Remember to play… and stay active! Evaluation of the effects, cost-effectiveness and implementation of exergaming for people living with dementia and their informal caregivers

The aim of this thesis was to examine the effects, cost-effectiveness and implementation of exergaming (interactive cycling) in day-care centres for community-dwelling people living with dementia and their informal caregivers. Chapter 1 describes the background and rationale of the research presented in this thesis, building up to the research questions. Being physically active can benefit people with (and without) dementia. However, dementia is often accompanied by symptoms that can hinder people with dementia from participating in (outdoor) physical activities. Exergaming can be defined as “physical exercise interactively combined with cognitive stimulation in a gaming environment”. Technology tracks the participants’ body movement, which influence the course of a digital game on a connected screen. Interactive cycling is a type of exergaming. Participants pick a movie of a route on a screen, and their pedalling pace on a stationary bicycle determines the speed and course of the film. Based on the knowledge gaps identified, the main research questions of the study presented in this thesis were: 1. Does exergaming have positive effects on performance of physical activities, mobility, physical, cognitive, emotional, and social functioning, and quality of life as compared to other activities usually offered to community-dwelling people with dementia visiting psychogeriatric day-care centres? 2. Does exergaming have positive effects on quality of life, experienced burden, and positive care experiences of informal caregivers of people living with dementia? 3. Is exergaming cost-effective from a societal perspective for the primary outcomes physical activity and mobility of the participants with dementia, and Quality-Adjusted Life-Years (QALYs) of persons with dementia and informal caregivers in comparison to regular activities in day-care centres? 4. What are conditions for successful implementation and recommendations for exergaming for community-dwelling people with dementia in day-care centres? Chapter 2 reports on a systematic literature review, in which we aimed to assess the current evidence of the effects of exergaming on physical, cognitive, emotional and social functioning and quality of life of people with dementia, and research into the cost-effectiveness of exergaming compared to usual care for this target group. Chapter 3 presents the protocol of the cluster RCT into exergaming for community-dwelling people with dementia visiting day-care centres, with a process evaluation and economic evaluation alongside. The design, setting, and methods are described in detail. Chapter 4 reports on the cluster RCT, in which we investigated the effects of six months of exergaming compared to activities as usual in day-care centres for participants with dementia and their informal caregivers regarding the outcomes as described in the protocol (chapter 3). Chapter 5 describes the economic evaluation to assess the cost-effectiveness of exergaming compared to care as usual from a societal perspective in people with dementia visiting day-care centres and their informal caregivers. Primary outcomes were physical activity and mobility of the participants with dementia, and QALYs of participants with dementia and informal caregivers. Chapter 6 reports on the process evaluation we conducted to investigate how exergaming for people with dementia was implemented in the day-care centres in the exergaming group during the RCT and to get insight into the conditions for successful implementation. We used a combination of quantitative and qualitative methods and data. Based on the MRC guidance for process evaluation, we categorized facilitators and barriers for successful implementation of exergaming for people living with dementia into implementation factors, mechanisms of impact factors and contextual factors. Chapter 7 discusses the main research study results and conclusions in light of the current knowledge from the literature. We reflect on methodological issues, scientific and clinical implications of our research, and provide clinical and research recommendations.