By Verhoeven K; Verbeyst L; & Dely, H.

Introduction

Physical activity is recommended in all stages of the dementia proces. Physical activity may improve cognition , mood , behavior , balance , sleep, and autonomy in people with dementia. However, people with dementia are often inactive, which is mostly due to physical problems, feelings of uncertainty, and a lack of motivation and guidance.

Technology can be used to increase physical activity and exercise motivation. The use of exergames (active video games) may be useful for this population because these games are fun, approachable, safe, can be played in familiar surroundings, and stimulate cognition, social interaction and selfworth . However research using exergames in this population is scarce.

In this study we used MIRA exergames to compose a physical activity program for people with early stage dementia. We evaluated the feasibility of this program and the possibility to implement the program in different care settings

Methods

Participants
•N=16 participants who were physically and mentally able to perform physical exercises with permission of a general practitioner)
• Participants were selected from different care settings : Long term care facility (N =9), day care centre (N =5), centre for short stay (N =1), home environment (N = 1)
• 6 males, 10 females ; mean age = 81 years (range=69-96); mean Mini Mental State Examination (MMSE) Score = 19,46 (range 10-27)

Measurements

MIRA Program
• 14 MIRA games were selected by physiotherapists and pretested by 2 persons with dementia
• The games trained indicators of autonomy and were clustered in blocks

• Frequency : Participants played 30 min/ session (18 active minutes); 3 sessions /week; during 4 weeks; Endurance and Executive functioning blocks were played every session ; Balance, Strength and Flexibility blocks were played once a week
• Gameplay occurred under the supervision of a trained physiotherapist informal caregiver

Results

•Adherence to the program was high: 50% completed 12 sessions (M=10 sessions ); 2 drop outs

Game experience
• Participants liked playing exergames (M=7,6/10):

- Musicbox , Follow , Piano , Fishing , Seasons and Firefly were enjoyed the most
- Signs of enjoyment were observed when participants obtained a high score; succesfully pushed their boundaries ; improved their play ; were praised for their good gamebehavior ; and when jokes were made by the supervisor

•We observed little signs of frustration . For instance : when participants were immersed in the game and made an error; movements were incorrectly done ; games were too difficult ; technical problems occured
• Exergaming was considered to be a light to moderately intense physical activity (M=11,58/20):
           -Piano and Music box were the most intensive games
• Some games were found more difficult (i.e. Seasons, Forest leaves , Move ) than others . Participants who experienced difficulties often had lower MMSE scores and more physical problems.
• We observed some signs of remembering : o ften in participants with higher MMSE scores. Some games were easier to remember because game tutorials were easier and the movements were more intuitive . These games were played more often .

Supervision
• Guidance from a supervisor is necessary for people with dementia, and is also important for the overall game experience
• We observed several guidance techniques used by the supervisors:

- Explaining and rehearsing game rules and importance of the game (i.e. ‘ this game is good to train your balance
- Verbal support (i.e. where is the object?’), physical support (i.e. supporting arm), practical support (i.e. chair placement), visual support (i.e. pointing at the screen)
- Adjusting movements (i.e. don’t hold your arm like that ’) and modelling movements (i.e. showing how to hold arm)
- Positive reinforcement (i.e. you did great !’) and encouragement (i.e. ‘keep going one more minute’)

Implementation
• Supervisors were overall excited to use MIRA exergames and intended to use these games in the future
• Reported barriers for implementation : Lack of time, impossibility to train more people at once, language
• Reported facilitators : A room where the device is displayed permanently , support of managing board

Conclusion

• People with dementia can play exergames and generally enjoy playing
• MIRA exergames are suitable to increase physical activity in this population . These games can be individually adapted , which may offer added value
• Supervison is necessary and recommended