Carers using assistive technology in dementia care at home: a mixed methods study

Introduction Informal carers support persons with dementia to live at home, even with deteriorating physical, social and cognitive issues. This study aims to examine the experiences and impact of Assistive Technology (AT) on carers, providing care for a person with dementia. Methods This is an explanatory sequential mixed methods study. The quantitative phase was an online and postal survey using the Carers Assistive Technology Experience Questionnaire and Short Form-12 (SF-12) questionnaire, with carers of persons with dementia in the UK, who used AT. The qualitative phase involved in-depth telephone interviews with a purposive sample of survey respondents and was analysed using hermeneutic phenomenology to develop, compare and explain the findings of the survey. Results The survey included data from 201 carers. Smartphones (45.5%) and tablet computers (45.0%) were the most frequently used AT. Multiple AT were used in the care of persons with dementia predominantly for safety (78.5%), communication (66.0%), and reminders (62.5%). The SF-12 indicated that carers in the 46–65 age group and carers who were not extremely satisfied with AT had lower mental component scores whilst carers who lived with the person with dementia and older carers had lower physical component scores. Twenty-three carers participated in the interviews, and 5 themes with 14 sub-themes were identified. The interviews helped confirm data from the survey on the impact of AT on the physical, mental and social wellbeing of the carers. It helped describe reasons for satisfaction with AT; how AT was used in daily life and strengthened caring relationships and how wider support systems enhanced the care of a person with dementia using AT. Conclusions This study describes the use of AT in the real-world context. AT supplements the care provided to people with dementia in the community. Appropriate use, access to AT and abilities of the carer can enhance the support provided through AT to both carers and the person with dementia. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-03167-4.


Introduction
Dementia is a public health priority [1]. It is a progressive illness, and even if functional challenges impede a person's ability to live independently, persons with dementia want to live at home [2]. Informal carers (family, friends and neighbours), hereafter referred to as carers, play a crucial role in supporting people living with dementia in the community. Caring for a person with dementia is not a static process [3] and Assistive Technology (AT) is suggested as one way of providing support to the person with dementia and their carers [4,5]. AT can be defined as: "any item, piece of equipment, product or system that is used to increase, maintain or improve the functional capabilities and independence of people with cognitive, physical or communication difficulties" [6]. Carers usually make the decision on purchase, support maintenance and decide on abandonment of AT [7] yet most research studies have focused on the use of AT from the perspective of persons with dementia [8][9][10] or the use of AT to support them in institutional settings [11,12]. Carers could be using the AT together with the person with dementia (e.g., safety alarms, tablet computers), independent of the person with dementia (e.g., video monitoring systems, GPS trackers) and/ or carers could be looking after someone with dementia, who uses AT independently of the carer (e.g., electronic medication dispensers, smart phones). While AT is viewed as a pervasive solution to supporting carers and persons with dementia to live for longer in the community [13][14][15], few attempts have been made to understand the experiences of carers, who use and support the use of AT. Carers make, and continue to make, decisions on the purchase and maintenance of AT [16]. Thus, involving and including carers and taking account of their views and experiences with AT should form an integral part of providing good care for a person with dementia within their own home [17]. Knowledge of carers' experience with AT, which types of AT carers use and prefer and how they use the AT as well as how it helps them, could provide information to those who procure health services (commissioners), health and care professionals and charities who prescribe/recommend AT, and industry partners who develop new AT. Understanding carers' perceptions of AT and the impact of these ATs on carers is important to continue to provide support for persons with dementia and carers.
Study objectives: This paper in addition to describing the results from the survey [18] provides context to the findings, by describing: 1. The experience of carers in using AT in the care of persons with dementia and. 2. The impact of AT on carers well-being and daily life.

Ethics and patient and public involvement
This study was approved by the University of Oxford Central University Research Ethics Committee (Reference number: R57703/RE001). All potential participants were provided with a participant information sheet (additional file 1) and interview participants provided informed written consent (additional file 2) prior to the interview. No personal identifiable information of participants is reported in this paper. This study is part of a larger research project which has a patient and public advisory group that meets twice a year. This group consists of two carers of persons with dementia and a person with dementia (all living in England). This group reviewed the final version of the CATEQ and informed the interview guide questions. This group has also committed to support dissemination of study results to other patient involvement groups and their wider networks.

