To develop technologies that are useful and valuable for persons with dementia, it is important to know what kind of assistance is needed. This requires a thorough understanding of the different types of dementia and associated impairments, individual experiences and coping mechanisms, and the continuous changing situation during the dementia “journey.” It is also important to be attentive to needs such as a sense of self-esteem and feeling respected, which are related to higher levels of well-being and quality of life, as highlighted in Maslow’s “hierarchy of needs” [25,17]. People with dementia can express their needs [26] and preferences [27] consistently, even in an advanced stage of dementia [28]. Therefore, to really understand what it is to live with dementia and which needs should be addressed, people with dementia should be asked about their needs and experiences and be involved early in the process of development of supportive tools and interventions. Till now, very few technologies have actually been designed to meet the specific needs of people living with dementia [29], and only few of these prototypes have been adopted for commercial development.

Technologies can be divided into those designed specifically for persons with dementia as opposed to technologies that have been developed in the mainstream and lend themselves well to support people with cognitive difficulties. For example, the functionality of some forms of telecare technology, such as GPS, webcams, and apps (Joint Improvement Team, 2016), is being superseded by readily accessible off-the-shelf devices that can successfully assist people to navigate their day. Also, recent work has confirmed that persons with dementia can be supported to use touchscreen computing for leisure and recreation in line with the rest of society [29]. Nevertheless, the complex sensory, perceptual, and cognitive changes caused by dementia can make using mainstream devices problematic for some persons with dementia, and therefore for the foreseeable future, some demand for bespoke devices will continue.

In developing assistive technologies in health care, there has been a shift from expert- and technology-led design toward a user-driven approach, and it is more common to now involve end users.

Examples of methods that support end user involvement and aim for sustainable eHealth innovations are the holistic approaches of the roadmap of the Centre for eHealth Research and Disease Management (CeHRes) [30] and Contextual Design [31]. Both methods are rooted in human-centered design (HCD) and emphasize 3 interrelated components: technology, people, and organization (health care environment). The CeHRes roadmap focuses, in particular, on the health domain and combines HCD principles with business modeling.

For dementia, the drive to ensure engagement at all stages of technology development is underpinned by the principles of person-centered care and, in a broader perspective, by a social inclusive society. This includes the coproduction of new innovations for research and for practice, with the involvement of end users from the outset [32,33]. In practice, however, people with dementia have rarely been involved in technology development, with user acceptability tending to be assessed via family carers and others [11,24,34]. Successful examples of collaborative working with people with mild-to-moderate dementia are emerging [14,33,35-37]. However, people with more severe dementia are less often included in development of assistive technologies.

Challenges in the development of assistive technology include the need for personalized and tailored technologies in dementia. A “one size fits all” is not an optimal solution because of the individual variations in needs and abilities. The development of sustainable assistive technology for persons with more severe dementia is a challenge, as is how to develop technologies in a way that will help to make the world a more “dementia-friendly” place [38]. Examples of assistive technologies that can help persons with dementia in their daily life are simple aids such as calendars and reminders but also more complicated devices such as robots that perform a social role or augment individual human capabilities through cognitive prosthetics [39]. There are companies who anticipate providing inclusive assistive technology solutions for older people, including those with dementia, for example, Alcove [40]. One research challenge is how to develop assistive technologies that address the emotional state of persons with dementia during everyday tasks [41]. One of the challenges in the field of health care technology, which supports organizational and supportive systems of dementia care, is to integrate technology into the built environment, such as lighting, floor coverings, and improved way-finding (eg, via improved signage), taking into account the varying and changing needs of the residents [42,43]. Another challenge is to integrate technology into the routine health care, using information and communication technology (ICT) in the clinical assessment of cognitive, behavioral, and physical functioning of persons with dementia [44].

Research has revealed that persons with dementia are enthusiastic about using assistive technology to remain independent and also about taking part in technology design [23,33]. At the same time, some challenges remain, such as how to personalize and tailor technologies to the individual and changing needs and abilities of persons with dementia. We envisage that the involvement of end users in developing new assistive technologies will continue to grow, and that more applications of existing technology using mobile phones or apps will be put to use to benefit persons with dementia.

