Perceived Need and Acceptability of an App to Support Activities of Daily Living in People With Cognitive Impairment and Their Carers: Pilot Survey Study

Technology that CARES: Enhancing dementia care through everyday technologies

"Everyday technologies" have long been suggested as digital tools to improve life for and enhance care of persons with Alzheimer's disease and related dementias (ADRD). Within this realm, there is a need to balance potential drawbacks of technologies with their ability to positively impact patient and care partner centered outcomes. To facilitate this goal, we endeavored to provide a common language and conceptual structure to understand digital technology use in ADRD care. Specifically, we describe the pathways by which researchers might develop and deploy technology, including via Cognitive offloading, Automation, Remote monitoring, Emotional/social support, and Symptom treatment (CARES). In addition, we highlight emerging issues in technology-based care research and provide relevant caveats regarding application of digital technologies in the real world. This discussion provides a framework to organize science on the application of technologies to ADRD care in the future. HIGHLIGHTS: "Everyday technologies" have long been suggested as digital tools to improve life for and enhance care of persons with Alzheimer's disease and related dementias (ADRD). However, the potential benefits of digital technologies must be balanced against their possible drawbacks. We describe the pathways by which researchers might develop and deploy technology that CARES, including via Cognitive offloading, Automation, Remote monitoring, Emotional/social support, and Symptom treatment. This discussion provides a framework to organize science on the application of digital technologies to ADRD care in the future.

DigiDOP: A framework for applying digital technology to the Differential Outcomes Procedure (DOP) for cognitive interventions in persons with neurocognitive disorders

We present a framework -Digi-DOP- that includes a series of evidence-based recommendations to design and apply cognitive interventions for people with Neurocognitive Disorders (NCDs) using a relatively new approach, the Differential Outcomes Procedure (DOP). To do so, we critically review the substantial experimental research conducted with relevant clinical and non-clinical populations, and the theoretical underpinnings of this procedure. We further discuss how existing digital technologies that have been used for cognitive interventions could be applied to overcome some of the limitations of DOP-based interventions and further enhance DOP benefits. Specifically, we present three digital DOP developments that are currently being designed, investigated and/or tested. Finally, we discuss constraints, ethical and legal considerations that need to be taken into account to ensure that the use of technology in DOP-based interventions proposed here does not widen disparities and inequalities. We hope that this framework will inform and guide digital health leaders and developers, researchers and healthcare professionals to design and apply DOP-based interventions for people with NCDs.

A systematic review of reminder and guidance systems for Alzheimer's Disease and Related Dementias patients: context, barriers and facilitators

PURPOSE

To present the latest available research assessing the actual impact of reminder and guidance technologies for daily activities in Alzheimer's Disease and Related Dementia's patients, outlining design implications for these technologies.

MATERIALS AND METHODS

The search was conducted in the ACM Digital Library, IEEExplore, ScienceDirect, PubMed, Cochrane Library, Sage Journal, ResearchGate, and SemanticScholar. An iteratively-developed Boolean search string was built including up to 18 AND/OR terms across Four categories (Memory Aids, Technology, Daily Activities, Memory Impairment). We qualitatively analyzed the findings and discussions of the findings reported in 40 studies in our corpus to determine common barriers to, and facilitators of, effective intervention implementation and adoption.

RESULTS

Forty studies fulfilled the inclusion and exclusion criteria. In existing studies, individuals with Alzheimer's Disease and Related Dementias understand the usefulness of different functions that can be provided within an app to assist with everyday tasks. There was a high level of heterogeneity regarding the studies' location, duration, and evaluation methodology.

CONCLUSIONS

There is a need for assistive reminder and guidance technologies to be tailored towards autonomy, identity and personalization. Future work should include motivating features to aid during mood changes and feelings of insecurity.

Researched Apps Used in Dementia Care for People Living With Dementia and Their Informal Caregivers: Systematic Review on App Features, Security, and Usability

BACKGROUND

Studies have shown that mobile apps have the potential to serve as nonpharmacological interventions for dementia care, improving the quality of life of people living with dementia and their informal caregivers. However, little is known about the needs for and privacy aspects of these mobile apps in dementia care.

