https://orcid.org/0000-0001-8535-792X
Figures
Abstract
People with dementia (PwD) are at risk of experiencing loneliness, which is associated with physical and mental health difficulties [1]. Technology is a possible tool to increase social connection and reduce loneliness. This scoping review aims to examine the current evidence regarding the use of technology to reduce loneliness in PwD. A scoping review was carried out. Medline, PsychINFO, Embase, CINAHL, Cochrane database, NHS Evidence, Trials register, Open Grey, ACM Digital Library and IEEE Xplore were searched in April 2021. A sensitive search strategy was constructed using combinations of free text and thesaurus terms to retrieve articles about dementia, technology and social-interaction. Pre-defined inclusion and exclusion criteria were used. Paper quality was assessed using the Mixed Methods Appraisal Tool (MMAT) and results reported according to PRISMA guidelines [2,3]. 73 papers were identified publishing the results of 69 studies. Technological interventions included robots, tablets/computers and other forms of technology. Methodologies were varied and limited synthesis was possible. There is some evidence that technology is a beneficial intervention to reduce loneliness. Important considerations include personalisation and the context of the intervention. The current evidence is limited and variable; future research is warranted including studies with specific loneliness outcome measures, studies focusing on PwD living alone, and technology as part of intervention programmes.
Author summary
More people are now living with dementia than ever before. People with dementia often experience loneliness. There has been increasing interest in using technology to help people with dementia connect with others and feel less lonely. Here we have searched for studies about people with dementia using technology for social interaction. We wanted to see what technologies are being used and if they are helpful or not. We found that there is a wide variety of types of technology being used to help social interaction for people with dementia. Types of technology included robots, tablet and desktop computers and a wide variety of other technologies. The studies we found used a diverse range of methods to see if the technology was helpful. Overall we found that technology could be a useful tool to help reduce loneliness in people with dementia. However there needs to be more research into this area. Future research could focus on helping people with dementia who live alone, and using technology as one part of broader intervention programmes.
Citation: Anderson M, Menon R, Oak K, Allan L (2022) The use of technology for social interaction by people with dementia: A scoping review. PLOS Digit Health 1(6): e0000053. https://doi.org/10.1371/journal.pdig.0000053
Editor: Matthew Chua Chin Heng, National University of Singapore, SINGAPORE
Received: January 12, 2022; Accepted: April 25, 2022; Published: June 6, 2022
Copyright: © 2022 Anderson et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant results data is included in the manuscript. The search strategy is available on the Open Science Framework (DOI: 10.17605/OSF.IO/E7C2S).
Funding: LA is supported by the National Institute for Health Research Applied Research Collaboration South West Peninsula (arc-swp.nihr.ac.uk). MA is an Academic Clinical Fellow supported by the National Institute for Health Research (nihr.ac.uk). The views expressed in this publication are those of the authors and not necessarily those of the National Institute for Health Research or the Department of Health and Social Care. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Introduction
It is estimated that there are 885,000 people in the UK living with dementia; this is projected to increase to over 1.5 million people by 2040 [4]. Dementia has wide ranging consequences; van Wijngaarden, et al. investigated what it means to live with dementia; they found life could be isolating and some participants expressed feeling imprisoned at home [5]. This supports findings from the Alzheimer’s society 2013 report: a third of PwD reported losing friends since diagnosis, 39% reported loneliness, increasing to 62% if they lived alone [6]. The impact of covid-19 has further negatively affected loneliness and mental health in PwD [7,8].
A scoping review by Courtin & Knapp looked at the relationship between loneliness and health in old age [1]. Of 128 studies included only two did not find a negative impact on health; consequences included increased risk of depression, increased risk of physical health conditions and negative impact on cognition. Loneliness is also associated with reduced quality of life overall [9].
