Reducing the Burdens of Paid Caregivers of Older Adults by Using Assistive Technology: A Scoping Review

Eligibility Criteria

The eligibility criteria were designed to capture literature that would provide an overview of evidence exploring the impacts of assistive technology on burdens experienced by paid caregivers working with older adults and would be applicable to the Canadian contexts. The articles would be included in the review if they (1) were published in peer-reviewed journals within the previous 5 years, in recognition of the rapid changes in some technologies; (2) described assistive technology that directly supports caregiving tasks or promotes older adults’ functionality, safety, or independence in performing ADLs; (3) included as primary study participants paid workers described as “caregivers” who provide care in clinical, community, and domiciliary healthcare settings ²¹ for older adults aged 65+, which could include personnel identified as long-term care staff, formal caregivers, home care aides, health and social care workers, paid home care providers, PSWs, and other similar roles; and (4) explored the effects of assistive technologies on caregiver burden, such as changes in workload, perceived changes in workload, stress levels, emotional or physical burden, and job satisfaction. The articles were excluded if they were (1) unavailable in English, due to the language competencies of the reviewing team; (2) review articles, such as systematic reviews, scoping reviews, or meta-analyses, since articles included in relevant review papers would be individually assessed; and (3) studies that focused exclusively on regulated healthcare professionals, such as occupational therapists, physiotherapists, nurses, and physicians, because the review was meant to capture impacts on burdens felt by workers who assist with ADLs, rather than those who provide medical care.

Search Procedures

Search procedures were developed using the iterative process suggested for scoping reviews, initially using broad exploratory searches, then refining terms to achieve more focused and relevant results.^28,30 During the exploratory phase, one team member used general terms, such as “assistive technology” and “caregiver burnout” in searches on PubMed. The team discussed the initial search results and used terms from relevant articles’ titles, abstracts, and keywords to develop a more focused strategy.

The main search was carried out from May to June 2022 in the following databases: PubMed, ASSIA, CINAHL, PsycINFO, Ovid MEDLINE, and Ovid Embase. Search terms focused on 3 categories. The first category was centered around “assistive technology” and other similar terms used in literature, such as “self-help devices,” “welfare technology,” and “ambient assisted living,” among others. The second category aimed to capture the impacts on caregiver burden, through search terms such as “caregiver burden,” “professional burnout,” and “attitude of health personnel.” The third category used terms relating to older adults, such as “older adult,” “frailty,” “aged care,” “elderly people,” and related terms. An example search used for PsycINFO can be found in Table 1. A total of 702 articles published from 2017 to 2022 were identified from the databases: PubMed (n = 372), PsycINFO (n = 141), Ovid MEDLINE and Ovid Embase (n = 7), CINAHL (n = 64), and ASSIA (n = 48). The examination of review article bibliographies identified 70 articles.

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Table 1.

PsycINFO Search Strategy (Year 2017-2022).

1	2	3
noft(assistive technology) OR noft(assistive robotics) OR noft(self-help devices) OR noft(welfare technology) OR noft(ambient assisted living) 2017-2022 Results: 2789	noft(attitude of health personnel) OR noft(caregiver burden) OR noft(occupational stress) OR noft(professional burnout) OR noft(caregiver well being) OR noft(caregiver health) OR noft(caregiver role strain) 2017-2022 Results: 34,524	noft(frail elder) OR noft(elderly) OR noft(aged) OR noft(older adults) OR noft(senior) OR noft(aging population) OR noft(65 years) 2017-2022 Results: 228,140

Combined results of 1 AND 2 AND 3 = 141 results.

