The Role of Adaptive Immersive Technology in Creating Personalised Environments for Emotional Connection and Preservation of Identity in Dementia Care: Insights from User Perspectives towards SENSE-GARDEN

Abstract

This paper presents early stage research on the development of an immersive, multisensory room for people living with dementia. Dementia is considered to be a public health priority on a global level. Our research addresses the challenge of meeting individual needs in dementia care, particularly in relation to social and emotional wellbeing. We draw upon findings from 52 interviews with users, including people with mild cognitive impairment, professional caregivers, and informal caregivers. These interviews were conducted to explore initial responses towards a personalised multisensory room called SENSE-GARDEN. Thematic analysis resulted in six themes: benefits for all, focus on the individual, past and present, emotional stimulation, shared experiences, and challenges to consider. This paper provides important theoretical considerations for the role of technology in not only the SENSE-GARDEN intervention, but in preserving the identities of people with dementia and providing opportunities for connection with others. Future work in this area should adopt an interdisciplinary approach to using technology in dementia care.

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The Role of Adaptive Immersive Technology in Creating Personalised
Environments for Emotional Connection and Preservation of Identity in Dementia
Care
Insights from User Perspectives towards SENSE-GARDEN
Gemma Goodall1, Ileana Ciobanu2, Ronny Broekx3, Jon Sørgaard1, Iulian Anghelache4, Catalina
Anghelache-Tutulan4, Mara Diaconu4, Sigrid Mæland5, Therese Borve5, Audun Digranes Dagestad5, Piet
Bormans6, Marleen Custers6, Katrin Losleben7, Rita Valadas8, Cristina Vaz de Almeida8, Alda Matias8, Andreea
Marin2, Kristin Taraldsen1, Walter Maetzler9, Mihai Berteanu2, J. Artur Serrano1,10
1Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, NTNU/Norwegian
University of Science and Technology, Norway
2University of Medicine and Pharmacy Carol Davila, ELIAS University Hospital, Bucharest, Romania
3Innovation Department, ePoint, Belgium
4 Research & Development Department, Compexin SA, Romania
5Odda Municipality, Norway
6Aan de Beverdijk, Vulpia Vlaanderen, Belgium
7Center for Women’s and Gender Research, UiT The Arctic University of Norway
8Santa Casa da Misericórdia de Lisboa, Portugal
9Department of Neurology, Christian-Albrechts-University, Kiel, Germany
10Norwegian Centre for eHealth Research, University Hospital of North Norway
Email: gemma.goodall@ntnu.no, ileanacuk@yahoo.co.uk, ronny.broekx@gmail.com, jon.sorgaard@ntnu.no,
a.iulian@compexin.ro, catalina.anghelache@compexin.ro, mara.diaconu@compexin.ro, sigrid.meland@odda.kommune.no,
therese.borve@odda.kommune.no, audun.digranes.dagestad@odda.kommune.no, piet.bormans@beverdijk.be,
marleen.custers@beverdijk.be, katrin.losleben@uit.no, rita.valadas@scml.pt, cristina.vazalmeida@scml.pt,
alda.matias@scml.pt, andreea.budrica@gmail.com, kristin.taraldsen@ntnu.no,
w.maetzler@neurologie.uni-kiel.de, mberteanu@gmail.com, artur.serrano@ntnu.no
Abstract— This paper presents early stage research on the
development of an immersive, multisensory room for people
living with dementia. Dementia is considered to be a public
health priority on a global level. Our research addresses the
challenge of meeting individual needs in dementia care,
particularly in relation to social and emotional wellbeing. We
draw upon findings from 52 interviews with users, including
people with mild cognitive impairment, professional
caregivers, and informal caregivers. These interviews were
conducted to explore initial responses towards a personalised
multisensory room called SENSE-GARDEN. Thematic
analysis resulted in six themes: benefits for all, focus on the
individual, past and present, emotional stimulation, shared
experiences, and challenges to consider. This paper provides
important theoretical considerations for the role of technology
in not only the SENSE-GARDEN intervention, but in
preserving the identities of people with dementia and
providing opportunities for connection with others. Future
work in this area should adopt an interdisciplinary approach
to using technology in dementia care.
Keywords-dementia; virtual environments; immersive
technology; human computer interaction; interpersonal
relationships
I. INTRODUCTION
This article builds upon a conference paper presented at
the Fourth International Conference on Human and Social
Analytics [1]. This extended version of the original paper
offers detailed results from a preliminary study on a virtual
adaptive environment for people with dementia.
Dementia is a syndromal term and can be caused by a
variety of diseases, including neurodegenerative diseases.
Memory, behaviour, and communicative abilities are often
affected [2]. There are approximately 47 million people
living with dementia worldwide [3]. With this number set to
increase to 131.5 million by 2050, it is of the utmost
importance to tackle dementia’s progressive impact on the
wellbeing of people living with this syndrome.
