The first reported use of touchscreen technology with people with dementia was in 1986 [17], where the use of a touch-sensitive screen was compared with a conventional computer monitor with a peripheral response device to deliver 2 cognitive assessments or screening tests. In the early 1990s, 2 articles described the incorporation of touchscreen technology into cognitive assessments: the Cambridge Neuropsychological Test Automated Battery (CANTAB) [18] and the French-language Examen Cognitif par Ordinateur (ECO) [19]. Touchscreens have continued to be used for these purposes, evidenced by more recent examples delivering tests of global cognition [20] or batteries of cognitive tests [21-23] for the detection of dementia or mild cognitive impairment (MCI).

In addition to global cognitive assessment, several articles reported the use of touchscreen technology to deliver tests of specific cognitive functions: visual attention [24], working memory [25], executive functioning [26], and visuomotor skills [27,28]. The remaining article in this theme [29] used computerized maze tests presented on a touchscreen computer to predict driving performance.

The vast majority of these articles developed original tests for the touchscreen format such as the Edinburgh Dementia App [23] and the Touch Panel-type Dementia Assessment Scale [22]. Only one study reported the adaptation of an existing test; the sparse-letter display test [24], which had previously been presented on a computer but not using the touchscreen format.

The majority of articles describe the use of touchscreen technology to provide an assistive function for the person with dementia or their caregivers, or to present interactive cognitive exercises.

Five of the reviewed papers discussed the Computer Interactive Reminiscence and Conversation Aid (CIRCA), a communication support tool using digital reminiscence materials to stimulate conversation between the person with dementia and a conversation partner [30-34]. Several other studies also used reminiscence materials presented on a touchscreen interface to provide other assistive functions [9,35-39]. The use of touchscreen technology to support therapists was also evident in the context of art therapy and occupational therapy [40-42]. Several articles reported the use of touchscreen technology to address multiple activities of daily living (ADL) for people with dementia [43-46], including calendars, diaries, video calling, and location tracking. Although different terminology was used to describe their focus, the remaining articles categorized in this section used touchscreen technology to present cognitive exercises to people with dementia, either using originally designed software [47-51] or existing software [52].

Several of the aforementioned articles have featured games or leisure activities; however, these have been designed to assess cognition [21,26], provide cognitive stimulation [37,45], or to assist in the delivery of therapeutic interventions [40,41]. Very few studies focused on games or activities purely for entertainment or leisure purposes.

Three of the reviewed articles described “Living In the Moment” (LIM) [31,53,54], a suite of touchscreen games and activities that at various stages of the project included virtual environments, skill games, games of chance, and creative activities, the common factor being that they were all designed in partnership with people with dementia. Original design was also utilized in 3 articles; 2 focusing on musical creativity [55,56] and 1 to provide enjoyable activity either independently or in a group setting [39]. The remaining articles included in this section investigated the use of existing touchscreen activities, rather than those developed specifically for people with dementia [5,10,13].

The touchscreen control method is widely regarded as intuitive [5,10,17,47] and easy to use [25,39], making it highly advantageous for people with dementia. Eliminating the need for external input devices, for example, a keyboard and a mouse, is beneficial as it reduces the cognitive load required to input information [10,17,24,47]. This was addressed directly in Tippett & Sergio [28], where the performance of people with dementia on a visuomotor test was highest when the touch-sensitive interface was placed directly over the computer monitor as opposed to when placed in front or to the side. A similar method was used in the study by Carr et al [17], who reported that participants in the group using an external response board would sometimes intuitively reach out to touch the screen. An alternative example can be seen in Ott et al [29], where participants were required to use a stylus to trace a path through the maze in order to replicate the “natural” method of using a paper and pen.

In administering cognitive tests, touchscreen computers are seen as a more practical solution for a number of reasons. These include increased accuracy of data input [18,25,29], flexible but also standardized administration [25], reduction in administration bias by avoiding experimenter effects [20], financially efficient implementation [22,25,29], and the wide availability of this technology in health care settings [23].

In addition, the use of touchscreen computers reduces the practical requirement for members of staff to prepare and manage multiple materials, for example, reminiscence materials [30,33,38,42,52]. This is highlighted as a potential time-saving measure for often busy clinical staff [41].

Programs and apps presented on touchscreen devices can be designed to facilitate customization, which allows for easy adaptation and consequently they can be responsive to the needs of the users [13,25,37,40,41]. Presenting customization options within programs in an accessible format allows a caregiver or therapist to tailor the program to each individual [40,41]. This is particularly beneficial for people with dementia as programs can become responsive to change in their cognitive functioning and abilities over time. For example, with games, it is important to include difficulty options so that each player can find a suitable entry point [37]. Another benefit to customization highlighted in the literature is with regards to administering cognitive assessments, where being able to easily manipulate experimental parameters can allow for repeat testing while avoiding learned responses [25].

A further advantage of touchscreen devices such as tablets and smartphones is that they can provide a wide range of functions for the user. As is reflected in the literature, these devices can address the multiple needs of people with dementia, for example, increasing socialization, providing memory prompts, facilitating activities, and delivering educative tools [10,13,36,37,44]. During reminiscence activities, for example, photographs and music can be accessed simultaneously, increasing their potential to trigger memories [38]. The fact that a wide variety of downloadable apps can be added to such devices only increases the availability of these functions [5,52]. It is also reported that built-in and attachable accessories, for example, cameras [35] and sensors [48] can even further increase the functionality available through these devices.

