”It’s Our Gang” - Promoting Social Inclusion for People with Dementia by Using Digital Communication Support in a Group Activity

ABSTRACT

Objectives

In the present paper we aim to contribute to the understanding of how people with dementia experience using a web-based communication support application on a tablet computer in a group activity. The specific focus of the present paper is on perception of social inclusion among people with dementia in a group activity using digital communication support.

Methods

The study is based on interviews with participants in a communication group for people with dementia where the application CIRCA, specifically designed to support interaction involving people with dementia, was used. Five individuals with dementia were recruited from a residential care home where they lived in different wards. Seven group interviews with the participating persons with dementia following directly after each session were carried out.

Results

The views of the participants were generally very positive, regarding many aspects of the activity. In the present study, the group activity seemed more important and beneficial for the participants, than the specific use of the application in itself.

Conclusions

Taking part in a group activity targeting communication made participants with dementia feel that they were part of a social group, that they had learnt things, and that they had been able to contribute with their expertise to others.

Clinical Implications

Group activities targeting communication give people with dementia the opportunity to exercise their social inclusion practices. Group activities may render a feeling of social community and a sense of belonging to the participants. The use of digital communication support may enhance such activities.

KEYWORDS:

• Dementia
• group activity
• social inclusion
• digital communication support

Introduction

The focus of the present paper is to explore how people with dementia experience participating in a conversation group activity using digital communication support. Loneliness and social isolation are common for people living with dementia (Kitwood, 1997; Örulv & Hydén, 2006; Sabat, 2002). In interview studies, people living with a dementia disease often describe how they experience diminished social relationships as the disease progresses (Ericsson, Hellström, & Kjellström, 2011; Saunders, de Medeiros, & Bartell, 2011), which in turn affects quality of life (Saunders et al., 2011; Schulz & O’Brien, 1994; Williamson & Schulz, 1993). Most dementia diseases comprise some kind of communication problems regardless of underlying pathology (Bourgeois & Hickey, 2009). Communication difficulties are partly due to problems with working memory, which makes it difficult to uphold conversations, as working memory is involved in, for example, keeping track of turns and topics (Alm et al., 2007). As the ability to communicate and interact is crucial for creating and maintaining social relations, a dementia diagnosis increases the risk of social exclusion and loneliness (Hansebo & Kihlgren, 2002; Kitwood, 1997; Örulv & Hydén, 2006; Sabat, 2002).

Several studies have highlighted the importance of engaging persons with dementia in activities that are meaningful to them (Phinney, Chaudhury, & O’Connor, 2007; Vikström, Josephsson, Stigsdotter-Neely, & Nygård, 2008). What constitutes meaningful engagement to people with dementia and what kind of activities that are preferred by this group is, however, so far largely unknown (Menne, Johnson, Whitlatch, & Schwartz, 2012). Phinney et al. (2007) suggest that a meaningful activity for a person with dementia should, among other things, be pleasant and enjoyable, and provide connection with others. In a large interview study including 216 persons living with dementia (Menne et al., 2012), socializing with others was the activity preferred by most participants. In a similar vein, a study by Tak, Kedia, Tongumpun, and Hong (2015) indicates that activities offered by care facilities, such as Bingo and card games, as such might not be particularly interesting to residents, but are primarily appreciated as an opportunity to meet other residents. In other words, activities that facilitate for people with dementia to connect with friends and “having a chat” seem to be desirable by many. Finding ways to provide opportunities for such social engagements should arguably be prioritized and would constitute important contributions to increased social inclusion for people with dementia.

