Best Practice Guidance
Human Interaction with Technology in Dementia

themes: Implementation

Evaluating the effectiveness of specific contemporary technology

The rapid growth of the technological landscape and related new services have the potential to improve the effectiveness and cost-effectiveness of health and social services and facilitate social participation and engagement in activities. But which technology is effective and how is this evaluated best? This section provides recommendations to evaluate the effectiveness of technology in daily life, meaningful activities and healthcare services as well as of technologies aimed to promote the Social Health of people with dementia. Examples of useful technologies in some of these areas are provided.
Technology for meaningful activities

Consider cost-effectiveness research into eHealth interventions

Guidance

Methodological sound effectiveness research into eHealth interventions for community dwelling persons with dementia is growing. To determine the added value of such interventions, it is important to look at their effects and costs. This gives a balanced picture and helps policy makers to make the right decisions when deploying eHealth interventions.

Explanation and example

Positive effects were found of exergaming compared to usual activities in day care centres. The provision of exergaming brought additional costs related to the equipment (purchase and maintenance) and staff involvement. Compared to non-technology based interventions, especially equipment costs can be a cost driver.

In the exergaming study, the participating organisations received a list of potential funders for the equipment to be used, and various funding organisations (charitable organizations) were willing to pay for it. In some cases this helped to participate in the study.

Taking into account the intervention costs may help day care centres to balance the positive effects of using the eHealth interventions (for people with dementia and their carers) against the long-term costs (to be covered by own funding or external funding). This will promote a well-informed implementation and securing of the eHealth intervention.

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Implementation of technology in dementia care: facilitators & barriers

Successful implementation of technology in dementia care depends not merely on its effectiveness but also on other facilitating or impeding factors related to e.g. the personal living environment (privacy, autonomy and obtrusiveness); the outside world (stigma and human contact); design (personalisability, affordability and safety), and ethics on these subjects.  This section provides recommendations on the implementation of technology in everyday life, for meaningful activities, healthcare technology and technology promoting Social Health.

Ensure multiple employees are responsible for exergaming to ensure successful implementation of this technology

Guidance

Exergaming in day care centres can be implemented more successfully by making more than one employee responsible for it.

Explanation and examples

We have asked day-care centres for people living with dementia, which factors were important for successful implementation of Exergaming. Sometimes, only one person in the day-care centre was responsible for the Exergaming activity. If this person was not at the day-care centre, because he/she was ill or left for another job, the Exergaming activity often was forgotten.

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Ensure the support from the management of care organisations to promote successful implementation of exergaming

Guidance

Employees of care organisations should be supported by the management in their responsibility for Exergaming as a new activity. Managers should be actively engaged in Exergaming and be kept updated on any developments with regard to Exergaming (i.e. positive experiences of people with dementia practising Exergaming, any potential issues with the activity).

Explanation and examples

We have asked day-care centres for people living with dementia, which factors played a role in successful implementation of Exergaming. The staff of these day-care centres sometimes did not feel supported by the management in supervising and implementing the Exergaming activity. This made it less likely for them to implement it.

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Explore and consult with the eHealth context to facilitate implementation of eHealth interventions

Guidance

To develop an eHealth intervention for caregivers of people with dementia that will be used in practice, developers should investigate the needs of the target population (people with dementia and their caregivers), and the needs of the people who will be implementing these interventions after a trial phase (such as case managers, hospital workers, volunteers or professionals associated with advocacy groups).

Explanation and examples

A systematic search was conducted into the implementation of studies including the terms ‘dementia’, ‘eHealth’, and ‘caregivers’. 2524 abstracts and 122 full texts were read, resulting in 46 studies meeting all criteria. Containing 204 statements on implementation. Most implementation statements could be grouped into 2 main themes: ‘Determinants associated with the eHealth intervention’ and ‘Determinants associated with the caregiver’. Very few statements were in the themes ‘Determinants associated with the implementing organization’ and ‘Determinants associated with the wider context’. Absence of knowledge on the contextual environment creates significant difficulties for health system planners and implementers who aim to translate these interventions into practice.

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Start making eHealth financing and business plans at the start of the development phase

Guidance

To ensure that the eHealth interventions for caregivers of people with dementia will continue to be available, supported, updated and compatible with changing software and hardware requirements, financing and business plans should be developed from the beginning.

