The use of free non-dementia-specific Apps on iPad to conduct group communication exercises for individuals with Alzheimer’s disease (Innovative Practice)

Abstract

This study examined the use of various iPad Apps to conduct group cognitive exercises for clients with mild or early stage dementia of Alzheimer’s type. A list of free non-dementia-specific Apps suitable for group sessions was compiled. The procedures in choosing these Apps and determining the most successful ones for group exercises were discussed. Based on participants’ and professionals’ responses to the use of these Apps, the results would render practitioners useful guidelines in replicating and running technology-based training for individuals with dementia.

Keywords

dementia communication exercise group exercise technology free Apps iPad

Introduction

As a result of the expanding range of choices and higher degree of accessibility of Applications (Apps), technology-based therapy for individuals with dementia or post-stroke aphasia has become a trend in the past decade (Holland, 2014; Kong, Law, Yeung, Lau, Tao, & Nan, 2016). Earlier reports, such as Alm, Astell, Ellis, Dye, Gowans, & Campbell (2004), have collectively suggested that the memory skills and everyday activity functioning of persons with acquired communication disorders can be facilitated by clinical training supplemented by carefully selected Apps. This conclusion validated the use of Apps that are not specifically developed for cognitive or language rehabilitation to support implementation of traditional therapy sessions.

Various studies have reported the positive effects in using Apps on tablet devices to conduct language or cognitive exercises on clients with acquired communication disorders (see review in Kong, 2015). For example, Leng, Yeo, George, and Barr (2014) have demonstrated that individuals with dementia showed positive changes of behaviors when they were engaged in group activities involving the use of iPad, as compared to traditional activities. In addition, Szabo and Dittelman (2014) suggested that the high-technology interface when one uses mobile technology, such as smartphones or tablet devices, could arouse users’ interest and curiosity. The fact that most of these Apps and tablet programs could empower patients to take control of their own process of rehabilitation as well as pace of conducting home practice (Kiran, Des Roches, Balachandran, & Ascenso, 2014) further makes it a popular (and effective) component of daily training.

In fact, the above-mentioned beneficial effects can also be found in neurologically unimpaired elderly. Chan, Haber, Drew, and Park (2014) reported the use of extensive iPad training involving a broad range of Apps among English-speaking older adults and its subsequent outcomes of the participants’ improved cognition for social engagement and facilitated executive function for everyday activities (such as banking). Interestingly, it has also been suggested that administering simple brain-training games on an iPad can detect subtle cognitive impairments (Tartaglione, Derleth, Yu, & Ioannou, 2014). In other words, it appears that implemented of Apps in the management of neurologically impaired population is not solely limited to the rehabilitation or process, but also the evaluation aspects of cognitive deficits.

Kong (2015) has recently reported a study to systematically compile a list of iTunes Apps suitable for usage with mild or early stage dementia. Procedures in determining the salient features of these Apps, all of which were either lite versions or free Apps for public to download, in relation to the participants’ strength and weaknesses were discussed. Moreover, the author used the selected Apps to conduct individual cognitive exercises and has led to the conclusion that iPad was a viable tool to supplement traditional clinical interventions for clients with dementia.

Aim

The purpose of this study is to extend Kong’s (2105) work by exploring the use of iPad Apps to conduct group cognitive exercises in a clinical setting for clients with early stage dementia. The procedures in choosing Apps through the iTunes market suitable for use with the dementia population were reported. The processes in evaluating each App, based on its potential capability to be implemented in group clinical settings and feedback from professionals and participants, were also given. A final list of Apps adopted to provide cognitively stimulating group therapy was compiled. Finally, suggestions for instructional applications in using these Apps on iPad during group therapy sessions were presented for potential replication.

