The Use of Visual Methods to Support Communication with Older Adults with Cognitive Impairment: A Scoping Review

Abstract

Older adults with cognitive impairment often face difficulties with comprehension and communication, which can impact other cognitive processes such as decision-making. This scoping review investigates how visual methods can support older adults with cognitive impairment. The review involved querying four databases. From these databases, eleven articles fit inclusion criteria. This paper examines the purposes, use contexts, types, and effectiveness of the visual methods described in each study. The two major use contexts were elicitation of thoughts, feelings, and preferences in everyday life and health/healthcare related uses. Studies that used visual methods for eliciting preferences generally employed static visualizations. Health-related contexts employed more complex and interactive visualizations. Three studies used visual tools to support older adults in understanding; six, communication; and three, decision making. None addressed all three outcomes of interest. This study provides recommendations and future directions for visual communication research with older adults with cognitive impairment.

Introduction

Dementia affects over 46 million people worldwide, and this number is expected to increase to 131.5 million by 2050.¹ The Center for Disease Control and Prevention (CDC) describes Alzheimer’s Disease as an “irreversible, progressive brain disorder that slowly destroys memory and, eventually, a person’s ability to perform even the simplest of tasks, such as bathing, feeding, and dressing.”² Communication impairment is an early sign of dementia, and communication skills gradually decline over the course of dementia.³ People with dementia may experience challenges participating in conversation due to difficulties with word finding, fluency of speech, and understanding.⁴ Furthermore, persons with cognitive decline may also experience difficulties holding a conversation if there are environmental distractions or other challenges, such as being unable to remember who they are conversing with, which can cause additional stress and frustration.^4,5

Limitations in comprehension and decision-making can impact quality of life.⁶ Over time, decisions are increasingly made by others such as caregivers,^7,8 which may or may not represent the preferences of the individual with cognitive decline.^9-12 Moreover, during care transitions such as a move from home to a nursing home, engagement in activities that people with cognitive impairment find meaningful also tend to decrease.¹³ Less involvement in decision-making has been associated with poorer quality of life.¹⁴ Thus, developing ways to enhance communication and participation in decision-making among persons with cognitive impairment are needed to ensure their quality of life and sense of wellbeing.

External forms of support such as memory books, memory wallets, and reminder cards can assist with recall and word-finding during conversations.¹⁵ Visual communication methods, including visual stimuli such as photos, pictograms (diagrams depicting concepts), videos, and interactive visual tools, can also facilitate communication. Existing research has shown that visual communication methods can help with comprehension and learning.^16,17 In a telemedical context, with older adults in general, photos have been associated with higher recognition rates compared to pictograms or clip art,¹⁸ and the use of pictographs with supplemental text has helped with comprehension and recall of hospital discharge instructions.¹⁹ Specifically in the context of dementia, reminiscence therapy supported by an interactive system that stimulates long-term memory showed promise as an alternative to traditional reminiscence sessions.²⁰ Though not focused on communication, participation in arts-based programs was connected with improved self-reported quality of life,²¹ as well as benefits such as conversation and social connection with other participants.²²

To our knowledge, there is limited research on how visual communication methods can help older adults with cognitive decline understand information and/or make decisions. We conducted a scoping review to investigate this gap. The review had three main goals: 1) to identify the purpose and use context of visual communication methods with older adults with cognitive impairment; 2) to describe the types of visual methods used; and 3) to characterize the effect of the visual methods on understanding, communication, and decision-making.

Materials and Methods

This scoping review employed a commonly used framework developed by Arksey and O’Malley²³ and later clarified by Levac and colleagues.²⁴ This framework involves five main steps: (1) identifying the research question; (2) identifying relevant studies; (3) study selection; (4) data charting; and (5) collating, summarizing, and reporting the results.

Data sources and search strategy

We performed an extensive literature search in four major bibliographic databases: (1) PubMed, (2) EMBASE, (3) CINAHL, (4) PsychInfo. These databases were selected to ensure coverage of diverse fields, including but not limited to medicine, nursing, and psychology; and include both clinical and applied research. We developed queries to target older adults with cognitive impairment and identify how visual communication methods can impact their decision-making, comprehension, or understanding. A health sciences librarian assisted us in the formulation of the queries. These queries followed the Population, Intervention, Comparison, Outcomes (PICO)²⁵ framework and included phrases related to cognitive impairment, comprehension, understanding, decision-making, and visualization. This framework has been shown to help with queries that are both specific and complex, yielding to more accurate search results.²⁶ Given the goals of the review (i.e., to provide an overview of visual communication methods that may be effective for communication in the context of cognitive impairment), we incorporated grey literature (non-peer reviewed studies) to increase the breadth of our search; however, the studies that ultimately fit within our inclusion criteria were all peer-reviewed. We include our search queries for each database in the Supplementary Materials.

