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Over the past decade, there has been an increase in the use of information technologies to educate and support people with dementia and their family caregivers. At the same time, chatbot technologies have become increasingly popular for use by the public and have been identified as having benefits for health care delivery. However, little is known about how chatbot technologies may benefit people with dementia and their caregivers.
This study aims to identify the types of current commercially available chatbots that are designed for use by people with dementia and their caregivers and to assess their quality in terms of features and content.
Chatbots were identified through a systematic search on Google Play Store, Apple App Store, Alexa Skills, and the internet. An evidence-based assessment tool was used to evaluate the features and content of the identified apps. The assessment was conducted through interrater agreement among 4 separate reviewers.
Of the 505 initial chatbots identified, 6 were included in the review. The chatbots assessed varied significantly in terms of content and scope. Although the chatbots were generally found to be easy to use, some limitations were noted regarding their performance and programmed content for dialog.
Although chatbot technologies are well established and commonly used by the public, their development for people with dementia and their caregivers is in its infancy. Given the successful use of chatbots in other health care settings and for other applications, there are opportunities to integrate this technology into dementia care. However, more evidence-based chatbots that have undergone end user evaluation are needed to evaluate their potential to adequately educate and support these populations.
Over the past decade, chatbot technologies have increasingly been used by people to meet a variety of daily needs, including social and emotional support and information seeking [
There has been a growing interest in developing and testing technologies that can improve the quality of life and care for people with dementia and their family caregivers. Indeed, in 2018, the Family Caregiving Institute held a Research Priorities in Caregiving Summit: Advancing Family-Centered Care Across the Trajectory of Serious Illness. Among the 10 research priorities identified, the first 2 are “evaluate technologies that facilitate choice and shared decision making” and “determine where technology is best integrated across the trajectory of caregiving” [
Previous research has found that people with dementia have the ability to use a number of technologies designed to fit their needs, including computers [
Chatbots may use a variety of platforms, including websites, smartphones (eg, Siri), mobile apps (specialized in a domain such as depression or for general purpose, such as WhatsApp and Messenger), SMS text messaging, and in-home smart technologies (eg, Alexa) chatbots. Loranjo et al [
One of the first established chatbots was programmed in the 1960s, called ELIZA, which was used for text-based psychiatric interviews [
Having been used for customer service, education, website user support, and entertainment, chatbots were found to have promising use in health care [
The benefits of using chatbots for health care have been identified for patients and health care systems alike. For example, chatbots may support patients in treatment management and moral support [
As the state-of-the-art advances, more older adults are using information technologies to meet a number of chronic health needs, such as increasing health self-efficacy, supporting self-care management, engaging in health promotion, and interacting with health care providers [
In the case of dementia care and caregiving, information technologies have specifically been identified as a potential way to overcome the existing challenges of accessing education and emotional support [
Many of the identified uses for chatbots, such as self-assessments and health education, are potentially helpful in educating and supporting people with dementia and their caregivers. Advancing such technologies for the purpose of dementia care is critical, given that states are projected to increase the incidence of neurodegenerative diseases by up to 33% between 2019 and 2025 [
Previous studies on smartphone apps informed the methodology for evaluating existing chatbots [
Chatbot apps were included for evaluation if they were programmed to engage in interactive dialog with the technology, verbally or through text; were focused on the topic of dementia; were designed for use by dementia caregivers and/or people with dementia; were available for download and use; were available in English; and were not games. Chatbots were excluded if they were programmed so that users chat with a live person, did not have content related to dementia, were designed to be used by providers, were not currently available for use, were not available in English, or were games. A total of 6 investigators were involved in evaluating apps for inclusion or exclusion criteria, and at least two investigators reviewed each app independently.
The evaluation tool of identified chatbots was developed using the framework developed by Radziwill and Benton [
Flowchart of the chatbot apps searched and the screening procedures conducted using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.
The results of the search strategy are shown in
General information about the chatbot apps.
