computer-supported personal interventions for elderly

Computer-Supported Personal Interventions for Elderly

People with Cognitive Impairment and Dementia

Thesis submitted in partial fulfillment

of the requirements for the degree of

“DOCTOR OF PHILOSOPHY”

by

Vardit Sarne-Fleischmann

Submitted to the Senate of Ben-Gurion University

of the Negev

Approved by the advisors

Approved by the Dean of the Kreitman School of Advanced Graduate Studies

September 2013

Beer-Sheva

2

This work was performed under the supervision of Prof. Noam Tractinsky and

Prof.Tzvi Dwolatzky.

In the Department: Industrial Engineering and Management

Faculty: Engineering

3

Research-Student's Affidavit when Submitting the Doctoral Thesis for

Judgment

I, VarditSarne-Fleischmann, whose signature appears below, hereby declare that

(Please mark the appropriate statements):

× I have written this Thesis by myself, except for the help and guidance offered by my

Thesis Advisors.

___ The scientific materials included in this Thesis are products of my own research,

culled from the period during which I was a research student.

___ This Thesis incorporates research materials produced in cooperation with others,

excluding the technical help commonly received during experimental work. Therefore, I

am attaching another affidavit stating the contributions made by myself and the other

participants in this research, which has been approved by them and submitted with their

approval.

Date: _________________ Student's name: ________________

Signature:______________

4

Acknowledgements

This dissertation could not have been initiated, conducted and completed without the

invaluable guidance, inspiration, and support of my wonderful advisors, Prof. Noam

Tractinsky and Prof. Tzvi Dwolatzky.

Prof. Noam Tractinsky has accompanied me from my first step as a researcher. I was

privileged to work with him, and to gain from his vast knowledge in the area of Human-

Computer Interaction and from his intelligent way of thinking. I deeply appreciate his

willingness to engage in this research, which combines the fields of computing as well

as the needs of older people with dementia. Incessantly, Noam was a role model for me

of a highly reliable, creative and systematic researcher, and most importantly, he was

extremely patient, supportive, and empathic for my needs in this highly demanding and

meaningful period of my life.

Prof. Tzvi Dwolatzky has introduced me to the fascinating world of clinical research,

and gerontology. Throughout our joint way I was deeply impressed by his professional

knowledge and skills as a physician as well as a researcher, and for most by his

humanistic approach towards his patients and colleagues. I appreciate his extremely

motivated and hopeful desire to help patients combat their illness.

I would also like to thank Prof. Arnold Rosin for his engagement in this study. I was

privileged to meet a wonderful person, who inspired me with his rich experience,

enthusiasm and his warm approach and kindness.

Many thanks to Inbal Rief and Studio 97, for developing the reminiscence system. I

would also like to thank Yehudith and Elimelech Lange who developed the Savion

software and provided new versions for this study.

There are many people who helped me conducting this study. I would like to thank

Moran Korem, Terry Hendin, Irit Levy, and the staff of the Memory Clinic in Beer-

Sheeva (Iris Weider, YuliaLipkin, Elad Robin, and Diana Sokolov), who helped in

conducting the evaluations of patients and family members. I would also like to thank

Yafit Fisher, Nelly Fein, Ariel Rosin and the many volunteers who devotedly worked

5

with the patients (Wendy Bocarsky , Sharon Finkel, Michael Kuttner, Mary Jo Elman,

Linda, Esther Puld, and Reuven Gruber).

My grateful thanks are also extended to Prof. Jonathan Rabinowitz for his valuable

guidance in the data analysis.

I would like to express my very great appreciation to the management and staff of the

day care centers where the study was performed, among them are: Moti Zelikowitz,

Marsha Donshik, Marta Milsztein, Ayelet Fisher, Heni Sher, Suzi Martziano, Yelena

Babayev, Klaudia Konson, Hadas Helbershtat, Dafna Green, Ifah Arbel and Shulamit.

My gratitude to Mandy Haner and Sergey Korotchenko who provided outstanding

technical support, to Itamar Doniger from Neurotrax for his help and advice, to Shimon

Amit (Neurotrax) for Mindstreams' technical support, and to Hadas Tractinsky for her

help in the long process of data entry.

I would also like to thank the patients who participated in this study and their family

members.

Lastly and most importantly, I wish to thank my wonderful family who has been my

source of strength and encouragement throughout my life: my parents Haya and

Yishayahu, my brothers David and Oz, my husband Moshe, and my daughters Noga

and Naama.

This study was supported (in part) by grant no.3-00000-9334from the Chief

Scientist Office of the Ministry of Health, Israel, and by the Israeli Ministry of Science

and Technology. I would also like to thank Mr. David (Dede) Goldschmidt from Valley

Venture Capital, for his generous donation in support of this research.

6

Dedication

I would like to dedicate this dissertation to my dearest family for their endless love,

support, and encouragement.

7

Abstract

Dementia is formally described as "a clinical syndrome of cognitive decline that is

sufficiently severe to interfere with social or occupational functioning" (Chertkow,

Feldman, Jacova & Massoud, 2013, p.2). In addition to the cognitive consequences of

dementia, people with dementia frequently experience a wide range of neuropsychiatric

symptoms.

Alzheimer's disease (AD) is the most common cause of dementia, representing

approximately two-thirds of those suffering from this syndrome. Currently there is no

cure for AD or for most of the diseases causing the dementia syndrome.

Pharmacological interventions have limited efficacy and are, at best, symptomatic.

Important for the management of patients with dementia are psychosocial and lifestyle

interventions, which aim primarily to relieve cognitive and behavioral symptoms, to

promote well-being and to provide caregiver support.

Two forms of non-pharmacological therapeutic intervention currently offered to patients

with dementia are reminiscence therapy and cognitive training. Studies have evaluated

the effects of these therapies and have suggested that they may improve cognitive

function in patients with dementia and in adults at risk of developing dementia.

However, due to methodological limitations, few controlled studies and the lack of

sensitive assessment tools, there is still no clear evidence for significant benefits of

these interventions.

Increasingly, computerized systems are being designed for the treatment of patients with

dementia, including web sites for providing information, computerized tools for

monitoring, assistive technology and computer systems offering emotion-oriented

treatments in dementia care.

The study that we performed evaluated two computer-supported interventions for

patients with dementia, namely personalized computerized reminiscence therapy and

computerized cognitive training. The personalized reminiscence system was developed

specifically for the purpose of this study to enable independent use and administration

for both patients and caregivers. The cognitive training system involved the use of a

commercial software for memory enhancement for people with Alzheimer's disease,

dementia and other causes of cognitive decline. In both interventions subjects with

dementia were compared to a control group. The comparison utilized Mindstreams

8

(NeuroTrax Corp., NJ),an innovative computerized neuropsychological tool for

assessing patients' cognitive function. In addition, the effects of the interventions on

family members were evaluated.

A total of 167older subjects with cognitive impairment or dementia, residing in the

community, were recruited for the study. All underwent a preliminary assessment to

determine their cognitive status. Following initial screening 95 suitable subjects were

randomly assigned to one of the following 3 groups: (1) Personal computer-based

reminiscence therapy; (2) Computer-based cognitive training; and (3) Control group.

Both those participants receiving reminiscence therapy as well as those using the

cognitive training program participated in 2 sessions a week, each of 30-minutes

duration, supervised by a mediator, for a period of 3 months. Assessments were

performed at baseline, at one month and at 3 months, and included an evaluation of

cognitive function using the Mindstreams computerized testing battery (NeuroTrax

Corp., NJ), the subject’s psychological and behavioral well-being (using QoL-AD,

WTL and NPI questionnaires), and caregiver burden (using the short version of Zarit

Caregiver Burden Interview).

Data analysis, including both parametric and non-parametric methods, was performed

ona total of 85 participants who, in addition to a baseline evaluation completed at least

one follow-up evaluation at 1 month (T1) and at 3 months (T3). No differences between

groups were found regarding demographic variables of the participants at baseline.

When comparing the reminiscence group vs. the control group, group effects were

found using the parametric analysis at both T1 and T3 for the following variables:

global cognitive score, QoL-AD-patient and WTL. These effects were also

demonstrated using the non-parametric analysis at T3. An improvement in the Go-

NoGo reaction time level 1 (RT L1) measure was demonstrated only at T1 using the

parametric method, while improvements in the Zarit Caregiver's Burden and the NPI

were demonstrated only at T3 using the non-parametric method. Overall, a higher

accordance of the two analysis methods was shown at T3 compared to T1.

When comparing the cognitive training and the control groups, an adverse tendency was

noted, since group effects were found only at T1. These were more modest and related

mostly to the following measures: orientation, verbal and Go-NoGo RT L1. The results

of the two methods of analysis corresponded only for the orientation measure.

9

Although this study has found some positive results for both computer-based

reminiscence and cognitive training interventions compared to a control group, due to

the limited sample size available for final analysis the effects demonstrated were not

adequate to draw firm conclusions. It is suggested that more randomized controlled

trials with a greater sample size and longer periods of evaluations should be conducted

to further test the efficacy of those intervention methods as well as to elucidate the

relative contribution of each intervention and the interesting differences between them.

Keywords: Dementia, Alzheimer's disease, reminiscence, cognitive training, HCI, psychosocial

interventions, assistive technology, emotion-oriented interventions, cognitive function.

10

Table of content

1. INTRODUCTION ...................................................................................................................................... 14

2. LITERATURE REVIEW……......................................................................................................................... 16

2.1 DEMENTIA…………... .................................................................................................................................. 16

2.1.1 Caregiver burden……………………………………………….………………. ........................................................... 17

2.2 PSYCHOSOCIAL INTERVENTIONS IN DEMENTIA CARE…………… ............................................................................. 18

2.2.1 Reminiscence Therapy……………………………………………………….............................................................. 19

2.2.2 Cognitive Training…………………………………………………………………. ........................................................ 21

2.3 COMPUTER-BASED SYSTEMS DESIGNED FOR PEOPLE WITH DEMENTIA…………. ....................................................... 23

2.4 STUDY OBJECTIVES.… ................................................................................................................................. 25

3. THE COMPUTER-BASED SYSTEMS….….. ................................................................................................. 27

3.1 THE REMINISCENCE SYSTEM…… .................................................................................................................... 27

3.1.1 Usability Testing………………………………………………….…………….. ........................................................... 28

3.1.2 Results and modifications of the system……………….……………. ........................................................... 29

3.1.3 Additional findings…………………………………………………………….............................................................. 32

3.2 THE COGNITIVE TRAINING SYSTEM……. .......................................................................................................... 33

3.2.1 Modifications of the Savion software…………………………………. ........................................................... 33

4. STUDY PREPARATION…………… .............................................................................................................. 37

4.1 ETHICS COMMITTEE APPROVALS…………. ........................................................................................................ 37

4.2 CONTACTING SUITABLE ADULT DAYCARE CENTERS……….. ................................................................................... 37

4.3 INTRODUCING THE STUDY TO THE STAFF……. ................................................................................................... 38

4.4 PRESENTING THE STUDY TO POTENTIAL SUBJECTS AND THEIR FAMILY MEMBERS.….. ................................................ 38

4.5 INSTALLATION……….. ................................................................................................................................. 39

4.6 THE ADDITION OF PERSONAL CONTENTS TO THE REMINISCENCE SYSTEM………........................................................ 39

5. METHODS…….… ...................................................................................................................................... 40

5.1 PATIENT SAMPLE…………. ............................................................................................................................ 40

5.2 DESIGN…………………… .............................................................................................................................. 42

5.3 PROCEDURE………………. ............................................................................................................................. 43

5.3.1 The reminiscence therapy session…………………….………………… ........................................................... 43

5.3.2 The cognitive training session……………………………………….……. ........................................................... 44

5.4 MEASUREMENTS…………. ............................................................................................................................ 44

5.4.1 Cognitive function assessment……………………………………….….. ........................................................... 44

5.4.2 Patients’ psychological/ behavioral well-being……………….….. ........................................................... 45

5.4.3 Caregiver burden…………………………………………………………….…. ........................................................... 46

11

6. ANALYSIS AND RESULTS………….. ........................................................................................................... 47

6.1 STATISTICAL ANALYSIS…… ............................................................................................................................ 47

6.2 BASELINE ANALYSIS……….. .......................................................................................................................... 49

6.3 OUTCOME MEASURES DATA…… .................................................................................................................... 51

6.4 ANALYSIS OF RESULTS…… ............................................................................................................................ 52

6.5 AN ALTERNATIVE STATISTICAL ANALYSIS……..................................................................................................... 61

6.6 SUMMARY OF FINDINGS….. .......................................................................................................................... 71

6.7 RESULTS SEGMENTED BY MMSE SCORES….. ................................................................................................... 73

6.7.1 Parametric evaluation………………………….……………………………............................................................. 73

6.7.2 Non-parametric evaluation……………………………………………….. ............................................................ 74

6.7.3 Summary of results according to grouped MMSE scores……………………………………………………………...74

7. DISCUSSION………… ................................................................................................................................. 75

7.1 THE REMINISCENCE THERAPY………… ............................................................................................................. 75

7.2 THE COGNITIVE TRAINING….. ........................................................................................................................ 77

7.3 LIMITATIONS AND FUTURE WORK…….. ........................................................................................................... 79

8. IMPRESSIONS AND CHALLENGES……. .................................................................................................... 81

8.1 IMPRESSIONS OF THE STUDY….. .................................................................................................................... 81

8.1.1 Reminiscence…………………………………………………………………….. ............................................................ 81

8.1.2 Cognitive training……………………………………………………………… ............................................................ 82

8.2 CHALLENGES………… .................................................................................................................................. 84

9. CONCLUSION……… .................................................................................................................................. 86

REFERENCES ................................................................................................................................................ 87

APPENDICES ................................................................................................................................................ 95

12

List of Figures

Figure 1: Navigating between the three levels of the reminiscence system -------------- 28

Figure 2. Old vs. new location of information icon; Old vs. new format of thumbnails

view icon. ------------------------------------------------------------------------------------------ 30

Figure 3. Old vs. new Info layer location and background --------------------------------- 31

Figure 4. Old vs. new audio default sign ------------------------------------------------------ 32

Figure 5. Randomization of participants in each day care center -------------------------- 43

Figure 6. Consort diagram of the study. ------------------------------------------------------- 48

Figure 7. Mean Global scores for study groups in T0, T1 and T3. ------------------------ 54

Figure 8. Mean differences in cognitive measures between T1&To, and T3&T0. ------ 55

List of Tables

Table 1: Psychosocial treatments (APA, 1997) .............................................................. 19

Table 2: The Savion usability evaluation - findings and recommendations ................... 34

Table 3: Inclusion and exclusion criteria ........................................................................ 40

Table 4: Baseline characteristics of the participants, according to study group............. 49

Table 5: Sample mean scores for outcome measures of each of the study groups ......... 52

Table 6: Comparing T1-T0 scores difference between reminiscence & control groups,

and between cognitive training & control groups - ANCOVA results........................... 58

Table 7: Comparing T3-T0 scores difference between reminiscence & control groups,

and between cognitive training & control groups - ANCOVA results........................... 60

Table 8: Changes in outcome measures for reminiscence group between T0 & T1, and

T0 & T3 – Wilcoxon signed-rank test. ........................................................................... 62

Table 9: Changes in outcome measures for cognitive training group between To & T1,

and T0 & T3 – Wilcoxon signed rank test...................................................................... 64

Table 10: Changes in outcome measures for control group between To & T1, and T0 &

T3 – Wilcoxon signed rank test. ..................................................................................... 65

Table 11: Comparing 1 month differences between Reminiscence and control groups

(Mann Whitney test) ....................................................................................................... 66

13

Table 12: Comparing 3 months differences between Reminiscence and Control groups

(Mann Whitney test) ....................................................................................................... 67

Table 13: Comparing 1 month differences between Cognitive training and Control

groups (Mann Whitney test) ........................................................................................... 68

Table 14: Comparing 3 months differences between Cognitive training and Control

groups (Mann Whitney test) ........................................................................................... 70

Table 15: Level of significance and effect size for effects found in the reminiscence

group compared to control group, according to the method of analysis. ....................... 71

Table 16: Level of significance and effect size for effects found in the cognitive

training group compared to control group, according to the method of analysis. .......... 72

Table 17: Comparing scores differences (T1-T0, T3-T0) between reminiscence &

control groups, and between cognitive training & control groups - ANCOVA results for

participants with high MMSE score ............................................................................. 101

Table 18: Comparing scores differences (T1-T0, T3-T0) between reminiscence &

control groups, and between cognitive training & control groups - ANCOVA results for

participants with low MMSE score. ............................................................................. 102

Table 19: Comparing 1 month differences between Reminiscence and control groups -

Mann Whitney test for participants with high MMSE score. ....................................... 103

Table 20: Comparing 3 months differences between Reminiscence and control groups -

Mann Whitney test for participants with high MMSE score. ....................................... 103

Table 21: Comparing 1 month differences between cognitive training and control

groups - Mann Whitney test for participants with high MMSE score.......................... 104

Table 22: Comparing 3 months differences between cognitive training and control


Table 23: Comparing 1 month differences between Reminiscence and control groups -

Mann Whitney test for participants with low MMSE score ......................................... 105

Table 24: Comparing 3 months differences between Reminiscence and control groups -

Mann Whitney test for participants with low MMSE score. ........................................ 105

Table 25: Comparing 1 month differences between cognitive training and control

groups - Mann Whitney test for participants with low MMSE score. .......................... 106

Table 26: Comparing 3 months differences between cognitive training and control


14

1. Introduction

According to the Alzheimer’s Association, dementia is "an overall term that describes a

wide range of symptoms associated with a decline in memory or other thinking skills

severe enough to reduce a person's ability to perform everyday activities"

(http://www.alz.org/what-is-dementia.asp).

Dementia typically appears in later life (in most cases after the age of 65 years), but

may rarely occur in individuals in the fourth or fifth decade of life. Patients with this

condition may experience a decline in many cognitive areas, including memory,

attention, language, communication, problem solving and reasoning.

Dementia not only affects the patient, but as the condition progresses and patients

become increasingly dependent on others, the primary burden of support falls on

caregivers. Compared to caregivers of older adults with normal cognition, caregivers of

people suffering from dementia are required to provide a greater degree of care for

longer periods of time (Thies & Bleiler, 2013).

Alzheimer's disease (AD) is the most common cause of dementia, representing

approximately two-thirds of those suffering from this syndrome (Plassman et al., 2007).

Currently there is no cure for AD or for most of the diseases causing the dementia

syndrome. Important for the management of patients with dementia are psychosocial

and lifestyle interventions, aiming primarily to relieve cognitive and behavioral

symptoms and to provide caregiver support.

Two forms of non-pharmacological therapeutic intervention currently offered to patients

with dementia are reminiscence therapy and cognitive training. Reminiscence therapy

stimulates the person's long-term memory (a capability that is generally more preserved

than short-term memory in patients with dementia) and encourages interactions by

means of a variety of familiar stimulations. Reminiscence therapy has been found to

decrease depressive symptoms, facilitate social involvement and encourage participants

to introspect on their lives and achievements (Gibson, 1994; Scogin & McElreath,

1994). To date, there is no clear evidence regarding the effect of reminiscence therapy

on cognitive function, and there is thus a need for additional studies in order to further

evaluate the positive trends that have been reported (Woods, Spector, Jones, Orrell &

Davies, 2005). Conducting reminiscence therapy, however, requires major efforts in

organizing the stimulating material and presenting it to the patient.

http://www.alz.org/what-is-dementia.asp

15

Cognitive training is another intervention that may be of benefit in maintaining

cognitive function, both in healthy aging as well as in those with mild cognitive

impairment and possibly even dementia. However, the benefits of cognitive training in

patients with early dementia are modest. Systematic reviews (Bahar-Fuchs, Clare &

Woods, 2013; Clare, Woods, Moniz-Cook, Orrell, & Spector, 2003) recommend that

further studies be performed in order to provide more definite evidence.


dementia. Project CIRCA (Computer Interactive Reminiscence and Conversation Aid)

that was designed in Scotland as a multimedia conversation aid system had great

success in prompting conversations, in promoting a more natural and relaxed

atmosphere, and in allowing the patients to interact with the system. The material

included in project CIRCA was mainly from the UK, with an emphasis on local material

from Dundee, Scotland, the area of residence of the patients. Whereas in project CIRCA

all the patients shared the same background and hence the same reminiscence-evoking

stimuli, we suggest that the effectiveness of such a system may be enhanced

significantly by individually adapting its content to the patient's particular background

and preferences, thus providing personal material for each patient. We previously

developed a prototypical reminiscence therapy system and conducted a preliminary

evaluation of its acceptability by five patients with AD and their caregivers in Israel

(Sarne-Fleischmann &Tractinsky, 2008). The results of our evaluation indicated high

levels of user-satisfaction with the system and a strong tendency for repeated use. We

also found a clear preference for the use of personal rather than general material when

both were available.

