Technology-aided pictorial cues to support the performance of daily activities by persons with moderate Alzheimer's disease
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
References (55)
- et al.
“Mini-Mental State” a practical method for grading the cognitive state of patients for the clinician
Journal of Psychiatric Research
(1975) - et al.
Taylored activities to manage neuropsychiatric behaviors in persons with dementia and reduce caregiver burden: A randomized pilot study
American Journal of Geriatric Psychiatry
(2008) - et al.
Technology-aided verbal instructions to help persons with mild or moderate Alzheimer's disease perform daily activities
Research in Developmental Disabilities
(2010) - et al.
Persons with mild or moderate Alzheimer's disease use a basic orientation technology to travel to different rooms within a day center
Research in Developmental Disabilities
(2011) - et al.
Engagement in activities is associated with affective arousal in Alzheimer's caregivers: A preliminary examination of the temporal relations between activity and affect
Behavior Therapy
(2008) - et al.
Emotion and consciousness
Trends in Cognitive Sciences
(2007) - et al.
Diagnosis and treatment of depression in Alzheimer's disease: Impact on mood and cognition
Panminerva Medica
(2007) Language-enriched exercise plus socialization slows cognitive decline in Alzheimer's disease
American Journal of Alzheimer's Disease and Other Dementias
(2007)- et al.
The Hamilton Depression Rating Scale: Has the golden standard become a lead weight?
American Journal of Psychiatry
(2004) - et al.(2009)
A planning system based on Markov decision processes to guide people with dementia through activities of daily living
IEEE Transactions on Information Technology in Biomedicine
Social validation of evidence-based practices in autism by parents, teachers, and administrators
Journal of Autism and Developmental Disorders
Comparing video prompting to video modeling for teaching daily living skills to six adults with developmental disabilities
Education and Training in Developmental Disabilities
A comparison of static picture prompting and video prompting simulation strategies using group instructional procedures
Focus on Autism and Other Developmental Disabilities
Dressing of cognitively impaired nursing home residents: Description and analysis
Gerontologist
A palmtop computer-based intelligent aid for individuals with intellectual disabilities to increase independent decision making
Research and Practice for Persons with Severe Disabilities
Brief training to promote the use of less intrusive prompts by nursing assistants in a dementia care unit
Journal of Applied Behavior Analysis
Applications of preference assessment procedures in depression and agitation management in elders with dementia
Clinical Gerontologist: The Journal of Aging and Mental Health
Long-term cognitive treatment of Alzheimer's disease: A single case study
Neuropsychological Rehabilitation
A rehabilitation protocol for empowering spatial orientation in MCI: A pilot study
Annual Review of Cyber Therapy and Telemedicine
Orientation behaviors in residents relocated to a redesigned dementia care unit
American Journal of Alzheimer's Disease and Other Dementias
Environmental adaptations improve everyday action performance in Alzheimer's disease: Empirical support from performance-based assessment
Neuropsychology
Community occupational therapy for older patients with dementia and their care givers: Cost effectiveness study
British Medical Journal
The elements of statistical learning: Data mining, inference, and prediction
Cost, utilization, and policy of provision of assistive technology devices to veterans poststroke by Medicare and VA
Medical Care
Behavior modification in applied settings
Single case designs for educational research
Cited by (37)
A contextual model of care for persons with dementia
2020, Functional Analysis in Clinical Treatment, Second EditionPersons with Alzheimer's disease engage in leisure and mild physical activity with the support of technology-aided programs
2015, Research in Developmental DisabilitiesCitation Excerpt :In the early phases of the disease, the persons lose more complex functions such as managing time and finances and using communication means (e.g., telephone) (Campbell et al., 2012; Cotrell, Wild, & Bader, 2006; Marson et al., 2000; Perilli et al., 2012). Subsequently, they also become affected in their performance of basic daily activities, such as preparing food or listening to music (Lancioni et al., 2010, 2012, 2014; Martyr & Clare, 2012). Eventually, they may become very passive/detached with no real occupational engagement or communication (Buettner & Fitzsimmons, 2002; Colling, 2004; Lancioni, O’Reilly et al., 2013; McHugh, Gardstrom, Hiller, Brewer, & Diestelkamp, 2012).
Inborn and Acquired Brain and Physical Disabilities
2015, Clinical and Organizational Applications of Applied Behavior AnalysisA computer-aided program for helping patients with moderate Alzheimer's disease engage in verbal reminiscence
2014, Research in Developmental DisabilitiesCitation Excerpt :A variety of pharmacological and behavioral intervention strategies have been suggested as means to slow down their deterioration process, support their positive engagement, and improve their overall social appearance (Bharwani, Parikh, Lawhorne, VanVlymen, & Bharwani, 2012; De Vries, 2013; Ferrero-Arias et al., 2011; Kim, Yoo, Jung, Park, & Park, 2012; Schecker, Pirnay-Dummer, Schmidtke, Hentrich-Hesse, & Borchardt, 2013). Frequently recommended behavioral intervention strategies include, among others, (a) technology-aided programs for assisting with the performance of daily activities, (b) orientation programs with or without the use of technology for supporting independent indoor travels, (c) reality orientation therapy for helping the patients update and maintain functional knowledge of their personal details and of the reality around them (e.g., time and space), and (d) memory training for helping the patients retrieve information about daily activities and persons (and related names) in particular (Boller, Jennings, Dieudonné, Verny, & Ergis, 2013; Caffò et al., 2012, 2014; Cavallo et al., 2013; Giordano et al., 2010; Lancioni et al., 2010, 2012; Lancioni, Perilli et al., 2013; Lancioni, Singh, O’Reilly, Sigafoos, et al., 2013; Onder et al., 2005; Small, 2013; Spector, Woods, & Orrell, 2008). Another behavioral intervention strategy advocated for the same patients is the reminiscence therapy (Blake, 2013; Chiang et al., 2010; Karimi et al., 2010; Kim et al., 2006; Okumura, Tanimukai, & Asada, 2008; Serrani Azcurra, 2012; Wingbermuehle et al., 2014; Woods et al., 2012).
Persons with moderate Alzheimer's disease use simple technology aids to manage daily activities and leisure occupation
2014, Research in Developmental DisabilitiesCitation Excerpt :The photos adopted for the single activities could present variations across patients, depending on their experience and the material employed. The photos were shown on the computer screen for specific times (e.g., between 5 and 30 s), which were programmed by the research assistant, based on observations of the patients’ performance of the related steps (Cohen-Mansfield et al., 2006; Lancioni et al., 2012). In fact, longer exposure times were programmed for the photos/instructions concerning more laborious (time-demanding) steps, and vice versa.
Supporting daily activities and indoor travel of persons with moderate Alzheimer's disease through standard technology resources
2013, Research in Developmental DisabilitiesCitation Excerpt :Indeed, the two studies reported here exposed the patients only to the new resources and cannot provide any indication as to what performance they would have had with the old (sophisticated) technology. Second, even in the absence of direct comparisons, one might argue that the overall percentages of correct steps observed during the activity trials of Study I were largely similar to the percentages reported for the majority of the 35 cases involved in previous research (e.g., Lancioni, La Martire et al., 2009; Lancioni, Pinto et al., 2009; Lancioni et al., 2010, 2012). This evidence supports the view that the new pictorial instructions program might be as effective as the previous (more sophisticated) technology package for patients like those involved in Study I.