The aging of the population will intensify in the coming decades, increasing the prevalence of disease and disability, in particular, the impairment of cognitive functions [1]. In Canada, for example, approximately 1 in 4 seniors aged ≥85 years have been diagnosed with dementia [2]. The growing number of people with cognitive impairment will result in high demands on health care systems. Cognitive impairment reduces the quality of life of older adults and increases the risk of dementia and mortality [3,4]. In this paper, the term cognitive impairment refers to the various etiologies known to characterize cognitive impairment, such as vascular conditions, neurological conditions, and stroke. The ability of people with cognitive impairment to retain information, learn new things, or concentrate is impaired, leading to a decrease in autonomy and independence and poor social participation. Cognitive impairment affects the patients and those around them, particularly family caregivers and the health care professionals providing care to alleviate the condition [5,6]. Family caregivers’ activities require a constant connection to the person with cognitive impairment and the activities they require to perform to function and live safely (eg, maintain a career, home, and family life). The burden experienced by people taking care of a person with cognitive impairment is associated with an adverse emotional state and can be more substantial in terms of physical sequelae and financial and social consequences [7].

Responsible health and social systems should support caregivers to help maintain persons with cognitive impairment in their homes for as long as possible. From the health care provider’s perspective, the delivery of quality patient-oriented care seems to be determined by their ability to understand the particular care and heterogeneous communication needs of people with cognitive impairment [8,9]. Digital health technology is a promising way of supporting patients with cognitive impairment in that technology can be an enabler of behavior change in patients, family caregivers, and health care professionals. One could imagine how technology may foster communication among users (patients, caregivers, and care providers) and affect daily routines among all stakeholders. This paper examines the use of digital health technology as a plausible way of supporting health care providers and family caregivers as they care for people with cognitive impairment. According to the US Food and Drug Administration, digital health technologies “use computing platforms, connectivity, software, and sensors for health care and related uses” [10]. Digital health technology has been deemed valuable and efficient in supporting health care providers and family caregivers in different populations, such as children with special health care needs [11], patients undergoing hematopoietic cell transplantation [12], and patients with Parkinson disease [13], as well as patients requiring cardiovascular care [14], pulmonary rehabilitation [15,16], mental health rehabilitation [17], and cognitive rehabilitation [18]. Digital health technology faces challenges at individual and system levels, such as lack of presence and in-person contact [19] as well as ethics and data governance [20]. The design of a digital health technology for patients with cognitive impairment is itself challenging because of their complex needs and because they may be in no condition to engage in the design processes. Creative technologists should be aware of the importance of actively including the end users in the design process [21] and that the involvement of end users with cognitive impairment can be a complex task [22], which is even more critical when older adults are the end users [23]. When designing a digital health technology that persons with cognitive impairment will use, the task is cumbersome for many reasons related to awareness about their health needs, knowledge of potential ideas based on technology, and level of technology literacy.

In practice, digital health technology is understudied in people with cognitive impairment, family caregivers, and health care providers. This paper focuses on information and communication technologies deployed with or without additional digital technologies to look more closely at digital health technology that claims to support health care professionals and family caregivers caring for patients with cognitive impairment by providing them with digital support and a sense of presence using technologies such as, but not limited to, anthropomorphic agents, digital tools, robots, apps, and multimedia systems. The typical intervention sought in this review would be based on technology that allows digital dyadic communication between patients with cognitive impairment and their health care providers and family caregivers.

In this paper, we aimed to depict the use of digital health technology to assist health care professionals and family caregivers in caring for patients with cognitive impairment who live in the community or in a facility. Recent literature portraying available technology applications to support the informal caregiver of a person with cognitive impairment showed the impact of technology in reducing the caregiver’s burden and the patient’s social isolation [24]. According to the literature, social support is still needed to improve the adherence and effectiveness of digital health technology–enabled telerehabilitation [25]. Although studies show an impact of technology on occupational performance and quality of life in community and health care settings [26,27], more research on the impact of digital health technology settings [26,27] and users’ existing knowledge and informational needs [25,27] as well as feasibility and acceptability [25] is needed. Furthermore, Bell et al [28] advocate for including motivational frameworks and behavior change interventions in digital health intervention development, increasing service engagement in young people and lived experience involvement in digital intervention development. The objectives of this paper were to (1) identify which digital health interventions were tested in patients with cognitive impairment, health care professionals, and family caregivers, as well as the associated behavior change strategies; (2) identify the behavior change theories involved in the included literature that relates to patients, health care providers, and family members; (3) provide an overview of the effects of these interventions on patients with cognitive impairment, health care professionals, and family caregivers; and (4) identify and comprehend the benefits, challenges, and influencers of using the digital health technology to assist health care professionals and family members caring for patients with cognitive impairment.

