Brookman et al.

BMC Geriatrics (2023) 23:867 BMC Geriatrics

https://doi.org/10.1186/s12877-023-04530-9

RESEARCH Open Access

Technology for dementia care: what would

good technology look like and do, from carers’
perspectives?
Ruth Brookman1*†, Simon Parker2, Leonard Hoon2, Asuka Ono3, Atsushi Fukayama3, Hisashi Matsukawa3 and
Celia B. Harris1†

Abstract
Background The development of technology in dementia care has largely been without consultation with carers,
and has primarily focused on safety, monitoring devices, and supporting activities of daily living. Further, while involv-
ing end-users in the design of technology has been recommended, this is yet to become common practice.
Method We conducted a mixed methods study with the aim of investigating carers’ values and priorities for technol-
ogy development, including prior experiences, barriers to use, and what they would like technology to do. Impor-
tantly, we asked carers for their design ideas and bespoke technology solutions for future development.
Results Carers of people living with dementia (N = 127), including both unpaid (n = 102) and paid carers (n = 25) resid-
ing in Australia, completed an online survey. In addition, a subsample of carers (n = 23) participated in semi-structured
interviews. Findings demonstrate that carers want technology to be person-centred, customisable, and to increase
opportunities for meaningful social connection. Findings also demonstrate the ability of carers to generate creative
design solutions for dementia care.
Conclusions These findings and implications will be discussed in relation to the importance of co-design with car-
ers and engineers during the design phase of assistive technology. Also, the importance of technology to enhance,
not replace, human-to-human social interactions is highlighted.
Keywords Dementia care, Assistive technology, Unmet needs, Social engagement, Carers, Technology design ideas

Introduction impacted by the disease, including unpaid carers such as

People living with dementia (PLWD) are a growing pop- family and friends; as well as paid carers like health and
ulation, with dementia affecting over 55 million peo- aged care staff [2]. The common feature of different types
ple globally [1]. An even larger population of carers are of dementia is that they lead to the progressive loss of
ability to independently perform everyday tasks such as
dressing, grooming, washing, preparing a meal or mak-
†
Ruth Brookman and Celia B. Harris contributed equally to this work. ing a phone call, as well as social disconnection and lone-
*Correspondence: liness for both PLWD and their family carers [3]. Given
Ruth Brookman the range of cognitive impacts associated with dementia,
ruth.brookman@westernsydney.edu.au
1
MARCS Institute for Brain, Behaviour and Development, Western Sydney
there is a great deal of focus on the potential for technol-
University, Penrith, NSW, Australia ogy to support the independence and care of PLWD, and
2
3
Deakin University, Geelong, VIC, Australia the quality of life of carers. Assistive technology has been
Nippon Telegraph and Telephone (NTT), Tokyo, Japan
described as technology devices that enable someone to

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Brookman et al. BMC Geriatrics (2023) 23:867 Page 2 of 19

complete a task that they would otherwise not be able reduction in late-night phone calls made by participants
to do or to complete it in an easier and safer manner [4]. to carers when distressed or confused [2, 18].
In the context of dementia care, assistive technology has The research evidence concerning the benefits of assis-
demonstrated potential to address some of the long-term tive technology in dementia care is inconsistent [2]. Their
care needs of PLWD and their carers [3] and can engage use with high-stakes activities such as taking medica-
with a consumer-driven model that promotes ‘active age- tion, for example, can be problematic when the device
ing’ and/or improvements to participation and quality of is not 100% accurate or effective in ensuring an activity
life for PLWD [5]. For carers, benefits of assistive tech- is completed [19]. Complex interfaces can also exacer-
nology can include a reduction in the demands of caring, bate rather than reduce PWLD’s frustration and distress
more opportunities for enjoyment and meaningful activi- levels [20, 21] and there are ethical concerns around the
ties, and reduced stress [6]. potential privacy invasion associated with video moni-
toring and tracking of PLWD [22]. There are also barri-
ers and limitations to the use of social robots in dementia
The role of assistive technology in dementia care care, such as their high cost, concerns about their child-
In recent decades, there has been a growth in research ish appearance, individual resistance, the inability of
examining the role that digital technologies can play as a the PLWD to engage with a robot, and ethical concerns
tool to support carers by compensating for the functional that robots will be used to displace human interaction
cognitive and physical decline on the PLWD’s capaci- [23, 24]. Further, relatively few devices have been devel-
ties to engage in everyday life [6–8]. Emerging technol- oped to support existing and new relationships between
ogy may also play a key role in addressing broader social people, such as enabling more frequent social contact
issues arising from population ageing, including a short- between PLWD and their friends and family, which pre-
age of care staff and high care costs associated with older sents as an under-developed area of technology devel-
adults living within formal residential care settings [2]. opment. This highlights the need for further research to
According to Blackman et al. [9], assistive technology establish best practices for the routine adoption and use
can be categorised according to their ‘generation’, from of assistive technology.
first- and second-generation devices involving low-tech
devices with some improvements such as automatic Challenges to the development of assistive technology
detection of hazards, to third generation devices such as in dementia care
complex smart-home systems, to the fourth generation The development and evaluation of the efficacy of assis-
of highly human-like social and service robots. That is, tive technology in dementia care can be challenging, and
a wide variety of assistive technologies have been devel- many devices have been developed for research purposes
oped and researched for people with dementia, focused only, not for largescale development and clinical use.
on a wide range of different functions and methods of General challenges include the usability and acceptability
operating. of technology for older populations, the different effects
There is some research evidence to support the value of technology on different people, and the ethical con-
of assistive technology in addressing unmet needs for siderations associated with use with a vulnerable people
PLWD and their carers. For example, to mitigate the risks group [22]. Specific barriers include the complexity of
of isolation and the pressure on carers to meet the social the device, a lack of familiarity with the technology, the
needs of PLWD, robots have been employed in care set- PLWD’s difficulty remembering to use the device and/
tings to provide social support, companionship, remi- or recall where they put it, and the inability to “trouble-
niscence therapy, and stimulation [4, 10, 11]. Research shoot” when something goes wrong [6]. These chal-
findings suggest benefits such as mood enhancement, lenges are further exacerbated by the progressive nature
social engagement, and a reduction in agitation, anxi- of dementia. Despite recommendations to the contrary,
ety, and loneliness [12, 13]. Also, to address carers’ safety assistive technology has not historically been adaptable
concerns [6, 8], and the risks associated with PLWD to the ever-changing needs of PLWD and their carers
“wandering away”, wearable monitoring devices and [25]. Similarly, the use of technological devices designed
movement sensors have been developed [4]. In addition, for the general population (e.g., smart phones and Google
assistive technology has been trialled to support the com- Home), has been constrained by a mismatch between the
pletion of ‘activities of daily living’ (ADL) such as hand complexity of the devices and the needs of PLWD and
and body washing, toilet assistance, dressing, food prepa- carers. Perhaps because of these challenges, technology
ration, and cleaning (e.g., [14–17]). Familiar interfaces solutions have frequently emerged from a “one-size-fits
such as computer screens have been used to help orien- all” approach that is not consistent with person-centred
tate PLWD to the time of day, resulting in an observable care. For instance, voice-activated technological home

