Exploring the views and the use of information and communication technologies to access post-diagnostic support by people living with dementia and unpaid carers: a systematic review

Abstract Objectives This systematic review examined how information communication technologies (ICT) has been used to access remote post-diagnostic support that address the needs people with dementia, or those of dyad, and explored care recipients’ views on accessing support remotely. Method Concepts relating to dementia and ICT were searched across six databases (PsychInfo, PubMed, Cochrane Library, CINAHL, Social Care Online, and Web of Science) in March 2021 and updated in March 2022. Studies published from 1990 and written in English, German or French were considered for inclusion. Methodological quality was appraised using the Hawker quality assessment tool and reporting structured according to PRISMA guidelines. Results The search yielded 8,485 citations. Following the removal of duplicates and screening processes, 18 papers reporting on 17 studies were included. Studies described a range of post-diagnostic support, including medical follow-ups and therapeutic sessions, and were often delivered on a one-to-one basis via videoconferencing software. Whilst often relying on assistance from unpaid carers, people with dementia directly engaged with ICT to access post-diagnostic support in 13 studies. Accessing post-diagnostic support remotely appears feasible, nevertheless, care recipients’ views were mixed. Access was frequently facilitated by supplying devices and providing ongoing technological support. Conclusions Accessing post-diagnostic support remotely is likely to benefit some care recipients, however, to prevent widening inequalities in access, services within the current hybrid landscape need to accommodate to people who are digitally excluded. Future research should capture the support provided by unpaid carers to facilitate the engagement of people with dementia to remote post-diagnostic support.


Background
Globally, an estimated 55 million people are currently living with dementia and projections suggest this will increase to 139 million by 2050(wHO, 2021)).Accessing support is paramount to living well with dementia, nevertheless, challenged with increasing demand and coupled with finite resources, the ability of strained health and care systems to sustainably provide equitable, responsive, and timely post-diagnostic support, is of mounting concern.
Following a dementia diagnosis, post-diagnostic support can be defined as services delivered to cater the changing care and support needs experienced by people with dementia and unpaid carers throughout the disease trajectory (Prince et al., 2016).The prompt identification and the holistic management of needs are key components to good post-diagnostic support (Bamford et al., 2021).Dementia care pathways differ across regions and countries.in the UK, the provision of post-diagnostic support services often involves a mixture of providers (private, public and voluntary) operating within three sectors (primary and secondary healthcare, social care and third sector), across various care settings.Sectors differ in funding streams and priorities.Post-diagnostic support within the healthcare sector may encompass services such as dementia medical reviews and psychological support, the social care sector may provide day care centres, respite care and carer's assessments, and the third sector may include centres, befriending services, and peer support groups (Frost et al., 2020).
Post-diagnostic support offers many potential benefits which extend from facilitating the initial adjustment phase, to dying well with dementia.Benefits include encouraging independence and positively impacting the social health of people with dementia (Giebel, Rodgers et al., 2020;Kelly & innes, 2016;willis et al., 2018).Post-diagnostic support may alleviate the caregiving burden and help to address feelings of depression and anxiety within unpaid carers (Carter et al., 2020;vandepitte et al., 2016).The usage of post-diagnostic support services should align with individual preferences whilst reflecting care recipients' evolving needs.Nevertheless, the service provision landscape is fragmented and access remains inequitably laden with potential hurdles.Factors contributing to the unmet needs include poor signposting of services, rural residency, and financial and or time constraints (Bayly et al., 2020;Bieber et al., 2019;Giebel, Sutcliffe, Darlington-Pollock et al., 2021;watson et al., 2021).whilst some barriers to accessing post-diagnostic support may span different contexts (Giebel, Robertson, et al., 2022;Ketchum et al., 2022), many are likely to require setting-specific approaches.
The potential role of information communication technology (iCT) in achieving universal health coverage is recognised, and may, for example, increase care recipients' access to services by overcoming barriers associated with rural residency (Bayly et al., 2020;Sekhon et al., 2021).Nevertheless, the adoption of iCT in practice has remained somewhat limited until the COviD-19 pandemic provoked, at least temporarily, a shift to remote service delivery.
Overall, research has largely focused on accessing remote services involved in forming a dementia diagnosis (Barth et al., 2018;Haralambous et al., 2019), assistive technology (Pappada et al., 2021), and post-diagnostic support which solely addresses the needs of unpaid carers (etxeberria et al., 2020;Leng et al., 2020).Prior to the pandemic, some studies reported on remote post-diagnostic support that addressed the needs of people with dementia or those of the dyad.These included medical follow-ups (Azad et al., 2012), and non-pharmacological services such as exercise health (Alonso et al., 2020;Dekker-van weering et al., 2019) and information provision (Hattink et al., 2016;Howe et al., 2020).whilst the support accessed was valued by both members of the dyad, unpaid carers often became the primary users and navigated the technology (Hattink et al., 2016;Howe et al., 2020).The impact following the curtailment of post-diagnostic support provision during the pandemic is concerning (Giebel, Cannon et al., 2020;Giebel, Lion, et al., 2022;Giebel, Lord, et al., 2020) and is likely to entail long-term implications.As some services shifted to remote service provision, studies reported on post-diagnostic support accessed through innovative mediums, including remote memory clinics (Benaque et al., 2020), exercise health interventions (Di Lorito et al., 2021) and singing groups (Lee et al., 2021).Although many care recipients valued accessing post-diagnostic support remotely during the pandemic, the support was sometimes delivered at inconvenient times, and was perceived as being unable to replicate the benefits offered by face-to-face contact.
Despite a growing evidence base exploring the feasibility and acceptability of accessing post-diagnostic support remotely, both prior to and during the ongoing pandemic, these studies have yet to be systematically reviewed.Thus, this systematic review sought to explore the use of iCT to access post-diagnostic support services that address the needs of people with dementia or those of the dyad and their accompanying views on accessing dementia-related post-diagnostic support services remotely.Specifically, this systematic review addressed the following interlinked review questions; 'How has ICT been used to access post-diagnostic support that address the needs of people with dementia and unpaid carers?What are the views of people with dementia and unpaid carers on accessing dementia-related post-diagnostic support services remotely?'Findings may provide insights and assist policymakers or service providers when planning and designing prospective remote dementia-related post-diagnostic support services.