We performed a scoping review of peer-reviewed scientific articles following the recommendations of Arksey and O’Malley [24] and Levac et al [25]. We followed the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines [26]. Information was extracted from the included manuscripts using customized calibrated forms that were tested by the team before their use. Data charting was performed by 1 coauthor per paper and was validated by a second team member. There was no consultation exercise at the end of this scoping review.

The dementia and cognitive impairment search concept was adapted from the Cochrane Dementia and Cognitive Improvement group [27]. To develop the search strategy, a health sciences librarian (CM) consulted with the team (MAC, FO, RU, and MC). Using a combination of controlled vocabulary and keywords, the team developed search concepts for telepresence and behavior changes (Multimedia Appendix 1). The telepresence search concept incorporated Medical Subject Headings (MeSH) terms and keywords representative of robotics and telecommunications, including the MeSH terms Artificial Intelligence, Human-Robot Interactions, Self-help Devices, Wearable Electronic Devices and Robotics. The behavior changes concept included the MeSH terms Health Behavior, Self-control, Self-examination, and Health Risk Behaviors. In addition, we excluded articles indexed as child or infant only and limited them to English.

To locate gray literature, the librarian searched in preprint servers, theses depositories, and various national and international dementia organizations’ websites with the keywords dementia or cognitive impairment and technology. The search extraction took place in April 2021 in the following databases: MEDLINE (Ovid; 1946-2021), PsycINFO (Ovid; 1806-2021), Scopus (1970-2021), and CINAHL with Full Text (EBSCOhost; 1981-2021). All records were exported to EndNote (version X9; Clarivate), and duplicates were removed [29]. The screening process was completed in Rayyan software [30].

To be included, the articles had to be written in English and present original qualitative or quantitative empirical data related to the use of a digital health technology (eg, a mobile app or a telepresence robot) to support health care delivery, family caregiving, and behavior change in patients with cognitive impairments. The articles had to refer to a part of, or an entire, behavior change approach and the related qualitative and quantitative instruments used to measure a patient’s behavior change, with reference to the behavior change technique taxonomy formulated by Michie et al [31]. The included articles had to be focused on adults with cognitive impairment (eg, dementia, traumatic brain injury, or stroke) and their health care providers and family caregivers. Search results reporting on surveys, technical development, perspectives, and literature reviews were excluded. Two independent reviewers performed the study selection. An article had to be judged relevant by both reviewers to be included. A third reviewer was consulted when the 2 first reviewers could not reach a consensus.

The search yielded 975 articles, with 726 (74.5%) remaining after duplicates were removed (Figure 1). After screening titles and abstracts, of the 726 articles, 66 (9.1%) were retained and read in their entirety to determine eligibility. As a result, 89% (59/66) of the articles were rejected for various reasons (Figure 1). Thus, of the initial 975 articles, 7 (0.7%) were finally included in this scoping review.

We gathered and charted the following information: the technology-enabled presence and telepresence interventions; technology used; profiles of the patients with cognitive impairment, family caregivers and health care professionals; outcome measures; intervention outcomes; and barriers to intervention implementation. Information about the factors affecting the success of digital health technology implementation was extracted from the discussion and limitations sections of the retrieved manuscripts and underwent thematic analysis. Two reviewers independently extracted the data, and all team members revised the extracted information and adjusted or completed the extraction if necessary. After a series of iterations and content validation, we charted the data and presented them in a tabular format in Microsoft Excel 2016.

The included studies were published between 2012 and 2020 in the United States (2/7, 29%), Canada (1/7, 14%), Mexico (1/7, 14%), Sweden (1/7, 14%), the Netherlands (1/7, 14%), and Japan (1/7, 14%). Of the 7 studies, 6 (86%) were peer-reviewed research articles, and 1 (14%) was a thesis presented to obtain the degree of doctor of occupational therapy [32]. Of the 7 manuscripts, 6 (86%) presented qualitative and quantitative information from small-scale empirical studies involving 2 to 18 participants in each profile studied (patients with cognitive impairment, health care providers, and family caregivers) [32-37]. The manuscripts centered around adults and older adults with Alzheimer disease, dementia, and Parkinson disease dementia living in various settings, such as geriatric residence, memory care unit, and home. Only 14% (1/7) of the studies presented data from a randomized controlled trial involving 81 family caregivers [38].

Table 1 describes the included digital health interventions and their effects on patients with cognitive impairment, health care professionals, and family caregivers. As per the objective of the scoping review, the included manuscripts presented data from interventions targeting patients and health care providers (3/7, 43%) [33-35]; patients and family caregivers (1/7, 14%) [32]; patients with cognitive impairment, health care providers, and family caregivers (2/7, 29%) [36,37]; and family caregivers only (1/7, 14%) [38].

