Providing Online Memory Interventions for Older Adults: A Critical Review and Recommendations for Development

The efficacy of internet-delivered cognitive-behavioral therapy for posttraumatic stress disorder according to the mean age of patients: a systematic review and meta-analysis

Internet-delivered cognitive-behavioral therapy (I-CBT) is effective in treating post-traumatic stress disorder (PTSD) symptoms, offering enhanced accessibility and cost-effectiveness. However, it's important to note that these technologies may not be suitable for all age groups. Therefore, we conducted a systematic review and meta-analysis to determine if the effectiveness of I-CBT in treating PTSD varies based on the patients' mean age. We conducted a systematic review of the literature, focusing on randomized controlled trials (RCTs) in the ISI Web of Science, PubMed/MEDLINE, and PsycINFO databases. Following this, we performed a meta-analysis and evaluated the risk of bias using the Cochrane risk of bias quality assessment tool. In this study, we examined patient-related factors (civil or military status, age, and gender), clinical characteristics (baseline PTSD severity and type of trauma), and treatment characteristics (type of intervention, synchronous or asynchronous delivery, and the number of sessions) as independent variables. The dependent variable was the reduction in mean PTSD symptoms. Five RCTs out of 1,552 screened studies were included in this review, all of which showed some level of concern regarding potential bias. Our meta-analysis indicates that I-CBT is equally effective regardless of patients' mean age. Since all RCTs included only provide the mean age of the patients, further randomized controlled trials should address the effectiveness of I-CBT among different age groups.

Feasibility, Acceptability, and Impact of a self-guided e-learning Memory and Brain Health Promotion Program for Healthy Older Adults

OBJECTIVES

To examine the feasibility (e.g., completion rate), acceptability (e.g., satisfaction), and participant-reported impact (e.g., memory concerns, behavior change, goal attainment) of a self-guided, e-learning adaptation of a validated, facilitator-guided, in-person memory intervention for older adults.

METHODS

Participants were 139 healthy older adults (mean age: 73 ± 7, 73% women). Participation tracking and pre/post questionnaires embedded within the e-learning program were used to assess feasibility, acceptability, and impact.

RESULTS

Sixty-eight percent of participants completed the program. Anonymous feedback data indicated a high level of satisfaction with the program, the pace and clarity of the learning modules, and the user interface. Suggested improvements included offering more interaction with others and addressing minor platform glitches. There was a 41% decrease in the prevalence of concern about memory changes from baseline to posttest. The majority of participants reported an increase in use of memory strategies and uptake of health-promoting lifestyle behaviors. All participants reported moderate-to-high satisfaction with personal goal attainment.

CONCLUSIONS

The program demonstrated good feasibility, acceptability, and lead to reduction in age-related memory concerns.

CLINICAL IMPLICATIONS

Self-guided, e-learning programming shows promise for fostering positive adaptation to age-related memory changes and improving the uptake of evidence-based strategies to promote brain health among older adults.

Promoting cognitive health: a virtual group intervention for community-living older adults

Group cognitive interventions can promote a sense of self-efficacy to older adults. Due to restrictive social distancing measures in the COVID-19 pandemic, face-to-face interventions that aimed to promote cognitive health needed to be adapted to a virtual offering.

Objectives

This study aimed to analyze the effects of promoting cognitive health in a virtual group intervention for community-living older adults.

Methods

This is a mixed, prospective, and analytical study. Before and after the intervention, the tests were applied: Brief Cognitive Screening Battery (BCSB) and the Subjective Memory Complaints Questionnaire (MAC-Q). Data were collected at semi-structured interviews related to the adoption of memory strategies. Statistical tests were conducted for initial and final intragroup comparison. The qualitative data were assessed using thematic analysis.

Results

A total of 14 participants concluded the intervention. With respect to mnemonic strategies, the most relevant for the qualifier "Did not use it before and started to do so after the group" were association (n=10; 71.4%) and dual-task inhibition (n=9; 64.3%). According to the tests, the intervention improved incidental, immediate, and delayed recall, as well as the perception of memory for "Remembering the name of the person they just met," "Remembering the telephone number you use at least once a week," "Remembering where they put an object," "Remembering news from a magazine article or television program," and "In general, how would you describe your memory now compared to when you were 40 years old."

