Developing CIRCA-BC and Exploring the Role of the Computer as a Third Participant in Conversation

Abstract

The Computer Interactive Reminiscence Conversation Aid (CIRCA) is a software program using touch screen technology and digital materials from public archives to support conversation between people with dementia and their carers. In this 2-phase study, we first worked with seniors’ focus groups to identify and select relevant content for a regional adaptation of CIRCA (British Columbia version of CIRCA [CIRCA-BC]). We then pilot tested CIRCA-BC with 3 participants having dementia and a conversation partner, analyzing their interactions to explore how they drew on program content and format to shape their conversations together. Findings provide insight into, first, how participants’ shared and distinct social histories influence reminiscence-based conversations and, second, how the computer can be viewed as a third “participant” in the interaction. These findings offer guidelines for ongoing adaptation and application of the CIRCA program in addition to contributing further evidence regarding the role of technology in facilitating meaningful interaction between people with dementia and their carers.

Introduction

The impact of dementia on communication abilities poses significant challenges in maintaining successful social interactions between people with dementia and their carers. For example, in Alzheimer’s disease (AD), progressive memory and language impairments are associated with problems such as word-finding difficulties and repetitiveness, even in relatively early stages of the disease. ¹ As the disorder progresses, people with AD have increasing difficulty making meaningful contributions to everyday talk while their conversation partners must gradually take on more of the work of initiating new topics, keeping conversation going, and repairing breakdowns when they occur. ^{2 –4} For carers who are not familiar with a person with dementia, these conversational challenges can significantly hamper their efforts to get to know that individual as a person with a unique history situated within a broader social context. ⁵ Without such knowledge, carers can be faced with additional challenges in finding common conversational ground, leading to fewer conversations together and placing the person with dementia at ever greater risk of social isolation.

One approach that has shown promise in identifying topics for conversations for people with dementia is reminiscing. ⁶ Long-term autobiographical memories are relatively well preserved in dementia, and memories formed in childhood and early adulthood in particular can be stimulated by means of photos or other artifacts to provide a shared context for conversations together. ^7,8 Recently, the proliferation of accessible digital technologies and online archives offers new approaches for supporting reminiscence-based conversations with persons having dementia. ^9,10 One example is a software program called Computer Interactive Reminiscence Conversation Aid (CIRCA), which uses touch screen technology to enable users to access generic (ie, nonpersonalized) digitized media including photos, short video clips, and music. ¹¹ CIRCA was developed in Dundee, Scotland, with approximately 600 media files intended to be relevant to residents of the Dundee area, both globally (eg, clips from movies like Casablanca or The Wizard of Oz) and locally (eg, photos of a local Dundee street). The program is easy to use, even for those with no previous computer experience; it uses neither mouse nor keyboard, and no training is required. Users are offered a choice of 3 of 7 possible themes (eg, entertainment, childhood, or Dundee life). After touching the screen to select a theme, they are offered a choice of photos (each accompanied by a title and short descriptive caption), music, or video clips, and subsequently make choices within the selected category.

A key feature of CIRCA is that it randomly selects media for each session. This feature promotes greater equality between participants because neither controls which media will be included in a given session. The touch screen technology further enhances this equality by making it easier for a participant with dementia to select from among the presented items. These features, in addition to the computer screen itself as a focus of joint attention, were found to contribute to greater engagement and enjoyment for people with dementia and their carers in a research study that compared their conversations together using CIRCA with those during a session in which carers supplied photos and other artifacts. ¹¹

These findings have led to the speculation that the content and format of the program make the computer an integral element that mediates the interaction between the 2 participants. ¹² However, this view of the computer as a third party in a social interaction has not yet been systematically explored, leaving several intriguing questions as yet unanswered.

