Keywords

1 Introduction

In order to delay the aging rate and activate the brain, many scholars are committed to studying the issue of dementia. Non-pharmacological therapy can delay the cognitive function decline caused by dementia. It is pointed out that cognitive functional training or external memory aids can be used in cognition and memory training to improve forgetful behavior (Beigl 2000; DeVaul and Corey 2003; Levinson 1997). Takeda et al. (2012) mentioned non-pharmacological therapy methods for mental symptoms, including cognitive training, cognitive rehabilitation, cognitive stimulation therapy, multisensory stimulation, reminiscence therapy, music therapy, etc. Reminiscence therapy is a treatment activity often used for the care of dementia patients, as it emphasizes the process of reminiscence as a pleasant experience. Re-experience through familiar activities can link with past life events, increase socialization, and produce self-confidence and pleasure effects (McDougall et al. 1997; Watt and Cappeliez 2000). Rubin et al. (1998) mentioned that reminiscence bumps occur when people look back at life, and the reminiscence trigger phase can cause a strong and positive response (Hepper et al. 2012).

Most studies show that proper technology introduction can effectively delay the degradation of the elderly. The game developed by Hall and Marston (2014) allows seniors to learn knowledge while playing to improve their quality of life; Foo et al. (2017) developed a guessing game “Guess it” to help caregivers analyze the patient’s cognitive status. Zheng et al. (2017) used game intervention to treat patient coordination, which improved both cognitive function and mental state. Related technology-assisted design emphasizes that cognitive function stimulation can help brain activation and reduce the risk of dementia. However, in addition to considering the daily activities, behavioral safety, and psychological symptoms of patients with dementia, technology-assisted design may also focus on companionship to increase patients’ interest in life, give appropriate sensory stimulation, and allow patients to continue using their brain.

In addition to reducing the burden on caregivers, improving the mood of dementia patients is a major research direction for the assistive technology for dementia. At present, system development in terms of the emotional factor is still relatively lacking, thus, there are still research and development issues to be explored. Patients with dementia can no longer judge or resolve things at the later stage, thus, if their cognitive function can be promoted at the early stage, in order to stabilize their current function and delay the progression of the disease, early treatment will provide the opportunity to prevent and slow the degradation. Therefore, the purpose of this research is to introduce a digital cognitive application system in the early stage of decline for patients with mild dementia. This study first performed application system prototype development, and then, conducted user experience evaluation surveys to achieve the benefit of delaying cognitive degradation.

2 Literature Review

2.1 Non-pharmacological Therapy for Dementia: Cognitive Stimulation

General cognitive functions include various functions, such as attention, memory, language ability, spatial orientation, decision-making, and execution, and dementia is an irreversible symptom that produces cognitive impairment. While clinical drugs related to dementia have been continuously developed, there are no exact drugs that can cure dementia, thus, seeking non-pharmacological therapy has become an important method for the treatment of dementia. Takeda et al. (2012) pointed out that non-pharmacological therapy has an improvement effect on cognitive function, the activities of daily living (ADL), and the behavioral and psychological symptoms of dementia (BPSD). Orrell et al. (2012) believed that cognitive stimulation aimed at memory and thinking capacity can improve the quality of life of patients with dementia and improve their communication and interaction skills.

Cognitive Stimulation Therapy (CST) is a non-pharmacological therapy proposed by Spector et al. (2003) and his research team. Cognitive stimulation training is divided into compensatory and restorative. The purpose of the compensatory strategy is to classify and organize the received information through internal and external training; the restorative strategy is to allow the subject to practice reminiscence of past things, such as reminiscence therapy and repeated memory training (Sitzer et al. 2006). The contents of such therapy cover a variety of different areas, including childhood, food, other types of memories, word spelling, and puzzle games, and are designed to improve patients’ brain activity and increase sensory stimuli, which is helpful to people with mild cognitive impairment and patients with moderate dementia (Craig 2018).

2.2 Reminiscence Therapy

Reminiscence therapy is a psychological intervention therapy widely used for dementia. This process involves discussions of past events and experiences, and specific prompts and props are used to evoke the patient’s memory or dialogue. Woods (1996) pointed out that reminiscence therapy is to recall profound past life experiences through the process of reminiscence, and then, increase the interactions between the elderly and others, thus, it is suitable for patients with dementia. This approach can improve patients’ psychological state (O’Philbin et al. 2018). Reminiscence can maintain personal self-identity and a stable psychological mood, which helps patients to be free from frustration and feelings of helplessness. Therefore, reminiscence therapy, which can effectively promote the cognitive function of dementia patients, is regarded as one of the important strategies for psychotherapy activities (Ball and Haight 2005; Hope 1998).