The World Health Organization has called for action on
dementia, presenting it as a public health priority at a global
level [2]. This action includes a call for research to identify
ways of supporting the needs of people living with dementia,
their caregivers, and the needs of society in the context of
costs, understanding, and awareness.
In recent years, studies have identified numerous
complex needs of people with dementia living in long-term
care. These include the management of challenging
behaviours, maintenance of social relationships, involvement

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of people with cognitive deficits in meaningful activities, and
supporting the emotional needs of all [4][5].
Emotion-oriented approaches to care have been shown to
be cost-effective ways of improving psychological wellbeing
and social behaviour amongst people with dementia [6][7].
These nonpharmacological approaches are often person-
centred, focusing on the social and emotional needs of the
individual. Reminiscence rooms, virtual gardens and virtual
reality forests are examples of how immersive technologies
have been integrated in emotion-oriented approaches
designed to create effective nonpharmacological
interventions for people with dementia [8][9].
However, this area of study has called for further
research in determining what works best for the individual
[10]. It has recently been suggested that an individualised
multisensory environment for people with dementia would
be a highly beneficial intervention, especially if family
members are included in the selection of stimuli [11]. Our
research is in line with this suggestion, creating not only a
personalised multisensory space and intervention, but one
that also incorporates immersive technology, all with the
inclusion of family members, friends, and professional care
staff.
This paper presents early stage research on a
multisensory room, SENSE-GARDEN, that is currently
being developed as an adaptive, immersive environment
integrating technology and multisensory stimulation for
reminiscence in people living with mild to moderately severe
dementia. We will first provide a brief overview of the
project (Section II), followed by a description of the
methodology used in research and development (Section III).
We will then discuss the results of the interviews in relation
to each of the six themes identified through thematic analysis
(Section IV). In Section V, the results are summarised and
discussed in relation to the role of technology in preserving
the identity of the person with dementia and facilitating an
environment in which relationships can be fostered. Finally,
in Section VI, we conclude with final remarks, the next steps
for SENSE-GARDEN, and suggestions for future research.
II. SENSE-GARDEN: AN OVERVIEW
SENSE-GARDEN is a psychosocial intervention that is
being developed to create individualised reminiscence
sessions for people living with dementia in residential care.
The intervention combines the use of technology for
reminiscence and multisensory stimulation, with human-to-
human informational and emotional communication.
Prototypes of the SENSE-GARDEN room are currently
being built across several countries in Europe, namely in
Norway, Portugal and Romania, with an initial prototype
already being tested in Belgium. These rooms are filled with
individualised stimuli such as familiar music, soundscapes,
imagery, films, and scents in order to stimulate memory and
encourage active participation of the person with dementia in
reminiscing activities. Particular emphasis is placed on using
autobiographical content such as family photographs, music
from childhood, and films of life events.
The use of large projection screens, scent dispensers, and
surround sound systems will integrate the various
multimedia of the room, creating an immersive environment.
For example, high-definition imagery of a forest could be
accompanied with the smell of pine trees and the sound of
birds, to evoke a completely immersive sensation.
SENSE-GARDEN will expand on currently established
sensory rooms, which are also known as ‘Snoezelen’ rooms.
Deriving from the Dutch terms for ‘sniffing’ and ‘dozing’,
Snoezelen was originally developed in the Netherlands as a
therapy for individuals with learning difficulties [12].
SENSE-GARDEN presents an innovative approach to
sensory rooms by utilising smart technologies that enable the
space to adapt to the individual preferences and needs of the
person with dementia. This focus on autobiographical
content is achieved through the use of individual user
profiles. Each profile has an associated media repository
consisting of digital photographs, films, and music that holds
significant meaning for the person with dementia.
Radio frequency identification (RFID) is used to allow
the SENSE-GARDEN system to identify the user. Upon
entering the room, the system automatically projects
autobiographical multimedia from the person with
dementia’s user profile.
The room is designed to be used by two main categories
of users. The first is the person with dementia (PwD), who is
also considered the primary user. The second is the
caregiver, who will either be informal (family/friend) or
formal (professional care staff). It is anticipated that together,
the PwD-caregiver dyad will interact with the immersive
environment to stimulate memory, conversation, sharing and
engagement.
III. METHODOLOGICAL APPROACH
SENSE-GARDEN is a multidisciplinary project
involving partners in Belgium, Norway, Portugal, and
Romania. The consortium brings together multiple
professions and competencies including technology
development, architecture, care home management, health
sciences and research.
There have been numerous calls to involve people with
dementia in the process of designing assistive technologies
[13][14]. Their contributions are thought to be of crucial
importance, along with input from their caregivers [15].
More recently, user centred design has been recommended
for the development and implementation of psychosocial
interventions [16].
The SENSE-GARDEN project embraces a user centred
design approach and is working co-creatively with user
groups throughout all its phases. The aim of this preliminary
research was to explore initial responses from user groups, so
that their ideas and feedback may be integrated into the next
phases of development of SENSE-GARDEN.