Study selection and criteria

The article inclusion criteria were as follows: (1) publication date of 2000 or later, (2) published in the English language, (3) identified a target population of older adults (age 65 and over) with cognitive decline, such as dementia or mild cognitive impairment, (4) employed a visual communication method or aid, such as an infographic, picture, or video, and (5) addressed or have outcomes relating to comprehension, understanding, or decision-making, where comprehension and understanding referred to a person’s ability to understand information, and decision-making referred to a person’s ability to make decisions, and could include both actual and hypothetical situations. Both quantitative and qualitative studies were included to increase the diversity of studies represented. Figure 1 features a PRISMA-ScR diagram depicting our workflow.²⁷

Figure 1.

PRISMA-ScR diagram depicting the article selection process.

Three authors (AT, MGA, and JZ) performed a title and abstract review, removing studies that did not meet inclusion criteria. To increase the breadth of our search and to potentially include alternate well-cited studies, we reviewed the titles of references from articles that fit our inclusion criteria and screened them for eligibility. Another author (AC) helped to resolve differences. We then evaluated the full text of eligible articles based on our inclusion criteria and excluded articles that were not relevant.

Data charting

We developed a data extraction table based on our identified goals. Two authors (JZ and AC) extracted key characteristics of the studies, including the sample, study design, data collection methods, data analysis methods, comparator, outcomes, visual communication method type, visual communication method purpose, and use context. The extractors performed the process iteratively, checking each other’s work, to ensure accuracy and comprehensiveness. Given the small number of studies, we chose to analyze the results of quantitative and qualitative studies together, but we provide additional notes in the tables for readers who prefer a more nuanced analysis (see Table 2).

Table 2.

Purpose and Type of Visual Communication Method

Article	Purpose						Visual Communication Method
	Preference Elicitation	Communication		Medical		Other	Video	Web- based decision aid	Image Type				With Text
		With Carers	With Doctors	Understand Test Results	Decision Making	Cognitive Deficits Assessment			Picture (unclear type)	Pictogram	Photo	Charts /Diagrams
Reeves et al. (2020)						X	X
Shell (2015)	X										X
Burshnic & Bourgeois (2020)											X		X
LeBlanc et al. (2008)	X										X		X
LeBlanc et al. (2006)	X										X
Ferm et al. (2010)
Murphy & Oliver (2013)	X									X			X
Gruters et al. (2021)	X	X			X					X			X
Chang & Bourgeois (2020)			X	X				X				X	X
Bilodeau et al. (2019)					X				X				X
Bogza et al. (2020)					X			X		X			X

Collating, summarizing, and reporting the data

We followed the recommendations of Levac and colleagues concerning the last stage of the Arksey and O’Malley framework.²⁴ We present a descriptive summary of the studies using tables and charts, as well as a thematic analysis informed by our research aims.

Results

Our search yielded a total 603 articles from four databases: PubMed (n = 205), EMBASE (n = 158), CINAHL (n = 106), and PsychInfo (n = 134). After reviewing the titles and abstract of these articles, 39 articles were selected for full-text review (6.4%). Of the 39 full-text articles reviewed, nine met the eligibility criteria detailed in the Methods section. A title review was performed on the references of these eligible articles, and three more articles were extracted and deemed eligible for review. One of the newly extracted articles was redundant as it was a dissertation of a published article. Thus, in total, we reviewed 11 articles for this scoping review (Table 1).

Table 1.

