Technology for activity participation in older people with mild cognitive impairment or dementia: expert perspectives and a scoping review

Abstract

Purpose:

This two-phased study aimed to collate, summarize and characterize – through the lens of an occupation-based, person-centred framework – ongoing research and practice featuring activity participation-supportive digital health technology (DHT) for direct use by older persons with mild cognitive impairment or Alzheimer’s disease and related dementias (PwMCI/ADRD).

Materials and methods:

Phase 1: Using scoping review procedures, PubMed, MEDLINE and PsycInfo were searched to identify primary research studies. Phase 2: Semi-structured interviews were completed with MCI/ADRD expert stakeholders identified through publicly available biographies and snowball referral. Thematic analysis was used to identify, synthesize and cross-compare emergent themes from both data sources that were subsequently organized into core facets of the Human Activity Assistive Technology (HAAT) model.

Results:

The scoping review resulted in 28 studies, which were primarily feasibility work with small sample sizes. Interviewed experts (N = 17) had 4+ years of MCI/ADRD experience, came from a variety of settings, 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.

Graphical Abstract

Introduction

Approximately 50 million people worldwide live with Alzheimer’s disease and related dementias (ADRD), with this number expected to grow to 132 million by 2050 [1]. ADRD – as well as mild cognitive impairment (MCI) which may precede ADRD in many cases [2] – jeopardizes health-related quality of life, affecting myriad domains of health and function, such as memory, motivation and social behaviour [1,3]. Meaningful participation in everyday activities – a “vital part of the human condition and experience” that contributes to life satisfaction and psycho-emotional 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, cognitive stimulation and assistance for daily activities [6,7]. A 2015 review of assistive technology for ADRD demonstrated that technology (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, connectivity, 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 experienced 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), perception problems (e.g., double vision and object/facial recognition) and speech-language barriers (e.g., reading and verbal expression). Despite these findings, researchers have pointed to the relative paucity of inclusion of PwMCI/ADRD as the target users and/or as key critics of technologies under study, with primary attention 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 theoretical framework, grounded in occupational therapy and rehabilitation engineering, that was designed to guide assessment, prescription and evaluation of assistive technology systems suitable for people with disabilities [18]. The respective components of the model are illustrated by a human (person) engaging in an activity (occupation) within a context (social, cultural, environmental and institutional) enabled by assistive technology (technology) [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 optimally supports actualization of their performance potential [19]. To our knowledge, no study has applied the HAAT model to summarize 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 framework 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 multidimensional digital divide and bring cutting-edge DHT to diverse older adults of the MCI/ADRD community in support of meaningful activity participation.

Methods

This study utilized a two-phase design that included a scoping review and expert interviews to capture complementary information 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 development 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 literature 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 activity participation-supportive DHT for PwMCI/ADRD?

We performed a literature search on 15 March 2020 of published 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 monitors”; “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 manual 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 participation 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 preparatory tasks (e.g., cognitive skill building, fine motor control improvement); or the intervention focused on telehealth processes. 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 consultation 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 headings: 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 summarized narratively for further analysis, and finally organized under HAAT model domains.

Table 1.

Characteristics of included studies in the Scoping Review Study Phase, as situated in the HAAT Model.

