INTRODUCTION

Globally, the number of people living with dementia is rising, from an estimated 46.8 million in 2015 to a predicted 131.5 million by 2050 [1]. The majority of people live with dementia at home supported by family and friends [1]. As there are currently no disease-modifying therapies, people must live as well as possible with dementia through adaptation and adjustments to their daily lives. This requires accommodation for the progressive cognitive deterioration people experience and the concomitant behavioral challenges which arise. One common adjustment is to reduce participation in activities inside and outside the home, which has a negative impact on social interaction, leading to both people with dementia and family caregivers experiencing social isolation [2].

Stigma is a common reason for people with dementia and family caregivers to reduce their activities. For example, it is commonly assumed that people with dementia have a poor quality of life, do not want to engage with others, cannot experience pleasure, and have lost their personhood [3]. This creates an obstacle for people with dementia to maintain activities or adopt new ones. Recently, touchscreen technologies have been identified as potential sources of engagement and mastery for people with dementia, empowering them to learn new skills and participate in mainstream activities [4]. To achieve this requires appropriate introduction to the technology, training, and available support to maintain technology engagement. This project aimed to equip staff and volunteers in day programs for people with dementia to confidently use tablets and provide a supportive, social environment.

METHOD

This is a mixed methods study, with measurement at pre- and post-intervention. The independent variable was time (pre- and post-), and the dependent variables differed based on participant group (Table 1).

Table 1.  Independent and dependent variables by participant group

Participant Group	Variables
	Independent Variable	Dependent Variables
Clients	Time (pre- and post-)	1. Social connectedness 2. Quality of life
Staff and volunteers	Time (pre- and post-)	1. Stigma towards people with dementia

Participants

Client participants (n=44) and staff and volunteer participants (n=30) were recruited from five community-based adult day programs for people with dementia and other age-related challenges (Table 2).

Procedures

Upon obtaining informed consent, each client participant completed a demographic questionnaire and three standardized measures: the Montreal Cognitive Assessment (MoCA [5]; score/30, below 26 = cognitive impairment); the 10-item Social Provisions Scale (SPS-10 [6]; score/40, higher = more socially connected); and the Quality of Life in Alzheimer’s Disease scale (QoL-AD [7]; score [poor] 13-52 [good]). Similarly, each staff or volunteer participant completed a demographic questionnaire and the Dementia Attitudes Scale (DAS [8]; score/140, higher = more positive attitudes, Comfort and Knowledge subscales /70 each).

After completing the demographic and pre-test measures, all staff and volunteer participants took part in a one-hour training session, where they learnt how to operate the technology and support clients with dementia to use it. Each training session consisted of a brief presentation, followed by demonstrations of the tablets and games, and interactive discussions. Staff and volunteer participants were provided with tablet training manuals, which detailed basic tablet operation (e.g. how to turn on/off the device), game instructions (e.g. setup, how to play), assistive devices (e.g. stylus pens, tablet stands), and the ways in which people with dementia can be supported to play tablet games (e.g. demonstrating a correct move, providing encouragement).

Table 2.  Participant demographics

Demographic Variable	Client Participants (n=44)	Staff and Volunteer Participants (n=30)
Age (years)	Mean: 81.9 (Range: 56-98)	Mean: 46.33 (Range: 18-75)
Sex (M/F)	19M (43.2%), 25F (56.8%)	4M (13.3%), 26F (86.7%)
MoCA (out of 30)	Mean: 9.18 (Range: 1-22)	N/A
Previous tablet use	Yes: 19.5% No: 70.7% Unsure: 9.8%	N/A
# years’ experience working with people with dementia	N/A	Less than 1 year: 13.8%   1-5 years: 24.1%   6-10 years: 13.8%   More than 10 years: 48.3%

Once the training was complete, participants were asked to take part in the Let’s Connect program. Let’s Connect is a 4-week program which involves participants playing a series of pre-selected games presented on touchscreen tablets (Figure 1). All pre-selected games were assessed using an evidence-based framework for evaluating the accessibility of touchscreen games for people with dementia. Additional games were evaluated and added to the tablet program on an ongoing basis, to suit the evolving needs and preferences of client participants.

Hour long tablet sessions were held in a group setting at each day program twice per week for four weeks (8 sessions). Trained staff and volunteer participants facilitated each tablet session by providing client participants with assistance (e.g. reminders, demonstrations) to support their participation. At least one member of the research team was present during each session to provide additional support as required. During each session, clients were able to choose whether to engage in independent play (i.e. individually), shared play (i.e. play between two clients), co-play (i.e. supported play between a client and a staff member or volunteer), or a combination of one of more types of play.

Immediately after the 4-week intervention, all participants were asked to complete the post-test measures, as well as participate in an audio-recorded, post-study interview. For client participants, post-test measures included the SPS-10 and QoL-AD; whereas, staff and volunteer participants were only asked to complete the DAS.

Data Analysis

Data collected from all five day programs were amalgamated for analysis and reporting purposes. Demographic information was analyzed descriptively by reporting means, ranges, counts, and percentages pertaining to the study sample. The means, ranges, and standard deviations of all outcome measures were calculated to describe the primary outcomes. Paired t-tests were used to compare pre- and post-intervention scores to determine if there were any significant differences between the dependent variables (specific to each participant group; see Table 1). A one-way ANOVA test with post hoc analyses was also performed to analyze the staff and volunteer DAS total and subscale scores. These analyses were conducted via SPSS v24, using a p-value of <0.05 and a confidence interval of 95%.

