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Assistive Technology develops accessible, at-home physical therapy.

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Digital Assistive Technology to Support Everyday Living in Community-Dwelling Older Adults with Mild Cognitive Impairment and Dementia

Apr 18, 2022

The Study Selection A total of 1452 references from the period 2017–2020 was identified. We used an adapted version of the Prisma statement for selecting papers. 25 After removing duplicates (47), 1405 references remained for screening to identify primary studies with the following selection criteria: MCI/D, technology, and home-dwelling. All titles were screened for relevance by all three authors using the Rayyan web-based tool, and those meeting the inclusion criteria were selected. 26 This resulted in 1365 papers being declined and 40 papers being deemed eligible for full-text reading. Twenty-six references were excluded after reading the full-text versions, due to wrong context (nursing home, assistive living or lab studies) (12), wrong population (not MCI/D) (3), wrong design (not primary study/trial) (10), or to being a conference paper (1). The number of remaining papers eligible for review was 14 ( Figure 1 ). Figure 1 PRISMA flowchart for selection of papers. Adapted from Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009) Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med. 2009;6(7): e1000097. 25 The Review Processes The three authors read all the 14 papers eligible for review. The quality of the papers was appraised according to the Mixed Method Appraisal Tool (MMAT), version 2018. 27 MMAT allows empirical studies, ie experimental, simulation or observational studies, and different research designs (qualitative, quantitative, and mixed method). Each author reviewed two-thirds of the papers, to meet the criteria of two authors being involved in the appraisal process and reaching agreement on each criterion. 27 Results The 14 studies included in this review took place in UK (7), France (1), Germany (2), Finland (1), Greece (1), Denmark (1), and USA (1). By comparison, the top three countries conducting trials on technology with older adults with MCI/D in the 2017 review were: UK (five studies), the Netherlands (five studies) and Sweden (four studies). Moreover, the research design had changed; while the 2017 review largely consisted of research papers with a qualitative design and few participants, the 2020 review consisted of more research papers with quantitative design and more participants. The study design of the reviewed papers was distributed as follows: 27 Design 1.Qualitative: 1 study Design 3.Quantitative non-randomized: 6 studies Design 4.Quantitative descriptive: 2 studies Design 5.Mixed method: 3 studies Table 2 shows an overview of the quality of the papers included, according to MMAT. Numbers of Y (yes) indicate higher quality, ie seven Ys indicate the highest quality. Numbers of N (no) or CT (cannot tell) indicate lower methodological quality. Table 2 Quality Assessment According To MMAT 20 Table 3 provides an overview of abstracted data structured in the following categories: name of author, title of paper, year of publishment, doi, and country; type of technology used in the trial; aim and purpose of the study; design according to MMAT and quality assessment; number of participants with MCI/D, family carers/staff and age; method; duration of intervention; reports on usability and acceptability; Reports on impact on QoL, occupational performance, human dignity; and results/conclusion. Table 3 Data Abstraction Sheet Types of Technologies Identified and Categorized To answer the first research question, the types of assistive technologies explored in trials with home-dwelling older adults with MCI/D during 2017–2020 can be categorized into five groups: 1.Wearables. Five papers on wearable technologies; wristband biosensors, smartwatches with GPS, wrist-worn activity monitors, and binaural hearing aids. 28 , 31 , 34 , 37 The purpose of these devices is to support safe and healthy living. 2.Environmental sensors and Internet-of-Things (IoT). Two papers on sensors communicating to promote reminders and safety at home and monitoring the home environment. 30 , 32 3.Apps. Three papers exploring mobile phone apps to support activities of daily living (ADL), reminiscence, and a web-based mobile app and smartwatch. 35 , 36 , 42 4.Tablet computers with touchscreen. Three papers on screens for prompting multi-step ADL tasks for viewing art. 29 , 33 , 41 5.Various other supportive devices. Two papers. One on comparing the performance of using a blood pressure monitor, mobile phone and e-book reader in people with MCI/D and cognitively healthy, and one on four different devices to support people with dementia at home: a GPS bracelet, a web chat tablet computer, an audio alarm and a motion sensor with reminder. 38 , 43 Usability and Acceptability of the Technologies in the Reviewed Papers The answers to the second research question about the outcomes of using the technologies with regard to usability and acceptability will be presented in the five sections below. Wearables The purpose of the studies in Group 1 was to monitor people with dementia and their body functions, report on activity, and report physical and physiological markers of significance. One pilot study from Greece, as part of the EU project INLIFE, explored a wearable wristband connected to a tablet and a telemonitoring platform. The wristband transmitted bio-parameters such as blood pressure, heart rate, daily steps, and hours of sleep. The application provided alerts, warnings and motivational messages to the user and family caregiver. The 230 participants with MCI/D, 160 family carers and 30 health care staff accepted the technology, and health care staff were enthusiastic about being able to remotely monitor patients. Usability of the wristband was not reported. 