Study Characteristics

Article	Sample Size	Level of cognition	Caregiver or family present?	Study Design	Data Collection Method		Evaluation Method
					Interview	Questionnaire	Quant.	Qual.
Reeves et al. (2020)	56	intact cognition, impaired cognition not sufficient to meet mild cognitive impairment (MCI), MCI, and AD	No	Descriptive	X	X	X
Shell (2015)	12	mild impairment (n=6), moderate impairment (n=6)	No	Descriptive	X	X		X
Burshnic & Bourgeois (2020)	21	severe cognitive impairment (N=21)	No	Analytic (Experimental)	X	X	X
LeBlanc et al. (2008)	9	moderate (n=5), severe (n=4) dementia	No	Analytic (Experimental)	X	X	X
LeBlanc et al. (2006)	4	moderate to severe (n=2), severe (n=2) dementia	No	Descriptive + Analytic (Experimental)	X	X	X
Ferm et al. (2010)	5	Huntington's Disease stages 2-3	No	Analytic (Experimental)	X		X	X
Murphy & Oliver (2013)	36	18 couples: early- (3), moderate- (13), and late-stage (2) dementia	Yes	Analytic (Experimental)	X	X	X	X
Gruters et al. (2021)	58	patients (n=30), family members (n=28), neuropsychology experts; diagnoses among the patients: no cognitive impairment (n=13), MCI (n=12), dementia (n=5)	Yes	User-centered design and evaluation	X	X	X	X
Chang & Bourgeois (2020)	20	mild (n=11), moderate (n=9) dementia	No	Analytic (Experimental)	X	X	X
Bilodeau et al. (2019)	50	older adults with dementia (OAWD) (n=23), family caregivers (n=27); level of cognition of OAWD: moderate (n=9), severe (n=9), very severe (n=5) dementia	Yes	Rapid review approach for developing decision aids which included engaging stakeholders		X	X	X
Bogza et al. (2020)	12	MCI	Yes	User-centered design and evaluation	X	X	X	X

Study design:

The studies employed a range of designs. Three were descriptive studies.^28-30 Six were analytic, incorporating some type of experimental design,^28,31-35 such as comparing responses to information presented in a visual format as opposed to a verbal only format. Three employed an iterative design method involving stakeholder engagement (i.e., user-centered design and rapid review of decision aids).^36-38 Most studies employed some quantitative assessment, such as comparing the number of utterance types (e.g., acknowledgment, elaboration, off-topic, requests),³¹ assessing the extent of engagement with items indicated as preferred via a visual method,^28,34 comparing scores assigned by observers or external raters,^28,29,31-34 and participant ratings.^36-38 One study employed only qualitative assessment,³⁰ and five used both quantitative and qualitative methods.^33,35-38

Sample:

There was considerable heterogeneity in sample composition, with most studies (n=9) comprised of samples involving persons with varying levels of cognitive impairment, and four involving caregivers and providers. As can be seen from Table 1, there was no clear association between the study design, method of evaluation, and the sample size, with some of the studies with smaller sample sizes employing quantitative forms of evaluation.^28,34 Of note, studies with sample sizes less than 10 often provided either rich quantitative data or qualitative commentary on intra-individual variation, which can be a valuable contribution to knowledge about how people may react differently to visual communication methods. For example, LeBlanc and colleagues present graphical depictions of intra-individual variability in engagement with items endorsed as preferred using a visual modality,³⁴ and Ferm and colleagues present qualitative observations concerning communication by each participant, illustrating the importance of analyzing not only what participants say, but also facial expression and body language to better understand other aspects of cognitive processing and communication such as uncertainty, insecurity, and engagement.³³ Three studies had larger sample sizes; of these, all included varying levels of cognitive impairment^29,36,38 and two included persons without cognitive impairment.^36,38

Purpose and Use Context of Visual Communication Methods

We observed two main use contexts for visual communication methods. Many of the studies employed visual methods to facilitate communication regarding participants’ needs, feelings, and preferences in everyday life (n=6). For example, Talking Mats is a tool comprised of a set of pictures depicting concepts, each with a small text caption, that are moved around on a textured mat during conversation.³⁵ Talking Mats was used in two studies involving older adults with dementia and their family caregivers, to elicit views and facilitate discussion on topics like personal care, getting around, housework, and activities.^33,35

A second common use for visual communication methods was in health-related contexts, particularly clinical care. One study described an iterative approach to developing a visual tool for explaining neuropsychological test results,³⁸ another presented an approach to facilitate decision-making among persons with dementia and their caregivers,³⁵ and three presented visual approaches to facilitate decision-making in medical contexts. The three studies involving medical contexts addressed a range of topics: options to maintain or improve cognitive function;³⁷ end-of-life care;³² choosing a non-pharmacological treatment to manage agitation, aggression, or psychotic symptoms; deciding whether or not to stop driving; and deciding whether or not to prepare a power of attorney to cover health, property, and financial matters.³⁶

One study was distinctly different from the others. Reeves and colleagues examined how participants’ performance on a narrative description task after watching a video was associated with level of dementia severity, suggesting that video clips might serve as a novel way to assess cognitive impairment.²⁹

Types of Visual Communication Methods

We observed a variety of different visual communication methods (Table 2). There were a number of web-based decision aids (n=3) and one study involving video clips (n=1). All other studies involved the use of static visualizations, with photos (n=4) and pictograms (n=3) being the most common.