The operation methods of reminiscence therapy are divided into individual therapy and group therapy. Compared with individual therapy, group therapy is a better choice when the staff and material resources for long-term care are limited (Syed Elias et al. 2015). The main advantages of group reminiscence therapy are to share experiences with each other, let individuals learn how to communicate with a group, and increase the ability to interact with society (Burnside and Haight 1994), thus, group reminiscence therapy will improve the elderly’s cohesion to and communication with the group and the parent-child relationship (Bender et al. 1998).

2.3 Technology-Assisted Care Therapy Applications

Technology is an indispensable part of modern people’s life with a wide range of uses, including safety, navigation, social networking, etc., and is used in many environments, such as medical or care systems (van der Roest et al. 2017). Researchers have begun to introduce technology into the deferral and treatment of dementia patients, and have developed many applications to train cognitive impairment. Lazar et al. (2018) believed that the introduction coverage of Information and Communication Technology (ICT) includes hardware, content, applications, and navigation. Compared with traditional nursing staffs, the introduction of technology on a tablet or computer can improve the patient’s self-confidence and sense of achievement. As mobile devices facilitate higher mobility, patients can conduct their own training at home, and even simple training will help patients improve their cognitive function and increase their interactions with their families (Kueider et al. 2014).

Doniger et al. (2018) introduced technology into their experiment to prevent dementia, where participants were middle-aged with a history of dementia in their families. They used virtual reality in combination with exercise to train, and the results showed that the risks for developing dementia were low for those who had participated in the experiment, which confirmed that the introduction of technology to delay dementia treatment has positive benefits. Linda, Adi, and Eric developed technology for dementia patients to introduce adjuvant therapy, which can improve the quality of life of dementia patients and their families. Therefore, there is still much room for improvement in the field of technology.

There are many application systems developed for people with dementia to perform non-pharmacological therapy in an entertaining manner. The < Sea Hero Quest > , as jointly developed by the Alzheimer’s Research Centre in the UK and Deutsche Telekom, trains sense and reactivity through games to help scientists study dementia and understand how the brain works to find more effective treatments and prevention methods (Rigg 2017). The extensive use of intelligent technology is an important strategy for contemporary non-pharmacological therapy to meet dementia patients’ needs for life and health care. Technical assistance brings new opportunities for the care and treatment of dementia, which can reduce the burden of care, improve the participation of non-pharmacological therapy, slow down degradation, control dementia behaviors and psychological symptoms, and assist in determining the degree of dementia.

2.4 User Experience

“Experience” can be obtained through activities, sensory and psychological feelings, and learning, and be simultaneously stimulated by physical sceneries and sounds in the context, as well as intangible services and experiences (Baker and Kennedy 1994; Tynan and McKechnie 2009). Regarding the user experience, Schmitt (1999) proposed Strategic Experiential Modules (SEMs), which divides the experience behavior into 5 factors, including the experiences of sense, think, feel, act, and relate, thus, a variety of experiences can be created through individual or multiple experience methods. These factors are described according to the needs of this research, as follows:

  1. 1.

    Sense: Create the perception of experience, which consists of sight, hearing, touch, taste, and smell, to achieve the purpose of experiencing through sensory stimulation, and explore what elements can trigger interest.

  2. 2.

    Think: Stimulate users to actively participate in solving tasks, trigger thinking in new and interesting ways in the process, and create a cognitive and problem-solving experience for users.

  3. 3.

    Feel: Feelings can be mild, tender, and positive feelings that can lead to joy, pride, and even strong emotions of excitement. It mainly explores which design will make users recall the past, and which will cause emotional changes and integrate into nostalgic situations.

  4. 4.

    Act: Through personal experience and interaction, it will affect life styles and behaviors, and change the original cognitive attitude, generate new life styles and interaction modes, and explore whether users will increase their willingness to participate in similar experience activities after experiencing the interactive technology.

  5. 5.

    Relate: Combine the above four experience modes to explore the correlation between the user and other users.

Referring to the strategy experience module, this research divided the experience behavior into 5 factors. Among them, the experience of act is an analysis factor that has been previously used, thus, this research mainly analyzed the situation of users in system usage, and the act experience was not included in this research analysis, meaning analysis was based on the experience factors of sense, think, feel, and relate.