First is the question of content: if the computer is to randomly select materials as topics for interactions, which materials are most likely to facilitate conversation between a participant with dementia and a conversation partner? This question is particularly important if the program is to be adapted for use beyond Dundee. The original CIRCA materials were not customized for individuals but, rather, were part of a shared cultural heritage in Dundee, with many of the items specific to that location. The success of CIRCA in stimulating reminiscence-based conversation is consistent with research findings that more durable emotional memories can be triggered by stimuli relevant to the place in which one spent one’s early years. ¹³ What is not known is how specific to a particular place (and time) these materials should be. This matter takes on additional significance in view of the changing demographics of today’s world, where communities are becoming more multilayered and diverse and growing numbers of seniors are aging in places other than those of their early years. These questions invite further research using a locally adapted version of CIRCA designed specifically to explore these issues. The current study represents a first step in this direction, with the primary objective being to develop and evaluate a process for adapting the CIRCA program for a specific location, drawing on the concept of place-based reminiscence to gain insight into the extent to which shared and distinct social histories of people from varied cultural and geographic communities should be represented.

Second is a question related to format. Although previous research about CIRCA suggests that technological features of the program facilitate participants’ interactions together, it does not specify exactly how participants with dementia and their conversation partners draw on these features to mediate their interaction. Pilot testing of a locally adapted version of CIRCA in the current study provided us with an opportunity to include a secondary objective, that is, to develop and evaluate a methodology for describing the interactions between participants with dementia, their conversation partners, and the computer itself.

Context for this Research

The context for this study is the Canadian province of British Columbia (BC), a large, geographically diverse region where most of the population is located in 2 metropolitan areas (Metro Vancouver and Victoria), with the remainder distributed across smaller towns and rural areas. In addition to First Nations people, immigrants primarily from Great Britain, Europe, Japan, China, and South Asia populated the province from the late 19th to mid-20th centuries. From 1951 to 2011, the population nearly quadrupled, primarily through immigration, from 1.17 to 4.40 million people, ¹⁴ adding to ethnic and linguistic diversity within the province.

For the purposes of the current study, we focused on a population cohort born between approximately 1920 and 1940 and growing up in urban and rural areas of BC. Also, our own research experience with First Nations and Japanese Canadian individuals with dementia ^15,16 highlighted the need to consider the perspectives of these groups, given the long history of colonization of First Nations peoples and the internment of Japanese Canadians in World War II.

Methods

The study included 2 phases. Phase 1 involved focus groups of community-dwelling seniors without dementia who participated in the evaluation and selection of media for a BC version of CIRCA (CIRCA-BC). Phase 2 involved pilot testing the CIRCA-BC program with dyads comprising a participant with dementia and a conversation partner. Ethics approval was received from all appropriate university and health authority behavioral ethics boards.

Phase 1: Building CIRCA-BC With Focus Groups

Participants

A combination of purposive and convenience sampling was used to recruit seniors with no significant cognitive impairment for a series of focus groups. In order to ensure some geographic diversity, initial recruitment was accomplished through community seniors’ programs in 2 geographically diverse regions of the province, one of which included a large urban center and the other a smaller resource-based (rural) community. Recruitment criteria specified an age range of 70 years or older, fluency in English, and self-identification as a long-time resident of BC. This final criterion was phrased in this way because, while it was our hope to recruit participants who had spent at least part of their childhood in the province, we were concerned that setting this as a recruitment criterion would be too restrictive, given the demographic characteristics of the province.

In all, 10 and 11 participants were recruited for the urban and rural focus groups, respectively. Because there appeared to be no Japanese Canadian or First Nations participants in either of these initial groups, purposive sampling was also used to invite participation of Japanese Canadian seniors in the urban setting and First Nations Elders in the rural setting (with the age criterion lowered for the latter group, due to difficulties in recruiting sufficient participants older than 70 years). In all, 7 Japanese Canadian seniors and 4 First Nations elders (one of whom had also participated in the first rural focus group) took part in new focus groups in these respective settings. For a final focus group, 8 participants were recruited through an independent living facility in the urban region. In total, there were 39 participants ranging in age from 64 to 87 years.

