Disability and Rehabilitation: Assistive Technology

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Technology for activity participation in older

people with mild cognitive impairment or
dementia: expert perspectives and a scoping
review

Stacey L. Schepens Niemiec, Elissa Lee, Raquel Saunders, Rafael Wagas &
Shinyi Wu

To cite this article: Stacey L. Schepens Niemiec, Elissa Lee, Raquel Saunders, Rafael
Wagas & Shinyi Wu (2022): Technology for activity participation in older people with mild
cognitive impairment or dementia: expert perspectives and a scoping review, Disability and
Rehabilitation: Assistive Technology, DOI: 10.1080/17483107.2022.2116114

To link to this article: https://doi.org/10.1080/17483107.2022.2116114

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DISABILITY AND REHABILITATION: ASSISTIVE TECHNOLOGY
https://doi.org/10.1080/17483107.2022.2116114

REVIEW

Technology for activity participation in older people with mild cognitive

impairment or dementia: expert perspectives and a scoping review
Stacey L. Schepens Niemieca , Elissa Leea, Raquel Saundersa, Rafael Wagasa and Shinyi Wub,c
a
Mrs. T.H. Chan Division of Occupational Science and Occupational Therapy, University of Southern California, Los Angeles, CA, USA; bSuzanne
Dworak-Peck School of Social Work, University of Southern California, Los Angeles, CA, USA; cDaniel J. Epstein Department of Industrial and
Systems Engineering, University of Southern California, Los Angeles, CA, USA

ABSTRACT ARTICLE HISTORY

Purpose: This two-phased study aimed to collate, summarize and characterize – through the lens of an Received 10 September 2021
occupation-based, person-centred framework – ongoing research and practice featuring activity participa- Accepted 17 August 2022
tion-supportive digital health technology (DHT) for direct use by older persons with mild cognitive impair-
KEYWORDS
ment or Alzheimer’s disease and related dementias (PwMCI/ADRD).
Alzheimer’s disease and
Materials and methods: Phase 1: Using scoping review procedures, PubMed, MEDLINE and PsycInfo related dementias; digital
were searched to identify primary research studies. Phase 2: Semi-structured interviews were completed health technology; activity
with MCI/ADRD expert stakeholders identified through publicly available biographies and snowball refer- participation; scoping
ral. Thematic analysis was used to identify, synthesize and cross-compare emergent themes from both review; older adults;
data sources that were subsequently organized into core facets of the Human Activity Assistive activities of daily living;
Technology (HAAT) model. digital divide
Results: The scoping review resulted in 28 studies, which were primarily feasibility work with small sam-
ple sizes. Interviewed experts (N ¼ 17) had 4þ years of MCI/ADRD experience, came from a variety of set-
tings, and held myriad roles. Real world and research-based use of DHTs held some commonalities,
particularly around support for social participation and instrumental activities of daily engagement. No
DHT for sleep or work/volunteerism were noted in either phase. People with milder MCI/ADRD conditions
were most often targeted users. Soft technology strategies facilitating implementation centred on product
design (e.g., prompting software, customisability, multimedia/multisensory experiences), instructional
methods and technology partner involvement.
Conclusions: This study demonstrates that although DHT supportive of activity participation is being
studied and integrated into the lives of PwMCI/ADRD, there are still key opportunities for growth to meet
the needs of diverse MCI/ADRD end users.

� IMPLICATIONS FOR REHABILITATION

� Mainstream digital health technologies (DHTs) are being utilized by persons with mild cognitive
impairment and Alzheimer’s disease and related dementias (PwMCI/ADRD) in everyday life, in limited
capacities, to support social participation, leisure, health management and instrumental activities of
daily living (IADL).
� Innovative research-based technologies to be used directly by PwMCI/ADRD are under development,
particularly to facilitate management of ADL, social participation and IADL in persons with mild-to-
moderate forms of cognitive impairment.
� Soft technology strategies to support technology implementation with MCI/ADRD target users
include close attention to design of the technology (e.g., customisability, sensory stimulators and
prompting features), instructional strategies that promote learning and motivation and involvement
of technology partners to facilitate engagement with the technology.
� Future studies will require more robust research designs with transparent reports of participant char-
acteristics and facilitative instructional methods to expand DHT’s potential to account for and better
meet the needs of diverse MCI/ADRD communities in real-world contexts.

Introduction [2] – jeopardizes health-related quality of life, affecting myriad

Approximately 50 million people worldwide live with Alzheimer’s domains of health and function, such as memory, motivation and
disease and related dementias (ADRD), with this number expected social behaviour [1,3]. Meaningful participation in everyday activ-
to grow to 132 million by 2050 [1]. ADRD – as well as mild cogni- ities – a “vital part of the human condition and experience”
tive impairment (MCI) which may precede ADRD in many cases that contributes to life satisfaction and psycho-emotional

CONTACT Stacey L. Schepens Niemiec schepens@usc.edu Chan Division of Occupational Science and Occupational Therapy, University of Southern California,
1540 Alcazar St, CHP-133, Los Angeles, CA 90089-9003, USA
Supplemental data for this article can be accessed online at https://doi.org/10.1080/17483107.2022.2116114.
� 2022 Informa UK Limited, trading as Taylor & Francis Group
2 S. L. SCHEPENS NIEMIEC ET AL.
wellbeing [4, p.640] – suffers in consequence. Getting dressed in
the morning, planning a trip to the grocery store, having an
intimate conversation with others, achieving restful sleep, or
enjoying a favourite pastime occupation can become arduous, if
not impossible.
Technological developments in the assistive technology arena
have been extensively and increasingly studied for integration into
ADRD care [5], particularly in the areas of cognitive assessment, cog-
nitive stimulation and assistance for daily activities [6,7]. A 2015
review of assistive technology for ADRD demonstrated that technol-
ogy (at that time) was primarily focused on memory aids, safety
and day-to-day tasks (i.e., food/kitchen tasks and personal hygiene);
very few innovations addressed leisure or recreational participation
[8]. This trend was observed once again in a later review suggesting
mobile health (mHealth) technologies tended to support basic
rather than higher-level human needs of PwADRD [9].
In the wake of COVID-19, technology-driven interventions have
become progressively vital to individuals’ health and function,
while simultaneously exacerbating persistent digital inequities
[10]. Older people, especially those with disabilities and from
under-resourced communities, have been historically overlooked
and underrepresented as target users of digital health technology
(DHT; i.e., technology that integrates “computing platforms, con-
nectivity, software, and sensors” [11, para 3] to support health
and wellbeing), creating a digital rift that threatens equal access
to health-beneficial innovations [12,13]. The intersectionality of
older age, disability and other markers of inequity that perpetuate
digital exclusion [13] worsens the risk persons with mild cognitive
impairment (PwMCI)/ADRD will be left behind as mainstream
technology developments continue to accelerate.
A recent review by Engelsma et al. [14] showed that older
PwADRD face unique challenges, in addition to the ones experi-
enced by the general ageing population, when using mHealth
technology. These ranged from cognitive barriers (e.g., planning
abilities and organizing thoughts) and “frame of mind” obstacles
(e.g., concentration and concern for stigmatization), to physical
ability impediments (e.g., gait unsteadiness and tremor), percep-
tion problems (e.g., double vision and object/facial recognition)
and speech-language barriers (e.g., reading and verbal expres-
sion). Despite these findings, researchers have pointed to the rela-
tive paucity of inclusion of PwMCI/ADRD as the target users and/
or as key critics of technologies under study, with primary atten-
tion oftentimes paid to care partners as the principal beneficiaries
and keepers of insightful perspectives [15,16]. Encouragingly,
more inclusive practices in ADRD technology development appear
to be an emerging trend in this line of inquiry [7,14,17].
Calls for adopting person-centred methods to advance
research and development of technologies for PwADRD have
been made [9,17] – examining the landscape of both research
and real-world practice in this domain through the lens of the
Human Activity Assistive Technology (HAAT) model [18] is one
way to contribute to this effort. The HAAT model is a popular the-
oretical framework, grounded in occupational therapy and
rehabilitation engineering, that was designed to guide assess-
ment, prescription and evaluation of assistive technology systems
suitable for people with disabilities [18]. The respective compo-
nents of the model are illustrated by a human (person) engaging
in an activity (occupation) within a context (social, cultural, envir-
onmental and institutional) enabled by assistive technology (tech-
nology) [19]. It proffers a person-centred approach, with the
essential outcome being facilitation of participation in preferred
activities to meet a client’s goals across relevant contexts [19].
Placing the person as central to the model ensures technology
satisfies the activity participation needs of the individual and opti-
mally supports actualization of their performance potential [19].
To our knowledge, no study has applied the HAAT model to sum-
marize and characterize the state of science and practice in the
area of DHT use by PwMCI/ADRD.
This study aims to collate, synthesize and characterize –
through the lens of a person-centred, occupation-based frame-
work and using a convergent design – evolving research and
practice featuring activity participation-supportive DHT for direct
use by older PwMCI/ADRD. The overarching goal of this study is
to complement and expand the work in this area, identifying
opportunities for future research that can help bridge the multidi-
mensional digital divide and bring cutting-edge DHT to diverse
older adults of the MCI/ADRD community in support of meaning-
ful activity participation.
Methods
This study utilized a two-phase design that included a scoping
review and expert interviews to capture complementary informa-
tion from the scientific arena and real-world practice. Methods for
each separate study phase are described below.
Phase I – scoping review
The first study phase featured a scoping review of the literature
to identify and characterize recent DHT under research and devel-
opment that supports activity participation in PwMCI/ADRD.
Scoping reviews aid in mapping broad topics and synthesizing
evidence to identify gaps in the literature [20]. We adopted
Arksey and O’Malley’s [20] methodological framework that
involved identifying a research question and relevant studies,
selecting studies, charting the data and summarizing results. The
review is reported according to the Preferred Reporting Items for
Systematic Reviews and Meta-Analyses extension for Scoping
Review (PRISMA-ScR) guidelines [21]. In characterizing the litera-
ture through use of the HAAT model, we asked the following
research questions: (1) What is the surrounding context in which
the research has been conducted? (2) What are the characteristics
of the target users (i.e., humans) who are being studied? (3) What
is the nature of the activity participation being supported? (4)
What is the nature of the DHT (i.e., assistive technology) and
related supportive strategies being studied? (5) What is the nature
of researchers’ recommendations to advance the science of activ-
ity participation-supportive DHT for PwMCI/ADRD?
We performed a literature search on 15 March 2020 of pub-
lished articles (January 2009–March 2020) indexed in PubMed. An
additional search was conducted on 4 June 2020 of indexed
articles (January 2009–May 2020) in MEDLINE (ProQuest) and APA
PsycInfo (ProQuest) and again on 21 February 2022 (spanning
January 2020–February 2022) in the same databases. Primary
search terms described the target population (e.g., “dementia”;
“cognitive impairment”) and DHT (e.g., “electronic activity mon-
itors”; “mobile health”). DHT was defined as technology used to
support health, function and wellbeing through use of
“computing platforms, connectivity, software, and sensors”[11,
para 3]. Some examples of DHT, without consideration for the
activity participation-supportive requirement, include devices like
wearable fitness trackers or software applications like a stress
management smartphone app. Given DHT involves connectivity
and computing power, low-tech health technologies such as man-
ual body weight scales, reachers and handheld magnifiers are not
included. Activity participation search terms were not used to

