Teknologi bantu untuk sokongan memori dalam demensia
Abstract
Background
The sustained interest in electronic assistive technology in dementia care has been fuelled by the urgent need to develop useful approaches to help support people with dementia at home. Also the low costs and wide availability of electronic devices make it more feasible to use electronic devices for the benefit of disabled persons. Information Communication Technology (ICT) devices designed to support people with dementia are usually referred to as Assistive Technology (AT) or Electronic Assistive Technology (EAT). By using AT in this review we refer to electronic assistive devices. A range of AT devices has been developed to support people with dementia and their carers to manage their daily activities and to enhance safety, for example electronic pill boxes, picture phones, or mobile tracking devices. Many are commercially available. However, the usefulness and user‐friendliness of these devices are often poorly evaluated. Although reviews of (electronic) memory aids do exist, a systematic review of studies focusing on the efficacy of AT for memory support in people with dementia is lacking. Such a review would guide people with dementia and their informal and professional carers in selecting appropriate AT devices.
Objectives
Primary objective
To assess the efficacy of AT for memory support in people with dementia in terms of daily performance of personal and instrumental activities of daily living (ADL), level of dependency, and admission to long‐term care.
Secondary objective
To assess the impact of AT on: users (autonomy, usefulness and user‐friendliness, adoption of AT); cognitive function and neuropsychiatric symptoms; need for informal and formal care; perceived quality of life; informal carer burden, self‐esteem and feelings of competence; formal carer work satisfaction, workload and feelings of competence; and adverse events.
Search methods
We searched ALOIS, the Specialised Register of the Cochrane Dementia and Cognitive Improvement Group (CDCIG), on 10 November 2016. ALOIS is maintained by the Information Specialists of the CDCIG and contains studies in the areas of dementia prevention, dementia treatment and cognitive enhancement in healthy people. We also searched the following list of databases, adapting the search strategy as necessary: Centre for Reviews and Dissemination (CRD) Databases, up to May 2016; The Collection of Computer Science Bibliographies; DBLP Computer Science Bibliography; HCI Bibliography: Human‐Computer Interaction Resources; and AgeInfo, all to June 2016; PiCarta; Inspec; Springer Link Lecture Notes; Social Care Online; and IEEE Computer Society Digital Library, all to October 2016; J‐STAGE: Japan Science and Technology Information Aggregator, Electronic; and Networked Computer Science Technical Reference Library (NCSTRL), both to November 2016; Computing Research Repository (CoRR) up to December 2016; and OT seeker; and ADEAR, both to February 2017. In addition, we searched Google Scholar and OpenSIGLE for grey literature.
Selection criteria
We intended to review randomised controlled trials (RCTs) and clustered randomised trials with blinded assessment of outcomes that evaluated an electronic assistive device used with the single aim of supporting memory function in people diagnosed with dementia. The control interventions could either be 'care (or treatment) as usual' or non‐technological psychosocial interventions (including interventions that use non‐electronic assistive devices) also specifically aimed at supporting memory. Outcome measures included activities of daily living, level of dependency, clinical and care‐related outcomes (for example admission to long‐term care), perceived quality of life and well‐being, and adverse events resulting from the use of AT; as well as the effects of AT on carers.
Data collection and analysis
Two review authors independently screened all titles and abstracts identified by the search.
Main results
We identified no studies which met the inclusion criteria.
Authors' conclusions
This review highlights the current lack of high‐quality evidence to determine whether AT is effective in supporting people with dementia to manage their memory problems.
PICO
Ringkasan bahasa mudah
Teknologi bantu untuk sokongan memori dalam demensia
Soalan ulasan
Kami ingin tahu dari ulasan bukti sama ada Teknologi Bantu boleh membantu orang dengan demensia mengatasi beberapa kesan masalah memori mereka.