Context					Human
Citation and country	Study design/research methods	Sample size (n) of MCI/ADRD	Length of testing/exposure	Setting where tech was studied	Mean age or age range; race/ethnicity n; female/male; education of MCI/ADRD	Diagnosis and severity
NLD [28]	Pilot randomized controlled trial	55	1–1.5-h training session + 3 months in-home trial	Home	Experimental: 72.7 yr; race/ethnicity NA; 12f/16m; ≤2° edu 14, higher edu 11 Control: 71.7 yr; race/ethnicity NA; 11f/20m; ≤2° edu 12, higher edu 10	MCI; mild dementia including AD, frontotemporal dementia, vascular dementia; very mild cognitive decline
USA [41]	Longitudinal, non-randomized, single-arm, repeated measures (pre-post)	7	3 months with weekly technical office hours available if needed	Adult living community with independent living, managed care and dementia care	81 years; race/ethnicity NA; 5 f/2 m; edu NA	MCI, AD, ADRD
UK [42]	Mixed-methods with participatory design and usability study	9	3 workshops across 4 months	Dementia NI group empowerment meetings and/or living space lab setting	60–81 yr; race/ethnicity NA; sex 3f/6m; edu NA	Mild-to-moderate dementia
UK [39]	Repeated observations	9	1–2 standard tasks within 4 different formats+ 1 individually chosen task exploration per visit (67 total visits among 9 participants)	Home	73–86 yr; race/ethnicity NA; 4f/5m; edu NA	Mild-to-moderate dementia
UK [47]	Beta test with pre-post interview	26	2 distinct phases (different samples), 4 weeks each	Home	80 yr; race/ethnicity NA; 12f/14m; edu NA	Mild-to-moderate cognitive impairment with dementia (AD, vascular, or mixed AD/vascular)
NOR, PRT [32]	Qualitative interview study	12	2–3 times/week for 16 weeks or 2–3 times/week for 12 weeks, with each session lasting 30–60 min	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
USA [30]	Pilot and feasibility study using a within-participant, counterbalanced, crossover design	10	One 3-h session	Lab	80.3 yr; white 8, unknown 2; 7f/3m; edu 16.4 yr (mean)	MCI, mild dementia, or “cognitive scores falling within [MCI through mild dementia] range”
NLD [46]	Mixed methods: interview, survey, observation	Interview: 6 Survey: 88 Observation: 4	Single session for each event (different recruitment procedures)	Interview: Home Survey: Home Observation: Home or university workstation	Interview: 71 yr (median); race/ethnicity NA; 1f/5m; edu NA Survey: 67 yr; race/ethnicity NA; 35f/44m (9 NA); edu NA Observation: 66.5 yr; race/ethnicity NA; 1f/3m; edu NA	MCI, AD, frontotemporal dementia, dementia with Lewy bodies
UK [27]	Secondary analysis of data from a randomized controlled trial	37	6-month period within 12-month parent study	Home	70.4 yr; race/ethnicity NA; 16f/21m; ≤2° edu 34, higher edu 3	AD, vascular dementia, Lewy body dementia, mixed dementia, dementia (type unspecified), MCI
CAN [45]	Longitudinal pre-post	3	Varying based on participant: 12, 24 and 9.5 months, including intervention (non-specific) until mastery, then regular and systematic post-intervention use	Home	69 yr; race/ethnicity NA; 1f/2m; edu 12,14, 21 yr (median 14)	AD and atypical AD
UK [36]	Exploratory: two-arm, non-randomized, repeated measures	30	3 sessions over 5-d period	Care service centre	84.2 yr; race/ethnicity NA; 22f/8m; edu NA	Dementia – non-specified
USA [31]	Feasibility cohort study	22	3 months	Home	Veteran group: 65 yr; Black 10, white 4, Hispanic/Latino 1; 0f/14m; edu NA Non-veteran group: 78 yr; Black 8, Hispanic/Latino 0; 3f/5m; edu NA	Dementia – non-specified (impaired to significantly impaired cognition)
ITA, ESP, AUT [43]	Multicenter field trial	30	12 weeks	Home	Intervention: 72 yr (median); race/ethnicity NA; 9f/6m; edu NA Control: 74 yr (median); race/ethnicity NA; 7f/8m; edu NA	Mild MCI due to AD or mild AD
