Ethical adoption: A new imperative in the development of technology for dementia

Technology in Dementia Education: An Ethical Imperative in a Digitized World

Technology can support the delivery of care and improve the lives of people living with dementia. However, despite a substantial body of evidence demonstrating the benefits and opportunities afforded by technology, gaps remain in how technology and technology ethics are addressed in dementia care education. Here we discuss disparities in current educational programming and highlight the ethical challenges arising from underdeveloped knowledge exchange about dementia care technology. We put forward that for technology to be ethically deployed and maximized to improve outcomes, it must be embedded into dementia education programs and made widely accessible to the caregiver community.

What Does ChatGPT Know About Dementia? A Comparative Analysis of Information Quality

The quality of information about dementia retrieved using ChatGPT is unknown. Content was evaluated for length, readability, and quality using the QUEST, a validated tool, and compared against online material from three North American organizations. Both sources of information avoided conflicts of interest, supported the patient-physician relationship, and used a balanced tone. Official bodies but not ChatGPT referenced identifiable research and pointed to local resources. Users of ChatGPT are likely to encounter accurate but shallow information about dementia. Recommendations are made for information creators and providers who counsel patients around digital health practices.

Assistive technologies and aging in place for people with dementia and disabilities: a proof-of-concept study with in-home passive remote monitoring with interactive communication functions

PURPOSE

Can assistive technologies (ATs) support aging in place for people with dementia and disability? In seeking to go beyond the persistent institutional care delivery paradigm, this proof-of-concept study tested the feasibility of home care delivery using sensors and remote communication devices. This article reports the collaborative efforts among care professionals, care recipients and family caregivers in their private home environment and the impact of in-home passive remote monitoring (PRM) system on the users. The purpose of this study was to investigate the usability and impact of a PRM system combining in-house passive remote monitoring and an interactive communication function.

METHODS

In order to realize AT-supported, person-centered aging in place, a new care delivery model was designed, developed and tested for the duration of 12 weeks. The study was conducted with 5 older people (1 with severe disability and 4 with dementia), their primary family carers with 15 care professionals as users.

RESULTS

The findings indicate that there were some technical issues. However, the overall assessment of the system performance was positive, and the users expressed favorable views regarding its preventive and interactive nature. The importance of team-based care delivery, adjusted to fit the PRM equipment, was also highlighted. Faced with the challenge of meeting the increasing demand for person-centered care with limited resources, there will be a greater need for better integration of improved ATs. The study indicates ATs' potential for enhancing the quality of life for those involved in caregiving, while stressing the significance of stakeholders' engagement, skills and teamwork.IMPLICATIONS FOR REHABILITATIONThis proof-of-concept study tested the feasibility of a home care delivery system using sensors and remote communication device for those with dementia and disabilities.A home care delivery system was successfully created for 12 weeks by collaborative efforts among care professionals, care recipients and family caregivers in their private home environment.The introduction of in-home passive remote monitoring system increased the possibility of the older adults being able to live independently, and enabled rehabilitation at home.The users had favourable views regarding the system's preventive and interactive nature and highlighted a greater need for better integration of improved assistive technology in long-term care and rehabilitation.

How I want technology used in my care: Learning from documented choices of people living with dementia using a dyadic decision making tool

While technologies for aging in place are promoted to support care partners and people living with dementia, perspectives of people living with dementia are underrepresented in both use decisions among families and discussions within academia and industry. This mixed-methods study examined the use preferences of twenty-nine people living with mild Alzheimer's disease (AD) for four categories of technologies: location tracking, in-home sensors, web-cameras, and virtual companion robots. Participants completed a novel dyadic intervention, Let's Talk Tech, where they documented their preferences of the four technology categories for care planning purposes. Post-test interviews were thematically analyzed and provide insight into selection processes. Technology preferences varied considerably by and within participant living with mild AD. Excepting location tracking, non-technology and low-technology options were more desirable than the featured technologies. Control over technology use was of great importance to people living with AD. Considerations given to technology preference selection imperfectly fit within the new Health Technology Acceptance Model (H-TAM) developed for older adults. These findings underscore the importance of including people living with dementia in decision making about technologies to support care at home and the need for further personalization and tailorable technological devices to accommodate and align with their preferences.

"Functioning better is doing better": older adults' priorities for the evaluation of assistive technology

Despite the benefits of assistive technology (AT), barriers to technology adoption still exist and are uniquely affecting older populations. Improving technology adoption can be achieved by involving end-users in the development and evaluation process. However, existing AT evaluation tools rarely take into account older adults' experiences. The goal of this study was to fill this gap by determining which AT evaluation criteria are important for older adults. We conducted 4 nominal group meetings with 21 participants aged 50+ in Vancouver, Canada. In the meetings, participants generated AT evaluation criteria and organized them in the order of importance. The content from the meetings was analyzed using qualitative content analysis. Final rankings were collated to reveal which criteria were the most important across the groups. We found that promotion of independence, affordability, ease of use and ethics are the most important AT evaluation criteria for older adults. Some aspects of ATs that older adults value, such as reliability, are not featured in AT evaluation tools. This study provides insight into older adults' priorities for AT evaluation criteria, and concerns that older adults have about AT use. The findings are supplemented with a comprehensive analysis of the group discussions that contextualizes the criteria.

Preliminary Efficacy of Let's Talk Tech: Technology Use Planning for Dementia Care Dyads

Background and Objective

Care partners of people living with dementia require support to knowledgeably navigate decision making about how and when to use monitoring technologies for care purposes. We conducted a pilot study of a novel self-administered intervention, "Let's Talk Tech," for people living with mild dementia and their care partners. This paper presents preliminary efficacy findings of this intervention designed to educate and facilitate dyadic communication about a range of technologies used in dementia care and to document the preferences of the person living with dementia. It is the first-of-its-kind decision-making and planning tool with a specific focus on technology use.

