Terms of Engagement: Understanding the Motivations, Preferences, and Attitudes of Older Adults Toward Mobile Cognitive Assessment and Training

BACKGROUND AND OBJECTIVES

The future of cognitive assessment is likely to involve mobile applications for smartphones and tablets; cognitive training is also often delivered in these formats. Unfortunately, low adherence to these programs can hinder efforts at the early detection of cognitive decline and interfere with examining cognitive training efficacy in clinical trials. We explored factors that increase adherence to these programs among older adults.

RESEARCH DESIGN AND METHODS

Focus groups were conducted with older adults (N = 21) and a younger adult comparison group (N = 21). Data were processed using reflexive thematic analysis with an inductive, bottom-up approach.

RESULTS

Three primary themes related to adherence were developed from the focus group data. Switches of engagement reflects factors that must be present; without them, engagement is unlikely. Dials of engagement reflects a cost-benefit analysis that users undergo, the outcome of which determines whether a person will be more or less likely to engage. Bracers of engagement reflects factors that nudge users toward engagement by minimizing barriers associated with the other themes. Older adults in general were more sensitive to opportunity costs, preferred more cooperative interactions, and were more likely to mention technology barriers.

DISCUSSION AND IMPLICATIONS

Our results are important for informing the design of mobile cognitive assessment and training apps for older adults. These themes provide guidance about ways apps could be modified to increase engagement and adherence, which in turn can more effectively facilitate the early detection of cognitive impairment and the evaluation of cognitive training efficacy.

Adherence Promotion With Tailored Motivational Messages: Proof of Concept and Message Preferences in Older Adults

This study examined the feasibility of using tailored text messages to promote adherence to longitudinal protocols and determined what facets of text message tone influence motivation. Forty-three older adults (Mage = 73.21, SD = 5.37) were recruited to engage in video-game-based cognitive training for 10 consecutive days. Participants received encouraging text messages each morning that matched their highest or lowest ranking reasons for participating in the study, after which they rated how effective each message was in motivating them to play the games that day. After 10 days, participants rated all possible messages and participated in semi-structured interviews to elicit their preferences for these messages. Results showed that messages matching participants' reasons for participating were more motivating than mismatched messages. Further, participants preferred messages that were personalized (i.e., use second person voice) and in formal tones. Messages consistent with these preferences were also rated as more motivating. These findings establish the feasibility of using message tailoring to promote adherence to longitudinal protocols and the relevance of tailoring messages to be personal and formal.

THE DEVELOPMENT OF ADHERENCE SUPPORT MESSAGES FOR AN AI-BASED REMINDER SYSTEM

Artificial Intelligence (AI) holds tremendous potential for aiding in the customization and tailoring of interventions. This talk will focus on the initial development of an adherence support system to maintain older adults' engagement with at-home cognitive training and assessment delivered via mobile devices. As part of the NIA funded Adherence Promotion with Person-centered Technology (APPT) project, a reminder and adherence support system is being developed to automatically detect adherence lapses and provide just-in-time reminders with tailored messaging to facilitate reengagement. The results of an initial study (N=40) will be presented in which participants were delivered reminders via SMS text messaging that were either tailored or not tailored to their self-reported motivation to engage with the intervention. Tailored messages were perceived as more motivating, and qualitative data informed additional ways in which messages might further be tailored based on individual preferences to support adherence.

Motivation to Engage in Aging Research: Are There Typologies and Predictors?

BACKGROUND AND OBJECTIVES

Study recruitment and retention of older adults in research studies is a major challenge. Enhancing understanding of individual differences in motivations to participate, and predictors of motivators, can serve the dual aims of facilitating the recruitment and retention of older adults, benefiting study validity, economy, and power.

RESEARCH DESIGN AND METHODS

Older adults (N = 472) past and potential participants were surveyed about motivations to participate in research, demographic, and individual difference measures (e.g., health status, cognitive difficulties). Latent class and clustering analyses explored motivation typologies, followed by regression models predicting individual motivators and typologies.

RESULTS

Older adults endorsed a diversity of research motivations, some of which could be predicted by individual difference measures (e.g., older participants were more motivated by the desire to learn new technology, participants without a college education were more motivated by financial compensation, and participants with greater self-reported cognitive problems were more likely to participate to gain cognitive benefit). Clustering analysis revealed 4 motivation typologies: brain health advocates, research helpers, fun seekers, and multiple motivation enthusiasts. Cognitive difficulties, age, employment status, and previous participation predicted membership in these categories.

