=Paper=
{{Paper
|id=Vol-499/paper-3
|storemode=property
|title=Computerized Personal Intervention of Reminiscence Therapy for Alzheimer’s Patients
|pdfUrl=https://ceur-ws.org/Vol-499/paper03-Sarne-Fleischmann.pdf
|volume=Vol-499
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==Computerized Personal Intervention of Reminiscence Therapy for Alzheimer’s Patients==
https://ceur-ws.org/Vol-499/paper03-Sarne-Fleischmann.pdf
Computerized personal intervention of reminiscence
therapy for Alzheimerʼs patients
Vardit Sarne-Fleischmann Noam Tractinsky Tzvi Dwolatzky
Industrial Engineering & Management Information Systems Engineering Health Sciences
1 1
Ben-Gurion University of the Negev Ben-Gurion University of the Ben-Gurion University of the Negev
1
+972 (54) 787-4386 Negev +972 (8) 640-1520
+972 (8) 647-2226
varditf@gmail.com tzvidov@bgu.ac.il
noamt@bgu.ac.il
ABSTRACT
The aim of our study is to determine the efficacy of a personalized
Keywords
multimedia system developed for use by patients and their Alzheimer’s disease, dementia, reminiscence therapy, multimedia,
caregivers in the treatment of mild Alzheimer's disease (AD). user-centered design, human computer interaction, rehabilitation
engineering, computerized cognitive training.
We have designed and developed a prototypical system and
conducted a pilot study in order to examine the feasibility of using
a personalized reminiscence system and evaluated its acceptability 1. INTRODUCTION
by patients and caregivers in Israel [1]. Alzheimer’s Disease (AD) is a degenerative brain disease that
gradually destroys a person’s brain cells and causes a progressive
Results from the pilot study indicate high satisfaction levels from decline in cognitive function. AD is the most common form of
those using the system as well as a strong tendency towards dementia (more than 50% according to [2]), a clinical syndrome
repeated use. There was also a clear preference for personal rather resulting from brain damage. AD patients experience a decline in
than general material when both were available. Based on these the areas of memory, attention, language, communication,
initial positive results with the prototypical system we are now in problem solving and reasoning. Life expectancy from the onset of
the process of designing a large scale study to further evaluate this the disease is 8-10 years on average. More than 24.3 million
system. people are currently estimated to have dementia, and 4.6 million
The research plan described here involves a collaborative effort new cases are diagnosed each year (one new case every 7
involving two projects utilizing behavioral interventions based on seconds). The number of people affected is expected to double
computerized systems for patients with AD (personalized every 20 years to 81.1 million by 2040 [3].
reminiscence therapy and cognitive training).
AD does not only affect the patient, but as the disease progresses
The reminiscence project which is the focus of this paper has two patients become increasingly dependent on others in many
objectives: (1) Developing a personalized reminiscence system, aspects, such as performing activities of daily living, caring for
which will enable independent use and administration for both their health and maintaining their welfare. The primary burden of
patients and caregivers. (2) Evaluating the contribution of the support for the patient usually falls on one person who takes on
system to the cognitive functioning and well-being of AD patients the role of caregiver. Green and Brodaty [4] describe four factors
and its effects on family members and caregivers. influencing caregiver’s burden, namely psychological, physical,
social and financial. Psychological effects include general distress
Categories and Subject Descriptors [5, 6] and depression [7, 8, 9]. Physical effects result in poorer
H.5.2 [Information Interfaces and Presentation]: User Interfaces – physical health of caregivers comparing to non-caregivers [10].
Evaluation/methodology, Screen design, User-centered design; Caregivers also experience social isolation because of the
J.3. [Computer Applications]: Life and Medical Sciences – caregiving role [6]. Also, there is a considerable financial strain
Health. on the caregivers as a result of the costs of care [4].
Currently there is no cure for AD. The available therapeutic
options include drugs, psychosocial and lifestyle interventions in
General Terms order to relieve both cognitive and behavioral symptoms.
Pharmacological interventions have limited efficacy and are, at
Design, Experimentation, Human Factors.
best, symptomatic [11, 12, 13]. Studies have demonstrated that
psychosocial treatments are able to decrease deterioration in
patients’ condition [14]. One of the most common psychosocial
treatments used in Alzheimer and elderly care is reminiscence
1
Address: P.O.B. 653, Beer-Sheva 84105, Israel. therapy. It is intended to stimulate the patients’ long-term memory
(a capability that is relatively preserved in AD patients compared
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to short-term memory) and to enable conversations by using a patients with mild AD by means of either personalized
variety of tangible familiar stimulations. Reminiscence therapy computerized reminiscence therapy or computerized cognitive
can decrease depression symptoms, facilitate social involvement training as compared to controls using the Mindstreams
and encourage participants to evaluate their lives and (NeuroTrax Corp., NJ) computerized neuropsychological
achievements [15,16]. assessment instrument [31] as the cognitive outcome measure.
