Evaluating and Motivating Activation in Long Term Care: Lessons from a pilot study
Event Type
Poster Presentation
TimeThursday, April 152:55pm - 2:57pm EDT
LocationDigital Health
DescriptionOlder adults living in long-term care facilities typically receive insufficient exercise and have long periods of the day when they are not doing anything other than sitting or lying down, watching television, or ruminating (Wilkinson et al., 2017). We developed an intervention called the Experiential Centivizer, which provides residents with opportunities to use a driving simulator, watch world travel videos, and engage in exercise. We assessed the intervention's impact on residents of a long-term care home in Fredericton, NB, Canada. In this paper, we report on the results observed and highlight the lessons learned from implementing a technological intervention within a long-term care setting. The technological development team was in Toronto, while the research team was located at two sites in New Brunswick (a two-hour drive from each other). The supervision of the study was carried out at a distance; however, the data collection was done on-site (the RAs traveled to Fredericton and collaborated with the CIRA Team members). The equipment was initially delivered to YCC in July 2019 and went through a trial period of staff training and a series of user tests that lasted between 1 and 2 hours. The equipment was available for use between September 2019 and January 2020 with some outages due to technical issues. During the study period, we made modifications and replaced equipment when needed to address technical problems and usability issues. Since the sample was relatively small, a Kolmogorov-Smirnov (K-S) test was used to test for the data's normality (Field et al., 2012).To compare between baseline (Pre-test) and post-intervention (Post-test1 at 4 months and Post-test2 at 6 months) measures, t-tests were carried out for the EuroQol-5D 5L C, MMSE, MOCA, Quality of Life AD measures, and a non-parametric Wilcoxon test was used for the Aggressive Behavior Scale scores. As expected, mean EuroQoL-5D 5L C scores and Quality of Life AD scores decreased significantly from pre-test to post-test1 due to the general decline in functioning that tends to occur together as dementia progresses.

Our discussions with staff and resident-users, data analysis, and anecdotal observation led to the findings and product modifications listed below.

1. Insufficient Reliability Testing
The units provided were not sufficiently reliable for sustained use in a LTCF setting. Our extensive prior usability testing did not anticipate the reliability issues that were uncovered:
• Battery-powered equipment was problematic because it was inconvenient to replace batteries, and troubleshooting was more difficult because the loss of battery power was always a possibility.
• Wireless Bluetooth connectivity, while reducing the number of wires (one of our earlier design goals), was unreliable, with connections tending to drop so that units would become disconnected from the rest of the system.
• System updates for various software components sometimes occurred, putting dialog windows up on the screen, which disabled the software.
• The steering wheel dynamics made it difficult for residents to control the simulated vehicle.
• The exercise pedals that we implemented in the units could not be used as hand pedals (when placed on the table) by most wheelchair users.

To address the usability and maintainability issues, the equipment has been redesigned in the following ways:
• To reduce complexity, we have replaced the Experiential Centivizer with two simpler products :
a. 2RaceWithMe, a competitive pedaling product where people ride over biking routes in videos on a large, curved screen.
b. 4VRYoung (pronounced "forever young"), where users immersively explore 360-degree travel videos with a VR headset.
• To improve reliability, we replaced batteries with a direct, continuous connection to power.
• To accommodate wheelchair users, we utilized combined hand and foot pedals where the hand pedals arc towards the person for reachability.
• To reduce setup complexity, we replaced Blue-tooth wireless connections with direct USB connections.

2. Improving Staff Involvement
A variety of factors, such as a strike, staffing shortages, competing research projects, limited staff engagement with the Centivizer equipment, and its facilitation. Adding new technology to a busy workplace is a complex socio-technical problem, and we recommend the following strategies:
• Planning and monitoring the change: Define clear roles and establish accountability in coordinating and implementing technologies among the staff members.
• Ownership and leadership: Provide recurring train-ing and information sessions about the technology, tailored to the staff mission statement and care approaches. Identify and engage staff champions early on in the process to facilitate the change ownership among the staff.
• Technical support: Provide dedicated technical support with associated contact information visible near the equipment so that staff members can quickly and easily submit a maintenance request.

3. Ensuring Sustainability
To move an idea from a research project to a regular service, financial aspects are key. This study was not designed for an economic evaluation (i.e., cost-effectiveness analysis). We recommend including economic evaluation in future research. On the other hand, for long-term sustainability, LTCFs need to develop revenue sharing models where interested families can then pay monthly subscriptions to unlock advanced features (such as videoconferencing with family members) for their loved ones. Revenue sharing with the LTCF can support intervention implementation.

The onset of the SARS-CoV-2 pandemic in LTCFs in early 2020 worsened existing problems of social isolation in residents, particularly when it was not possible for family and friends to visit them. We have addressed this problem by adding a new feature to 2RaceWithMe where families can videoconference with their loved ones while they are pedaling. Social interactions, and exercising, while viewing engaging video content, can provide people with enjoyment and dis-tract them from ruminating about their situation.