Research Design and Methods

We used a 1-group pretest-post-test design and paired t tests to assess change over 2 time periods in measures of technology comprehension, care partner knowledge of the participant living with mild Alzheimer's disease's (AD) preferences, care partner preparedness to make decisions about technology use, and mutual understanding. Thematic analysis was conducted on postintervention interview transcripts to elucidate mechanisms and experiences with Let's Talk Tech.

Results

Twenty-nine mild AD dementia care dyads who live together completed the study. There was statistically significant improvement with medium and large effect sizes on outcome measures of care partners' understanding of each technology, care partners' perceptions of the person living with dementia's understanding of each technology, knowledge of the person living with dementia's preferences, decision-making preparedness, and care partners' feelings of mutual understanding. Participants reported that it helped them have important and meaningful conversations about using technology.

Discussion and Implications

Let's Talk Tech demonstrated promising preliminary efficacy on targeted measures that can lead to informed, shared decision making about technologies used in dementia care. Future studies should assess efficacy with larger samples and more diverse sample populations in terms of race, ethnicity, and dementia type.

Moral distress and ethical decision-making of eldercare professionals involved in digital service transformation

AIM

Technology affects almost all aspects of modern eldercare. Ensuring ethical decision-making is essential as eldercare becomes more digital; each decision affects a patient's life, self-esteem, health and wellness.

METHODS

We conducted a survey and interviews with eldercare professionals to better understand the behavioural ethics and decision making involved in the digital transition of eldercare.

CONCLUSION

Our qualitative analysis showed three recurrent roles among eldercare professionals in regard to digital service transformation; makers, implementers and maintainers. All three encountered challenging and stressful ethical dilemmas due to uncertainty and a lack of control. The matter of power relations, the attempts to standardize digital solutions and the conflict between cost efficiency and if digital care solutions add value for patients, all caused moral dilemmas for eldercare professionals. The findings suggest a need for organizational infrastructure that promotes ethical conduct and behaviour, ethics training and access to related resources.Implications for rehabilitationThe transition to digital care service is not neutral, but value-laden. Digital transformation affects ethical behaviour and decision-making.The decision as to which digital services should be developed and deployed must include eldercare professionals and not lay solely in the hands of managers, technologists and economists.We must move away from attempting to fit standardized solutions to a heterogenous group of older patients; accommodating the pluralism of patients' needs and wants protects their dignity, autonomy and independence.As digital care practices evolve, so too must organizational structures that promote ethical conduct.

Advance Planning for Technology Use in Dementia Care: Development, Design, and Feasibility of a Novel Self-administered Decision-Making Tool

BACKGROUND

Monitoring technologies are used to collect a range of information, such as one's location out of the home or movement within the home, and transmit that information to caregivers to support aging in place. Their surveilling nature, however, poses ethical dilemmas and can be experienced as intrusive to people living with Alzheimer disease (AD) and AD-related dementias. These challenges are compounded when older adults are not engaged in decision-making about how they are monitored. Dissemination of these technologies is outpacing our understanding of how to communicate their functions, risks, and benefits to families and older adults. To date, there are no tools to help families understand the functions of monitoring technologies or guide them in balancing their perceived need for ongoing surveillance and the older adult's dignity and wishes.

OBJECTIVE

We designed, developed, and piloted a communication and education tool in the form of a web application called Let's Talk Tech to support family decision-making about diverse technologies used in dementia home care. The knowledge base about how to design online interventions for people living with mild dementia is still in development, and dyadic interventions used in dementia care remain rare. We describe the intervention's motivation and development process, and the feasibility of using this self-administered web application intervention in a pilot sample of people living with mild AD and their family care partners.

METHODS

We surveyed 29 mild AD dementia care dyads living together before and after they completed the web application intervention and interviewed each dyad about their experiences with it. We report postintervention measures of feasibility (recruitment, enrollment, and retention) and acceptability (satisfaction, quality, and usability). Descriptive statistics were calculated for survey items, and thematic analysis was used with interview transcripts to illuminate participants' experiences and recommendations to improve the intervention.

RESULTS

The study enrolled 33 people living with AD and their care partners, and 29 (88%) dyads completed the study (all but one were spousal dyads). Participants were asked to complete 4 technology modules, and all completed them. The majority of participants rated the tool as having the right length (>90%), having the right amount of information (>84%), being very clearly worded (>74%), and presenting information in a balanced way (>90%). Most felt the tool was easy to use and helpful, and would likely recommend it to others.

CONCLUSIONS

This study demonstrated that our intervention to educate and facilitate conversation and documentation of preferences is preliminarily feasible and acceptable to mild AD care dyads. Effectively involving older adults in these decisions and informing care partners of their preferences could enable families to avoid conflicts or risks associated with uninformed or disempowered use and to personalize use so both members of the dyad can experience benefits.

Toward an Integrated Context-Based Design Approach for Dementia Residential Care Homes: A Review of Key Operational Design Problems

OBJECTIVES, PURPOSE, OR AIM

This article seeks to develop a context-based management system focusing on assessing key operational and design problems and affecting wayfinding in dementia residential care homes.

BACKGROUND

Dementia is multifaceted neurocognitive impairments largely attributed to cognitive deterioration manifested in memory loss and visuospatial deficit which have wider practical implications to both environmental safety and wayfinding and navigation of dementia user. Two key questions were addressed in this context: (1) How can cognitively facilitating assistive technology (AT) be made more user-focused to mitigate the impacts of cognitive impairments on environmental safety and wayfinding? (2) How can design intervention and changes in design topology, colors and texture, and internal finishing aid wayfinding, navigation, and orientation in dementia residential care homes?