OBJECTIVE

This review seeks to understand the landscape of existing mobile apps in dementia care for people living with dementia and their caregivers with respect to app features, usability testing, privacy, and security.

METHODS

ACM Digital Library, Cochrane Central Register of Controlled Trials, Compendex, Embase, Inspec, Ovid MEDLINE, PsycINFO, and Scopus were searched. Studies were included if they included people with dementia living in the community, their informal caregivers, or both; focused on apps in dementia care using smartphones or tablet computers; and covered usability evaluation of the app. Records were independently screened, and 2 reviewers extracted the data. The Centre for Evidence-Based Medicine critical appraisal tool and Mixed Methods Appraisal Tool were used to assess the risk of bias in the included studies. Thematic synthesis was used, and the findings were summarized and tabulated based on each research aim.

RESULTS

Overall, 44 studies were included in this review, with 39 (89%) published after 2015. In total, 50 apps were included in the study, with more apps developed for people living with dementia as end users compared with caregivers. Most studies (27/44, 61%) used tablet computers. The most common app feature was cognitive stimulation. This review presented 9 app usability themes: user interface, physical considerations, screen size, interaction challenges, meeting user needs, lack of self-awareness of app needs, stigma, technological inexperience, and technical support. In total, 5 methods (questionnaires, interviews, observations, logging, and focus groups) were used to evaluate usability. There was little focus on the privacy and security aspects, including data transfer and protection, of mobile apps for people living with dementia.

CONCLUSIONS

The limitations of this review include 1 reviewer conducting the full-text screening, its restriction to studies published in English, and the exclusion of apps that lacked empirical usability testing. As a result, there may be an incomplete representation of the available apps in the field of dementia care. However, this review highlights significant concerns related to the usability, privacy, and security of existing mobile apps for people living with dementia and their caregivers. The findings of this review provide a valuable framework to guide app developers and researchers in the areas of privacy policy development, app development strategies, and the importance of conducting thorough usability testing for their apps. By considering these factors, future work in this field can be advanced to enhance the quality and effectiveness of dementia care apps.

TRIAL REGISTRATION

PROSPERO CRD42020216141; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=216141.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1159/000514838.

A systematic review of digital health technologies for the care of older adults during COVID-19 pandemic

Objective

During the Coronavirus Disease 2019 (COVID-19) pandemic, digital health technologies (DHTs) became increasingly important, especially for older adults. The objective of this systematic review was to synthesize evidence on the rapid implementation and use of DHTs among older adults during the COVID-19 pandemic.

Methods

A structured, electronic search was conducted on 9 November 2021, and updated on 5 January 2023, among five databases to select DHT interventional studies conducted among older adults during the pandemic. The bias of studies was assessed using Version 2 of the Cochrane Risk-of-Bias Tool for randomized trials (RoB 2) and Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I).

Results

Among 20 articles included in the review, 14 (70%) focused on older adults with chronic diseases or symptoms, such as dementia or cognitive impairment, type 2 diabetes, and obesity. DHTs included traditional telehealth interventions via telephone, video, and social media, as well as emerging technologies such as Humanoid Robot and Laser acupuncture teletherapy. Using RoB 2 and ROBINS-I, four studies (20%) were evaluated as high or serious overall risk of bias. DHTs have shown to be effective, feasible, acceptable, and satisfactory for older adults during the COVID-19 pandemic compared to usual care. In addition, some studies also highlighted challenges with technology, hearing difficulties, and communication barriers within the vulnerable population.

Conclusions

During the COVID-19 pandemic, DHTs had the potential to improve various health outcomes and showed benefits for older adults' access to health care services.

Digital healthcare for dementia and cognitive impairment: A scoping review

BACKGROUND

Cognitive disorders, such as Alzheimer's disease, are a global health problem. Digital healthcare technology is an innovative management tool for delaying the progression of dementia and mild cognitive impairment. Thanks to digital technology, the possibility of safe and effective care for patients at home and in the community is increasing, even in situations that threaten the continuity of care, such as the COVID-19 pandemic. However, it is difficult to select appropriate technology and alternatives due to the lack of comprehensive reviews on the types and characteristics of digital technology for cognitive impairment, including their effects and limitations.

OBJECTIVE

This study aims to identify the types of digital healthcare technology for dementia and mild cognitive impairment and comprehensively examine how its outcome measures were constructed in line with each technology's purpose.