ITA [49]	Non-concurrent multiple baseline	11	3 min × 3–6 baseline sessions; 3–5 min/intervention sessions, 2–4 sessions/day, 51–107 sessions based on participant availability	Centres for people with ADRD	83 yr; race/ethnicity NA; 6f/5m; edu NA	Moderate AD
ITA [33]	Two studies: non-concurrent multiple baseline	Study 1: 8 Study 2: 9	Study 1: 1.5–2-h sessions, including 1st baseline 2–4 sessions, 2nd baseline 3–6 sessions, 3–4 introductory sessions, and 37–82 intervention sessions based on participant availability Study 2: 3min × 3–7 sessions/day, 4–11 baseline sessions, 73–119 intervention sessions based on participant availability	Centres for people with ADRD	Study 1: 84.8 yr; race/ethnicity NA; 3f/5m; edu NA Study 2: 79.6 yr; race/ethnicity NA; 5f/4m; edu NA	Study 1: mild-to-moderate AD Study 2: moderate-to-severe AD
ITA [34]	Non-concurrent multiple baseline	26	5-min sessions, 3–5 sessions/day, 21–38 pairs of sessions (control + intervention)	Residential social-medical centres	Group 1: 83 yr; race/ethnicity NA; sex NA; edu NA Group 2: 85 yr; race/ethnicity NA; sex NA; edu NA	Advanced AD
ITA [50]	Adapted non-concurrent multiple baseline	Group 1: 4 Group 2: 4	2–3 h sessions, including 3–5 baseline 1 sessions (no tech), 3–5 baseline 2 sessions (no tech), 3–4 introductory sessions (tech), and 34–78 intervention sessions (tech)	Activity and care centres	Group 1: 71 yr; race/ethnicity NA; 3f/1m; edu NA Group 2: 75 yr; race/ethnicity NA; 4f/0m; edu NA	Mild-to-moderate AD
DEU [51]	Open-label, non-randomized, cross-sectional, mono-centric pilot	14	15 min training, 15 min task completion × 1 session	Hospital campus	71.9 yr; race/ethnicity NA; 9f/5m; edu 6–10 yr	Mild-to-moderate AD
AUS [35]	Qualitative study with observation, focus groups, and interview	3	6 months	Dementia wing of long-term care facility	76–87; race/ethnicity NA; 1f/2m; edu NA	Moderate-to-advanced dementia including Lewy body disease, AD, and dementia (non-specified)
USA [26]	Pilot randomized controlled trial	48	6 months	Home	All: 74.9yr Intervention: 74.2 yr; Non-Hispanic white 16, Hispanic white 2, ≥2 races 1; 11f/9m; ≤2° edu 4, higher edu 16 Control: 75.4 yr; Non-Hispanic white 20, Asian 1, ≥2 races 2; 14f/14m; ≤2° edu 7, higher edu 20	Dementia, MCI, self-identified memory concern
Not specified [40]	Non-concurrent multiple baseline	5	Mean 7-min sessions (10 min max), 1–2 sessions/day, 3–5 baseline sessions (no tech), 5 intervention practice sessions (tech), 20–50 intervention sessions (tech)	Day centre for persons with ADRD	80 yr; race/ethnicity NA; 5f/0m; edu NA	Mild-to-moderate AD
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 2: 17 (same subject pool for both phases)	Phase 1: 1 introductory and user testing session Phase 2: 4-week in-home test+ 1 in-clinic user evaluation session	Phase 1: Clinical setting Phase 2: Home	Blekinge site (BTH): 77 yr; race/ethnicity NA; 3f/6m; edu NA Barcelona site (CST): 80 yr; race/ethnicity NA; 5f/5m; edu NA	MCI, mild dementia
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 (varying lengths and total completed/participant): 8 without support, 12 with CIRCA, 9 with CIRCUS	Home	“Older women” – no age specified; race/ethnicity NA; 3f/0m; edu NA	Dementia (non-graded)
AUS [53]	Pilot feasibility study	15	12 weeks total: Weeks 1–2: 40 min/week Weeks 3–4: 60 min/week Weeks 5–6: 80 min/week Weeks 7–8: 100 min/week Weeks 9–12: 120 min/week	Home	83 yr; race/ethnicity NA; 7f/8m; edu 11 yr (mean)	Mild-to-moderate dementia
DNK [48]	Mixed methods: longitudinal, pre-post, case studies	6	8 weeks	Home	69.7 yr; race/ethnicity NA; 2f/4m; edu NA	Early stage dementia (mild-to-moderate impairment)
JPN [25]	Two experiments: modified ABABAB method; ABBA method	4 (same subjects for exp)	Exp 1: 40-min sessions × 3–8d Exp 2: 20- and 30-s videos 9–15 d over ~2 weeks	Home	78.8 yr; race/ethnicity NA; 4f/0m; edu NA	AD, varying severity

