An Individual Cognitive Stimulation Therapy App for People with Dementia and Carers: Results from a Feasibility Randomized Controlled Trial (RCT)

Exploring the effectiveness and experiences of people living with dementia interacting with digital interventions: A mixed methods systematic review

Background: As dementia care evolves, digital interventions are being developed to improve the quality of life of people living with dementia. It is also increasingly recognised that some people living with dementia can use and benefit from using digital interventions themselves. Therefore, exploring the effectiveness and experiences of using such interventions is essential to optimise digital intervention development and delivery.Method: 5 databases were searched (MEDLINE (Ovid), PsycINFO, EMBASE, CINAHL and Web of Science) for papers reporting effectiveness outcomes or experiences, involving people living with dementia or mild cognitive impairment engaging with digital interventions for improving their quality of life. 73 relevant papers published between 2018-2023 were identified, 59 included effectiveness data and 18 included data on experiences.Results: The integration of evidence identified that people living with dementia can benefit from engaging in digital interventions, if they are motivated, and provided with tailored training, support, appropriate devices and content. Benefits were seen within the domains of cognition, health and well-being and social relationships. Benefits were more frequent when digital interventions were provided in the home environment with specified daily/weekly usage requirements.Conclusion: This review provides an overview of the current state of research exploring engagement of digital interventions by people with dementia for improving their quality of life. The findings provide guidance on how to optimise the method of delivery. Future research should explore how digital interventions can improve social relationships and self-concept of people living with dementia, the long-term sustainability of digital interventions, and how individuals with dementia form attitudes towards technology.

Exploring the Discontinuous Usage Behavior of Digital Cognitive Training Among Older Adults With Mild Cognitive Impairment and Their Family Members: Qualitative Study Using the Extended Model of IT Continuance

BACKGROUND

Digital cognitive training (DCT) has been found to be more effective than traditional paper-and-pencil training in enhancing overall cognitive function. However, a significant barrier to its long-term implementation is that older adults with mild cognitive impairment (MCI) do not continue to use it or even show a dropoff in usage after the initial engagement. Such short-term engagement may limit the potential benefits of DCT, as sustained use is required to achieve more pronounced cognitive improvements. Exploring the reasons for the shift in discontinuous usage behavior is crucial for promoting successful DCT implementation and maximizing its positive effects.

OBJECTIVE

This study aimed to explore the intrinsic reasons for the transition from initial acceptance to discontinuous usage behavior among older adults with MCI throughout the DCT process, by employing the extended model of IT continuance (ECM-ITC).

METHODS

We employed a qualitative research methodology and conducted 38 semistructured interviews before and after the use of DCT (3 times per week over 1 month, with each session lasting 30 minutes) with 19 older adults with MCI (aged 60 years or older) and 4 family members between January and March 2024. Thematic analysis and deductive framework analysis were used to identify the reasons for the discontinuous usage of DCT, with mapping to the ECM-ITC.

RESULTS

Most participants failed to complete the standard dosage of DCT. Data analysis revealed the reasons for the shift to discontinuous usage. Despite their need to improve cognitive function, participants found the cognitive training confusing and discovered that DCT did not align with their preferred method of training upon actual use. The disparity between their vague expectations and reality, combined with the contradiction between the "delayed gratification" of DCT and their desire for "immediate gratification," made it difficult for them to discern the usefulness of DCT. Participants also viewed DCT as an additional financial burden and tended to avoid training under family pressure. They relied on motivational measures, which further weakened their intention to continue DCT, ultimately leading to the inability to develop continuous usage behavior.

CONCLUSIONS

Continuous usage behavior differs from initial acceptance as it evolves dynamically with user experience over time. To encourage older adults with MCI to persistently engage with DCT, it is essential to not only thoroughly consider their genuine preferences and the potential disruptions DCT may bring to their lives but also bridge the gap between expectations and actual experiences. While ensuring that older adults receive appropriate external incentives and encouragement, it is equally important to foster their intrinsic motivation, thereby gradually cultivating the habit of sustained DCT usage.