Conclusions

The synchronous virtual group intervention was shown to be feasible for the elderly in the community who participated in the study.

The experiences of carers in supporting a person living with dementia to participate in virtual cognitive stimulation therapy during the COVID-19 pandemic

OBJECTIVES

Cognitive stimulation therapy (CST) is an evidence-based group intervention for people with dementia. In response to the COVID-19 pandemic, many existing CST groups moved virtually and this required carers of people living with dementia to assist with setting up the appropriate technology. This study aimed to explore the roles and experiences of carers in accessing virtual CST (vCST).

METHODS

This qualitative study used semi-structured individual interviews, via telephone or videoconference, to explore the roles and experiences of carers. Interviews were recorded, transcribed verbatim and thematically analysed.

RESULTS

Twelve family carers (age: 51-75 years) reported a range of experiences, from novice to expert knowledge in terms of accessing digital devices (mainly laptops and iPads) and connecting to Zoom. Accessing vCST provided carers an immediate application of new knowledge. Carers reported positive responses to vCST that provided their family member living with dementia with social contact and cognitive stimulation during lockdown.

CONCLUSION

Accessing vCST required carers to have an existing adequate level of technological competence in order to learn and use the Zoom platform. Adult learning principles can be used to improve carers' digital literacy required for vCST and other telehealth initiatives.

An Agile Development Cycle of an Online Memory Program for Healthy Older Adults

Online interventions for older adults should be tailored to their unique needs to increase the efficacy of and adherence to the intervention. The agile development cycle is a dynamic model to solicit and incorporate feedback from older adults during the design process. We combined this approach with the framework of Harvard University's clinical and translational phases that provide a clear structure for evaluating new health programs before they are offered in the community. We based our online memory program on the empirically validated in-person Memory and Aging Program. The aim of the present study was to combine the agile development cycle with the clinical and translational phases framework to develop and pilot an online memory program tailored to the unique needs of older adults. Study 1 involved piloting individual program modules on site and integrating participant feedback into the program's design to optimize usability. Study 2 involved two sequential pilots of the program accessed remotely to evaluate preliminary clinical outcomes and obtain feedback for iterative modifications. Plans for further validation and limitations are discussed. The successful application of the agile development cycle implemented in this series of studies can be adapted by others seeking to offer online content for targeted end users.

Cognitive performance in older people after mild traumatic brain injury: Trauma effects and other risk factors

OBJECTIVE

Cognitive symptoms are common in the initial weeks after mTBI, but recovery is generally expected within three months. However, there is limited information about recovery specifically in older age cohorts. Therefore, this study investigated cognitive outcome three months after mTBI in older adults (≥ 65 years) compared to trauma and community age-matched controls and explored risk factors for outcome after traumatic injury.

METHODS

Older mTBI patients (n = 40) and older adults with mild traumatic injury but without head injury (n = 66) were compared to a noninjured community control group (n = 47). Cognitive assessment included neuropsychological and computerized tests. Group differences were compared on individual tasks and overall cognitive performances using composite scores. Regression analyses identified predictors of outcome for trauma patients and moderator analyses explored possible interactions of mTBI severity with age and cognition.

RESULTS

As well as lower performances in processing speed and memory, both trauma groups had significantly lower performance on composite neuropsychological (d = .557 and .670) and computerized tasks (d = .783 and .824) compared to noninjured controls. Age, education, and history of depression were direct predictors of cognitive performance after mild traumatic injury (with or without head injury). Further moderation analysis demonstrated that mTBI severity (Glasgow Coma Scale < 15) moderated the impact of older age on computerized assessment (β = -.138).

CONCLUSIONS

Three months after mild trauma (regardless of head injury), older people demonstrate lower cognition compared to noninjured peers. However, severity of mTBI (Glasgow Coma Scale < 15) can interact with older age to predict poorer cognitive outcomes.