Explanation and examples

A mixed-methods study followed up on the 12 publications included in Boots et al.’s (2014) widely cited systematic review on eHealth interventions for informal caregivers of people with dementia, to explore implementation into practice. Publicly available online information, implementation readiness (ImpRess checklist scores), and survey responses were assessed. The majority of survey respondents identified commercialization and having a business plan as facilitators to implementation. There was little evidence for any of the 12 applications being put into practice.

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Implementation of technology in dementia care: facilitators & barriers

Guidance

Ensure new technology is compatible with a range of relevant platforms to promote implementation.

Explanation and examples

Findings from the feasibility trial showed that people with dementia use a range of devices with various software versions (e.g. smartphones, touch-screen tablets, and personal computers) to access apps and other services. New technology which aims to be compatible with these different devices, can lead to increased uptake and may contribute to successful implementation.

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Health care technologies

Ensure management engagement when implementing complex health technologies

Guidance

Consider active engagement of nursing home management as a crucial component when designing complex health care technologies for nursing homes. Their commitment to the project’s success will help to ensure staff have sufficient time and other resources to participate in the new programme.

Explanation

A lack of time is one of the most important barriers for implementing advance care planning (ACP) in nursing homes. Therefore, it is crucial staff gets enough time to engage and work with the intervention in order to properly implement it. When staff is given time to spend on intervention-related tasks, instead of having to spend this time on other tasks, this will increase their ownership of the intervention.

Example

In the ACP+ programme all nursing home managers signed a contract stating they would allow their staff to spend time on the intervention. Training sessions were held during working hours and staff got paid while attending these sessions.

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Target multiple levels when implementing complex health technology in a specific context

Guidance

When implementing Advance care planning (ACP) as a complex health technology in a complex setting such as a nursing home, multiple levels should be targeted, including management, nurses, care staff, volunteers, visiting or residing physicians, families, cleaning or other staff.

Explanation

The implementation process will have a higher chance of succeeding when multiple levels are targeted within the nursing home. Colleagues in the nursing home can help each other to implement the intervention, creating a positive and open environment to learn and develop new skills and deliver the best care possible. In this way the intervention can produce a shift in working culture and attitudes and deliver sustainable change.

Example

The ACP+ intervention targeted not only the (head) nurses, but also other care staff and cleaning, kitchen and maintenance staff. Also, engagement of the management was required for participation in the trial. A few highly motivated people were extensively trained in conducting ACP conversations and this knowledge was past onwards to colleagues via internal training sessions. In this way the whole nursing home was involved in the intervention, leading to greater participation of all nursing home employees.

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Take into account the level of cognitive impairment when implementing technologies

Guidance

The level of cognitive impairment must be taken into account in the design of technology because people with severe dementia have different needs vs. mild dementia.

Explanation and Example

People with severe cognitive impairment will have more problems learning to use different and new devices. They need more explanation and a longer learning time, due to limited cognitive capacities. For example, the clinical experience with Gradior shows that people with moderate and severe dementia should have the therapist as a permanent guide. According to this, Gradior possibly would have to adopt new systems and tools to become effective in people with moderate and severe dementia, and in turn, allow a level of autonomy of the person with dementia who uses this technology. Indeed, the help of a therapist in the first steps of applying a technological-based therapy is strategic for implementing and accepting the approach.

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Nursing home managers should ensure the appropriate conditions for implementation of EPR systems

Guidance

Issues such as access to the EPR system, appropriate training and system development and support should all be considered by nursing homes before and during the implementation of EPR systems.

Explanation and Examples

Access or non-access to various parts of the EPR system should be discussed and put in place. For instance, management should consider whether auxiliary staff should be allowed to access medical information, such as dementia diagnosis, and whether this would consequently entail training in the field of dementia. Appropriate training in the EPR system according to individual staff needs is also required, as some staff may be more experienced in the use of technology than others. Training ‘on the job’ was found to be preferred by many over classroom-based teaching. Finally, software developers should consider working alongside nursing homes during the design of EPR systems in order to ensure software is appropriate for their needs. Developers should continue to be involved in improving the EPR following implementation, as part of an iterative cycle.