Cognitive Stimulation Therapy: Making a Difference for Older Missourians Experiencing Dementia

Cognitive Stimulation Therapy (CST) is an evidence-based, non-pharmacological intervention designed to enhance cognitive function, quality of life, and emotional well-being in individuals with dementia. With the high prevalence of dementia and Alzheimer's disease in Missouri, CST provides an effective approach to address dementia-related symptoms. This paper aims to inform healthcare professionals about the benefits and practical applications of CST, demonstrating its effectiveness in addressing the cognitive, emotional, and social needs of dementia patients. Despite the heavy reliance on pharmacological treatments for dementia, CST stands out as a viable alternative, offering improvements in memory, language, executive function, and alleviating symptoms of depression and anxiety. CST's adaptability across diverse settings, including community centers, residential care homes, and virtual platforms, ensures broad accessibility. Research and training initiatives led by Saint Louis University further highlight CST's growing role in dementia care within the US healthcare system. Embracing CST in clinical practice is not just an option but a necessity to improve the lives of individuals with dementia and alleviate the growing burden on healthcare systems in Missouri and beyond.

Carer Involvement in Rehabilitation for People Living With Dementia: A Systematic Review

AIMS

To examine the role and impact of carer involvement in rehabilitation for community-dwelling individuals with dementia, focusing on cognitive stimulation therapy, cognitive rehabilitation, cognitive training, cognitive behavioural therapy, and exercise.

DESIGN

A systematic review and synthesis without meta-analysis.

DATA SOURCES

Five electronic databases, reference lists, and citations were searched (2017-2024), targeting primary research that reported results concerning one or more of those five focused rehabilitation interventions for people with dementia and their carers.

METHODS

Results were synthesised using narrative approaches. The Cochrane Risk of Bias Tool and the Mixed Methods Appraisal Tool were used to appraise the quality of included studies.

RESULTS

Forty-one studies (12 main trials, 22 pilot studies, and 7 sub-studies) were included. While the patterns between carer involvement level and types of rehabilitation were observed, their relationship to intervention effectiveness was unclear. High carer involvement in cognitive stimulation therapy and exercise was associated with improved cognition and quality of life for people with dementia and better health-related quality of life for carers. Pilot studies showed mixed but generally positive trends, with increased depressive symptoms in carers needing further investigation. Qualitative findings highlighted social interaction and improved caregiving knowledge as key enablers to positive experiences, whereas lack of motivation was the main barrier to rehabilitation engagement.

CONCLUSION

This review identified several patterns between the level of carer involvement and intervention types. However, the mechanism underlying different involvement levels and rehabilitation success remains unclear. More rigorous research is needed to determine the relationship between carer involvement and the effects of rehabilitation interventions on supporting the independence of people with dementia.

IMPACT

This review enhanced the understanding of carers' roles and impacts in supporting dementia rehabilitation and possible links to optimal health outcomes.

REPORTING METHOD

Synthesis Without Meta-analysis (SWiM) reporting guideline.

PATIENT OR PUBLIC CONTRIBUTION

No patient/public contribution.

DigiDOP: A framework for applying digital technology to the Differential Outcomes Procedure (DOP) for cognitive interventions in persons with neurocognitive disorders

We present a framework -Digi-DOP- that includes a series of evidence-based recommendations to design and apply cognitive interventions for people with Neurocognitive Disorders (NCDs) using a relatively new approach, the Differential Outcomes Procedure (DOP). To do so, we critically review the substantial experimental research conducted with relevant clinical and non-clinical populations, and the theoretical underpinnings of this procedure. We further discuss how existing digital technologies that have been used for cognitive interventions could be applied to overcome some of the limitations of DOP-based interventions and further enhance DOP benefits. Specifically, we present three digital DOP developments that are currently being designed, investigated and/or tested. Finally, we discuss constraints, ethical and legal considerations that need to be taken into account to ensure that the use of technology in DOP-based interventions proposed here does not widen disparities and inequalities. We hope that this framework will inform and guide digital health leaders and developers, researchers and healthcare professionals to design and apply DOP-based interventions for people with NCDs.

