The number of people living with Alzheimer and related dementia is projected to triple by 2050 [1-3]. Persons living with dementia can have complex physical health concerns, comorbid medical conditions, and exhibit behavioral and psychological symptoms of dementia (BPSD) [4-11]. In fact, professional caregivers of persons living with dementia already note that responding to BPSD is one of the greatest care challenges and can negatively affect the health of caregivers [12-14] especially in long-term health care facilities, where two-thirds of residents have dementia [9,13,15,16]. Family caregivers of persons living with dementia are also are at risk for higher rates of depression, health and sleep issues, social isolation, and mortality [14,17].

Pharmacological or nonpharmacological interventions can help manage BPSD in older adults with moderate-to-severe cognitive impairment. Medications may control the physical aspects of BPSD but can have many side effects [18]. Nonpharmacological approaches, such as reminiscence therapy, music therapy, or behavior management techniques, are preferred because they sustain cognitive function, improve quality of life, and mitigate BPSD [19-25]. The growing number of persons living with dementia, overall care challenges, and the negative effects of pharmacological interventions combine to highlight the need, as well as the opportunity, for additional nonpharmacological interventions.

Availability of tablets and mobile phones has changed how nonpharmacological interventions can be delivered to older adults. Tablets can enhance residents’ emotions through the use of multisensory activities. Individuals can now obtain informational content, interact socially (including participating in Web-based games), listen to music, or reminisce about the past or a recent special event. Easy access to information and communication technologies (ICTs) such as tablets facilitates the delivery of nonpharmacological interventions especially for persons living with dementia and their caregivers [26-28]. For persons living with dementia, ICTs such as YouTube, a Web-based video service, can be used to deliver reminiscence therapy interventions on a tablet through an app [29]. For these individuals, the use of ICTs mitigates motor and sensory impairments; compensates for memory deficits; or enhances latent skills and abilities for sensory awareness, musical responsiveness, and emotional memory [30,31]. Overall, the use of ICTs to deliver nonpharmacological interventions for persons living with dementia benefits care recipients’ well-being and mood; communication and interactions; and caregivers’ mental health (eg, depression and anxiety), self-efficacy, and relationship with the care recipient [26,28,29,32-39]. An additional benefit is the potential for persons living with dementia to remain in the home for as long as possible. This outcome is a widespread aspiration, with “Nearly 90 percent of people over age 65 [wanting] to stay in their homes for as long as possible” [40]. Therapeutic approaches that help persons living with dementia live at home longer also reduces overall health care costs [41].

Although successful use of tablets originated and empirically documented about a decade ago in Great Britain, with investigations continuing into the present both in Europe and beyond [42-47], its adoption in the United States has been slow [34,48-55]. Two Great Britain studies offer a progressive look at how tablets can be applied to improve communications between persons living with dementia and their caregivers [56,57]. The first study compared a traditional reminiscence programs (noncomputer) with computerized touchscreen, one-on-one, reminiscence sessions and tested the hypothesis that caregivers offer greater choices and engage in more conversational activities during the touchscreen sessions than during the traditional one-on-one reminiscence sessions with physical properties [56]. After comparing the 2 types of sessions across both verbal and nonverbal parameters, such as laughter, singing, pointing, and eye gaze, the touchscreen system was shown to provide greater benefits for both caregivers and persons living with dementia. The second study was based on the central concept that “external memory aids have demonstrated a reduction in resistance to care...” [57], and using the iPad as the focus of joint attention not only relieves some of the burden of communication for caregivers but also provides the opportunity for the caregiver to support greater independence in persons living with dementia through scaffolding behavior.

The project described in this study extends this seminal international work to implement a tablet intervention using multiple device management and software apps in different community settings and document the effect on mood with older adults, as well as the impact of engagement on their caregivers. This manuscript reports aggregate findings from a pilot study evaluating the impact of personalized tablet engagement sessions. Four project aims represent the purpose of this study to examine study variables effects on mood changes in (1) the overall care recipient sample, (2) the subsample of care recipients being treated in skilled nursing facilities (SNFs), (3) care recipients in home care only, and (4) caregivers’ daily activities.

