This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Mental Health, is properly cited. The complete bibliographic information, a link to the original publication on https://mental.jmir.org/, as well as this copyright and license information must be included.
Digital health technology is a promising way of supporting health care providers and family caregivers as they care for patients with cognitive impairment.
This scoping review aimed to portray the use of digital health technology to assist health care providers and family caregivers in caring for patients with cognitive impairment who live in the community or in a facility.
We conducted a scoping review of peer-reviewed scientific articles available in MEDLINE, PsycINFO, Scopus, and CINAHL with Full Text, as well as gray literature available in preprint servers, theses depositories, and various national and international dementia organizations’ websites. The search yielded 975 articles, of which we included 7 (0.7%) in the review.
Of the 7 interventions included in the retrieved manuscripts, 2 (29%) were digital calendar reminder systems to support activities of daily living and medication management; 2 (29%) were apps on tablet devices to simulate the presence of family before therapy interventions; 1 (14%) was a social robot used in therapeutic sessions to include elements of musicotherapy, reminiscence, cognitive games, and relaxation; 1 (14%) was a commercially available computer system that provides access to various recreational leisure activities; and 1 (14%) was a web-based self-management support system that helps family caregivers to deal with behavior changes in a relative with dementia. Of the 7 articles, only 1 (14%) reported on the use of a behavior change theory, namely a comprehensive process model of engagement coupled with cognitive stimulation therapy.
Literature on the topic is scarce, recent, and heterogeneous. There is a clear need for a theoretical framework to conceptualize and govern the use of behavior change models that incorporate technology for patients with cognitive impairment.
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 [
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 [
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 [
We performed a scoping review of peer-reviewed scientific articles following the recommendations of Arksey and O’Malley [
The dementia and cognitive impairment search concept was adapted from the Cochrane Dementia and Cognitive Improvement group [
To locate gray literature, the librarian searched in preprint servers, theses depositories, and various national and international dementia organizations’ websites with the keywords
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 [
The search yielded 975 articles, with 726 (74.5%) remaining after duplicates were removed (
Study selection process.
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 [
The included studies involved the following presence and telepresence interventions, all detailed in
Two digital calendar reminder systems to support activities of daily living [
Two apps on tablet devices to simulate the presence of family before therapy interventions [
A social robot used in therapeutic sessions to include elements of musicotherapy, reminiscence, cognitive games, and relaxation [
A commercially available computer system that provides access to various recreational leisure activities to encourage the engagement of people with dementia in activities and social interactions [
A web-based self-management support system that helps family caregivers deal with behavior changes in a relative with dementia [
Intervention description and effects on patients with cognitive impairment, health care professionals, and family caregivers.
Technology used | Intervention description | Patients | Health care professionals | Family caregivers | Outcome measure | Outcome | Reference number |
Digital calendar with active reminders to support activities of daily living—description: RemindMe, a digital calendar developed to support people with cognitive impairment that includes three core functions: (1) scheduling of activities and customizing reminders in a user-friendly digital calendar, (2) active confirmation of reminders sent by SMS text message requiring users to acknowledge the prompt actively by responding to the SMS text message, and (3) a feedback system that registers information based on the user’s interaction; use: stand-alone | Patients received an individualized introduction, a written manual, and individual weekly conversations for 2 months with follow-up assessments after 2 and 4 months. All occupational therapists received training. The patients received rehabilitation as usual at the rehabilitation clinic together with structured support in the use of RemindMe as a support for memory and to plan and structure activities of daily living; setting: rehabilitation clinics | Eight patients (6 women) with a median age of 58 (range 26-68) years from 3 rehabilitation clinics in Sweden, who had cognitive impairment and needed support with planning, organizing, and remembering to perform activities of daily living | Seven female occupational therapists, specialists in rehabilitation for people with neurological impairments in primary care, with 2 to 25 years of experience; 5 had a bachelor’s degree in occupational therapy, and 2 had a bachelor’s degree with 1 year’s postgraduate education; all were experienced in using digital health technology for their patients, but no one was specialized in developing information and communication technologies | N/Aa |
