Dementia is a neurodegenerative chronic condition characterized by a progressive decline in a person’s memory, thinking, learning skills, and ability to perform activities of daily life (ADLs). Currently, dementia affects 47 million people worldwide, and these numbers are expected to increase to 75 million in 2030 and 132 million by 2050 [1]. As a result, the World Health Organization has declared it a public health priority and launched a public health plan in 2017 [2]. A diagnosis of dementia also has a significant impact on family members of people with dementia (PwD), who often bear the responsibility of caring for them as their health deteriorates [3]. Individuals who provide unpaid and continuous assistance and have not been formally trained, such as spouses, children, or other family members, are referred to as informal caregivers, in contrast to formal caregivers, who offer paid professional services [3]. Furthermore, it is often the case that informal caregivers provide care to PwD in circumstances where formal health care does not reach because of health care systems infrastructure, socioeconomic status, or cultural preferences, among others [4].

Smart Health technologies (s-Health technologies) [5] are the result of the natural synergy between m-Health and smart cities, from the Information and Communication Technologies (ICT) perspective, as well as that of individuals and society. Nowadays, a wide variety of s-Health technologies are being developed to help the elderly, chronic patients, and their informal caregivers at home, showing promising results [6,7]. The use of s-Health technologies for dementia includes assisted living technology, ambient assisted living technologies, and smart homes. Cahill et al proposed [8] that s-Health technologies fall into 4 main categories, namely, (1) those used to promote safety, (2) those that foster communication and address memory loss problems, (3) those that provide multisensory stimulation, and (4) those that act as memory enhancers. The scientific literature points out that s-Health technologies may have a role in supporting informal caregivers of PwD for situations often associated with informal caregiving, such as symptoms of depression, stress and anxiety, or caring burden [9,10]. Recent research on the topic [11], however, has found that many of these systems fail to be effective in real-life cases because of their low acceptance and adoption, often relating this to usability issues.

Technology can facilitate the delivery of care, but there are certain factors that can diminish its effectiveness. Obstacles to adoption are many and can range from design choices to complex scenarios like potential ethical issues such as data ownership or privacy concerns derived from their use [12]. In terms of usability, challenges increase for dementia as we must also consider the cognitive and behavioral issues [13]. For PwD, even once familiar devices, such as washing machines, microwaves, kettles, or telephones, can be problematic, as the appearance and design of these have changed so much that they do not resemble the ones they had grown accustomed to [14].

Current trends in health information technologies suggest that solutions should be designed not only to be effective, acceptable, and nonharmful but also to be pleasant and engaging [15,16]. The use of user-centered design (UCD) principles generates systems that are easy to learn, have higher user acceptance and satisfaction, and lower user errors [17-19]. Design for PwD should consider dementia-related symptoms [13]. Furthermore, informal caregivers of PwD provide substantial care at home, at times with little assistance from paid professionals [3]. Informal caregivers of PwD spend large amounts of time caring for PwD and are very acquainted with the problems they face [20]. However, they are seldom included in the design process for s-Health technologies, which could prove beneficial.

To the best of our knowledge, there are no guidelines specifically created for designing s-Health technologies for PwD and their informal caregivers. There are sets of design recommendations such as the one created by Astell et al for motor-based technologies for people with cognitive impairment [21], Boman et al’s work on using ICTs for persons with cognitive impairment [22], or Matthews et al’s [23] summary of adoption factors for caregivers of dementia. However, these recommendations do not expand on the process of design, develop, and most of all, implementation of s-Health technologies [21].

The objective of this study was to examine the factors influencing PwD and their informal caregivers’ adoption of s-Health technologies for home care and provide some recommendations for their design.

Scoping review methodology aims to map the key concepts underpinning a research area, especially where an area has not been reviewed comprehensively before [24-26]. The Arksey and O’Malley methodology [24] was followed to produce a scoping review that provides a narrative description of the scientific literature on factors influencing s-Health technology adoption for PwD and their informal caregivers. A qualitative thematic analysis [27] was conducted on the results of the scoping review to generate a list of design recommendations that aim to help future s-Health technologies for PwD and their informal caregivers’ researchers and designers.

The aim of this study was to review existing literature to explore the factors influencing PwD and their informal caregivers’ adoption of s-Health technologies for home care.

We conducted a search on available literature on s-Health technologies for PwD and their informal caregivers following the selection criteria (see below). The search was conducted in the following databases: PubMed, Cochrane library, IEEE library, and Scopus. Initially, titles and abstracts of all publications retrieved from the initial search were screened by 2 researchers (EGF and LMM), and a full-text analysis of potentially suitable publications was then conducted by 1 researcher (EGF).