Participation in group activities can be challenging for people with dementia (Ericsson et al., 2011; Lindholm, 2013; Örulv, 2008). This is especially true for activities centered around talk (Lindholm, 2016). In group conversations, several participants may initiate a turn at talk simultaneously, which creates overlapping talk where individual utterances are hard to identify. Overlapping talk and parallel conversations are demanding for people with dementia as, apart from hearing impairment recurrently following aging, attention deficits often associated with dementia can make concentrating on simultaneous stimuli difficult (Baddeley, Baddeley, Bucks, & Wilcock, 2001; Bayles & Tomoeda, 2007). There are several studies arguing for the benefits of using digital communication support in interaction with people with dementia based on analysis of interactional features (e.g., Astell & Parsons, 2010; Ekström, Ferm, & Samuelsson, 2017; Smith & Astell, 2018). In a recent review by Hitch, Swan, Pattison, and Stefaniak (2017) a range of exploratory research related to the use of tablets by people with dementia was identified. It was concluded that the evidence of tablets as a compensatory method is inconclusive, but that there are promising results showing that it can support meaningful engagements in activities. Communication support based on a multimedia system often stimulates joint attention by the interlocutors and is also argued to be more enjoyable for both people with dementia and caregivers compared to traditional communication support (Alm et al., 2004; Astell et al., 2010). Some findings have also indicated that the use of touch screen computers in communicative activities may maintain and improve social relationships and interaction between carers and people with dementia (Astell et al., 2010). Some studies focusing on the use of digital communication support in interaction involving people with dementia have been carried out, but few studies have considered the perspectives and experiences of people with dementia. In a recent study by Samuelsson and Ekström (2019), semi-structured interviews with persons with dementia regarding the use of digital communication support in dyadic interaction were carried out, and it was demonstrated that the participants with dementia found the applications useful and supporting regarding their social engagements (Samuelsson & Ekström, 2019). Building on this work, the current study aims to contribute to the understanding of how people with dementia experience participating in a conversation group activity using a web-based communication support application on a tablet computer.

Aim

The aim of the present study is to add to the knowledge of the potentials of digital communication support for people with dementia by examining how persons with dementia describe their experience of using a web-based application in a group activity. In the study, we explore the potential to increase feelings of social inclusion and connection among people living with dementia through participation in a conversation group activity facilitated by digital communication support.

Methods

Participants

Five individuals with dementia were recruited from a residential care home where they lived in different wards (Table 1). Inclusionary criteria were known dementia disease, Swedish as the first language, and ability to give informed consent to participate in the study. The severity of the dementia disease varied among the participants as rated by the professional carers at the residential home (Table 1). The professionals rating the severity of dementia were staff at the care home who were all trained in dementia care, and who also knew the participants well. They made the ratings by choosing between “mild,” “moderate,” and “severe” cognitive decline according to their experience of working with people with dementia in general as well as on their specific knowledge about these particular participants. For individuals with a large individual variation in symptoms they chose “uncertain.”

Table 1. Participants in the CIRCA group

Participant with dementia, fictive name with initial in parenthesis	Age	Gender	Degree of dementia
Folke (F)	70 years	Male	Uncertain
Kurt (K)	80 years	Male	Severe
Elsa (E)	80 years	Female	Mild
Hildegard (H)	89 years	Female	Mild
Leonora (L)	62 years	Female	Uncertain

The participants had varying backgrounds with different work experiences. Kurt’s previous profession was civil engineer specializing in rock mechanics. Hildegard had been working in a chocolate factory when she was young, but after having children she was a housewife. Folke was previously working with plumbing, and he had been traveling throughout the world for work. Elsa’s profession was high school teacher of physics and chemistry, and Leonora had been working as a secretary at a large private company.

Procedure and material

The study is part of a larger project focusing on the use of the web-based digital communication support application CIRCA in a group activity where data collection comprised two parts: i) a seven-session CIRCA-based leader-led group activity and ii) seven group interviews with the participating persons with dementia following directly after each session. The use of the CIRCA application on a tablet computer was central to this project. There are activities in care homes based on photos and books, but in this project the aim was to investigate the possibilities of using the digital format since its inter alia is considerably less time-consuming regarding preparation of sessions and offers much greater variability in terms of content. CIRCA (Computer Interactive Reminiscence and Communication Aid), specifically designed to support interaction involving people with dementia, was used. The web-based version of CIRCA is developed from a previous version for stand-alone devices (Alm et al., 2004; Astell et al., 2010). In a recent study, the web-based CIRCA was compared to the previous stand-alone version regarding effects on cognition and quality of life, and it was demonstrated that there was no significant difference between the versions of CIRCA, but both of them had significant positive effects on cognitive abilities and on quality of life (Astell, Smith et al., 2018). CIRCA is connected to a large database of pictures, videos, and music files belonging to six different main categories randomly selected to be presented three at a time: childhood, sports, entertainment, recreation, people and events, and everyday life. For each main category, the photo material is sorted in five subcategories. When starting the application, the user is presented with the choice to view photos, watch video clips or listen to music. If the user chooses to view photos, he/she is then presented with the five subcategories for the chosen main category (see Figure 1). CIRCA was adapted to Swedish within the European project INdependent LIving support Function for the Elderly (IN LIFE), and the Swedish version was used in this study (Astell, Gradisek et al., 2018).