Thus far, 52 qualitative semi-structured interviews have
been conducted with user groups across Belgium, Norway,
Portugal, and Romania. The aims of these interviews were to
collect responses and attitudes towards the SENSE-
GARDEN room concept, and to identify challenges that may
arise during the course of the project.

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TABLE I. RESPONDENT INFORMATION
Country
People with Mild Cognitive Impairment
Informal Caregivers
Formal Caregivers
N
Mean Age
Gender
N
Mean Age
Gender
N
Mean Age
Gender
Male
Female
Male
Female
Male
Female
Belgium
3
89.6
2
1
6
57
1
5
4
31.5
1
3
Norway
4
84
0
4
4
59.3
0
4
4
38.8
1
3
Portugal
3
79.7
0
3
3
55.7
0
3
3
44.3
0
3
Romania
6
67.2
3
3
6
50.7
0
6
6
42.7
2
4
Total
16
77.9
5
11
19
55.3
1
18
17
39.4
4
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The specific research questions for this study were as
follows: (1) What are the users’ attitudes towards the concept
of SENSE-GARDEN? (2) What benefits, if any, do users
think SENSE-GARDEN could provide in the care of people
living with dementia?
In order to answer these research questions, the interview
was designed in a way that allowed for an in-depth
exploration of the users’ beliefs surrounding SENSE-
GARDEN. The interview was semi-structured with open-
ended questions and lasted for approximately 30 minutes.
Interview questions focused on the overall concept of
SENSE-GARDEN, the individual components of the
intervention, and potential benefits.
The respondents included 16 people living with a
diagnosis of mild cognitive impairment, 19 informal
caregivers, and 17 professional caregivers. Table 1 gives an
overview of the respondent information.
In order to conduct an in-depth exploration of the ideas
and perspectives given by the users, data was analysed using
thematic analysis. Thematic analysis is a qualitative method
in which prevalent patterns of ideas and responses are
identified amongst data. The analysis procedure for this
study undertook the following phases, given by Braun and
Clarke [17]:
1) Familiarisation with the data: All the data was
thoroughly read and re-read, along with notating initial ideas
and interpretations of the dataset.
2) Coding: The ideas were used to generate codes,
which identify interesting features across the data. In this
study, data was manually coded in an inductive manner,
meaning that the codes and themes were developed directly
from the content of the data, rather than being developed by
pre-existing ideas.
3) Searching for themes: The codes were used to
search for themes, which represent patterned responses or
meanings across the data.
4) Reviewing themes: The themes were reviewed to
ensure that they accurately represent the views of the users
and the view from the entire dataset.
5) Defining and naming themes: The essence of each
theme was identified, along with its relevance to the research
questions.
6) Producing the report: Finally, the themes were
considered in their relationship to one another, and a
narrative about the dataset was created. This narrative is
supported by direct quotes from the dataset.
In order to stay true to the ‘voice’ of the users, codes and
themes were constantly checked back against original data.
Braun and Clarke [17] emphasise the importance of
flexibility in thematic analysis and identify the process as
one of continuous reflection on the reading, shaping, and
checking of data and themes.
IV. RESULTS
Six themes were identified through the thematic analysis:
(A) Benefits for All, (B) Focus on the Individual (C) Past and
Present, (D) Emotional Stimulation, (E) Shared Experiences,
and (F) Challenges to Consider. A thematic map is shown in
Figure 1 to provide a visual summary of all six themes and
their respective subthemes.
This thematic map also demonstrates the interactive
nature of the themes and their relationship to one another.
Numerous subthemes falling under different main themes are
related to each other. For example, the subtheme of
‘stimulating emotional memory’ (under the theme of
Emotional Stimulation) can be connected to the subtheme of
‘avoiding negative memories’ (under the theme of challenges
to consider). In this way, all the themes presented provide an
overarching narrative of the users’ beliefs, views, and
attitudes towards SENSE-GARDEN and the technology
within it.
The following subsections will discuss each of the six
themes in turn. The full dataset from the interviews has been
made available online, along with the interview guide, and
coding from thematic analysis [18].
A. Benefits for All
There was a resounding view from all users that SENSE-
GARDEN may be able to provide benefit in some way.
These benefits were grouped into five subthemes: benefits
for the person with dementia, benefits for the family, benefits
for professional caregivers, benefits in practice, and benefits
beyond dementia care.
Benefits for the person with dementia. All users believed
that SENSE-GARDEN has the potential to provide
numerous benefits for people living with dementia. These
benefits included improvements in memory, mood and
overall quality of life: “Stimulating memory and improving
quality of life, the person with dementia and caregivers can
enjoy life more”..., “This can enrich their [people with
dementia] everyday life”...,“I am sure this will be of value.

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Figure 1. Thematic map of themes and subthemes identified across the dataset.
The person with dementia gets a good experience every day.