Data Items and Analysis

The data charting categories were developed to align with the review’s goal, ²⁸ to provide an overview of evidence on the impacts assistive technology has on burdens experienced by paid caregivers working with older adults. Information pertaining to the following categories was included in the evidence synthesis summary results: (1) the country where the research study was conducted, as settings are important for generalizability of research findings; (2) participant care roles, to ensure appropriate comparisons; (3) study methods or design, to gauge strengths and weaknesses of the body of evidence; (4) main outcomes; and (5) types of assistive technology. Charted data were analyzed using techniques suggested for scoping reviews, with numerical description of the body of literature, and qualitative content analysis of themes found within the articles.^28-30

Although scoping reviews are ideally conducted with 2 or more reviewers independently carrying out article selection and data charting,^29,30 due to time constraints, screening and data charting were conducted by 1 team member, with the others providing input at meetings held every 2 weeks. All team members took part in the interpretation and analysis of the body of literature.

Study Characteristics

The articles reported the results of studies in 9 countries. The United States of America,^32,33 Australia,^42,45 Canada,^35,36 France,^38,39 Hong Kong,^43,46 and the United Kingdom^37,40 were sites reported in 2 articles each. Japan, ⁴⁴ the Netherlands, ⁴¹ and Thailand ³⁴ were sites reported in 1 article each.

The literature was methodologically diverse. Eight articles (54%) described quantitative approaches,^{32-34,38,39,41,43,46} 5 (33%) described qualitative study designs,^{36,37,40,42,44} and 2 (13%) described mixed-method strategies.^35,45 Most quantitative studies employed surveys or questionnaires to assess emotional or physical caregiver burdens. For example, Chen et al ⁴⁶ utilized the Neuropsychiatric Inventory Questionnaire caregiver distress subscale, and Dupuy et al ³⁹ utilized the Maslach Burnout Inventory (MBI) and the Instrumental Activity of Daily Living (IADL) support scales. Sun et al ³² assessed the physical burdens of caregiving through a survey and hand force analysis. Phetsitong and Vapattanawong ³⁴ used a quantitative questionnaire based on the Caregiver Burden Inventory (CBI). Two quantitative studies used pilot or prospective RCT designs.^41,46 Qualitative studies relied on interviews or focus groups.^{36,37,40,42,44} Two studies employed mixed-method designs. Khaksar et al ⁴⁵ used interviews, observation, and focus groups for the qualitative aspect of their study and equation modeling for the quantitative component of their study. King et al ³⁵ used qualitative observational methodology, complemented by quantitative risk factor analysis.

Physical or Mobility Aids

Five articles reported the effects on the caregiver burden of technologies that provide mobility and physical support for older adults. Two examined impacts of handrails and grab bars. King et al ³⁶ explored whether PSWs found grab bars helpful when helping older adults in at-home bathrooms, while Phetsitong and Vapattanawong ³⁴ assessed the impacts of handrails on the physical burden of caregivers. Both studies reported that handrails and grab bars made caregiving processes physically easier and safer in their respective settings.^34,36 Phetsitong and Vapattanawong’s ³⁴ survey using the CBI found that caregivers working in households with one handrail were 58% less likely to suffer from a high physical burden than caregivers of non-handrail households. However, King et al ³⁶ reported that incompatibility of such devices with the physical surroundings, such as grab bars in a small washroom, could limit their utility and safety.

Three articles explored impacts of technologies designed to reduce physical strain on caregivers when helping older adults with ADLs, such as toileting ³⁵ or transferring between beds and wheelchairs.^32,33 Bidet seats were shown to prevent nonneutral posture by 15% and severe flexion by 32% by eliminating the need for perineal care. ³⁵ The benefit demonstrated in the study by King et al ³⁵ is likely underestimated, as PSW participants each carried out only 2 simulated sessions, while the same PSWs reported providing toileting assistance to approximately 4 clients per day when at work. Transfer devices were also tested in a simulated environment, where a client was transferred from one side of the bed to the other, from a wheelchair to a bed, or from a bed to a wheelchair.^32,33 Both Sun et al ³² and Hwang et al ³³ reported that transfer devices reduced physical loads on caregivers. Hwang et al ³³ demonstrated with electromyography that transfer and turning devices could prevent awkward postures, with flexion in the lower back and shoulders, that are normally encountered while caring for older adults.