Little research so far has been conducted in the field of assistive technologies in community dementia care and support, with only 3 studies exploring usability in supporting everyday life with a Day Navigator [46], a GPS [47] and a timer device [48]. In the study by Meiland et al, 42 participants and carers considered the Day Navigator to be mainly user-friendly, but conclusions about usefulness were limited due to insufficient duration of the testing period [46]. The GPS system was tested among 33 dyads, with only 1 leaving the study because of technical reasons. Participants with dementia who went outside unaccompanied took the GPS with them 67% of the time. Also, 80% (20/25) of the caregivers said that the use of the technology was not difficult, and almost all of them felt that they were in control of the secured website where they could track and trace their relatives (92%; 23/25). The study does not provide specific information about usability outcomes apart from ease and frequency of use and the fact that the participants with dementia did not seem to mind that they heard a voice from their GPS without notification [47]. The timer device was used for a stove and tested with 9 older adults with cognitive impairment or dementia and 5 relatives. The authors found that end users scarcely participated in the process of choosing and adapting the device. Although the device provided increased safety, there were also some unforeseen problems, such as not fully understanding how the device worked. The authors stressed the importance of actively involving users in home modifications with assistive technologies and providing medium- and longer-term follow-up of the technological support [48].

In research on technology to participate in meaningful and pleasurable activities, for example, cognitive interventions for persons with dementia, usability issues are often not mentioned. Jelcic et al [49] reported a positive perception of technology-based cognitive therapy, as participants would recommend it to others and were satisfied with the utility and appeal of this intervention. Zaccarelli et al [50] found that the educational level of users was important, as results of the studies on people with Alzheimer’s disease, mild cognitive impairment and healthy adults showed that participants with a higher education level found it easier to learn how to use the ICT platform. Lee et al [51] reported that the usability of their computer-based cognitive intervention was good. Persons with dementia were highly motivated in using it, and their sense of achievement was enhanced; they took pride in showing others that they could operate the computer [51]. Gillespie et al [52] suggested that large-scale studies of assistive technology to improve cognition should also focus on functional areas, for example, prompting, navigating, and reminding, rather than on the specific content of the devices itself.

Over time, persons with dementia may have reduced ability for new learning, which may impact actual use of technology because learning and technology use are inseparable and proceed together [53]. Understanding how persons with dementia access and embrace technology is vital in order to develop usable and acceptable technological solutions. Technology use by older adults has been criticized for not eliciting and including their interests [54]. Devices should be adjusted to each individual, achieving better tailored interventions, and assistive technologies should be embedded in a person-centred model [55]. A good example of this is the provision of feedback sessions to ensure that the person with dementia and carer understand the assistive technologies, to answer questions, and to collaboratively discuss recommendations for improvement [56]. A recent review (not limited to dementia) on mHealth applications suggested the adoption of automated evaluation mechanisms to improve the empirical methods to assess usability [57].

Furthermore, a good match between the person and the technology is required because if this is not achieved well from the end user’s perspective, the technology may be ignored or not be used optimally [58]. Bardram et al [59] emphasized the importance of deploying assistive technologies in a real-world setting, outside the laboratory, and also the need to perform longitudinal studies that assess the evolution of the relationship between the end user and the technology [59]. A person’s acceptance of assistive technologies can vary during the course of dementia. For example, acceptance can improve when symptoms start to threaten the independence of the person [60]. The ability to use assistive technology may also vary. Over time, a decreasing use of technology is seen in people with cognitive impairment [61].

It has been suggested that usability studies of assistive technologies should be designed in several stages: predeployment (observation sessions, focus groups with people with dementia, carers, and professionals); deployment (carrying out long-term observations and quantitative and qualitative assessments in real settings); and postdeployment (feedback sessions) in close partnership with end users, carers, and specialists [62].