2°: 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: 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: Portugal; SWE: Sweden; tech: technology; UK: United Kingdom; USA: United States of America; yr: year(s).

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
Citation	Activity Targeted activity	System/intervention description	Hard technology	Design elements to maximize performance/engagement	Instructional strategies	Technology partner(s) description and involvement
[28]	Health management, education, social participation	FindMyApps is a self-service Web app containing a database of apps that support self-management, social participation, and meaningful activity engagement.	Touchscreen tablet interface	Personalized settings for app user profile including large font size, minimal text, use of non-animated pictures, Dutch language-only app choices, simplified gesture-control for operation, and more detailed instructions in the help feature; explanation button when help is needed.	One- to 1.5-h training to instruct PwMCI/ADRD and caregivers on how to use the tablet and FindMyApps selection tool; errorless learning strategies were implemented (e.g., stepwise approach, discouraging guessing during task performance, mistake-free repetition) to instruct on basic and complex tasks within the app; training was accompanied by a written 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.	Caregivers were trained on use of the app and how to provide continued support to the PwMCI/ADRD during the intervention. Research staff provided dyads with initial training on the tablet and app and operated an email/phone helpdesk during the trial.
[41]	ADL	Visual mapping software presented on a tablet to assist people with memory difficulties to complete ADL.	Touchscreen tablet interface	Home screen automatically appears upon task completion, showing next scheduled ADL; “Next” and “Previous” navigation buttons; customisable template library of ADL visual maps, which caregivers were trained to modify and personalize.	Visual mapping using keywords/pictures sequencing; caregivers trained to demonstrate and support; weekly tech support available.	Caregivers identified ADL to be addressed and guided participants in carrying out tech-supported ADL. Research staff remained available for troubleshooting.
[42]	Social participation	InspireD, a digital app featuring photographs, videos, and music, facilitates joint reminiscence for PwD and their carers.	Touchscreen tablet interface	Minimalistic design; clear, bold colours segmenting the user interface; combination of typography and iconography to guide navigation and help users understand app functionalities; step-by-step linear approach for cognitively challenging tasks (e.g., uploading photos); non-stigmatizing language.	Use of the app was demonstrated by research staff on a large screen and tablet. Set-up instructions were provided to participants and choices of layout, wording, and usability were agreed upon.	Carer involvement was optional. Carers reported providing explanation and demonstration support, “keeping track” of device, implementing enrolment process, and troubleshooting device and software.
[39]	ADL, IADL	Customisable prompting app for multistep tasking.	Touchscreen tablet interface	Text, recorded voice, picture, and video prompts; researchers manually triggered prompts when participant appeared ready; built-in delay of “Next Step” button so users can process prompt without being distracted by the idea of moving to next steps; appearance, position, and 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”).	Progressive, ongoing support based on participant need, including reiterating instructions, pointing, and physical demonstration; different prompt types were studied; user-led exploratory approach for one individualized task.	Caregiver present during implementation to provide reassurance; supported identification of meaningful tasks prior to intervention. Research staff assisted with task completion as needed.
[47]	ADL, IADL	App-based prompter for everyday tasks.	Touchscreen tablet interface	Audio, picture, and text prompts; carers could set up series of prompts, combining type of prompts used, tailored to PwD’s needs and ADL; “Touch here for next step” button leading to next sequential step; tablet set to only run the prompting software, all other apps were disabled to decrease distraction.	Device prompting and instruction manual provision; phase 1 included tech training demo to user-carer dyad; phase 2 had no demo, just reliance on intuitive design.	Carer-user dyads worked as a team for the full tech implementation process Carer involvement varied (e.g., selection of multi step tasks and step-by-step prompts).
[32]	Social participation	SENSE-GARDEN is a room within a dementia care setting that features digital tech and multisensory stimuli (e.g., aromas, movement-based games, music, large-screen projections) based on an individual’s life story, to engage PwADRD in socially supported, reminiscence activities.	Large-screen projector; aroma dispenser; game controller; stationary bike	Personalized digital media to trigger memory; interactive features to engage multiple senses; large-screen projections that do not require tech manipulation on the PwADRD’s part.	Written instructions along with video tutorials on how to set up and implement SENSE-GARDEN sessions were provided to care staff; an online helpdesk for tech support was available as needed.	via the SENSE-GARDEN tablet app, formal caregivers (professional care staff) worked with family members of the PwADRD to prepare personalized SENSE-GARDEN sessions and facilitated the intervention. Family members collaborated with care staff to prepare SENSE-GARDEN sessions by 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 respond to participants’ technical issues.
[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.	Smartphone touchscreen interface; device placed in a carrying case to keep on the user’s person.	Simple interface with large, clear text and buttons; time-based auditory alerts/ prompts to draw attention and trigger task initiation; brief text indicating task goals and instructions; regular reminders and nudges; photo log of task completion to promote task tracking; points awarded for logging completed tasks to address motivation.	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.	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.
