Kinect bowling groups for people with dementia or mild cognitive impairment

Original Research

By Erica Dove & Arlene Astell

Physical activity and exercise provide many health-related benefits. However, access to exercise is particularly difficult for people with dementia or mild cognitive impairment (MCI).

For example, some exercises may involve multiple steps or instructions, which place a high cognitive demand on the exerciser. Second, there is also a prevalence of dementia and MCI among older adults with mobility issues, which decreases their ability to exercise (1). Finally, difficulties with understanding language can impact the exerciser’s ability to follow instructions within traditional exercise programs (2).

How can we make exercise more accessible and available for these populations? We describe our work with the Xbox Kinect, a form of motion-based technology, to facilitate a bowling group for people with dementia and MCI. This bowling group activity was the only Canadian program featured in the Alzheimer’s Disease International 2019 movie, “Every Three Seconds,” as a creative intervention for people living with dementia or MCI (3).

Dementia and Mild Cognitive Impairment

Individuals with MCI have cognitive changes exceeding what would be expected at their age, but these changes do not affect the individual’s ability to carry out everyday activities (4). Symptoms of MCI include mild but noticeable changes in thinking and memory abilities, such as the ability to remember recent events and appointments (5). People with MCI are at greater risk of developing dementia (4); some experts consider MCI as the transition phase between healthy cognition and dementia.

In contrast, dementia is a chronic progressive brain disorder that affects cognitive function including memory, attention, and language (5). These changes are severe enough to affect the individual’s ability to carry out everyday activities, unlike MCI (5). There are over 747,000 Canadians living with dementia (6). By 2050, the worldwide number of people living with dementia worldwide is predicted to reach 152 million (7).

With no medications to treat dementia or MCI, interventions are urgently needed to help affected individuals maximize their well-being. There is a general misapprehension that people with dementia or MCI cannot learn new skills or activities due to memory and attention difficulties. However, people with dementia or MCI can learn new information or skills with the right teaching methods (8,9). For example, errorless learning (8), a technique where errors are prevented from occurring during the learning process, can be used to guide the person with dementia or MCI to the correct response.

Motion-Based Technologies Support Rehabilitation 

Recently, research and rehabilitation activities are incorporating motion-based technologies to help people with dementia or MCI. When motion-based technologies are blended with games, actions made in the real world are copied by a virtual character on a screen.

The Xbox Kinect is a commercially available system that is controlled through the player’s movements with no need for a hand-held controller. For example, the player swings their leg when playing in a virtual soccer game, which appears on the screen as kicking the ball.

Motion-based technologies are fun and engaging, resulting in better adherence to exercise (10). They can also be used in various settings such as therapy clinics, community-based services (e.g., adult day programs), long-term care homes, and personal homes. These technologies are easy to use, reducing the cognitive demands on users.

“Motion-based technologies are fun and engaging, resulting in better adherence to exercise… These technologies are easy to use, reducing the cognitive demands on users.” 

Use of motion-based technology with people with dementia or MCI has great rehabilitation potential, offering an engaging and accessible means of physical activity. However, we need to address a critical gap in understanding how people with dementia or MCI are introduced, taught, and supported to use motion-based technologies (11).

Figure 1: Bowling Game

The Kinect Project

Observational Study (2016)
To address this knowledge gap, we conducted a research study at a community-based adult day program that regularly used an Xbox Kinect. Program participants included people living with dementia or MCI who enjoyed a range of Xbox Kinect activities. Our aim was to observe how the staff introduced, taught, and supported the clients to play games using motion-based technology (12).

Twenty-three participants were observed once per week for twenty weeks as they played games on the Xbox Kinect. We made notes describing our observations, then analyzed this data. We identified three key themes highlighting how motion-based technology can provide meaningful group activities. These were: (a) the importance of an experienced trainer; (b) learning versus mastery; and (c) playing independently together (12).
The theme of “the importance of an experienced trainer” refers to effective teaching methods including verbal prompts, gesture demonstrations, and light physical guidance (e.g., placing a hand over theirs) to introduce, teach, and support participants to learn motion-based technology.

The second theme of “learning versus mastery” refers to the ability of people to learn how to play games using motion-based technology and improve over time: participants eventually played with less support from the trainer, but also began to display a level of mastery (i.e., comprehensive knowledge or skill in a subject). In the bowling game, for example, some participants adjusted their aim and stance to hit difficult (e.g., corner) pins, as well as developing a professional-looking “bowling stance” without being taught by the trainer. These observations suggest that people with dementia or MCI can build on their initial instruction to reach their own level of mastery.