gather the initial set of potentially eligible papers. Supplementary
Table 1 details the search strategy.
Studies were included if (1) they were available in English; (2)
they tested a DHT-based intervention designed to facilitate par-
ticipation in meaningful activities or occupations a person needs
or wants to do (i.e., engagement in physical, cognitive, and social
activities, including activities of daily living [ADL] and instrumental
ADL [IADL]); and (3) primary target users of the DHT were older
adults with MCI/ADRD. Studies were excluded if target users were
the MCI/ADRD care partners; the technology’s purpose was for
diagnosis, assessment, MCI/ADRD prevention or facilitation of pre-
paratory tasks (e.g., cognitive skill building, fine motor control
improvement); or the intervention focused on telehealth proc-
esses. Eligibility was further limited to primary studies and the
most recent or key study of an intervention by the same
research team.
Search results were organized using Covidence systematic
review software (Veritas Health Innovation, Melbourne, Australia,
available at www.covidence.org). Citations from the literature
search were uploaded into Covidence and duplicates were
removed. Two reviewers independently screened all articles. At
each stage, conflicts regarding eligibility were resolved in consult-
ation with a third reviewer; decisions were based on consensus.
During the initial screening stage, selection criteria were
applied to titles and abstracts. Review studies were excluded after
reference lists were hand searched for relevant citations. Two
independent reviewers conducted a full-text review of remaining
articles, extracting data to a spreadsheet with the following head-
ings: study purpose, study design, sample size, demographics,
activity participation domain targeted, technology characteristics,
intervention implementation methods and key findings. Based on
extraction results, additional articles were eliminated. Results were
synthesized in tabular format (see Tables 1 and 2) and summar-
ized narratively for further analysis, and finally organized under
HAAT model domains.
Phase II – Expert stakeholder interviews
The second study phase featured interviews of MCI/ADRD expert
stakeholders, referred hereafter as experts. This phase was con-
ducted with the purpose of gaining experts’ real-world viewpoints
on technology use among older PwMCI/ADRD, thereby producing
a complementary set of perspectives that could be compared
with the research landscape characterized from the scoping
review, and allowing convergence of findings from both the sci-
entific and practice arenas. The University of Southern California
Institutional Review Board approved all procedures. Using a pur-
posive sampling strategy, we sought individuals from wide-rang-
ing backgrounds and experiences relevant to MCI/ADRD.
Participants were identified using the research team’s professional
network combined with an online search of publicly available aca-
demic, professional, clinical and community organization biogra-
phies. Snowball referral supplemented these tactics. Enrolment
was limited to persons who were English-speaking, had �1 year
of experience in MCI/ADRD, and were actively working with the
target population in some capacity (e.g., providing therapy, con-
ducting research and volunteering).
Interviews were conducted by trained research personnel via
telephone or video call, and took place between October 2019
and June 2021. Researchers followed a semi-structured interview
guide to ensure consistency [50], and interviews were approved
to last 1 h or less. Participants were asked open-ended questions
to allow free expression of viewpoints; probing questions elicited
TECHNOLOGY FOR ACTIVITY PARTICIPATION IN DEMENTIA 3
additional details as needed. Queried topics centred on needs of
the MCI/ADRD population; instructing PwMCI/ADRD in new tasks,
especially those involving technology; and application of technol-
ogy with consideration of facilitators and barriers.
A manifest (surface-level) content analysis [51,52] of tran-
scribed interviews – managed using spreadsheets – was con-
ducted to identify themes specific to technology use and related
supportive strategies and design for PwMCI/ADRD. Such analysis
permits classification of qualitative information using a predeter-
mined coding scheme. Initial categorical codes (e.g., technology
use in daily life, barriers to technology use and technology facili-
tation strategies) developed from the semi-structured interview
guide were agreed upon at a team meeting and were subse-
quently applied by two independent coders. As data were sorted
into the overarching categories, coders developed sub-codes as
appropriate (e.g., accessibility barriers, technology design barriers).
Through regular discussions between coders, the researchers
modified their sub-codes as needed (e.g., adding a sub-code to
coder one’s coding scheme that coder two had found relevant)
and were later checked by a third analyst. Discrepancies were dis-
cussed by all three analysts until consensus was reached.
Summaries of the overarching themes were created and specific
quotes were highlighted when they captured the essence of a
particular theme. Finally, content was organized within relevant
HAAT model domains.
Merging phase I and II
Strands of data from both study phases were merged using the
spreadsheet created for extracting and synthesizing data for the
scoping review phase as the foundation. This decision was made
based on the in-depth level of granularity organizing data result-
ant from characterization and analysis of the scoping review
articles. Summarized data from the expert interviews were
mapped onto the scoping review table to facilitate cross-study
comparison. The team searched for and discussed similarities, dis-
crepancies and convergence. Where gaps were noted in available
data that could be cross-referenced, coders of the interview data
revisited transcripts to seek, extract and map additional informa-
tion as necessary. Organization of the results under HAAT model
domains facilitated cross-phase synthesis.
Results
Phase I – Scoping review
The screening and review process is depicted in the PRISMA flow-
chart (Figure 1). The PRISMA-ScR checklist [21] was applied for
transparency (Supplementary Table 2). Database searches yielded
2227 articles and hand searching systematic review references
added 67, leaving 1713 after deduplication. Title and abstract
screenings resulted in 42 articles for full-text review. After data
extraction, 28 studies were included in the final review. Figure 2
provides a high-level summary of the scoping review phase
results as situated within the HAAT model.
Context of research
Table 1 contains basic characteristics of included studies, as
organized within the HAAT model, providing information about
the context of the research conducted and the humans (PwMCI/
ADRD) who were studied. All but one study from Japan [49] were
conducted in Western countries/regions, with most from the UK
(n¼ 6), Italy (n¼ 5), and the USA (n¼ 4). Most were small-scale
(median MCI/ADRD sample size ¼ 10) feasibility/pilot studies and

Table 1. Characteristics of included studies in the Scoping Review Study Phase, as situated in the HAAT Model.
Context
Study design/
Citation and country research methods
Pilot randomized controlled trial
NLD [28]
Longitudinal, non-randomized,
USA [41] single-arm, repeated measures
(pre-post)
Mixed-methods with participatory
UK [42] design and usability study
Repeated observations
UK [39]
UK [47] Beta test with pre-post interview
NOR, PRT [32] Qualitative interview study
USA [30] Pilot and feasibility study using a
within-participant,
counterbalanced, cross-
over design
NLD [46] Mixed methods: interview, survey,
observation
UK [27] Secondary analysis of data from a
randomized controlled trial
CAN [45] Longitudinal pre-post
UK [36] Exploratory: two-arm, non-
randomized, repeated measures
USA [31] Feasibility cohort study
ITA, ESP, AUT [43] Multicenter field trial
ITA [49] Non-concurrent multiple baseline
Sample size
(n) of MCI/ADRD Length of testing/exposure
55 1–1.5-h training session þ 3 months
in-home trial
7 3 months with weekly technical
office hours available if needed
9 3 workshops across 4 months
9 1–2 standard tasks within 4 different
formats þ 1 individually chosen
task exploration per visit (67 total
visits among 9 participants)
26 2 distinct phases (different samples),
4 weeks each
12 2–3 times/week for 16 weeks or 2–3
times/week for 12 weeks, with
each session lasting 30–60 min
10 One 3-h session
Interview: 6 Single session for each event
Survey: 88 (different recruitment procedures)
Observation: 4
37 6-month period within 12-month
parent study
3 Varying based on participant: 12, 24
and 9.5 months, including
intervention (non-specific) until
mastery, then regular and
systematic post-intervention use
30 3 sessions over 5-d period
22 3 months
30 12 weeks
11 3 min x 3–6 baseline sessions;
3–5 min/intervention sessions,
2–4 sessions/day, 51–107 sessions
based on participant availability
4
Human
Setting where tech Mean age or age range; race/ethnicity
was studied n; female/male; education of MCI/ADRD Diagnosis and severity
Home Experimental: 72.7 yr; race/ethnicity NA; 12f/ MCI; mild dementia including AD,
16m; �2o edu 14, higher edu 11 frontotemporal dementia,
Control: 71.7 yr; race/ethnicity NA; 11f/20m; vascular dementia; very mild
�2o edu 12, higher edu 10 cognitive decline
Adult living community 81 years; race/ethnicity NA; 5 f/2 m; edu NA MCI, AD, ADRD
with independent
living, managed care
and dementia care
Dementia NI group 60–81 yr; race/ethnicity NA; sex 3f/6m; Mild-to-moderate dementia
S. L. SCHEPENS NIEMIEC ET AL.
empowerment edu NA
meetings and/or
living space
lab setting
Home 73–86 yr; race/ethnicity NA; 4f/5m; edu NA Mild-to-moderate dementia
Home 80 yr; race/ethnicity NA; 12f/14m; edu NA Mild-to-moderate cognitive
impairment with dementia (AD,
vascular, or mixed AD/vascular)
Care home 84.1 yr; race/ethnicity NA; sex NA; edu NA Moderate-to-severe dementia
including AD, dementia with
Parkinson’s, dementia with Lewy
bodies, vascular dementia,
alcohol-related dementia, and
unspecified
Lab 80.3 yr; white 8, unknown 2; 7f/3m; edu MCI, mild dementia, or “cognitive
16.4 yr (mean) scores falling within [MCI through
mild dementia] range”
Interview: Home Interview: 71 yr (median); race/ethnicity NA; MCI, AD, frontotemporal dementia,
Survey: Home 1f/5m; edu NA dementia with Lewy bodies
Observation: Home or Survey: 67 yr; race/ethnicity NA; 35f/44m
university (9 NA); edu NA
workstation Observation: 66.5 yr; race/ethnicity NA; 1f/3m;
edu NA
Home 70.4 yr; race/ethnicity NA; 16f/21m; �2o edu AD, vascular dementia, Lewy body
34, higher edu 3 dementia, mixed dementia,
dementia (type unspecified), MCI
Home 69 yr; race/ethnicity NA; 1f/2m; edu 12,14, AD and atypical AD
21 yr (median 14)
Care service centre 84.2 yr; race/ethnicity NA; 22f/8m; edu NA Dementia – non-specified
Home Veteran group: 65 yr; Black 10, white 4, Dementia – non-specified (impaired
Hispanic/Latino 1; 0f/14m; edu NA to significantly
Non-veteran group: 78 yr; Black 8, Hispanic/ impaired cognition)
Latino 0; 3f/5m; edu NA
Home Intervention: 72 yr (median); race/ethnicity Mild MCI due to AD or mild AD
NA; 9f/6m; edu NA
Control: 74 yr (median); race/ethnicity NA; 7f/
8m; edu NA
Centres for people 83 yr; race/ethnicity NA; 6f/5m; edu NA Moderate AD
with ADRD
(continued)
Table 1. Continued.
Context Human
Study design/ Sample size Setting where tech Mean age or age range; race/ethnicity
Citation and country research methods (n) of MCI/ADRD Length of testing/exposure was studied n; female/male; education of MCI/ADRD Diagnosis and severity
ITA [33] Two studies: non-concurrent Study 1: 8 Study 1: 1.5–2-h sessions, including Centres for people Study 1: 84.8 yr; race/ethnicity NA; 3f/5m; Study 1: mild-to-moderate AD
multiple baseline Study 2: 9 1st baseline 2–4 sessions, 2nd with ADRD edu NA Study 2: moderate-to-severe AD
baseline 3–6 sessions, 3–4 Study 2: 79.6 yr; race/ethnicity NA; 5f/4m;
introductory sessions, and 37–82 edu NA
intervention sessions based on
participant availability
Study 2: 3 min � 3–7 sessions/day,
4–11 baseline sessions, 73–119
intervention sessions based on
participant availability
ITA [34] Non-concurrent multiple baseline 26 5-min sessions, 3–5 sessions/day, Residential social- Group 1: 83 yr; race/ethnicity NA; sex NA; edu Advanced AD
21–38 pairs of sessions medical centres NA
(control þ intervention) Group 2: 85 yr; race/ethnicity NA; sex NA;
edu NA
ITA [50] Adapted non-concurrent Group 1: 4 2–3 h sessions, including 3–5 Activity and Group 1: 71 yr; race/ethnicity NA; 3f/1m; edu Mild-to-moderate AD
multiple baseline Group 2: 4 baseline 1 sessions (no tech), 3–5 care centres NA
baseline 2 sessions (no tech), 3–4 Group 2: 75 yr; race/ethnicity NA; 4f/0m;
introductory sessions (tech), and edu NA
34–78 intervention sessions (tech)
DEU [51] Open-label, non-randomized, cross- 14 15 min training, 15 min task Hospital campus 71.9 yr; Mild-to-moderate AD
sectional, mono-centric pilot completion � 1 session race/ethnicity NA; 9f/5m; edu 6–10 yr
AUS [35] Qualitative study with observation, 3 6 months Dementia wing of long- 76–87; race/ethnicity NA; 1f/2m; edu NA Moderate-to-advanced dementia
focus groups, and interview term care facility including Lewy body disease, AD,
and dementia (non-specified)
USA [26] Pilot randomized controlled trial 48 6 months Home All: 74.9 yr Dementia, MCI, self-identified
Intervention: 74.2 yr; Non-Hispanic white 16, memory concern
Hispanic white 2, �2 races 1; 11f/9m; �2o
edu 4, higher edu 16
Control: 75.4 yr; Non-Hispanic white 20, Asian
1, �2 races 2; 14f/14m; �2o edu 7,
higher edu 20

