This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR mhealth and uhealth, is properly cited. The complete bibliographic information, a link to the original publication on http://mhealth.jmir.org/, as well as this copyright and license information must be included.
Alzheimer's disease (AD) is an irreversible brain disease that slowly destroys memory and thinking skills, and eventually the ability to carry out the simplest daily tasks. Recent studies showed that people with AD might actually benefit from physical exercises and rehabilitation processes. Studies show that rehabilitation would also add value in making the day for an individual with AD a little less foggy, frustrating, isolated, and stressful for as long as possible.
The focus of our work was to explore the use of modern mobile technology to enable people with AD to improve their abilities to perform activities of daily living, and hence to promote independence and participation in social activities. Our work also aimed at reducing the burden on caregivers by increasing the AD patients’ sense of competence and ability to handle behavior problems.
We developed ADcope, an integrated app that includes several modules that targeted individuals with AD, using mobile devices. We have developed two different user interfaces: text-based and graphic-based. To evaluate the usability of the app, 10 participants with early stages of AD were asked to run the two user interfaces of the spaced retrieval memory exercise using a tablet mobile device.
We selected 10 participants with early stages of AD (average age: 75 years; 6/10, 60% males, 4/10, 40% females). The average elapsed time per question between the text-based task (14.04 seconds) and the graphic-based task (12.89 seconds) was significantly different (
We found that people with early stages of AD used mobile devices successfully without any prior experience in using such devices. Participants’ measured workload scores were low and posttask satisfaction in fulfilling the required task was conceivable. Results indicate better performance, less workload, and better response time for the graphic-based task compared with the text-based task.
Alzheimer's disease (AD) is an irreversible brain disease that slowly destroys memory and thinking skills, and eventually the ability to carry out the simplest daily tasks. Currently, there is no cure for the disease, which worsens as it progresses, and eventually leads to death. The Alzheimer's Association estimates that 1 in 8 older Americans is living with AD totaling approximately 5 million Americans [
AD is the most common cause of dementia among older people. Dementia is the loss of cognitive functioning including thinking, remembering, and reasoning and the loss of behavioral abilities, to such an extent that it interferes with a person's daily life and activities. Dementia ranges in severity from the mildest stage, when it is just beginning to affect a person's functioning, to the most severe stage, when the person must depend completely on others for basic activities of daily living [
Health care professionals have tended to overlook the needs and the requirements of Alzheimer's individuals for physical exercises and activity programs. Because of the memory retention problems, many health care professionals feel that the majority of persons with AD have little, if any, rehabilitation potential. Besides retention problems, many clinicians also take the "they're just going to get worse anyway" approach in their clinical decision making [
Recent studies [
For individuals with AD, rehabilitation should focus on people's abilities, rather than their disability. The goal is to maintain as high a quality of life as possible for as long as possible [
In recent years, mobile devices have improved rapidly in processing power, embedded sensors, storage capacity, and network data rates. Mobile devices today have evolved from merely being phones or simple personal digital assistances to full-fledged computing, sensing, and communication devices. These advances in mobile device technology have paved the way for exciting new apps. Mobile devices can be used as medical devices for measuring blood pressure, measuring glucose levels, performing portable ultrasounds, and even testing for sexually transmitted diseases.
In previous research [
AD is currently an incurable disease and worsens progressively. Our approach in dealing with this disease focuses on two aspects: finding ways to help the patient cope with the disease, and slowing down the pace of decline in quality of life as the disease worsens. A combination of advanced mobile devices equipped with near field communication (NFC) and NFC tags will be used to meet the challenges of the two focus areas. Mobile devices running the Google Android operating system (OS) have been selected because currently, many mobile devices supporting NFC are running the Android OS.
Our approach was based on general standards recommended when dealing with people with dementia [
Since AD is not a curable disease, our approach focused on maintaining the highest possible quality of life of AD patients. An app, named ADcope, with several modules was developed on mobile devices to support this approach [
The first module is a memory wallet, as suggested by Bourgois et al [
The second module is a calendar with reminders of all daily activities that need to be performed. The events can refer to information in the memory wallet such as photos to help the patient recognize the person he needs to talk to or the place he needs to go. The calendar also includes the recurring event to review the memory wallet.
The third module uses NFC tags that are placed on various things, including drawers and doors. As the person touches these with the mobile device, the mobile device displays a list of content of the drawer or room. This saves the person from having to open them for inspection when looking for something. This can also be used by a new caretaker to facilitate fetching items requested or needed by the patient since they may not have prior knowledge of how things are arranged.
