The use of technology by seniors with neurocognitive disorders in long-term care: a scoping review

Background To map the current state of knowledge about the use of technology with seniors with neurocognitive disorders in long-term care to foster interactions, wellness, and stimulation. Methods Cumulative Index to Nursing and Allied Health Literature (CINAHL Plus); MEDLINE; PsycINFO; Embase and Web of Science were searched in eligible literature, with no limit of time, to describe the current use of technology by seniors with neurocognitive disorders in long-term care. All types of literature were considered except for theses, editorial, social media. This scoping review was built around the recommendations of Peters et al. (2020 version). Three researchers collaborated on the selection of articles and independently reviewed the papers, based on the eligibility criteria and review questions. Results The search yielded 3,605 studies, of which 39 were included. Most technology type reported was robotics. Included studies reports different positive effects on the use of such technology such as increase of engagement and positive. Conclusion The study highlights different types and potential benefits of technology for long-term care residents with neurocognitive disorders, emphasizing the crucial need for additional research to refine interventions and their use.


Background
According to the World Health Organization (WHO), the percentage of older adults aged 60 years and over will double by 2050 [1].Since neurocognitive disorders (NCD) occur in older age, their incidence and prevalence rates are thus on the rise.This trend is more common in low-and middle-income countries and regions [2].It is estimated that the number of individuals with NCD will double every 20 years and reach over 115 million worldwide, by 2050 [3].
A NCD is a degenerative disease that progresses over time as the individual becomes increasingly dependent in conducting daily and domestic activities.According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), a major NCD is mainly characterized by a cognitive decline from a previous level of performance in one or more cognitive areas, eventually interfering with the level of independence during everyday activities [4].This includes Alzheimer's disease, frontotemporal lobar degeneration, Lewy body disease and vascular disease.
As the disease progresses, older adults with NCD may need to relocate to long-term care (LTC) homes to obtain the needed assistance and support in their daily activities.About 80% of LTC residents suffer from a NCD [5].
LTC homes are progressively integrating technology, including those oriented for the use of residents suffering from NCD.In their article, Gibson et al. identified three types of available technology for people with NCD.The first type represents all devices that are used on people with NCD, to improve provided care, such as telecare, fall detectors, GPS locators, key safes, etc. [6].Different literature reviews have explored these technologies.For example, a recent scoping review listed 54 studies on technologies linked to NCD care, fall detection, and ambient-assisted living technologies [7].Another systematic review studied the digital care technologies used in people with NCD living in LTC homes to prevent falls and manage the behavioral and psychological symptoms of NCD [8].The second type includes devices that are used by people with NCD [6].This type of technology is usually used to provide some support for, and to facilitate their daily activities (e.g., medication dispensers, reminder alarms) [6].Finally, there are devices that are used with people with NCD [6].This third type fosters technologies that promote interaction between a person with NCD and other people or between the person and the technology itself (e.g., telephones, puzzles and games, electronic games & apps).People with Alzheimer's disease and other NCD can suffer rapid and deleterious consequences from a lack of stimulation and contact with significant people [9].Recent studies found that videoconferencing helped seniors stay in contact with their families during the COVID-19 pandemic [9][10][11].Research has also examined the use of robotic pets to reduce neuropsychiatric symptoms as well as to improve on well-being and loneliness [12,13].Even though the use of technology has greatly increased in LTC since the COVID-19 pandemic, there is a lack of knowledge synthesis (i.e., scoping review, systematic review, or literature review) on technology devices used with people with NCD.In fact, LTC home restrictions on visits and activities have led to the deployment of several technologies to stimulate residents with major NCD and preserve contact with family caregivers.Aim of this scoping review is to map the evidence on the use of technology in LTC by the elderly with neurocognitive disorders.

Research questions
The main question guiding this scoping review is: What literature is available on the use of technology with seniors with major NCD in LTC to foster interactions, wellness, and stimulation?

Research sub-questions
1) What type of technology is used by the elderly with neurocognitive disorders in long-term care?2) What are the key findings on potential effects of the use of technology reported in the included literature?

Design
Considering our research objectives, this scoping review was conducted based on the recommendations of Peters et al. [14].It is a Nine-step method comprised of the following stages: 1) Defining and aligning the objectives and questions; 2) Developing and aligning the inclusion criteria with the objectives and questions; 3) Describing the planned approach to search for evidence, including selection, data extraction, and presentation of the evidence; 4) Searching for evidence; 5) Selecting evidence; 6) Extracting evidence; 7) Analysis of evidence; 8) Presentation of results; and 9) Summarizing evidence in relation to the purpose of the review, making conclusions and noting any implications related to the findings [14].A protocol for the study was developed and a comprehensive search conducted in electronic databases.The protocol was registered on the institutional repository CorpusUL (http:// hdl.handle.net/ 20.500.11794/ 135363).