Examination of the Feasibility, Acceptability, and Efficacy of the Online Personalised Training in Memory Strategies for Everyday (OPTIMiSE) Program for Older Adults: Results from a Single-Arm Pre-Post Trial (Preprint)

BACKGROUND

Memory strategy training for older adults helps maintain and improve cognitive health but is traditionally offered face-to-face, which is resource intensive, limits accessibility, and is challenging during a pandemic. Web-based interventions, such as the Online Personalised Training in Memory Strategies for Everyday (OPTIMiSE) program, may overcome such barriers.

OBJECTIVE

We report on OPTIMiSE's feasibility, acceptability, and efficacy.

METHODS

Australians aged ≥60 years reporting subjective cognitive decline participated in this single-arm pre-post web-based intervention. OPTIMiSE is a 6-module web-based program offered over 8-weeks with a 3-month booster. It has a problem-solving approach to memory issues, focusing on psychoeducation about memory and aging, knowledge and practice of compensatory memory strategies, and personalized content related to individual priorities. We examined the feasibility (recruitment, attrition, and data collection), acceptability (recommendation to others, suggestions for improvement, and withdrawal reasons), and efficacy (change in goal satisfaction, strategy knowledge and use, self-reported memory, memory satisfaction and knowledge, and mood; thematic content analysis of the most significant change; and the application of knowledge and strategies in daily life) of OPTIMiSE.

RESULTS

OPTIMiSE was feasible, demonstrated by strong interest (633 individuals screened), a satisfactory level of attrition (158/312, 50.6%), and minimal missing data from those completing the intervention. It was acceptable, with 97.4% (150/154) of participants agreeing they would recommend OPTIMiSE, the main suggestion for improvement being more time to complete modules, and withdrawal reasons similar to those in in-person interventions. OPTIMiSE was also efficacious, with linear mixed-effects analyses revealing improvements, of moderate to large effect sizes, across all primary outcomes (all P<.001): memory goal satisfaction (Cohen d after course=1.24; Cohen d at 3-month booster=1.64), strategy knowledge (Cohen d after course=0.67; Cohen d at 3-month booster=0.72) and use (Cohen d after course=0.79; Cohen d at 3-month booster=0.90), self-reported memory (Cohen d after course=0.80; Cohen d at 3-month booster=0.83), memory satisfaction (Cohen d after course=1.25; Cohen d at 3-month booster=1.29) and knowledge (Cohen d after course=0.96; Cohen d at 3-month booster=0.26), and mood (Cohen d after course=-0.35; nonsignificant Cohen d at booster). Furthermore, the most significant changes reported by participants (strategy use, improvements in daily life, reduced concern about memory, confidence and self-efficacy, and sharing and shame busting with others) reflected the course objectives and were consistent with themes arising from previous in-person interventions. At the 3-month booster, many participants reported continued implementation of knowledge and strategies in their daily lives.

CONCLUSIONS

This feasible, acceptable, and efficacious web-based program has the potential to enable access to evidence-based memory interventions for older adults worldwide. Notably, the changes in knowledge, beliefs, and strategy use continued beyond the initial program. This is particularly important for supporting the growing number of older adults living with cognitive concerns.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12620000979954; https://tinyurl.com/34cdantv.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.3233/ADR-200251.

Observed Strategies on Naturalistic Associative Memory Tasks in Healthy Older Adults and Amnestic Mild Cognitive Impairment

BACKGROUND

Understanding the strategies people with amnestic mild cognitive impairment (aMCI) spontaneously use can inform targeted memory training.

METHOD

Strategy use was observed for 99 people with aMCI and 100 healthy older adults (HOA) on two memory tasks.

RESULTS

No differences were found between aMCI and HOA in the amount or types of strategies used, but strategy use varied with task. Association was more effective for one task, whereas on the other task, use of written notes or multiple strategies were detrimental to performance and related to poorer performance than active (spaced) retrieval, for aMCI.