The purpose of the study described in this manuscript was to evaluate two computer

supported interventions for patients with dementia, namely personalized computerized

reminiscence therapy and computerized cognitive training. A personalized

reminiscence system was developed specifically for the purpose of the study, and

subjects using either intervention for a period of up to 3 months were compared to a

control group.

16

2. Literature Review

The literature review is structured as follows: Initially I will describe dementia and the

effect of this syndrome on both patients and caregivers. Therapeutic interventions are

then presented, concentrating particularly on reminiscence therapy and cognitive

training. Subsequently, existing computerized systems designed for people with

dementia will be described. Based on the review, the rationale and objectives of the

study will be presented.

2.1 Dementia

A formal definition of dementia describes "a clinical syndrome of cognitive decline that

is sufficiently severe to interfere with social or occupational functioning" (Chertkow et

al., 2013, p.2).

Alzheimer's Disease is the most common cause of dementia, accounting for 60-80

percent of all dementia cases over the age of 65 (Thies & Bleiler, 2013). Other causes of

dementia include vascular dementia (VaD), diffuse Lewy body disease (DLBD), fronto

temporal dementia (FTD), Parkinson's disease dementia (PDD), and Creutzfeldt-Jakob

disease (CJD), mixed dementia (associated vascular and neurodegenerative disease),

among others (Thies & Bleiler, 2013).

While average life expectancy from the onset of symptoms in AD is approximately 8-10

years, it is postulated that the disease process begins long before the appearance of

symptoms.

The number of people suffering from dementia is increasing worldwide. In 2005, a

panel of 12 international experts was assigned by Alzheimer's Disease International to

provide a consensus estimate for the prevalence of dementia worldwide (Ferri et al.,

2005). Based on published studies of dementia, the experts estimated that there were

24.3 million people with dementia in 2001, predicting an additional 4.6 million new

cases annually. The number of people affected was expected to double every 20 years

and to reach 81.1 million by the year 2040. In 2012, the panel's coordinating group

reappraised the global prevalence of dementia, estimating some 35.6 million people

living with dementia in 2010 worldwide, and predicting this to reach 90.3 million by

2040, being approximately 10% higher than the previous report (Prince et al., 2013).

17

Currently there is no cure for AD or for most of the diseases causing the dementia

syndrome. Pharmacological interventions have limited efficacy and are, at best,

symptomatic (Thies & Bleiler, 2013; O'Brien & Burns, 2011; Birks, 2006; Courtney et

al., 2004).Important for the management of patients with dementia are psychosocial and

lifestyle interventions, aiming primarily to relieve cognitive and behavioral symptoms

and to provide caregiver support. Behavioral and Psychological Symptoms of Dementia

In addition to the cognitive consequences of dementia, people with dementia frequently

experience a wide range of neuropsychiatric symptoms, termed the Behavioral and

Psychological Symptoms of Dementia (BPSD) by a workgroup of the International

Psychogeriatric Association (Finkel, Costa E Silva, Cohen, Miller & Sartorius, 1997).

BPSD is defined as "Symptoms of disturbed perception, thought content, mood or

behavior that frequently occur in patients with dementia" (Finkel & Burns, 1999).

Symptoms include apathy, depression, irritability, agitation and anxiety (the most

common symptoms in dementia patients), aggression, wandering, delusions, and sleep

disturbances. Less commonly patients may experience euphoria, hallucinations, and

disinhibition (Cerejeira, Lagarto & Mukaetova-Ladinska, 2012).

BPSD affects the quality of life both of patients and of caregivers and is often

associated with a high level of distress.

2.1.1 Caregiver burden

Dementia does not only affect the patient, but as the condition progresses patients

become increasingly dependent on others, with the primary burden of support falling on

the caregiver. Compared to caregivers of older adults with normal cognition, caregivers

of people suffering from dementia are required to provide a greater degree of care for

longer periods of time (Thies & Bleiler, 2013).

Caring for a person with dementia is very stressful and has negative implications on

caregivers. Brodaty and Donkin (2009) describe four elements of caregiver burden,

namely psychological morbidity (general distress and depression), physical morbidity

(poor physical health), social isolation (due to the role of caregiving) and financial

burden (due to the costs of dementia care and the loss of earnings).

Baumgarten et al (1992) argue that the stressfulness of caring for a demented person

"stems from its novelty, unpredictability, long duration and ambiguity" (Baumgarten et

al, 1992, p.61).

18

In addition to affecting the caregiver's health, the burden of caregiving was also found

to be associated with early placement of relatives with dementia in a nursing home

(Etters, Goodall, & Harrison, 2008).

Both caregiver and patient factors influence the level of burden (Schӧlzel-Dorenbos,

2009, as cited in: Beinart , Weinman, Wade & Brady, 2012). According to these

authors, caregiver characteristics influencing the level of burden include: age (older age

predicts higher burden), duration of caregiving, workload, gender (male caregivers are

inclined to physical illness, whereas female caregivers are more inclined to suffer from

psychological symptoms), educational background, income (lower socioeconomic status

predicts higher burden), psychological state, and relationship with patient, among

others. Patient attributes include the duration and severity of disease, disease symptoms

(behavioral, psychiatric and cognitive), functional abilities, poor quality of life and

educational background.

2.2 Psychosocial interventions in dementia care

The goals of psychosocial (also called non-pharmacological) interventions in dementia

care are to improve quality of life and to manage the behavioral and psychological

symptoms associated with dementia. The effectiveness of this form of treatment has

been increasingly studied and its potential for reducing behavioral and psychological

symptoms, as well as relieving caregiver burden, has been described (Brodaty &

Arasaratnam, 2012; Vernooij-Dassen, Vasse, Zuidema, Cohen-Mansfield & Moyle,

2010; Vasse et al. 2012; Gitlin, Kales & Lyketsos, 2012).

The American Psychiatric Association (APA, 1997) has classified four categories of

psychosocial treatments for people with dementia, namely Emotion-oriented, Behavior-

oriented, Cognition-oriented and Stimulation-oriented (see Lawrence, Fossey, Ballard,

Moniz-Cook & Murray (2012) conducted a systematic review and meta-synthesis of

qualitative studies presenting the use and effectiveness of psychosocial interventions for

people with dementia in nursing homes. Their aim was to identify the beneficial

elements comprising a successful intervention from the perspective of both patients and

staff. Based on their findings, successful psychosocial interventions were perceived by

those

with dementia as enabling them to connect with others, provide the feeling that they

were making a meaningful contribution, and allowing them an opportunity to reminisce.

http://www.ncbi.nlm.nih.gov/pubmed?term=Vernooij-Dassen%20M%5BAuthor%5D&cauthor=true&cauthor_uid=20813074


http://www.ncbi.nlm.nih.gov/pubmed?term=Zuidema%20S%5BAuthor%5D&cauthor=true&cauthor_uid=20813074


http://www.ncbi.nlm.nih.gov/pubmed?term=Moyle%20W%5BAuthor%5D&cauthor=true&cauthor_uid=20813074

http://www.ncbi.nlm.nih.gov/pubmed?term=Kales%20HC%5BAuthor%5D&cauthor=true&cauthor_uid=23168825

http://www.ncbi.nlm.nih.gov/pubmed?term=Lyketsos%20CG%5BAuthor%5D&cauthor=true&cauthor_uid=23168825

19

Table 1).

Lawrence, Fossey, Ballard, Moniz-Cook & Murray (2012) conducted a systematic

review and meta-synthesis of qualitative studies presenting the use and effectiveness of

psychosocial interventions for people with dementia in nursing homes. Their aim was to

identify the beneficial elements comprising a successful intervention from the

perspective of both patients and staff. Based on their findings, successful psychosocial

interventions were perceived by those

with dementia as enabling them to connect with others, provide the feeling that they

were making a meaningful contribution, and allowing them an opportunity to reminisce.

Table 1: Psychosocial treatments (APA, 1997)

EMOTION-

ORIENTED

APPROACHES

BEHAVIOR-

ORIENTED

APPROACHES

COGNITION-

ORIENTED

APPROACHES

STIMULATION-

ORIENTED

APPROACHES

Supportive

psychotherapy

Behavior therapy Reality orientation

Skills training

Activity therapy

Recreation therapy

Validation therapy Art therapy

Sensory integration

Simulated presence

therapy

Reminiscence Therapy

The authors argue that adjusting the psychosocial interventions to individual patients

will enhance the clinical benefits. With regard to staff, successful psychosocial

interventions improved their awareness of the person and his family (beyond the

dementia), broadened the concept of their role in caregiving, and better reflected their

approach to influencing the patient.

2.2.1 Reminiscence Therapy

Reminiscence therapy is one of the psychosocial interventions most often included in

European dementia guidelines (Vasse et al., 2012). This form of therapy stimulates the

person's long-term memory (a capability that is generally more preserved than short-

http://www.ncbi.nlm.nih.gov/pubmed?term=Ballard%20C%5BAuthor%5D&cauthor=true&cauthor_uid=23118034


http://www.ncbi.nlm.nih.gov/pubmed?term=Murray%20J%5BAuthor%5D&cauthor=true&cauthor_uid=23118034

20

term memory in patients with dementia) and encourages interactions by means of a

variety of familiar stimulations. Reminiscence therapy can ameliorate depressive

symptoms, facilitate social involvement and encourage participants to evaluate their

lives and achievements (Gibson, 1994; Scogin & McElreath, 1994). Reminiscence

therapy can be conducted in groups or on an individual basis.

A Cochrane review of reminiscence therapy for people with dementia and their

caregivers (Woods, Spector, Jones, Orrell & Davies, 2005) found the intervention to

have promise, but concluded that more high quality studies were needed to reach

conclusive evidence. The inconclusive evidence may be due to methodological

limitations, the limited number of controlled studies and the lack of sensitive assessment

tools.

A recent systematic review conducted by Ponnusamy and Woods (2012) identified five

randomized control trials (RCT's) evaluating individualized reminiscence therapy for

people suffering from dementia. Sample sizes ranged from 17 to 101 and the total

number of treatment sessions from 6 to 12. The authors found potential for psychosocial

benefit in three trials that included a personalized approach, whereas in the two studies

that employed a general form of reminiscing no benefit was found. None of the five

RCT studies evaluated the impact of the interventions on family members or staff

caregivers.

To date, there is no clear evidence regarding the effect of reminiscence therapy on

cognitive function. Some studies did not demonstrate a significant improvement in

cognition (Jackson, 1991; Nomura, 2002), possibly related to methodological issues.

For example, Goldwasser, Auerbach& Harkins (1987) – included inWoods et al's

(2005) review mentioned previously-studied the cognitive, affective and behavioral

effects of reminiscence group therapy on demented elderly patients, and found a slight

but insignificant improvement in cognitive status. They concluded that rather than using

the Mini-Mental Status Examination (MMSE), which was the cognitive outcome

measure in their study, a more sensitive assessment tool is required for evaluating short

term changes in cognitive status . Similarly, Thorgrimsen, Schweitzer & Orrel (2002) –

also included in the Woods et al's review - conducted a pilot study which included 11

subjects, to evaluate the effects of reminiscence in people with dementia. They found

the MMSE score of people attending the reminiscence group to be stable following 20

weeks of therapy, while the control group decreased by almost 4 points during this

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period. However, this difference did not reach statistical significance. They conclude

that as significant results are more difficult to obtain with a limited number of

participants, a multicentered randomized controlled trial is required to further evaluate

the positive trend reported.

On a more positive note, some studies have reported a significant improvement in

cognitive function due to reminiscence therapy. Baines, Saxby & Ehler (1987) –

included in Woods et al's review - compared reminiscence and reality orientation (RO)

therapies and found an improvement in cognitive function only for the group of

participants who had received RO therapy prior to receiving reminiscence therapy.

Haight, Gibson and Michel (2006) – included in Ponnusamy and Woods' review -

evaluated the effect of life review (a more structured type of reminiscence therapy)

among people with mild to moderate dementia. The study found that compared to a

control group, patients receiving life review treatment had better cognitive measures as

evaluated by MMSE. Similarly, Morgan and Woods (2010) –included in Ponnusamy

and Woods' review- found a significant improvement in autobiographical memory

comparing to the control group. Haslam et al. (2010) - included in Ponnusamy and

Woods' review- compared group reminiscence to individual reminiscing using a control

group playing a social game. They have also found an improvement in cognitive

function, as measured by the Addenbrooke’s Cognitive Examination Revised tool

(Mioshi, Dawson, Mitchell, Arnold, & Hodges, 2006), only for participants who were

included in the group reminiscence sessions, and not in the individual sessions.

2.2.2 Cognitive Training

According to Bahar-Fuchs et al., (2013) cognitive training is defined as an intervention

which "typically involves guided practice on a set of standardised tasks designed to

reflect particular cognitive functions such as memory, attention or problem-solving"

under the assumption that "any effects of practice will generalise beyond the immediate

training context" (p.7). Similar to reminiscence therapy, cognitive training may be

administered either in groups or individually.

Cognitive training may be of benefit in maintaining cognitive function, both for healthy

older people as well as for those with mild cognitive impairment and possibly even

dementia. A systematic review of ten cognitive and memory training trials in adults

22

with mild cognitive impairment, found a moderate effect on memory performance in

seven of the trials (Gates, Perminder, Fiatarone Singh and Valenzuela, 2011). However,

the benefits of cognitive training in patients with early dementia are modest. A pilot

study involving 22 patients with mild to moderate AD showed an initial improvement in

functional status following cognitive training, and patients tended to regress to the pre-

training level after three months (Farina et al., 2002). However, the cognitive benefit of

the training procedure was minimal in this study. A randomized study evaluating a 6-

week memory training program for 34 patients with mild AD showed a modest

improvement in learning and memory (Cahn-Weiner, Malloy, Rebok & Ott, 2003). A

subsequent systematic review to evaluate the impact of cognitive training, cognitive

stimulation and cognitive rehabilitation for people in the early stages of Alzheimer's

disease or vascular dementia did not find strong support for the use of these

interventions in patients with these conditions (Clare, Woods, Moniz-Cook, Orrell &

Spector,2003). This conclusion was based on the fact that there are methodological

limitations, and that a very limited number of randomized controlled studies are

available. The authors recommended that further studies be performed in order to

provide more definite evidence. A recent update of this review by Bahar-Fuchs et al.

(2013) included 11 randomized controlled trials of cognitive training. Again, no strong

indication for the effectiveness of this intervention was found, and the authors conclude

that more high level RCT's are required, using more sensitive tools as outcome

measures in order to identify changes that may have been missed in previous trials.

In conclusion, both types of interventions (namely reminiscence therapy and the

cognitive training) currently share a set of limitations that prevent researchers from

reaching clear conclusions about their efficacy for people with dementia. These include

methodological limitations, a limited number of controlled studies and a lack of

sensitive uniform assessment tools. Therefore, additional methodologically sound large

RCTs employing more sensitive evaluation tools are needed to determine the value of

these interventions on various aspects of cognitive function of the patients, and to

elucidate the potential benefits for family caregivers.

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2.3 Computer-based systems designed for people with dementia

Increasingly, computerized systems are being designed for the use of people with

dementia. Lauriks et al. (2007) present four areas of needs for computerized services for

this target users' group: (1)providing general and personalized information regarding the

disease; for both patients and informal carers; (2)supporting the patient with regard to

dementia symptoms; (3) determining social needs; (4) monitoring health and safety.

Addressing these needs, there is a growing trend towards the design of Web sites

catering specifically for the needs ofpeople with dementia (The Alzheimer’s Forum;

Freeman et al., 2005; Holsapple, Pakath & Sasidharan, 2005), the design of

computerized tools for monitoring (Kinney, Kart, Murdoch & Conley, 2004; Taylor,

2005; Lauriks et al. 2007), and the development of assistive technology (LoPresti,

Mihailidis & Kirsch, 2004; Carswell et al., 2009, Lauriks et al., 2007).

A growing trend towards the design of computer systems for the purpose of emotion-

oriented treatments in dementia care is also noticeable (Topo et al., 2004; The Story

Table). An important landmark in the efforts to provide computerized support for such

forms of treatment of dementia is project CIRCA (Computer Interactive Reminiscence

and Conversation Aid). The project was designed in Scotland as a multimedia

conversation aid system, which addresses the challenge of supporting reminiscence

therapy by using contemporary technologies to provide a computer-based, user-friendly

alternative to the traditional methods employed. The project had success in prompting

conversations, in promoting a more natural and relaxed atmosphere, and in allowing

patients to interact with the system (Alm et al., 2004). The material included in project

CIRCA was mainly from the UK, with an emphasis on local material from Dundee,

Scotland, the area of residence of the participating patients. Whereas in project CIRCA

the same material was used by all patients, a similar project focusing rather on

personalized multimedia systems (with a limitation of the supported technology) was

initiated in Baycrest Center, Toronto, Canada (Cohene, Baecker, Marziali & Mindy,

2006).

The importance of a personalized system is especially salient in immigrant or in highly

mobile societies, due to the heterogeneous background of the patients. This is reflected

by the variety of locations, events and languages that can promote reminiscing in

patients in these societies. Moreover, patient-adapted external aids in dementia care are

considered more effective, because they better meet the patients’ capabilities and needs

http://www.ncbi.nlm.nih.gov/pubmed?term=Carswell%20W%5BAuthor%5D&cauthor=true&cauthor_uid=19822946

24

(Woods, 1994; McPherson et al., 2001; Topo et al., 2004) and increase their motivation

(Hofmann, Hock, Kühler& Müller-Spahn, 1996).

Another prototypical personalized reminiscence system was developed and evaluated

for its acceptability by patients and caregivers in Israel (Sarne-Fleischmann

&Tractinsky, 2008). The system improved upon existing systems in several ways.

Unlike the study at Baycrest, the main focus was on open-ended, extensive personal

content rather than on predefined life stories. In addition, the system was web-based

with a more flexible and intuitive user interface including a touch screen as the input

device – rather than a remote control. The technology used in the design of the system

was similar in structure to that used in the CIRCA project. However, whereas CIRCA

included only general content, the personalized system included personal content

relevant to the patient's background and preferences. The system was evaluated by five

patients suffering from AD treated at the Psychogeriatric Institute at the Tel-Aviv

Sourasky Medical Center. Each patient completed2 sessions interacting with the system

with the support of a caregiver. The participants’ behavior during the sessions was

observed and videotaped, and interviews were conducted with both patients and

caregivers. Content analysis was undertaken in order to investigate the effects of the

system on the patients, its usability, patient satisfaction with the system, and the

identification of additional benefits of the system on both patients and caregivers. The

results of the study indicated high levels of user-satisfaction from the experience of

using the system, with a strong tendency for repeated use. The system was found to be

effective in prompting conversations and in evoking personal memories; it was also

helpful in facilitating patient–caregiver interaction. The results also showed a clear

preference for personal rather than general material when both were available. Patients

and caregivers alike recognized the advantage of using the system rather than traditional

reminiscence methods, since various objects are included in one easily accessible

system, and there was a positive effect on the patient's self-esteem as a consequence of

being able to use a computer.

This study was included in a review by Subramaniam and Woods (2010) which

presented11 studies using information and communication technology in reminiscence

work (personal and general forms) for people with dementia, most of them in a

preliminary level. Sample sizes of the studies ranged from one to 23.The authors

concluded that feasibility of these systems was established, and suggest that they should

25

"make it easier for carers to converse and develop and maintain relationships with the

person with dementia, rather than simply keeping the person entertained."

(Subramaniam &Woods, 2010, p.121).