Participants were asked to complete a questionnaire about their place of birth, places of residence throughout their life, and other areas of BC that were familiar to them. Analysis of the 35 questionnaires that were returned indicated a high degree of mobility, with only 3 participants having lived all their lives in the same region. Eighteen were born in the province with 3 more having spent at least part of their childhood there. Fourteen had moved to BC as adults, with 10 of these having lived there for at least 40 years. Twenty-eight participants had lived outside of BC at some point in their lives, and many described themselves as having spent considerable time both in urban and rural regions of the province.

Focus groups

There were 3 focus groups in the urban region and 2 in the rural region. The first focus group in each study region met over 3 sessions, with the same participants (or a subset) attending all 3 sessions. Sessions were conducted using an iterative design, with goals and activities for successive sessions shaped by previous findings. The first session was structured to explain the research goals, to introduce the CIRCA program (including its role in dementia care), and to engage participants in generating possible topics for CIRCA-BC. Media selected by the research team on the basis of findings from the first session were presented via PowerPoint in 2 subsequent sessions so participants could comment through discussion and/or feedback forms that were designed to elicit ratings regarding specific items (eg, “keep idea, keep picture” or “keep idea, find different picture”) and to give participants an opportunity to provide feedback if they did not want to speak out in the group. Each session lasted approximately 2 hours, with 5 to 10 participants per session in each region.

The next round of focus groups in each region was designed to elicit perspectives of specific groups. These included the focus groups for Japanese Canadian seniors in the urban region and for First Nations elders in the rural region. Each of these focus groups met on 2 occasions to generate topics and review materials.

A final focus group was conducted in the urban region in an independent living facility, where 8 participants were asked to evaluate relevance of a selection of media from the Dundee version of CIRCA. Although recruitment criteria were the same for this group as for the others, all but 1 of the 8 participants had moved to BC as adults, with 3 having lived in the province for less than 40 years. Unlike the other groups, this group met for only one 2-hour session.

Media sources for CIRCA-BC

The original CIRCA program was used as a template to create a CIRCA-BC version so that differences between the 2 would be limited to the content. Although some items from the original version were included, media for CIRCA-BC were selected primarily from a wide variety of public digital archives. These included online archives in museums, public libraries, university special collections, public radio and television broadcasters, and creative commons Internet sources. Where required, permissions were obtained for use of media for research purposes.

Data analysis

All sessions were audiorecorded and transcribed by a research assistant. We used 2 kinds of analysis to address the study aims. These included a line-by-line analysis to examine how participants’ talk reflected their shared and distinct social histories, paying careful attention to comments like “Everyone used those!” or “I think you would only know him if you were from Vancouver.” These line-by-line codes allowed us to explore how these shared and distinct social histories influenced participants’ views on whether or not to include particular topics and materials in the program. The second analysis was a thematic analysis using constant comparison across the transcripts, supplemented by ratings from the feedback forms, to identify topic categories and themes that grouped these topics together. The thematic analysis also facilitated the identification of gaps, providing direction for subsequent focus groups and media searches. Media selected through these procedures were incorporated into a CIRCA-BC version to be used in pilot testing in phase 2. A last step was to write titles and captions for all photos. These were drawn from participant comments during focus groups and information provided in archival sources. The final CIRCA-BC program included 475 photos, 58 video clips, and 105 music clips distributed across 7 themes: people, places, and events; school days; entertainment; home and community life; working life; sports and recreation; and going places.

Phase 2: Pilot-Testing CIRCA-BC

Participants

Three participants living in a long-term care facility took part in pilot testing. All were women between 81 and 90 years, and all were described by facility staff as having moderate dementia. Although family or friends who completed personal history questionnaires on their behalf described all 3 as long-time residents of BC, none had lived in the province during their childhood or early adult years. P1 was born in Britain and immigrated to Vancouver not long after World War II. P2 was born in Germany, moved to Britain as a bride after the war and then moved with her young family to a small town in BC. P3 was born in a Canadian prairie province and moved to Vancouver after her marriage. A care aide (also Canadian but not from BC) who was somewhat familiar with all 3 women took part as a conversation partner in all 3 sessions (1 session with each participant with dementia), after receiving a brief orientation to the program.