CONCLUSION

Our findings suggest the importance of identifying ineffective habits, in addition to instruction in more beneficial approaches.

Preventing Delirium and Promoting Long-Term Brain Health: A Clinical Trial Design for the Perioperative Cognitive Enhancement (PROTECT) Trial

BACKGROUND

Perioperative neurocognitive disorders (PND), including postoperative delirium (POD), are common in older adults and, for many, precipitate functional decline and/or dementia.

OBJECTIVE

In this protocol, we describe a novel multidisciplinary, multicomponent perioperative intervention that seeks to prevent or reduce POD and associated cognitive decline.

METHODS

We will conduct a prospective, single-blind, pragmatic, randomized-controlled trial to compare our tailored multi-disciplinary perioperative pathway against current standard of care practices. We will recruit a total of 692 elective surgical patients aged 65 years or more and randomize them in a 1:1 design. Our perioperative intervention targets delirium risk reduction strategies by emphasizing the importance of early mobilization, nutrition, hydration, cognitive orientation, sensory aids, and avoiding polypharmacy. To promote healthy behavior change, we will provide a tailored psychoeducation program both pre- and postoperatively, focusing on cardiovascular and psychosocial risks for cognitive and functional decline.

RESULTS

Our primary outcome is the incidence of any PND (encapsulating POD and mild or major postoperative neurocognitive disorder) at three months postoperative. Secondary outcomes include any incidence of POD or neurocognitive disorder at 12 months. A specialized delirium screening instrument, the Confusion Assessment Method (3D-CAM), and a neuropsychological test battery, will inform our primary and secondary outcomes.

CONCLUSION

Delirium is a common and debilitating postoperative complication that contributes to the cognitive and functional decline of older adults. By adopting a multicomponent, multidisciplinary approach to perioperative delirium prevention, we seek to reduce the burden of delirium and subsequent dementia in older adults.

Evaluation of a Short-Term Digital Group Intervention to Relieve Mental Distress and Promote Well-Being Among Community-Dwelling Older Individuals During the COVID-19 Outbreak: A Study Protocol

Older individuals are at an increased risk of experiencing adverse social and health consequences due to both the COVID-19 pandemic and the measures taken to manage it, such as social distancing. To promote community-dwelling older individuals' well-being during this time, the aims of the current project are to develop effective strategies in order (a) to increase older individuals' digital literacy, and (b) to help them acquire behavioral and cognitive skills that will improve their coping abilities with the stressful situation created as a result of the pandemic, as well as reducing adverse mental health effects. The project comprises an intervention arm that includes digital group sessions for older individuals meant to improve their digital literacy, promote their effective coping, and relieve their mental distress and loneliness. Subjects receive a short-term (seven sessions), twice-weekly, digitally guided group intervention through Zoom (a video conferencing app), and WhatsApp (instant messaging app). The wait list control-group participants receive twice-weekly telephone calls from a research assistant during a parallel period. Web-based questionnaires are filled in pre- and post-participation. The effectiveness of the intervention will be analyzed by comparing pre- and post-measures, between intervention and control groups. This protocol offers a model for helping to support vulnerable populations during the COVID-19 pandemic. However, it is applicable regardless of the outbreak of a global health crisis or the imposition of lockdown rules; in fact, it has the potential to contribute to the social inclusion of vulnerable populations during routine times as well as during emergencies. Furthermore, ideas for future expansion include the integration of multilingual facilitators in order to reach seniors from underserved minority groups in various social contexts, even across borders.

