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Feature Article

Use of an Ambient Activity Technology for Long-Term Care Residents With Dementia

    Published Online:https://doi.org/10.3928/00989134-20211206-05

    Abstract

    The purpose of the current pilot study was to determine the impact of an ambient activity technology, ABBY®, on responsive behavior and family visiting in a long-term care (LTC) home. We were also interested in family and staff perceptions of the technology. A mixed methods research study was conducted over a 6-month period and data were collected using standardized measures and focus groups. Although no significant differences were noted in responsive resident behaviors, focus group data showed the ABBY enriched the care environment and provided additional opportunities for families and staff to engage residents. Although the introduction of a new technology can create challenges for staff, with time, these challenges can be overcome. [Journal of Gerontological Nursing, 48(1), 35–41.]

    Introduction

    The World Health Organization (2020) estimates there are 50 million people worldwide with dementia, with an additional 10 million new cases identified each year. In addition to cognitive decline, common manifestations of dementia include a gradual loss in abilities to perform activities of daily living and the presence of responsive behaviors. As the disease progresses, many people with dementia require admission to a long-term care (LTC) home (Alzheimer's Society of Canada, 2019). There are estimates that >60% of people living in LTC have some form of cognitive impairment, including dementia (Canadian Institute for Health Information, 2018). The importance of addressing quality of life for people who are living with dementia is reflected in Canada's first national strategy on dementia. This strategy includes attending to residents' psychosocial as well as health needs, and building capacity in LTC staff to provide holistic care (Public Health Agency of Canada, 2019). Evidence shows quality of life can be enhanced in LTC homes with environmental interventions and individualized approaches to care (Adlbrecht et al., 2021; Anderson et al., 2016; Beerens et al., 2013; Holopainen et al., 2019; Jing et al., 2016; O'Rouke et al., 2015).

    An important consideration for care and treatment in LTC is their effects on quality of life (Sawan et al., 2020). Despite the best efforts of staff, many factors negatively affect quality of life for those living with dementia in LTC, including staff behaviors, LTC culture, and staffing levels (Draper et al., 2000; Haunch et al., 2021; Judge et al., 2000). A common challenge in addressing quality of life in LTC is the responsive behaviors frequently associated with dementia (Haunch et al., 2021; Wilkinson et al., 2018). Responsive behaviors (i.e., behavioral and psychological symptoms of dementia) can include agitation, aggression, aberrant motor behavior, anxiety, irritability, depression, apathy, repetitive verbalizations, delusions, and hallucinations (Wilkinson et al. 2018). These responsive behaviors affect approximately one half of people living with dementia and can present significant challenges for those who provide dementia care (Haunch et al., 2021). Responsive behaviors are a critical contributor to caregiver burden because they can occur at any time and require staff to redirect their attention from other care activities. Responsive behaviors can also be distressing to other residents and family members (Draper et al., 2000). Boredom and lack of meaningful activities in LTC have been associated with increases in responsive behaviors (Haunch et al., 2021). In contrast, environments that provide meaningful activities that engage residents have been shown to alleviate responsive behaviors (Judge et al., 2000; Zadeh et al., 2018).

    There is evidence indicating that nonpharmacological therapies tailored to individual backgrounds, interests, and skills are effective in reducing responsive behaviors in people living with dementia (Marshall & Hutchinson, 2001; Menne et al., 2012). Self-determination theory posits that well-being may be attained through fulfillment of the psychological need for autonomy, competence, relatedness, and meaning in life, which ultimately leads to internally motivated action (Deci & Ryan, 2000; Hadden & Smith, 2019). Further evidence supports the notion that engaging individuals in activities that are meaningful to them facilitates well-being and quality of life (Eakman et al., 2010; Goodall et al., 2021; Mmako et al., 2020).

    Ambient activity technologies use information and communication technologies to enrich environments and promote engagement and social connectedness (Blackman et al., 2016). Ambient activities are those that are specifically designed to easily integrate into an existing environment in a non-intrusive manner and are easy to use for the target population. The ABBY®, developed by Ambient Activity Technologies (access http://www.ambientactivity.com/abby), uses technology to engage residents by embracing person-centered care principles and focusing on individuals' abilities and interests (Wilkinson et al., 2018). The ABBY (Figure 1) is a device with an interactive touch-screen monitor and sensors with familiar tactile and pleasurable experiences, such as petting a cat or visualizing personalized media content (e.g., personal photos, videos). Using Bluetooth technology, residents wearing a specialized beacon are presented with individualized music, videos, and activities when they approach the ABBY. This personalized content provides cognitive, physical, and emotional stimulation to engage residents' existing functioning and past interests (Wilkinson et al., 2018).