A common characteristic among studies was that the visual communication methods also included some text (n=8). Some studies explored the use of visual aids in conjunction with supplementary text. For example, Burshnic and Bourgeois (2020) used Google Images with text captions, and found that there were significantly fewer requests for clarification with this delivery method as opposed to a verbal only format. Trends in the incorporation of text suggest that images without text are often used when the primary goal is having participants express views, feelings, and preferences, whereas text accompanying images is more often used to communicate ideas to the person with dementia. For example, one study asked participants to take photos that hindered or supported their happiness and used the photos in the subsequent interview.³⁰ This technique, called photovoice or photo-elicitation, is a participatory action research method in which participants are provided cameras and asked to take photographs to express or communicate some aspect of their lives,³⁹ and can be effective in cueing memory, facilitating interview planning, sharing stories, and capturing meaning.^39,40

In health-related contexts, we observed the use of visualization types that were not observed in the other settings, such as interactive web-based decision aids and charts or diagrams representing abstract concepts, as opposed to pictograms and photos. We also observed greater use of text, and one study employed vignettes.³² The three studies that involved the design of web-based decision aids all incorporated stakeholders in the design of the tools, either through user-centered design^37,38 or rapid review.³⁶ Consulting with target users led to the addition of pictograms and facilitated the development of text and tasks that were more intuitive to the target users.

Stakeholder input can help designers to understand how potential users might interact with a visual tool. In some cases, the high-level feedback was fairly straightforward – simply that pictures were needed in addition to text – but some feedback was more nuanced, such as using the ‘priority’ instead of ‘preference’, and using checklists instead of Likert-type rating scales.³⁶ Bogza and colleagues reported revising their decision aid to provide more explanations of interactive features and simplifying navigation by eliminating the need to click to other pages.³⁷ These studies underline the importance of iterative and phased development, with the engagement of multiple stakeholders, in the development of health-related media.

The development of visualizations also varied among studies. Other than photovoice,³⁰ a few studies employed photos taken by the researchers,^28,34 and another study used images, graphics, or other visual aids from an image repository (Google Images), and employed cognitive testing to develop text captions.³¹ Researchers first asked participants what they thought images represented, and then later showed them the images with the captions and asked if there was a better way to express intended concepts. Some studies used an iterative development process, incorporating feedback and opinions from both field experts and participants.^36-38

Effect of Visual Support on Comprehension, Communication, and Decision-Making

We also considered the effectiveness of the visual communication methods with respect to three main outcomes: increasing participants’ understanding, improving communication, and facilitating decision making (Table 3). Understanding was defined in terms of the participants’ ability to comprehend and interpret presented information. Three studies considered understanding, with two reporting results that suggested participants’ understanding improved with the aid of the visual communication method.^31,32 In one study, most participants said that their understanding improved as a result of having the visual tool, but there was no difference in information retention.³⁸

Table 3.

Outcomes. Empty cells indicate that the outcome was not a focus of the study.

	Outcomes
	Understanding	Communication	Decision Making
			Improved decision making capacity	Improved values clarity	Improved feeling of being informed
Reeves et al. (2020)
Shell (2015)		YES (qualitative observation)
Burshnic & Bourgeois (2020)	YES - significant differences in requests for clarification	NO - no difference in consistency of preference ratings
LeBlanc et al. (2008)		YES - terms endorsed in the multimedia only condition resulted in higher levels of engagement
LeBlanc et al. (2006)		NO
Ferm et al. (2010)		YES
Murphy & Oliver (2013)		YES (qualitative observation)
Gruters et al. (2021)	YES - patients rated 'agree' or better for 'better able to understand information'
Chang & Bourgeois (2020)	YES		YES
Bilodeau et al. (2019)
Bogza et al. (2020)				YES	YES

