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The use of technology for social interaction by people with dementia: A scoping review [1]

['Merryn Anderson', 'College Of Medicine', 'Health', 'University Of Exeter', 'Exeter', 'United Kingdom', 'Rachel Menon', 'Cornwall Partnership Nhs Foundation Trust', 'Bodmin', 'Katy Oak']

Date: 2022-08 

People with dementia (PwD) are at risk of experiencing loneliness, which is associated with physical and mental health difficulties [ 1 ]. Technology is a possible tool to increase social connection and reduce loneliness. This scoping review aims to examine the current evidence regarding the use of technology to reduce loneliness in PwD. A scoping review was carried out. Medline, PsychINFO, Embase, CINAHL, Cochrane database, NHS Evidence, Trials register, Open Grey, ACM Digital Library and IEEE Xplore were searched in April 2021. A sensitive search strategy was constructed using combinations of free text and thesaurus terms to retrieve articles about dementia, technology and social-interaction. Pre-defined inclusion and exclusion criteria were used. Paper quality was assessed using the Mixed Methods Appraisal Tool (MMAT) and results reported according to PRISMA guidelines [ 2 , 3 ]. 73 papers were identified publishing the results of 69 studies. Technological interventions included robots, tablets/computers and other forms of technology. Methodologies were varied and limited synthesis was possible. There is some evidence that technology is a beneficial intervention to reduce loneliness. Important considerations include personalisation and the context of the intervention. The current evidence is limited and variable; future research is warranted including studies with specific loneliness outcome measures, studies focusing on PwD living alone, and technology as part of intervention programmes.

More people are now living with dementia than ever before. People with dementia often experience loneliness. There has been increasing interest in using technology to help people with dementia connect with others and feel less lonely. Here we have searched for studies about people with dementia using technology for social interaction. We wanted to see what technologies are being used and if they are helpful or not. We found that there is a wide variety of types of technology being used to help social interaction for people with dementia. Types of technology included robots, tablet and desktop computers and a wide variety of other technologies. The studies we found used a diverse range of methods to see if the technology was helpful. Overall we found that technology could be a useful tool to help reduce loneliness in people with dementia. However there needs to be more research into this area. Future research could focus on helping people with dementia who live alone, and using technology as one part of broader intervention programmes.

Funding: LA is supported by the National Institute for Health Research Applied Research Collaboration South West Peninsula ( arc-swp.nihr.ac.uk ). MA is an Academic Clinical Fellow supported by the National Institute for Health Research ( nihr.ac.uk ). The views expressed in this publication are those of the authors and not necessarily those of the National Institute for Health Research or the Department of Health and Social Care. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Data Availability: All relevant results data is included in the manuscript. The search strategy is available on the Open Science Framework (DOI: 10.17605/OSF.IO/E7C2S ).

Copyright: © 2022 Anderson et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

The current body of evidence suggests that tablets, computers, and robot technologies are useful tools for PwD facilitating SI with people in the same location. However, this does not encapsulate other mediums of technology, nor does it provide information on the use of technology for distance communication. This scoping review uses a broad definition of technology and aims to look at the current evidence regarding the use of technology by PwD to facilitate SI.

Technology is used to connect with family, friends, and strangers all around the world. Although this has raised concerns regarding confidentiality and replacement of human care, it has the potential to be a tool to reduce loneliness in PwD. Studies have found that in the ‘older adult’ population increased internet usage is associated with reduced loneliness [ 10 , 11 ]. The systematic review by Brown & O’Connor into the use of mobile health applications by PwD found seven of nine studies had outcomes related to social health [ 12 ]. Mobile health applications stimulated conversation and facilitated intergenerational relationships. Focusing on the use of low-cost pet robots by PwD a scoping review found eight of the identified studies had outcomes related to communication/social interaction (SI) and that robots had an overall positive effect [ 13 ]. A systematic review including eighteen studies found that tablets, social robots, and computers have been used to support communication between PwD and their carers. They found that devises facilitated ‘breaking the ice’, increased interaction, facilitated understanding of the PwD and reduced pressure for the conversation partner [ 14 ].

A scoping review by Courtin & Knapp looked at the relationship between loneliness and health in old age [ 1 ]. Of 128 studies included only two did not find a negative impact on health; consequences included increased risk of depression, increased risk of physical health conditions and negative impact on cognition. Loneliness is also associated with reduced quality of life overall [ 9 ].