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Brookman et al. BMC Geriatrics (2023) 23:867 Page 3 of 19

systems require initiation on the part of the user, which practice in dementia care. Second, we aimed to explore
may be a lost skill for those in the middle and later stages carers’ experiences with assistive technology and record
of dementia. their design ideas for future technology to solutions to
improve dementia care in both home and residential
Carer perspectives in the design process of assistive settings. These aims were addressed through conduct-
technology ing an online survey with paid and unpaid carers, and
Carers have reported limited adoption of technology due in-depth interviews with a subset of carers. In both data
to the lack of affordability, poor installation and fit of the collection procedures, we adopted a person-centred
device into the caring environment, limited informa- approach, by including open-ended questions about what
tion, training, and support to use of the device [7]. Car- priorities and opportunities carers perceived for technol-
ers have also reported an increase to their sense of ‘carer ogy development.
burden’, whereby efforts to implement the assistive tech- Specific research questions are detailed below:
nology added to their caregiving load [7]. Identifying the
unmet needs and the priorities of carers before mapping 1. Needs: What do carers identify as the most important
technology solutions onto those already impacted by the dementia-related needs for PLWD and themselves?
stressors of their caregiving role, will facilitate the devel- 2. Experiences: What are carers’ day-to-day experiences
opment of more useful assistive technology [7]. However, – barriers and benefits – of assistive technology in
a significant challenge facing the developers of assistive dementia-care settings?
technology – engineers with expert technology knowl- 3. Design solutions: What would good technology look
edge but limited dementia experience – can be in iden- like and do from carers’ perspectives: What are car-
tifying the needs of carers and adapting to the variability ers’ design ideas for novel dementia-care technology
of these needs over time. When carer-perspectives have solutions in home and residential care settings?
been sought, they detail a desire for technology that it is
easy to use, reliable, offers practical support, integrates It is anticipated that findings will guide the develop-
with other support such as health systems, and is cus- ment of technology solutions that enable those with
tomisable. Despite this knowledge, prevalence studies dementia to live independently for longer, receive a
indicate that the uptake of technology remains low, and higher quality of life, and meet needs such as autonomy
purchased devices are frequently abandoned and remain and privacy, while simultaneously reducing carer burden
unused [6]. This suggests a need for more in-depth con- [2].
sultation with carers to identify the most effective ways
to overcome barriers to the adoption and ongoing use of Methods
assistive technology in dementia care [6], and also to har- Research context and approach
vest technology design ideas from those involved in the The study was conducted in Australia with paid and
hands-on-care of PLWD. unpaid carers. Australia is a large continent with a small
To the authors’ knowledge, there are no studies that population, 80% of which is located primarily in five
have examined the carers’ lived experience and its rel- major cities. Similar to other countries, the incidence
evance for the design of person-centred technology of dementia in Australia is increasing [26], and there is
solutions in dementia care. This is despite survey data a demand for unpaid carers that corresponds to a short-
indicating that caregivers want to be involved in the age of paid carers [27]. Approximately one third (36%) of
developmental process of new technology [6]. Identifying Australian people with dementia are living in the com-
carers’ experiences with assistive technology, the ways in munity, and just over a half (55%) are receiving support
which it has been useful and not useful in everyday care, from paid and unpaid carers [28]. There are approxi-
as well as their vision for how technology would address mately 134,900 to 337,200 unpaid carers, almost all of
this gap. This person-centred consultation with end-users whom are providing continuous care (60 or more hours
would also inform the future design and development of per week) [28]. Carer services are not always accessible,
assistive technology from the perspective of carers. and there are policy efforts to increase the support avail-
able to carers of PLWD [27].
The present study The qualitative component of this research was con-
In two iterative studies, our overall objective was to ducted under a realism paradigm [29] which occupies the
bridge the gap between unmet needs, and carer experi- middle ground between constructivism (an individual’s
ence and perspectives in assistive technology design experience of reality) and positivism (50), and values the
ideas. First, we aimed to identify carers’ perceived needs use of multiple data collection procedures and analytical
to focus assistive technology interventions and best approaches to compare perceptions of reality. As such,

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Brookman et al. BMC Geriatrics (2023) 23:867 Page 4 of 19

the present study employed a concurrent nested and In Sect. 2 (‘Unmet Needs’), participants were asked the
sequential explanatory study design to incorporate our following open-ended questions; "In your opinion, what
mixed methods approach to data collection and analysis are the three issues or difficulties that impact the most
[30]. The mixed methods approach occurs across both on the lives of PLWD?” and “In your opinion, what are
iterations of the study from data collection to analysis. the three issues or difficulties that impact the most on the
The first round of data collection in the concurrent lives of carers of PLWD?”. Participants were also asked to
nested design consisted of an online survey in which respond to closed-ended questions using a 5-point Likert
quantitative and qualitative data were collected (see scale (1 = ‘little or no assistance’; 5 = ‘a great deal of assis-
Fig. 1). The predominant data collection method was tance’) to rate how much assistance was/is required for
quantitative in nature. However, open-ended questions the PLWD in their care to complete activities across the
were nested within the survey, which enabled the inte- following life domains: 1. leisure, 2. financial, 3. mobil-
gration of both qualitative and quantitative data in our ity and transport, 4. socialisation, 5. basics of home,
analysis. The survey results informed a subsequent phase food and clothing, and 6. physical health. The items for
of data collection, which involved more detailed inter- assessing needs were adopted from the Disability Assess-
views with a subset of survey participants. The subset of ment for Dementia Scale (DAD) [31]. For each domain,
interviewed participants self-selected in response to an an open-ended question was also asked, “What strategies
invitation at the end of the survey. This follow-up phase have you used to support yourself or a PLWD with these
adopted a sequential exploratory design and involved kind of activities?”.
qualitative data obtained through semi-structured inter- In Sect. 3 (‘Experiences with technology’), partici-
views. The aim of these interviews was to enable more in- pants were asked to use a Likert rating scale (1 = ‘never
depth exploration and interpretation of the findings from used and not interested’, 2 = ‘never used and interested’,
the surveys. 3 = ‘used a little but have not continued to use it’, and
4 = ‘currently use this support’) to rate how frequently
Materials they used different forms of support (e.g., medications,
Survey home modifications, and assistive technology). Open-
The online carer survey consisted of closed- and open- ended questions were also employed to explore partici-
ended questions designed by researchers to fit into three pants’ experiences regarding the benefits and barriers to
main sections; 1. Demographic and Background infor- using technology in dementia care. Example questions
mation, 2. Unmet Needs, and 3. Experiences with Tech- include: “What might be helpful about using technol-
nology. The survey was designed collaboratively by the ogy in the context of living with dementia?", and “What
research team with the goal of understanding the priori- might be hard about using technology in the context of
ties of carers and their experiences of caring, as well as living with dementia?”. In addition, respondents were
their experiences and opinions about the role of technol- invited to provide their email address and/or telephone
ogy in supporting care. number if they were interested in participating in an in-
In Sect. 1 (“Background”), participants provided demo- depth interview about their responses.
graphic information (age, gender), details about their
experience with dementia, their role in dementia care Carer interview
(e.g., spouse, nurse, etc.) and how frequently they inter- The semi-structured interview employed a set of core
acted with PLWD. interview questions designed to explore the carers’

