An ongoing discourse is taking place about the possibility and importance of using Information and Communication Technology (ICT) to meet the needs and support the quality of life of an increasing number of elderly people. This, among other things, was manifested in the Ambient Assisted Living Roadmap of the EU’s seventh framework programme [1]. In this discourse, the possibility of developing cognitive digital assistive technology to support “aging in place”, having the possibility to live at home for as long as possible, for people with dementia living in their private homes and their carers is of special interest [2]. This can be seen as a way of supporting well-being and person-hood cf [3]. There is documented experience, however, that the introduction of new ways of providing support for elderly people, such as the use of ICT solutions, is often resisted by professional caregivers because of their perceptions and values [4]. For people with dementia, professional caregivers’ perceptions about the use of digital Assistive Technology (AT) devices is of importance, since the carer has the power to suggest or decide about access. Professional carers’ perceptions are built on knowledge about the disease, experiences of the limitations and benefits of assistive digital devices, along with values related to the use of assistive digital devices.

For people with cognitive problems, the maintenance of the sense of self, and consequently a sense of dignity, is a desirable goal and a fundamental base for the experience of well-being. A common and central concept in understanding the sense of self of people with dementia is “personhood”, defined as being a human. Being understood to be someone unique is something that strengthens the feeling of being a human and is a prerequisite for human encounter [3]. The importance of maintaining the feeling of being a human is described in several studies conducted with people living with dementia as one of the most major concerns in their daily lives. This is very closely associated with maintaining control and independence [5], not being treated as a syndrome, “the disease” [6], receiving understanding and support from relatives and being listened to with respect [7]. Moreover, being able to perform or participate in meaningful activities, which enable the person with dementia to experience feelings of pleasure and enjoyment; feeling a sense of connection and belonging; and retaining a sense of autonomy and personal identity [8]. For a long time, a person’s life story and different forms of memory support have been used to assist people suffering from dementia. Mc Keown et al., [9], for example, described how collecting different aspects from earlier life and from a person’s current life is a way to facilitate the maintenance of the life story, with the purpose being to support people in their actual situation. The life story is described as having the potential to enhance person-centred care for people suffering from dementia in their surroundings [10]. The work is often collaboration between relatives or significant others and the result can be, for example, pictures, collage or a collection of memory books. If it is possible to catch the life story of a person with dementia, it is necessary to start examining the story in time, that is, while the person is still able to present her/his own picture of her/his life [11, 12]. Basset and Graham [13] stated that there is a possibility of maintaining the identity of persons with cognitive impairment by regularly working with their life stories. A person’s life story, identity and sense of self is connected to persons, places, events and objects and it can be assumed that the experience of home plays an important role in the life story.

The basis for the discussion about the benefits of “aging in place” is the assumption that the home is experienced to be an invaluable resource and a special place of overriding importance when aging [14-16]. The home is highly valued and, for the person living in it, it means, among other things, security and freedom [16]. One way of supporting older people who want to age in place in their own home is to explore the possibilities of using specific assistive digital devices to support independence and promote well-being [17]. One can assume that a person who receives a diagnosis of dementia will probably strive to continue to live at home for as long as possible, to continue to have the possibility of independent living and maintain an ordinary way of life, including, for example, the ability to go out shopping, take a walk in familiar surroundings and to engage in enjoyable informal interactions with friends and neighbours, cf. [18]. For a person with dementia the use of digital assistive technology might contribute to enhanced independence, wellbeing and a feeling of being autonomous [19]

Values like self-determination have a central role when a person is in need of support, especially when the support and care is given at home. Self-determination is a central aspect of autonomy and is something that can be exercised even under changed and restricted circumstances as long as there is a possibility of making decisions from a set of alternatives that can be offered in whatever the surroundings, even if they are outside the home [20].