Technology is used to connect with family, friends, and strangers all around the world. Although this has raised concerns regarding confidentiality and replacement of human care, it has the potential to be a tool to reduce loneliness in PwD. Studies have found that in the ‘older adult’ population increased internet usage is associated with reduced loneliness [10,11]. The systematic review by Brown & O’Connor into the use of mobile health applications by PwD found seven of nine studies had outcomes related to social health [12]. Mobile health applications stimulated conversation and facilitated intergenerational relationships. Focusing on the use of low-cost pet robots by PwD a scoping review found eight of the identified studies had outcomes related to communication/social interaction (SI) and that robots had an overall positive effect [13]. A systematic review including eighteen studies found that tablets, social robots, and computers have been used to support communication between PwD and their carers. They found that devises facilitated ‘breaking the ice’, increased interaction, facilitated understanding of the PwD and reduced pressure for the conversation partner [14].
The current body of evidence suggests that tablets, computers, and robot technologies are useful tools for PwD facilitating SI with people in the same location. However, this does not encapsulate other mediums of technology, nor does it provide information on the use of technology for distance communication. This scoping review uses a broad definition of technology and aims to look at the current evidence regarding the use of technology by PwD to facilitate SI.
Methods
Data sources
This paper utilises the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR; S1 PRISMA Checklist) guidance to provide the review structure [3]. A literature search was conducted using Medline, Cochrane database, NHS evidence, Trials registers, Open Grey, PsychINFO, Embase and CINAHL on 23rd April 2021. A sensitive search strategy was constructed using combinations of free text and thesaurus terms to retrieve articles about dementia, technology, and SI (S1 Table). An additional amended search using the equivalent search terms was performed on ACM Digital Library and IEEE Xplore. The search was conducted by a specialist librarian (KO) and was registered with the Open Science Framework (DOI: 10.17605/OSF.IO/E7C2S). No limits were applied.
Study selection
Titles and abstracts were screened for relevance and adherence to the inclusion criteria by one reviewer (MA), a random selection (10%) was screened by a second reviewer (RM) for comparison. Studies were included if they investigated the use of a technological device (e.g., tablet, robot etc.) by PwD and the study reported an outcome related to SI. Full texts were reviewed for exclusion, disagreements were resolved through consensus. Studies were excluded if they did not include primary data, if the population was not PwD, purpose of the technology was not SI, or if there were no outcomes related to SI. There were no exclusions related to study design. Although review articles without primary data were excluded from the results table, they were used to identify additional references.
Papers were assessed for quality using the Mixed Methods Appraisal Tool (MMAT), this tool allows studies using different methodologies to be compared. For each study type there are 5 specific criteria to allow quality assessment and comparison [2].
Synthesis
Studies were grouped for comparison based on study methodology as defined by the MMAT [2]. Studies were sub-divided by technology type and outcome measure. A narrative approach was used to explore study results, identify themes, and provide comparison. Qualitative studies and Mixed Methods studies were read to identify commonalities in the emergent themes. These were then used to generate overarching themes related to the outcomes of this review.
Results
The search identified 9161 papers (duplicates removed) of those 73 papers satisfied the inclusion/exclusion criteria. The PRISMA diagram is shown in Fig 1.
Of the 73 papers identified eight published results from four studies. Astell, et al. published two papers with results from the same participants using CIRCA [15,16]. Karlsson, et al. published two papers with results from the same participants using a digital photography activity diary [17,18]. D’Onofrio, et al. [19] and Casey, et al. [20] published results from a study using MARIO in residential care. To avoid over-representation of these studies the most recent papers have been included for analysis. Moyle, et al. published two papers with results from a study using Giraff in residential care [21,22]; the 2014 paper publishes more details of outcomes relevant to this review and is included in the analysis [21]. Three papers published results from more than one study Lancioni, et al. published results from two interventions [23], Huldgren, et al. published results from three interventions [24] and Smith published results from one intervention in two settings [25].
