Interactive Games as a Rehabilitation Tool for Elderly with Dementia: A Pilot Study


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Interactive Games as a Rehabilitation Tool for Elderly with Dementia: A Pilot Study

Nanyang Polytechnic

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  • Greetings
  • This is the Outliine of the presentation for today.Firstly, I will be bringing to you the introduction of the project, description of our participants and outcome measure and our ex proceduresNext, my team member zhirong ,will be coming in to present to you, our results findings, discussion, clinical implication of our project, our study limitation s, sharing with you our suggested recommnedationsfor future studies and ending off with our conclusion.
  • 1.Now, let me first give everyone a clear idea of what our project is all about. This, is the objective of our project.2.We investigated the effects of Wii Bowling on Selective attention, Simple Reaction Time and Quality of Life in a group of elderly with dementia from a day care centre in singapore.3.Now ,lets us move on ,as I will be presenting you more on the background of our study , how we have actually derived the need for this study to be done.
  • 1.Firstly, advancing age itself is a risk factor for dementia. Singapore is facing an aging population( click) and it has been reported that the prevalence of Dementia cases will be on the rise,from 22 per 1000 people in 2005 to 52.5 per 1000 in 2020 and 186.9 per 1000 in 2050. These figures are indeed alarmingisnt it. Although we are aware that Dementia cannot be prevented orcured, it is still possible find ways to slow down the progression of dementia at its early stages.(click) Thus we start to think of what we can do as physiotherapist for dementia patient in terms of rehabilitation 2. Next, we begin our quest by looking at what the current society can offer us ,and the increasing number of patients. (click) and we found out that with the advanced technology now, technology transfer into rehabilitation is one area with huge potential to explore into, This means Rehabilitation technology may be an useful tool to us.3.(click) Virtual Reality (VR) is one area of technology that has penetrated into physiotherapy rehabilitation for various groups of patients ranging from children w CP to healthy elderly. There are also studies that show that some forms of VR has beneffited the elderly w dementia.4.However, (click) despite the existence of these studies it has not been reported that they are widely used on Asian population and more importantly, in Singapore yet. 5. (click)With the above in mind, it formulated the initial stage of our study, to find out if any form of Virtual reality can helps to slow down the progression of dementia at its early stages, among patients from our very own population in Singapore.
  • Next,we need to know what are the domains that are affected at the early stages of Dementia(click) so that we can see if Wii will have an effect on these domains. The list is not exclusive ,we have chosen to focus on 3 domains ,selective attention (click), simple reaction time(click) and QOL (click) Why selective attention (click)? This is because studies have shown that impairment in attention correlates to the functional abilities of Dementia patient,andalso,attention is much needed to encode any memories,this could potentially mean that in order for memory dysfunction to take place, attention has to be first affected. And why selective attention here specifically? This is because in all types of attention, selective attention has been shown the first deficit to occur in Dementia patientsNext ,SRT. Reaction time itself is a hallmark and early sign of Dementia.(click) Reaction time consists of a sensory motor input part which is measured by (Click) Simple reaction time and a decision-making component measured by choice reaction time. Simple Reaction time is chosen here as its been shown that decision making component is affected only at the later stages of dementia.Lastly QOL, (click). existing clinical researches have also established the importance of assessing QOL in populations with Dementia ,We feel that As physiotherapist, psychosocial aspects of patients are just as important as their physical aspects. ( Quality of Life (QOL) will be an useful aspect (click) to consider when looking at efficacy of treatment approach for patients.
  • Now I’m moving on to the next part of background .Why Wii among the many other VR rehab tools?To this question we have these 3 reasons as you can see from the above.First (click) Among the VR rehabilitation tools, Wii Gaming has been the most popular and Wii bowling being the most welcomed among elderlyFurthermore, (click) Wii has its existing efficacy, in a recent study, Wii has shown to improve motor functions, compliance in therapy and social interaction in older adults.And it has also been shown to have improved motor recovery for the stroke patients. So it occurs to us since it has been shown to help older adults and also stroke patients , why not dementia patient.Thirdly,(click) Wii is a convenient tool, it is affordable for most household here and easy to operate, it can even be played with others such as family members thus it can conveniently be part of rehabilitation at home. Therefore, we hypothesized(click) that Wii can be a potential treatment tool for our dementia patients
  • This is the Outliine of the presentation for today.Firstly, I will be bringing to you the introduction of the project, description of our participants and outcome measure and our ex proceduresNext, my team member zhirong ,will be coming in to present to you, our results findings, discussion, clinical implication of our project, our study limitation s, sharing with you our suggested recommnedationsfor future studies and ending off with our conclusion.
