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Assistive technology for the inclusion of students with disabilities: a systematic review

• Cultural and Regional Perspectives
• Open access
• Published: 10 June 2022
• Volume 70 , pages 1911–1930, ( 2022 )

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• José María Fernández-Batanero 1 ,
• Marta Montenegro-Rueda 1 ,
• José Fernández-Cerero 1 &
• Inmaculada García-Martínez 2  

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The commitment to increase the inclusion of students with disabilities has ensured that the concept of Assistive Technology (AT) has become increasingly widespread in education. The main objective of this paper focuses on conducting a systematic review of studies regarding the impact of Assistive Technology for the inclusion of students with disabilities. In order to achieve the above, a review of relevant empirical studies published between 2009 and 2020 in four databases (Web of Science (WoS), Scopus, ERIC and PsycINFO) was carried out. The sample consists of 31 articles that met the inclusion criteria of this review, out of a total of 216 identified. Findings of this study include that the use of Assistive Technologies is successful in increasing the inclusion and accessibility of students with disabilities, although barriers such as teacher education, lack of information or accessibility are found.

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Introduction

In the educational field, students with disabilities face a set of barriers that limit their learning and achievement in different activities that take place in the classroom setting. It is essential that these students have access to the same opportunities to participate in society as their peers. In this context, digital technologies are a tool to access the curriculum. In this regard, evidence has shown that digital technologies (computers, laptops and mobile devices) have changed many students’ lives (Bond, 2014 ). Despite these changes affecting education, little attention has been paid to how students with disabilities have incorporated technologies into their daily lives (Passey, 2013 ; European Schoolnet, 2014 ). This is not surprising, given that existing research on children with disabilities is scarcely developed (McLaughlin et al., 2016 ), while generic research often excludes this sector of the student population (Connors & Stalker, 2007 ). This may be a challenge in terms of ensuring equal opportunities to access and benefit from digital technologies.

This concern to ensure equality and equity is evidenced in most of the international initiatives over the past decade, for example the UNESCO-Weidong Group project “Harnessing ICTs for Education 2030” which will, over four years, support participating Member States in harnessing the potential of ICTs to achieve ODS 4 by 2030. The United Nations also adopted, during its General Assembly on 13 December 2006, the resolution drafted by the International Convention on the Rights of People with Disabilities, in order to promote measures for research and development of disability-friendly technologies and their availability and use, including specific technical devices designed to improve the daily lives of people with disabilities.

Conceptualization

“Assistive Technology” (hereinafter AT) according to the World Health Organization (WHO), is a generic term that designates all systems and services related to the use of assistive products and the performance of services (WHO, 2001 ). Generally and according to the Assistive Technology Act of 1998, in the U.S. it is defined as “any item, piece of equipment or system, whether acquired commercially, modified, or customized, that is commonly used to increase, maintain, or improve the functional capabilities of people with disabilities” (Buning et al, 2004 , p. 98). For Lewis ( 1993 ), AT has two main purposes: on the one hand, to increase a person’s capabilities so that his or her abilities balance out the effects of any disability. And second, to provide an alternative way of approaching a task so that disabilities are compensated.

AT is proposed as an alternative for the interaction between students with disabilities and new digital devices (Emiliani et al., 2011 ), which:

Refers to the technologies (devices or services) used to compensate for functional limitations, to facilitate independent living, to enable older people and people with activity limitations to realise their full potential. Some technologies, even if not purposely designed for people with activity limitations, can be configured in such a way as to provide assistance or assistive functions when needed. The term AT covers any kind of equipment or service capable of meeting this definition. Examples include wheelchairs, prosthesis, communicators and telecommunication services. In eInclusion, AT includes, for example, equipment and services for access to information (e.g., for seeing, hearing, reading, writing), interpersonal communication and control of the environment. (p. 102)

AT is divided into low technologies, which do not use programming, such as magnifiers and pencil holding devices, and high technologies, which use programming, such as computers (McCulloch, 2004 ). Authors such as Cook and Hussey ( 1995 ) and Bryant & Crews ( 1998 ) also classify AT into two types: low or simple technology and high and complex technology. Low or simple technology has been described as equipment that is most often low cost and easy to create or obtain. These require a simplified process for operation (pencils, calculator loupes, paper communication boards, wheelchairs, etc.). Complex technology concerns equipment that has electronic technology (computers, electronic communication boards, electric wheelchairs, etc.).

To understand the role of AT regarding people with disabilities, it becomes necessary to review the concept of disability as well. In this regard, it must be said that disability has had different readings depending on the era and the predominance of health models. The contexts have been varied and even complementary, so explaining disability is a difficult task. The International Classification of Functioning, Disability and Health (ICF), published by the World Health Organization (WHO, 2001 ), is a bridge between the medical and social models, since it understands disability as the interrelationship between a person’s health condition and the environmental factors that affect his/her lifestyle. Thus, disability is understood as the circumstance of negative aspects of the individual’s interaction and its contextual factors, activity limitations and participation barriers. In the traditional medical model, a “disability” is defined as any form of impairment or limitation placed on an individual’s normal functioning, so “impairment” implies a reduction or weakening of normal functioning, and “limitation” implies a reduction of normal activity. In this way, we understand limitation as the multiple barriers that limit student learning and participation (Echeita, 2013 ).

AT is the basis for creating inclusive education systems in which students with disabilities enjoy the same training and learning as their peers who are not limited in their daily activities.

The scientific literature reports both the benefits of AT for students with disabilities and the barriers to teaching and learning processes. Regarding the possible benefits, authors such as Angelo ( 2000 ) studied how specialized technologies contribute to the development of skills that provide stimulation and support to this group of students. For Murray & Rabiner ( 2014 ), AT is able to fit instantly to a student’s level and provide instant feedback for improved learning. In addition, they support students with disabilities in performing tasks or functions that they would otherwise be unable to do (Sullivan & Lewis, 2000 ). For their part, Nelson et al., ( 2013 ) focused on improvements in academic performance and language development. Howard-Bostic et al., ( 2015 ) conducted research on the use of Multimedia Assistive Technology (MAT), finding that these tools improve the performance of university students.

NcNicholl et al., ( 2019 ) in a systematic review of AT use for students with disabilities in higher education identified four analytical themes: AT as a facilitator of academic engagement; barriers to effective AT use can hinder academic participation; the transformative possibilities of AT from a psychological perspective; and AT as a facilitator of participation. In this regard, other studies conclude that the potential use of AT for students with disabilities will promote inclusion and decrease stigma (De Witte et al., 2018 ; Asongu et al., 2019 ).

In relation to potential barriers, Byrd and Leon (2017) focused on three main aspects that prevent the inclusion and approach of students with disabilities in the use of so-called specialized Assistive Technologies: 1- AT is not available or accessible to students with disabilities. 2- High costs and precarious financing represent a limitation for the placement of AT for students with disabilities. 3- Lack of training in the use of virtual devices and platforms is the most prevalent barrier to the development of students with disabilities.

Copley & Ziviani ( 2004 ) identified limitations to their use in the field of education for people with disabilities. These include lack of suitable training and support for teachers, negative attitudes, insufficient assessment and planning processes, inadequate funding, difficulties in managing equipment and time-related barriers. Along these lines, there are many studies that have highlighted the lack of teachers’ training in the application of Assistive Technology programs (Murray & Rabiner, 2014 ; Howard-Bostic et al., 2015 ).

Purpose and research questions

AT aims to help people with disabilities overcome their limitations (Sauer et al., 2010 ). Due to the rapid development of technology, there is a need to update research results on the impact of AT for the inclusion of students with disabilities. Therefore, the purpose of this research is aimed in two directions: on the one hand, to assess the overall state of AT research to improve the inclusion of students with disabilities. On the other hand, to investigate the themes and future lines of research in this field.

