The study was approved by the Ethics Committee of the German Society for Nursing Science (EK-22-038), and it complies with the Declaration of Helsinki. Prior to enrollment in the study, all participants provided written informed consent. All participants were anonymized. They did not receive any compensation.

This study used a qualitative triangulation approach combining observations and interviews, with data from each method systematically aligned. The study was conducted in Germany and follows the SRQR (Standards for Reporting Qualitative Research) [10]. A summary of the study design and methodical approach is presented in Figure 1.

The study included participants aged 50-90 years with mild cognitive impairment or early-stage dementia. They had to reside in Germany and were required to have sufficient verbal communication skills and adequate vision and hearing. Previous experience with mobile devices was intentionally not set as an inclusion criterion. Recruitment and access to participants were achieved by attending events; presentations in support groups; and visits to outpatient, semi-inpatient, and inpatient care facilities in Southwest Germany.

Data collection was done in day care centers or in participants’ homes, using overt, external participant observations and guided context-driven interviews, which were recorded using a sound recorder. The process of data collection was divided into three phases:

We selected the interview questions considering the limited cognitive abilities of the participants. Therefore, they were formulated in a language that was easy to understand. Textbox 1 provides a summary of the key interview topics, along with representative examples of the types of questions posed.

Each main question was followed by additional questions to gain a deeper insight into the context and motivations behind the participants’ responses, ensuring a comprehensive understanding of their perspectives. We used a variety of open-ended and closed questions.

Two researchers conducted the data collection process. One researcher provided support during the use of the application by offering verbal assistance and aiding in the execution of the tasks to promote its use (Multimedia Appendix 2). The second researcher observed the process and made field notes based on predefined criteria, including attention span, facial expressions, and gestures, during the use of the application.

After transcribing the meaning of the collected data, we carried out a qualitative content analysis according to Kuckartz [11]. The observation protocols were triangulated with the interviews. This allowed for unspoken aspects to be included in the analysis. Following the initial coding, related codes were grouped into categories, facilitating data organization and pattern recognition. Broader themes emerged through categorization, which was essential for understanding the data’s underlying meaning. During data analysis, we supplemented deductive categories with inductive categories (Figure 1).

The characteristics of the participants are presented in Table 1. The participants showed great heterogeneity in terms of skills and previous experience with technology, resulting in varying levels of proficiency in using a tablet computer. This is likely influenced by their prior experience, such as owning or not owning a mobile device. Overall, the participants demonstrated a high level of engagement while using the application, as indicated by focused attention on videos and comments related to the content. A majority of the participants expressed positive feedback regarding the application; however, many were unable to envision using the tablet computer independently.

Most participants were proficient in recognizing visual elements, including both images and videos. However, observations regarding the varying effects of auditory stimuli on participants highlighted the challenge of designing an application that is balanced and accessible to different user groups.

Initially, most participants were hesitant to use the tablet independently but were willing to try it after receiving positive reinforcement from the researcher.

It was noticeable that the participants often sought contact with the researchers for personal support and reassurance, frequently sharing personal stories, even while watching videos or receiving task instructions. This highlighted a strong desire for communication and social interaction while using the application.

When uncertain, the participants appreciated clear instructions from the researchers and were not hesitant to ask further questions (Figure 2). Data suggests that these positive feelings toward the researchers—whether, derived from sympathy, their presence or social interaction likely influenced their perceived acceptance and evaluation of the application positively. The participants’ politeness also contributed to their willingness to engage with the application and give positive feedback. In addition, participation in the study and the resulting change in the participants’ daily routine may have positively influenced the overall evaluation of the application.

The findings indicate that personal support is crucial for a successful overall interaction while using the application. If it is not possible for people with dementia to use the application independently, alternative scenarios for use must be considered. One such scenario is one-to-one support by CRs or caregivers, which fosters social interaction. This support can motivate users and encourage device use, highlighting the relational aspects of care that are important for people with dementia. However, providing direct support requires time, a resource that is often limited for caregivers [13]. Additionally, one-to-one support can be a financial burden, as CRs perceive the associated expenses as high and, consequently, may refrain from using the application [14].

We discovered that the type of task and the visual presentation of cognitive tasks (image-based, text-based, or auditory) were secondary in importance. Instead, the content of the tasks played a more crucial role. To develop tasks that activate cognition, it is necessary to design content that establishes an emotional connection for people with dementia with their prior experiences and interests. This approach is fundamental for the acceptance of the technology. Additionally, including relational aspects, such as sharing relevant anecdotes or engaging in social interaction, further enhances the effectiveness of the technology and its acceptance by people with dementia.

The reliability of the study may be reduced due to participants potentially adopting a desirable response and behavior during interviews. To address this, we triangulated the data by including observations along with mutual verification among the researchers. The researchers’ reflexivity regarding their own roles in the study ensures a higher level of objectivity.

In a previous study, expert interviews were conducted to analyze the requirements for an application for people with dementia. The application tested in the current study was designed based on those findings [15].

According to our study, acceptance is the base for a successful engagement with the application. A systematic review reported similar results, emphasizing the importance of acceptance [6]. For a successful engagement, social context is another crucial factor, as highlighted by our study findings. Smith et al [16] discovered that technology use is perceived more as a social event by people with dementia when they are in the presence of others or in groups. The tablet computer serves as a catalyst for conversation, facilitating the exchange of interesting anecdotes [16].

Woods et al [17] demonstrated that biographical reference plays an important role in solving cognitive tasks for people with dementia. Although they often struggle to recall recent events, they are able to retain childhood memories. Tasks that include biographical references can be easier for people with dementia, as they include leveraging their cognitive strengths and minimizing overload.

While designing an application for patients with dementia, it is important to consider the heterogeneity in this group and dependence on their daily fluctuating cognitive state. Therefore, providing opportunities for individualized adaptation of the technology is crucial for addressing diverse interests and abilities. Biographical content-related tasks can have a positive impact on cognitive activation. It is therefore reasonable to suggest that such interventions linked to biography could also be employed in individuals with other neurodegenerative diseases with the objective of preserving cognitive abilities and memories.

The participants in this study expressed a common interest in social interaction. Therefore, it is important to consider the significant role of personal support when developing and implementing technology, and ensuring easy access. Potential users, CRs, and caregivers should face as few barriers as possible when learning, purchasing, and using the application. This is particularly important, given the short period of use due to the changing cognitive state. If these conditions are met, this application has the potential to promote independent living among people with dementia.