Post-study interview responses were qualitatively analyzed using basic thematic analysis, which involves analyzing, examining, and recording patterns (or ‘themes’) within the data. Firstly, audio-recorded responses to post-study interviews were transcribed verbatim by members of the research team to ensure reliability, validity, and accuracy of qualitative data collection. Major themes and subthemes regarding barriers and facilitators to adopting touchscreen tablets in community-based settings were iteratively extracted from the transcripts through reading, re-reading, and grouping.

RESULTS

Client Results

Comparison of the people with dementia’s perceptions of social connectedness on the SPS-10 before the tablet program and after revealed no significant changes (t=-0.63, p=0.950; Table 3). Similarly, there was no significant change in the people with dementia’s assessment of their quality of life on the QoL-AD after the Let’s Connect program compared to when they started (t=-1.632, p=0.122; Table 3).

Table 3. Pre- and post-intervention scores for both participant groups

Measure	Clients (n=44)		Staff and Volunteers (n=30)
	Pre- intervention mean (SD)	Post- intervention mean (SD)	Pre- intervention mean (SD)	Post- intervention mean (SD)
SPS-10/40	34.389 (5.59)	34.44 (4.5)	-	-
QoL-AD: 13-52	38.65 (3.46)	40.59 (5.81)	-	-
DAS/140	-	-	127.48 (6.27)	129.65 (5.63)
DAS Comfort	-	-	61.48 (4.4)	63.74 (3.89)
DAS Knowledge	-	-	66.0 (3.19)	65.91 (4.23)

Thematic analysis of the post-study interview transcripts revealed six key themes that described clients’ experiences while participating in the tablet program (Table 3).

Table 3.  Client post-study interview themes

Theme	Client sample quotation
Social Interactions	“Well, it gave something for us to do together.” (1001-011-002-CCCL)
Enjoyment	“…it was lots of fun learning it and I enjoyed it so much I went out and bought an iPad. So you can tell I really enjoyed it.” (1007-011-002-CCAP)
Facilitator Assistance	“…I didn’t have any experience what to do, but someone was always there. I enjoy the assistance… it’s encouraging.” (1010-011-002-HILE)
Learning	“I felt I was learning and doing things.” (1005-011-002-ASDR)
Novelty	“For the first time I was experiencing a new thing.” (1010-011-002-HILE)
Stimulation	“Keeps your mind working, gives you something to think about.” (1003-011-002-HILE)

Staff and Volunteer Results

Comparison of the staff and volunteer total DAS total scores after the intervention compared to baseline revealed a significant difference in their attitudes towards people with dementia (F=4.935, p=0.037; Table 3). Posthoc analysis of the two subscales (Knowledge and Comfort; [8]) revealed a significant improvement in the Comfort subscale (t=-3.048, p=0.006; Table 3) but not on the Knowledge subscale (t=0.117, p>0.05; Table 3).

Thematic analysis of the post-study interview transcripts revealed six key themes that described staff and volunteer perceptions of the tablet program, such as benefits and challenges experienced (Table 4).

DISCUSSION

The results confirm the potential for training staff and volunteers to support people with dementia to engage with tablet technology. This sample of people living with mild to substantial cognitive impairment, as indicated by their MoCA scores, engaged with the Let’s Connect group activity, completed formal measures, and post-intervention interviews. The themes from their interviews highlight the benefits to them of learning a new activity, the mental stimulation provided, and the importance of novelty and the enjoyment derived from the activity. The finding that there was no significant change on the quality of life and social connectedness scales may reflect that clients who attend adult day programs are not socially isolated. Although there was no significant different on these formal measures, the interviews revealed that people found the social aspect of learning and playing together a big benefit. The use of tablets in a group setting provides multiple opportunities for meeting different individual’s needs for solo play or partnered play, which may reflect participant’s level of cognitive impairment. This suggests that Let’s Connect could provide social interaction for people who are more socially isolated, such as those receiving home care. The importance of support and assistance was also highlighted by the client participants, particularly as the majority of people with dementia had no prior experience of tablets.

Table 4.  Staff and volunteer post-study interview themes

Theme	Subtheme	Staff & volunteer sample quotation
Benefits	Client enjoyment	“Because it engages them, it gives them something to do... and it gave them a sense of achievement.” (6002-011-002-HILE)
	Debunking stigma	“I learned that people with dementia are probably able to do more than I thought they could.” (5003-011-022-CCAP)
	Social interactions	“I think you get to know them and get to know their interests and what they like, and you just build relationships, through playing the tablet.” (5001-011-002-ASDR)
Challenges	Ongoing support	“There were a couple of clients who weren’t picking up on the game as well. That was a little more difficult, trying to teach them how to do it.” (6006-011-002-HILE)
	Client disinterest	“We still had a couple that just did not want anything to do with it.” (6002-011-002-CCCL)
	Technical issues	“I did find a few clients who on accident would turn off the tablet altogether despite getting it all set up for them.” (6001-011-002-HILE)

In addition to the benefits for people with dementia we also found a positive impact on the staff and volunteer participants. There was a significant improvement on the Comfort subscale of the DAS, indicating that they felt more at ease in their interactions with people with dementia as a result of the tablet program, even though the majority had several years prior experience. There was no increase in the Knowledge subscale but this was already quite high at baseline. As with the clients, the staff and volunteer participants also highlighted the importance of the social interaction provided by the group activity as well as the opportunity tablet games provide for people with dementia for achievement and mastery. The staff and volunteers also highlighted the importance of appropriate and responsive support to teach and then empower them to continue. Additionally, and importantly for overcoming the barriers to participation faced by people with dementia, participation in the Let’s Connect program appeared to tackle stigma by challenging the low expectations of their abilities held by other people, an ongoing major problem for this population [3].