Who should make the decision on the use of GPS for people with dementia?

Personalized Technological Support for Informal Caregivers of Older People with Dementia: A Co-Design Approach Involving Potential End Users and Healthcare Professionals in Three Focus Groups in Italy

Informal/family caregivers (ICs) of older people with dementia (PwD) can suffer from depression and burnout. However, digital solutions can potentially provide innovative ways to facilitate care provision. The aim of this study was to analyze the opinions of end users (EUs), i.e., PwD aged 65 years and over and their ICs and healthcare professionals (HPs), on the use of digital technology to support care activities. Qualitative data were collected during the co-design phase of the European project "DemiCare-Personalized support for informal caregivers of people with dementia". This study focused on the Italian context and included two PwD, three ICs, and seven HPs. Three focus groups were held in April-June 2022. Qualitative data were analyzed using MaxQDA 2020 software. Seven thematic areas were identified: daily activities, care tasks, information needs, support received, relationship with and expectations from technology, functionality of the DemiCare integrated system, and ethical issues. Smart devices seemed to be received positively by ICs and HPs, although older PwD seemed to have difficulty accepting the technology. Overall, despite the low number of participants, it seems important and potentially effective to consider the needs and preferences of PwD during exploratory co-design to allow social interactions with them. This study was not registered.

Mobile Safety Alarms Based on GPS Technology in the Care of Older Adults: Systematic Review of Evidence Based on a General Evidence Framework for Digital Health Technologies

Background

GPS alarms aim to support users in independent activities. Previous systematic reviews have reported a lack of clear evidence of the effectiveness of GPS alarms for the health and welfare of users and their families and for social care provision. As GPS devices are currently being implemented in social care, it is important to investigate whether the evidence of their clinical effectiveness remains insufficient. Standardized evidence frameworks have been developed to ensure that new technologies are clinically effective and offer economic value. The frameworks for analyzing existing evidence of the clinical effectiveness of GPS devices can be used to identify the risks associated with their implementation and demonstrate key aspects of successful piloting or implementation.

Objective

The principal aim of this study is to provide an up-to-date systematic review of evidence based on existing studies of the effects of GPS alarms on health, welfare, and social provision in the care of older adults compared with non–GPS-based standard care. In addition, the study findings were assessed by using the evidence standards framework for digital health technologies (DHTs) established by the National Institute for Health and Care Excellence (NICE) in the United Kingdom.

Methods

This review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Primary studies published in peer-reviewed journals and gray literature from January 2005 to August 2020 were identified through searches in 13 databases and several sources of gray literature. Included studies had individuals (aged ≥50 years) who were receiving social care for older adults or for persons with dementia; used GPS devices as an intervention; were performed in Canada, the United States, European Union, Singapore, Australia, New Zealand, Hong Kong, South Korea, or Japan; and addressed quantitative outcomes related to health, welfare, and social care. The study findings were analyzed by using the NICE framework requirements for active monitoring DHTs.

Results

Of the screened records, 1.6% (16/986) were included. Following the standards of the NICE framework, practice evidence was identified for the tier 1 categories Relevance to current pathways in health/social care system and Acceptability with users, and minimum evidence was identified for the tier 1 category Credibility with health, social care professionals. However, several evidence categories for tiers 1 and 2 could not be assessed, and no clear evidence demonstrating effectiveness could be identified. Thus, the evidence required for using DHTs to track patient location according to the NICE framework was insufficient.

Conclusions

Evidence of the beneficial effects of GPS alarms on the health and welfare of older adults and social care provision remains insufficient. This review illustrated the application of the NICE framework in analyses of evidence, demonstrated successful piloting and acceptability with users of GPS devices, and identified implications for future research.

Electronic tracking devices in dementia care: A systematic review of argument-based ethics literature

BACKGROUND

Wandering is a behavioral symptom of dementia that often results in patients eloping from home or care facilities, leading to high-risk situations for injury or death. To mitigate this serious problem, caregivers use electronic tracking devices (ETDs) to manage wandering. As these devices can track, record, and monitor wearers, profound ethical questions are raised related to their use in this vulnerable population. The objective of this review was to identify the ethical frames, concepts, and arguments used in the normative literature that focused on ETDs in dementia care.