Fig. 1 Diagram of the concurrent nested and sequential exploratory study design

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Brookman et al. BMC Geriatrics (2023) 23:867 Page 5 of 19

experiences with caring for PLWD, their unmet needs, each interview was approximately 1 h (mean: 66 min;
experiences with technology (barriers and benefits), range: 44–88 min). The content of the interviews was
and design ideas for future technology. The questions audio and video recorded, and data files were saved for
were also designed to explore the strategies that carers later transcription and analysis by researchers.
had found successful in addressing barriers experienced
by the PLWD. Example questions included: “Have you Data analysis
tried any strategies or tools to support your care?” and Survey data and closed-ended questions were statisti-
“Imagine you can invent a new technology that will sup- cally analysed using SPSS 22.0. Participant responses
port dementia care—what would it do?” (See Additional to the open-ended questions were tabled in an Excel
file 1). spread sheet, scanned for difference and similarity, read
for each participant, and then inductively coded by the
Procedure first and last authors, both female, using content analysis
The Qualtrics survey platform was used to manage data and a thematic analysis approach which is a method for
collection of the online carer survey. The survey was identifying, analysing, and interpreting patterns of mean-
completed anonymously and in English. Participants ing (or ‘themes’) within and across participant responses
were invited to access an online survey via an online link [32].
or QR code and to complete the survey at a time that Participant interview audio files were transformed into
was convenient to them from their home. Survey com- a written transcripts using automatic transcription soft-
pletion took approximately 30 min. An opening screen ware, Otter.ai. These initial transcripts were then manu-
provided information about the study, and participants ally checked by researchers for accuracy against the
were informed that by continuing they were indicating audio recording. Written transcripts of the interviews
their consent to participate in the study. For the analy- were carefully analysed by the first and last authors using
sis, we only took into consideration responses from sur- thematic analysis [32]. Both authors (females) had post-
veys where participants had completed more than 70% graduate training and experience in qualitative research
resulting in a total of 127 responses. In return for their and analysis. The first author was employed as an associ-
participation, participants were invited to leave an email ate research fellow and registered psychologist and had
address and be entered into a draw to win one of ten previous lived experience as a secondary family carer of
$100 AUD gift vouchers, which were drawn and issued a person with dementia. The lived experience motivated
at random. her research interests and may have created bias through
The follow-up semi-structured interviews with car- identification with interviewees. However, this was miti-
ers were scheduled in September through to November gated by her clinical training and experience. The last
2020. Interviews were conducted remotely via Zoom to author was employed as a senior research fellow in cogni-
accommodate social distancing restrictions associated tive neuroscience. Transcripts were compared with each
with the COVID-19 global pandemic, whereby univer- other as themes were identified. Participants did not pro-
sity policies periodically restricted researchers from con- vide feedback on the data. No additional software plat-
ducting conduct face-to-face interviews with vulnerable forms were used to manage the data. Themes were not
population groups such as participants over the age of identified in advance but were derived from the data.
65 years, depending on the prevalence of the virus and
government-implemented lockdowns. One interview Results
was conducted face-to-face in the participants’ home, Participants
after the COVID-19 restrictions had eased. Interviews Participants (N = 127) were recruited via online net-
were conducted by a female interviewer, the first author works of Australian carers and across social media,
(PhD/M.Clin.Psy) an associated research fellow and reg- including groups for Australian carers, professional
istered psychologist, with experience conducting inter- networks of nurses and aged care workers, and a spon-
view with vulnerable populations. The interviewer did sored Facebook advertisement. The majority of partici-
not have a prior relationship with participants, who were pants identified themselves as unpaid, familial carers
aware of the interviewers’ professional backgrounds and (n = 102). Of these, 18 were currently in a full-time car-
research interests. The interviewer had previous lived ing role, 50 were friends or family of PLWD, 13 were
experience as a secondary carer of a family member with previously caring but no longer, and 21 were previously
dementia, which motivated her research interests. All friends or family of people living with dementia. Unpaid
core interview questions were open-ended and phrased carers were most frequently the adult child (68%) of a
conversationally, to allow maximum flexibility in accom- person with dementia (i.e., caring for a parent or parent-
modating the needs of participants. The mean length of in-law), but relationships also included spouses (14%),

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Brookman et al. BMC Geriatrics (2023) 23:867 Page 6 of 19

grandparent/grandchild (3%), aunt/niece (4%), siblings to describe the three issues or difficulties that impacted
(4%), and friends (7%). Unpaid carers (90% female, 10% PLWD and themselves as carers. Participants had space
male) were aged on average 60 years and ranged in age to provide up to three separate responses. We coded all
from 29 to 86 years. The remaining participants were responses to determine most common themes. Responses
paid, formal carers (n = 25). Of these, 19 were currently could be broadly clustered under 9 emergent themes or
caring and six were previously caring. Formal carers domains. The distribution of responses was virtually iden-
had a diverse range of roles, and included nurses, nurs- tical for unpaid and paid carers, and chi-square analysis
ing home managers, support workers, pastoral carers, indicated no differences in the distribution of responses
physiotherapists, and neuropsychologists. Formal car- between carer types, X(8) = 7.04, p = 0.533 (see Fig. 2).
ers (96% female, 4% male) were aged on average 54 years The most common needs described by carers were
and ranged in age from 27 to 74 years. Formal carers associated with completing ADL and/or maintaining
supported individuals with dementia at all levels of dis- independence. This included general statements (e.g.,
ease progression, ranging from mild to severe. “independence”; “short term memory loss”; “forgetful-
Detailed interviews were conducted with a subset ness”; “difficulty following instructions”) and references
of 23 carers (unpaid n = 17; paid n = 6) who had com- to specific activities (e.g., “hygiene and feeding self ”, “dif-
pleted the survey. The invitation to participate in the ficulty working out day and time”; “eating well”; “medica-
follow-up interview was placed within the body of tions”; “safety at home”; “being up and down all night”).
the online survey. Interested survey respondents were The second most common domain for needs of PLWD
invited to provide their contact details at the end of related to the need for social engagement and maintain-
the survey if they wished to schedule a follow up inter- ing connections. This included difficulties maintaining
view. All participants who indicated interest and who relationships (e.g. “inability to recognise loved ones”;
responded to our invitation to schedule an interview “not engaging with the family”; “friends losing contact”;
time with us were interviewed. “need for meaningful connections with others”; “being
included”), difficulties with social situations (e.g. “inter-
Most important needs for people living with dementia acting with people”; “loss of social confidence”), chal-
Survey responses lenges with communication (e.g. “stopped using hearing
To understand the domains where PLWD might need sup- aids”; “unable to express feelings”; “difficulty hearing
port from technological solutions, the survey asked carers or following conversation”; “not making sense”), and

Fig. 2 The most important needs for people living with dementia

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Brookman et al. BMC Geriatrics (2023) 23:867 Page 7 of 19

feelings of isolation and loneliness (e.g. “feeling discon- their sense of identity, which can be reinforced through
nected from others”; “feeling alone”). supporting relationships with others and social engage-
The other domains in our analysis were mentioned less ment. This is especially important as loneliness and iso-
frequently, and included a need for meaningful activi- lation can be exacerbated by the loss of communication
ties (e.g., “boredom”; “not having a sense of purpose in and memory skills that accompany dementia. As one
the day”), difficulties with managing finances and deci- paid carer noted, “They’re not just somebody living with
sion making (e.g., “money management”; “vulnerability dementia, but somebody that lived a really great life …
to scams”; “banking and bill paying”), and difficulties with and we need to keep that alive”. The loss of ‘memory of
mobility and transport (e.g., “can’t go out”; “forgetting a relationship’ was reportedly exacerbated by geographi-
where he is going”; “sitting all the time”). We also coded cal separation and the stay-in-place strategies associated
several responses as mentioning specific psychologi- with the COVID 19-pandemic. Also, most family carers
cal symptoms of dementia (e.g., “anxiety”; “compulsive reported that the PLWD tended to lose their memory of
behaviour”; “confusion”; “apathy”). Several comments ref- key family members who resided interstate, or overseas,
erenced social issues such as a need for better social ser- and who were unable to physically visit the PLWD on a
vices (reflected prominently in the next section on carer regular basis. This was especially the case as the disease
needs), better carer support, and the stigma surround- progressed and the PLWD could no longer recognise
ing ageing and cognitive impairment. Figure 2 presents people on the phone.
the frequency of responses across domains and carer
types, noting that each individual provided up to three
P5. (Unpaid/family carer). Social interaction, like I
responses.
think that the major thing is connection … All these
behaviours are being caused from loneliness, and
Carer interviews being confused, there’s no one around to say ’It’s
The interview responses aligned with the stated needs in okay. They’ll be here soon’.
survey responses. ADL and maintaining social engage- P18. (Unpaid/family carer). You do not need any
ment also arose as important areas of need for PLWD medical training to be a good dementia carer, you
and their carers. need a lot of relationship training.
P7. (Paid carer). In residential aged care, there is
Independence In terms of independence and manag- such a high task focus for staff that there is not a
ing ADL, carers spoke about the ways in which cogni- lot of time for people to actually interact ... It’s very
tive changes associated with dementia led to difficulties rushed ... I see that is a big issue.
keeping track of daily tasks and the completion of activi- P10. (Paid carer). I think one of the other challenges
ties, impacting on the PLWD’s ability to continue living is isolation and loneliness. And another one is lack-
independently. ing purpose. I’d say these are the, they’re the big ones
... people can become lonely, and they still have … all
P2. (Unpaid/family carer). I mean, he can wash the dishes these ongoing emotional needs just like anyone else,
if I asked him, but that’s as much as he does. to know that they belong to people, that they are
loved by people. And they can get very isolated.