The included studies involved the following presence and telepresence interventions, all detailed in Table 1:

Overall, using multiple methods and designs, the studies showed positive effects on patients with cognitive impairment, health care providers, and family caregivers (Table 1), without adverse effects on any digital health technology users. The studies reported some barriers faced by health care providers and family caregivers to implementing and using digital health technology.

The study by Cruz-Sandoval et al [34] was the only one reporting on using a behavior change theory, which consisted of applying a comprehensive process model of engagement and cognitive stimulation therapy. None of the other studies explicitly applied a behavior change theory.

This scoping review aimed to portray the use of digital health technology to assist health care professionals and family caregivers caring for patients with cognitive impairment who live in the community or in a facility. Literature on the topic is scarce, recent, and heterogeneous. Previous literature [39] explored the use of eHealth technologies as a plausible approach to supporting aging with cognitive impairment and identified cognitive training solutions and supportive web platforms as the most effective interventions on a limited number of outcomes. More research is needed to solve methodological difficulties observed in the current literature, according to Dequanter et al [39], and development should focus on solutions for leisure and reminiscence as well as outcomes directly relevant to independent living. Di Lorito et al [40] gathered evidence on the effectiveness of digital health interventions on physical, cognitive, behavioral, and psychological outcomes as well as activities of daily living in people with dementia and mild cognitive impairment. The authors recommend considering different modalities of supervision while administering digital health interventions. “A mix of remote and face-to-face delivery could maximize benefits and optimize costs,” according to Di Lorito et al [40]. This paper is the first literature review that gathers the available digital health technology to support health care professionals and family caregivers caring for patients with cognitive impairment and synthesizes the implementation outcomes of using these technologies in the community or in a facility. We were able to retrieve only 7 manuscripts, including 6 (86%) peer-reviewed journal articles and 1 (14%) doctoral thesis, reporting on studies conducted over the last decade involving various technologies. Of these 7 studies, 4 (57%) reported on systems embedded into computers and tablet devices as gaming systems, self-management systems, and apps, whereas 3 (43%) reported on digital calendar reminder systems to support activities of daily living and medication management and a social robot used in therapeutic sessions. The interactions among patients with cognitive impairment, health care providers, and family caregivers identified in the included manuscripts were diverse and heterogeneous. Overall, the literature reported on the use of digital health technology to support bilateral interactions between patients and health care providers or between patients and family caregivers or a trilateral integration with support provided to all 3 groups, whereas 14% (1/7) of the studies reported on technology to support family caregivers only (people with dementia indirectly). The trilateral integration of technology complements the portrait presented by Huisman et al [41], who reported on technology targeting a person with dementia, the informal caregiver, or both.

Our scoping review indicates that the retrieved publications lack clarity regarding adopting a behavior change theory and associated model to carry out digital health technology intervention. Most (6/7, 86%) of the studies examined in this review did not include any explicit behavior change theory or model. The study by Cruz-Sandoval et al [34] was the only one reporting on using a behavior change theory, namely a comprehensive process model of engagement followed by cognitive stimulation therapy [34]. Two authors involved other theories such as activity theory [37] and simulated presence therapy intervention [35], but these are not behavior change models. The rest (4/7, 57%) of the articles did not mention any behavior change theory or model. This phenomenon can be explained by a lack of application of theoretical frameworks to conceptualize and govern the behavior change models that incorporate technology for patients with cognitive impairment. The shortcomings of using general theories and models for designing interventions aimed at this profile of patients with cognitive impairment were discussed in a recent scoping review of behavior change theories in adults without dementia [42]. The study aimed to adapt and develop a model promoting physical activity in people with dementia (the “PHYT in dementia”) [42] and presented an ad hoc model for the promotion of physical activity. Our scoping review indicates the direction that future studies may follow to eventually observe outcomes with a larger impact, that is, crafting a model that can be applied and replicated to inform the design of systems that support people with dementia to change their behavior.