Method

Participants

Fifteen individuals (eight men and seven women) with Alzheimer’s Disease, as reflected by results of the Montreal Cognitive Assessment (MoCA), with an average score of 15.33 (S.D.=1.05), participated. The participants were between 50 and 86 years and had educational statuses between high school graduate and doctorate degree. None of them demonstrated significant executive dysfunction. All participants were aware of their memory impairment and provided consent to participate in the study. They met two times per week and were provided with cognitive stimulation and light physical exercise in a social milieu.

App selection and use

The steps of app selection in this study largely followed the framework described in Kong (2015). First, the iTunes market was accessed through an iPad device to search for suitable Apps using terms “dementia,” “Alzheimer’s,” “cognitive,” “brain fitness,” “brain age,” “word games,” “language,” “attention,” “puzzles,” and “memory.” A total of 43 Apps that were free or had a ‘lite’ version in the iTunes market were downloaded (Table 1). These Apps were evaluated by professionals as mentally stimulating that could potentially encourage engagement in a group setting.

Table 1.

Apps Considered in Current Study Listed in Alphabetical Order (n=43)

	App name (sub-task), “developer” searched on iTunes market that were initially considered to be mentally stimulating, effective to engage clients and applicable for use in a group setting	Finalized Apps for group exercise in this study (n=18)	Reason(s) of excluding from the current study
		Finalized Apps for group exercise in this study (n=18)	High visual demands on the participants	Timer function hindered responses from participants	Activity wasnot preferred by participants
1	4 Pics 1 Word, “LOTUM GmbH”		X
2	Brain Age Games, “Burlaciuc Vlad”		X
3	Brain Jog, “Queen’s University Belfast”*			X
4	Brain Labs, “SixDead Entertainment”		X
5	Brain Train Age, “fang gu”			X
6	BrainBaseline, “Digital Artefacts L.L.C.”		X
7	BrainyApp, “Alzheimers Australia”		X
8	Chain of Thought, “Jay Bacal”	X
9	Conundra Math, “Sarah Pierce”				X
10	Doodle Buddy, “Pinger, Inc.”	X
11	Draw Something, “OMGPOP”				X
12	Einstein Brain Trainer, “BBG Entertainment GmbH”			X
13	Family Feud® & Friends, “Ludia”		X	X
14	Fit Brains Trainer (Concentration), “Rosetta Stone Canada Inc.”	X
15	Fit Brains Trainer (Memory), “Rosetta Stone Canada Inc.”	X
16	Getty Images, “Getty Images Inc.”				X
17	Jigsaw Puzzle, “Critical Hit Software, LLC”	X
18	Lumosity (brain trainer), “Lumos Labs, Inc.”				X
19	Matching 2, “IntelleQuest Education Company”	X
20	Memory Matches 2, “Lumate, LLC”			X
21	Missing Link, “Sarah Pierce”	X
22	Number Link, “Tapps Tecnologia da Informação Ltda.”	X
23	PCS Bingo, “DynaVox Mayer-Johnson”			X	X
24	Pictoword, “Kooapps”	X
25	PopWords!, “Sarah Pierce”	X
26	SingFit, “Musical Health Technologies”				X
27	Spider Solitaire, “MobilityWare”		X
28	Spot the Difference! What's the Difference?, “ReignDesign”	X
29	29. SpotDiff, “Cookie Apps, Inc.”		X
30	Sudoko, “Finger Arts”		X		X
31	Tan Zen Lite, “Little White Bear Studios, LLC”	X
32	This2That, “Mobile Magic Developers”				X
33	What the Photo, “Rumpus”			X
34	What's the Phrase, “Zynga Inc.”		X		X
35	What's The Word, “JN Interactive AB”	X
36	Word Challenge, “PMovil”	X
37	Word Jigsaw, “Sarah Pierce”	X
38	Word Search Free, “MobilityWare”				X
39	Word Solitaire, “Candywriter, LLC”		X
40	Word to Word, “MochiBits, Inc.”	X
41	Word Wall, “MochiBits, Inc.”	X
42	Word Wrap Extreme, “Brain Media”	X
43	WordSearch Unlimited, “VirtueSoft.com”		X		X

Note: *: At the time this manuscript was being prepared, the app has been removed from the App Store.