METHODS

According to the Preferred Reporting Items for Systematic reviews and Meta-Analysis extension for Scoping Reviews guidelines, a literature search was conducted in August 2021 using Medline (Ovid), EMBASE, and Cochrane library. The search terms were constructed based on Population-Concept-Context mnemonic: 'dementia', 'cognitive impairment', and 'cognitive decline'; digital healthcare technology, such as big data, artificial intelligence, virtual reality, robots, applications, and so on; and the outcomes of digital technology, such as accuracy of diagnosis and physical, mental, and social health. After grasping overall research trends, the literature was classified and analysed in terms of the type of service users and technology.

RESULTS

In total, 135 articles were selected. Since 2015, an increase in literature has been observed, and various digital healthcare technologies were identified. For people with mild cognitive impairment, technology for predicting and diagnosing the onset of dementia was studied, and for people with dementia, intervention technology to prevent the deterioration of health and induce significant improvement was considered. Regarding caregivers, many studies were conducted on monitoring and daily living assistive technologies that reduce the burden of care. However, problems such as data collection, storage, safety, and the digital divide persisted at different intensities for each technology type.

CONCLUSIONS

This study revealed that appropriate technology options and considerations may differ depending on the characteristics of users. It also emphasises the role of humans in designing and managing technology to apply digital healthcare technology more effectively.

Usability evaluation of mHealth apps for elderly individuals: a scoping review

BACKGROUND

Usability is a key factor affecting the acceptance of mobile health applications (mHealth apps) for elderly individuals, but traditional usability evaluation methods may not be suitable for use in this population because of aging barriers. The objectives of this study were to identify, explore, and summarize the current state of the literature on the usability evaluation of mHealth apps for older adults and to incorporate these methods into the appropriate evaluation stage.

METHODS

Electronic searches were conducted in 10 databases. Inclusion criteria were articles focused on the usability evaluation of mHealth apps designed for older adults. The included studies were classified according to the mHealth app usability evaluation framework, and the suitability of evaluation methods for use among the elderly was analyzed.

RESULTS

Ninety-six articles met the inclusion criteria. Research activity increased steeply after 2013 (n = 92). Satisfaction (n = 74) and learnability (n = 60) were the most frequently evaluated critical measures, while memorability (n = 13) was the least evaluated. The ratios of satisfaction, learnability, operability, and understandability measures were significantly related to the different stages of evaluation (P < 0.05). The methods used for usability evaluation were questionnaire (n = 68), interview (n = 36), concurrent thinking aloud (n = 25), performance metrics (n = 25), behavioral observation log (n = 14), screen recording (n = 3), eye tracking (n = 1), retrospective thinking aloud (n = 1), and feedback log (n = 1). Thirty-two studies developed their own evaluation tool to assess unique design features for elderly individuals.

CONCLUSION

In the past five years, the number of studies in the field of usability evaluation of mHealth apps for the elderly has increased rapidly. The mHealth apps are often used as an auxiliary means of self-management to help the elderly manage their wellness and disease. According to the three stages of the mHealth app usability evaluation framework, the critical measures and evaluation methods are inconsistent. Future research should focus on selecting specific critical measures relevant to aging characteristics and adapting usability evaluation methods to elderly individuals by improving traditional tools, introducing automated evaluation tools and optimizing evaluation processes.

Interactive Somatosensory Games in Rehabilitation Training for Older Adults With Mild Cognitive Impairment: Usability Study

BACKGROUND

In aging societies, dementia risk increases with advancing age, increasing the incidence of dementia-related degenerative diseases and other complications, especially fall risk. Dementia also escalates the care burden, impacting patients, their families, social welfare institutions, and the social structure and medical system.

OBJECTIVE

In elderly dementia, traditional card recognition rehabilitation (TCRR) does not effectively increase one's autonomy. Therefore, from the usability perspective, we used the Tetris game as a reference to develop an interactive somatosensory game rehabilitation (ISGR) with nostalgic style for elders with mild cognitive impairment (MCI). Through intuitive gesture-controlled interactive games, we evaluated subjective feelings concerning somatosensory game integration into rehabilitation to explore whether the ISGR could improve the willingness to use and motivation for rehabilitation among elders with MCI.

