The use of technology in creating individualized, meaningful activities for people living with dementia: A systematic review:

Gemma Goodall; Kristin Taraldsen; J Artur Serrano

doi:10.1177/1471301220928168

The use of technology in creating individualized, meaningful activities for people living with dementia: A systematic review:

Goodall, Gemma; Taraldsen, Kristin; Serrano, J Artur 2020-05-31 00:00:00 There is a growing interest in using technology to provide meaningful activities for people living with dementia. The aim of this systematic review was to identify and explore the different types of digital technologies used in creating individualized, meaningful activities for people living with dementia. From 1414 articles identified from searches in four databases, 29 articles were included in the review. The inclusion criteria were the study used digital technology to deliver an individ- ually tailored activity to participants with dementia, the process of individualization was described, and findings relating to the mental, physical, social, and/or emotional well-being of the participant were reported. Data extracted from the included studies included participant demographics, aims, methods, and outcomes. The following information on the technology was also extracted: purpose, type, training, facilitation, and the individualization process. A narrative synthesis of the results grouped the various technologies into four main purposes: reminiscence/ memory support, behavior management, stimulating engagement, and conversation/communica- tion support. A broad range of technologies were studied, with varying methods of evaluation implemented to assess their effect. Overall, the use of technology in creating individualized, meaningful activities seems to be promising in terms of improving behavior and promoting relationships with others. Furthermore, most studies in this review involved the person with Corresponding author: Gemma Goodall, Norwegian University of Science and Technology, Trondheim 7491, Norway. Email: [email protected] Goodall et al. 1443 2 Dementia 0(0) dementia in the individualization process of the technology, indicating that research in this area is adopting a more co-creative and inclusive approach. However, sample sizes of the included studies were small, and there was a lack of standardized outcome measures. Future studies should aim to build a more concrete evidence base by improving the methodological quality of research in this area. Findings from the review indicate that there is also a need for more evidence concerning the feasibility of implementing these technologies into care environments. Keywords dementia, technology, psychosocial, person-centered, systematic review Introduction Dementia is an umbrella term for various neurodegenerative syndromes that impact pri- marily memory, cognition, language, and behavior. There are currently around 50 million people living with dementia worldwide, and it is estimated that there are almost 10 million new cases of dementia each year (Prince et al., 2015). Given the increasing prevalence and incidence of dementia, the World Health Organization (WHO) has stressed the need to invest in research and cost-effective approaches to meet the needs of people living with dementia and their caregivers (WHO, 2015). Psychosocial approaches to supporting those living with dementia include the use of meaningful activities to promote well-being. Previous literature that aims to deﬁne the term “meaningful activity” in the context of dementia care has often done so from the perspective of people with dementia, their family, and health-care professionals (Harmer & Orrell, 2008; Phinney et al., 2007). Focus is placed on values and beliefs that resonate with past roles, interests, and routines of the individual with dementia. Harmer and Orrell (2008) categorized activities considered to be “meaningful” into reminiscence, family and social, musical, and individual activities. This literature review focuses on the last of these activities, although the four types tend to overlap. Harmer and Orrell (2008) describe individual activities as being adapted to the preferences and capabilities of the person with dementia, and discuss the importance of relating these activities to the past lifestyle of the individual. This review uses the term “individualized” to emphasize that the fact that a process has taken place to adjust the activity to the speciﬁc preferences and abilities of the individual. While work in this ﬁeld has long focused on person-centered care (Brooker, 2003; Kitwood, 1997), ﬁndings from previous literature reviews concerning the individualization of activities for people with dementia appear to be mixed. Travers et al. (2016) recommend that individualized activities may be effective for behavioral and psychological symptoms of dementia, especially with regard to improving passivity and agitation, and increasing plea- sure and interest. Subramaniam and Woods (2012) conducted a systematic literature review on the impact of individual reminiscence therapy for people with dementia. The authors suggest that conducting a life review with a person with dementia, in which a life storybook is produced, has a positive impact on cognition and well-being. They also suggest that personhood and well-being can be promoted using individualized reminiscence approaches that meet speciﬁc needs of the individual with dementia. Despite these suggestions, however, a recent Cochrane review found very little evidence for personally tailored activities being 1444 Dementia 20(4) Goodall et al. 3 able to improve psychosocial outcomes for people living with dementia (Mohler € et al., 2018). While offering personally tailored activities (such as listening to individualized music playlists or making puzzles from familiar photographs) to people with dementia in long-term care may slightly improve challenging behavior, effects on mood were uncertain, and the authors were unable to make recommendations about speciﬁc activities. Constant advances in technology provide potential for designing new and innovative ways of meeting speciﬁc needs of individuals with dementia. In a very recent overview of technology and dementia, Astell et al. (2019) identiﬁed leisure and activity as one of the main domains of technology development within dementia care. The authors remark that technology—such as smartphones, tablets, wearables, robots, virtual reality, and artiﬁcial intelligence—is prompting thought on how care services can be better delivered to address the well-being of people with dementia. The authors also argue that the rapid pace of technology development requires a holistic view of dementia. In expanding the view of dementia beyond a narrow medical approach, technology may be used to empower people with dementia, supporting them to live a more meaningful life. For instance, a recent study suggested that the use of a social robot for hospital patients with dementia promoted a sense of self and facilitated social connection with others (Hung et al., 2019). Arthur (2009) deﬁnes technologies as assemblies of practices and components put to use in order to fulﬁll a speciﬁc purpose. In recent years, there has been much work done on the use of various technologies for providing meaningful activities in dementia care. Digital technologies, such as mobile and tablet apps, have been suggested to enable collaborative explorations of life events by people with dementia and caregivers, encouraging the care- giver to reﬂect and learn more about the individual (Maiden et al., 2013). Purves et al. (2011) also comment on the role that multimedia technologies (e.g., digital life stories) have on conveying the narrative of people living with dementia, and the authors stress that further work needs to be done in understanding how these technologies can be used in everyday practice. In a review on touchscreen technology for people with dementia, Joddrell and Astell (2016) commented that the primary use of touchscreen technology has been to deliver assessments and screening tests, and they called for more focus on how this technology can be used to deliver independent activities for meaningful occupation. To date, there are no literature reviews that provide an overview of the evidence on using technology to create individualized, meaningful activities for people with dementia. Furthermore, there is arguably a need to take qualitative and mixed-method studies into account in this area of research, especially given that meaningful activity within dementia care is often measured in subjective terms of enjoyment (Harmer & Orrell, 2008). While the importance of thorough quantitative meta-analyses remains, much can be learnt from qual- itative and mixed-method research in addition to quantitative studies. The Cochrane Qualitative and Implementation Methods Group Guidance Series highlights the important role of qualitative and mixed-method reviews in understanding how interventions work and how they are implemented (Noyes et al., 2018). Therefore, this literature review will consider qualitative, quantitative, and mixed-methods research to acquire a comprehensive overview of the work that has been done on this topic. The main purpose of this review is to answer the following research question: What are the different digital technologies used to create individualized activities for people with dementia, and how are these facilitated? For the purpose of this review, we deﬁne digital technologies as devices, systems, or applications that can be used to create, store, view and/ or share information electronically. In order to further explore the ﬁndings from this Goodall et al. 1445 4 Dementia 0(0) question, the review will also answer the following secondary research questions: (a) How are these technologies individualized? and (b) What is known about the effects of these technologies on the well-being of people living with dementia? Methods This systematic review was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Moher et al., 2009a). Eligibility criteria The SPIDER strategy (Sample, Phenomenon of Interest, Design, Evaluation, Research type) was used as a tool for shaping the search. SPIDER has been adapted from the PICO formulation (Population, Intervention, Comparison, Outcome) to be more suitable for qualitative and mixed methods research (Cooke et al., 2012). The SPIDER strategy for this review was as follows: • Sample: people living with dementia. • Phenomenon of interest: technology-based, meaningful activities tailored speciﬁcally for the person with dementia. • Design: case study, observational study, randomized controlled trial, quasi-experimental study, questionnaire, interviews, and focus groups. • Evaluation: outcomes related to the mental, physical, social and/or emotional well-being of the person with dementia. • Research type: quantitative, qualitative, or mixed-method. Only studies published in a peer reviewed journal and in English language were consid- ered for review. In order to focus on more recent technologies, studies published before 2005 were not considered for review. Additionally, as another systematic review focusing on meaningful interventions for people living with dementia noted, person-centered care prac- tices were not widely adopted until 2005 (Travers et al., 2016). Given that the scope of this review is to focus on individualized activities, it was deemed appropriate to limit the results to being published in 2005 or later. Inclusion criteria. Studies were included if they met all of the following criteria: (a) uses digital technology to deliver an individually tailored activity to participants with dementia, (b) describes the process of individualization, and (c) reports on ﬁndings directly relating to the mental, physical, social, and/or emotional well-being of the person with dementia. Exclusion criteria. Studies were excluded if they met any of the following criteria: (a) reports solely on the well-being of caregivers or (b) reports ﬁndings solely relating to the technology rather than the person with dementia. Literature reviews, study protocols, theoretical papers, conceptual papers, and position papers were also excluded from the review. 1446 Dementia 20(4) Goodall et al. 5 Information sources Given the interdisciplinary nature of this topic, four databases were used for the search, with the aim of capturing as many potential articles as possible. The following databases were used: CINAHL, Embase, PubMed, and Scopus. A combination of Boolean operators and truncations were used. MeSH Terms were also used where applicable. Table 1 gives a summary of the search terms. Search Study selection. The selection of articles for review was conducted by the ﬁrst author. All articles underwent a ﬁrst screening after duplicates were removed. This consisted of titles and abstracts being screened against the inclusion and exclusion criteria. Included articles then underwent an assessment for eligibility, which involved a reading of the article in full. Additionally, backward citation searching and forward citation tracking was conducted on these articles. Articles from this additional search that met the inclusion criteria were includ- ed for review. Coauthors Kristin Taraldsen and J Artur Serrano independently checked the ﬁnal selection of articles against the inclusion and exclusion criteria.There were no discrep- ancies, and therefore this ﬁnal selection of articles was approved by all authors. Data extraction and synthesis. Data relating to the study aims, design, demographics, data collection, methods, and ﬁndings were extracted from each article. Additionally, informa- tion on the purpose of technology studied, type of technology, media contents and services, the individualization process, environment of technology use, training on technology use, and facilitation of the intervention/activity was also extracted. Due to the heterogeneity of the results and the novelty of this ﬁeld of research, no meta- analysis was conducted. The application of technology for meaningful activities is still an emerging area of work, with many different approaches and devices being used. Therefore, results are presented through a narrative synthesis. Findings from the studies are summa- rized to answer each of the research questions in turn. Results Study selection The initial search returned 1414 articles: 217 from PubMed, 507 from Scopus, 139 from CINAHL, and 551 from Embase. An overview of the study selection is shown in Figure 1. Table 1. Summary of search terms. Search Terms #1 dement* OR alzheimer’s #2 personal OR personalized OR personalised OR person-centred OR person-centered OR person-focused OR individualized OR individualised OR individualistic OR meaningful OR biographical OR autobiographical OR tailored #3 technology OR virtual OR augmented OR media OR multimedia OR touchscreen OR iPad OR app OR mobile OR ICT OR tablet* #4 #1 AND #2 AND #3 Goodall et al. 1447 6 Dementia 0(0) Figure 1. PRISMA flow diagram of study selection process. Adapted with permission from Moher et al. (2009b). In short, 906 records were screened and 837 were excluded. Reference list checking and forward citation tracking was conducted on the remaining 69 articles to identify additional records. From these searches, 8 articles were identiﬁed, meaning that a total of 77 articles were assessed for eligibility. This assessment resulted in a total of 29 articles for review. Study characteristics Twenty-nine studies (reported in 29 separate articles) were included for review. From these studies, 12 were qualitative, 13 used mixed-methods, and 4 were quantitative. An overview of study characteristics is given in Table 2, which summarizes study design, participant information, aims of the study, interaction with technology, measures, and ﬁndings for each study. The most commonly used study design was the case study (N¼ 12). Only two randomized trials were included. Other designs included ﬁeld trials and explorative studies. A total of 231 participants were included across the 29 studies (ranging from 1 to 51, with a median of ﬁve participants per study). The mean age of participants ranged from 52 to 87. However, two studies only reported the age range of participants, and seven studies did not specify 1448 Dementia 20(4) Table 2. Study characteristics. Participants with dementia Author Study design Interaction with Measures Findings N Mean age Type and severitya Study aim(s) technology Critten and Case study 3 83.3 Mild to moderate Study the role of an indi- Creation of multi- Interviews, field The app facilitated the elicita- Kucirkova dementia vidualized multimedia media story notes, tion, storage and sharing of (2017) iPad app (Our Story) in over 7 weeks observations special memories. All partic- the stimulation, preser- ipants experienced positive vation and sharing of feelings of confidence, special memories empowerment and increased self-esteem Damianakis et al. Exploratory feasi- 12 79.6 Early to advanced Observe participant Production of Observations, Multimedia biographies stimu- (2010) bility study AD (N¼ 6), responses to personal- DVD biogra- interviews lated reminiscence, evoked MCI (N¼ 6) ized multimedia phies followed feelings of mostly joy but biographies by weekly occasionally sadness, and screenings for 6 stimulated social months interactions Davis and Shenk Mixed-methods 10 84.3 Late moderate Compare effects of per- Video screenings OME, language Slight preference for looking at (2015) study dementia, mean sonalized and generic over 6 weeks patterns from personalized videos first. FAST score 5.2 multimedia