New AT is becoming increasingly readily available in society as a whole, also could have an impact on elderly people living at home [21]. There is an emerging field of research that indicates that the provision of AT when getting older can play a role in facilitating daily living [22, 23]. For example, like supporting the independence of, providing a sense of security to and increasing the feeling of well-being of people with dementia and their relatives [24]. Independence and feeling secure are often mentioned as important and desirable states of existence, which the use of AT has the potential to contribute to [23-25]. When healthy elderly people were asked about their perceptions about the use of AT in the event of them becoming dependent on care, they expressed mixed feelings on an individual basis, they could see that there would be positive and negative sides to the use of assistive technology services [26]. Some studies indicated that, for people with dementia, the use of AT is a complex issue that involves prejudices and conflicting feelings. There is a fear that the increased use of ICT might contribute to inhuman care with a loss of dignity, and at the same time be a promoter for human care [4, 26], thereby helping to ensure that certain values are maintained as others are lost. This is a complex issue and a vital one if standards are to be ensured. As people with mild dementia described having technology-related concerns when using both the more-familiar technology like televisions, and new technology like computers and cell phones, there is a need for these people to receive support with technologies at home and out in society [27].

A review of the literature shows that research conducted up to now about the possibility of supporting people with mild dementia in their private homes through the use of AT has only been studied to a limited extent. More research is needed focusing on enabling persons with early-stage dementia to continue to live in their homes for as long as possible [2]. Therefore it is of great importance to explore professional caregivers’ perceptions, and through this, to comprehend the values that are associated with the use of a specific assistive digital device to support the life-stories for people living with dementia. The use of AT to support and maintain a person’s life-story in different ways is a rather new phenomenon and needs to be studied carefully and evaluated.

This study falls within the boundaries of a project where a new assistive digital device to support the maintenance of the life-stories of persons in the early stage of dementia is tested [28]. The device was developed to capture information about daily life events, and enables the information to be retrieved in a context-dependent manner subsequently. The tested assistive digital device in the project is comprised of three different components, a digital wearable camera, a computer and a smart phone, as clarified (Table 1). The camera is worn around the neck with a cord and takes photographs automatically that are uploaded onto the computer later on. The smart phone has a Global Positioning System (GPS) and collects information about the places visited. A computer with a touch screen is placed in the home and, together with a relative or member of staff, it is possible for the person with dementia to review and discuss the events of the day with the aid of the photos. All information is for personal use, and no one can access the collected information. Through the regular reviews conducted, a digital library of information is built-up that serves as a digital photo diary on which to build and maintain a life-story that includes the past and the present.

The aim of this study was to describe caregiver’s perceptions of how persons with mild dementia are likely to experience the usage of a specific digital photo diary.

The research collection strategy presented here took the form of a questionnaire, and was conducted in Sweden with caregivers involved in or responsible for the care of people living with dementia.

The results focus on the background questions (part I), and concern what the informants believed the fictive person (Hilda) in the questionnaire felt when wearing the camera at home and outdoors (part II), and what the informants believed the fictive person (Hilda) in the questionnaire felt when viewing and sorting the uploaded photos while sitting in front of the computer with a relative (part III).

Differences in Factors Scores Between Different Positions and Gender when Using the Camera

A Mancova was performed using age as a covariate to investigate if there were any differences in the factor scores between different positions and/or the gender of the caregivers. The interaction between ‘present position’ and ‘gender’ was significant (p<0.0005). Both ‘gender’ (p=0.048) and ‘present position’ (p<0.0005) were also significant as main effects in the multivariate tests, although ‘gender’ is a borderline case. The numbers of men who responded to the survey were few, 17 of a total 408. The interaction between ‘gender’ and ‘present position’ mainly consist of a lack of variation in factor scores between different work categories for men, i.e. men have practically the same factor scores across all work categories, which is not the case for women. Due to the small number of men in the sample we think it is still appropriate to present results regarding the main effect for ‘present position’, which is done in the following. Further, since ‘gender’ is on the border of significance and the sample sizes for men and women respectively are vastly different, we resist the temptation of making conclusive statements about gender differences.

The follow-up univariate analyses indicated that ‘present position’ had an impact on the score of the factors Sense of self-esteem and Sense of trust. Occupational therapists and physiotherapists had a significantly lower factor score compared to registered nurses and care administrators on the factor Sense of self-esteem (Fig. 1). This can be seen as occupational therapists and physiotherapists had a tendency to rate the included items in a more positive way than other positions. Furthermore, the occupational therapists and physiotherapists had a significantly higher average score than the group comprised of leaders, project leaders and care developer, and registered nurses on the factor Sense of trust (Fig. 2). This indicates that occupational therapists and physiotherapists have a tendency to disagree that the use of the camera can contribute to a sense of trust.

