Abstract and Introduction
Background: A decline in the ability to perform daily intentions—known as prospective memory—is a key driver of everyday functional impairment in dementia. In the absence of effective pharmacological treatments, there is a need for developing, testing, and optimizing behavioral interventions that can bolster daily prospective memory functioning. We investigated the feasibility and efficacy of smartphone-based strategies for prospective memory in persons with cognitive impairment.
Methods: Fifty-two older adults (74.79 ± 7.20 years) meeting diagnostic criteria for mild cognitive impairment or mild dementia were enrolled in a 4-week randomized controlled trial. Participants were trained to use a digital voice recorder app or a reminder app to off-load prospective memory intentions. Prospective memory was assessed using experimenter-assigned tasks (e.g., call the laboratory on assigned days), standardized questionnaires, and structured interviews. Secondary dependent measures included days of phone and app usage, acceptability ratings, quality of life, and independent activities of daily living.
Results: Participant ratings indicated that the intervention was acceptable and feasible. Furthermore, after the four-week intervention, participants reported improvements in daily prospective memory functioning on standardized questionnaires (p < 0.001, η p 2 = 0.285) and the structured interview (p < 0.001, d = 1.75). Participants performed relatively well on experimenter-assigned prospective memory tasks (51.7% ± 27.8%), with performance levels favoring the reminder app in Week 1, but reversing to favor the digital recorder app in Week 4 (p = 0.010, η p 2 = 0.079). Correlational analyses indicated that greater usage of the digital recorder or reminder app was associated with better prospective memory performance and greater improvements in instrumental activities of daily living (completed by care partners), even when controlling for condition, age, baseline cognitive functioning, and baseline smartphone experience.
Conclusions: Older adults with cognitive disorders can learn smartphone-based memory strategies and doing so benefits prospective memory functioning and independence.
The ability to remember to perform daily intentions, or prospective memory, has been called a "signature" decline of Alzheimer's disease and related dementias (ADRD). Everyday prospective memory tasks include remembering to attend appointments, deliver messages, and take medications as prescribed. In this way, prospective memory is critical to maintaining independent daily functioning.[2,3]
With FDA-approved treatments for mild ADRD possibly extending duration of living with the disease, there is an urgent need for behavioral treatments that extend functionality and quality of life. Current nonpharmacological approaches to supporting prospective memory include cognitive "brain" training, mnemonic strategies, and electronic memory aids. With few exceptions, brain training paradigms have not produced clinically significant benefits to everyday prospective memory functioning. Training healthy adults to use mnemonic strategies has shown promise in laboratory settings, but the evidence is mixed as to whether persons with ADRD can effectively use mnemonic strategies in naturalistic settings.[7,8]
Electronic memory aids allow intentions to be "off-loaded" onto digital devices so that they can be accessed anytime. A recent meta-analysis indicated that electronic memory aids may be the most effective intervention for prospective memory in persons with cognitive impairment. One example of an electronic memory aid is using a digital voice recorder to verbalize and later review one's intentions. Another example would be recording the intention to an electronic device that can provide automated reminders to perform the intention at specific times or locations.[11,12] Digital recorder and reminder apps are now widely available on smartphones, and smartphones are now owned by more than half of older adults (aged 65 and older), even those with geriatric cognitive disorders. Despite the prevalence and potential value of such devices, studies of electronic memory aids for prospective memory have typically lacked random assignment, rigorous blinding procedures, and adequate sample sizes (median N = 5).[5,14]
We conducted a randomized controlled trial of persons with mild cognitive impairment (MCI) and mild dementia to investigate whether one could support prospective memory with a smartphone-based electronic memory aid: either a reminder app or a digital recorder app. We addressed whether such individuals could and would use smartphones (feasibility/acceptability) across 4 weeks (adherence), and whether doing so benefitted self-reported and objective prospective memory outcome measures (efficacy). We hypothesized that participants would use the smartphone on most days, but that usage would be lower in participants with worse cognitive functioning and less prior experience with smartphones. Additionally, we hypothesized that the reminder app would lead to larger improvements in prospective memory functioning than the digital recorder app because the former can provide time- and location-based reminders.
J Am Geriatr Soc. 2022;70(2):459-469. © 2022 Blackwell Publishing