Not specified [40] Non-concurrent multiple baseline 5 Mean 7-min sessions (10 min max), Day centre for persons 80 yr; Mild-to-moderate AD
1–2 sessions/day, 3–5 baseline with ADRD race/ethnicity NA; 5f/0m; edu NA
sessions (no tech), 5 intervention
practice sessions (tech), 20–50
intervention sessions (tech)
CAN [29] Phase 2: Qualitative observation 3 One 30-min session Long-term care facility 81–90 yr; race/ethnicity NA; 3f/0m; edu NA Moderate dementia
ESP, SWE [44] Feasibility-usability study Phase 1: 19 Phase 1: 1 introductory and user Phase 1: Clinical setting Blekinge site (BTH): 77 yr; race/ethnicity NA; MCI, mild dementia
Phase 2: 17 testing session Phase 2: Home 3f/6m; edu NA
(same subject pool for Phase 2: 4-week in-home test þ 1 in- Barcelona site (CST): 80 yr; race/ethnicity NA;
both phases) clinic user evaluation session 5f/5m; edu NA
UK [52] Qualitative study with interviews 15 12 weeks Home 61–94; race/ethnicity NA; 6f/9m; edu NA Mild-to-moderate dementia
SWE [37] Qualitative observation and interview 3 29 sessions among 3 participants Home “Older women” – no age specified; race/ Dementia (non-graded)
(varying lengths and total ethnicity NA; 3f/0m; edu NA
completed/participant): 8 without
support, 12 with CIRCA, 9
with CIRCUS
AUS [53] Pilot feasibility study 15 12 weeks total: Home 83 yr; race/ethnicity NA; 7f/8m; edu Mild-to-moderate dementia
Weeks 1–2: 40 min/week 11 yr (mean)
Weeks 3–4: 60 min/week
Weeks 5–6: 80 min/week
Weeks 7–8: 100 min/week
Weeks 9–12: 120 min/week
TECHNOLOGY FOR ACTIVITY PARTICIPATION IN DEMENTIA

(continued)
5
 6 S. L. SCHEPENS NIEMIEC ET AL.

featured qualitative components; only three studies included a

Spain; Exp: experiment; f: female; HAAT: Human Activity Assistive Technology; ITA: Italy; JPN: Japan; m: male; min: minute(s); MCI: mild cognitive impairment; NA: not available; NLD: Netherlands; NOR: Norway; PRT:
2o: secondary; AD: Alzheimer’s disease; ADL: activity of daily living; ADRD: Alzheimer’s disease and related dementias; AUS: Australia; AUT: Austria; CAN: Canada; edu: education; DEU: Germany; DNK: Denmark; ESP:
randomized controlled trial [22,30,41]. Intervention/trial periods
Diagnosis and severity
Early stage dementia (mild-to-
were as short as a single session to as long as 24 months.

moderate impairment)
Settings where technology implementation took place were pri-
marily where PwMCI/ADRD lived (n¼ 19) or at community venues
AD, varying severity
(e.g., day centres; n¼ 7); Purves et al. [43] was the only study
describing a rural context.

MCI/ADRD end users (humans)

Mean/median age of the target users, for those reported, ranged
Human

from 65 to 85 years. Participants’ ethnoracial information was

n; female/male; education of MCI/ADRD
Mean age or age range; race/ethnicity

specified in only three studies [28,33,41]. Roughly equal numbers

69.7 yr; race/ethnicity NA; 2f/4m; edu NA

78.8 yr; race/ethnicity NA; 4f/0m; edu NA

of males and females participated (pooled sex distribution: 227

females vs. 247 males). Seven studies reported education level.
Alzheimer’s disease was the most frequently cited diagnosis
(n¼ 17). Fourteen studies included participants with either mild or
mild-to-moderate conditions; four included advanced-stage ADRD
[27,35,36,40]. Three neither reported specific diagnoses nor condi-
tion severity [32,41,46].

Activity supported with DHT

The second two components of the HAAT model (i.e., activity and
assistive technology) that characterize the scoping review studies
Setting where tech

are presented in Table 2. The DHT interventions for PwMCI/ADRD

was studied

targeted participation in various domains of activity – subse-

quently classified using occupation categories from the
Occupational Therapy Practice Framework 4th ed [53]. Several
(n¼ 12) were multi-focused. Most facilitated engagement in ADL
Home

Home

(n¼ 12), social participation (defined as activities involving social

interaction with others [53]; n¼ 11), and/or IADL (n ¼ 10). Other
DHTs facilitated participation in health management (n¼ 6), edu-
Exp 2: 20- and 30-s videos 9–15 d
Length of testing/exposure

Exp 1: 40-min sessions � 3–8 d

cation (n¼ 4) and leisure (defined as non-obligatory activities

engaged in during discretionary time; n¼ 2). None addressed
Portugal; SWE: Sweden; tech: technology; UK: United Kingdom; USA: United States of America; yr: year(s).

rest/sleep or work/volunteerism.
over �2 weeks

Digital health technology (assistive technology)

Although labelled as assistive technology, the HAAT model can
8 weeks

accommodate technology more broadly [19], and in this study’s

case encapsulates DHTs. Details of the researched DHT systems/
interventions are available in Table 2. Activity prompting systems
facilitated ADL, IADL and leisure activity completion [25,28,36]).
(n) of MCI/ADRD

4 (same subjects for

Videophone systems [42,49] and multimedia apps loaded with

Sample size

photographs, videos and music [24,34,40] fostered social partici-

both exp)

pation. Electronic day planners and organizers [31,44] and Web

portals/apps with curated health information [22,29] assisted with
IADL, education, and health management.
6

Two experiments: modified ABABAB

Hard technology. To further characterize technological compo-

Mixed methods: longitudinal, pre-

nents, the HAAT model differentiates hard and soft technology

[19]. The hard technology (i.e., tangible, physical components) was
research methods
Study design/

method; ABBA method

almost exclusively mainstream, regularly featuring touchscreen tab-

post, case studies

lets and smartphones [23,26,28]. Other less frequently reported

hard technology included smartwatches [34,41,48], Bluetooth ear-
pieces [36–38], computers [36,42,49], durable protective cases
[32,34] and easy-to-activate microswitches [36,42].