Fig. (1). The mean of the scores illustrates the impact of the present position occupied by the respondent on the factor Sense of self-esteem when wearing the camera and smart phone at home and outside.

Fig. (2). The mean of the scores illustrates the impact of the present position occupied by the respondent on the factor Sense of trust when wearing the camera at home and outside.

From the above presented results it is clear that occupational therapists and physiotherapists differ from the other positions on Self-esteem and Sense of trust. Even if it is not significant the assistant nurses have a tendency to agree that sense of self-esteem could be supported by using the camera.

Differences in Factors Scores Between Different Positions and Gender when Viewing and Sorting the Uploaded Photos

Differences in the factor scores between different positions occupied by and/or the gender of the caregivers were analyzed with a MANCOVA, using age as a covariate. The interaction between ‘present position’ and ‘gender’ was not significant at the 5%-level (p=0.071) and was therefore excluded from the model. ‘Present position occupied’ was significant (p=0.037) as a main effect in the multivariate tests, whereas ‘gender’ was on the border of significance (p=0.052). For the same reasons as above regarding sample size differences for men and women, no conclusive statements about gender differences are made.

The follow-up univariate analyses indicated that ‘present position’ has an impact on the score of factor Sense of autonomy; the difference between leaders, project leaders and care developers, as one group, and occupational therapists and physiotherapists; and assistant nurses was significant. This result indicates that these groups of position seams to disagree that the sense of autonomy can be supported by viewing the uploaded photos. The care administrators had lower score on the factor Sense of autonomy. It is interesting that occupational therapists and physiotherapists and assistant nurses are close to each other in their statements compared to the others position (Fig. 3).

Fig. (3). Means of the score illustrate the impact of the present position occupied by the caregivers on the factor Sense of autonomy when viewing and sorting photos on the computer alongside a relative.

In order to clarify and elucidate the professional caregivers’ perceptions on how persons with mild dementia might experience the usage of a specific digital photo diary, the professional caregivers were asked to rate their perceptions on a scale based on a semantic differential technique that comprised 22 bipolar adjectives. The results are interpreted as professional caregiver’s view of using the digital photo diary was positive overall. The main finding from the factor analysis was that Sense of autonomy was the dominant factor from the both parts, wearing the camera and viewing and sorting photographs.

The interpreted factors Sense of autonomy, Sense of self-esteem and Sense of trust are all related to identity and perception of self. Sabat [36] has applied social construction theory to the analysis of selfhood in the conversational discourse of a person with mild to moderate dementia. Self is divided into three aspects in his work: the first aspect describes personal identity, the second describes mental and physical attributes, and the third one is connected to the self as a social person in interaction with others.

The factor Sense of autonomy, refers to the Sabat’s second aspect of self, namely, describing mental and physical attributes [36]. Persons with dementia have difficulty remembering persons, places and events, and by documenting these with the camera and afterwards viewing and sorting the photos together with a relative, they could possibly manage to continue to be aware of what is happening to them despite their memory issues. The support obtained affecting maintaining control through the use of digital AT was also described by Engström et al., [37]. These authors stressed that, when people with dementia use communication technology as a support, it gives them a feeling of maintaining control and autonomy. Visiting familiar places, shopping and being able to perform activities of special personal interest all contribute to the well-being of people with dementia [18]. Furthermore, being able to maintain the memory of these persons, places and events through the documentation provided by the camera can contribute to enhanced sense of well-being and a feeling of strengthened self-esteem. By having the opportunity to use the digital photo diary and of being able to interact independently with others, the person could possibly perceive herself/himself as a competent valuable person who is in control; thereby strengthening the person’s sense of self [36]. Losing autonomy and control over the decision-making relevant to one’s own life has been described by researchers as a loss of self-esteem and a diminution of self [38-40]. In contrast, being able to do meaningful activities with the support of the digital photo diary and relatives as support is associated with maintaining a sense of self cf. [38]. Our interpretation and conclusion of the results is that the factors, Sense of autonomy, Sense of self-esteem and Sense of trust all relate to the second and the third aspect of self cf. [36].