Methods
The Preferred Reporting items for Systematic Reviews and Meta-Analyses (PRiSMA) guidelines were followed when conducting and reporting this systematic review (Liberati et al., 2009).The review protocol was registered on PROSPeRO international prospective register of systematic reviews (iD = CRD42021233776).

Search strategy
A total of six databases were searched (APA Psych info, PubMed, Cochrane Library, CiNHAL Plus, Social Care Online and web of Science) in March 2021 and updated in March 2022.whilst not all iCT are internet-based, the majority are likely to require connectivity.As the internet was not widely available in commercial and public settings prior to 1990, a search restriction was applied to exclude studies published prior to 1990.Owing to the international make-up of the team, the search was extended to includes studies written in German, French and english.input from a University of Liverpool specialist librarian was sought when devising the search strategy.The principle of Setting, Population, intervention, Control and evaluation (SPiCe) was applied when selecting the search terms (Booth, 2006).Using a combination of Boolean operators and truncations, the same terms were searched within the titles and abstracts of studies across the databases (Population: 'mild cognitive impairment' , Dement*, Alzheimer*, MCi; intervention: 'e health' , 'information technology ' , 'technology based' , 'web based' , eHealth, internet, online, telehealth, telemedicine).A controlled search was conducted where available, and subject headings were adjusted according to the different databases.Additional hand searches were conducted, and included screening the reference list and tracking the citations, using Google Scholar, of all included studies.

Eligibility
Post-diagnostic support was defined as 'all services delivered following a dementia diagnosis to cater for the changing care and support needs of people with dementia and unpaid carers and informal carers during the disease trajectory, until end of life' (Prince et al., 2016).eligible studies reported on the use of iCT access dementia-related remote post-diagnostic support that addressed the needs of people with dementia and or the dyad.Studies focusing on community dwelling people with dementia and or unpaid carers and satisfying the inclusion criteria outlined in Table 1 were included.Studies reporting on individuals not living with dementia or people with dementia not residing in community were excluded.Studies frequently report, notably during the pandemic, on participants who identify or self-report as living or caring for someone with dementia, without confirming the diagnosis (e.g.Giebel, Cannon, et al., 2020;Giebel, Hanna, Tetlow et al., 2021;Talbot & Briggs, 2022).Thus, to draw conclusions from a wider pool of evidence, confirming the dementia diagnosis of the participants did not form a requirement to be considered for inclusion in our review.