Figure 1. Screenshot from CIRCA where the different categories are shown

In this project, the CIRCA sessions were carried out under the guidance of two research assistants, with one assistant acting as a conversation leader while the other assistant kept field notes. The sessions took place in a secluded room in the care home’s common areas. The data collection took place over a three-week period February–March 2018. During the conversation sessions, the participants received no instruction on the topic of conversation or how they should act during the sessions, in order to create as natural a situation as possible. The timing and duration of the sessions were determined in consultation with the staff of the at the care home in order to get the best fit possible for the participants and to avoid concurrence with other activities. The timing of the sessions was also adjusted according to the participants mood and health condition, resulting in varying length of the video recordings.

The sessions began with the conversation leader (a research assistant in the project) presenting the participants with the opportunity to choose between looking at photographs, listening to music, or watching movies clips on the tablet. After the choice of media, three randomly selected main categories were presented on the tablet and the participants were then asked to make a new choice. In some of the sessions, it also happened that the conversation leader made a choice of category if, for example, none of the participants expressed a preference. During sessions 1–4, the conversation leader gave all participants the opportunity to make the choice, by openly asking the whole group, which resulted in a tendency toward a bias for some of the participants repeatedly answering very quickly. During sessions 5–7, therefore, the conversation leader decided to direct the possibility to choose categories to one participant at a time in order to include everyone and to meet the interests of all participants.

At the end of each conversation session, unstructured interviews took place with the participants regarding their experiences of CIRCA and the session. All seven interviews were video recorded and transcribed verbatim. After the last session, a semi-structured interview was carried out by both group leaders according to an interview guide (see appendix). After sessions one to six, shorter open interviews on the participants’ experiences of the session were carried out. All interviews were performed in the group setting, and the questions were adapted to the participants’ cognitive and linguistic ability. The short interviews lasted for 23 minutes in total, ranging from about 2 min to about 6 min for each interview. The final interview after session seven lasted for about 15 min. For detailed information on the interviews see Table 2. In the present paper, focus is on the evaluations of the CIRCA sessions (both the short interviews after each session, and the final more extensive interview), thus the analysis is limited to the second data set.

Table 2. Description of interviews and group constallations

Session	Date	Group constallation	Duration of Interview
1	180,220	Group constallation 1*	06:30
2	180,222	Group constallation 2*	03:21
3	180,223	Group constallation 1	04:52
4	180,228	Group constallation 1	02:51
5	180,302	Group constallation 3*	02:10
6	180,306	Group constallation 1	05:15
7	180,309	Group constallation 4*	15:02

* Group constellation 1: Conversation leader, all participants

* Group constellation 2: Conversation leader, all participants except for Elsa

* Group constellation 3: Conversation leader, all participants

* Group constellation 4: Conversation leader, all participants except for Leonora

Analysis

The interviews were analyzed using thematic analysis as described by Braun and Clarke (2006), and followed the six steps they propose:

• Familiarizing yourself with your data

• Generating initial codes: Coding interesting features of data

• Searching for themes: collating codes into potential themes

• Reviewing themes: generating thematic ’map’ of analysis

• Defining and naming themes: ongoing analysis to refine

• Producing report

The analysis started by watching and transcribing all interviews verbatim (step 1). Thereafter, all authors watched the films together repeatedly and identified relevant codes related to the five themes in the interview guide (step 2). During the analytic process, the authors decided to keep the original themes in the interview guide as a main structure for organizing the results. This was mainly due to uncertainties when interpreting the participants answers. In the next analytic step, 13 main subcategories were created from the codes in step 2 (step 3 & 4). The final map of the major themes basically followed the themes of the interview guide used in the final extended interview, and 1–4 subcategories were derived for each major theme. The three authors discussed all responses until consensus on each subcategory was reached (step 5). Following the thematic analysis, the interviews were analyzed in more detail. Illustrative examples were chosen and are displayed in the results section.