METHODS

We conducted a systematic literature review of normative literature that focused on ETDs in dementia care.

RESULTS

Twenty-two articles met the inclusion requirements. The majority of articles utilized a principlist approach, with arguments concerning ETDs largely falling under the four principles of biomedical ethics: respect for autonomy, non-maleficence, beneficence, and justice. Privacy and informed consent were specifically emphasized. The normative literature recognizes that ETDs may have a dual effect, potentially bolstering or eroding the values connected to each principle.

CONCLUSIONS

The prevailing use of principlism in the normative literature on ETDs indicates that there is a need to pursue new ethical approaches and expand upon the few non-principlist approaches already in use. In addition, many of the ethical issues around ETD use involve value-laden questions present during their design. Therefore, future ethical orientations or frameworks should account for ethical questions that exist along the design continuum on the use of ETDs.

Perspectives of Stakeholders on Technology Use in the Care of Community-Living Older Adults with Dementia: A Systematic Literature Review

Although technology has the potential to promote aging in place, the use of technology remains scarce among community-living older adults with dementia. A reason might be that many stakeholders are involved who all have a different perspective on technology use (i.e., needs, wishes, attitudes, possibilities, and difficulties). We systematically searched the literature in order to provide an overview of perspectives of different stakeholders on technology use among community-living older adults with dementia. After selection, 46 studies were included. We mainly found perspectives of informal caregivers and, to a lesser extent, of persons with dementia and formal caregivers. Perspectives of suppliers of technology were not present. Shared perspectives among persons with dementia and informal and formal caregivers were, among other things, ease of use, stability and flexibility of technology, importance of privacy, and confidentiality. We also found that among older persons, fun and pleasure, in addition to enhancing freedom and independence, facilitates technology use. Informal caregivers' peace of mind and relief of burden also appeared to be important in using technologies. Formal caregivers value the potential of technologies to improve monitoring and communication. Insight in shared, and conflicting perspectives of stakeholders are essential to enhance the use of technology.

Ethical issues related to the use of gerontechnology in older people care: A scoping review

BACKGROUND

Demographic trends indicate growth of population aged 65 and older in Western countries. One of the greatest challenges is to provide high-quality care for all. Technological solutions designed for older people, gerontechnology, can somewhat balance the gap between resources and the increasing demand of healthcare services. However, there are also ethical issues in the use of gerontechnology that need to be pointed out.

PURPOSE

To describe what ethical issues are related to the use of gerontechnology in the care of community-dwelling older people.

METHODS

A scoping review was performed to identify and analyse studies concerning ethical issues when using gerontechnology in the home care of older people. The literature search was limited to studies published after 1990 and addressed to the electronic databases CINAHL, PubMed, Cochrane, Medic, IEEE Explore and Web of Science. The search was performed in July-August 2018. Data from empirical studies were analysed using thematic analysis.

ETHICAL CONSIDERATIONS

This scoping review was conducted in accordance with good scientific practice. The work of other researchers was respected and cited appropriately.

RESULTS

A total of 17 studies were identified. Two main themes were found. 'Balancing between the benefits of using gerontechnology and the basic rights of older people', consisted of the subthemes safety, privacy and autonomy. The other main theme, 'Gerontechnology as a risk of insecurity for older people', included the subthemes fear of losing human contact and concern and fear. Surveillance and monitoring technologies were mainly studied.

CONCLUSION

These results suggest that there may be ethical issues related to the use of gerontechnology and they must therefore be taken into consideration when implementing technology in the care of community-dwelling older people.

Factors Influencing the Adoption of Smart Health Technologies for People With Dementia and Their Informal Caregivers: Scoping Review and Design Framework

Background

Smart Health technologies (s-Health technologies) are being developed to support people with dementia (PwD) and their informal caregivers at home, to improve care and reduce the levels of burden and stress they experience. However, although s-Health technologies have the potential to facilitate this, the factors influencing a successful implementation in this population are still unknown.

Objective

The aim of this study was to review existing literature to explore the factors influencing PwD and their informal caregivers’ adoption of s-Health technologies for home care.