In this we have faith”. One person with mild cognitive
impairment discussed the role of the intervention in tackling
issues of helplessness that are associated with not only
dementia, but illness in general: “When ill, it is like you are
closed in a dark place you cannot leave by yourself. SENSE-
GARDEN can help you out”.
Benefits for the family. Many of the caregivers, both
informal and formal, commented on SENSE-GARDEN
being able to provide ways for the family to strengthen
relationships with loved ones who have dementia: “It’s hard
to be a relative, so little competence, dialogue is difficult.
This [SENSE-GARDEN] is a great tool for having a nice
time together”.
Benefits for the professional. Formal caregivers
considered SENSE-GARDEN as a tool for getting to know
people with dementia better. The highly personalised nature
of the intervention means that staff have the opportunity to
gain insight into the resident’s life in a way that is perhaps
not possible in day-to-day care: “The advantage is that you
can have full focus on the patient, being able to be alone with
him or her. We get to know the patient better. It creates
security.”..., “This will also mean that the staff become better
acquainted with the person with dementia”. Another
caregiver commented as follows: “It’s good for the staff to
see the person with dementia in another way”. These
comments go to suggest that digital media can create
opportunities for learning more about individuals with
dementia, which could be especially important for people in
later stages of dementia, who may not be able to coherently
express themselves.
Benefits in practice. As well as presenting individual
benefits, users believed that SENSE-GARDEN could benefit
the healthcare system in terms of cost and practice: “Why
has nobody thought of this before? Many of these things
should have already been at the nursing home even if one
does not have a SENSE-GARDEN”..., “May become
important in terms of reducing the cost of dementia care over
time”.
Benefits beyond dementia care. There was a consensus
across the respondents that SENSE-GARDEN could also
provide benefits to people living without dementia: “It is
always good to go back to childhood and youth, for all of us.
No need to be a person with dementia”.
The users’ positive outlook on SENSE-GARDEN
captures a range of benefits that not only apply to the person
with dementia, but also to caregivers and care practice as a
whole. Future studies on SENSE-GARDEN will need to
incorporate outcome measures that evaluate these various
aspects.
B. Focus on the Individual
The key concept of SENSE-GARDEN is creating an
environment in which the person with dementia is the central
focus. The users not only valued this focus on the person
with dementia, but they also offered their suggestions on to
how best create an individualised environment. These
suggestions are grouped into the following subthemes:
familiarity, meaningful stimuli, sensory stimulation, and
empowering and engaging.
Familiarity. With the SENSE-GARDEN being a new
and unfamiliar concept, both informal and formal caregivers
stressed the importance of providing a familiar surrounding
for the person with dementia: “A familiar environment,
familiar objects to touch, is mandatory”..., “At least for the
first sessions, the SENSE-GARDEN room must include

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familiar items, besides the personal records used for
projection and music”.
Meaningful stimuli. Users believed that the stimuli used
in SENSE-GARDEN should have significant meaning for
the person with dementia: “Family photo album, with photos
from important emotional occasions”..., “Meaning from
one’s own trips. You must remember a trip, but also the
reason you went on that trip, the scope”.
Sensory stimulation. There was an overall positive
attitude towards SENSE-GARDEN’s proposed methods of
sensory stimulation. Users commented on the ability for such
stimulation to trigger memories and improve mood:
“Imagine what scent can bring forth, the idea of what this
can do, it’s gorgeous”. There were also numerous
suggestions for SENSE-GARDEN to broaden its current
plans for sensory stimuli, such as including tactile elements:
“Maybe something more for the sense of touch. When you
see a mountain and smell the fern tree, why not touch a fern
tree branch?”.
Empowering and engaging. SENSE-GARDEN was
perceived as an opportunity for people with dementia to
actively engage and express themselves: “The person with
dementia has to be reassured that life has not come to an end
when diagnosed with dementia, and reality is not limited by
the walls of the bedroom. They still have things to show and
share with us all”.
The suggestions given by the users imply that whilst the
technology and media within the SENSE-GARDEN needs to
be individualized, there are additional ways in which
individualisation can be achieved. This is through caregiver
facilitation, tactile stimuli, and the physical design of the
room. All of these factors will need to be taken into
consideration throughout the development of the
intervention.
C. Past and Present
Given that SENSE-GARDEN borrows techniques from
reminiscence therapy, it is of no surprise that discussion
regarding memories arose during the interviews. However,
the users identified links between interaction with the past
and with the present, as well as the impression of overall
improvement of memory in general. Therefore, the
subthemes are: interacting with the past, interacting with the
present, and improving memory over sessions.
Interacting with the past. In discussing the benefits of
SENSE-GARDEN, all respondents believed that the
individualised nature of the virtual environment could trigger
autobiographical memories. This was linked to helping
people with dementia connect with their past: “Personal
videos and photos are important. You resonate with your
past”.