Latar belakang
Demensia menyebabkan masalah memori yang menyukarkan aktiviti harian, contohnya memasak, mengingat janji‐temu, mengambil ubat. Masalah memori yang dialami boleh memberi impak negatif yang besar kepada orang dengan demensia, dan mungkin menyebabkan kekeliruan, kegelisahan, malu, atau kemurungan. Kekurangan upaya untuk melakukan aktiviti harian boleh menyebabkan stres kepada penjaga yang bimbang tentang keselamatan dan kesejahteraan seseorang. Pelbagai peranti elektronik ‐ sering dirujuk sebagai Teknologi Bantu (AT ‐ diguna sepanjang ulasan ini), dan kadangkala sebagai Teknologi Bantu Elektronik (EAT) ‐ telah dibangunkan untuk menyokong orang dengan demensia. Peranti tersebut boleh dibahagikan kepada empat kategori yang menawarkan sokongan dengan maklumat umum dan peribadi (contohnya carta digital sosial); sokongan praktikal dengan masalah disebabkan oleh simptom demensia, terutamanya hilang memori (contohnya kotak pendispens pil elektronik, diari elektronik); sokongan dengan kontak sosial dan peneman (contohnya telefon bergambar, robot ‘haiwan peliharaan’ interaktif); dan sokongan risiko terhadap kesihatan dan keselamatan (contohnya peranti penjejakan, sensor jatuh). Dalam ulasan ini, kami menumpu kepada peranti yang bertujuan membantu orang mengurus masalah memori mereka. Kami ingin tahu sama ada AT berkesan membantu orang yang bermasalah memori akibat demensia untuk menjalankan aktiviti harian mereka, dan sama ada ia membuat mereka kurang bergantung kepada orang lain, memperbaiki kualiti hidup mereka atau memberi kesan kepada kemasukan ke institusi penjagaan. Kami juga ingin tahu jika ia memberi sebarang impak kepada keluarga dan penjaga berbayar.
Ciri‐ciri kajian
Kami mencari secara sistematik semua kajian penyelidikan yang menilai AT dengan memperuntukkan orang dengan demensia secara rawak kepada peranti AT atau ‘penjagaan biasa’ atau penyelesaian bukan teknologi untuk menyokong memori dan seterusnya membandingkan hasil‐hasil. Carian kami menyertakan semua bukti sedia ada sehingga 10 November 2016.
Keputusan utama
Kami tidak menemui kajian yang memenuhi kriteria kami.
Kualiti bukti
Ulasan ini mengenal pasti banyak literatur tentang pembangunan AT, termasuk laporan penyelidik yang bekerja dengan orang dengan demensia dan penjaga mereka untuk menentukan jenis dan reka bentuk AT yang mungkin berguna. Terdapat juga banyak panduan ditulis untuk profesional kesihatan dan bakal pengguna AT. Kami menemui beberapa kajian kecil yang telah menguji keberkesanan peranti AT terpilih, tetapi kaedah yang digunakan adalah tidak cukup berkualiti tinggi untuk memenuhi kriteria ulasan ini. Oleh itu kami tidak pasti buat masa ini sama ada AT boleh membantu atau tidak orang dengan demensia mengurus masalah memori mereka. Kami percaya lebih banyak penyelidikan perlu dibuat dalam bidang ini.
Authors' conclusions
Background
Daily life without Information Communication Technology (ICT) is almost unthinkable to many people nowadays. ICT serves many purposes including safety, navigation, or social contact and is applied in many environments, including health and social care settings. The cost of electronic devices have decreased over the years to a current level where even complex devices are affordable for most people. This raises a societal expectation to exploit the potential of these devices to support people with disabilities. New developments in health care to support people in improving their well‐being by means of ICT are encouraged by governments (Kamel Boulous 2009). Also, the European Commission stimulates the development of Assistive Technology to prevent people with disabilities being excluded from society by funding programmes like e‐Inclusion and Ambient Assisted Living (AAL) (European Commission 2010). Consequently, in the last two decades ICT has increasingly been developed to support people with cognitive impairment, including impairment related to dementia, in their daily lives.
ICT‐based devices developed for people with dementia are usually referred to as Assistive Technology (AT), but other terminology is also used, including Electronic Assistive Technology (EAT), telecare, cognitive prosthetics, technology‐based reminding support, and pervasive computing. AT has been developed to support people with dementia and their carers to manage their daily activities and to enhance safety. Several reports describe designing AT for groups with cognitive impairment (Cahill 2007; Hanson 2007; Meiland 2007; Mulvenna 2010; Nugent 2008; Rialle 2008; Sixsmith 2007; Span 2013; Sterns 2005; Van der Roest 2008). Some successful AT devices like electronic pill boxes, picture phones, or mobile tracking devices are already commercially available but, due to the lack of well‐designed trials and small sample sizes, their usefulness and effectiveness for people with dementia are not always clear. Furthermore, a wide range of devices and participants with a diversity of cognitive impairments are involved in the different studies, which makes it difficult to draw firm conclusions on the usefulness and effectiveness of AT for this group (Fleming 2014; Lauriks 2007; Topo 2009).