Methods

Following the Arksey and O’Malley methodology, this study is a scoping review providing a narrative description of the scientific literature on factors influencing s-Health technology adoption for PwD and their informal caregivers. A search was conducted using PubMed, the Cochrane library, the IEEE library, and Scopus. Publications screening was conducted by 2 researchers based on inclusion criteria, and full-text analysis was then conducted by 1 researcher. The included articles were thematically analyzed by 2 researchers to gain an insight into factors influencing adoption that PwD and their informal caregivers have to encounter when using s-Health technologies. Relevant information was identified and coded. Codes were later discussed between the researchers for developing and modifying them and for achieving a consensus, and the researchers organized the codes into broader themes.

Results

Emerging themes were built in a way that said something specific and meaningful about the research question, creating a list of factors influencing the adoption of s-Health technologies for PwD and their informal caregivers, including attitudinal aspects, ethical issues, technology-related challenges, condition-related challenges, and identified gaps. A design framework was created as a guide for future research and innovation in the area of s-Health technologies for PwD and their informal caregivers: DemDesCon for s-Health Technologies. DemDesCon for s-Health Technologies addresses 4 domains to consider for the design and development of s-Health technologies for this population: cognitive decline domain, physical decline domain, social domain, and development domain.

Conclusions

Although s-Health technologies have been used in health care scenarios, more work is needed for them to fully achieve their potential for use in dementia care. Researchers, businesses, and public governments need to collaborate to design and implement effective technology solutions for PwD and their informal caregivers, but the lack of clear design guidelines seems to be slowing the process. We believe that the DemDesCon framework will provide them with the guidance and assistance needed for creating meaningful devices for PwD home care and informal caregivers, filling a much-needed space in the present knowledge gap.

What do we know about technologies for dementia-related wandering? A scoping review: Examen de la portée : Que savons-nous à propos des technologies de gestion de l'errance liée à la démence?

BACKGROUND

Occupational therapists use technologies to manage wandering-related risks to promote safety and independence among individuals with dementia living in the community.

PURPOSE

The purpose of this review was to examine types of technologies used to manage wandering behaviour.

METHOD

Using a modification of Arksey and O'Malley's methodology, we systematically searched peer-reviewed and grey literature on technologies used in home or supportive care environments for persons with dementia at risk for wandering. Data from the studies were analyzed descriptively.

FINDINGS

The literature described 83 technologies. Nineteen devices were clinically tested. Interventions ranged from alarm products to mobile locator devices. Benefits included reductions in risk and caregiver burden.

IMPLICATIONS

Occupational therapy strategies include technologies to enhance function in persons with dementia. Technologies can also reduce risks of wandering and should be affordable. Ethical issues of the use of technology must be addressed. More research is needed to increase levels of evidence.

How to respond to resistiveness towards assistive technologies among persons with dementia

It is a common experience among care professionals that persons with dementia often say 'no' to conventional caring measures such as taking medication, eating or having a shower. This tendency to say 'no' may also concern the use of assistive technologies such as fall detectors, mobile safety alarms, Internet for social contact and robots. This paper provides practical recommendations for care professionals in home health care and social care about how to respond to such resistiveness towards assistive technologies. Apart from the option of accepting the 'no', it discusses a number of methods for influencing persons with dementia in order to overcome the 'no'. These methods range from various non-coercive measures-including nudging-to coercion. It is argued that while conventional caring measures like those mentioned are essential for survival, health or hygiene, assistive technologies are commonly merely potentially beneficial supplements. With this in mind, it is concluded that care professionals should be more restrictive in using methods of influence involving some degree of pressure regarding assistive technologies than regarding conventional caring measures.

Assistive technologies for people with dementia: ethical considerations

The sustainable development goals (SDGs) adopted by the United Nations in 2015 include a new target for global health: SDG 3 aims to “ensure healthy lives and promote well-being for all at all ages.” Dementia care of good quality is particularly important given the projected increase in the number of people living with the condition. A range of assistive technologies have been proposed to support dementia care. However, the World Health Organization estimated in 2017 that only one in 10 of the 1 billion or more people globally who could benefit from these technologies in some way actually has access to them. For people living with dementia, there has been little analysis of whether assistive technologies will support their human rights in ways that are consistent with the United Nations Convention on the Rights of Persons with Disabilities. The aim of this paper is to examine the relevant provisions of the convention and consider their implications for the use of assistive technologies in dementia care. Assistive technologies can clearly play an important role in supporting social engagement, decision-making and advance planning by people living with dementia. However, concerns exist that some of these technologies also have the potential to restrict freedom of movement and intrude into privacy. In conclusion, an analysis of the implications of assistive technologies for human rights laws is needed to ensure that technologies are used in ways that support human rights and help meet the health-related SDG 3.