One of the primary advantages in using a tablet for engagement activities for persons living with dementia is the ability to personalize activities because every person has a unique lifetime of experiences. For this program, the term personalized tablet engagement reflects a tablet engagement session that is designed by a caregiver based on the personal history of the care recipient. The session is presented to the care recipient, who is given the option of participating. In this way, tablet engagement is both based on an individual’s interests, abilities, and preferences and allows the individual to exercise autonomy.

Since 2015, Generation Connect initiated partnerships to evaluate the effectiveness of tablet interventions in dyads of caregivers and persons living with dementia. The Music & Memory Foundation used tablet computers that were preconfigured with recommended apps, deployed with management software, and implemented with training resources created and facilitated by Generation Connect. These tablets allowed tailored interactions to residents’ interests or hobbies to expedite engagement and enhance emotions through multisensory activities.

This study describes a naturalistic study in which the Music & Memory Foundation and a Visiting Angels in-home care agency franchise collaborated with Generation Connect to develop and conduct an ongoing tablet engagement pilot study involving 5 different programs across time (2017-2018). Multimedia Appendix 1 describes the 5 programs contributing the tablet engagement session data analyzed for this study. 

The intervention was designed to be useful for persons living with dementia, and all participating communities opted into the pilot study and self-selected the residents that participated, no standardized test was used to record non-normative memory loss. The sessions were not limited restricted to a dementia population and contained a variety of other conditions as well. However, participants’ demographics beyond these primary challenges were not collected in the pilot programs.

All data were reviewed for accuracy and completeness. In addition, data cleaning and label standardization ensured response uniformity before analysis. Our team then reviewed and converted the variables into the following categories:

Facility type was self-reported as skilled nursing, home care, or other (which consist of Continuing Care Center, Assisted Living Facility, Long-Term Care Facility, and Veterans Hospital). Facility locations were classified as rural or urban using the US Department of Agriculture Rural-Urban Continuum Code, and for Canadian facilities, rural or urban status was determined through website search.

Frequency distributions were computed for each of the study variables, including the type of care recipients’ mood changes. All variables were collected as categorical and ranged from dichotomous, trichotomous, up to 6 categories. Chi-square tests of association were calculated to determine the influence of the variables on mood changes for all care recipients, as well as those being treated in SNFs and in-home, and then those that affected caregivers’ daily activities.

The project was determined to constitute quality improvement or program evaluation and in accordance with federal regulations, the project did not constitute research as defined under 45 Code of Federal Regulations 46.102(d).

Posthoc power analysis for the chi-square tests demonstrated superior power for all analyses. The power levels calculated for all 4 project aims conformed to Cohen’s accepted standard of a four-to-one weighting between type II and type I error risks [66]. In addition, no significant chi-square results were associated with more than 33% of contingency table cells having expected counts of less than 5.

Frequencies were computed for each study variable and each of the analyzed samples (ie, full sample, SNFs only, and home care only), as shown in Multimedia Appendix 5, which also demonstrates a relatively unequal distribution of resident mood changes after use of the tablet.

Table 1 represents overall mood improvement after the use of the app technology among individuals with various disabilities and is further illustrated when examining frequencies within each of the mood change categories.

Table 2 contains the frequencies for each study variable within the 4 separate mood change categories, which provides insight into the category of each variable that contributed to the mood effect.

This study is one of the first in the United States to focus on the implementation of tablets across institutional (eg, SNFs) and in-home settings for persons living with dementia. The most apparent implication from this study was the substantial benefit of the tablet interventions to most care recipients. Less than 8% of the entire sample evidenced either the transition of positive to negative mood (8/1089, 0.73%) or the sustainment of negative moods (72/1089, 6.61%) after caregiver engagement sessions. That is, for the vast majority of the entire sample, positive care recipient moods were either maintained or enhanced or were achieved after beginning the session in a negative mood. The unequivocal therapeutic benefit of personalized tablet engagement with music and other approaches seems a function not only of the effectiveness of the particular intervention but also of caregiver commitment to and compassion for the care recipient.