videos on transcriptions Generic videos produced engagement using prede- wider range of conversa- fined codes tional topics and phrasal patterns. Davison et al. Randomized, 11 86 Mild to severe Assess the effects of a per- Use of multimedia CMAI; CSDD; Significant reduction in depres- (2016) single-blinded dementia. Mean sonalized multimedia system for 4 RAID, sion and anxiety scores. No cross-over MMSE 16.2 system (Memory Box) weeks interviews significant change in agitation study on agitation, depression scores and anxiety De Leo et al. Case study 1 80 AD, FAST Stage 4 Assess whether a slideshow Use of smart Recent events DVD of daily life pictures (2011) of daily life moment pic- phone for 4 memory recall helped the participant recall tures captured by a weeks. DVD of test (non-stan- recent events significantly smart phone can support recent events dardized) and better autobiographical viewed once a satisfaction memory week questionnaire Ekstrom € et al. Case study 1 52 AD Explore the effects of a Use of device over Video recordings, (2015) personalized digital 2 weeks interview (continued) Goodall et al. 1449 Table 2. Continued. Participants with dementia Author Study design Interaction with Measures Findings N Mean age Type and severitya Study aim(s) technology device application Application use increases inter- (GoTalk NOW) on active and communicative communication actions Hashim et al. Case study 1 74 Mild AD To test a personalized digi- Weekly sessions Observations, The participant felt the tool (2015) tal memory book over 8 weeks evaluation form enhanced reminiscence. (myBook) for usability, (non- Observations indicated functionality, reminis- standardized) improvement in social inter- cence, and cognition action and communication Hung et al. (2018) Mixed-methods 4 Range 69– AD/Vascular/ Explore the feasibility and iPad simulated Video ethnogra- Four themes: (a) positive feasibility and 80 Parkinson’s acceptability of using an presence ther- phy, observa- responses, (b) person-cen- acceptability Dementia iPad Simulated Presence apy over 2 tions, semi- tered care, (c) video con- study Therapy intervention weeks structured tent, and (d) technical skills. interviews with hospital staff Karlsson et al. Explorative multi- 7 Range Alzheimer’s Explore the process of Use of digital Interviews, obser- The digital photograph diary (2014) ple case study 72–81 disease acceptance and integra- photograph vations, field contributed to increased tion of a digital photo- diary over 22 notes, MMSE, communication, promoted graph diary as a tool for weeks PGCMS, Free relationships, and was per- remembrance of and recall memory ceived as a stimulating joint conversations about index, recogni- activity daily life events tion memory index Karlsson et al. Explorative study 7 77 Alzheimer’s dis- Explore how sense of self Use of digital Audio recorded Two themes from discourse (2017) ease, Mean and identity are mani- photograph communication analysis: manifestations of MMSE 22 fested in narrations diary over 3 sessions, obser- sense of self and sense of self about recent events months vations, field in relation to others. Digital enabled by a digital pho- notes photography diary sup- tograph diary ported communication Kerssens et al. Qualitative study 7 77 Dementia (N¼ 4), Test the usability, feasibility Use of Goal attainment, The Companion facilitated (2015) MCI (N¼ 3) and adoption of a touchscreen observations, meaningful and positive touchscreen computer computer interview engagement intervention (The intervention Companion) (continued) 1450 Dementia 20(4) Table 2. Continued. Participants with dementia Author Study design Interaction with Measures Findings N Mean age Type and severitya Study aim(s) technology over an average of 31 days Khosla et al. Field trial 4 – – Measure the impact of a Use of assistive Video recordings The robot had positive impact (2014) personalized assistive robot over 6 of interaction, on emotional well-being and robot on emotional months activity data, provided sensory enrich- engagement emotional ment and social connectivity. responses, quality of robot experience survey Khosla et al. Longitudinal field 5 – – Evaluate the impact of a Use of assistive Observational Positive experience with the (2016) trial personalized assistive robot over 3–6 videos, interac- robot, improvement in sen- robot in the context of months tional data, sory enrichment home-based dementia quality of robot care experience survey Laird et al. (2018) Quasi-experimen- 30 79 Early to moderate Measure the effect of tech- Use of the iPad Mutuality Scale, Significant increases in mutuali- tal feasibility dementia nology-enabled reminis- app over 12 QCPR, WHO- ty, quality of carer and study cence iPad app weeks 5 patient relationship, and (InspireD) on mutuality, subjective well-being quality of carer and patient relationship and subjective well-being Massimi et al. Pre/post-test 1 84 AD, moderate Assess whether a bio- Use of ambient GDS-30; GAS, Improvement in apathy and (2008) single case graphical ambient display display over 1 AES-I; SIP-AD; positive self-identity. No study (Biography Theatre) month TST; AMI; improvement in autobio- improves autobiographi- MMSE; graphical memory, anxiety, cal memory and sense of IQCODE; depression and general identity custom inter- cognition views and questionnaires McAllister et al. Case study 3 82 Lewy body dis- To explore the use of a Field notes, focus Five themes: experienced and (2020) ease, AD, personalized iPad app groups and expected benefits of (continued) Goodall et al. 1451 Table 2. Continued. Participants with dementia Author Study design Interaction with Measures Findings N Mean age Type and severitya Study aim(s) technology dementia non- (Memory Keeper) with Use of app over 6- individual Memory Keeper; engage- specific, mod- regard to barriers, facili- month trial interview ment of the person with erate to tators, benefits and period dementia and their response advanced incorporation into care. to memory keeper; recruit- ment, media collection, set- up training and handover; use of memory keeper in long term care setting Navarro et al. Case study 1 70 AD, MMSE 17 Study the effect of an Use of system NPI-Q; AES, care- Use of systems had a positive (2015) ambient display system over 16 weeks giver diary, effect in reducing challenging (AnswerBoard) and interviews behaviors mobile app (AnswerPad) on behavioral symptoms Navarro et al. Field study 2 N1¼ N2¼ 73 AD, MMSE scores 17 and Study the effec- Use of system NPI-Q; AES (2016) “Over 21 tiveness of over 16 weeks 70”, assisted cogni- tion system (AnswerBoard/ AnswerPad) to support occu- pational thera- py interventions Use of systems had a positive effect in reduc- ing challenging behaviors O’Connor et al. Single-system 1 83 Vascular dementia, To evaluate the effect of Video simulated Observations, Significant reduction in resis- (2011) ABA withdraw severe video-simulated pres- presence for 14 adapted tance to care with the use of design PAS¼ 21 ence for decreasing days Positive video simulated presence resistance to care Response Schedule (continued) 1452 Dementia 20(4) Table 2. Continued. Participants with dementia Author Study design Interaction with Measures Findings N Mean age Type and severitya Study aim(s) technology Park et al. (2017) Multi-site case 7 – Early stage Assess how digital story- Seven-session Observational Overall enjoyment of sessions, study dementia telling affects quality of workshop over field notes, ability to share stories, life in terms of relation- 6 weeks audio recorded enhance relationships, ships and self-identity workshop ses- increase in communication sions and and interaction interviews Peeters et al. Formative 5 – Early to severe Evaluate the use of a per- Single time use of Observations, Observed positive effects on (2016) evaluation dementia sonalized music platform music platform interview memory recall, mood, and (Music ePartner) social interaction Piasek et al. (2012) Case study 1 87 Early-stage Explore whether SenseCam Use of SenseCam Interview, obser- No change in psychometric dementia images can encourage for 7 weeks. vations, field measures, confusions about meaningful discussions Viewing of notes, psycho- source of images, did not about recent memories images twice a metric tests stimulate discussions and help maintain sense week (not specified) of identity Ryan et al. (2018) Qualitative study 15 78 – To explore the impact of a Use of iPad app Semi-structured Six themes: usability, revisiting personalized reminis- over 12 weeks interviews the past; home use; impact cence program facilitated on the person with demen- through an iPad app tia; gains and abilities; impact (InspireD) on relationships Samuelsson and Dyad case studies 3 – – To understand how digital Single time use of Video recordings CIRCA and CIRCUS support Ekstrom € (2019) communication support digital commu- conversation topics, person- may be used in interac- nication app al photographs in CIRCUS tion with people with are more engaging dementia Silva et al. (2017) Single-blind ran- 51 73.7 Mild Alzheimer’s To assess the effects of Use of SenseCam GDS-30, IAFAI, Significant reduction in depres- domized trial disease wearable camera for 6 weeks. WHOQOL- sion with SenseCam and memory aid (SenseCam) Images OLD Memoþ compared to diary on well-being compared reviewed twice control condition to paper memory train- a week ing program (Memoþ) and written diary (control) (continued) Goodall et al. 1453 Table 2. Continued. Participants with dementia Author Study design Interaction with Measures Findings N Mean age Type and severitya Study aim(s) technology Subramaniam and Multiple case 6 82.2 Mild to moderate To compare the use of a Digital storybooks QOL-AD; AMI-E; Five out of six participants Woods (2016) study dementia, CDR multimedia digital life created over 7– GDS-12R; showed improvement in scores of 1 storybook vs. conven- 10 weeks, DVD QCPR; Semi- quality of life and autobio- (N¼ 5) and 2 tional life storybook then given to structured graphical memory after (N¼ 1) participants for interview having the digital storybook regular viewing for 4 weeks Welsh et al. Case study 11 – Moderate to To explore whether a per- Use of digital app Interviews, work- Three themes: promoting and (2018) severe sonalized digital app over 4 weeks shop managing reminiscence; (Ticket to Talk) can sup- across 6 visits discussions starting and maintaining port communication conversation; redistributing between people with agency dementia and younger people Woodberry et al. Within-subject 6 72 AD, mild to mod- To compare the effects of Use of wearable Memory recall Recall significantly more details (2014) longitudinal erate, using a wearable camera camera for 3.5 tests, interview of events in the camera study Addenbrooke’s vs. a written diary to aid months condition for five out of six Cognitive retrospective recall of participants compared to the Examination significant personal written diary condition mean 70.8 events Yasuda et al. ABCA design 15 77.3 AD, Mean MMSE To assess whether person- Single event of Video recorded 80% of participants showed (2009) 14.3 alized photo video obtain viewing photo responses mea- more attention to personal- more attention com- videos sured in terms ized reminiscence photo pared to generic TV of concentra- video than other TV shows. shows tion and dis- Higher concentration scores traction scores for moderate and severe dementia participants Note: Symbol “–” indicates not specified. AD: Alzheimer’s Disease; MCI: Mild cognitive impairment; FAST: Functional Assessment Staging Tool; OME: Observational measure of engagement; CMAI: Cohen-Mansfield Agitation Inventory; CSDD: Cornell Scale for Depression in Dementia; RAID: Rating Anxiety in Dementia; MMSE: Mini-mental state examination; PGCMS: Philadelphia Geriatric Center Morale Scale; QCPR: Quality of the Caregiver Relationship questionnaire; WHO-5: World Health Organization Five Well-being Index; GDS-30: Geriatric Depression Scale-30; GAS: Goldberg Anxiety Scale; AES-I: Apathy Evaluation Scale-Informant; SIP-AD: Self-Image Profile-Adults; TST: Twenty Statements Test; AMI: Autobiographical Memory Interview; IQCODE; Informant Questionnaire of Cognitive Decline in the Elderly; NPI-Q; Neuropsychiatric Inventory Questionnaire; AES: Apathy Evaluation Scale; PAS: Psychogeriatric Assessment scales; IAFAI; Adults and Older Adults Functional Assessment Inventory; WHOQOL-OLD: World Health Organization Quality of Life-OLD module; CDR: Clinical Dementia Rating scale; QOL-AD: Quality of life Alzheimer’s disease scale; AMI-E: Autobiographical Memory Interview extended version; GDS-12R: Geriatric Depression Scale (Residential). Type and severity as reported in the study. 1454 Dementia 20(4) Goodall et al. 13 age. The severity of dementia varied across the studies, with all stages being covered from mild to severe. Two studies included participants with mild cognitive impairment in addition to participants with more advanced dementia. The most common type of dementia was Alzheimer’s disease (N¼ 14). There were inconsistencies in reporting participant demo- graphics, with four studies failing to report either type or severity of dementia. Most studies aimed to assess the impact of the technology-based activity on memory, communication or engagement. Some studies adopted a more exploratory approach and aimed to report any effects that the technology may have had on the person with dementia. Interviews and observations were the most popular tools for data collection, with thematic analysis and discourse analysis being used to draw ﬁndings. In quantitative and mixed- methods studies, there was a large variety of standardized measures used that focused on numerous domains (for details see Supplementary Material, Table S1). The studies were also greatly varied in terms of length of technology use, ranging from single-time use to use of the technology for six months. Across the 29 studies, the average time spent using the technol- ogy was seven weeks. Synthesis of results What are the different technologies used to create individualized, meaningful activities for people with dementia, and how are these facilitated? A wide array of technology, with varying media con- tents and services, has been explored for creating individualized, meaningful activities for people with dementia. This review categorized the technologies into four main purposes that all tackle common challenges people living with dementia face, namely: reminiscence/ memory support, behavior management, stimulating engagement, and conversation/com- munication support. Table 3 gives an overview of the technologies studied with regard to their purpose, type, media contents and services, individualization process, environment of use, any training provided and the way in which the technology was facilitated in the study. Environment, training, and facilitation. The majority of studies (N¼ 18) were conducted within the homes of participants, who were living in the community (Critten & Kucirkova, 2017; Damianakis et al., 2010; De Leo et al., 2011; Ekstrom € et al., 2015; Hashim et al., 2015; Karlsson et al., 2014, 2017; Kerssens et al., 2015; Khosla et al., 2014, 2016; Laird et al., 2018; Massimi et al., 2008; Navarro et al., 2015, 2016; Piasek et al., 2012; Ryan et al., 2018; Samuelsson & Ekstrom, 2019; Welsh et al., 2018). Family members were often the facilitator of the technology use. In most studies, the presence of another person was required for the full facilitation of the intervention/activity. Whether it be family member, professional caregiver or therapist, it was deemed important that the technology was used as a joint activity. Even in the case where the person with dementia was encouraged to use the device or app independently, support from caregivers was available. Therefore, training of the technology was often given to both the person with dementia and their caregiver. Most studies were quite vague about the instructions given. However, a few studies described extensive training procedures (Davison et al., 2016; Kerssens et al., 2015; Laird et al., 2018). For example, in the study of the InspireD app (Laird et al., 2018), an IT assistant provided training to participants with dementia and their family members, who were living at home. In addition to this, participants also received reminiscence training. There were a couple of cases where the person with dementia was trained individually. Davison et al. (2016) reported that each of the 11 participants (with mild to severe dementia) Goodall et al. 1455 Table 3. Overview of technology, individualization, and facilitation. Media contents and Purpose Type Study Name services Individualization process Setting Training Facilitation Reminiscence or Lifelogging: De Leo et al. – Photos taken on Photos taken of everyday Home Given to people with People with dementia uses memory wearable (2011) smartphone life at 5-minute intervals. dementia and care- smartphone indepen- support camera lanyard Photos then saved to giver by researchers dently, then watches devices DVD DVD of photos with caregiver Karlsson SenseCam/digital Photos taken by Wearable camera Home Given to people with People with dementia uses et al. (2014, photograph wearable (SenseCam) takes dementia and family device, family uploads 2017) diary camera, captions photos of daily events. member by photos. They review with geolocation Photos then uploaded researchers photos together onto touchscreen com- puter (Digital photo- graph diary) Piasek et al. SenseCam Photos taken by Wearable camera takes Home Given to people with