Six studies employed visual methods to facilitate communication. Two of these involved dialogic interaction between parties (e.g., researcher, participant, clinician),^33,35 and four involved participants’ ability to communicate with a researcher (preference/view elicitation).^28,30,31,34 The results of these studies were mixed. Four concluded that visual methods facilitated or improved communication over a control condition such as verbal only.^30,33-35 One study reported that there was no difference in communication when information was delivered verbally or with and visual-and-text supports.³¹ The remaining study examining communication involved four participants and four modalities (verbal, pictorial, textual, and tangible); the verbal only modality was most effective for three of the participants, and the tangible modality the most effective for the fourth.²⁸

Studies also showed that visual communication methods can have other benefits, such as being better able to remember what is being discussed and feeling more involved in the discussion.³⁵ In the context of receiving neuropsychological test results, other benefits for patients and family members included being able to see cognitive profiles in one glance, interpreting their performance in comparison to a reference group, understanding implications for daily life, and having something to refer to later.³⁸

Three studies incorporated visual communication to facilitate decision-making and, depending on the study, used measures common in the assessment of decision aids (e.g., values clarification)³⁷ or decisional capacity.³² One study, employing a stakeholder-engaged method to develop a decision aid, introduced visualizations as a result of participant feedback.³⁶ The study design did not involve comparison to a control condition, making it difficult to determine the effectiveness of the tool. However, the qualitative comments in the article provided insights concerning user preferences. For example, participants felt it was important to include visuals to break up monotony of a purely textual presentation. Moreover, Bilodeau and colleagues reported benefits of the decision aid such as facilitating reasoning by enabling side-by-side comparison of options and provoking thought.³⁶ However, many of the reported observations were based on feedback from caregivers rather than from persons with cognitive deficits.

Of the remaining studies that sought to facilitate decision-making, a study involving a web-based decision aid reported improved values clarification and feelings of being informed.³⁷ Chang and Bourgeois³² investigated the effectiveness of a visual aid with respect to four decision-making skills/capacities that are often considered in the context of dementia: understanding, reasoning, expressing a choice, and appreciation, defined as the ability to express agreement/disagreement with treatment benefits and to appropriately justify one’s choice.¹¹ Improvements were noted in understanding, reasoning, and appreciation, but not in expressing choice.³²

The findings from these studies suggest that there are indeed benefits of visual communication methods in terms of understanding, communication, and decision-making, but also limitations. Burshnic and Bourgeois reported that, when compared to verbal communication alone, using a visual aid supported with text resulted in fewer requests for clarification from residents in nursing homes and assisted living facilities.³¹ However, use of visual aids did not improve social and leisure preference ratings among residents. In the context of the web-based decision aid developed by Gruters and colleagues,³⁸ despite benefits including increased understanding and satisfaction with the consultation and the tool, information retention remained low. With respect to decisional capacity, it is perhaps important to note that visual aids did not result in an improvement in expressing a choice, the fourth of the decisional capacities studied in the study by Chang and Bourgeois.³² Given the limited number of studies in this review, more research is needed.

Aside from the outcomes of participant understanding, communication, and decision making, there are other impacts of the visual communication method to consider, particularly as they impact the nature of interaction in an interview/consultation. For example, Ferm and colleagues reported a higher mean score of communicative effectiveness with Talking Mats compared to unstructured and structured verbal communication methods, but they also noted that the sessions took more time.³³ Further, the interviewer tended to use fewer words, emphasize the most important information, and speak slower. Gruters and colleagues observed that seeing the visual tool prompted questions, thus facilitating communication, and participants appreciated the fact that they had materials to take home.³⁸ Thus, it is also important to consider how visual tools influence the quality of consultation and information retention.

Discussion

In this scoping review, we observed two main use contexts for visual communication methods used with older adults with cognitive impairment: 1) the elicitation of thoughts, feelings, and preferences in everyday life; and 2) health- and healthcare related uses. We summarize the purpose, visualization type, challenges, and recommendations for each context in Figure 2. At the top of Figure 2, we depict the interaction between the users, tasks, and visualization in each context. This figure is inspired by the Center for Research and Education on Aging and Technology Enhancement (CREATE) Model of Aging and Technology,⁴¹ which characterizes design needs in terms of the interactions between users, tasks, and a technology system.

Figure 2.

Summary and Recommendations for Visual Communication Methods in Everyday and Health-Related Contexts. PwCI = Person with cognitive impairment.