Characteristics of the included studies
Key study information including design and methodology is summarised in Table 1. Studies were conducted in Asia, Europe, South America, North America, Australia and New Zealand. The interventions, study design and outcome measures are heterogeneous. Study setting was varied: 31 in residential care, 15 in participants’ homes, 11 in day care, 3 in labs, 2 in hospital, 2 in community groups, 1 in a workshop and 8 used a mixture of settings. Proportion of studies in each setting is shown visually in Fig 2.
Three different clusters of technology type were identified: Robots, Computer/tablet programmes, and other forms of technology. An overview of broad technology type and main purpose of technological intervention is given in Fig 3.
Blues: Robot technologies, Greens: Tablet/computer based technologies, Oranges: Other technologies.
Robot based interventions
Studies have been grouped by robot type: social robots, pet robots and telepresence robots. A description of the different robots can be found in Table 2.
Social robots. Two studies used MARIO to prompt SI with the robot and other people [20,26]. Robinson, et al. compared Guide with Paro for impact on interaction with the robot and other people [27].
Three studies used social robots from the Nippon Electric Company (NEC), two looked at SI with the robot and other people [28,29] and one looked at interaction with the robot alone [30].
Three studies used different versions of the Telenoid robot, one compared Telenoid facilitated reminiscence with traditional reminiscence, studying SI with the robot and within the group [31]. The other two studies investigated interaction with the robot alone [32,33]. Cruz-Sandoval & Favela investigated ‘Eva’s’ ability to stimulate interaction using different communication strategies [34]. Pou-Prom, et al. compared the Milo R25 robot using autonomous speech to the same robot with a Wizard-of-Oz setup and human interaction [35]. Begum, et al. studied the use of an assistive robot for a tea-making exercise studying SI with the robot [36]. Lima, et al. studied the acceptability of the Hybrid Face Robot and reported results on interaction by the PwD with technology [37].
Pet robots. Nine studies used Paro; most of these studies looked at SI with the robot and other people prompted by the robot [38–43,46]. Two looked at interaction with the robot alone [44,45].
The two studies that used AIBO looked at interaction with AIBO and other people [47,48].
Two studies used cat like robots and studied interaction with the robot and others [49,50]. Feng, et al. used a sheep robot and investigated interaction with the robot and others [51].
Telepresence robots. Two studies used Giraff to facilitate SI with people in a different location to the PwD [21,52].
Computer or tablet based interventions
The computer and tablet based interventions fell into different groups based on the purpose of the programme: reminiscence, conversation prompts, SI, communication networks and other. A description of the different types of computer and tablet based interventions can be found in Table 3.
Eleven studies used reminiscence programmes [16,53–62]. Nine used technologies as a conversation prompt [23,63–70]. Three used programmes to prompt SI. Park et al. used ‘WeVideo’ in a workshop format [72]. Upton, et al. looked at a variety of tablet based interventions that had already been rolled out into care settings and investigated the impact on SI [71]. Smith presents two studies in her PhD thesis investigating the use of a variety of Apps by PwD in Day Care and home settings [25]. Two of the studies used technology for communication with other people in a different location to the PwD [73,74]. Burdea, et al. used BrightBrainerTM and had an outcome of SI as reported by carers [75]. Beentjes, et al. included SI as an outcome for participants using the FindMyApps programme [76].
Other forms of technology
Some studies used forms of technology that do not fall into the previous groups. They ranged from basic interventions such as a phone with pictures [87] to virtual reality [81]. The main focus of these studies was reminiscence, although two of the studies used gaming technology to prompt conversation in group settings [85,86].
Quality of included studies
Key methodological problems in the identified studies were: unclear research question, brief/poor reporting of methodology, limited explanation of data analysis, small number of participants, participants were subset of a larger study, multiple outcome measures, and lack of accounting for confounders. The MMAT was used to assess papers for quality and risk of bias [2], details of MMAT score can be found in Table 1 and Fig 4 shows the frequency of each score. Most papers had a score of three or less indicating that the studies are limited by the quality of the methodology and risk of bias.