Soft technology: design. By nature of studying DHT, the soft tech-

Citation and country
Table 1. Continued.

nologies were much more prominent and varied. Soft technology

refers to external supports enabling individuals to learn and use
products successfully, such as instruction manuals, software, strat-
egies and other people [19]. Table 2 divides the DHT systems’ soft
DNK [48]
Context

JPN [25]

technology into design elements of the software, instructional

strategies implemented and technology partner descriptions and
Table 2. Characteristics of the Digital Health Technology Interventions Featured in the Scoping Review Study Phase, as Situated in the HAAT Model.
Digital health technology
(Assistive technology)
Soft Technology
Activity System/intervention Design elements to maximize Technology partner(s) description and
Citation Targeted activity description Hard technology performance/engagement Instructional strategies involvement
[28] Health management, FindMyApps is a self-service Web Touchscreen Personalized settings for app user profile One- to 1.5-h training to instruct PwMCI/ADRD Caregivers were trained on use of the app
education, social app containing a database of tablet interface including large font size, minimal text, use and caregivers on how to use the tablet and and how to provide continued support to
participation apps that support self- of non-animated pictures, Dutch FindMyApps selection tool; errorless learning the PwMCI/ADRD during the intervention.
management, social language-only app choices, simplified strategies were implemented (e.g., stepwise
participation, and meaningful gesture-control for operation, and more approach, discouraging guessing during task Research staff provided dyads with initial
activity engagement. detailed instructions in the help feature; performance, mistake-free repetition) to training on the tablet and app and
explanation button when help is needed. instruct on basic and complex tasks within the operated an email/phone helpdesk during
app; training was accompanied by a written the trial.
instruction manual; caregivers were trained in
using errorless learning techniques;
demonstration video uploaded to the tablet
covering tablet and app functions; phone and
email support was made available.
[41] ADL Visual mapping software Touchscreen Home screen automatically appears upon Visual mapping using keywords/pictures Caregivers identified ADL to be addressed
presented on a tablet to assist tablet interface task completion, showing next scheduled sequencing; caregivers trained to demonstrate and guided participants in carrying out
people with memory difficulties ADL; “Next” and "Previous" navigation and support; weekly tech support available. tech-supported ADL.
to complete ADL. buttons; customisable template library of
ADL visual maps, which caregivers were Research staff remained available for
trained to modify and personalize. troubleshooting.
[42] Social participation InspireD, a digital app featuring Touchscreen Minimalistic design; clear, bold colours Use of the app was demonstrated by research Carer involvement was optional. Carers
photographs, videos, and tablet interface segmenting the user interface; staff on a large screen and tablet. Set-up reported providing explanation and
music, facilitates joint combination of typography and instructions were provided to participants and demonstration support, “keeping track” of
reminiscence for PwD and iconography to guide navigation and help choices of layout, wording, and usability were device, implementing enrolment process,
their carers. users understand app functionalities; step- agreed upon. and troubleshooting device and software.
by-step linear approach for cognitively
challenging tasks (e.g., uploading photos);
non-stigmatizing language.
[39] ADL, IADL Customisable prompting app for Touchscreen Text, recorded voice, picture, and video Progressive, ongoing support based on Caregiver present during implementation to
multistep tasking. tablet interface prompts; researchers manually triggered participant need, including reiterating provide reassurance; supported
prompts when participant appeared instructions, pointing, and physical identification of meaningful tasks prior to
ready; built-in delay of “Next Step” button demonstration; different prompt types were intervention.
so users can process prompt without studied; user-led exploratory approach for one
being distracted by the idea of moving to individualized task. Research staff assisted with task completion
next steps; appearance, position, and as needed.
wording of a self-forwarding feature
allows user to move at own pace;
wording of self-forwarding feature
changed based on task (“Next Step” vs.
“Next Page”).
[47] ADL, IADL App-based prompter for Touchscreen Audio, picture, and text prompts; carers Device prompting and instruction manual Carer-user dyads worked as a team for the
everyday tasks. tablet interface could set up series of prompts, combining provision; phase 1 included tech training full tech implementation process
type of prompts used, tailored to PwD’s demo to user-carer dyad; phase 2 had no
needs and ADL; "Touch here for next demo, just reliance on intuitive design. Carer involvement varied (e.g., selection of
step" button leading to next sequential multistep tasks and step-by-
step; tablet set to only run the prompting step prompts).
software, all other apps were disabled to
decrease distraction.
[32] Social participation SENSE-GARDEN is a room within a Large-screen projector; Personalized digital media to trigger memory; Written instructions along with video tutorials on via the SENSE-GARDEN tablet app, formal
dementia care setting that aroma dispenser; interactive features to engage multiple how to set up and implement SENSE-GARDEN caregivers (professional care staff) worked
features digital tech and game controller; senses; large-screen projections that do sessions were provided to care staff; an online with family members of the PwADRD to
multisensory stimuli (e.g., stationary bike not require tech manipulation on the helpdesk for tech support was available prepare personalized SENSE-GARDEN
aromas, movement-based PwADRD’s part. as needed. sessions and facilitated the intervention.
games, music, large-screen
TECHNOLOGY FOR ACTIVITY PARTICIPATION IN DEMENTIA

projections) based on an Family members collaborated with care staff

individual’s life story, to engage to prepare SENSE-GARDEN sessions by
(continued)
7

Table 2. Continued.
Activity System/intervention
Citation Targeted activity description
PwADRD in socially supported,
reminiscence activities.
[30] ADL SmartPrompt is a smartphone-
based reminder app designed
to improve daily function in
older adults with MCI/mild
ADRD by addressing
impairments in executive
function to facilitate everyday
task completion.
[46] Health Online patient portal with
management, educational/ informational
education content, patient-provider
communication tools, and
social support features.
[27] Education, health CAREGIVERSPRO-MMD is an online
management, social social-media style platform to
participation provide informational support
(e.g., articles on ADRD services
and events) and social support
(e.g., shared posts among
friends) to PwD and
their carers.
[45] ADL, IADL AP@LZ is an electronic day
planner and organizer app to
support memory for daily
activity engagement.
[36] Leisure Customized accessibility settings
for two commercial game apps.
Digital health technology
(Assistive technology)
Design elements to maximize
Hard technology performance/engagement
Smartphone Simple interface with large, clear text and
touchscreen buttons; time-based auditory alerts/
interface; device prompts to draw attention and trigger
placed in a carrying task initiation; brief text indicating task
case to keep on the goals and instructions; regular reminders
user’s person. and nudges; photo log of task completion
to promote task tracking; points awarded
for logging completed tasks to
address motivation.
No specific hard Welcome Page describing main functionalities
technology noted of portal using “clear font, calm
backgrounds, and contrasting colours”;
clicking Welcome page functions leads
users further into the website with
additional options from which to choose;
accessible language, animations, photos,
videos, and messaging.
Touchscreen Curated information specific to PwD and
tablet interface their carers.
Smartphone Predetermined list of appointment types
touchscreen provided; all other apps on the phone are
interface blocked; number of functions and options
limited to reduce confusion; ringtone
volume softened to decrease reluctance to
use; pictures to accompany text info;
auditory reminders/alarms.
Touchscreen tablet Game page ready on screen upon
interface; maximized presentation; notifications disabled.
volume and
Soft Technology
Instructional strategies
Target users underwent a brief 10–15-min hands-
on training prior to device use. Research staff
followed a detailed script that involved
verbalized instructions paired with
demonstration and practice of desired tasks.
Users received a handout to follow during
verbal instructions. The handout included brief
text aside images of task steps, highlighted
with red arrows/circles to direct attention to
key details. Staff reviewed all instructions once
and prompted questions and repeated
instructions as often as participants needed
until understanding was confirmed. Caregivers
received a non-interactive, brief training
session with verbal instruction and
demonstration of device/task setup. They
completed a performance quiz to demo
understanding.
Accessibility and community interaction
considered in programme design; testing
intuitiveness of design through hands-on tasks
(no training apparent).
At an in-home visit, PwD-carer dyads were
provided 2 touchscreen tablets and instructed
on how to use the CAREGIVERSPRO-MMD
platform. Optional group training sessions that
included platform tutorials and written step-
by-step guides were offered 4 times per
month as follow-up support.
Structured, 3-phased training sessions including
errorless learning: 1) Acquisition – participant
completes series of tasks given 3� in random
order; learning curve calculated based on
number of correct responses. 2) Application –
role-play to act out real life scenarios when
one would use the app; trainer omitted details
about events to prompt user to ask questions.
3) Adaptation–user inputted 5–6 real activities
into the app.
Research staff led a singular, standardized,
physical demonstration of gameplay
accompanied by verbal instruction.
8
Technology partner(s) description and
involvement
providing photographs, videos, and other
personal life story information about the
PwADRD. They were invited to attend
sessions with the PwADRD.
A technical team was made available through
an online helpdesk to receive and
S. L. SCHEPENS NIEMIEC ET AL.
respond to participants’ technical issues.
Caregivers received training in how to
programme tasks and reminders into the
SmartPrompt app.
Research staff trained target users and
caregivers in device use and
task completion.
No specific tech partner involvement noted.
Carers received their own tablet to access the
platform independently. They attended
initial training and could attend optional
group training sessions. Carers provided
PwD assistance in using the platform.
Research staff provided initial and follow-up
trainings to dyads and groups of users.
Research staff led systematic tech training
sessions.
Caregiver involvement required as part of
study to help as needed (e.g.,
encouraging device carrying, reminding
participant to note activities in the app).
Research staff preset games on screen and
encouraged participants to play
independently if support was requested.
(continued)
Table 2. Continued.
Digital health technology
(Assistive technology)
Soft Technology
Activity System/intervention Design elements to maximize Technology partner(s) description and
Citation Targeted activity description Hard technology performance/engagement Instructional strategies involvement
brightness; stable, Solitaire features: consolidated control
durable case to methods to only drag-drop; option to
protect device and alter input method that triggers toolbar
power button from and to enhance visual emphasis of auto-
accidental shutdown prompts.

Bubble Explode features: simplified layout of

[31] ADL Visual maps, which included step-
by-step guidance with pictures
and keywords, displayed on a
tablet to assist users in
organizing and accomplishing
ADL like bathing and dressing.
[43] IADL MEMENTO includes 2
interconnected e-ink tablets
with handwriting recognition
housed in a protective
notebook cover, a commercial
all-day worn smartwatch to
relay assistance, and a web
interface. The system assists
with everyday activities like
medication management,
scheduling, and shopping.
Caregivers have access to a
web interface for system setup
and monitoring.
[49] ADL Smartphone-based intervention for
goal-directed ambulation and
object use that integrated a
walker-affixed smartphone with
Bluetooth and light sensors,
battery-powered lights, and
audio stimulation delivered
through headphones.
[33] ADL, leisure Mobile device interventions
involving:
Study 1: customisable app that
provides reminders and verbal
instructions, delivered on a
tablet or smartphone and
paired to a Bluetooth earpiece,
to aid completion of daily
activities.
Study 2: shoe-affixed microswitch
paired with a notebook
opening screens; minimized text feedback
that were distractors; auto-prompts for
user inactivity; audiovisual redirection
prompts after invalid input.
Tablet Pictures and keywords presented in a step-
touchscreen by-step sequence to support ADL
interface performance; individualization through
self-selection of visual maps based on
preferences and needs; option to include
images from one’s own environment to
personalize visual maps.
Connected e-ink Large font; clear language; symbols and
touchscreen tablets; images connected to text-based
inconspicuous information; individualization using
protective notebook personal photographs; design modelled
cover to avoid on familiar, analogue desktop calendars
stigmatization; and notebooks; information and
smartwatch; stable reminders accessible on tablet/smartwatch
charger for any time; smartwatch reads lists aloud
easy handling and calls caregiver if needed; one-button
panic option to contact caregiver and
relay user’s location.
Smartphone with Audio, single-step instructions delivered
Bluetooth connected through headphones; praise statements at
to headphones/ completion of task steps; repetition of
earpiece eliminated instructions until task completed or timed
need to interact out; preferred stimulation (songs, hymns,
with tech directly comic sketches) as determined by staff
and families, delivered at successful
task completion.
Smartphone/tablet Study 1: pre-scheduled activities with verbal
connected to audio reminders to begin tasks; verbal 1-
Bluetooth earpiece or 2-step instructions separated by pre-
to eliminate need to determined individualized intervals based
carry mobile device; on participant and activity type; praise
microswitch paired statements during task performance;
with activities and frequency of verbal
notebook computer reminders adapted based on
characteristics of participants.
Study 2: audio stimulation and verbal
prompts delivered through earpiece,
eliminating need to carry a device; brief
Nondescript training was provided by
research staff.
Guidance and support from a peer contact was
provided while participants (and caregivers
when available) tried the system’s
functionalities at an in-home visit.
Three to six “familiarization sessions” in which
research staff used verbal and physical
guidance to ensure accurate task completion.
Study 1: 3–4 introductory/ practice sessions with
explanations and guidance from research staff
at activity initiation to facilitate accurate task
performance.
Study 2: five “introductory sessions” led by
researcher staff who used physical and verbal
guidance to familiarize participants and allow
them to experience prompts and
performance-contingent stimulation.
Research staff conducted initial training and
development of ADL maps.
When available, caregivers were included in
the in-home orientation to the system.
Caregivers could monitor system usage
and user location through a web
interface.
Research staff (presumably) installed the
system.
A peer contact provided system orientation
and close-contact support throughout the
trial. Biweekly check-in calls/meetings
were provided.
Research staff set up tech for use during
intervention and provided user training
and guidance.
Families and day-centre staff provided
recommendations for preferred content to
be used as stimulation.
Study 1: activities were selected, adapted,
and scheduled based on individual
participant characteristics (authors did not
specify by whom).
Study 2: research and day-centre staff
collaborated to determine preferred
content to be used as stimulation;
research staff set up tech for participant
use and provided guidance during
introductory sessions as needed.
TECHNOLOGY FOR ACTIVITY PARTICIPATION IN DEMENTIA