Effect of digital technology interventions for cognitive function improvement in mild cognitive impairment and dementia: A systematic review and meta-analysis

The development and commercialization of digital therapeutics are increasing. The aim of this study was to determine the effects of digital technology interventions on cognitive function, thereby providing evidence for the development and practical application of interventions to manage cognitive function in patients with mild cognitive impairment and dementia. We conducted a systematic review and meta-analysis of randomized controlled trials according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines. Randomized controlled trials on digital technology interventions published until April 2023 were searched in PubMed, Embase, Cochrane Library, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases without a period limit. Articles that identified the effects of digital technology interventions on cognitive function improvement in dementia and mild cognitive impairment were integrated and analyzed. RevMan software 5.4 was used for quality assessment and meta-analysis. Twelve out of 708 studies were included in the review and meta-analysis. Digital technology interventions had significant effects on global cognitive function (standardized mean difference [SMD] = 0.31; 95% confidence interval [CI] = 0.04-0.57; p = 0.02; I² = 60%). In addition, these interventions had significant effects on neuropsychological characteristics, including attention (SMD = 1.17; 95% CI = 0.36-1.97; p = 0.004; I² = 84%), visuospatial perception (SMD = 0.68; 95% CI = 0.19-1.17; p = 0.006; I² = 57%), and memory (SMD = 0.45; 95% CI = 0.19-0.71; p = 0.0007; I² = 22%). The results suggest that digital technology interventions help improve cognitive function in patients with dementia and mild cognitive impairment.

Iterative Patient Testing of a Stimuli-Responsive Swallowing Activity Sensor to Promote Extended User Engagement During the First Year After Radiation: Multiphase Remote and In-Person Observational Cohort Study

BACKGROUND

Frequent sensor-assisted monitoring of changes in swallowing function may help improve detection of radiation-associated dysphagia before it becomes permanent. While our group has prototyped an epidermal strain/surface electromyography sensor that can detect minute changes in swallowing muscle movement, it is unknown whether patients with head and neck cancer would be willing to wear such a device at home after radiation for several months.

OBJECTIVE

We iteratively assessed patients' design preferences and perceived barriers to long-term use of the prototype sensor.

METHODS

In study 1 (questionnaire only), survivors of pharyngeal cancer who were 3-5 years post treatment and part of a larger prospective study were asked their design preferences for a hypothetical throat sensor and rated their willingness to use the sensor at home during the first year after radiation. In studies 2 and 3 (iterative user testing), patients with and survivors of head and neck cancer attending visits at MD Anderson's Head and Neck Cancer Center were recruited for two rounds of on-throat testing with prototype sensors while completing a series of swallowing tasks. Afterward, participants were asked about their willingness to use the sensor during the first year post radiation. In study 2, patients also rated the sensor's ease of use and comfort, whereas in study 3, preferences were elicited regarding haptic feedback.

RESULTS

The majority of respondents in study 1 (116/138, 84%) were willing to wear the sensor 9 months after radiation, and participant willingness rates were similar in studies 2 (10/14, 71.4%) and 3 (12/14, 85.7%). The most prevalent reasons for participants' unwillingness to wear the sensor were 9 months being excessive, unwanted increase in responsibility, and feeling self-conscious. Across all three studies, the sensor's ability to detect developing dysphagia increased willingness the most compared to its appearance and ability to increase adherence to preventive speech pathology exercises. Direct haptic signaling was also rated highly, especially to indicate correct sensor placement and swallowing exercise performance.

CONCLUSIONS

Patients and survivors were receptive to the idea of wearing a personalized risk sensor for an extended period during the first year after radiation, although this may have been limited to well-educated non-Hispanic participants. A significant minority of patients expressed concern with various aspects of the sensor's burden and its appearance.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03010150; https://clinicaltrials.gov/study/NCT03010150.