Sense of autonomy is an important dimension of the usage of the digital photo diary. Autonomy is more or less related to independence and can be seen as the individual person having the ability to make significant decisions regarding his or her life [41]. As the cognitive impairments of a person suffering from dementia result in loss of autonomy, it is crucial to support and maintain the autonomy of these persons. It seems that the caregivers’ perceptions of the usage of the assistive digital device, notably, that AT has the potential to help to maintain the autonomy of people with dementia corresponds to the findings of Powell [42], who reported that carers expressed a general enthusiasm for the benefits, such as gains in or the retention of autonomy when using new information and communication technologies among people with dementia.

The second factor from the factor analysis and also rated with the lowest mean value, indicating that Sense of self-esteem was measured as an important outcome when using the digital photo diary. When considering the person with dementia taking photos and viewing uploaded photos, both these activities alone or in a familiar atmosphere in the company of and with the assistance of a relative, were perceived to be acts that would strengthen the person’s self-esteem. This corresponds with the findings of Sabat and Harre [43], who found that, when positive social interaction took place and there was an opportunity for self-expression, self-esteem was supported. According to Baumeister and Twenge [44], who stressed that having close and meaningful human relationships are crucial parts of the self, one can assume that the relatives’ contribution is of great importance for the usage of the digital photo diary to be meaningful for the person with dementia. One study [45] reported that the relatives play an important role as a trigger for people suffering from dementia to be able to re-construct their memory through conversation. The results of our study can be interpreted in the same way: by taking photos and talking about the day’s events, the life-story of that one day, for that person, through an active interaction with others and relatives, it is perceived that the person with dementia would be able to retain a sense of self-identity and to recount the story that is important for himself/herself.

There were some differences between how different professional groups perceived the usage of the camera and viewing the uploaded photos. A notable trend was that the occupational therapists, physiotherapists, assistant nurses tended to have similar views on different issues. For example, both Sense of self-esteem when wearing the camera and smart phone at home and outside, and Sense of autonomy when viewing and sorting photos on the computer alongside a relative, were measured in the same way by these professionals.

A possible explanation is that assistant nurses are the professional group working most closely with the people with dementia, giving them a particular insight into the everyday lives of the sufferers while occupational therapists and physiotherapists, because of the nature of their job, tend to focus on rehabilitation challenges. A notable difference is that care administrators, care developers and project leaders tended to have significantly different views on the use of the camera compared to occupational therapists, physiotherapists and assistant nurses. These differences are difficult to explain.

The above-discussed results of differences between positions raises a considerable number of questions about how the differences can be explained, however we do not have enough information in our results to make qualified assumptions.

The investigation reported here focused on caregivers’ perceptions of how persons with mild dementia are likely to experience the usage of a digital photo diary. When discussing the results it must be considered that none of the participants had actually seen the digital photo diary in operation; it was introduced to them via the fictive scenario of Hilda. Nevertheless, we think that the structured way of using a scenario involving a person with dementia (Hilda) and the detailed description of the assistive digital device being used ought to guarantee the uniformity of the responses. By using fictive scenarios of this kind it is possible to perceive the use of an assistive digital device as has been discussed by Fung et al., [46]. However, it is also likely that the way the participants responded may have been influenced by the way the scenario was presented. It is therefore reasonable to assume that the results might have been different if the age, gender and the context of the person taking centre-stage in the scenario were different.

In the evaluation of the digital photo diary considered in this investigation, the usages of the camera and of the viewing function were at the first FA evaluated separately. But the fact is that the two situations for use of the digital photo diary are dependent on each other. The reason for reducing some of the variables after the first FA was made was to have the possibility to make a comparison of the two situations for use of the device. It seems reasonable to reduce the aforementioned adjectives due to their complexity as concepts in the colloquial language and they were also very similar to some other adjectives. The excluded bipolar adjectives were Satisfied/Dissatisfied, Confirmed/Unconfirmed, Cherished/Abandoned, Energetic/Lethargic and Cosy/ Worse.

In addition, the labelling of factors is always a matter of interpretation, and therefore, there is an inherent risk of misinterpretations being made. This risk was handled by discussing the interpretations thoroughly between the authors.

A representative group of professional caregivers working with people with dementia perceive the use of the digital photo diary to possibly support autonomy and independence for persons living with dementia. Thus, caregivers have an overall positive view that supports a further development of the digital assistive photo diary. The next step is to evaluate the use of the digital photo diary with persons living the experience of mild dementia in order to find out their perspectives of using it and then compare the findings of both studies.

Declared none.