Patient satisfaction (assessed with QUEST 2.0b) Field notes (patients’ opinions or interests or intentions) Logs in the calendar Interviews with occupational therapists (appropriateness, patient ability, implementability, and fit of RemindMe within the infrastructure) Data regarding the cost for patients to use RemindMe |
Acceptability: +c Demand: + Implementation: challenges Practicality: challenges Integration: + |
[ |
Social robot Eva—description: an assistive anthropomorphic robot used in therapeutic sessions to include elements of musicotherapy, reminiscence, cognitive games (complete with wisdom sayings), and relaxation; use: stand-alone | Cognitive stimulation therapy that aims to actively mentally stimulate people with dementia through cognitive activities and reminiscence, multisensory stimulation, and group social contact. The cognitive stimulation therapy included a set of therapeutic sessions conducted by the robot Eva. The study was conducted in a lounge of the geriatric residence where all participants live; setting: nursing home | Nine people (6 women) with dementia living in a geriatric residence, aged between 74 and 95 (mean 83.77, SD 8.13) years | Six caregivers (4 women) participated in the study; they had an average of 3.2 years of experience as caregivers in a geriatric residence | N/A |
Frequency and intensity of problematic behaviors (assessed with the NPI-NHd) Qualitative analysis |
Decrease in frequency and intensity of problematic behaviors, agitation, depression, delusion, apathy, and irritability (–e) Behavior and mood change: cooperation, positive mood, less isolation, and positive facial and corporal expressions (+) Activities of daily living: feeding improvement, activity-level change, fewer naps, and participation in residence activities (+) Socialization: talkative, singing and laughing, and influence on other residents (+) Prevalence of the impact: fewer problematic behaviors, impact on caregivers’ burden, and sustained impact on behavior (+) |
[ |
Tablet device (large screen size to accommodate potential visual impairment)—description: tablet-simulated presence therapy intervention; use: human enacted | Family caregivers asked to self-record a personalized 1-minute video based on how they would typically communicate with the study participant. Family videos are recorded either directly into the tablet device on the unit or at home using a personal device and later uploaded to the tablet device. Content tailored to help with particular challenges (eg, medication refusal and responsive [aggressive] behaviors); setting: hospital | Four hospitalized older adults (3 women) with dementia, aged 69 to 80 years. They had different types of diagnoses, including Alzheimer disease, vascular dementia, and Parkinson disease dementia | Two experienced full-time nurses who had basic training in dementia care. One had practiced 14 years in dementia care, and the other had 18 years of experience | N/A |
Filmed footage and interviews |
Patients: positive changes in the mood of all 4 older adults (+) How health care providers and health care professionals used the tablet device to interact with the patients significantly affected the outcomes. The care interaction among the patients required a person-centered approach. When a video delivered an effective message, it bridged the connection and helped older adults with dementia feel safe (+) |
[ |
Tablet device—description: apps for reducing agitations and supporting caregivers’ education; use: human enacted | Tablet device–based program for family caregivers’ education and reducing problem behaviors in older adults with cognitive impairments. Four apps were used for the agitation-reduction component of the program. For the educational component, meetings or email correspondence with family caregivers occurred to discuss important information about dementia and how to interact with people with dementia; setting: care unit | Five older adults with dementia | N/A | Eight family caregivers received educational information; data were only collected from 6 of the participants |
Participants’ scores on the Agitated Behavior Scale Interviews |
Patients: a notable reduction in agitation during the use of the apps (–) Family caregivers: knowledge about specific aspects of dementia increased significantly after participating in the program (+) |
[ |