It is estimated that there are 885,000 people in the UK living with dementia; this is projected to increase to over 1.5 million people by 2040 [ 4 ]. Dementia has wide ranging consequences; van Wijngaarden, et al. investigated what it means to live with dementia; they found life could be isolating and some participants expressed feeling imprisoned at home [ 5 ]. This supports findings from the Alzheimer’s society 2013 report: a third of PwD reported losing friends since diagnosis, 39% reported loneliness, increasing to 62% if they lived alone [ 6 ]. The impact of covid-19 has further negatively affected loneliness and mental health in PwD [ 7 , 8 ].

Studies were grouped for comparison based on study methodology as defined by the MMAT [ 2 ]. Studies were sub-divided by technology type and outcome measure. A narrative approach was used to explore study results, identify themes, and provide comparison. Qualitative studies and Mixed Methods studies were read to identify commonalities in the emergent themes. These were then used to generate overarching themes related to the outcomes of this review.

Papers were assessed for quality using the Mixed Methods Appraisal Tool (MMAT), this tool allows studies using different methodologies to be compared. For each study type there are 5 specific criteria to allow quality assessment and comparison [ 2 ].

Titles and abstracts were screened for relevance and adherence to the inclusion criteria by one reviewer (MA), a random selection (10%) was screened by a second reviewer (RM) for comparison. Studies were included if they investigated the use of a technological device (e.g., tablet, robot etc.) by PwD and the study reported an outcome related to SI. Full texts were reviewed for exclusion, disagreements were resolved through consensus. Studies were excluded if they did not include primary data, if the population was not PwD, purpose of the technology was not SI, or if there were no outcomes related to SI. There were no exclusions related to study design. Although review articles without primary data were excluded from the results table, they were used to identify additional references.

This paper utilises the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR; S1 PRISMA Checklist ) guidance to provide the review structure [ 3 ]. A literature search was conducted using Medline, Cochrane database, NHS evidence, Trials registers, Open Grey, PsychINFO, Embase and CINAHL on 23rd April 2021. A sensitive search strategy was constructed using combinations of free text and thesaurus terms to retrieve articles about dementia, technology, and SI ( S1 Table ). An additional amended search using the equivalent search terms was performed on ACM Digital Library and IEEE Xplore. The search was conducted by a specialist librarian (KO) and was registered with the Open Science Framework (DOI: 10.17605/OSF.IO/E7C2S ). No limits were applied.

Key methodological problems in the identified studies were: unclear research question, brief/poor reporting of methodology, limited explanation of data analysis, small number of participants, participants were subset of a larger study, multiple outcome measures, and lack of accounting for confounders. The MMAT was used to assess papers for quality and risk of bias [ 2 ], details of MMAT score can be found in Table 1 and Fig 4 shows the frequency of each score. Most papers had a score of three or less indicating that the studies are limited by the quality of the methodology and risk of bias.

Some studies used forms of technology that do not fall into the previous groups. They ranged from basic interventions such as a phone with pictures [ 87 ] to virtual reality [ 81 ]. The main focus of these studies was reminiscence, although two of the studies used gaming technology to prompt conversation in group settings [ 85 , 86 ].

Eleven studies used reminiscence programmes [ 16 , 53 – 62 ]. Nine used technologies as a conversation prompt [ 23 , 63 – 70 ]. Three used programmes to prompt SI. Park et al. used ‘WeVideo’ in a workshop format [ 72 ]. Upton, et al. looked at a variety of tablet based interventions that had already been rolled out into care settings and investigated the impact on SI [ 71 ]. Smith presents two studies in her PhD thesis investigating the use of a variety of Apps by PwD in Day Care and home settings [ 25 ]. Two of the studies used technology for communication with other people in a different location to the PwD [ 73 , 74 ]. Burdea, et al. used BrightBrainer TM and had an outcome of SI as reported by carers [ 75 ]. Beentjes, et al. included SI as an outcome for participants using the FindMyApps programme [ 76 ].

The computer and tablet based interventions fell into different groups based on the purpose of the programme: reminiscence, conversation prompts, SI, communication networks and other. A description of the different types of computer and tablet based interventions can be found in Table 3 .

Telepresence robots. Two studies used Giraff to facilitate SI with people in a different location to the PwD [ 21 , 52 ].

Two studies used cat like robots and studied interaction with the robot and others [ 49 , 50 ]. Feng, et al. used a sheep robot and investigated interaction with the robot and others [ 51 ].

The two studies that used AIBO looked at interaction with AIBO and other people [ 47 , 48 ].