Study Design Sequential explanatory mixed-method study:
The combined use of quantitative and qualitative approaches would provide a better understanding of carers' experiences and impact of using AT than either approach alone. A better understanding can be obtained by combining survey (quantitative) data results with interview (qualitative) data to thereby enhance the validity of any inferences that are made [19]. Collection of quantitative data and analysis of the results followed by collection of qualitative data and analysis of the results and "mixing" the analysis of the qualitative data to explain the findings from the quantitative data is called the sequential explanatory mixed-method design [20][21][22].
We carried out a survey among carers of persons with dementia in the UK [16]. This provided a broad understanding of the experiences of carers using AT. This survey provided information on the current use, satisfaction and impact of AT use among carers of persons with dementia. The survey was conducted using the Carers Assistive Technology Experience Questionnaire (CATEQ) [23] and the SF-12 (version 1) [24]. The SF-12 contains items covering physical functioning, social functioning, role functioning (physical and mental), vitality, bodily pain, mental health and general health. The SF-12 generates two summary scores: The Physical Component Score and the Mental Component Score (PCS and MCS respectively). The PCS and MCS are generated using norm-based methods and are standardised, using scores from the general population [24,25], to have a mean of 50 (SD 10). A higher score indicates better quality of life. To gain better insight into these findings, interpret them and to enrich the understanding of the experience and impact of using AT on carers, quantitative data collection and analysis was followed by collection and analysis of qualitative data using semi-structured interviews with a sample of survey participants to help explain the quantitative data.
Integration in a mixed-method study may take place at more than one stage of the research process, using a wide variety of strategies. For this study, integration of the quantitative and qualitative phases of the study was made at recruitment, data collection and data analysis stages. Data collection for this study took place in separate and sequential stages [26] (i.e., quantitative survey data was collected before qualitative interview data was collected), but the results of the survey informed the recruitment of carers and questions that were used for data collection in the interviews. At the analysis and interpretation stage, integration was achieved through discussion of how the qualitative findings explain and elaborate upon the findings from the quantitative study and discussion of implications of findings from both studies for future research and support for carers and persons with dementia ( Fig. 1). The cross-sectional survey was carried out between April to July 2020. Following the survey analysis, interview questions were formulated to gain further understanding into carers' experiences as identified in the survey. Interview participants were recruited and interviewed between October -December 2020.

Participants
Survey participants were recruited using online databases via the Join Dementia Research website [27], Oxford Dementia and Aging Research (OxDARE) [28] and through health care professionals who prescribe AT for persons with dementia. Participants were carers of persons with dementia based in the United Kingdom. The inclusion criteria were: adult carers-family, friends or neighbours-providing at least 10 h of care (e.g. shopping, leisure, personal care, finance) per week to a person with dementia who lives in their own home, with the carer living together with or away from the person with dementia; and carers needed to have used at least one AT device at home in the previous year. For the interviews, an email with the participant information sheet [Additional file 1] was sent to survey participants who gave consent to be contacted. From those who replied expressing an interest in participating, a purposive sample reflecting variations in age, sex, living arrangements, rurality, and relationship with persons with dementia were selected for the interviews.

Data collection
For the survey, questionnaires were completed and returned by post (for those who requested a paper copy) Fig. 1 Flowchart of mixed methods design for carers using assistive technology in dementia care study or by using an anonymous online survey link. Data collection for the quantitative study is described in detail elsewhere [16]. For the qualitative study, semi-structured interviews were conducted over the telephone after gaining consent using postal forms [Additional file 2], due to the restrictions from the COVID-19 pandemic [29]. The interview focused on caregiving experience, the use and impact of AT on carers and on caring for the person with dementia. All questions and prompts in the interview topic guide [Additional file 3] were open ended and informed by an earlier systematic review [5], qualitative study [7] and the survey [16] and confirmed as meeting the needs for answering the research questions by the patient and public advisory group. All interviews were carried out by VS. Demographic data was taken from the survey responses and confirmed as being accurate with the participant at the start of the interview. The background of the interviewer as an Occupational Therapist and consequent interest in the research topic was discussed with participants. The participants were not known to the interviewer or the other authors before recruitment. Trust in the interviewer was built by establishing rapport with the participants through email and prior to answering questions as part of the telephone interview. Interviews lasted between 30-50 min, were audio-recorded, and later transcribed by a professional transcriber, verbatim with names of participants, names of the person with dementia, and any towns/cities mentioned in the interviews pseudonymised to ensure confidentiality.