ADcope modules and interfaces.
Although AD is an incurable disease, some memory exercises may help in retaining critical information longer. Researchers have identified several exercises and training techniques that patients with dementia should perform periodically. The exercises include Audio Assisted Memory Training as identified by Arkin [
These exercises have been integrated into the ADcope app as separate modules. The Audio Assisted Memory Training module replicates the audiocassette recorder approach by playing back audio files of the biographical information and quizzing the patient regarding the information. The targeted answers are very short and mostly consist of one or two words. The simplicity of the answers is critical for successful exercises based on the general recommendations when dealing with AD patients. The simplicity of the answers also enables the use of voice recognition techniques to automatically validate correctness of responses.
The Spaced Retrieval exercise module has been designed to execute in two phases: an assessment phase and a training phase. During the assessment phase, the current memory recall ability is assessed by presenting a piece of information, and then the patient is quizzed about it at a later time. If the recall fails, the information is reiterated, and quiz repeated again later. The length of time between quizzes is reduced until memory recall is successful. The final duration between information presentation and successful recall is stored as the basis for initial duration in future training. The second phase is the training phase in which the module follows the Spaced Retrieval recommendations for training recall of information. The module starts with the duration of time between information presentation and quizzing as determined in the first phase and the length of time between information presentation and quizzing is lengthened with every successful retrieval and maintained with every failure.
The modules described in the previous sections require substantial setup and training. The ADcope app includes a setup module, which will guide the caregiver (or patient if he is able to) through all of the setup steps, which is outlined in
The app needs to be able to recognize voices and match voice replies with correct answers. The ADcope app includes a separate module for training the voice recognizer. The module displays words and asks the patient to read them. A spectral analysis is then done on the words and stored for future voice recognition.
Recording audio files of biographical data: the user is asked to narrate the desired biographical phrases and signal the termination of recording. The user can record several audio files that are randomly played back in the Audio Assisted Memory Training module.
Recording of biographical quiz questions and answers: the user is repeatedly asked for questions that are recorded. After each question, the user is asked to type in the correct answer. The answers are currently limited to numbers (such as age, year, and quantities) or single words due to the limitation of the voice recognition libraries used in the development of the app.
Spaced retrieval exercises: the ADcope app has some built-in spaced retrieval exercises based on general knowledge facts. However, the setup module allows the user to add additional fact-question pairs. The user also has the option to setup the Spaced Retrieval module to exclusively use the user-added facts.
Memory Wallet initialization: the user is asked to take photos of people, places and events and type in a word or a phrase for each one. The user can also optionally tag the photo with a voice sample of the person in the photo. The user is allowed to defer this part of the setup to later and build the memory wallet as he meets people or visits places.
NFC tagging: The user is asked to enter a note that describes the item being tagged. For example, this could be contents of drawers. The user is then asked to place the smartphone next to the tag and the ADcope app uses the internal NFC writer of the smartphone to write the information to the tag.
Calendar: In the last step of the setup procedure. The user is asked to enter recurring calendar event with optional photos for each event.
In this study, we evaluate the usability of the proposed ADcope app. Specifically our main objective is to evaluate the usability of the Spaced Retrieval exercise. The following section describes in details the selected participants, apparatus, study procedure, and the collected measures.
The participants considered in the study were volunteers from Darat Samir Shamma, a senior residential care facility and housing located in Amman, Jordan. The participants were primarily seniors, with early stages of AD. It is important to note that finding participants with early stages of AD was very challenging. Ten participants were asked to perform the Spaced Retrieval exercise on a tablet device while sitting in a room (NCT02005380). The mean age of the participants was 75 years and the SD was 9.6. Basic demographic characteristics were recorded for each participant.
As shown in
Participants' demographics summary (N=10).