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Telehealth should be recognised as a valuable adjunct to traditional occupational therapy service provision, requiring dedicated financial, legislative and informative resources

Guidance

Occupational therapists must adopt telehealth practices as a supplement to in-person occupational therapy to avoid service disruption in times of crisis. This requires legislation and public promotion, clear strategies and guidelines for health service managers, and finally, training and continuous support for end-users.

Explanation and Examples

A global online needs-assessment survey among occupational therapists was undertaken to determine the impact of the COVID-19 pandemic on telehealth practices in occupational therapy worldwide and to get insight into facilitators and barriers in utilising this form of service delivery. The survey was circulated in the occupational therapy community by the World Federation of Occupational Therapists (WFOT) between April and July 2020, collecting responses to closed-ended questions, in addition to free-text comments. 2750 individual responses from 100 countries were received. The results revealed a significant increase in the use of telehealth strategies during COVID-19, with many reported benefits. Occupational therapists who used telehealth were more likely to score higher feelings of safety and positive work morale and perceived their employer’s expectations to be reasonable. Restricted access to technology, limitations of remote practice, funding issues and slow pace of change were identified as barriers for some respondents to utilising telehealth. Facilitators included availability of supportive policy, guidelines and strategies, in addition to education and training.

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Digital Health Technologies are recommended to support fully Comprehensive Geriatric Assessments, because they improve communication and data transfer of patient medical data, health decision-making, and sharing of assessment responsibility between different professionals, thereby reducing the psychological burden of individual healthcare professionals

Guidance

To provide high-quality elderly and dementia care, Digital Health Technologies (DHTs) can potentially help achieve the full capacity of Comprehensive Geriatric Assessments (CGAs). In addition they can improve communication and data transfer on patients’ medical and treatment plan information between care settings and stakeholders as well as improve health decision-making. Finally, they can help to share the responsibility of the geriatric assessment between professionals, thereby avoiding overloading the workload of individual users and reducing their psychological stress.

Explanation and Examples:

Due to the higher rate of transitions between care settings in older populations, associated with the complexity of an ageing population and the shift from institutional care to home care, CGAs have become an important assessment tool as they encompass multiple domains and address the variety of complex problems in frail older people. They are considered as multidimensional assessments, using quantitative assessment scales, that support multidisciplinary care teams in clinical decision-making and personalized care planning to meet the needs of older people, their families and carers, focusing on functional status and quality of life.

However, to reach the full potential of CGAs, their implementation should be supported by electronic data systems, which provide relevant outputs and allow timely sharing of information within multidisciplinary teams of healthcare professionals and between different healthcare settings. The use of DHTs can potentially help them reach their full capacity and overcome the data transfer limitations between care settings and stakeholders. To improve the usability and implementation of these DHTs, the following features are recommended: a) accessibility of individual assessment by multiple healthcare professionals and the possibility of splitting sections according to professional expertise to share responsibility for assessments; b) the use of secure data storage, such as clouds; c) automatization of real-time calculation of scales and outcomes with a graphical representation of the person’s profile and health status; d) automatic alerts, notifications and continuous monitoring of item completion; and e) provision of personalized care plans according to the data collected.

Well-designed digital health technologies can contribute to the safety of the potential users (e.g. healthcare professionals and stakeholders) and reduce psychological stress, including burnout and low morale, by avoiding overloading the workload of healthcare professionals. For example, by sharing the responsibility for carrying out the assessments between different professionals.

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Social Health Domain 1: Fulfill ones potential and obligations

Researchers and designers of web-based psychosocial interventions for people with dementia and carers are strongly recommended to collaborate with dementia support organisations as they can support implementation, dissemination, and use of these interventions

Guidance

Researchers and developers of web-based psychosocial interventions for people with dementia and carers should consider working together with existing dementia charities and support organisations during the intervention development. During the implementation and dissemination phase, these charities and organisations can be supportive in informing the public about the intervention, thereby increasing its potential use.

Explanation and Examples:

Existing research has shown the need for easily accessible psychosocial interventions for people with dementia and carers. Many people affected by dementia reach out to existing and well-established dementia support organisations and charities, such as Alzheimer’s Society UK in the UK, after they received the diagnosis. We conducted focus groups with 17 people with dementia and family carers to inform the development of a web-based psychosocial intervention. In these consultations, several participants pointed out that the intervention needs to be easy to find. Therefore, they suggested integrating it into the online content of dementia support organisations since these organisations are often the first source of support for people with dementia and carers. For example, the dementia support organisation (e.g., Alzheimer’s Society UK) could have a link on its website for people with dementia and carers that leads them to the intervention. Working together with these dementia support organisations during the intervention development phase can enhance the intervention’s implementation, dissemination, and future use. It will also enable easy access to the intervention and enhance its credibility and trustworthiness.

