Behavioral Interventions to Prevent or Delay Dementia: Protocol for a Randomized Comparative Effectiveness Study

Health concerns and attitudes towards research participation in a community of rural Black Americans

OBJECTIVES

Describe health concerns of Black Americans as they age and what influences their participation in aging and clinical research.

METHODS

Fifty participants attended focus groups and completed questionnaires to identify barriers to research participation and attitudes toward dementia screening. Bivariate correlations explored associations between barriers to research participation and attitudes toward dementia screening.

RESULTS

Cancer, hereditary conditions, vascular conditions, memory disorders, and psychological disorders were the greatest health concerns. Time demands, mistrust, lack of knowledge about potential research, and stigma were identified as barriers for research participation. Incentives, better understanding of how proposed research will benefit the community, lifestyle modification studies, active presence of principal researchers/clinicians, and community investment were identified as factors to improve participation. Questionnaires revealed mistrust and religious beliefs to be among the primary barriers. Attitudes toward dementia screening reflected perceived stigma, suffering, and subsequent loss of independence. Higher barriers to participation were associated with perceived stigma and loss of independence related to dementia screening.

CONCLUSIONS

Successfully recruiting Black Americans for aging and clinical research remains a challenge. This study identifies barriers to participation and offers suggestions for planning and recruitment.

Psychotherapeutic interventions in individuals at risk for Alzheimer's dementia: a systematic review

BACKGROUND

Expanding technologies of early detection of Alzheimer's disease allow to identify individuals at risk of dementia in early and asymptomatic disease stages. Neuropsychiatric symptoms, such as anxiety and depression, are common in the course of AD and may be clinically observed many years before the onset of significant cognitive symptoms. To date, therapeutic interventions for AD focus on pharmacological and life style modification-based strategies. However, despite good evidence for psychotherapy in late-life depression, evidence for such therapeutic approaches to improve cognitive and emotional well-being and thereby reduce psychological risk factors in the course of AD are sparse.

METHODS

A systematic review was conducted in PUBMED, PsycINFO, Web of Science, and Clinical Trials to summarize the state of evidence on psychotherapeutic and psychoeducational interventions for individuals at risk for Alzheimer's dementia. Eligible articles needed to apply a manualized and standardized psychotherapeutic or psychoeducational content administered by trained professionals for individuals with subjective cognitive decline or mild cognitive impairment and measure mental health, quality of life or well-being.

RESULTS

The literature search yielded 32 studies that were included in this narrative summary. The data illustrates heterogeneous therapeutic approaches with mostly small sample sizes and short follow-up monitoring. Strength of evidence from randomized-controlled studies for interventions that may improve mood and well-being is scarce. Qualitative data suggests positive impact on cognitive restructuring, and disease acceptance, including positive effects on quality of life. Specific therapeutic determinants of efficacy have not been identified to date.

CONCLUSIONS

This review underlines the need of specific psychotherapeutic and psychoeducational approaches for individuals at risk of Alzheimer's dementia, particularly in terms of an early intervention aiming at improving mental health and well-being. One challenge is the modification of psychotherapeutic techniques according to the different stages of cognitive decline in the course of AD, which is needed to be sensitive to the individual needs.

Behavioral Interventions in Mild Cognitive Impairment (MCI): Lessons from a Multicomponent Program

Comparative effectiveness of behavioral interventions to mitigate the impacts of degeneration-based cognitive decline is not well understood. To better address this gap, we summarize the studies from the Healthy Action to Benefit Independence & Thinking (HABIT®) program, developed for persons with mild cognitive impairment (pwMCI) and their partners. HABIT® includes memory compensation training, computerized cognitive training (CCT), yoga, patient and partner support groups, and wellness education. Studies cited include (i) a survey of clinical program completers to establish outcome priorities; (ii) a five-arm, multi-site cluster randomized, comparative effectiveness trial; (iii) and a three-arm ancillary study. PwMCI quality of life (QoL) was considered a high-priority outcome. Across datasets, findings suggest that quality of life was most affected in groups where wellness education was included and CCT withheld. Wellness education also had greater impact on mood than CCT. Yoga had a greater impact on memory-dependent functional status than support groups. Yoga was associated with better functional status and improved caregiver burden relative to wellness education. CCT had the greatest impact on cognition compared to yoga. Taken together, comparisons of groups of program components suggest that knowledge-based interventions like wellness education benefit patient well-being (e.g., QoL and mood). Skill-based interventions like yoga and memory compensation training aid the maintenance of functional status. Notably, better adherence produced better outcomes. Future personalized intervention approaches for pwMCI may include different combinations of behavioral strategies selected to optimize outcomes prioritized by patient values and preferences.

