In quest of tablet apps for elders with Alzheimer’s disease: A descriptive review

Abstract

Caregivers search for apps that offer meaningful and enjoyable activities that would simultaneously enhance the preserved cognitive and functional abilities of those under their care. The purpose of this review article was to describe the current state of tablet apps with which elders with Alzheimer’s disease and a related form of dementia may engage as users. Using the keywords–”app,” “Alzheimer’s” and “dementia”–a sample of 83 apps was selected from the iTunes Store, Google, and discussion boards of Apple Support Communities. A descriptive content analysis was conducted using a coding scheme on the characteristics of tablet apps activity and the requirements of functional abilities of the users. This review found that the activities of the selected apps included games, simple watching and viewing, music and sounds, memory training, learning and information, and social interaction starters. A high-level cognitive and physical ability such as eye-hand coordinated motor ability is often required to play the majority of the game apps. A few apps are designed specifically for the population. Individuals’ variability in cognitive and functional abilities necessitates a person-centered approach in designing and selecting games and activities for apps in order to increase engagement and promote positive experiences in the elders.

Introduction

A day in the life of an elderly person with Alzheimer’s disease or a related form of dementia is often filled with boredom and excessive idle time. Low levels of activity engagement contribute to adverse behavioral symptoms, depression, sleep disturbances, and poor quality of life in elders with dementia [1–3]. In particular, evidence has shown that an excessive amount of unoccupied time leads to behavioral symptoms such as apathy, restlessness, irritability, and aggression among elders with dementia. Approximately 39% of community-dwelling elders with dementia and 78% of nursing home residents exhibit behavioral and psychological symptoms [4, 5]. These symptoms are very challenging and difficult to manage for caregivers and healthcare teams [6–8]. Research has shown that engagement in daily meaningful activities can fill unoccupied time, increase engagement in cognitive tasks, elicit positive emotional affect, and significantly decrease behavioral symptoms among elders with dementia [1–3, 9–10].

Due to the advancements in computer technology in recent years, a variety of apps may offer new activity options for elders with dementia in a convenient manner [11–13]. Hand-held tablet computers help ensure that apps are easily accessible without the restriction of time and place [14–16]. Furthermore, the intelligent and adaptive capabilities of computers allow users to engage in activities as many times as they want, adjust the pace of interaction, and change the level of challenge [12–16]. Cueing and timed repetitions are effective strategies in improving automatic procedural memory in elders with dementia [17, 18]. Tablet apps may have great potential to provide activities to elders with dementia that are cognitively stimulating, emotionally enjoyable, and socially connecting [12–16, 19].

However, some of the largest barriers to their activity engagement are the cognitive and functional impairments associated with their illness. Alzheimer’s disease is the most common form of dementia that causes memory loss and creates difficulties in thinking, problem solving, or language ability. The disease affects one in nine people over the age of 65 and about a third of those aged 85 years and above [20]. Globally, 46.8 million people lived with dementia in 2015 and this number is expected to increase to almost 75 million by 2030 [21]. People with dementia are likely to face limitations in physical functioning and require assistance with carrying out their daily activities. Evidence also shows that limitations in daily-life activities may be linked to preclinical Alzheimer’s disease and its transition to mild cognitive impairment [21–22]. Previous studies have found that elders are not able to participate in computer activities if those activities require cognitive skills and physical functioning beyond their individual competencies [19, 23–24]. Thus, it is critical that activities are person-centered and individualized to their interests as well as their abilities so that elders with dementia can engage in computer activities despite having cognitive or physical impairments [2, 10, 12, 15, 16, 24, 25]. Furthermore, according to a recent initiative regarding person-centered care for persons with dementia [26, 27], activities for this population need to be relevant, meaningful, and personalized. Person-centered care emphasizes respect for individuals’ uniqueness, capitalizes on their preserved strengths and capabilities, and empowers them to choose activities that meet both their needs and abilities.

Thus, the purpose of this review article was to explore the current state of tablet apps, which intend to promote activity engagement among elders with Alzheimer’s disease and other related forms of dementia.

Methods

A descriptive review was used to examine the characteristics of tablet app activities and the functional abilities required for individuals to engage in these activities. The method is useful in providing an overview of the extent and range of existing knowledge that represents the state-of-the-art data on a particular topic [28]. This type of review employs a structured search strategy, relevant sample selection, and content analysis while using frequency analysis for synthesizing and analyzing findings.