App name | App ID | Developer name | Operating system | Downloads (N) | Price | Privacy statement |
CogniCare mobile app | 1 | CogniHealth Ltd (in partnership with Alzheimer Scotland) | Android and iOS | ≥1000 | Free | Yes |
CogniCare (Alexa Skills version) | 2 | CogniHealth Ltd (in partnership with Alzheimer Scotland) | Alexa Skills | Not reported | Free | Yes |
My Life Story | 3 | Z55-Studios | Alexa Skills | Not reported | Free | Yes |
Dementia Types | 4 | T Tillman | Alexa Skills | Not reported | Free | Yes |
Build Your Brain Power | 5 | Fire Up Your Goals LLC | Alexa Skills | Not reported | Free | Yes |
Everything Memory | 6 | jaimiles23 | Alexa Skills | Not reported | Free | Yes |
Assessment tool informed by the framework developed by Radziwill and Benton and evaluation of apps by the research team.
Category, Quality attributea | App IDs | |||||||||||
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1 | 2 | 3 | 4 | 5 | 6 | |||||
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Robustness to unexpected input | ✓b | —c | ✓ | — | — | — | ||||
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Avoids inappropriate utterances and is able to perform damage control | N/Ad | — | ✓ | — | — | N/A | ||||
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Effective function allocation and provides appropriate escalation channels to humans | — | N/A | ✓ | — | — | N/A | ||||
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Accurate speech synthesis | N/A | — | ✓ | — | ✓ | ✓ | ||||
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Interprets commands accurately | ✓ | — | ✓ | — | ✓ | ✓ | ||||
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General ease of use | ✓ | — | ✓ | ✓ | ✓ | ✓ | ||||
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Executes requested tasks | ✓ | — | — | ✓ | ✓ | ✓ | ||||
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Contains breadth of knowledge and is flexible in interpreting it | ✓ | — | N/A | ✓ | ✓ | ✓ | ||||
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Passes the Turing test | N/A | — | ✓ | — | — | — | ||||
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Convincing, satisfying, and natural interaction | N/A | — | ✓ | — | — | ✓ | ||||
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Able to respond to specific questions | ✓ | — | N/A | — | N/A | N/A | ||||
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Able to maintain themed discussion | N/A | — | N/A | ✓ | N/A | N/A | ||||
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Provides greetings and conveys personality | N/A | ✓ | ✓ | ✓ | ✓ | ✓ | ||||
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Gives conversational cues | N/A | — | N/A | ✓ | ✓ | ✓ | ||||
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Exudes warmth and authenticity | N/A | ✓ | ✓ | ✓ | — | ✓ | ||||
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Makes tasks more fun and interesting | ✓ | — | ✓ | ✓ | — | ✓ | ||||
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Entertains and/or enables participant to enjoy the interaction | ✓ | — | ✓ | ✓ | — | ✓ | ||||
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Ethics and cultural knowledge of users | ✓ | ✓ | — | — | — | — | ||||
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Protects and respects privacy | ✓ | ✓ | ✓ | ✓ | — | ✓ | ||||
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Sensitivity to safety and social concerns | ✓ | ✓ | — | — | — | ✓ | ||||
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Trustworthiness (of information source) | ✓ | ✓ | — | — | — | — | ||||
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Awareness of trends and social context (in language and conversation) | — | — | — | — | — | — |
aApps were evaluated in May 2020.
bEvaluators could observe the attribute and/or the app-performed attribute function, as described earlier.
cThe attribute or function was nonfunctional or inconsistent in functionality when accessed.
dN/A: not applicable.
For all apps, their functions and features were described in detail on Google Play Store or Alexa Skills pages. A total of 2 apps (app number 4 and 6) had more detailed instructions for getting started with using the apps than the others. One app (app number 2) offered an extensive guide to using the app with Alexa, although this guide was found on the developer’s website and was not linked or listed on Amazon.com, where the app could be found and accessed. On Amazon.com, there was only a list of voice commands in speech bubbles that suggested questions to ask the chatbot. This posed challenges for the evaluators who initially accessed the apps for evaluation. The mobile text–based chatbot (app number 1) was the easiest to get started.