The next stage involved the use a questionnaire (similar to Kong, 2015) to determine the clients’ preferences of activities they wish to participate in. Prior to working with the iPad device, each participant was interviewed for approximately five minutes to obtain a brief history of knowledge or experience in using technology as well as information about activities (s)he would like to join in a communication group. Based on participants’ concerns about the visual demands and speed of providing responses of these Apps, the original list of 43 Apps was then reduced to 36. Specifically, Apps that were visually too distracting and/or with timer functions that were considered to be too short for participants to respond were removed from the list. The number of Apps was then further reduced to 18 in the final list.

In the final stage, the 18 Apps were implemented in two group settings, four small groups of three to six participants and a large group of all 15 participants. The small groups were assembled with consideration for members’ cognitive strengths and preferences. Thirty-minute group sessions were conducted for all groups once a week for three weeks. Each app was displayed by projecting the iPad screen on an adjacent wall. This increased the screen size and reduced the visual demand. After testing each app, the participants were asked to evaluate each app through a scoring system of 0 to 10, with 10 being the most enjoyable experience with perceived benefit on engaging participation of a communication group. The professionals also provided reviews on each app based on their observation of the running of the activities, including participants’ responses, interaction, and engagement level in the group as well as effective strategies for clinical implementation.

Results

Table 1 displays more detailed information about the perceived limitations of Apps not selected for use in the current study. Based on the professionals’ reflection, a strategy effective for small group implementation was to establish with participants the activity goal for each app. To facilitate smooth running of an activity, the practitioners might provide examples, reiterate the instructions, or provide reminders during the app implementation. The large group setting proved to be more challenging, but some useful strategies included verbally presenting materials to reduce visual demand and displaying the app on an Apple TV or projector to increase screen size. It was also observed that the large group setting limited low-functioning clients’ ability to participate. It is recommended that groups be arranged based on current functioning level to reduce frustration of clients. Additional implementation strategies or observations were recorded for each app in the final list (Table 2).

Table 2.

Finalized Apps Used (n=18) with Participants’ Rating and practitioners’ Review.