Inclusion criteria were as follows:

Exclusion criteria were as follows:

The keywords and search terms used were organized into 3 main groups for clarity purposes: (1) dementia dementia-related keywords, (2) informal caregiver–related keywords, and (3) s-Health technologies–related keywords. A complete list of all keywords and the search string can be found in Multimedia Appendix 1.

In total, 2 researchers (EGF and LMM) completed the study selection process; disagreements were resolved by involving a third researcher (CB). The selection and analysis process was managed with EndNote X8 software for Mac (Clarivate Analytics, Philadelphia).

Our search strategy retrieved 2373 publications from the selected sources. After removing duplicates, publications were screened by title and then by abstract, which identified 808 papers to read by full text. A total of 109 publications met our inclusion criteria and were included for analysis. The study workflow selection can be seen in Figure 1.

Data extraction forms were created to obtain and organize information from the included studies, such as author(s), year and journal of publication, title, type of publication, study design and aim, target population, intervention, the type of technology included, outcomes, and potential technology adoption challenges described. A summary of the included publications can be seen in Table 1 and Figure 2.

Only qualitative and narrative data that could be obtained from the studies were included. The qualitative analysis was performed using NVivo software version 12 for Mac (QSR International, Melbourne, Australia). Data analysis was conducted independently by the 2 main researchers (EGF and LMM). Through the iterative process, relevant information was identified and coded. Codes were later discussed between the researchers for developing and modifying them, achieving a consensus. Researchers organized the codes into broader themes that said something specific and meaningful about the research question. Finally, a list of design considerations was created based on our findings, as a guide for future research and innovation in the area of s-Health technologies for PwD and their informal caregivers.

In this section, we provide a detailed description of the emerging themes and factors influencing the adoption of s-Health technologies for PwD and their informal caregivers that rose from our qualitative analysis of the included results. An overview is presented in Table 2.

A user’s attitude toward technology is crucial for its adoption. Having a positive attitude toward technology and having previous positive experiences are known to improve adoption [28,29]. Negative attitudes can act as barriers, resulting in nonadoption [8].

The use of s-Health technologies is not without ethical concerns as issues of autonomy, beneficence, and justice, among other moral issues, can be presented. Questions such as PwD’s ability to provide truly informed consent, how is their privacy protected, or how confidential the information given is are present throughout the literature [52].

Technology is becoming part of PwD and informal caregivers’ daily lives, but many devices require a number of different tasks to be performed for them to function properly. There are certain aspects that need to be addressed for the PwD and their informal caregivers to feel that s-Health technologies were not dropped into their lives with little to no information or guidance on how to use it [36].

There are a series of issues that PwD face as a result of living with the condition and the natural age-related changes. This gradual deterioration affects the performance of specific functional tasks as well as cognitive deficits that impair learning new systems and interfaces, impacting the interaction with new technologies [40].

There is a common concern in the literature that there are many gaps in terms of the market availability of technological developments for PwD and informal caregivers, and lack of practical guidelines for the design and implementation of technologies [14].

The emerging themes obtained during our scoping review allowed the extraction of valuable insight that was grouped to create a series of design considerations for s-Health technologies for PwD and informal caregivers. We have called these Dementia Design Considerations for Smart Health Technologies or DemDesCon for s-Health technologies. Following the works of Astell et al [21], we have presented these design considerations as different domains to be taken into account. Each design consideration is detailed below. An overview of DemDesCon for s-Health technologies is presented in Figure 3.

Designers of s-Health technologies are encouraged to consider these different domains in their approach to the design process of solutions for PwD and informal caregivers and to reflect on the ramifications of their designs.

PwD undergo a series of cognitive decline issues that affect how they can relate to new technologies. The following sections reflect on design considerations regarding their cognitive capabilities.

The gradual and progressive physical deterioration that PwD go through requires for potential s-Health technologies to take special notice to some particular condition-related aspects. Below are design considerations relevant to the physical decline of PwD.

It is common for people and health care providers to, sometimes without noticing, infantilize PwD, thus taking their autonomy away from them. The following design considerations attempt to emphasize ways in which s-Health technologies can encourage PwD to stay active and offer them positive reinforcement.

s-Health technologies are becoming more pervasive, but there is much room left for improvement in regard to creating solutions that are useful and meaningful for the intended audiences. The following design considerations aim to call for attention from researchers, developers, and designers as to what seems to be missing in the field of s-Health technologies for PwD.

This scoping review is the first study of its kind to explore factors influencing the adoption of s-Health technologies for PwD and informal caregivers. A total of 109 papers were reviewed and thematically analyzed, providing insight into factors influencing s-Health technologies adoption when using these types of technologies for the home care environment. Emerging themes were divided and classified for better understanding. Furthermore, the insights that this review provides were used to produce a series of design considerations for future work in s-Health technologies for dementia home care. No other study has provided a similar list of design considerations for use in s-Health technologies for dementia before.