Search Strategy and Sample Selection

A sample of tablet apps were identified by searching for three websites —iTunes App Store, Apple Support Communities and Google. The keywords used for this search were “app,” “Alzheimer’s” and “dementia.” Initially, 264 apps were identified. After excluding the duplicates, 126 were reviewed using the following inclusion criteria: (1) being accessible for use on the iPad, a portable tablet computer, and (2) providing a recreational, social, and cognitive activity. With these inclusion criteria, 43 apps were excluded because they were not accessible, included only medical information and management tools (caregivers’ tools, disease management, or dementia prevention), or contained only an assessment of cognitive ability. Finally, 83 apps were selected for the study’s descriptive review. Figure 1 presents the flow diagram of the search summary.

Figure 1.

Summary of tablet apps identification and selection

Data Coding and Analysis

A descriptive content analysis technique [29, 30] was used in this study for the review of the data pertaining to 83 tablet apps. The data included the app descriptions in the iTunes stores, screenshots, and app demonstration videos on YouTube to confirm their contents and functionalities. The content analysis of the data was conducted using a coding scheme that included the following: the information of the apps (name, company/developer, release date, version, access, and price), the functionality of apps (design, features, and navigation), the characteristics of apps activity (objective, task description, and outcome), and the required skills and abilities (cognitive and functional).

The initial-level analysis led to the construction of categories along with descriptive codes by comparing the data from the 83 apps. These categories were then refined or reorganized based on new information that appeared as subsequent data was analyzed [31]. The data analysis included codebook development. Patterns describing the characteristics of apps activity and the requirements of functional abilities arose during the review of the category data. As commonalities became apparent, the codes were revised by grouping and collapsing them. All information was repeatedly reviewed and analyzed by three coders. Prior to the coding the apps, they reviewed the coding scheme and categories and, then, coded the apps independently. The validity of the coding was strengthened by overall data review and discussion of any discrepancy in coding until an agreement was reached. Detailed record-keeping was implemented for an audit trail that provided the evidence and consistency in the analysis processes. Microsoft Excel and Atlas.ti computer programs were used for the analysis and the organization of qualitative data.

Findings

The majority of the apps were available for all users without any specific condition. Only 6 out of the 83 apps (7.2%) explicitly stated that they were specifically designed for people with Alzheimer’s disease or other related forms of dementia, while for five apps, kids were indicated as the target users. The prices of the apps ranged from 0 to $7.99 (mean = $0.68, SD = 1.3). The majority of the apps were available for free (n =56, 67.5%).

The results of the content analysis were organized into the following two major categories: (1) the characteristics of tablet apps activity (type, feature for engagement, and outcome) and (2) the requirements of functional abilities (cognitive ability, physical function, and the severity of dementia). First, in terms of the characteristics of tablet apps activity, the majority of apps were games (n = 39, 47.0%). These games were either animated or simulated. They included card games, board games, sports games, word games and puzzles, arcade and casino games, trivia and quizzes, and video games (see Supplemental Digital Content 1: Examples of apps and screen shots). Another type of apps activity involved watching and viewing (n = 21, 25.3%). These watching or viewing activities often entailed listening to music when watching slideshows of art pieces, animals, or real-time streaming videos or archived videos of animals. However, there were also app activities that focused on solely music (n = 9, 10.8%), including playing music, songs, rhythmical sounds, and musical instruments. Other apps were designed for the promotion of memory training (n = 7, 8.4%), social interaction using conversational starters (n = 5, 6.0%), exploration and search of the internet (n = 2, 2.4%), and learning a topic or a skill (n = 2, 2.4%).

Various features were utilized to enhance user engagement experiences in app activities. They enabled a user to track their performance progress and scores, express emotion and creativity, enjoy audio-visual sensory stimulation, engage in social conversations and interaction, practice cognitive exercises repeatedly, take quizzes and test knowledge, and search the Internet, and participate in nurturing and caregiving experience. As per the results of using the apps, enjoyment and positive affect (n = 74, 89.2%) were found to be the most prevalent intended outcomes in the analysis. In addition, a large number of apps aimed to improve memory, focus, and general cognition (n = 51, 61.4%). Another outcome included promotion of relaxation (n = 40, 48.2%) and learning (n = 2, 2.4%).