People with dementia uses (2012) wearable photos of daily events. dementia and family device, images reviewed camera Photos then reviewed by researchers with therapist Silva et al. on computer Hospital/clinic Given to people People with dementia uses (2017) with dementia by device, images reviewed researchers with neuropsychologist Woodberry – People with dementia uses et al. (2014) device, researcher or spouse uploads photos Digital app Critten and Our Story Photos taken on Story captured in Home/club for Given to people with Independent use by people Kucirkova iPad and found “conversational style” people with dementia by authors with dementia (with (2017) online, text cap- with people with dementia researcher support if tions, audio dementia. People with needed) narration dementia find own photos. Hashim et al. myBook Daily routine Caregivers supplied infor- Home Given to people with People with dementia and (2015) reminders, mation and photos to dementia and care- caregiver use together family photos, authors giver by authors games Laird et al. InspireD Photos, videos, People with dementia and Home Given to people with People with dementia and (2018) music family upload media dementia and family family use together contents with help of by IT assistant (þ reminiscence trainer reminiscence training) (continued) 1456 Dementia 20(4) Table 3. Continued. Media contents and Purpose Type Study Name services Individualization process Setting Training Facilitation Ryan et al. People with dementia and – (2018) family upload media contents to app Peeters et al. Music ePartner Music with text Questionnaire filled in by Day center Given to people with People with dementia and (2016) captions and people with dementia/ dementia and care- caregiver use together photos caregiver and given to giver by researcher authors Multimedia Damianakis – Photos, video, Student collaboration with Home People with dementia and biography et al. (2010) voice-over nar- people with dementia family use together (DVD/video- ration, music and family using based) workbook Park et al. – Photos, voice People with dementia, Community club Given to people with People with dementia and (2017) recordings, Family and researcher dementia and family family use together music, animation by authors guided by workshop facilitator Subramaniam – Photos, music, nar- Participatory design— Care home Digital life book played on and Woods ration, video people with dementia TV in people with (2016) and Family, researcher as dementia’s room co-editor Yasuda et al. – Photos, narration, Caregivers provided Hospital People with dementia (2009) music photos to researchers watched by him/herself Touchscreen Massimi et al. Biography theatre Photos, music, Authors worked with Home – Independent use by people device (2008) video, narration people with dementia with dementia and family Stimulate Social robot Khosla et al. – Music, photo, social Real-time individualization Home – Use by people with engagement (2014, 2016) connectivity, by robot capturing dementia and family games emotional responses PowerPoint Davis and – Photos, music, Students used photos pro- Memory care unit – Facilitated by student Shenk video vided by family volunteer (2015) Digital app McAllister et al. Memory Keeper Family photos, Researcher collaboration Long-term care Given to family by People with dementia and (2020) music, video, with people with facility researchers family member use book covers, dementia and family together themed images Memory Box Nursing home (continued) Goodall et al. 1457 Table 3. Continued. Media contents and Purpose Type Study Name services Individualization process Setting Training Facilitation Behavior Multimedia Davison et al. Movies, music, Researcher collaboration 2.5 hours training given Main use by people with management touchscreen (2016) photos, video with people with to people with dementia, support from device messages from dementia and family dementia, staff, family and staff carers family, family family by photos researchers Kerssens et al. The Companion Photos, captions, Life story interview with Home Given to people with Use by people with (2015) music, people with dementia dementia and care- dementia and family reminders, and family giver by expert in messages assistive technology Navarro et al. AnswerBoard/ Reminders, per- Researcher collaboration Home – Use by people with (2015, 2016) AnswerPad sonalized games with caregiver dementia with therapist Tablet with Hung et al. – Video from family Researcher collaboration Hospital – Used by professional carer video only (2018) with family O’Connor et al. – Video from family Family pre-recorded Care home Given by researchers Used by professional carer (2011) messages Communication/ Digital app Ekstrom € et al. GoTalk NOW Photos, video, text Collaboration between Home Given to people with Used by people with conversation (2015) captions, digi- people with dementia dementia and family dementia and family support tized and syn- and speech therapist member by thetic speech over 3 days researchers Samuelsson and CIRCUS Photos, films, Upload function on app Home Given by researchers Used by people with Ekstrom € music, videos to caregivers only dementia and profes- (2019) sional caregiver Welsh et al. Ticket to Talk Photos, sounds, Young person creates user Home/care home – Used by young person, (2018) videos profile with help from people with dementia family. App provides and family/carer prompts to invite young person to find out more about the people with dementia’s life Note: Symbol “–” indicates not specified. 1458 Dementia 20(4) Goodall et al. 17 received 2 hours of individual training to use a personalized multimedia touchscreen device. This training utilized spaced retrieval learning principles and involved research staff dem- onstrating procedures and asking the participant to imitate them. Despite this training, however, some participants were unable to use the device due to cognitive or sensory impair- ment. Similarly, participants (with mild to moderate dementia) in the study of the OurStory iPad app were trained to use the app independently, however they experienced practical difﬁculties such as not being able to hold the device or being unable to use the keyboard (Critten & Kucirkova, 2017). Facilitation ranged from professional caregivers having complete control of the technol- ogy (e.g., simulated presence on iPad apps in Hung et al., 2018; O’Connor et al., 2011), to joint use between people with dementia and family members (e.g., multimedia apps in Laird et al., 2018; Ryan et al., 2018, digital life storybooks in Critten & Kucirkova, 2017; Park et al., 2017, social robots in Khosla et al., 2014, 2016), and to more independent use by the person with dementia (e.g., Biography Theatre in Massimi et al., 2008). The most indepen- dently used devices were the lifelogging technologies. The SenseCam (Karlsson et al., 2014, 2017; Piasek et al., 2012; Silva et al., 2017; Woodberry et al., 2014) and the smartphone lanyard used by De Leo et al. (2011) were worn by the person with dementia during the day. However, in all studies of lifelogging technologies, support was needed from another indi- vidual to upload the photographs onto a DVD or computer. Reviewing the photographs then became a joint activity. How are these technologies individualized? Most of the studies described the individualization process as a collaboration between the person with dementia, the family member, and often a researcher. While most studies were unclear on the length of time taken to individualize the technology, there were some that used several weeks for the process. For example, digital stories were created over a 6-week period in Park et al. (2017) and an average of 8.3 weeks in Subramaniam and Woods (2016). Despite common collaboration between participants with dementia, family and research- ers, approaches to individualizing the app/device still differed. Examples include structured workbooks (Damianakis et al., 2010), a chronological approach by listing major life chap- ters (Massimi et al., 2008), stories captured in a “conversational style” (Critten & Kucirkova, 2017), life story interview (Kerssens et al., 2015), questionnaire (Peeters et al., 2016), participatory design (Subramaniam & Woods, 2016), in-app prompts (Welsh et al., 2018), and participants uploading their own media content to apps (Laird et al., 2018; Ryan et al., 2018; Samuelsson & Ekstrom, € 2019). The resonating theme among all these approaches is that of capturing the life story of the individual using photographs, music, and narratives (both textual and audio-recorded). Several studies used theory to inform the individualization process. For instance, Positioning Theory (Harr & Van Langenhove, 1998) informed Karlsson et al.’s (2017) work on the SenseCam. The approach to the study was to understand narrations about recent events as being co-constructed between the person with dementia and their partner. Park et al. (2017) was inﬂuenced by Bruner’s paradigm of narrative knowing and construc- tivism (Bruner, 2003). Damianakis et al. (2010) was informed by a framework that supports coherence of ego integrity and personhood during phases of impairment. Finally, Ryan et al.’s (2018) work on the InspireD app was underpinned by Kitwood’s notion of person-centered care (Kitwood, 1997). These four studies that used theoretical foundations Goodall et al. 1459 18 Dementia 0(0) for narrative creation all reported positive effects on self-identity and/or engagement from qualitative methods including discourse analysis, interviews, observations and ﬁeld notes. What is known about the effects of these technologies on the well-being of people living with dementia? Overall, the evidence from the included studies suggest that individualized, digital technol- ogies can have positive effects on the well-being of people living with dementia. Particularly promising areas of improvement include behavior and mood, sense of identity, and relation- ships and engagement with others. Speciﬁc domains of well-being are reported on in further detail below. Memory. The impact of these technologies on memory was mixed, and methods to assess memory were varied. Based on observational and interview data, several studies found that personalized multimedia can stimulate reminiscence (Critten & Kucirkova, 2017; Damianakis et al., 2010; Hashim et al., 2015; Welsh et al., 2018). The use of formal tests on memory was scarce. Two studies used the Autobiographical Memory Interview (AMI) (Kopelman et al., 1989), including Subramaniam and Woods (2016) who found that the use of a digital life storybook improved autobiographical memory after using the storybook for four weeks. Contrastingly, the study of a personalized biographical ambient display did not improve AMI scores after one month of use (Massimi et al., 2008). Mixed results were also present in the study of lifelogging technologies. De Leo et al. (2011) and Woodberry et al. (2014) found that pictures taken by a wearable camera enabled the participants to recall signiﬁcantly more details of recent events, as measured by non-standardized memory recall tests. However, a single case study of SenseCam conducted by Piasek et al. (2012) reported that the participant was confused about the source of images. Karlsson et al. (2017) also reported that there were certain situations where participants with Alzheimer’s disease were unable to recall any information related to the event shown from SenseCam photographs. Behavior and mood. Overall, the technologies included for review showed beneﬁcial effects on behavior and mood. Furthermore, studies that focused on this domain were more consistent in using standardized outcome measures. The AnswerBoard (public ambi- ent display) and AnswerPad (mobile phone app) devices were shown to have a positive effect in reducing challenging behaviors after 16 weeks of use, as indicated by decreased NPI-Q scores (Navarro et al., 2015, 2016). Another study on an ambient display system used the Apathy Evaluation Scale and found that the use of the system reduced the participant’s apathy after one month of use (Massimi et al., 2008). A personalized multimedia system was shown to signiﬁcantly reduce depression and anxiety after four weeks of use, as measured by the CSDD and RAID (Davison et al., 2016). Silva et al. (2017) found that the use of the SenseCam signiﬁcantly reduced depression scores, using the Geriatric Depression Scale. Studies focusing on simulated presence to reduce problematic behaviors had positive results. O’Connor et al. (2011) found that presenting residents with an iPad containing a video-recorded message from a family member for 14 days was able to signiﬁcantly reduce resistance to care. Similarly, Hung et al. (2018) also tested iPad-facilitated video simulated presence for 14 days and found that hospital patients with dementia responded positively. As well as improving behavior, the iPad intervention also resulted in positive changes in the mood of all participants. However, the authors noted that video content with too many family members with multiple messages provoked anxiety, emphasizing the importance of 1460 Dementia 20(4) Goodall et al. 19 acknowledging the individual needs of the person with dementia and being aware of possible over stimulation. Self-identity. Results from the identiﬁed studies suggest that a sense of self can be pre- served, even in later stages of dementia. Critten and Kucirkova (2017) found that the Our Story app gave participants conﬁdence, empowerment and increased self-esteem. Karlsson et al. (2017) studied the SenseCam in relation to self and identity. From discourse analysis, the authors identiﬁed two key themes: manifestations of sense of self and self in relation to others. With regard to sense of self, the authors found that even if the participant could not relate to the event shown in the photograph, the material still stimulated conversation about personal experience. When the participants’ partners had been involved in events captured by the SenseCam, narrating and remembering the event became a joint activity. However, it is important to note that some participants became stressed when the conversation became interrogative. The only study to use outcome measures for self-identity was Massimi et al. (2008) who used the Twenty Statements Test and the Self Image Proﬁle (Adult). The authors found that use of the Biography Theatre for one month led to an improvement in positive self-identity. It is also important to note that studies which included the person with demen- tia in the individualization process of the technology empowered the individual to become more connected with their sense of self. For example, participants in a digital storytelling workshop enjoyed the process of creating and sharing their stories over a six-week period (Park et al., 2017). Social relationships and engagement. Given the highly interactive nature of the technolo- gies, many studies found improvements in relationships, communication and engagement. Social robots were identiﬁed as a way of facilitating engagement and interaction for people with dementia (Khosla et al., 2014, 2016). Personalized digital media was considered as a tool for starting conversations (Davis & Shenk, 2015; Karlsson et al., 2014; Samuelsson & Ekstrom, € 2019; Yasuda et al., 2009), supporting interaction (Hashim et al., 2015; Park et al., 2017), and improving relationships between people with dementia and their caregivers (Karlsson et al., 2014; Laird et al., 2018; Park et al., 2017; Ryan et al., 2018). It was also reported that such media provided caregivers, and sometimes even family members, with new insights and heightened perspectives into the life of the person with dementia (Damianakis, 2010; Ryan et al., 2018; Samuelsson & Ekstrom, € 2019). The majority of these ﬁndings were based on interview or observation data. However, Laird et al. (2018) used the Quality of Carer and Patient Relationship scale (Spruytte et al., 2002) and the Mutuality Scale (Archbold et al., 1990) to assess the effect of the InspireD app on the relationship between the person with dementia and their caregiver. Scores on both scales were signiﬁcantly improved after 12 weeks of using the iPad app. There were some cases where tensions in the relationship were reported. For example, Ekstrom et al. (2015) found that problems associated with dementia were foregrounded during joint interaction with a tablet computer. The person with dementia became depen- dent on their conversational partner to be able to use the technology. Similar issues were experienced with the SenseCam. The participant in Piasek et al.’s (2012) study of SenseCam relied on his wife while reviewing photographs together with a therapist. Participants in another SenseCam study were reportedly frustrated when they felt the conversation about the photographs had become a test of their memory (Karlsson et al., 2017). Goodall et al. 1461 20 Dementia 0(0) Emotional well-being. Observations of interaction with technology were used to assess emotional reactions from the participants. Technologies that featured reminiscence activities or other autobiographical material provided participants with an enjoyable experience (Critten & Kucirkova; Damianakis et al., 2010; Hashim et al., 2015; Kerssens et al., 2015; Khosla et al., 2014, 2016; McAllister et al., 2020; Park et al., 2017; Peeters et al., 2016; Ryan et al., 2018; Samuelsson & Ekstrom, € 2019; Subramaniam & Woods, 2016). However, due to the highly personal nature of these activities, there is a potential for sensitive topics to cause