A computer system designed for older adults in community settings—description: a commercially available system that encourages the engagement of people with dementia in activities and social interactions by providing access to various recreational leisure activities; use: human enacted | The system was made available for use, as part of a 6-month study, in a 26-apartment MCUf for people with mild-to-severe dementia. The system was placed in the dining room of the MCU and was used there by health care professionals. It was wheeled into a side room or resident’s room by the researchers for individual sessions; setting: care unit | Five older adults residing in the MCU, aged ≥50 years | Seven health care professionals in the MCU, aged ≥18 years, interact directly with the individuals in the MCU | Four family caregivers of older adults living in the MCU, aged ≥18 years, who have visited their relative residing in the MCU at least monthly in the year preceding the study |
Interviews with health care professionals and family caregivers |
Health care professionals and family members reported benefits for residents, such as enjoyment, interactions and connections with others, and mental stimulation (+) |
[ |
Medication reminder device—description: an automatic pill dispenser with audible and visual stimuli that remind users when to take their medication. When the alarm rings, the correct dose of medication is released into the lid opening. Users must then invert the device to obtain medication and stop the alarm; use: human enacted | If participants did not find any difficulty using the device, the device and its use were customized. Customized conditions included medication loaded into the device, loading schedule, location in the home, time of the alarm, and other individual considerations. The caregivers monitored device use during the first week of its use. They were asked to provide minimal assistance to users in using the devices (only when required); setting: home care ad community care | A total of 18 older adults (15 women) with dementia (mean age 81.2, SD 6.2, years), living at home, with a history of missed medication doses, overdoses, or need for verbal reminders to take medication once or more during a week | Eight caregivers and visiting nurses | Ten family members living separately |
Self-administration medication rate is defined as the ratio of the number of doses taken independently to the number of all prescribed doses during 1 week Open questioning of users and their caregivers |
Self-administration medication rate during 1 week showed improvement at 3 months (13/18 users; +) Reminder devices can improve medication adherence (+) Caregivers reported maintenance of normal blood pressure, reduction of caregivers’ burdens, and decreased care costs (+) Users reported gaining self-confidence and success at learning the skills necessary to use the device (+) |
[ |
Web-based self-management support—description: web-based self-management support intervention to help family caregivers deal with behavior changes in a relative with dementia; email contact of a specialist dementia nurse and web-based videos and e-bulletins; use: human enacted | Family caregivers received 3 personal email contacts with a specialist dementia nurse (during 12 weeks). The nurse supported the family caregivers in managing behavior changes by giving feedback on assignments and tailoring support to the personal needs of the family caregivers. Other family caregivers received links to 6 web-based videos with assignments about different types of behavior changes, and they could choose how many videos they watched and assignments they completed. A third group of family caregivers received 6 e-bulletins containing practical information about different types of changes in behavior and how to manage them; setting: web based (caregiver support) | N/A | N/A | A total of 81 family caregivers (partner or relative) of people with dementia who live at home. They had contact with the person with dementia at least once a week |
Primary outcome variable (self-efficacy) was measured using the Trust in Our Own Abilities instrument, a questionnaire in Dutch Presence and reaction scores for mood and behavior problems, measured by the Revised Memory And Behavioral Problem Checklist Occurrence of disruptive behavior and family caregivers’ reaction Dyadic Relationship Scale used to assess relationship between person with dementia and family caregiver |
The web-based self-management support intervention involving email contacts did not lead to positive effects compared with web-based interventions without personal email contacts (–) The medium intervention involving web-based videos and e-bulletins showed no statistical improvements compared with the minor intervention involving e-bulletins only (no significant change) |
[ |
aN/A: not applicable.
bQUEST 2.0: Quebec User Evaluation of Satisfaction With Assistive Technology, version 2.0.
c+: positive effect.
dNPI-NH: Neuropsychiatric Inventory, Nursing Home version.
eNegative effect.
fMCU: memory care unit.
Overall, using multiple methods and designs, the studies showed positive effects on patients with cognitive impairment, health care providers, and family caregivers (
The study by Cruz-Sandoval et al [
Thematic analysis of the information extracted from the discussion and limitations sections of the included papers about the factors influencing digital health technology success revealed 18 factors.