In their review, Lauriks 2007 described AT that is intended to support people with dementia in the four needs areas of: general and personalised information; practical support with regard to symptoms of dementia (including memory problems); social contact and company; and health monitoring and perceived safety. This review builds further on the work of Lauriks 2007 and focuses on AT for memory problems, one of the most common symptoms in people with dementia, which has a high impact on functioning in daily life. Many people with dementia, as well as their informal carers, report a lack of adequate support for memory problems. In fact, relative to other unmet needs, support for memory problems is the most frequently mentioned unmet need by people with dementia and carers (Van der Roest 2009). In addition to the more traditional means of memory support, for example diaries, written signs, journals or notes, ICT applications could potentially offer effective alternatives. It is expected that electronic memory support devices will enable people with dementia to live more independently and will alleviate carer burden (Cahill 2007).
Description of the condition
A dementia syndrome is usually caused by a chronic or progressive disease of the brain. The most common forms of dementia are Alzheimer's disease and vascular dementia. Dementia is characterized by impairment in higher cortical functioning, including memory, thinking, orientation, language, comprehension, action, and judgement. Cognitive impairment in dementia is often preceded or accompanied by the deterioration of emotional control, social behaviour, or motivation (WHO 2007). Functional decline is one of the core diagnostic criteria in all types of dementia (American Psychiatric Association 1994). Performing tasks of daily living becomes increasingly difficult. Initially the more complex instrumental activities of daily living (IADL) are affected and then later on also personal ADL tasks (Liu 2007; Öhman 2001; Sikkes 2009; Van Wielingen 2004). In the advanced stage of dementia people become totally dependent on the help of others (Agüero‐Torres 1998; Wimo 1999).
It is estimated that currently 44.4 million people worldwide live with dementia, and this total is expected to rise by 71% to reach 75.6 million by 2030 and 135.5 million by 2050 (Alzheimer's Disease International 2013). Many people in the advanced stage of dementia are admitted to a long‐term care facility to receive full‐time care. It is estimated that in high‐income countries approximately 34% of the people with dementia live in long‐term care facilities (Alzheimer's Disease International 2010).
People with dementia usually experience memory problems. The type of memory impairment experienced is dictated by the underlying condition, the associated site, and the extent of the brain lesion. Prospective memory (PM) is essential for living independently as it involves remembering to do things in the future without any prompting; whilst retrospective memory (RM) involves recalling or recognising information that one has acquired in the past (Maylor 2002).
Due to the progressive nature of dementia, people with dementia will increasingly depend on the support of others. This help is frequently provided by relatives, the so‐called informal carers, who provide unpaid care. If informal care is no longer sufficient, feasible, or available, paid staff (formal carers) step in to provide support. The estimated global costs for dementia are currently estimated to be USD 604 billion, of which the majority is attributed to informal care (42%) and social care (care provided by community care professionals and in long‐term care settings) (42%). The direct medical costs are much lower (16%) (Alzheimer's Disease International 2010). With an estimated increase in costs of 85% by the year 2030, Alzheimer's Disease International stresses the urgent need to develop cost‐effective packages of medical and social care for people with dementia.
Description of the intervention
Research has shown that people with mild dementia would appreciate devices to support both their prospective and retrospective memory. Examples of prospective memory support would be reminding them of actions needed at particular times, such as taking medication, eating, or keeping appointments. Retrospective memory support could include helping them to locate lost items, remember names of people, or keep track of the day and time (Nugent 2007).