negative reactions. There were numerous reports of sadness being experienced, especially when personal photographs of those who had passed away were used (Damianakis, 2010; Ryan et al., 2018). In these cases, it is important to remember that emotions are highly complex. Damianakis et al. (2010) commented on the possibility of observing both happi- ness and sadness simultaneously in reaction to pictures of a deceased loved one. Furthermore, family members involved in the study felt that it was important to include photographs and stories of loved ones, even if they had passed away. Discussion Summary of evidence This review has identiﬁed the varying types of digital technologies that are being used to create individualized, meaningful activities for people with dementia. Overall, the ﬁndings suggest the use of individualized technology to be promising in contributing to and advanc- ing dementia care. Technology can be used to complement psychosocial approaches to care such as reminiscence therapy, simulated presence therapy, occupational therapy and life story work. Additionally, this review has demonstrated how theory-based knowledge may be used to complement technology-based activities in dementia care. Studies that used the- oretical foundations for the individualization process of the technology all found positive impacts on a sense of self and/or engagement, suggesting that theory-based knowledge can be beneﬁcial for technology development. Findings from the review also indicate the amount of progress that has taken place in this ﬁeld. Only 7 of the 29 included studies did not actively involve the person with dementia in the individualization process of the technology. This contrasts to a 2008 literature review on technology studies to meet the needs of people with dementia and their caregivers. Topo (2008) found that very few studies actively involved the person with dementia in using the technology. Studies identiﬁed in this review not only involved the person with dementia as users of the technology, but in most cases, they were involved in the individ- ualization process, acting as co-creators of their own narratives. There was also a case where the individuals with dementia were involved in the development of the technology itself. The InspireD app was co-created by a User Development Group that consisted of six people with dementia working together with researchers (Laird et al., 2018; Ryan et al., 2018). Future work in this area should adopt a similar approach, involving people with dementia as co-creators from the onset of the technology development. Opportunities afforded by technology. Findings from this review are in accordance with other literature reviews in this area, in terms of the beneﬁts that technology can provide to people living with dementia. A systematic review of technology for reminiscence therapy found that using information and communication technologies for reminiscence therapy interventions 1462 Dementia 20(4) Goodall et al. 21 has beneﬁts such as providing access to rich multimedia materials, providing opportunities for social interaction, provision of memory support and ownership of conversations (Lazar et al., 2014). Similar results are resonated in this review, especially with regard to social interaction. Furthermore, the use of technology to preserve, share and explore the narrative of the person with dementia is consistent with earlier ﬁndings in this area (Maiden et al., 2013; Purves et al., 2011). One particularly meaningful beneﬁt of technology is that it provides a means of being able to access a wealth of images and other types of media. This can be very important, especially for those who may not have many photographs from their past. Participants using the OurStory iPad app found access to external images important (Critten & Kucirkova, 2017). This continuous and endless access to media also provides an opportunity to engage with not just the past, but also the present. Participants using the InspireD app were able to take pictures on the iPad and include them as part of their reminiscence program (Laird et al., 2018; Ryan et al., 2018). SenseCam captures everyday moments of daily life, enabling people to recollect upon recent events. The upload feature in CIRCUS (Samuelsson & Ekstrom, 2019) also allows participants to engage with media from recent events, if they wish to do so. Technology also presents life histories in a new way, which can be beneﬁcial for all individuals involved its use. Participants in the study of a digital life book were excited about seeing their life history: “I feel like I’m famous. I feel very excited,” “I can’t believe this, my mother will be proud of me . . . I feel like I’m being appreciated” (Subramaniam & Woods, 2016). Additionally, caregivers felt that technology provided a way of learning more about the life of the person with dementia (Damianakis et al., 2010; Ryan et al., 2018; Samuelsson & Ekstrom, 2019; Subramaniam & Woods, 2016). As Purves et al. (2011) sug- gest, technology can be a way of shaping an interactional environment in which narrative can be explored together: “With these technologies at our disposal, we not only have better ways to elicit and convey narratives . . . but we also have better ways to share these narratives with others, over time and across place” (p. 240). The technologies identiﬁed in this review provide examples of how this may be achieved. Challenges going forward. The results from this review have raised some potential issues that could be faced when implementing individualized technologies into practice. Associated costs are an important issue. The Memory Box device (Davison et al., 2016) cost 12,000 U.S. dollars for four units. Installation of the Biography Theatre took an experienced technologist 30–40 hours over the course of one month (Massimi et al., 2008). In Laird et al.’s (2018) study of the InspireD app, which itself is free, the training sessions cost 2750 GBP per dyad. Most studies were conducted in the homes of people with dementia, and this may be due to the fact that support from another individual was often needed in order to be able to use the technology. Care institutions such as nursing homes are often busy environments, in which one-to-one interaction may not always be possible due to time constraints. Additionally, home-dwelling individuals with dementia tend to be in more mild–moderate stages of dementia and therefore may be able to use the technology on a more independent level. This then raises the question of how practical it is to introduce such technology into care homes for individuals in more severe stages of dementia. Also, the issue of capacity was raised in Subramaniam and Wood’s (2016) study of the digital life book. It was questioned Goodall et al. 1463 22 Dementia 0(0) whether members of staff could be expected to take on the role of coproducing the life stories together with the person with dementia. Additionally, and maybe most importantly, there is a question of how well these tech- nologies can be introduced to this vulnerable group, especially in later stages of dementia. Numerous participants across the studies experienced difﬁculties in being able to interact with the technology. Examples include physical issues with being able to hold the device or press buttons, issues with being able to see the screen, or difﬁculties with general operation of the technology. Piasek et al. (2012) witnessed a particular struggle with SenseCam in getting the participant, John, to remember that he was the one wearing the camera: “The SenseCam technology seemed confusing for someone with such severe memory impair- ments. It also seemed pointless to continuously explain what SenseCam is and that is was John who wore it.” Even in studies where participants were aware of the SenseCam, they did not always respond positively to it. For example, one gentleman felt embarrassed by wearing the camera and felt it drew attention to him (Woodberry et al., 2014). These issues highlight the need to continue to develop awareness in potentially problematic areas such as physical limitations or sensory issues as well as self-consciousness or stigma. It is important that devices and technologies are developed with these issues in mind, so that they may be feasible for use by the target population. Limitations This is a relatively new ﬁeld of research and new technologies are constantly being pre- sented, meaning that the evidence on its impact and effectiveness is still somewhat limited. The ﬁndings from this review are limited by the small sample sizes of the included studies. Given the amount of time and effort required for individualizing technologies, especially when the identiﬁcation and collection of personalized multimedia is involved, it is under- standable that most studies had small sample sizes. Seven studies included only one partic- ipant. While these small case studies are valuable for providing rich, in-depth accounts, the ﬁndings are hard to generalize to a wider population. There is a clear need for studies with larger sample sizes with standardized outcome measures. Additionally, the time of use of the devices was highly varied among the studies. The use of the technology ranged from single- time use to six months. Another limitation of this review is the lack of a quality appraisal of the included studies. Given the fact that the use of individualized technologies in dementia care is still an emerg- ing ﬁeld, we wanted to include a variety of studies in order to gain a broad overview of the topic. Most of the research in this area consists of small case studies, and excluding these studies based on their quality would have resulted in a limited understanding of how these technologies can be potentially used in dementia care. There is some level of quality of assurance, given the fact that only articles from peer-reviewed journals were included for review. However, there may be potential bias from studies where researchers acted as collaborators or co-editors in the individualization process. For example, participants in Critten and Kucirkova’s (2017) study of the Our Story app enjoyed the process of remi- niscing together with the ﬁrst author and commented that the activity had brought back some ‘happy times’ that the participants were keen to share with the researcher at later interviews. Massimi et al. (2008) stated that a relationship had developed between the par- ticipant and the researcher in their role as “biographer.” The authors state that this rela- tionship shifted focus from the participant being “an old man with a bad memory” to being 1464 Dementia 20(4) Goodall et al. 23 a human being. However, this is to be expected, given that participatory design and co- creative approaches are increasingly being adopted in dementia research. Once more knowl- edge exists in this area, there will be a need to critically evaluate the quality of the evidence. Finally, a considerable number of articles had to be excluded for review due to lacking reports on the effects on the well-being of the person with dementia. This meant that other emerging technologies in this area were not commented on. It is important to be aware of other technologies beyond those included in this review, and how they can also create opportunities for the conveying of narrative. For example, virtual reality can be a means of recreating environments from the past (Hodge et al., 2018). Another example is a project called SENSE-GARDEN, which is developing multisensory spaces that combine music, ﬁlm, pictures, and scent with innovative technology to create an immersive environment tailored speciﬁcally for the individual with dementia (Goodall et al., 2019). Conclusion Various technologies can add value to the individualization of meaningful activities in dementia care. This review highlights the need to focus on how these types of technologies could potentially be implemented into care practice, particularly in nursing home environ- ments. Previous reviews of technology studies have raised issues that are still present today, with this review showing that studies are still highly varied in terms of design, sample sizes, methods of assessment, and the type of technology being used. This review has also highlighted several important aspects to bear in mind when devel- oping technologies for people with dementia. Findings suggest that people with dementia are able to learn how to use new technologies in more severe stages of dementia; however, support from caregivers is likely to still be needed. In order to further inform practice, future studies should assess time consumption, training requirements, costs, and long-term bene- ﬁts. It is also important that technology is used as means to support people with dementia in fulﬁlling meaningful occupation, rather than as a means of interrogation. By developing technology in a user-friendly and user-conscious way, ideally with direct involvement of people with dementia, the right balance between support and empowerment can be identiﬁed. To conclude, this review suggests that the use of individualized, digital technologies can have a positive impact on the well-being of people living with dementia. The included studies provide valuable information on how to individualize and facilitate the use of such tech- nologies, which may serve as useful recommendations for implementing these technologies into practice and conducting future research. However, given the methodological limitations of research conducted in this area, more work is needed to strengthen the evidence base for using individualized, digital technologies in dementia care. Acknowledgement The authors would like to thank Ingrid I Riphagen for her assistance in conducting the literature search. Declaration of conflicting interests The author(s) declared no potential conﬂicts of interest with respect to the research, authorship, and/or publication of this article. Goodall et al. 1465 24 Dementia 0(0) Funding The author(s) disclosed receipt of the following ﬁnancial support for the research, authorship, and/or publication of this article: This review was performed in the frame of the European Union project SENSE-GARDEN (AAL/Call2016/054-b/2017), with implementation period June 2017–May 2020, funded by AAL Programme, co-funded by the European Commission and National Funding Agencies of Norway, Belgium, Romania, and Portugal. ORCID iD Gemma Goodall https://orcid.org/0000-0001-5726-3889 Supplemental material Supplemental material for this article is available online. References Archbold, P. G., Stewart, B. J., Greenlick, M. R., & Harvath, T. (1990). 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JBI Database of Systematic Reviews and Implementation Reports, 14(12), 163–225. https://doi.org/10.11124/jbisrir-2016-003230 Welsh, D., Morrissey, K., Foley, S., McNaney, R., Salis, C., McCarthy, J., & Vines, J. (2018). Ticket to talk: Supporting conversation between young people and people with dementia through digital media [Paper presentation]. Proceedings of the 2018 CHI Conference on Human Factors in Computing Systems (p. 375). ACM. Woodberry, E., Browne, G., Hodges, S., Watson, P., Kapur, N., & Woodberry, K. (2014). The use of a wearable camera improves autobiographical memory in patients with Alzheimer’s disease. Memory, 23(3), 340–349. https://doi.org/10.1080/09658211.2014.886703 World Health Organization. (2015). The epidemiology and impact of dementia: Current state and future trends. Yasuda, K., Kuwabara, K., Kuwahara, N., Abe, S., & Tetsutani, N. (2009). Effectiveness of person- alised reminiscence photo videos for individuals with dementia. Neuropsychological Rehabilitation, 19(4), 603–619. https://doi.org/10.1080/09602010802586216 Gemma Goodall, MA, is a PhD candidate at the Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology. She holds a master’s degree in the psy- chology of music, and her main research interests focus on the use of the arts in dementia care. She is currently working within the European Union-funded project SENSE- GARDEN, https://www.sense-garden.eu, which is developing individualized, multisensory spaces for people living with dementia. Goodall et al. 1469 28 Dementia 0(0) Kristin Taraldsen, PhD, is part of the research group in geriatrics, movement, and stroke at the Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology. Her main research interests are on prevention of functional decline, activity monitoring and physical activity interventions, and implementation of dementia research. She is part of the consortium conducting the European Union-funded project Mobilise-D, https://www.mobilise-d.eu/, where the goal is to validate health-care technology. J Artur Serrano, PhD, is a professor in Assistive Technologies at the Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU). His main research interests are on new approaches to dementia treatment based on immersive tech- nologies, social robots for care, and the general area of user involvement in research. He has been the primary investigator on over 10 research projects including 7 European Union- funded projects. He is the leader of the Immersive Technology and Robotics lab (ImRo-lab) at NTNU. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Dementia: The International Journal of Social Research and Practice SAGE http://www.deepdyve.com/lp/sage/the-use-of-technology-in-creating-individualized-meaningful-activities-E13qBDVZb3

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Her main research interests are on prevention of functional decline, activity monitoring and physical activity interventions, and implementation of dementia research