The specific research questions addressed are:

Q1. What are the trends in scientific production on assistive technology for students with disabilities in the field of education? Q2. What are the findings on the use of Assistive Technology for students with disabilities between 2009 and 2020 in education? Q3. What are the limitations on the application of Assistive Technology among students with disabilities in education? Q4. What are the main lines of research in this field according to the keywords of the reviewed papers in the field of education?

A systematic review of bibliographic analysis has been carried out using analytical screening techniques and document quantification (Fernández-Batanero, Reyes-Rebollo & Montenegro-Rueda, 2019 ) in accordance with the guidelines and standards for systematic reviews of the PRISMA Statement (Preferred Reporting Items for Systematic reviews and Meta-Analyses) (Liberati et al., 2009 ), as an effort to locate all relevant scientific studies that aim to assess the impact of AT on improving the inclusion of students with disabilities. Likewise, social network analysis techniques have been used (Knoke & Yang, 2008 ) using visual representation with the VOSviewer software. This methodology enables the quantification of scientific output related to inclusion and assistive technology.

Data sources and search strategy

To carry out this review of the literature, four databases have been used to find eligible studies on Assistive Technology for students with disabilities. The databases included were Web of Science, Scopus, ERIC and PsycINFO. Consequently, the main reasons for choosing these four databases were their scientific impact and internationally recognized prestige in the academic community of the social sciences and education fields.

To obtain the articles, we applied an advanced search model using the following descriptors in the title, summary or key words fields: assistive technology (AT), inclusion and disability. To give greater accuracy to the study, Boolean operators “AND” and “OR” were incorporated into the different searches. We also tracked reference lists from relevant papers. Searches for studies were limited from 2009 to 2020, in order to extract the most current research in this field. The bibliographic search was carried out in March 2021, and obtained 741 results. After the elimination of duplicate studies, 321 articles remained for eligibility screening.

Eligibility criteria

Firstly, the PICO strategy (Population, Intervention, Comparison, and Outcome) was used to define the eligibility criteria. In this regard, we followed the recommendations of Pertegal-Vega, Oliva-Delgado and Rodríguez-Meirinhos ( 2019 ): population, phenomenon of interest, context, and study design.

The procedure for the selection of publications, in order to obtain in-depth evaluation about the validity of all included studies, was carried out through a double screening using the inclusion-exclusion criteria. Articles were restricted to peer-reviewed journal articles in the last decade. The following inclusion and exclusion criteria were used to identify study articles (Table  1 ):

Process flow of the systemactic review

Using these inclusion and exclusion criteria, we filter the publications following the recommendations for systematic reviews and meta-analyses. Figure  1 shows the PRISMA flow diagram followed for search, identification, screening, eligibility and inclusion processes (Moher et al. 2009). To increase reliability, all authors of the manuscript participated in the selection of the studies to include.

A first initial search, based on a combination of the different selected descriptors, identified 188 articles in the four selected databases. It was also completed with a manual search by reviewing the reference lists of the identified articles, selecting 28 articles. In total, 216 articles have been selected.

After a first reading of titles and abstracts, duplicate articles were removed, resulting in the elimination of 86 items. Subsequently, an exhaustive verification of the remaining 130 articles was carried out, assessing the established selection criteria, and 99 items were deleted for the following reasons: type of document (52) or inadequate context (47). Finally, 31 articles were obtained (Fig.  1 ).

Sample selection flowchart

Coding procedures and data analysis

To analyse the 31 selected studies, a data extraction table was developed to facilitate the review, which included (a) identification of authors and year of publication, (b) participants’ information, (c) methodological design of the study, (d) results and AT included in the study, (e) number of citations of article, and (f) country, resulting in a database that has subsequently been presented descriptively (Appendix 1).

This section reports the results, both quantitative and qualitative, obtained in this study. The data are shown in the following sections in response to each of the research questions stated above.

Overview of research on Assistive Technology for students with disabilities

This systematic literature review has drawn 31 articles from the different databases analysed. The review focused on scientific articles produced between 2009 and 2020, which aimed to evaluate the impact of the use of assistive technology in the education of students with disabilities. As see in Fig.  2 (below), where the distribution of the relevant studies published during this period is shown, there is an increasing trend in research in this field. Looking at the analysis of the year of publication of these studies, it is shown that the publication trend starts from the year 2017 to the present. Between the years 2009–2016 there was a small number of articles published. However, from 2017 onwards, an increase in the number of publications on this topic can be observed.

Distribution of articles by year

Figure  3 displays the number of studies provided by each country. Looking at the location of the countries where these studies analysed were carried out, we can show that they were mainly carried out in the USA (n = 16), followed, although less substantially, by Brazil (n = 4) and Turkey (n = 3). The figure shows that research attracts interest in countries all over the world.

Distribution of the articles analysed by country

The analysis of the study design used does not provide an overview of how research in this field is being approached. These data indicate that, in terms of study design, 58.06% of the studies are conducted qualitatively. Quantitative studies are less common (38.71%), while only one study reviewed is classified as mixed (3.23%) (Fig.  4 ).

Type of methodology used

Research into the use of assistive technology applied to any stage of education has been undertaken. Thus, the data show that the educational level with the highest application of assistive technology is secondary education (41.94%), followed by primary education (38.71%). Studies aimed at the university stage are lower (12.90%). In the case of Early Childhood Education, there are very few (6.45%).

Citation analysis is one of the types of research that determine the impact of publications in scientific processes (Cañedo Andalia, 1999 ). In this way, the quality and impact of the research in this field is not yet relevant, because most of the publicationshave received between 0 and 5 citations (70.97%), 19.35% between 5 and 10 citations and only 9.38% have received more than 10 citations.

Benefits of using Assistive Technology for students with disabilities

Among the type of Assistive Technology used for this group of students, we find a wide variety of tools. Among them, the use of Web 2.0 stands out (28.57%), such as the use of social networks, websites, browsers…; mobile learning (25%), among which we find the Tablet, the iPad or the mobile phone; or the use of hardware or software (21.43%) (Fig.  5 ).

Main Assistive Technology for student inclusion

Considering the articles reviewed, these tools are being used mainly with visually impaired students (25%), followed by hearing impaired students (21.43%) and physically impaired students (14.29%). Students with autism (10.71%), intellectual disability (7.14%) or behavioural disorder (3.57%) are less likely to be used. The rest of the publications (17.86%) do not specify the type of disability (Fig.  6 ).

Students using assistive technology

AT provides students with a set of benefits such as inclusion (20.95%) and accessibility (20.95%) to school, as stated by the articles selected in this review. Among other benefits, we find that they improve the teaching-learning process (13.51%), the development of autonomy and independence (18.92%), the acquisition of social skills (11.49%), the participation (9.46%) and the motivation (4.73%) of students (Fig.  7 ).

Benefits of the use of Assistive Technology

Limitations of the use of Assistive Technology with students with disabilities

All the articles reviewed point out the importance of the use of Assistive Technology as a required tool for students with disabilities at school. However, there are still different challenges that schools must overcome in order to apply these tools with their students. Among the main difficulties found, there are mainly the need for teacher training and education (42.86%), as well as the difficulties of access to them (32.14%) (Fig.  8 ).

Difficulties in the use of Assistive Technology

Lines of research on the use of Assistive Technology with students with disabilities

In order to analyse the research topics addressed in the literature in this field, an analysis of the relationships between the automatically extracted keywords or Key Words Plus (KW+) from the 31 studies analysed was carried out using the VOSviewer programme. Using the process of analysing the network map, three main themes were identified through analysis in the data. These were: “AT as an enabler of inclusion and participation” (cluster 1), “barriers to effective use of AT” (cluster 2) and “possibilities and benefits of AT” (cluster 3).

Therefore, a total of 45KW + has been extracted. In Fig.  9 , the 3 groups or clusters can be clearly observed, which have been generated according to the similarity between them. The size of each node and their distance from each other sets the relationship between them.