3 Research Method

A digital cognitive system designed in the Taiwanese nostalgic style was developed for patients with dementia by this research, which combined photo story sharing and cognitive training questions, in order to analyze the benefits of a digital cognitive system for reminiscence therapy, and explore the experience of use by patients with dementia.

3.1 Research Method and Implementation

Application System Prototype Development Phase.

The initial period of this research was system design, which focused on nostalgic image investigation, interface design for the elderly, evaluation, and prototype design of dementia care units. System prototype design and revision were carried out with the literature research method, questionnaire survey method, expert in-depth interviews, and other methods.

  1. (1)

    Preliminary prototype design of the application system: This digital reminiscence system was named “Recall”, with “playing together, reminisce, longing for more” as the core. The nostalgic elements collected in the system design reference were the design style and cognitive question bank. The nostalgic old songs familiar to people with dementia were used as the background music to enable them to be in a nostalgic atmosphere. The number of participants was 2–4 each time, which allowed participants and accompanying persons to enter the nostalgic situation and play together to achieve the purpose of interacting with people.

  2. (2)

    A total of 4 medical experts and interactive technology design experts were invited to conduct system evaluation. The opinions of the experts were obtained via semi-structured interviews to revise the cognitive question bank, in order to better meet the cognitive training needs of dementia patients.

  3. (3)

    In order to come up with operational suggestions, such as the system and experimental procedures, pre-tests were performed after the system prototype was completed. A total of 5 non-dementia patients over 65 years of age were recruited in the pre-test experimental stage, and all of them had used smartphones for an average of 7 years or more. Observation and interview methods were used to give them operational tasks to understand their technology use behaviors.

  4. (4)

    System modification: Corrections were made based on the above survey results.

Usability Experience Analysis. In order to explore the experience of patients with dementia when using digital cognitive systems, observations, interviews, and questionnaires were used for investigation. The study subjects were 16 patients with mild dementia in the Dementia Service Base (Deyiyuan) of the Changhua Christian Hospital’s Chinese District, with an average age of 79.6 years. The experimental tool used is the digital cognitive system, as constructed in this research, for group reminiscence therapy. The entire experiment was recorded with a camera for subsequent research and analysis. During the experiment, researchers observed the behavior of the subjects and recorded them on paper, and after the experiment, the records were used in combination with the questionnaires to investigate the users’ experience.

In order to understand the differences in the use of traditional and digital cognitive training in patients with dementia, this experiment was divided into two groups, the traditional group and the digital group. The subjects’ faces are blocked or blurred to protect the privacy and meet the requirements of academic ethics.

3.2 The Research Hypotheses

The purpose of this research was to investigate the differences in usability and experience between patients with dementia in the digital group and the traditional group. The research hypotheses are, as follows:

  • H1: The traditional group has significant positive correlation in the use of cognitive training.

  • H2: The digital group has significant positive correlation in the use of cognitive training.

  • H3: The traditional group has significant impact on the experience of patients with dementia.

  • H4: The digital group has significant impact on the experience of patients with dementia.

  • H5: Compared with the traditional group, the digital group can significantly affect the experience of patients with dementia.

3.3 Digital Cognitive Application System

System Development.

This research developed the system based on the literature review and field visit data, and consulted relevant medical experts. After several tests and corrections, a tool for this research experiment was produced. The content of this research question bank is shown in Fig. 1.

Fig. 1.
figure 1

System architecture diagram

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System Interface.

Due to the participants’ lack of scientific and technological operation experience, system operation was performed by touch, in order to reduce the operating burden. This system’s operation process starts from the homepage with character selection and teaching guidance in order. After entering the nostalgic old street, users can freely choose any level (Fig. 2). Among them, simple questions must be answered in the grocery store and leather-silhouette show be conducted before one can challenge the questions to receive a reward.

Fig. 2.
figure 2

System interface

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3.4 Experimental Process

Experimental Design.

This research arranged a pre-test experiment 2 weeks before the formal experiment to simulate the possible problems in the formal experiment, and a total of 5 elderly people were recruited as the pre-test subjects.

In this research, in cooperation with Changhua Christian Hospital, the experiment was conducted in a place familiar to the subjects. The formal experiment was divided into the experimental group (digital group) and the control group (traditional group). The formal experimental test was performed once a week for two weeks. The subjects were all patients with mild dementia, as diagnosed by the hospital, and two or three patients were tested in one group. Two experiments were performed in each group, and the total time of each experiment was about 90 min. In order to prevent the subjects having prior knowledge and considering the subjects’ forgetful characteristics, the two groups of experiments were separated by at least 7 days to avoid being affected. Prior to the start of the experiment, the researchers explained the experiment and participants signed the consent form. After the experiment ended, the researchers conducted 1-to-1 interviews and participants filled out a questionnaire.