METHOD

A systematic literature review and analysis was undertaken to assess the efficacy of key cognitively-related AT to support activities of daily living and environmental safety of dementia sufferers in a care home and aid wayfinding, navigation, and orientation.

RESULTS

Several key design variables to facilitate wayfinding and spatial orientation were identified which include design topology, floor finishing, signposting, and use of color and texture strengthened by meaning, emotional connection to places and cognitively focused intervention via memory cueing and objects-centered recognition.

CONCLUSIONS

Key operational and design guidelines were proposed to assist built environment, care home developers, clinicians and healthcare professionals, and care services providers. There is a need to move toward a dementia-centered design to address the challenges facing people living with dementia in care homes. This should be based on the interrelated behavioral, cognitive, and communication factors.

Factors Influencing Barriers and Facilitators to In-home Video Telehealth for Dementia Management

OBJECTIVES

Quality dementia care, which recognizes caregivers as vital care partners, is a scarce resource. Innovative solutions like video telehealth may increase the reach of extant clinicians; however, little is known about perceived barriers and facilitators to in-home video telehealth for dementia management from the perspectives of caregivers.

METHODS

Twenty-four caregivers of community-dwelling Veterans with dementia participated in semi-structured interviews. Questions gathered perceived facilitators and barriers to in-home video telehealth for dementia management through experience with related technology. Transcripts were analyzed using directed content analysis which was guided by factors previously identified as influencing older adults' adoption of technology.

RESULTS

Caregiver experience with related technology was mostly facilitative to video telehealth, which was thought best suited for follow-up care. Increased access and decreased patient-caregiver stress were potential benefits. Barriers included perceived limitations of video and the belief that persons with dementia would have limited ability to manage technological aspects and to engage in video telehealth on their own.

CONCLUSIONS

This study improves our understanding of the factors that caregivers perceive as barriers and facilitators to in-home video telehealth for dementia management.

CLINICAL IMPLICATIONS

Strategies to optimize video telehealth include capitalizing on caregivers' social network and providing targeted training.

Control Matters in Elder Care Technology:: Evidence and Direction for Designing It In

Studies find that older adults want control over how technologies are used in their care, but how it can be operationalized through design remains to be clarified. We present findings from a large survey (n=825) of a well-characterized U.S. online cohort that provides actionable evidence of the importance of designing for control over monitoring technologies. This uniquely large, age-diverse sample allows us to compare needs across age and other characteristics with insights about future users and current older adults (n=496 >64), including those concerned about their own memory loss (n=201). All five control options, which are not currently enabled, were very or extremely important to most people across age. Findings indicate that comfort with a range of care technologies is contingent on having privacy- and other control-enabling options. We discuss opportunities for design to meet these user needs that demand course correction through attentive, creative work.

User perspectives on emotionally aligned social robots for older adults and persons living with dementia

Introduction

Socially assistive robots are devices designed to aid users through social interaction and companionship. Social robotics promise to support cognitive health and aging in place for older adults with and without dementia, as well as their care partners. However, while new and more advanced social robots are entering the commercial market, there are still major barriers to their adoption, including a lack of emotional alignment between users and their robots. Affect Control Theory (ACT) is a framework that allows for the computational modeling of emotional alignment between two partners.

Methods

We conducted a Canadian online survey capturing attitudes, emotions, and perspectives surrounding pet-like robots among older adults (n = 171), care partners (n = 28), and persons living with dementia (n = 7).

Results

We demonstrate the potential of ACT to model the emotional relationship between older adult users and three exemplar robots. We also capture a rich description of participants’ robot attitudes through the lens of the Technology Acceptance Model, as well as the most important ethical concerns around social robot use.

Conclusions

Findings from this work will support the development of emotionally aligned, user-centered robots for older adults, care partners, and people living with dementia.

Developing practice standards for engaging people living with dementia in product design, testing, and commercialization - a case study

 AbstractTo successfully create assistive technologies for persons with dementia, product developers must understand the capacity of people with dementia to use these technologies. Capacity assessment is typically done through user experience research. However, the published literature is bereft of guidelines to conduct optimal user experience research in samples of persons with dementia.We recruited persons with dementia from community-based organizations and private partners to participate in user experience research for an assistive technology platform. After a testing session, we used semi-structured interviews to ask participants about their involvement in the user experience process. We employed an inductive thematic approach to analyze the interview transcripts and draft guidelines to meaningfully engage persons with dementia in user experience research in the future.Ten participants with mild to moderate dementia (6 females, 4 males) participated in the study. Nine participants had previous experience with mobile devices. Thematic analysis yielded three overarching themes: 1) the techniques, approaches and attributes of the interviewer; 2) participants' views on being part of the user experience research process; and 3) specific items to optimize the research process. Resulting guidelines were divided into recommendations for the interviewer specifically, and for the broader research process.

Emerging topics in dementia care and services

BACKGROUND

The National Institute on Aging (NIA), in conjunction with the Department of Health and Human Services as part of the National Alzheimer's Project Act (NAPA), convened a 2020 Dementia Care, Caregiving, and Services Research Summit Virtual Meeting Series. This review article summarizes three areas of emerging science that are likely to grow in importance given advances in measurement, technologies, and diagnostic tests that were presented at the Summit.

RESULTS

Dr. Cassel discussed novel ethical considerations that have resulted from scientific advances that have enabled early diagnosis of pre-clinical dementia. Dr. Monin then summarized issues regarding emotional experiences in persons with dementia and their caregivers and care partners, including the protective impact of positive emotion and heterogeneity of differences in emotion by dementia type and individual characteristics that affect emotional processes with disease progression. Finally, Dr. Jared Benge provided an overview of the role of technologies in buffering the impact of cognitive change on real-world functioning and their utility in safety and monitoring of function and treatment adherence, facilitating communication and transportation, and increasing access to specialists in underserved or remote areas.