Improving memories over sessions. As well as
stimulating memories of the past, respondents also believed
that memory could be strengthened over the course of the
SENSE-GARDEN sessions. Some users suggested using
visual markers in the SENSE-GARDEN components in
order to trigger memory in consequent sessions: “Using
memory anchors will improve experience and stimulate
reality connection”. An example of this would be to use a
recent photograph of a familiar place that holds significant
meaning for the person with dementia. The same photograph
could then be presented to the user in the next SENSE-
GARDEN session to see if they remember the meaning
connected to that picture.
Interacting with the present. There was a suggestion that
even if the person with dementia does not have the capacity
for long term memory of the sessions, the individual could
still benefit from the ‘in-the-moment’ experience of SENSE-
GARDEN: “They probably do not remember afterwards, but
think about being happy one hour every day. That’s a good
benefit”. Respondents also considered interaction with the
past an activity for strengthening self-identity in the present
moment: “Nowadays we forget who we are. SENSE-
GARDEN will help us all relive forgotten events and
identities”.
This symbiotic relationship between past and present has
been much discussed in regards to selfhood. Surr [19] adopts
a socio-biographical approach to explain how people with
dementia use their past in the context of telling their life
story to others, in order to maintain a sense of self in the
present. Technology may have much to offer in this
maintenance of self, ideas of which will be given in detail in
the discussion section of this paper.
D. Emotional Stimulation
Whilst emotion was a prominent topic amongst all of the
themes, the comments from the users proved emotion to be
highly complex. It was therefore decided to include a more
detailed discussion of emotion. The subthemes are as
follows: sensory stimulus and emotion, stimulating
emotional memory, emotional self-expression, and shared
emotional experiences.
Sensory stimulus and emotion. The users believed that
stimulating the senses through imagery and music could
stimulate positive emotions in the person with dementia:
“One connects so much to music, there are a lot of
emotions”..., “Stimulating senses brings joy and memories”.
Stimulating emotional memory. The users focused
primarily on familiar music in being able to stimulate
emotional memory in the person with dementia. “Just three
notes will bring back that special moment if music is
connected to that moment”....,“When we hear a song, we
think of something and then we will be happy”.
Emotional self-expression. Individuals with dementia are
capable of experiencing and expressing a wide range of
emotions, even in later stages of the disease [6][20]. Building
upon the idea of sensory stimulation triggering emotional
memories, the users also believed that SENSE-GARDEN
could enable people with dementia to express themselves in
ways that transcend typical verbal communication: “Some
people stop talking, but they can sing”. Furthermore, they
believed that people may be able to experience a heightened
state of feeling through the intervention: “SENSE-GARDEN
is an intermediary space, between the memories and the here
and now, a space we can all access and we can remember
how to feel, by one’s self and together, without shame or
fear”.

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Shared emotional experiences Finally, the discussion of
emotion went beyond individual feelings. The users
expressed the value of SENSE-GARDEN in being able to
help people connect with one another: “Sharing the
experience is most important for reconnecting”. One person
with mild cognitive impairment also highlighted the
importance of how these shared experiences should be
shaped: “The therapist is very important and can instil peace
and wellbeing. A special emotional environment must be
created for SENSE-GARDEN to work.” The idea of creating
a “special emotional environment” goes to suggest that it is
not the intervention alone that can provide benefits to the
relationships, but it is also the individuals present who can
shape the experience of SENSE-GARDEN.
This theme has demonstrated the intricate nature of
emotions, and how they can be manifested through the
stimulation of the senses, through the remembrance of past
events, and through our relationships with others.
E. Shared Experiences
SENSE-GARDEN is designed to be a joint experience
between the person with dementia and their caregiver. As
discussed in the previous subtheme, the users expressed the
importance of sharing the experience together. This current
theme goes beyond that of emotions and discusses the shared
experience in relation to the following subthemes: caregiver
facilitation, relationships, communicating, and creating
opportunities through technology.
Caregiver facilitation. Many users believed that carefully
planned facilitation of SENSE-GARDEN is required for the
intervention to work. Particular stress was placed on the
importance of being accompanied by a familiar individual:
“We must have people accompany us- internal people we
know”. Users also believed that effective facilitation could
shape a positive environment in which the benefits of the
intervention could be maximised: “The caregiver must be
well trained and possess good communication skills...to be
able to support and fructify the person with dementia’s gains
in terms of cognitive and behavioural improvements”.
Relationships. Respondents believed that SENSE-
GARDEN could improve understanding and relationships
between people with dementia and their caregivers- both
formal and informal. There was a sense of the intervention
being able to ‘restore’ what dementia had taken away from
the relationship, such as self-identify and communication:
“Family and friends can be with the patient as they were
before”. SENSE-GARDEN was considered a catalyst for
fostering relationships and providing opportunities for self-
expression and understanding between people with dementia
and their families. This improvement in relationships was
considered important in easing caregiver burden: “Improving
relationships with family members and staff, easing
caregiver burden on the staff and family”.