Results of included studies
Participants
Studies were limited by small participant numbers, and some had no justification for this (e.g. power calculation). Many of the studies were pilot or feasibility studies with an aim of investigating acceptability, usability, and functionality of the technology before further full-scale studies were carried out.
Study type, outcome measures related to SI and results
There was a wide variety of study type in the papers found. To aid comparison, the papers have been grouped according to the study type and subdivided by technology. There was insufficient homogeneity in outcome measure to combine analyses.
Qualitative studies
Twenty-three of the studies used qualitative methodology. Two papers included quantitative measurements in their study, but as they were not related to SI these papers have been included in this section [42,49]. An overview of the specific qualitative methodology and outcomes are shown in Table 4.
Six of the qualitative studies investigated the use of robots; one used a social robot and five used pet robots. The themes related to SI identified in the studies were conceptually similar and can be grouped into three broad themes: ‘Relationships with the robot’, ‘Conversation point’ and ‘Concerns’. A summary of the specific themes identified in each paper can be found in Table 5.
All six of the studies had themes encompassing ‘Relationships with the robot’. PwD referred to robots as friends [20] and demonstrated a sense of emotional connectedness [43,50]. Pet robots led to a sense of purpose [50]. Communication was prompted and participants could speak to the robot in ways they couldn’t with other people [42,46].
The five studies using pet robots had themes or concepts that fell into the overarching theme ‘Conversation Point’ and noted that participants spoke to the robot and to others about the robot [42,43,46,49,50].
Five of the studies had themes or concepts that can be grouped under the heading ‘Concerns’. Some participants had a negative reaction to the robot [42,46,50]. A concern was raised that robots could be seen as a replacement for human interaction [20]. Gustafsson et al. found that the sense of responsibility for the robot could be too much [49].
Nine of the qualitative studies used technology for reminiscence. The themes related to SI identified in the studies were conceptually similar and can be grouped into the three broad themes; ‘Communication prompt’, ‘Relationship facilitator’ and ‘Considerations’. A summary of the specific themes identified in each paper can be found in Table 6.
All the studies had themes that fall under the broad theme ‘Communication prompt’; the media presented was noted to directly prompt communication by PwD in all the studies [18,24,54–56,58,59,70,77]. Three studies found that technology prompted conversation that was more PwD led [24,54,55]. Three found the nature of conversation changed when media was personalised or relevant to individual PwD [18,54,55]. One study noted that technology was a particular benefit for prompting intergenerational communication [77].
Five of the studies had themes related to the broad theme ‘Relationship facilitator’. Participating in a study was noted to be beneficial [56] and the media presented prompted social activity [59]. Other studies found that the media promoted relationships more generally and reduced the power imbalance between ‘carer’ and ‘cared for’ [24,70,77].
Considerations raised in these papers included that the type/content of media influenced outcome [18,24,54], as did the setting [24,54]. As with the pet robots, it was noted that that technological interventions were not for everyone [59]. However, the study by Welsh, et al. suggested challenging topics shouldn’t be avoided and media should allow and encompass a full range of emotions [70].
Five of the papers used technology as equipment for a shared activity which encouraged SI. The relevant themes were conceptually similar and can be grouped into the three broad themes; ‘Communication Prompt’, ‘Relationship facilitator’ and ‘Considerations’. A summary of the specific themes identified in each paper can be found in Table 7.
All the papers had themes encompassed by ‘Communication Prompt’ where technology facilitated communication between PwD and others [25,71,72,85,86]. All but one of the studies had outcomes that fall under the theme ‘Relationship facilitator’. The shared activity helped provide a scaffold for SI and overcame barriers [71,85,86]. When PwD were interacting with those without dementia technology promoted a partnership rather than a ’teacher and student’ relationship [25].
All of these papers had themes that encompassed ‘Considerations’. Personalisation was found to be important to maximise engagement [85]. Some papers found that if the technology was too far outside a PwD’s ‘comfort zone’ they engaged less [25,85,86], however PwD welcomed new experiences [86]. There were problems with equipment such as weight, connectivity [71] and usability [72].