Technologies to Support Community-Dwelling Persons With Dementia: A Position Paper on Issues Regarding Development, Usability, Effectiveness and Cost-Effectiveness, Deployment, and Ethics

BACKGROUND

With the expected increase in the numbers of persons with dementia, providing timely, adequate, and affordable care and support is challenging. Assistive and health technologies may be a valuable contribution in dementia care, but new challenges may emerge.

OBJECTIVE

The aim of our study was to review the state of the art of technologies for persons with dementia regarding issues on development, usability, effectiveness and cost-effectiveness, deployment, and ethics in 3 fields of application of technologies: (1) support with managing everyday life, (2) support with participating in pleasurable and meaningful activities, and (3) support with dementia health and social care provision. The study also aimed to identify gaps in the evidence and challenges for future research.

METHODS

Reviews of literature and expert opinions were used in our study. Literature searches were conducted on usability, effectiveness and cost-effectiveness, and ethics using PubMed, Embase, CINAHL, and PsycINFO databases with no time limit. Selection criteria in our selected technology fields were reviews in English for community-dwelling persons with dementia. Regarding deployment issues, searches were done in Health Technology Assessment databases.

RESULTS

According to our results, persons with dementia want to be included in the development of technologies; there is little research on the usability of assistive technologies; various benefits are reported but are mainly based on low-quality studies; barriers to deployment of technologies in dementia care were identified, and ethical issues were raised by researchers but often not studied. Many challenges remain such as including the target group more often in development, performing more high-quality studies on usability and effectiveness and cost-effectiveness, creating and having access to high-quality datasets on existing technologies to enable adequate deployment of technologies in dementia care, and ensuring that ethical issues are considered an important topic for researchers to include in their evaluation of assistive technologies.

CONCLUSIONS

Based on these findings, various actions are recommended for development, usability, effectiveness and cost-effectiveness, deployment, and ethics of assistive and health technologies across Europe. These include avoiding replication of technology development that is unhelpful or ineffective and focusing on how technologies succeed in addressing individual needs of persons with dementia. Furthermore, it is suggested to include these recommendations in national and international calls for funding and assistive technology research programs. Finally, practitioners, policy makers, care insurers, and care providers should work together with technology enterprises and researchers to prepare strategies for the implementation of assistive technologies in different care settings. This may help future generations of persons with dementia to utilize available and affordable technologies and, ultimately, to benefit from them.

Using diffusion of innovation theory to describe perceptions of a passive positioning alarm among persons with mild dementia: a repeated interview study

BACKGROUND

Problems with memory and decline in cognitive abilities are common during development of dementia. Different kinds of technologies may be useful in supporting persons with dementia and their relatives in daily life. Tracking technologies have the potential to improve independence among persons with dementia. Consequently, the aim of the present study was to describe perceptions of a passive positioning alarm (PPA) among persons with mild dementia.

METHODS

A repeated interview study was conducted in Sweden with a strategic sample of 11 persons with mild dementia. Roger's Diffusion of Innovation Theory was used to deductively analyse the data.

RESULTS

Regarding the advantages of the PPA, participants described perceived safety and security for, both themselves, and their relatives, as well as freedom and independence. However, they also expressed concern about the cost of the PPA, reflected on who might be the receiver of the alarm from the PPA, emphasized the importance of opportunities to test the device before becoming a user and early introduction before their problems start, thus allowing them to decide for themselves.

CONCLUSIONS

Supporting persons with dementia in their own homes using, e.g., a PPA may enable them and their relatives to remain longer in their own homes and be safer in their own neighbourhoods.

A systematic review of barriers and facilitators to and interventions for proxy decision-making by family carers of people with dementia

BACKGROUND

Relatives of people with dementia report that proxy decision-making is difficult and distressing. We systematically reviewed the literature about barriers and facilitators to family carers of people with dementia making proxy decisions, and interventions used to facilitate their decision-making.