Selection procedure
The searches were conducted by TC.The PRiSMA guidelines (Liberati et al., 2009) were followed when reporting this systematic review.All titles were screened and abstracts of relevant titles were read by TC and studies were excluded if they did not satisfy the inclusion criteria.For studies that appeared to satisfy the inclusion criteria, the study was read in full.if there was any uncertainty relating to the suitability of a study for inclusion, it was discussed amongst the review team members and included if in unanimous agreement.

Quality appraisal
The methodological quality of all included studies was appraised by quality assessment tool developed by Hawker and colleagues (Hawker et al., 2002), which accommodates for the methodological review of studies with disparate research paradigms.The tool consists of nine components to appraise the methodology of studies by examining the introduction and aims; methodology; sampling; data analysis; ethics and bias; results; transferability and generalisability of findings; and the implications and usefulness of findings to policy and practice.each component is rated according to a four-point Likert scale (good, fair, poor and very poor) and numerical value are attributed to each scale (overall score range: 9-36), with an overall score of 36 indicating studies with rigorous methodologies.TC appraised the methodological quality of all included studies and no study was excluded based on their methodological quality.

Data extraction and analysis
A bespoke form extracted relevant data from included studies, including the country of origin, year of publication, study objectives, design, sample, data collection, type of iCT used, characteristics of the post-diagnostic support accessed and/ or the views of accessing remote dementia-related post-diagnostic support.TC extracted the data of the included studies.A meta-analysis was not feasible due to the heterogeneity of the included studies in terms of study designs employed and types of post-diagnostic support described.Therefore, following the guidance developed by the economic and Social Research Council (eSRC) (Popay et al., 2006), the results were narratively synthesised and presented in a tabular format.

Results
The initial search yielded 8,485 citations.Following the removal of duplicates and screening the titles and abstracts (Stage 1), a total of 56 studies were retrieved.Subsequent to full-text screening (Stage 2), a total of 18 papers reporting on 17 studies were included (Figure 1).
All included studies were of good methodological quality, with scores ranging between 33-36 points, from a possible maximum of 36 points (Appendix, Table 1).
Outcomes.Overall, adherence to remote post-diagnostic support was high (Dal Bello-Haas et al., 2014;Ptomey et al., 2019;Rogalski et al., 2016).Moderate physical activity levels increased in care recipients participating in Ptomey et al. (Ptomey et al., 2019)'s exercise classes, and people with dementia improved in speech and language outcomes (Dial et al., 2019;Rogalski et al., 2016).increased gains and confidence were maintained six months following the interventions (Rogalski et al., 2016) and long-term improvements were comparable to benefits received from accessing speech and language treatment in-person (Dial et al., 2019).Compared to the control group, increased Mini-Mental State examination (MMSe) scores, decreased behavioural and psychological symptoms, notably depression, was found in people living with dementia who had accessed telephone orientation therapy, and outcomes positively impacted unpaid carers' levels of distress (Panerai et al., 2021).
The MMSe scores of people with dementia who attended long-term medical management through telemedicine and in-person were comparable.The MMSe score of people with dementia with less severe initial impairments decreased less in the telemedicine group than the in-person group (Kim et al., 2017).Following the implementation of social distancing, people with dementia were found to have a lower quality of life, worsening symptoms and language abilities (Capozzo et al., 2020).• Post-intervention (4 weeks): dyadic interview and questionnaire.
• PlWD and unpaid carers interested in remote exercise.
• High attendance rate, dyads enjoyed the intervention.
Chodosh et al., (Chodosh et al., 2015) 2015 USA to compare the effectiveness and costs of telephone only approach to in person plus telephone for delivering an evidence-based coordinated care management program for dementia Quantitative • n = 144 dyads.
• UnPAiD CAReRS: Average of 50 years; 65.3% female.n = 77 adult child; n = 33 unrelated; n = 25 spouse.• Random allocation to in-person and telephone format, or only through telephone calls.
• Unpaid carer questionnaire: dementia care quality, PlWD health care utilization, hospitalisation, nursing home placement.• improvement in care quality in both groups • Similar unpaid carer burden, PlWD problem behaviours, retention and health care utilization across both groups

