Feasibility of the SmartPrompt for Improving Everyday Function in Dementia

The exorbitant health care costs associated with dementia relative to other illnesses are a significant concern in the US and other countries with aging populations. Difficulty completing everyday tasks is a primary reason for the high cost of care, loss of caregiver paid hours, and general caregiver burden. As older adults become more computer literate, assistive technologies hold promise as an inexpensive solution to improve daily functioning and ultimately promote aging in place, reduce caregiver burden, and reduce healthcare expenditures due to secondary health issues that arise when everyday tasks are neglected. Electronic reminder applications are a type of assistive technology that deliver cues to perform important daily activities (e.g., take medication). Electronic reminders are widely available, but, few of these applications have been designed specifically to 1) target the numerous cognitive difficulties that impede the recall and completion of everyday tasks in people with dementia (i.e., premature decay of task goals, decreased motivation to perform tasks, etc.); 2) circumvent the sensory/motor difficulties that older adults face when using technology (i.e., simple, user-friendly interface); and 3) be accessible at a low cost (i.e., easily integrated with consumer devices like smartphones). Additionally, there is a dearth of fundamental knowledge and quantitative data on the feasibility of electronic reminder applications for older adults with dementia. This revised R21 application (PAR-15-351/PAR-18-179) proposes a Stage I feasibility study that will address gaps in fundamental knowledge on the efficacy and usability of an electronic reminder aid for commercially available smartphones specifically designed for people with dementia. Aim 1 (efficacy): To investigate the hypothesis that a reminder application designed to target the specific cognitive impairments that preclude task completion in dementia and to circumvent sensory/motor challenges faced by many older adults (SmartPrompt) is efficacious for promoting everyday task completion. The SmartPrompt includes six features to address cognitive impairments that cause task failure in dementia: 1) reminder alert (prospective memory impairment); 2) choice to respond to reminder immediately or at a later time (distractibility); 3) instructions (semantic knowledge degradation); 4) persistent reminder until task is completed (poor monitoring); 5) activity logging via photos (episodic memory impairment); 6) gaming rewards for task completion (apathy). Diverse participants with mild dementia (N = 40) and their caregivers will be asked to track performance of a target task (medication, meals, or hydration) twice per day for two weeks. Using an AB/BA crossover design, participants will use the SmartPrompt for one of the two weeks (SmartPrompt Condition) and will perform the task as usual during the other week (Control condition; order counterbalanced across participants). Efficacy outcomes, including caregiver/participant daily logs of task completion and reports of caregiver burden and participant frustration, will be examined using repeated-measures analyses comparing the Control vs. SmartPrompt Conditions. Aim 2 (usability)- To evaluate the usability of the SmartPrompt using measures obtained from caregivers, participants with dementia, the study team, and the study smartphone. The investigators expect that the design features of the SmartPrompt will be perceived favorably by participants and will require minimal technical support from the study team and caregivers during the one-week SmartPrompt testing period. The investigators also expect that the structure and support embedded in the SmartPrompt application design will lead to favorable caregiver and participant usability ratings relative to published standards. All technical problems reported by the participant and/or caregiver will be logged and analyzed by the study team for future design modifications. Metrics obtained directly from the smartphone (e.g., response times to reminder alarms) also will be evaluated as objective measures of usability. Exploratory Aim: To examine participant and caregiver features that are associated with SmartPrompt efficacy/usability. Features of primary interest include participant sex, level of education, level and type of cognitive/functional impairment, caregiver and participant computer literacy/self-efficacy, and desire to change. The investigators will recruit a diverse older adult sample and administer measures of cognition, performance-based testing of everyday function, and questionnaires on mood/anxiety, computer literacy/proficiency/self-efficacy, and desire for behavior change. Bivariate correlations and multiple regression analyses will be performed with participant/caregiver features as predictors and efficacy/usability outcomes as the dependent variables. Results of this aim will be used to 1) develop a working framework of barriers and facilitators for the efficacy and usability of electronic reminder applications that will be tested in future studies and 2) inform modifications of the SmartPrompt training protocol and/or design for a future Phase II clinical trial. Considering the limited success of pharmaceutical treatments for dementia, there has been surprisingly little rigorous research on the potential to leverage relatively simple assistive technologies to improve daily functioning for people with dementia. Even relatively modest improvements in daily function could have a host of positive downstream effects, including increased autonomy and quality of life and improved health for people with dementia and reduced cost of care and reduced burden for caregivers.