	App name (sub-task), “developer”	Average participant rating*	Practitioners’ observation**	Practitioners’ recommendation for future replication
1	Chain of Thought, “Jay Bacal”	10	+ Once participants understood the word associations, they seemed to be engaged with the application+ After initial instruction, minimal cueing was needed- Establishing an understanding of the required abstract thinking process proved to be challenging for low-functioning clients	Facilitators should operate the iPad and highlight word orders Have participants brainstorm possible pairings as a group and shout out possible connections using the provided words in the application More suitable for use with high-functioning clients
2	Fit Brains Trainer (Memory), “Rosetta Stone Canada Inc.”	10	+ Participants were engaged with the application- The app was intended for a single user and its effectiveness did not translate well into a group setting- The app is timed, making it difficult on the demand of processing speed	Facilitators should operate the iPad and verbally present the item list at the top of the screen and read items down to the bottom Allow participants to call out answers Verbal support provided by facilitators to minimize the visual demand and assist visually impaired participant is suggested
3	Fit Brains Trainer (Concentration), “Rosetta Stone Canada Inc.”	10	+ Some participants commented the app was easy and engaging- The app was intended for a single use, proving it difficult to use effectively in groups- The provided timer seemed to be an obstacle for some participants due to pressure in providing an answer	Facilitators should operate the iPad As stimulus items are introduced the facilitator should verbally present the sequence (to minimize visual demand) Have participants call out the missing item from the sequence
4	What's The Word, “JN Interactive AB”	10	+ Once participants understood how to arrive at an answer, including developing a word from the letters provided, minimal cueing was needed+/- Maximum cueing (e.g., examples) was needed at the beginning	Facilitators should operate the iPad Descriptions of the four pictures should be given to the participants without the specific answer given Instructions should include using the provided letters at the bottom of the screen
5	Pictoword, “Kooapps”	9.33	+ Most participants were engaged and commented they enjoyed the app+ Once given an example, participants were able to generate answers with minimal cueing- Facilitators might need to reiterate instructions	Facilitators should operate the iPad, explain what the pictures are, and highlight the provided letter bank The number of letters in the answer can be used to help guide the participants to the target response
6	Doodle Buddy, “Pinger, Inc.”	9.25	+ High-level participants were engaged and enjoyed the app- Some participants commented difficulties in understanding the flow of the activity- Some participants were unaware of the purpose of this app	Facilitators may operate the iPad and draw different items for participants to guess A category name (e.g., fruit) and the number of letter in the word can be given to facilitate participants’ responses Semantic, grapheme, and phoneme cues are optional To enhance group interaction, facilitators can invite participants to come and draw items for others to guess
7	Tan Zen Lite, “Little White Bear Studios, LLC”	9.125	+ Provided a great deal of interaction among participants as they debated where the pieces of the application should go+ A participant with a background in contracting was the most engaged and went up to the projected image to manipulate the pieces+ Directions were called out by other group participants	Facilitators may operate the iPad and have clients step up to the projected image and physically mimic the movements to drag, drop, rotate, and flip pieces Participants can take turns and call out answers If the image proves challenging then provide cues and place pieces to jumpstart the process
8	Word to Word, “MochiBits, Inc.”	8.9	+ This application was successfully used as a big group activity+ Visual demand was lessened by verbally presenting materials- Input from high-functioning participants could hinder low-functioning participants from joining	Facilitators should verbally present the word in the first item and the list of words in the second column Allow participants to call out answers of associations A pause between presentation of words and invitation of responses should be given to allow low-functioning participants time to formulate associations
9	Missing Link, “Sarah Pierce”	8.875	+ This app prompted high level of engagement by all participants+/- Reading out the provided words greatly lessened the visual demand and allowed all participants to join	Facilitators should operate the device Allow participants to come up to the project image and push the desired buttons or allow them to call out answers Reiterate that the missing letters must fit in all provided words Read words for visually impaired participants
