of nursing home residents do not receive any assistance in activities of daily living (Jones, Dwyer, Bercovitz, & Strahan, 2009). If computer activities require excessive cognitive skills and physical functioning beyond individual competencies, residents with dementia are not likely to engage in the activities. Special attention to individual interests and functional competencies is essential to increase engagement and positive experiences for individuals with dementia. Therefore, the purpose of the current pilot study was to examine the differences in preferred computer activities among individuals with severe, moderate, and mild dementia. In addition, the effect of computer activities on cognitive ability was explored.
Observational Data and Study Participants
The current pilot study used a secondary analysis of observation data from nursing home residents with dementia who participated in a computer activity program.
Computer activity data included 473 activity observation logs of 15 participants with dementia who were recruited from three nursing homes in a southern U.S. state. Their mean age was 82 years (SD = 10.2, range = 61 to 102 years). The mean education level was 12th grade (SD = 2.8, range = 6 to 16 years). Nine participants were African American (60%), and six were Caucasian. More women (60%) participated than men. Participants were screened for their cognitive ability at enrollment and after the computer activity program using the Mini-Mental State Examination (MMSE). The MMSE is a widely used instrument that has an 11-item test with a total score of 0 (severe impairment) to 30 (no impairment) (Folstein, Folstein, & McHugh, 1975). If participant MMSE scores were ≤10, they were considered to have severe dementia; those with an MMSE score between 11 and 19 were regarded as having moderate dementia; and those with scores between 20 and 25 had mild dementia (Lopez, Charter, Mostafavi, Nibut, & Smith, 2005). Seven (47%) participants had moderate dementia, four (27%) had mild dementia, and four (27%) had severe dementia. The numbers of activity observation logs from participants with different levels of dementia were as follows: severe = 115; moderate = 234; and mild = 124. No significant difference existed in demographic variables among groups with different levels of dementia (i.e., severe, moderate, and mild).
In addition, all participants completed a brief screening for vision, hearing, and hand-and-finger function (HFF). In the vision assessment, all participants except one were able to read an 18-point font letter on the computer screen. All were able to hear sounds at the highest volume of the computer speaker. HFF was measured by using a subscale of the Arthritis Impact Measurement Scales (Meenan, German, Mason, & Dunaif, 1982; Meenan, Mason, Anderson, Guccione, & Kazis, 1992). The mean score for HFF was 9.9 (SD = 5.4, range = 4 to 19), indicating poor function.
Study participants were recruited with approval from the university institutional review board. Study participants met the following inclusion criteria: (a) 60 or older, (b) had a diagnosis of dementia in the medical record, (c) had a MMSE score of 4 to 25, (d) was able to follow the one-step command on the MMSE, (e) experienced no change in psychoactive medications within the past 30 days, and (f) resided in the facility for at least 2 weeks. Each participant’s responsible party provided written consent, along with the participant’s assent prior to his or her enrollment in the study. The pilot study used observational data from the 15 study participants who completed the computer activity intervention, as well as both a baseline assessment and follow up of the MMSE at 12 weeks.
Initially, 46 residents in total provided their consent to participate in the study. Participants were excluded from the study because they (a) did not meet the eligibility criteria (n = 12); (b) moved to another place (n = 5); (c) belonged to a control group (n = 6); (d) did not complete a follow-up cognitive assessment (n = 4); (e) died (n = 2); (f) lacked support from the nursing facility (n = 1); and (g) withdrew due to lacking interest in computer activities (n = 1). Study participants who completed the study received $40 in their personal account.
Computer Activity Program
All computer activity sessions were recorded using an activity observation log that included the total time spent in a session (minutes and seconds), the names of all the activities that participants engaged in, and the time spent in each activity (minutes).
Format. Computer activity sessions were offered weekdays between 9 a.m. and 5 p.m. for 12 weeks. Although participants were encouraged to attend all computer sessions offered during the program period, attendance was voluntary. In addition, study participants were encouraged to select and engage in the activities of their choice. If an individual did not show interest in and did not wish to continue an activity, research staff stopped the session after three attempts to engage him or her. On average, participants attended 32 sessions and spent 896 minutes on the activities over the 12-week program. They attended approximately three sessions per week. Each session lasted an average of 27 minutes. No significant differences existed in mean time spent for 12 weeks, mean number of sessions attended, and mean minutes spent per session among groups with different levels of dementia.
Activity Room Setup. Computer activity sessions were held in a room equipped with a personal computer, printer, and other accessories (e.g., trackball, touch-screen, headphones) in nursing homes. Participants had opportunities to familiarize themselves with the computer equipment and try a computer activity during two 30-minute individual orientation sessions prior to the program.