The use of computerized cognitive training systems may also be of value in providing a

more standardized approach to this form of intervention (Hofmann et al., 1996;

Schreiber, Lutz, Schweizer, Kalveram & Jäncke,1998). A prospective study involving

19 residents of a home for the elderly (mean age 83.5 years) who participated in a 14-

week computer-assisted cognitive training program found significant improvements in

working memory, with the positive effect on learning maintained even at follow-up

after 5 months (Günter, Schafer, Holzner & Kemmler, 2003). A more recent

randomized controlled study conducted by the Memory Clinic at the Beersheva Mental

Health Center found a clear benefit on memory and global cognitive function in patients

with dementia who participated in a bi-weekly computerized cognitive training program

for the duration of one month (Dwolatzky, Zilbershlag, Friger & Grinshpun, 2009).

2.4 Study Objectives

In the literature review we indicated the potential benefits of using computerized and

personalized interventions in dementia care, alongside their high availability and their

ease to use, especially when designed to address patients' specific needs and

capabilities. However, there is no empirical evidence for these hypothesized benefits

due to insufficient studies in this area and due to methodological limitations of existing

studies (Bahar-Fuchs et al., 2013; Ponnusamy and Woods, 2012).

Thus, the objectives of this study is to conduct a methodologically sound study to

evaluate the efficacy of the computer-based personalized reminiscence and cognitive

training interventions on the cognitive function and well-being of patients with

dementia, as well as the effects on family caregiver burden, as compared to controls.

We hypothesized that the use of the personalized reminiscence system would result in

improved psychological and behavioral measures (including a relief in caregiver

burden), whereas the cognitive training system would result in improved cognitive

measures.

26

With this purpose in mind, a personalized reminiscence system was developed, which

enabled independent use and administration for both patients and caregivers. The next

section describe these systems in detail.

27

3. The Computer-Based Systems1

The research project involved the use of three computerized systems: A reminiscence

therapy system, a cognitive training system, and a computerized neuropsychological

tool for assessing cognitive function. The reminiscence therapy system was developed

specifically for the purpose of this study and was based on a preliminary pilot study

involving five patients with AD (Sarne-Fleischmann & Tractinsky, 2008). The cognitive

training system involved the use of Savion (Melabev, Jerusalem), a commercial

software for memory enhancement for people with Alzheimer's disease, dementia and

other causes of cognitive decline (Dwolatzky et al, 2009). The neuropsychological

assessment tool was Mindstreams (NeuroTrax Corp., NJ) a computerized testing battery

validated for age-related cognitive decline and dementia (Dwolatzky et al., 2003;

Dwolatzky, Dimant, Simon & Doniger., 2010).

3.1 The reminiscence system

Based on our findings in the pilot study (Sarne-Fleischmann & Tractinsky, 2008), a new

Flash web-based application was developed to enable independent use and

administration for both patients and caregivers by including two main components in

the structure. The front-end component supports the patient’s interaction with the

system during the therapeutic sessions. The back-end component facilitates the addition,

update, and management of content. This component was designed for the use of

caregivers and family. The application was developed by an experienced subcontractor

according to a detailed design and the specifications provided.

Great emphasis was placed on the system’s design and on simplicity of use, given the

specific characteristics and limitations of the target users. Features included a very

simple interface (offering the user a limited number of options in order to avoid

cognitive overload); minimizing visual distractions on the display; avoiding the use of

animations or competing stimuli at any given time; using subtle graphics through

calming color schemes; and using a touch screen for all required interactions to support

______________________________

1Portions of this chapter, were published in: Sarne-Fleischmann, V., Tractinsky, N. Dwolatzky, T. and

Rief, I. Personalized reminiscence therapy for patients with Alzheimer's disease using a computerized

system. In: Proceedings of PETRA. 2011, 48-48.

28

the most natural interaction style.

The new system's hierarchy included only three levels to support simple and intuitive

flow:

1. Login – Entering the system by identifying the patient.

2. Select Album – Selecting the required album from up to six albums presented.

3. Album View – Watching the media files associated with the selected album.

The navigation between the three levels isdone hierarchically and is bi-directional (See

Figure 1).

Figure 1: Navigating between the three levels of the reminiscence system

The reminiscence system has two different interfaces: Hebrew and English. The two

interfaces are separated (each is accessible via a different link) so there is no option of

switching to a different language while interacting with the system.

3.1.1 Usability Testing

In order to evaluate the ease-of-use of the new system, and its appropriateness for the

target audience, a usability evaluation was conducted prior to the commencement of the

evaluation study. Three Alzheimer's patients (one woman and two men) from the

memory clinic in Beer-Sheva were separately asked to test the system. Each evaluation

session lasted up to 45 minutes, and consisted of three parts: Introduction, Using the

system and Summary. The Introduction part began with an explanation regarding the

purpose of the meeting, followed by a general description of the system. The patients

were then asked a few questions regarding their personal preferences (e.g Do you like to

watch photo albums? What kind of photos do you like to watch? Do you like to listen to

Login Select Album

Album View

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music? What kind of music do you like?). In the second part (Using the System) the

patient was given the opportunity to use the system by selecting an album and watching

its media files. At each step the patients were asked two questions: 1) What would they

like to do now? 2) How do they intend to accomplish this? In the case of the patient

mentioning an activity that was not supported by the system, he/she would be directed

to the existing functions available in each case. This had two purposes: 1) Evaluating

the intuitiveness of the system's user interface, and 2) Establishing the users' mental

model of how to interact with the system. The Summary part of the usability evaluation

included general questions regarding the system and its user interface (e.g Did you like

the system? Would you use it again? What did you like about it? Were there things you

didn't like? What additional functionality would you like the system to include?)

3.1.2 Results and modifications of the system

Based on the usability evaluation's results, several modifications were made to improve

the system.

1. Information – The information icon (c), originally located next to the media

presented, was moved to be aligned with the bottom of the media presented (see Figure

2). This change provided better isolation for the icon from the navigation arrow icon,

thus preventing potential confusion between these icons. In addition, the layer

presenting the information text (d), which originally partially overlapped the media

object, was moved to the side of the object, in order to keep the object visible while

reading the text. In addition, the transparency of the text layer was cancelled to

maximize the visibility of the text (using an opaque background) and to reduce any

distractions (see Figure 3).

2. Thumbnails view icon – The thumbnails view icon (a), originally located at the top

left hand of the screen, caused distractions at times, despite being relatively in low

contrast to the screen’s background. To remedy this problem the icon was moved to the

bottom of the screen, and its colors were made even more subtle (see Figure 2). These

changes moderated the presence of the icon on the screen, leaving it mainly for the use

of the caregiver.

30

Figure 2.Old vs. new location of information icon; Old vs. new format of thumbnails view icon

(Upper and lower figures respectively).

3. Audio default sign – The audio default sign (which is presented when an audio file is

played) confused the participants – perhaps because it was too complex due to the

a

b c

a

b

c

31

inclusion of variety of different note shapes. Consequently, it was changed from a

winding set of musical notes to a much simpler sign (seeFigure 4).

Figure 3. Old vs. new Info layer location and background (Upper and lower figures respectively)

d

d e

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4. Navigation arrow icons - Although the "clickable" surface of the navigation arrow

icons (b) was larger than the graphics itself (enabling an easier activation), the

participants still experienced slight difficulty with the bounded icons. To overcome this

problem, the arrow icons and their “clickable” boundarieswere enlarged, to facilitate the

press action (seeFigure 2).

Figure 4. Old vs. new audio default sign (left and right figures respectively)

3.1.3 Additional findings

During the evaluation, additional questions regarding the design of the system were

raised. Following a thorough discussion, it was decided to disengage selected findings

in order to sustain a most comfortable screen view with minimal distractions.

One of these findings presented a dilemma, whether to add text labels to icons that were

not intuitively understood by the participants (i.e switch to thumbnails view (a),

information (c) and add to favorite (e) icons). The conclusion was that since these icons

were designed mainly for the use of the caregiver, the lack of accompanying texts will

not influence the patient's capability of using the system, while the texts addition might

have a major effect on the user interface.

We considered whether to include all six albums on the same screen view, and thus

avoid the current navigation between two album screens. Here too, it was decided not to

implement this change, which requires a substantial reduction in the size of the albums

icons.

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3.2 The Cognitive Training System

The Savion software provides training in four cognitive functions, namely language

skills, calculation, non-verbal memory and visual-spatial skills. It is used either with the

support of a therapist or alone (depending on the user's capabilities). The level of the

training can be easily adjusted to accommodate the user's level of competence.

Although the interface is designed for standard input devices (i.e keyboard and mouse),

in this study the Savion was operated using a touch screen (in those areas supported by

this feature) in order to enable an intuitive operation, and to reduce the user's workload.

It is important to note that the use of the touch screen is not supported by all of the areas

of training provided by the Savion software, since they require the insertion of numbers

using the standard keyboard (the calculation and the non-verbal memory training areas).

Savion has two major versions – English and Hebrew. Both interfaces are installed

jointly, and can be accessed via the same interaction (the interface language can be

switched during the session), as opposed to the reminiscence system.

A new Russian version was developed prior to the commencement of the study. This

version required a separate installation and did not support the switching between the

other two interface languages (Hebrew or English).The Savion main screens are

presented in Appendix A.

3.2.1 Modifications of the Savion software

For the purpose of the study the Savion software was modified to include an improved

user interface, and a tool for tracing the interactions. In addition, the new Russian

version of the Savion was evaluated.

3.2.1.1 Modifications of the UI

Savion is a commercial software which has been used by older people at their homes

and at adult day-care centers, for more than 15 years. The software was developed in

collaboration with an experienced occupational therapist from Melabev, and was

designed for use by patients with significant cognitive impairment.

For the purpose of the study, the usability of the Savion software was evaluated from

the viewpoint and according to the mental model of a novice user, and based on key-

34

principals for designing for the elderly. Each of the available functions was evaluated,

and a number of issues that needed to be revised were found. Table 2 presents the major

findings and the recommendations that were made to the Savion developers to enhance

the usability of the software.

Table 2: The Savion usability evaluation - findings and recommendations

Finding Recommendation

1 Use of colors – In all screens there

seemed to be an intensive use of colors.

The overload was salient in the number

of colors used (more than the maximum

five which is recommended), in the

colors palette (strong colors), and in the

colors combinations, which influenced

the contrast and the visibility of the text.

Due to the loss of visual acuity in

elderly people, combination of colors

should be carefully considered

(especially combinations of yellow,

blue and green, which might be difficult

for elderly people to distinguish). Also,

the use of multiple colors should be

reduced, and subtle hues should be

used.

2 Text – In some of the screens there was

an excessive use of text (usually for

detailed instructions).

Long strings of text used for

instructions should not be presented on

main screens but located in "help"

screens that will be displayed upon

user's request.

General instructions should be

simplified.

3 Critical functions - Command buttons

with critical functionality had the same

appearance as less pivotal buttons. As a

result, critical functions (e.g. exiting the

screen) could be performed

unintentionally.

Critical command buttons should be

distinguished from others by using

different colors and a distant location

on the screen.

4 Inconsistency -With regard to font type To provide a consistent conceptual

35

Finding Recommendation

and size, screens layout, and command

button's size.

structure of screens and functionality,

to enhance familiarity across

all screens.

5 Font - Use of serif typeface font, which

made reading the screen difficult.

Using sans- serif typeface, which is

recommended for elderly users. The

sans-serif typeface does not include the

small lines at the ends of the characters,

and therefore enhances legibility.

6 Setup - A redundant update of setup

features at the beginning of each session

of the specific training areas.

Similar setup features (such as

determining interface language,

defining sounds, or setting general

thresholds) should be grouped into one

setup screen, which will be presented

upon the user's request.

7 Mouse interface – Some of the

functions were supported only by the

keyboard interface and could not be

operated through the mouse interface.

Functionality should be fully operable

through a mouse interface in addition to

a keyboard interface. This will maintain

interface consistency and support the

operation using a touch screen.

The Savion software was modified by its developers, though not all of the

recommendations were implemented. For example, the multiplicity of colors was seen

as enhancing the users' enjoyment of the interaction and awareness of the current

training area (by using different background colors). Another example was the use of

complementary input devices (keyboard in addition to mouse instead of maintaining a

complete input set supported by the mouse only), which was seen by the developers as a

means of enhancing cognitive training.

36

3.2.1.2 Adding a tracing tool

In order to follow each of the sessions conducted with Savion, a new tracing tool was

added by the developers, which recorded the time spent in each of the four training

areas for each session. The tool required the insertion of the participant's number at the

beginning of the session, and generated the date and time while entering and exiting

each of the training areas. The data of all participants who used Savion on the same PC

was saved in a text file. A limitation of the tracing tool was the fact that it did not record

the time that was actually spent on active training (for example: it could not report

whether the user was responding to the exercises, setting up the characteristics of

training, or even having a short break during the session).

3.2.1.3 Preparation of the Russian language user interface

For the purpose of the study, a Russian language user interface was also required to

support a group of Russian speaking participants. The development of a new Russian

version of Savion was completed by the commencement of the study but it was not

scientifically validated. The new version was evaluated by a native Russian-speaker in

order to assure the quality of the translation, and to inquire about the appropriateness of

the selected words in the 'language skills' training area. The evaluation resulted in a few

corrections to the list of words.

37

4. Study Preparation

4.1 Ethics committee approvals

In order to conduct the research in the different geographical locations – three proposals

for clinical trials in human subjects were submitted to the relevant institutional review

boards (IRBs). Proposals were submitted to the Soroka Medical Center Helsinki

committee, the Shaare Zedek Medical Center Helsinki committee, and the Ben-Gurion

University of the Negev Human Subjects Research committee.

The proposals were revised according to each committee's suggestions and requirements

and were subsequently approved.

4.2 Contacting suitable adult daycare centers

The study was designed to be conducted either in adult daycare centers or in assisted

living residences. This decision stemmed from the need to use wide touch screens for

the reminiscence treatments, and since these were not easily portable it was preferred to

situate them in a permanent place at these sites for the duration of the study.

Nine adult daycare centers and one assisted living residence for Alzheimer's patients

were approached in order to determine their willingness to participate in the study. The

institutions' suitability for the study was also evaluated, in terms of the characteristics of

the population attending the centers (demented, high or low functioning elderly), the

number of people visiting the center each day, and the available resources (quiet room

and network connection for conducting the interventions). Seven of the daycare centers

were found to be suitable sites for participation in the study. This included three in

Beer-Sheva, two in Jerusalem, one in Ramat-Gan and one in Bnei-Brak. One assisted

living residence was found suitable for participation, but after several meetings with the

director in order to plan the project, a decision was made by the management to

withdraw from partaking in the study based on procedural considerations.

38

4.3 Introducing the study to the staff

After obtaining the approval of the directors, meetings were held with key members of

the staff in each of the adult daycare centers. The aim of these meetings was to present

the study to the staff and to discuss practical details regarding the performance of the

study. This was an opportunity for both sides to raise questions, discuss potential

difficulties, make detailed plans and find solutions at the local level. Among the issues

that were raised were the best way to approach the subjects and their family members,

the level of qualifications required for those assisting the subjects in performing the

interventions, the availability of the computer room where the treatments would take

place, and who should accompany the subjects to the computer room (for the low

functioning subjects in particular), among others.

In addition, meetings were held with each of the assessors who were responsible for the

evaluation of the subjects. In these meetings, the assessors were introduced to the

study's plan. The questionnaires were presented and discussed, with emphasis on their

major elements based on formal instructions and guidelines. The appropriate way of

approaching both subjects and family members was also discussed. The group of

assessors included: a neuropsychologist, a social worker, a nurse, a physician, and an

assessor with a background in the field of education. The researcher also took part in the

evaluations, particularly that were conducted prior to commencement of treatment (at

T0).

4.4 Presenting the study to potential subjects and their family members

In order to contact potential subjects and their family members before enrollment,

different approaches were adopted at the various sites. In four of the daycare centers, a

lecture explaining the purpose and possible benefits of the study was given in the

evening, to which all members of the daycare center and their families were invited. In

one of the centers the project was presented to family members at a routine family

evening activity, with the older participants subsequently receiving a lecture describing

the study as one of their morning activities.

The next step was to approach potential subjects individually. Three of the daycare

centers preferred to approach the potential subjects and their family members directly.

39

For that purpose, a list of subjects who met the inclusion criteria (see ‎5.1) based on the

opinion of staff members who knew them well was prepared, and family members were

contacted personally by phone in order to provide a more detailed description of the

study and to answer questions that emerged. Those subjects and their families who

expressed an interest and willingness to participate in the project were invited to a

meeting with the researchers to sign informed consent for participation in the study (see

Methods section).

4.5 Installation

At each of the adult daycare centers a PC with a touch screen was installed and

connected to the available internet resource (LAN or WIFI). Savion and Mindstreams

were installed on the PC's. In two centers where participants were native Russian

speakers, the Savion Russian version was installed instead of the Hebrew/English

version, and the operating system was set to support Russian. Links to the reminiscence

software were also added.

4.6 The addition of personal contents to the reminiscence system

For those participants randomly assigned to the reminiscence study group (see ‎5.2),

family members of participants were approached to provide personal materials for use

in the reminiscence sessions, as well as accompanying information for each item (i.e a

title and a short description of the item). The material was sent directly to the daycare

center or submitted electronically by mail in the few cases where digital files were

available. The contents were scanned and edited in order to enhance their visibility and

quality. In some cases additional information regarding the background of the

participant and his/her areas of interest was requested, and other relevant material was

found using an internet search engine. In addition, extra material was added as

necessary by relatives during the study. In some cases, participants provided their own

materials.

40

5. Methods

5.1 Patient sample

The participants of this study were older subjects with cognitive impairment or

dementia who resided in the community and regularly attended an adult daycare center

at least twice a week.

The inclusion and exclusion criteria are described in Table 3.

Table 3: Inclusion and exclusion criteria

Inclusion criteria Exclusion criteria

(1) Age – above sixty years old (5) Psychiatric disease

(2) Cognitive impairment – mild cognitive

impairment (MCI) or dementia (MMSE

score of 14-26)not associated with a

known medical condition (such as stroke,

vitamin deficiencies, impaired thyroid

function, among others)

(6) Significant visual or auditory

impairments or any other impairment

which may prevent the participant from

using either of the two computerized

interventions

(3) English / Hebrew / Russian speakers (7) Inability to understand the questions

presented in the Savion software program,

or inability to communicate coherently as

required for the performance of

reminiscence therapy.

(4) Have close relatives who could act as

informants

Due to the diverse symptoms of MCI and dementia, and in order to maintain a certain

level of homogeneity, the age criterion (1) was determined in order to exclude cases of

early onset dementia. In order to encourage the inclusion of subjects with an organic

etiology for their cognitive impairment, participants with psychiatric disease (5) were

excluded from the study. The language criterion (3) was based on the availability of

these interfaces in the two computer systems (see ‎3.1and‎3.2). Due to the requirements

of the screening tools (as will be described below) – crucial information regarding the

41

functional capabilities of the participants were to be obtained from a family informant

(4). Moreover, the periodic evaluations (to be described in‎5.4) included the impressions

of family members who serve as the participants' main caregivers.

Each competent participant, as confirmed by an independent geriatrician, was asked to

provide written informed consent prior to participation in the study. For those patients

who were not competent, the legal guardian was required to provide informed consent.

Subjects without a legal guardian who were determined not to be competent were not

enrolled in the study.

After providing informed consent, the participants' medical files were reviewed in order

to ensure that they conform with inclusion and exclusion criteria, and that their

cognitive impairment was not the result of an associated medical condition (such as

stroke, vitamin deficiencies, impaired thyroid function, among others). In addition, the

participants underwent a preliminary assessment in order to determine the stage of their

illness. The assessment included cognitive and functional evaluations using the

following instruments (see Appendix F):

Mini-Mental State Examination for cognitive screening (Folstein et al., 1975).

Clock Drawing test (Freedman et al., 1994) and CogSym questionnaire for

cognitive screening (Memory Clinic, Mental Health Center, Beersheva). The

latter is a numerical scale based on 10 questions used for elucidating cognitive

symptoms, and is completed both by subjects and by informants.

Lawton and Brody’s Instrumental Activities of Daily Living (IADL) for

assessing functional capabilities (Lawton et al., 1969). This questionnaire is

directed at the participants' informant.

