Chapter discussion and conclusion

Throughout chapter 4, we describe the development process of Musiquence, which is a platform that health professionals can use to provide music and reminiscence cognitive stimulation for PwD. In the same chapter, we aimed to answer research question RQ.1- How to develop a therapeutic game using technology and the benefits of music and reminiscence? To answer RQ.1, we addressed two sub-questions: RQ.1.1- Which “out-of-the-shelf” technologies are more suitable for PwD? and RQ.1.2- Which interaction modalities are more intuitive for PwD?

To answer RQ.1.1- Which “out-of-the-shelf” technologies are more suitable for PwD? We invited 12 PwD to interact with a variety of technologies, and we evaluated their user experience (see section 4.1). As participants used the technologies to perform virtual related tasks, we identified potential issues such as assistance provided, comprehension issues, perception issues, interaction issues, and discomfort. We also studied how the patient's profile would affect performance in those different tasks and technologies. Finally, we provided a set of recommendations for the selection, use, and design of virtual tasks for these technologies. Our main findings show significant effects of technology on performance regarding comprehension, interaction, and discomfort.

Overall, participants were able to complete all tasks using all technologies. However, a clear outcome of the study is that there is no absolute best technology for PwD, but this is both task and patient profile dependent. In general, the use of technologies that require direct interaction is advisable, given that cognitive performance gradually declines in PwD, as it relies on fewer cognitive resources than indirect interaction devices. We observed that cognitive skills, as assessed by the MMSE test, did influence participants' perception, comprehension, and interaction, and required more assistance.

Additionally, schooling is also a factor to be considered; the lack of experience and exposure to such technologies can lead to confusion and anxiety, which interferes with user experience.

A cost-effectiveness analysis comparing price and issues identified in all technologies used suggests that the best trade-off of performance and cost is achieved with the Mouse, the most effective technology is HMD, and the most expensive one is AR. Through these insights, the experiment provides newer insights for health professionals, informal caregivers, and engineers regarding the use and design of novel technologies for PwD to (1) maximize their success in using such technologies to fulfill virtual tasks and (2) safeguard their psychological wellbeing.

In summary, participants in the study presented in section 4.1 were able to handle the technologies to complete virtual tasks. Interestingly, the overall success in using technologies by PwD depends on different variables such as patient profile, type of task, and interaction modality. Our study provides a quantitative analysis that contributes towards a better understanding of the complex relationship among those factors. Finally, by translating our findings into a set of guidelines, we hope to

80

facilitate technological interventions and to enhance the user experience of PwD when performing virtual tasks with "out-of-the-shelf" technologies.

However, the study had some limitations. We had a small number of participants, and not all participants interacted with all technologies. Consequently, if we applied Bonferroni correction for multiple comparisons, statistical significances during posthoc analysis do not remain. Hence, a larger sample size would have provided higher statistical power for the analysis. Also, having a control group of healthy age- and sex- match participants, would have been informative to discriminate age and dementia-related issues such as perception problems. Future studies should consider adding a control group to draw additional conclusions regarding the usage of "out-of-the-shelf " technologies to perform virtual reality tasks. Nevertheless, adding a control group presented some challenges.

Firstly, we interacted with a population that cannot adequately express themselves in the same way healthy elderly do. Therefore, we had to use very time-consuming methodologies, such as independent annotation of hours of video recordings, categorization, and extraction of data so that a quantitative analysis could be performed. Consequently, we would have to use the same methodology with the control group (that would not require it), making it not feasible for us, given the time needed and available human resources. Secondly, even if we did so, our experience tells us that the two groups would not be directly comparable even if performing the same activities because PwD required constant stimulation and assistance by researchers and health professionals to understand and perform the tasks.

Thirdly, the level of autonomy of PwD in performing the activities is not comparable to that of a healthy old adult.

Also, when performing the cost-effectiveness analysis, we have considered different approaches such as the normalization of costs and issues; however, we realized that the resulting values did obscure the actual relation to either cost or actual issues, making it very difficult to interpret. Moreover, we considered performing an "issues per euro" analysis; yet such an approach was also problematic since the metric favored expensive equipment. That is, the more expensive the equipment, the less the issues/cost ratio. Similarly, very cheap equipment such as the Mouse always presents a very high (comparatively) issue/cost ratio. Therefore, in the cost-effectiveness analysis, we gave the same weight to issues and cost because (1) it is fairer to compare and (2) easier to interpret.

Moreover, the usage of assessment tools should be considered for additional qualitative data analysis such as the Individually Prioritised Problem Assessment (IPPA) and the Psychosocial Impact of Assistive Devices Scale (PIADS) to evaluate how technology impacts the daily life of PwD. Finally, some video recordings were corrupted and, although we also used written notes, some level of detail may have been lost.

81

To answer RQ.1.2- Which interaction modalities are more intuitive for PwD? We developed the first version of a stimulation tool using an AR setup, which had a set of activities designed to target cognitive and physical skills (see section 4.2). The purpose of the experiment was to study how PwD interact with an AR system while performing a variety of tasks through different interactions. Overall, participants enjoyed doing the activities and were able to complete these with a high success rate.

Nevertheless, assistance was occasionally provided to participants to complete the tasks. The number of assistance given is dependent on individual characteristics, such as cognitive and physical conditions. Also, during task completion, participants were able to remember and share interesting information regarding past events of their life. This is an important finding as it suggests that the participants were engaged while doing the tasks and that the activities developed can be used for stimulation purposes. Another goal of this study is to gather information to evaluate the usefulness of the AR system for stimulation purposes in PwD at initial to intermediate stages of dementia. According to the results of the questionnaires and interviews, therapists demonstrated high interest in using the system for their therapy sessions in the future. However, therapists showed some concerns regarding the appropriateness of some of the content presented for such a population.

Consequently, in section 4.3, we added a Game Editor that allows health professionals to create and customize activities to the patient’s needs and preferences. Also, we developed Musiquence as being highly platform compatible as it supports different technologies besides AR, such as PC, Tablet, Interactive Tables, Kinect, and Leap Motion. As shown in section 4.1, PwD may have difficulties in using specific technologies (i.e., lack of experience, physical/cognitive related issues, anxiety, among other reasons, see section 4.1). Thus, health professionals can transfer the same set of activities to different technologies according to the cognitive profile, experience, and comfort of PwD.

In section 4.4, after developing a complete version of Musiquence, we performed a usability study of the Game Editor with health professionals to safeguard the quality of the platform. In general, participants were efficient in completing the proposed tasks without significant problems and were fast in doing so. The Game Editor did not lead to any stressful experience for participants. Overall, healthcare professionals rated the usability of the Game Editor as “good,” despite the language barrier and minor functionality issues. One of the significant results retrieved from the experiment is that participants recognized the usefulness of the platform to customize activities for PwD. As stated in section 2.2, most of the existing software and technology platforms follow a generalized design approach that does not take into consideration the individual needs of PwD.

To conclude chapter 4, it is essential to involve healthcare professionals and PwD throughout the design process of the platform. The input and opinions shared by both healthcare professionals and PwD led to many iterations in the platform, which resulted in a fully functional therapeutic tool that can

82

be used as a complementary tool to aid healthcare professionals and informal caregivers during the therapy session. In the next chapter, we will present a novel learning method based on musical distortions, which is based on the principle of preserved musical memory in PwD.

83

Chapter 5 – Developing a novel learning