computer that delivered verbal prompts (1–3 words) delivered

stimulating audio (e.g., music) after lack of participant response;
(continued)
9
Table 2. Continued.
Activity System/intervention
Citation Targeted activity description
and verbal prompts through an
earpiece, to
encourage ambulation.
[34] ADL, A smartphone programme that
health management made use of an audio-based
smart-prompting app, radio
frequency code-tagged objects,
and a “receiving” smartphone
and app that responded to
participant performance, to
encourage upper extremity
exercise with everyday objects.
[50] ADL, IADL Customisable app that provides
verbal audio reminders and
instructions, delivered via a
tablet paired to a Bluetooth
earpiece, to aid completion of
everyday activities.
[51] IADL Smartphone assistive device that
facilitates autonomous
environmental navigation/
orientation.
[35] Social participation Tablet app loaded with personal
and stock multimedia (e.g.,
photos, books, music, family
movies) to stimulate
reminiscence and social
interaction.
[26] Social participation Smartphone app that employs
facial recognition software
linked to a smartwatch to assist
with identification of people
during social encounters.
[40] IADL, social Computer-aided telephone system
participation with video-displayed images
and a microswitch for device
operation to enable
independent phone
call completion.
Digital health technology
(Assistive technology)
Design elements to maximize
Hard technology performance/engagement
participant-preferred stimulation (songs,
hymns, prayers) that triggered positive
reactions, delivered at successful
task completion.
Smartphone; radio Verbal audio prompts/ encouragement if no
frequency-code- response from participant (10–15 s);
tagged objects preferred stimulation (songs, hymns),
delivered at successful task completion.
Tablet paired to a Pre-scheduled, personally relevant activities
wireless Bluetooth with verbal audio reminders to begin
earpiece allowed tasks; single-step instructions strung
audio prompts to together in 2–5 sets at a time (dependent
travel with task, on cognition); programmed interval
while tablet length between instructions varied based
kept remotely on participant performance.
Smartphone Verbal and acoustic direction prompts
touchscreen delivered at decision points (i.e.,
interface intersections); redirection provided if PwD
made a wrong turn; use of photo-realistic
images of environment (vs. abstract
maps); arrows to indicate correct
direction; audible sound when device
provides new info.
Tablet Media personalized to PwD and their carers.
touchscreen
interface
Smartphone; App automatically recognizes individuals and
smartwatch sends alert via smartwatch vibration,
displaying the person’s image, name, and
relationship to PwD; high-capacity
database to enrol up to 1,000 individuals.
Computer; telephone Switch activation prompts computer to
with video display; perform tasks such as listing available call
microswitch activates partners (1 at a time), calling a partner, or
system with minimal disconnecting a call; 4–5 s delay to allow
hand contact response time; lack of switch activation
prompts system to display next available
call partner in sequence; programme
provides picture and verbal identification
Soft Technology
Instructional strategies
Four to six practice sessions whereby research
staff provided verbal and physical guidance so
participants could experience prompts and
performance-contingent stimulation.
Three to four practice sessions whereby research
staff provided explanation and guidance so
participants could become independent in
activity performance, as well as error
correction when activity could not proceed if
left unaddressed.
Scripted verbal instruction from research staff
prior to releasing the device to the PwD.
Research staff provided individualized training
(unspecified) to family members on adding
content to Memory Keeper and using the app
with the PwD. Paper-based instructions were
provided in one case.
Research staff demonstrated the tech and
“trained” participants to use it in a single in-
person session; ongoing tech support
as needed.
Five practice sessions to familiarize patients with
the system (i.e., how to rely on audiovisual
info presented and respond by switch
activation); physical and verbal prompts from
research staff if patient failed to activate
system or make a selection.
10
Technology partner(s) description and
involvement
Families and day-centre staff recommended
preferred content to be used as
stimulation.
S. L. SCHEPENS NIEMIEC ET AL.
Research staff set up tech for participant use
and provided guidance during practice
sessions as needed.
Research staff (presumably) selected relevant
activities and timing for completion; audio
recorded verbal instructions; set up tech
at the beginning of each session; and
provided guidance at initial sessions, error
correction as needed, and praise upon
activity completion.
Research staff provided verbal instructions
upon giving participants device, and
verbal reassurance/encouragement and
redirection as needed.
Significant others were responsible for
uploading content to the app and
facilitating use with the PwD during visits.
Long-term care facility staff were also
encouraged to use the device with the
PwD.
Research staff provided user training
and guidance.
Target users and caregivers participated as
dyads; caregivers reported providing
explanation and demonstration support,
“keeping track” of device, implementing
enrolment process, and troubleshooting
device and software.
Research staff provided training and tech
support as needed.
Phone call partners consisted of family,
friends, and caregivers.
Research staff (presumably) set up tech (e.g.,
identifying call partners,
uploading photos).
(continued)
Table 2. Continued.
Activity System/intervention
Citation Targeted activity description
[29] Social participation Mobile app enabling access to
locally and globally relevant
digitized media including
photos, short video clips, and
music, to facilitate reminiscent-
based conversation.
[44] ADL, IADL, health Support Monitoring and Reminder
management, Technology for Mild Dementia
education (SMART4MD) health app
adapted for individuals with
mildly impaired cognition to
assist with daily task
completion through use of
reminders, cognitive support
tools/tasks, and
information sharing.
[52] Social participation Individual Specific Reminiscence in
Dementia (InspireD) tablet app
is a home-based, personalized
reminiscence programme to
facilitate reminiscence and
social interaction.
[37] Social participation Two web-based apps, CIRCA and
CIRCUS, enabling access to
curated multimedia (e.g.,
pictures, videos, music), either
generic or personalized,
respectively, to facilitate
reminiscence and conversation.
[53] Health management StandingTall a fall prevention
exercise programme consisting
of balance training exercises
and assessment delivered via
Digital health technology
(Assistive technology)
Design elements to maximize
Hard technology performance/engagement
of call partner’s name or relationship to
patient; partner’s picture is displayed
during conversation.
Touchscreen Sequential presentation of information –
monitor interface theme selection leads to media categories
(photos, music, videos), followed by
further choices in each category; the
programme (not the users) randomly
selects topics to promote equality
between PwD and conversation partner;
media included brief titles and captions to
prompt conversational engagement; use
of materials linked to shared cultural
heritage to trigger durable emotional
memories of younger years.
Touchscreen Built-in cognitive supports like appointment
tablet interface reminders, a calendar, and brain games;
user agency to share health and status
information with family/friends/carers;
personalized health information; simplified
home screen with solid background and
deletion of non-essential app icons;
disabled notifications of other apps;
horizontal/vertical lock; deactivated
screen lock.
Tablet Limited limiting apps on home screen to
touchscreen only those necessary; bright colours; large
interface buttons; icons with brief text.
Tablet Sequential presentation of information –
touchscreen theme selection leads to media categories
interface (photos, music, videos), followed by
further choices in each category.
CIRCA: the programme (not the users)
randomly selects pre-established topics to
promote equality between PwD and
conversation partner and constrain choice
thereby dissuading repetition of same
conversations.
CIRCUS: includes personalized categories and
uploadable multimedia (photos, videos,
digitized materials) organized into a
digital memory book to activate
early memories.
Tablet Audiovisual-based demos of desired tasks;
touchscreen automated progress tracking; in-app
interface exercise scheduling; built-in coaching and
automated tailoring of exercises and
intensity based on user-inputted self-
Soft Technology
Instructional strategies
A nondescript “brief orientation to the program”
was given to the conversation partner. No
training was described for the PwD. “The
program is easy to use [ … ], no training
is required”.
One-time, “thorough and accessible” introduction
to the tablet and app, first with the person
with MCI and then the carer, in a clinical
environment. The app was explained and its
use was demonstrated. Dyads practiced tasks
after the demonstration. Lingering questions
were answered before in-home testing began.
A paper-based manual was provided.
Nondescript “information technology and
reminiscence” training was provided by
research staff.
Basic instructions on tablet use and use of CIRCA
and CIRCUS were provided to the care-aid. No
training was described for the PwD.
A research physiotherapist introduced the
programme to the participant-caregiver dyad
at a home-visit. App features “were explained
and demonstrated”. Phone support and
scheduled and as-needed home visits were
Technology partner(s) description and
involvement
Dyad structure consisted of PwD paired with
care-aide, who functioned as a
conversation partner and facilitated
engagement with tech (e.g., encouraging
interaction with touchscreen, selection
of topics).
Carers were considered “main users”
alongside persons with MCI and were to
assist when needed. They were trained to
use the app at outset.
Research staff provided introduction to the
equipment and app. Weekly support calls
were offered to all persons with MCI-carer
dyads and staff could be contacted
anytime.
Each participant had at least one partner
who was a relative (spouse, child, or
grandchild) who would engage in the app
with them.
Dyad structure consisted of PwD paired with
professional carer. The carer functioned as
a conversation partner, facilitated
engagement with tech, and progressed
conversation when necessary.
Research staff (presumably) set up tech (e.g.,
uploading personalized pictures).
Caregivers participated in the system
orientation and assisted participants with
app usage during exercise sessions,
TECHNOLOGY FOR ACTIVITY PARTICIPATION IN DEMENTIA
information entry (e.g., perceived exertion
ratings), and safety monitoring.
(continued)
11
Table 2. Continued.
Activity System/intervention
Citation Targeted activity description
tablet, with on-screen text,
video demos, and voice-overs.
[48] IADL Use of
smartphones þ smartwatches
loaded with an activity and
location monitoring app, a
calendar app with appointment
reminders, and a self-report
app to provide personalized
support of daily activities and
objective monitoring of goal-
based activity behaviours.
[25] ADL, IADL, social Two videophone-based systems:
participation (1) remote reminiscence
conversation system to
promote conversational
engagement and psychological
wellness and (2) schedule
prompter system to assist PwD
to perform household tasks.
Notes: AD: Alzheimer’s disease; ADL: activity/activities of daily living; ADRD: Alzheimer’s disease and related dementia; app: application; demo(s)¼demonstration(s); IADL: instrumental activity/activities of daily living;
MCI: mild cognitive impairment; PC: personal computer; PwMCI/ADRD: person(s) with dementia; QoL: quality of life; tech: technology.
Digital health technology
(Assistive technology)
Design elements to maximize
Hard technology performance/engagement
ratings of exertion; automated time-out
and session closure if failure to interact
with the app.
Smartphone Self-report app prompts user to input info;
touchscreen standard home screen displaying time,
interface; appointments, and step count can be
smartwatch individualized (e.g., add a picture dialling
feature); data collection app ran in
background without needing user
engagement to track activity and location
data; Google Calendar was one app
selected for its simplicity and provided
to all.
Touchscreen PC PC remotely booted by conversation partner;
interface with auto-launch of software when PC turned
web camera on.
Remote Reminiscence Conversation
System: personal photos scanned onto PC
and used by partner during conversation.
Schedule Prompter System: audiovisuals (i.e.,
“beautiful pictures and soothing/ nostalgic
music”) to draw users’ attention to PC;
short 5-min videos to motivate (i.e., old
music videos, motor exercise video, photo
videos of participant) followed by
scheduler video to cue household task
completion (e.g., take medication,
prep meal)
Soft Technology
Instructional strategies
made available to address issues with the
programme. Instructions to complete exercises
included onscreen text, video guides/demos,
and voice-over.
Devices were introduced and personalized at a
tech orientation visit for the participant and
caregiver. Participants were shown how to use
the apps. Instructions were repeated at a 1-
week follow-up visit. Tech support was
available via phone and at visits as needed.
An illustrated manual was provided.
No instruction for participants or caregivers
was reported.
12
Technology partner(s) description and
involvement
A research physiotherapist introduced the
programme and equipment to the dyads
and provided in-person and phone-
based support.
Live-in caregiver involved in all aspects of
tech use (e.g., training, implementation,
S. L. SCHEPENS NIEMIEC ET AL.
data reporting).
Research staff (trained in psychology)
collaborated with participants to develop
individualized goals, and provided tech
support as necessary.
Research staff (systems engineer) set up and
maintained tech in partner’s and
participant’s home for study length.
Caregiver ensured tech stayed powered on
for study length and observed and
reported on participant behaviours.
Remote Reminiscence Conversation
System: research volunteer functioned as
conversation partner and remotely
activated tech; caregiver supplied photos
(presumably);
caregiver þ partner þ participant
collectively scheduled calls.
Schedule Prompter System:
caregiver þ memory clinic
therapist þ participant selected and
scheduled tasks. Therapist or caregiver
was videoed explaining tasks.

Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart of the screening and inclusion process of literature for the scoping
review phase.
involvement. The DHTs investigated shared three primary design
features: prompting software, customisability and multimedia/mul-
tisensory experiences. Prompting software was implemented to
address device inactivity [32], to provide redirection and support
user decision making [39], and to simplify device navigation [23].
Customisability enabled individualized tailoring to enhance motiv-
ation to engage, such as by offering menu options from which
users could select meaningful activities [26]. Multimedia and mul-
tisensory experiences, such as use of soundscapes [27], videos
[29,43], and vibration alerts [41] were also used to maximize
attention and engagement.
Soft technology: instructional strategies. Descriptions of soft tech-
nology related to instructional strategy supports were frequently
brief; four studies [33,43,45,49,] included non-descript summaries
or made no mention of them at all. Popular reported (or infer-
able) strategies included hands-on practice [28], training a second
person involved in technology implementation [44], demonstra-
tion [22] and prompting/cueing from research staff [39]. Four
studies [22,26,44,48] featured a supplemental user manual.
Soft technology: technology partners. A partner to support target
users with the DHT during the intervention was described in all
but one study [29]. Research staff and care partners frequently
served together as technology partners, with level of involvement
varying from minimal [32] to substantial [41]. Research staff most
commonly provided the DHT training and technical support [49].
Care partners, too, played a role in troubleshooting [24], encour-
agement to engage with the technology [25], and technology
customization [41].
TECHNOLOGY FOR ACTIVITY PARTICIPATION IN DEMENTIA 13
Researcher recommendations to advance the science
Commonalities emerged from an analysis of the recommendations
researchers had made to advance science in DHT for PwMCI/
ADRD, which could be similarly organized within the HAAT model
constructs. All but one study [46] noted future research should
entail enhanced study design contexts. They recommended lon-
ger, larger-scale trials with more robust methodologies
[23,33,47,48], as well as closely studying integration of DHTs into
real-life contexts such as within routine rehabilitation processes
[31] or environments that pose higher safety risk [39]. Researchers
also recommended more attention to care partners situated
within PwMCI/ADRD immediate context by finding ways to reduce
their support burden [27,40], studying their wellbeing and care
burden outcomes [31,45,47], and gathering their perspectives on
practicality of the DHTs in daily context [35].
Meeting human needs was also at the top of researchers’
minds. They acknowledged the progressive, variable nature of
ADRD diagnoses poses a challenge to DHT development [45] and
that future DHT should accommodate diagnosis subtypes, comor-
bidities and changing needs as cognition and function decline
[22,28,32,40]. They stated more time should be spent on personal-
ization and tailoring DHT to match what PwMCI/ADRD truly desire
from the technology and to ensure it fits within their daily lives.
Others also suggested measurement of additional person-centred
outcomes such as social engagement [48], comfort with the DHT
[41], physiological benefits [35], mood [42] and perceived draw-
backs of the technology [ 38]. In only a few studies, broadening
the sample diversity on key levels – socioeconomic status, race/
ethnicity, targeted geographical regions, international participa-
tion, stages of ADRD – was noted as important [26,27,41,43,44,].
14 S. L. SCHEPENS NIEMIEC ET AL.
Figure 2. Common components of research studies addressing activity participation-supportive digital health technology for PwMCI/ADRD, as situated in the HAAT
Model. AD: Alzheimer’s disease; HAAT: Human Activity Assistive Technology; IADL: instrumental activity(ies) of daily living; PwMCI/ADRD: person(s) with mild cognitive
impairment or Alzheimer’s disease and related dementias; tech: technology; yr: years.
Advancing science in the activity domain was not discussed by
many aside from two studies with intentions to expand the capa-
bilities of the DHT to address more variety of activities [28,35].
Regarding future research recommendations for the studied assistive
technology, researchers supported continued involvement of PwMCI/
ADRD in ongoing DHT design and development processes
[22,28,34,41,42,], including those with more advanced stage ADRD [27].
Desired upgrades to the DHTs’ designs and functionalities were specific
to each study, ranging from adjusting timing of prompts [39] and mak-
ing onboarding less cumbersome [41], to increasing button colour con-
trast [24] and supplementing audio-alone elements with audiovisual
options [42]. Several researchers planned to explore ways to reduce reli-
ance on soft technology supports from others, such as by refining
accompanying training for target users and/or tech partners
[22,24,28,31,39,40], introducing more system automation [27], and
developing a more context aware (“smarter”) system [22,24,28,31,39,40].
Phase II – Expert stakeholder interviews
All experts (N¼ 17) had �4 years of experience working/practic-
ing/volunteering with older PwMCI/ADRD; most had 12þ years
(n¼ 7). Respondents were primarily female (n¼ 14) and from the
USA (n¼ 16), representing Western (n¼ 8), Northeastern (n¼ 5),
Southeastern (n¼ 2) and Midwestern (n¼ 1) states. One partici-
pant was from Ontario, Canada. Regarding sub-types of condi-
tions/diagnoses of the older adults with whom the experts
interacted, all reported working with persons diagnosed with MCI
and AD. The next most common sub-types experts reported see-
ing in their practice were vascular dementia, Parkinsonian demen-
tia and mixed dementia. Figure 3 depicts the breadth of
experience, roles held and settings represented by experts. All
experts held multiple roles in their practice, ranging from clini-
cians and researchers to advocates, technology consultants and
personal caregivers. Their practice settings spanned the con-
tinuum of care, varying from outpatient and hospitals to commu-
nity centres and home health. Figure 4 provides a high-level
summary of the expert stakeholder interview phase results as situ-
ated within the HAAT model.
Activity participation supported with technology
Experts discussed several ways older PwMCI/ADRD were presently
using or seeking assistance to utilize mainstream technology for
activity participation. Most commonly was technology for social
participation and leisure as recalled by one expert: “A lot of them
do Words With Friends. Or they also use it [smartphone] to just
stay connected with family, especially right now [during COVID-
19]. They do a lot of [ … ] apps that you can connect with people
on, like WhatsApp or Facebook”. Experts noted increased use of
wearables and virtual platforms and portals for health manage-
ment. “I have several clients who call me just to get on their
Zoom yoga classes”. Technology-supported IADL mentioned were
managing finances on banking websites, general IADL manage-
ment via digital alarms/reminders, and community mobility (e.g.,
bus transit apps). Other activity categories such as sleep, basic
ADL, work/volunteering and education were not discussed.
Influential factors and strategies for technology implementa-
tion/uptake
Experts described a number of factors and considerations that
should be made – relevant to the remaining domains of the
 TECHNOLOGY FOR ACTIVITY PARTICIPATION IN DEMENTIA 15

Figure 3. MCI/ADRD-relevant practice settings represented and roles held by interviewed expert stakeholders. Several experts reported multiple roles across various
contexts in their professional and personal histories.

Figure 4. Expert stakeholder viewpoints of influential factors relevant to digital health technology, as situated in the HAAT Model. HAAT: Human Activity Assistive
Technology; IADL: instrumental activity(ies) of daily living; PwMCI/ADRD: person(s) with mild cognitive impairment or Alzheimer’s disease and related dementias;
tech: technology.