The evaluators also faced linguistic challenges when initially accessing the functions of the voice chatbot apps. For instance, some instances of Alexa’s voice recognition were not flexible with the user’s pronunciation of commands or required a specific command to get started in the chatbots, which was not immediately understood by the researchers. This may also be the reason that for voice chatbots, the evaluators noted that they would perform some of their described features, but not others. Only 1 chatbot (number 3) performed well on all 3 performance attributes. This was an audio chatbot that went through a series of questions about the user’s life history, where the information was programmed into the app and the chatbot would tell the user their life story on command. For 3 of the chatbots, not all performance attributes were applicable.
In general, the chatbots were evaluated more favorably for their functionality, compared with the other categories assessed. In total, 5 of the 6 chatbots were found to be easy to use once the researchers were able to get the programs started. Of the 5 chatbots designed to educate about dementia, 3 were found to have a breadth of knowledge and flexibility in interpreting information.
All apps demonstrated the ability to interact with users through voice or text responses to users’ input. Although users found the apps’ responses to their input to be understandable and logical, their responses were perceived to be more automated than natural conversation. Only 1 app (app number 3) passed the Turing test, which is the extent to which one can tell the difference between conversing with a human and the chatbot. The researchers also found that the programmed dialog in all the chatbots was limited in scope, which made extended language exchange between the user and chatbot to also be constrained. For example, 1 chatbot (app number 4) provided a definition for each type of dementia, but there was no additional content for a true back-and-forth exchange.
In general, the evaluators assessed the chatbots as having features aimed at increasing the user’s enjoyment while using them. For instance, 1 app (number 3) played calm music in the background while the users accessed its other features. All audio chatbots provided greetings and/or conveyed personality. Only 3 chatbots appeared to provide conversational cues to facilitate the user’s ongoing engagement. For example, 1 chatbot would instruct the user to “Say, ‘tell me more’” after it completed its dialog (app number 4). A total of 3 apps were evaluated as having the potential to make caregiving tasks more enjoyable or interesting.
Safety and privacy protection were evaluated for chatbot apps. In total, 5 apps had privacy statements describing the terms of use and security of users’ input. In all the privacy statements, the developer confirmed that none of the users’ information would be shared with third parties, unless the user gave permission to do so. In total, 2 apps (app number 2 and 6) included statements in their app descriptions that the chatbot was not a substitute for medical care or advice. In terms of trustworthiness of information, 4 apps were created by private developers. Two of the chatbot apps (app number 1 and 2) were developed by the same entity, which partnered with the nongovernmental organization Alzheimer Scotland to develop both the apps. It should be noted that since the time of review of the chatbots, the organization has also partnered with the University of Edinburgh for development. Hence, these apps were viewed as having the highest perception of trustworthiness.
Although the apps had content and functions that were deemed interesting and useful, some of the limitations in programmed content (as described earlier) presented challenges in this category as well. For instance, none of the apps were available in languages other than English, although 1 app (number 2) listed that their app was available in English from 5 different countries. The evaluators were not able to assess whether this resulted in language differences (eg, idioms and pronunciations) that were country specific. None of the apps were programmed to respond to patterns or the social context of user input.
At the time of this review, it was found that commercially available chatbot apps for people with dementia and their caregivers appeared to be in an early stage, with only 6 identified apps that met the search criteria across Google Play Store, the Apple Store, Amazon Alexa Skills, and the internet. All but one of these chatbot apps was the Alexa Skills app. Although chatbots, and specifically intelligent voice assistants, have been suggested as a potential source of assistance for older adults in general [
Limited program content also created challenges in having extended and/or varied conversations between users and chatbots. Owing to the complexity of dementia and variations in symptoms, this could limit the amount of education and support provided to a diverse population of people with dementia and their caregivers. This could impede the use of chatbots for information seeking and support. However, the hardware required for intelligent voice assistant platforms, such as Alexa, is recognized as having potential benefits for people with dementia and their caregivers. For instance, Alexa Skills relies on voice for navigation, which may be easier for older adults than typing, and does not require technical accessories, such as a mouse or keyboard. Hence, it may be worthwhile to further investigate how chatbots can be designed with user-friendly features for older adults, especially those who may have cognitive or memory impairments.