Within this broader framework, this paper focuses specifically on
To date, there is no clear evidence regarding the effect of the personalized reminiscence system.
reminiscence therapy on cognitive function. Some studies did not
demonstrate a significant improvement [17, 18], possibly related The reminiscence system research has two objectives:
to methodological issues. For example: Goldwasser, Auerbach &
Harkins [19] studied the cognitive, affective and behavioral (1) To develop a personalized computerized reminiscence system,
effects of reminiscence group therapy on demented elderly allowing for independent use and administration of both patients
patients and found a slight but insignificant improvement in and caregivers. The importance of a personalized system is
cognitive status. They concluded that a more sensitive assessment especially salient in immigrant or in highly mobile societies, due
tool is required for evaluating short term changes in cognitive to the heterogeneous background of the patients. This is reflected
status than the Mini-Mental Status Examination (MMSE) which by the variety of locations, events and languages that can promote
was used in their study. Similarly, while Thorgrimsen, Schweitzer reminiscing in AD patients in these societies. Moreover, patient-
& Orrel [20] conducted a pilot study to evaluate the effects of adapted external aids in dementia care are considered more
reminiscence in people with dementia, they found that the MMSE effective, because they better meet the patients’ capabilities and
score of people attending the reminiscence group was almost needs [28, 32, 33] and increase their motivation [24].
identical after 20 weeks while the control group scored almost 4 (2) To evaluate the contribution of the system on cognitive
points less, yet this difference did not reach statistical function in patients with AD, as well as on patient well-being, and
significance. They thus concluded that as significant results are its effects on family members and caregivers.
more difficult to obtain with a limited number of participants, a
multicentered randomised controlled trial is needed to confirm the
positive trend that they reported. 2. Preliminary Results
We have developed a prototypical system and conducted a pilot
Nevertheless, certain studies did find significant improvement in study in order to examine the feasibility of our personalized
cognitive function due to reminiscence therapy. Baines, Saxby & reminiscence system and its acceptability by patients and
Ehler [21] compared reminiscence and reality orientation (RO) caregivers in Israel [1]. Our system improved upon existing
therapies and found an improvement in cognitive function only systems (see above) in several ways. Unlike Baycrest’s study, we
for the group of participants who received RO therapy prior to concentrated on open-ended, extensive personal content rather
receiving reminiscence therapy. Also, a more recent study [22] than on predefined life stories. In addition, we developed a web-
evaluated the effect of life review (a more structured type of based system with a more flexible and intuitive user interface
reminiscence therapy) among people with mild to moderate including a touch screen as the input device – rather than a remote
dementia. The study found that, compared to a control group, control. This technology was similar to the one used in the
patients under the life review treatment had better results in terms CIRCA project. However, whereas CIRCA included only general
of cognitive measure (MMSE), depression level, mood and content, our system also included personalized content according
communication. to patients’ background and preferences.
Increasingly, computerized systems are being designed for The aim of the pilot study was to assess the suitability of the
therapeutic treatment of Alzheimer patients. Most of these system for Alzheimer's patients and their caregivers. Since at that
systems address the cognitive decline of the patients by trying to point we were interested in understanding the qualities of the
compensate for the loss [23] or to offer a cognitive training [24]. interaction itself rather than the system’s effects on the cognitive
Lately, there is a growing trend towards the design of Web sites functioning of the patients, we used qualitative evaluation to
for Alzheimer’s patients [25, 26] and of computer systems for the identify relevant human interactions and processes. Our system
purpose of psychosocial treatments in Alzheimer care [27, 28]. was evaluated by 5 Alzheimer’s patients from the Psychogeriatric
Institute at the Tel-Aviv Sourasky Medical Center. Each patient
A notable landmark in the efforts to provide computerized support
completed 2 interactive sessions using the system with the support
for therapeutic treatment of AD is project CIRCA (Computer
of a caregiver. The participants’ behavior during the sessions was
Interactive Reminiscence and Conversation Aid). The project was
observed and videotaped, and interviews were conducted with the
designed in Scotland as a multimedia conversation aid system,
patients and the caregivers. Content analysis was performed in
which addresses the challenge of supporting reminiscence therapy
order to investigate the effects of the system on the patients, its
by using contemporary technologies to provide a computer-based,
usability, and the patients’ satisfaction with using the system, as
user friendly alternative to the traditional process. The project had
well as to identify any additional effects of the system on both
success in prompting conversations, in promoting more natural
patients and caregivers.
and more relaxed atmosphere, and in allowing the patients to
interact with the system [29]. More recently, a project of creating The results of the study indicated high user-satisfaction levels
personalized multimedia systems was initiated in Baycrest in with the system and a strong tendency towards repeated use. The
Canada [30]. system was found effective in prompting conversations and in
evoking personal memories; it was also helpful in facilitating
We have designed a collaborative study involving two projects
patient–caregiver interaction. The results also showed a clear
utilizing behavioral interventions based on computerized systems
preference of personal over general material when both were
for patients with AD. We aim to evaluate the efficacy of treating
available. Patients and caregivers alike recognized the advantage
12
of using the system rather than traditional reminiscence methods, basis improves or moderates these behavioral symptoms.
since it brought together various objects into one easily accessible
system and improved the patient’s self esteem as a consequence of 3.2.3 The effect of the system on main caregivers /
being able to use a computer. family members:
This evaluation is aimed at finding whether using the system on a
3. Research Plan regular basis eases the caregiver’s work, reduces the burden on
To test the effects of the reminiscence system more rigorously, we family members, or has any other effect on patient-caregiver and
have embarked on a research project that will be described below. patient-family relations.