34 A second study tested usability and acceptability of two equivalent GPS clocks on 17 dyads among individuals with MCI/D and their family caregivers. They tested one of two commercially available smartwatches for four weeks. Thereafter, the dyads tried the second smartwatch for four new weeks. The results showed that even though the products were similar, the dyads preferred one smartwatch over the other, resulting in new knowledge on design features. The device should contain few buttons, show a clear font with parsimonious text, and have a battery capacity of at least 24 hours. The usability score decreased after four weeks of use, which may indicate that the users’ expectations could not be fully met or that technical difficulties may have contributed to fewer ratings of usability. 37 One study by Farina et al measured physical activity in 26 community-dwelling people with dementia using wrist-worn activity monitors and evaluated acceptability and feasibility of the monitors. 31 The study found that most of the participants were underactive. The wristband was accepted and was feasible for use by people with dementia. Furthermore, the participants saw project participation as vital to learning about their own activity profile as well as to contributing to dementia research. The participants’ suggestion for avoiding non-use of the activity monitors was to incorporate the device as part of a daily routine. However, technology malfunctions were reported in eight of the 17 activity monitors, which failed to report all activity during the four weeks. The eight devices stopped recording prior to the 30-day record capacity, probably due to battery insufficiency. The reason why the devices could not record during the whole period of only 23 days may have been due to an error in the device or because the researcher provided a device that was not fully charged. 31 A more common wearable is hearing aids. It was hypothesized that older adults with MCI/D and age-related hearing loss (ARHL) would demonstrate fewer behavioral symptoms if provided with binaural hearing aids. Binaural aids are devices that are fitted to both ears and connected to give an overall sound. This ensures that the wearer can understand their surroundings without being overloaded with too many different sounds. The study found that access to hearing aids neither reduced neuropsychiatric symptoms nor increased quality of life. The paper did not report on usability or acceptability. 28 Environmental Sensors and the Internet of Things Group 2 concerns technologies that have emerged from smart homes and home-based technology aimed at promoting safety and well-being using the Internet of Things (IoT). One study (Technology Integrated Health Management (THIM)) discussed a technology-assisted monitoring system that uses IoT. 30 It combined machine learning algorithms to analyze the correlation between environmental data (from PIR sensors, movement sensors, door sensors and pressure sensors) and psychological data (from measuring blood pressure, heart rate, body temperature and weight, and hydration twice daily) to detect changes in health status and well-being in people with MCI/D. The algorithms were trained to recognize agitation and unusual patterns with up to 80% accuracy, which is useful for diagnostic work and decision-making in caring for and supporting people with MCI/D and their family caregivers. The paper did not report on usability or acceptability of the technologies. 30 A second study explored how family caregivers could monitor a non-cohabiting person with dementia by monitoring sensors (3rings digital plug) connected to a bedside lamp, TV or electric kettle via a mobile application. After a four-month trial, all the individuals with dementia were happy to be connected to the family caregiver through the device, and 18 of the 30 family caregivers reported a decrease in burden of care. If no alerts occurred in the morning, they could relax. This study provided an understanding of the use of monitoring technology, and the device was found acceptable and useful by the participants. 32 Mobile Applications The objective of the assistive technology presented in Group 3 was to support memory in people with MCI/D to better cope with daily activities and to better structure their everyday life. Applications made for smartphones can contain different functionalities. One study described a holistic cloud-based solution with a calendar that interacted with other features such as contacts, diary notes, memos and checklists, and that explored the applicability and usability of such an app for people with MCI/D and for their caregivers. 42 The participants, 112 people with MCI/D and 98 family caregivers, had to download and activate the app themselves. Sixty-five people with MCI/D used the app for 90 days. They were divided into four groups according to frequency of use: 1) short use, 1–10 days, 2) early abandonment, 11–31 days, 3) late abandonment, 32–90 days, and 4) adopters, 90 days or longer. Different methods were used to investigate usability and applicability of the app and how often it was used. Timely introduction may explain successful adoption. However, 47 of the participants with MCI/D and 78 of the family caregivers never activated the app. The reasons for this varied; some felt it was too early to introduce the application or found it too difficult to use, while others preferred to buy alternative off-the-shelf solutions or to continue with a paper diary. The small number of participants made it difficult to draw any conclusions. 