HAAT model – as well as supportive soft technology strategies
that were deemed influential to technology implementation and
uptake in PwMCI/ADRD.
Contextual factors. Experts highlighted several contextual factors
dictating technology feasibility and uptake. They posited society’s
limited understanding of MCI/ADRD conditions has led to ineffect-
ive or unusable products for PwMCI/ADRD. They also explained a
nexus of access, availability and affordability as highly influential.
Reliable and affordable internet access, especially for people from
rural regions, was a key issue. “The number one reason people
don’t want to participate [in research] is because they say, ’Oh
well, I don’t have Internet,’” remarked an expert who conducts
technology-based research in rural communities. Similarly, an
expert who serves older adults with lower socioeconomic statuses
highlighted cost as a barrier: “Not everyone has an unlimited data
plan, [ … ] a lot of health apps tend to use up [data]”. Availability
of support systems as well as timely and preventive support,
including assisting novice users or those with higher levels of cog-
nitive impairment in technology navigation, was a broad need
identified. “[I]n the early stages of cognitive decline [ … ] our cur-
rent way of supporting someone is kind of watchful waiting. [ … ]
16 S. L. SCHEPENS NIEMIEC ET AL.
We just kind of wait for something to happen before we
really help”.
Human factors. Users’ prior experience with technology, especially
before cognitive decline, was a frequently cited human determin-
ant of use. Users “pick it up” easier with previous familiarity.
Some described inexperienced users’ anxieties: “The number one
fear people have is that they’re going to destroy it [device] [ … ]
they’re so afraid I’m going to push this and try it and it’s gonna
go kapoof on you [ … ]”. Along this vein, diagnosis type and asso-
ciated cognitive capacity was emphasized: “It depends on the per-
son [ … and] type of dementia they have, [ … ] it is so dependent
on their abilities”. Experts described how memory issues could
impede technology use, such as recalling the necessary proce-
dures to operate the technology/software (e.g., steps to delete an
email) or remembering to use the technology at all (e.g., donning
a sleep-tracking smartwatch before bedtime each night). Other
human factors were said to play a role, including motivation and
interest to use technology and having a clear understanding of
the value technology would add to one’s life. If the technology
“helps that person do what they want to do, it’s meaningful, and
it has a positive outcome, that is going to motivate [ … ]
the person”.
Soft technology: design factors. Experts criticized lack of accom-
modations for PwMCI/ADRD’s unique needs when it came to cur-
rent technology design – mainstream not assistive technology
was referenced and discussions centred on soft not hard design.
“Older adults are fighting not just what they need to learn that’s
new, but they’re also fighting the challenges of learning it on
something that might not be well designed for them. [ … ] Things
as basic as just the size and the style of what is being communi-
cated through a digital device can have a huge effect on their
frustration tolerance of learning something new”. One expert
remarked the problem stems from failure to involve PwMCI/ADRD
in technology development: “We are designing it for what we
imagine they want rather than what they actually might want”.
Experts’ recommendations to improve technology design cen-
tred on simplification. One expert highlighted Jitterbug, a smart-
phone for older adults, as ideal to ease clients’ transition to new
mobile technology. “It’s a little more simplified [ … ,] very organ-
ised [ … and] designed for ease of use”. They cautioned, however,
to make technology “simple but not childish” and to balance sim-
plicity and interactivity: “That’s counterintuitive to a lot of design-
ers who want to make it [ … ] active and interesting, but we want
it very simple”. Another expert suggested the technology’s con-
tent should minimize the need for abstract thinking, a challenge
for PwMCI/ADRD. Experts also emphasized technology should be
designed to serve a meaningful purpose, assisting people with
valued activities. In reference to physical activity-supportive tech-
nology, “We can’t just assume that we know exercise is important
for them”. They suggested customisable components to help
accommodate differences in users’ needs, functional level and
context. The iPhone’s facial recognition feature – to easily unlock
the phone – was an example given of customisation fostering
ease-of-use. Like simplicity, a caveat was noted: “Customisation is
a tricky one. If it’s done well, it can be helpful and not well, it can
be so confusing”.
Soft technology: instructional strategies. Experts described several
soft technology instructional approaches they utilize to support
learning and functional use of technology by PwMCI/ADRD.
Popular didactic techniques included modelling and
demonstration with visual aids. One expert draws on abilities indi-
viduals are likely to retain despite cognitive decline, by incorpo-
rating multimedia: “[ … ] using the skills that this person actually
has—they are losing a lot of words—so whenever I communicate
[ … ] I use rhythm and music and visual cues”. Others capitalized
on group dynamics, engaging PwMCI/ADRD in dyadic or small
group learning sessions. Repetition, consistency, and routine also
surfaced as key. One expert repeatedly introduces technology
“the same time every day [ … ,] routine is very important for this
population”. Another explained making new technology compre-
hensible to PwMCI/ADRD by linking it to individuals’ lived
experiences.
Additionally, experts touted intuitive instructional design (i.e.,
structuring content to eliminate the need to think about how to
respond) as beneficial. Using plain language, step-by-step instruc-
tion, and simplified content was recommended, as true for one
expert’s client who wanted to learn his iPhone’s calendar app:
“We were able [ … ] to break down steps and write them for him
to follow”. Even with those strategies, however, the expert said
the learning process was “overwhelming” for that client. Other
strategies mentioned included scaffolding, errorless learning,
chunking, guided discovery, monitoring frustration and limiting
instructional time.
Consideration of user motivation carried through to experts’
instructional approaches. If a technology’s meaningfulness to
activity participation was not immediately apparent, some would
first educate users about what the tool offered – “letting people
know [ … ] what is it and why is it important” – before advancing
to device operation. Another stated, “I would get their attention
to see the value of it for them to do other things in their life”.
One expert posited motivation and complicatedness of learning
technologies are inextricably linked: “If you have more motivation,
you can deal with greater complexity. [ … ]People with dementia
are figuring out how to use Zoom because it’s a way of being
connected socially”.
Soft technology: technology partners. Embedded in experts’ dis-
cussions of soft technology instructional practices was engage-
ment of technology partners – typically care partners, family
members or experts themselves. They described technology
implementation in PwMCI/ADRD as a dyadic, collaborative process
initiated immediately upon introduction of new technology. “You
just need to make sure there’s a person to do it [operate a
device] with them. Everything you’re going to do is gonna be
together”. Some pointed to the serious challenge this poses for
PwMCI/ADRD who have limited social support (a contextual
consideration).
Experts commonly involved care partners in didactic sessions,
offering firsthand exposure of the “dementia experience” with
technology use. They identified "troubleshooter" as an important
role of the partner that helped minimize users’ cognitive load.
The assistant must be “friendly” and able to “communicate in a
way they [PwMCI/ADRD] understand”. Experts remarked technol-
ogy partners supplement shortcomings in design features by pro-
viding real-time prompting and encouragement of device usage.
When users have more advanced ADRD, care partners serve as
surrogate deciders of what technology would be meaningful to
the user: “It’s going to probably be the family caregiver who sees
this need”. Finally, having someone available to monitor use over
time was deemed critical: “[ … ] there needs to be another care
partner [ … ] who is going to ensure that this person remains safe
as their cognition continues to decline”.