Ethical considerations

This study was approved by the ethical committee in Region Östergötland 2016–06-02, Dnr: 2016/247-32. All participants gave informed written consent to participate. Information was given both orally and in writing repeatedly during the study, and for participants with more advanced dementia the written consent could be given by witnessed consent from a significant other.

Results

The main result of the present study was that the experience of using CIRCA in a group activity was very positive. In relation to most of the topics of the interviews, the social aspects of being in a group were mentioned by all participants. The results are presented following the five questions/themes from the interview guide used in the final, extended interview:

• General views of today’s session

• Views of the conversation in the presence of the tablet

• Views of the different CIRCA categories

• Views of the use of the tablet

• Views of attending a group activity where CIRCA is used

Each theme generated 1–4 different subcategories (see Figure 2).

Figure 2. Figure illustrating the five question related themes that emerged from the interview regarding the experience of using CIRCA in a group acitivity (the medium-sized circles), and the sub categories that emerged within each theme (the small circles)

The views of the participants are generally very positive, regarding many aspects of the activity; the group setting, the tablet itself, the CIRCA application, and communication as a group activity. There were in total 13 general positive comments, 9 specific positive comments on the content of CIRCA, and 8 positive comments on the benefits of being part of a social group. Below, each of the main themes and the related subcategories are presented (although not all exemplified) and discussed in more detail.

Perceptions of today’s experience

All interviews started with a version of the question “What did you think of today’s activity?” directed to the group as a collective, and any of the participants could volunteer to respond. This initial question was often followed by the interviewer directing the question at specific participants to hear their opinion. The initial response always consisted of a positive evaluation of the activity. Recurrently, the initial positive assessment was upgraded in a second contribution as in “Yes, very good” after a first “I think it was good” (see Figure 2). The extract in Example 1 is generated by the initial open question about today’s experience ending the sixth session.

Example 1.

Leader 1:

What did you think about today, then?

Leonora:

Really good. I enjoy it here.

Leader 1:

Yes, that’s great.

Hildegard:

Yes, really pleasing and positive.

Leader 1:

Yes, really good.

Leader 1:

What did you think about today, Elsa?

Elsa:

Yes it was good.

Leader 1:

Great. What about you then, Kurt?

Kurt:

Yes well, it is fun to have a little of such music and different variants that wecan enjoy together, I think.

Leader 1:

Yes yes

Example 1 illustrates the subcategory of general positive assessments of today’s experience of using CIRCA in the group activity and demonstrates that the participants in addition to the general comments may provide more specific positive comments on this particular activity, for example listening to music together. This comment also points to the positive feeling of togetherness in the group in enjoying listening to music together.

There were also specific comments on the content of CIRCA (see Figure 2). These comments could consist of appreciations of specific content in CIRCA, most often the music, but also the way CIRCA as an application was organized. In several sessions, Kurt specifically mentioned the organization of the content in CIRCA into different categories as especially beneficial. Example 2 comes from the interview after the fifth session.

Example 2.

Leader 2:

How do you think it has been today?

Leonora:

Nice.

Leader 2:

Nice? Yes.

Folke:

Yes.

Leader 2:

Nice as well.

Kurt:

It is good to get such a setup with different directions. Good that we can direct ourselves.

In example 2, Kurt elaborates on the other participants’ general positive assessments with a specification of the fact that it is the content and the layout in CIRCA that he appreciates, and that he finds this organization advantageous for the group’s focus, demonstrating that Kurt is concerned about the well-being and performance at the group level. This is something he comes back to in several interviews.