Clinical Dementia Rating (CDR) scale as a global measure rating the severity of

dementia (Morris, 1993). This questionnaire includes two parts: the first is

directed at the informant and the second at the participant, comparing the latter's

response to that of the informant.

Short version (15 questions) of the Geriatric Depression Scale (GDS) as a

screening instrument for depression (Yesavage et al., 1983).

All questionnaires directed to informants were administered by face-to-face or

telephone interviews with first-degree relatives of the participants. All other scales were

42

administered by face-to-face interviews with the participants during morning hours at

the adult daycare centers.

At the end of the screening process, the results of all evaluations were reviewed by a

physician specializing in the treatment of cognitive syndromes, and the cognitive

diagnosis was determined to be either MCI or dementia based on accepted criteria.

5.2 Design

At the completion of screening, subjects were assigned randomly to one of three groups:

1. Personal reminiscence therapy intervention (using the computerized

reminiscence system with personal contents for each participant).

2. Cognitive training intervention (using the Savion computerized cognitive

training system).

3. Control group which continued usual activities in the adult daycare center. This

group did not receive any computerized intervention involving interaction with

one of the research staff. The reason for not offering the control group an

alternative intervention was based on the need to create a 'neutral' group with no

elements of intervention similar to those of computerized reminiscence therapy

or cognitive training.

The usual activities of all participants at the daycare centers and at their homes were not

controlled. The purpose of randomization was to assure as much as possible that

baseline characteristics of the participants of the three groups were similar.

Randomization was stratified according to the daycare center, and to the severity of

cognitive impairment (with CDR scores of 0.5 and 1 representing a milder degree of

cognitive impairment, and CDR scores of 2 and 3 representing more severe

impairment), see Figure 5.

43

Figure 5.Randomization of participants in each daycare center

5.3 Procedure

Both those participants receiving reminiscence therapy as well as those using the

cognitive training program participated in two sessions a week, each of 30-minutes

duration, over a period of three months. The treatments were conducted in a quiet room

at the adult daycare centers in the morning hours, and supervised by a trained mediator.

At the end of each session, the mediator provided a short description of the interaction,

relating to the course of the session and to special occurrences.

5.3.1 The reminiscence therapy session

At the beginning of the session the subject was presented with the albums (the themes)

and was asked to select one and to commence viewing its objects. In those instances

where the subject could not decide as to which album to begin with – the mediator

encouraged him/her to make a selection. While the subject was encouraged to talk about

the presented object, no limitation was placed on the content of the conversation. In

fact, the subject could talk about any topic that the object brought to mind, with no

obligation to provide information about the object itself. When relating to the various

objects the mediators were cautious not to let the subjects feel that their memory was

being tested, but rather to explore the object together (for example, instead of asking

"Do you remember this place?" they would refer to the object as follows: "What a nice

place. What do you think it could be?").

Day care center

CDR 0.5-1

Reminiscence Cognitive Training

Control

CDR 2-3

Reminiscence Cognitive Training

Control

44

The mediators encouraged the subjects to operate the system themselves, by selecting

the required albums, navigating through the objects, and controlling the session and the

discussion as they wished.

5.3.2 The cognitive training session

At the beginning of the session the intervention mediators asked the subjects to choose

their preferred cognitive area for commencing their training session. In the case where

the subject expressed no preference – the mediator would offer him/her one of the four

topics. The mediators were advised to include all four topics in each session, although

this was not mandatory. In those instances where the subject refused to work on one of

the topics – the mediator made an effort to encourage the subject to work on that area in

the next session.

At the end of each session the level that the subject achieved on each topic was

documented, and in addition a short description of the session was noted, as mentioned

previously. This ensured continuity and allowed for intellectual stimulation.

5.4 Measurements

The following describes the measurements that were employed in the study. All

assessments were performed at baseline (T0), at one month (T1) and at 3 months (T3).

Responses from subjects' relatives were obtained by face-to-face or telephone

interviews. The name of the subject's relatives was provided by the staff of the adult

day-care centers.

5.4.1 Cognitive function assessment

In order to evaluate the efficacy of each of the interventions as compared to controls

with regard to cognitive function, the subjects’ cognitive function was measured by the

Mindstreams computerized assessment battery (Dwolatzky et al., 2003; Dwolatzky et

al., 2010). The Moderate-Severe Impairment Battery was administered. This tool takes

about 20 minutes to administer and tests the following cognitive domains:

1. Orientation to time and place

2. Language skills

3. Memory

45

a. Nonverbal memory

b. Delayed nonverbal memory

4. Executive function

a. Similarities and judgment

b. Reality testing

c. Go-NoGo basic test

5. Spatial orientation

At the end of the test, data is uploaded to a server, scores are provided forall of the

individual test components, andin addition a global score indexis calculated for the

test.A summary score for each domain (including the global score) reflects the level of

accuracy, ranging between 0-100 (with 100 being the highest level of accuracy).

Using a computerized tool for assessing cognitive function has several advantages over

using traditional assessment instruments. The computerized evaluation enhances the

sensitivity of test, is able to minimize ceiling or floor effects, is much easier to

administer (in terms of time and cost) and is widely available since it is internet-based.

(Dwolatzky et al., 2003).

The Mindstreams batteries for mild and moderate impairment were validated by

Dwolatzky el al. (2003, 2010) and were found to be effective in providing a clear and

detailed cognitive status of the patients.

Samples of the Mindstreams screens and reports are presented in Appendix B.

5.4.2 Patients’ psychological/ behavioral well-being

Behavioral outcomes were assessed using the NPI - Neuropsychiatric Inventory

(Cummings et al., 1994), which was completed by the subject's first-degree relative.

This tool includes 12 areas, each relating to the presence of a particular behavior, its

frequency, severity and the level of caregiver distress. A total score is calculated

according to the frequency and severity, and ranges between 0-144 (a higher score

reflecting a higher level of symptomatology). Psychological well-being was assessed

using the QoL-AD instrument (Logsdon et al., 1999), and a general question from the

Will to Live questionnaire was administered (Carmel, 2011). The QoL-AD instrument

obtains responses regarding the subject's quality of life both from the subject and the

46

relative, and includes 13 items rated on a four-point scale. Total score of the instrument

ranges between 13-52 (a higher score reflecting better quality of life). The Will to Live

questionnaire was rated by the subject, and ranges between 0-5 (a higher score

reflecting a greater will to live). The questionnaires are presented in Appendix F.

5.4.3 Caregiver burden

For the assessment of caregiver burden and psychological morbidity, the short version

of the Zarit Caregiver Burden Interview (Bedard et al., 2001) was used. This

questionnaire was administered to the subjects' first-degree relatives, and ranges

between 0-48 (a higher score reflecting a higher level of burden). The questionnaire is

shown in Appendix F.

47

6. Analysis and Results

Of the 95 subjects who entered the study, 32 were assigned to the reminiscence therapy

intervention, 32 to the cognitive training intervention, and 31 to the control group.

Attrition in the reminiscence group was the highest (9 participants), though this was

mainly prior to commencing the intervention. Six participants did not receive the

intervention: 3 were excluded due to lack of cooperation of family members (who did

not provide the required personal materials), 1 left the day care center and 2 declined (or

family member declined) to participate in the study. All the participants who were

assigned to the cognitive training group commenced the intervention. One participant

from the control group withdrew due to ill health before T0 evaluation.

Of the remaining 88 participants who underwent T0 evaluation, 11 did not complete T3

evaluation due to the following reasons: Illness (4), death (1), withdrew (2), left the day

care center (1) and excluded due to prolonged absence (3).

Figure 6 presents the number of participants who were enrolled, were assigned to each

study group and completed T1 and T3 evaluations. Since family members'

responsiveness was lower, samples of family evaluations were usually smaller and

therefore are reported separately for each of the statistical tests. Reported analysis

relates to a total of N=85 participants who, in addition to T0 evaluation completed at

least one of T1and T3 evaluations.

6.1 Statistical analysis

SPSS v.20 was used for data entry and statistical analysis. The analysis included the

evaluation of baseline demographic and clinical variables for the three study groups,

followed by an analysis of outcome measures, at T1 and T3compared to T0. All tests

were designed as two tailed.

All effects reported in this chapter relate to improvements in the intervention groups

compared to the control group, unless stated otherwise.

48

Figure 6.Consort diagram of the study(Excluded from study: due to lack of cooperation of participants/family members, or absence)

167 subjects were assessed for eligibility

95 entered study and underwent randomization

32 were assigned to Reminiscence group

23 completed T1 follow up 3 remained in the study but

were lost to follow up

23 completed T3 follow up

1 withdrew

2 were excluded

2 withdrew

1 left day care center 3 were excluded

32 were assigned to Cognitive Training group

28 completed T1 follow up 2 remained in the study but

were lost to follow up


1 withdrew 1 left day care center

1 withdrew due to ill health

1 was excluded 1 withdrew due to ill health

31 were assigned to Control group


2 remained in the study but were lost to follow up


1 died 1 withdrew due to ill

health

2 withdrew due to ill health

72 were excluded: 46 did not meet inclusion criteria

16 declined to participate 6 did not receive family approval 4 were absent when screening

tests took place

49

6.2 Baseline analysis

The mean age of participants was 83.9 years (Standard Deviation [SD] 5.6), ranging

from 71 to 98. MMSE minimum and maximum scores were 14 and 26 respectively with

a mean of 21.40 (SD2.9). Most of them were diagnosed as having a CDR score of 1

(60%), with only one subject having a CDR score of 3. The majority of participants

were female (77.6%).Most were widowed (61.1%). The participants' mean number of

children was 3.4 (SD1.9).

Most were born in West Europe/America/Australia (36.5%) or Africa/Asia (24.7%).

The mean total years of education was 10.55 (SD4.6). Mean scores for clinical tests

were: 7 (SD3.4) for Clock drawing test, 3.8 (SD3.3) for GDS, 21.8 (SD7.8) for IADL,

and 5.5 (SD1.9) for CogSym. Almost half of the participants used medications to treat

dementia (44.7%).A cognitive diagnosis of dementia was the most common and

accounted for almost half of the participants (47.1%).

Demographic and clinical variables were compared between study groups. The Kruskal-

Wallis test was used to compare interval and ordinal variables, and Chi square test was

used for comparing categorical variables. No significant differences between groups

were found for any of the variables (Table 4).

Table 4: Baseline characteristics of the participants, according to study group

Number of participants N=85

Reminiscence Cognitive

Training

Control Kruskal-Wallis

test

Characteristics n=26 (%) n=30 (%) n=29 (%) Statistic Sig.

Age (Mean+SD) 84.35 (5.585) 84.13 (6.202) 83.21 (5.130) 1.468 0.480

Gender (n) 0.766a 0.682

Male 6 (23.1) 8 (26.7) 5 (17.2)

Female 20 (76.9) 22 (73.3) 24 (82.8)

Years of education

(Mean+SD)

10.38 (3.920) 10.73 (4.856) 10.52 (5.054) 0.042 0.979

50



Training


test


Place of birth (n) 3.893a 0.867

Israel 1 (3.8) 4 (13.3) 2 (6.9)

West Europe,

America,

Australia

8 (30.8) 13 (43.3) 10 (34.5)

East Europe 5 (19.2) 4 (13.3) 5 (17.2)

Former Soviet

Union

4 (15.4) 4 (13.3) 4 (13.8)

Africa, Asia 8 (30.8) 5 (16.7) 8 (27.6)

Marital status (n) 1.438a 0.838

Married 10 (38.5) 12 (40) 9 (31)

Widowed 16 (61.5) 17 (56.7) 19 (65.5)

Divorce 0 (0) 1 (3.3) 1 (3.4)

Number of children

(Mean+SD)

3.08 (1.262) 3.10 (1.520) 3.86 (2.489) 1.808 0.405

Missing data 0 1 0

Background diseases

(n)

HTN 15 (57.7) 20 (69) 20 (74.1) 1.682a 0.431

IHD 14 (53.8) 7 (24.1) 11 (40.7) 5.135a 0.077

CVA 6 (23.1) 7 (24.1) 5 (18.5) 0.286a 0.867

NIDDM 6 (23.1) 7 (24.1) 6 (22.2) 0.029a 0.986

Psychiatric 1 (3.8) 0 (0) 0 (0) 2.296a 0.317

Missing Data 0 1 2

Medicine (n) 4.787a 0.571

Rivastigmine 2 (8.7) 3 (11.1) 6 (24)

Donepezil 4 (17.4) 4 (14.8) 5 (20)

Memantine 2 (8.7) 2 (7.4) 0 (0)

None 15 (65.2) 18 (66.7) 14 (56)

Missing data 3 3 4

MMSE (Mean+SD) 20.81 (3.163) 21.77 (2.812) 21.55 (2.640) 1.696 0.428

Clock drawing test

(Mean+SD)

5.96 (3.092) 7.10 (3.498) 7.79 (3.331) 4.140 0.126

51



Training


test


Missing data 0 1 0

CDR (n) 2.663a 0.85

0.5 8 (30.8) 11 (36.7) 9 (31)

1 17 (65.4) 16 (53.3) 18 (62.1)

2 1 (3.8) 2 (6.7) 2 (6.9)

3 0 (0) 1 (3.3) 0 (0)

GDS (Mean+SD) 3.38 (3.395) 3.90 (3.044) 3.97 (3.530) 0.783 0.676

IADL (Mean+SD) 21.92 (6.958) 22.38 (8.330) 21.21 (8.095) 0.132 0.936

Missing data 1 1 0

CogSym (Mean+SD) 5.50 (1.241) 5.87 (2.145) 5.24 (2.132) 2.133 0.344

Cognitive diagnosis (n) 2.339a 0.674

MCI 8 (30.8) 10 (33.3) 5 (17.2)

AD 7 (26.9) 7 (23.3) 8 (27.6)

Other dementia 11 (42.3) 13 (43.3) 16 (55.2)

a χ

2 test

6.3 Outcome measures data

Data for analysis included results of the cognitive measurements yielded from the

Mindstreams computerized testing battery (primary outcome measures) and results of

behavioral and psychological measurements derived from the questionnaires (secondary

outcome measures).

The Mindstreams data comprised,in addition to the global score and its five

components, two variables from the raw data. These variables were derived from the

executive function domain but were not included in its summary score. Both variables

reflected reaction time for the Go-NoGo task. The first variable (Go-NoGo RT L1)

measures the average response time at level 1, i.e. the appearance of a green square. The

second variable (Go-NoGo RT L2) measures the average response time at level 2, i.e.

the appearance of a white squarein the inhibition stage.Missing data were reported

where insufficient data were recorded for either of these two variables. A higher rate of

52

missing data wasascribed for the Go-NoGo RT L2, as reported in the analysis

tables(Tables 6-14).

Missing data for the behavioral and psychological variables were due to the following

reasons: low responsiveness of family members, partial completion of questionnaires,

and irrelevant questions on scales (e.gthe Qol-AD includes a rank for marriage, which is

not relevant for widowed participants). In order to create an equal basis of comparison,

imputation of incomplete questionnaire items (for a maximum of 40% missing data),

was conducted according to the following rule: imputed total score was calculated as the

completed items' average multiplied by the total number of items.

This was conducted for the QoL-Ad scale (with 5 maximum missing itemsout of a total

of 13), and the short version of the Zarit Caregiver's Burden scale (with 2 maximum

missing itemsof a total of 12).

For the NPI– an average of the total sum of frequency × severity (for completed items)

was calculated (with 5 maximum missing 'frequency × severity' itemsout of a total of

12). Due to the missing data rate, a new variable was created to record the number of

disturbing behaviors, which was reported more often.

For the purpose of comparison between groups, two new variables were created for each

of the outcome measures. The new variables measure the differences between T1and T0

and between T3 and T0. The value of these variables was calculated as pre intervention

scores (T0) subtracted from post intervention scores (T1 and T3 respectively).

6.4 Analysis of results

Mean scores for outcome variables for each of the study groups are described in Table

5. Examination of the mean Global Score over time (see Figure 7) indicates a

progressive increase in both intervention groups, with no dose-response relationship in

the control group (although differences in both cognitive training and control groups

were very slight).

Table 5: Sample mean scores for outcome measures of each of the study groups

Means (SD)

Measure Group T0 T1 T3

Global Rem 71.22 (14.54) 75.86 (12.36) 77.63 (13.22)

CT 77.16 (16.25) 77.62 (17.18) 80.20 (18.19)

Control 77.40 (10.84) 76.10 (13) 79.53 (10.36)

53

Means (SD)


Orientation

Rem

65.96 (28.13)

64.43 (29.51)

68.78 (29.57)

CT 66.03 (33.80) 67.29 (32.89) 69.70 (31.11)

Control 74.72 (23.44) 66.67 (30.35) 72.85 (25.45)

Verbal Function Rem 79.23 (15.71) 85.22 (13.14) 84.26 (16.84)

CT 80.77 (19.70) 84.79 (16.69) 86.04 (19.91)

Control 83.07 (10.16) 83.52 (10.32) 84.74 (11.61)

Memory Rem 64.06 (24.18) 75.72 (18.63) 76.21 (23.69)

CT 79.85 (20.17) 81.94 (21.12) 82.54 (23.33)

Control 76.70 (17.81) 78.08 (19.36) 83.80 (15.65)

Executive function Rem 77.48 (13.86) 80.43 (11.97) 81.94 (11.12)

CT 78.22 (15.55) 80.15 (18.81) 82.15 (18.87)

Control 78.98 (12.96) 77.33 (14.38) 81.42 (10.35)

Visual Spatial Rem 70.73 (20.15) 66.17 (20.14) 72.22 (20.01)

CT 74.70 (20.98) 62.54 (19.66) 73.41 (22.56)

Control 72.13 (19.95) 69.48 (19.78) 64.56 (21.22)

Go-NoGo RT L1 Rem 759.62 (391.13) 676.09 (307.57) 861.04 (496.26)

CT 924.83 (447.47) 854.25 (437.10) 788.81 (389.91)

Control 769.61 (330.31) 923.96 (444.23) 828.52 (364.88)

Go-NoGo RT L2 Rem 610.77 (226.25) 672.45 (304.67) 684.33 (400.95)

CT 694.88 (370.09) 699 (341.10) 624.87 (278.98)

Control 630.13 (201.26) 668.25 (271.08) 644.61 (278.47)

QoL-AD

participant

Rem 33.03 (5.93) 36.88 (4.76) 35.13 (6.61)

CT 33.36 (5.95) 34.63 (6.27) 33.08 (7.01)

Control 32.93 (7.17) 33.45 (6.47) 32.74 (7.54)

WTL Rem 3.56 (1.42) 4.22 (1.17) 4.22 (1.17)

CT 3.97 (1.07) 4.17 (0.81) 4.08 (1.16)

Control 3.66 (1.17) 3.74 (1.20) 3.48 (1.45)

QoL-AD caregiver Rem 31.53 (7.51) 32.77 (6.24) 31.05 (6.84)

CT 29.46 (5.68) 29.12 (6.39) 30.22 (6.71)

Control 29.13 (5.95) 28.26 (6.35) 30.15 (7.29)

Zarit Caregiver

Burden

Rem 16.86 (8.64) 15.53 (8.94) 13.53 (8.45)

CT 14.47 (9.49) 16.28 (9.83) 11.04 (7.03)

Control 13.91 (7.90) 14.95 (9.34) 12.85 (9.44)

54

Means (SD)


NPI-Average Rem 0.68 (0.77) 0.40 (0.63) 0.80 (1.15)

CT 0.86 (0.95) 0.53 (0.77) 0.84 (1.64)

Control 0.78 (0.74) 0.78 (0.94) 1.06 (1.60)

NPI-Number of

behavioral

disturbances

Rem 3.32 (3.00) 2.16 (1.74) 2.40 (2.66)

CT 3.62 (3.17) 2.52 (2.31) 2.96 (2.58)

Control 3 (2.84) 2.65 (2.21) 2.55 (2.65)

Rem=Reminiscence, CT=Cognitive training.

Figure 7.Mean Global scores for study groups in T0, T1 and T3.

Differences from baseline at T1 and T3, for each of the remaining cognitive measures

(except for the Go-NoGo RT L2variable whose sample size was lower due to missing

data)are presented in Figure 8.

