Technology and Dementia: The Future is Now

Abstract

Background:
Technology has multiple potential applications to dementia from diagnosis and assessment to care delivery and supporting ageing in place.

Objectives:
To summarise key areas of technology development in dementia and identify future directions and implications.

Method:
Members of the US Alzheimer's Association Technology Professional Interest Area involved in delivering the annual pre-conference summarised existing knowledge on current and future technology developments in dementia.

Results:
The main domains of technology development are as follows: (i) diagnosis, assessment and monitoring, (ii) maintenance of functioning, (iii) leisure and activity, (iv) caregiving and management.

Conclusions:
The pace of technology development requires urgent policy, funding and practice change, away from a narrow medical approach, to a holistic model that facilitates future risk reduction and prevention strategies, enables earlier detection and supports implementation at scale for a meaningful and fulfilling life with dementia.

Full text

© 2019 The Author(s)
Published by S. Karger AG, Basel
Original Research Article
Dement Geriatr Cogn Disord
Technology and Dementia: The Future
is Now
Arlene J. Astell a–d Nicole Bouranis e Jesse Hoey f Allison Lindauer g
Alex Mihailidis a Chris Nugent h Julie M. Robillard i Technology and
Dementia Professional Interest Area ...
a Department of Occupational Sciences and Occupational Therapy, University of Toronto,
Toronto, ON, Canada; b Department of Psychiatry, University of Toronto, Toronto, ON,
Canada; c Toronto Rehabilitation Institute, Toronto, Toronto, ON, Canada; d School of
Psychology and Clinical Language Sciences, University of Reading, Reading, UK; e Layton
Aging and Alzheimer’s Disease Center, Oregon Health and Science University, Portland,
OR, USA; f David R. Cheriton School of Computer Science, University of Waterloo, Waterloo,
ON, Canada; g Oregon Roybal Center for Aging and Technology (ORCATECH), Oregon
Health and Science University, Portland, OR, USA; h School of Computing, Ulster University,
Northern Ireland, UK; i Faculty of Medicine, University of British Columbia, Vancou ver, BC,
Canada
Keywords
Technology · Dementia · Aging · Big data · Policy
Abstract
Background: Technology has multiple potential applications to dementia from diagnosis and
assessment to care delivery and supporting ageing in place. Objectives: To summarise key
areas of technology development in dementia and identify future directions and implications.
Method: Members of the US Alzheimer’s Association Technology Professional Interest Area
involved in delivering the annual pre-conference summarised existing knowledge on current
and future technology developments in dementia. Results: The main domains of technology
development are as follows: (i) diagnosis, assessment and monitoring, (ii) maintenance of
functioning, (iii) leisure and activity, (iv) caregiving and management. Conclusions: The pace
of technology development requires urgent policy, funding and practice change, away from
a narrow medical approach, to a holistic model that facilitates future risk reduction and pre-
vention strategies, enables earlier detection and supports implementation at scale for a
meaningful and fulfilling life with dementia. © 2019 The Author s
Published by S. Karger AG, Basel
Published online: ■■■
Arlene J. Astell
School of Psychology & Clinical Lan guage Sciences
University of Reading
Reading (UK)
E-Mail a.astell @ reading.ac.uk
www.karger.com/dem
DOI: 10.1159/000497800
This article is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 Interna-
tional License (CC BY-NC-ND) (http://www.karger.com/Services/OpenAccessLicense). Usage and distributi-
on for commercial purposes as well as any distribution of modified material requires written permission.