P3. (Unpaid/family carer). He literally is totally

Most important needs for carers
dependent on mum, to take him wherever he wants
Survey responses
to go, because he now can no longer just take the car.
To understand the domains in which carers might most
P6. (Unpaid/family carer). She struggles with every-
need support from technological solutions, the survey
thing. She can’t remember if she’s eaten or not. She
asked carers to describe, in their own words, “What are
can’t remember if she’s taking medication or not.
the three issues or difficulties that impact the most on
P9. (Unpaid/family carer). She was trying to make
the lives of dementia carers?”. Participants had space in
something she’d made all her life. And she just said,
the survey to provide up to three separate responses,
“I tried to make your Raspberry slice and I can’t do
that were broadly clustered under 4 emergent themes
it”. You know, it was a loss ... I think the biggest thing
or domains. The distribution of responses was virtu-
for [mum] was that she started to feel that she was
ally identical for unpaid and paid carers, and chi-square
useless.
analysis indicated no differences in the distribution of
Social engagement and loneliness Carers spoke about responses between carer types, Χ(4) = 1.86, p = 0.762
the importance of PLWD maintaining connection to (see Fig. 3).

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Brookman et al. BMC Geriatrics (2023) 23:867 Page 8 of 19

The most common domain of need reported by carers support for themselves and the PLWD. Unpaid carers also
was support with their own physical or mental health. This reported distress associated with the change in their rela-
included frequent references to being “exhausted”, “burnt tionship to the PLWD. This was often evident when the
out”, and “stressed”. Many mentioned difficulties with PLWD loses their independence and/or is no longer able
the aged care system, in terms of navigating the system, to perform previously held roles within their family. Many
accessing support or respite, or coordinating services. Car- of the family carers noted that they missed the “independ-
ers also mentioned having difficulty with their knowledge ent and capable” PLWD and had to adjust to the increas-
of dementia care, including knowing how best to interact ingly “dependent” person, who eventually required 24/7
with the person with dementia, lacking knowledge about supervision and care. Many carers likened their change in
dementia, not knowing how best to help or support the role to that of becoming a parent again. As such, they val-
PLWD, and having difficulty determining the right bal- ued any kind of support that enabled them to find a “cir-
ance between independence and care for the person liv- cuit breaker” or “snippet of time” free from the intensive
ing with dementia. Finally, carers mentioned the financial nature of their caring responsibilities.
impacts of caring, particularly where they had given up
P1. (Unpaid/family carer). But living with her was
paid employment in order to meet the demands of caring.
difficult because dementia, as you know, for some-
body on a “sundowner” is quite difficult. So, in the
Carer interviews afternoon, evenings, she’d often get quite distressed …
Responses from the in-depth interviews elaborated on And then the night times … they sleep poorly … she’d
the potential negative impacts of the caring role on well- be up and down, up and down.
being (carer burden) and the need for carer support.
There were numerous practical challenges experienced P9. (Unpaid/family carer). I was losing more of my
by all carers (paid and unpaid), with regards to commu- identity … I had gone from being an independent,
nication, loss of independence with ADL, managing chal- active social person to just being a ‘carer’… your will
lenging behaviours, safety concerns, and time constraints just goes down until your life is just this little pinprick.
in the caring role. And you just have to dedicate yourself entirely to
them, and you don’t have a choice … you’re just there.
Unpaid carers There were challenges that were unique to
unpaid carers, which included issues such as social isola- P15. (Unpaid/family carer). Really, you just have
tion in the caring role, and difficulty accessing appropriate that “circuit breaker” and it needs to be longer.

Fig. 3 Most important needs for carers of people living with dementia

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Brookman et al. BMC Geriatrics (2023) 23:867 Page 9 of 19

Paid carers Paid carers were employed in a variety of themselves) and what they found useful. We asked car-
different roles such as: nurse, nursing unit manager, pas- ers to rate different types of solutions or supports in
toral care worker, aged care facility manager, support terms of their prior use. For each solution, participants
worker, hospital-based Dementia Advisor (Psycholo- selected from the following options: “never used and not
gist), and Therapeutic Engagement Specialist. During interested”, “never used but interested”, “have used but
the in-depth interviews, most paid carers described their not continued”, “currently use”. We compared responses
caregiving role as both rewarding (“I just feel my role is to three types of solutions: (1) care options or medical
amazing”) and challenging (“… there is such a high task approaches; (2) everyday tools involving technology; (3)
focus that there is not a lot of time to actually interact”). everyday tools not involving technology.
Paid carers reported a desire to spend more time with
the individual PLWDs that they cared for, and to improve Unpaid carers Ratings for unpaid carers’ use of eve-
their capacity to provide person centred care. Those in ryday tools are presented below, showing the number
management positions such as residential care manag- of people endorsing each response option (see Fig. 4).
ers or nursing unit managers also identified challenges Technological tools included smart home options such as
related to staffing-patient ratios, and access to additional automated lights, cameras, doorbells; location trackers or
funding and education for their staff. GPS-enabled wearables such as an Apple Watch or Fitbit;
reminders provided by a phone or other device; memento
P7. (Paid carer). So, a staff member [who] is a
technology such as digital photo frames or music players;
really empathetic person … she said to me, “I can’t
and social technology such as companion robots. Most
make eye contact when I go in the room sometimes,
commonly participants reported that they had not pre-
because I’m in such a hurry … So, I often don’t make
viously used the technology and were divided between
eye contact, and I talk without looking” … And I
‘not interested’ and ‘interested’. This reflects an ambiva-
said, “How do you feel about that?” And [the staff
lence about the value of technology as many carers were
member] started to tear up and she said … “I feel
sceptical regarding its value in their daily life and caring
dreadful, that’s not why I got into the industry. And I
responsibilities. The one exception to this was techno-
don’t know how to do it any other way.”
logical mementoes such as digital photo frames or other
ways of supporting reminiscing about the past, which
Carer experiences with technology
carers reported using. The next most common techno-
Survey responses
logical tool being used was GPS-enabled wearables, with
Given the large number of assistive technologies that
about a quarter of carers reporting using such devices.
have been tested in previous studies, and the interest in
Strikingly, carers reported not using social robots, and
assistive technology for a growing population of PLWD,
were evenly split between disinterest and interest in such
we explored whether carers had adopted any techno-
social support tools. Non-technological tools included
logical solutions to meet the needs of the PLWD (or