Types and Purposes of Visual Communication Methods

The type and purpose of visual communication methods in each context differed. Studies in which visuals were used for elicitation generally employed static visualizations comprised of photos or pictograms. More complex and interactive visualizations, particularly web-based decision aids, were utilized in health-related contexts.

Though visualizations in the two contexts may share some similar high-level purposes such as the facilitation of communication, there are also differences between the contexts which may impact the type of visual communication methods used. In everyday situations, one common goal was to elicit participants’ views and preferences. In these contexts, keeping conversations and visual communication methods open-ended ensured greater opportunity for the person with cognitive impairment to share their thoughts. Similarly, a scoping review on innovative methods in qualitative research with persons with dementia reported that most studies in the review employed visual participatory approaches, particularly photovoice.⁴² Important considerations in the selection of these methods were inclusion, empowerment, self-expression, flexibility, repeat contact, observation, and engagement.

Visual tools in healthcare contexts, on the other hand, often had the goal of conveying concepts to persons with cognitive impairment to facilitate understanding, communication, and/or decision making. To do so, there was increased use of interactive, web-based visual tools, text along with visual representations, and graphics representing abstract concepts.

Challenges of Employing Visual Communication Methods with Persons with Cognitive Impairment

Despite the promise of visual communication methods in each context, there are also challenges. Visual participatory methods such as photovoice can empower participants to express what is important to them.^30,39 However, there may also be challenges with these methods, such as persons with cognitive impairment not remembering the context in which photos are taken.³⁹ A visual tool that facilitates more structured conversations, such as Talking Mats, could help with this,³³ as well as help participants to feel more involved.³⁵ With the more structured format however, there is potential for the conversation to take more time or become an ‘interrogation.’³³ It is ultimately important to ensure that visual tools help persons with cognitive impairment feel engaged but not overwhelmed.

There may also be challenges in facilitating communication in clinical settings. At the outset, understanding test results and engaging in decision making can involve complex information and reasoning, and challenges exist in supporting these cognitive processes. One potential approach might be to provide scaffolding to break up complex tasks into parts. For example, in the process of decision-making, people could be encouraged to focus on understanding options first, and then reasoning. However, employing a structured flow might conflict with the goal of keeping a session more open. Thus, in developing a visual tool, designers should consider the goals of the clinical/research context carefully to make decisions about how to facilitate interaction with the tool.

In research in healthcare-related contexts that engaged caregivers, family, and providers, their voices were found to be more prominent in the qualitative findings than those of the persons with cognitive impairment. A review of decision aids in the context of dementia also reported that most decision aids targeted caregivers or surrogate decision makers.⁴³ Since preferences of individuals with dementia often differ from those of their caregivers,⁴⁴ we recommend that studies focus more on eliciting and incorporating feedback from individuals with cognitive impairment.

Novel technologies can facilitate interaction between persons with cognitive impairment and their loved ones. For example, though not included in the review, a digital reminiscence intervention employing interactive digital communication aids with visual components (film, photos, and music) improved quality of life,⁵³ However, there is also the risk that the novel technology itself can become the focus of interactions, drawing the focus away from the discussion topic.⁵⁴ Thus, it is important to engage stakeholders in the design of the technologies and ensure that the technologies optimally support their intended communication goals.

Recommendations for Practice

Though there is a need for additional research, extant literature suggests that use of visual communication methods can enhance communication in clinical, care and research settings. Using a visual tool to augment communications does more than simply conveying information via images; use of the tool can change the behavior of the persons involved in a dialogue. For example, use of a visualization tool prompted questions in clinical consultations,³⁸ and Ferm and colleagues reported that use of Talking Mats made communication more focused on the part of the participant, and slower and more deliberate on the part of the researcher,³³ which could perhaps be of benefit in clinical settings as well. Visual tools might also be used in conjunction with other types of communication interventions, such as speech-language pathologist interventions,⁴⁵ to enhance the communication of persons with cognitive impairment and their loved ones.

Use of visual tools may also help preserve personhood, or treating persons with dementia with dignity and respect, in the context of care.⁴⁶ From the perspective of persons with dementia, aspects of preserving personhood include continuing to be active and participate in activities,⁵² honesty, truth, and respect.⁴⁷ From the caregivers’ points of view, personhood requires knowing the preferences of persons with cognitive impairment, understanding who they are, and engaging and connecting with the person⁴⁷ (for additional background on personhood, see for example, ^47-49). Despite the potential for visual communication methods to support personhood, barriers to promoting personhood may arise in practice, including lack of understanding of dementia.⁴⁷ In care facilities, there may also be tensions between safety and quality of life for residents,⁵⁰ and other pressures such as staffing shortages.⁵¹ It is therefore important to ensure that individuals who make use of visual tools in care, such as nurses, social workers, and other providers, receive training on the purpose of the tools and how to use them effectively with persons with dementia, prior to using the tools with patients.