CONCLUSIONS

National policy initiatives, supported by strong advocacy and increased federal investments, have accelerated the pace of scientific inquiry and innovation related to dementia care and services but have raised some new concerns regarding ethics, disparities, and attending to individual needs, capabilities, and preferences.

The Time Is Now: A FASTER Approach to Generate Research Evidence for Technology-Based Interventions in the Field of Disability and Rehabilitation

Current approaches for generating high-quality research evidence for technology-based interventions in the field of disability and rehabilitation are inappropriate. Prevailing approaches often focus on randomized controlled trials as standard and apply clinical trial practices designed for pharmaceuticals; such approaches are unsuitable for technology-based interventions and are counterproductive to the goals of supporting people with disabilities and creating benefits for society. This communication is designed to: (1) advocate for the use of alternative approaches to generating evidence in the development and evaluation of technology-based interventions; (2) propose an alternative framework and guiding principles; and (3) stimulate action by multiple disciplines and sectors to discuss, adopt, and promote alternative approaches. Our Framework for Accelerated and Systematic Technology-based intervention development and Evaluation Research (FASTER) is informed by established innovation design processes, complex intervention development, evaluation, and implementation concepts as well as our collective experiences in technology-based interventions research and clinical rehabilitation practice. FASTER is intended to be meaningful, timely, and practical for researchers, technology developers, clinicians, and others who develop these interventions and seek evidence. We incorporate research methods and designs that better align with creating technology-based interventions and evidence for integration into practice. We propose future activities to improve the generation of research evidence, enable the selection of research methods and designs, and create standards for evidence evaluation to support rigor and applicability for technology-based interventions. With this communication we aim to improve and advance technology-based intervention integration from conception to use, thus responsibly accelerating innovation to have greater positive benefit for people and society.

Realizing the Potential of Robotics for Aged Care Through Co-Creation

Socially assistive robots have the potential to improve aged care by providing assistance through social interaction. While some evidence suggests a positive impact of social robots on measures of well-being, the adoption of robotic technology remains slow. One approach to improve technology adoption is involving all stakeholders in the process of technology development using co-creation methods. To capture relevant stake holders' priorities and perceptions on the ethics of robotic companions, we conducted an interactive co-creation workshop at the 2019 Geriatric Services Conference in Vancouver, BC. The participants were presented with different portrayals of robotic companions in popular culture and answered questions about perceptions, expectations, and ethical concerns about the implementation of robotic technology. Our results reveal that the most pressing ethical concerns with robotic technology, such as issues related to privacy, are critical potential barriers to technology adoption. We also found that most participants agree on the types of tasks that robots should help with, such as domestic chores, communication, and medication reminders. Activities that robots should not help with, according to the stakeholders, included bathing, toileting, and managing finances. The perspectives that were captured contribute to a preliminary outline of the areas of importance for geriatric care stake holders in the process of ethical technology design and development.

The Impact of a Global Pandemic on People Living with Dementia and Their Care Partners: Analysis of 417 Lived Experience Reports

Background:

The COVID-19 pandemic is impacting the physical and emotional health of older adults living with dementia and their care partners.

Objective:

Using a patient-centered approach, we explored the experiences and needs of people living with dementia and their care partners during the COVID-19 pandemic as part of an ongoing evaluation of dementia support services in British Columbia, Canada.

Methods:

A survey instrument was developed around the priorities identified in the context of the COVID-19 and Dementia Task Force convened by the Alzheimer Society of Canada.

Results:

A total of 417 surveys were analyzed. Overall, respondents were able to access information that was helpful for maintaining their own health and managing a period of social distancing. Care partners reported a number of serious concerns, including the inability to visit the person that they care for in long-term or palliative care. Participants also reported that the pandemic increased their levels of stress overall and that they felt lonelier and more isolated than they did before the pandemic. The use of technology was reported as a way to connect socially with their loved ones, with the majority of participants connecting with others at least twice per week.

Conclusion:

Looking at the complex effects of a global pandemic through the experiences of people living with dementia and their care partners is vital to inform healthcare priorities to restore their quality of life and health and better prepare for the future.

A Qualitative Study of the Cognitive Rehabilitation Program GRADIOR for People with Cognitive Impairment: Outcomes of the Focus Group Methodology

In recent years, technology has been implemented in the field of interventions for older adults. GRADIOR 4.5 is a cognitive software within the wide variety of available multimedia programs that support healthcare professionals in cognitive assessment and neuropsychological rehabilitation. The study aimed to evaluate the new version of GRADIOR (v4.5) based on the experience of people with mild cognitive impairment (MCI), people with dementia (PWD), and healthcare professionals. A qualitative study using the focus group methodology was carried out involving 13 people with MCI, 13 PWD, and 11 healthcare professionals. An analysis of the content and the level of feedback was performed. The study showed that GRADIOR 4.5 might be sufficiently adapted to PWD and people with MCI. Participants were motivated to use GRADIOR 4.5, showed high acceptability of the software, and a positive attitude towards technology. However, healthcare professionals suggested significant improvements to the software. GRADIOR 4.5 appeared to be a promising intervention that, because of its positive experience and acceptability, could be systematically implemented to complement cognitive rehabilitation interventions for older adults with MCI and dementia. Finally, it is advisable to consider the suggestions gathered in this study for future developments.

