Elsevier

Research in Developmental Disabilities

Volume 33, Issue 1, January–February 2012, Pages 265-273
Research in Developmental Disabilities

Technology-aided pictorial cues to support the performance of daily activities by persons with moderate Alzheimer's disease

https://doi.org/10.1016/j.ridd.2011.09.017Get rights and content

Abstract

We developed a technology-aided intervention strategy relying on pictorial cues alone or in combination with verbal instructions and assessed these two versions of the strategy with three persons with moderate Alzheimer's disease. In Section I of the study, the strategy version with pictorial cues plus verbal instructions was compared with an existing technology-based strategy with verbal instructions. Each strategy was used with one specific activity. In Section II of the study, the strategy version with pictorial cues alone was compared with the aforementioned strategy with verbal instructions. Again, each strategy was used with one activity. Both strategy versions were effective with all three participants. The percentages of correct activity performance observed with those versions increased to above 90, and were comparable with those obtained with the existing verbal instructions strategy. A social validation assessment of the version with pictorial cues alone and the existing strategy with verbal instructions (employing university psychology students as raters) showed differences in favor of the latter strategy in terms of practicality and in favor of the former in terms of respect of participants’ dignity. The implications of the findings were discussed.

Highlights

► We assessed a technology-aided intervention strategy using pictorial cues or pictorial cues together with verbal instructions. ► The two versions of the aforementioned strategy were compared with an existing verbal instructions strategy. ► The participants were three persons with moderate Alzheimer's disease. ► Both versions of the new strategy produced positive effects matching those of the verbal instructions strategy.

Introduction

Alzheimer's disease and other forms of dementia are irreversible neurodegenerative conditions characterized by a progressive decline in memory and higher cognitive functions with a consequent deterioration of the person's social and occupational behavior (Arkin, 2007, Fernandez et al., 2006, Giovannetti et al., 2007, Gitlin et al., 2008, Graff et al., 2008, Raggi et al., 2007). The person may develop apathy, withdrawal, and depression and gradually lose the ability to perform daily living activities (i.e., self-help and occupational or domestic activities) (Appleby et al., 2007, Onor et al., 2007, Tsuno and Homma, 2009, Williams and Tappen, 2007, Williams and Tappen, 2008, Wood et al., 2009). The person may also show increasing signs of spatial disorientation with uncertainty and eventually failure in effective traveling within indoor contexts such as daily care centers and homes (Gibson et al., 2004, Lancioni et al., 2011, Marquardt and Schmieg, 2009, Provencher et al., 2008).

During the early phases of the disease, behavioral interventions might be useful to counter the main activity and orientation problems the person is facing and reduce the intensity and impact of those problems (Engelman et al., 2003, Gadler et al., 2009, Lancioni et al., 2008, Lancioni et al., 2011, Mihailidis et al., 2007, Wood et al., 2005). While no data are available to determine whether this intervention could interfere with (slow down) the progression of the disease, the resulting practical/functional improvement may have immediate and highly valuable benefits for the person and his or her social context (i.e., direct caregivers and staff). The person may become less apathetic, recover a sense of dignity and self-efficiency, and improve his or her mood (Boger et al., 2006, Giovannetti et al., 2007, Labelle and Mihailidis, 2006, Lancioni et al., 2009b, Mihailidis et al., 2007, Moore et al., 2007, Phinney et al., 2007, Vernooij-Dassen, 2007, Wood et al., 2005, Wood et al., 2009). Direct caregivers and staff may find the improvement a source of personal and professional motivation (reinforcement) strengthening their intervention efforts and their positive emotional involvement (Gitlin et al., 2008, Lancioni et al., 2008, Mausbach et al., 2008, Tsuchiya and Adolphs, 2007).

An intervention strategy, which has been recently adopted to help these persons recover daily activities, consists of the use of technology-based verbal instructions. In essence, the technology ensures that the person receives one verbal instruction at a time in relation to the single steps of the activities that he or she is to perform (Lancioni et al., 2008, Lancioni et al., 2009a, Lancioni et al., 2009b, Lancioni et al., 2009c, Lancioni et al., 2010). The activities targeted in the research studies included morning-bathroom routine, shaving, dressing, table setting, coffee and tea preparation, snack or salad preparation/sharing, and use of make-up. Data generally indicated performance improvement (i.e., high percentages of correct activity steps). Evidence was also reported of mood improvement (Lancioni et al., 2009b, Lancioni et al., 2009c).

The positive results obtained with the aforementioned strategy are very encouraging, but also suggest the desirability (need) of devising other strategies so as to have extra options that could fit different personal situations (i.e., different requirements). One of those alternative strategies might involve the use of pictorial cues (instructions) together with verbal instructions or in place of them. Obviously, the use of pictorial cues would require a new type of support technology as compared to the one previously employed with verbal instructions. This pilot study served to develop and assess a technology-aided intervention strategy involving pictorial cues alone or combined with verbal instructions. Both versions of this strategy were compared with the existing technology-based strategy with verbal instructions with three persons with moderate Alzheimer's disease. Also, a social validation assessment of the strategy with pictorial cues alone and the existing strategy with verbal instructions was carried out with university psychology students serving as raters.

Section snippets

Participants

The participants (Becky, Agnes, and Dawn) were 73, 77, and 79 years of age, respectively. All three of them were considered to function at a moderate level of Alzheimer's disease, with scores of 12–18 on the Mini-Mental State Examination (Folstein, Folstein, & McHugh, 1975). Two of them (i.e., Becky and Dawn) were diagnosed with mild depression, based on their scores of 15 and 10 on the Hamilton Depression Rating Scale (17-item version) (Bagby, Ryder, Schuller, & Marshall, 2004). At the time of

Results

The three graphs of Fig. 1 summarize the data of the three participants during Section I of the study. The empty circles and black squares represent mean percentages of correct steps over blocks of baseline and intervention trials for the activity assigned to pictorial cues plus verbal instructions and the activity assigned to verbal instructions, respectively. Blocks include five trials except when arrows are present. In those cases, they include two to four trials. During baseline, the

Discussion

The results of the two sections of the study indicate that the new technology-aided strategy with pictorial cues alone or combined with verbal instructions was effective with all three participants. The overall levels of correct activity performance observed with the two versions of the strategy were comparable with the levels obtained with the existing verbal instruction strategy, which served as a form of criterion procedure (Barlow et al., 2009, Kennedy, 2005). The results of the social

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