The mean scores for orientation in both reminiscence and control groups were lower

than baseline (with a lower decrease in the reminiscence group), whereas the cognitive

training group demonstrated an improvement on this scale.An increase in verbal score

55

Figure 8.Mean differences in cognitive measures between T1&To, and T3&T0 (Error bars show

95% confidence interval).

56

was demonstrated in all three groups with higher ratio for the intervention groups. The

difference in memory scores was higher in the reminiscence group relative to the other

two groups. While reaction time for level 1 was increased in the control group

(representing a slower response over time), reaction time for the cognitive training

group improved. The reminiscence group demonstrated an improved reaction time only

for T1.

In order to compare the two intervention groups to the control group, a univariate

analysis of covariance (ANCOVA) was performed with the difference scores as the

independent variables and the baseline scores as covariates. This would control for

initial group differences on any of the outcome measures. Another reason for using

ANCOVA rather than ANOVA was to overcome a potential bias of the extent of

change. Since a high level on the pretest score actually limits the maximum change

possible (a change of score from 95 to 100, which is the maximum score, does not have

the same relevance as a change from 70 to 75), controlling for baseline scores would

enhance the level of change.

Prior to the performance of the ANCOVA test, the distribution properties of the

dependent variables were examined using skewness and kurtosis measures (Appendix

C). Skewness was not demonstrated for any of the variables, though kurtosis was

demonstrated for some of them (Doane & Seward, 2011).

ANCOVA results for the comparison of T1 and T0 (see Table 6) between reminiscence

and control groups, revealed a significant difference in Go-NoGo RT L1score (p=0.034,

effect size=0.659), which reflected a possible improvement in reaction time (a decrease

of the mean score). An additional significant difference was found in the QoL-AD-

participant score (p=0.047, effect size=0.621). Lastly, marginal significant differences

were found in the Global score (p=0.1, effect size=0.464) and in the WTL score

(p=0.065, effect size=0.492).A marginal significant difference was also found in

Orientation score when comparing T1 and T0 between cognitive training and control

groups (p=0.085, effect size=0.293).

The ANCOVA comparison of T3 and T0 (Table 7) found consistent though slightly

more robust results. Comparison between reminiscence and control groups revealed

significant differences in the QoL-AD-participant score(p=0.06, effect size=0.590), and

in the WTL score (p=0.007, effect size=0.837). A marginally significant difference was

57

found in the Global score (p=0.096, effect size=0.381). Comparison of T3 and T0

between cognitive training and control groups found no significant differences.

The results described above should be interpreted with caution. First, these are

exploratory results. The multiplicity of statistical tests might require the adjustment of

p-value to a lower value, which may significantly decrease the power of the findings.

Secondly, it is important to bear in mind the possible bias in these results due to those

methodological limitations described in chapter 7.

58

Table 6: Comparing T1-T0 scores difference between reminiscence & control groups, and between

cognitive training & control groups - ANCOVA results.

Measure p-Value Effect size a p-Value Effect size

a

Reminiscence (n=23) vs.

Control (n=27)

Cognitive Training (n=28) vs.

Control (n=27)

Global 0.1 0.464 0.287

Orientation 0.614 0.085 0.293

Verbal Function 0.301 0.145

Memory 0.268 0.531

Executive function 0.24 0.274

Visual Spatial 0.654 0.126

Reminiscence (n= 23) vs.

Control (n= 24)

Cognitive Training (n= 28) vs.

Control (n=24)

Go-NoGo RT L1 0.034*b

0.659 0.137

Reminiscence (n= 20) vs.

Control (n= 19)

Cognitive Training (n= 20) vs.

Control (n=19)

Go-NoGo RT L2 0.636 0.344


Control (n=27)


Control (n=27)

QoL-AD participant 0.047* 0.621 0.534

WTL 0.065 0.492 0.234


Control (n=21)


Control (n=21)

QoL-AD caregiver 0.157 0.661


Control (n=19)


Control (n=19)

Zarit Caregiver

Burden

0.474 0.789

59


a


Control (n=15)

Cognitive Training (N=17) vs.

Control (N=15)

NPI-Average 0.417 0.398


Control (n=21)

Cognitive Training (n=24)

vs.Control (n=21)

NPI-Number of

behavioral

disturbances

0.215 0.28

Go-NoGo RT L1=Go-NoGo Response Time Level 1.


a Cohen's d effect size was calculated only for significant and marginally significant

effects. b A Negative difference (T1<T0).

60

Table 7: Comparing T3-T0 scores difference between reminiscence & control groups, and between

cognitive training & control groups - ANCOVA results.


a


Control (n=27)


Control (n=27)

Global 0.096 0.381 0.51

Orientation 0.595 0.523


Memory 0.819 0.476b



Go-NoGo RT L1 0.708 0.257


Control (n=21)


Control (n=21)

Go-NoGo RT L2 0.955 0.377


Control (n=27)


Control (n=27)

QoL-AD participant 0.06 0.590 0.802

WTL 0.007**

0.837 0.153


Control (n=17)


Control (n=17)

QoL-AD caregiver 0.787 0.9

Zarit Caregiver

Burden

0.277 0.122


Control (n=13)

Cognitive Training (N=16) vs.

Control (N=13)

NPI-Average 0.382 0.605

61


a


Control (n=17)

Cognitive training (n=22)

vs.Control (n=17)

NPI-Number of

behavioral

disturbances

0.717 0.861



aCohen's d effect size was calculated only for significant and marginally significant

effects. b A Negative difference (T3<T0).

6.5 An alternative statistical analysis

In light of the questionable normal distribution of the dependent variables (the

difference scores) used for the ANCOVA test, an alternative analysis using non-

parametric tests is proposed. The non-parametric analysis also addresses the limited

sample size in each of the study groups.

As in the case of the parametric analysis, the results described in this chapter should be

interpreted with caution, despite their presented statistical power.

First, Wilcoxon signed rank tests were performed for each of the study groups to

compare their outcome variables scores between T1&T0 andT3&T0. In the

reminiscence group (Table 8) significant differences were observed between T1&T0for

the following variables: memory (p=0.012, effect size= 0.522), executive function

(p=0.048, effect size= 0.412) ,QoL-AD-participant (p=0.016, effect size= 0.504), and

WTL (p=0.007, effect size= 0.558). A significant difference was also found in the NPI-

Num-of-Behav (p=0.030, effect size= 0.560), which reflects an improvement in the

number of disturbing behaviors over time (a decrease of the mean score). In addition,

marginal differences were observed for the global score variable (p=0.057, effect

size=0.396) and for the verbal variable (p=0.080, effect size=0.365).

62

When comparing the reminiscence group at T3 to T1(Table 8), significant effects were

observed for the following variables: global score (p=0.003, effect size=0.623), verbal

(p=0.011, effect size= 0.529), memory (p=0.004, effect size= 0.596), QoL-AD-

participant (p=0.039, effect size=0.440 ), and WTL (p=0.001, effect size=0.685 ). A

significant difference was also found in the Zarit caregiver's burden score (p=0.010,

effect size= 0.607), which reflects a possible decreased burden. Only a marginal

significant difference was observed in the NPI-Num-of-Behav variable (p=0.1, effect

size=0.377), which again reflects a possible improvement in the number of disturbing

behaviors over time (a decrease of the mean score).

Table 8: Changes in outcome measures for reminiscence group between T0 & T1, and T0 & T3 –

Wilcoxon signed-rank test.

Reminiscence

Measure Change between T0 & T1 Change between T0 & T3

n p-Value Effect sizea n p-Value Effect size

a

Global 23 0.057 0.396 23 0.003**

0.623

Orientation 23 0.281 23 0.673

Verbal 23 0.080 0.365 23 0.011* 0.529

Memory 23 0.012* 0.522 23 0.004

** 0.596

Executive 23 0.048* 0.412 23 0.131

Visual

Spatial

23 0.638 23 0.808

Go-NoGo

RT L1

23 0.420 23 0.144

Go-NoGo

RT L2

20 0.852 17 0.796

QoL patient 23 0.016* 0.504 22 0.039

* 0.440

WTL 23 0.007**

0.558 22 0.001* 0.685

QoL

caregiver

15 0.432 18 0.862

Zarit 15 0.789 18 0.010*b 0.6067

NPI 11 0.185 10 0.400

NPI-Num

Behaviors

15 0.030*b 0.560 19 0.100

b 0.377

a Effect size was calculated only for significant and marginally significant effects.

bNegative effect.

63

In the cognitive training group (Table 9), significant differences were observed between

T1&T0 for the following variables: verbal (p=0.009, effect size= 0.491), NPI (p=0.026,

effect size=0.541), and NPI-Num-of-Behav (p=0.021, effect size=0.469 ). For the two

NPI variables a negative difference was observed, which reflected a possible

improvement in behavior (a decrease in scores). However, a significant negative

difference was observed for the visual-spatial variable (p=0.007, effect size= 0.507),

which reflects a possible decreased functionality over time.

When comparing the cognitive training group at T3 to T0 (Table 9), significant

differences were observed for the following variables: verbal (p=0.007, effect

size=0.520), executive function (p=0.036 , effect size=0.405 ), and Zarit caregiver's

burden (p=0.042 , effect size=0.433), which had a negative difference reflecting a

possible decrease in burden.

64

Table 9: Changes in outcome measures for cognitive training group between To & T1, and T0 &

T3 – Wilcoxon signed rank test.

Cognitive Training



a

Global 28 0.387 27 0.136

Orientation 28 0.344 27 0.260

Verbal 28 0.009**

0.491 27 0.007**

0.520

Memory 28 0.249 27 0.360

Executive 28 0.172 27 0.036* 0.405

Visual

Spatial

28 0.007**b

0.507 27 0.573

Go-NoGo

RT L1

28 0.333 27 0.186

Go-NoGo

RT L2

20 0.243 20 0.911

QoL patient 29 0.186 26 0.416

WTL 29 0.249 26 0.463

QoL

caregiver

24 0.875 22 0.626

Zarit 24 0.177 22 0.042*b

0.433

NPI 17 0.026*b

0.541 16 0.142

NPI-Num

Behaviors

24 0.021*b

0.469 23 0.280


bNegative effect.

In the control group (Table 10), a significant difference was observed between T3&T0

memory score (p=0.028, effect size= 0.423). In addition, two negative direction

differences (reflecting a decrease in measure scores) were observed: A significant

differencebetween T3&T1was found in the visual-spatial variable (p=0.036, effect size=

0.403), and a marginal significant difference between T1&T0 was observed in the

orientation variable (p=0.06, effect size= 0.362).

65

Table 10: Changes in outcome measures for control group between To & T1, and T0 & T3 –

Wilcoxon signed rank test.

Control



a

Global 27 0.525 27 0.761

Orientation 27 0.060b 0.362 27 0.257

Verbal 27 0.548 27 0.528

Memory 27 0.294 27 0.028* 0.423

Executive 27 0.773 27 0.614

Visual

Spatial

27 0.345 27 0.036* b

0.403

Go-NoGo

RT L1

24 0.179 27 0.368

Go-NoGo

RT L2

19 0.432 21 0.357

QoL patient 27 0.770 27 0.869

WTL 27 0.364 27 0.906

QoL

caregiver

21 0.643 17 0.435

Zarit 19 0.270 17 0.509

NPI 15 0.814 13 0.386

NPI-Num

Behaviors

21 0.177 17 0.230


bNegative effect.

Although most of the differences were demonstrated within the two intervention groups,

additional comparisons were required to compare the differences between groups. For

this purpose Mann Whitney comparisons were performed between reminiscence and

control groups, and between cognitive training and control groups. Two comparisons

were conducted for each of the pairs, using the difference scores as the dependent

variables (T1-T0, and T3-T0), for each of the outcome variables (TablesTable 11Table

14).

66

When comparing the reminiscence and control groups, significant group effects were

found only for T3-T0 (Table 12). These were found for global score (p=0.037, effect

size= 0.295), and for WTL (p=0.007, effect size= 0.385).Also, marginal significant

effects of group for T3-T0 were observed for QoL-participant (p=0.089, effect size=

0.243), and for Zarit caregiver's burden (p=0.069, effect size= 0.308). For the latter, a

lower mean rank was observed in the reminiscence group, which possibly reflects lower

levels of burden for the reminiscence group in relation to the control group. Lastly, a

marginal significant effect for T3-T0 was found for NPI (p=0.084, effect size= 0.361),

with higher mean rank in the reminiscence group, possibly reflecting lower levels of

disturbing behavior for the control group in relation to the reminiscence group.

Table 11: Comparing 1 month differences between Reminiscence and control groups (Mann

Whitney test)

Measure Mean Rank Statistics

Reminiscence Control U Z p- value Effect

sizea

n=23

n=27

Global 28.80 22.69 234.5 -1.479 0.139

Orientation 26.41 24.72 289.5 -.437 0.662

Verbal 27.74 23.59 259 -1.027 0.304

Memory 28.59 22.87 239.5 -1.384 0.166

Executive 28.54 22.91 240.5 -1.363 0.173

Visual Spatial 24.70 26.19 292 -.361 0.718

n=23 n=24

Go-NoGo RT

L1

20.74 27.13 201 -1.596 0.110

n=20 n=19

Go-NoGo RT

L2

19.35 20.68 177 -0.365 0.715

n=23 n=27

QoL patient 28.89 22.61 232.5 -1.519 0.129

WTL 28.52 22.93 241 -1.448 0.148

n=15 n=21

QoL caregiver 20.07 17.38 134 -0.756 0.449

67



sizea

n=15 n=19

Zarit 15.2 19.32 108 -1.210 0.226

n=11 n=15

NPI 12.14 14.50 67.5 -0.787 0.431

n=15 n=21

NPI-Num

Behaviors

16.97 19.60 134.5 -0.758 0.449

a Effect size was calculated only for significant and marginal significant effects.

Table 12: Comparing 3 months differences between Reminiscence and Control groups (Mann

Whitney test)



sizea

n=23

n=27

Global 30.15 21.54 203.5 -2.083 0.037* 0.295

Orientation 26.78 24.41 281 -0.605 0.545

Verbal 28.00 23.37 253 -1.144 0.253

Memory 27.65 23.67 261 -0.966 0.334

Executive 27.48 23.81 265 -0.886 0.376

Visual Spatial 28.76 22.72 235.5 -1.463 0.143

n=23 n=27

Go-NoGo RT

L1

27.02 24.20 275.5 -0.681 0.496

n=17 n=21

Go-NoGo RT

L2

18.50 20.31 161.5 -0.499 0.618

n=22 n=27

QoL patient 28.84 21.87 212.5 -1.700 0.089 0.243

WTL 30.82 20.26 169 -2.697 0.007**

0.385

68

n=18 n=17

QoL caregiver 16.94 19.12 134 -0.628 0.53

Zarit 14.94 21.24 98 -1.820 0.069 0.308

n=10 n=13

NPI 14.75 9.88 37.5 -1.730 0.084 0.361

n=19 n=17

NPI-Num

Behaviors

18.03 19.03 152.5 -0.292 0.771

aEffect size was calculated only for significant and marginal significant effects.

When comparing the cognitive training and control groups, no significant group effects

were found. However, marginally significant group effects (Table 13) were found for

T1-T0 for orientation (p=0.052, effect size= 0.263), for verbal (p=0.097, effect size=

0.224, and for Go-NoGo-RT-L1 (p=0.086, effect size= 0.238).

Table 13: Comparing 1 month differences between Cognitive training and Control groups (Mann

Whitney test)

Mean Rank Statistics

Measure Cognitive

training

Control U Z p-value Effect

sizea

n=28

n=27

Global 30 25.93 322 -0.943 0.346

Orientation 31.95 23.91 267.5 -1.947 0.052 0.263

Verbal 31.39 24.48 283 -1.661 0.097 0.224

Memory 28.64 27.33 360 -0.304 0.761

Executive 30.45 25.46 309.5 -1.153 0.249

Visual Spatial 25.52 30.57 308.5 -1.173 0.241

n=28 n=24

Go-NoGo RT

L1

23.16 30.40 242.5 -1.716 0.086 0.238

69

n=20 n=19

Go-NoGo RT

L2

20.93 19.03 171.5 -0.520 0.603

n=29 n=27

QoL patient 29.83 27.07 353 -0.632 0.528

WTL 28.21 28.81 383 -0.154 0.878

n=24 n=21

QoL caregiver 23.69 22.21 235.5 -0.377 0.707

n=24 n=19

Zarit 21.96 22.05 227 -0.025 0.980

n=17 n=15

NPI 14.91 18.30 100.5 -1.034 0.301

n=24 n=21

NPI-

Num Behaviors

21.25 25 210 -0.979 0.328


70

Table 14: Comparing 3 months differences between Cognitive training and Control groups (Mann

Whitney test)

Mean Rank Statistics

Measure Cognitive

training

Control U Z p- value Effect

sizea

n=27

n=27

Global 29.69 25.31 305.5 -1.021 0.307

Orientation 29.91 25.09 299.5 -1.166 0.244

Verbal 30.89 24.11 273 -1.613 0.107

Memory 25.24 29.76 303.5 -1.059 0.290

Executive 30.59 24.41 281 -1.445 0.148

Visual Spatial 29.65 25.35 306.5 -1.010 0.313

n=27 n=27

Go-NoGo RT

L1

24.15 30.85 274 -1.566 0.117

n=20 n=21

Go-NoGo RT

L2

20.10 21.86 192 -0.470 0.639

n=26 n=27

QoL patient 27.94 26.09 326.5 -0.436 0.663

WTL 28.19 25.85 320 -0.579 0.562

n=22 n=17

QoL caregiver 19.82 20.24 183 -0.113 0.910

Zarit 18.18 22.35 147 -1.138 0.255

n=16 n=13

NPI 15.25 14.69 100 -0.177 0.859

n=22 n=17

NPI-Num

Behaviors

20.18 19.76 183 -0.118 0.906


71

6.6 Summary of findings

Table 15 and Table 16 summarize the significant and marginally significant effects that

were found in the between group analyses. Effect size was determined according to

Cohen's criteria (Cohen, 1988).All effects described in the tables represent possible

improvements in the intervention group (reminiscence or cognitive training) compared

to control group.

Table 15: Level of significance and effect size for effects found in the reminiscence group compared

to control group, according to the method of analysis.

T1-T0 T3-T0

Measure ANCOVA Mann Whitney ANCOVA Mann Whitney

Global MS

(ES=Medium)

--- MS

(ES=Small-

Medium)

S

(ES=Medium)

Go-NoGo RT

L1

S

(ES=Medium)

--- --- ---

QoL-AD

patient

S

(ES=Medium)

--- MS

(ES=Medium)

MS

(ES=Small-

Medium)

WTL MS

(ES=Medium)

--- S

(ES=Large)

S

(ES=Medium)

Zarit --- --- --- MS

(ES=Medium)

NPI --- --- --- MS

(ES=Medium)

MS=Marginally significant

S=Significant

ES=Effect Size

--- = No effect found

72

Table 16: Level of significance and effect size for effects found in the cognitive training group

compared to control group, according to the method of analysis.

T1-T0 T3-T0

Measure ANCOVA Mann Whitney ANCOVA Mann Whitney

Orientation MS

(ES=Small)

MS

(ES=Small-

Medium)

--- ---

Verbal --- MS

(ES=Small-

Medium)

--- ---

Go-NoGo RT

L1

--- MS

(ES=Small-

Medium)

--- ---

MS=Marginally significant

S=Significant

ES=Effect Size


The summary of results shows some consistency over time for the effects that were

found in the reminiscence group (Table 15) for the following measures: global score,

QoL-AD-patient and WTL. Although these effects were not demonstrated using the

non-parametric analysis in the T1-T0 comparison, they are salient in all other three

analyses. Improvements in the Go-NoGo RT L1 measure was demonstrated only in T1-

T0 analysis when using the parametric method, while improvements in the Zarit

Caregiver's Burden and the NPI were demonstrated only in T3-T0 analysis when using

the non-parametric method.

Overall, a higher accordance of the two analysis methods was shown in the T3-T0

analysis compared to the T1-T0 analysis.

When comparing the cognitive training and the control groups (Table 16), an adverse

tendency was noticed. Here, effects were found only in T1-T0 analysis. These were

more modest (in terms of significance level and effect size), and related mostly to the

73

following measures: orientation, verbal and Go-NoGo RT L1. Accordance of the two

analysis methods was found only for the orientation measure.