METHODS

A total of 15 elders with MCI (7 males and 8 females with an average age of 78.4 years) underwent 2 experiments for 15 minutes. During experiment 1, TCRR was performed, followed by completing the questionnaire of the System Usability Scale (SUS). After 3-5 minutes, the second experiment (the ISGR) was conducted, followed by completing another SUS. We used SUS to explore differences in impacts of TCRR and ISGR on willingness to use among elders with MCI. In addition, we further investigated whether the factor of gender or prior rehabilitation experience would affect the rehabilitation willingness or not.

RESULTS

The novel ISGR made the elderly feel interested and improved their willingness for continuous rehabilitation. According to the overall SUS score, the ISGR had better overall usability performance (73.7) than the TCRR (58.0) (t₂₈=-4.62, P<.001). Furthermore, the ISGR individual item scores of "Willingness to Use" (t₂₈=-8.27, P<.001), "Easy to Use" (t₂₈=-3.17, P<.001), "System Integration" (t₂₈=-5.07, P<.001), and "Easy to Learn" (t₂₈=-2.81, P<.001) were better than TCRR. The somatosensory game was easier to learn and master for females than for males (t₁₃=2.71, P=.02). Besides, the ISGR was easier to use (t₁₂=-2.50, P=.02) and learn (t₁₄=-3.33, P<.001) for those without prior rehabilitation experience. The result indicates that for elders with no rehabilitation experience ISGR was easier to use and simpler to learn than TCRR.

CONCLUSIONS

Regardless of prior rehabilitation experience, the ISGR developed in this study was easy to learn and effective in continuously improving willingness to use. Furthermore, the adoption of a nostalgic game design style served the function of cognitive training and escalated interest in rehabilitation. The ISGR also improved user stickiness by introducing different game scenarios and difficulties, increasing long-term interest and motivation for rehabilitation. For future research on the adoption of interactive somatosensory games in rehabilitation, additional rehabilitation movements can be developed to benefit the elderly with MCI.

Mobile Health Interventions to Support Caregivers of Older Adults: An Equity-Focused Systematic Review

Background

Informal caregivers, hereafter referred to as caregivers, provide support to older adults so that they can age safely at home. The decision to become a caregiver can be influenced by individual factors, such as personal choice, or societal factors such as social determinants of health, including household income, employment status, and culture-specific gender roles. Over time, caregivers’ health can be negatively affected by their caregiving roles. Although programs exist to support caregivers, the availability and appropriateness of services do not match caregivers’ expressed needs. Research suggests that supportive interventions offered through mobile health (mHealth) technologies have the potential to increase caregivers’ access to supportive services. However, a knowledge gap remains regarding the extent to which social determinants of health are considered in the design, implementation, and evaluation of mHealth interventions intended to support the caregivers of older adults.

Objective

This study aimed to conduct a systematic review to determine how health equity is considered in the design, implementation, and evaluation of mHealth interventions for caregivers of older adults using Cochrane Equity’s PROGRESS-Plus (place of residence, race, ethnicity, culture, language, occupation, gender, religion, education, social capital, socioeconomic status–plus age, disability, and sexual orientation) framework and synthesize evidence of the impacts of the identified caregiver-focused mHealth interventions.

Methods

A systematic review was conducted using 5 databases. Articles published between January 2010 and June 2021 were included if they evaluated or explored the impact of mHealth interventions on the health and well-being of informal caregivers of older adults. mHealth interventions were defined as supportive services, for example, education, that caregivers of older adults accessed via mobile or wireless devices.

Results

In total, 28 articles met the inclusion criteria and were included in the review. The interventions evaluated sought to connect caregivers with services, facilitate caregiving, and promote caregivers’ health and well-being. The PROGRESS-Plus framework factors were mainly considered in the results, discussion, and limitations sections of the included studies. Some PROGRESS-Plus factors such as sexual orientation, religion, and occupation, received little to no consideration across any phase of the intervention design, implementation, or evaluation. Overall, the findings of this review suggest that mHealth interventions were positively received by study participants. Such interventions have the potential to reduce caregiver burden and positively affect caregivers’ physical and mental health while supporting them as caregivers. The study findings highlight the importance of making support available to help facilitate caregivers’ use of mHealth interventions, as well as in the use of appropriate language and text.