METHODS

We searched electronic databases and references of included papers up to February 2014. Two authors independently evaluated study quality using a checklist.

RESULTS

We included the 30/104 papers from our search which fitted predetermined criteria and prioritized higher quality papers. Family carers report that proxy decision-making is challenging and can be distressing, especially when decisions are made against the wishes of the care recipient and support from healthcare professionals is lacking. Decision-specific manualized aids have been developed, and while results for those supporting decisions about respite and percutaneous endoscopic gastrostomy (PEG) feeding have shown promising results in pilot trials, no intervention has yet been shown to significantly reduce decisional conflict or carer burden, or increase knowledge in randomized controlled trials; a decision aid for advance care planning increased decisional conflict.

CONCLUSIONS

We recommend development and testing of decision aids targeting the decisions carers report finding most distressing, including those around where people should live, accessing services, and end of life treatments. Being provided with information to make decisions which have not previously been considered may increase feelings of conflict, suggesting these aids should be carefully targeted.

Emerging roles for telemedicine and smart technologies in dementia care

Demographic aging of the world population contributes to an increase in the number of persons diagnosed with dementia (PWD), with corresponding increases in health care expenditures. In addition, fewer family members are available to care for these individuals. Most care for PWD occurs in the home, and family members caring for PWD frequently suffer negative outcomes related to the stress and burden of observing their loved one’s progressive memory and functional decline. Decreases in cognition and self-care also necessitate that the caregiver takes on new roles and responsibilities in care provision. Smart technologies are being developed to support family caregivers of PWD in a variety of ways, including provision of information and support resources online, wayfinding technology to support independent mobility of the PWD, monitoring systems to alert caregivers to changes in the PWD and their environment, navigation devices to track PWD experiencing wandering, and telemedicine and e-health services linking caregivers and PWD with health care providers. This paper will review current uses of these advancing technologies to support care of PWD. Challenges unique to widespread acceptance of technology will be addressed and future directions explored.

Effects of tracking technology on daily life of persons with dementia: three experimental single-case studies

OBJECTIVES

To investigate the effects of using tracking technology on independent outdoor activities and psychological well-being in 3 persons with dementia (PwDs) and their spouses.

METHODS

Three experimental single-case studies with an A1B1A2B2 design. The intervention entailed access to a passive positioning alarm and technical support. Continual daily measures of independent outdoor activities among PwDs' and spouses' worries about these activities were made during all phases.

RESULTS

Access to a tracking technology consistently increased the independent outdoor activities of 2 PwDs. One of the spouses consistently reported decreased worry during B phases, another's worry decreased only in B2, and the third showed little variability in worrying across all phases.

CONCLUSION

Tracking technology may support PwDs to engage in independent outdoor activities and decrease spouses' worries; however, randomized controlled group studies are needed to investigate whether these results can be replicated on a group level.

Applicability of global positioning system for the assessment of walking ability in patients with arterial claudication

OBJECTIVE

This study determined for the first time the clinical applicability of a global positioning system (GPS)-monitored community-based walking ability assessment in a large cohort of patients with peripheral artery disease (PAD).

METHODS

A multicenter study was conducted among PAD patients who complained of intermittent claudication. Patients equipped with a GPS device performed a community-based outdoor walk. We determined the number of technically satisfactory GPS recordings (attempt No. 1). Patients with unsatisfactory GPS recordings were asked to perform a second attempt (attempt No. 2). From the satisfactory recordings obtained after attempts No. 1 and No. 2, we analyzed several GPS parameters to provide clinical information on the patients' walking ability. Results are reported as median (interquartile range).

RESULTS

A total of 218 patients performed an outdoor walk. GPS recordings were technically satisfactory in 185 patients (85%) and in 203 (93%) after attempts No. 1 and No. 2, respectively. The highest measured distance between two stops during community walking was 678 m (IQR, 381-1333 m), whereas self-reported maximal walking distance was 250 m (IQR, 150-400 m; P < .001). Walking speed was 3.6 km/h (IQR, 3.1-3.9 km/h), with few variations during the walk. Among the patients who had to stop during the walk, the stop durations were <10 minutes in all but one individual.