6.7 Results segmented by MMSE scores

In order to gain a wider insight regarding the potential effect of both treatments on the

participants' cognitive function, a further analysis of the primary outcome measures was

conducted. The analysis was based on the separation of participants into different

groups according to their MMSE scores: a high MMSE score group (where scores

ranged from 22 to 26), and a low MMSE score group (where scores ranged from 14 to

21). Both parametric and non- parametric evaluations were conducted for each of the

MMSE score groups (see appendices D and E respectively).

6.7.1 Parametric evaluation

ANCOVA results of the comparison between reminiscence and control groups in the

high MMSE group, revealed only marginally significant differences in the following

variables when comparing T3 and T0: global score (p=0.051, effect size=0.736) and

verbal function (p=0.088, effect size=0.59). No differences were demonstrated for the

T1 to T0 comparison (Table 17). In the low MMSE group, no differences were found in

any of the T1-T0 or T3-T0 comparisons (Table 18).

The ANCOVA comparison between cognitive training and control groups in the high

MMSE group, revealed a decrease of the visual-spatial score in the cognitive training

group at T1 compared to T0, which was marginally significant (p=0.094, effect

size=0.928). No effects were found for the T3 to T0 comparison (Table 17). However, a

positive effect was observed in the low MMSE group (Table 18): T3- T0 yielded a

significant difference in the visual-spatial score (p=0.047, effect size=0.82), reflecting

an improvement in the cognitive training group over time. In addition, the comparison

of T1 to T0 revealed a marginally significant difference in the global score (p=0.071,

effect size=0.84).

74

6.7.2 Non-parametric evaluation

Analysis of primary outcome measures using Mann Whitney evaluation showed similar

results. When comparing the reminiscence and control groups, a group effect was found

only in the high MMSE group. The effect was revealed in the global score for T3-T0

comparison (Table 12), and was marginally significant (p=0.053, effect size=0.369).

When comparing the cognitive training and control groups, the high MMSE group

showed a significant group effect for T1-T0 (Table 21), which was observed in the

visual-spatial score (p=0.005, effect size=0.497), with a lower mean rank for the

cognitive training group, which again, reflects a decrease over time. No effects were

found for T3-T0 comparison in this group (Table 22). However, differences were found

in the low MMSE group: For T1-T0 comparison (Table 25), significant effects were

found for global score (p=0.031, effect size=0.442) and orientation (p=0.042, effect

size= 0.448). Also, marginally significant effect was observed in the verbal function

score (p=0.084, effect size=0.367). Lastly, a marginally significant difference was found

also in T3-T0 comparison (Table 26), for the visual-spatial score (p=0.067, effect size=

0.387).

6.7.3 Summary of results according to grouped MMSE scores

Table 17 presents the summary of the results, and includes the main findings that were

observed in both methods (parametric and non-parametric).

Table 17: Summary of results segmented by MMSE scores – main findings

High MMSE Low MMSE

Group T1-T0 T3-T0 T1-T0 T3-T0

Reminiscence --- Global score --- ---

Cognitive

Training

Visual Spatial(b)

--- Global score

Orientation

Verbal

Visual Spatial


b=Negative effect

75

7. Discussion

Based on the current research of using individual reminiscence therapy and cognitive

training interventions in dementia care, this study's objective was to evaluate the

benefits of two such computer-based interventions, while addressing the calls for more

rigorous studies. This was done by taking the following steps mentioned by

Subramanian and Woods (2012) and Bahar-Fuchs et al. (2013).

1) Selecting a wide range of outcome measures, in order to assess impact on both

subjects and family members. Outcome variables included aspects of cognitive

function, behavior, quality of life (from both subject and caregiver's points of view) and

caregiver burden.

2) Including subjects with a wide range of cognitive impairment (MMSE score of 14-

26) to address 'ceiling' or 'floor' effects

3) Including subjects from seven different day care centers in order to mitigate the effect

of 'institution's settings'.

4) Controlling for baseline differences between treatment and control groups by

stratifying the allocation to groups according to the severity of pre-treatment cognitive

impairment in each daycare center.

5) Ensuring the quality of the implementation of the interventions (reminiscence therapy

and cognitive training) in order to create a clear format for each intervention,

minimizing the effect of other elements as much as possible.

Based on the study’s results, both the computer-based reminiscence and cognitive

training interventions demonstrated possible differences over time for several outcome

measures. The results showed different trends in the effects of each of the interventions.

However, most of these results are of low statistical power and need to be cautiously

interpreted since they may be due to methodological limitations.

7.1 The reminiscence therapy

A between- subjects analysis comparing the reminiscence and control groups showed

some improvement in the intervention group in three measures: global cognitive score,

QoL-AD-patient and WTL. Although this improvement was not significant in most

76

instances, it was consistent at both the one month and the three months follow-up

evaluations, representing a medium effect size.

Since no effects were found for any of the individual measures constituting the global

score (orientation, verbal function, memory, executive function and visual-spatial), the

subtle change found in the global score may be ascribed to the accumulation of small

but consistent improvements in some or all of its five components.

Both quality of life and the will to live (as reported by the participants) showed a subtle

change over time in the reminiscence group compared to the control group. Since the

WTL measure was found in previous study to be influenced by the perceived quality of

life (Carmel, 2001), the change in both measures strengthen the findings that the

computer-based reminiscence intervention might had a positive effect on the

psychological well-being of the participants. This effect was not seen in the cognitive

training group, and therefore might be explained by the therapeutic nature of the

reminiscence intervention, which is classified as a combination of cognitive and

emotion-focused approaches (Ponnusamy and Woods ,2012).

It is interesting to note that although quality of life, as perceived by the participants,

seemed to have improved in the reminiscence group –this finding was not corroborated

by family members (no effect was found in the QoL-AD-family measure). This could

stem from the fact that the QoL-AD tool evaluates subjective impressions. Both

participants and family members are asked to rate each of the 13 aspects of life

according to their own beliefs. Some of these aspects do not necessarily reflect mood

(for example: physical health, living situation, friends, money, etc).While the participant

might feel an improvement in QoL and thus rate life aspects higher, the family member

may not alter impressions of his relative’s quality of life (apart from energy, memory

and mood that may have changed due to the intervention).Also, most of the participants

did not live with their family informants, and therefore subtle changes in the patients'

QoL could have been missed by the caregivers.

Marginally significant effects of the reminiscence intervention were found in the NPI

and Zarit caregiver's burden's measures, but only at three months of treatment.

However, these effects were demonstrated only when using the non-parametric analysis

method, and did not reach a level of significance. Together with the fact that the sample

size of the analyzed data of both measures was low (due to a high rate of missing data),

only tentative conclusions can be reached based on this finding.

77

Regarding the Zarit caregiver's burden measure: lower levels of burden reported by

family members could be the result of a methodological bias, reflecting their awareness

that their relative was being engaged in a treatment that might be beneficial (family

members of participants in the reminiscence group were not blinded to the assignment

to groups, since they had to provide the personal materials that was used in the

intervention). This is also supported by the fact that no effect was found in the quality of

life of patients as perceived by family members.

The possible improvement that was observed in the NPI measure concur with the

conclusions of Brodaty and Arasaratnam's meta-analysis (2012) that psychosocial

interventions may be effective in reducing behavioral symptoms. However, as has been

argued, this finding should be regarded with caution due to the particular high rate of

missing data associated with the NPI tool in our study.

In the reminiscence group, we found a reduced reaction time in the Go-NoGo task,

which is included in the executive function index, as determined by the ANCOVA in

T1. This effect was not demonstrated either by using the non-parametric analysis or at

the T3 evaluations. Although this effect was found to be significant at T1, the relevance

of this finding is limited, since the use of ANCOVA assumes normal distribution of the

data.

7.2 The cognitive training

When comparing the cognitive training intervention group to controls, only marginally

significant effects were found after one month of treatment. However, no effects were

observed at three months. At T1, a possible improvement in orientation was found in

both methods of analysis, with a small to medium effect size. When referring to the four

cognitive areas of training of the program (language skills, calculation, non-verbal

memory and visual-spatial skills), this finding seems surprising since there was no

specific orientation training administered. In contrast, other areas that are included in

the Savion training software (such as verbal and memory skills) did not demonstrate any

change. If this finding may be ascribed to the routine of treatments (the conduction of

frequent training sessions over a period of time, it should have been also observed in the

reminiscence group. However, whereas the reminiscence group demonstrated a subtle

general change in the global cognitive score, the cognitive training group demonstrated

78

a specific change in the orientation skill, which might be the result of general reinforced

senses achieved by the constant practice of this training.

Additional effects were observed in verbal function and in the reaction time of the Go-

NoGo task, though these findings were not confirmed when using the parametric

analysis method.

These findings may imply that there might be a positive effect of the computer-based

cognitive training intervention on some of the cognitive function measures. This is in

line with Bahar-Fuchs et al.'s (2013) systematic review on RCTs of cognitive training

interventions, which found no clear indication of benefit for cognitive training but

concluded that more sensitive tools are needed for evaluation. The current study used

the Mindstreams tool which enables a more sensitive and detailed evaluation of aspects

of cognitive function, and subtle changes following one month of treatment were

noticed. However, the significant results of a previous study (Dwolatzky, 2009), which

included a similar intervention (a one month bi-weekly treatments with the Savion

system), were not replicated in this study. Whereas Dwolatzky found clear evidence for

the effectiveness of cognitive training after one month in global score and memory in

subjects with mild dementia, these effects were not demonstrated in the current study.

This could be due to a greater range of pre-intervention cognitive impairment of the

participants in our study, since we included participants with cognitive impairment

ranging from mild cognitive impairment (MCI) to mild and moderate dementia.

Nevertheless it should be noted that the analysis of results segmented by MMSE scores

for the cognitive outcome measures showed that whereas the high MMSE group

(MMSE score of 22-26) demonstrated only a decrease in the visual-spatial measure in

the cognitive training group compared to control (at one month), more significant

changes with a larger effect size were found in fact in the low MMSE group. These

included effects in global score and orientation at T1 evaluation, and effect in visual-

spatial measure at T3 evaluation.

Conversely, the low MMSE group demonstrated no effects in the reminiscence group

compared to control, while the high MMSE showed marginally significant effects with

medium effect size in global score and verbal function. Despite the limited samples size

which decrease the statistical power of the results, the difference in trends between the

two types of interventions might be ascribed to the nature of each intervention: whereas

79

cognitive training demands lower cognitive capabilities and can be applied using a very

low level of exercise (the Savion software supports the adjustment of difficulty level),

reminiscence therapy requires a reasonable ability for conversing and speaking

coherently in order to benefit from the intervention.

7.3 Limitations and future work

Despite addressing the limitations in previous studies, which were noted by

Subramanian and Woods (2012) and Bahar-Fuchs et al. (2013), this study is not free of

its own limitations. First, allocation to the groups was not blinded, and therefore

subjects' self report could have been influenced by their knowledge

of group assignment. Family members of subjects who were assigned to the

reminiscence group were also aware of the allocation, since they had to provide the

personal materials, and were therefore at the same risk for bias.

Second, the assessors were not blinded to the subjects’ condition, thus having a

potential bias on the evaluation. Of note though is that in the case of administering the

cognitive function evaluation using the Mindstreams tool, the evaluation process is

structured and is minimally dependent on the administrator's input, and therefore the

potential for bias in assessing the participants’ cognitive functioning is limited, although

still exist.

Third, the control group was not offered an alternative intervention in order to create a

"neutral" or "sham therapy" group. The fact that the control group was not engaged in a

one-on-one intervention could also serve as a bias factor, since it can be argued that the

personal contact between the subject and the person administering the intervention may

have a beneficial effect on the participants. However, since different effects were found

for each of the intervention groups in this study, it can be concluded that the personal

contact with the mediator was not the main factor for the improvements that were

found, but rather the intervention itself. Moreover, a previous study by Haslam et al.

(2010) which compared group intervention of reminiscence, individual reminiscence

and group participation in a social activity, found enhanced memory performance and

enhanced well being in the group-based interventions rather than in the individual

reminiscence group. This finding mitigates the effect of the one-on-one interaction.

80

Fourth, we could not reach the desired sample size of the study. This study was initially

planned to include 159 subjects for a treatment duration of six months. Due to various

challenges in the recruitment process (See Section 8.2 for more details), a final sample

size of only 95 participants out of 167 recruited patients actually entered the study and

underwent randomization (see chapter 6). Due to a high rate of withdrawal during the

study, only 81% of participants completed all three evaluations. In addition, missing

data further decreased the sample size. The limited sample size available for analysis

significantly weakened the statistical power of the data analysis. The duration of

treatment was also shortened to three months instead of the planned six months, as a

result of the various challenges we encountered. However, the treatment's duration and

frequency of this study is still more extensive than most of the RCT studies that

evaluated individualized reminiscence therapy for people suffering from dementia

(Ponnusamy and Woods ,2012).

Fifth, since this was an exploratory study, multiple statistical tests were conducted to

inquire possible effects. According to the recommendations for the analysis of these

types of studies, corrections to the p-value which was used were not done, since this

could decrease the power of finding and as a result major findings might be missed

(Bender & Lange, 2001; Perneger, 1998; Rothman, 1990) .As a result, the likelihood of

type I error was high, and thus interpretation of the results should be made cautiously.

Sixth, strict adherence to protocol was sometimes difficult to maintain, due to external

factors that were beyond our control. For example: evaluations that were postponed or

missed due to participants' absence, a change in the schedule of the day care center or a

family member who could not be reached for an interview. Also, missing treatments due

to similar reasons resulted in postponing or even cancelling scheduled evaluations.

Rocket attacks in the southern district of Israel during November 2012 led to 3 of the

adult day care centers located in Beer-Sheva being closed for 8 days. This had

implications on the study in terms of breaking the continuity of treatments, postponing

evaluations and placing more stress on participants.

Lastly, another limitation stemmed from the fact that the adult day care centers' staff

proposed a list of potential participants who they believed would meet the inclusion

criteria, and these participants were approached to participate in the study. Although all

the participants underwent screening to evaluate their suitability, other suitable

candidates may have been overlooked.

81

8. Impressions and Challenges

In addition to the statistical analyses, I collected data and personal observations, both

my own and those of the other research staff who administered the interventions to the

study participants. The main impressions from those observations are presented in this

chapter.

8.1 Impressions of the study

Although the participants’ initial responses to the computerized systems varied, a

common trend was noticed following the first few sessions. When first introduced to

either system most of the participants expressed concern over their lack of experience in

working with computers and that they may not succeed in working with the software.

After the second session most subjects were used to the software, knew what to expect

at any point and could operate the software themselves. The ease of use of the

reminiscence system by the subjects was also demonstrated in our previous study

(Sarne-Fleischmann & Tractinsky, 2008).

In general, most of the participants liked the interventions, many looked forward to their

bi-weekly treatments and a number even came to look for the research assistant

administering the intervention, or would wait for outside the computer room for their

turn. This was true particularly for the higher functioning subjects whose schedule was

more free, and who used to select their own activities at the day care center.

The following sections describe impressions of each group's intervention.

8.1.1 Reminiscence

A range of behaviors was observed in the reminiscence group. Some subjects were more

verbal and tended to converse fluently with the person administering the session. These

participants were satisfied with only a few objects during a session, and usually used

them as a trigger for additional associative memories. However, more introverted

participants tended to observe more objects during a session and were rather "bounded"

to the presented object. Consequently, the "optimal" number of objects for each

participant was, to some extent, dependent on the level of the participant's cognitive

function. Participants who suffered from significant memory impairment would relate to

82

the same objects every session, repeating the same stories, whereas participants with

higher cognitive function would feel bored when watching the same objects. Still, for

the participants who repeated the same stories, eventually new details that had not been

mentioned previously would emerge, triggered by the same objects.

Photos of deceased family members or friends usually provoked distressful feelings,

although some participants nevertheless wished to relate to them in their discussions.

It usually took more time for the participants in the reminiscence group to trust the

research staff member and to speak more freely about their memories (compared to the

participants in the cognitive training group). This was to be expected since the

reminiscence intervention involved more personal content, and therefore a basic level of

familiarity was required in order to establish a meaningful conversation. This may also

support the statistical finding of stronger effects in the reminiscence group after three

months of treatments than after one month of working with the system.

Adjusting the contents to the participant seemed to be one of the key factors for the

success of the computer-based system. The personal contents must include materials

that the participant would like to talk about and this should be constantly reappraised.

Family members, who in most cases served as the agents who provided the personal

materials, were not always aware of their relative's areas of interest. Therefore,

materials obtained from family members should be used as baseline objects, but there is

also a constant need for renewing the repository of personal contents, according to the

impressions gained in the course of treatments. Such monitoring and updating is likely

to increase the benefit of personalized reminiscence therapy.

Lastly, the computer-based reminiscence sessions must be handled carefully by an

appropriate and qualified administrator, who is sensitive enough to the participant's

needs, and is able to navigate the conversation according to the feedback received

during each session.

8.1.2 Cognitive training

Most of the subjects in the cognitive training group were able to use the system and

worked the computer themselves, with only a little assistance from supervisors. Some

also used the keyboard themselves when needed (in the case of typing numbers).

83

However, subjects usually preferred to use the touch screen interface, for all features

that were supported by the program.

Participants who expressed their satisfaction from using the system also seemed to

become more alert during the 3 months duration of the treatment sessions. One of the

participants defined the contribution of treatment as helping her to become more

attentive to questions she is being asked, and solving problems more easily in daily life.

Another subject's daughter has reported an improvement in her mother's behavior, as

she remembered to take her daily medicines.

Subjects usually became more confident and positive through working on the computer.

A few subjects refused to participate initially, but usually became more enthusiastic

later on.

Most of the participants had 1-2 areas of cognitive training that they liked most, and

one area they felt to be more challenging. Some of the participants preferred to work

more with the areas they felt they were more competent with, while some preferred to

work on those areas presenting a greater challenge.

It was sometimes difficult to keep participants focused at the training session, since as

the supervisors and the subject got to know each other better, the subjects would prefer

to talk about other matters. In such instances, time was allotted for discussion at the end

of the session.

84

8.2 Challenges

The study posed many administrative challenges due to the special characteristics of the

study population and the influence of many external factors.

The study demanded a long period of preparation, mainly because of the need to

coordinate with different centers and personnel that were not part of the research team,

and usually had their own busy timetable. For example: asking for informed consent of

participants required coordination between the signing researcher, the independent

specialist (who confirmed the competence of candidates), the staff of the day care

center, and the candidate’s availability (due to different days of attending the day care

center).

Also, the process of attaining approvals from the management of the day care center

was longer than expected in some, due to formal administrative requirements or

managerial decisions. For example, the manager of a large day care center canceled its

participation in the study just before the study was about to commence.

In addition, major efforts were made in approaching the candidates' family relatives and

introducing them to the study's goals and procedure, in order to obtain their approval for

participation. Presenting the study to groups of relatives at the day care centers as well

as individual telephonic approaches yielded a very modest response, and resulted in a

prolonged recruitment process.

Cooperation of family relatives remained a challenge throughout the study. This was

reflected many times in the need for recurrent requests to complete interviews for the

purpose of screening and periodic evaluations (T0, T1 and T3), which sometimes led to

missing evaluations where responses were delayed. Furthermore, numerous instances of

lack of cooperation were found in the reminiscence group, when subjects' relatives were

asked to provide personal contents for the intervention sessions. Lack of responsiveness

of the relatives after several attempts usually led to the exclusion of the subject from the

study (in cases where the subject could not provide the personal contents himself).

One of the study’s major challenges was to maintain the continuity of treatments,

adhering to the protocol requirements of two treatments per a week for each subject, for

a duration of three months. The difficulties stemmed from a range of reasons: First,

subjects' absence due to illness, medical tests, personal events and external carers'

unavailability (in the case where escort to the day care center was required). Secondly, a

changing schedule of activities at the day care centers (due to: trips, special lectures,

85

parties, etc) also affected the planned schedule of treatments, in addition to holiday

vacations when the centers were closed. Although we tried as much as possible to

address these changes and to reschedule treatment sessions , this was not always

possible due to the different days each subject attended the day care center, or to

unavailability of the computer rooms that in some centers were used for other purposes

on different days and hours.