    Figure 1.
    Figure 1.

    The ABBY®.

    In the current study, an ABBY was mounted on the wall in highly visible and easily accessible locations in two units of one LTC home. Residents on the units could approach the ABBY at any time, either alone or with staff, family, or other residents. Staff and family were also encouraged to use the ABBY to help engage residents with their personalized content. We examined the impact of the ABBY on residents, family members, and staff. Specific research questions were: (1) Does the ABBY reduce responsive behaviors among residents with dementia?; (2) Does the ABBY enhance visitor satisfaction for family members by providing a means of engaging residents?; (3) Does the ABBY reduce staff strain and burden?; and (4) What impact does the ABBY have on residents, families, and staff?

    Method

    Study Design

    An exploratory descriptive mixed methods design was used to answer the research questions. This study was conducted in one LTC home in Atlantic Canada. An ABBY was mounted on the wall in two units of the LTC home throughout the entire study.

    Sample

    A convenience sample of residents, family members, and staff was used. All residents with cognitive impairment were eligible to participate. Family members of eligible residents were approached about the study and if interested, informed consent was obtained for themselves and their loved one. Family members were informed that their own participation was not contingent on the participation of their loved one; a family member could provide consent on behalf of their loved one without having to participate themselves, or vice versa. All full-time, part-time, and casual direct-care staff assigned to work on the study units, regardless of their position (e.g., RNs, care aides), were eligible to participate. A total of 35 residents, 11 family members, and 16 staff were enrolled in the study.

    Data Collection

    Standard data collection tools were administered at different points in the study.

    Measures. Three tools were used to answer the first research question of whether the ABBY reduces responsive behaviors: the Behaviour Pathology in Alzheimer's Disease Rating Scale (BEHAVE-AD) (Sclan et al., 1996), the Cohen-Mansfield Agitation Inventory–short version (Cohen-Mansfield et al., 1989), and staff time directed toward managing responsive behaviors. The BEHAVE-AD (Sclan et al., 1996) is a 25-item tool that is scored on a 4-point scale ranging from 0 to 3, with 3 being the most severe. The Cohen-Mansfield Agitation Inventory is a highly reliable and validated measure of agitation. This tool measures 14 items of agitated behavior on a scale of 1 to 7, with 1 indicating never and 7 indicating several times an hour (Cohen-Mansfield et al., 1989). Designed specifically for the current study, staff time directed toward managing disruptive behavior required staff to keep weekly diaries on time spent managing disruptive resident behaviors each day. These three tools were completed by staff at baseline, 3 months, and 6 months after the ABBY was introduced.

    Family members were asked questions about visit frequency, length of time, and if visits were worthwhile. These data were collected by a research assistant prior to baseline, 4 weeks after the ABBY was installed, and at completion of the study. The Strain in Dementia Care Scale (Edberg et al., 2015) was used to determine the impact of the ABBY on staff. The Strain in Dementia Care Scale collects data from staff on situations, feelings, or thoughts that arise when caring for people with dementia. The scale is a 27-item tool rated on a 4-point scale, with 1 indicating never and 4 indicating very often (measuring job strain in everyday situations). A research assistant met with all staff participants at baseline and completion of the study to obtain these data.

    The final research question about the impact of the ABBY was answered using focus groups and staff diaries. Separate focus groups were conducted with family and staff 1 month and 6 months after the introduction of the ABBY. These focus groups were conducted by a research assistant and recorded and exported into NVivo software. During focus groups, family members and staff were encouraged to discuss their perceptions of and experiences with the ABBY.

    Data Analysis

    Data from standardized measures were entered into Excel 2016 and later exported to SPSS 27 for analysis. General characteristics of participants were analyzed using descriptive statistics. Descriptive statistics and analysis of variance were conducted on measures to determine differences before and after use of the ABBY. Thematic analysis of focus group data was conducted in NVivo data analysis software.