Data analysis Quantitative data analysis
Survey data was analysed using IBM SPSS Statistics version 26. Descriptive statistics were used to examine the findings from the CATEQ which included types of AT used, what the AT was used for, costs of the AT, perceived value for money and satisfaction with the AT. Bivariate analyses were conducted to examine differences in socio-demographic variables between respondents and SF-12 scores. The level of significance was set at p < 0.05 for all analyses.

Qualitative data analysis
The data was analysed using Hermeneutic Phenomenology, a process outlined by Lindseth and Norberg and others [30][31][32] and used in our previous qualitative study [7]. Hermeneutic phenomenology focusses on the subjective accounts of individuals own experiences in context, and thematic analysis seeks to identify and describe topic categories raised by interviewees in describing and explaining the survey results. VS listened to each of the interviews and read the transcripts multiple times (first step). Line by line coding of each transcript was carried out using the software package NVivo 12 [33] (second step). The data analysis was ongoing throughout the period of data collection, this ongoing method allowed earlier transcripts to be recoded to reflect new codes. All the coded units were grouped into themes and underlying sub-themes (third step). Data collection continued after 20 interviews to ensure no new codes were developed and at the twenty third interview, it was concluded that data saturation was reached.

Mixing analysis
The themes were developed, compared and interpreted in context of the survey results [26]. All authors coded selected transcripts independently and met regularly to discuss and agree ongoing data collection, generate themes, interpretation and integrating data analysis with survey results. Reflexivity (the examination of own beliefs, judgments and practices during the research process and how these may have influenced the research) [34,35] and integrity of the research process was maintained by all authors. The authors' experience and previous research with people with long-term conditions, including dementia, provided the necessary expertise for this research. However, it is acknowledged that this experience may have influenced the coding and interpretation of the themes.

Results
Full results from the survey is reported elsewhere [16]. A brief overview of the findings is given here to provide context. Data from 201 carers was analysed. There were 131 (65.2%) women and 65 men (32.3%) with 1 participant self-identifying as non-binary and 4 missing values. Participants' age ranged from 33 to 92 with a mean age of 62 (SD 12) with most participants between 46 and 65 years (n = 105; 52.2%) followed by participants between 66 and 85 years (n = 74; 36.8%). Participants were predominantly white (n = 186; 92.5%), currently married (n = 158; 78.6%) and with a university degree (n = 127; 63.2%). Participants were children of a person with dementia (n = 110; 54.7%) or a spouse of a person with dementia (n = 72; 35.8%). Additional participant characteristics from the survey is described in Table 1. AT were predominantly used for safety, communication, and reminders. Multiple AT devices were used in the care of persons with dementia and the number of AT used was associated with perceived satisfaction. Carers reported that AT helped them reduce effort of caring for a person with dementia and reduced perceived stress. Additional support was needed to support purchase and continued use of AT, and AT devices were abandoned when the person with dementia could no longer use them. The SF-12 indicated carers in the 46-65 age group and carers who were not extremely satisfied with AT had lower mental component scores and carers who lived with the person with dementia and older carers had lower physical component scores. A summary of important findings from the survey is provided in Table 2.
For the qualitative study 23 carers (18 women, 4 men, 1 non-binary) participated in the interviews. Participants' age ranged from 51 to 85. Table 3 provides further details of the interview participants.

Themes
Five themes and 14 sub-themes were identified in the analysis. We describe the themes from the qualitative interviews and situate them in context of the survey results. Additional illustrative participant quotes are provided in Table 4.

Use of AT
In the survey, carers indicated using a wide variety of AT including smart phones, tablet computers and video monitoring systems. They also reported staggered purchase or use of AT. Some AT devices such as pendant alarms and audio books were frequently abandoned as the person with dementia was no longer able to use them.
a.Staggered purchase and use of AT Interview participants confirmed that as a person with dementia's needs worsened, AT devices were added to support them and as these AT were purchased  to meet specific needs, the satisfaction with these devices were higher.

"The clock was one of the first things that I got because she really struggled with time and day". [Participant 19, Daughter, Living with person with dementia]
Computers and tablet computers were already in use by carers or the person with dementia and were adapted to support caring needs.

"Well, I already had the laptop…and she started using it for memory [games]". [Participant 13, Husband, Living with person with dementia]
Carers had to anticipate future needs of the person with dementia and added the AT devices as and when a need arose. Ease of using AT The ease of using AT had an impact on satisfaction, continued use or abandonment of AT. This in turn affected the impact the AT had on carers.

