Developing Computer-based Cognitive Interventions for Aging Populations: A Review

Abstract

Research fields have continually developed methods to prevent and improve cognitive decline in the ever-growing aging population. In this paper, we explain the subtleties that may go unnoticed in cognitive decline in the aging population. Especially because of these subtleties, we emphasize the importance of early detection and intervention in cognitive decline, as well as seeking for assistance to maintain independence. Through recent research, we introduce the Computer-based Cognitive Interventions approaches (Augmented Reality and Virtual Reality) to improve cognitive decline. Furthermore, we evaluate the effectiveness of Computer-based Cognitive Interventions in supporting everyday living in the aging population.

Computer-based Cognitive Interventions are most effective when applied at the early stages of cognitive decline. They provide great improvements in neurocognitive domains and can last long after intervention. These Computer-based Cognitive Interventions also provide support in everyday living activities for increased safety and autonomy. When combined with other approaches such as physical training, there are significant potential effects in cognitive decline.

Keywords:
Cognition: all mental processes to acquire, store, retrieve, and process information
Cognitive impairment: difficulty with memory, learning, concentrating, or making decisions ranging from mild to severe
Neurocognitive domain: conscious mental activities that can be classified into language, learning and memory, social cognition, complex attention, executive function, and perceptual-motor function
Computer-based cognitive interventions (CCIs): approaches to address cognitive impairments and their impacts on neurocognitive domains using technology
Cognitive training (CT): guided practices with structured tasks in a range of difficulties according to individual to train cognitive processes
Cognitive stimulation (CS): wide range of activities to stimulate multiple cognitive domains (e.g. reality orientation)
Cognitive rehabilitation (CR): patients work together with healthcare professionals and family to perform everyday tasks according to individualized goals
Immersive/Non-Immersive Virtual Reality (VR): virtual environment that immerses user directly and shuts out physical world (e.g. head-mounted display) / indirectly (eg. computer)
Augmented Reality (AR): virtual content overlaid on physical world and enhance physical world environment

Introduction

Forgetting to turn the faucet off may seem like a trivial error, but if this forgetfulness repeats itself and goes untreated, the dismissal of the lapse in memory may significantly impair the ability to live independently. One woman dismissed these seemingly insignificant problems with her memory, but began to have trouble doing habitual tasks, such as driving or paying the bills (Ellison, 2024). Eventually, the condition can progress to a more severe decline in mental ability, just as in Dr. M., who showed great variability in emotion–lucid then agitated and distraught. He was admitted to the same hospital he was a director at and required constant attendance in cases where he wandered off. Dr. M. talked to the other patients like he was still a doctor there and could even be seen at the clinic writing prescriptions (Sacks, 2019).

These two patients both experienced decline in cognitive abilities–to varying degrees– beyond normal aging. While the fields of medicine and health have had tremendous successes over the last century, increasing life expectancy to about 80 years of age, preservation of cognitive health has remained a fundamental challenge. Pharmacological treatments have had a limited positive effect on cognition (Zuschnegg et al., 2023). Developing approaches to improve the quality of life in the elderly has therefore become a focus in research, especially with growing interest in Computer-based Cognitive Interventions (CCIs).

Employing the power of computers to preserve or improve cognition, these non-pharmacological treatments provide an alternative to pharmacological treatments. Among CCIs’ many benefits, they are easily personalized to each individual and have minimal maintenance costs compared to medications, which require continual usage and monitoring (Smart et al., 2017; Zuschnegg et al., 2023). As decline in cognitive abilities interfere with activities of daily living, including showering, eating, or brushing teeth, CCIs support aging population’s ability to live independently for as long as possible.

This paper will present how computer-based cognitive interventions can assist aging populations in twofold: explaining the varying tools of CCIs and expanding on their potential application areas.

Computer-based Cognitive Interventions (CCIs)

Augmented Reality (AR)

AR can be implemented on emerging technologies such as AR glasses or handheld devices like a mobile phone. AR applications are easily adaptable to technologies often found in homes, and thus provide a promising prospect for application in home settings for the aging population. With AR’s ability to overlay information in a real-world context, AR allows for contextualization in environments and scalability to communities as a software-based solution (Blattgerste et al., 2019). The technology also endows aid in everyday situations. Ranging from navigation to identifying objects around the user, AR lends a multitude of usages.

Among AR technologies, AR glasses represent an emerging field in technology. Some of their features include object recognition and eye-tracking, which enables features such as selecting objects and monitoring visual attention to a location AR glasses. They are easily portable, providing more autonomy, and expect to decrease in price as the field continues to develop. In terms of design, studies have shown that aging population have not found the glasses to be physically constraining. For ease of understanding, symbolic or pictorial representations are most helpful on the AR glasses (Blattgerste et al., 2019). AR glasses can be equipped with varying input modalities, allowing for a great scope of ways to help the cognitively impaired.