  • The following table sums up the information of our subjects in terms of AgeGenderMini mental state examination scoreBarthel IndexGrip strengthSubjects were relatively homogenous except in terms of gender and grip strength
  • Next for our outcome measures, We had chosen 3 highly reliable, valid and specific tools to measure our 3 variablesThey are:1.TEA specifically its Map search and Telephone search tests for selective attention 2.Online SRTT ,a simple to use tool for measuring srt3. QOL-AD , the english and also the chinese versions, a QOL questionaire which measures the qol of dementia pt specifically
  • Insert ah guan photo on bottom right hand side
  • NEXT, let me bring you through our study protocol1.(click) 20 subjects from New Horizon Centre, a day care centre for dementia patients, were recruited .2. (click) They were then screened for inclusion and exclusion criterias which includes (click) the ability to understand simple instructions, minimum grip strength to hold the wii controller and w/o any acute conditions that will hinder safety or prevent physical activity.3 (click) After these ,(click) 6 were excluded 4. (click) the rest were allocated to experimental group and control group acc to the subjects’ preference5.(click)The participants in the experimental group underwent 4 weeks of interventions6.(click) 2 subjects were excluded in the process, 1 was unable to complete all the wii bowling sessions Another subject was absent on the post-baseline.7.(click) So for post-baseline, the results of 6 participants in each group respectively were analysed
  • In week 1, pre-baseline outcome measures were taken and prior to that informed consent was obtained. 1 session was also conducted to intro Wii bowling to the elderly 2 weeks before the actual intervention. The intervention was started on week 2 to 5, participants played wii bowling in addition to daily daycare centre activities, consisting of 4 once a week sessions, 2 games of Wii bowling game lasting for approx half an hr each session. The participant followed a standardized 4 steps instructions to play the game and each session were facilitated by the physio student volunteers frmnyp.Participants played the game either in standing or sitting positionsPlayed individually or with another participantGame score and timing were recorded downProgression is by an improvement of 10% of previous game score. To prevent ceiling effect if any participant hit the maximum score, the particular subject has to aim to improve the time taken to complete each game by 10% the next session. the facilitator also play the role to ensure that subjects are haemodynamically stable before and after every gameStandardized equipments Television setWii-controllerFollowed a standardized 4-step instructions
  • Thank you Jie Ying. I would like to continue with the results, discussion, clinical implications for phyisotherapists, recommendations and end off with a conclusion. To calculate the results for our study, we used the Mann-Whitney U test as our data is non-parametric. We used this test to formulate the p-values to see if there is any significant difference.
  • For our 3 outcome measures, they all have p values that are more than 0.05. However if we look into the different sub-components for QOL-AD questionnaire, we can see that for QOL-AD Participants, the 2 subcomponents of Family and Self as a whole has p values of 0.021 and 0.045 respectively. On the other hand, for QOL-AD caregiver questionnaire, the subcomponent of Friends has a significant difference with a p value of 0.042. This implies that even though Wii was not able to change the quality of life for elderly with dementia as a totality, but in different subcomponents, Wii does have an effect.
  • Even though the p-values did not show any significant difference, by looking at the raw data, we can still see an overall significant percentage improvement for all of the 3 outcome measures in the intervention group. This goes to show that the elderly in our intervention group who played Wii bowling did show an improvement in regards to their pre and post baseline measurement of selective attention, simple reaction time and quality of life.
  • Next , we will move on to discussion. We can see an overall percentageimprovement for QOL-AD in the 2 questionnaires. For the intervention group, both participants and the caregivers of the elderly find that their Quality of Life improved after playing Wii. However for the control group, participants rate themselves as being worse off while caregivers find that the elderly with dementia remain the same for their Quality of Life.As seen above, we note that there is a significant difference in the 3 subcomponents of QOL-AD, namely, Family, Self as a whole for QOL-AD (participants) and Friends in QOL-AD (Caregiver). Possible reasons why there could be a significant change in the Family aspect for QOL-AD (Participant) questionnaire is that the elderly would have more topics to talk to their family about, hence improving their social and communication skills. Our results is consistent with a study done by Jung et al., 2010 which states that Wii improves the social well-being aspect for elderly. For significant changes in subcomponent of self as a whole by the participant, possible factors could be the elderly getting better mood while playing Wii, being more confident of handling technologies, thus having a better feeling of themselves. This is also consisent with a study done on dementia patients with a virtual reality baby doll by Yonemitsu et al., 2001In the subcomponent of friends done by caregivers for the QOL-AD questionnaire, one of the possible reasons could be because the elderly would strategize with each other regarding how to achieve better scores. This would then increase their interaction time and improve relationships between each other. This result also shows consistency with Jung et al., 2010.