[46]	Health management, education	Online patient portal with educational/informational content, patient-provider communication tools, and social support features.	No specific hard technology noted	Welcome Page describing main functionalities 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.	Accessibility and community interaction considered in programme design; testing intuitiveness of design through hands-on tasks (no training apparent).	No specific tech partner involvement noted.
[27]	Education, health management, social participation	CAREGIVERSPRO-MMD is an online social-media style platform to 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.	Touchscreen tablet interface	Curated information specific to PwD and their carers.	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.	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.
[45]	ADL, IADL	AP@LZ is an electronic day planner and organizer app to support memory for daily activity engagement.	Smartphone touchscreen interface	Predetermined list of appointment types provided; all other apps on the phone are 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.	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 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).
[36]	Leisure	Customized accessibility settings for two commercial game apps.	Touchscreen tablet interface; maximized volume and brightness; stable, durable case to protect device and power button from accidental shutdown	Game page ready on screen upon presentation; notifications disabled. Solitaire features: consolidated control methods to only drag-drop; option to alter input method that triggers toolbar and to enhance visual emphasis of autoprompts. Bubble Explode features: simplified layout of opening screens; minimized text feedback that were distractors; auto-prompts for user inactivity; audiovisual redirection prompts after invalid input.	Research staff led a singular, standardized, physical demonstration of gameplay accompanied by verbal instruction.	Research staff preset games on screen and encouraged participants to play independently if support was requested.
[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.	Tablet touchscreen interface	Pictures and keywords presented in a step-by-step sequence to support ADL 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.	Nondescript training was provided by research staff.		Research staff conducted initial training and development of ADL maps.
[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.	Connected e-ink touchscreen tablets; inconspicuous protective notebook cover to avoid stigmatization; smartwatch; stable charger for easy handling	Large font; clear language; symbols and images connected to text-based information; individualization using personal photographs; design modelled on familiar, analogue desktop calendars and notebooks; information and reminders accessible on tablet/smartwatch any time; smartwatch reads lists aloud and calls caregiver if needed; one-button panic option to contact caregiver and relay user’s location.	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.		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.
[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.	Smartphone with Bluetooth connected to headphones/earpiece eliminated need to interact with tech directly	Audio, single-step instructions delivered through headphones; praise statements at completion of task steps; repetition of instructions until task completed or timed out; preferred stimulation (songs, hymns, comic sketches) as determined by staff and families, delivered at successful task completion.	.		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.
[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 computer that delivered stimulating audio (e.g., music) and verbal prompts through an earpiece, to encourage ambulation.	Smartphone/tablet connected to Bluetooth earpiece to eliminate need to carry mobile device; microswitch paired with notebook computer	Study 1: pre-scheduled activities with verbal audio reminders to begin tasks; verbal 1- or 2-step instructions separated by predetermined individualized intervals based on participant and activity type; praise statements during task performance; activities and frequency of verbal reminders adapted based on characteristics of participants. Study 2: audio stimulation and verbal prompts delivered through earpiece, eliminating need to carry a device; brief verbal prompts (1–3 words) delivered after lack of participant response; participant-preferred stimulation (songs, hymns, prayers) that triggered positive reactions, delivered at successful 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.		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.
[34]	ADL, health management	A smartphone programme that 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.	Smartphone; radio frequency-code-tagged objects	Verbal audio prompts/encouragement if no response from participant (10–15 s); preferred stimulation (songs, hymns), delivered at successful task completion.	Four to six practice sessions whereby research staff provided verbal and physical guidance so participants could experience prompts and performance-contingent stimulation.		Families and day-centre staff recommended preferred content to be used as stimulation. Research staff set up tech for participant use and provided guidance during practice sessions as needed.
[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.	Tablet paired to a wireless Bluetooth earpiece allowed audio prompts to travel with task, while tablet kept remotely	Pre-scheduled, personally relevant activities with verbal audio reminders to begin tasks; single-step instructions strung together in 2–5 sets at a time (dependent on cognition); programmed interval length between instructions varied based on participant performance.	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.		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.