Another subcategory in the answers to the initial question about the participants’ experiences of today’s session specifically concerns the social aspects of the group (see Figure 2). Responses regarding the social aspects of the group activity point out the participants’ appreciation of seeing each other.

Example 3.

Leader 2:

And Hildegard? What did you think about today?

Hildegard:

It was good.

Leader 2:

It was good. Has it been nice?

Hildegard:

Yes nice, to see all the faces.

Leader 2:

I also find that pleasing and amusing.

Hildegard:

This is our gang.

Leader 2:

Yes this is our gang (laughter).

In example 3, Hildegard specifically expresses that she likes to see the faces of everybody, and that the participants constitute a social entity that she belongs to; ”our gang.” The participants all live in the same residential home, but they live in different wards so they do not know each other from before. This example comes from the third session, indicating that the feeling of being socially related to the others has developed rather quickly for Hildegard.

The last subcategory of answers generated from the initial open question about experiences of today’s session concerns the learning aspects of using CIRCA, and the exchange of knowledge that can take place during the sessions (see Figure 2). Comments related to this aspect only occurred a couple of times and were in one of the occasions initiated by the group leader, but the participants nevertheless expressed that they enjoyed the exchange of knowledge that the group activity facilitated. The specific mentioning of the exchange points to the importance of being in a group.

Perceptions of the conversation in presence of the tablet

The second theme of the interviews concerns the participants’ views and perceptions of using a tablet in the conversations. This theme differs from the first theme as it more specifically targets the participants’ experiences of using CIRCA (as a support for conversations). Questions related to this second theme were mainly posed during the final evaluative interview. The first subcategory of this theme demonstrates that the rather specific question on conversational aspects of using CIRCA often generated quite general comments. Example 4 comes from the first session with the group.

Example 4.

Leader 2:

How did the rest of you think that it went to talk when we used this?

Leonora:

It went well.

Hildegard:

I am a little hard of hearing I think now.

Leader 2:

((Turns and lean toward Hildegard)) How did it go to talk when we used this((holds up the tablet)), was it easy or hard?

Hildegard:

Yes, some of it is hard.

Leader 2:

But did it go well to talk while we used this one?

Hildegard:

Yes, mm.

Example 4 illustrates how Leonora provided general positive assessments of using CIRCA as a support for conversation, whereas Hildegard offers a more nuanced assessment, but all answers state the participants’ views in rather general terms. The format of the questions is closely linked to the way the participants answer: the questions clearly project some sort of evaluation which the participants provide. Example 4 also demonstrates how the interviewer sometimes needs to further specify the questions when interviewing people with dementia. As Hildegard does not quite hear the question the first time, the group leader reformulates the question for her adding two alternatives for her answer: was it easy or difficult to use the tablet computer when they were talking? While Hildegard attributes her difficulties of answering the question to a hearing problem, from the leader’s reframing of the question and restricting the answer to only include two choices, it could be inferred that she also, at least partly, ascribed Hildegard’s difficulties to a problem of understanding the question.

The questions about how the conversations went also generated more specific comments, especially concerning the content of CIRCA. However, this may also be related to the fact that on many occasions, the questions regarding this theme needed more specific follow up questions which, at least to some extent, directed the participants to certain possible areas for their answers. The following examples, in addition to demonstrations of the subcategories, also illustrate the need for specification of the questions.

Example 5.

Leader 1:

Did you think that there was anything interesting that you could sit and chatabout?

Folke:

A lot. ((quiet voice))

Kurt:

Yes but it is always interesting with reviews like this and I think about this with the fairytales and that it is very large variations in them and I find it beneficial to get that experience.

Leader 1:

That it was a lot of difference or?

Kurt:

YES exactly, that they are different and they are that are taken up by someone can be transformed to something else by someone else.

The mentioning of reviews and variation in example 5 suggests that the participants experience that CIRCA gives them interesting things to talk about in rather specific ways. Folke does not just confirm that he thinks CIRCA contains some interesting material to talk about, he upgrades the term used in the question – something that was interesting – to “a lot” (that was interesting and that they could talk about). Kurt aligns with Folke with an agreement token, and then contributes an expanded description of how he thinks the content of CIRCA has been valuable to the group’s conversation. These answers are generated by a somewhat leading question, but still demonstrate specific and elaborate answers from the participants.