Labelled bibliometric map

The 3 thematic clusters that defined the main research topics in this field are:

Cluster1: identified in red, this is the main theme on which this study focuses, i.e. the impact of Assistive Technology on the inclusion and accessibility of students with disabilities. It can be noted that this cluster includes terms such as assistive technology, inclusion, technology, resource, impact, software, web, tablet, support, social technology, and robotic.

Cluster 2: it appears in blue, and it is related to the barriers or obstacles that hinder the application of Assistive Technology in education. In this group some of the most prominent elements are teacher training, education, higher education, society, school, context, training, and evidence.

Cluster 3: is shown in green. This group stands out for the benefits of applying these tools to students with educational needs. It also refers to the possibilities offered by Assistive Technology to make accessible education for all. It highlights items such as: autonomy, participation, social skill, access, assistant teacher, inclusive education, motivation, disability, and skill.

On the other hand, we include the bibliometric density map where it is shown the relevance of the analyzed keywords. Therefore, the following cores can be highlighted (Fig.  10 ):

In the middle zone of the map (yellow color) are placed, due to their importance and co-occurrence, those most relevant keywords in the scientific production about Assistive Technology for students with disabilities (student, disability, assistive technology, teacher).

In the peripheral zone of the map (colors that tend to green), evidence shows less interest and level of co-occurrence in the current scientific production (impact, inclusive education, social technology, experience, assistant teacher).

Bibliometric map tagged

Discussion and conclusions

This review explores the impact of scientific production related to Assistive Technology on the inclusion of students with disabilities published between 2009 and 2020. According to our findings, these tools emerge as suitable instruments for both accessibility and inclusion of students, as well as for meeting their educational needs during their learning process (Clouder et al., 2019 ; Satsangi et al., 2019 ).

Thus, among the papers reviewed, several noteworthy findings will be discussed, in response to the research questions proposed in this study. First, considering the first question on trends in scientific production over time (RQ1), we can mention that there are possible trends and indications that suggest an increase in the use of AT in education in the last few years. Research in this field over the last decade is not very relevant; however, from 2017 to the present, a progressive increase has taken place. We can also highlight that the impact and repercussion of these studies is not very high, since most of the articles have a very low citation rate. The more frequently a paper is cited, the more often the scientific community recognises the influence or impact of the cited topic (Cañedo Andalia, 1999 ). The scarce existence of scientific literature and its low impact is one of the main problems that may hinder the implementation of these tools in the classroom, because this field is underdeveloped. Similarly, the limited existence of scientific literature on the use of AT for the care of students with disabilities makes it difficult to answer the research questions posed. Even so, the findings help us to lay the foundations for working to improve the education of these people, both by offering technological solutions and by working on training and awareness-raising in this regard (Molero-Aranda et al., 2021 ).

With respect to the countries that concentrate the greatest scientific production in this field, it should be said that AT is of world-wide attention, so that AT research has been developed in different countries, mainly in the United States, followed by Brazil and Turkey. This fact enables a reflection on future research in order to know if the country and its context affect the use of these technologies for the inclusion of students.

In relation to the research designs that prevail in the studies analyzed, it should be noted that these mainly show a qualitative approach, with observation and interviews prevailing as data instruments, followed by quantitative ones.

The second research question (RQ2), related to the results of using AT with students with disabilities, aims to synthesise the positive impacts in terms of the improvements or benefits they bring to students. AT has a significant impact on academic engagement. The use of these tools was found to improve the academic performance of students with disabilities (Fortes Alves & Pereira, 2017 ; Tamakloe & Agbenyega, 2017 ; Bouck et al., 2020 ; Sivakova, 2020 ). Some articles also reported the benefits of AT for the development of autonomy and participation (Harper et al., 2017 ; Mercado de Queiroz & Presumido Braccialli 2017 ; McNicholl et al., 2020 ). The results show an increase in the acquisition of social skills (Ari & Inan, 2010 ; Murry, 2018 ). Finally, it is worth mentioning that these tools promote motivation and increase students’ attention (Paula, 2003 ; Arpacik et al., 2018 ; Bondarenko, 2018 ). The results analysed point out that there are different types of Assistive Technology used according to the functionality that they want to provide, highlighting mainly the use of Web 2.0. Although there are still digital gaps, most schools and teachers have access to the Internet which means that they can use this available and low-cost resource, and it can support both student inclusion and learning (Lyner-Cleophas, 2009; Kamali Arslantas et al., 2019 ; Ok & Rao, 2019 ). Mobile learning also stands out (25%), including the iPad or smartphone. These devices are very useful because they are small and portable, and they enable the installation of relevant applications for these students (Ismaili & Ibrahimi, 2017 ; Brinsmead, 2019 ), a fact that has resulted a trend in the use of these tools in recent years, agreeing with previous studies (Fichten et al., 2014 ). In this way, we can outline that the most generic resources are mainly used (McNicholl et al., 2020 ). The use of other useful resources to encourage the participation of this group of students using hardware or software should also be highlighted (21.43%) (Emcarnaçao et al., 2017 ).

These tools are mainly relevant for visually impaired students, followed by hearing impaired and physically handicapped students (Quinn et al., 2009 ; Ferreira et al., 2013 ; Ismaili & Ibrahimi, 2017 ). Thus, it can be stated that AT is successful and necessary to ensure the inclusion of this population in the classroom; however, although it has many benefits for all students, its use also involves challenges and barriers associated with the use of AT in the classroom. These barriers can hinder the effective use of AT.

In this regard, in response to the third research question (RQ3), all articles identified situations where AT cannot be used effectively. These include inadequate training in the use of ATs with learners with disabilities by teachers or difficulties in accessing these tools (Copley & Ziviani, 2004 ; Johnstone et al., 2009 ; Coleman et al., 2015 ; Alammary et al., 2017 ; Ismaili & Ibrahimi, 2017 ; Byrd & León, 2017 ). Teacher training in AT is related to improved student academic performance by being able to select the most appropriate tool to meet the needs of their students (Jones & Hinesmon-Matthews, 2014 ; Laloma, 2005 ; Malcolm & Roll, 2017 ; Yankova, 2019 ). Difficulties of access hinder the implementation of AT in education. These are mainly associated with economic factors, lack of adequate supports or lack of funding (McNicholl et al., 2019; Atanga et al., 2020 ).These tools may effectively support student inclusion by providing adaptations, but their high cost, because some resources such as the iPad are quite expensive, limits their access to wealthier consumers (Flanagan et al., 2013 ; Koch, 2017 ; Brinsmead, 2019 ). As a result, it is clear that rural areas have less resources and greater difficulties to access them than urban areas (Davis et al., 2013 ).

The main research topics in this field (RQ4) taking into account both the review of the articles and the analysis of the bibliometric maps helped to identify the different main topics involved within this field of research. Firstly, the importance of the use of AT as a facilitating element for school inclusion is highlighted, providing access for all students to education, including those with some kind of disability or educational need. Secondly, it highlights the benefits of implementing Assistive Technology with students with disabilities. Finally, it is related to the barriers or obstacles that hinder the application of Assistive Technology in the education of students with disabilities. As well as the possibilities offered by Assistive Technology to access education for the whole population. Research and applications of the use of assistive technology with learners with disabilities have been conducted around the world. However, despite these efforts, it has not been possible to integrate the appropriate tools to satisfy the main needs of these students. This review has identified important directions for future research and possible ways in which schools should consider integrating AT into the learning of students with disabilities. Teachers have a primary role in promoting the use of ATs, therefore, in order to achieve inclusion of students with disabilities, teacher need to acquire the necessary skills and competences (De Sousa, 2014 ; Roque, Perreira, Neto & Macario, 2018 ; Ahmed, 2020 ; Viana & Fontoura Teixeira, 2019 ; Arori, Al Attivah, Dababneh & Hamaidi, 2020 ). The results show that many of the generic devices (smartphones, digital board...) are used as AT, due to the fact that many offer accessibility features. Looking ahead, it is a need to integrate universal design into teacher technology training to maximise the benefits for all learners (Messinger-Willman & Marino, 2010 ).