Pet robots. Nine studies used Paro; most of these studies looked at SI with the robot and other people prompted by the robot [ 38 – 43 , 46 ]. Two looked at interaction with the robot alone [ 44 , 45 ].

Three studies used different versions of the Telenoid robot, one compared Telenoid facilitated reminiscence with traditional reminiscence, studying SI with the robot and within the group [ 31 ]. The other two studies investigated interaction with the robot alone [ 32 , 33 ]. Cruz-Sandoval & Favela investigated ‘Eva’s’ ability to stimulate interaction using different communication strategies [ 34 ]. Pou-Prom, et al. compared the Milo R25 robot using autonomous speech to the same robot with a Wizard-of-Oz setup and human interaction [ 35 ]. Begum, et al. studied the use of an assistive robot for a tea-making exercise studying SI with the robot [ 36 ]. Lima, et al. studied the acceptability of the Hybrid Face Robot and reported results on interaction by the PwD with technology [ 37 ].

Three studies used social robots from the Nippon Electric Company (NEC), two looked at SI with the robot and other people [ 28 , 29 ] and one looked at interaction with the robot alone [ 30 ].

Social robots. Two studies used MARIO to prompt SI with the robot and other people [ 20 , 26 ]. Robinson, et al. compared Guide with Paro for impact on interaction with the robot and other people [ 27 ].

Studies have been grouped by robot type: social robots, pet robots and telepresence robots. A description of the different robots can be found in Table 2 .

Three different clusters of technology type were identified: Robots, Computer/tablet programmes, and other forms of technology. An overview of broad technology type and main purpose of technological intervention is given in Fig 3 .

Key study information including design and methodology is summarised in Table 1 . Studies were conducted in Asia, Europe, South America, North America, Australia and New Zealand. The interventions, study design and outcome measures are heterogeneous. Study setting was varied: 31 in residential care, 15 in participants’ homes, 11 in day care, 3 in labs, 2 in hospital, 2 in community groups, 1 in a workshop and 8 used a mixture of settings. Proportion of studies in each setting is shown visually in Fig 2 .

Of the 73 papers identified eight published results from four studies. Astell, et al. published two papers with results from the same participants using CIRCA [ 15 , 16 ]. Karlsson, et al. published two papers with results from the same participants using a digital photography activity diary [ 17 , 18 ]. D’Onofrio, et al. [ 19 ] and Casey, et al. [ 20 ] published results from a study using MARIO in residential care. To avoid over-representation of these studies the most recent papers have been included for analysis. Moyle, et al. published two papers with results from a study using Giraff in residential care [ 21 , 22 ]; the 2014 paper publishes more details of outcomes relevant to this review and is included in the analysis [ 21 ]. Three papers published results from more than one study Lancioni, et al. published results from two interventions [ 23 ], Huldgren, et al. published results from three interventions [ 24 ] and Smith published results from one intervention in two settings [ 25 ].

The search identified 9161 papers (duplicates removed) of those 73 papers satisfied the inclusion/exclusion criteria. The PRISMA diagram is shown in Fig 1 .

Results of included studies

Participants Studies were limited by small participant numbers, and some had no justification for this (e.g. power calculation). Many of the studies were pilot or feasibility studies with an aim of investigating acceptability, usability, and functionality of the technology before further full-scale studies were carried out.

Study type, outcome measures related to SI and results There was a wide variety of study type in the papers found. To aid comparison, the papers have been grouped according to the study type and subdivided by technology. There was insufficient homogeneity in outcome measure to combine analyses.

Quantitative descriptive studies Six of the studies were non-comparative studies using a descriptive methodology. The study by Kelly, et al. was a before-and-after time series study however the data obtained relating to SI did not include any comparison between intervention/exposure and as such is quantitative descriptive data [44]. An overview of the outcome measures used (related to SI) and the results are shown in Table 11. PPT PowerPoint slide

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TIFF original image Download: Table 11. Overview of papers using a Quantitative Descriptive Study methodology including outcome measures and results. https://doi.org/10.1371/journal.pdig.0000053.t011 Two studies found Paro improved SI [38,44]. Three studies looked at social robots, using observation methods to count behaviours during the intervention. One found that interaction with robots and others increased over time [28], one found no statistically significant change in verbal engagement with the robot over time, but questionnaire feedback response was positive [29] and the other study found no change over a shorter time period [37]. Finally, Howe, et al. investigated the impact of an online chat and support forum finding no benefit of the platform on SI for PwD [73].

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[1] Url: https://journals.plos.org/digitalhealth/article?id=10.1371/journal.pdig.0000053

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