42 Another study examined the use of a reminiscence app with 30 dyads of MCI/D and family caregivers for 12 weeks. 36 A technology-based reminiscence app can facilitate opportunities for people with MCI/D to retain an empowered role and enjoy conversations around memories. However, access to relevant materials relies on the caregivers’ willingness to participate and on source memorabilia. The study aimed to investigate how the dyads engaged in the app and how machine learning could identify behavioral clusters that typified different levels of user engagement. The participants were divided into four clusters: 1) independent and consistent use of the app, 2) reliant on family caregiver for support in using the app and unpredictable usage patterns, 3) highly reliant on family caregiver for engagement with the app and inconsistent usage patterns, and 4) infrequent usage. The family caregivers’ views on and attitudes toward the technology impacted the relationship with and significance of the app. Those who did not accept the app could not support its use. 36 A third study explored the feasibility and utility of a web-based mobile app and smartwatch called Social Support Aid (SSA) employing facial recognition software. It aimed to promote social engagement by assisting older adults with memory impairment to recall people they interacted with. The app was tested by 20 participants in the intervention group and 28 participants in the control group, with data collection after three and six months. 35 The facial recognition failed because the camera only worked from certain angles. It took time to take photos and did not work in all types of lighting. Moreover, some found the device too heavy and bulky to carry around the neck, and the text too small to read. After six months, most of the participants concluded that the app was not useful for reasons of complexity and functionality, impracticality and stigma, and the enrollment process. However, some participants felt the device had potential to be useful and recommended improvements. 35 Tablet Computers One study explored how a tablet computer could prompt multi-step tasks at home for people with MCI/D by providing instructions in the form of text, photos/pictures, video clips or verbal messages. The study found that instructions with photo/picture prompts and video prompts required too much interpretation and therefore distracted the users if used alone. The combination of recorded voice audio prompts reinforced with text prompts was more effective, powerful, and best understood. 29 Another study explored whether a “DIY-kit prompter package” consisting of a touchscreen with a user-friendly interface, a multi-step prompting software, and a manual could be used independently by people with MCI/D and their family caregivers at home, with little or no training. 33 The prompter package aimed to support people with MCI/D to cope independently with daily tasks such as food preparation and household chores. Fourteen dyads were recruited, of which three withdrew and 11 participated by trying the prompter package for four weeks. All 11 family caregivers reported to have succeeded in loading at least one activity and its steps onto the tablet. Eight of the 11 people with MCI/D had been able to read and follow the steps and complete at least one activity successfully. There were no significant differences between the participants regarding cognitive functioning, though the successful dyads used the prompter more often than the unsuccessful dyads. Another finding was that family caregivers initiated use of the prompter more often than did the person with MCI/D. 33 One study described how an art app on a tablet computer could be used for art-based interventions to provide well-being in 12 people with MCI/D and their family caregivers. 41 The aim was to explore the impact of viewing art on a tablet computer; how it impacted subjective well-being in people with MCI/D, how they experienced the activity, and the family caregivers’ impressions of the impact of the activity on their relative. The tablet contained pictures from different art genres, and the dyads were asked to use it at least five times over two weeks. The art viewing sessions lasted 20 minutes and included 30 pictures on average. The qualitative findings indicated that reminiscence and cognitive stimulation occurred spontaneously, that the dyads had enjoyable conversations, and that they found a new shared activity that led to engagement in new activities such as visiting an art gallery or collecting new images from library books. The results suggest touchscreen-based art activities to be usable, acceptable and to yield well-being for this target group, ie older adults with MCI/D. 41 Supportive Devices and Safety Systems Some assistive technology may be presented as having a supportive purpose for home-dwelling people with MCI/D and their family caregivers. One German study assessed the occupational performance of 80 older adults, 39 with MCI and 41 healthy controls, using a blood pressure monitor, a mobile phone and a paper diary. 