Data collection

Each CIRCA-BC session was conducted in a quiet room of the facility. The 2 participants sat side by side in front of a 17-in touch screen monitor connected to a laptop running the CIRCA-BC program. Two tabletop microphones were connected to a digital video camera that was positioned facing the participants so it could record their interactions with each other and with the monitor. A screen-capture software program (CamStudio ¹⁷ ) was used to create an audio video interleaved (AVI) file of all the computer screens during the session. Sessions lasted approximately 30 minutes.

Data preparation and analysis

The 2 video recordings of each session (one of the participants and one of the computer screen) were transcribed separately. Transcription of the screen shots included a standardized description of each screen. Transcription of the participants’ interactions, verified by 2 members of the research team, included verbal comments, gestures, physical interaction with the touch screen monitor, positioning with respect to the monitor and to each other, and gaze direction. Each screen transcript was then integrated with the interaction transcript to allow the content of each screen to be represented as a part of the conversation.

Descriptive analysis of the transcripts identified ways that the program content was integrated into participants’ social interaction, with particular attention given to how their responses suggested shared versus distinct social histories. A second line-by-line analysis of the transcripts allowed us to identify and describe how program format influenced interactions, identifying features such as, for example, the participants’ use of positioning and gaze with respect to each other and to the computer to manage conversational topic. Each session was analyzed separately, with similarities and differences noted across the 3 sessions.

Results

Phase 1 (Focus Groups)

To contextualize the focus group findings in terms of how they reflect shared versus distinct social histories, comments are warranted about the outcome of our purposive sampling strategy within each focus group. First, our differentiation of groups as either rural or urban emerged more as a reflection of the setting in which the group was conducted than as a description of participant background, because both groups included participants who had lived in both regions. Even our differentiation of rural versus urban was an oversimplification; for instance, 1 participant in the rural group pointed out that, in contrast to his own experience of growing up on a farm, “the comments that we’ve been getting here lead me to believe that most of the people were from some kind of a city or something that had an infrastructure and stuff.” Nevertheless, differences emerged in the nature and range of topics suggested by the rural versus urban group with many of these differences being related to place. For example, topics generated in the rural group suggested a larger geographic footprint than that of the urban group, including communities, towns, and geographic features spread over a much larger region than that referenced in the urban group.

In contrast to the other focus groups, comments in the Japanese Canadian and the First Nations groups reflected a strong sense of shared history within each group. For example, a participant in the Japanese Canadian group describing the impact of internment during the war stated, “It’s a shared experience that we’ve all shared so it’s one thing that really defines us together” while another participant added, “because we were no longer a part of the overall community you see. That was another community—just ours alone because of the war.” Reflecting this orientation, many topics generated by the Japanese Canadian participants were associated with their shared experiences in the war. Further, participants considered it important to include images from internment life in a BC version of CIRCA with 1 participant explaining that for people with dementia using the program, internment would be a “very very strong part of their life.”

The First Nations participants too acknowledged a shared history, with residential schools being a principal feature. However, their discussion on this topic focused on differences across their experiences, highlighting the point that a shared history does not necessarily mean shared experiences. Participants pointed out that while some First Nations people have come to acknowledge their experiences of residential schools as an important part of who they are, many others do not want to be reminded of their past. Topics for reminiscence-based conversation were suggested in this focus group, but there was also broader discussion about how, or even if, to use a reminiscence-based program with First Nations people with dementia.

Negotiating the continuum of shared to distinct social history

Within the groups, participants drew on several strategies to position themselves along a continuum of shared to distinct social histories. One strategy for suggesting a shared history was to use the pronoun “we” without specifying a referent, as in the following example: “we all had to move in some way, and we moved by bicycle. We moved on foot, by streetcar…” or, more locally, “the Vancouver hotel pictures…those were landmarks that we could all identify with.” Another strategy was to contribute a personal recollection as part of a shared topic, such as dances held in rural communities: “I slept behind the piano more than once when I was tiny.”