Recruitment of a multi-site randomized controlled trial of aerobic exercise for older adults with amnestic mild cognitive impairment: The EXERT trial

INTRODUCTION

Effective strategies to recruit older adults with mild cognitive impairment (MCI) into nonpharmacological intervention trials are lacking.

METHODS

Recruitment for EXERT, a multisite randomized controlled 18-month trial examining the effects of aerobic exercise on cognitive trajectory in adults with amnestic MCI, involved a diverse portfolio of strategies to enroll 296 participants.

RESULTS

Recruitment occurred September 2016 through March 2020 and was initially slow. After mass mailings of 490,323 age- and geo-targeted infographic postcards and brochures, recruitment rates increased substantially, peaking at 16 randomizations/month in early 2020. Mass mailings accounted for 52% of randomized participants, whereas 25% were recruited from memory clinic rosters, electronic health records, and national and local registries. Other sources included news broadcasts, public service announcements (PSA), local advertising, and community presentations.

DISCUSSION

Age- and geo-targeted mass mailing of infographic materials was the most effective approach in recruiting older adults with amnestic MCI into an 18-month exercise trial.

Latent Factor Structure of Outcome Measures Used in the HABIT® Mild Cognitive Impairment Intervention Programs

BACKGROUND

In Alzheimer's disease and related disorders (ADRD) research, common outcome measures include cognitive and functional impairment, as well as persons with mild cognitive impairment (pwMCI) and care partner self-reported mood and quality of life. Studies commonly analyze these measures separately, which potentially leads to issues of multiple comparisons and/or multicollinearity among measures while ignoring the latent constructs they may be measuring.

OBJECTIVE

This study sought to examine the latent factor structure of a battery of 12-13 measures of domains mentioned above, used in a multicomponent behavioral intervention (The HABIT® program) for pwMCI and their partners.

METHODS

Exploratory factor analysis (EFA) involved 214 pwMCI-partner pairs. Subsequent Confirmatory factor analyses (CFA) used 730 pairs in both pre- and post-intervention conditions.

RESULTS

EFA generated a three-factor model. Factors could be characterized as partner adjustment (29.9%), pwMCI adjustment (18.1%), and pwMCI impairment (12.8%). The subsequent CFA confirmed our findings, and the goodness-of-fit for this model was adequate in both the pre- (CFI = 0.937; RMSEA = 0.057, p = 0.089) and post-intervention (CFI = 0.942; RMSEA = 0.051, p = 0.430) groups.

CONCLUSION

Results demonstrated a stable factor structure across cohorts and intervention conditions suggesting that three broad factors may provide a straightforward and meaningful model to assess intervention outcome, at least during the MCI phase of ADRD.

Truly Cross-fit: The Association of Exercise and Clinical Outcomes: Introduction to a JINS Special Section

We introduce a JINS special section inspired by a symposium presented at INS 2020 in Denver. The symposium was entitled Truly Cross-fit: The Association of Exercise and Cognitive Reserve. The collection of papers herein spans diverse methods, a range of developmental and clinical conditions, and a variety of outcomes all reflecting on the association of exercise and cognition-related outcomes. Taken together, the studies in this Special Section direct us to the variety of dimensions to be considered in understanding this association including what mode, intensity, duration, and timing of physical activity and aspects of age, sex, genetics, baseline characteristics, and disease status moderate these findings. We hope this Special Section will not only provide a framing for important future research on exercise and clinical outcomes but also inspiration to pursue them.

Comparative Effects of Physical Exercise and Other Behavioral Interventions on Functional Status Outcomes in Mild Cognitive Impairment

OBJECTIVES

Lifestyle modifications for those with mild cognitive impairment (MCI) may promote functional stability, lesson disease severity, and improve well-being outcomes such as quality of life. The current analysis of our larger comparative effectiveness study evaluated which specific combinations of lifestyle modifications offered as part of the Mayo Clinic Healthy Action to Benefit Independence in Thinking (HABIT) program contributed to the least functional decline in people with MCI (pwMCI) over 18 months.