    Ethical Considerations

    An information session was held with family members of residents with dementia on the study units. This session included a demonstration of the ABBY and an explanation of the study, including what participation would mean for themselves and their loved ones. Family members were informed that the ABBY would be available for all residents and family members irrespective of their enrollment in the study, and that data would only be collected on those who consent to participate in the study. A research assistant obtained proxy consent for residents and/or consent from the family member. The study was approved by the Research Ethics Board of the University of New Brunswick and the Loch Lomond Villa Nursing Home where the study took place.

    Results

    Of the 55 residents eligible to participate, consent was obtained from 45, and 10 died or became palliative during the study and were required to withdraw. The 35 residents who completed the study were predominantly female (n = 32, 91.4%) ranging in age from 64 to 101 years (mean = 85.3, SD = 8.5). Residents' mobility at baseline included independent with or without an assistive device (n = 19, 54.3%), assistance from others with or without an assistive device (n = 7, 20%), and dependent on others (n = 9, 25.7%). Mobility was relatively unchanged at completion of the study except for one participant who progressed from requiring assistance to becoming dependent. Participants' mean cognitive status, as measured by the Mini Mental State Examination (Folstein et al., 1975), was 9.2 (SD = 9.95) at baseline and 7.13 at completion of the study, representing a significant decline in cognitive status (p = 0.0028). Of the 11 family participants, most were children of a resident (n = 9, 81.8%), with one spouse and one niece (9.09% each). All family members ranged in age from 50 to >80 years and reported visiting their loved one an average of three times per week for 69.54 minutes each visit. Of the 16 staff participants, 25% (n = 4) were RNs, 31.3% (n = 5) were nursing assistants, 37.5% (n = 6) were unregulated resident attendants, and 6.3% (n = 1) were other.

    Prior to the introduction of the ABBY, almost none of the participants participated in recreational activities all of the time, 11.4% never participated, and 54% only participated when prompted by staff or family. In contrast, 6 months after the introduction of the ABBY, 20% always participated and only 6.67% relied on staff and family prompting, and 13.3% never participated. As measured by the Cohen-Mansfield Agitation Inventory (Cohen-Mansfield et al., 1989), an insignificant decrease in resident agitation (p = 0.7066) was noted, with a mean score of 1.83 at baseline and 1.68 at completion of the study.

    Prior to the introduction of the ABBY, almost all family participants rated visits with residents as worthwhile either very frequently or frequently (n = 10, 90%), and some families reported visits were more worthwhile after the ABBY was in place (Table 1).

    Table 1

    Table 1 Family Satisfaction With Visitation (%)

    Do you feel your visits are worthwhile for yourself?Baseline1 Month6 Months
    Very frequently72.7345.4560
    Frequently18.1845.4530
    Some of the time9.099.0910
    Infrequently000
    Not at all000

    A non-significant decrease in time staff spent managing disruptive resident behavior was reported. Staff reported an average of 25.96 minutes devoted to managing responsive behavior at baseline, which decreased to 16.93 minutes after 6 months (p = 0.75). No statistical difference was found in the Strain in Dementia Care Scale (Edberg et al., 2015) between baseline and completion of the study; average score at baseline was 56.6 (SD = 25.9), which slightly increased at 6 months to 57.4 (SD = 26.2) (p = 0.27).

    Qualitative Data

    A total of six focus groups were conducted with family members and staff. Eight family members and 14 staff participated in a focus group at the onset and completion of the study. Focus groups were recorded and later transcribed. Thematic analysis yielded two main themes, namely Challenges in Working With Technology and Facilitating Resident Engagement.

    Challenges in Working With Technology. Family members and staff identified a number of challenges with the ABBY. For staff, the ABBY introduced a number of challenges, including residents becoming upset if disturbed while using the ABBY, and spending too much time with the ABBY and not allowing other residents to interact with the device. Some residents also required staff assistance to interact with the ABBY, particularly those with limited dexterity and inability to push buttons or select activities. Initially, there were challenges with the resident beacons, including having to identify where to place beacons on residents, lost or misplaced beacons, and a need for day and evening staff to coordinate placement and removal of beacons from residents clothing and/or mobility aids. Although challenges associated with beacons persisted throughout the study, these were mostly resolved by the end of the study and posed little challenge for staff.