Finally, three studies investigated unique technological interventions. Asghar, et al. studied a technologically mediated communication network aiming to link PwD with their neighbours. They found that as practical needs were met SI occurred [74]. Johnson, et al. investigated how PwD used an online support forum and found that post purpose could fall into four categories: emotional; informational; companionship; other [84]. Topo, et al. investigated the use of a modified telephone with stored numbers and picture prompts. They found the technology enabled independent call making, however technical issues made the phone difficult to use at times and a carer was needed to help with the phone programming [87].
Quantitative Randomised Controlled Trials (RCT)
Seven of the papers used a RCT design. An overview of the outcome measures used, and results are shown in Table 8.
The two pet therapy studies had SI related outcomes that demonstrated a benefit of technology compared to control [39,51]. Technology facilitated reminiscence was not consistently better compared to controls [53,57,60]. The study using ‘FindMyApps’ did not find statistically significant benefits in SI related outcomes [76] and the study using a augmentative and alternative communication (AAC) device found voice output reduced conversation by the PwD [83].
Quantitative Non-randomised Trials
Before-and-after time series: Eleven studies used a before-and-after time series design. One study used a non-randomised trial methodology, this study has been included in this section as the outcomes related to SI were only measured in the intervention arm [45]. An overview of the outcome measures used, and the results are shown in Table 9.
Three studies used social robots and found varied results [26,33,34]. Only one of these studies found a benefit and it compared robots using different conversational strategies and did not compare robot to human interaction [34]. One study looked at the impact of a pet robot and found it increased SI [45]. Six looked at technology that promoted reminiscence and/or conversation. Two found a neutral effect when compared to baseline [62,78], and four reported positive effects [23,61,65,66]. One study looked at the impact of computer games on a PwD and found that the intervention had a positive effect on verbal responses and openness for SI [75].
Cross-over design. Six of the studies used a cross-over design. An overview of the outcome measures used, and the results are shown in Table 10.
The five robot interventions all demonstrated a negative or neutral effect of technology compared to control. These papers used counting methods to look at conversation [31,41,47,48] or social behaviour tools to rate SI [40]. The study utilising Telenoid R3 found PwD spoke more in a traditional reminiscence session compared to a robot facilitated session [31]. The other four robot studies were pet therapy models and compared robots to toys [41,48], a real pet and human interaction [47] or no intervention [40]. Two of these studies found that the presence of the robots reduced communication overall [47,48] although Kramer, et al. found that conversation was initiated by PwD more in the robot group [47]. The study by Takayanagi, et al. found that in the robot group there was less talking between people but more spoken interaction with the robot when compared to the toy group [41]. Song’s study found no significant change in the social behaviour outcome measures [40].
Astell, et al. used a cross-over design to look at the effect of CIRCA compared to a traditional reminiscence session [16]. They found that technology improved SI. PwD were offered and made more choices, initiated conversations more and carers used conversation maintenance techniques less.
Quantitative descriptive studies
Six of the studies were non-comparative studies using a descriptive methodology. The study by Kelly, et al. was a before-and-after time series study however the data obtained relating to SI did not include any comparison between intervention/exposure and as such is quantitative descriptive data [44]. An overview of the outcome measures used (related to SI) and the results are shown in Table 11.
Two studies found Paro improved SI [38,44]. Three studies looked at social robots, using observation methods to count behaviours during the intervention. One found that interaction with robots and others increased over time [28], one found no statistically significant change in verbal engagement with the robot over time, but questionnaire feedback response was positive [29] and the other study found no change over a shorter time period [37]. Finally, Howe, et al. investigated the impact of an online chat and support forum finding no benefit of the platform on SI for PwD [73].