Sensor and Monitoring Systems

Five articles reported the effects of sensor and monitoring technologies on the burdens of paid caregiver. Some sensors were worn by older adults to continuously monitor their vital signs. ³⁷ One study used satellite-based GPS tracking devices that could identify the location and activities of older adults. ³⁷ Other studies used emplaced sensors. The sensor devices assessed in the study by Lauriks et al ⁴¹ included automated lighting and automated sun blinds. In the case of automated lighting, sensors could detect movement and automatically turn on and off lights when a person got out of bed, entered the bathroom, or when an area was detected with insufficient lighting. Rondon-Sulbaran et al ⁴⁰ evaluated a variety of sensor alarms that could detect and notify caregivers when older adults fell, alarms that could detect flooding or leaking water, and sensors that alerted the caregivers when doors were left open. They reported that bed sensors alerted caregivers when care recipients rose to answer telephone calls, reducing the need to stop other tasks to attend to the calls. ⁴⁰ Dupuy and Sauzéon ³⁸ employed motion, mattress, and gait sensors linked to digital tablets to detect falls, measure older adults’ day-to-day motion activities, and provide updates to paid caregivers. Dupuy et al ³⁹ used similar sensor technologies and tablets to monitor activities. For example, a sensor would be set up by the front door to trigger an alarm when an older adult wanders or leaves the door open. Dupuy et al ³⁹ reported mixed impacts of sensors and tablets on paid caregiver burden. The MBI indicated no significant subjective benefit (eg, in emotional exhaustion), while the IADL support scale indicated that sensor notifications attenuated burdens associated with supporting instrumental ADLs. ³⁹

Socialization Enhancement Technologies

Seven articles examined the use of technologies that enhance socialization. In addition to describing sensor and monitoring systems, the 2 articles by Dupuy et al ³⁹ and Dupuy and Sauzéon ³⁸ also described the use of tablets to promote older adults’ social participation. Tablets were used to make social networks more accessible by enabling video calling and collaborative gaming, simplifying the electronic mailing system, and notifying older adults of upcoming social events in the community.^38,39

Five articles assessed the use of social or companion robots to enhance social interactions or provide behavioral interventions.^42-46 Paro is a seal-like robotic pet and was the most mentioned robot model, assessed in 3 articles.^42,44,46 Other types of robots included a humanoid social communication robot called Kabochan that was designed to promote cognitive function ⁴⁶ and a social robot called Matilda, which had communicative and singing capabilities. ⁴⁵ Articles reported that social robots could reduce caregiver stress,^42,46 make tasks easier, ⁴⁴ reduce workload, save time, and increase productivity for paid caregivers. ⁴⁵ However, Kolstad et al ⁴⁴ reported that the use of robots also required additional time and effort from paid caregivers, and Chen et al ⁴³ suggested that increased workload associated with the adoption of new robots may be a reason for the lack of positive effects reported by caregivers.

Paid Caregivers’ Views on Assistive Technologies

Paid caregivers expressed a range of perspectives on the impacts of assistive technology on their work. One recurring theme was ways that technologies could make caregivers’ duties easier. Participants interviewed in a study of sensor and monitoring technology described the system reducing the need for direct supervision and promoting older adults’ independence, thereby freeing some time and improving job satisfaction. ⁴⁰ Participants working with social robots often described positive impacts due to the devices calming agitated older adults, which reduced caregivers’ stress and could lower workload and improve productivity.^42,44,45 One caregiver explained that when older adults were interacting with robots, it allowed caregivers to work on other tasks or rest. ⁴⁵

Caregivers’ perspectives on assistive technologies were not always positive, and some articles reported mixed or negative views. Caregivers identified perceived inadequacies that hindered the effectiveness of grab bars, walkers, and mats and increased risk of injury due to their incompatibility with constrained spaces in care recipients’ homes. ³⁶ One caregiver explained,

[I wish there was] some way that we could get equipment that was portable enough, small enough, to manage these clients in an average, normal bathroom . . . Hoyer lifts are a wonderful thing if you’ve got 4 feet of space to get it through, [but in a bathroom] it’s not very practical.^36(p7)