    Family members experienced challenges, including identifying personal content that was meaningful and relevant to their loved ones given their cognitive status and compromised memories. Some family members shared challenges experienced by loved ones in operating or engaging with the ABBY. Two family members identified the popularity of the ABBY as being problematic at times as it limited its availability. One family member reported their loved one preferred to spend time with visitors rather than interact with the ABBY:

    “You know, I've tried to engage mom with it while we are there, now even today going by after lunch I said, ‘Hey mom look at the cat, pet the cat,’ and she was not interested…”

    Facilitating Resident Engagement. Although family and staff identified challenges with the ABBY, they overwhelmingly supported its use and its ability to engage residents. Family and staff discussed ways the ABBY facilitated their engagement with residents. Family members cherished the times when a personal photo displayed on the ABBY triggered a memory or provided an opportunity to engage a loved one: “She recognizes some people. Of course some she doesn't, but to sit and talk with her, the memories, I think it's wonderful.” Family members also appreciated the ABBY's ability to share residents' personal information with others, providing staff and other family members a glimpse into residents' former lives. The ABBY's ability to share information was perceived by family members as a way for residents to reinforce their identity as individuals and not just as people with cognitive impairments.

    For staff, the display of personal information on the ABBY allowed them to learn new things about residents that they otherwise would not have known, providing opportunities to connect with them on a deeper level. One staff member stated: “It gives the resident the opportunity to introduce their family to us, then we're able to use that information as a reference to connect with them.” Staff also expressed unexpected situations where residents engaged with the ABBY. Several staff members shared stories of a participant who spent long periods of time playing an interactive game on the ABBY, then later learning that the resident was a heavy user of video lottery terminals when she was younger; this was information about the resident's past that staff were previously unaware. Another story involved a resident who kept mental notes of scores achieved in games that were displayed on the ABBY. Staff described the cognitive and motor benefits of residents' interactions, noting the cognitive efforts required to remember scores and the fine motor skills required to interact with the ABBY. The ABBY's capacity to play individualized music for residents was noted by staff as a particularly effective way to engage residents: “Our people do love music, it's a favorite thing and probably the most engaging thing that we can do with them.”

    Having the ABBY constantly available in an easily accessible location allowed staff to engage residents spontaneously, at any time of the day, even for brief periods of time. The ABBY was described by staff as a “conversation starter.” When engaged with the ABBY, staff could pause momentarily and comment on what a resident was viewing or doing. Similarly, staff recalled situations where several residents would conjugate around the ABBY and engage in meaningful interactions.

    Discussion

    Data obtained from this study overwhelmingly supported the ABBY, suggesting it is helpful in addressing needs related to resident engagement and distraction. Although improvements were noted in select indicators, except for cognition, none of the improvements noted were significant. The significant change noted in cognition was not unexpected given the progressive nature of dementia and the fact that the aim of the ABBY is to ultimately improve quality of life and not to alter the progression of dementia. Although insignificant, decreased responsive behavior and staff time devoted to managing responsive behavior is positive nonetheless. Staff time in LTC is a precious resource, with much of this time spent in 1- to 3-minute interactions with residents (Mallidou et al., 2013), suggesting even small differences in time managing responsive behaviors can be positive.

    The finding that resident participation in recreational activities improved is noteworthy given long-standing reports of residents spending much of their time alone and unengaged (Buettner & Fitzsimmons, 2003; Donovan et al., 2014; Hartmann et al., 2018; Neves et al., 2019). The advantage of the ABBY over many other activities that aim to engage residents is that when placed in a highly visible and easily accessible location, residents can independently approach and interact with the ABBY. This easy access is important because heavy workloads and competing demands can impede staff's ability to interact and engage with residents (Montayre & Montayre, 2017). Similarly, residents report not having enough things to do in LTC, which can be detrimental to their well-being and sense of purpose (Moyle et al., 2011; Paque et al., 2018). Even when homes offer a variety of structured activities, these are not always tailored to the abilities and interests of individual residents, nor are they always delivered at times that are convenient for staff or residents (Mitchell & Li, 2021). Leisure activities, such as the ABBY, can serve as nonpharmacological interventions to minimize or alleviate responsive behaviors and disengagement among LTC residents.