Online Personalised Training in Memory Strategies for Everyday (OPTIMiSE) Program for Older Adults with Cognitive Concerns: Pilot Study Protocol

Memory interventions for older adults with cognitive concerns result in improved memory performance and maintenance of cognitive health. These programs are typically delivered face-to-face, which is resource intensive and creates access barriers, particularly for those with reduced mobility, limited transportation, and living in rural or remote areas. The COVID-19 pandemic has created an additional access barrier, given the increased risk this disease poses to older adults. Internet-based interventions seek to overcome these barriers. This paper describes the protocol of a pilot study that aims to evaluate the feasibility, acceptability, and efficacy of one such internet-based intervention: the Online Personalised Training in Memory Strategies for Everyday (OPTIMiSE) program. OPTIMiSE focuses on improving knowledge regarding memory and providing training in effective memory strategies for everyday life. The pilot study described in this protocol will be a single-arm pre-post study of 8 weeks duration, with a single maintenance session 3 months post-intervention. Participants will be Australian adults aged ≥60 years reporting cognitive changes compared with 10 years ago. Primary outcome measures will address feasibility, acceptability, and efficacy. Secondary outcome measures assessing sense of community and self-efficacy will be administered at the 8-week and 3-month timepoints. Data collection will conclude mid-2021, and results will be presented in a subsequent publication. Translation of memory interventions to internet-based delivery has the potential to remove many access barriers for older adults; however, the acceptability and feasibility of this modality needs investigation. OPTIMiSE is the initial step in what could be an important program enabling access to an evidence-based memory intervention for older adults worldwide. Trial registration: Australian New Zealand Clinical Trials Registry (ANZCTR), ACTRN12620000979954.

Online memory training intervention for early-stage dementia: A systematic review and meta-analysis

OBJECTIVES

To evaluate the effectiveness of online memory training interventions in improving memory of patients diagnosed with early-stage dementia. The secondary outcomes comprised cognitive and psychological outcomes.

DESIGN

This review was conducted for accordance to the Cochrane Handbook for Systematic Reviews of Interventions.

DATA SOURCE

A comprehensive search from six electronic databases: PubMed, Embassy, The Cochrane Library, The Cumulative Index to Nursing and Allied Health Literature, Scopus and Web of Science was conducted (2000-2020).

REVIEW METHODS

The populations included in this review comprised adults who had been clinically diagnosed with early-stage dementia and involved in online memory training interventions. Two reviewers appraised the risks of bias through the Cochrane Collaboration's tool and performed the meta-analysis, including the assessment of heterogeneity.

RESULTS

Eleven randomized controlled trials retrieved from six databases demonstrated low to moderate levels of quality of evidence according to the GRADE approach. The meta-analysis revealed that online memory training interventions have demonstrated a moderate effect size in improving memory outcomes (d = 0.57; 95% confidence interval 0.28-0.85; p = 0.0001). Additionally, such interventions have shown improvements in secondary outcomes of cognition and psychological with small to medium effects. Duration of each online memory training session and its frequencies did not affect the memory outcome. As opposed to the conventional face-to-face interventions conducted for a group, it is more effective to be conducted for an individual setting.

CONCLUSIONS

Online memory training intervention was effective in improving the memory for adults with dementia.

IMPACT

Memory interventions have the prospect of reducing everyday problems caused by lapses in memory and improving well-being. With factors such as limited resources and restriction of social gathering due to pandemic, this review could offer relevant information for clinical decision-makers when planning online memory training interventions for adults with dementia.

Bridging the gap between clinical trials and community care: Translating a memory group for older people with mild cognitive impairment into a community-based organisation

OBJECTIVES

Older people with mild cognitive impairment (MCI) are seeking interventions for maintaining independence. This study investigates the feasibility of translating a research-evaluated memory group (LaTCH) into a community-based organisation by evaluating the experiences of clients and trained staff.

METHODS

Dementia Australia staff trained as facilitators of memory groups for 274 people with MCI and families. Clients and staff were interviewed regarding experiences from group participation.

RESULTS

Clients and staff reported benefits of shared experience through group participation, leading to greater use of compensatory strategies. Staff observed client improvement in memory-related self-confidence, thereby reducing anxiety and increasing re-engagement in life activities. In their own professional roles, staff reported increased self-efficacy, leading to greater role satisfaction. Several challenges in running and sustaining the program were also identified.

CONCLUSIONS

Memory group interventions can be feasibly delivered in a community setting and increase service access opportunities for older people with memory problems.