Characteristics | ||
|
|
|
Average | 75.1 | |
SD | 9.6 | |
|
||
Male | 6 (60) | |
Female | 4 (40) | |
|
||
Current | 7 (70) | |
Never | 3 (30) | |
|
||
>1/day | 4 (40) | |
1/day | 3 (30) | |
<1/day | 3 (30) | |
|
||
|
Yes | 3 (30) |
|
No | 7 (70) |
Seven-inch Samsung Galaxy Tab 2 devices running Android OS were used in this study. The app was developed using the Android software development kit (SDK). The app kept a log of participants’ response times, total time of each trial, and the total time for each participant to complete his/her overall task. At the beginning of each experiment, participants were briefed about the goal of the study and instructions on how to use the device and run the app to complete the required task. Upon completion of the trials, participants were requested to fill in a posttask questionnaire to rate the performed task degree of difficulty along with the National Aeronautics and Space Administration task load index (NASA-TLX) workload assessment [
NASA-TLX [
As described in the Approach Section, the Spaced Retrieval exercise has been designed to execute in two phases; an assessment phase and a training phase. During the assessment phase, the current memory recall ability is assessed by presenting a piece of information, and then the patient is quizzed about it at a later time. If the recall fails, the information is reiterated, and the quiz is repeated again later. The length of time between quizzes is reduced until memory recall is successful. The final duration between information presentation and successful recall is stored as the basis for initial duration in future training.
In the assessment phase of our developed spaced retrieval exercise, one sentence piece of information along with a text button at the bottom of the screen labeled “tap the screen to continue” was displayed on the tablet’s screen. Participants were instructed not to move onto the question until they felt they had known the content of the presented information. When the participant taps on the screen, the sentence disappears and a question with four choices related to the previously presented sentence appears on the screen after some delay. The delay was initially set to 90 seconds at the first trial. Once the participant taps on the screen, s/he was not allowed to go back to the passage. If the participant taps on the correct answer, the time space between the presented information and the related question for the next trial was increased by 10 seconds. If the participant taps on the wrong answer or fails to answer within 60 seconds, the same information was represented again and the time space was decreased by 10 seconds for the next trial. The assessment phase was limited to 10 different questions or 30 minutes of time. The delay time between the presented piece information and the display of the question for the last trial was used for the training phase of the program and was referred to as the recall time for the participant.
The second phase was the training phase, in which the same procedure as the assessment phase was repeated where one sentence piece of information was presented followed by a question with four different choices. The recall time logged at the end of the assessment phase is used for the duration of time between information presentation and quizzing. The length of time between information presentation and quizzing is lengthened with every successful answer and maintained with every wrong answer. Once the participant selects a correct answer, a feedback appears for 5 seconds on the screen, which read "correct answer" before moving to the next question. If the selected answer was incorrect a "wrong answer" feedback appeared on the screen for 5 seconds before repeating the same information for the failed trial. The training phase for our experiment was limited to 10 questions. Upon successfully completing all of the trials, a feedback appears at the bottom of the page, which read "well done, task completed."
The ADcope Spaced Retrieval exercise offers two types of quizzes: text-based and graphic-based scenarios. In this study, participants performed both of the two scenarios.
In this scenario, a one sentence piece of information was displayed on the tablet’s screen. The sentence was composed of 5 to 9 long words. After a delay, a question related to the previously presented sentence appears on the screen with four choices. Each of the answer choices consists of 1 to 2 words. The questions were general knowledge questions in sports, history, geography, and movies. Both of the assessment phase and training phase consist of 10 different questions each. The same presented sentences' order along with the same multiple choices were used for all participants. A screenshot of one of the presented information and the multiple-choice question screens are shown in
As some of the participants in our study have difficulties in reading text, we have used text to speech Android SDK to read the information, the questions, and the associated multiple-choices aloud. The developed app also supports two languages: English and Arabic. Participants were instructed to use their preferred language.
Screenshots of the text-based spaced retrieval exercise.
In this scenario, a shape or image was displayed on the tablet’s screen followed by a four multiple-choice images of which one matched the earlier presented image. The questions were created using simple geometrical shapes, flags, and traffic signs. The same 10 presented images order along with the 40 multiple choices were used for all participants. A screenshot of one of the presented information and the multiple-choice question screens are shown in
Experimental Measures
The recorded measures during the experiments are presented in
Collected measures.
Measure | Description |
Average response time | The elapsed time between the question presentation and the participant selection of one of the answer choices. |
Average elapsed time per question | The average elapsed time for answering presented question, excluding the recall delay time. |
Correct answer score | Percentage of questions answered correctly from the first trial. |
Posttask questionnaire score | Participants’ feedback related to his/her overall satisfaction in fulfilling the required task (between 0 and 7). |
NASA-TLXa score | The overall NASA-TLX subjective workload score (between 0 and 100). |
aNational Aeronautics and Space Administration task load index.