Fig. 4 Unpaid carers’ use of technology-based and non-technology-based solutions

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Brookman et al. BMC Geriatrics (2023) 23:867 Page 10 of 19

reminders provided by paper tools such as calendars (both paid and unpaid) talked about the importance of
or shopping lists, physical mementoes such as photo using technology in a person-centred way and lamented
albums, and physical social supports such as pets or that “one size does not fit all” in dementia care. This was
dolls. Such non-technological tools were most frequently especially the case when using technology for leisure
reported to be ‘currently used’. and/or to engage the PLWD in activities that were mean-
ingful to them e.g., listening to classical (versus) popu-
Paid carers The responses of paid carers showed a lar music. Also, in a hospital setting when patients were
sharp contrast with those of the unpaid carers. Paid car- unable to use the nurses “call bell”, because the detail was
ers were much more likely to report currently using a too small and complicated for them to use. The follow-
variety of tools, including both technological and non- ing examples demonstrate the creative, idiosyncratic, and
technological (see Fig. 5). For those who did not cur- DYI bespoke ways that carers had found to make generic
rently use a particular tool, they were likely to express technology personalised and meaningful for individuals,
being interested in it. This pattern is especially striking including focusing on personalised content or targeting
for social technologies such as social robots, which were particular times of day or contexts when technology use
the least commonly used but of interest to most paid car- is beneficial.
ers. Paid carers rarely selected the “never and not inter-
P6. (Paid carer). The most amazing thing I have
ested” option. This suggests that paid carers are engag-
found is a digital day clock. It’s fantastic. It comes
ing a range of technological and non-technological tools
up with the date, the day, whether it’s afternoon or
already and are also more open to adopting new techno-
morning. [For example] it would say it is 2:15 pm on
logical solutions across device types.
Thursday afternoon. It would give the year as well.
Some of them can set alarms still which is great ... I
know my Lewy Body [client], her alarms are all set -
Specific examples of technology use in care practice
timed for her medication.
Follow-up interviews provided rich details about the spe-
cific ways that carers embedded technology within their
P8. (Paid carer). Some families have hooked up DVD
practice, meeting a range of needs including addressing
players [to the resident’ TV], others get a hard drive
isolation, loneliness, and agitation and enhancing per-
and load all the movies and music into the back of
sonal meaning and connection to self. This was particu-
the TV… we’ve [also] got iPads and Samsung tablets
larly the case for paid carers who reported higher rates
that we use, and then the staff will sit down with
of incorporating technological tools into their care prac-
the residents … either take them out in the garden
tice, as such the example responses below are drawn only
or in their room and call their families … We’ve
from carers with experience using technology. Rather
got a few that do [use it by themselves]. Not every-
than using technology in a generic way, these carers
body because some just don’t cope … they just don’t

Fig. 5 Paid carers’ use of technology-based and non-technology-based solutions

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Brookman et al. BMC Geriatrics (2023) 23:867 Page 11 of 19

understand who’s on the end of it … I’ve got a lady has about 40 h of opera and ballet selections on USB
who’s Italian [who] misses her family … She under- [that I downloaded for him], which plugs directly
stands English [but] doesn’t speak it as well anymore into the television. The staff can choose something he
… She has a phone call every morning and then she doesn’t mind watching it over and over again.
video calls [her daughters] every evening because she
“sundowns” really quite badly. And the girls will do a P20. (Unpaid/family carer). Dad ... he was more of a
video call when she’s getting unsettled. classical music person. So, he was more into Mozart
and Beethoven and, and that sort of stuff. Whereas
P12. (Paid Carer). With some of our patients with they [the staff ] tend to play more the old popular
dementia we we’ve got a special symbol … just a music.
big white ‘bell’ [on a] … a big white soft button … P10. (Paid carer). I take the iPad in everywhere,
the OTs [Occupational Therapists] got them for us. every day, because I don’t know how I’m going to use
And we say to [PLWD] I’m the nurse, if you want me it [for example] looking up places.... Google Maps,
press this button, and… [they] can understand. Now things like that. Many of the residents have an iPod
I’ve got the button. If I press this button, the nurse too, and that’s their own personalised music playlist
will come. with headphones. Because music’s hugely significant
for people … the family give us a list of their prefer-
Carers talked about different tools they had used to
ences. And then that gets put on the [PLWD’s] iPod.
facilitate social interaction and reminiscing. Carers gen-
erally recognised that connecting the PLWD to their In one residential care setting, subscription to a multi-
identity, and their past employment, culture, roles, and media music platform was used specifically to address
relationships was important. Tools were often non-tech- agitation in residents, particularly at night-time if resi-
nological, such as photos or life story books, developed dents were unable to sleep, and when scheduled activities
deliberately by the carer to be used as a resource for were absent. This platform provided 24–7 visual footage
sharing memories and for telling other people (e.g. paid and songs from a familiar era for the PLWD. They found
carers) about the PLWD. Many talked about music and this was helpful to some residents at night-time and pro-
its ability to connect people to their past, to provide a vided a sense of company in addition to ‘calming’ visual
meaningful activity and a way of engaging them. Most and auditory stimuli.
paid carers were open to the possibility of technology,
P8. (Paid Carer). Silver Memories’ [is] a radio sta-
when tailored to the individual’s needs, and recognised
tion here in [city] [that plays] continual reminiscent
the potential for technology to provide tools to facilitate
music that runs 24-7 with visual pictures and... it’s
reminiscing, and/or engagement with PLWD, reinforce-
hooked up to the facility [and] every resident’s tel-
ment of the PLWD’s identity, and promote relation-
evision. So, if someone’s having a hard time sleeping
ships and connection to meaningful activities. In terms
at night, [the PLWD or staff ] can put that on … For
of technology for social engagement, some comments
those residents that ... go to church on Sunday, they
below indicated the need for multimodal stimulation to
can play ‘Hymns of Praise’ ... Because there’s so many
maintain the attention of the PLWD – being able to see
[residents] whose body clocks just do a “flip-flop” on
as well as hear a person they are talking to or being able
them when they’re living with dementia. So, all of a
to touch as well as see photos.
sudden, they’re awake all night, and the staff during
P15. (Unpaid/family carer). We’ve used WhatsApp the night [need] to engage them … ‘Silver Memories’
on the phone with my sister. So, because Mum’s rec- has helped give them company - that they’re not
ognition of a phone now is that she doesn’t under- alone ... a lot of its music from the 50s and 60s ... The
stand what a phone is. She hears my sister’s voice, visuals can be just beautiful landscapes and can be
and she wants to know where she is. With What- anything that becomes a reminiscence thing as well.
sApp, she could see my sister and therefore she
In another residential care setting, staff had worked
related much better to.
together to create a DYI, bespoke immersive device
that included the creative use of video footage to famil-
P4. (Unpaid/family carer). He just likes, you know,
iar activities and settings for residents. Staff had used a
the love of classical music [it] is probably one of the
Go Pro to obtain a video footage of a variety of every-
last things that to go. He came from a very musical
day activities such as familiar car trips around the local
family… Television itself distresses him, especially
city, bike rides through the bush, and feeding penguins.
if it’s left on accidentally between something bland,
Each video footage of an activity lasts for 30 min and was
and it gets into airline disasters or something. But he