  • Next, for selective attention, there is an improvement in the intervention group. Our results also concur with other studies that use video games for college students. That study showed that selective attention improves after playing video games. By looking at the descriptive statistics, there is also an improvement for the control group in terms of selective attention using map search. This can be explained as the control group only had 1 participant who was able to complete the map search test. Thus, results may not truly represent the entire control group. In addition, studies have shown that there is a positive co-relation between Simple reaction time and selective attention. Hence if there is an increase in selective attention, there should be an increase in simple reaction time. Our results showed consistency with other studies even though it only showed an improvement of 0.15% for the intervention group.
  • Some of the clinical implications that physiotherapists could get from this study is that, interactive games can be incorporated into conventional physiotherapy programme for elderly with dementia. They could also act like an additional option of tools, for elderly who prefer a more challenging and interactive rehabilitation program. This could also help promote social interactions between therapists and patients, thus resulting in a more compliant patient.
  • This is to highlight that this is a very novel study that has used Wii as a rehabilitation tool for elderly with dementia, therefore with these results, it justifies the need of future studies in this line. Hence, we would like to propose future studies on doing a replication of our study with a larger sample size. In addition, studies should also be done to investigate the long term effects of Wii-bowling.Also, the intervention time for each participant should be consistent such that if they were to have their intervention in the morning for the first week, they should continue doing the same for the rest of the weeks. This would reduce any unwanted implications such as sundown’s syndrome. Future studies can also look into different interactive games that could mimic functional activities for participants.
  • In conclusion, we would like to summarise our findings. Firstly, improvements were shown for the elderly in the intervention group. They had Wii-bowling in addition to their normal routine for 4 weeks. Next, there is also a significant difference for Family and Self as a whole in QOL-AD (Participant) Questionnaire and Friends in QOL-AD (Caregiver) questionnaire.
  • In addition, Wii bowling has its benefits for the elderly. It would be to allow them to have a better mood, more social interaction with each other, more receptive to latest technology and feel less lonely.
  • Last but not the least, Wii caused no harm to the elderly. Instead it brought a smile to their faces! Hence this goes to show that we should incorporate interactive games into the usual rehabilitation programs.
  • We would like to say a big thank you to the following people who have rendered help to us through this course of study. We have now come to an end of our presentation. Thank you!
  • Interactive Games as a Rehabilitation Tool for Elderly with Dementia: A Pilot Study

    1. 1. Interactive Games as a Rehabilitation Tool for Elderly with Dementia: A Pilot StudyLim Jie Ying 085586FAng Xue Yi Zoe 085813UAnna Teo Mei Lun 085598LMuhammad Hasbullah Bin Yusoff 086426LYee Zhi Rong 085601X
    2. 2. CONTENT•Introduction •Results•Methods •Discussion •Conclusion
    3. 3. INTRODUCTION - Objective To investigate the effects of Wii Bowling on Selective Attention, Simple Reaction time and Quality of Life in elderly with dementia
    4. 4. INTRODUCTION - Background Technology transfer: Rise of interactive Aging games for rehab Insufficientpopulation (Goldman,R.J., 2003) evidence of ↑Dementia interactive games incidences on Dementia (MOH, 2007) population Well-being of dementia patients
    5. 5. INTRODUCTION - Background Early stages of DementiaSelective Simple Quality ofAttention Reaction Life (Bolata and Faust., Time (Wierenga & Bondi, 2007)2001; Perry, Watson (Gorus et al., 2008; & Hodges., 2000) Alzheimer’s Association.,2010)