The objective measures are:
The average response time: the elapsed time between the question presentation and the participant selection of one of the answer choices. It measures the average time it takes the participant to comprehend the question and select one of the four multiple-choice answers.
Average elapsed time per question: the average elapsed time for answering presented question excluding the recall delay time. This measures the average time it takes the participant to successfully answer the question correctly excluding the delay between information presentation and quizzing.
Correct answer score: measures the percentage of questions answered correctly by the participants from the first trial.
The subjective measures are:
Post task questionnaire score: measure the participants’ feedback related to his/her overall satisfaction in fulfilling the required task.
NASA-TLX: measures the overall participants’ workload score in fulfilling the required task.
Screenshots of the graphic-based spaced retrieval exercise.
To investigate the between-groups (text-based and graphic-based) difference, analysis of variance (ANOVA) test was conducted (
Results compariosn between text- and graphic-based experiements.
Measure | Mean | Minimum | Maximum | SD |
|
|
|
|
|
|
23.94 | .001 | |||
|
Text-based | 14.04 | 6.60 | 20.50 | 4.98 |
|
|
|
Graphic-based | 12.89 | 5.90 | 19.50 | 4.49 |
|
|
|
|
5.48 | .047 | ||||
|
Text-based | 53.81 | 9.30 | 186.00 | 54.67 |
|
|
|
Graphic-based | 34.84 | 9.30 | 82.50 | 25.21 |
|
|
|
|
|
26.87 | <.001 | |||
|
Text-based | 7.60 | 4.00 | 10.00 | 2.32 |
|
|
|
Graphic-based | 8.30 | 6.00 | 10.00 | 1.70 |
|
|
|
|
7.69 | .02 | ||||
|
Text-based | 5.80 | 4.50 | 7.00 | 0.89 |
|
|
|
Graphic-based | 6.00 | 4.50 | 7.00 | 1.03 |
|
|
|
|
|
|
|
104.44 | <.001 | |
|
Text-based | 31.50 | 10.00 | 48.00 | 14.77 |
|
|
|
Graphic-based | 27.20 | 10.00 | 40.00 | 10.64 |
|
|
aNational Aeronautics and Space Administration task load index
In order to investigate the relationship between the experimental measures and the participants’ performance in fulfilling their required task successfully, correlation analyses were run among all pairs of the experimental measures. The correlation results are shown in
Correlation analysis for the text- and graphic-based tasks.
Measure | Correlation value |
|
|
|
|||
|
Average response time | −.84 | .002 |
|
Average elapsed time per question | −.72 | .02 |
|
NASA-TLXa | −.66 | .04 |
|
|||
|
Average response time | −.78 | .008 |
|
Average elapsed time per question | −.93 | <.001 |
|
NASA-TLXa | −.79 | .006 |
aNational Aeronautics and Space Administration task load index
Our study showed that patients with early stages AD could use mobile devices successfully without any prior experience. Participants were able to comprehend, recognize, and recall information from our mobile app ADcope, and performed better in the graphic-based tasks compared to text-based tasks with a lower response time. The workload for completing these tasks was low, and participants were satisfied in completing the tasks successfully based on the posttask questionnaire scores. These are good indications for the app, as Yurko et al [
Many researchers have focused on using mobile devices and social networks for monitoring elderly patients by relatives and health professionals [
Some researchers proposed various devices to help AD patients to cope with the symptoms. Imbeault et al [
Bouchard et al [
Lim et al [
Much research has focused on usability studies of devices, apps, and games that are targeting Alzheimer’s patients. Boulay et al [
AD is the most common cause of dementia among older people causing the loss of cognitive functioning including thinking, remembering, and reasoning. Currently, there is no cure for the disease, which worsens as it progresses, and eventually leads to death. In this paper, we have conducted usability study for the spaced retrieval memory exercise using mobile devices on 10 participants with early stages of AD. We have found that people with early stages of AD have been successfully able to use the mobile device without having any prior experience in using such devices. Participants’ measured workload was found to be low and posttask satisfaction in fulfilling the required task has shown to be conceivable. Results also indicated better performance, less workload, and better response time for the graphic-based user interface compared with the text-based user interface.
Alzheimer’s disease
analysis of variance
National Aeronautics and Space Administration task load index
near field communication
operating system
software development kit
The authors are greatly indebted to Darat Samir Shamma’s staff for their assiduous assistance and support.
None declared.