[51]	IADL	Smartphone assistive device that facilitates autonomous environmental navigation/orientation.	Smartphone touchscreen interface	Verbal and acoustic direction prompts delivered at decision points (i.e., 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.	Scripted verbal instruction from research staff prior to releasing the device to the PwD.		Research staff provided verbal instructions upon giving participants device, and verbal reassurance/encouragement and redirection as needed.
[35]	Social participation	Tablet app loaded with personal and stock multimedia (e.g., photos, books, music, family movies) to stimulate reminiscence and social interaction.	Tablet touchscreen interface	Media personalized to PwD and their carers.	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.		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.
[26]	Social participation	Smartphone app that employs facial recognition software linked to a smartwatch to assist with identification of people during social encounters.	Smartphone; smartwatch	App automatically recognizes individuals and 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.	Research staff demonstrated the tech and “trained” participants to use it in a single in-person session; ongoing tech support as needed.		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.
[40]	IADL, social participation	Computer-aided telephone system with video-displayed images and a microswitch for device operation to enable independent phone call completion.	Computer; telephone with video display; microswitch activates system with minimal hand contact	Switch activation prompts computer to perform tasks such as listing available call partners (1 at a time), calling a partner, or disconnecting a call; 4–5 s delay to allow response time; lack of switch activation prompts system to display next available call partner in sequence; programme provides picture and verbal identification of call partner’s name or relationship to patient; partner’s picture is displayed during conversation.	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.		Phone call partners consisted of family, friends, and caregivers. Research staff (presumably) set up tech (e.g., identifying call partners, uploading photos).
[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.	Touchscreen monitor interface	Sequential presentation of information – 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.	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”.		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).
[44]	ADL, IADL, health management, education	Support Monitoring and Reminder Technology for Mild Dementia (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.	Touchscreen tablet interface	Built-in cognitive supports like appointment 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.	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.		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.
[52]	Social participation	Individual Specific Reminiscence in Dementia (InspireD) tablet app is a home-based, personalized reminiscence programme to facilitate reminiscence and social interaction.	Tablet touchscreen interface	Limited limiting apps on home screen to only those necessary; bright colours; large buttons; icons with brief text.	Nondescript “information technology and reminiscence” training was provided by research staff.		Each participant had at least one partner who was a relative (spouse, child, or grandchild) who would engage in the app with them.
[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.	Tablet touchscreen interface	Sequential presentation of information – theme selection leads to media categories (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.	Basic instructions on tablet use and use of CIRCA and CIRCUS were provided to the care-aid. No training was described for the PwD.		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).
[53]	Health management	StandingTall a fall prevention exercise programme consisting of balance training exercises and assessment delivered via tablet, with on-screen text, video demos, and voice-overs.	Tablet touchscreen interface	Audiovisual-based demos of desired tasks; automated progress tracking; in-app exercise scheduling; built-in coaching and automated tailoring of exercises and intensity based on user-inputted self-ratings of exertion; automated time-out and session closure if failure to interact with the app.	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 made available to address issues with the made available to address issues with the programme. Instructions to complete exercises included onscreen text, video guides/demos, and voice-over.		Caregivers participated in the system orientation and assisted participants with app usage during exercise sessions, information entry (e.g., perceived exertion ratings), and safety monitoring. A research physiotherapist introduced the programme and equipment to the dyads and provided in-person and phone-based support.
[48]	IADL	Use of smartphones + 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.	Smartphone touchscreen interface; smartwatch	Self-report app prompts user to input info; standard home screen displaying time, appointments, and step count can be 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.	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.		Live-in caregiver involved in all aspects of tech use (e.g., training, implementation, data reporting). Research staff (trained in psychology) collaborated with participants to develop individualized goals, and provided tech support as necessary.
[25]	ADL, IADL, social participation	Two videophone-based systems: (1) remote reminiscence conversation system to promote conversational engagement and psychological wellness and (2) schedule prompter system to assist PwD to perform household tasks.	Touchscreen PC interface with web camera	PC remotely booted by conversation partner; auto-launch of software when PC turned 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)	No instruction for participants or caregivers was reported.		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 + partner + participant collectively scheduled calls. Schedule Prompter System: caregiver + memory clinic therapist + participant selected and scheduled tasks. Therapist or caregiver was videoed explaining tasks.