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Brookman et al. BMC Geriatrics (2023) 23:867 Page 12 of 19

played on a large screen in the recreation room. Several Potential benefits of existing technology
different “stands” were custom built for residents to phys- Given the relatively low uptake of assistive technology
ically engage while watching the virtual video footage, reported in the survey, especially by unpaid carers, we
including a stand with a car steering wheel on it, and a asked carers to describe what they would find existing
stand with push bike handles that could be placed in front technology useful for in the context of dementia care,
of residents’ chairs. The resident was then able to “drive” both for the PLWD and for the carer, using their own
or go on a “bike ride through the bush” or feed the birds, words. We coded responses for the themes present, to
thus reliving previously enjoyed activities again. The per- enable us to understand what unmet needs good tech-
sonalised content – filmed on location by staff members nology might meet (see Fig. 6). Most commonly, car-
to match specific PLWD’s life experiences – was key to ers described that technology might help to support the
the benefit of this device, as well as the personal meaning safety of a PLWD by allowing monitoring of them in their
and sense of independence provided by the simulation of homes. The next most common response was that tech-
driving or riding. nology might be useful in providing meaningful activi-
ties, supporting leisure and engagement, and reducing
P8. (Paid Carer). He [staff member] put the GoPro
boredom. In terms of support for carers, responses were
on [his] car ... and drove from [city] to [regional
more likely to be that technology could reduce stress
town] which is about two hours away. Then [he]
and give peace of mind, particularly through monitor-
made me a steering wheel on the stand. I’ve got [the
ing safety and alerting the carer of emergencies. Carers
pre-recorded video] on a USB, the USB in and play-
also described that technology could give them a break
ing on the big screen. When I play that video on the
by engaging the PLWD in activities or supporting inde-
big TV in the activity room … He [a resident] was
pendent completion of ADL. Although the most frequent
a GP - he’s ‘driving’ - he thinks he’s driving up to
themes were similar for both unpaid and paid carers,
[regional town] to see patients. We had another lady
unpaid carers (versus paid carers) were more likely to rate
[sitting in front of the steering wheel stand] driving to
technology as ‘not helpful’, for the PLWD, and the carer.
wherever, she has never had a licence! And I started
talking to her. She said, “Don’t talk to me, I’m driv-
ing. Can’t you see that?” Perceived barriers to technology use
In the survey, we asked carers to describe aspects of
Several carers noted that they had used dolls, soft toys, existing technologies that make it unhelpful or present
or basic social robots to support the PLWD, particularly barriers to use in the context of dementia care. The most
noting that these tools reduced anxiety and were soothing common concern or experience with technology was
for the PLWD. Cats/pets were the most common, with no related to technology being “impossible to learn” and use
references to more high-tech or humanoid robots. Their for PLWD, who have challenges with memory and learn-
main function was managing the psychological symp- ing new information (56.67% of responses). These can
toms of dementia rather than providing social interac- be illustrated by quotes such as the following, “Mobile
tion, and carers who mentioned using them noted the phone/ smartphone become impossible for him to use.
need to target them to the right person at the right time. Aged care homes etc. need old-fashioned phones in the
P10. (Paid Carer). I also have a robotic cat. You rooms. So frustrating when he called and then was obvi-
know, it’s got batteries, very lifelike, it meows, it ously holding the phone upside down” and “many peo-
purrs, it stretches, kneads its paws. And it’s been ple didn’t use technology in their lives so teaching them
delightful, with residents who like cats. Not all resi- something new is difficult”. Carers commented on the
dents like cats, so I don’t use it with them. And some challenges with technology interfaces, particularly their
residents know it is not real, and they still think it is lack of familiarity to PLWD. This concern applied to all
amazing. And other residents think it is real. And it mainstream devices such as smartphones and tablets,
is very soothing. which were reportedly too complex and too small for a
P13. (Unpaid/family carer). Robotic cats ... I found it PLWD to use independently, e.g. “It needs to be very sim-
helped other people in the [residential] cottage, so it ple, with one big button that can be easily identified.”
seems to really reassure people. And it is quite amaz- A second, related theme was the carer’s observations
ing really. It is life-size. It purrs and reacts to light and and concern that technology use contributed to higher
does all of the things a cat would do. And at Gran’s levels of anxiety, distress, and/or disorientation for the
stage of dementia, they kind of think it is real. So, if I PLWD, meaning that introducing assistive technology
had tried that with Gran 5 years ago, she would have could do more harm than good (21.67% of codes) e.g.,
been really pissed off. Things have changed. “New technology causes distress and frustration—ipads/

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Brookman et al. BMC Geriatrics (2023) 23:867 Page 13 of 19

Fig. 6 Perceived uses of existing technology for (a) people with dementia, and (b) carers of people with dementia

phones/ digital tv—all unfamiliar [for the PLWD].” Car- without the help of the carer (8.33% of codes) e.g., “[the
ers noted that PLWD have difficulties with the additional PLWD] cannot use technology on their own”. Carers also
management tasks required by many mainstream devices expressed concern that technology could not replace
such as turning a device on and off and charging it. They human connection and that PLWD needed human inter-
also described heightened frustration for the PLWD action and not technology (5.00% of codes) e.g., “Tech-
when they experienced difficulties “troubleshooting” nology doesn’t work. Mum [PLWD] responds well to
or problem-solving when something unexpected hap- being tactile, small chitchat, lots of hugs and kisses”.
pened with the technology e.g., “The issue with technol- There was some general scepticism or concern about
ogy is that unless they know how to use it when there is the push towards technology in care settings, the deper-
a problem, it isn’t helpful.”; “Dad would get frustrated at sonalisation or care, and the loss of human connection
the alarm and inability to turn it off ”. Technology is inap- especially regarding social technologies such as robots.
propriate in the context of dementia care when it makes Carers also noted that PLWD’s vision or hearing impair-
errors, is unintuitive, or is unpredictable. ments made interacting with technology impossible
Additional concerns that were reported less commonly (4.17% of codes) e.g., “Technology needs to be BIGGER if
by carers were that PLWD could not use technology you expect [PLWD] to handle it themselves.”

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Brookman et al. BMC Geriatrics (2023) 23:867 Page 14 of 19

Carer design ideas: Form and function of future technology tasks or domestic activities at home. Suggestions ranged
In the follow-up interviews we asked carers to describe from a voice prompt to remind a family member to eat
what they would like to see developed if they had the their lunch, to a multi-modal prompting system that
opportunity to ‘wave a magic wand’ and create anything could walk them through the series of steps required to
that might assist in the context of dementia care. This brush their teeth.
enabled us to understand what novel technology might
P1. (Unpaid/family carer). Personal hygiene [you
be most useful and valued in terms of features and func-
could] have some footage in the bathroom of some-
tion, and to suggest directions for technology develop-
one washing their hands, because she forgets
ment that might better align with the needs of PWLD
...Whether you have someone brushing your teeth,
and their carers.
“This is how we brush our teeth...”, “This is how we
wash our hair …", “This is how we comb our hair …"
Multi‑modal technology to facilitate social engagement P5. (Unpaid/family carer). It would be so helpful if
Carer’s design suggestions were diverse, but most focused somebody said, “It’s lunchtime, grab your lunch out
on facilitating social engagement that was more frequent of the fridge!”. Even if you could record your own
and casual, especially when the PLWD was in residential [voice]…. In our situation if I could record something
care. Family carers wanted to be supported to interact that could say that, and it was timed, then that
in meaningful ways with their loved one. As such, they would suit my situation.
envisioned ways in which technology might facilitate rich
multi-modal remote interactions when face-to-face inter-
action were not possible. This seemed particularly impor- Capitalising on familiar interfaces that compensate
tant for familial carers in the context of the COVID-19 for sensory losses
restrictions and residential care lockdowns. The most More generally, carers envisioned technology that har-
frequently mentioned recommendations are illustrated nessed familiar interfaces rather than contemporary inter-
by the quotes presented below. faces such as smart phones and tablets which they said
P1. (Unpaid/family carer). If people can’t be in the were too small. They therefore recommended interfaces
room, maybe some way to ‘virtually’ do that. So, that were large as well as familiar, such as the television.
these days we’re very much a fragmented society. We P7. (Paid carer). I was thinking that the generation
live all around the world … Maybe a large screen we’re talking about doesn’t really interact with com-
in each … room and some way that you could ‘tap puter technology, but the TV screen is a very famil-
into’ [it] ... So, you tap a button and you’re zooming iar format. So, I’ve often thought we should really
into my house. I’m in the kitchen … [the PLWD’s] in use the TV screen, so it is not an alien form which
her facility, and we’re just having a chat, [on a] big the computer can be … It would be great to have
enough [screen] that she can see it … and it’s easy something with the familiarity of the TV, but I think
to access … [as a] regular thing that you could do it needs to be interactive.
each day, just checking-in on things, “What you did
today?”, “What did you have for breakfast?”. ... Imag- P15. (Unpaid/family carer). When [Mum] sees her
ine ... a big sort of interactive screen … I could see [sister] on the little phone. It’s too small, the screen is
that could really work. That screen could also link in quite small. So, if that was the TV, I know she would
with music, which I think is really such an impor- be much more engaged with it.
tant thing.
P15. (Unpaid/family carer). It would be nice if the Self‑initiating (pre‑programmed) or voice activated
technology for the phone could work through the TV, technology
because [PLWD] would have a bigger picture [and] Carers talked about the challenges of interfaces that
they could interact much better. Because the screen require the PLWD to remember to use it, or to learn a
on a phone is not so sharp. I mean, you could do it complex series of steps. As a solution, several carers
on a tablet … but the TV would be much, much, suggested self-initiated activation that did not require
much better. facilitation by the PLWD or a family carer. They wanted
technology that required no or minimal action on the
part of the PLWD. For example, a device that could be
Technology to support activities at home pre-programmed to dispense verbal prompts at certain
Family carers also made suggestions for technology that times during the day, or that could be voice activated by
could support PLWD to complete routine personal care the PLWD.