(BrookerD. (2003). What is person-centred care in dementia? Reviews in Clinical Gerontology, 13(03), 215–222. 10.1017/s095925980400108x)
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Lillian Hung, Mario Gregorio, Jim Mann, Christine Wallsworth, Neil Horne, Annette Berndt, Cindy Liu, E. Woldum, A. Au-Yeung, H. Chaudhury (2019)
Exploring the perceptions of people with dementia about the social robot PARO in a hospital setting
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His main research interests are on new approaches to dementia treatment based on immersive technologies, social robots for care, and the general area of user involvement in research
Anna Ekström, Ulrika Ferm, Christina Samuelsson (2017)
Digital communication support and Alzheimer’s disease
Dementia, 16
Megan Graham, A. Fabricius (2018)
Vital correspondence: Exploring tactile experience with resident-focused mandalas in long-term care (Innovative practice)
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Lillian Hung, A. Au-Yeung, C. Helmer, Alice Ip, Levi Elijah, Michael Wilkins-Ho, H. Chaudhury (2018)
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Copyright: Copyright © 2022 by SAGE Publications
ISSN: 1471-3012
eISSN: 1741-2684
DOI: 10.1177/1471301220928168
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Abstract

There is a growing interest in using technology to provide meaningful activities for people living with dementia. The aim of this systematic review was to identify and explore the different types of digital technologies used in creating individualized, meaningful activities for people living with dementia. From 1414 articles identified from searches in four databases, 29 articles were included in the review. The inclusion criteria were the study used digital technology to deliver an individ- ually tailored activity to participants with dementia, the process of individualization was described, and findings relating to the mental, physical, social, and/or emotional well-being of the participant were reported. Data extracted from the included studies included participant demographics, aims, methods, and outcomes. The following information on the technology was also extracted: purpose, type, training, facilitation, and the individualization process. A narrative synthesis of the results grouped the various technologies into four main purposes: reminiscence/ memory support, behavior management, stimulating engagement, and conversation/communica- tion support. A broad range of technologies were studied, with varying methods of evaluation implemented to assess their effect. Overall, the use of technology in creating individualized, meaningful activities seems to be promising in terms of improving behavior and promoting relationships with others. Furthermore, most studies in this review involved the person with Corresponding author: Gemma Goodall, Norwegian University of Science and Technology, Trondheim 7491, Norway. Email: [email protected] Goodall et al. 1443 2 Dementia 0(0) dementia in the individualization process of the technology, indicating that research in this area is adopting a more co-creative and inclusive approach. However, sample sizes of the included studies were small, and there was a lack of standardized outcome measures. Future studies should aim to build a more concrete evidence base by improving the methodological quality of research in this area. Findings from the review indicate that there is also a need for more evidence concerning the feasibility of implementing these technologies into care environments. Keywords dementia, technology, psychosocial, person-centered, systematic review Introduction Dementia is an umbrella term for various neurodegenerative syndromes that impact pri- marily memory, cognition, language, and behavior. There are currently around 50 million people living with dementia worldwide, and it is estimated that there are almost 10 million new cases of dementia each year (Prince et al., 2015). Given the increasing prevalence and incidence of dementia, the World Health Organization (WHO) has stressed the need to invest in research and cost-effective approaches to meet the needs of people living with dementia and their caregivers (WHO, 2015). Psychosocial approaches to supporting those living with dementia include the use of meaningful activities to promote well-being. Previous literature that aims to deﬁne the term “meaningful activity” in the context of dementia care has often done so from the perspective of people with dementia, their family, and health-care professionals (Harmer & Orrell, 2008; Phinney et al., 2007). Focus is placed on values and beliefs that resonate with past roles, interests, and routines of the individual with dementia. Harmer and Orrell (2008) categorized activities considered to be “meaningful” into reminiscence, family and social, musical, and individual activities. This literature review focuses on the last of these activities, although the four types tend to overlap. Harmer and Orrell (2008) describe individual activities as being adapted to the preferences and capabilities of the person with dementia, and discuss the importance of relating these activities to the past lifestyle of the individual. This review uses the term “individualized” to emphasize that the fact that a process has taken place to adjust the activity to the speciﬁc preferences and abilities of the individual. While work in this ﬁeld has long focused on person-centered care (Brooker, 2003; Kitwood, 1997), ﬁndings from previous literature reviews concerning the individualization of activities for people with dementia appear to be mixed. Travers et al. (2016) recommend that individualized activities may be effective for behavioral and psychological symptoms of dementia, especially with regard to improving passivity and agitation, and increasing plea- sure and interest. Subramaniam and Woods (2012) conducted a systematic literature review on the impact of individual reminiscence therapy for people with dementia. The authors suggest that conducting a life review with a person with dementia, in which a life storybook is produced, has a positive impact on cognition and well-being. They also suggest that personhood and well-being can be promoted using individualized reminiscence approaches that meet speciﬁc needs of the individual with dementia. Despite these suggestions, however, a recent Cochrane review found very little evidence for personally tailored activities being 1444 Dementia 20(4) Goodall et al. 3 able to improve psychosocial outcomes for people living with dementia (Mohler € et al., 2018). While offering personally tailored activities (such as listening to individualized music playlists or making puzzles from familiar photographs) to people with dementia in long-term care may slightly improve challenging behavior, effects on mood were uncertain, and the authors were unable to make recommendations about speciﬁc activities. Constant advances in technology provide potential for designing new and innovative ways of meeting speciﬁc needs of individuals with dementia. In a very recent overview of technology and dementia, Astell et al. (2019) identiﬁed leisure and activity as one of the main domains of technology development within dementia care. The authors remark that technology—such as smartphones, tablets, wearables, robots, virtual reality, and artiﬁcial intelligence—is prompting thought on how care services can be better delivered to address the well-being of people with dementia. The authors also argue that the rapid pace of technology development requires a holistic view of dementia. In expanding the view of dementia beyond a narrow medical approach, technology may be used to empower people with dementia, supporting them to live a more meaningful life. For instance, a recent study suggested that the use of a social robot for hospital patients with dementia promoted a sense of self and facilitated social connection with others (Hung et al., 2019). Arthur (2009) deﬁnes technologies as assemblies of practices and components put to use in order to fulﬁll a speciﬁc purpose. In recent years, there has been much work done on the use of various technologies for providing meaningful activities in dementia care. Digital technologies, such as mobile and tablet apps, have been suggested to enable collaborative explorations of life events by people with dementia and caregivers, encouraging the care- giver to reﬂect and learn more about the individual (Maiden et al., 2013). Purves et al. (2011) also comment on the role that multimedia technologies (e.g., digital life stories) have on conveying the narrative of people living with dementia, and the authors stress that further work needs to be done in understanding how these technologies can be used in everyday practice. In a review on touchscreen technology for people with dementia, Joddrell and Astell (2016) commented that the primary use of touchscreen technology has been to deliver assessments and screening tests, and they called for more focus on how this technology can be used to deliver independent activities for meaningful occupation. To date, there are no literature reviews that provide an overview of the evidence on using technology to create individualized, meaningful activities for people with dementia. Furthermore, there is arguably a need to take qualitative and mixed-method studies into account in this area of research, especially given that meaningful activity within dementia care is often measured in subjective terms of enjoyment (Harmer & Orrell, 2008). While the importance of thorough quantitative meta-analyses remains, much can be learnt from qual- itative and mixed-method research in addition to quantitative studies. The Cochrane Qualitative and Implementation Methods Group Guidance Series highlights the important role of qualitative and mixed-method reviews in understanding how interventions work and how they are implemented (Noyes et al., 2018). Therefore, this literature review will consider qualitative, quantitative, and mixed-methods research to acquire a comprehensive overview of the work that has been done on this topic. The main purpose of this review is to answer the following research question: What are the different digital technologies used to create individualized activities for people with dementia, and how are these facilitated? For the purpose of this review, we deﬁne digital technologies as devices, systems, or applications that can be used to create, store, view and/ or share information electronically. In order to further explore the ﬁndings from this Goodall et al. 1445 4 Dementia 0(0) question, the review will also answer the following secondary research questions: (a) How are these technologies individualized? and (b) What is known about the effects of these technologies on the well-being of people living with dementia? Methods This systematic review was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Moher et al., 2009a). Eligibility criteria The SPIDER strategy (Sample, Phenomenon of Interest, Design, Evaluation, Research type) was used as a tool for shaping the search. SPIDER has been adapted from the PICO formulation (Population, Intervention, Comparison, Outcome) to be more suitable for qualitative and mixed methods research (Cooke et al., 2012). The SPIDER strategy for this review was as follows: • Sample: people living with dementia. • Phenomenon of interest: technology-based, meaningful activities tailored speciﬁcally for the person with dementia. • Design: case study, observational study, randomized controlled trial, quasi-experimental study, questionnaire, interviews, and focus groups. • Evaluation: outcomes related to the mental, physical, social and/or emotional well-being of the person with dementia. • Research type: quantitative, qualitative, or mixed-method. Only studies published in a peer reviewed journal and in English language were consid- ered for review. In order to focus on more recent technologies, studies published before 2005 were not considered for review. Additionally, as another systematic review focusing on meaningful interventions for people living with dementia noted, person-centered care prac- tices were not widely adopted until 2005 (Travers et al., 2016). Given that the scope of this review is to focus on individualized activities, it was deemed appropriate to limit the results to being published in 2005 or later. Inclusion criteria. Studies were included if they met all of the following criteria: (a) uses digital technology to deliver an individually tailored activity to participants with dementia, (b) describes the process of individualization, and (c) reports on ﬁndings directly relating to the mental, physical, social, and/or emotional well-being of the person with dementia. Exclusion criteria. Studies were excluded if they met any of the following criteria: (a) reports solely on the well-being of caregivers or (b) reports ﬁndings solely relating to the technology rather than the person with dementia. Literature reviews, study protocols, theoretical papers, conceptual papers, and position papers were also excluded from the review. 1446 Dementia 20(4) Goodall et al. 5 Information sources Given the interdisciplinary nature of this topic, four databases were used for the search, with the aim of capturing as many potential articles as possible. The following databases were used: CINAHL, Embase, PubMed, and Scopus. A combination of Boolean operators and truncations were used. MeSH Terms were also used where applicable. Table 1 gives a summary of the search terms. Search Study selection. The selection of articles for review was conducted by the ﬁrst author. All articles underwent a ﬁrst screening after duplicates were removed. This consisted of titles and abstracts being screened against the inclusion and exclusion criteria. Included articles then underwent an assessment for eligibility, which involved a reading of the article in full. Additionally, backward citation searching and forward citation tracking was conducted on these articles. Articles from this additional search that met the inclusion criteria were includ- ed for review. Coauthors Kristin Taraldsen and J Artur Serrano independently checked the ﬁnal selection of articles against the inclusion and exclusion criteria.There were no discrep- ancies, and therefore this ﬁnal selection of articles was approved by all authors. Data extraction and synthesis. Data relating to the study aims, design, demographics, data collection, methods, and ﬁndings were extracted from each article. Additionally, informa- tion on the purpose of technology studied, type of technology, media contents and services, the individualization process, environment of technology use, training on technology use, and facilitation of the intervention/activity was also extracted. Due to the heterogeneity of the results and the novelty of this ﬁeld of research, no meta- analysis was conducted. The application of technology for meaningful activities is still an emerging area of work, with many different approaches and devices being used. Therefore, results are presented through a narrative synthesis. Findings from the studies are summa- rized to answer each of the research questions in turn. Results Study selection The initial search returned 1414 articles: 217 from PubMed, 507 from Scopus, 139 from CINAHL, and 551 from Embase. An overview of the study selection is shown in Figure 1. Table 1. Summary of search terms. Search Terms #1 dement* OR alzheimer’s #2 personal OR personalized OR personalised OR person-centred OR person-centered OR person-focused OR individualized OR individualised OR individualistic OR meaningful OR biographical OR autobiographical OR tailored #3 technology OR virtual OR augmented OR media OR multimedia OR touchscreen OR iPad OR app OR mobile OR ICT OR tablet* #4 #1 AND #2 AND #3 Goodall et al. 1447 6 Dementia 0(0) Figure 1. PRISMA flow diagram of study selection process. Adapted with permission from Moher et al. (2009b). In short, 906 records were screened and 837 were excluded. Reference list checking and forward citation tracking was conducted on the remaining 69 articles to identify additional records. From these searches, 8 articles were identiﬁed, meaning that a total of 77 articles were assessed for eligibility. This assessment resulted in a total of 29 articles for review. Study characteristics Twenty-nine studies (reported in 29 separate articles) were included for review. From these studies, 12 were qualitative, 13 used mixed-methods, and 4 were quantitative. An overview of study characteristics is given in Table 2, which summarizes study design, participant information, aims of the study, interaction with technology, measures, and ﬁndings for each study. The most commonly used study design was the case study (N¼ 12). Only two randomized trials were included. Other designs included ﬁeld trials and explorative studies. A total of 231 participants were included across the 29 studies (ranging from 1 to 51, with a median of ﬁve participants per study). The mean age of participants ranged from 52 to 87. However, two studies only reported the age range of participants, and seven studies did not specify 1448 Dementia 20(4) Table 2. Study characteristics. Participants with dementia Author Study design Interaction with Measures Findings N Mean age Type and severitya Study aim(s) technology Critten and Case study 3 83.3 Mild to moderate Study the role of an indi- Creation of multi- Interviews, field The app facilitated the elicita- Kucirkova dementia vidualized multimedia media story notes, tion, storage and