In other cases, participants explored the extent to which their own recollections were part of a broader shared social history, usually after first locating those recollections in reference to a particular time or place. For example, in a discussion of rationing, a participant who had lived in New York during the war commented: “I don’t know if you guys had this, but at least in New York we were encouraged to save old bacon fat and other drippings …”. This led to others contributing different examples of rationing, both locally and from other places, with a participant concluding: “The whole cycle of rationing is, would be important to everybody alive at that time.”

Finally, there were numerous instances in which participants marked activities, people, or events as part of a social history distinct from their own, again, often referencing the participant’s location in a different time or place. For example, in considering whether the photo of a particular individual who was well-known in Vancouver should be included in the category “Famous British Columbians,” a participant in the urban group commented: “I was brought up in Victoria and I have no idea who that is.”

Another way that social histories were differentiated was through discussion of different perspectives on a shared topic. For instance, hockey as a national spectator sport was suggested in the urban group; in the rural group, it was also remembered as a community team sport, and, further, as an informal, local recreation “getting the old reject lumber from some sawmill, putting the boards up, and getting some old hoses from the forestry and turning the water on and freezing it.” Such differences suggested a variety of ways for selecting media within a shared category that could resonate with people’s different experiences.

In some cases, however, differences with respect to a particular topic were so divergent that they could not be accommodated even within a common theme. The topic of trains, for example, emerged in several groups. In the rural group, trains were described as part of everyday life (“that was the only way to get around”) and as a valued experience (“one of the best things we ever had as far as I was concerned—winter travel particularly”). These meanings were all consistent with the theme of going places. In contrast, although Japanese Canadian participants also described trains as a significant part of their experience (“we all experienced train stations”), it was associated with the negativity of internment (“It was a very sad occasion for us, “cause we were all being shipped out”). For them, a photo of members of their community saying good-bye as they “were all being shipped out” by train to an internment camp could not be included in the theme of going places. Instead, they elected to include such images in the category “Internment” under the theme of people, places, and events. However, not all photos associated with internment fell under this theme; some were identified as reflecting other themes, such as home and community life for a photo of a woman knitting outside a tent in an internment camp.

Phase 2: Pilot-Testing CIRCA-BC

Findings from the 3 pilot sessions highlighted several ways in which the content of CIRCA-BC supported social interaction between each participant and a conversation partner, providing opportunities not only for reminiscence-based conversation but also for exploring other topics and ideas together. Findings also suggested ways in which the format of the program itself, including the platform for program delivery, influenced those interactions. Each of these 2 topics will be addressed separately.

Influence of program content on social interaction

Familiarity with the CIRCA-BC content varied considerably across the 3 participants, with P1 and P3 responding to the majority of content as familiar while P2 responded to the majority as unfamiliar. Analysis revealed several strategies similar to those identified in the focus groups that the 3 participants used to indicate how media content was (or was not) relevant to their own experiences, marking that content as part of a shared versus distinct social history. In some cases, acknowledgment of a place or event as part of a participant’s unique experiences was either explicit (P1: “I’ve been there [the Carnegie Library] umpteen times”) or implicit (P1 singing the words to familiar songs). In other cases, content was described as part of a widely shared social history (P2: “I think this kind of game is in every country”). Participants also used strategies to mark content as part of a social history that was different from but related to their own experiences. For example, when the care aide asked P1 what a video clip about war brides made her think of, she replied “different events of the war than I experienced…I was in the—we were supposedly doing clerical work.” Participants also marked content as part of a social history that did not overlap at all with their own, with the most explicit examples found early in the session with P2: “I’ve never heard of anything… See, with not being born in this country and things like that, I haven’t got all that much knowledge about things.”