Recommendations for Future Research

Given the small number of studies included in our review, there is clearly a need for additional research. Studies with small sample sizes provide important contributions in terms of detailed observations about intra-individual observation, and there remains a need for such studies. However, given variation in cognitive impairment and the need to include feedback from multiple stakeholders, studies including larger sample sizes are also warranted.

With respect to visualization design, studies in both contexts employed methods of pre-testing images or refining them as a part of an iterative design process. With the more complex visual tools, the extant literature reports that at times participants were confused by visualizations. As visualizations involving more complex concepts were scant in this review, there is a need for additional research on the design of visualizations to represent abstract concepts with this population.

There are also opportunities to explore visual communication methods that were not observed in this review. Though not specifically involving persons with cognitive impairment, previous work has found that a video decision support tool, as opposed to a verbal description, was associated with changes in preferences with respect to future medical care.⁵⁵ Furthermore, virtual reality is an area of increasing interest in the context of dementia^56,57 and may facilitate meaningful experiences among persons with cognitive impairment and their loved ones.⁵⁸

Another potentially fruitful research direction is to employ visualization to better characterize cognitive processes in the context of cognitive impairment. For example, research has reported that strategies for supporting decision-making among persons with dementia are scarce and not carefully adapted for persons with dementia.⁵⁹ With respect to decision-making capacity,³² studies in our review reported benefits related to understanding, reasoning, and appreciation, but not related to expressing a choice. Though additional research is needed to learn whether these findings would be replicated with larger samples, if expressing choices is in fact a particular challenge, the question arises concerning the origin of the difficulty (e.g., an issue with expression or capacity to decide) and whether visual supports may be of assistance.

Limitations

There are various limitations of this scoping review. Although we queried four major bibliographic databases, there are potentially other relevant articles that may have been found in databases that were not included in our search. In addition, our search was confined to certain keywords relating to visualization, and it is possible that had we broadened our set of keywords to include related methods or tools such as interview elicitation techniques or patient decision aids, we may have had a larger sample. Moreover, we focused on particular outcomes in our search -- comprehension, understanding, or decision-making -- and visual communication methods might have other important effects that were not covered in our search strategy and analysis. The majority of the reviewed studies featured a majority White or Caucasian study population or were conducted in Western countries such as the United States or Canada. As there can be cultural differences in the meaning of symbols and images,⁶⁰ there is a need for additional research on effective visual communication methods with other populations. Lastly, as specified in the Methods section, we did not rate the quality of the studies included our review. While quality rating is not a standard practice with scoping reviews, it may be worthwhile for readers to consider this in their interpretation of the implications of this review.

Conclusion

This scoping review investigated methods for communicating with older adults with cognitive impairment, focusing on the purposes and use contexts of these visualizations, the types of methods used, and the effects of these visualizations. Articles published after 2000 involving visual communication methods for use with persons with cognitive impairment were searched in four databases: PubMed, EMBASE, CINAHL, and PsychInfo. A total of 11 articles were identified. Among these studies, two main use contexts were identified: elicitation of thoughts, feelings, and preferences; and health- and healthcare- related uses. Studies in which visuals were used for elicitation generally employed static visualizations comprised of photos or pictograms; more complex and interactive visualizations, particularly web-based decision aids, were observed in health-related contexts. Stakeholder-engaged methods, such as user-centered design, were often employed in the development of these visualizations. The studies suggest that visual support can enhance comprehension, understanding, and decision-making, and there is potential to utilize them in clinical contexts to facilitate communication. The small number of studies identified and their heterogeneous nature in terms of visual communication methods and study design indicate that there is a great need for additional research on the development and effectiveness of these methods.

Highlights.

• Scoping review of visual communication of older adults with cognitive impairment

• Foci were purposes and contexts of visualizations, methods, and effectiveness

• Two main contexts were everyday life contexts and health/healthcare related uses

• Visuals for elicitation generally employed static visualizations

• Complex and interactive visualizations were observed in health-related contexts