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Introduction
Smartphones and tablets have opened up personal computing to many new audiences
and have created increasing interest in how such devices can be used across all aspects of our
lives and society. Similarly, wearables, smart home systems (e.g., Amazon Alexa, Google Home
Hub), robots, virtual reality (VR), artificial intelligence (AI) and autonomous (i.e., driverless)
vehicles are triggering questions about how we can deliver better services, create efficiencies
and improve wellbeing, including for those living with dementia. Although research applying
technology to dementia has only recently gained mainstream attention, work has been taking
place alongside biomedical and health informatics research for many decades. This article
produced by members of the Alzheimer’s Association Technology Professional Interest Area
Executive Committee introduces the main areas of technological focus in dementia and impli-
cations for the future. Our views of where technology is going are informed by our direct
experience of working with people with dementia with past and present technology.
Diagnosis, Assessment and Monitoring
The longest-standing use of technology in dementia is in assessment. Two touchscreen-
based cognitive assessment batteries – Cambridge Neuropsychological Test Automated Battery
[1] and Examen Cognitif par Ordinateur [2] were developed in Europe in the 1980s and 1990s.
More recently multiple web-based and app-based cognitive assessments have emerged [3]
including digitized versions of pen and paper tasks, such as clock drawing [4] including a digital
clock-drawing pen [5]. In addition, the manner in which people use technology and changes in
their patterns of use has been identified as an early indicator of emerging cognitive impairment
[6, 7]. Technological assessment of functional activities extends to tasks such as making tea and
toast [8], coffee-making [9], as well as instrumental activities of daily living [10].
In terms of dementia diagnosis, there have been increasing applications of various
machine learning approaches, most commonly with imaging data for diagnosis and disease
progression [11]. This includes amyloid PET imaging [12], MR imaging [13] and combined
PET and MR imaging [14]. Non-imaging studies have generally focused on demographic data
and cognitive measures [15], although more recent studies have utilized novel linguistic
analysis [16] and unobtrusive monitoring of gait patterns over time [17].
The use of big data in dementia research has also recently emerged. The Big Data for
Advancing Dementia Research project initiated by the G8 Health Ministers to explore the use
of big data in dementia research, concluded that big data could potentially accelerate dementia
research and technology development by helping recognize factors that contribute to
dementia, identifying individuals with dementia earlier, promoting better support for
dementia care and creating new analysis methods (e.g., data mining) that could result in new
research opportunities [18]. Examples of data mining in dementia include working with large,
pre-existing data registries and health records to investigate co-morbidities with dementia
and other diseases [19], combining different data sources including fluid biomarkers and MRI
[20] and Alzheimer’s disease drug repositioning [21].
Maintenance of Function
Ongoing monitoring using technology has the potential to both detect progression of
dementia over time [22] and to provide prompts and support to individuals to maintain their
activities [23]. In 2007, Carrillo et al. [24] identified a gap in knowledge around the delivery of
digital prompts, specifically, how best to prompt, what to prompt or when to prompt. A body
of work has emerged addressing prompting with Cognitive Assistive Technologies [23]. For
example, the Cognitive Orthosis for Assisting aCtivities at Home (COACH) [25] system was
created to prompt people with dementia to take them through the hand washing procedures.