Devices developed for different purposes have specific functional capabilities. Some ATs can be customised to react to the environment or the user in a dynamic way, for example sensors that activate a warning, alarm, or camera if no movement is detected in a defined period of time. Whilst some devices are stand‐alone, like electronic calendars, others are integrated into a more comprehensive, remotely configurable system, like the COGKNOW Day Navigator. As well as memory support, this also offers communication, activity and safety support (Meiland 2007). Other devices can support in ADL tasks, for instance the COACH that facilitates in handwashing by prompting (Mihailidis 2008). Devices can also be mobile, enabling the user to take the device with them outside their home; for example the 'Take Me Home' device, developed in the same COGKNOW project, guides people to their home by means of spoken instruction and images when they are lost. Since impairments in prospective memory are generally more often reported than retrospective memory impairments in people with dementia and seem to have greater impact (Smith 2000), AT devices that aim to support prospective memory functioning will usually need to be more advanced, because the first have to anticipate future events and changing environments. Effective prospective memory devices will have a larger impact on the daily lives of people with dementia than AT devices for retrospective memory problems, since prospective AT will enable people to function independently for a longer period of time.
How the intervention might work
People with memory problems often rely on others around them or on static reminders or cues, like written notes or diaries, to support their memory. By providing an AT device that reminds them of meaningful events, previous daytime activities, or guides them through complex situations or tasks, people with dementia may act more independently. They will attain their daily goals (for example appointments and activities), may be less agitated or confused, and will experience a better quality of life; and their informal carers may experience less burden (Cahill 2007). Ideally the assistive technology should be adapted and fine‐tuned to dementia‐related and other personal and context‐related factors (Dröes 2010). Levels of technology used for AT devices vary from low technology to higher level personalised technology and context‐aware (smart) environments. Electronic calendars are examples of low‐technology devices, as they do not take into account whether or not the person with dementia follows the given reminder. Mobile tracking devices that automatically provide a warning when a person with dementia is leaving his or her familiar area are examples of more context‐aware devices. Although technology for context‐aware environments does exist, it is not yet widely provided due to its current sensitivity to errors and false alarms.
Why it is important to do this review
Many assistive devices have been developed for memory support in people with cognitive impairment. However, in order for AT to be effective a device should be user friendly, so that a carer can manage or configure the device him‐ or herself; and the person with dementia should be able to use the device for his or her goals, regardless of their level of cognitive decline. To optimise the user friendliness people with dementia and informal carers were increasingly involved in the AT development process in the past decade. Methods for such design processes have been described (Meiland 2012; Meiland 2017; Span 2013). Despite the effort to carefully design AT and the conviction that AT can be beneficial for people with dementia in alleviating memory problems, robust evidence on its efficacy and effectiveness in everyday life and the user‐friendliness of these devices, especially for people with dementia, is scarce. Although reviews of (electronic) memory aids do exist (Bharucha 2009; Caprani 2006; Fleming 2014; Fritschy 2004; Lauriks 2007; Lindenberger 2008; Topo 2009), a systematic review of high‐quality studies focusing on the efficacy of AT for memory support in people with dementia is lacking. This review is intended to investigate the extent and quality of the evidence for existing devices intended to support people with dementia manage different types of memory problems. A comprehensive overview of evidence‐based devices will guide people with dementia and their informal and professional carers in selecting an appropriate memory device to match the user's needs. The review also provides useful information for AT developers in this rapidly growing area, by addressing the gaps in, and shortcomings of, existing AT for memory support. It highlights questions which need further evaluation using robust research methodologies.
Objectives
Primary objective
To assess the efficacy of AT for memory support in people with dementia in terms of daily performance of personal and instrumental activities of daily living (ADL), level of dependency, and admission to long‐term care.
Secondary objective
To assess the impact of AT on: users (autonomy, usefulness and user‐friendliness, adoption of AT); cognitive function and neuropsychiatric symptoms; need for informal and formal care; perceived quality of life; informal carer burden, self‐esteem and feelings of competence; formal carer work satisfaction, workload and feelings of competence; and adverse events.
Methods
Criteria for considering studies for this review
Types of studies
Randomised controlled trials (RCTs) and cluster randomised trials with blinded assessment of outcome were included (including those with inadequate sequence allocation). Studies reported in any language were eligible for inclusion.
Types of participants
Participants needed to be diagnosed with dementia according to the Diagnostic and Statistical Manual IV (American Psychiatric Association 1994) or ICD‐10 (WHO 2007). If participants' diagnostic information was not described in potential studies, primary authors were asked for additional information. If the information provided met the set criteria, studies were included. No further inclusion criteria for participants were applied.