"The increase in [motion sensor] alarms has gone on as he has deteriorated and that is really
Carers found some AT helped a person with dementia, even when they lived away. This provided the carer with a sense of reassurance. Problems using AT: While most of the AT devices that were currently in use were perceived as being user-friendly, carers also reported problems in the AT themselves or in their design. Some of the AT equipment such as electric beds      and electric hoists were large and unwieldy in a home environment.

"I mean, all the equipment's large, but that [electric hoist] is really cumbersome". [Participant 18, Wife, Living with person with dementia]
Some of the problems encountered with AT was a result of the ability of the person with dementia to look after the devices.

"Now the problem with the electronic alarm, the electronical alarm watch lasted about four months and then it got dropped in the bath by [person with dementia]". [Participant 15, Friend, Visits daily]
The design features of some of the AT also caused problems, did not serve their intended purpose or caused confusion in the person with dementia.

Satisfaction with AT
The survey showed that carers who had more than 5 AT devices expressed more satisfaction from using AT. During the interview, carers confirmed how they made the decision to use AT to support a person with dementia based on their needs, which included other co-morbidities not associated with dementia and described how the use of AT strengthened their relationship.
Ability of the person with dementia While most of the AT were used to support difficulties a person experienced, because of dementia, some of the AT were used to support a person with dementia for other illnesses.

"We use it [electric bed] as unfortunately she's also got severe osteoarthritis". [Participant 12, Daughter, Visits every three weeks].
Persons with dementia benefitted from AT to support them with cognitive issues, however as they were still physically active, carers continued to struggle with providing adequate care. Some AT were later put in place when the situation of the person with dementia deteriorated.
"The first years [since diagnosis] were in some ways more difficult because she was still active and would go walkabout… She then broke her hip and that was it, her mobility went. She wouldn't bear weight thereafter…so we had to use these equipment [

electric bed and hoist]". [Participant 13, Husband, Living with person with dementia]
Carers also used AT to support persons with dementia, when their own abilities meant they could no longer participate in activities with the person with dementia.

"So, he quite likes walking and getting about and I can't no longer do the length of walk that he would like so we use the tracker [GPS tracker device]". [Participant 3, Wife, Living with person with dementia]
Some of the AT were also abandoned when the person with dementia's situation worsened due to non-dementia related reasons. Strengthened relationships Survey participants (75.21%) described that AT gave additional time for themselves and the use of AT (46.05% of carers) helped to improve the care they provided. Carers described that the AT helped strengthen their relationship with the person with dementia and described it as another reason for their increased satisfaction with using AT.
Carers felt that the AT helped provide reassurance to the person with dementia, that the carer was still trying to keep them safe. AT also helped some carers spend more time together with the person with dementia.

Impact of AT on carers
Survey participants in the 46-65 age group and carers who were not extremely satisfied with AT had lower mental health component scores, carers who lived with the person with dementia and older carers had lower physical component scores on the SF-12. The interviews explored if AT had an impact on carers and to explain the variations in SF-12 physical and mental health component scores.
Physical wellbeing Carers had multiple physical health problems, this was not always a result of caring or looking after a person with dementia, age or illness associated physical health problems. They reflected on their own health, which may explain the lower scores especially among older carers.

"As for myself, I haven't got very good health. I'm suffering from very bad back pain". [Participant 1, Wife, Living with person with dementia]
While some of these issues were long standing, a few physical health issues arose because of caring for the person with dementia.

"I mean, I have picked him up and ended up in hospital because I had done the disc in my back". [Participant 17, Wife, Living with person with dementia]
Carers also made changes to their lifestyle as part of the caring role for the person with dementia.
"Even things like, you know, my diet is affected, because he has to be fed completely and his ability to chew and swallow is, is impaired. So, therefore I tend to think, "Oh, well, I'll eat just whatever he's eating".
[Participant 9, Wife, Living with person with dementia] In this context, AT did have a positive impact on the physical wellbeing of carers, especially for moving and handling of the person with dementia.

"It's certainly taken the strain off of my body, off my muscles and off my back. So it's been a great help, both the [electric] bed and the hoist". [Participant 11, Wife, Living with person with dementia]
The reassurance provided by AT used for safety, especially for carers who lived away from the person with dementia, assisted carers in better sleep and maintaining an active and healthy lifestyle. Social wellbeing In addition to physical and mental health impacts, AT also had an impact on social wellbeing of carers and the person with dementia.