Another subcategory that emerges from the question about how the conversations went, concerns evaluations of the (personal or group) performance during the CIRCA sessions. In some of the answers to questions regarding how the participants think the sessions went, the participants provided what could be understood as evaluations of how they themselves or the group performed during the session, see for example Hildegard’s contributions in example 6.

Example 6.

Leader 2:

How did the rest of you think that it went to talk when we used this?

Leonora:

It went well.

Hildegard:

I am a little hard of hearing I think now.

Leader 2:

((Turns and lean toward Hildegard)) How did it go to talk when we used this((holds up the tablet)), was it easy or hard?

Hildegard:

Yes, some of it is hard.

Leader 2:

But did it go well to talk while we used this one?

Hildegard:

Yes, mm.

Perceptions of the different CIRCA categories and of the use of the tablet

The third theme follows the question about the participants’ perceptions of the music, video, and photographs in CIRCA. The participants mention the newsworthiness of the CIRCA material and also express that they like the variation. Kurt has come back to the variation aspect in several previous examples (1, 2, and 5).

Example 7.

Leader 1:

What do you like the most then? To listen to music or?

Elsa:

Music.

Leader 1:

Or video or photo?

Leader 1:

What do you think Folke?

Folke:

Video, music and photos.

Leader 1:

All of them?

Folke:

Mm.

Hildegard:

And so nice pictures that we haven’t seen before.

Leader 1:

But there is also a lot that you have seen before that you.

Hildegard:

Yes, oh yes.

Hildegard:

Yees (.) variety and everything can be good.

Leader 1:

Yes.

Example 7 illustrates how the group leader asks if the participants prefer to listen to music and Elsa confirms that she prefers music. Folke responds by mentioning all the categories. Hildegard adds that she also likes the fact that the material is new to them. The group leader continues by saying that there are a lot of familiar material as well, and Hildegard adds that she also likes the variation in the application. This is similar to how Kurt is referring to variation, for example, in example 5.

There was also a theme related to the question about the tablet itself, not particularly the CIRCA application. There were two subcategories concerning the degree of difficulty and the learnability when using the tablet. A couple of participants expressed that they found it hard to use the tablet, but others found it very easy. The opinions differed somewhat in these categories, but the overall perception was that it was fairly easy to use the tablet.

Perceptions of the group

The last theme emerges from the question about how the participants perceive being in a group and the comments mainly concern the social community that is made possible through the group.

Example 8.

Leader 2:

Mm we also sat in a different way (points)) today.

Kurt:

Yes.

Hildegard:

Yes.

Leader 2:

It might have been that then.

Hildegard:

Siblings’ ring.

Leader 2:

Yes exactly ((laughter)).

In this last example, during the last extended evaluation interview, the participants are talking about how they were seated during the session initiated by the group leader. Hildegard associates with a concept of childhood saying that they sat in a ”siblings’ ring” (and old concept referring to children sitting in a ring). This particular wording could be associated with a perception of social community as experienced in her childhood.

Discussion

The main purpose of the present study was to increase the understanding of how people with dementia experience using digital communication support in a group activity and to explore the potential to increase feelings of social inclusion and connection for this group. The findings demonstrate that, in general, the participants’ views on using a tablet with the CIRCA application in a group setting are positive. This is in line with previous (Ekström et al., 2017; Samuelsson & Ekström, 2019) and ongoing research on dyadic interaction. In a group activity involving multiple people with dementia, there may be several factors that could influence the experience and possibility to participate negatively (Ericsson et al., 2011; Lindholm, 2013; Örulv, 2008). However, in the present study, the social aspects of the activity, the being part of a group conversation seems to be the most appreciated and beneficial for the participants (cf. Tak et al., 2015). All of the participants specifically mention that they appreciate the group setting. The social qualities of the activity are mentioned on several occasions also in relation to, for example, the first question on general perceptions of the experience. Several answers highlight the participants’ appreciation of being in a group and thus part of a social activity, and to be able to share experiences, opinions, and knowledge with each other. Also, the participants who found it hard to use the tablet expressed that they enjoyed the activity and belonging to a group.