Notes: AD: Alzheimer’s disease; ADL: activity/activities of daily living; ADRD: Alzheimer’s disease and related dementia; app: application; demo(s)=demonstration(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.

Phase II – Expert stakeholder interviews

The second study phase featured interviews of MCI/ADRD expert stakeholders, referred hereafter as experts. This phase was conducted 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 scientific and practice arenas. The University of Southern California Institutional Review Board approved all procedures. Using a purposive sampling strategy, we sought individuals from wide-ranging 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 academic, professional, clinical and community organization biographies. 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, conducting 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 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 technology with consideration of facilitators and barriers.

A manifest (surface-level) content analysis [51,52] of transcribed interviews – managed using spreadsheets – was conducted 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 predetermined coding scheme. Initial categorical codes (e.g., technology use in daily life, barriers to technology use and technology facilitation strategies) developed from the semi-structured interview guide were agreed upon at a team meeting and were subsequently 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 discussed 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 resultant 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, discrepancies 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 information 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 flowchart (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.

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.

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.

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 (n = 6), Italy (n = 5), and the USA (n = 4). Most were small-scale (median MCI/ADRD sample size = 10) feasibility/pilot studies and featured qualitative components; only three studies included a randomized controlled trial [22,30,41]. Intervention/trial periods were as short as a single session to as long as 24 months. Settings where technology implementation took place were primarily where PwMCI/ADRD lived (n = 19) or at community venues (e.g., day centres; n = 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 from 65 to 85 years. Participants’ ethnoracial information was specified in only three studies [28,33,41]. Roughly equal numbers 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 (n = 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 condition 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 are presented in Table 2. The DHT interventions for PwMCI/ADRD targeted participation in various domains of activity – subsequently classified using occupation categories from the Occupational Therapy Practice Framework 4th ed [53]. Several (n = 12) were multi-focused. Most facilitated engagement in ADL (n = 12), social participation (defined as activities involving social interaction with others [53]; n = 11), and/or IADL (n = 10). Other DHTs facilitated participation in health management (n = 6), education (n = 4) and leisure (defined as non-obligatory activities engaged in during discretionary time; n = 2). None addressed rest/sleep or work/volunteerism.

Digital health technology (assistive technology)

Although labelled as assistive technology, the HAAT model can 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]). Videophone systems [42,49] and multimedia apps loaded with photographs, videos and music [24,34,40] fostered social participation. Electronic day planners and organizers [31,44] and Web portals/apps with curated health information [22,29] assisted with IADL, education, and health management.

Hard technology.

To further characterize technological components, the HAAT model differentiates hard and soft technology [19]. The hard technology (i.e., tangible, physical components) was almost exclusively mainstream, regularly featuring touchscreen tablets and smartphones [23,26,28]. Other less frequently reported hard technology included smartwatches [34,41,48], Bluetooth earpieces [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 technologies 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, strategies and other people [19]. Table 2 divides the DHT systems’ soft technology into design elements of the software, instructional strategies implemented and technology partner descriptions and involvement. The DHTs investigated shared three primary design features: prompting software, customisability and multimedia/multisensory 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 motivation to engage, such as by offering menu options from which users could select meaningful activities [26]. Multimedia and multisensory 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 technology 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 inferable) strategies included hands-on practice [28], training a second person involved in technology implementation [44], demonstration [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], encouragement to engage with the technology [25], and technology customization [41].

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 longer, 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, comorbidities and changing needs as cognition and function decline [22,28,32,40]. They stated more time should be spent on personalization 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 drawbacks of the technology [38]. In only a few studies, broadening the sample diversity on key levels – socioeconomic status, race/ethnicity, targeted geographical regions, international participation, stages of ADRD – was noted as important [26,27,41,43,44,]. Advancing science in the activity domain was not discussed by many aside from two studies with intentions to expand the capabilities 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 making onboarding less cumbersome [41], to increasing button colour contrast [24] and supplementing audio-alone elements with audiovisual options [42]. Several researchers planned to explore ways to reduce reliance 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 (N = 17) had 4 years of experience working/practicing/volunteering with older PwMCI/ADRD; most had 12+ years (n = 7). Respondents were primarily female (n = 14) and from the USA (n = 16), representing Western (n = 8), Northeastern (n = 5), Southeastern (n = 2) and Midwestern (n = 1) states. One participant was from Ontario, Canada. Regarding sub-types of conditions/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 seeing in their practice were vascular dementia, Parkinsonian dementia 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 clinicians and researchers to advocates, technology consultants and personal caregivers. Their practice settings spanned the continuum of care, varying from outpatient and hospitals to community centres and home health. Figure 4 provides a high-level summary of the expert stakeholder interview phase results as situated within the HAAT model.