Types of interventions
The review included studies that evaluated AT for people with dementia: devices driven by electronics and used with the single aim of supporting memory problems. The AT under evaluation could be stand alone or integrated in a service system (configured remotely); and stationary or mobile. The devices under study are most likely to require configuration or set‐up help by carers. The focus of the studies was to be primarily on the person with dementia, but the impact on carers was also reviewed. Studies that evaluated a combination of devices that were provided to meet different aims were not included. The control interventions could either be 'care (or treatment) as usual' or non‐technological psychosocial interventions (including interventions that use non‐electronic assistive devices) also specifically aimed at supporting memory problems.
Types of outcome measures
The primary outcome measures regarding the efficacy of the AT under study related to ADL and the level of dependency of people with dementia. The secondary outcome measures related to clinical and care‐related outcomes of the AT for people with dementia, to their perceived quality of life and well‐being, and also the effects of AT on their carers — informal carers for community‐based interventions and formal carers for institutional‐based interventions. Adverse events resulting from use of AT for people with dementia and carers (informal and formal) were to be included. All reported time frames were to be included; all outcomes measures were to be listed, and their validity and reliability considered.
Primary outcomes
Daily functioning
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Activities of daily living (ADL): personal (PADL) and instrumental (IADL).
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Level of dependency (self‐report or proxy report).
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Admission to long‐term care (for community‐based interventions).
Secondary outcomes
User reports
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Experienced autonomy (self‐report).
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Experienced usefulness and user‐friendliness of AT (self‐report).
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Adoption of AT.
Clinical
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Cognitive functioning.
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Neuropsychiatric symptoms (behavioural and mood problems).
Care
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Need for informal care.
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Need for formal care.
Well‐being
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Perceived quality of life or well‐being (self‐report or proxy report).
Informal carer
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Carer burden.
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Self‐esteem.
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Feelings of competence.
Formal carer
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Work satisfaction.
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Workload.
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Feelings of competence.
Adverse events
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Clinical.
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Care.
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Informal carer.
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Formal carer.
Search methods for identification of studies
Electronic searches
The Cochrane Dementia and Cognitive Improvement Group Information Specialist searched ALOIS (www.medicine.ox.ac.uk/alois), the Cochrane Dementia and Cognitive Improvement Group’s Specialised Register, on 10 November 2016, using a search strategy devised by HvdR. The search terms used were: assistive OR technology OR device OR devices OR electronic OR locator OR "pill dispenser" OR calendar OR clock OR telecare.
ALOIS is maintained by the Cochrane Dementia and Cognitive Improvement Group Information Specialist. It contains studies in the areas of dementia prevention, dementia treatment and cognitive enhancement in healthy people. The studies are identified from:
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monthly searches of a number of major healthcare databases: MEDLINE, Embase, CINAHL, PsycINFO and LILACS;
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monthly searches of trial registers: ISRCTN; UMIN (Japan's Trial Register); the World Health Organization (WHO) portal (which covers ClinicalTrials.gov; ISRCTN; the Chinese Clinical Trials Register; the German Clinical Trials Register; the Iranian Registry of Clinical Trials and the Netherlands National Trials Register, plus others);
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quarterly search of the Cochrane Library’s Central Register of Controlled Trials (CENTRAL);
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six‐monthly searches of a number of grey literature sources: ISI Web of Knowledge Conference Proceedings; Index to Theses; Australasian Digital Theses.
To view a list of all sources searched for ALOIS see About ALOIS on the ALOIS web site.
Details of the search strategies used for the retrieval of trial reports from the healthcare databases, CENTRAL and conference proceedings can be viewed in the ‘Methods used in reviews’ section within the editorial information about the Dementia and Cognitive Improvement Group.
Additional searches were performed in many of the sources listed above to cover the period between the last search performed in ALOIS and completion of the review to ensure that the search was as up to date and as comprehensive as possible. The search strategies used can be seen in Appendix 1.
Two authors (HvdR and JW) carried out further searches in the following specialist sources, adapting the search strategy as needed.
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PiCarta (to October 2016).
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OTseeker (to February 2017).
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ADEAR (to February 2017).
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AgeInfo (to June 2016).
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Social Care Online (to October 2016).
