Rehabilitation in advanced dementia through computer-assisted exergaming with Able-X: A collective case study

Psychosocial interventions have been found to have similar outcomes as pharmacological interventions for people with dementia (PWD). Cognitive stimulation has been found to benefit cognition and there is evidence of self-reported quality of life (QOL) and wellbeing improvement in this population. However, little research has been carried out in exploring the association between QOL and computer-assisted exergaming in PWD. This study explored if a programme of computer-assisted exergaming interventions, utilising exergaming technology (Able-X), as an adjunct to existing activities and treatments, could deliver improvements in QOL, including cognitive and physical function for 10 people diagnosed with dementia.  An ontological approach of social pragmatism, combined with interpretive epistemology, within a collective convergent parallel case study (CS) methodological design was used. The study was carried out in three aged care residential units in New Zealand (NZ) that catered for people with dementia. As far as possible the principle of errorless learning (EL) (Terrace, 1963) was applied to the gaming environment when utilising the Able-X gaming interface, which was not entirely errorless. EL is based on the principle that it is difficult for people with impaired memory to remember and correct errors made while trying to learn or relearn something.  Pre-and post-gaming qualitative data were collected through semi-structured interviews with lead care staff and the next of kin for each participant, health record review, observation of video footage of the gaming experiences and computer-generated exergaming scores. In addition, several quantitative measures were used: Mini-Mental State Examination-2-BV, Global Deterioration Scale, Functional Assessment Staging Test, Quality of Life–AD, Cornell Scale for Depression in Dementia and the Rating Scale for Anxiety in Dementia. Data were generated over a 10-month period (excluding postscript comments). Data triangulation included application of the theoretical framework of ‘embodied selfhood’ (Kontos, 2003, 2004) to demonstrate participants’ agency through intentionality of individualistic bodily movements, gestures and a sentient affinity with the social environment, and through habitus of the social relational body that implicitly understands the socio-cultural ways of being-in-the-world.  The analysis revealed five emergent themes and six novel concepts that lend themselves to further inquiry. The first three themes: ‘Sentient interaction with the social gaming environment’, ‘Initiation and gaming advancement in partnership’, and ‘Levels of gaming intentionality’, focused on the gaming environment, including gaming initiation, engagement and progress. The other two themes: ‘Hand-eye coordination’ and ‘Aspects of QOL’, evidenced the similarities and differences across each case in terms of the main findings.  The key findings were significant improvements in hand-eye coordination, global QOL, and anxiety levels. Furthermore, cognitive scores improved for five participants and depression scores for seven participants, however, these improvements were not significant. In addition, there was qualitative evidence of enhanced motivation to re-engage in psychosocial social activities for all participants, improved behavioural symptoms of dementia for nine participants, enhanced communication for nine participants and enhanced functioning of skills relating to activities of daily living tasks for seven participants.  This study demonstrated that improved hand-eye coordination and overall QOL were the results of computer-assisted exergaming with Able-X and EL strategies. Irrespective of the stage of dementia, significant benefits can be achieved through either solo or small group facilitated exergaming sessions.