Conclusions

The successful uptake and spread of mHealth interventions to support caregivers of older adults will depend on creating opportunities for the inclusive involvement of a broad range of stakeholders at all stages of design, implementation, and evaluation.

Refining a Digital Therapeutic Platform for Home Care Agencies in Dementia Care to Elicit Stakeholder Feedback: Focus Group Study With Stakeholders

Background

Persons living with dementia require increasing levels of care, and the care model has evolved. The Centers for Medicare and Medicaid Services is transitioning long-term care services from institutional care to home- or community-based services, including reimbursement for nonclinical services. Although home care companies are positioned to handle this transition, they need innovative solutions to address the special challenges posed by caring for persons living with dementia. To live at home longer, these persons require support from formal caregivers (FCGs; ie, paid professionals), who often lack knowledge of their personal histories and have high turnover, or informal caregivers (eg, family or friends), who may have difficulty coping with behavioral and psychological symptoms of dementia. The Generation Connect platform was developed to support these individuals and their formal and informal caregivers. In preliminary studies, the platform improved mood and influenced caregiver satisfaction. To enhance platform effectiveness, Generation Connect received a grant from the National Institutes of Health Small Business Innovation Research to improve clinical outcomes, reduce health care costs, and lower out-of-pocket costs for persons living with dementia who receive care through home care agencies.

Objective

This study aims to evaluate information elicited from a series of stakeholder focus groups to understand existing processes, needs, barriers, and goals for the use of the Generation Connect platform by home care agencies and formal and informal caregivers.

Methods

A series of focus groups were conducted with home care agency corporate leadership, home care agency franchise owners, home care agency FCGs, and informal caregivers of persons living with dementia. The qualitative approach allowed for unrestricted idea generation that best informed the platform development to enable home care providers to differentiate their dementia care services, involve informal caregivers, improve FCG well-being, and extend the ability of persons living with dementia to age in place. Using the Technology-Enabled Caregiving in the Home framework, an inductive and iterative content analysis was conducted to identify thematic categories from the transcripts.

Results

Overall, 39 participants participated across the 6 stakeholder focus groups. The following five overarching themes were identified: technology related; care services; data, documentation, and outcomes; cost, finance, and resources; and resources for caregivers. Within each theme, the most frequent subthemes were identified. Exemplar stakeholder group statements provided support for each of the identified themes.

Conclusions

The focus group results will inform the further development of the Generation Connect platform to reduce the burden of caregiving for persons living with dementia, evaluate changes in cognition, preserve functional independence, and promote caregiver engagement between these individuals. The next step is to evaluate the effectiveness of the revised platform in the National Institutes of Health Small Business Innovation Research phase 2 clinical trial to assess the efficacy of its evidence-based interventions and market viability.

Titrating Support: Stakeholder Perspectives on Improving a Mobile Telepresence Robot for People with Alzheimer's Disease and Related Dementias (Preprint)

Background

By 2050, nearly 13 million Americans will have Alzheimer disease and related dementias (ADRD), with most of those with ADRD or mild cognitive impairment (MCI) receiving home care. Mobile telepresence robots may allow persons with MCI or ADRD to remain living independently at home and ease the burden of caregiving. The goal of this study was to identify how an existing mobile telepresence robot can be enhanced to support at-home care of people with MCI or ADRD through key stakeholder input.

Objective

The specific aims were to assess what applications should be integrated into the robot to further support the independence of individuals with MCI or ADRD and understand stakeholders’ overall opinions about the robot.

Methods

We conducted in-person interviews with 21 stakeholders, including 6 people aged >50 years with MCI or ADRD living in the community, 9 family caregivers of people with MCI or ADRD, and 6 clinicians who work with the ADRD population. Interview questions about the robot focused on technology use, design and functionality, future applications to incorporate, and overall opinions. We conducted a thematic analysis of the data obtained and assessed the patterns within and across stakeholder groups using a matrix analysis technique.