• greater costs when delivering intervention in-person
Rogaliski et al., (Rogalski et al., 2016) 2016 USA to determine if internet-based delivery of speech and language therapy was feasible for individuals with progressive aphasia symptoms.
• Post-intervention: dyadic semistructured interview • increase in functional gains and confidence in communication at 2-months follow-up, maintained at 6-month follow up.
Kim et al., (Kim et al., 2017) 2017 South Korea to assess the feasibility of telemedicine in the long-term management of patients with dementia based on cognitive function as the primary outcome Quantitati to assess the feasibility ve • PlWD: n = 188.
• CDR; Korean version of MMSe scale • no statistically significant difference in MMSe scores between PlWD accessing medical follow-ups remotely and in-person.
• telemedicine may be useful to care recipients residing in rural areas.
Killin et al., (Killin et al., 2018) 2018 UK, Scotland to determine the feasibility of improving the quality of life of PlWD and informal carers with the Digital Support Platform (DSP).
• During the intervention: attendance, minutes of MPA.Scale.
• therapists recorded time travelling and spent with participants.
• improvements in CMi and PCi in both intervention arms.
• Same time to deliver the intervention, remote delivery significantly reduced therapists' travel time.
(Continued) • Ranked reasons for participating in telemedicine intervention • Follow-up visits delivered as successfully through telemedicine as in in-person format.
• telemedicine may offer benefits (reduce travel distance and PlWD routine), but may not be suitable for all dyads.
Masoud et al., (Masoud et al., 2021) 2021 USA to provide insight into the experiences of PlWD and informal carers who regularly attend Memory Cafes. to explore how these gatherings, affect perceptions of social connectedness.
• individual and dyadic semistructured interviews • Highlights benefits offered by attending Memory Cafes.• Accessed in a telehealth suite.
• One investigator attended the first two sessions and provided on-site training and evaluate participants' ability to set-up equipment and exercise safely.• 40-45minutes sessions, twice a week for four weeks.
• warm-up, aerobic exercise using an upper extremity cycle ergometer, and a cool down.
• led by a research assistant in a telehealth suite in the Saskatoon Regional Health Authority, another research assistant attended the sessions with the participants in the telehealth suite in the rural regional health authority.• PlWD observed laughing and smiling during some sessions.
• Overall intervention rated as good-to-excellent; good voice quality, good-toexcellent visual quality, the ability to engage with the facilitator and with the group was excellent.
• Participants enjoyed the intervention, being able to exercise with people and easy to use iCt.
• One participant mentioned the lack of variety between sessions.• Account set up for each participant.• initial evaluation, eight one-hour video-conferencing treatment sessions and two evaluations (two-and six-months post-enrolment).
• treatment followed impairment-based approaches, activity and / or participation approaches.
• individualised home exercise program • Provided ongoing disease education, counselling and support.• 16/31 dyads reported that the intervention 'exceeded' their expectations.
• Out of 30 dyads, several stated that the pre-recorded videos were helpful, 37% would not change anything and 20% would like more sessions.• DSP pre-installed on devices.
• in-person demonstration of DSP.• living it up: a wellbeing portal.Provides information, advice and community networks.
• Jointly: a care coordination services that enables all unpaid carers to communicate and access shared tools.
• Click and go: a support appointment scheduling interface for families with statutory package of care in place.
• Participants had accessed the DSP for at least two months.
• lack of a perceived current need for the DSP.
• Understood as suitable for people at latter stages of disease trajectory.
• Carers were the primary users, and some carers and PlWD found the DSP too difficult to use.
• 'But she's not a teacher -she finds it very difficult… And it can be a bit upsetting as well.She's much better than me but she's not very happy trying to take me by the hand and leading me through the procedure and she gets very frustrated as well' (PlWD) • telephone or team Viewer for trouble shooting.• Document which included written instructions and screenshots to install the videoconferencing software.
• Additional support provided by telephone or team Viewer.
• An iPad Air with pre-installed software was provided to participants who did not own a computer or webcam.• lRt treatment: trained to use word finding strategies capitalizing on the retrieval of residual semantic, phonological, orthographic and autobiographical or episodic knowledge.Cueing hierarchy.
• ViStA treatment: facilitate grammaticality, intelligibility and fluency of connected speech.Script training.
none reported.
• iPad pre-installed software and videos explaining how to use the iCt.
• in-person raining on iCt use.• 30-minute exercise sessions via video-conferencing, three times per week, over 12 weeks.
• groups of 5-8 dyads, each in their own home.-A warm up, MPA and a cooldown.MPA included walking, sit to stand, dance movement and resistance exercises.
• Context of sessions varied, led by a health coach • each dyad attended a monthly 15 min education / support session with the health coach.
• PlWD and unpaid carers enjoyed the program.
• 28.6% of unpaid carers experienced difficulties when connecting the iPad to the internet and, 14.3% reported difficulties connecting the Fitbit to the iPad.
• All unpaid carers reported it was easy to navigate the iPad and the Zoom app.
• Assessment based on a structured question to identify significant changes since last evaluation (behaviour, personality, language, sleep disturbances, nutritional status, swallowing capacity, respiratory function, access to rehab, SAlt, pharma therapy) • Satisfied with voice quality: 81% very satisfied; 19% fairly satisfied; not satisfied at all: 0%.
• Able to talk as during in person consultation: yes: 82% and no: 18%.
Moo et al., (Moo et al., 2020) • Videoconferencing software (CiSCO Jabber) • telephone for trouble shooting • Provided videoconferencing software access and, if required, a webcam.
• technician called unpaid carers to identify home computer and internet capabilities.
• Provided support to download and install videoconferencing software over the telephone.
• Conducted a test run before intervention.
• Participants received an email with appointment time and log in details. • telemedicine visits complimented in-person follow-up visits.
• Conducted by a behavioural neurologist and lasted 45 min.
• topics covered included: changes in cognition, behaviour, mood, sleep, appetite, continence, mobility issues, safety concerns, independent activities of daily living and activities of daily living.
• Recommendations communicated with unpaid carers and medication changes or referrals inputted into the medical record.
• next visit scheduled depending on need (ranged from 2 weeks − 9 months).
• Convenience regarding travel and to maintain PlWD's routine • Similar satisfaction regardless if accessed remotely and in-person or in-person only.
• Decreased in travel distance when service accessed remotely • Participants reported being at least as satisfied with remote visits as when accessed in-person.• Calls mostly by voluntary organisations, sometimes by nHS staff.
• Asked how the person / dyad were managing, engage in conversation (social or identifying support needs).
• Source of positivity during lockdown.Valued and helpful.
• and he's really enjoyed that… it was the other members that we've got to know since we've been on the Zoom.And we've made real friends with them, haven't we?Through Zoom.' (Unpaid carer) • Facetime and videoconferencing software to access groups.• limited provision of remote support, telephone calls were sometimes at inconvenient times.Did not replace in-person support • Hearing impairments impaired engagement with remote services.
• ' …but it's not quite the same as in person is it, and I know you can see somebody on a screen but it's not quite the same as sitting down and having a cup of coffee and a good chat is it really' (Unpaid carer) • 'he [PLWD] also struggles we've noticed with understanding using like a zoom, my brother will set up zoom and we can zoom and I've noticed he has certain faces he uses when he's finding a way to answer a question he doesn't understand' (Unpaid carer) • 'there has been no outside support at all erm other than we did have 1 phone call from the Care Navigators… so maybe about 3 or 4 weeks ago just to see how my mother in law was getting on and whether she needed anything which was really lovely but possibly a little late' (Carer)