METHODS

We undertook to compare evidence-based interventions with one another rather than to a no-treatment control group. The interventions were five behavioral treatments: computerized cognitive training (CCT), yoga, Memory Support System (MSS) training, peer support group (SG), and wellness education (WE), each delivered to both pwMCI and care partners, in a group-based program. To compare interventions, we randomly withheld one of the five HABIT® interventions in each of the group sessions. We conducted 24 group sessions with between 8 and 20 pwMCI-partner dyads in a session.

RESULTS

Withholding yoga led to the greatest declines in functional ability as measured by the Functional Activities Questionnaire and Clinical Dementia Rating. In addition, memory compensation (calendar) training and cognitive exercise appeared to have associations (moderate effect sizes) with better functional outcomes. Withholding SG or WE appeared to have little effect on functioning at 18 months.

CONCLUSIONS

Overall, these results add to the growing literature that physical exercise can play a significant and lasting role in modifying outcomes in a host of medical conditions, including neurodegenerative diseases.

Computerized Cognitive Training (CCT) versus Yoga Impact on 12 Month Post Intervention Cognitive Outcome in Individuals with Mild Cognitive Impairment

There is currently limited and mixed evidence for the cognitive benefits of Computerized Cognitive Training (CCT) and yoga in persons with Mild Cognitive Impairment (pwMCI). The objective of this study was to investigate the benefit of computerized cognitive training (CCT) vs. physical (yoga) intervention on cognitive abilities. Participants in this study were part of the larger Mayo Clinic’s Healthy Action to Benefit Independence and Thinking (HABIT) program comparative effectiveness trial. The HABIT program is designed for pwMCI and their care partner and consists of five behavioral interventions: CCT, Memory Support System-Calendar (MSS-Calendar), wellness education, support groups, and yoga. The subtractive study design randomly withheld one of the interventions for a total of five study arms. Longitudinal mixed-effects regression models were used to investigate the hypothesis that CCT and yoga has a greater positive impact on psychomotor and basic attention abilities at 12 months post-intervention as compared to the other HABIT interventions. Findings showed CCT had a positive impact compared to yoga on the Cogstate psychomotor/attention composite at 12 months post-intervention (ES = 0.54; unadjusted p value = 0.007, adjusted p value = 0.021). The impact of yoga or combining CCT with yoga did not show statistically significant improvement. Continued CCT practice at home showed further benefit on psychomotor/attention at 12 months post-intervention. There was no significant benefit of CCT or yoga on Cogstate learning/working memory composite.

Psychometric properties of the self-efficacy for managing mild cognitive impairment scale

OBJECTIVES

We adapted a self-efficacy measure for managing chronic illness to be specific to persons with mild cognitive impairment (pwMCI). The aim of this study was to investigate the psychometric properties of the scale, the self-efficacy for managing MCI scale, for use in research.

METHODS

Analyses involved data from pwMCI enrolled in a behavioral intervention study that completed the measure five times from intervention enrollment to 18-month post-intervention. Factor structure, construct validity, internal consistency, and test-retest reliability were analyzed.

RESULTS

Factor analysis identified two factors, related to self-efficacy for daily activities and managing MCI, which corresponded with domains from the original chronic illness self-efficacy scale. Consistent with prior research, construct validity analysis suggested an association between memory-loss self-efficacy and psychosocial distress, but not cognitive or functional ability. Further analyses supported the scale's internal and test-retest reliability.

CONCLUSIONS

Currently, no "gold standard" scale of memory-loss self-efficacy for pwMCI exists, despite the positive impact self-efficacy may have on modifiable health behaviors. Overall, results supported the notion that the scale is a valid and reliable measure of memory-loss self-efficacy for pwMCI.

Self-Efficacy Mediates the Association Between Physical Function and Perceived Quality of Life in Individuals with Mild Cognitive Impairment

BACKGROUND

Research has shown that individuals with mild cognitive impairment (MCI) value quality of life (QoL) above and beyond cognitive function or other potential outcomes in MCI. There is evidence supporting the negative impact of poor physical function on QoL ratings.

OBJECTIVE

The study explored whether a modified measure of self-efficacy for managing MCI and education mediated and/or moderated the relationship between physical function and QoL in persons with MCI.