Communicating. During the interviews, discussions
turned to benefits of creative activity in dementia care. In
particular, there were strong references to the ability of
visual media and music to provide alternative forms of
communication beyond that of verbal means. Users believed
that the inclusion of music and visual imagery in SENSE-
GARDEN would be able to provide tools for sharing
information: “Being able to tell stories, if one has lost the
language, pictures and movies can tell things.” Users also
believed that SENSE-GARDEN may be able to play a role in
triggering conversation topics: “If I visit, there are always
dead moments. This will help to get the life back into the
conversations.”
Creating opportunities through technology. Users with
mild cognitive impairment displayed a sense of exploration
and adventure when discussing the components of SENSE-
GARDEN. The use of virtual environments was perceived as
providing ways of visiting new places and experiencing an
outdoor environment: “Maybe a place you never went to, but
you want to see”. One user was particularly impressed with a
component of SENSE-GARDEN called “Life Road”, which
allows the person with dementia to cycle on a stationary bike
in front of a film of a familiar place: “We are afraid to ride
outside so this option is great. To be safe on a bike.” This
technology was also considered to provide opportunities for
individuals to see places that they can no longer visit: “My
mother wants to see her old street again, but we can’t do it.
With this she can visit again”.
These quotes from the users have highlighted the amount
of work that goes into creating meaningful experiences for
people with dementia. However, with the right kind of
facilitation, SENSE-GARDEN may be able to provide these
experiences for not only people with dementia, but also for
their caregivers.
F. Challenges to Consider
This final theme is perhaps one of the most important in
going forward with the SENSE-GARDEN project. The users
raised important issues to be aware of when preparing and
implementing the SENSE-GARDEN intervention. These
concerns are given in the following subthemes: avoiding
negative memories, creating personal databases, integrating
physical activity, managing symptoms of dementia, and
attitudes towards technology.
Avoiding negative memories. Many users emphasised the
importance of avoiding stimuli that could evoke negative
emotions, such as photographs of relatives who have passed
away, for example: “It is necessary to note that there are
memories that are not good, and that it is necessary to have
very careful prior fieldwork”.
Creating personal databases. The main purpose of
SENSE-GARDEN is to create experiences that are tailored
to the individual with dementia and their past. However,
users suggested that there might be challenges in collecting
necessary information to achieve this. Issues included the
lack of information from family and friends, but potential
solutions were also offered by the users: “How you create a
database for a lonely person- general triggers in an
exploratory approach”..., “The reduced availability of family
and friends can be a hindrance. The process of collecting
personal data can be eased by using a questionnaire
developed for the future SENSE-GARDEN users”. A formal
caregiver also raised the issue of collecting visual imagery:
“We have to see who has videos and films because in this
rural area only a few had them”.

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Integrating physical activity. Whilst many of the
respondents emphasised the importance of physical health,
issues in implementing physical activity were discussed. One
user had a concern regarding the use of a stationary bike for
the “Life Road” component of SENSE-GARDEN: “One
should reassess the issues of physical activity. For example,
bicycles must be those where the person rests and pedals
almost lying down”.
Managing symptoms of dementia. As in any intervention
for people with dementia, it is important to consider how
symptoms will be managed and prevented during the
sessions: “The person conducting the SENSE-GARDEN
session will be essential and must have backup for
interventions when disturbed behaviours occur. You don’t
know how the person will react, even if what you show was
a best experience for him”. Other issues relating to
hallucinations and medication were also raised.
Attitudes towards technology. There was quite a strong
sense among the respondents that technology should be
hidden during the SENSE-GARDEN sessions: “The
experience will be richer when the technology is hidden”...,
“The room must be very tempting, persuading- all
technology must be hidden”. These comments could be
interpreted in two ways. Firstly, technology should be hidden
to create a more realistic, immersive environment.
Contrastingly, it could be that users were referring to the
potential reservations that some people have against
technology. Some users explicitly expressed negative
attitudes towards technology: “Many beware technology”.
There were also respondents who preferred experiences in
natural environments compared to virtual scenarios: “I’d
prefer to walk the person with dementia in a real park”…,
“SENSE-GARDEN must be just an intermediary step to
outdoor and social activities.”
This theme has highlighted that whilst the users see many
potential benefits for SENSE-GARDEN, they are also aware
of the challenges that lay ahead. This affirms the inclusion of
not only caregivers, but also people with cognitive
impairment in the development of interventions, and the
value of adopting a user centred design in interventional
research.
V. DISCUSSION
The findings from these user interviews have covered a
large variety of ideas regarding the SENSE-GARDEN
intervention. Firstly, the respondents were persistent in their
beliefs that the environment, the facilitation of the
intervention, and the stimuli all need to be tailored to the
individual with dementia visiting the SENSE-GARDEN. It
should be acknowledged that the task of individualisation is
not an easy feat. As human beings, we are all individualistic
by nature, with different tastes, preferences, and desires.