Post-diagnostic support accessed by unpaid carers
Chodosh et al., (Chodosh et al., 2015) • telephone • Some unpaid carers were not engaging with care managers due to limited minutes included in phone plan.
• Provided phones with unlimited minutes for eight unpaid carers.• 12 months intervention delivered by social workers.
• initial and 6-months assessment guided intervention and assessed unmet needs for assistance; lack of social support; educational needs; difficulty with managing dementia related behavioural issue and safety concerns; need for respite; depression of the PlWD and carer; management of other chronic medical issues; need for diagnostic information and assistance with acute medical issues.
• Complimented with counselling, education and selfmanagement skills, referrals for community services and medical care.
• Minimum of seven contacts with participants, either in-person or telephone calls.
none reported.
• Delivered by care team from two hubs -University of California and University of nebraska.
• Care team navigators telephoned dyads on average 15 times during the 12-month intervention.Responded to unpaid carer's initial needs, screened for problems and provided personalised support and standardised support.
• Additional contact by email and mail.Care team navigators • lighter version offered, included educational materials though the post, possibly to contact care team navigators if required.• 97% reported that they would recommend the care ecosystem to another unpaid carers • 45.4% were very satisfied; 32.9% were satisfied; 17.5% were neutral; 2.8% were unsatisfied and 1.2% were very unsatisfied with the intervention (Continued) • Research assistant often remotely assisted to log in and during the home visit.• A home safety evaluation (40-45 min) • Scale 1 (strongly disagree) − 5 (strongly agree).• Opportunity to loan a tablet with pre-installed software.
• in person videoconferencing demonstration.• Up to eight consultation (60 min) over 16 weeks.
• Participants in telehealth group received two sessions in person, six over telehealth.
• theory-based intervention delivered by an occupational therapist, consisted of an assessment of PlWD, unpaid carer and environment.
• Works with unpaid carer to solve, educate, build skills and stress management.Works with the dyad to promote activity engagement • Moderate-high levels of satisfaction with programme.
• in-person intervention yielded more favourable satisfaction scores.