Mixed method studies
Sixteen of the studies utilised a mixed methods methodology. Studies were only included in this section if the quantitative and qualitative parts of the study had outcomes related to SI. The studies were subdivided by type of quantitative methodology used. There were no mixed methods studies that included a RCT. Nine studies included a before-and-after time series methodology [27,32,35,64,68,69,79,80,82]. One used a cross-over design [63]. Six used quantitative non comparative methodologies [21,29,36,52,67,81]. An overview of the outcome measures used (related to SI) and the results are shown in Table 12.
Most of the studies found either a neutral/mixed or positive impact of technology. Five of the studies looked at the impact of social robots [27,29,32,35,36]. Five looked at reminiscence technology or programmes [63,79–82]. Two investigated the benefits of movable videoconferencing technology [21,52]. Finally four used technology as a way to prompt SI and communication through games and other apps [64,67–69].
Perspective of the Person with Dementia
Of the 69 papers included in this review 34 included the opinion of the PwD about the technology they had been using. PwD’s perspective was included in 13 of the 29 robot studies, 13 of the 27 tablet/computer studies and 8 of the 13 studies using other forms of technology. Overall PwD enjoyed using technology however some found it difficult to use.
Discussion
Having a diagnosis of dementia is associated with increased loneliness and social isolation; this has been worsened by the Covid-19 pandemic [5,6,8]. Technological innovations are one possible tool to alleviate loneliness and increase social connection, however their use is not without potential risks. This scoping review gives a comprehensive overview of the current available evidence related to the use of technology to benefit SI for PwD.
This review has shown that there is continued interest in PwD using technology to reduce feelings of loneliness and facilitate social connection. There is a variety of technological innovations that have been studied using various methodologies. Outcome measures are heterogeneous and limited comparison and synthesis has been possible.
The impact of different technology types
This review presents weak evidence that robots reduce loneliness and/or increase social connectivity in PwD. The studies were frequently unclear regarding the intent of the intervention and what it was replacing or supplementing. When compared to person facilitated activities studies found negative or mixed results of robots [31,33,35,39,47], however there was evidence of more PwD led conversation with robots [32,47]. There were negative reactions to the robots reported in some studies [32,35]. However, if robot technology was going to be used it could be an addition rather than an alternative to human led activities. This might be more obvious in pet robots compared to social robots explaining why overall pet robots resulted in more positive outcomes than social robots. The study that compared a social robot to a pet robot found no significant difference in interaction time, but more smiling, touching and speaking to Paro compared to Guide [27].
The majority of papers utilising tablet or computer-based programmes found a positive effect; none found an overall negative effect. The most common purpose of intervention was to prompt reminiscence or conversation between people who were in the same place. A common finding was that the content or type of communication changed when a technological intervention was used compared to traditional conversation. Three studies found that the proportion of conversation led by PwD increased when using a tablet/computer [16,53,63]. Furthermore the content of the conversation changed, being more PwD led and reciprocal [16,53–55,58,61]. There was a theme that technology facilitated communication and collaboration between people of different generations, helping carers get to know the people they were caring for [68,71]. However, over-reliance on technology could lead to these conversations becoming superficial or ‘question and answers’ rather than reciprocal conversations [70].
The broad group of ‘other’ forms of technology allowed limited comparison. As this review was not limited by date of publication many of these interventions represent older technologies, however this does not make the results irrelevant to current practice. Simple solutions may be more accessible to PwD due to cost and familiarity. Coelho, et al. was the only paper found that used virtual reality (VR), they looked at SI between the PwD using VR and a conversation partner in the (real) room [81]. Although some may have concerns that technology such as VR may not be suitable for use by PwD this study found that it was beneficial and led to SI both during the intervention and in the preparatory sessions.
Technology as an intervention to reduce loneliness and/or increase social connectivity
The 69 papers included in this study looked at 73 different interventions; of these 64 involved face-to-face interactions with other people in the same place. This suggests that the technology is being used as a facilitator for interaction that may have already been taking place. It also limits the applicability of the interventions to those who are at highest risk of loneliness, those who live alone or with limited opportunities to meet with others face-to-face. Thirteen of the interventions facilitated interaction with technology alone (without including face-to-face interaction with other people as part of the intervention) and six with other people who were in a different location to the PwD.