43 By video-recording their performance and analyzing the video clips, they compared the two groups’ performance and handling of assistive technology. People with MCI made more mistakes and needed more support in using the devices than the healthy controls. Frequent errors included incorrect arm position or placement of the blood pressure cuff. The attitudes toward technology did not differ between the groups, even though all of them were relatively inexperienced users of technology. The study did not report on usability or acceptability of the technologies. 43 Another study in this group explored the ability of four different assistive technologies to support family caregivers’ work and to support independence in people with MCI/D: a GPS safety bracelet, a web chat tablet, a short-range audio alarm and a reminder with motion sensor. 38 The four technologies were tested for 25 and 38 days by four people with MCI/D at home and five people in an assisted living facility, respectively. The solution with the motion sensor and the mat pressure sensors connected at the short-range alarm to monitor door exits was perceived as useful and easy to use, despite seven of nine participants finding the sound quality poor. However, the study revealed problems regarding disturbances affecting the video phones and the battery in mobile applications quickly running out of power. The technology based on wireless networks and browser-based service management systems was particularly susceptible to failure. Far from all these issues could be resolved during the project period. The conclusion was that assistive technologies have the potential to support people with MCI/D and their family caregivers if the devices are found usable and easy to install, maintain and tailor individually to the user. 38 In sum, findings on user-friendliness and acceptability of technology among the user groups continue to diverge. Impact on Occupational Performance, QoL, and Human Dignity for Independent Living Our third research question dealt with the impact of the technologies on occupational performance, QoL, and human dignity for independent living. Column nine in Table 3 presents the findings related to QoL, occupational performance, and human dignity in the reviewed studies ( Table 3 ). None of the papers reported any explicit impact of technology to improve QoL in the participants. Some terms other than “quality of life” were used, ie reduced burden of care and positive impact on relationship, which can be linked to QoL. 32 , 36 , 41 The term “occupational performance” was reported in only one of the 14 papers, ie on occupational performance from using three different devices. 43 Human dignity was neither studied nor reported in any of the 14 papers. Purposes of Digital Assistive Technology in the Review Table 4 presents an overview of technologies evaluated and grouped according to the Norwegian Directorate of Health’s categorization, also used in our 2017 review: 15 However, multi-purpose technologies were challenging to categorize since they could fit into more than one category. Table 4 Overview of Types and Purposes of Technologies ● technology for safe walking indoors and outdoors, ● technology for safety at home, ● technology for independent living, and ● technology for entertainment and social communication. Discussion This review aimed to compare the technologies explored in trials with older adults with MCI/D from the decade 2007–2017 and from the past three years (2017–2020), and to discuss usability and acceptability of new digital solutions regarding occupational performance, QoL, and human dignity for independent living. To summarize, we found that assistive technology solutions seem to have become more multifunctional over the past three years, with wearables, apps and sensor technology often combined with computers, functionality for two-way communication, with or without a camera. The studies placed more emphasis on supporting coping strategies and independence in the person with MCI/D by use of apps, and computer technology for entertainment, cognitive stimulation and for prompting successful performance of tasks to improve independence and well-being. 29 , 33 , 36 , 38 , 41 , 42 , 44 Furthermore, sensor technology for monitoring physical health markers such as blood pressure, oxygen uptake, heart rate, etc. and for monitoring environmental conditions such as indoor temperature, controlling lighting, detecting presence or falls, predicting actions and alerting if something is wrong. 30 , 32 , 34 , 43 This may indicate that the smaller studies elaborated knowledge that could be built on in quantitatively designed studies. It may also be that digital assistive technologies have become cheaper and more available for research projects. Monitoring technologies make it easier to evaluate use and benefit through logged events. Interestingly, the search results in September 2020 for the previous three years (2017–2020) identified far more studies on trials than did the 2017 search for the period 2007–2017, with 1452 titles compared with 359 in 2017. Many studies on digital assistive technology among various user groups are currently taking place worldwide, and although MCI/D and home-dwelling people were inclusion criteria, several papers that also appeared in the search results reported on acquired brain impairment (ABI), cognitive impairments in children and adolescents, studies in nursing homes, and lab studies. Moreover, the number of participants had also increased in terms of people with MCI/D, family carers, and health care workers ( Table 2 ). A quick calculation reveals a tendency toward including almost twice as many participants in the studies in the 2017–2020 review, as in the 2007–2017 review. The technologies explored in trials with people with MCI/D and their family carers seem to have shifted since the 2017 review from stand-alone devices at home toward technologies that can be worn on the body to monitor body functions and report states or imbalances. Moreover, research interest is more focused on mobile phones with apps and in wearables providing reminders and timely support, and monitoring health status. Types of Technology As stated above, digital assistive technologies seem to have developed between the two reviews, and have become smaller, more integrated systems, often with multiple purposes. 