sharing of (2017) iPad app (Our Story) in over 7 weeks observations special memories. All partic- the stimulation, preser- ipants experienced positive vation and sharing of feelings of confidence, special memories empowerment and increased self-esteem Damianakis et al. Exploratory feasi- 12 79.6 Early to advanced Observe participant Production of Observations, Multimedia biographies stimu- (2010) bility study AD (N¼ 6), responses to personal- DVD biogra- interviews lated reminiscence, evoked MCI (N¼ 6) ized multimedia phies followed feelings of mostly joy but biographies by weekly occasionally sadness, and screenings for 6 stimulated social months interactions Davis and Shenk Mixed-methods 10 84.3 Late moderate Compare effects of per- Video screenings OME, language Slight preference for looking at (2015) study dementia, mean sonalized and generic over 6 weeks patterns from personalized videos first. FAST score 5.2 multimedia videos on transcriptions Generic videos produced engagement using prede- wider range of conversa- fined codes tional topics and phrasal patterns. Davison et al. Randomized, 11 86 Mild to severe Assess the effects of a per- Use of multimedia CMAI; CSDD; Significant reduction in depres- (2016) single-blinded dementia. Mean sonalized multimedia system for 4 RAID, sion and anxiety scores. No cross-over MMSE 16.2 system (Memory Box) weeks interviews significant change in agitation study on agitation, depression scores and anxiety De Leo et al. Case study 1 80 AD, FAST Stage 4 Assess whether a slideshow Use of smart Recent events DVD of daily life pictures (2011) of daily life moment pic- phone for 4 memory recall helped the participant recall tures captured by a weeks. DVD of test (non-stan- recent events significantly smart phone can support recent events dardized) and better autobiographical viewed once a satisfaction memory week questionnaire Ekstrom € et al. Case study 1 52 AD Explore the effects of a Use of device over Video recordings, (2015) personalized digital 2 weeks interview (continued) Goodall et al. 1449 Table 2. Continued. Participants with dementia Author Study design Interaction with Measures Findings N Mean age Type and severitya Study aim(s) technology device application Application use increases inter- (GoTalk NOW) on active and communicative communication actions Hashim et al. Case study 1 74 Mild AD To test a personalized digi- Weekly sessions Observations, The participant felt the tool (2015) tal memory book over 8 weeks evaluation form enhanced reminiscence. (myBook) for usability, (non- Observations indicated functionality, reminis- standardized) improvement in social inter- cence, and cognition action and communication Hung et al. (2018) Mixed-methods 4 Range 69– AD/Vascular/ Explore the feasibility and iPad simulated Video ethnogra- Four themes: (a) positive feasibility and 80 Parkinson’s acceptability of using an presence ther- phy, observa- responses, (b) person-cen- acceptability Dementia iPad Simulated Presence apy over 2 tions, semi- tered care, (c) video con- study Therapy intervention weeks structured tent, and (d) technical skills. interviews with hospital staff Karlsson et al. Explorative multi- 7 Range Alzheimer’s Explore the process of Use of digital Interviews, obser- The digital photograph diary (2014) ple case study 72–81 disease acceptance and integra- photograph vations, field contributed to increased tion of a digital photo- diary over 22 notes, MMSE, communication, promoted graph diary as a tool for weeks PGCMS, Free relationships, and was per- remembrance of and recall memory ceived as a stimulating joint conversations about index, recogni- activity daily life events tion memory index Karlsson et al. Explorative study 7 77 Alzheimer’s dis- Explore how sense of self Use of digital Audio recorded Two themes from discourse (2017) ease, Mean and identity are mani- photograph communication analysis: manifestations of MMSE 22 fested in narrations diary over 3 sessions, obser- sense of self and sense of self about recent events months vations, field in relation to others. Digital enabled by a digital pho- notes photography diary sup- tograph diary ported communication Kerssens et al. Qualitative study 7 77 Dementia (N¼ 4), Test the usability, feasibility Use of Goal attainment, The Companion facilitated (2015) MCI (N¼ 3) and adoption of a touchscreen observations, meaningful and positive touchscreen computer computer interview engagement intervention (The intervention Companion) (continued) 1450 Dementia 20(4) Table 2. Continued. Participants with dementia Author Study design Interaction with Measures Findings N Mean age Type and severitya Study aim(s) technology over an average of 31 days Khosla et al. Field trial 4 – – Measure the impact of a Use of assistive Video recordings The robot had positive impact (2014) personalized assistive robot over 6 of interaction, on emotional well-being and robot on emotional months activity data, provided sensory enrich- engagement emotional ment and social connectivity. responses, quality of robot experience survey Khosla et al. Longitudinal field 5 – – Evaluate the impact of a Use of assistive Observational Positive experience with the (2016) trial personalized assistive robot over 3–6 videos, interac- robot, improvement in sen- robot in the context of months tional data, sory enrichment home-based dementia quality of robot care experience survey Laird et al. (2018) Quasi-experimen- 30 79 Early to moderate Measure the effect of tech- Use of the iPad Mutuality Scale, Significant increases in mutuali- tal feasibility dementia nology-enabled reminis- app over 12 QCPR, WHO- ty, quality of carer and study cence iPad app weeks 5 patient relationship, and (InspireD) on mutuality, subjective well-being quality of carer and patient relationship and subjective well-being Massimi et al. Pre/post-test 1 84 AD, moderate Assess whether a bio- Use of ambient GDS-30; GAS, Improvement in apathy and (2008) single case graphical ambient display display over 1 AES-I; SIP-AD; positive self-identity. No study (Biography Theatre) month TST; AMI; improvement in autobio- improves autobiographi- MMSE; graphical memory, anxiety, cal memory and sense of IQCODE; depression and general identity custom inter- cognition views and questionnaires McAllister et al. Case study 3 82 Lewy body dis- To explore the use of a Field notes, focus Five themes: experienced and (2020) ease, AD, personalized iPad app groups and expected benefits of (continued) Goodall et al. 1451 Table 2. Continued. Participants with dementia Author Study design Interaction with Measures Findings N Mean age Type and severitya Study aim(s) technology dementia non- (Memory Keeper) with Use of app over 6- individual Memory Keeper; engage- specific, mod- regard to barriers, facili- month trial interview ment of the person with erate to tators, benefits and period dementia and their response advanced incorporation into care. to memory keeper; recruit- ment, media collection, set- up training and handover; use of memory keeper in long term care setting Navarro et al. Case study 1 70 AD, MMSE 17 Study the effect of an Use of system NPI-Q; AES, care- Use of systems had a positive (2015) ambient display system over 16 weeks giver diary, effect in reducing challenging (AnswerBoard) and interviews behaviors mobile app (AnswerPad) on behavioral symptoms Navarro et al. Field study 2 N1¼ N2¼ 73 AD, MMSE scores 17 and Study the effec- Use of system NPI-Q; AES (2016) “Over 21 tiveness of over 16 weeks 70”, assisted cogni- tion system (AnswerBoard/ AnswerPad) to support occu- pational thera- py interventions Use of systems had a positive effect in reduc- ing challenging behaviors O’Connor et al. Single-system 1 83 Vascular dementia, To evaluate the effect of Video simulated Observations, Significant reduction in resis- (2011) ABA withdraw severe video-simulated pres- presence for 14 adapted tance to care with the use of design PAS¼ 21 ence for decreasing days Positive video simulated presence resistance to care Response Schedule (continued) 1452 Dementia 20(4) Table 2. Continued. Participants with dementia Author Study design Interaction with Measures Findings N Mean age Type and severitya Study aim(s) technology Park et al. (2017) Multi-site case 7 – Early stage Assess how digital story- Seven-session Observational Overall enjoyment of sessions, study dementia telling affects quality of workshop over field notes, ability to share stories, life in terms of relation- 6 weeks audio recorded enhance relationships, ships and self-identity workshop ses- increase in communication sions and and interaction interviews Peeters et al. Formative 5 – Early to severe Evaluate the use of a per- Single time use of Observations, Observed positive effects on (2016) evaluation dementia sonalized music platform music platform interview memory recall, mood, and (Music ePartner) social interaction Piasek et al. (2012) Case study 1 87 Early-stage Explore whether SenseCam Use of SenseCam Interview, obser- No change in psychometric dementia images can encourage for 7 weeks. vations, field measures, confusions about meaningful discussions Viewing of notes, psycho- source of images, did not about recent memories images twice a metric tests stimulate discussions and help maintain sense week (not specified) of identity Ryan et al. (2018) Qualitative study 15 78 – To explore the impact of a Use of iPad app Semi-structured Six themes: usability, revisiting personalized reminis- over 12 weeks interviews the past; home use; impact cence program facilitated on the person with demen- through an iPad app tia; gains and abilities; impact (InspireD) on relationships Samuelsson and Dyad case studies 3 – – To understand how digital Single time use of Video recordings CIRCA and CIRCUS support Ekstrom € (2019) communication support digital commu- conversation topics, person- may be used in interac- nication app al photographs in CIRCUS tion with people with are more engaging dementia Silva et al. (2017) Single-blind ran- 51 73.7 Mild Alzheimer’s To assess the effects of Use of SenseCam GDS-30, IAFAI, Significant reduction in depres- domized trial disease wearable camera for 6 weeks. WHOQOL- sion with SenseCam and memory aid (SenseCam) Images OLD Memoþ compared to diary on well-being compared reviewed twice control condition to paper memory train- a week ing program (Memoþ) and written diary (control) (continued) Goodall et al. 1453 Table 2. Continued. Participants with dementia Author Study design Interaction with Measures Findings N Mean age Type and severitya Study aim(s) technology Subramaniam and Multiple case 6 82.2 Mild to moderate To compare the use of a Digital storybooks QOL-AD; AMI-E; Five out of six participants Woods (2016) study dementia, CDR multimedia digital life created over 7– GDS-12R; showed improvement in scores of 1 storybook vs. conven- 10 weeks, DVD QCPR; Semi- quality of life and autobio- (N¼ 5) and 2 tional life storybook then given to structured graphical memory after (N¼ 1) participants for interview having the digital storybook regular viewing for 4 weeks Welsh et al. Case study 11 – Moderate to To explore whether a per- Use of digital app Interviews, work- Three themes: promoting and (2018) severe sonalized digital app over 4 weeks shop managing reminiscence; (Ticket to Talk) can sup- across 6 visits discussions starting and maintaining port communication conversation; redistributing between people with agency dementia and younger people Woodberry et al. Within-subject 6 72 AD, mild to mod- To compare the effects of Use of wearable Memory recall Recall significantly more details (2014) longitudinal erate, using a wearable camera camera for 3.5 tests, interview of events in the camera study Addenbrooke’s vs. a written diary to aid months condition for five out of six Cognitive retrospective recall of participants compared to the Examination significant personal written diary condition mean 70.8 events Yasuda et al. ABCA design 15 77.3 AD, Mean MMSE To assess whether person- Single event of Video recorded 80% of participants showed (2009) 14.3 alized photo video obtain viewing photo responses mea- more attention to personal- more attention com- videos sured in terms ized reminiscence photo pared to generic TV of concentra- video than other TV shows. shows tion and dis- Higher concentration scores traction scores for moderate and severe dementia participants Note: Symbol “–” indicates not specified. AD: Alzheimer’s Disease; MCI: Mild cognitive impairment; FAST: Functional Assessment Staging Tool; OME: Observational measure of engagement; CMAI: Cohen-Mansfield Agitation Inventory; CSDD: Cornell Scale for Depression in Dementia; RAID: Rating Anxiety in Dementia; MMSE: Mini-mental state examination; PGCMS: Philadelphia Geriatric Center Morale Scale; QCPR: Quality of the Caregiver Relationship questionnaire; WHO-5: World Health Organization Five Well-being Index; GDS-30: Geriatric Depression Scale-30; GAS: Goldberg Anxiety Scale; AES-I: Apathy Evaluation Scale-Informant; SIP-AD: Self-Image Profile-Adults; TST: Twenty Statements Test; AMI: Autobiographical Memory Interview; IQCODE; Informant Questionnaire of Cognitive Decline in the Elderly; NPI-Q; Neuropsychiatric Inventory Questionnaire; AES: Apathy Evaluation Scale; PAS: Psychogeriatric Assessment scales; IAFAI; Adults and Older Adults Functional Assessment Inventory; WHOQOL-OLD: World Health Organization Quality of Life-OLD module; CDR: Clinical Dementia Rating scale; QOL-AD: Quality of life Alzheimer’s disease scale; AMI-E: Autobiographical Memory Interview extended version; GDS-12R: Geriatric Depression Scale (Residential). Type and severity as reported in the study. 1454 Dementia 20(4) Goodall et al. 13 age. The severity of dementia varied across the studies, with all stages being covered from mild to severe. Two studies included participants with mild cognitive impairment in addition to participants with more advanced dementia. The most common type of dementia was Alzheimer’s disease (N¼ 14). There were inconsistencies in reporting participant demo- graphics, with four studies failing to report either type or severity of dementia. Most studies aimed to assess the impact of the technology-based activity on memory, communication or engagement. Some studies adopted a more exploratory approach and aimed to report any effects that the technology may have had on the person with dementia. Interviews and observations were the most popular tools for data collection, with thematic analysis and discourse analysis being used to draw ﬁndings. In quantitative and mixed- methods studies, there was a large variety of standardized measures used that focused on numerous domains (for details see Supplementary Material, Table S1). The studies were also greatly varied in terms of length of technology use, ranging from single-time use to use of the technology for six months. Across the 29 studies, the average time spent using the technol- ogy was seven weeks. Synthesis of results What are the different technologies used to create individualized, meaningful activities for people with dementia, and how are these facilitated? A wide array of technology, with varying media con- tents and services, has been explored for creating individualized, meaningful activities for people with dementia. This review categorized the technologies into four main purposes that all tackle common challenges people living with dementia face, namely: reminiscence/ memory support, behavior management, stimulating engagement, and conversation/com- munication support. Table 3 gives an overview of the technologies studied with regard to their purpose, type, media contents and services, individualization process, environment of use, any training provided and the way in which the technology was facilitated in the study. Environment, training, and facilitation. The majority of studies (N¼ 18) were conducted within the homes of participants, who were living in the community (Critten & Kucirkova, 2017; Damianakis et al., 2010; De Leo et al., 2011; Ekstrom € et al., 2015; Hashim et al., 2015; Karlsson et al., 2014, 2017; Kerssens et al., 2015; Khosla et al., 2014, 2016; Laird et al., 2018; Massimi et al., 2008; Navarro et al., 2015, 2016; Piasek et al., 2012; Ryan et al., 2018; Samuelsson & Ekstrom, 2019; Welsh et al., 2018). Family members were often the facilitator of the technology use. In most studies, the presence of another person was required for the full facilitation of the intervention/activity. Whether it be family member, professional caregiver or therapist, it was deemed important that the technology was used as a joint activity. Even in the case where the person with dementia was encouraged to use the device or app independently, support from caregivers was available. Therefore, training of the technology was often given to both the person with dementia and their caregiver. Most studies were quite vague about the instructions given. However, a few studies described extensive training procedures (Davison et al., 2016; Kerssens et al., 2015; Laird et al., 2018). For example, in the study of the InspireD app (Laird et al., 2018), an IT assistant provided training to participants with dementia and their family members, who were living at home. In addition to this, participants also received reminiscence training. There were a couple of cases where the person with dementia was trained individually. Davison et al. (2016) reported that each of the 11 participants (with mild to severe dementia) Goodall et al. 1455 Table 3. Overview of technology, individualization, and facilitation. Media contents and Purpose Type