Discussion
Informed by a scoping review and expert interviews, and analysed
through the lens of an occupation-based, person-centred frame-
work, this study aimed to collate, summarize, and characterize
evolving research and practice featuring activity participation-sup-
portive DHT for direct use by older PwMCI/ADRD. Application of
the HAAT model in this study provided a framework that
acknowledges the fundamental interconnectedness among
PwMCI/ADRD, the activities in which they desire to participate,
and the DHT that can enable such participation, all with mindful-
ness to the overarching influence of the sociocultural, environ-
mental and institutional contexts. In characterizing and cross-
comparing both the ongoing research practices and expert expe-
riences, findings suggest both convergences and points of depart-
ure relevant to each domain of the HAAT model. Exploring the
strengths and opportunities of growth in each area could expand
DHTs’ potential to account for and better meet the needs of
diverse MCI/ADRD communities in real-world contexts.
Nature of the context
The scoping review revealed that within the research and devel-
opment context of DHT for activity participation and use by
PwMCI/ADRD, work is still in its early stages despite more than a
decade’s worth of research. Only three studies presented pilot
randomized controlled trials; all others described preliminary feasi-
bility work with small sample sizes. This finding is aligned with
reports from past reviews of technology relevant to the MCI/
ADRD community [54,55]. Moreover, studies almost exclusively
took place in Western regions of the world. This latter limitation
is not uncommon: Eastern countries’ research, aside from
Australia, is not typically represented thus resulting in Western-
biased interpretations of MCI/ADRD technological advancements
[5]. A 2015 review of assistive technology for ADRD care identified
at the time a need for more cross-cultural studies to broaden the
applicability and uptake of technology being developed across
the globe [8]. At the more meso/micro environmental level, and
as a key strength, research frequently was conducted in the pla-
ces where PwMCI/ADRD lived or at community venues, whether
that was in private homes, long-term care facilities or older adult
community centres. This is important as it provides more eco-
logically valid insights and sets the stage for easier transfer of the
DHT from a research to real-world context [56].
Consideration of social contextual factors was of primary con-
cern to experts, but those did not appear as salient in the scoping
review studies. Experts described issues of access, resource avail-
ability and affordability as strongly influential to why more tech-
nology was not taken up in the MCI/ADRD community. Although
many of the DHTs featured in the scoping review relied on widely
available mainstream technologies (i.e., tablets and smartphones)
that are generally affordable in comparison with assistive technol-
ogies [57], access may still be out of reach for many. For instance,
older adults with socioeconomic challenges and from commun-
ities of colour – groups with disproportionate risk and prevalence
of MCI/ADRD [58,59] – oftentimes lack familiarity with and oppor-
tunity to experience mainstream and assistive technology, despite
eagerness to engage [60–62]. Digital inequities like these stem-
ming from PwMCI/ADRD social context, as noted by the experts,
are likely to continue perpetuating the digital divide [12,13].
TECHNOLOGY FOR ACTIVITY PARTICIPATION IN DEMENTIA 17
Characterizing PwMCI/ADRD as target end users
Transparency in characterizing the basic human factors of the
study samples was lacking in the scoping review research. Details
typically centred on age, sex/gender, broad diagnosis or condition
severity and occasionally educational level. Other key sociodemo-
graphic characteristics including race/ethnicity, socioeconomic sta-
tus or residence locale were not reported, save for four studies
[28,33,41,43]. A review of mHealth apps for PwADRD noted similar
omissions in the literature [16]. This leaves a limited understand-
ing for whom present-day DHTs are being designed and devel-
oped and whether or not key person-centred, as well as
aforementioned contextual factors influential to DHT access and
uptake, are being considered.
Experts highlighted human factors (mostly different from those
characterizing study samples in the scoping review) that afford
certain PwMCI/ADRD advantages to successful technology use:
having familiarity and comfort with technology prior to diagnosis,
higher cognitive functioning and relevant motivation and interest
to use the technology. Indeed, each of these factors has been
identified as influential to technology use in an ADRD population
[16]. Honing on diagnosis and cognitive function characteristics,
in no instances did experts describe end users with moderate-to-
severe ADRD of any diagnosis type; the “digital disability divide”
facing persons with more severe impairments [63] were apparent
from their reports. In contrast, several scoping review DHTs under
development provided high-level assistance appropriate for per-
sons with moderate-stage impairments and, in a few rare studies,
severe cognitive deficits. In these studies, the DHTs addressed sig-
nificant barriers to engagement in ADL and IADL in particular –
ones also noted in a review of mHealth usability barriers experi-
enced by PwADRD [14] – such as task sequencing and decision-
making, offering solutions like video-based, step-by-step task
guidance. DHT options to address activity participation for this
subset of PwADRD with greater cognitive impairments are import-
ant, as quality of life is closely linked to ADL performance in later
stages of ADRD [64]. Some researchers of the scoping review also
endorsed directing future DHT development towards those with
greater impairments. Continued technology development to assist
persons with more advanced ADL disability, and making it widely
accessible is vital, as demand for ageing in place grows and care
partner support ratios decline [65].
Nature of the activity participation supported
Two activity participation domains supported with technology –
social participation and IADL – emerged as high on the list of
commonly reported and overlapped to varying degrees across the
two study phases. DHT enabling social participation was particu-
larly desirable to older PwMCI/ADRD, as accounted by experts
who described PwMCI/ADRD using mainstream technologies to
stay connected with friends and family. This finding aligns with
research that consistently shows staying socially active is highly
valued by PwMCI/ADRD [66]. Unfortunately, social participation
remains a top unmet need in this population [67]. One promising
pathway to improving social participation opportunities for
PwMCI/ADRD and meeting human needs at multiple levels [9] is
through appropriately designed technology that enables one to
compensate for functional challenges with social interactions in a
non-stigmatizing manner [67]. The scoping review demonstrated
researchers are steadily working towards this goal, developing
digital assistive technologies ranging from a computer-aided tele-
phone system with caller video display [42] to reminiscent-based
conversation starters featuring personalized multimedia [43].
18 S. L. SCHEPENS NIEMIEC ET AL.
Youasaf and team’s review of research-based and commercial
health apps for PwMCI/ADRD had noted “leisure and socialization”
apps – the one common category to our DHTs discussed –
although not as frequently available as apps for activity prepara-
tory purposes (i.e., cognitive training) or for care partners, have
begun to penetrate the commercial market [7].
Technology to manage one’s IADL with autonomy was
addressed in both study phases, but with different emphases.
Experts reported persons with mild cognitive deficits were using
mainstream technology to organize their routines (e.g., electronic
calendars) and to provide reminders to complete activities like
taking medication or attending appointments. Electronic calendars
have shown to be useful in promoting ADL engagement in
healthy older adults and PwMCI/ADRD [68]. Digital assistive tech-
nologies [69] compensating for cognitive impairments beyond
prospective memory lapses relevant to IADL were not discussed
by experts, but were regularly featured in the scoping review
studies. As noted above, research-based DHTs were available to
help compensate for the more advanced cognitive barriers (e.g.,
recognition, decision-making, thinking speed [14]) that can cause
obstacles to IADL completion.
Activity participation domains addressed in neither study
phase included rest/sleep and working/volunteering. Because
sleep disturbance is highly prevalent in the MCI/ADRD [70], there
is ample opportunity and need for researchers and commercial
developers alike to produce innovations in DHT supportive of
quality sleep. Likewise, volunteerism proffers occasions for highly
meaningful, productive and social activity engagement, while
building resilience and slowing functional decline [71,72], but
PwMCI/ADRD are often excluded from such activities as they are
typically structured for high-functioning individuals [71,72]. DHTs
that could enable PwMCI/ADRD to more readily engage in volun-
teerism in promotion of quality of life is an avenue ripe for
investigation.
Nature of the activity participation-supportive DHT and
relevant strategies
A unique angle to our study was the focus on PwMCI/ADRD,
rather than care partners, as end users. Accordingly, we paid spe-
cial attention to characterizing the DHT (both hard and soft
technological components and strategies) implemented with
these target users – information noted by others as relatively
absent in the literature [73]. Hard technology identified in either
study phase was almost exclusively mainstream (i.e., tablets,
smartphones, smartwatches and Bluetooth), with only reference
to protective cases as adaptive hard technology. The crux of DHT
characterization comes in discussion of the soft technol-
ogy components.
Soft technology design
Customisability to accommodate users’ unique needs, combined
with simplicity for ease of use was design characteristics encour-
aged by experts and present in the reviewed DHT. Careful atten-
tion to assistive features also crosscut the study phases. DHTs
within the scoping review studies frequently included auto-
prompting – whether to encourage use, to direct attention, or to
assist in step-by-step task completion – to supplant the need for
human ADL support often shouldered by care partners [74].
According to experts’ descriptions, tech-based prompting used by
PwMCI/ADRD was limited to reminder alarms to trigger activity
completion (e.g., taking medication); more advanced prompting
was supplied by care partners to offset shortcomings in product
design/functionalities. Unfortunately, the latter level of support
has been linked to care partner burden [75] and older adults’ feel-
ings of dependency [64], highlighting the imperativeness of bring-
ing this research-based DHT into mainstream use.
Consideration of sensory experiences was a focal point of tech-
nology design to facilitate activity participation. One expert
explained stimulating auditory senses using technology that deliv-
ers sound and music promotes learning and enjoyment, a similar
position held by Dixon and Lazar [76]. Likewise, many research
teams in the scoping review recognized the importance of multi-
modal interaction and sensory stimulation. Use of touchscreens
with haptic feedback, music to reward performance, and personal-
ized photos to stimulate conversation were just a few multisen-
sory features built into the DHTs’ designs and likely enhanced
motivation to engage. Along a similar vein, others have found use
of touchscreen tablets in an MCI/ADRD population promotes par-
ticipation, social engagement and enjoyment [73]. Limiting sen-
sory distractors, such as icon clutter on home screens, was
another successful technique described in our study. Researchers
have recommended “intentional sensory stimulation”, whereby
technology affords tailoring directly by the MCI/ADRD user for an
optimal sensory experience, as a key design component for future
technology [76]. The aforementioned customisability of the
reviewed DHT suggests developers are moving in the
right direction.
Instructional strategies
Although the above design recommendations/practices by experts
and technology developers overlapped substantially, soft technol-
ogy instructional strategies to support learning, motivation and
functional use of technology appeared critical primarily to experts.
They spoke at length about successful instructional techniques,
ranging from step-by-step guidance and demonstration with vis-
ual aids, to enfolding learning activities into routine, and capitaliz-
ing on intrinsic motivators to learn new technology. These
strategies have been recommended by others to support learning
in people with cognitive impairments [77–80] and are consistent
with those summarized in a review of considerate mHealth design
for PwADRD [14]. The scoping review studies, on the other hand,
provided little detail of instructional activities and supports, save
for one team [31,81], and yet acknowledged refinement of train-
ing and instruction as important for future research. This is a vital
omission in the literature for DHT implementation in MCI/ADRD
populations. Long-standing is research showing technology adop-
tion in older adults is strongly influenced by the training and sup-
port they receive [82]. This warrants not only the development of
technology training protocols that accommodate new-generation
technologies and evolving user needs [83] as older people grow
increasingly accustomed to integrating technology into everyday
life [84], but also greater transparency in what instructional strat-
egies and protocols involve.
Technology partners
Inclusion of technology partners was paramount in both study
phases, aligning with research suggesting that having an available
technology support network is key for uptake in older people
with memory complaints [85], particularly for those with more
severe ADRD [17]. Experts described care partners (most often) or
themselves as assuming tech-support responsibilities, whereas
research staff aided by care partners frequently acquired those
duties in the scoping review studies. Experts characterized appro-
priate technology partners as friendly, knowledgeable with device
use, available and communicative. Indeed, access to the just-right

technology partner and tech support is critical, as older adults’
decisions to abandon technology is partly informed by dissatisfac-
tion with available assistance [86]. As researchers bring products
to market, they will also need to consider who can feasibly
replace research staff to fulfil tech-support roles. Shifting such
responsibility to care partners could threaten long-term sustain-
ability given additional burden on care partners’ loads is a known
barrier to older care recipients’ technology use [87], and an area
researchers in the scoping review noted required further
investigation.
Beyond tech support, experts discussed the need for technol-
ogy partners to monitor technology use over time, particularly in
terms of safety – an acknowledgement of ADRD’s progressive
impact on function [88]. In contrast, this topic was addressed in
only one team’s work [31,81] in the scoping review studies.
Researchers’ lack of attention to the progressive nature of ADRD
may be a limitation of the short-term study designs or an over-
sight of designers to consider the effect such decline could have
on long-term use of DHT. Failure to consider this may have
harsher consequences for socio-demographically disadvantaged
groups. For instance, older adults with MCI and low education lev-
els are at risk for greater decline in everyday technology use and
progression to dementia – patterns of use are not solely dictated
by diagnosis [89]. Those from minoritized sectors should be moni-
tored and more closely supported to avoid deprivation from
meaningful activities that can be enabled through technol-
ogy [90].
Limitations
This two-phased study is limited in several ways. The scoping
review phase involved multiple database searches conducted sev-
eral months apart due to logistical delays from COVID-19 that
severely extended the timeline of the review. Limited resources
prohibited us from exploring non-English publications and grey
literature. Qualitative content analysis from the expert interview
phase was limited to surface-level investigation. More in-depth
interviews with detailed qualitative analyses are warranted.
Although interviewees represented a variety of professions and
held multiple roles as stakeholders who practice within the MCI/
ADRD community, most were recruited from the United States of
America, and only one person had a dual experience of being an
expert stakeholder and having an MCI/ADRD diagnosis.
Accordingly, expert views presented in this paper are limited
almost exclusively to those of Western perspective and were not
end users of the DHT. A wider net of expert stakeholders across
the globe, as well as a deep dive into the first-hand lived experi-
ences of PwMCI/ADRD using DHT for activity participation would
expand the work presented here.
Conclusion
Aligned with the international call for research on technology
application for ADRD management [91,92], this study has offered
a broad sweeping summary – through the lens of an occupation-
based person-centred framework – of the nature and crossover of
ongoing research and real-world practices regarding activity par-
ticipation-supportive DHT for PwMCI/ADRD. Our study points to
remaining opportunities for growth in this arena. Transparent
reports of targeted users’ characteristics who have informed
development of current DHT, expansion of DHT innovation to
activity domains yet to receive attention in the MCI/ADRD com-
munity (namely sleep and volunteerism), and providing more
TECHNOLOGY FOR ACTIVITY PARTICIPATION IN DEMENTIA 19
detailed accounts of soft technology instructional protocols
adopted to ensure success of DHT implementation are just a few
examples of where directed efforts can be made to continue
advancing the science and mainstream penetration of DHT sup-
portive of activity participation in PwMCI/ADRD.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Funding
This work was supported by the National Institute on Ageing of
the National Institutes of Health under award number R21
AG052838-02S1. The content is solely the responsibility of the
authors and does not necessarily represent the official views of
the National Institutes of Health.
ORCID
Stacey L. Schepens Niemiec http://orcid.org/0000-0002-
3766-7015
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