“These observations suggest that people with dementia or MCI can build on their initial instruction to reach their own level of mastery.”

The third theme of “playing independently together” refers to the enjoyable experience of playing Kinect bowling as a group, with participants supporting each other during play. For example, participants celebrated improvements in their performance through positive comments such as, “Last time all I got were gutter balls, this time I got a strike!” and, “Oh, look at that! Just wonderful.”

Development and Pilot Study (2017)
We used the findings from the 2016 study to develop a group intervention for people with dementia or MCI who had never used motion-based technology. The research team leading the bowling activity used the same teaching methods observed in the first study, such as encouraging social interaction among players to boost enjoyment. We ran the study at three separate adult day programs. Participants had 20 sessions (60-minute sessions twice weekly for 10 weeks) using the Xbox Kinect bowling game.

To learn the bowling activity, participants were instructed to do five steps (Figure 2a-e): (a) raise their main arm above their head; (b) place their arm to the side, parallel to the ground; (c) close their hand to make a fist; (d) swing their arm behind them; and (e) swing it forward again while opening their hand.

Figure 2a-e: Bowling Instructions

Twenty-three people with dementia or MCI took part in this study. Their average age was about 75 years and nine of them used a mobility device. We used errorless learning methods to train these participants to play the bowling game. At least one staff member was included per day program so that they could learn how to continue running the groups after the research was done.

Video recording was used to capture a complete view of the participants while they played (13). The recording data were analyzed for the following three signs of learning: (a) the number of prompts given to participants; (b) the number of bowling turns completed independently; and (c) the duration of participants’ bowling turns. We also measured participant’s learning over time.

We found that the participants significantly improved on all three signs of learning. Interestingly, they continued to improve over time, which challenges the negative stereotype that people with dementia or MCI cannot learn new things.

Based on the positive feedback from the participants and program staff, each day program purchased a motion-based technology system in order to continue to offer the activity. We developed a training manual to facilitate motion-based technology use in their regular programming. We also asked the staff what they felt they needed to know about the motion-based technology system and the bowling activity, then developed an in-person training session. These materials addressed the three themes from our 2016 study (12) and championed staff to become experienced trainers in their Xbox Kinect bowling groups with people with dementia or MCI.

“This success highlights the possibility and potential of including motion-based technologies into the daily lives of people with dementia or MCI.”

Since the end of the 2017 study, other day programs have contacted us for support to set up their own groups and have now adopted motion-based technologies into their daily schedules. This success highlights the possibility and potential of including motion-based technologies into the daily lives of people with dementia or MCI. However, we also needed to learn about the impact of using motion-based technologies to deliver interventions to people with dementia or MCI (14).

Figure 3: Scores on the three measures at start, middle, and end sessions – Figure A from 2019 paper

Efficacy Study (2018-2019)
We are currently exploring the impact of a group motion-based technology intervention on balance, movement confidence, and cognitive function among people with dementia or MCI (15). The rationale is that repeating a learned skill involving both cognitive and physical performance will help individuals do better on tasks requiring these two elements.

Twenty-eight individuals participated in a program using the Xbox Kinect bowling format (12,13). Their balance and cognitive function were assessed before and after the program (16,17). We have also collected video recordings at the start, middle, and end of the program to see whether participants move more confidently over time. Two of the four adult day programs completed the study before the advent of COVID-19 and, with our support, implemented Xbox Kinect bowling as a regular group activity for their program users.

Overall, we are encouraged by the new opportunities and avenues for rehabilitation that this motion-based technology brings to people living with dementia and MCI. However, we also recognize barriers including the lack of electrical outlets to plug in the technology, unreliable Wi-Fi connectivity, financial constraints, limited space to run the group in day programs, and lower technical confidence of the staff (the latter can be improved with training, such as that provided in our manuals and videos).

Figure 4: Participant celebrating

Over the past four years, we have shown that this motion-based technology is accessible for people with dementia and MCI and that it is an enjoyable activity that gets people moving. Providing an activity in which people can improve and have fun is important for many groups, especially for those aging with disabilities and individuals with dementia or MCI.

Want to learn more? Want to implement this program for a loved one at home or in your local adult day program? Visit us online in our Dementia Ageing Technology Engagement (DATE) lab as we continue promoting positive aging.

Acknowledgements

Featured illustration by Ariadna Villalbi for rehabINK.

To refer to this article, it can be cited as:

Dove E & Astell A. Kinect bowling groups for people with dementia or mild cognitive impairment. rehabINK. 2020:9. Available from: https://rehabinkmag.com

rehabINK Link to Survey Icon_FINAL

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