Implications for further research

The limitations found have been addressed taking into account the results of this review because, although it has been possible to note how current research in this field is developing worldwide, it would be useful to identify the most appropriate AT to meet the needs of students according to their disabilities, as well as to promote training plans for teachers in order to implement these tools properly in the classroom.

In this way, researchers should explore the use of AT in relation to the type and degree of disability of learners. In this sense, it is also necessary to investigate effective teaching and learning strategies for these learners. In order to do so, it is necessary for teachers to have an adequate level of training, so that they can apply these tools in the classroom.

Limitations

A limitation of this paper is that the selection of the articles analyzed is restricted to the databases selected by the authors, although they are the most important for the educational scientific community. Therefore, in future research it would be desirable to study this topic with a wider and more extensive scope, including other articles from journals indexed in other databases with less scientific recognition, but which may include good practices.

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Fernández-Batanero, J.M., Montenegro-Rueda, M., Fernández-Cerero, J. et al. Assistive technology for the inclusion of students with disabilities: a systematic review. Education Tech Research Dev 70 , 1911–1930 (2022). https://doi.org/10.1007/s11423-022-10127-7

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PERSPECTIVE article

Intellectual disability and assistive technology: opening the gate wider.

• 1 Centre for Global Health and School of Psychology, Trinity College Dublin, Dublin, Ireland
• 2 Centre for Practice and Healthcare Innovation, Trinity College Dublin, Dublin, Ireland
• 3 GATE Group, Essential Medicines & Health Products, World Health Organization, Geneva, Switzerland
• 4 Centre for Rehabilitation Studies, Stellenbosch University, Stellenbosch, South Africa
• 5 Olomouc University Social Health Institute, Palacky University, Olomouc, Czech Republic

The World Health Organization has launched a program to promote Global Cooperation on Assistive Technology (GATE). The objective of the GATE program is to improve access to high quality, affordable assistive technology for people with varying disabilities, diseases, and age-related conditions. As a first step, GATE has developed the assistive products list, a list of priority assistive products based on addressing the greatest need at population level. A specific group of people who can benefit from user appropriate assistive technology are people with intellectual disabilities. However, the use of assistive products by people with intellectual disabilities is a neglected area of research and practice, and offers considerable opportunities for the advancement of population health and the realization of basic human rights. It is unknown how many people with intellectual disabilities globally have access to appropriate assistive products and which factors influence their access. We call for a much greater focus on people with intellectual disabilities within the GATE program. We present a framework for understanding the complex interaction between intellectual disability, health and wellbeing, and assistive technology.

Only 10% of the people who are in need of assistive products actually have access to them, despite such access being claimed to be a human right ( 1 , 2 ). An assistive product is any product (including devices, equipment, instruments, and software), either specially designed and produced or generally available, whose primary purpose is to maintain or improve an individual’s functioning and independence and thereby promote their wellbeing ( 3 ). Common examples of assistive products are spectacles, hearing aids, wheelchairs, prosthetics, communication boards, incontinence products, pill organizers, and therapeutic footwear. Assistive products can improve the quality of life for people with impairments, including the extent of their inclusion and participation in society. However, the use of assistive products by people with an intellectual disability (ID) is a neglected area of research and practice and offers considerable opportunities for the advancement of population health and the realization of basic human rights. About 1% of the total population have ID, with higher prevalence rates in low- and middle income countries ( 4 ). ID is defined by the American Association on Intellectual and Developmental Disabilities, the Diagnostic and Statistical Manual of Mental Disorders V, and the International Classifications of Diseases 10 (mental retardation) as an IQ below 70, manifested during the developmental period (<18 years of age), with impairments in adaptive functioning, such as communication skills, social skills, personal independence, school, or work functioning ( 5 – 7 ).

The World Health Organization has launched a program to promote Global Cooperation on Assistive Technology (GATE) to implement those parts of the United Nations Convention on the Rights of Persons with Disabilities referring to assistive technology ( 3 , 8 , 9 ). The GATE program’s objective is to improve access to high quality, affordable assistive products for people with varying disabilities, diseases, and age-related conditions. As a first step, GATE has developed the assistive products list (APL) of priority assistive products to address the greatest needs at population level ( 10 ). To be effective, the APL will require countries to develop national assistive technology policies; source appropriate products; train specialized personnel; and develop effective and efficient systems of provision ( 10 ).

However, barriers that people with ID experience regarding access to assistive products have not yet been sufficiently considered. Worldwide, people with ID are still generally regarded as a devalued and stigmatized group, and at least part of their relatively poor health status is due to health inequities. People with ID are still often disadvantaged when attempting to access or secure health services and assistive products ( 11 , 12 ). It is unknown what proportion of people with ID globally actually has access to appropriate assistive products. It has been suggested that for people with ID there is a high rate of underdiagnosis and misdiagnosis; so that too often they do not receive the correct treatment and that the need for rehabilitation arises as a result of absent or ineffective health care ( 13 ). The atypical presentation of symptoms by people with ID is often a challenge for their care system. With accurate assessment and appropriate interventions, the use of assistive products can be not only enabling and empowering, but also transformative in facilitating new life skills and opportunities for people with ID.

Compared to the general population, people with ID have a higher prevalence of comorbidities which could be better managed with assistive products (see Figure 1 ). For instance, motor disabilities are present in a significant proportion (26%) of people with ID ( 14 ). Visual impairment has a prevalence of 19.2% in adults with ID compared to 1.9% in adults of the general population. For hearing impairment, the prevalence is 30 vs 17%, respectively; and for dementia, it is 13.1 vs 5.4%, respectively ( 15 ). People with ID are now recognized as a group with a disproportionately greater need for assistive products due to higher rates of frailty and multimorbidity (including increased severity and earlier onset) than the general population ( 16 , 17 ). The result is a greater prevalence of disabilities in daily functioning and mobility with increased care needs and support required ( 18 – 20 ). Multimorbidity (the presence of two or more chronic conditions) is of particular concern with an 80% prevalence rate in adults >50 years with ID ( 17 ). Besides the association with age, multimorbidity, and frailty are also associated with a severe and profound level of ID ( 16 , 17 ). The life expectancy of people with ID is increasing in line with the general population trends. Therefore, the prevalence of older people with ID is also likely to increase along with the demand for access to assistive products ( 21 ).

Figure 1. Factors related to the use of assistive technology by people with intellectual disabilities .

Access to assistive products presents three distinct challenges if people with ID are going to benefit from the increased provision aspired by GATE (see Figure 1 ). First, impairments in cognitive and adaptive functioning intrinsic to ID should be adequately catered for within population-level systems of assistive technology policy, products, health care personnel, caregivers, and provision. That means, communication skills and physical examinations by health care personnel need to be adapted to the intellectual and emotional level of the person with ID, to get the correct diagnosis and ensure the appropriate assistive product(s) are prescribed. The use of assistive products requires information, instruction, and support that are both accessible and understandable to the person with ID, if it is to be used effectively. In addition, a multidisciplinary approach to develop protocols for the training and support of people with ID is needed in order to direct the effective use and evaluation of the assistive products. For example, hearing aids require a customized habituation training program adjusted to an individual’s level of ID. This needs to be implemented in collaboration with the speech and language therapist, behaviorist, and caregiver together to help the person with ID to accept and benefit from the use of the new product.

A second challenge for people with ID to benefit from the APL is increased awareness among caregivers and health personnel of comorbidities that people with ID often experience; such as sensory impairments and dementia. These comorbidities may require the use of assistive products, and so the needs of the users with ID must be more often taken into account.