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Centre for Reviews and Dissemination (CRD) Databases (to May 2016).
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The Collection of Computer Science Bibliographies (to June 2016).
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DBLP Computer Science Bibliography (to June 2016).
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Networked Computer Science Technical Reference Library (NCSTRL) (to November 2016).
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Computing Research Repository (CoRR) (to December 2016).
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IEEE Computer Society Digital Library (to October 2016).
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Springer Link Lecture Notes (to October 2016).
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HCI Bibliography: Human‐Computer Interaction Resources (to June 2016).
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Inspec (to October 2016).
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J‐STAGE: Japan Science and Technology Information Aggregator, Electronic (to November 2016).
The search was adapted as needed for each database. There was no language restriction. See Appendix 2 for the search strategies used for these databases.
Searching other resources
Additionally, Google Scholar and OpenSIGLE were searched for grey literature. References of identified articles were handsearched using the snowball method in order to find other potentially relevant studies.
Data collection and analysis
HvdR and JW divided the databases between them and executed the search strategies as described.
Selection of studies
The search results were merged using reference management software and duplicate records were removed. HvdR and JW independently screened study titles and abstracts for appropriateness. We removed obviously irrelevant reports and linked multiple reports of the same study.
We obtained full‐text versions of potentially relevant reports. HvdR and JW examined these independently to assess compliance with the predefined eligibility criteria. If suitability of a study was unclear after examining the full text, we contacted the corresponding author to request clarification or additional information, or both. HvdR and JW compared and discussed their results. In the case of disagreement we examined abstracts and full papers in more detail until agreement was reached. Studies excluded for not meeting the predefined eligibility criteria are listed in the 'Characteristics of excluded studies' table together with the reasons for exclusion.
Results
Description of studies
See: Characteristics of excluded studies.
The initial search identified a total of 1246 citations after de‐duplication and first assessment by the CDCIG information specialist. After screening the titles and abstracts, nine full‐text papers were retrieved and one clinical trial was considered for further assessment. Two papers were looked at in more detail because they were reviews on assistive technology for cognition (Gillespie 2012) and late‐life mental disorders (Westphal 2010). Both reviews discriminated between studies of AT for dementia and AT for other disorders, however no studies were described that met the inclusion criteria for this review.
HvdR and JW independently evaluated the remaining papers and clinical trials for study design and methodological quality (Hofmann 2003; ISRCTN 86537017; Labelle 2006; Lancioni 2010; Mihailidis 2004; Mihailidis 2008; Ownby 2012; Spring 2011). It was agreed that none of the studies met the review eligibility criteria. See Figure 1 for an overview.
Flow diagram
Excluded studies
The following studies were evaluated in detail but excluded as discussed above.
Hofmann 2003 studied an interactive computer‐based training programme that relates to activities of daily living. This intervention did not meet the inclusion criteria and the study had a non‐randomised longitudinal group design. Lancioni 2010 described two studies on the use of verbal instructions and support technology to enable people with dementia to perform daily activities — making coffee or setting the table (Study I) and preparing a fruit or vegetable salad (Study II). Neither study had a randomised design. The study conducted by Labelle 2006 to evaluate an automated prompting system to support handwashing was not eligible for inclusion due to the multiple‐treatment, single‐subject design. Mihailidis 2004 and Mihailidis 2008 described two studies to assess the efficacy of COACH (Cognitive orthosis for assisting activities in the home), a computerised prompting system that supports people with dementia in the process of handwashing, but both were ineligible because they used a single subject design. Ownby 2012 used a randomised design to evaluate improvement of medication adherence using an electronic pill bottle, but the study was excluded as, although participants were clinically judged to have memory impairment, there was no validated dementia diagnosis. Spring 2011 described a computerised decision support system intervention used in primary care practice for treating mental illness; this study was excluded as neither the intervention nor the participants met the review eligibility criteria.