Domain Experts on Dementia-Care Technologies: Mitigating Risk in Design and Implementation

There is an urgent need to learn how to appropriately integrate technologies into dementia care. The aims of this Delphi study were to project which technologies will be most prevalent in dementia care in five years, articulate potential benefits and risks, and identify specific options to mitigate risks. Participants were also asked to identify technologies that are most likely to cause value tensions and thus most warrant a conversation with an older person with mild dementia when families are deciding about their use. Twenty-one interdisciplinary domain experts from academia and industry in aging and technology in the U.S. and Canada participated in a two-round online survey using the Delphi approach with an 84% response rate and no attrition between rounds. Rankings were analyzed using frequency counts and written-in responses were thematically analyzed. Twelve technology categories were identified along with a detailed list of risks and benefits for each. Suggestions to mitigate the most commonly raised risks are categorized as follows: intervene during design, make specific technical choices, build in choice and control, require data transparency, place restrictions on data use and ensure security, enable informed consent, and proactively educate users. This study provides information that is needed to navigate person-centered technology use in dementia care. The specific recommendations participants offered are relevant to designers, clinicians, researchers, ethicists, and policy makers and require proactive engagement from design through implementation.

Immersive virtual reality health games: a narrative review of game design

BACKGROUND

High quality head-mounted display based virtual reality (HMD-VR) has become widely available, spurring greater development of HMD-VR health games. As a behavior change approach, these applications use HMD-VR and game-based formats to support long-term engagement with therapeutic interventions. While the bulk of research to date has primarily focused on the therapeutic efficacy of particular HMD-VR health games, how developers and researchers incorporate best-practices in game design to achieve engaging experiences remains underexplored. This paper presents the findings of a narrative review exploring the trends and future directions of game design for HMD-VR health games.

METHODS

We searched the literature on the intersection between HMD-VR, games, and health in databases including MEDLINE, Embase, CINAHL, PsycINFO, and Compendex. We identified articles describing HMD-VR games designed specifically as health applications from 2015 onwards in English. HMD-VR health games were charted and tabulated according to technology, health context, outcomes, and user engagement in game design.

FINDINGS

We identified 29 HMD-VR health games from 2015 to 2020, with the majority addressing health contexts related to physical exercise, motor rehabilitation, and pain. These games typically involved obstacle-based challenges and extrinsic reward systems to engage clients in interventions related to physical functioning and pain. Less common were games emphasizing narrative experiences and non-physical exercise interventions. However, discourse regarding game design was diverse and often lacked sufficient detail. Game experience was evaluated using primarily ad-hoc questionnaires. User engagement in the development of HMD-VR health games primarily manifested as user studies.

CONCLUSION

HMD-VR health games are promising tools for engaging clients in highly immersive experiences designed to address diverse health contexts. However, more in-depth and structured attention to how HMD-VR health games are designed as game experiences is needed. Future development of HMD-VR health games may also benefit from greater involvement of end-users in participatory approaches.

Are friends electric? The benefits and risks of human-robot relationships

Social robots that can interact and communicate with people are growing in popularity for use at home and in customer-service, education, and healthcare settings. Although growing evidence suggests that co-operative and emotionally aligned social robots could benefit users across the lifespan, controversy continues about the ethical implications of these devices and their potential harms. In this perspective, we explore this balance between benefit and risk through the lens of human-robot relationships. We review the definitions and purposes of social robots, explore their philosophical and psychological status, and relate research on human-human and human-animal relationships to the emerging literature on human-robot relationships. Advocating a relational rather than essentialist view, we consider the balance of benefits and harms that can arise from different types of relationship with social robots and conclude by considering the role of researchers in understanding the ethical and societal impacts of social robotics.

Video-Enhanced Care Management for Medically Complex Older Adults with Cognitive Impairment

OBJECTIVE

This pilot study assessed feasibility of video-enhanced care management for complex older veterans with suspected mild cognitive impairment (CI) and their care partners, compared with telephone delivery.

DESIGN

Pilot randomized controlled trial.

SETTING

Durham Veterans Affairs Health Care System.

PARTICIPANTS

Participants were enrolled as dyads, consisting of veterans aged 65 years or older with complex medical conditions (Care Assessment Need score ≥90) and suspected mild CI (education-adjusted Modified Telephone Interview for Cognitive Status score 20-31) and their care partners.

INTERVENTION

The 12-week care management intervention consisted of monthly calls from a study nurse covering medication management, cardiovascular disease risk reduction, physical activity, and sleep behaviors, delivered via video compared with telephone.

MEASUREMENTS

Dyads completed baseline and follow-up assessments to assess feasibility, acceptability, and usability.

RESULTS

Forty veterans (mean (standard deviation (SD)) age = 72.4 (6.1) years; 100% male; 37.5% Black) and their care partners (mean (SD) age = 64.7 (10.8) years) were enrolled and randomized to telephone or video-enhanced care management. About a third of veteran participants indicated familiarity with relevant technology (regular tablet use and/or experience with videoconferencing); 53.6% of internet users were comfortable or very comfortable using the internet. Overall, 43 (71.7%) care management calls were completed in the video arm and 52 (86.7%) were completed in the telephone arm. Usability of the video telehealth platform was rated higher for participants already familiar with technology used to deliver the intervention (mean (SD) System Usability Scale scores: 65.0 (17.0) vs 55.6 (19.6)). Veterans, care partners, and study nurses reported greater engagement, communication, and interaction in the video arm.

CONCLUSION

Video-delivered care management calls were feasible and preferred over telephone for some complex older adults with mild CI and their care partners. Future research should focus on understanding how to assess and incorporate patient and family preferences related to uptake and maintenance of video telehealth interventions.