Content. The computer activity program included computerized games and slide show modules that promoted cognitive stimulation and positive emotion in a visual and auditory manner. Various computer games that were free or commercially available (i.e., tidy-up, solitaire, balloon pops, blocks, jacks, pinball, sticks, poker, bingo, blackjack fever, and greeting-card making) were used. Slideshow modules were created by a computer technician using the Microsoft® PowerPoint program. Along with a timed transition of visual contents, the modules were presented with songs and music that were previously used for older adults and individuals with dementia (Bednar-Haynes, 2004a,b). Visual content was selected from more than 3,000 photographs and scenes of nature, art, and life.
Procedure. A research staff member was available to provide assistance with turning on the computer and setting up equipment, such as the printer, during each activity session. Participants chose one or more activities that interested them from an activity menu on the computer screen. If needed, staff provided assistance but avoided unnecessary interaction and attention. Using a stopwatch, the research assistant filled out an activity observation log, including time spent on each activity at the end of each session.
Activity observation logs were examined using descriptive statistics (i.e., mean, standard deviation, and percentage) for session attendance, time spent (minutes) per session, frequency of attendance in each activity, time spent (minutes) in each activity, and total time spent (minutes) for 12 weeks. Means and standard deviations were calculated for MMSE scores at both baseline and follow-up assessments. A one-way analysis of variance (ANOVA) was used to examine the difference in preferred computer activities among groups with different severity levels of dementia. In addition, the effect of computer activities on cognitive ability was analyzed using repeated measures ANOVA. In these analyses, an effect was statistically significant if p < 0.05.
Significant differences existed in preferred computer activities among groups with severe, moderate, and mild dementia. The group with severe dementia spent significantly more time watching slide shows with music than the two other groups (F [2,12] = 9.72, p = 0.003). Preference in the tidy-up game also differed significantly across the three groups (F [2,12] = 4.87, p = 0.028). Individuals with moderate dementia preferred the tidy-up game and spent more time playing it than those with severe or mild dementia. Computer games, such as solitaire, balloon pops, and bingo, were almost never selected by individuals with severe dementia. Some of the computer games and activities (e.g., pinball, poker, greeting-card making) were excluded from data analysis because the mean time spent playing them for the 12 weeks was less than 10 minutes. The Figure illustrates the comparison of mean time spent on preferred computer activities among groups with severe, moderate, and mild dementia.
Comparisons of preferred computer activities by groups with severe, moderate, and mild dementia.
Note. For participants, N = 15, and for observations, N = 473. Activities were excluded if the mean time spent on them for 12 weeks was less than 10 minutes.
In addition, in an effort to examine the effects of computer activities on cognitive ability, the changes in MMSE scores from baseline to follow-up were explored by comparison among the three groups (Table 1). The groups with both mild and moderate dementia showed a small improvement in MMSE scores, whereas the group with severe dementia showed a decrease in MMSE scores at follow up. However, differences in the changes were not statistically significant both within and between groups.
Changes in MMSE Scores Grouped by Severity of Dementia
The findings of the current study indicate that computer activities should be tailored to an individual’s cognitive ability. Individuals with severe dementia preferred watching slide shows while listening to music and rarely selected cognitively challenging activities, such as solitaire, balloon pops, and bingo. Those with moderate dementia preferred simple games, such as the tidy-up game, that required one-step tasks (e.g., picking up an object on the floor). In contrast, those with mild dementia enjoyed a full selection of activities and games, although they preferred cognitively challenging games, such as balloon pops and solitaire. Cognitive ability played a critical role in performing cognitive tasks, such as remembering to click a particular icon to move to the next step in a computer game. It was evident that impaired cognitive ability prevented an individual from engaging in a computer activity or game if it required a high level of planning or sequencing or a goal-directed process with accuracy and speed.
Along with cognitive ability, computer activities require vision, hearing, and HFF (Astell et al., 2009; Schaie, 2004; Tak et al., 2013). Both vision and hearing ability are vital to see a computer screen and listen to sound. In addition, an older adult with limited HFF may have problems using a keyboard or mouse. Because individuals with dementia experience varied severity of dementia and physical functioning, it is critical to assess their cognitive and physical abilities before offering computer activities. Computer activities must be matched to the abilities of an individual based on these assessments. Evidence shows that a selection of activities appropriate to individuals’ competence was important to improve the level of activity engagement, increase satisfaction, and facilitate a positive experience with computer activities in individuals with dementia (Riley et al., 2009; Tak et al., 2013; van Rijn et al., 2010). Therefore, a practical guideline based on cognitive and physical assessments has been developed for tailoring computer activities. The guideline, with examples of activities, is presented in Table 2.