A tutorial on discourse analysis in healthy and pathological ageing

BACKGROUND

Age is a key factor when dealing with language and speech disorders, as it entails a progressive loss of neuroplasticity even in healthy individuals. Apart from this, ageing also affects our word-retrieval abilities, and thus, our discursive skills, particularly in people suffering from neurodegenerative diseases. Therefore, descriptions and/or measures of communicative performance always need to be interpreted through the lens of variation across the lifespan.

AIM

This paper's main objective is to create a general tutorial for researchers willing to start delving into discourse analysis, both in healthy and pathological ageing.

METHODS

An eight-step tutorial on discourse analysis in the elderly is presented. Each of these steps starts with general recommendations and progresses to more specific topics that may be relevant when conducting this type of research. All of the steps have been extrapolated from an extensive literature review on discourse analysis.

MAIN CONTRIBUTIONS

This work presents an easy-to-follow, step-by-step tutorial on discourse analysis in the elderly. It is aimed at clinical researchers who are taking their first steps in discourse analysis.It may also be useful for those who are already familiar with the methodology but may be interested in reading a general overview on the topic. Moreover, it offers new insights into the following topics: types of research questions, advantages and disadvantages of the different research methodologies and ethical considerations for data production in clinical linguistics.

CONCLUSIONS

Discourse analysis in the elderly is a highly complex issue that may require researching from different approaches and disciplines. This implies following a well-planned and thorough process, which we have detailed through the following eight steps: (i) reviewing literature; (ii) formulating the research question; (iii) designing the study; (iv) producing data; (v) selecting technological tools for data treatment; (vi) transcribing the corpus; (vii) annotating the corpus and (viii) analysing and interpreting the results.

WHAT THIS PAPER ADDS

What is already known on the subject Approaches in discourse analysis in elderly adults, and particularly, in people suffering from dementia have already been analysed by previous researchers and categorised into three main trends: the quantitative-experimental approach, the qualitative-naturalistic approach and an in-between path, the quantitative-naturalistic approach. Also, several handbooks on general discourse analysis have presented comprehensive revisions on potential resources and methodologies that can be applied to researching discourse in elderly populations. What this paper adds to existing knowledge This paper takes these three main approaches and analyses how the most recent research on language in ageing and dementia fits into them. Furthermore, it reviews the advantages and disadvantages each of them may bring for beginners in the field of discourse analysis. Moreover, it adds some studies that may fit into a fourth approach: the qualitative-experimental. This article also presents information about several of the main steps when analysing data from the pragmatic perspective: the formulation of the research question, data production and the transcription/annotation process. What are the potential or actual clinical implications of this work? This work has been devised for linguists who may want to read a systematization of the steps for analysing discourse in elderly populations. It may also be of interest to specialists from different fields such as speech therapy, psychology, gerontology or neurology who desire to start applying methods from discourse analysis in their work and aim to have a comprehensive scope of the main research trends within the field of clinical pragmatics.

Cognitive Training with Older Adults Using Smartphone and Web-Based Applications: A Scoping Review

INTRODUCTION

The present scoping review focused on: i) which apps were previously studied; ii) what is the most common frequency for implementing cognitive training; and iii) what cognitive functions the interventions most focus on.

METHODS

PRISMA guidelines were followed, and the search was conducted on Web of Science, PsycInfo, Cochrane, and Pubmed. From 1733 studies found, 34 were included.

RESULTS

it was highlighted the necessity for forthcoming investigations to tackle the methodical restrictions and disparities in the domain.

DISCUSSION

great diversity in intervention protocols was found. Incorporating evaluations of physical fitness in conjunction with cognitive evaluations can offer a more all-encompassing comprehension of the impacts of combined interventions. Furthermore, exploring the efficacy of cognitive training applications requires additional scrutiny, considering individual variances and practical outcomes in real-life settings.