Third, people with ID will experience physical impairments not necessarily associated with ID, which are equally common in other sections of the population. For instance, a person with ID may need to learn to use a prosthesis or walking aids and—as above—the effective use of such products requires information, instruction, and support that is as accessible and understandable as possible. While it is known that the use of assistive products, such as a prosthesis, is influenced by a range of psychosocial factors, such research derives almost exclusively from users of assistive products without ID ( 22 , 23 ).

Without a concerted and systematic approach to consider the challenges that ID presents, for the users, caregivers, and providers of assistive products, profound inequities in health, in life opportunities, and therefore in the quality of life for people with ID will persist. We call for a much greater focus on people with ID within the GATE program and in particular regarding national initiatives to adopt the APL.

Author Contributions

FB: substantial contributions to the conception and design of the work; drafting the work; final approval of the version to be published; agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. JD, CK, and MM: substantial contributions to the conception and design of the work; revising the work critically for important intellectual content; final approval of the version to be published; agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Conflict of Interest Statement

The authors alone are responsible for the views expressed in this article and they do not necessarily represent the views, decisions or policies of the institutions with which they are affiliated. None of the authors have any competing interests in the manuscript.

The reviewer DB and handling Editor declared their shared affiliation, and the handling Editor states that the process nevertheless met the standards of a fair and objective review.

This research was supported by funding from the charity RESPECT and the People Programme (Marie Curie Actions) of the European Union’s Seventh Framework Programme (FP7/2007-2013) under REA grant agreement no. PCOFUND-GA-2013-608728.

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Keywords: intellectual disabilities, assistive technology, assistive devices, global health, public health policy, health inequality, World Health Organization

Citation: Boot FH, Dinsmore J, Khasnabis C and MacLachlan M (2017) Intellectual Disability and Assistive Technology: Opening the GATE Wider. Front. Public Health 5:10. doi: 10.3389/fpubh.2017.00010

Received: 08 December 2016; Accepted: 19 January 2017; Published: 22 February 2017

Reviewed by:

Copyright: © 2017 Boot, Dinsmore, Khasnabis and MacLachlan. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Fleur Heleen Boot, bootf@tcd.ie

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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Original research

Impact of digital assistive technologies on the quality of life for people with dementia: a scoping review, charlotte schneider.

1 Department of Management, Technology and Economics, ETH Zürich, Zurich, Switzerland

Marcia Nißen

2 University of St. Gallen, St. Gallen, Switzerland

Tobias Kowatsch

3 Institute of Technology Management, University of St. Gallen, St. Gallen, Switzerland

4 Institute for Implementation Science in Health Care, University of Zurich, Zurich, Switzerland

Rasita Vinay

5 Institute of Biomedical Ethics and History of Medicine, University of Zurich, Zurich, Switzerland

Associated Data

bmjopen-2023-080545supp001.pdf

bmjopen-2023-080545supp002.pdf

bmjopen-2023-080545supp003.pdf

bmjopen-2023-080545supp004.pdf

Data are available in a public, open access repository. All data relevant to the study are included in the article or uploaded as supplementary information.

Digital assistive technologies (DATs) have emerged as promising tools to support the daily life of people with dementia (PWD). Current research tends to concentrate either on specific categories of DATs or provide a generic view. Therefore, it is of essence to provide a review of different kinds of DATs and how they contribute to improving quality of life (QOL) for PWD.

Scoping review using the framework proposed by Arksey and O’Malley and recommendations from Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews.

Data sources

Cochrane, Embase, PubMed, Scopus and Web of Science (January 2013 to May 2023).

Eligibility criteria for selecting studies

Completed scientific literature with a primary focus on DATs for PWD, perspectives of caregivers, family members or healthcare workers in relation to a PWD, people living in diverse settings and all severities of dementia.

Data extraction and synthesis

Screening and data extraction were conducted, followed by quantitative and qualitative analyses using thematic analysis principles and Digital Therapeutics Alliance categories for DAT grouping.

The literature search identified 6083 records, with 1056 duplicates. After screening, 4560 full texts were excluded, yielding 122 studies of different designs. The DATs were categorised into digital therapeutics (n=109), patient monitoring (n=30), digital diagnostics (n=2), care support (n=2) and health system clinical software (n=1). These categories were identified to impact various aspects of QOL: preserving autonomy, engagement, and social interaction, health monitoring and promotion, improving activities of daily living, improving cognition, maintaining dignity, managing behavioural and psychological symptoms of dementia and safety/surveillance.

Conclusions

Various DATs offer extensive support, elevating the QOL of PWD. Digital therapeutics are predominantly used for ageing-in-place and independent living through assistance with daily tasks. Future research should focus on less-represented digital health technology categories, such as care support, health & wellness or software solutions. Observing ongoing DAT developments and their long-term effects on QOL remains essential.

Strengths and limitations of this study

• The study conducted an extensive search across five electronic databases spanning a decade to identify relevant literature on digital assistive technologies (DATs) and their impact on the quality of life (QOL) for people with dementia.
• By excluding conference proceedings, book chapters, pilot and feasibility studies, the review might have missed ongoing or planned research that could offer insights into different DATs or QOL impacts.
• While the scoping review approach allowed for a broad overview, it did not assess the quality of included studies or intervention effectiveness, potentially introducing bias and limiting in-depth analysis.
• The study’s emphasis on patient-facing DATs could have introduced bias, highlighting digital therapeutics in the included literature while potentially overlooking other assistive technology categories.

Introduction

In 2023, more than 55 million individuals worldwide are affected by dementia, with approximately 10 million new cases diagnosed yearly. 1 Dementia encompasses various impairments regarding language, memory, cognition and the ability to perform daily activities. 1 It progressively worsens over time and primarily affects individuals over 65, however can also affect those younger than 65, known as young onset dementia. 1 Globally, dementia currently ranks as the seventh leading cause of death, significantly contributing to disability and dependency among the older population. 1 The changing demographic landscape presents difficulties for caregivers and our healthcare system. As a result, there is a growing focus on using digital assistive technologies (DATs) to address these challenges and help sustain the independence of people with dementia (PWD). 2

DAT is an umbrella term covering technologies used for education and rehabilitation, to overcome participation and activity restrictions, and to improve cognitive, sensory and motor abilities. It encompasses any technology that empowers individuals with functional constraints in everyday routines, educational pursuits, occupational endeavours or recreational engagements. 3 DATs offer a valuable means for individuals and caregivers to manage various aspects of their daily routines effectively. They hold great promise for the care and support of PWD, and to alleviate the challenges associated with caregiving, such as maintaining autonomy and dignity. 4 Here, autonomy can be understood as the principle for self-governance and decision making, where capacity is closely related to consent. However, as PWD progress along their dementia journey, their decision-making capacity may start to be impacted, and therefore maintaining dignity shifts as the greater value. Therefore, both these concepts require a commitment from caregivers in order to provide a quality of care, and hence also form important considerations from rising DATs.

Recently, technological advancements have paved the way for creating devices and applications that leverage sensory data tailored specifically for PWD. Notably, smartphones and wearables are now being employed to track physical activities, enabling in-home care assistance 4 and serving as location trackers for monitoring wandering behaviour. 5 Moreover, the emergence of artificial intelligence has led to the development of social assistive robots. These robots are designed to provide companionship and engage in therapeutic activities, such as the robotic seal Paro, which serves as an illustrative example. 6 These technologies extend beyond basic assistance with daily tasks; they also contribute to the preservation of social interactions, memory support, participation in leisure activities, location tracking and health monitoring. 2 7

Maintaining a good quality of life (QOL) is essential for PWD and must be considered when assessing the impact of DATs. QOL encompasses physical and mental well-being and extends to social and emotional dimensions (eg, emotional stability, social integration or self-esteem). 8 Various tools such as questionnaires and self-assessment scales measure the overall perceived QOL; activity-based assessments or cognitive status evaluations serve as diverse means for quantifying QOL. 9 Consequently, these measures and evaluation instruments should be regarded as guiding tools in determining the QOL experienced by PWD.