One of the input modalities AR glasses can pair with is a Brain-Machine Interface (BMI). BMI is an assistive technology that translates the brain’s signals into device commands. The device then uses this information to take into account a user’s current mental state. Developing to become affordable, BMI can be widely used in elderly care.

While with relatively limited input options, AR handheld devices provide the most adaptability and flexibility. These handheld devices be applied on household devices. Through AR applications on handheld devices, handheld AR devices can help patients and their caregivers. Caregivers can remotely supervise the elderly through the application. The devices are also easy to understand, as more elderly learn to navigate using technology (Blattgerste et al., 2019).

Virtual Reality (VR)

The immersive nature of VR–whether directly or indirectly–promises a future in intervention for the aging population. Immersive VR immerses the user to create the illusion of being inside a virtual world, usually through a Head Mounted Display (HMD). Many VR devices use gesture-based interactions, which can be especially useful since the user can not see their hands or body. This method of interaction allows easier usability and visualization in a virtual world (Zuschnegg et al., 2023).

Non-immersive VR allows for awareness of the user’s environment, an example being video games. Studies with non-immersive VR as CCIs are rare, but have the potential to be useful in CR and CS. Non-immersive VR’s approach permits straightforward integration into everyday living to support the aging population’s independence in living at home.

How can CCIs be applied?

The CCIs described above have the potential to apply to specific neurocognitive domains according to each individual (see Figure 2). In addition, CCIs can apply to multiple cognitive impairments ranging in the stage of cognitive decline (see Figure 3). To help the aging population, CCIs support treatment and assistance in daily living activities. By combining with other intervention methods, the effect on treating and preventing cognitive decline is bolstered.

Box 1

Neurocognitive domains

Those with cognitive impairments show a decline in one or more of the neurocognitive domains. Each neurocognitive domain includes subdomains, referring to specific abilities in cognitive processes. Identification of the neurocognitive domain and its subdomains affected in one’s cognitive impairments not only help to diagnose the cognitive impairment, but also assist in targeting specific cognitive abilities to support cognitive interventions. Cognitive interventions are directed to specific cognitive domains to personalize according to each individual. Each of the six cognitive domains shown in Figure 2 are explained below (Harvey, 2019):

1. Complex attention: abilities to choose what to pay attention to and to focus on multiple things simultaneously
   • Selective attention: ability to attend to relevant information and ignore irrelevant information
2. Executive function: high-level cognitive abilities to coordinate other cognitive abilities and perform tasks such as problem-solving and decision-making
   • Working memory: ability to temporarily store information, such as remembering digits of a phone number
3. Perceptual-motor function: abilities to interact with the environment through our senses and body movements
4. Language: abilities allowing for communication
5. Learning and memory: abilities supporting the recording of information and retrieving it
   • Free/cued recall: ability to retrieve information from memory without/with cues or prompts
   • Recognition memory: ability to recognize a familiar item or person
   • Semantic and autobiographical long-term memory: ability to store verbal information and personal history in long-term
   • Implicit learning: learning without conscious awareness
   •  Social cognition: process information between people to explain and predict the behavior of others and self
6. Social cognition: process information between people to explain and predict the behavior of others and self
   • Theory of mind: ability to understand others’ mental state
   • Insight: ability to reinterpret a situation to produce a new, nonobvious interpretation (e.g. understanding a joke or metaphor)

Box 2

Cognitive Impairments

Below are the three main cognitive impairments studied in the implementation of CCIs in order of progression in cognitive decline.

1. Subjective Cognitive Decline (SCD): Those with SCD perceive themselves to have cognitive decline although they have normal clinical cognitive abilities. SCD is one of the earliest noticeable symptoms for dementia, and early identification enables the alleviation of the future impact of cognitive impairments and to slow progression in cognitive decline. Having SCD leads to a greater risk to develop MCI, Alzheimer’s disease, or another neurocognitive disorder (Smart et al., 2017).
2. 2)  Mild-Cognitive Impairments (MCI): MCI is the intermediate stage between cognitive changes from normal aging to dementia. The condition may include problems with memory, language, or judgment, but does not interfere with daily living activities, fundamental to living independently. MCI may increase the risk of dementia caused by Alzheimer’s disease or other brain disorders (Mild Cognitive Impairment (MCI), 2024).
3. 3)  Dementia: Dementia, also known as major neurocognitive disorder, refers to a group of symptoms causing a significant decline in memory, thinking, and social abilities–interfering with daily life. Several diseases can cause dementia, and the most common cause for dementia in older adults is Alzheimer’s disease. Dementia can cause tragic effects in a person, leading to not only cognitive decline, but a loss of self (Dementia, 2024).