In the area of computer technologies, usability of interfaces has received special attention. Research on the preferences of persons with dementia has indicated that touchscreen devices are preferred over mouse or keyboard input devices [63]. Direct response devices using a touchscreen reduce the distance between the subject (seeing the stimuli) and the causal effect (providing the answer), which enhances the person´s involvement in the task. The previous experience of people with dementia with computers affects which type of interface device they prefer, with experienced users preferring the mouse. However, although the mouse is the most demanding device in terms of cognitive and motor demands, there can also be problems with touchscreens in terms of accuracy that may be frustrating for the end user [64]. Computer literacy has an important role in usability: lack of computer experience was reported to decrease the odds of successful use of technology [65]. Thus, pretest, treatment, or intervention training sessions could be used to enable persons with mild cognitive impairments and early dementia to become familiar with novel technologies [66-69]. The need for including performance tests to enhance the ecological validity of assistive technologies has been highlighted, such as measuring the user’s motivation [54]. Although there is a prejudice that assistive technologies are not “elderly friendly,” in fact the evidence points in the opposite direction: when older adults get the opportunity to use computers, they regard them as a “status symbol” often associated with youth; as a consequence, the use of computers could have a positive effect on self-confidence and self-esteem [70].

Regarding the assessment of the usability of assistive technologies and user satisfaction, various tools were used, for example, the usefulness, satisfaction and ease of use questionnaire [71]; the Everyday Technology Use Questionnaire [72]; the Quebec User Evaluation of Satisfaction with Assistive Technology [51]; and the model of technology acceptance, specifically developed to test the acceptance of assistive social agents by older adults [73]. There is a lack of tools to evaluate the usability of assistive technologies in persons with severe dementia.

To conclude, despite advances in the field of technology-based interventions for persons living with dementia, few applications have been analyzed for their usability. Technologies can be used by many persons with dementia, but additional support is often needed from informal caregivers or professionals. To promote better utilization of technologies in dementia care, a better understanding is needed of their usability for persons with dementia, people’s preferences for specific interfaces, and their acceptance of different technologies.

Within this domain, many devices have been tested for their effectiveness. For example, a calendar was positively evaluated by more than half of the 21 participants [74]; a training device (based on errorless learning) to guide people with dementia in using a mobile phone was reportedly effective [75]; prompting devices to support in activities of daily life or in memory were found useful [76,77] and effective [76-80]; and prompts were found effective for traveling [81-84]. However, another prompting device found no impact on quality of life [85], which might have resulted from the many technological problems encountered during the effect pilot study. The NeuroPage [86] was tested in a randomized controlled trial (RCT) and showed a significant reduction in memory and planning failures by providing prompts; however, this study included patients with brain injury, and only a small number had dementia. Although tracking devices are said to be effective [87,88], 1 study showed that only a minority used such devices successfully, and 1 patient was injured by a passing vehicle [89]. Two studies also identified positive effects of tracking devices for caregivers (relief or reduction of emotional distress) [87,90].

Within the domain of technologies for meaningful or pleasurable activities, computer programs with cognitive training applications showed improvements in task performance or cognition in persons with Alzheimer’s dementia [70,91], recall [92], global cognitive functioning, and emotion [93,94]. However, devices with prompts for creative activities were found to be not effective [95,96], although participants liked the activities with an ePAD (Engaging Platform for Art Development) [95]. Social robot therapy for stimulating interaction showed an improvement in brain activity in half of the 14 participants [97]. Research into the use of multimedia tools to support people with dementia has reported improvements in well-being [98,99], mood [100], psychological stability [101], and social interaction and engagement [100,102-107]. In another study, a music tool was enjoyed by its users, but the prompts proved difficult to understand for the person with dementia [96]. Telephones or videophones have been reported as being easy to use for persons with dementia and helpful for maintaining social contacts, and they positively affected self-esteem [108-110].

Health care technologies to facilitate health care delivery for people with dementia included sensors to monitor behavior, virtual reality, and video conferences. Sensors and smart home technologies are said to provide a good image of performed activities [111] and were reportedly successful in preventing major incidents [48,112,113]. Reported effectiveness of these tools in helping persons with dementia to live longer in the community varied [114,115]. One large controlled study [15] concluded that smart home technologies helped persons with dementia by improving confidence, ability to maintain community living for a longer time, and reducing need for care visits. A single case study found a reduction in required support, perceived anxiety, and confusion by the person with dementia [116]. Comparison of the use of video conferences for, for example, clinical assessment showed no differences compared with face-to-face assessments [117-119]. Clinical improvements were found for almost half of the study sample that received telecare, which consisted of telemedicine, tele-education, and telecounseling services [120], and this kind of telecare could be promising for rural populations [119].