A second related finding was how the range of familiarity across content gave opportunities for different kinds of talk within each session. Photos sometimes inspired personal anecdotes, such as P3 describing her fear as a child when someone put her on a horse that was too big for her. In other instances, photos prompted more generic descriptions of everyday life (P1: “When I was a kid they [horses] were there. The milk was delivered with a horse and cart. The coal was delivered horse and cart. Everything was horse and cart”). P2 used the unfamiliarity of content as an opportunity to describe her experiences moving from Germany to England and then Canada: “My main language is German, but I was married to an Englishman…and I lived in England for a time, so it was up to me to learn, not for them to learn my tongue.” This was a major topic for her, which she returned to several times throughout the session, sometimes repeating the same sentences but at other times extending the topic to add new information.

Unfamiliar content also provided participants with opportunities to explore topics that were new to them. For example, P1 expressed interest in the Japanese Canadian internment photos: “Internment? That’s an unusual thing on there.” Her comments as she and the care aide looked closely at all the photos and read the captions together suggested that she had not known of these events, which she described overall: “that’s a very sad thing you’re showing us, you know.” In another instance, P3, after answering that she was not familiar with a particular British comedy offered as a video option, commented, “I’d like to watch it though.” P2 also took advantage of the opportunity to explore new ideas; the photographic category of “Women in Wartime Industry” engaged her for an extended period (over 5 minutes), including talk about the range of work that women were shown to be doing, about how women’s roles in the workplace had changed over time and, finally, about equality for men and women in the workplace.

Influence of program format on social interaction

The format of the CIRCA program was designed to enable participants with dementia to have more control in selecting media. Findings revealed how media titles and captions as well as touch screen technology promoted user engagement, albeit differently across the 3 sessions. P1 and P2 sometimes read the titles of different choices on the screen; for P1, this prompted the care aide to ask which topic she would like to talk about, with the result that although it was the care aide who always touched the screen, it was P1 who often chose the media, commenting, for example, “Visit Vancouver. Let’s have a look at what Vancouver looked like back then.” In contrast, in talking with P2 (who was the most reluctant to engage with the program), the care aide interpreted her reading of particular titles as expressions of interest, for example, commenting as he touched the screen, “that one [‘Women in Wartime Industry’] has caught your interest.” On the other hand, in the last session with P3 (who almost never read titles aloud), the care aide encouraged her to make choices by touching the screen herself.

In addition to giving participants some control in initiating topics of conversation, photo titles and captions also supported them in sustaining talk on those topics. This was noted most often for P1 who often read captions aloud, following up with her own comments or questions. It was also observed (though to a lesser extent) for P2, with the care aide treating her reading of words or phrases as a conversational contribution that he could build on. Photo captions also provided background information that supported talk in all 3 sessions for both conversation partners when neither was familiar with the topic.

In contrast to photos, music and videos provided opportunities for different kinds of interactions together. P1, in addition to talking about music that was playing, also sang the words. P3 too sometimes sang or hummed and sometimes moved in rhythm to favorite songs. Short videos were also part of every session. Although these sometimes prompted talk (either relevant or on a different topic), participants also sometimes watched them together with relatively little talk in what appeared to be a companionable silence.

Finally, findings revealed how the physical arrangement of the monitor and the 2 conversation partners became a feature of their social interaction together. Throughout their sessions, the conversation partners shifted their gaze and/or their position back and forth between the monitor and each other. When both partners’ attention was focused on the monitor (with occasional quick glances toward the other person), they were typically talking about explicit features of the content shown there, while they tended to move their gaze toward each other when extending the topic in some way (eg, talking about a personal journey after looking at a photo of a ship) or changing it altogether (eg, P2 resuming the earlier topic of her own language background). This tendency was reflected in an overall pattern across the sessions: P1, who was most engaged with the program content, focused on the monitor for the majority of the session, whereas P2, who was least engaged with the program, turned away from the monitor to look at the care aide throughout most of their session together. Participants (including the care aide) also used a shift in gaze and body position from the partner to the monitor (or vice versa) as a way to make a topic change. For example, P1, after looking at the care aide while talking about her experience in the army, turned to look back at the monitor; the care aide followed her lead by shifting his focus to the monitor and asking about a new topic.