While paid caregivers often described monitoring technologies positively, they were conscious of imperfections in technologies and feared being blamed for accidents. ³⁷ Some participants interviewed in the study by Hall et al ³⁷ described how bed-monitoring systems not only improved confidence and coordination of activities but also led to a higher frequency of alarms alerting them for assistance and contributed to a sense of overburden. Similarly, the study by Lauriks et al ⁴¹ investigating the effects of various automated sensor technologies reported a negative evaluation of “work circumstance appreciation” during the implementation phase, without benefiting job satisfaction or workload. Social robots were also the subject of mixed perceptions. While paid caregivers appreciated beneficial impacts, some feared being replaced by robots that are capable of being active 24 hours per day, as well as of having their performance tracked by such technology. ⁴⁵ Caregivers also expressed concerns about the cost and lack of funding for social robots at long-term care facilities. ⁴²

Implications for Policy and Research

While the findings of this scoping review are not sufficient in themselves to guide policy, the literature overview suggests some preliminary insights about actions that may help optimize beneficial impacts on paid caregivers. The mixed perception of assistive technologies reported in some articles may be due in part to additional effort required while implementing new technologies. Difficult transitions during implementation could be eased by providing appropriate training and supports, particularly with the more complex technologies, such as sensor and monitoring systems and social robots.^38,41,43,44 Policies could also assist with integration of physical and mobility aids. Some Canadian provinces offer grants or tax incentives for home modifications to support aging in place, which could be applied to installation of handrails, grab bars, and bidet seats. Adoption of similar supports in jurisdictions that do not already offer them would help offset costs involved in personalizing the use of assistive devices for the unique situations and needs of older adults whom paid caregivers serve. ³⁶

Importantly, this scoping review reveals several gaps in the literature on the potential of assistive technologies to reduce paid caregiver burdens. As described earlier, none of the 3 types of assistive technology has a robust-enough body of literature to permit rigorous evaluation of efficacy in the context of paid caregiving. Furthermore, studies are required to provide essential data on the impacts of physical and mobility aids, sensor and monitoring systems, and social enhancement technology on paid caregivers’ physical burdens, stress, and job satisfaction. Some potentially important assistive technologies are also absent from the literature describing impacts on paid caregivers. One example that was not captured in the review and warrants attention is electronic medication management technology. ⁴⁹ Medication management is an essential aspect of providing care to older adults who have chronic conditions, and future studies could explore the impact of medication dispensers on caregiver burden, medication adherence, and overall healthcare outcomes for older adults.

Finally, only 1 of the reviewed articles specifically examined the impacts of assistive technologies on turnover among paid caregivers. ⁴³ Workload and injury are important reasons for paid caregivers to leave their employment,^13,22,50 and additional research is needed that examines relationships between the use of assistive technology in the care of older adults and turnover rates among paid caregivers. Such research will be challenging, as multiple factors potentially contribute to paid caregiver turnover, but well-designed studies would make valuable contributions in this area.

Limitations

This scoping review has several limitations. Although the team met frequently to provide input into the review process, the decision to have only 1 member screen articles and chart data, along with the time constraints on carrying out the review, may have resulted in the omission of relevant articles. Also, articles reporting results of studies conducted in English-speaking countries, such as Australia, Canada, the United Kingdom, and the United States of America, constitute over half (53.3%) of the reviewed literature. It is possible that the requirement for included articles to be available in English resulted in omission of relevant articles published in other languages. Finally, all but one ³⁴ of the included studies were conducted in high-income countries, and the findings may not be applicable to the work of paid caregivers in low- and middle-income countries.

Conclusion

The overview this scoping review offers is encouraging and suggests that several types of assistive technology have the potential to reduce some of the burdens that paid caregivers working with older adults experience. Further research is needed to fully examine the efficacy of these technologies for supporting paid caregivers and understanding how they impact turnover among workers providing care for older adults.