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.

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 management. “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 management 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 implementation/uptake

Experts described a number of factors and considerations that should be made – relevant to the remaining domains of the 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 ineffective 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 cognitive impairment in technology navigation, was a broad need identified. “[I]n the early stages of cognitive decline […] our current way of supporting someone is kind of watchful waiting. […] 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 determinant 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 associated cognitive capacity was emphasized: “It depends on the person [… 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 procedures 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 accommodations for PwMCI/ADRD’s unique needs when it came to current 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 communicated 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 centred on simplification. One expert highlighted Jitterbug, a smartphone for older adults, as ideal to ease clients’ transition to new mobile technology. “It’s a little more simplified [… ,] very organised [… and] designed for ease of use”. They cautioned, however, to make technology “simple but not childish” and to balance simplicity and interactivity: “That’s counterintuitive to a lot of designers who want to make it […] active and interesting, but we want it very simple”. Another expert suggested the technology’s content 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 technology, “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 individuals are likely to retain despite cognitive decline, by incorporating 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 comprehensible 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 instruction, 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’ discussions of soft technology instructional practices was engagement 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 technology partners supplement shortcomings in design features by providing 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 framework, this study aimed to collate, summarize, and characterize evolving research and practice featuring activity participation-supportive 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 mindfulness to the overarching influence of the sociocultural, environmental and institutional contexts. In characterizing and crosscomparing both the ongoing research practices and expert experiences, findings suggest both convergences and points of departure 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 development 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 feasibility 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 Westernbiased 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 places 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 ecologically 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 concern to experts, but those did not appear as salient in the scoping review studies. Experts described issues of access, resource availability and affordability as strongly influential to why more technology 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 technologies [57], access may still be out of reach for many. For instance, older adults with socioeconomic challenges and from communities of colour – groups with disproportionate risk and prevalence of MCI/ADRD [58,59] – oftentimes lack familiarity with and opportunity to experience mainstream and assistive technology, despite eagerness to engage [60–62]. Digital inequities like these stemming from PwMCI/ADRD social context, as noted by the experts, are likely to continue perpetuating the digital divide [12,13].

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 sociodemographic characteristics including race/ethnicity, socioeconomic status 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 understanding for whom present-day DHTs are being designed and developed 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 persons with moderate-stage impairments and, in a few rare studies, severe cognitive deficits. In these studies, the DHTs addressed significant barriers to engagement in ADL and IADL in particular – ones also noted in a review of mHealth usability barriers experienced 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 important, 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 particularly 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 telephone system with caller video display [42] to reminiscent-based conversation starters featuring personalized multimedia [43]. 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 preparatory 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 technologies [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 volunteerism 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 special 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 technology components.

Soft technology design

Customisability to accommodate users’ unique needs, combined with simplicity for ease of use was design characteristics encouraged by experts and present in the reviewed DHT. Careful attention to assistive features also crosscut the study phases. DHTs within the scoping review studies frequently included autoprompting – 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’ feelings of dependency [64], highlighting the imperativeness of bringing this research-based DHT into mainstream use.

Consideration of sensory experiences was a focal point of technology design to facilitate activity participation. One expert explained stimulating auditory senses using technology that delivers 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 multimodal interaction and sensory stimulation. Use of touchscreens with haptic feedback, music to reward performance, and personalized photos to stimulate conversation were just a few multisensory 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 participation, social engagement and enjoyment [73]. Limiting sensory 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 technology 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 visual aids, to enfolding learning activities into routine, and capitalizing 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 training 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 adoption in older adults is strongly influenced by the training and support 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 strategies 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 appropriate 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 dissatisfaction 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 sustainability 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 technology 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 oversight 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 levels 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 monitored and more closely supported to avoid deprivation from meaningful activities that can be enabled through technology [90].

Limitations

This two-phased study is limited in several ways. The scoping review phase involved multiple database searches conducted several 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 experiences 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 participation-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 community (namely sleep and volunteerism), and providing more 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 supportive of activity participation in PwMCI/ADRD.

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 characteristics 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.