Discussion

Findings from the current study highlight several important points concerning, first, the process of adapting the content of the CIRCA program to capitalize on the concept of place-based reminiscence and, second, the process of exploring how people with dementia and their conversation partners draw on program content and format in their interactions together. First, with respect to adapting content, findings from focus groups and pilot testing in the current study are consistent with previous research supporting the use of publicly available versus personal content. ¹⁸ However, our findings build on that research by drawing attention to important considerations in selecting that content. One key question guiding our selection of media was how these could, or should, accommodate shared versus distinct social histories. The series of focus groups in this study was designed to elicit a diversity of perspectives which, though not intended to be comprehensive, would nonetheless allow us to explore the interplay of shared and distinct social histories revealed through participants’ talk together. Results not only from those focus groups but also from the pilot-testing sessions highlight the value of including media along a continuum of locally to more globally relevant materials, with “locally” defined in reference to a variety of places and a variety of perspectives. This diversity allowed participants, including those with and those without dementia, to explore specific ways in which their individual social histories were shared or distinct, with reference both to their conversational partners and to the program content. In addition, it created opportunities in pilot sessions for conversation that was not solely reminiscence based as participants with dementia also expressed interest in exploring topics that were not part of their own social history.

Second, although we had initially assumed that it would be important for the program content to reflect the place of a participant’s childhood and early adult years in order to prompt place-based reminiscing, our findings, preliminary though they are, suggest that this may not be the case. Instead, the notion of place as shown in the CIRCA-BC program emerged both in the focus groups and in the pilot sessions as the shared context of “where-we-are-now,” allowing participants to situate their own histories with reference to that place. This possibility can only be substantiated through further testing with more participants, but it does suggest that a place-specific program such as CIRCA-BC may be appropriate for a broader range of participants than originally anticipated. This is a particularly important finding, given the migration patterns and diversity of today’s aging population, which was to some extent reflected in our focus groups and in our pilot testing. The fact that the majority of participants in our final focus group and in our pilot-testing phase (all of whom were recruited through long-term care facilities) had moved to BC only after their early adult years may be due to the small sample size, but it could also represent a demographic trend that is more evident in long-term care. These findings suggest that future testing of CIRCA-BC needs to ensure greater diversity of backgrounds across participants with dementia using the program. In follow-up to the current study, this would include, for example, people who lived in different areas of BC during childhood, as well as Japanese Canadian seniors and First Nations elders.

With respect to the second study objective regarding a process for exploring how the participants draw on the format of the CIRCA-BC program to mediate their interaction, findings suggest that a productive starting point is to view the technology, not as a support mechanism, but rather as an integral part of the interaction. In the current study, methodological attention to the participants’ gaze, proxemics, and gestures highlighted specific ways in which both partners in the dyad interacted with the computer to shape their talk together. These interactions created, in effect, a conversational triad in which the computer’s contributions comprised the media items selected by the participants. In contrast to previous studies of CIRCA, screen descriptions were integrated into the transcripts in this study, facilitating analysis of them as part of the ongoing talk. This approach revealed specific ways in which the computer itself provided a focus for joint attention, facilitating topic introduction and topic maintenance as the participants used the computer to introduce new topics or to draw on the content provided by photograph descriptions, for example, to extend their talk. Results also supported previous research highlighting the contributions of touch screen technology, random-access selection, and the inclusion of different kinds of media for supporting social interaction. ¹¹

In conclusion, there is clearly a place for technology in addressing the need for meaningful social interaction between people with dementia and those who care for them. Building on previous research, which has shown that computer-mediated interactions between people with dementia and their carers are more engaging and enjoyable than those that incorporate actual photographs and artifacts, the current study has identified a process for adapting CIRCA to a local context. In doing so, findings highlight how such a program can help us to see a person with dementia not only as a unique individual, but also as part of a broader community comprising both shared and distinct social histories.