Lastly, the findings of the content analysis revealed the major category of functional requirements such as cognitive ability and physical functionality. A large number of these apps required high-level cognitive ability and physical functionality to interact and complete activity tasks therein. In particular, eye-hand coordinated motor abilities were important aspects of app activities, including games (n = 48, 57.8%). Furthermore, some apps required fast motor reactions in response to a moving target or the ability to skillfully maneuver interactive devices (n = 15, 18.1%). Cognitive requirements varied depending on the type of app. For example, some apps required advanced and complex cognitive abilities to analyze options and make a choice by predicting consequences or to understand and remember the rules and instructions (n = 31, 48.2%). Yet, other apps only required the ability to maintain focus or perform a one-step cognitive task at a time and permitted elders with dementia to engage in in-app activities (n = 40, 37.3%). The characteristics of the app activities are presented in Table 1.

Table 1.

Apps for elders with dementia: activity type, descriptions and examples

Activity type	Description	Examples
Games	Play simulated card, board, sports, arcade, or casino games	Card: Solitaire
		Board: Tic-Tac Toe, Mahjong, Labyrinth
		Sports: Table tennis, Bowling
		Arcade/Casino: Air Hockey, Slot machines
	Engage in animated puzzles, trivia quizzes, and video games	Puzzles: Crossword, Sudoku, Rail maze
		Trivia/Quizzes: 60’s Pop Culture Quiz, Bible
		Video games: Dodge dots, BeeCells, Bubble Shootix, Sand slides
Arts, crafts, and painting	Use finger to draw or paint on their own	Fingerpaint Magic
	Choose drawings from collections and color them	Draw
	Create pottery while choosing shape and decoration designs	Let’s create pottery
	Create a personalized postcard from photos from their own mobile device or social media sites or other cloud services	Postagram postcards
Music, sound, and musical instruments	Use fingers to hit virtual simulated musical instruments to play on the screen and enjoy music without having to know playing techniques and musical knowledge	Simulated musical instruments (e.g., piano, congas, harp, percussive, Tongue Drum, Cajon), Virtuoso
	Create and record and share relaxing and pleasant melodies by tapping the screen along with their accompanying simple but colorful visualizations, a simple composition tool without musical knowledge and experience (e.g., Bloom) Choose and listen to personalized radio stations (e.g., Pandora)	Bloom, Raindrops, Healing Voice Lite
	Uses ambient sounds, nature sounds, realistic wind chimes, pleasant melodies, and binaural beats with a visual escape for relaxation and meditation	Just Chimes, Relaxing sounds of nature
	Listen to old time radio shows in the 1920s-1950s	Yesterday USA, Pandora
Social interaction	Choose from categories such as seasons, airplanes, celebrations, roses, and each category is accompanied by a starter, story, song, and pictures.	Alzheimer’s Story Starters
	Contact people through text/video messaging and voice/video calls	Skype
	Label family photos in an app by typing a few words on the photos (and save/ print) when sitting with visitors and caregivers and help trigger memories and familiar activities	Photo Labeler
Memory training	Practice with words, pictures, and text.	Alzheimer’s Cards
	Must memorize the shape, position, and color of objects and touch the correct case. Work on memory targets such as names, facts, and routines	iRecognize
	Use specific cognitive training protocols such as spaced retrieval techniques	Spaced retrieval therapy
	Provides scoring, and feedback and tracks progress and performance	Clevermind
Education and learning	Provide information and images on a topic of interest	Aircraft of WWII
Watching and viewing	Watch real-time, streaming videos or archived videos of animals	Pocket Penguins, YouTube
	View various kinds of themes such as a rainy street, beach, or park as if the user feel like looking out a real open window of house using virtual reality simulator or look through a slideshow of images and inspirational gallery, such as garden paths, bridges, benches, or ponds around the world by professional photographers	Pocket Window, Japanese gardens
	Provide a personal pond or animal and take care of them or interactive with them with a simple finger touch	Pocket Pond, Koi Pond, iQuarium
	Provides beautiful time-lapse views from around the world to any display to watch nature imagery such as sunrises, sunsets, cities, oceans, and more or view live scenes of major cities that slowly progress over time on screen in a live wallpaper format	Magic Window
	View master art collections of famous artists or styles or view art pieces in a format of art gallery from national museums	Art Gallery