Post-diagnostic support accessed by unpaid carers
Studies described care management interventions (Chodosh et al., 2015;Possin et al., 2019), a home safety evaluation (Gately, Trudeau et al., 2020) and a supportive intervention (Laver et al., 2020), which were delivered on a one-to-one basis and accessible from participants' home.Support accessed ranged from a single home safety evaluation (Gately, Trudeau et al., 2020) to a care management intervention lasting a year (Possin et al., 2019).Two studies reported on follow-ups with time frames of six months (Chodosh et al., 2015;Possin et al., 2019).
Outcomes.The care management intervention decreased the caregiving burden, behavioural problems and health care utilisation, regardless if unpaid carers accessed the support remotely or in-person (Chodosh et al., 2015).Compared to unpaid carers who had accessed care management remotely, a greater decline in the quality of life of people with dementia and more visits to the emergency department were found in the control group from baseline to 12 months (Possin et al., 2019).The depression scores of unpaid carers who accessed the care management declined more than the control group at 23 months (Possin et al., 2019).The supportive intervention, when accessed remotely or in-person, increased caregiving mastery and perceptions of caregiving.People with dementia in the remote group experienced greater a functional decline, but experienced greater improvements in behavioural problems compared to the in-person group (Laver et al., 2020).Delivering a care management and supportive intervention in an in-person format required greater expenditures (Chodosh et al., 2015) and travelling (Laver et al., 2020).
Overall, views were mixed.People with dementia and unpaid carers enjoyed participating in exercise classes (Dal Bello-Haas et al., 2014;Ptomey et al., 2019), willing to continue accessing the intervention, and unpaid carers reported an increase in exercising independently (Ptomey et al., 2019).During the exercise class, care recipients were able to focus without distraction, privacy was respected and able to engage with the facilitator (Dal Bello-Haas et al., 2014).People with dementia enjoyed accessing speech language treatment remotely, would have liked to received more sessions, and found the pre-recorded videos helpful (Rogalski et al., 2016).Care recipients chose to access medical follow-ups remotely due to convenience, increased contact with service providers and to maintain the routine of the person with dementia (Moo et al., 2020).Accessing remote medical follow-ups yielded high satisfaction (Capozzo et al., 2020;Moo et al., 2020), care recipients were at least as satisfied when remotely accessing medical follow-ups as when attending visits in-person (Moo et al., 2020), and many would like to continue access appointments remotely (Capozzo et al., 2020).During the medical follow-ups, care recipients felt able to talk as when during in-person follow-ups, comfortable accessing care remotely (Capozzo et al., 2020) and staff answered their questions satisfactorily (Moo et al., 2020).Unpaid carers were satisfied with remotely accessing home safety evaluations (Gately, Tickle-Degnen et al., 2020), supportive (Laver et al., 2020) and care management interventions (Possin et al., 2019).The remote safety evaluation was perceived as being time efficient and unpaid carers felt comfortable using the technology (Gately, Tickle-Degnen et al., 2020).Nevertheless, when comparing in-person to remote service delivery, unpaid carers were slightly more favourable towards accessing home safety evaluations (Gately, Tickle-Degnen et al., 2020) and supportive interventions (Laver et al., 2020) in an in-person format.whilst some people with dementia and unpaid carers valued the information provided on the information portal (Killin et al., 2018), it did not align with their perceived present needs and many experienced difficulties whilst navigating the technology, which contributed to the underuse of the service.
During the COviD-19 pandemic, check-up calls (Giebel, Hanna, Callaghan, et al., 2021;O'Rourke et al., 2021), memory cafes (Masoud et al., 2021) and peer support group (Cousins et al., 2022;Giebel, Hanna, Callaghan et al., 2021) provided valuable support, an opportunity to engage in activities and to connect with others.whilst some people with dementia recognised their friends remotely, some were unable to (Giebel, Hanna, Callaghan, et al., 2021;Masoud et al., 2021).Some unpaid carers reported that due to behavioural problems and general disinterest in technology, remote memory cafes were unsuitable for people with dementia (Masoud et al., 2021).Remote memory cafes rendered it difficult to meaningfully connect with others (Masoud et al., 2021) and remote memory cafes and support groups were 'not the same' as when meeting people in-person (Giebel, Hanna, Callaghan, et al., 2021;Masoud et al., 2021).Furthermore, these were perceived to provide fewer benefits (Masoud et al., 2021), and may be unsuitable for people with visual impairments (Giebel, Hanna, Callaghan, et al., 2021) or dementia-related behavioural problems (Masoud et al., 2021).
Two studies reported reasons for declining remote post-diagnostic support.These included being unable to access or being unacquainted with the technology (Masoud et al., 2021;Moo et al., 2020), difficulties in engaging with the remote format and being unable to form meaningful connections with others remotely (Masoud et al., 2021).