METHODS

Baseline data from 200 participants with MCI were obtained from a larger study assessing the effectiveness of a behavioral intervention. Physical function was assessed by the Short Physical Performance Battery. QoL was assessed with the Quality of Life in Alzheimer's Disease scale. Memory-related self-efficacy was assessed using a modified 9-item version of the Chronic Disease Self-Efficacy Scales. Mediation and moderation analyses tested the hypotheses that self-efficacy and education alter the association between physical function and QoL in individuals with MCI. All analyses were adjusted for age, cognitive severity, and sex.

RESULTS

Self-efficacy for managing MCI was a significant mediator of the association between physical function and perceived QoL. Individuals with better physical function reported higher self-efficacy which was associated with higher QoL ratings.

CONCLUSIONS

Greater self-efficacy for managing MCI mediated the negative association between physical function and quality of life in this exploratory study. Interventions aimed at enhancing memory self-efficacy in MCI may improve perceived QoL, even in the presence of poor physical function. Future research is needed to investigate this further.

A Combined Treatment Approach to Support Everyday Function and Promote Brain Health in Older Adults: A Pilot Study

Objective: Subtle changes in functional abilities are an early indicator of cognitive impairment. Early intervention may be key to prolonging independence. This study describes the development and program evaluation of an intervention designed to (1) bolster the use of compensation strategies that support everyday executive and memory functioning and (2) utilize these strategies to promote engagement in brain health activities.Method: Older adults (n = 35) with subjective cognitive complaints completed an eight-week group program targeting compensation strategies (e.g., calendars) and brain health activities (e.g., physical exercise). Participants completed outcome measures at first, last, and 3 month follow-up sessions.Results: Compensation strategy use can be successfully taught to and implemented by older adults, and increasing engagement in brain health behaviors is possible, although particular lifestyle changes are challenging to implement.Conclusion: Findings support the use of interventions aimed at increased engagement in compensation strategies to aid everyday memory and executive functioning.Clinical Implications: Early intervention may help to promote prolonged functional independence.

Functional ability is associated with higher adherence to behavioral interventions in mild cognitive impairment

Objective: Behavioral interventions during early memory decline hold promise in delaying the development of dementia. In the present study, participants in a multimodal behavioral intervention study were assessed for post-intervention adherence and predictors of adherence.Methods: Participants (N = 272, mean age = 75.04 ± 7.54) diagnosed with amnestic Mild Cognitive Impairment (aMCI) were assigned to intervention groups receiving four out of five behavioral intervention components, including yoga, memory compensation training, computerized cognitive training, support groups, and/or wellness education. Length of the intervention was 10 days, 4 h per day, with post-intervention follow-up at 6, 12, and 18 months.Results: Two-hundred and thirty-seven participants completed the 6-month post-intervention follow-up measures, 228 participants completed the 12-month measures, and 218 participants completed the 18-month measures. Participants fully adhered to a mean of 2 out of the 4 taught intervention components. Eighty-nine percent of participants were at least partially adherent to one or more taught intervention components at 6-, 12-, and 18-month post-intervention follow-up. Physical activity was the most adhered to intervention while group support was the least adhered to intervention across all three follow-up time-points. Higher educational level, higher baseline depressive symptoms, higher baseline global cognitive functioning, and better baseline and concurrent functional abilities were associated post-intervention adherence.Conclusion: Changes in functional abilities are associated with disease progression among persons with aMCI. In the present study, individuals with aMCI who have higher education, higher depressive symptoms, and better baseline functioning abilities are more likely to adhere to behavioral intervention components over time. Post-intervention adherence also associates with concurrent daily function.

Memory Support System training in mild cognitive impairment: Predictors of learning and adherence

This study aimed to identify predictors of learning and adherence to a previously validated compensatory calendar and note-taking system (Memory Support System; MSS) in persons with amnestic mild cognitive impairment (aMCI). Age, education, global cognition, depression, and memory-related self-efficacy were studied as predictors of individuals' ability to learn the use of the MSS during the two-week training and of their adherence to the MSS 6, 12, and 18 months after training. How well an individual was able to learn the use of the MSS was itself examined as a predictor of adherence. Two-hundred-and-fifteen older adults with aMCI and their study partners (e.g., spouse, adult child) received MSS training one-hour daily for 10 days. Ordinal logistic regression analyses indicated that (1) global cognition predicted MSS learning at end of training, and (2) MSS learning at end of trainng predicted MSS adherence at 6, 12, and 18 months post-training. The current study suggests that offering compensatory strategies as early as possible for those with MCI might be of most benefit, and might have implications for long-term adherence.