All of these issues and challenges strained the study’s resources and required constant

monitoring and adjustments in study administration, prolonged its duration and

decreased the number of participants in the study and of data points (i.e., evaluations at

T1 and T3) of those who did participate in the study.

Lastly, the multiplicity of centers and their dispersed locations, the long duration of

treatments, and the large number of screening and evaluation tests needed for both

subjects and family caregivers, required considerable financial support. Unfortunately,

the support for this study was limited, only partially addressing its actual needs.

Working within these limited resources required occasionally creative solutions to

overcome the difficulties and to preserve the continuity of the study.

86

9. Conclusion

Reminiscence therapy and cognitive training are two different non-pharmacological

treatments that are used in dementia care. Due to methodological limitations, few

controlled studies and lack of sensitive assessment tools, there is still no clear evidence

as to whether these interventions provide significant benefits in patients with cognitive

impairment.


dementia, while some of them are used to support existing treatment interventions.

The goal of this dissertation was to conduct a methodologically sound study to evaluate

the contribution of computer-based personalized reminiscence and cognitive training

interventions on the cognitive function and well-being of patients with dementia, as well

as the effects on family caregiver burden.

This study found some positive results for both computer-based reminiscence and

cognitive training interventions over an intervention period of three months compared to

a control group. These included improvements in some aspects of cognitive function in

the two intervention groups, and improvements in quality of life and the will to live

among the reminiscence group's participants. However, due to the limited sample size

available for final analysis these effects were insufficient to draw firm conclusions.

An interesting finding was the difference in the outcomes of each intervention, which

supports the benefits of the interventions themselves rather than the possible effect of

personal contact with a supervisor.

In light of our findings, we believe that these two computer-supported interventions

have potential as therapeutic modalities for elderly people with cognitive impairment

and dementia. Since computer-based systems improve the availability of these

interventions, patients may benefit from using them in their own homes with the support

of family members or personal caregivers. In addition, this would allow for ongoing

exposure to the programs and increase the possible clinical and research prospects of

these non-pharmacological interventions.

87

References

[1] Alm, N., Astell, A., Ellis, M., Dye, R., Gowans, G., & Campbell, J. (2004). A

cognitive prosthesis and communication support for people with dementia. Journal

of Neuropsychological Rehabilitation 14 (1&2), 117-134.

[2] Bahar-Fuchs, A., Clare, L. & Woods, B. (2013). Cognitive training and cognitive

rehabilitation for mild to moderate Alzheimer’s disease and vascular dementia.

Cochrane Database of Systematic Reviews, Issue 6.

[3] Baines, S., Saxby, P. & Ehlert, K. (1987). Reality orientation and reminiscence

therapy. A controlled cross-over study of elderly confused people. The British

Journal of Psychiatry 151, 222-231.

[4] Baumgarten, M., Battista, R., Infante-Rivard, C., Hanley, J., Becker, R. & Gauthier,

S. (1992). The psychological and physical health of family members caring for an

elderly person with dementia. Journal of Clinical Epidemiology, 45, 61–70.

[5] Bédard, M., Molloy, D. W., Squire, L., Dubois, S., Lever, J. A. & O'Donnell, M.

(2001). The Zarit Burden Interview: A New Short Version and Screening Version.

Gerontologist, 41, 652-657.

[6] Beinart, N., Weinman, J., Wade, D. & Brady, R. (2012). Caregiver burden and

psycho educational interventions in Alzheimer's disease: a review. Dementia and

Geriatric Cognitive Disorders Extra, 2(1), 638-48.

[7] Bender, R. & Lange, S. (2001). Adjusting for multiple testing-when and how?

Journal of Clinical Epidemiology, 54, 343–349.

[8] Birks, J. (2006). Cholinesterase inhibitors for Alzheimer's disease (2006). Cochrane

Database Systematic Reviews, 25 (1).

[9] Brodaty, H. & Arasaratnam, C. (2012). Meta-analysis of non pharmacological

interventions for neuropsychiatric symptoms of dementia. American Journal of

Psychiatry, 169, 946–953.

[10] Brodaty, H. & Donkin, M. (2009). Family caregivers of people with

dementia. Dialogues in Clinical Neuroscience, 11,217–228.

http://psy.st-andrews.ac.uk/people/lect/aja3.shtml

http://www.ncbi.nlm.nih.gov/pubmed?term=B%C3%A9dard%20M%5BAuthor%5D&cauthor=true&cauthor_uid=11574710

http://www.ncbi.nlm.nih.gov/pubmed?term=Molloy%20DW%5BAuthor%5D&cauthor=true&cauthor_uid=11574710

http://www.ncbi.nlm.nih.gov/pubmed?term=Squire%20L%5BAuthor%5D&cauthor=true&cauthor_uid=11574710

http://www.ncbi.nlm.nih.gov/pubmed?term=Dubois%20S%5BAuthor%5D&cauthor=true&cauthor_uid=11574710

http://www.ncbi.nlm.nih.gov/pubmed?term=Lever%20JA%5BAuthor%5D&cauthor=true&cauthor_uid=11574710

http://www.ncbi.nlm.nih.gov/pubmed?term=O%27Donnell%20M%5BAuthor%5D&cauthor=true&cauthor_uid=11574710

88

[11] Cahn-Weiner, D. A, Malloy, P. F., Rebok, G. W. & Ott, B. R. (2003). Results of

a randomized placebo-controlled study of memory training for mildly impaired

Alzheimer's disease patients. Applied Neuropsychology, 10(4), 215-223.

[12] Carmel, S. (2001). The will to live: gender differences among elderly persons.

Social Science and Medicine , 52, 949-958.

[13] Carmel, S. (2011). The will to live as an indicator of well-being and a predictor

of survival in old age. In: Poon, L. & Cohen-Mansfield, J. (Eds.), Understanding

well-being in the oldest-old (pp. 281-289). Cambridge: Cambridge University Press.

[14] Carswell, W. , McCullagh, P. J., Augusto, J. C, Martin, S., Mulvenna, M.

D., Zheng, H. et al. (2009). A review of the role of assistive technology for people

with dementia in the hours of darkness. Technology and health care 17(4), 281-304.

[15] Cerejeira, J., Lagarto, L. & Mukaetova-Ladinska, E. B. (2012). Behavioral and

psychological symptoms of dementia. Frontiers in Neurology 3, 73.

[16] Chertkow, H., Feldman, H. H., Jacova, C. & Massoud, F. (2013). Definitions of

dementia and predementia states in Alzheimer's disease and vascular cognitive

impairment: consensus from the Canadian conference on diagnosis of dementia.

Alzheimer's Research and Therapy, S(Suppl 1):S2; 1-8.

[17] Clare, L. & Woods, B. (2008). Cognitive rehabilitation and cognitive training

for early-stage Alzheimer’s disease and vascular dementia. The Cochrane Library;

Issue 4.

[18] Clare, L., Woods, R.T., Moniz-Cook E.D., Orrell, M. & Spector, A. (2003).

Cognitive rehabilitation and cognitive training for early stage Alzheimer’s disease

and vascular dementia. Cochrane Database of Systematic Reviews, Issue 4.

[19] Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.).

Hillsdale, NJ: Lawrence Erlbaum Associates.

[20] Cohene, T., Baecker, R. M., Marziali, E., & Mindy, S. (2006). Memories of a

life: A design case study for Alzheimer’s disease. In J. Lazar (Ed.), Universal

Usability (pp. 357–487). Chichester: John Wiley and Sons.

[21] Courtney, C., Farrell, D., Gray, R., Hills, R., Lynch, L., Sellwood, E., et al.

(2004). Long-term donepezil treatment in 565 patients with Alzheimer's disease

(AD2000): randomized double-blind trial. Lancet 363, 2105-2115.

http://www.ncbi.nlm.nih.gov/pubmed?term=McCullagh%20PJ%5BAuthor%5D&cauthor=true&cauthor_uid=19822946

http://www.ncbi.nlm.nih.gov/pubmed?term=Augusto%20JC%5BAuthor%5D&cauthor=true&cauthor_uid=19822946

http://www.ncbi.nlm.nih.gov/pubmed?term=Martin%20S%5BAuthor%5D&cauthor=true&cauthor_uid=19822946

http://www.ncbi.nlm.nih.gov/pubmed?term=Mulvenna%20MD%5BAuthor%5D&cauthor=true&cauthor_uid=19822946

http://www.ncbi.nlm.nih.gov/pubmed?term=Mulvenna%20MD%5BAuthor%5D&cauthor=true&cauthor_uid=19822946

http://www.ncbi.nlm.nih.gov/pubmed?term=Zheng%20H%5BAuthor%5D&cauthor=true&cauthor_uid=19822946

http://europepmc.org/search?page=1&query=AUTH:%22Courtney+C%22

http://europepmc.org/search?page=1&query=AUTH:%22Farrell+D%22

http://europepmc.org/search?page=1&query=AUTH:%22Gray+R%22

http://europepmc.org/search?page=1&query=AUTH:%22Hills+R%22

http://europepmc.org/search?page=1&query=AUTH:%22Lynch+L%22

http://europepmc.org/search?page=1&query=AUTH:%22Sellwood+E%22

89

[22] Cummings, J.L., Mega, M., Gray, K., Rosenberg-Thompson, S., Carusi, D.A. &

Gornbein, J. (1994). The Neuropsychiatric Inventory: comprehensive assessment of

psychopathology in dementia. Neurology 44, 2308-2014.

[23] Doane, D.P. & Seward, L.E. (2011). Measuring Skewness: A Forgotten

Statistic? Journal of Statistics Education, 19(2),1-18.

[24] Dwolatzky, T., Dimant, L., Simon, E. S & Doniger G. M. (2010). Validity of a

short computerized assessment battery for moderate cognitive impairment and

dementia. International Psychogeriatrics, 22(5), 795-803.

[25] Dwolatzky, T., Whitehead, V., Doniger, G.M., Simon, E.S., Schweiger, A.,

Jaffe, D. et al. (2003). Validity of a novel computerized cognitive battery for mild

cognitive impairment. BMC Geriatrics 3, 4-16.

[26] Dwolatzky, T., Zilbershlag, Y., Friger, M. & Grinshpun, Y. Computerized

cognitive training in patients with mild dementia. (2009, July). Presented at: The

19th International Association of Gerontology and Geriatrics World Congress of

Gerontology and Geriatrics, Paris, France.

[27] Etters, L., Goodall, D. & Harrison, B.E. (2008). Caregiver burden among

dementia patient caregivers: a review of the literature. Journal of the American

Academy of Nurse Practitioners, 20(8), 423–428.

[28] Farina, E., Fioravanti, R., Chiavari, L., Imbornone, E., Alberoni, M., Pomati, S.

et al. (2002). Comparing two programs of cognitive training in Alzheimer's disease:

a pilot study. Acta Neurologica Scandinavica, 105, 365-371.

[29] Ferri, C. P., Prince, M., Brayne, C., Brodaty, H., Fratiglioni, L., Ganguli, M. et

al. (2005). Global prevalence of dementia: A Delphi consensus study. Lancet

366:2112–2117.

[30] Finkel, S. I, Costa E Silva, J., Cohen, G., Miller, S. & Sartorius, N. (1997)

Behavioural and psychological signs and symptoms of dementia: a consensus

statement on current knowledge and implications for research and treatment.

International Journal of Geriatric Psychiatry 12 (Issue 11), 1060-1061.

[31] Folstein, M. F., Folstein, S. E., McHugh, P. R. (1975). "Mini-Mental State": a

practical method for grading cognitive states of patients for the clinician. Journal of

Psychiatric Research 12, 189-98.

http://www.aggjournal.com/medline/record/ivp_00016314_105_365






http://www.ncbi.nlm.nih.gov/pubmed?term=Ferri%20CP%5BAuthor%5D&cauthor=true&cauthor_uid=16360788

http://www.ncbi.nlm.nih.gov/pubmed?term=Prince%20M%5BAuthor%5D&cauthor=true&cauthor_uid=16360788

http://www.ncbi.nlm.nih.gov/pubmed?term=Brayne%20C%5BAuthor%5D&cauthor=true&cauthor_uid=16360788

http://www.ncbi.nlm.nih.gov/pubmed?term=Brodaty%20H%5BAuthor%5D&cauthor=true&cauthor_uid=16360788

http://www.ncbi.nlm.nih.gov/pubmed?term=Fratiglioni%20L%5BAuthor%5D&cauthor=true&cauthor_uid=16360788

http://www.ncbi.nlm.nih.gov/pubmed?term=Ganguli%20M%5BAuthor%5D&cauthor=true&cauthor_uid=16360788

90

[32] Freedman, M., Leach, L., Kaplan, E., Delis, D., Shulman, K. & Winocur, G.

(1994). Clock drawing: a Neuropsychological Analysis. New York: Oxford

university press.

[33] Freeman, E., Clare, L., Savitch, N., Royan, L., Litherland, R., & Lindsay, M.

(2005). Improving website accessibility for people with early-stage dementia: A

preliminary investigation. Aging & Mental Health 9(5), 442-448.

[34] Gates, N., Sachdev, P., Fiatarone-Singh, M. & Valenzuela, M. (2011). Cognitive

and memory training in adults at risk of dementia: A Systematic Review. BMC

Geriatrics 11(1), 55-69.

[35] Gibson, F. What can reminiscence contribute to people with dementia? (1994).

In J. Bornat (Ed), Reminiscence reviewed: Evaluation, Achievements, Perspectives

(pp.46-60). Buckingham: Open University Press.

[36] Gitlin, L. N., Kales, H. C. & Lyketsos, C. G. (2012). Nonpharmacologic

management of behavioral symptoms in dementia. The Journal of the American

Medical Association, 308, 2020–2029.

[37] Goldwasser, A.N., Auerbach, S.M. & Harkins, S.W. (1987). Cognitive, affective

and behavioral effects of reminiscence group therapy on demented elderly.

International Journal of Aging and Human Development 25(3), 209-222.

[38] Günter, V. K., Schafer, P., Holzner, B. J., Kemmler, G. W. (2003). Long-term

improvements in cognitive performance through computer-assisted cognitive

training: a pilot study in a residential home for older people. Aging Mental Health,

7(3), 200-206.

[39] Haight, B. K., Gibson, F., Michel, Y. (2006) The Northern Ireland life

review/life storybook project for people with dementia, Alzheimer's & Dementia 2,

56-58.

[40] Haslam, C., Haslam, S. A., Jetten, J., Bevins, A., Ravenscroft, S. & Tonks, J.

(2010). The social treatment: the benefits of group interventions in residential care

settings. Psychology and Aging, 25, 157–167.

[41] Hofmann, M., Hock, C., Kühler, A., & Müller-Spahn, F. (1996). Interactive

computer-based cognitive training in patients with Alzheimer’s disease. Journal of

Psychiatric Research 30(6), 493-501.

91

[42] Holsapple, C. W., Pakath, R. & Sasidharan, S. (2005). A website interface

design framework for the cognitively impaired: A study in the context of

Alzheimer’s disease. Journal of Electronic Commerce Research 6(4), 291-303.

[43] http://www.alz.org/what-is-dementia.asp. Last accessed: September 2013.

[44] Jackson, A. (1991). To reminisce or not to reminisce. Irish Journal of

Psychological Medicine, 8(2), 147-148.

[45] Kinney, J. M., Kart, C. S., Murdoch, L. D., & Conley, C. J. (2004). Striving to

provide safety assistance for families of elders: The SAFE house project. Dementia,

3, 351-370.

[46] Lauriks, S., Reinersmann, A., Van der Roest, H. G., Meiland, F. J., Davies, R.

J., Moelaert, F., et al. (2007). Review of ICT-based services for identified unmet

needs in people with dementia. Ageing Research Reviews, 6(3), 223–46.

[47] Lawrence, V., Fossey, J., Ballard, C., Moniz-Cook, E. & Murray, J. (2012).

Improving quality of life for people with dementia in care homes: making

psychosocial interventions work. British Journal of Psychiatry, 201(5), 344-51.

[48] Lawton, M.P. & Brody, E.M. (1969). Assessment of older people: self-

maintaining and instrumental activities of daily living. Gerontologist, 9(3), 179-186.

[49] Logsdon, R. G., Gibbons, L. E., McCurry, S. M. & Teri, L. (1999). Quality of

life in Alzheimer's disease: patient and caregiver reports. Journal of mental health

and aging, 5, 21-32.

[50] LoPresti, E.F., Mihailidis, A., & Kirsch, N. (2004). Assistive technology for

cognitive rehabilitation: state of the art. Neuropsychological Rehabilitation, 14, 5-

39.

[51] McPherson, A., Furniss, F.G., Sdogati, C., Cesaroni, F., Tartaglini, B., &

Lindesay, J. (2001). Effects of individualized memory aids on the conversation of

persons with severe dementia: a pilot study. Aging & Mental Health 5(3), 289-294.

[52] Mioshi, E., Dawson, K., Mitchell, J., Arnold, R., & Hodges, J. R. (2006). The

Addenbrooke’s Cognitive Examination Revised (ACE-R): A brief cognitive test

battery for dementia screening. International Journal of Geriatric Psychiatry, 21,

1078–1085.

http://www.alz.org/what-is-dementia.asp


http://www.ncbi.nlm.nih.gov/pubmed?term=Moniz-Cook%20E%5BAuthor%5D&cauthor=true&cauthor_uid=23118034

http://www.ncbi.nlm.nih.gov/pubmed?term=Murray%20J%5BAuthor%5D&cauthor=true&cauthor_uid=23118034

92

[53] Morgan, S. & Woods, R.T. (2010). Life review with people with dementia in

care homes: a preliminary randomized controlled trial. Non-pharmacological

Therapies in Dementia,1, 43–59.

[54] Morris, J. (1993). The CDR: current version and scoring rules. Neurology, 43,

2412-2413.

[55] Nomura, T. (2002). Evaluative research on reminiscence groups for people with

dementia. In: Webster, J. D. & Haight, B. K. (Eds) Critical advances in

reminiscence work: From theory to application (pp. 289-299). New York, NY, US:

Springer Publishing Co.

[56] O'Brien, J. T. & Burns, A. (2011). Clinical practice with anti-dementia drugs: a

revised (second) consensus statement from the British Association for

Psychopharmacology. J Psychopharmacology, 25(8), 997-1019.

[57] Perneger, T. V. (1998). What's wrong with Bonferroni adjustments, British

Medical Journal, 31, 1236-1238.

[58] Plassman, B. L., Langa, K. M., Fisher, G. G, Heeringa, S. G., Weir, D. R.,

Ofstedal, M. B., et al. (2007). Prevalence of dementia in the United States: The

aging, demographics, and memory study. Neuroepidemiology, 29(1–2), 125–32.

[59] Prince, M., Bryce, R., Albanese, E., Wimo, A., Ribeiro, W. & Ferri, C. P.

(2013). The global prevalence of dementia: A systematic review and meta analysis.

Alzheimer's & Dementia 9(1), 63-75. e2.

[60] Rothman, K. J. (1990). No adjustments are needed for multiple comparisons.

Epidemiology ,1(1), 43-6.

[61] Sarne-Fleischmann, V. & Tractinsky, N. (2008). Development and evaluation

of a personalized multimedia system for reminiscence therapy in Alzheimer’s

patients. Int. J. Social and Humanistic Computing, 1(1), 81–96.

[62] Schreiber, M., Lutz, K., Schweizer, A., Kalveram, K.Th. & Jäncke, L. (1998).

Development and Evaluation of an Interactive Computer-Based Training as a

Rehabilitation Tool for Dementia. Psychologische Beitraege, 40(1), 85-102.

[63] Schӧlzel-Dorenbos, C. J., Draskovic, I., Vernooij-Dassen, M. J. & OldeRikkert,

M. G. (2009). Quality of life and burden of spouses of Alzheimer disease patients.

Alzheimer Disease and Associated Disorders, 23, 171–177.

http://cirrie.buffalo.edu/database/journals/489/

93

[64] Scogin, F. & McElreath, L. (1994). Efficacy of psychosocial treatments for

geriatric depression: a quantitative review. Journal of Consulting and Clinical

Psychology, 62, 69-74.

[65] Subramaniam, P. & Woods, B. (2010) Towards the therapeutic use of

information and communication technology in reminiscence work for people with

dementia: a systematic review, International Journal of Computers in Healthcare

1(2), 106 – 125.