Discussion
Findings from our systematic review suggest that, whilst remote post-diagnostic support may help to address some of the needs presented by people with dementia, or the dyad, care recipients' views on accessing services remotely remained mixed.The increased reliance on remote service delivery during the COviD-19 pandemic has shed light on the duality of the use of iCT in service delivery (wheatley et al., 2022), and lessons learnt are invaluable to construct future resilient services.As some elements of remote service delivery are likely to endure as part of routine delivery, the use of iCT in service provision needs to be carefully considered, as to avoid further widening inequalities in access.
Remote post-diagnostic support may offer several benefits, nevertheless, these are likely to be limited to people with dementia and unpaid carers who can access and engage with iCT.Benefits include positively impacting on care recipients' quality of life, behavioural problems, caregiving burden, speech and language abilities and level of physical activity (Panerai et al., 2021;Ptomey et al., 2019;Rogalski et al., 2016).Some studies found benefits to be comparable to those offered through in-person service delivery (Chodosh et al., 2015;Dial et al., 2019;Kim et al., 2017;Laver et al., 2020;Possin et al., 2019).However, remote formats may be unable to replicate some benefits relating to social health, such as meaningfully engaging with others (Giebel, Hanna, Callaghan et al., 2021;Lee et al., 2021;Masoud et al., 2021), which is important to living well with dementia (Reilly et al., 2020).Accessing remote post-diagnostic support may not be suitable for people with advanced dementia (Rogalski et al., 2016) or sensory impairments (Giebel, Hanna, Callaghan et al., 2021), conditions which often form part of the exclusion criteria of studies exploring remote interventions (Yi et al., 2021).This highlights the importance of identifying when along the disease trajectory remote post-diagnostic support is suitable, and that the presence of comorbidities may hinder the ability to optimally engage with remote services.
A person-centred approach is integral to the delivery of dementia care pathways (NiCe, 2018).People with dementia and unpaid carers should be offered a range of tailored post-diagnostic support services that cater to their changing needs, and be presented with choices on how to access them.Prior to the COviD-19 pandemic, some care recipients preferred to access post-diagnostic support remotely, and the shift to remote service delivery during the pandemic was welcomed by some.Remote services may offer practical benefits such as reduced travel and associated costs, preservation of the person with dementia's routine, and help to circumvent mobility and caring constraints (Lee et al., 2021;Masoud et al., 2021;Sekhon et al., 2021).People with dementia and unpaid carers were satisfied with accessing some forms of post-diagnostic support remotely (Dal Bello-Haas et al., 2014;Ptomey et al., 2019;Rogalski et al., 2016), which aligns with findings of previous research (Hattink et al., 2016;Howe et al., 2020;Sekhon et al., 2021).During the COviD-19 pandemic, remote post-diagnostic support was greatly valued, helped to scaffold much needed routines and to reduce loneliness (Capozzo et al., 2020;Cousins et al., 2022;Masoud et al., 2021;O'Rourke et al., 2021).Nevertheless, when comparing remote to in-person service delivery, care recipients' views were mixed (Gately, Tickle-Degnen et al., 2020;Laver et al., 2020;Moo et al., 2020) and unpaid carers felt that remote memory cafes were overall less beneficial, and unsuitable to people with dementia with behavioural problems (Masoud et al., 2021).when interpreting the views on accessing post-diagnostic support remotely during the COviD-19 pandemic, it is important to acknowledge that in-person service delivery was either unavailable or undesirable at that time.Thus, the hybrid delivery landscape needs to accommodate to presenting needs whilst empowering care recipients to access post-diagnostic support in their preferred format.
Many people with dementia and unpaid carers received iCT devices and ongoing technology support from study teams, which aligns with the findings of previous reviews (Gately et al., 2019;Sekhon et al., 2021).Nevertheless, after receiving devices and in-person orientation sessions, some care recipients continued to experience difficulties whilst engaging with iCT to access post-diagnostic support remotely (Killin et al., 2018).This queries the capacity of the current health and social care system to sustainably adopt similar delivery models without increasing the digital divide.Accessing services remotely is likely to require a suitable device, adequate digital literacy, which are likely to be intrinsically related to socio-demographic factors (Hargittai et al., 2019).People with dementia often relied on assistance from unpaid carers to access remote post-diagnostic support by installing the technology or facilitating their engagement with the service (Giebel, Hanna, Callaghan et al., 2021;Ptomey et al., 2019;Rogalski et al., 2016).whilst the participation or presence of unpaid carers, alongside the person with dementia, formed a requirement to satisfy the inclusion criteria of several studies included in this review, the support provided by unpaid carers was not systematically captured.Understanding the degree of reliance on unpaid carers, and characterising the support provided is important, as some people with dementia live alone, and the ability of unpaid carers to provide technological support, is likely to be related to socio-demographic factors, notably the age (Arighi et al., 2021).Additionally, unpaid carers may benefit from respite when people with dementia attend or engage with post-diagnostic support (Giebel, Hanna, Tetlow, et al., 2021).Thus, if unpaid carers are required to provide support to facilitate the access or engagement of people with dementia with remote post-diagnostic support, this may limit the downtime they receive.Although beyond the scope of this systematic review, the assistance provided by service providers to promote meaningful engagement with people with dementia remotely is likewise fundamental (Di Lorito et al., 2021;Yi et al., 2021), and ensuring service providers are adequately supported is key to the sustainable delivery of quality of support.