Comparative Effectiveness of Behavioral Interventions on Quality of Life for Older Adults With Mild Cognitive Impairment: A Randomized Clinical Trial

IMPORTANCE

Recommendations to engage in behavioral strategies to combat clinically significant cognitive and behavioral symptoms are routinely given to persons with mild cognitive impairment (MCI). The comparative effectiveness of these behavioral interventions is not well understood.

OBJECTIVE

To compare the incremental effects of combinations of 5 behavioral interventions on outcomes of highest importance to patients with MCI.

DESIGN, SETTING, AND PARTICIPANTS

In this multisite, cluster randomized, multicomponent comparative effectiveness trial, 272 patients from 4 academic medical outpatient centers (Mayo Clinic, Rochester, Minnesota; Mayo Clinic, Scottsdale, Arizona; Mayo Clinic, Jacksonville, Florida; and University of Washington, Seattle) were recruited from September 1, 2014, to August 31, 2016, with last follow-up March 31, 2019. All participants met the National Institute on Aging-Alzheimer's Association criteria for MCI.

INTERVENTIONS

The intervention program was modeled on the Mayo Clinic Healthy Action to Benefit Independence and Thinking (HABIT) program, a 50-hour group intervention conducted during 2 weeks, including memory compensation training, computerized cognitive training, yoga, patient and partner support groups, and wellness education. In our study, 1 of 5 interventions was randomly selected to be withheld for each intervention group. Participants and their partners had 1-day booster sessions at 6 and 12 months after intervention.

MAIN OUTCOMES AND MEASURES

Quality-of-life measurement of participants with MCI at 12 months was the primary outcome, selected based on the preference rankings of previous program participants. Mood, self-efficacy, and memory-based activities of daily living were also highly ranked.

RESULTS

A total of 272 participants (mean [SD] age, 75 [8] years; 160 [58.8%] male and 112 [41.2%] female) were enrolled in this study, with 56 randomized to the no yoga group, 54 to no computerized cognitive training, 52 to no wellness, 53 to no support, and 57 to no memory support system. The greatest effect size for quality of life was between the no computerized cognitive training and no wellness education groups at 0.34 (95% CI, 0.05-0.64). In secondary analyses, wellness education had a greater effect on mood than computerized cognitive training (effect size, 0.53; 95% CI, 0.21-0.86), and yoga had a greater effect on memory-related activities of daily living than support groups (effect size, 0.43; 95% CI, 0.13-0.72).

CONCLUSIONS AND RELEVANCE

These results provide further support for behavioral interventions for persons with MCI. Different outcomes were optimized by different combinations of interventions. These findings provide an initial exploration of the effect of behavioral interventions on patient-advocated outcomes in persons with MCI.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02265757.

A Survey of Patient and Partner Outcome and Treatment Preferences in Mild Cognitive Impairment

BACKGROUND

The patient-centered movement in health care is increasing efforts to design studies and interventions that address the outcomes that matter most to patients and their families. Research has not adequately addressed Alzheimer's disease patient and caregiver preferences.

OBJECTIVE

To survey the outcome and treatment preferences of patients and caregivers who had completed a multicomponent behavioral intervention for mild cognitive impairment (MCI).

METHODS

Extending prior work, we conducted an online survey regarding outcome and intervention preferences. Participants were patients with MCI and partners who completed the HABIT Healthy Action to Benefit Independence & Thinking ® program.

RESULTS

Both patient and partner respondents ranked patient quality of life as the highest priority, followed by patient self-efficacy, functional status, patient mood, and patient memory performance. Distressing behaviors and caregiver outcomes (burden, mood, and self-efficacy) had low rankings. Regarding the importance of HABIT ® program components, memory compensation training was ranked highest and wellness education lowest by all groups.

CONCLUSION

Additional research should compare patient preference for patient reported outcomes, traditional neuropsychological and clinician outcomes, and modern biomarker outcomes.