Another prominent theme of the studies found was that many included customisable or personalised interventions. Tablet interventions gave more benefit if the media was personally relevant [54,55]. The qualitative and mixed methods studies gave more insight into the importance of this. The study by Karlsson, et al. found two emergent themes related to this: ‘Manifestations of Sense of Self’ and ‘Sense of Self in Relation to Others’. They noted that the degree of personal identification that a PwD felt with an image/media influenced how they responded to it, if both the PwD and their conversation partner identified with the image/media this led to the most in-depth conversations [18]. This was also true in ‘off the shelf’ games as studied by Hicks. In this study although the game content wasn’t necessarily customisable the choice and content of the activity programme could be personalised. They found that individually tailored activities increased interest, communication, and interaction, whereas if individualisation couldn’t happen the PwD participated less. Technology was viewed to be a scaffold for interaction, if it was too far outside the PwD’s experience or comfort zone, they were more reluctant to engage [85].
A striking finding from this study is the proportion of papers that published the opinion of the PwD. Less than half of the papers included any subjective feedback directly from the PwD. Although people with more severe dementia might struggle to remember previous sessions, they would often still be able to give an opinion during the session. Using a carer or family member’s opinion is not a substitute for the PwD’s opinion as they do not always have the same perceptions or experiences of dementia [88]. There is no reason why people with milder dementia would not be able to communicate their needs, how the robot met or failed to meet those needs or how the robot might be improved to enhance its efficacy.
Strengths and limitations
This study has provided new insights into the breadth of technology that has been studied to improve SI or reduce loneliness in PwD. It provides a comprehensive overview of the current available evidence. It has highlighted the limited amount of data available in using technology to facilitate distance communication.
This study can only draw limited conclusions about the effectiveness of technological intervention for reducing loneliness/social isolation in PwD. It has been unable to generate any statistical comparison to allow robust conclusions to be made. This is due to the variability in outcome measures, heterogeneity in study design and comparison interventions. Many of the studies had multiple additional outcome measures and were not primarily designed to assess the impact on loneliness and/or social connection. None of the studies had a primary outcome measure that directly measured perceived loneliness. The studies also often lacked a clear ‘real life’ aim of how the intervention might be used to allow assessment of clinical/social efficacy. The quality of the interventions was variable as assessed by the MMAT [2].
Future research
This review has identified multiple areas for future research. Homogeneity in outcome measures would be beneficial to aid comparison and allow meta-analysis. Increased focus on PwD at highest risk of loneliness or with reduced technology literacy would increase insights and improve clinical/social application. In particular focusing on PwD living in the community, and PwD who live alone or in more socially isolated locations would increase clinical/social relevance. Areas for future research regarding technology type include technology that facilitates social interaction between people in different locations and technology that is used as part of complex interventions to reduce loneliness and social isolation.
Conclusion
Given the prevalence and impact of loneliness on PwD and the wide interest in using technology to help alleviate this it is important that there is robust research to investigate how best technology can be used. This needs to include the type of technology, the setting the technology is used in and clear outcome measures that provide meaningful data. There is less research looking at technological interventions connecting those in different locations which would be more applicable to those living alone and in rural communities and particularly pertinent given the Covid-19 pandemic.
There is evidence that technology could be a useful and beneficial intervention to help reduce loneliness and facilitate social connection. From the results found interventions that can be personalised and include some aspect of face-to-face intervention are promising. As a result of the lack of consistency between the studies available it is difficult to directly compare their results and generate conclusions that can translate into and inform clinical practice.
Supporting information
S1 PRISMA Checklist. Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist.
https://doi.org/10.1371/journal.pdig.0000053.s001
(DOCX)
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