Caregiver supports that maintain interest and participation, as well as promote feelings of achievement and mastery, create a positive experience for participants and caregivers with tablets [33]. Successful interactions should provide achievable goals facilitating feelings of self-worth, which require the caregiver to be in the moment and select apps based on resident mood to promote engagement [33]. Study results extend this concept further, indicating that app selection should target multiple strategies (eg, reminiscing or socialization) to facilitate improvements in resident moods.

Our findings also offer guidance around the care recipient and caregiver engagement process. Specifically, the use of a single app, especially YouTube, resulted in moderate to substantial improvements in resident mood across the entire sample. This influence of YouTube supports additional research, indicating that exposure to YouTube videos improves participants’ well-being and mood, as well as their communication, interaction, and engagement [29]. In our study, YouTube was primarily used to share music or stories through video and strategies related to reminiscing, socialization, or music. One resident encounter convincingly illustrates tablet impact on resident mood:

This session successfully targeted all 3 strategies, and the resident’s mood improved the greatest extent possible, from sad to joyful. Years of experience has shown that YouTube holds great potential for personalization because of the nearly unlimited number of topics available. When given the choice of activity, caregivers are choosing to work with YouTube.

Interestingly, using gaming apps (eg, Puzzable or Solitaire) to engage care recipients did not statistically improve mood, especially compared with other engagement strategies. For these care recipients, the complexity of playing the game may have undermined mood improvement. For example, one resident reported the following:

Although an unfortunate reaction, this finding supports research suggesting that gaming apps are not as useful for promoting engagement as apps targeting relaxation or telling an individual’s life story in this population [34]. Conversely, other research demonstrates that interactive computer games (eg, a Nintendo Wii) affected participant cognition [67]. These contradictory findings warrant further research to examine the specific gaming features and the interaction of these features with care recipient characteristics and cognitive conditions that prompt mood changes.

Mood changes differed by location. Overall, 82.9% (339/409) of care recipients in rural areas reported more negative moods (sad, confused, angry, anxious, or indifferent) at baseline versus those in urban areas (286/680, 42.1%). Similarly, 88.2% (329/373) of care recipients in SNFs began sessions with a negative mood compared with 40.1% (267/666) of individuals in home care settings. However, after tablet engagement, only 7.5% (28/373) of individuals were assessed with a negative mood. A potential explanation for this finding is a greater continuity of care existing between caregivers and care recipients in home care sessions, including more frequent and sustained interactions. How facility-setting characteristics influence care recipient or caregiver mood and mood changes, along with their feelings of isolation or loneliness, remains crucial research topics when implementing tablets or other ICTs.

Although illustrating numerous areas for investigation, this study had limitations. First, to ease data collection burden on caregivers, no resident or caregiver attributes (such as gender, age, or duration of the primary challenges) or years of caregiving service were documented. Second, although efforts were made to systematize training and data collection, there may have been variability in these processes either across or within programs. For example, the key strategy (eg, music or reminiscing) may have been recorded inconsistently. Third, as caregiver observations determined mood baseline and changes, knowledge of study objectives or varying assessments of residents’ mood could, even unintentionally, introduce bias. Fourth, the time allotted for the care recipient and caregiver interaction may have affected mood changes but was not collected. Finally, findings related to the caregivers’ day suggest that the intervention was beneficial overall, but the effect may differ for larger samples or other care recipient or caregiver samples.

This study documents further evidence that ICTs, in particular, tablets such as iPads and apps such as YouTube or using a Personal Playlist, improve mood in older adults and enhance caregiver perceptions about their care recipient interactions, especially with persons living with dementia. Importantly, these pilot data substantiate ICTs, as part of a personalized engagement approach, as beneficial alternatives to pharmaceutical interventions for mood enhancement. As was done for this study, matching engagement methods and types of strategies and apps, based on care recipient preferences or other features to maximize their mood effects, is critical for strengthening the utility of this approach. Accumulating evidence and the additional research questions emerging from this nascent examination offer exciting prospects for continued empirical inquiry and bettering care recipient well-being.