    6. 6. INTRODUCTION - Background Interactive Games - Wii Existing Popularity efficacy Convenience (Sugarman et al., (Shubert,2010; 2009) (Saposnik et al.,2010) Saposnik et al., 2010)
    7. 7. CONTENT•Introduction •Results•Methods •Discussion •Conclusion
    8. 8. PARTICIPANTSCharacteristics Intervention Group Control GroupAge (y) 75.7 ± 10.5 78.2 ± 5.5Male/Female (n) 3/3 0/6MMSE Score 20.2 ± 5.1 /30 17.2 ± 6.3 /30Barthel Index 98.3 ± 4.1 /100 95.0 ± 8.7 /100Grip Dynamometer 20.3 ± 5.3 11.4 ± 4.9Strength
    9. 9. OUTCOME MEASURES Test of Online Quality Everyday Simple of Life - Attention Reaction AD (TEA) Time Test
    10. 10. High test-retest reliabilitycorrelation coefficients of 0.61to 0.9 (Robertson et al.,1994)
    11. 11. Test-retest reliabilitycorrelation coefficientof 0.627
    12. 12. English form: High test-retest reliability correlation coefficient of 0.76 (participant) and 0.92 (caregiver) (Logsdon et al., 2002)Chinese form:Test-retest reliability ICC of 0.7(participant) and 0.8 (caregiver) (Yapet al., 2007)
    13. 13. STUDY PROCEDURES Subjects recruited - Early Dementia Program (n=20) - Able to understand simple instructions Inclusion Excluded (n=6) and - Normal grip strength (Methiowetz et al., 1985) exclusion criteria met Experimental Control (n=8) (n=6) Excluded (n=2) 4 weeks of intervention Post baseline Post baseline (n=6) (n=6)
    14. 14. STUDY PROCEDURES • Informed consent Week 1 • Pre-baseline outcome measures Intervention Group Control Group • Wii bowling + day care • Day care activities activitiesWeeks 3 -6 • 2 games per session • Post-baseline outcome measures Week 7
    16. 16. CONTENT•Introduction •Results•Methods •Discussion •Conclusion
    17. 17. RESULTSOutcome Measures P-Values Z-ValuesSelective Map Search 0.897 -0.130Attention Telephone 0.402 -0.839Simple Reaction Time 0.347 -0.940Quality of Life Participant 0.751 -0.317 • Family 0.021- AD • Self as a whole 0.045 Caregiver 0.248 -1.156 • Friends 0.042
    18. 18. RESULTSOutcome Measures Intervention Group Control Group (%) (%)Selective Map (+) 5.22 (+) 40.00Attention Telephone (+) 38.19 (-) 41.12Simple Reaction Time (+) 0.15 (-) 11.54Quality of Life Participant (+) 15.89 (-) 2.27 Caregiver (+) 6.80 0.00 (+): Improvement (-): Deterioration
    19. 19. CONTENT•Introduction •Results•Methods •Discussion •Conclusion
    20. 20. RESULTS
    21. 21. DISCUSSION• QOL-AD (Participants) ▫ “Family”  Improve relationships (Jung et al., 2010) ▫ “Self as a whole”  Better mood while playing (Yonemitsu et al., 2001)• QOL-AD (Caregiver) ▫ “Friends”  Promotes social interaction (Jung et al., 2010)
    22. 22. DISCUSSION• Selective Attention ▫ Improvement in the intervention group ▫ Consistent with studies (Green C.S. and Bavelier D, 2003)
    23. 23. RESULTS
    24. 24. DISCUSSION• Simple Reaction Time ▫ Positive co-relation between SRT and selective attention (Salthouse, 1996; Salthouse, 2000; Verhaeghen & De Meersman, 1998)
    25. 25. RESULTS
    26. 26. CLINICAL IMPLICATIONS• Consider incorporating interactive games into rehabilitation programs• An additional option of tools• Promote social interactions between therapist and patients
    27. 27. RECOMMENDATIONS • Replication • Long term effects • Consistent intervention time for each participant • Interactive games that mimic functional activities
    28. 28. CONTENT•Introduction •Results•Methods •Discussion •Conclusion
    29. 29. CONCLUSION• Improvements were shown for intervention group• Significant differences shown for: ▫ QOL-AD (Participants)  Family  Self as a whole ▫ QOL-AD (Caregiver) • Friends
    30. 30. CONCLUSION• Benefits of Wii Bowling ▫ Better mood ▫ More social interaction ▫ More receptive to technology ▫ Less lonely
    31. 31. Wii Bowling = NO Harm
    32. 32. Special Thanks To:1. All the staffs and participants at New Horizon Centre2. Dr. Bala S Rajaratnam- SHS Project Manager3. Ms. Bernadine Teng- FYP Coordinator- SHS Physiotherapy Lecturer4. Ms. Chia Choon Yee- SHS Lecturer5. Mr. Patrick Tan- SHS Technical Support Officer6. Dr Phillip Yap- Khoo Teck Puat Hospital7. All Physiotherapy Student Volunteers