Focusing on Emotional and Social Intelligence Stimulation of People With Dementia by Playing a Serious Game—Proof of Concept Study

Context: Dementia is one of the top five chronic diseases, which has an overwhelming impact on patients' life quality, family, and caregivers. Currently, research relating to people with dementia (PwD) focuses on the deterioration of cognitive abilities. A more innovative approach, and the one taken by this paper, is focusing on methods to maintain and improve functionality, communication and quality of life of PwD by building on remaining capacities in the yet unexplored domain of emotional and social intelligence (ESI). The use of serious games for PwD (SG4D) aimed at building social and emotional capacity is a budding field of research.

Objectives: Proof of concept that the, low cost, easy to deploy SG4D, called “My Brain Works” (MBW), co-designed with PwD, enhances ESI, based on the Bar-On ESI model.

Methods: 27 PwD, clients at MELABEV dementia day center, participated in a mixed methods 12 weeks pilot, proof of concept study using a tablet SG4D co-designed with PwD. Quantitative performance data was collected automatically by the tablet during game sessions. In this paper we focus on the analysis of the qualitative and quantitative data related to ESI, observed by 10 different researchers, during each game session.

Results: Quantitative data revealed: both the PwD with high and low MoCA scores had similar average ESI scores. Qualitative analysis revealed that the PwD demonstrated 9 sub-components of the Bar-On ESI Model.

Conclusion: While there is no drug to stop cognitive decline associated with dementia, interventions related to ESI, on the other hand, may improve functioning and quality of life. Despite declines in cognitive abilities, our study shows that a tablet based SG4D can stimulate their ESI and evoke responses in self-awareness, empathy, social and communication capacities. Using SG4D to exercise and maintain social skills is an area that may be promising in the future and may help counter the negative effects of social isolation and loneliness. Such games, while not focusing on cognitive improvement, may also impact on cognitive functioning and help bridge the gap between caregiver and PwD. More research is needed with larger sample sizes.

Remote cognitive and behavioral assessment: Report of the Alzheimer Society of Canada Task Force on dementia care best practices for COVID-19

INTRODUCTION

Despite the urgent need for remote neurobehavioral assessment of individuals with cognitive impairment, guidance is lacking. Our goal is to provide a multi-dimensional framework for remotely assessing cognitive, functional, behavioral, and physical aspects of people with cognitive impairment, along with ethical and technical considerations.

METHODS

Literature review on remote cognitive assessment and multidisciplinary expert opinion from behavioral neurologists, neuropsychiatrists, neuropsychologists, and geriatricians was integrated under the auspices of the Alzheimer Society of Canada Task Force on Dementia Care Best Practices for COVID-19. Telephone and video approaches to assessments were considered.

RESULTS

Remote assessment is shown to be acceptable to patients and caregivers. Informed consent, informant history, and attention to privacy and autonomy are paramount. A range of screening and domain-specific instruments are available for telephone or video assessment of cognition, function, and behavior. Some neuropsychological tests administered by videoconferencing show good agreement with in-person assessment but still lack validation and norms. Aspects of the remote dementia-focused neurological examination can be performed reliably.

DISCUSSION

Despite challenges, current literature and practice support implementation of telemedicine assessments for patients with cognitive impairment. Convergence of data across the clinical interview, reliable and brief remote cognitive tests, and remote neurological exam increase confidence in clinical interpretation and diagnosis.

Clinical Information Systems - Seen through the Ethics Lens

OBJECTIVE

The more people there are who use clinical information systems (CIS) beyond their traditional intramural confines, the more promising the benefits are, and the more daunting the risks will be. This review thus explores the areas of ethical debates prompted by CIS conceptualized as smart systems reaching out to patients and citizens. Furthermore, it investigates the ethical competencies and education needed to use these systems appropriately.

METHODS

A literature review covering ethics topics in combination with clinical and health information systems, clinical decision support, health information exchange, and various mobile devices and media was performed searching the MEDLINE database for articles from 2016 to 2019 with a focus on 2018 and 2019. A second search combined these keywords with education.

RESULTS

By far, most of the discourses were dominated by privacy, confidentiality, and informed consent issues. Intertwined with confidentiality and clear boundaries, the provider-patient relationship has gained much attention. The opacity of algorithms and the lack of explicability of the results pose a further challenge. The necessity of sociotechnical ethics education was underpinned in many studies including advocating education for providers and patients alike. However, only a few publications expanded on ethical competencies. In the publications found, empirical research designs were employed to capture the stakeholders' attitudes, but not to evaluate specific implementations.

CONCLUSION

Despite the broad discourses, ethical values have not yet found their firm place in empirically rigorous health technology evaluation studies. Similarly, sociotechnical ethics competencies obviously need detailed specifications. These two gaps set the stage for further research at the junction of clinical information systems and ethics.

Assistive technology designed to support self-management of people with dementia: user involvement, dissemination, and adoption. A scoping review

BACKGROUND

Assistive technology is advocated as a key solution to the need for support among people living with dementia. There is growing awareness of the benefits of user involvement in the design and test of these technologies and the need to identifying applicable and effective methods for implementation. The aim of this review was to explore and synthesize research addressing assistive technology designed to be used by people with dementia for self-management. Further research aims were to explore if and how user involvement, dissemination, and adoption of assistive technology were addressed.

METHOD

Electronic databases were searched using specified search terms. Key publications and grey literature sources were hand-searched. Materials published until year end 2018 were included. The results were summarized according to the research aims.

RESULTS

Eleven papers derived from eight studies were included. The studies presented data from prototype design and testing, and the review showed great variation in study scope, design, and methodology. User involvement varied from extensive involvement to no user involvement. Methods for adoption also varied widely and only targeted prototype testing. None of the studies addressed dissemination.

CONCLUSION

The results of this review underline the need for well-designed high-quality research into all the aspects that are essential to deliver applicable, effective, and sustainable assistive technology to support self-management of people with dementia. There is a need for evidence-based methods to promote and qualify user involvement, dissemination, and adoption. The results also point to the need for standardized outcome measures and standards for conducting and reporting research to improve its quality and impact.