Study Name services Individualization process Setting Training Facilitation Reminiscence or Lifelogging: De Leo et al. – Photos taken on Photos taken of everyday Home Given to people with People with dementia uses memory wearable (2011) smartphone life at 5-minute intervals. dementia and care- smartphone indepen- support camera lanyard Photos then saved to giver by researchers dently, then watches devices DVD DVD of photos with caregiver Karlsson SenseCam/digital Photos taken by Wearable camera Home Given to people with People with dementia uses et al. (2014, photograph wearable (SenseCam) takes dementia and family device, family uploads 2017) diary camera, captions photos of daily events. member by photos. They review with geolocation Photos then uploaded researchers photos together onto touchscreen com- puter (Digital photo- graph diary) Piasek et al. SenseCam Photos taken by Wearable camera takes Home Given to people with People with dementia uses (2012) wearable photos of daily events. dementia and family device, images reviewed camera Photos then reviewed by researchers with therapist Silva et al. on computer Hospital/clinic Given to people People with dementia uses (2017) with dementia by device, images reviewed researchers with neuropsychologist Woodberry – People with dementia uses et al. (2014) device, researcher or spouse uploads photos Digital app Critten and Our Story Photos taken on Story captured in Home/club for Given to people with Independent use by people Kucirkova iPad and found “conversational style” people with dementia by authors with dementia (with (2017) online, text cap- with people with dementia researcher support if tions, audio dementia. People with needed) narration dementia find own photos. Hashim et al. myBook Daily routine Caregivers supplied infor- Home Given to people with People with dementia and (2015) reminders, mation and photos to dementia and care- caregiver use together family photos, authors giver by authors games Laird et al. InspireD Photos, videos, People with dementia and Home Given to people with People with dementia and (2018) music family upload media dementia and family family use together contents with help of by IT assistant (þ reminiscence trainer reminiscence training) (continued) 1456 Dementia 20(4) Table 3. Continued. Media contents and Purpose Type Study Name services Individualization process Setting Training Facilitation Ryan et al. People with dementia and – (2018) family upload media contents to app Peeters et al. Music ePartner Music with text Questionnaire filled in by Day center Given to people with People with dementia and (2016) captions and people with dementia/ dementia and care- caregiver use together photos caregiver and given to giver by researcher authors Multimedia Damianakis – Photos, video, Student collaboration with Home People with dementia and biography et al. (2010) voice-over nar- people with dementia family use together (DVD/video- ration, music and family using based) workbook Park et al. – Photos, voice People with dementia, Community club Given to people with People with dementia and (2017) recordings, Family and researcher dementia and family family use together music, animation by authors guided by workshop facilitator Subramaniam – Photos, music, nar- Participatory design— Care home Digital life book played on and Woods ration, video people with dementia TV in people with (2016) and Family, researcher as dementia’s room co-editor Yasuda et al. – Photos, narration, Caregivers provided Hospital People with dementia (2009) music photos to researchers watched by him/herself Touchscreen Massimi et al. Biography theatre Photos, music, Authors worked with Home – Independent use by people device (2008) video, narration people with dementia with dementia and family Stimulate Social robot Khosla et al. – Music, photo, social Real-time individualization Home – Use by people with engagement (2014, 2016) connectivity, by robot capturing dementia and family games emotional responses PowerPoint Davis and – Photos, music, Students used photos pro- Memory care unit – Facilitated by student Shenk video vided by family volunteer (2015) Digital app McAllister et al. Memory Keeper Family photos, Researcher collaboration Long-term care Given to family by People with dementia and (2020) music, video, with people with facility researchers family member use book covers, dementia and family together themed images Memory Box Nursing home (continued) Goodall et al. 1457 Table 3. Continued. Media contents and Purpose Type Study Name services Individualization process Setting Training Facilitation Behavior Multimedia Davison et al. Movies, music, Researcher collaboration 2.5 hours training given Main use by people with management touchscreen (2016) photos, video with people with to people with dementia, support from device messages from dementia and family dementia, staff, family and staff carers family, family family by photos researchers Kerssens et al. The Companion Photos, captions, Life story interview with Home Given to people with Use by people with (2015) music, people with dementia dementia and care- dementia and family reminders, and family giver by expert in messages assistive technology Navarro et al. AnswerBoard/ Reminders, per- Researcher collaboration Home – Use by people with (2015, 2016) AnswerPad sonalized games with caregiver dementia with therapist Tablet with Hung et al. – Video from family Researcher collaboration Hospital – Used by professional carer video only (2018) with family O’Connor et al. – Video from family Family pre-recorded Care home Given by researchers Used by professional carer (2011) messages Communication/ Digital app Ekstrom € et al. GoTalk NOW Photos, video, text Collaboration between Home Given to people with Used by people with conversation (2015) captions, digi- people with dementia dementia and family dementia and family support tized and syn- and speech therapist member by thetic speech over 3 days researchers Samuelsson and CIRCUS Photos, films, Upload function on app Home Given by researchers Used by people with Ekstrom € music, videos to caregivers only dementia and profes- (2019) sional caregiver Welsh et al. Ticket to Talk Photos, sounds, Young person creates user Home/care home – Used by young person, (2018) videos profile with help from people with dementia family. App provides and family/carer prompts to invite young person to find out more about the people with dementia’s life Note: Symbol “–” indicates not specified. 1458 Dementia 20(4) Goodall et al. 17 received 2 hours of individual training to use a personalized multimedia touchscreen device. This training utilized spaced retrieval learning principles and involved research staff dem- onstrating procedures and asking the participant to imitate them. Despite this training, however, some participants were unable to use the device due to cognitive or sensory impair- ment. Similarly, participants (with mild to moderate dementia) in the study of the OurStory iPad app were trained to use the app independently, however they experienced practical difﬁculties such as not being able to hold the device or being unable to use the keyboard (Critten & Kucirkova, 2017). Facilitation ranged from professional caregivers having complete control of the technol- ogy (e.g., simulated presence on iPad apps in Hung et al., 2018; O’Connor et al., 2011), to joint use between people with dementia and family members (e.g., multimedia apps in Laird et al., 2018; Ryan et al., 2018, digital life storybooks in Critten & Kucirkova, 2017; Park et al., 2017, social robots in Khosla et al., 2014, 2016), and to more independent use by the person with dementia (e.g., Biography Theatre in Massimi et al., 2008). The most indepen- dently used devices were the lifelogging technologies. The SenseCam (Karlsson et al., 2014, 2017; Piasek et al., 2012; Silva et al., 2017; Woodberry et al., 2014) and the smartphone lanyard used by De Leo et al. (2011) were worn by the person with dementia during the day. However, in all studies of lifelogging technologies, support was needed from another indi- vidual to upload the photographs onto a DVD or computer. Reviewing the photographs then became a joint activity. How are these technologies individualized? Most of the studies described the individualization process as a collaboration between the person with dementia, the family member, and often a researcher. While most studies were unclear on the length of time taken to individualize the technology, there were some that used several weeks for the process. For example, digital stories were created over a 6-week period in Park et al. (2017) and an average of 8.3 weeks in Subramaniam and Woods (2016). Despite common collaboration between participants with dementia, family and research- ers, approaches to individualizing the app/device still differed. Examples include structured workbooks (Damianakis et al., 2010), a chronological approach by listing major life chap- ters (Massimi et al., 2008), stories captured in a “conversational style” (Critten & Kucirkova, 2017), life story interview (Kerssens et al., 2015), questionnaire (Peeters et al., 2016), participatory design (Subramaniam & Woods, 2016), in-app prompts (Welsh et al., 2018), and participants uploading their own media content to apps (Laird et al., 2018; Ryan et al., 2018; Samuelsson & Ekstrom, € 2019). The resonating theme among all these approaches is that of capturing the life story of the individual using photographs, music, and narratives (both textual and audio-recorded). Several studies used theory to inform the individualization process. For instance, Positioning Theory (Harr & Van Langenhove, 1998) informed Karlsson et al.’s (2017) work on the SenseCam. The approach to the study was to understand narrations about recent events as being co-constructed between the person with dementia and their partner. Park et al. (2017) was inﬂuenced by Bruner’s paradigm of narrative knowing and construc- tivism (Bruner, 2003). Damianakis et al. (2010) was informed by a framework that supports coherence of ego integrity and personhood during phases of impairment. Finally, Ryan et al.’s (2018) work on the InspireD app was underpinned by Kitwood’s notion of person-centered care (Kitwood, 1997). These four studies that used theoretical foundations Goodall et al. 1459 18 Dementia 0(0) for narrative creation all reported positive effects on self-identity and/or engagement from qualitative methods including discourse analysis, interviews, observations and ﬁeld notes. What is known about the effects of these technologies on the well-being of people living with dementia? Overall, the evidence from the included studies suggest that individualized, digital technol- ogies can have positive effects on the well-being of people living with dementia. Particularly promising areas of improvement include behavior and mood, sense of identity, and relation- ships and engagement with others. Speciﬁc domains of well-being are reported on in further detail below. Memory. The impact of these technologies on memory was mixed, and methods to assess memory were varied. Based on observational and interview data, several studies found that personalized multimedia can stimulate reminiscence (Critten & Kucirkova, 2017; Damianakis et al., 2010; Hashim et al., 2015; Welsh et al., 2018). The use of formal tests on memory was scarce. Two studies used the Autobiographical Memory Interview (AMI) (Kopelman et al., 1989), including Subramaniam and Woods (2016) who found that the use of a digital life storybook improved autobiographical memory after using the storybook for four weeks. Contrastingly, the study of a personalized biographical ambient display did not improve AMI scores after one month of use (Massimi et al., 2008). Mixed results were also present in the study of lifelogging technologies. De Leo et al. (2011) and Woodberry et al. (2014) found that pictures taken by a wearable camera enabled the participants to recall signiﬁcantly more details of recent events, as measured by non-standardized memory recall tests. However, a single case study of SenseCam conducted by Piasek et al. (2012) reported that the participant was confused about the source of images. Karlsson et al. (2017) also reported that there were certain situations where participants with Alzheimer’s disease were unable to recall any information related to the event shown from SenseCam photographs. Behavior and mood. Overall, the technologies included for review showed beneﬁcial effects on behavior and mood. Furthermore, studies that focused on this domain were more consistent in using standardized outcome measures. The AnswerBoard (public ambi- ent display) and AnswerPad (mobile phone app) devices were shown to have a positive effect in reducing challenging behaviors after 16 weeks of use, as indicated by decreased NPI-Q scores (Navarro et al., 2015, 2016). Another study on an ambient display system used the Apathy Evaluation Scale and found that the use of the system reduced the participant’s apathy after one month of use (Massimi et al., 2008). A personalized multimedia system was shown to signiﬁcantly reduce depression and anxiety after four weeks of use, as measured by the CSDD and RAID (Davison et al., 2016). Silva et al. (2017) found that the use of the SenseCam signiﬁcantly reduced depression scores, using the Geriatric Depression Scale. Studies focusing on simulated presence to reduce problematic behaviors had positive results. O’Connor et al. (2011) found that presenting residents with an iPad containing a video-recorded message from a family member for 14 days was able to signiﬁcantly reduce resistance to care. Similarly, Hung et al. (2018) also tested iPad-facilitated video simulated presence for 14 days and found that hospital patients with dementia responded positively. As well as improving behavior, the iPad intervention also resulted in positive changes in the mood of all participants. However, the authors noted that video content with too many family members with multiple messages provoked anxiety, emphasizing the importance of 1460 Dementia 20(4) Goodall et al. 19 acknowledging the individual needs of the person with dementia and being aware of possible over stimulation. Self-identity. Results from the identiﬁed studies suggest that a sense of self can be pre- served, even in later stages of dementia. Critten and Kucirkova (2017) found that the Our Story app gave participants conﬁdence, empowerment and increased self-esteem. Karlsson et al. (2017) studied the SenseCam in relation to self and identity. From discourse analysis, the authors identiﬁed two key themes: manifestations of sense of self and self in relation to others. With regard to sense of self, the authors found that even if the participant could not relate to the event shown in the photograph, the material still stimulated conversation about personal experience. When the participants’ partners had been involved in events captured by the SenseCam, narrating and remembering the event became a joint activity. However, it is important to note that some participants became stressed when the conversation became interrogative. The only study to use outcome measures for self-identity was Massimi et al. (2008) who used the Twenty Statements Test and the Self Image Proﬁle (Adult). The authors found that use of the Biography Theatre for one month led to an improvement in positive self-identity. It is also important to note that studies which included the person with demen- tia in the individualization process of the technology empowered the individual to become more connected with their sense of self. For example, participants in a digital storytelling workshop enjoyed the process of creating and sharing their stories over a six-week period (Park et al., 2017). Social relationships and engagement. Given the highly interactive nature of the technolo- gies, many studies found improvements in relationships, communication and engagement. Social robots were identiﬁed as a way of facilitating engagement and interaction for people with dementia (Khosla et al., 2014, 2016). Personalized digital media was considered as a tool for starting conversations (Davis & Shenk, 2015; Karlsson et al., 2014; Samuelsson & Ekstrom, € 2019; Yasuda et al., 2009), supporting interaction (Hashim et al., 2015; Park et al., 2017), and improving relationships between people with dementia and their caregivers (Karlsson et al., 2014; Laird et al., 2018; Park et al., 2017; Ryan et al., 2018). It was also reported that such media provided caregivers, and sometimes even family members, with new insights and heightened perspectives into the life of the person with dementia (Damianakis, 2010; Ryan et al., 2018; Samuelsson & Ekstrom, € 2019). The majority of these ﬁndings were based on interview or observation data. However, Laird et al. (2018) used the Quality of Carer and Patient Relationship scale (Spruytte et al., 2002) and the Mutuality Scale (Archbold et al., 1990) to assess the effect of the InspireD app on the relationship between the person with dementia and their caregiver. Scores on both scales were signiﬁcantly improved after 12 weeks of using the iPad app. There were some cases where tensions in the relationship were reported. For example, Ekstrom et al. (2015) found that problems associated with dementia were foregrounded during joint interaction with a tablet computer. The person with dementia became depen- dent on their conversational partner to be able to use the technology. Similar issues were experienced with the SenseCam. The participant in Piasek et al.’s (2012) study of SenseCam