Discussion

The findings identified the seven types of activities in the 83 tablet apps with which elders with Alzheimer’s disease and other related forms of dementia may engage as users. Although the apps were originally not designed for them, it was interesting to find out that these apps were either being currently used by or recommended for elders with dementia. Many of these apps were familiar games such as card games and board games, which were simulated and made available in the form of tablet apps. As these games are automated, elders can enjoy them in a convenient manner with the help of timely prompts, feedback, options for multiple repetitions, and gradual progress in terms of difficulty levels. Furthermore, most apps in this study were visually and auditorily pleasing for this population.

An app activity can be not only enjoyable but also therapeutic. According to Malone [31], a computer game can be cognitively stimulating as well as therapeutic if it has the ultimate aim to provide feedback to users regarding their performance and progress in achieving the goal and multiple opportunities to achieve sub-goals even if the ultimate goal might be beyond reach. In addition, it is important to incorporate cognitive rehabilitation principles if a game is considered to be therapeutic for an individual with dementia. These principles involve external cue usage, reliance on implicit memory, guided repetition, and progression from simple to complex [17, 18]. It is recommended that activities need to utilize implicit, automatic, and unconscious cognitive memory processes for persons with severe dementia, to capitalize on the remaining cognitive abilities for those with moderate dementia, and to strengthen the retained abilities and promote the exercise of cognition for those with mild dementia [24, 32, 33].

The findings also indicated that elders with dementia may experience difficulty in carrying out the activities required by a majority of game apps. Due to their impaired cognitive abilities, people suffering from dementia cannot complete multi-step cognitive tasks, remember facts and information to answer questions or quizzes, and understand the rules or directions of games. In fact, a few apps in this study were considered too cognitively demanding for persons with dementia. For example, Labyrinth, a physics simulation game, required a steel ball to be controlled and the user to react to the moving ball while maintaining a high level of concentration, utilizing strategy and analytical ability, and maneuvering the device. Thus, it is critical to consider cognitive and physical abilities in the development of an app for this population.

Literature suggests that a simple activity is appropriate for elders with all levels of dementia [34–36]. The app Pocket Penguin selected in this study allows users to watch African penguins through a real-time streaming video from the California Academy of Sciences and listen to biologists answering questions from the visitors during daily mealtime. These kinds of apps may provide highly engaging and socially connecting activities to elders with dementia. In addition, the art, craft, and painting apps allowed users to select colors and utilize their fingers to draw and color drawings or paint and clear any coloring to start over as they wish. A few apps were highly interactive and enjoyable and did not require full control or in-depth knowledge of the device. With a simple touch or doodle style on-screen finger movements, elders with dementia can create an amazing art piece or pleasant music and songs without having any prior knowledge or experience in these areas. It is also enjoyable to play with an animated cat or dog that responds to users or repeats what they say. Evidence shows that elders with dementia like activities that are interactive, interesting, and relevant to their interests acquired from past occupations, hobbies, or leisure activities [1, 10, 15, 37].

Enjoyable activities play a critical role in the lives of elders with Alzheimer’s disease and other related forms of dementia. Activities not only reduce the excessive amount of unoccupied time spent doing little or nothing but also provide opportunities to engage in cognitive exercises, enjoyment, and social interaction [1, 2, 10, 12, 18]. Evidence indicates that elders with dementia prefer a variety of activities that are meaningful as well as interesting [18, 24, 34, 35, 38]. Caregivers find it tremendously challenging to provide various, sufficient, and beneficial activities that meet the needs of elders with impaired cognitive and physical functioning. Apps for tablet computers developed in recent years have great potential to provide a variety of interactive multi-sensory activities for this population [12–16, 19].

However, it was challenging to find an app suitable for use by elders with dementia. The search for apps with the key words Alzheimer’s or dementia often leads to a large number of apps that focus only on knowledge about dementia, medical information, caregivers’ tools, and disease prevention and management. Moreover, some apps involve childish activities such as dressing and accessorizing paper dolls or using children as cartoon characters. Other apps include horror and fear themes, such as fantasy violence, are not appropriate for elders with dementia because they may cause confusion, delusion, or unnecessary fear. Frequently, caregivers have been requesting recommendations for an app appropriate for use by elders with dementia, either for their amusement or to enable them to engage in discussion blogs or social media websites. Yet, the shortage of apps specifically designed for elders with dementia make it difficult to locate apps that fit their needs and abilities.