Addressing the Ethics of Telepresence Applications Through End-User Engagement

Portacolone et al.'s Ethics Review highlights the ethical challenges associated with the implementation of telepresence devices and applications in the context of aging and dementia. In this response, we review ethical considerations as they relate to specific modalities of telepresence, with an emphasis on the continuum of potential interaction agents, from known individuals to fully automated and intelligent interlocutors. We further discuss areas in need of empirical evidence to inform regulatory efforts in telepresence. We close with a call for meaningful end-user engagement at all stages of technology development.

Evaluation Tools for Assistive Technologies: A Scoping Review

OBJECTIVE

Assistive technologies (ATs) support independence and well-being in people with cognitive, perceptual, and physical limitations. Given the increasing availability and diversity of ATs, evaluating the usefulness of current and emerging ATs is crucial for informed comparison. We aimed to chart the landscape and development of AT evaluation tools (ETs; ATETs) across disparate fields in order to improve the process of AT evaluation and development.

DATA SOURCES

We performed a scoping review of ATETs through database searching of MEDLINE, Embase, CINAHL, HaPI, PsycINFO, Cochrane Reviews, and Compendex as well as citation mining.

STUDY SELECTION

Articles explicitly referencing ATETs were retained for screening. We included ETs if they were designed to specifically evaluate ATs.

DATA EXTRACTION

We extracted 5 attributes of ATETs: AT category, construct evaluated, conceptual frameworks, type of end user input used for ATET development, and presence of validity testing.

DATA SYNTHESIS

From screening 23,434 records, we included 159 ATETs. Specificity of tools ranged from single to general ATs across 40 AT categories. Satisfaction, functional performance, and usage were the most common constructs of 103 identified. We identified 34 conceptual frameworks across 53 ETs. Finally, 36% incorporated end user input and 80% showed validation testing.

CONCLUSIONS

We characterized a wide range of AT categories with diverse approaches to their evaluation based on varied conceptual frameworks. Combining these frameworks in future ATETs may provide more holistic views of AT usefulness. ATET selection may be improved with guidelines for conceptually reconciling results of disparate ATETs. Future ATET development may benefit from more integrated approaches to end user engagement.

Shaping technologies for older adults with and without dementia: Reflections on ethics and preferences

As a result of several years of European funding, progressive introduction of assistive technologies in our society has provided many researchers and companies with opportunities to develop new information and communication technologies aimed at overcoming the digital divide of those at a greater risk of being left behind, as can be the case with healthy older people and those developing cognitive decline and dementia. Moreover, in recent years, when considering how information and communication technologies have been integrated into older people's lives, and how technology has influenced these individuals, doubts remain regarding whether technologies really fulfil older users' needs and wishes and whether technologies developed specifically for older users necessarily protect and consider main ethical values. In this article, we address the relevance of privacy, vulnerability and preservation of autonomy as key factors when involving older individuals as target users for information and communication technology research and development. We provide explanatory examples on ethical issues involved in the particular case of developing different types of information and communication technology for older people (from robotics to serious games), what previously performed research tells us about older adults' preferences and wishes for information and communication technology and what steps should be taken into consideration in the near future.

Ethical Issues Raised by the Introduction of Artificial Companions to Older Adults with Cognitive Impairment: A Call for Interdisciplinary Collaborations

Due to the high costs of providing long-term care to older adults with cognitive impairment, artificial companions are increasingly considered as a cost-efficient way to provide support. Artificial companions can comfort, entertain, and inform, and even induce a sense of being in a close relationship. Sensors and algorithms are increasingly leading to applications that exude a life-like feel. We focus on a case study of an artificial companion for people with cognitive impairment. This companion is an avatar on an electronic tablet that is displayed as a dog or a cat. Whereas artificial intelligence guides most artificial companions, this application also relies on technicians "behind" the on-screen avatar, who via surveillance, interact with users. This case is notable because it particularly illustrates the tension between the endless opportunities offered by technology and the ethical issues stemming from limited regulations. Reviewing the case through the lens of biomedical ethics, concerns of deception, monitoring and tracking, as well as informed consent and social isolation are raised by the introduction of this technology to users with cognitive impairment. We provide a detailed description of the case, review the main ethical issues and present two theoretical frameworks, the "human-driven technology" platform and the emancipatory gerontology framework, to inform the design of future applications.

Ethical concerns with the use of intelligent assistive technology: findings from a qualitative study with professional stakeholders

Background

Advances in artificial intelligence (AI), robotics and wearable computing are creating novel technological opportunities for mitigating the global burden of population ageing and improving the quality of care for older adults with dementia and/or age-related disability. Intelligent assistive technology (IAT) is the umbrella term defining this ever-evolving spectrum of intelligent applications for the older and disabled population. However, the implementation of IATs has been observed to be sub-optimal due to a number of barriers in the translation of novel applications from the designing labs to the bedside. Furthermore, since these technologies are designed to be used by vulnerable individuals with age- and multi-morbidity-related frailty and cognitive disability, they are perceived to raise important ethical challenges, especially when they involve machine intelligence, collect sensitive data or operate in close proximity to the human body. Thus, the goal of this paper is to explore and assess the ethical issues that professional stakeholders perceive in the development and use of IATs in elderly and dementia care.

Methods

We conducted a multi-site study involving semi-structured qualitative interviews with researchers and health professionals. We analyzed the interview data using a descriptive thematic analysis to inductively explore relevant ethical challenges.

Results

Our findings indicate that professional stakeholders find issues of patient autonomy and informed consent, quality of data management, distributive justice and human contact as ethical priorities. Divergences emerged in relation to how these ethical issues are interpreted, how conflicts between different ethical principles are resolved and what solutions should be implemented to overcome current challenges.