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COACH combines computer vision for tracking the current stage of activity with AI techniques
to decide what prompt is required to deliver verbal and visual prompts when people wash
their hands. This highly influential work has informed many subsequent systems and led to
the notion of “zero effort technologies” [26], which require little or no effort from the people
who use them. Zero effort technologies perform the collection, analysis and application of data
about the user and/or his/her context using advanced computing techniques, such as computer
vision, sensor fusion, decision-making and planning, machine learning and the Internet of
things (IoT). Recent work focusses on integrating models of identity and emotion into
prompting systems to make them easier to integrate seamlessly into people’s lives [27].
Other examples of Cognitive Assistive Technologies combine sensors with AI and machine
learning embedded in living environments to create “smart homes,” which can detect and analyse
health [28] and other events. These first emerged in the late 1990s and have evolved to address
the needs of people with dementia, informal (family) caregivers, formal (clinical) caregivers and
social (i.e., nonmedical) caregivers [29]. The Gloucester Smart Home [30], an early prototype for
individuals with dementia coupled bath and cooker monitors with an automated nightlight, item
locator and digital message board to provide visual and verbal prompts such as “time for your
medication.” More recent examples leverage advances in sensor technology, AI and machine
learning to support cooking [31], dressing [32] and reduce demands for caregiving [29]. In
addition, smart home technologies are becoming available for individuals to install themselves
[33], creating huge potential for conducting scalable clinical trials at home [34, 35].
The availability of cloud computing allows dementia researchers and practitioners to
utilize powerful computing resources without the need for specialized computing back-
grounds. The result is that research is less expensive and faster to produce results. For these
reasons, many novel research projects investigating cloud-based solutions to dementia care,
treatment and diagnosis have recently emerged. Examples include supporting aging-in-place
and activity monitoring [36], providing location tracking [37], and supporting analysis and
interpretation of neuroimaging data [38].
Leisure and Activities
Supporting social and leisure activities is another area of technological focus in dementia.
Musical memory is relatively spared in dementia [39] and multiple technology projects have
leveraged this including the one-button radio [40], simple music-making interface [41] and
collaborative music making [42]. Enjoying art has also led to programmes such as House of
Memories1, an interactive art installation for care homes [43], making art as an enjoyable
pastime [44] and a more focused art therapy programme [45, 46].
Participating in activities outside the home remains important for persons with dementia.
Navigation and route-finding can, however, become challenging and numerous technological
solutions have been developed to support these activities [47] and enable “safe walking” [48,
49]. Smart phones with GPS and map functions, offer functionality to support wayfinding
[50], including identifying indicators of disorientation to support navigation prompting [51].
For those who have difficulty getting out or participating in regular exercise, virtual cycling
[52] and navigating virtual environments [53] can offer enjoyable alternatives.
Socialising is another key activity that people want to do that is important for their well-
being and maintenance of cognitive function. CIRCA (Computer Interactive Reminiscence and
Conversation Aid) [54], a multimedia touchscreen application promotes social interaction
which benefits caregiving relationships [55] and improves cognition and quality of life of
people with dementia [56]. Socialising through storytelling has been demonstrated with
1http://www.liverpoolmuseums.org.uk/learning/documents/house-of-memories-evaluation-report.pdf

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“StoryTable” (de Waag Society) [57], and remote socialising with family and friends using
videoconferencing technologies (e.g., Skype, FaceTime) increases positive emotions [58] and
reduces agitation [59].
Games and other digital pastimes have also been widely explored [60], with both bespoke,
for example, Eldergames [61], Living in the Moment [62] and consumer products (e.g., gaming
consoles, tablets) utilised for people with dementia. The potential of digital activities for brain
training either to reduce dementia risk has attracted much popular attention. However, while
there is consistent evidence of improvement in the aspect of cognitive function that is trained
(e.g., processing speed), to date there is no substantial evidence for dementia prevention or
delaying decline [63]. However, the FINGER trial has demonstrated that computerised
cognitive training can be beneficial in reducing dementia risk as one part of a multidimen-
sional lifestyle intervention [64].
From a leisure and pleasure perspective, mainstream mobile applications can be acces-
sible for people with dementia [65] and motion-based gaming systems (e.g., Nintendo Wii and
Xbox Kinect) can provide enjoyable group activities [66]. VR for dementia has also attracted
recent attention [67], not just as a leisure activity, but also an assessment tool [68] and for
delivering cognitive training [69]. The potential of VR and augmented reality, so-called mixed
reality technologies, to support people with dementia in everyday activities, is currently
being explored [70].
Caregiving and Management
Caregiving is another key target of dementia technology. While the potential of robots to
complement or even replace human caregivers has attracted much recent attention, research
has been underway for many years (e.g., [71, 72]). Recent projects have coupled social
presence robots with remote monitoring using sensors and videoconferencing (via tablets)
to deliver “virtual visits” [73]. Other robotics-based applications that have been explored for
persons with dementia include supporting food preparation [25], eating [74] and partici-
pation in recreational activities [75] in care homes.
Supporting informal caregiving (e.g., [76–78]), and delivering care remotely (e.g., [79,
80]) are major challenges that can be addressed at least in part through dementia technology.
Across the world, the majority of people with dementia live at home cared for by family
members [81]. This caregiving activity represents approximately USD 1 trillion per annum
[81] and takes a greater toll on caregiver mental and physical health than caring for other
conditions [82]. Unsurprisingly, a large part of caregiver Internet use relates to the demands
of caregiving and managing their own health [83]. Despite a large amount of Internet-based
interventions being developed and launched for caregivers, there is lack of systematic, large-
scale studies examining their efficacy [84]. Further, research that unobtrusively assesses
caregiver burden is in the early, but promising, stages (Thomas et al., this issue [95]).
In terms of care management, the IoT facilitates the connection between items in the
real world and computer systems, providing data more easily, efficiently and economi-
cally. IoT in dementia research [85] includes early detection through in-home sensors
[86], wearable monitoring [87] and integration of devices for healthcare management
[88].
Future Scoping
Future directions in dementia therapy are predicted to include nanotechnology either to
“repair” brain damage [89] or for drug delivery [90]. While there are still many obstacles to
resolve, work on nanoparticle and implantable therapeutics to locally deliver chemotherapy
for treating brain tumours [91], opens up huge possibilities for delivering new types of inter-
ventions for people either with dementia or ideally, before dementia develops. New means of