Tailoring Computer Activities for Individuals with Dementia
Adaptive accessories may be useful to compensate for cognitive and physical disabilities and improve the level of engagement in computer activities among individuals with dementia. The speed and repetition of activity content may be easily adjusted to meet the needs of an individual. In the case of poor vision, a screen/video magnifier can be used to enlarge the size of letters or objects on the screen. An articulating arm can be attached to the computer monitor so that older adults stay close to the computer screen. Instead of using a mouse or keyboard, a trackball, touch screen, or speech recognition program can improve human–computer interaction when an older adult experiences difficulty with HFF. A simple adjustment to a high volume or use of headphones/amplification systems can help an individual hear sound or music. In addition, a portable computer workstation can be beneficial when nursing home residents with dementia prefer to do computer activities in their own rooms instead of an activity room.
In a recent survey of nursing home administrators of Alzheimer’s care units, the majority of participants were interested in making computer activities available for their residents, as computer-literate baby boomers move into the older population (Tak et al., 2007). Currently, activity choices and opportunities are limited for nursing home residents with dementia. An innovative approach to expand and improve enriching activities is imperative. According to the American Recovery and Reinvestment Act (2009), it is important to use technology in aging services and examine the potential use of new aging services and technology to help individuals with disabilities (USDHHS, 2012). Computer activities have the potential to serve as important and effective supplementary activities that can be individualized with cognitively stimulating multi-media features.
Because the current findings were based on a pilot study with a small sample, the study’s generalizability is limited. Recruiting nursing home residents with dementia was challenging. Exclusion and refusal rates are high in research studies with individuals with dementia because participating in a study usually requires availability of an informant, consent of legal guardians, and the limitations of significant physical comorbidities or neuropsychiatric symptoms. It is estimated that one in 10 individuals with Alzheimer’s disease may be eligible and willing to participate in clinical trials (Cooper, Ketley, & Livingston, 2014). A recent protocol based on partnership among individuals with dementia, their legally authorized representatives, the researchers, and key nursing home staff members may provide a practical guideline for recruiting and obtaining informed consent and assent in the population (Batchelor-Aselage, Amella, Zapka, Mueller, & Beck, 2014).
Conclusion and Implications
A growing interest exists in making computer activities available to nursing home residents with dementia who are limited in activity engagement. The current pilot study provides an understanding of computer activities preferred by individuals with different severity levels of dementia. It is critical to consider individuals’ interests and functional abilities when computer activities are provided for individuals with dementia. The authors suggest introducing an assessment process to support nurses in tailoring computer activities to an individual’s cognitive and physical competence. The results of the current study offer a practical guideline for future assessment and intervention work. Further research, including large-scale clinical trials, is warranted to examine the effects of tailored computer activities on cognition and other health outcomes among individuals with dementia.
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Changes in MMSE Scores Grouped by Severity of Dementia
||Severe (n = 4) Mean (SD)
||Moderate (n = 7) Mean (SD)
||Mild (n = 4) Mean (SD)
Tailoring Computer Activities for Individuals with Dementia
||Examples of Computer Activities
||Severe impairment (MMSE score = 4 to 10): Use implicit, automatic, and unconscious cognitive memory process
Watching a rotating screen display family pictures
Listening to an audiotaped family member’s voice
Reviewing a slideshow of mountains while listening to a sound of a stream
|Moderate impairment (MMSE score = 11 to 19): Capitalize on retained cognitive abilities
||Playing a simple computer game (e.g., Rabbit)
|Mild impairment (MMSE score = 20 to 25): Strengthen retained abilities and promote exercise of cognition
Playing a complicated computer game (e.g., puzzles, country driver, Scrabble®, solitaire)
Creating a card, clip art, or banner
||Ability to read an 18-point letter on a computer screen
||No/poor: Use of visual adaptive accessories
||Any activity that has an audio component
||Any computer activity that requires an interaction with a computer screen
||Subscale of Arthritis Impact Measurement Scales
||Poor (HFF score <15): Minimum use of a keyboard or mouse; trackball use is encouraged
Listening to news channels on the Internet
Playing a computer bingo game that requires only a few mouse clicks
|Good (HFF score >15): Extensive use of a mouse or keyboard
||Creating a banner or art project using Print Shop®
||Ability to hear a sound from a speaker
||No/poor: Headphone use is encouraged
||Any activity that does not require listening to an audio component (e.g., viewing a slideshow, writing letters in Microsoft® Word)
||Any computer activity that has an audio clip