4 Research Results and Discussion

4.1 Analysis of Subject’s Basic Data

A total of 16 subjects were recruited in this research, with an average age of 79.5 years, a maximum age of 94 years, and a minimum age of 65 years; 7 subjects received the clinical dementia CDR score of 0.5, and 9 received the score of 1. The educational level for most subjects was from elementary school to middle school; nearly half of the subjects had never used any interactive technology.

4.2 Questionnaire Reliability and Validity Analysis

A total of 16 valid questionnaires were collected in this research experiment. After reliability analysis, the Cronbach’s Alpha value of the questionnaire of the traditional group was 0.887 and higher than 0.7, and the Cronbach’s Alpha of the questionnaire of the experimental group was 0.850 and higher than 0.7, indicating that the questions have reliability. The traditional group questionnaire data was orthogonally rotated using the maximum variation method of the main axis method. A total of 10 factors were extracted, which could explain a total of 94.376% of the amount of variation; a total of 9 factors were extracted for the digital group, which could explain a total of 90.300% of the variation, showing that the scale has construct validity.

4.3 Correlation Coefficient Analysis of Usability Factors

In order to understand the correlation between the various factors of the questionnaire and the topic, the Pearson correlation analysis method was used for analysis. The analysis results show that the usability of traditional cognitive training had significant positive correlation with efficiency of the r value (14) = .615, p = .011, efficacy of r (14) = .892, p < .001, task of r (14) = .957, p < .001, and learning of r (14) = .901, p < .001, while the usability and satisfaction of r (14) = .105 and p = .70 had no significant correlation (as shown in Table 1).

Table 1. Usability correlation matrix for traditional group
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The usability of digital cognitive training had significant positive correlation with efficiency of the r value (14) = .666, p = .005, efficacy of r (14) = .808, p < .001, task of r (14) = .872, p < .001, and cognitive use of r (14) = .617, p < .011, while usability was not significantly correlated to the learning of r (14) = .470, p = .066 or the satisfaction of r (14) = .286, p = .284 (Table 2).

Table 2. Usability correlation matrix for digital group
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4.4 Experience Correlation Analysis of Traditional Group

The experience of traditional cognitive training was significantly positively correlated in feel r (14) = .781, p < .001, relate r (14) = .778, p < .001, and think r (14) = .765, p = .001, and negatively correlated in the factor of sense r (14) = −.068, p = .804 (Table 3).

Table 3. Experience correlation matrix of traditional group
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According to the results of the traditional group questionnaire analysis, it was found that the experience factors of feel, relate, and think were more influential (Fig. 3) in the experiment, and the subject would think of his or her own memories through the nostalgic elements of traditional cognitive training materials, and thus, extend more relevant memories.

Fig. 3.
figure 3

Link diagram of experience correlation of traditional group

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4.5 Experience Correlation Analysis of Experimental Group

Digital cognitive training had significant positive correlations with sense of the r value (14) = .730, p = .001, relate of r (14) = .807, p < .001, and think of r (14) = .580, p = .019, but had no significant correction with the factor of the feel of r (14) = .385, p = .14 (Table 4).

Table 4. Digital group experience correlation rotation component matrix
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According to the analysis results of the digital group, it was known that sense, relate, and think had greater impact on user experience (Fig. 4). The subjects were happy in the experiment due to the sound effects of the digital cognitive system. When sharing photos or answering cognitive training questions, there was discussions with each other, and they also recalled the past through the nostalgic elements in the system and further shared their experiences. The sense of experience of the digital group was significantly related to the factors of sense, relate, and think.

Fig. 4.
figure 4

Link diagram of digital group experience

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4.6 Analysis of Differences in Experience Between Two Groups

In order to explore the differences between the subjects in the digital and traditional experience, the questionnaire was used for t testing of the dependent samples for each factor and the overall experience. The traditional group and the digital group had significant differences in the related factors and overall experience. The results are shown in Table 5:

Table 5. T-Test results of difference between experience of two groups
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The analysis of the above hypotheses is integrated into Table 6:

Table 6. Analysis results research hypotheses
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4.7 Behavior Observation Analysis

The experiences of the two groups were discussed on the basis of the results of behavior observations:

  1. (1)

    Sense factor: The overall design of the content of this system was based on the visual style of nostalgic elements, the auditory stimulation of old songs, the tactile sensation of physical characters, traditional retro microphones, and intuitive screen touch operations to shape the perception experience and enable the overall nostalgic impression, and the digital group was provided with better sensory pleasure and satisfaction than the traditional group.