Research recommends that apps suitable for elders with dementia may include the following features: (1) large selection buttons on the touch screen, (2) large fonts and intuitive interfaces, (3) simplified screen display, (4) simplified games and social apps, (5) options with levels ranging from easy to difficult in terms of varied cognitive and skill requirements, and (6) personalized content in activities (e.g., individualized music that corresponds with the user’s interests) [2, 10–12, 24]. At present, interactive features of apps need to give attention to users’ eye-hand coordination, motor reaction skills, focus and sustainability, and device maneuverability [11–14, 19]. Yet, in the future, the interactions may use speech recognition such as My Intelligent Robotic Assistant, visual depiction of dialogue, and voice command controls.

Lastly, elders with Alzheimer’s disease and other related forms of dementia do not participate in an activity that is not enjoyable, relevant, or meaningful to them [2, 25, 38, 39]. The findings of the study indicate that a person-centered approach is critical to engage this population in app activities [1, 2, 10, 11, 24, 26, 27, 35–37, 40]. Figure 2 presents the three factors that are needed to be considered based on the person-centered perspective through which caregivers may select apps and assist this population by encouraging them to engage in activities according to their abilities and needs: First, the preference factor includes individual characteristics such as demographics (e.g., age, gender, religion, and culture), previous and current occupations, and favorite leisure pastimes and hobbies. Second, the functional ability factor involves cognitive ability and physical functioning (e.g., vision, hand, and finger functions and hearing) and is considered critical according to the practice guideline of designing computer activities for individuals with dementia [24]. Cognitive and functional impairments may result in limitation in the selection of a favorite activity. Last, other influencing factors directly affect the level of engagement in activities, including individual physiological and psychological needs, the activity environment, and the availability of assistance. Activities tailored to an individual’s preferences and functional abilities may not only facilitate a higher level of engagement but also result in positive health outcomes. A person-centered approach may provide guidance in not only selecting an activity for elders with dementia but also designing apps for them.

Figure 2.

Factors for activity selection and engagement among elders with dementia

Limitations

Our search focused exclusively on the apps that elders with Alzheimer’s disease and other related forms of dementia can engage in as a leisure activity. A limitation in this study might be that the search keywords “Alzheimer’s” and “dementia” might have limited the apps we identified. Other apps that do not belong in these categories may turn out to be usable and appropriate for activity engagement for elders with dementia. Moreover, since new apps are being constantly added and revised, this may have limited the generalizability of our results. Yet, this article provided a snapshot of the current state-of-the-art tablet app activities for elders with Alzheimer’s disease and other related forms of dementia. Further, the article’s findings promote a person-centered approach and serve as a basis for promoting improvement in engagement experiences and satisfaction levels of elders with dementia who are engaging in the app activities. Future research is needed to examine the effects of engagement in tablet app activities on health outcomes, such as emotional affects, cognition, and behaviors in this population. In addition, it is necessary to examine the types of app activities and their effects on these individuals depending on the severity of dementia. Furthermore, future research is needed to determine the ability of apps activities to reduce caregivers’ burden.

Conclusions

Along with the impending the “Silver Tsunami,” as predicted by the current demographics surveys, the percentage of people with Alzheimer’s disease and other related forms of dementia is expected to increase dramatically in the coming years. The most significant challenge in caring for elders with dementia often lies in helping them engage in enjoyable and meaningful activities on a daily basis. Although there is a growing interest among caregivers and healthcare service providers with regard to using such leisure activity engagement apps for the elders with dementia under their care, only a few apps are tailored to fulfill the needs and functional competencies of this population. Thus, a person-centered approach may be implemented to provide guidance to app designers and, at the same time, assist caregivers in selecting apps that maybe not only appropriate but also enjoyable, cognitively stimulating, and socially connecting for elders with dementia.

Supplementary Material

Supplemental Data File (.doc, .tif, pdf, etc.)

SUPPLEMENTAL DIGITAL CONTENT 1: Examples of apps and screen shots.