A thorough review of the scientific literature highlights how previous works where technology has been used for dementia home care leave room for confusion with an ample array of terms and terminologies employed. The lack of a uniform nomenclature or taxonomy becomes apparent as a variety of concepts are frequently used together, even within the same publications, making it quite difficult to distinguish which type of technology is being referenced [102,103].

s-Health technologies for PwD and informal caregivers seem to be created nowadays with either the PwD [77] or the informal caregivers [44,81,104] in mind. It is less common in the cases where the services are being designed for both of them and integrated under the same tool [105,106]. This is in conflict with recommendations for designing technology in this population, as one of the essential points is the comprehensive creation and a participatory design [14,95]. Despite these issues and facing great difficulties, PwD and informal caregivers appear to be embracing dementia home care technologies slowly yet increasingly to facilitate and to assist them with their ADLs.

Another interesting finding in our scoping review is the significant emphasis that studies placed on feasibility, reliability, usability and user experience, and user engagement, regardless of overall goals of behavioral change. It would seem that the latter was not often accounted for or corroborated in the results. Furthermore, the methodology used in the studies varied even for assessing similar variables, making it difficult to extrapolate conclusions [107].

Working up from the gaps and themes that we discovered in our study, we turn our attention to the actual s-Health technologies design for PwD. Current trends in s-Health technologies design claim that UCD processes increase their adoption and use by the intended users [17]. In UCD, the needs and perspectives of users are placed in the highest of priorities and the product is designed to accommodate them [19]. Ideally, this should be an iterative design process, where the final users contribute with their knowledge and experience to develop a product that can be adapted to meet their own needs in a user-friendly manner. By following these design principles, systems that are easier to learn, have higher user acceptance and satisfaction, and have lower user errors are generated [17-19].

The design of s-Health technologies for PwD unfortunately does not follow the above approaches. In many cases, PwD and informal caregivers are not involved during the design process, so the value of their experiences and expertise is lost. It is more likely that they are involved in a user evaluation exercise that takes place after the design process has already reached an advanced stage. Thus, intended users have to make a great effort to understand and become familiar with the particularities of each device. In many cases, this is not successful, resulting in the device being abandoned for not being found useful or fit for its purpose [31]. There is a necessity to better understand the needs and perceptions of PwD and informal caregivers regarding technology, and to use this knowledge to address the deficits outlined above. Therefore, we believe that our work will provide light in those gray and diffuse areas where there are no guidelines at the moment.

As it stands, DemDesCon for s-Health technologies is aligned with current design models for technologies that advocate the need to consider condition-specific factors [108,109]. In addition, some frameworks also suggest involving stakeholders to ensure that the designed technology is more meaningful to end users [110]. We have included 28 publications [111-139] in Multimedia Appendix 1.

One of the main limitations of this study relies on its research methodology, as scoping reviews do not explore the totality of all available studies; rather, it provides a descriptive view of the area of study. In addition, the scoping reviews do not seek for quality and weight of evidence or quality of the methodology of the primary research publications. It also has to be considered that the amount of information collected can lead into difficulties for the width and depth of the information to cover.

Furthermore, no quantitative or statistical analysis was performed on the included papers, but this is in line with the scoping review methodology. It is possible that the selection criteria may have left out studies that would be relevant to this research’s goal, such as non-English publications that could hold relevant studies in other languages. Focusing on community-living PwD and their informal caregivers may have neglected other suitable studies conducted in caring homes or in other types of people with other chronic diseases that could also benefit from these types of interventions. In addition, young-onset dementia interventions have not been taken into account, and this could be a bias as we have mentioned in our paper; an early introduction is a key factor for technologies adoption.

Although s-Health technologies have been used in health care scenarios, more work is needed for them to fully achieve their potential for use in dementia care. As was present in the revised literature, s-Health technologies are seen by some as a complementary support tool that could improve the quality of life (QoL) of PwD and informal caregivers, who are willing to use these technologies if the conditions are right.

Our study found that the way of matching the appropriate technology to each individual, and at the right time, is not clear yet and more difficult than what it may seem. Researchers and companies are working toward developing valuable technologies for PwD and informal caregivers, but the lack of clear design guidelines seems to be slowing the process. This study offers a series of design recommendations under the shape of a framework: DemDesCon for s-Health technologies. We believe DemDesCon can provide guidance and assistance for creating meaningful devices for home care for PwD and informal caregivers, filling a much-needed space in the gap of knowledge. Nevertheless, more research needs to be conducted with longitudinal studies to appreciate how s-Health technologies work in the users’ environment and how they interact with them.