Conclusions

Our findings indicate a general agreement among professional stakeholders on the ethical promises and challenges raised by the use of IATs among older and disabled users. Yet, notable divergences persist regarding how these ethical challenges can be overcome and what strategies should be implemented for the safe and effective implementation of IATs. These findings provide technology developers with useful information about unmet ethical needs. Study results may guide policy makers with firsthand information from relevant stakeholders about possible solutions for ethically-aligned technology governance.

Smartphone technology for fostering goal-directed ambulation and object use in people with moderate Alzheimer's disease

Purpose: This study was aimed at assessing a smartphone-based intervention to help 11 individuals with moderate Alzheimer's disease and ambulation problems to manage goal-directed, walker-assisted ambulation and object use (i.e., to reach specific destinations and put away objects at those destinations independently).Method: The study was carried out according to a non-concurrent multiple baseline design across participants. Two measures were recorded, that is, the number of target responses performed correctly (with each target response consisting of reaching a destination and putting away an object), and the number of observation intervals with indices of enjoyment/appreciation (e.g., smiles and positive comments). During baseline, the participants were provided with a walker and three objects that were to be transported to and put away at specific destinations. During the intervention, the participants also had the smartphone-based technology that provided them with instructions about the destinations and objects, praise, and preferred stimulation.Results: During baseline, the mean frequency of correct target responses was virtually zero. The mean frequency of intervals with indices of enjoyment/appreciation ranged from zero to close to one. During the intervention, the mean frequencies for the two measures were slightly below three and just over three, respectively. The maximum frequencies possible were three and four, respectively.Conclusions: A smartphone-based intervention may be suitable to foster goal-directed, walker-assisted ambulation and object use as well as enjoyment/appreciation in participants like those involved in this study.IMPLICATIONS FOR REHABILITATIONA smartphone-based intervention may be used to promote goal-directed, walker-assisted ambulation and object use as well as indices of enjoyment/appreciation in persons with moderate Alzheimer disease.The technology for such intervention might involve (a) a smartphone with Android operating system, light sensor, Bluetooth v4.0, and MacroDroid, (b) Bluetooth headphones or earpieces, and (c) battery-powered light sources.The technology may provide the participants with instructions about the destinations to reach and the objects to put away at those destinations, and with praise and brief periods of preferred stimulation at the target destinations.The technology may be considered easy to access, friendly for the participants, and suitable for use by staff within daily contexts.

Technology and Dementia: The Future is Now

BACKGROUND

Technology has multiple potential applications to dementia from diagnosis and assessment to care delivery and supporting ageing in place.

OBJECTIVES

To summarise key areas of technology development in dementia and identify future directions and implications.

METHOD

Members of the US Alzheimer's Association Technology Professional Interest Area involved in delivering the annual pre-conference summarised existing knowledge on current and future technology developments in dementia.

RESULTS

The main domains of technology development are as follows: (i) diagnosis, assessment and monitoring, (ii) maintenance of functioning, (iii) leisure and activity, (iv) caregiving and management.

CONCLUSIONS

The pace of technology development requires urgent policy, funding and practice change, away from a narrow medical approach, to a holistic model that facilitates future risk reduction and prevention strategies, enables earlier detection and supports implementation at scale for a meaningful and fulfilling life with dementia.

Why Older Adults and Their Children Disagree About In-Home Surveillance Technology, Sensors, and Tracking

Background and Objectives

Despite the surveilling nature of technologies that allow caregivers to remotely monitor location, movements, or activities, the potential differences in comfort with remote monitoring between caregivers and care recipients have not been examined in depth. On the dyad and aggregate level, we compare preferences of older adult women and their adult children for three remote monitoring technologies. Their assessments of each technology’s impact on privacy, safety, independence, freedom, relationship with family member, social life, and identity are also compared.

Research Design and Methods

This dyadic study used cognitive-based interview probing and value-centered design methods. Twenty-eight individual, in-depth, structured interviews were conducted with 18 women who are Meals on Wheels clients and 10 of their adult children.

Results

Meals on Wheels participants reported multiple chronic conditions and an average of 1.7 ADL and 3.3 IADL difficulties; two thirds were enrolled in Medicaid. Adult children preferred each technology more than their mothers did and underestimated both their mothers’ ability to comprehend the functions of the technologies and the importance of engaging them fully in decision making. Most were confident that they could persuade their mothers to adopt. For both groups, privacy was the most-cited concern, and participants perceived significant overlap between values of privacy, independence, identity, and freedom.

Discussion and Implications

Studying privacy in isolation overlooks privacy’s instrumental role in enabling other values. Shared decision-making tools are needed to promote remote monitoring use consistent with older adults’ values and to prevent conflict and caregiver overreach.

User experience and clinical effectiveness with two wearable global positioning system devices in home dementia care

INTRODUCTION

The user experience and clinical effectiveness with wearable global positioning system (GPS) devices for persons with dementia (PwDs) and caregivers (CGs) remain unclear although many are available.

METHODS

Using a crossover design, 20 dyads tested two similar commercial GPS watches (products A and B) at home for 4 weeks each. Usability, product functions, design features and product satisfaction at home and the clinic were investigated. Caregiver burden and quality of life assessed clinical effectiveness.

RESULTS

The final 17 dyads rated the usability, telephone function, overall design features, font, buttons, and battery life of B significantly better than A. PwDs rated the overall design features and buttons of A significantly better than CGs. Product satisfaction with both products was significantly lower at home. Clinical effectiveness was not found.

DISCUSSION

User experience can be improved by optimizing specific product details. This might translate to clinical effectiveness. Social desirability bias may explain different product satisfaction ratings.