Ongoing studies
The ATTILA project (Assistive Technology and Telecare to maintain Independent Living At home for people with dementia), a registered clinical trial started in 2013, aims to support people with dementia to remain more independent for longer in their own home with the help of AT and telecare (ATT) (ISRCTN 86537017). The type of ATT used in the intervention will vary per participant, depending on individual needs. The study uses a multicentre randomised controlled trial design. The range of AT utilised within the study may not all be provided with the exclusive aim of supporting memory problems, so critical evaluation of the study design and results will be required to decide whether to include it or not. One of the two primary outcome measures — time from randomisation to admission to long‐term care — meets the review inclusion criteria, as do the secondary outcome measures: caregiver burden, quality of life, number and severity of adverse events, information on acceptability, applicability and reliability of the ATT offered. The trial is ongoing and no results are published yet.
Risk of bias in included studies
Not applicable since no studies met the inclusion criteria.
Effects of interventions
No studies met the inclusion criteria for this review.
Discussion
Summary of main results
We did not identify any completed studies that met the inclusion criteria for this review. One ongoing study, ATTILA, may meet the inclusion criteria, although the intervention will be tailored to the needs of the individual participant, and so will vary from person to person (ISRCTN 86537017). Prospective study results will need to be examined critically to decide on inclusion, as AT is not always provided with the sole aim of supporting memory problems, and will therefore not meet the review inclusion criteria. Studies that were evaluated in detail were excluded primarily because of study design, with longitudinal, non‐randomised and single‐subject designs being used. All of them had small sample sizes, for reasons not discussed in the publications. In general the AT could not be applied in large‐scale study designs because personalisation of the devices was required to meet the needs of their users: test settings, in which were installed sophisticated technical equipment to execute, monitor, and assess the interventions, were set up in the living environments of participants (Labelle 2006; Lancioni 2010); training was provided in some instances (Hofmann 2003); or many task rehearsals were needed (Lancioni 2010), as was intensive data collection in some studies (Lancioni 2010; Mihailidis 2004; Mihailidis 2008). The studies also used advanced technology to assess the performance of the people with dementia using the AT, making the studies expensive, and reducing the opportunity to include large study samples. It should be noted that all of the studies reported (moderately) positive results on functional domains.
AT to support people with dementia was first introduced into practice in approximately the year 2000, so this is a relatively new area. We therefore did not expect to find many randomised controlled trials at this stage, but the total lack of them is surprising. For every study including vulnerable groups, including people with cognitive impairment of whom some may be not mentally competent, gaining ethical governance is subject to strict regulations. Meeting these strict regulations can cause challenges in conducting studies in people with cognitive impairment and might be one of the reasons why no RCTs meeting the inclusion criteria were identified in this review. We also found that there is a lack of standardised terminology for AT. We had to use a large number of search terms, and there were a lot of false positives among the search results. Two prominent terms that were used in the literature were "technology" and "device", but in addition we also found terms such as "computerised" and "automated" that were used in combination with terminology addressed in the search strategy. Standardisation of terminology is needed to help identify studies in this developing area.
Quality of the evidence
No evidence was reviewed.
Agreements and disagreements with other studies or reviews
The lack of robust evidence for the effectiveness of AT for memory support for people with dementia is reflected across the spectrum of AT research, including other elderly populations. Various reviews of AT to support people with dementia have been conducted, and all report moderate or promising effects of small‐scale studies. Martin 2008 did not identify any eligible studies of smart home technologies for health and social care support of people with a physical disability, dementia or learning disability. Lauriks 2007 identified numerous small‐scale uncontrolled studies that evaluated the use of assistive devices providing practical support with the symptoms of dementia, (personalised) information, monitoring and perceived safety, and social contact and company. The same applies to Bemelmans 2012, Buettner 2010, Carswell 2009, Ciro 2014, Fleming 2014, Huschilt 2012, Mohktari 2012, Rigaud 2011, and Span 2013.
Peterson 2012 highlight the absence of an international consensus on a classification system for AT; and call for the several professional groups involved in developing and evaluating AT in dementia to use a common language to define and describe technology. The authors suggest that the societal impact of AT will emerge when the definitions, goals and outcomes are clearly set.
There is some published research on the involvement of people with dementia in developing AT to meet their own needs (e.g. Davies 2009; Dröes 2010; Mulvenna 2010; Sixsmith 2007; Span 2013; Topo 2009). Since needs are a consequence of the symptoms and impairments of dementia, they will vary per person, and so it is important that AT devices can be tailored to the individual user (Peterson 2012). AT devices are of no use if they exceed the skills level of their user (Dröes 2010; Mayer 2013; Meiland 2017).