30 , 34 Three strategies for support seem evident: prompting and reminding people with dementia, and monitoring people with dementia at home using environmental sensors and biosensors, and providing safety outdoors using GPS. 30 , 32 , 37 , 38 , 43 Several of the papers aimed to evaluate feasibility and usability of the devices, reveal the preferred kind of prompting format, and to offer compensatory strategies using different apps. 29 , 33 , 35 , 36 , 42 A few studies aimed to explore how tablet computers can offer entertainment and meaningful leisure. 41 , 44 In the screening process we came across several papers describing trials with robot technology and augmented reality (AR). 45–50 However, these were lab studies, or scoping studies and thus did not meet the inclusion criteria in the current review. Moreover, earlier trials have stressed usability issues such as user interface applicability for people with dementia. Grundy stated that technology should aim to make challenges associated with ageing less limiting. 51 We would like to add challenges associated with cognitive impairment. Thus, new technology, which to a great extent is wearable or is provided as apps, must be explored with regard to user interface applicability for people with MCI/D. Moreover, wearable technologies should be comfortable, self-explanatory, usable, and acceptable by older adults with MCI/D. Regarding Usability and Acceptability of the Technologies in the Review Usability and acceptability are important to ensure older adults’ adoption of technologies. Column 8 in Table 3 presents details on usability and acceptability of the technologies explored in the trials. None of the papers explicitly addressed the concepts of usability and acceptability. Five of 14 papers did not use these terms at all. However, some used the terms useful, successful use, sense of gain, acceptable or utility in the sense that the technology may be user-friendly and of use. Two of the papers reported less usability of the technology due to technical problems, functionality, and complex user interfaces. 35 , 38 User-friendly technology is perceived as a requirement for acceptability and adoption. The need for adapting technologies to older adults’ individual skills and preferences determines whether the technology will be used and found acceptable Person-centered tailoring of digital assistive technology is thus important. Research has found that appropriate services based on a whole systems approach to care is of importance to facilitate technology-enriched accommodation for people with dementia. 52 Such knowledge indicates that a more extensive collaboration between health care and technology development companies is required to ensure that technology enriches older adult’s accommodations in a trustworthy way rather than create barriers and unreliable services. Moreover, user participation workshops for piloting technology regarding interfaces, user-friendliness, etc. will still be required to optimize usability and acceptability. A more recent term, “intuitive design”, defines intuitive use as a characteristic of the interactive process between a specific user and the design. 53 It means that the product’s design is based on principles from other domains that are well known to us, so that we can use our past experience to reason how it should be used. The designer must thus acquire knowledge of the target audience in order to succeed. None of the reviewed papers discussed intuitive design. This actualizes the call for user involvement in research and technology development. Impact on Occupational Performance, QoL, and Human Dignity for Independent Living The main interest in the 14 reviewed papers concerned feasibility and effectiveness of the technology. One study only explored occupational performance (Schmidt and Wahl). No questions were asked about QoL or human dignity. We may interpret this to indicate that developers are more interested in the technological features and possibilities than in how the technology influences everyday living. We argue that timely access to technology may support people with MCI/D to better cope with everyday situations by facilitating and simplifying occupational performance. This may lead to an improved sense of quality of life and human dignity. 54 Most of us have an innate need to master daily activities that are important to us and to be respected as human beings. If technology were to address these issue, maybe more older adults would be willing to adopt digital assistive technology. User Involvement in Technology Development Research None of the papers reported on user/caregiver/stakeholder involvement in the design process of the technology evaluated. However, one study invited participants to keep notes in a diary about using the device, and at the end of the trial they were interviewed about their opinions on and satisfaction with wearing and using the device. 