Eligibility criteria
To meet the aim of this scoping review, we selected the literature that meets the Population, Concept and Context (PCC) framework proposed by Peters et al. [14].

Population
For the population, we included individuals aged a) 65 years and older, of b) all genders, with c) NCD.The individuals most have a diagnosis of NCD as defined by the DSM-5 [4] and include many types of degenerative disorders, such as Alzheimer's, frontotemporal lobar degeneration, Lewy body disease, and vascular disease.

Concept
In terms of the eligibility criteria for the Concept element, the core concept that was used is technology.The definition proposed by Neal et al. was selected, that is "any device or associated software that is able to communicate over a network or respond to the external environment" (p.914) [15].This includes other associated concepts, such as computers, smartphones, phones, electronic tablets, robotic devices, and video games.The technology will need to be used, with or without assistance, by seniors, for recreational purposes, wellness or to foster interactions.All studies that included technologies in the service of care will be excluded.

Context
The last element of the framework, i.e., the context criteria, allowed the consideration of studies made in the LTC sector.Literature from all countries will be included.

Search strategy
The following databases were selected for their relevance to nursing, healthcare, and social care: Cumulative Index to Nursing and Allied Health Literature (CINAHL Plus); MEDLINE; PsycINFO; Embase and Web of Science.A comprehensive search strategy was conducted in the databases by the authors in collaboration with an experienced librarian, using search terms based on the five concepts (see Table 1).Literature in English and French were considered for the database search, because those are the shared and mastered languages of authors.Databases were searched with no limit of time, to describe the current use of technology by seniors of NCD in LTC.All types of literature were considered except for theses, editorial, social media, personal blogs, conference proceedings, books or book chapters and study protocol.

Data management
The literature that emerged from the search strategy was imported into EndNote 20 ™ software, then transferred to Covidence software.All duplicates were removed using Covidence to proceed with the selection process and to produce a PRISMA flow diagram presenting the search and selection process.

Selection process
All titles and abstracts identified in the literature search were screened by the authors (MSH, CS, CF), independently.The full text of articles selected by either author in the initial screening stage were reviewed to select the final list of articles.During the selection process, any disagreements or conflicts between the primary reviewers (CS, CF) were resolved by the principal researcher (MSH).Moreover, references for all the considered articles were hand-searched to identify any relevant reports that may have been missed in the search strategy.

Data extraction and synthesis
Data were extracted independently by two authors (CS, CF) and checked by comparing extracted data between both authors to reduce errors and bias [14].Data extraction templates included information on the first authors and date of the publication; title; country where the studies were conducted; study design; population; type of technology; description of intervention and key findings.Extracted data was reported narratively and summarized in tables.A precise description was made of the link between the data obtained from the eligible articles and our research objective and questions [14].The process of data extraction was iterative, which means that elements were added as needed as the articles were read.The quality of included studies was not formally assessed, as this is a scoping review.Indeed, Munn et al. note that "an assessment of methodological limitations or risk of bias of the evidence included within a scoping review is generally not performed." (p. 3) [16].

Results
A total of 3,605 studies were identified after removal of duplicates (Fig. 1).After exclusion of non-relevant results by title and abstract screening, 132 articles were screened by full text and 39 studies were included.Most studies were excluded for not following inclusion criteria on the type of literature, providing nonspecific results or the unavailability of the studies' full texts.

Overview of included studies characteristics
The primary studies included in this scoping review took place mainly in Australia and the United States, followed by other countries such as Canada, Ireland, New Zealand, and few European and Asian countries as shown in Table 2.
Of the 39 studies included, 24 were quantitative studies, 5 qualitative studies, and 6 mixed methods studies in addition to 2 systematic reviews and 2 scoping reviews.Most participants in the included studies were LTC residents aged over 65 years old with major NCDs and were predominately women.Few studies recruited LTC staff or relatives.
The characteristics of the included studies are presented in Table 3.