The project includes the development of the system, followed by
testing its effects. The research is therefore divided into 2 main 4. Methods
phases as described below:
4.1 Patient sample
3.1 The system’s development
This phase will concentrate on the development of the A total of 150 patients (50 patients in each group) with
reminiscence therapy support system. The system will include 2 Alzheimer's disease according to DSM-IV criteria residing in
main components- front-end and back-end. The former assisted living facilities will participate in this study. The
component will support the interactions during the therapeutic inclusion criteria will be: age (sixty years old and above) and mild
sessions. The design of this component will be based on the stage of the disease (according to the Clinical Dementia Rating
prototypical system and the preliminary results described above Scale). The exclusion criteria will be: visual and auditory
and also on up-to-date studies describing user interfaces for impairments or any other physical impairment which may prevent
Alzheimer patients and the elderly in general. The latter the participants from using the computerized systems used in this
component will facilitate addition and update of content by study.
caregivers and family members. The system will be developed
using internet technology, which will allow the users to The participants will undergo a preliminary assessment in order to
comfortably access it from any location (e.g., medical institutions, determine the stage of their illness. The assessment will be
clubs for the elderly, or the home of the patient or family performed by the staff of a multidisciplinary Memory Clinic at the
member). Beersheva Mental Health Center and will include a medical,
cognitive and functional assessment using the following
The development of the system will be performed in an iterative instruments:
manner. Throughout the development we will use feedback from
both patients and caregivers concerning the ease of use of the • Mini-Mental State Examination for cognitive screening [35].
system and its appropriateness for the intended user population.
• Clock Drawing test for cognitive screening [36].
3.2 Testing of the effects of the system • Lawton and Brody’s Instrumental Activities of Daily Living
The effects of using the personalized reminiscence therapy (IADL) for assessing functional capabilities [37].
support system can be divided to three aspects. The first two • Clinical Dementia Rating (CDR) scale as a global measure
aspects relate to the potential effects of the system on the patients. rating the severity of dementia [38].
The third aspect addresses its effect on the patients’ family
members and main caregivers. The following describes the main • Mindstreams computerized cognitive assessment battery [31].
objectives of the evaluations:
4.2 Experimental Design
3.2.1 The effect of the system on patients’ cognitive The participants will be assigned randomly to one of the following
function: 3 treatment groups:
The objective of this study is to determine whether using the
system on a regular basis improves cognitive function in patients 1. Personal reminiscence therapy (using the computerized
with AD. reminiscence system with personal contents for each participant)
2. Cognitive training (using the Savion software program
3.2.2 The effect of the system on patients’ [Melabev, Jerusalem]).
psychological/ behavioral well-being: 3. No treatment – This group will receive neither the above
In the early stages of AD patients may suffer from personality interventions nor any other similar interventions. In order to
changes, irritability, anxiety and depression [34]. In this phase of overcome possible Hawthorne effect, the participants in this group
the study we will evaluate whether using the system on a regular will be meeting a caregiver for a personal discussion of current
events. This will ensure that the participants in this group are
given personal attention of a different nature to the other two
Permission to make digital or hard copies of all or part of this work for
personal or classroom use is granted without fee provided that copies are treatments.
not made or distributed for profit or commercial advantage and that
copies bear this notice and the full citation on the first page. To copy 4.3 Procedure
otherwise, or republish, to post on servers or to redistribute to lists,
requires prior specific permission and/or a fee.
Patients receiving reminiscence therapy as well as those using the
Conference’04, Month 1–2, 2004, City, State, Country. cognitive training program will participate in 2 – 3 sessions a
Copyright 2004 ACM 1-58113-000-0/00/0004…$5.00. week, each of 30-minutes duration over a period of 6 months,
13
supervised by a caregiver or research assistant. Each of the Control CFA, CFA, CFA, CFA,
participants in the control group will meet a caregiver or research
N-D, Z N-D, Z N-D, Z N-D, Z
assistant for the same frequency to discuss current events. Taking
the rate of recruitment into account, the study is expected to
continue for a period of up to two years. CFA: Cognitive Training Assessment
N-D: Neuropsychiatric Inventory (NPI), Dementia Quality of Life (DQoL)
4.4 Measurements Z: Zarit Caregiver Burden Interview
The following describes the measurements that will be used in our
research:
4.4.1 Cognitive function assessment 6. ACKNOWLEDGMENTS
This study is partially supported by grants from the Israeli
The participants’ cognitive function will be measured by the
Ministry of Health and from Myers-JDC-Brookdale Institute of
Mindstreams computerized testing battery. The assessment will be
Gerontology and Human Development, and Eshel - the
done at baseline, at one month, at 3 months and at study
Association for the Planning and Development of Services for the
termination (t, t+1, t+3, and t+6). This will allow us to evaluate
Aged in Israel.
the efficacy of the interventions compared to controls with regard
to cognitive function.
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