Treatment

“Time is brain,” said David Weisman, director of clinical research at Abington Neurological Associates in Abington, P.a., and current doctor of Dershem. First and foremost, early diagnosis is key to the effectiveness of interventions. Early diagnosis can delay progression and also lead to discovering a disorder or disease causing cognitive decline.

CCI extends another treatment option to patients, where pharmacological treatment may not have helped. There is mixed evidence for the positive impact of pharmacological treatments treating cognitive impairments, and taking these medications may also produce dangerous side effects (Ellison, 2024). In fact for those with SCD, CCI is one of their only options to treat their condition, as it is difficult to pinpoint a target using pharmacological treatments.

Since CCI works best when the cognitive impairment is diagnosed early, people with SCD and MCI can reap the most benefits from CCI. Those with SCD have relatively preserved cognitive function at present, which allows for a greater likelihood of benefiting from CCI before significant cognitive difficulties. At this early stage in cognitive decline, a web-based CT on a PC reported significant benefits on memory.

Adding to the benefits of CCI, CCI produced a significant effect for people with MCI immediately after the intervention, improving attention and executive functioning (see Figure 3 and 1 and 2 of Box 2). Ranging from non-immersive VR to AR, CCI has shown numerous effective applications to those with MCI. Computerized CT programs on a PC showed benefit to cognition in those with MCI, and VR-based cognitive interventions have improved attention and processing speed. One study has shown significant improvements in patients with MCI even 6 months after the intervention in memory and working memory (Zuschnegg et al., 2023).

Support in Daily Life

In addition to preserving or improving cognitive abilities, CCIs support those with cognitive impairments in everyday situations. One common challenge faced by those with cognitive impairments is wayfinding. CCI has developed to support the cognitive domains executive function and learning and memory. AR glasses provide a solution for navigation by displaying instructions on the lenses. While there may be concerns as to how cognitive impairments may influence the ability to follow the displayed directions, those with MCI have been able to understand and follow along.

Another difficulty as the aging population face cognitive decline comes remembering objects in a room and the location of their items. A handheld AR application annotates the environment to help identify objects, which can replace caregivers labeling objects or drawers with Post-it Notes (see Figure 4). One handheld AR device not only helps to identify objects and other people, but also tracks current location and medication intake to allow their caregivers to ensure their safety.

CCI can be employed to assist the elderly with cognitive impairments in everyday tasks and situations. Through CR, AR glasses are capable of aiding in tasks such as cooking, including elderly with dementia. AR glasses paired with a BMI can also bring improvement in the interactive abilities of the aging population. In addition, AR has seen positive impacts in complex tasks. Driving employs multiple cognitive domains, and cognitive impairments can significantly affect driving capabilities. With an AR windshield screen displaying navigation cues and warnings, those with MCI made fewer navigation errors and had improved selective attention (see 1a from Box 1; Blattgerste et al., 2019). CCI thus provides benefits not just in treating cognitive decline, but also supporting the aging population with cognitive impairments in various situations.

Combinations of Interventions

While CCI has positive impacts for cognitive impairments on its own, it is possible to boost the effects of CCI by combining physical training with CT. A analysis of 18 physical training studies with the aging population has shown that physical exercise has a “robust” effect on cognition in the elderly, therefore combining the added effects of each type of physical and cognitive training can prove more beneficial to cognitive functions in the elderly (Zokaei et al., 2017).

With a more severe neurocognitive disorder, interventions have a less to moderate effect. There can be limited capacity for improvements from training. One study examined the efficacy of aerobic training and exergaming, combining exercise with video games or a virtual environment. Exergaming employs a non-immersive virtual environment and CS, requiring mental flexibility and cognitive processes employing multiple cognitive domains such as problem-solving.

The study used CT in a relatively short 12-week training program adjusting the level of difficulty to each elderly’s progression in cognitive decline in dementia. After the program, it was concluded that the non-immersive VR improved psychomotor speed, which can be significant since it contributes to predicting cognitive decline. Yet, the program had limited effect on cognitive domains, as for those with dementia, it is more difficult to improve cognition in the latter stages of cognitive decline (Karssemeijer et al., 2019).

As CCI and its applications continue to be researched, there should be more studies that focus on the long-term effectiveness of the interventions. This emerging field of CCI would grow as applications for the aging population in home settings are developed.

Conclusion

In conclusion, CCI offers resources to enhance cognition and address cognitive impairments in novel ways. Their abilities to immerse users and utilize the practices of CT, CR, and CS provide ways to support a healthy quality of life for the aging population. CCI has proven to be especially effective in early intervention for those with MCI and SCD. For those with dementia, the effectiveness of CCI decreases, but a combination of CCI with physical training makes the most out of their individual advantages to improve cognitive abilities.

CCI and their implementations for the aging population continue to develop. Ultimately, CCI has the potential to transform the approaches to assisting the aging population through personalizing the intervention to specific cognitive domains and supporting the autonomy of the aging population.

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