10	Jigsaw Puzzle, “Critical Hit Software, LLC”	8.66	+ Participants were very engaged+ The greatest level of engagement was seen with a participant who had background in contracting- There was great visual demand and thus excluded some participants from joining- The 9-piece version was used; however, some participants reported that this version was too easy	Participants should be invited to mimic necessary movements on the projected image to complete the puzzle or call out directions for the facilitator to carry out Cueing should be provided as needed The 16-piece version can be introduced to increase the challenge level for some participants
11	Spot the Difference! What's the Difference?, “ReignDesign”	8.5	+/- Re-instruction and re-direction were required for some participants- Challenging to low-level participants and hindered their engagement	This app is recommended for use with high-functioning groups Project both images and allow participants to go up and touch the differences or call them out Touch the area of difference on the device to highlight it on the pictures
12	Number Link, “Tapps Tecnologia da Informação Ltda.”	7.25	+ Some participants enjoyed this application- Very challenging to visually impaired participants due to its high level of visual demand- This application was trialed with a low-functioning group and maximal cueing was needed from the practitioners	Two facilitators are recommended for this application: one to operate the device and another to physically outline the pathways connecting the numbers More suitable for high-functioning groups Participants can come up to the projected image or call out directions to the facilitator A step-by-step process should be used to build pathways (e.g., first go left, then up, up more, now right, etc.)
13	Word Wall, “MochiBits, Inc.”	7.22	+ This application was used in large groups+ The app required participants to make word pairs from larger groups of words- Some participants wanted answers more quickly than the application allowed, leaving some participants feeling frustrated	This application should be used in a group whose functioning levels of clients are more similar, allowing more tailored instruction on strategy Words should be presented verbally to minimize visual demand
14	PopWords!, “Sarah Pierce”	7.2	+ Engaging as each time a word was formed, those letters would disappear and new letters were introduced+ A grid of letter (similar to boggle) was introduced and participants could call out words by connecting the letters+/- Moderate levels of engagement were observed with this app, depending greatly on participants’ level of functioning- Some participants felt the app moved too quickly	This application does not accept one or two letter words; therefore, a white board should be utilized to record all one- and two-letter words identified by the participants Facilitators should operate the iPad and connect words as they are identified by participants and record answers on whiteboard as needed
15	Word Challenge, “PMovil”	5.875	+ This app was used in the large group setting with all participants- Differences between high- and low-functioning participants proved to be a challenge for lower-level clients- Many participants were given insufficient time to answer before other participants shouted out the correct response	Facilitators should operate the iPad and allow participants to call out answers. Alternatively, pausing between presentation of words and answering may be utilized Further instruction of the use of strategies to arrive at answers can be presented to facilitate participants’ responses
16	Matching 2, “IntelleQuest Education Company”	5.33	- This application was used only with a low-functioning group and was very challenging- Re-instruction of directions was provided frequently- Participants demonstrated difficulty in identifying what item they were looking for- The high visual demand excluded participants with visual impairment	Facilitators should run this application The directions should be explained and re-explained throughout the activity Cueing should be used to help participants identify which item they are looking for and give a general proximity as to where to find the match if needed
17	Word Wrap Extreme, “Brain Media”	5	+/- The application was modified to have the clients find one word per board and then move to the next board, thus restarting the timer and minimizing frustration- The timer feature on this application could not be turned off. This interrupted participation and seemed to frustrate some participants due to their reduced speed of processing secondary to dementia	Facilitators should operate the iPad and allow clients to call out words as they are identified A whiteboard may be used to identify one- and two-letter words and assist in strategy instruction
18	Word Jigsaw, “Sarah Pierce”	3.33	+ This application was trialed with a high-functioning group. Engagement by many participants was observed+ Participants demonstrated the use of two different strategies: 1) using the letters to form words to build the grid, 2) using the shapes to form the grid and then deciding if the words make sense. It was interesting to see both of these strategies then come together to complete the task- Participants reported that they did not like that they did not know some of the words	This application should be operated by the facilitator The clients should be invited to come up to the projected image and manipulate the pieces or call out directions to the facilitator A dictionary or computer should be close by to look up unfamiliar words and minimize frustration