While the current literature focuses on specific classes of DATs, often highlighting particular outcomes, there is a lack of a comprehensive overview of the different DATs and their impact on the QOL of PWD. This scoping review aims to fill this gap.

The primary aim of this scoping review is to provide an overview of DATs for PWD and the ways in which they influence an individual’s QOL. Therefore, the following research question was formulated: ‘What is the impact of DATs on the QOL for people with dementia?’

In this scoping review, the opportunities of DATs and their role in enhancing caregiving practices and the QOL of PWD were investigated. Through a compilation of prevailing literature, this review can enhance the decision-making process by facilitating stakeholders’ comprehension of the spectrum of accessible DATs and their efficacy in effectively elevating the QOL as a secondary objective.

Search strategy

The methodological framework proposed by Arksey and O’Malley 10 and the recommendations from PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation 11 were adopted to conduct this scoping review. A protocol for the scoping review was published on 13 December 2023 12 and the study was preregistered on the Open Science Framework Registry on 5 May 2023 ( https://osf.io/zcnx8/ ).

Search terms were derived from a preliminary search and analysed by comparing the words found in titles, abstracts and keywords, following a ‘patient/population, intervention, outcome’ (PIO) concept. Additionally, to enhance the accuracy and comprehensiveness of the search results, all authors were involved in a consensus process, and an additional expert was consulted to validate the identified terms and suggest any additional relevant keywords. A comprehensive search was performed on 17 May 2023 across five electronic databases: Cochrane, Embase, PubMed, Scopus and Web of Science, to locate published literature surrounding the research question. To focus on recent technological advancements, only articles published between 1 January 2013 and 17 May 2023 were considered, allowing for a more up-to-date review. The search terms using the PIO table and full electronic search strategy can be seen in online supplemental file 1 .

Supplementary data

Inclusion and exclusion criteria

The articles were screened following specific inclusion and exclusion criteria, established by all authors and consolidated by an additional expert. Table 1 shows the eligibility criteria to ensure the relevance of the included studies to the research question.

DATs, digital assistive technologies; PWD, people with dementia.

Screening, data extraction and analysis

The search results were extracted and uploaded onto a literature review software, Rayyan ( www.rayyan.ai ) for screening. From May to June 2023, CS and RV screened all eligible articles’ titles and abstracts to determine their suitability for a full-text review according to the inclusion and exclusion criteria. Potential discrepancies were discussed between the authors and resolved through discussion and consensus. CS piloted the data extraction using five articles; checked and consulted by RV. An example of the data extraction form is described in online supplemental file 2 . A full-text review of the final sample of included studies was conducted by CS and further consolidated by RV. A critical appraisal of individual sources of evidence was not done for this scoping review as it is beyond the scope of this article.

A narrative synthesis accompanied by frequency analysis was performed of the included literature to present findings on (1) author locations, (2) study approach, (3) type of article (4) study locations, (5) digital health technology (DHT) categories (see Coding strategy), (6) target population and (7) instruments measuring QOL. The QOL measures were initially evaluated according to the protocol. 12 Based on a pilot of the extraction of the articles, it became obvious that there was rarely one distinct ‘QOL instrument’ used throughout all articles. However, these metrics were discovered to be excessively diverse and unsuitable to be reported consistently, leading to their omission. Instead, indirect outcomes, which also influence the QOL, were additionally recorded (eg, activity instruments, cognitive status, rating of the individual’s QOL, etc 9 ). Furthermore, the protocol outlined the analysis of the type of DATs and sensory distribution channels. 12 During the extraction of the articles, it became evident that the type of DATs and sensory distribution channels would not provide consistent reporting across the studies, and were instead replaced with DHT categories. Several studies discussed different DATs employing distinct sensory distribution channels, making it impossible to provide a uniform report, resulting in their exclusion.

Coding strategy

The codes for QOL measures/outcomes were generated by CS and RV based on thematic analysis. 13 The Flanagan Quality of Life Scale served as the basis for the code, which forms the general ideas about concepts for evaluating the QOL. 14 In addition, QOL scales such as QOL-AD and DQOL were explored to identify relevant concepts for PWD. 15 Physical, social and environmental concepts were also included to have a broader impact on QOL than just health-related QOL. 16 Ethical considerations were integrated into the coding strategy by drawing on principles of biomedical ethics (ie, dimensions such as autonomy and dignity). 17 Furthermore, it should be noted that the priorities of these principles may shift as an individual’s dementia progresses. For instance, autonomy might be more important for individuals with mild dementia, while maintaining dignity becomes paramount for those with severe dementia. This consideration enabled providing a holistic overview of QOL dimensions across all stages of dementia, aligning with the evolving ethical dimensions of care. CS applied the codes to the articles using the ATLAS application ( www.atlasti.com ), and uncertainties were resolved by RV.

All the included studies were initially categorised using an inductively created classification scheme. However, it became apparent that this method was inadequate for representation purposes. Subsequently, the classification scheme was deductively realigned with the Digital Therapeutics (DTx) Alliance categories, and all the studies were reclassified accordingly.

The DTx Alliance introduced eight (industry-facing and admin-facing, healthcare provider and patient-facing) DHT categories: non-health system software/digital health solutions, health system operational software, health system clinical software, health & wellness, patient monitoring, care support, digital diagnostics and digital therapeutics. 18 To apply these categories to the included studies, some of the definitions were adapted (see table 2 for an adapted version of the definitions):

The eight DHT categories with their adapted definitions and examples

Source: DTx Alliance ( https://dtxalliance.org ). 18 141

DH, digital health; DHT, digital health technology; HIT, health information technology.

• Initially, the patient monitoring category exclusively monitored specific patient health data. However, in the context of this scoping review, location data were included as well to be able to classify studies that discuss tracking devices.
• Only studies explicitly mentioning self-management or similar concepts were assigned to the care support category. Otherwise, nearly all papers would qualify for this category, as they predominantly aim to assist patients in various ways.
• The criteria for the digital therapeutics category have been refined and a broader range of digital technologies was encompassed that generate and deliver medical interventions, while the initial definition pertained to ‘health software designed to treat or alleviate a specific disease or medical condition by generating and delivering a medical intervention’. 18 It is important to note that not all of them qualify as medical devices or products, and may not be subject to regulation based on the adapted definition for the purpose of this scoping review.

Patient and public involvement

Patients and/or public were not involved in this research.

Search findings

The search identified 6083 records from the electronic databases. A total of 1056 duplicates were identified and removed, leaving 5027 articles and trial records to be screened. Title and abstract screening led to the exclusion of 4560 records, resulting in 467 full texts that needed to be assessed for eligibility. Of these, 122 studies were included (see online supplemental file 3 ) and 345 were excluded for the following reasons: 72 did not focus only on PWD or their results could not be separated (wrong population), 69 had the wrong design and 59 pursued wrong aims or outcomes, 42 were the wrong publication type or language (ie, editorials, book chapters, protocols, news articles, non-English), 30 were only trial registry records, 26 could not be accessed, 25 were either pilot, feasibility or usability studies which only tested the viability of intervention, 12 did not deal with QOL and 10 did not include DATs. These are reported in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses flowchart in figure 1 .

PRISMA flow chart. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses; QOL, quality of life.

Characteristics of included studies

Scientific literature from 1 January 2013 to 17 May 2023 was included to capture the most recent findings. Figure 2 represents the number of articles published for each year in the date range included for this scoping review.

The graph displays the trend of the number of studies published per year.