Adding the constantly fluctuating progression of dementia
to this individuality makes it a difficult task in designing
technology for these users [21][22]. This is something that
the SENSE-GARDEN project will have to tackle through
rigorous work and collaboration with users, technology
developers, and researchers of various disciplines.
Secondly, the respondents also emphasised the
importance of interaction between the SENSE-GARDEN
stimuli, the person with dementia, and the caregiver. The
respondents` numerous ideas regarding this interaction can
be taken forward into a theoretical consideration of
technology and its role within SENSE-GARDEN.
A. Technology as the Storyteller: The Potential of Digital
Media in Preserving Narrative Identity
Dementia’s impact on memory, behaviour and
communicative abilities can have detrimental implications
for a person’s identity. However, there is evidence to suggest
that individuals may preserve a sense of self to some extent,
even in more severe stages of dementia [19][23]. In this
study, there was an overall sense of the immersive
environment being able to stimulate autobiographical
memory, which was valued as important for preserving a
sense of identity. The perspectives of respondents are in
agreement with previous research on virtual environments
for people with dementia. Siraraya and Ang [24] describe the
virtual world as a ‘memory sanctuary’, in which selfhood
and relationships are maintained.
In order to understand how technology and media may be
able to preserve identity, we have first to consider what
identity means to people with dementia and how it can be
shaped by other individuals. The role of others should not be
underestimated in maintaining the identity of the person with
dementia. In discussing the needs of people with dementia,
Kitwood [25] stresses the importance of others in the
maintenance of personhood. Westius, Kallenberg, and
Norburg [26] present the notion of ‘intertwined narrative’ in
which the life story of the person with dementia is integrated
with the narrative of their family carer. Thus, if the person
with dementia should become unable to independently recall
their story, the intertwined narrative of the caring
relationship may provide the opportunity for the maintenance
of self.
Earlier literature presents similar ideas. Mills [27]
suggests that people with dementia bestow their life stories
to another, therefore continuing their sense of identity. Mills
states that in this sense, the narrative of the individual never
disappears, regardless of the inevitable fading of the person’s
memory.
One way of preserving this narrative is through the use of
digital life books. Digital storytelling, an activity in which
technology is used to create innovative forms of narrative,
has been shown to educate nursing home staff about the
person with dementia [28]. This is especially important for
people with dementia living in care homes with little or no
family, a challenge mentioned by one of the users included
in the present study. Technology and personalised media
contents may be the answer to not only preserving, but also
sharing that individual's life story with care staff.
SENSE-GARDEN could potentially offer a method for
assisting professional caregivers, family and friends in
preserving the life story of the person with dementia.
Furthermore, the technology of SENSE-GARDEN goes
beyond the “life book” concept by offering an entire
environment shaped around a person’s life. It offers the

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opportunity for individuals to become completely immersed
in their past. The next section will discuss the technology’s
place in the overall environment.
B. Beyond Physical Space: Creating ‘Emotional’
Environments through a Transactional Relationship
The respondents emphasised the significance of creating
an environment in which the person with dementia and their
caregiver could share an emotional experience together.
Here, respondents applied meaning beyond the physical
space to include emotional and social factors that contribute
to the experience of space. In this sense, it is important to
have a holistic understanding of what constitutes as an
‘environment’.
There is growing acknowledgement of the environment
being defined as more than just a physical space. According
to literature, an environment is composed of psychosocial
elements as well as physical factors [29]. In considering how
an environment can shape social interaction, Freund’s
concept of space is particularly relevant. He writes “space is
not merely a place in which social interaction occurs, it
structures such interaction” [30].
The way in which an environment simultaneously
influences the behaviour of individuals and interpersonal
relationships, and yet is shaped by those persons, can be
referred to as the transactional relationship. The notion of
‘transaction’ was firstly used in this context by the
philosopher John Dewey, who asserted “Everything that
exists in far as it is known and knowable is in interaction
with other things. It is associated, as well as solitary, single.”
[31]. In the context of SENSE-GARDEN, it could be said
that a transactional relationship exists between the various
technologies (the intervention environment), the person with
dementia, and the caregiver. This transactional relationship is
conceptualised visually in Figure 2. The figure highlights the
numerous interactions that take place between SENSE-
GARDEN and its users.
To understand the transactional relationship as a whole,
one must consider the individual interactions that take place
between each of the three components:
Person with dementia and SENSE-GARDEN stimuli: The
SENSE-GARDEN stimuli has a direct effect on the person
with dementia, e.g., the system plays a song that evokes a
positive reaction in the person with dementia. The SENSE-
GARDEN, in turn, will also be influenced by the reactions of
the person with dementia. Feedback will enable the system
to learn more about the user with each session and therefore,
future visits to the SENSE-GARDEN will become
increasingly personalised.
Caregiver and SENSE-GARDEN stimuli: The SENSE-
GARDEN stimuli may also have an effect on the caregiver.