Technology types and their aim of use
We categorised the technology used in different interventions into 10 major types, as shown in Table 4.
Most of the included studies utilized robotics [15,17,20,22,24,25,29,31,35,36,[40][41][42][43]50].This category encompasses 2 types of social robots that were employed in these studies: humanoid or pet robot.These robots were used mainly to stimulate the cognitive and physical abilities of residents through integrated applications.They were also used to provide therapeutic emotional and intentional communication through motion recognition, vocalization, gestures, emotive expressions, singing, or dancing.
Virtual reality was the second most popular technology.Five studies [18,23,28,32,44] employed software and hardware to create interactive immersive environments presented through video games or 3D videos/images that can be accompanied by music.This technology was used to stimulate residents and improve their cognitive functions, such as psychomotor abilities and memory; to promote physical activity; to reduce responsive behaviors; to increase pleasure or visual and social engagement, especially in a COVID-19 context, as showcased in one of the studies.
Tablets such as iPads were also commonly used.Four studies [9,34,40,46] employed tablet software appdriven activities such as games, music, images, etc. to stimulate reminiscences; to increase pleasure and engagement and to permit residents to communicate with their families and loved one's through videoconferences.
Four studies [33,34,43,52] used multimedia computer systems that consisted of computer-based interventions with the integration of other software and hardware parts and accessories.Computer activities included email, internet search, games, and slideshow modules or simply broadcasting music played on a laptop through a speaker.Garland et al. [19] Khosla et al. [20] McAllister et al. [21] Moyle et al [22] Moyle et al. [23] Moyle et al. [24] Neal et al. [15] Pu et al. [25] Australia, New Zealand, Europe

United States
They aimed to promote cognitive stimulation and positive emotions for residents, or simply exposing residents to music.Video/Audiotapes, and interactive screens were reported in three studies, each.Video/audiotapes in these studies [19,27,45] consisted of personalized audio or videotape recordings of either simulated family presence, preferred music to treat behavioural and psychological symptoms and improve quality of life of residents with NCD or to stimulate their reminiscence and memory.Interactive screens consisted of the use of computers or projecting screens without the use of keyboard or mouse by the resident to take part in different in-app activities, such as games or audiovisual programs and shows, to stimulate reminiscence and memory and improve or enhance social connection, facilitate entertainment, and implement cognitive training through various brain fitness programs.A scoping review focused on assistive technologies, primarily social robots, and computer systems, to deliver psychosocial interventions; and another study explored social participation among residents with NCD through various digital devices, including mobile apps, video games, video conferencing, social robots, VR technology, and more.
One study utilized a videophone, a telephone device transmitting and receiving a visual image, as well as the sound through the handset, to permit residents to communicate with their family and loved ones, on a weekly basis.

Overview of study findings on potential effects of technology use to foster interactions, wellness, and stimulation
The review identified a diverse range of technology-based interventions implemented in long-term care facilities for residents with NCD.Table 3 showcased interventions with different technologies explored various outcomes including behavioural and psychological symptoms, cognitive function, quality of life, social and behavioral engagement, medication use, physical and motor activity, daily life activities, sleep patterns etc.
Several other key findings emerged, shedding light on various aspects of technology's impact on older adults' well-being and foster positive interactions.For instance, interventions were observed to have varying effects on agitation levels among residents, with some showing reductions [19,30,40,46,50], meanwhile a study reported no significant changes [22].Similarly, few interventions were found to impact overall behavioral and psychological symptoms of dementia (BPSD) demonstrating a decrease in these symptoms [19,22,38,40,46], while others showed inconclusive results on this outcome [27].Other studies have shown the potential for some technology to enhance communication among residents and their caregivers [21,26,31,32,41,42,48].Furthermore, physical activity outcomes were examined highlighting the potential for technology interventions to promote physical activity and exercise among seniors with NCD [18,42,43].These findings, in conjunction with those related to engagement, cognitive function, and quality of life, underscore the multifaceted benefits of technology interventions in enhancing various aspects of residents with NCDs well-being and functioning in LTC environments.

Discussion
This comprehensive scoping review delves into the landscape of technological interventions in LTC for older adults with NCD.Among 3,605 screened articles, 39 met