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data collection, ubiquitous monitoring technologies, population surveillance, data mining
and modelling may all play a key role in accelerating the development pipeline of preventive
therapeutics for dementia.
Discussion/Conclusion
Alongside the rapid pace of innovation, policy and practice move much more slowly.
To maximise the current and future benefits of technology for dementia, urgent change is
needed in services and policies. This includes radically rethinking what people with
dementia need in order to live with this condition now and in the future, and how this is
going to be provided. Continuing to view dementia as purely a clinical matter addressed
with medication and, to a limited extent direct healthcare, is no longer an option as it fails
to address the majority of concerns, needs and wishes of people with dementia in their
everyday lives. Existing technology can collect prospective data, model risk and provide
supportive monitoring. Mainstream devices have the potential to empower people with
dementia in many activities and pursuits; however, adoption rates remain low, in part due
to lack of awareness or challenges in accessibility (including financial) and support.
Harnessing the power of everyday (i.e., off the shelf) technologies raises major questions
about funding and finance, not only in insurance-based healthcare systems, but also in
publicly funded systems, as many consumer devices (e.g., smart phones) are not classified
as medical devices and therefore cannot be “prescribed” by clinicians. While specific
software, such as cognitive assessments could be so classified, the use of standard func-
tions of a smart device for maintaining social interaction (through calls, texts, videocon-
ferencing) or cognitive stimulation (through playing games) may not be classified as a
medical intervention.
Expanding our view of dementia beyond healthcare can be understood as akin to physical
and intellectual disabilities that influence all aspects of a person’s life. Taking this view as a
starting point, policies are needed that provide people with dementia and their caregivers
access to devices, services and other tools to live as well as possible with their condition. This
includes creating direct funding streams for technology, providing maintenance and updating
support services, delivering new types of digitally enabled services with tech-savvy staff for
people with dementia, harnessing big data to predict patterns of need and proactively identify
people at risk, and supporting rapid development, testing and deployment of next-generation
technological interventions. Supporting the technology-enabled provision of preventive and
care interventions also requires a number of ethical issues to be addressed, including privacy,
data ownership, sharing and usage, risk, rights, responsibilities and relationships (including
data sharing) between private corporations and statutory bodies [92, 93].
With the current research and commercial technology, we have the tools to tackle
many of the perceived problems currently associated with dementia. First, technology can
be used to target lifestyle factors that are associated with the risk of developing dementia
[94]. For those who are diagnosed with dementia, providing them with technology (e.g.,
apps, wearables, smart home systems), from the point of diagnosis we can monitor the
progression of their condition, identify problems emerging, deliver interventions and
avoid unnecessary emergency admissions and hospital stays. Such technology can also
provide prompts and reminders both within and outside the home to support mainte-
nance of cognitive, social and physical functioning as well as continued completion of daily
activities. Technology can also contribute both directly and indirectly to caregiving,
reducing demands on families and formal services, which are major contributors to the
economic costs of dementia.

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Statement of Ethics
The authors have no ethical conflicts to disclose.
Disclosure Statement
The authors declare that they have no conflicts of interest to disclose.
Author Contributions
A.J.A. drafted the article, N.B., J.H., A.L., C.N., A.M., and J.M.R. all contributed to the development of the
concepts and revised the manuscript.
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