Several of the chatbots reviewed included educational information, although references were not provided for the informational sources; therefore, it was unclear whether health-related information provided by the chatbots is evidence based or whether information has been updated as needed. Designers should consider providing and using peer-reviewed references used in programming chatbots. In addition, although chatbot apps appeared to focus on education about dementia and engagement, the apps did not offer much information on caregiving skills and activities. However, the guidebook found for the CogniCare Alexa Skills chatbot reported that such content was being planned for the future. Such content would increase the usefulness of the chatbots for caregivers, who often feel isolated and have low caregiving self-efficacy.
We found that most chatbots did not pass the Turing test, which mainly means that they were unable to keep the conversation going while pretending to be human. We note that acting human may not be enough if the chatbot does not achieve its goals of educating or helping caregivers or patients. Most early research on chatbots has focused on the humanity aspect [
It is important to explore how chatbots may be used to educate and support people with dementia and their families. There are many potential chatbot functions that those affected by dementia may value depending on their preferences and needs. For instance, given the previous applications of chatbots to adult learning, chatbots could be used to educate and train caregivers on a variety of topics, especially those who feel isolated [
When considering people with dementia as targeted end users, designers should also consider that there is a continuum of severity in dementia symptomology and assess how content and functions may be appropriate for different stages of disease progression or adaptable to be used as symptoms progress. For example, people with mild dementia may look for and benefit from features that support independence or memory-building activities. However, people in later stages of dementia and their caregivers may prefer features that promote engagement and reminiscence, such as a recorded message from a loved one or a favorite song. Listening to music can be a shared enjoyable activity by the care recipient and caregiver, and music therapy has been found to be therapeutic in managing behavioral disturbance in people with dementia [
Although there are opportunities to advance the state of the science on dementia-focused chatbots in general, it is important that such chatbots should be evidence based. It is unclear whether the chatbots included in this review underwent empirical user testing. It should be noted that since conducting the chatbot review, the developers of CogniCare have published a peer-reviewed article on the development of their apps [
There are particular potential benefits of integrating chatbot technology into dementia care settings. People with dementia and their caregivers are at an increased risk of social isolation, especially for people with dementia who are in long-term care settings. The potential for chatbots for socially isolated populations has been particularly evident during the COVID-19 pandemic, where the Center for Disease Control and Prevention launched its Clara Bot app as an interactive way to educate the public and provide emotional support [
A key obstacle in integrating chatbots into care delivery is the Health Insurance Portability and Accountability Act (HIPAA) compliance needed for the chatbot to be able to exchange information with a health care entity (covered entity). Fortunately, Amazon Alexa has recently begun offering HIPAA-compliant skills [
There are limitations to this critical review that should be considered when interpreting the results. Despite the extensive search and review process used to identify chatbots, it is possible that there may be additional chatbots that address dementia but were not identified. In addition, there are no standardized measurement tools for chatbot technology. The authors initially attempted to conduct this review using the widely used mobile app rating scale [
Although chatbots offer the potential for an engaging technology that can benefit people with dementia and their caregivers, more work is needed to develop evidence-based chatbots that are easy to use for these populations. Future research in this area should involve interdisciplinary scientific teams that have the expertise to develop a high-performing chatbot technology as well as expertise in dementia or health education.
Health Insurance Portability and Accountability Act
VH is the founder of SmartBot360, which is a health care chatbot company. SmartBot360 was not included in this survey, as it does not focus on dementia caregivers.