Authors and country of studies Study Count
Caserta et al. [45] Ford et al. [46] Hamel et al. [47] Hensel et al. [48] Kerssens et al. [49] Libin et al. [50] Sautter et al. [51] Tak et al. [52] Tak [53] Total 39     A detailed examination of the technologies used reveals a diverse array of devices used with people to foster interactions, wellness, and stimulations.Robotics, encompassing social humanoid and pet robots, emerged as the most frequently studied technology [15,17,20,22,24,25,29,31,35,36,[40][41][42][43]50].The pre-eminence of robotics in the studied interventions indicates a growing interest in leveraging advanced technologies.These social robots were mainly used to provide cognitive and physical stimulation, emotional communication, and therapeutic engagement.A recent scoping review has presented growing evidence that supports the potential of these technologies to improve the well-being of elderly individuals living in assisted care [55].Virtual reality's prominence as the second most reported technology indicates the revolutionary potential of immersive environments for residents with NCD living in LTC to enable them to experience the world.The varied applications, from enhancing cognitive functions to promoting physical activity, showcase this technology's versatility [18,23,28,32,44].A study highlighted the potential of virtual reality interventions in mitigating social isolation among LTC residents [56].The immersive and interactive nature of virtual reality experiences, as suggested by Hung et al. [56], could offer a novel approach to enhance social engagement and alleviate feelings of loneliness.Additionally, the study emphasizes the importance of considering the specific needs and cognitive abilities of residents when implementing such technologies, especially since a lot of people living with NCD have shown great interest in using this technology [56].Tablets, with their user-friendly interfaces and portability, emerged as valuable tools to stimulate reminiscence and facilitate communication with families.The adoption of tablets in LTC settings aligns with the broader trend of integrating consumer technologies into healthcare.
The main findings of the objective and effects of the use of technology with seniors with NCD in different studies align with the broader goals of LTC, emphasizing positive interactions, reduced isolation, and increased engagement.While most studies report positive effects, the limited quantity and quality of available research requires caution in drawing overarching conclusions.The diverse study designs and outcomes challenge direct comparisons, emphasizing the need for standardized methodologies and outcome measures for future research.For instance, the focus on residents' engagement and pleasure aligns with the person-centered care approach, recognizing the importance of individual experiences and preferences [57].The call for more comprehensive research on the impact of various technologies in reducing isolation and loneliness among residents in LTC facilities echoes the growing recognition of technology as a potential solution to address the social and emotional well-being of older adults [58].A systematic review has acknowledged the positive effects of technology in improving the overall quality of life for older individuals [59].However, a literature gap persists concerning the optimal selection of technology, its recommended duration of use, and the appropriate mode of utilization, considering the characteristics of the residents and stages of NCD.To bridge this gap, forthcoming research should prioritize investigating the intricate relationships between technology use and the effects on residents.It is crucial to consider the distinct challenges associated with various stages of NCD, particularly found in individuals with major NCD.This clientele, which is prevalent in LTC, is often excluded from research studies, due to ethical concerns [60].This creates a knowledge void in understanding the specific needs of these residents and the care required to meet them.The ethical considerations surrounding research involving LTC residents with NCD cannot be overstated.This population's vulnerability requires a thoughtful and ethical approach to ensure their well-being [60].

Limits of the study
In acknowledging the limitations of this scoping review, it is essential to highlight that no formal process was employed to assess the quality of the included studies.
While every effort was made to select relevant and reliable literature, the absence of a quality assessment process may introduce some degree of uncertainty regarding the robustness of the findings.Furthermore, the significant heterogeneity observed in both the outcomes and methodologies across the included studies presents a challenge.This diversity limits the comparability of findings and underscores the complexity of synthesizing results.As such, caution must be exercised in making overarching conclusions about the true effectiveness of the reported technologies.These limitations underscore the need for future research to employ more rigorous methodologies and standardize outcome measures to facilitate more reliable assessments of technological interventions.

Implications for future research
This scoping review identifies several gaps and areas for future research in the realm of technological interventions with LTC residents with NCD.The limited geographical diversity of studies calls for broader global representation to account for cultural and contextual variations.
The predominance of robotics in the current literature highlights the need for research exploring the optimal integration of different technologies.Studies assessing the feasibility and effectiveness of various technological modalities with residents at different stages of NCD could further guide LTC managers and practitioners in the selection of technologies and orient their use to achieve desired outcomes.
Further investigations into the effects of these technologies among LTC residents are imperative through standardized methodologies and outcome measures to provide direct comparison.

Conclusion
The use of technology with residents in LTC facilities shows promise in enhancing socialization, reducing loneliness, and improving quality of life.However, further research may be needed to fine-tune and adjust the interventions.In-depth studies addressing the specific needs of individuals at different stages of NCD, coupled with robust ethical considerations, would not only contribute to academic discussions, but also offer valuable guidance in the LTC field for the well-being of seniors.

Table 2
Included studies count by country

Table 3
Characteristics of studies included in the review

Table 4
Count of studies per technology type