[66] Subramaniam, P. & Woods B. (2012). The impact of individual reminiscence

therapy for people with dementia: systematic review. Expert Review of

Neurotherapeutics, 12(5), 545-555.

[67] Taylor, F. (2005). Care managers’ views on assistive technology. Journal of

Dementia Care, 13, 32-36.

[68] The Alzheimer’s Forum .http://www.alzforum.org. Last accessed: September

2013.

[69] The Story Table. http://www.storytable.com/html/home.html. Last accessed:

September 2013.

[70] Thies, W. & Bleiler, L.(2013). Alzheimer’s disease facts and figures.

Alzheimer's & Dementia 9, 208-245.

[71] Thorgrimsen, L., Schweitzer, P. & Orrell, M. (2002). Evaluating reminiscence

for people with dementia: a pilot study. The Arts in Psychotherapy, 29, 93–97.

[72] Topo, P., Mäki, O., Saarikalle, K., Clarke, N., Begley, E., Cahill, S., et al. (2004)

Assessment of a music-based multimedia program for people with dementia.

Dementia 3(3), 331-350.

[73] Vasse E., Vernooij-Dassen, M., Cantegreil, I., Franco, M., Dorenlot, P., Woods,

B. et al. (2012). Guidelines for psychosocial interventions in dementia care: a

European survey and comparison. Int. Journal of Geriatric Psychiatry, 27(1),40-48.

[74] Vernooij-Dassen, M., Vasse, E., Zuidema, S., Cohen-Mansfield, J. & Moyle, W.

(2010). Psychosocial interventions for dementia patients in long-term care.

International Psychogeriatrics, 22(7),1121-1128.

[75] Woods, B. (1994). Management of memory impairment in older people with

dementia. International Review of Psychiatry 6, 153–161.

http://www.inderscience.com/info/inarticle.php?artid=37457



http://www.alzforum.org/

http://www.storytable.com/html/home.html


http://www.ncbi.nlm.nih.gov/pubmed?term=Vasse%20E%5BAuthor%5D&cauthor=true&cauthor_uid=20813074


http://www.ncbi.nlm.nih.gov/pubmed?term=Cohen-Mansfield%20J%5BAuthor%5D&cauthor=true&cauthor_uid=20813074

http://www.ncbi.nlm.nih.gov/pubmed?term=Moyle%20W%5BAuthor%5D&cauthor=true&cauthor_uid=20813074

http://www.ncbi.nlm.nih.gov/pubmed/20813074

94

[76] Woods, B., Spector, A. E, Jones, C. A, Orrell, M. & Davies, S. P. (2005).

Reminiscence therapy for dementia. Cochrane Database of Systematic Reviews,

Issue 2.

[77] Yesavage, J.A., Brink, T.L., Rose, T.L., Lum, O., Huang, V., Adey, M.B et al.

(1983). Development and validation of a geriatric depression screening scale: A

preliminary report. Journal of Psychiatric Research, 17, 37-49.

95

Appendices

Appendix A: Savion screens

Language - Synonyms

Math

96

Memory

Shapes

97

Appendix B: Mindstreams sample report and screens

100

Appendix C: Normality test for dependent variables - results of skewness and Kurtois

measures for primary outcome measures

N Skewness Kurtosis

Statistic Statistic Std. Error Statistic Std. Error

Global_T1T0 78 .099 .272 -.130 .538

Orientation_T1T0 78 -.110 .272 -.144 .538

Verbal_T1T0 78 .770 .272 1.044 .538

Memory_T1T0 78 -.001 .272 .828 .538

Executive_T1T0 78 -.627 .272 1.707 .538

VisualSpatial_T1T0 78 .512 .272 .449 .538

Go-NoGo RT L1_T1T0 75 .595 .277 2.512 .548

Go-NoGo RT L2_T1T0 59 .654 .311 2.619 .613

Global_T3T0 77 .201 .274 1.301 .541

Orientation_T3T0 77 .217 .274 .852 .541

Verbal_T3T0 77 -.070 .274 .127 .541

Memory_T3T0 77 -.301 .274 1.779 .541

Executive_T3T0 77 .301 .274 1.576 .541

VisualSpatial_T3T0 77 .421 .274 .615 .541

Go-NoGo RT L1_T3T0 77 -.308 .274 .604 .541

Go-NoGo RT L2_T3T0 58 -.588 .314 3.137 .618

Valid N (listwise) 49

101

Appendix D: High and low MMSE groups – parametric analysis

Table 17: Comparing scores differences (T1-T0, T3-T0) between reminiscence & control groups,

and between cognitive training & control groups - ANCOVA results for participants with high

MMSE score (between 22-26)

T1-T0

Measure Reminiscence (n=11) vs.

Control (n=17)


Control (n=17)

p-value Effect size a p-value Effect size

a

Global 0.103 0.960



Memory 0.174 0.639


Visual Spatial 0.847 0.094 b 0.928

T3-T0


Control (n=17)


Control (n=17)


a

Global 0.051 0.736 0.402


Verbal Function 0.088 0.59 0.105

Memory 0.209 0.706



a Cohen's d effect size was calculated only for significant and marginal significant

effects. b A Negative difference (lower decrease in score in the control group comparing to the

cognitive training group).

102

Table 18: Comparing scores differences (T1-T0, T3-T0) between reminiscence & control groups,

and between cognitive training & control groups - ANCOVA results for participants with low

MMSE score(between 14-21).

T1-T0

Measure Reminiscence (n=12) vs.

Control (n=10)


Control (n=10)


a

Global 0.351 0.071 0.84



Memory 0.705 0.409



T3-T0


Control (n=10)


Control (n=10)


a

Global 0.685 0.447



Memory 0.351 0.316


Visual Spatial 0.167 0.047* 0.82

a Cohen's d effect size was calculated only for significant and marginal significant

effects.

103

Appendix E: High and low MMSE groups – non parametric analysis

Table 19: Comparing 1 month differences between Reminiscence and control groups - Mann

Whitney test for participants with high MMSE score (between 22-26).


Reminiscence

(n=11)

Control

(n=17)

U Z Exact

p-value

Effect

sizea

Global 17.18 12.76 64 -1.388 0.175

Orientation 14.09 14.76 89 -0.230 0.853

Verbal 16.05 13.50 76.5 -0.820 0.430

Memory 13.50 12.53 60 -1.579 0.122

Executive 16.55 13.18 71 -1.059 0.306

Visual Spatial 14.09 14.76 89 -0.212 0.853


Table 20: Comparing 3 months differences between Reminiscence and control groups - Mann

Whitney test for participants with high MMSE score(between 22-26).


Reminiscence

(n=11)

Control

(n=17)

U Z Exact

p-value

Effect

sizea

Global 18.27 12.06 52 -1.952 0.053 0.369

Orientation 14.73 14.35 91 -0.123 0.926

Verbal 16.73 13.06 69 -1.180 0.264

Memory 17.41 12.62 61.5 -1.510 0.134

Executive 17.18 12.76 64 -1.390 0.175

Visual Spatial 15.91 13.59 78 -0.730 0.487


104

Table 21: Comparing 1 month differences between cognitive training and control groups - Mann

Whitney test for participants with high MMSE score (between 22-26).


CT

(n=14)

Control

(n=17)

U Z Exact

p-value

Effect

sizea

Global 14.64 17.12 100 -0.754 0.468

Orientation 16.68 15.44 109.5 -0.390 0. 710

Verbal 16.36 15.71 114 -0.210 0.860

Memory 14.93 16.88 104 -0.599 0.570

Executive 17.39 14.85 99.5 -0.774 0.444

Visual Spatial 11.04 20.09 49.5 -2.768 0.005**b

0.497

CT=Cognitive Training a Effect size was calculated only for significant and marginal significant effects. bNegative effect (lower decrease in score in the control group comparing to the cognitive training group)

Table 22: Comparing 3 months differences between cognitive training and control groups - Mann

Whitney test for participants with high MMSE score(between 22-26).


CT

(n=14)

Control

(n=17)

U Z Exact

p-value

Effect

sizea

Global 16.00 16.00 119 0 1.0

Orientation 17.25 14.97 101.5 -0.723 0.493

Verbal 17.89 14.44 92.5 -1.098 0.297

Memory 15.25 16.62 108.5 -0.419 0.681

Executive 17.39 14.85 99.5 -0.774 0.444

Visual Spatial 15.07 16.76 106 -0.518 0.625

CT=Cognitive Training a Effect size was calculated only for significant and marginal significant effects.

105

Table 23: Comparing 1 month differences between Reminiscence and control groups - Mann

Whitney test for participants with low MMSE score (between 14-21).


Reminiscence

(n=12)

Control

(n=10)

U Z Exact

p-value

Effect

sizea

Global 12.71 10.05 45.5 -0.956 0.346

Orientation 12.46 10.35 48.5 -0.799 0.456

Verbal 12.42 10.40 49 -0.743 0.497

Memory 12.21 10.65 51.5 -0.561 0.582

Executive 12.75 10.00 45 -0.990 0.346

Visual Spatial 12.00 10.90 54 -0.397 0.722


Table 24: Comparing 3 months differences between Reminiscence and control groups - Mann



Reminiscence

(n=12)

Control

(n=10)

U Z Exact

p-value

Effect

sizea

Global 12.75 10.00 45 -0.989 0.346

Orientation 12.21 10.65 51.5 -0.602 0.582

Verbal 12.04 10.85 53.5 -0.437 0.674

Memory 11.21 11.85 56.5 -0.232 0.821

Executive 11.58 11.40 59 -0.066 0.974

Visual Spatial 13.25 9.40 39 -1.390 0.180


106

Table 25: Comparing 1 month differences between cognitive training and control groups - Mann



CT

(n=14)

Control

(n=10)

U Z Exact

p-value

Effect

sizea

Global 15.14 8.80 33 -2.167 0.031 0.442

Orientation 15.00 9.00 35 -2.193 0.042 0.448

Verbal 14.64 9.50 40 -1.799 0.084 0.367

Memory 13.96 10.45 49.5 -1.203 0.235

Executive 13.43 11.20 57 -0.761 0.472

Visual Spatial 14.32 9.95 44.5 -1.498 0.138


Table 26: Comparing 3 months differences between cognitive training and control groups - Mann

Whitney test for participants with low MMSE score(between 14-21).


CT

(n=13)

Control

(n=10)

U Z Exact

p-value

Effect

sizea

Global 13.88 9.55 40.5 -1.520 0.131

Orientation 12.77 11.00 55 -0.641 0.563

Verbal 13.23 10.40 49 -0.997 0.343

Memory 10.46 14.00 45 -1.245 0.232

Executive 13.62 9.90 44 -1.303 0.208

Visual Spatial 14.27 9.05 35.5 -1.857 0.067 0.387


107

Appendix F: Screening and evaluation tools

GDS

Choose the best answer for how you have felt over the past week:

Score 1 0

No Yes 1. Are you basically satisfied with your life?

Yes No 2. Have you dropped many of your activities and interests?

Yes No 3. Do you feel that your life is empty?

Yes No 4. Do you often get bored?

No Yes 5. Are you in good spirits most of the time?

Yes No 6. Are you afraid that something bad is going to happen to you?

No Yes 7. Do you feel happy most of the time?

Yes No 8. Do you often feel helpless?

Yes No 9. Do you prefer to stay at home, rather than going out and

doing new things?

Yes No 10. Do you feel you have more problems with memory than

most?

No Yes 11. Do you think it is wonderful to be alive now?

Yes No 12. Do you feel pretty worthless the way you are now?

No Yes 13. Do you feel full of energy?

Yes No 14. Do you feel that your situation is hopeless?

Yes No 15. Do you think that most people are better off than you are?

2

התערבויות אישיות מבוססות מחשב עבור זקנים עם ירידה קוגניטיבית ודמנציה

"דוקטור לפילוסופיה"מחקר לשם מילוי חלקי של הדרישות לקבלת תואר

מאת

פליישמן-סרנה ורדית

הוגש לסינאט אוניברסיטת בן גוריון בנגב

3102ספטמבר ד"תשרי תשע

באר שבע

3

התערבויות אישיות מבוססות מחשב עבור זקנים עם ירידה קוגניטיבית ודמנציה

"דוקטור לפילוסופיה"מחקר לשם מילוי חלקי של הדרישות לקבלת תואר

מאת

פליישמן-סרנה ורדית

הוגש לסינאט אוניברסיטת בן גוריון בנגב

________________________________________יםאישור המנח

________________________________________

______________ש קרייטמן"אישור דיקן בית הספר ללימודי מחקר מתקדמים ע

3102 ספטמבר ד"תשרי תשע

באר שבע

4

:העבודה נעשתה בהדרכת

נעם טרקטינסקי' פרופ

ר צבי דוולצקי"ד

הנדסת תעשייה וניהול: במחלקה

הנדסה: בפקולטה

5

הצהרת תלמיד המחקר עם הגשת עבודת הדוקטור לשיפוט

(:אנא סמן: )בזאתה /אני החתום מטה מצהיר

להוציא עזרת ההדרכה שקיבלתי מאת , חיברתי את חיבורי בעצמי___

.ים/מנחה

___ החומר המדעי הנכלל בעבודה זו הינו פרי מחקרי מתקופת היותי

תלמיד/ת מחקר.

למעט עזרה , בעבודה נכלל חומר מחקרי שהוא פרי שיתוף עם אחרים___

לפי כך מצורפת בזאת הצהרה על .טכנית הנהוגה בעבודה ניסיונית

.שאושרה על ידם ומוגשת בהסכמתם, תרומתי ותרומת שותפי למחקר

_________________ה /שם התלמיד________ תאריך

__________חתימה

6

תקציר

דמנציה מוגדרת באופן רשמי כתסמונת רפואית של ירידה קוגניטיבית חמורה מספיק בכדי להפריע

בנוסף להשלכות הקוגניטיביות של (. 3' עמ, 3102, ועמיתיו Chertkow)לתפקוד חברתי או תעסוקתי

.םפסיכיאטריי-אנשים עם דמנציה חווים מגוון רחב של תסמינים נוירו, דמנציה

שלישים ממספר הלוקים ואחראית לכשני, מחלת האלצהיימר היא הגורם הנפוץ ביותר של דמנציה

כיום אין עדיין תרופה למחלת האלצהיימר או לרוב המחלות הגורמות לתסמונת . בתסמונת זו

ובמקרה הטוב הן יכולות לתת מענה , להתערבויות תרופתיות ישנה יעילות מוגבלת. הדמנציה

מינים יכולות להקל על תס, התערבויות פסיכו סוציאליות והקפדה על סגנון חיים. לתסמינים

.קוגניטיביים והתנהגותיים ולתת תמיכה למטפלים

מחקרים שבדקו . שתי התערבויות שאינו תרופתיות הינן טיפול בהעלאת זיכרונות ואימון קוגניטיבי

את ההשפעות של טיפולים אלו סברו כי בכוחן לשפר את התפקוד הקוגניטיבי באנשים עם דמנציה

מספר מועט של , בשל מגבלות מתודולוגיות, עם זאתיחד . ובמבוגרים עם סיכון לפתח דמנציה

אין עדיין עדות ברורה לתועלות משמעותיות , מחקרים מבוקרים וחוסר בכלי הערכה רגישים דיים

.של התערבויות אלו

נעשה תכנון של מערכות ממוחשבות לטיפול באנשים עם דמנציה הכולל אתרי , באופן גובר והולך

טכנולוגיה מסייעת ומערכות מחשב למטרות , ממוחשבים לניטור כלים, אינטרנט המספקים מידע

.טיפולים על בסיס רגשי בטיפול בדמנציה

מערכת ממוחשבת לטיפול : מחקר זה בדק שתי התערבויות מבוססות מחשב עבור חולי דמנציה

שתי ההתערבויות הושוו לקבוצת . ומערכת ממוחשבת לאימון קוגניטיבי, אישי בהעלאת זיכרונות

ההשוואה נעשתה באמצעות כלי נוירו פסיכולוגי ממוחשב המיועד להערכת התפקוד . ביקורת

.בנוסף נבדקו ההשפעות של ההתערבויות על בני משפחות החולים. הקוגניטיבי של החולים

גויסו למחקר ועברו , המתגוררים בקהילה, נבדקים מבוגרים עם ירידה קוגניטיבית או דמנציה 061

נבדקים שובצו באופן אקראי לאחת 59מתוכם . על מנת לקבוע את חומרת המחלההערכה ראשונית

אימון קוגניטיבי מבוסס ( 3); העלאת זיכרונות אישית מבוססת מחשב( 0: )משלוש הקבוצות הבאות

הנבדקים שקיבלו טיפול בהעלאת זיכרונות או אימון קוגניטיבי השתתפו . קבוצת ביקורת( 2); מחשב

. חודשים 2למשך תקופה של , י מטפל"שהועברו ע, דקות כל אחד 21בני , ועבשני טיפולים בשב

: וכללו, חודשי טיפולים 2ולאחר , לאחר חודש של טיפולים, ההערכות בוצעו לפני תחילת הטיפולים

, (NeuroTraxשל חברת , י שימוש במבחן המיינדסטרימס הממוחשב"ע)הערכת תפקוד קוגניטיבי

, AD-Qolי שימוש בשאלוני איכות חיים "ע)ות התנהגותיות אצל החולים רווחה פסיכולוגית והפרע

י שימוש בגרסה "ע)ועומס בקרב המטפל , (NPIוהפרעות התנהגותיות , WTLהרצון לחיות

(.Zarit Caregiver Burden Interviewהמקוצרת של שאלון עומס מטפל

משתתפים אשר בנוסף 59ונים לגבי וכלל נת, פרמטריות-ניתוח הנתונים נעשב בשיטות פרמטריות וא

לא נמצאו הבדלים בין . חודשים 2השלימו לפחות אחת מהערכות חודש או , לביצוע הערכות הבסיס

.הקבוצות מבחינת המשתנים הדמוגרפיים בתחילת המחקר

השפעות של הקבוצה נמצאו בניתוח , בהשוואה בין קבוצת העלאת הזיכרונות לקבוצת הביקורת

, נבדק-איכות חיים, global score: חודשים עבור המשתנים הבאים 2חודש ובזמן הפרמטרי בזמן

7

שיפור במדד זמן התגובה . חודשים 2פרמטרי בזמן -שיפורים אלו נמצאו גם בניתוח א. והרצון לחיות

Go-NoGo RT L1 בעוד ששיפור בעומס המטפל , נמצא רק בהערכת חודש בשיטה הפרמטרית

(enZarit Caregiver's Burd ) ובהפרעות ההתנהגותיות(NPI ) חודשים 2נמצאו רק בהערכות

2הייתה תאימות גבוהה יותר בין שתי שיטות הניתוח בהערכת , באופן כללי. פרמטרית-בשיטה א

.חודשים יחסית להערכת חודש

היות וההשפעה , נצפתה מגמה הפוכה, בהשוואת קבוצת האימון הקוגניטיבי מול קבוצת הביקורת

השפעה זו הייתה מועטה והתייחסה בעיקר למדדים . ה נמצאה רק בהערכת חודששל הקבוצ

תאימות בין שתי שיטות הניתוח . NoGo RT L1-Goזמן תגובה -ו orientation ,verbal: הבאים

.orientation-נמצאה רק עבור מדד ה

עבור שתי ההתערבויות מבוססות המחשב בהשוואה חיוביותלמרות שהמחקר מצא תוצאות

ההשפעות שנמצאו , בשל גודלו המצומצם של המדגם עליו בוצע הניתוח הסופי, לקבוצת הביקורת

נדרשים מחקרים מבוקרים אקראית נוספים , לפיכך. אינן מספיקות להסקת מסקנות חד משמעיות

ים שנמצאו בין שני סוגי ההתערבויות ראוי כי ההבדלים המעניינ, בנוסף. בעלי מדגם רחב יותר

.ייחקרו לעומק יותר

-אינטראקצית אדם, אימון קוגניטיבי, העלאת זיכרונות, מחלת אלצהיימר, דמנציה: מילות מפתח

תפקוד , התערבויות מוכוונות רגש, טכנולוגיה מסייעת, התערבויות פסיכו סוציאליות, מחשב

.קוגניטיבי

computer-supported personal interventions for elderly

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