This paper presents a real-time vision-based system to assist a person with dementia wash their hands. The system uses only video inputs, and assistance is given as either verbal or visual prompts, or through the enlistment of a human caregiver's help. The system combines a Bayesian sequential estimation framework for tracking hands and towel, with a decision-theoretic framework for computing policies of action. The decision making system is a partially observable Markov decision process, or POMDP. Decision policies dictating system actions are computed in the POMDP using a point-based approximate solution technique. The tracking and decision making systems are coupled using a heuristic method for temporally segmenting the input video stream based on the continuity of the belief state. A key element of the system is the ability to estimate and adapt to user psychological states, such as awareness and responsiveness. We evaluate the system in three ways. First, we evaluate the hand-tracking system by comparing its outputs to manual annotations and to a simple hand-detection method. Second, we test the POMDP solution methods in simulation, and show that our policies have higher expected return than five other heuristic methods. Third, we report results from a ten-week trial with seven persons moderate-to-severe dementia in a long-term care facility in Toronto, Canada. The subjects washed their hands once a day, with assistance given by our automated system, or by a human caregiver, in alternating two-week periods. We give two detailed case study analyses of the system working during trials, and then show agreement between the system and independent human raters of the same trials. (c) 2010 Elsevier Inc. All rights reserved.