Effectiveness of non-pharmacological therapies on cognitive function in patients with dementia-A network meta-analysis of randomized controlled trials

Objective

Non-pharmacological therapies (NPTs) have received increasing attention from researchers as a category of treatment to improve cognitive impairment in patients with dementia because of their fewer side effects. In this study, photobiomodulation (PBM), enriched environment (EE), exercise therapy (ET), computerized cognitive training (CCT), and cognitive stimulation therapy (CST) were selected to compare the effects of NPTs that improve dementia by quantifying information from randomized controlled trials (RCTs).

Methods

We did a systematic review and network meta-analysis. We searched PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), China National Knowledge Infrastructure Database, Wan Fang Database, Chinese Biomedical Literature Database, Web of Science, and VIP Database from the time of database creation to 1 August 2022. Two investigators independently screened the literature, extracted information, and assessed the RCTs' quality with the Cochrane Collaboration Network Risk of Bias 2.0. Network meta-analysis was performed using R language (X64 version 4.1.3) and STATA 17.0.

Results

We identified 1,268 citations and of these included 38 trials comprising 3,412 participants. For improving dementia, the results of the network meta-analysis showed that compared with the control group (CON), PBM (SMD = 0.90, 95% CI: 0.43-1.37), EE (SMD = 0.71, 95% CI: 0.02-1.41), ET (SMD = 0.42, 95% CI: 0.16-0.68), and CST (SMD = 0.36, 95% CI: 0.11-0.62) were significantly different (P < 0.05); There was no significant difference in CCT (SMD = 0.41, 95% CI: -0.07-0.88) (P > 0.05). The ranked results showed that PBM has more potential to be the best intervention (P = 0.90). In addition, there was a significant difference between PBM and CST in improving cognitive function (SMD = 0.54, 95% CI: 0.00; 1.08, P < 0.05).

Conclusion

In this study, NPTs have excellent potential to improve cognition in people with dementia, and PBM may have more significant benefits in improving cognition than the other four NPTs.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42022363746.

Cognitive stimulation to improve cognitive functioning in people with dementia

BACKGROUND

Cognitive stimulation (CS) is an intervention for people with dementia offering a range of enjoyable activities providing general stimulation for thinking, concentration and memory, usually in a social setting, such as a small group. CS is distinguished from other approaches such as cognitive training and cognitive rehabilitation by its broad focus and social elements, aiming to improve domains such as quality of life (QoL) and mood as well as cognitive function. Recommended in various guidelines and widely implemented internationally, questions remain regarding different modes of delivery and the clinical significance of any benefits. A systematic review of CS is important to clarify its effectiveness and place practice recommendations on a sound evidence base. This review was last updated in 2012.

OBJECTIVES

To evaluate the evidence for the effectiveness of CS for people with dementia, including any negative effects, on cognition and other relevant outcomes, accounting where possible for differences in its implementation.

SEARCH METHODS

We identified trials from a search of the Cochrane Dementia and Cognitive Improvement Group Specialized Register, last searched on 3 March 2022. We used the search terms: cognitive stimulation, reality orientation, memory therapy, memory groups, memory support, memory stimulation, global stimulation, cognitive psychostimulation. We performed supplementary searches in a number of major healthcare databases and trial registers to ensure the search was up-to-date and comprehensive.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) of CS for dementia published in peer review journals in the English language incorporating a measure of cognitive change.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. As CS is a psychosocial intervention, we did not expect those receiving or delivering CS to be blinded to the nature of the intervention. Where necessary, we contacted study authors requesting data not provided in the papers. Where appropriate, we undertook subgroup analysis by modality (individual versus group), number of sessions and frequency, setting (community versus care home), type of control condition and dementia severity. We used GRADE methods to assess the overall quality of evidence for each outcome.