relied on his wife while reviewing photographs together with a therapist. Participants in another SenseCam study were reportedly frustrated when they felt the conversation about the photographs had become a test of their memory (Karlsson et al., 2017). Goodall et al. 1461 20 Dementia 0(0) Emotional well-being. Observations of interaction with technology were used to assess emotional reactions from the participants. Technologies that featured reminiscence activities or other autobiographical material provided participants with an enjoyable experience (Critten & Kucirkova; Damianakis et al., 2010; Hashim et al., 2015; Kerssens et al., 2015; Khosla et al., 2014, 2016; McAllister et al., 2020; Park et al., 2017; Peeters et al., 2016; Ryan et al., 2018; Samuelsson & Ekstrom, € 2019; Subramaniam & Woods, 2016). However, due to the highly personal nature of these activities, there is a potential for sensitive topics to cause negative reactions. There were numerous reports of sadness being experienced, especially when personal photographs of those who had passed away were used (Damianakis, 2010; Ryan et al., 2018). In these cases, it is important to remember that emotions are highly complex. Damianakis et al. (2010) commented on the possibility of observing both happi- ness and sadness simultaneously in reaction to pictures of a deceased loved one. Furthermore, family members involved in the study felt that it was important to include photographs and stories of loved ones, even if they had passed away. Discussion Summary of evidence This review has identiﬁed the varying types of digital technologies that are being used to create individualized, meaningful activities for people with dementia. Overall, the ﬁndings suggest the use of individualized technology to be promising in contributing to and advanc- ing dementia care. Technology can be used to complement psychosocial approaches to care such as reminiscence therapy, simulated presence therapy, occupational therapy and life story work. Additionally, this review has demonstrated how theory-based knowledge may be used to complement technology-based activities in dementia care. Studies that used the- oretical foundations for the individualization process of the technology all found positive impacts on a sense of self and/or engagement, suggesting that theory-based knowledge can be beneﬁcial for technology development. Findings from the review also indicate the amount of progress that has taken place in this ﬁeld. Only 7 of the 29 included studies did not actively involve the person with dementia in the individualization process of the technology. This contrasts to a 2008 literature review on technology studies to meet the needs of people with dementia and their caregivers. Topo (2008) found that very few studies actively involved the person with dementia in using the technology. Studies identiﬁed in this review not only involved the person with dementia as users of the technology, but in most cases, they were involved in the individ- ualization process, acting as co-creators of their own narratives. There was also a case where the individuals with dementia were involved in the development of the technology itself. The InspireD app was co-created by a User Development Group that consisted of six people with dementia working together with researchers (Laird et al., 2018; Ryan et al., 2018). Future work in this area should adopt a similar approach, involving people with dementia as co-creators from the onset of the technology development. Opportunities afforded by technology. Findings from this review are in accordance with other literature reviews in this area, in terms of the beneﬁts that technology can provide to people living with dementia. A systematic review of technology for reminiscence therapy found that using information and communication technologies for reminiscence therapy interventions 1462 Dementia 20(4) Goodall et al. 21 has beneﬁts such as providing access to rich multimedia materials, providing opportunities for social interaction, provision of memory support and ownership of conversations (Lazar et al., 2014). Similar results are resonated in this review, especially with regard to social interaction. Furthermore, the use of technology to preserve, share and explore the narrative of the person with dementia is consistent with earlier ﬁndings in this area (Maiden et al., 2013; Purves et al., 2011). One particularly meaningful beneﬁt of technology is that it provides a means of being able to access a wealth of images and other types of media. This can be very important, especially for those who may not have many photographs from their past. Participants using the OurStory iPad app found access to external images important (Critten & Kucirkova, 2017). This continuous and endless access to media also provides an opportunity to engage with not just the past, but also the present. Participants using the InspireD app were able to take pictures on the iPad and include them as part of their reminiscence program (Laird et al., 2018; Ryan et al., 2018). SenseCam captures everyday moments of daily life, enabling people to recollect upon recent events. The upload feature in CIRCUS (Samuelsson & Ekstrom, 2019) also allows participants to engage with media from recent events, if they wish to do so. Technology also presents life histories in a new way, which can be beneﬁcial for all individuals involved its use. Participants in the study of a digital life book were excited about seeing their life history: “I feel like I’m famous. I feel very excited,” “I can’t believe this, my mother will be proud of me . . . I feel like I’m being appreciated” (Subramaniam & Woods, 2016). Additionally, caregivers felt that technology provided a way of learning more about the life of the person with dementia (Damianakis et al., 2010; Ryan et al., 2018; Samuelsson & Ekstrom, 2019; Subramaniam & Woods, 2016). As Purves et al. (2011) sug- gest, technology can be a way of shaping an interactional environment in which narrative can be explored together: “With these technologies at our disposal, we not only have better ways to elicit and convey narratives . . . but we also have better ways to share these narratives with others, over time and across place” (p. 240). The technologies identiﬁed in this review provide examples of how this may be achieved. Challenges going forward. The results from this review have raised some potential issues that could be faced when implementing individualized technologies into practice. Associated costs are an important issue. The Memory Box device (Davison et al., 2016) cost 12,000 U.S. dollars for four units. Installation of the Biography Theatre took an experienced technologist 30–40 hours over the course of one month (Massimi et al., 2008). In Laird et al.’s (2018) study of the InspireD app, which itself is free, the training sessions cost 2750 GBP per dyad. Most studies were conducted in the homes of people with dementia, and this may be due to the fact that support from another individual was often needed in order to be able to use the technology. Care institutions such as nursing homes are often busy environments, in which one-to-one interaction may not always be possible due to time constraints. Additionally, home-dwelling individuals with dementia tend to be in more mild–moderate stages of dementia and therefore may be able to use the technology on a more independent level. This then raises the question of how practical it is to introduce such technology into care homes for individuals in more severe stages of dementia. Also, the issue of capacity was raised in Subramaniam and Wood’s (2016) study of the digital life book. It was questioned Goodall et al. 1463 22 Dementia 0(0) whether members of staff could be expected to take on the role of coproducing the life stories together with the person with dementia. Additionally, and maybe most importantly, there is a question of how well these tech- nologies can be introduced to this vulnerable group, especially in later stages of dementia. Numerous participants across the studies experienced difﬁculties in being able to interact with the technology. Examples include physical issues with being able to hold the device or press buttons, issues with being able to see the screen, or difﬁculties with general operation of the technology. Piasek et al. (2012) witnessed a particular struggle with SenseCam in getting the participant, John, to remember that he was the one wearing the camera: “The SenseCam technology seemed confusing for someone with such severe memory impair- ments. It also seemed pointless to continuously explain what SenseCam is and that is was John who wore it.” Even in studies where participants were aware of the SenseCam, they did not always respond positively to it. For example, one gentleman felt embarrassed by wearing the camera and felt it drew attention to him (Woodberry et al., 2014). These issues highlight the need to continue to develop awareness in potentially problematic areas such as physical limitations or sensory issues as well as self-consciousness or stigma. It is important that devices and technologies are developed with these issues in mind, so that they may be feasible for use by the target population. Limitations This is a relatively new ﬁeld of research and new technologies are constantly being pre- sented, meaning that the evidence on its impact and effectiveness is still somewhat limited. The ﬁndings from this review are limited by the small sample sizes of the included studies. Given the amount of time and effort required for individualizing technologies, especially when the identiﬁcation and collection of personalized multimedia is involved, it is under- standable that most studies had small sample sizes. Seven studies included only one partic- ipant. While these small case studies are valuable for providing rich, in-depth accounts, the ﬁndings are hard to generalize to a wider population. There is a clear need for studies with larger sample sizes with standardized outcome measures. Additionally, the time of use of the devices was highly varied among the studies. The use of the technology ranged from single- time use to six months. Another limitation of this review is the lack of a quality appraisal of the included studies. Given the fact that the use of individualized technologies in dementia care is still an emerg- ing ﬁeld, we wanted to include a variety of studies in order to gain a broad overview of the topic. Most of the research in this area consists of small case studies, and excluding these studies based on their quality would have resulted in a limited understanding of how these technologies can be potentially used in dementia care. There is some level of quality of assurance, given the fact that only articles from peer-reviewed journals were included for review. However, there may be potential bias from studies where researchers acted as collaborators or co-editors in the individualization process. For example, participants in Critten and Kucirkova’s (2017) study of the Our Story app enjoyed the process of remi- niscing together with the ﬁrst author and commented that the activity had brought back some ‘happy times’ that the participants were keen to share with the researcher at later interviews. Massimi et al. (2008) stated that a relationship had developed between the par- ticipant and the researcher in their role as “biographer.” The authors state that this rela- tionship shifted focus from the participant being “an old man with a bad memory” to being 1464 Dementia 20(4) Goodall et al. 23 a human being. However, this is to be expected, given that participatory design and co- creative approaches are increasingly being adopted in dementia research. Once more knowl- edge exists in this area, there will be a need to critically evaluate the quality of the evidence. Finally, a considerable number of articles had to be excluded for review due to lacking reports on the effects on the well-being of the person with dementia. This meant that other emerging technologies in this area were not commented on. It is important to be aware of other technologies beyond those included in this review, and how they can also create opportunities for the conveying of narrative. For example, virtual reality can be a means of recreating environments from the past (Hodge et al., 2018). Another example is a project called SENSE-GARDEN, which is developing multisensory spaces that combine music, ﬁlm, pictures, and scent with innovative technology to create an immersive environment tailored speciﬁcally for the individual with dementia (Goodall et al., 2019). Conclusion Various technologies can add value to the individualization of meaningful activities in dementia care. This review highlights the need to focus on how these types of technologies could potentially be implemented into care practice, particularly in nursing home environ- ments. Previous reviews of technology studies have raised issues that are still present today, with this review showing that studies are still highly varied in terms of design, sample sizes, methods of assessment, and the type of technology being used. This review has also highlighted several important aspects to bear in mind when devel- oping technologies for people with dementia. Findings suggest that people with dementia are able to learn how to use new technologies in more severe stages of dementia; however, support from caregivers is likely to still be needed. In order to further inform practice, future studies should assess time consumption, training requirements, costs, and long-term bene- ﬁts. It is also important that technology is used as means to support people with dementia in fulﬁlling meaningful occupation, rather than as a means of interrogation. By developing technology in a user-friendly and user-conscious way, ideally with direct involvement of people with dementia, the right balance between support and empowerment can be identiﬁed. To conclude, this review suggests that the use of individualized, digital technologies can have a positive impact on the well-being of people living with dementia. The included studies provide valuable information on how to individualize and facilitate the use of such tech- nologies, which may serve as useful recommendations for implementing these technologies into practice and conducting future research. However, given the methodological limitations of research conducted in this area, more work is needed to strengthen the evidence base for using individualized, digital technologies in dementia care. Acknowledgement The authors would like to thank Ingrid I Riphagen for her assistance in conducting the literature search. Declaration of conflicting interests The author(s) declared no potential conﬂicts of interest with respect to the research, authorship, and/or publication of this article. Goodall et al. 1465 24 Dementia 0(0) Funding The author(s) disclosed receipt of the following ﬁnancial support for the research, authorship, and/or publication of this article: This review was performed in the frame of the European Union project SENSE-GARDEN (AAL/Call2016/054-b/2017), with implementation period June 2017–May 2020, funded by AAL Programme, co-funded by the European Commission and National Funding Agencies of Norway, Belgium, Romania, and Portugal. ORCID iD Gemma Goodall https://orcid.org/0000-0001-5726-3889 Supplemental material Supplemental material for this article is available online. References Archbold, P. G., Stewart, B. J., Greenlick, M. R., & Harvath, T. (1990). 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Neuropsychological Rehabilitation, 19(4), 603–619. https://doi.org/10.1080/09602010802586216 Gemma Goodall, MA, is a PhD candidate at the Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology. She holds a master’s degree in the psy- chology of music, and her main research interests focus on the use of the arts in dementia care. She is currently working within the European Union-funded project SENSE- GARDEN, https://www.sense-garden.eu, which is developing individualized, multisensory spaces for people living with dementia. Goodall et al. 1469 28 Dementia 0(0) Kristin Taraldsen, PhD, is part of the research group in geriatrics, movement, and stroke at the Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology. Her main research interests are on prevention of functional decline, activity monitoring and physical activity interventions, and implementation of dementia research. She is part of the consortium conducting the European Union-funded project Mobilise-D, https://www.mobilise-d.eu/, where the goal is to validate health-care technology. J Artur Serrano, PhD, is a professor in Assistive Technologies at the Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU). His main research interests are on new approaches to dementia treatment based on immersive tech- nologies, social robots for care, and the general area of user involvement in research. He has been the primary investigator on over 10 research projects including 7 European Union- funded projects. He is the leader of the Immersive Technology and Robotics lab (ImRo-lab) at NTNU.

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Dementia: The International Journal of Social Research and Practice – SAGE

Published: May 31, 2020

Keywords: dementia; technology; psychosocial; person-centered; systematic review

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The use of technology in creating individualized, meaningful activities for people living with dementia: A systematic review:

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