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Brookman et al. BMC Geriatrics (2023) 23:867 Page 15 of 19

P5. (Unpaid/family carer). Definitely something that engagement that was more frequent and casual, espe-
doesn’t need prompting … That can [initiate], just cially when the PLWD was in residential care. They also
say, “The weather is...” or “Today is going to be hot, wanted technology that was customisable, large in size,
make sure you put on a t-shirt". and that incorporated familiar interfaces.
P11. (Unpaid/family carer). I suppose if she could All carers (paid and unpaid) emphasised the impor-
have a screen as big as a big screen.... maybe if she tance of person-centred approaches to dementia care,
could voice activate it. If I had a big screen like I’ve and the need to support individuals to maintain their
got here on my computer now, and she said, “What’s individual identity and connection to their life story and
the weather like?” or “Can I see my grandchildren’s relationships. PLWD value opportunities to engage in
photos?”. That would be wonderful. That would give personally meaningful activities, to live a full life that is
her a sense of contact with people ... That would not defined solely by their dementia diagnosis [33].
give her some entertainment … Something where
she could say, I want to do a crossword or a quiz or Technology and unmet needs
something, and you could have the clue written in When carers answered open ended questions about
big letters. She’s missing the stimulation that she has the biggest issues in dementia care, the most common
when she has people contact. response related to independence and ADL, the sec-
ond concerned social isolation and loneliness, and the
Technical support for carers third concerned the psychological symptoms of demen-
Finally, as a minor theme, some carers were aware of their tia such as anxiety and frustration. Social connection is
own challenges in learning new technology and often one of the most common unmet needs in dementia care
reported feeling out of their depth when engaging with and can remain undetected [34], and PLWD want to be
new devices or knowing what to try. They wanted access enable to maintain social connections with family and
to technology support and recommendations for tech- friends [35]. Consistent with the literature, carers in our
nology that would be appropriate for their circumstances. study reported being limited in the time available to them
P21. (Paid carer). But you need a tech support line. to meet the social needs of those in their care, especially
So, it’s like, “Is there a device that can do this?”, or when the physical aspects of care are demanding and
“How do I go about setting up a webcam at home?”, time consuming [36].
or “What are some good apps?”. When carers were asked to describe what they would
find existing technology useful for in the context of
Discussion dementia care, the most frequently endorsed response
We aimed to understand the day-to-day lived experience was for safety and monitoring. Despite this, most of the
of unpaid and paid carers of PLWD, including their needs solutions that carers imagined focused on social engage-
and experiences with various kinds of assistive technol- ment and meaningful activities. These findings consistent
ogy and their design ideas for future technology. We ana- with the literature indicating that carers adopt assistive
lysed responses from carers who completed and online technology in the home environment (e.g., surveillance
survey and from carers who participated in and in-depth cameras and wearable tracking devices) primarily for
interviews. Results indicated that the needs in dementia safety reasons to monitor the PLWD [6, 8], indicating
care were widespread, with the main themes confirming that currently available technology may be mostly applied
previous findings by identifying the need for independ- to this function. However, there were a diversity of needs,
ence in ADL, social engagement, and management of and a particular prevalence of unmet need relating to
negative psychological symptoms such as anxiety and independence and social engagement, and these needs
frustration. Results from questions exploring experiences appear to not be well met by existing assistive technology
with assistive technology, indicated that unpaid carers [4]. Several common themes were identified as crucial
reported low rates of use, and their responses reflected take home messages and will be discussed below.
some scepticism about their value. Unpaid carers (versus
paid carers) were more likely to rate technology as ‘not Technology needs to relieve and not add to carer burden
helpful’. Also, both paid and paid carers practiced the Despite the number of unmet needs for PLWD, and the
adaptation of existing technology to make it more per- potential for technology to meet them, most unpaid car-
sonalised in order to better meet the needs of the people ers reported that they had not previously used a range
they cared for. Finally, carers’ design solutions demon- of assistive technology options. Carers were split evenly
strated the capacity to generate creative technology when given the option of being ‘interested’ or ‘not inter-
ideas, with most focused-on technology facilitating social ested’ in technological solutions. Unpaid carers reported

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Brookman et al. BMC Geriatrics (2023) 23:867 Page 16 of 19