Strengths and limitations
To our knowledge, this systematic review is the first to synthesis evidence relating to accessing remote post-diagnostic support that address the needs of people with dementia or those of the dyad, and the explore care recipients' on accessing services remotely.Searches were conducted across six databases and studies written in english, German and French were considered for inclusion.whilst included studies were of good methodological quality, some limitations ought to be acknowledged when interpreting our results.Firstly, due to a lack of resources, only one study team member screened the citations, appraised the methodological quality of studies and extracted the relevant data.Although any uncertainties were discussed and agreed upon with all study team members, the lack of a second reviewer independently screening the citations may have led to some citations being missed.Grey literature was not searched, and studies that did not confirm the self-reported dementia diagnosis of participants were included in our review.evidence synthesised came from six countries (mainly the US and UK) and only one study explored the access to remote post-diagnostic support with people from minority groups (Chodosh et al., 2015).Cognisant that digital access and literacy is likely to be influenced by several socio-economic factors, our findings may not be representative nor generalisable to settings which are less economically developed, or populations coming from minority groups.Furthermore, several included studies lacked long follow-up time frames, control groups and the support provided by unpaid carers was not systematically captured.The study designs and tools employed in future studies would benefit from including longer follow-up time frames, control groups, capturing the support provided by unpaid carers, as well as investigating the feasibility and acceptability of remotely accessing different types of post-diagnostic support, notably those relating to social health, to reflect the diverse range of post-diagnostic important to living well with dementia.

Conclusion
This systematic review suggests that accessing post-diagnostic support remotely is likely to benefit some care recipients, nevertheless, views towards accessing services remotely remained mixed.Access to remote post-diagnostic support was frequently facilitated by providing iCT devices and ongoing technological support.These are important factors to consider whilst employing iCT within service delivery, and to avoid widening inequalities in access, it is important that services operating within the current hybrid service delivery landscape remain accessible to care recipients who are digitally excluded or who prefer to access services in-person.

Table 1 .
Study inclusion and exclusion criteria.

Table 3 .
Summary of post-diagnostic support accessed and iCt formats employed.
• 'one of them will ring you, and say 'how's things going?' and all of the rest of it, you know, and then if you've got any problems that come up during the conversation, you'll find someone will follow it up, and then ring you back,

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'The thing is, that if we didn't have these (the groups) it would be a bit bleak.I think all the online things they do at least give you a feeling, you known, that you are still part of a community' (PlWD)