The authors’ location was collected for each study, ensuring unique country attribution per study while capturing all countries affiliated with each author. There were 180 entries recorded. The countries with the highest number of entries were the UK (n=38, 21.1%), Australia (n=17, 9.4%), the USA (n=14, 7.8%), Canada, China and Norway (n=11, 6.1% each). Notably, European countries showed significant numbers of contributions, including Germany and the Netherlands (n=8, 4.4% each). Sweden and Italy (n=6, 3.3% each) and France (n=4, 2.2%). From the Asian and Oceania continent, contributions were made by Japan (n=6, 3.3%), Taiwan and South Korea (n=5, 2.8% each), New Zealand and Singapore (n=3, 1.7% each), Pakistan and Qatar (n=2, 1.1% each) and India, Indonesia and Malaysia (n=1, 0.6% each). From the African continent, there were only contributions from South Africa (n=4, 2.2%). Some countries, such as Brazil, Cyprus, Czech Republic, Denmark, Greece, Malta, Portugal, Spain and Switzerland, had limited representation, with only 1–2 (0.6%, 1.1%, respectively) contributions each ( figure 3 ).

Distribution of the authors’ locations. The countries are coloured based on the number of country attribution, while encompassing all countries associated with each author.

A variety of study designs were used in the included studies ( figure 4 ), comprising of 56 (46%) reviews, 16 (13%) randomised controlled trials (RCTs), 15 (12%) case studies, 13 (11%) intervention studies, 8 (6%) pilot or feasibility studies, 5 (4%) interviews/surveys, 5 (4%) trials, 2 (2%) cohort studies and 2 (2%) observation studies.

The distribution of the study designs. RCT, randomised controlled trial.

In total, there were 36 (30%) quantitative studies, 52 (43%) qualitative studies and 34 (28%) that adopted a mixed-methods approach.

The study locations were diverse with 73 different study locations identified. The highest number of studies was carried out in the UK (n=15, 20.5%), followed by Australia (n=9, 12.3%), the USA (n=7, 9.6%), Sweden (n=6, 8.2%) and Norway (n=5, 6.8%). Other locations included Canada, Italy and the Netherlands (n=4, 5.5% each), Denmark and France (n=3, 4.1% each) and Japan and Taiwan (n=2, 2.7% each). There was one study (1.4%) each from China, Cyprus, Germany, Ghana, Greece, Korea, New Zealand, Singapore and Spain. Within these locations, different study settings were used; home-based (n=25, 33.8%), residential care (n=10, 13.5%), long-term care and nursing homes (n=9, 12.2% each), daycare centres (n=7, 9.5%), community-based and hospital (n=4, 5.4% each), other care facilities or memory clinics (n=3, 4.1% each) and a laboratory setting (n=1, 1.4%).

Diverse target groups of the included studies were identified, as presented in table 3 . As indicated in the review process and as part of the exclusion criteria, only research articles that could separate results for PWD from other comorbidities or conditions were included.

The different target groups of the included studies sorted by the number of studies

The frequency of each class is indicated (as the number of studies), along with the corresponding references.

MCI, mild cognitive impairment; PWD, people with dementia.

Characteristics of DATs

Categories of dats.

The DATs of the 122 included studies underwent classification into the DHT categories provided by the DTx Alliance. 18 Some studies discussed different DATs and therefore were assigned to multiple categories due to their varying applicability (see table 4 ).

The different classes of DATs

The frequency of each category is indicated, along with the corresponding references.

DATs, digital assistive technologies; DH, digital health; DHT, digital health technology.

Qualitative aspects of QOL

Positive impact of dats on qol dimensions.

Through qualitative analysis of the included studies, recurring themes were identified that reflect the different aspects of how DATs influence QOL for PWD: preserving autonomy, engagement and social interaction, health monitoring and promotion, improving activities of daily living (ADL), improving cognition, maintaining dignity, managing behavioural and psychological symptoms of dementia (BPSD) and safety/surveillance ( online supplemental file 4 ). These concepts can influence each other, and it is possible for a single DAT to simultaneously have multiple effects. In the following sections, these impacts will be discussed in more detail based on the analysis of the included studies.

Preserving autonomy

Autonomy can be understood as an individual’s ability to be involved in decision making, consent, receiving treatment or intervention (ie, to choose and act independently without coercion). 17 Within healthcare, the preservation of autonomy has emerged as a significant topic, most importantly known as the principle of respect for autonomy. DATs can be seen as a useful tool for promoting autonomy and, therefore, positively contributing to PWD’s lives. The use of DATs is intended to increase the capacity of an individual to participate in decision making 19 20 and promote independent living, and enable ageing-in-place. 21

From 50 of the included studies, the following were used to promote autonomy: patient monitoring, 19–44 care support 30 45 and digital therapeutics. 8 21–23 25–31 33 35 37 40 41 44–65

Engagement and social interaction

The topic of engagement and social interaction was highlighted in 64 studies. They differentiated between cases where DATs increased social interaction 23 31 40 54–56 58 64 66–83 and fostered higher engagement (ie, in therapy settings). 8 20 23 31 44 45 53 55 61 63–65 68 69 71–73 77 79 82 84–113

Sixty-two of the included studies demonstrated that digital therapeutics play a significant role in promoting social interaction and engagement, 8 23 31 40 44 45 53–56 58 61 63–75 77–113 including other DATs from the patient monitoring 40 and care support categories. 30 45

Health monitoring and promotion

Health monitoring refers to monitoring bodily functions and reporting their states or imbalances. Ten studies reported using DATs to monitor and promote health for PWD. 21 23 30 32 37 40 41 46 56 114 This was achieved, for example, through social assistive robots 56 and wearables, 32 including wristwatches that measure movement, skin temperature and pulses. 37

Improving ADL

DATs support PWD in maintaining or regaining their ability to perform ADL such as meal preparation, managing medication or communication. Forty-five of the included studies highlight this field’s broad spectrum of possibilities, for instance, they range from the implementation of interventions from the patient monitoring category, 20 24 26 29 31 33 34 40 43 care support, 30 45 to digital therapeutics. 8 22 25 26 28–31 33 35 37 40 45–53 55–63 65 86 94 97 103 107 115–119

Improving cognition

The varied application of DATs can enhance cognitive abilities, as indicated by 34 studies. They demonstrated that patient monitoring, 43 care support 30 45 and digital therapeutics 21–23 26–28 30 31 40 45 46 53–55 65 71 75 83–85 90 95 98 103 115–117 119–124 can lead to improvements in cognitive functioning.

Maintaining dignity

In contrast to autonomy, dignity refers to the ability to preserve self-respect and personhood, while being recognised and valued in society, and discussed in 13 studies using diverse DAT categories: digital therapeutics 21 25 35 41 and patient monitoring. 8 21 22 25 35 41 56 58 62 77 78 81 108 These categories are specifically designed to uphold and promote ageing in place, as demonstrated in the review of Gettel et al , 21 by the use of pet robots to maintain the resident’s dignity and self-worth. 78

Managing BPSD

There are 12 BPSD, which include aberrant motor behaviour, agitation, anxiety, apathy, appetite changes, delusions, depression, disinhibition, elation/euphoria, hallucinations, irritability and sleep changes. 125 Different BPSD were shown to be managed by DATs in 64 studies through digital therapeutics 8 23 26–28 30 40 41 48 55 60 67–72 75 77 78 81–86 88 89 91–93 95 97–102 104 105 107 109 111–113 115–117 120 122–124 126–136 or by patient monitoring devices. 30 48 69 86 93 98 133 All the DATS were reported to have a positive effect on BPSD.