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Social Health Domain 3: Technology to promote social participation

Make sure social robots work well with residents and consider practical challenges when implementing social robots in nursing homes

Guidance

Understanding how social robots positively impact nursing home residents as well as analysing practical challenges are important when implementing robotic assistive technology in nursing homes

Explanation and examples

An important facilitating factor to the acceptance of social robots in nursing homes is understanding and seeing how social robots positively impact residents, for example by improving the communication, decreasing loneliness, providing joy to residents, calming agitated residents or generally increasing their wellbeing. Understanding these benefits will facilitate the acceptance of social robots by staff as well as by relatives, but is also important for the resident to accept the social robot, as their acceptance will be influenced by the views and attitudes of staff and relatives.

On the other hand, one of the key hindering factors to the acceptance of social robots in nursing homes are practicalities of everyday life in the nursing home, such as storage, hygiene, finding a quiet place, scheduling time for robot use or the need to charge the robot.

We conclude, that applying an acceptance model of social robots (here the Almere Model) is an interesting and feasible way to trace facilitators and barriers of implementation of social technology in nursing homes, where involvement in social activities and enhancing positive experiences are important foci of interventions to improve social health.

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Consider different contextual factors to implement social robots in dementia care

Guidance

Technology developers and researchers should be aware of the different contextual factors that can affect the translation of research on social robots to real-world use.

Explanation and examples

Barriers and facilitators affecting the implementation of social robots can occur at different levels. For example, they relate to the social robots’ features, or relate to organisational factors or external policies. A scoping review was conducted to understand the barriers and facilitators to the implementation of social robots for older adults and people living with dementia. 53 studies were included in this review. Most existing studies have disproportionately focused on understanding barriers and facilitators relating to the social robots, such as their ease of use. However, there is significantly less research that has been conducted to understand organisational factors or wider contextual factors that can affect their implementation in real-world practice. Future research should pay more attention to investigating the contextual factors, using an implementation framework, to identify barriers and facilitators on different levels to guide the further implementation of social robots.

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Users of tablet based interventions and care-providers should make evidence-based decisions about implementation strategy, taking into account important context, implementation and mechanisms of impact factors

Guidance

There are many considerations when planning to implement technological interventions. The issues can be grouped into context, implementation and mechanism of impact factors. Evidence from the FindMyApps project has identified, within these categories, specific factors that are important for successful implementation of a tablet-based intervention, such as FindMyApps. Potential tablet-users and care providers are advised to base their decisions on this evidence.

Explanation/examples:

The FindMyApps project compared the FindMyApps intervention to usual tablet use by community-dwelling people with mild cognitive impairment (MCI) or mild dementia. The following factors were identified as influencing the success of implementation of both the FindMyApps intervention and a standard tablet:

  • Context:
    • People with MCI/mild dementia who previously used a tablet are more likely to use the intervention. Intensive one-on-one support is recommended to those who have never used a tablet.
    • People with MCI and younger people with MCI/mild dementia may use the intervention more. Extra support is recommended for older people with dementia.
    • People experiencing apathy may benefit more from dementia-specific tablet programmes, such as FindMyApps, which provide easy access to selected apps, than from a standard tablet.
  • Implementation:
    • People with slower Wi-Fi connections may find the tablet harder to use.
    • It is often feasible to provide support by telephone and/or video-call but face-to-face contact is more suitable for those who have never used a tablet before.
    • Few people use passive support, such as a telephone helpdesk. It is therefore recommended to pro-actively offer support to those who may need it (see above).
  • Mechanisms of impact:
    • Tablet-use may support social contact and engagement in meaningful activities, more than instrumental activities of daily living. It is recommended to set personal goals accordingly.
    • Limitations of specific tablet-apps (e.g. pop-up advertising, requirements for user-accounts with passwords) should be considered.
    • The quality of tablet-use, seems more important for social health than the quantity (frequency of duration) of tablet use. Set personal goals and evaluate accordingly.
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