Note: *: range of 0 to 10, with 10 being the most enjoyable with the highest degree of perceived benefit by participants; **: + and - indicates practitioners’ positive and negative perception, respectively, of app implementation.

Discussion

The present study is one of the pioneer reports in the literature that have discussed the innovative use of everyday Apps to conduct communication group for individuals with dementia. Our results extended findings of some previous investigations on application of technology-based training to dementia (Kong, 2015; Leng et al., 2014): clinical use of iPad Apps continued to demonstrate as a viable supplement to conventional behavioral training. This is especially the case when it came to arousing attention and engaging individuals with dementia during daily clinical practice. Consistent with the report in Lopez-Samaniego, Garcia-Zapirain, and Mendez-Zorrilla (2014) for which mathematical and memorization exercises were completed using iPad for individuals with mild-moderate cognitive impairments in Spain, this ‘game playing’ (instead of standard rehabilitation) approach of conducting exercises and users’ accurate responses during the training promotes their overall interest, satisfaction level, and willingness to participate.

Practitioners who use Android or other non-Apple products may also download some of the Apps described in this study from the Google Play platform. Given that the choice of Apps, whether they are free or not, is constantly expanding in the market, professionals are encouraged to explore additional Apps that are suitable for their clients. With reference to the experience reported by the clinical professionals in this study, consideration of participants’ premorbid demographic characteristics, such as their occupations, hobbies, or education status, when selecting relevant Apps/activities should enhance their engagement level into the exercises. In additional, use of Apps that are designed and dedicated to the dementia population or that can address the limitations in memory skills, processing speed, and/or attention associated with dementia can facilitate the use of technology-based exercises to enhance everyday communication in this population.

Footnotes

Acknowledgments

The author is grateful to the participants for their participation in the study and Ms. Peggy Bargmann, Director of the Brain Fitness Club at the First United Methodist Church of Winter Park, for her assistance in the present investigation.

Declaration of Conflicting Interests

The author declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: The author reports no declarations of interest. Part of the results of this study was presented in The 2013 American Speech-Language-Hearing Association (ASHA) Convention held in Chicago, IL, USA.

Funding

The author disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The research reported in this article was funded in part by the Learning Institute for Elders at the University of Central Florida, Inc (LIFE@UCF) through the 2012-13 Competitive Grant and 2013-14 Competitive Grant awarded to the author.

Anthony Pak-Hin Kong is an associate professor in the Department of Communication Sciences and Disorders at University of Central Florida. His research interests include Chinese aphasia, discourse analyses, and neurogenic communication disorders in multilingual speakers. He has served as Consultant to provide research, clinical, or professional consultations to international agencies, including Aphasia United, Hong Kong Hospital Authority, Self Help Group for the Brain Damaged, Hong Kong Association of Speech Therapists, Hong Kong Society for Rehabilitation, and Hong Kong Productivity Council.

References

Alm

Astell

Ellis

Dye

Gowans

Campbell

(2004). A cognitive prosthesis and communication support for people with dementia. Neuropsychological Rehabilitation, 14, 117–134.

Chan

M. Y.

Haber

Drew

L. M.

Park

D. C.

(2014). Training older adults to use tablet computers: Does it enhance cognitive function? Gerontologist, 56(3), 475–484. DOI:10.1093.geront/gnu057

Holland

A.L.

(2014). iRehab: Incorporating iPads and other tablets in aphasia treatment. Seminars in Speech and Language, 35(1), 1–2.

Kiran

Des Roches

Balachandran

Ascenso

(2014). Development of an impairment-based individualized treatment workflow using an iPad-based software platform. Seminars in Speech & Language, 35(1), 38–50. DOI:10.1055/s-0033-1362995

Kong

A.P.H.

(2015). Conducting cognitive exercises for early dementia with the use of apps on iPads. Communication Disorders Quarterly, 36(2), 102–106. DOI: 10.1177/1525740114544026

Kong

A.P.H.

Law

S.P.

Yeung

C.C.L.

Lau

Tao

K.W.

Nan

(2016, December). A multiple-case study of the effectiveness of blended learning using CASTA for aphasia naming rehabilitation in Hong Kong. Poster presented at The 16th International Conference on the Processing of East Asian Languages (ICPEAL), Guangzhou, China

Leng

F.Y.

Yeo

George

Barr

(2014). Comparison of iPad applications with traditional activities using person-centred care approach: Impact on well-being for persons with dementia. Dementia, 13(2), 265–273.

Lopez-Samaniego

Garcia-Zapirain

Mendez-Zorrilla

(2014). Memory and accurate processing brain rehabilitation for the elderly: LEGO robot and iPad case study. Bio-Medical Materials and Engineering, 24, 3549–3556. DOI:10.3233/BME-141181

Szabo

Dittelman

(2014). Using mobile technology with individuals with aphasia: Native iPad features and everyday apps. Seminars in Speech and Language, 35(1), 5–16.

10.

Tartaglione

E. V.

Derleth

Ioannou

G. N.

(2014). Can computerized brain training games be used to identify early cognitive impairment in cirrhosis? American Journal of Gastroenterology, 109, 316–323. DOI:10/1038/ajg.2013.306