Digital health technology can take multiple forms depending on the intervention it should deliver. It is important to note that only 14% (1/7) of the studies reported on implementing a robot as a conversational agent [34], and no other study presented another type of conversational agent, which can provide exciting opportunities for developing new ways of communicating with people with cognitive impairment. As other researchers have stated [43], implementing conversational agents to deliver interventions to people with dementia is still a poorly explored domain that deserves more attention and interdisciplinary work. This knowledge gap creates a new quandary in using established theoretical frameworks (eg, behavior change theories in our case) when building and deploying digital health technology. Our findings show that the use of digital health technology may bring real-world evidence [34] that is not supported by existing theoretical frameworks. This gap in real-world evidence documentation is a whole understudied research question. One can wonder whether technology must be used to support the adoption of behavior change approaches or whether it is introducing a new strategy that may prove effective but has not yet been defined and theorized. This dilemma may also raise the fundamental question of the necessity for behavior change theories to assist health care professionals and family caregivers caring for patients with cognitive impairment. Digital health technology may be perceived as a novel technique that has shown effectiveness (real-world proof) but has yet to be conceptualized as a posteriori. In this context, Bell et al [28] emphasize the importance of including perspectives of young people and lived experience, motivational frameworks, and behavior change interventions in developing digital health solutions. Our scoping review revealed 2 critical factors to consider when comprehending digital health technology for patients with cognitive impairment. The first factor is the operation mode. Digital health technology can be designed to operate with, or independently of, other hardware or software. A technology that operates independently of other technologies is called a stand-alone technology, which is usually easier to learn and use than a non–stand-alone technology. The second factor is the number of users. Although some of the digital health technologies presented in the retrieved studies are considered stand-alone technologies, the interventions needed more support from others. Understandably, end users may need the support of other people around them, especially when the end users are patients with cognitive impairment. Often, digital health technology is designed to enable family caregivers to access it, too, even if they are not required to act to deliver the intervention.

The design of technology and the inherent intervention seems critical in implementing and using digital health technology with end users. Di Lorito et al [40] recommend considering accessibility, acceptability, and sustainability for end users as prerequisites for the development of digital health interventions. Beyond exploring the effects of digital health technology on patients with cognitive impairment and their interaction with health care providers and family caregivers, this scoping review aimed to identify what determines the success of a digital health intervention. Design wise, only 29% (2/7) of the studies included in this review followed a user-centered design approach, despite the importance of such methodology when addressing a specific population with particular needs, namely patients with cognitive impairment [21-23]. A secondary observation from our scoping review is that designing a digital health technology for a patient with cognitive impairment necessitates collaboration with secondary stakeholders such as family caregivers and tertiary stakeholders from specialized institutions and clinics, in addition to actively and repeatedly involving the end user. Hung et al [35] followed a thorough user-centered approach involving patients and caregivers using video-ethnographic methods, video-recorded observations, and health care professionals’ interviews. Andreassen et al [33] validated the app with end users [44] and caregivers [45], but there is no explicit design process described. Including caregivers in the design is uncommon (in this scoping review, only a single study [35] did so) and represents a future research possibility. It is also important to note the complete absence of co-design and cocreation of solutions when this has been demonstrated to be a valuable methodology [46]. Co-design can be challenging for people with severe dementia or cognitive impairments, but it is still viable for people with less complex conditions as well as caregivers [47,48]. Because of their firsthand experience, caregivers can contribute to cocreating solutions for contexts they know well. This type of information is difficult to capture, formalize, and convey in interviews but is more naturally communicated and incorporated in cocreation endeavors.

The findings of this study contribute to filling a significant knowledge gap regarding the value of using emerging digital health technologies to assist health care professionals and family caregivers in caring for patients with cognitive impairment. Although the portrait is limited to 7 manuscripts, this scoping review presents many compiled results and recommendations based on the primary authors’ observations. This knowledge is one of the priorities identified in the literature over the last decade, and its importance has grown since the COVID-19 pandemic significantly affected the delivery of rehabilitation services. This paper has presented the evidence as of April 2021, and there may be ongoing yet unpublished research work applied to the COVID-19 context. Although the findings are helpful for pandemic-related decision-making, the presented findings were interpreted without regard for the pandemic. This review did not focus on addressing cognitive impairment from a therapeutic perspective, and we did not discuss the use of digital health technology as a clinical approach. Although it was built as exhaustive as possible, our search strategy may have lacked some terms; for example, we did not include critical MeSH terms such as Mobile Applications and Telemedicine because these were expected to yield the same manuscripts as search strings 1 to 6 (Multimedia Appendix 1). In addition, we planned to include only peer-reviewed articles, but we added a doctoral thesis because of the scarcity of articles. Therefore, we discourage hasty generalization of the results owing to the heterogeneity of the technologies and contexts of the interventions and the small number of manuscripts included. 

This paper showed that despite a plethora of theoretical frameworks available on the use of behavior change models, there is an apparent lack of application of theories incorporating technology for patients with cognitive impairment. This scoping review depicted existing digital health technology to support health care providers and family caregivers while caring for patients with cognitive impairment and highlighted the lack of reliance on behavior change theories and models despite studies showing their positive effects on patients with cognitive impairment, health care providers, and family caregivers with no adverse effects on any digital health technology users. This scoping review depicted the benefits, challenges, and influencers of using digital health technology to support patients with cognitive impairment, health care providers, and family caregivers to bolster future research and implementation.