"So, having the Facetime or the WhatsApp [on smart phone] has been very good, so she can see them [family] and keep, keep in touch". [Participant 14, Daughter, Visits daily]
It also provided an opportunity for carers to continue to engage in social activities that they enjoyed before the diagnosis and progression of illness for the person with dementia.
"We were still able to use assistive technology [GPS tracker, web camera] while mobile so that we could, we could still go out and about and be able to get the alarms or the, the contact if there was an issue [Participant 2, Son, Visits weekly].

AT use in daily life
From the survey, carers revealed that the AT had not significantly changed the level of care provided to the person with dementia by them but reported that AT helped in reducing the need for paid/formal care, which was one of the reasons for carers recommending AT use to others.
Coping with caring AT is perceived by carers as supplementary to the care that they provide. As the abilities of the person with dementia deteriorates with progress of the illness, AT helps carers cope with caring needs. In some instances, AT provided access to healthcare professionals, however carers had to provide extra support and time for the person with dementia to access these services.

Discussion
The prevalence of dementia is steadily increasing [36]. The attention on person-centred care has enabled people with dementia to live longer lives in the community. Without adequate support for their progressive physical and cognitive needs, the majority of persons with dementia may end up in care homes. Predictions are that availability and ability of carers to continue to support persons with dementia in the community will not match demand [37]. Using technology and especially AT is seen as a solution in supporting persons with dementia and carers. This study explains and describes the impact of AT use among carers who look after persons with dementia living at home. Carers view AT as an adjunct to providing care for the person with dementia and in addition use AT themselves for leisure and improved social contacts and mental wellbeing. Carers continued to modify existing 'off the shelf ' AT to meet their unique needs and requirements and in most instances, carers were satisfied with the use of AT. We have also explained how AT use in dementia care may not solely rely on the dementia related needs of a person with dementia; it is also dependent on the co-morbidities of persons with dementia and the carers themselves. Carers with existing physical and psychological challenges exacerbated by their own age and health, experience additional burden while caring for a person with dementia and AT use in these instances helps reduce their burden and improves their perceived quality of life. Similar to earlier studies [38] we found that older carers are less likely to access and use new AT, as they may be unaware of these devices and are less likely to request support in acquiring and continued use of these AT. We also explained how carers expressed better satisfaction with AT, when it is integrated into daily life and how they adapted their role and routines to better use the AT in supporting the person with dementia at home. Dementia changes the dynamics of the relationships between the person with dementia and their carer [39], while caregiving may be perceived as stressful, we found that AT does tend to strengthen the caregiving relationship, as the AT itself becomes a socially connective device and facilitates additional time spent using the AT together, especially for leisure and communication. While there exists sophisticated AT and smart homes, we found the use of this alongside simpler devices and non-electronic AT enhanced satisfaction and met carers needs, as reiterated in one of the largest AT Trial [40]. This study also highlights that AT augments the amount of time carers provide care for a person with dementia, however there is a need for respite care [41,42] for carers, and social communication with wider family members who could look after the person with dementia and substitute for the main carer cannot be replaced with AT solutions. Most carers did not consider data sharing and privacy issues connected with AT use, however some carers were specifically concerned about this and limited the type of AT being used, this is likely to require further research and policy intervention as AT devices become sophisticated and ubiquitous in use. This study reinforces earlier findings [5,7] of a mixed picture of use and usefulness of AT and adds to the literature on the impact of AT use on carers. AT alone or in combination with simple devices, formal carers and other interventions has the potential to be an important addition to efforts to improve the safety and welfare of people with dementia, who wish to continue to live at home and that of carers who support them.

Strength and limitations
The interviews provided an opportunity to explain and delve deeper into the findings of the survey that explored the experiences and impact of AT use in dementia care amongst carers. Selecting participants from across the UK ensured that geographical limitations of procuring and using AT did not limit the transferability of our findings. The interviews were conducted over telephone due to restrictions from the COVID-19 pandemic and this might have missed out on non-verbal cues and interactions. Despite our repeated efforts, only one participant in the interview, was from an ethnic minority group. It would be important to further investigate how carers from Black, Asian or other Minority Ethnic communities in the UK are using AT and if they are impacted by using AT.

Conclusions
This study demonstrates that AT has a beneficial impact on carers who look after persons with dementia. AT devices with the right functionality and when used at those times when needs arose are regarded as useful and satisfactory and are integrated into daily life and routines. Technology development for dementia care requires involvement and consultation with carers. There is a requirement for policy, funding and clinical practice change to a long-term care model that not only facilitates prevention and risk reduction but also encourages education and accessibility of AT to all carers.