The touchscreen devices used in the reviewed articles range in size, largely determined by whether a monitor (largest), tablet, or smartphone (smallest) was used. Fourteen articles reported and specified using a touchscreen monitor or a touch-sensitive interface in combination with a monitor [17,21-25,28-30,33,34, 40, 46,51,53]. Screen size in these studies ranged from 14˝ to 32˝ with a mode size of 20˝. Six articles reported and specified using a tablet device, all with a screen size of 9.7˝ [5,10,39,42,52]. Three articles reported and specified using a mobile smartphone, with sizes of 2.8˝ [46], 3.5˝ [13], and 3.8˝ [43].

With regard to size, a larger screen can be advantageous for people with cognitive impairment, particularly when there is the addition of a visual impairment [56]. This would support the use of monitors, however the portability of tablet devices and smartphones is also seen as advantageous [25], as is the availability and ease of access to downloadable apps [5,52]. There should be consideration for the suitable placement of tablet devices during interactions, given their size and weight, with the recommendation of placing the device on a surface (eg, table) and raising the height to a comfortable level for the user to reduce muscle stress [25]. Finally, the small size of smartphone screens has been highlighted as a potential issue for people with dementia during user testing [43].

All the studies that reported using tablets, and specified which device, used an Apple iPad [5,10,39,42,52]. In discussing the reason for selecting an iPad, and therefore the Apple iOS, Lim et al [10] commented on its ease of use when compared with Android OS or Windows OS, a factor that is particularly important where the intended users are people with dementia. Android [48], Windows [43] and Apple [13] were each used as the OS in studies that specified smartphone use. In the study by Zmily et al [48] involving the use of near-field communication (NFC) technology, the Android OS was selected primarily because, at the time, the majority of mobile devices with NFC functionality used Android. Commenting on app development, Pang and Kwong [37] stated that apps designed for people with dementia should be developed for both Apple and Android to allow people the choice in what device to purchase, particularly in relation to cost.

There were many examples of studies using a training or demonstration phase before participants were expected to use a device independently [13,24-26,28,48,57]. In several cases, this involved the researcher or clinician demonstrating or instructing device use, followed by a familiarization phase where the participant would be observed using the device so that their understanding could be verified [24,25,28,57]. In one example using this method, the familiarization phase would only end once the clinician was satisfied that the participant could use the device independently, up to a maximum of 8 trials [28]. In another example, a simplified version of the actual trial test was used during this phase to prevent learning bias [24]. Zmily et al [48] predicted that this demonstration would be necessary, given that the target population is generally less experienced using computer devices, which was supported in their results. In their case study, Astell et al [13] concluded that the participant’s successful adoption of several forms of new technology was achieved because of the high level of appropriate training and support delivered by the researcher, which will not always be feasible.

Many of the articles described the use of integrated prompts within their software to direct or regain the attention of the user, although the outcomes are varied. In developing the LIM games, the research team considered and experimented with many different forms of prompts including text boxes, animations, the spoken voice, and an avatar [53,54]. The idea of an avatar was rejected due to the potential for it to be overly distracting, while the spoken voice prompt was implemented but often ignored (possibly due to its synthetic nature being unrecognizable), or relied on too heavily, resulting in a passive experience where the user would just wait until they next received an instruction. In contrast, the text boxes and animations were found to be more successful, with the conclusion being that overly intrusive prompts were unnecessary [54]. Other studies reported using spoken prompts in their programs [20,22,35,48], either through human recording or synthesized text-to-speech. Inoue et al [22] reported that participants were more likely to find prompts useful in the earlier stages of dementia. In Meiland et al [44], the use of visual and audio prompts was reported to be largely unsuccessful, with users either not noticing the prompt or ignoring it.

There was also variety between the studies in how prompts were triggered, for example, following a period of inactivity [53,54]; following a predetermined number of errors [26]; or using artificial intelligence to detect a reduction in engagement, measured through eye-tracking and screen touches [41].

The importance of feedback in response to user input when designing or selecting touchscreen software for use by people with dementia was discussed in several articles [24,54,56]. Feedback should involve either an animation or sound effect (or both) contextual to the input and should be immediate, to acknowledge the user interaction [54].

When designing interfaces specifically for people with dementia on touchscreen devices, the reviewed literature recommends the avoidance of complexity [35,37,40,56]. The number of steps to navigate or achieve goals should be kept to a minimum [35-37,56], with uncluttered interfaces [56], and the consistent use of colors and icons so that users have a sense of context [35-37]. The traditional design of apps may be problematic for people with dementia, with drop-down menus and ambiguous icons without text, and therefore should be avoided [36,37]. Icons, text, and graphics should be appropriately sized for people who may have visual impairment [36,37,47] and the interactive elements should be of a large enough size to allow for less precise motor control [47].

The multitouch control method popular on market-leading touchscreen devices has the potential to allow for easier and more engaging interactions for people with dementia [41]. However, with multitouch, there is the risk of accidental gestures caused by users resting their hand on one part of the screen while interacting with another [17,56], although considered programming can prevent this [17,41]. Using familiar imagery to cue users into their activity can be helpful for people with cognitive impairment [54], and offering activities that are familiar to people, such as virtual representations of everyday environments to explore [53] or digital versions of existing games to play [10] has also shown to be popular with this population.

To support the design process, Astell et al [33] recommended educating all members of the research and development team on dementia and enabling everyone to spend time talking with people with dementia and seeking their input. An iterative design process in collaboration with users is also recommended [32,53]. This can reduce the risk of releasing products that have poor performance, stability issues, or are not fit for purpose, which is highlighted as being crucial in order to achieve acceptance and adoption by people with dementia, their families, and services supporting them [44].