The results of the present study add to the existing knowledge on the possibilities and pitfalls of using digital communication support in a group activity for people with dementia, since the interviews give a more nuanced picture than for example questionnaires (Astell, Smith et al., 2018). The different subcategories that emerged from the questions asked in the interview represent the areas that the persons with dementia came up with spontaneously in relation to the questions. Of particular interest are the categories about learning, sharing information, and social aspects since these are areas that have been described as particularly challenging for people with dementia (de Werd, Boelen, Rikkert, & Kessels, 2013; Kitwood, 1999). The fact that these aspects are pointed out by the participants themselves suggests that they find these areas important and that they find the activity beneficial for increasing their feelings of inclusion in a social group.

While the results presented are both novel and of great importance for the development of technological solutions targeting people with dementia (cf. Blackstone, Williams, & Wilkins, 2007; Buchholz, Ferm, & Holmgren, 2018), they should be seen in light of some limitations. The primary limitation of the present study is the small sample size making it impossible to generalize the results to a larger population. Another limitation concerns the circumstances of the interviews. The interviews in the study were carried out by the same persons that led the activity, which may have affected the participants’ answers and ways of responding. Given the communicative problems of the participants, it is hard to tell what the participants really evaluate, since it is sometimes difficult to know if they are referring to the tablet, to CIRCA, or to the activity as such. In this study, we have shown how problems with communication and cognition in dementia can partly be handled by the interviewer who may ask questions with a restricted number of possible answers and specify questions in order to help the person with dementia when needed. The interviewers may also clarify questions by adding pointing gestures and by holding up or hiding the topic of the question, that is the tablet. By observations of the video recorded interviews in the present study, the positive oral evaluations of the activity are supported by the fact that the participants laugh together when talking about the tablet, the application, and the activity. For future research, it would be interesting to see how an application such as CIRCA could be used in a group activity without any participation by a facilitator or a group leader.

Clinical implications

• People with dementia appreciated taking part in a communication activity in a group setting, and they found this activity meaningful.

• Taking part in a group activity targeting communication made participants with dementia feel that they were part of a social group, that they had learnt things, and that they had been able to contribute with their expertise to others.

• In order to create possibilities for people with dementia to experience social inclusion, it is useful to let communication is an activity in its own rights; a digital communication application can facilitate such an activity.

• In many parts of the western society, the digitalisation of elderly care is spreading, and it is fairly common that tablet computers are available in care homes. The results of the present study demonstrate that the introduction of group sessions targeting communication could easily be implemented in care homes since an application such as CIRCA does not need any particular preparations by the activity facilitator.

Ethical approval

This study was approved by the ethical committee in Region Östergotland 2016-06-02, Dnr: 2016/247-32.

Acknowledgments

The work was conducted within the project Life with dementia: communication, relations, and cognition which was financially supported by FORTE: Swedish Research Council for Health, Working Life and Welfare. Thanks to the people with dementia for participating in the project.

Disclosure statement

The authors declare that there is no conflict of interest regarding the publication of this article.

Correction Statement

This article has been republished with minor changes. These changes do not impact the academic content of the article.

Additional information

Funding

This work was supported by the Forskningsrådet om Hälsa, Arbetsliv och Välfärd.

Appendix A

Interview guide (translated from Swedish)

Main areas

How did you think it went to talk when we used the tablet/CIRCA today? (easy/hard, goog/less good, comfortable/uncomfortable)

Was it easy or hard to come up with topics to talk about?

Which were the nicest subjects to talk about?

Additional questions

What did you think about using the tablet/CIRCA in a group?

Did you think that the tablet/CIRCA was easy or hard to use?

Did you think that the tablet/CIRCA was boring or pleasant to use?

Did it work better or worse to talk when we used tha tablet/CIRCA?

How did you think that it went to understand what the other persons in the group said when using the tablet/CIRCA?

How did you think that the others understood you when using the tablet/CIRCA?

How did it go to come up with things to talk about when we used the tablet/CIRCA?