Safety/surveillance

Thirty-four of the included studies demonstrated that DATs can enhance the safety of PWD, for instance through patient monitoring, 19–31 33–44 46 88 137 138 care support 30 and digital therapeutics. 21 23 25–27 29–31 37 44 49 53 56 62 71 138

Negative impacts of DATs on QOL dimensions

Among the included studies, 18 studies reported negative impacts of DATs on the QOL. 8 25 38 41 53 55 56 60 61 63 65 81 97 101 104 120 127 130 ‪These negative impacts included increased anxiety, 8 81 97 worsened agitation, 127 decreased interactions with caregivers, 55 confusion, 53 worsened BPSD, 31 53 127 increased hallucinations and decreased mood, 53 anxiety towards the technology, 8 75 81 as well as aggression, rejection or disliking the technology. 81

Instruments measuring the QOL

As demonstrated, DATs can diversely impact aspects of QOL. It was observed that numerous studies employ specific measures to assess these impacts, which can manifest in various forms. During the charting process, 33 studies revealed the utilisation of different units of measurement in this context. In 18 studies, the Quality of Life in Alzheimer’s Disease Scale (QOL-AD ) was used, 8 22 41 48 55 67 71 77 92 95 97 105 110 112 115 122 127 130 and in 11 studies, the Quality of Life in Late-Stage Dementia scale (QUALID ). 8 27 60 70 71 77 97 112 126 127 134 Additionally, the self-reported Dementia Quality of Life measure (DEMQoL ) was employed in 4 studies, 60 79 97 114 the Dementia Quality of Life Instrument (DQoL ) in 3 studies 27 28 71 and the EQ-5D-5L in 3 studies. 60 62 124 Other measuring instruments were used only once in each case: Quality of Life (GQL8 ), 119 Quality of Life for People with Dementia (QUALIDEM ), 71 Quality of Life Alzheimer’s disease (QoL) scale , 117 SF-36 quality of life instrument , 32 Cantril QoL ladder , 93 Carer-Qol-7D, 79 EUROHIS-QoL-8 and EuroQoL 5 Dimension Questionnaire . 8

This scoping review and synthesis of 122 studies provided a detailed mapping of the different kinds of DATs available which target QOL for PWD, and the diverse study designs contributing to the research community. This is particularly useful for future researchers to identify whether certain designs (ie, reviews, n=56) have been more extensively explored than others (ie, RCTs, n=16; case studies, n=15), encouraging more empirical evidences to be reached in order to truly understand the effects of DATs in improving the QOL of PWD.

DATs were categorised into the DTx Alliance categories, with the largest category being digital therapeutics (n=109), followed by patient monitoring (n=30), digital diagnostics (n=2), care support (n=2) and health system clinical software (n=1). This distribution can be attributed to the search strategy, which specifically targeted DATs with a therapeutic focus.

This review highlights that DATs have the potential to impact the QOL of PWD in several identified thematic areas: preserving autonomy, engagement, social interaction, health monitoring and promotion, improving ADL, cognition, maintaining dignity, managing BPSD and safety/surveillance. The different categories of DATs can provide diverse forms of support to PWD across these thematic areas, enhancing their overall QOL. DATs help PWD to age in place, live independently and maintain their dignity, especially when supported by DATs that help PWD keep or regain their ability to engage in daily activities. DATs were also shown to help promote health by tracking bodily functions and encouraging engagement and social contact. Overall, impacts could be seen on individuals’ cognitive abilities, to manage BPSD, and improvements to their general well-being and safety.

However, in a few instances, negative impacts of DATs on the QOL of PWD were also identified. 53 55 81 97 127 For example, worsened BPSD, worries about negative results, anxiety and aggression towards the technology, or disliking the technology.

In addition to the qualitative impacts, various quantitative quality-of-life instruments were examined. It was found that 12 different instruments were used across 18 of the included studies. The most frequently employed instrument was the Quality of Life in Alzheimer’s Disease Scale (QOL-AD ). Furthermore, it was observed that DATs are used to support therapy, 27 and can serve as therapeutic tools to even constitute a distinct form of therapy in themselves. 84

Strengths and limitations

This scoping review first attempted to provide an extensive overview of various DATs and their impact on the QOL for PWD. A comprehensive search strategy was implemented to achieve this, covering five electronic databases over a decade. However, considering the rapidly expanding landscape of DATs and the exclusion of conference proceedings, book chapters, pilot and feasibility studies, it is conceivable that this scoping review might overlook ongoing or planned studies that could shed light on alternative DATs or different impacts on QOL. Additionally, concepts of autonomy and dignity were not incorporated in the initial search strategy as their prominence in relevant literature was only discovered by authors during the coding stage. Therefore, there is a possibility that this could have led to some missed studies relating to these concepts. Further, it should also be pointed out that while ‘accessible DATS’ were not further defined in the objectives of this study, we used the terms colloquially to imply that there might be solutions that cannot be accessed by our search strategy.

Conducting a scoping review instead of a systematic review has its limitations. In this approach, an assessment of the quality of the included studies or an evaluation of intervention effectiveness needs to be incorporated. Therefore, the validity of interventions on their measured outcomes may present bias or need to be better analysed and reported in included studies. The search strategy prioritised patient-facing DATs, thereby introducing a potential bias that elucidates the high predominance of digital therapeutics in the included literature. Another limitation of this work arises from the challenge of providing a conclusive quantitative assessment of the effects of DATs on QOL. While the primary objective of our work was to offer a comprehensive and broad understanding of the subject, we envision that this scoping review can lay the groundwork for subsequent systematic reviews and meta-analyses, which would employ specific research questions and analytical strategies for dedicated quantitative evaluations.

Nonetheless, due to the restricted availability of evaluative research in this domain, the primary objective was to explore the impact of DATs on the QOL for PWD, which this study has provided.

A variety of DATs are available, offering versatile applications and holding the potential to serve as promising instruments for enhancing the QOL among PWD. Further research must be conducted to examine the ongoing developments in DATs and their increasing impact on QOL, including their long-term effects, and a deeper conceptual understanding of how certain interventions correlate to improving QOL. Moreover, future research could consider placing a particular emphasis on the less-represented DHT categories, such as care support, health & wellness or software. Digital innovations offer significant potential in addressing the global increase in the elderly population and revolutionising various aspects of elderly care. 4 Considering future research directions, for example, in the context of voice assistants and advancements in large language models, 139 140 would be of importance, as they facilitate the development of an interface that is more intuitive and natural, without demanding a high degree of dexterity.

Supplementary Material

Contributors: All authors have made substantial intellectual contributions to developing this scoping review and its revisions. The search question was conceptualised by TK and RV, and further developed by CS. The review approach and design were conceptualised by RV, with advice from TK. CS and RV developed and tested search terms with input and revisions from TK. CS and RV jointly screened all the studies resulting from the search strategy. CS conducted the full-text data extraction, with RV, MN and TK reviewing and providing consultation. CS drafted the first manuscript, and all authors were involved in the revision of the manuscript. All authors approved the final version of the manuscript. TK is the author responsible for the overall content as the guarantor.

Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Map disclaimer: The depiction of boundaries on this map does not imply the expression of any opinion whatsoever on the part of BMJ (or any member of its group) concerning the legal status of any country, territory, jurisdiction or area or of its authorities. This map is provided without any warranty of any kind, either express or implied.

Competing interests: MN and TK are affiliated with the Centre for Digital Health Interventions (CDHI), a joint initiative of the Institute for Implementation Science in Health Care, University of Zurich, the Department of Management, Technology, and Economics at ETH Zurich and the Institute of Technology Management and School of Medicine at the University of St. Gallen. CDHI is funded in part by CSS, a Swiss health insurer. TK is also a co-founder of Pathmate Technologies, a university spin-off company that creates and delivers digital clinical pathways. However, neither CSS nor Pathmate Technologies was involved in this research. All other authors declare no conflict of interest.

Patient and public involvement: Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Provenance and peer review: Not commissioned; externally peer reviewed.

Supplemental material: This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

Data availability statement

Ethics statements, patient consent for publication.

Not applicable.

Ethics approval