CONCLUSIONS

GPS is applicable for the nonsupervised multicenter recording of walking ability in the community. In the future, it may facilitate objective community-based assessment of walking ability, allow for the adequate monitoring of home-based walking programs, and for the study of new dimensions of walking in PAD patients with intermittent claudication.

The full spectrum of ethical issues in dementia care: systematic qualitative review

BACKGROUND

Integrating ethical issues in dementia-specific training material, clinical guidelines and national strategy plans requires an unbiased awareness of all the relevant ethical issues.

AIMS

To determine systematically and transparently the full spectrum of ethical issues in clinical dementia care.

METHOD

We conducted a systematic review in Medline (restricted to English and German literature published between 2000 and 2011) and Google books (with no restrictions). We applied qualitative text analysis and normative analysis to categorise the spectrum of ethical issues in clinical dementia care.

RESULTS

The literature review retrieved 92 references that together mentioned a spectrum of 56 ethical issues in clinical dementia care. The spectrum was structured into seven major categories that consist of first- and second-order categories for ethical issues.

CONCLUSIONS

The systematically derived spectrum of ethical issues in clinical dementia care presented in this paper can be used as training material for healthcare professionals, students and the public for raising awareness and understanding of the complexity of ethical issues in dementia care. It can also be used to identify ethical issues that should be addressed in dementia-specific training programmes, national strategy plans and clinical practice guidelines. Further research should evaluate whether this new genre of systematic reviews can be applied to the identification of ethical issues in other cognitive and somatic diseases. Also, the practical challenges in addressing ethical issues in training material, guidelines and policies need to be evaluated.

A pilot study on the use of tracking technology: feasibility, acceptability, and benefits for people in early stages of dementia and their informal caregivers

OBJECTIVES

Caregivers and clinicians may be confronted with the dilemma whether to allow people in early stages of dementia to go outside independently with the risk of getting lost, or to limit their autonomy and mobility. Newly available technology may offer a solution. This pilot study is focused on the feasibility, acceptability, and effectiveness of a three-month use of Global Positioning System (GPS) by care receivers and caregivers.

METHOD

Numbers and percentages of participants with positive responses to self-report questions were calculated. Differences between the pre- and post-test scores of role-overload and worry were tested with paired t-tests and effect-sizes were calculated.

RESULTS

Of the 33 dyads of care receivers and caregivers, 28 remained in the study (dropout rate 15%). The majority of the caregivers was able to use the technology and integrate the use into their daily routines and would recommend the use of GPS. Almost half of the participants with dementia experienced more freedom and were less worried when they were outside unaccompanied, a quarter mentioned that they were more outside independently and a fifth that they had less conflicts with their caregiver after three months. Caregivers showed a trend to feel less worried, especially caregivers who could reach their relative using the telephone connection. No changes in caregivers' feelings of role-overload were found.

CONCLUSION

The GPS device used in this study seems to be promising for people in early stages of dementia and their informal caregivers. A next step is to carry out a randomized controlled trial.

Ethical aspects of using GPS for tracking people with dementia: recommendations for practice

BACKGROUND

Problems with out-of-home mobility are among the more common behavioral disturbances in dementia. Today people with dementia can be aided by easily accessible assistive technologies, such as tracking devices using Global Positioning Systems (GPS). Attitudes toward these technologies are still inconclusive and their use with people with dementia raises ethical concerns. The lack of ethical consensus on the use of GPS for people with dementia underlines the need for clearer policies and practical guidelines.

METHODS

Here we summarize qualitative and quantitative findings from a larger research project on the ethical aspects of using GPS for tracking people with dementia.

RESULTS

The findings are formulated in a list of recommendations for policy-makers as well as for professional and family caregivers. Among other points, the recommendations indicate that the preferences and best interests of the people with dementia should be central to the difficult decisions required in dementia care. Further, no-one should be coerced into using tracking technology and, where possible, people with dementia must be involved in the decision-making and their consent sought.

CONCLUSIONS

The decision whether, when and how to use GPS for tracking people with dementia should be made at the time of diagnosis jointly by the person with dementia, his/her family and professional caregivers. This decision should be made in formal structured meetings facilitated by a professional team.