Benefits, challenges, and influencers of using digital health technology to support patients with cognitive impairment, health care professionals, and family caregivers.
|
Benefits | Challenges | Influencers |
Patient with cognitive impairment |
Engagement in the activity Habit forming [ Gaining self-esteem, motivation, and “having something to which to look forward” [ Technology replaced or augmented activities [ |
Relevance and quality of the content Video content does not have to be older for residents to relate to it [ Older content may be frustrating (“Residents were frustrated knowing they should recognize materials from a certain era but not being able to do so”) [ Technical issues Technical issues and lack of user-friendliness of the system are frustrating for people with dementia [ Improper operation of the device may be a reason for cessation [ Patient-centered content Applications designed for the general population and ill-suited for patients with cognitive impairment [ Gaming stations not suited to disease-related disabilities (eg, wheelchair vs access to station and station height) [ |
Planning and delivery of activities Whether the system was used one-on-one or in a group (intervention would probably be more beneficial in a one-on-one setting or small group) [ Frequency of use [ |
Health care professional |
Support and resources Equipped, trained, and having access to educational resources [ The use of technology, specifically the iPad, throughout the program provided an easy and convenient way to deliver both interventions and education [ |
Workload Weekly telephone calls during a more extended period can become time consuming and problematic to implement in practice [ Telephone calls might reveal other, new, problems, and therefore frequent telephone calls can be problematic to implement in daily practice [ Lack of resources, especially time and personnel [ Technology use The difficulty of keeping up to date with rapid technological development [ Knowing how to use a tablet device and video applications [ Not knowing how to use features or where applications were located [ Limited previous experience in providing self-management support through email contacts [ Attractiveness of content Boredom caused by limited content (too few episodes of television shows or movies) [ |
Involvement and professional development Involvement as a facilitator and motivator [ Instruction and increased awareness of the importance of the integrated use of the various elements in an intervention [ Adding information about the apps and creating case studies [ Quality of content and convenience of technology Service accessed from various computers [ Convenience and availability of information and media [ Collaboration with families to improve care [ Sustainability Long-term use: the health care professionals would have everything they need in 1 place for both education and intervention purposes [ Cost Apps can be downloaded for little to no cost [ |
Family caregiver |
Involvement Involvement leads to a better relationship [ |
Collaboration needed with a health care provider The family caregiver asked the occupational therapist for support in deciding about content building (what to include in videos) [ |
Involvement Involvement leads to a better relationship as well as safer and higher quality of care [ Involvement as a facilitator and motivator [ Caregiver’s help is a prerequisite for the use of the medication reminder device [ Technology should be developed as a technical aid for use with family caregivers’ help [ Resources and skills Family caregivers all had internet access and were often relatively young and well educated [ Increased comfort with technology and finding information makes family caregivers more self-assured with accessing and using knowledge about dementia [ Ease of use of the technology Adding information about the apps and creating case studies [ |
Although digital health technology encourages patients to participate in activities (videoconferencing and visualization of memories through photos and videos), they may encounter technical difficulties, find content less relevant than expected, and be less adapted to their conditions. The quality of activity planning seems to be a determinant of the success of digital health technology implementation.
Although health care providers feel supported and resourceful when incorporating digital health technology into their interventions, they may face technical difficulties, find content less appealing than expected, and feel burdened by the increased workload. The success of digital health technology implementation seems to be influenced by health care providers’ active participation in the development and integrated use of the technology, collaboration with families, the technical quality of the digital health technology, and its convenience and cost.
Although family caregivers believe that their involvement in the therapy provided to their relative leads to a better relationship, they may require more support from, and collaboration with, health care providers. The success of digital health technology implementation seems to be influenced by family caregivers’ participation as active facilitators in the delivery of care, the ease of use of digital health technology, access to the internet, and the caregivers’ literacy and technology literacy.
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 [
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 [
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 [
The design of technology and the inherent intervention seems critical in implementing and using digital health technology with end users. Di Lorito et al [
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
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.
Search strategy.
Medical Subject Headings
Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews
This research was supported by a joint grant from Victoria Hospital Foundation and Research Manitoba.
None declared.