To summarize, various benefits of assistive technologies for persons with dementia have been reported. However, the results described need to be interpreted with caution because the majority of the included studies were uncontrolled studies with relatively small sample sizes. Reviews on cost-effectiveness studies of assistive and health care technologies in dementia were not found.

According to the Ambient Assisted Living Association (AALA) [121], “the market is growing beyond its traditional boundaries and this is attracting a growing interest by potential investors, the ICT industry and all service and care providers.” The landscape of the market will be deeply modified by a combination of a demand pull (by the rapidly growing population of older persons) and a technology push (through development of new ICT solutions and services) ([121], p. 76). A key recommendation of the AALA was to develop a European observatory with the mission to become the main source of trusted and high-quality information and data on the market to inform all stakeholders.

The next 3 paragraphs consider factors that influence deployment related to demand pull of stakeholders in general, health care professionals, and persons living with dementia.

Stakeholders need trusted and high-quality information from HTAs or HSTAs. However, reviewing the current situation of HTA or HSTA delivers disappointing results in that these data, mainly provided by national bodies, are often incomplete, with many variations in definitions, information provided, and quality and reliability of the data [121].

The users of these data include health care providers, health service researchers, policy makers, funders, consumers, and information professionals (eg, in United States [122]; United Kingdom [123]; Germany [124]). Solely searching the HTA databases that provide English literature with the search term “assistive technology dementia” reveals few results (ie, United States: 14 books; United Kingdom: 3 items). Two of them provide facilitators and barriers (expanded upon later) to the deployment of technology: Jimison et al [125] and Finkelstein et al [126]. One is a systematic review on the effectiveness of assistive technology which does identify some of the barriers that are also mentioned in Jimison et al [125] and Finkelstein et al [126], and the other is a bibliographic record of an ongoing health technology assessment being undertaken [127]. One result was a Cochrane protocol focusing on the efficacy of assistive technology for memory support in dementia [128]. The other results were either not related to dementia or were not focusing on assistive technology.

A range of constraints limiting deployment and related to the technology and health care sectors were identified at a workshop (2014) involving Ambient Assistive Living (AAL) and Joint Programme for Neurodegenerative Diseases (JPND) stakeholders; 25% of the projects funded by AAL and JPND are about developing ICT-based solutions for support and care of older adults with cognitive impairments [129]. These constraints came from a range of sectors including health and social care and business, covering aspects such as open standards, finance and business models, skills, and simply knowing what is available and where there are gaps in the market.

When assistive technology is used to enable support and care processes, barriers include the following: lack of usability; problems with access to the health IT application, low computer literacy in patients and clinicians, insufficient basic formal training in health IT applications; physicians’ concerns about more work; workflow issues; problems related to new system deployment, including concerns about confidentiality of patient information; depersonalization; incompatibility with current health care practices; lack of standardization; and problems with reimbursement [121]. Facilitators for the utilization of health IT included ease of use, perceived usefulness, efficiency of use, availability of support, comfort in use, and site location [126].

Barriers for deployment of assistive technologies for the end user, which might also apply to a wider audience than dementia, include the following: usability problems, unreliable technology, the lack of consumers’ perceived benefit from using the system, inconvenience, data entry being cumbersome, and the intervention not fitting into the user’s daily routine. Deployment appeared to be more successful if the intervention could be delivered by technology that consumers already use daily for other purposes, and that satisfactorily meet their needs [125].

In conclusion, to promote successful deployment of assistive and health technologies in dementia care, it is essential that the technologies are reliable, user friendly, and useful; and that there is a single centrally funded access point to high-quality information regarding assistive technology products relating to dementia for all stakeholders. The Assistive Technology Dementia website [130] provides such a platform but is reliant on short-term funding (donations and grants), which means that optimization of information and sustainability are compromised. Furthermore, education and training in the field of technologies in dementia care should be available for all stakeholders.