  2. (2)

    Feel factor: The textbook content of this experiment was novel to the subjects, and all of them showed positive emotions during the two-week experiment; however, the textbook of the traditional group could stimulate the nostalgia of the subjects more than the digital group to generate the emotional links of personal memory; the teaching materials of the digital group initially caused tension and psychological rejection for some subjects. Both groups were given feedback and physical rewards, which were also helpful to the subject’s emotional encouragement, in order that they could be immersed in the activity and have positive participation, and joyful emotions were even induced. The content design of this topic can provide good stimulation for feelings. Especially regarding some of the subjects that had never been exposed to such systems; they felt very powerful when they suddenly realized that they could also use computers, which gave them a higher sense of accomplishment and identity.

  3. (3)

    Think factor: The think factor requires intelligence. The thinking training at each level of this experiment can stimulate the subjects’ problem-solving ability and motivate their longing for freshness and attempt to try. This shows the difficulty of the design of this experiment can effectively meet the cognitive stimulation of the two groups.

  4. (4)

    Relate factor: Relevance includes the above three factors (sense, feel, and think), which allowed the subjects to integrate into the group life via this activity, and have a good interactive relationship through this experimental activity. In addition to rational cognitive thinking during the experimental process, the subjects also exchanged their memories and solved problems with each other. The end result shows that the two groups were significantly different, emotional memory links were generated through system guidance, and self-value was built in the activity.

It was clearly observed in the overall experience that the subjects felt the novelty of using the touch screen, there was a lot of excitement in the activities of the digital group, the interactions between the subjects were obviously more than those of the traditional group, and the group members helped each other to answer questions. In contrast, photos sharing or answers in the traditional group were made by the subjects themselves, and there were fewer opportunities for communication. The digital group was more willing to share photos and past memories, the subjects actively helped other subjects with weaker capacity in cognitive problem solving, and they were more intoxicated by the singing activities than the traditional group. In the interviews after the experiment, some subjects stated that they had less exposure to digital technology in the past. They felt it was refreshing and fun, as the pictures and nostalgic elements in the system could trigger their memories and make them recall the details of their past lives.

5 Conclusion

This research cooperated with Changhua Christian Hospital in Taiwan, took local patients with mild dementia as the research subjects, designed a digital cognitive application system “Recall” for patients with dementia via Non-pharmacological therapy combining cognitive stimulation, cognitive training, reminiscence therapy, etc., and explored the user experience of a digital cognitive application system for patients with dementia through behavior observations, questionnaires, and interviews.

This research conducted a survey of the usability and experience of patients with mild dementia, and found that most patients with mild dementia had no obstacles in the operation of the system, and they highly praised the rewards provided by the system and the feedback of the sound effects. The patients in the digital group were more willing to share memories with others and interacted more frequently with each other. They were also immersed in thinking about the cognitive training questions designed for the digital group, and actively assisted their peers when answering the questions. They happily swayed their bodies with the randomly chosen melodies during music therapy. The experience of patients with dementia in the factor of sense showed happiness, a sense of accomplishment, and pride; in terms of the factor of relate, it could effectively promote their social skills; for the factor of think, it generated resonation and inspired more memories. This system allows patients with mild dementia to be integrated into reminiscence therapy, which can promote cognitive stimulation training for people with mild dementia, be connected to emotions and memories, and help enhance positive emotional factors and promote social interaction.

One part of the cognitive training system developed by this research is nostalgic storytelling and the spontaneous process of reminiscence therapy to recall memories through storytelling, and such cognitive training can help stimulate memory and language skills, promote communication and increase socialization, and generate confidence and pleasure. The other part is cognitive training, which mainly trains memory, logical judgment, and other abilities. Cognitive training can slow the decline of cognitive ability, thus, in addition to helping patients with dementia, it can strengthen the brain and prevent degradation in elderly people without dementia. The introduction of technology will contribute to the application of dementia treatment.

This study has both research and practical value, as it is combined with the hospital’s professional dementia medical team, and is a research cooperation integrating design, technology, and medical fields. The integration and use of different professional knowledge, resources, and experience can be implemented in the clinical application of reminiscence therapy and knowledge training in the future, and will directly contribute to dementia patients and their families.