31 The current review demonstrates the necessity to evaluate new digital technology with the target groups. Recruiting people with MCI/D and their family carers to research projects will create knowledge about cognitive impairment and how consequences manifest in everyday living as well as how technology could be incorporated. Such knowledge contributes to improved awareness of user needs for people with MCI/D and their carers. Careful assessment of and dialog with the target groups are needed to obtain this knowledge. It requires meeting places for mapping and discussing user needs and the time to exchange views. One study by Lund et al reports on dialog cafés as a method of co-creation of knowledge. 55 The time aspect proved to be particularly important, since the participants needed time to acquaint themselves with the form of involvement, and to feel comfortable in the groups and with the technology topics that were introduced. The study gave an example of how dialog cafés facilitated user involvement and enabled older adults to express their needs and provide their perspectives on assistive technologies, which in fact directed research and development in the main project. 55 Adoption of technology is known to be slow in older adults. One study on older adults’ perspectives on assistive technology found that 60 of 82 respondents perceived themselves to be too old to get involved with technology. Furthermore, 55 of 82 agreed that technology was useful for others but not for them, yet 49 of 82 reported being accustomed to using computers, mobile phones and other technical equipment. 56 This may indicate that there are huge differences in older adults’ knowledge of and practice in using technology. One may conclude that adoption of technology is dependent upon technology literacy. However, it could also be due to lack of information and training, of Wi-Fi or of the economic resources to buy equipment and subscriptions to data services and programs. One recent study found that older adults could learn to use a tablet with a touchscreen successfully through five coping strategies: 1. having a supportive environment encouraging the person to use it and offer help to do so; 2. interest and motivation were created when they realized they could continue doing meaningful activities on the tablet, such as reading newspapers; 3. operating the tablet seemed easy for many, which led to positive experiences and confidence in using it; 4. being able to maintain contact with family, friends and society was the most important aspect of using the tablet; and 5. having personal strategies to ease use of the tablet, such as using the little finger or a tablet pen to be sure to click on the right button contributed to a positive experience. 57 Possible Biases Several biases may threaten the credibility of our study. First, due to terminological variations in the databases and the large number of keywords in our search strategy, we had to convert the keywords to relevant MeSH terms for each database. For example, the original keyword “assistive technology” was converted to “assistive or self-help or everyday or daily living or dementia friendly or welfare, technology or device* or aid” ( Table 1 ). However, using the same search strategy as in the 2017 review was found to be fruitful and appropriate for exploring the field three years later. Moreover, the quality assessment process using the MMAT criteria was carried out separately by each author, before the three authors met to agree on the ratings. If any discrepancies arose, the author who had not rated the paper in question was asked to assess it. Conclusion Research interest in technology to support older citizens with MCI/D at home is increasing. This is important because there is a need for more knowledge on how technology works in practical settings and how it influences everyday living for people with MCI/D. This systematic review demonstrates that research studies conducted over the past three years have increasingly reported on wearable and environmental digital assistive technologies, often with multiple purposes. Three strategies for support seem evident: prompting and reminding people with dementia, monitoring people with dementia at home using environmental sensors and biosensors and providing safety outdoors. Nonetheless, dementia-friendly technologies have yet to be developed. Thus, there is still a need for further research on the impact of these technologies on occupational performance, QoL, and human dignity for independent living. Acknowledgments We want to thank librarians Linn Kristine Kristensen, Malene Wøhlk Gundersen and Hege Kristin Ringnes at Oslo Metropolitan University for their supervision and support in performing systematic searches in all the relevant databases. Disclosure References 1. Morgendagens omsorg. Meld.St 29 (2012-2013). [The Care of Tomorrow]; 2013. 2. Meld. St. 15 (2017-2018). Leve hele livet - en kvalitetsreform for eldre. Helse- og omsorgsdepartementet. [A full life - all your life — a Quality Reform for Older Persons. Ministry of Health and Care Services]; 2018. 3. World Health Organization. Global action plan on the public health response to dementia. World Health Organization. Available from: https://apps.who.int/iris/bitstream/handle/10665/259615/9789241513487-eng.pdf;jsessionid=4DA480FA93471AC53988E52B35F416D8?sequence=1 . Accessed . 10. Winblad B, Palmer K, Kivipelto M, et al. 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