low rates of assistive technology use, and their responses Adaptations of existing technology
reflected some scepticism about their value, while they Our findings of creative adaptation of existing tech-
showed much higher rates of adoption for non-techno- nology, provides evidence that carers modify existing
logical assistance. Paid carers had higher rates of tech- technology to meet their PLWD’s needs, rather than pur-
nology usage and were also interested in technology that chasing off-the-shelf products [7]. Our results extend
they were not already using. This ambivalence regarding existing research by findings that this “do-it-yourself ”
the value of technology in dementia care, may be related practice occurs in residential care settings by paid carers,
to carer stress and burnout. The biggest issues carers in addition to home environments by unpaid carers. For
faced for themselves related to the negative impact of example, paid staff in one residential aged care facility
caring on their physical health and psychological health, provided innovative examples of modifying existing tech-
using words such as “stress”, “exhaustion”, and “burnout”. nology, (e.g., Go Pro video footage), and making it inter-
Consistent with the literature, carers also reported bar- active (e.g., steering wheel, push-bike handles), to provide
riers to technology use for PLWD [6, 7], particularly that bespoke multi-modal immersive interventions that were
technology is challenging to learn, and interfaces are customisable and therefore person-centred e.g., “driving”
unfamiliar for PLWD, contributing to anxiety and frustra- the familiar route to work for a retired GP. This practice
tion rather than resolving them [20, 21]. Some carers saw is consistent with previous research suggesting that older
potential for assistive technology to reduce the demands adults in the community tend to adopt and use technol-
of caring, provide more opportunities for enjoyment and ogy in a contingent rather than in a systematic manner
meaningful activities, and reduced stress [6]. However, to [37, 38]. Further, due to barriers associated with existing
achieve this, successful technology will need a specialised technology, and the lack of customisability, carers will act
user interface, reducing complexity as well as incorporat- as mediators between technology and the PLWD and will
ing familiar ways of interacting rather than requiring the tend to use available materials to adapt technology to the
PLWD to learn a new way of interacting with a device. changing needs to the PLWD over time [7].
Technological solutions will need to integrate easily
into daily life rather than adding to the load of carers. Carer design solutions
This also includes consideration of the individual needs Paid and unpaid carers offered creative and innovative
of both unpaid and paid carers, who may not be experi- design solutions from their lived experience, contribut-
enced or confident with setting up and maintaining tech- ing unique value to the existing literature on carer per-
nological devices, and who are busy with many demands spectives. Carer design ideas included technologies that
on their time to complete basic care tasks. support meaningful activities (e.g., listening to music, or
doing a word game), connect the PLWD to identity (e.g.,
Customisable technology reminiscing), and promote social engagement (e.g., face-
A common theme emerging from both studies was to-face virtual connection on a large screen that did not
the need for technology to accommodate to the ever- involve staff mediation). Design ideas put forward by car-
changing needs of the PLWD; both across time (due ers were rich, engaging, and multi-modal, incorporating
to disease progression) and across the course of a day vivid visual stimuli as well as sounds, touch, and other
(due to environmental influences), as well as based tools. For example, visiting the ocean “virtually” through
on an individual’s life experiences, values, and prefer- an immersive video experience in a residential aged care
ences. This is consistent with the literature that indi- setting, while also smelling the sea air and feeling the sea
cates that people with early-stage dementia emphasise spray. These design ideas mapped directly onto unmet
how important maintaining a good quality of life is needs identified in the survey data and described func-
for them as their disease progresses [25]. Technology tions that most carers addressed in their interviews.
solutions need to be customisable to meet the needs of Carer design ideas also advocated for the use of technol-
PLWD as the disease progresses and symptoms fluc- ogy that was familiar to the PLWD, such as televisions as
tuate daily. It may not be realistic for PLWD to inde- opposed to handheld touchscreen devices. The television
pendently initiate or operate technology solutions in represents a major source of entertainment and infor-
the later stages of the disease progression. Technology mation for PLWD [39] and could be leveraged by future
for PLWD living in residential aged care, will look very technology as the platform for remote social interactions.
different, and may need to be operated by carers e.g., Carers also expressed a vision for the television (versus
virtual activities in recreation room, or social inter- smaller handheld devices) to be used as a platform for
actions with family. The use of assistive technology social interactions.
needs to be person-centred and shaped around the In terms of design features, carers commonly men-
goals and capacities of the individual. tioned that “large” technology is necessary, and that

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Brookman et al. BMC Geriatrics (2023) 23:867 Page 17 of 19

less complexity is better. When designing solutions, lived experience of restricted access to loved ones in resi-
the temptation to make them too complex needs to be dential care, for both paid and unpaid carers, may have
avoided. Technology in dementia care should ideally be motivated the desire for user-friendly future technology
integrated easily into everyday life, without additional that facilitates social interaction but is not dependent on
burden for the carer. For example, technology that is staff mediation. Future technology development should
fixed in location would avoid issues of the PLWD mis- consider this need as an obvious focal point for future
placing and/or forgetting to use the technology. In gen- development, particularly as Covid-19 related lockdowns
eral, carers reported that mainstream devices such as and restrictions associated with outbreaks of infectious
smartphones and tablets had not been useful beyond the disease continue in residential aged care.
early stages of dementia, as they are too small and com- The creative adaptations and design solutions offered
plex to interact with. As alternatives, carers imagined by both paid and unpaid carers indicate the value of co-
technology that was self-initiated, and could prompt the design between front-end engineers of technology and
PLWD to complete daily tasks e.g., when to eat a meal, people with close lived experience of dementia. Our find-
or what to wear if it was cold. They described technol- ings support this collaboration as an important step in
ogy that they could be pre-programmed according to the addressing the many challenges facing effective technol-
fluctuating interests and abilities of the PLWD. Likely ogy development. The ability of carers to adapt existing
solutions, therefore, need to be simple, using a familiar technologies and creatively generate new ones, can be
interface, self-initiating or initiated remotely by carers, leveraged to guide future technology that is customisable
and tailorable to individuals’ needs, routines, capabilities, due to its development in consultation with end-users [6,
and interests. Very practically, this means devices that are 7, 37]. Our findings highlight carers as a valuable source
large enough, and stimulating and multi-modal enough of creative design ideas. As such, co-design strategies will
to engage the PLWD and avoid the issues with existing likely ensure relevance and usability of assistive technology
videoconferencing where the PLWD cannot follow or solutions [2]. The placement of dementia care end-users
attend to the interaction. at the centre of the design process, however, is not com-
Finally, in terms of the function of the solution, paid and mon practice in technology research and development
unpaid carers emphasised the key importance of mean- [37], despite the recommendation that user-perspectives
ingful engagement, instead of the physical aspects of should be engaged throughout the design process in
care. This is perhaps unsurprising given that carers often dementia care [41], together with the creative design solu-
experience rupture to relationships, which can lead to tions offered by carer participants in this study. It is there-
social exclusion that co-occurs with the PLWD’s declining fore recommended that carers be included in the design
communication skills and cognitive abilities [40]. Carers phase of assistive technology – in addition to the evalua-
wanted technology that can facilitate social engagement, tion phase – to increase the usefulness and uptake of new
especially with family. While carers reported robotic pets devices in the everyday lives of PLWD and their carers.
to have a beneficial role in residential care settings in
reducing the negative symptoms of anxiety and agitation, Limitations and future directions
and improving mood in [12, 13], they are not considered a It is noted that data was collected for this study dur-
solution to meet the social needs of PLWD. Unpaid carers ing the Covid-19 pandemic and associated lockdown
want technology to facilitate real relationships with real in Australia, during which there were stringent restric-
people, as opposed to creating social partners that are vir- tions on the ability of families to visit loved ones in
tual or robotic. They want technology to simple enough aged care. While it is not anticipated that this directly
to be used independently by PLWD to support frequent, impacted on the findings of this study, the stay-in-place
incidental social interactions to compliment face-to-face strategies associated with the COVID 19-pandemic
interactions, or to replace them when geographical sepa- may have heightened the carers’ requests for assistive
ration precluded “in-person” visits. technology that supports remote social interaction.
Future research could examine whether the promi-
Implications nence of social themes remains as the restrictions on
This is the first study to invite paid and unpaid carers to visiting aged care have eased. We also recruited a
offer their creative technology design ideas to support convenience sample, using online methods of contact
dementia care in both home and residential care settings. including email and zoom interviews. This means our
Carers confirmed previous findings by articulating both sample was likely more proficient with technology than
their needs and limited experience with assistive tech- average. We note that our findings regarding relatively
nology. They also expressed a desire for technology that low uptake of assistive technology are striking in the
facilitated, not replaced human interaction. The Covid-19 context of our digitally-literate participant cohort, and

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Brookman et al. BMC Geriatrics (2023) 23:867 Page 18 of 19

a truly representative sample recruited through other Consent for publication

Not applicable.
means would likely show even lower uptake of techno-
logical solutions. Competing interests
The authors declare no competing interests.
Conclusion
Our findings exploring unmet needs and technology Received: 3 May 2023 Accepted: 29 November 2023
experiences (potential barriers and benefits) of assis-
tive technology in dementia care, are consistent with
previous findings regarding carer experiences [6, 42].
However, this study extends the literature by also con-
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