MAIN RESULTS

We included 37 RCTs (with 2766 participants), 26 published since the previous update. Most evaluated CS groups; eight examined individual CS. Participants' median age was 79.7 years. Sixteen studies included participants resident in care homes or hospitals. Study quality showed indications of improvement since the previous review, with few areas of high risk of bias. Assessors were clearly blinded to treatment allocation in most studies (81%) and most studies (81%) reported use of a treatment manual by those delivering the intervention. However, in a substantial number of studies (59%), we could not find details on all aspects of the randomisation procedures, leading us to rate the risk of selection bias as unclear. We entered data in the meta-analyses from 36 studies (2704 participants; CS: 1432, controls: 1272). The primary analysis was on changes evident immediately following the treatment period (median length 10 weeks; range 4 to 52 weeks). Only eight studies provided data allowing evaluation of whether effects were subsequently maintained (four at 6- to 12-week follow-up; four at 8- to 12-month follow-up). No negative effects were reported. Overall, we found moderate-quality evidence for a small benefit in cognition associated with CS (standardised mean difference (SMD) 0.40, 95% CI 0.25 to 0.55). In the 25 studies, with 1893 participants, reporting the widely used MMSE (Mini-Mental State Examination) test for cognitive function in dementia, there was moderate-quality evidence of a clinically important difference of 1.99 points between CS and controls (95% CI: 1.24, 2.74). In secondary analyses, with smaller total sample sizes, again examining the difference between CS and controls on changes immediately following the intervention period, we found moderate-quality evidence of a slight improvement in self-reported QoL (18 studies, 1584 participants; SMD: 0.25 [95% CI: 0.07, 0.42]) as well as in QoL ratings made by proxies (staff or caregivers). We found high-quality evidence for clinically relevant improvements in staff/interviewer ratings of communication and social interaction (5 studies, 702 participants; SMD: 0.53 [95% CI: 0.36, 0.70]) and for slight benefits in instrumental Activities of Daily Living, self-reported depressed mood, staff/interviewer-rated anxiety and general behaviour rating scales. We found moderate-quality evidence for slight improvements in behaviour that challenges and in basic Activities of Daily Living and low-quality evidence for a slight improvement in staff/interviewer-rated depressed mood. A few studies reported a range of outcomes for family caregivers. We found moderate-quality evidence that overall CS made little or no difference to caregivers' mood or anxiety. We found a high level of inconsistency between studies in relation to both cognitive outcomes and QoL. In exploratory subgroup analyses, we did not identify an effect of modality (group versus individual) or, for group studies, of setting (community versus care home), total number of group sessions or type of control condition (treatment-as-usual versus active controls). However, we did find improvements in cognition were larger where group sessions were more frequent (twice weekly or more versus once weekly) and where average severity of dementia among participants at the start of the intervention was 'mild' rather than 'moderate'. Imbalance in numbers of studies and participants between subgroups and residual inconsistency requires these exploratory findings to be interpreted cautiously.

AUTHORS' CONCLUSIONS

In this updated review, now with a much more extensive evidence base, we have again identified small, short-term cognitive benefits for people with mild to moderate dementia participating in CS programmes. From a smaller number of studies, we have also found clinically relevant improvements in communication and social interaction and slight benefits in a range of outcomes including QoL, mood and behaviour that challenges. There are relatively few studies of individual CS, and further research is needed to delineate the effectiveness of different delivery methods (including digital and remote, individual and group) and of multi-component programmes. We have identified that the frequency of group sessions and level of dementia severity may influence the outcomes of CS, and these aspects should be studied further. There remains an evidence gap in relation to the potential benefits of longer-term CS programmes and their clinical significance.

Adapting and Implementing Apps for Mental Healthcare

PURPOSE OF REVIEW

To describe examples of adapting apps for use in mental healthcare and to formulate recommendations for successful adaptation in mental healthcare settings.

RECENT FINDINGS

International examples are given to explore implementation procedures to address this multitude of challenges. There are only few published examples of adapting apps for use in mental healthcare. From these examples and from results of studies in implementation science in general clinical settings, it can be concluded that the process of adapting apps for mental healthcare needs to address clinician training and information needs, user needs which include cultural adaptation and go beyond mere translation, and organizational needs for blending app use into everyday clinical mental healthcare workflows.