DISCUSSION AND IMPLICATIONS

Results provide an understanding of different participant motivations beyond differences between younger and older adults and begin to identify different classes of older adults motivated to participate in research studies. Results can provide guidance for targeted recruitment and retention strategies based on individual differences in stated or predicted motivations.

The Effect of Reminder Message Tailoring on Cognitive Intervention Adherence

To examine the potential impact of tailored messaging on adherence and attitudes toward text message reminders, a pilot study conducted in advance of the APPT randomized controlled trial systematically manipulated the match between text message content and participants’ self-reported motivations to participate in a cognitive intervention study. Older adults (n=40) were asked to engage in cognitive training, in the form of gamified neuropsychological tests, 30 minutes a day for 10 consecutive days, and adherence was tracked remotely over time. Critically, each day text message reminders alternated between messages consistent or inconsistent with participants’ previously reported motivations for entering the study. This talk presents results, derived from multilevel modeling, that explore the effectiveness of this simple and cost-effective message tailoring approach for facilitating adherence and engendering positive attitudes toward the reminder system, and implications for programs requiring long-term adherence.

A Qualitative Understanding of Motivations, Preferences, and Attitudes Toward Adherence-Based Technology

Missouri Quality Initiative (MOQI) was a CMS-funded enhanced care and coordination provider demonstration project (2012-2020) that successfully reduced avoidable hospitalizations and improved nursing home (NH) care quality. Little is known about the influence of race in multiple hospital transfers from NHs. Using a mixed-methods approach we analyzed hospitalization root cause analysis data from 2017-2019 for 1410 residents in 16 MOQI NHs. There were 113 residents who were transferred 609 times. Those with multiple transfers (four or more transfers/year) were compared by race and key characteristics (e.g., code status, diagnosis). A subset of residents with multiple transfers were examined qualitatively to identify and describe key cases. Findings suggest that Black residents have a higher probability for multiple transfers. Findings highlight the need for transfer prevention efforts for Black residents including early assessment and intervention, early/frequent discussion about goals of care, advance directives, resuscitation status, and family/resident understanding of treatment effectiveness.

An Introduction to the Adherence Promotion With Person-Centered Technology Project

The massive potential of cognitive training and longitudinal cognitive assessment to detect and prevent age-related cognitive decline and dementia will not be realized unless individuals are willing and able to engage with these protocols for an extended period of time. Unfortunately, similar to other health behaviors, adherence to home-based assessment and training is frequently poor. Addressing the gap between potential and realized benefits is an urgent goal as the population ages. APPT investigates these and related issues within samples of older adults with and without cognitive impairment. Ultimately, two randomized controlled trials will test whether an adaptive, tailored, and integrated technology-based adherence support system can boost adherence, with the ultimate goal being the early detection and treatment of age-related cognitive decline and dementia. Initial algorithm development and application to existing datasets will be presented that will inform the design of a smart reminder system that will later be assessed.

Changing similarity: Stable and flexible modulations of psychological dimensions

Successfully categorizing objects requires discriminating between relevant and irrelevant dimensions (e.g., shape, color). Categorization can lead to changes in the visual system that stretch psychological space, making relevant dimensions more distinct and irrelevant dimensions more similar. These changes are known as dimensional modulation (DM) and they can be both stable and flexible in nature. The current study examined the interaction between stable DM and flexible DM, as well as the time course of relative changes in similarity. Using a two-dimensional space of cars, participants learned to categorize the space and then completed a target identification task during EEG recording. We found that attention, operationally defined as the selection negativity, was sensitive to category-relevance and appeared to selectively enhance previously irrelevant differences in the service of a target detection task. In contrast, we found that late decisional stages, operationally defined as the P3 b, were less sensitive to relevance and instead more sensitive to the number of morphsteps that separated targets from non-targets. Thus, it appears that relative similarity between targets and non-targets dynamically changed over the time course of individual decisions. Similarity between exemplars was greater along the irrelevant than the relevant dimension early on in the time course but a compensatory allocation of attention led to similarity being optimized among all dimensions for later stages. This finding is important because it 1) provides a new source of converging evidence for stable DM and 2) links a neural measure of attentional modulation with facilitation of an unpracticed, but task-relevant perceptual dimension.