For example, a familiar song might hold significant meaning
for an informal caregiver, as well as the person with
dementia. In this way, the caregiver may experience their
own emotional reaction towards particular stimuli.
Alternatively, the caregiver may be indirectly affected by the
stimuli through emotional contagion. Emotional contagion
refers to the process of an individual’s emotional state
becoming triggered by emotions displayed in another person
Figure 2. Conceptual model of the transactional relationship that takes
place between the person with dementia, caregiver and the SENSE-
GARDEN stimuli during the intervention
[32]. In the context of SENSE-GARDEN, the caregiver’s
emotions may be shaped in response to the reactions of the
person with dementia. The caregiver will also be able to
configure the SENSE-GARDEN environment based on these
reactions, e.g., they can choose to immediately stop a video
if it prompts negative behaviour in the person with dementia.
Person with dementia and caregiver: The interpersonal
relationship between the person with dementia and the
caregiver will shape the entire SENSE-GARDEN
experience. For example, if the person with dementia and the
caregiver are spouses with a close relationship, they might
spend the SENSE-GARDEN session reminiscing on shared
moments from their past. However, if the session is taking
place between a person with dementia and a new
professional caregiver who is not so acquainted with the
individual, then their session may involve SENSE-GARDEN
providing prompts for the caregiver in order for them to ask
questions about the person with dementia’s life.
Applying this theoretical frame to the SENSE-GARDEN
environment may provide insight into how the intervention
works. It will not be possible to gain a full insight into the
effects of SENSE-GARDEN without studying the numerous
components of the environment. Later literature on emotion
echoes Dewey’s view, suggesting a need to study the
complex relationship between person and environment, for
emotions cannot be comprehended by one or the other alone
[33].
These ideas can be linked to current thoughts on the
nature of technology design, which has been described as
“deeply contextual” [22]. Therefore, incorporating the study
of context, environment and relationships seems appropriate
for both dementia studies and technology development. The
interaction between environment and the people within it is
vital. How does SENSE-GARDEN, and technology as a
whole, fit into this interaction? What role does it play? Going
forward, research should adopt a holistic approach to
evaluating technology, considering the wider context in
which the technology is situated.

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VI. CONCLUSION AND FUTURE WORK
This paper has demonstrated the value and usefulness of
including user groups in the development of not only
innovative technologies, but also of interventions for
dementia care. Viewing a project through the lens of the user
can offer contrasting perspectives with fresh insight into
solutions. In the present study, the user interviews yielded
valuable insights for the progression of the SENSE-
GARDEN project.
The users’ value for the relationships within the SENSE-
GARDEN suggests that the social and emotional aspects of
virtual environments should not be underestimated. This
view is supported by previous literature which has called for
more research on social interaction in dementia care settings
[34]. The results highlight the significance users find in
fostering relationships through means of self-identity and
emotional relationships. A focus on social and emotional
interactions between technology, users, and interpersonal
relationships could provide very fruitful results in the context
of dementia care. This research provides rationale for the
study of emotional engagement and interaction not only in
the SENSE-GARDEN project, but also in the wider context
of assistive technologies.
The next steps for SENSE-GARDEN include a focus on
this emotional aspect. The full trials, planned for summer
2019, will adopt a mixed-methods approach to studying the
intervention. Whilst qualitative methods capture rich
personal accounts of user experiences, it is important to
recognise the value of quantitative measures. Therefore,
physiological data will be collected in addition to data from
questionnaires, interviews and observation measures. The
Empatica E4 wristband [35] will be used to collect
information on heart rate and electrodermal activity (EDA).
These measures will be assessed during the SENSE-
GARDEN visits, as a reaction to different stimuli.
Combining this data with qualitative accounts of the SENSE-
GARDEN experience will provide a stronger overview of
the processes that occur within the intervention.
This research also provides rationale for theoretical work
on the role of technology for people with dementia. Firstly,
ways of meeting individual needs need to be identified.
Respondents stressed the importance of familiarity for the
person with dementia, and they raised issues regarding the
identification of individual preferences and behaviours.
Secondly, the role of technology as an active contributor
to environments, and interactions within those environments,
should not go unnoticed. This paper has discussed the
SENSE-GARDEN technology in the context of a
transactional relationship, but other theories may apply.
Finally, this paper demonstrates the highly
interdisciplinary nature of this topic. The users’ comments
have formed a piece of work that lays at the intersection of
human centred design, technology, psychology, sociology,
and arguably the creative arts. Future work within dementia
care can benefit from incorporating knowledge from these
various disciplines.
ACKNOWLEDGMENT
This study was performed in the frame of the EU project
SENSE-GARDEN (AAL/Call2016/054-b/2017, with
implementation period June 2017 - May 2020) funded by
AAL Programme, co-funded by the European Commission
and National Funding Agencies of Norway, Belgium,
Romania, and Portugal.
We would like to thank all participants in the study.
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