    No significant differences were noted in participant scores in the Cohen-Mansfield Agitation Inventory; however, based on earlier research on anxiety and depression in LTC, this finding was not entirely surprising. There is evidence that agitation and responsive behaviors are common and fluctuate among LTC residents (Chau et al., 2018; Legere et al., 2017). Although it is possible that the intervention influenced these findings, it is also possible that changes noted in our participants are comparable to residents who did not participate in the current study. Identifying changes in behavior and agitation of LTC residents in general was beyond the scope of this study. Future research should explore changes in behaviors over time, which could provide a benchmark in the pursuit of best practices for LTC.

    Attitudes expressed within focus groups demonstrated the potential that technology may have with resident engagement. Data indicated that despite having issues with technology, staff and family experiences with the ABBY were overwhelmingly positive. Family members discussed how the ABBY offered them a vehicle to interact and connect with their loved one on their dementia journey. The significance of this level of interaction cannot be overestimated. Björk et al. (2017) found that engagement in everyday activities can aid a resident's ability to thrive within LTC. By allowing residents and family members the opportunity to share stories, the ability of residents and families to adapt to life in LTC may be enhanced.

    Although beyond the scope of this study, it would be important to know which residents would benefit most from ambient technologies, such as the ABBY. The two units included in this study had comparable resident populations in terms of mobility, age, and care needs. Future studies should explore the level of cognition that yields the most benefit from the ABBY; when this intervention should be introduced; and if residents, family members, and staff interest in and engagement with the ABBY changes over time.

    As noted in this study, there are challenges associated with integrating the ABBY into the LTC setting that must be overcome. First, the placement of beacons must be individualized for each resident. In this study, beacons were placed on mobility aids for some residents, but for others they were fastened to clothing, and in some cases, to the backs of clothes where they could be hidden from residents. The placement, removal, and storage of beacons also require consideration. After consultation with staff, sign-in and sign-out sheets were created to monitor the use of beacons. In addition, a system for storing beacons was developed to ensure they could be easily located and that beacons assigned to each resident could be easily stored and retrieved. Although it is possible that residents would tire of the content and require periodic updating, this was not the case in our study. Changing content or adjusting the language used for individual residents could easily be done by staff with minimal training. Like other communal items in LTC, the need to regularly clean and disinfect the ABBY was critical. Finally, there were some incidences where beacons became lost or damaged and had to be replaced; fortunately, beacons are relatively inexpensive and extra beacons were always on hand.

    Limitations

    The current study has a number of limitations that must be considered when interpreting findings. The relatively small sample size and homogeneous population limits generalization of findings to other settings and groups, such as special dementia care units. This study was a pilot and took place over a relatively short time period. Future longitudinal studies should explore the impact of the ABBY with a particular focus on residents' long-term interest in their individualized content, ongoing attention of staff to managing beacons and updating content, and the feasibility of the ABBY for engaging residents who do not have a diagnosis of dementia. The LTC home where this study took place is an accredited person-centered care facility. The primacy given to resident engagement prior to this study may have limited the ability of the ABBY to make significant changes in study outcomes. Although family focus groups were conducted separately from staff focus groups to ensure they could answer and speak freely during the session, it is possible that family members' overwhelmingly positive reports on the ABBY were influenced by a desire to satisfy the LTC staff. Finally, family members in this study were predominantly children of residents, and it is possible that other family members, in particular spouses and siblings of residents, would have had different experiences with using a technological device, such as the ABBY.

    Conclusion

    Technological innovations are offering promising approaches to engage LTC residents. Our data show that although there are challenges in introducing new technologies in LTC, with time, these challenges can be easily addressed. Most of the measures used in this study to assess the effectiveness of the ABBY did not show any significant improvements; however, reports from family members and staff overwhelmingly supported the ABBY. This finding highlights the importance of exploring qualitative and quantitative measures when testing new interventions and the need to balance objective and subjective outcomes. This exploration of measures is particularly important in the complex and multifactorial context of individuals with dementia who are living in LTC. Our findings show that technologies, such as the ABBY, can play an important role in enriching care environments and engaging residents.

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