Results

Overall, most stakeholders across groups felt positively about the robot’s ability to support individuals with MCI or ADRD and decrease caregiver burden. Most ADRD stakeholders felt that the greatest benefits would be receiving help in emergency cases and having fewer in-person visits to the doctor’s office. Caregivers and clinicians also noted that remote video communication with their family members using the robot was valuable. Adding voice commands and 1-touch lifesaving or help buttons to the robot were the top suggestions offered by the stakeholders. The 4 types of applications that were suggested included health-related alerts; reminders; smart-home–related applications; and social, entertainment, or well-being applications. Stakeholders across groups liked the robot’s mobility, size, interactive connection, and communication abilities. However, stakeholders raised concerns about their physical stability and size for individuals living in smaller, cluttered spaces; screen quality for those with visual impairments; and privacy or data security.

Conclusions

Although stakeholders generally expressed positive opinions about the robot, additional adaptations were suggested to strengthen functionality. Adding applications and making improvements to the design may help mitigate concerns and better support individuals with ADRD to live independently in the community. As the number of individuals living with ADRD in the United States increases, mobile telepresence robots are a promising way to support them and their caregivers. Engaging all 3 stakeholder groups in the development of these robots is a critical first step in ensuring that the technology matches their needs. Integrating the feedback obtained from our stakeholders and evaluating their effectiveness will be important next steps in adapting telepresence robots.

A Mobile App-Based Intervention Program for Nonprofessional Caregivers to Promote Positive Mental Health: Randomized Controlled Trial

BACKGROUND

While nonprofessional caregivers often experience a sense of fulfillment when they provide care, there is also a significant risk of emotional and physical burnout. Consequently, this can negatively affect both the caregiver and the person being cared for. Intervention programs can help empower nonprofessional caregivers of people with chronic diseases and develop solutions to decrease the physical and psychological consequences resulting from caregiving. However, most clinically tested intervention programs for nonprofessional caregivers require face-to-face training, and many caregivers encounter obstacles that hinder their participation in such programs. Consequently, it is necessary to design internet-based intervention programs for nonprofessional caregivers that address their needs and test the efficacy of the programs.

OBJECTIVE

The aim of this study was to evaluate the effectiveness of a smartphone app-based intervention program to increase positive mental health for nonprofessional caregivers.

METHODS

This study was a randomized controlled trial of 3 months' duration. A total of 152 caregivers over 18 years of age with a minimum of 4 months' experience as nonprofessional caregivers were recruited from primary health care institutions. Nonprofessional caregivers were randomized into two groups. In the intervention group, each caregiver installed a smartphone app and used it for 28 days. This app offered them daily activities that were based on 10 recommendations to promote positive mental health. The level of positive mental health, measured using the Positive Mental Health Questionnaire (PMHQ), and caregiver burden, measured using the 7-item short-form version of the Zarit Caregiver Burden Interview (ZBI-7), were the primary outcomes. Users' satisfaction was also measured.

RESULTS

In all, 113 caregivers completed the study. After the first month of the intervention, only one factor of the PMHQ, F1-Personal satisfaction, showed a significant difference between the groups, but it was not clinically relevant (0.96; P=.03). However, the intervention group obtained a higher mean change for the overall PMHQ score (mean change between groups: 1.40; P=.24). The results after the third month of the intervention showed an increment of PMHQ scores. The mean difference of change in the PMHQ score showed a significant difference between the groups (11.43; P<.001; d=0.82). Significant changes were reported in 5 of the 6 factors, especially F5-Problem solving and self-actualization (5.69; P<.001; d=0.71), F2-Prosocial attitude (2.47; P<.001; d=1.18), and F3-Self-control (0.76; P=.03; d=0.50). The results of the ZBI-7 showed a decrease in caregiver burden in the intervention group, although the results were inconclusive. Approximately 93.9% (46/49) of the app users indicated that they would recommend the app to other caregivers and 56.3% (27/49) agreed that an extension of the program's duration would be beneficial.

CONCLUSIONS

The app-based intervention program analyzed in this study was effective in promoting positive mental health and decreasing the burden of caregivers and achieved a high range of user satisfaction. This study provides evidence that mobile phone app-based intervention programs may be useful tools for increasing nonprofessional caregivers' well-being. The assessment of the effectiveness of intervention programs through clinical trials should be a focus to promote internet-based programs in health policies.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN14818443; http://www.isrctn.com/ISRCTN14818443.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s12889-019-7264-5.