A Tablet-Based Volunteer-Mediated Intervention for Cognitively Impaired Older People: A Pretest

Abstract

Purpose:

This study evaluated the potential effectiveness of a tablet-based, volunteer-led intervention (Lok Chi In-home Training) for cognitively impaired older people in improving cognitive and emotional health.

Method:

A one-group pretest and posttest design was adopted, involving 57 community-dwelling older people with cognitive impairments (Montreal Cognitive Score between 13 and 22, without neuropsychiatric behavioral problem). Trained volunteers performed eight in-home training sessions using a tablet to facilitate. Outcome measures include cognitive function, depression, activity of daily living, and instrumental activity of daily living.

Results:

A paired sample t test indicated that after receiving Lok Chi In-home Training, participants showed significantly large improvements on cognitive ability, moderate improvements on depression, and small improvements on instrumental activity of daily living.

Conclusions:

This study demonstrated the feasibility and potential benefits of Lok Chi intervention for improving cognition and emotion.

Keywords

cognitive impairment depression tablet-based intervention volunteer one-group pretest–posttest design

Hong Kong is challenged by a rapidly aging population. The number of people aged 65 and older has more than doubled over the past three decades, from 8% in 1986 to 17.1% in 2018 (Hong Kong Census and Statistics Department, 2018). It is projected that in 2039, there will be nearly 3 million people aged 60 and above in Hong Kong. This increase in the aging population has resulted in an increase in the number of people with noncommunicable diseases including cognitive impairment and dementia. The prevalence of dementia doubles with every 5-year increase in age after 65 (Hong Kong Food and Health Bureau, 2018).

Cognitive impairment and depression are the two predominant mental health issues in older people that significantly undermine their quality of life and produce emotional and financial burdens on their caregivers (Banerjee et al., 2009; Potter & Steffens, 2007; Yasamy, Dua, Harper, & Saxena, 2013). Dementia is irreversible and results in dependency on continued support services (Livingston et al., 2017). Data show that 91.9% of older Hong Kong people are living in a domestic household (Hong Kong Census and Statistics Department, 2018), and the primary caregivers are their family members. It is a great challenge for these caregivers to care for older adults when they are fragile, especially when they are suffering from mental and/or cognitive impairment.

Dementia management often requires a wide range of interventions to maximize the benefits of independence and quality of life (Gauthier et al., 2006; Livingston et al., 2017). Mild cognitive impairment (MCI) is defined as a condition with subjective cognitive decline but does not interfere notably with activities of daily life, and it is regarded as a precursor of overt dementia (Gauthier et al., 2006). It is an important condition to identify and implement intervention to delay or prevent progression to dementia (Petersen, 2016). The therapeutic effects of pharmaceutical treatment on cognitive impairment are still uncertain, whereas several systematic reviews and meta-analyses have reported that nonpharmaceutical cognitive interventions (including cognitive simulation, cognitive training, and cognitive rehabilitation) are encouraging (Li et al., 2011; Liang et al., 2019; Livingston et al., 2017; Reijnders, van Heugten, & van Boxtel, 2013). Other modifiable lifestyle factors such as regular physical activities (Baker et al., 2010; Sungkarat, Boripuntakul, Chattipakorn, Watcharasaksilp, & Lord, 2017; Vaughan et al., 2014), maintaining social engagement (Hughes, Flatt, Fu, Chang, & Ganguli, 2013; Pitkala, Routasalo, Kautiainen, Sintonen, & Tilvis, 2011), and addressing diabetes and diet (Cooper, Sommerlad, Lyketsos, & Livingston, 2015) have the potential to reduce the risk of cognitive decline and delay clinical progression from MCI to dementia.

However, conventional cognitive interventions are usually group-based, conducted by trained professionals, and/or carried out in nursing homes/community centers (Martin, Clare, Altgassen, Cameron, & Zehnder, 2011; Woods, Aguirre, Spector, & Orrell, 2012). Therefore, we have developed a theory-driven, home-based cognitive intervention to provide psychological care and cognitive training to older people with signs of cognitive and/or mental impairment. The comprehensive intervention, titled Lok Chi In-home Training (Lok Chi), is based on Body–Mind–Spirit (BMS) theory, reminiscence therapy, and reality orientation, and it contains eight standardized training sessions that are executed by trained volunteers (Lo & Lou, 2015).

The BMS model addresses the importance of considering a person as a whole and finds that personal well-being is influenced by an individual’s cognitive, behavioral, emotional, physical, and spiritual dimensions. The BMS intervention approach has demonstrated its effectiveness in improving physical and psychosocial outcomes among cancer patients (Chan et al., 2006), people with dementia (Chow, Chow, Shinsei, & Chan, 2017; Young, Ng, & Cheng, 2017), and community-dwelling older adults (Lee, Yoon, Lee, Yoon, & Chang, 2012). In addition, the positive effects of reminiscence therapy on quality of life, cognition, communication, and mood of people with dementia and depression have been reported by several randomized control studies (Cotelli, Manenti, & Zanetti, 2012; Subramaniam & Woods, 2012; Woods, O’Philbin, Farrell, Spector, & Orrell, 2018). Reality orientation also demonstrates positive effects on cognition and behavior in dementia patients (Baines, Saxby, & Ehlert, 1987; Spector, Woods, Orrell, & Davies, 2000; Woods et al., 2012).

Although BMS model, reminiscence therapy, and reality orientation have been shown effective in various settings, limited recourses, in particular among health-care professionals, social workers, and occupational therapist and nurses, constrain the implementation of community-based intervention for cognitively impaired people. In addition, traveling or joining group intervention is not the optimal option for older people with dementia living alone or with very limited family support. Considering the growing dementia population, a new intervention delivery model that is effective, accessible, and affordable is desired.

In view of the rise of technology, applying innovative technology in cognitive training and care has received much attention in recent years (Des Roches, Balachandran, Ascenso, Tripodis, & Kiran, 2015; Sun, Rau, Li, Owen, & Thimbleby, 2016). A meta-analysis by García-Casal et al. (2017) showed that computer-based cognitive intervention has greater treatment effects in improving cognition and emotion in people with dementia compared with noncomputer-based traditional intervention. With the wide penetration of information technology into our daily lives, computerized intervention offers an opportunity to provide standardized, accessible, cost-effective, and continued cognitive care for older people (Kueider, Parisi, Gross, & Rebok, 2012). Therefore, we transformed the Lok Chi In-home training protocols into a tablet-based application, which makes a unique contribution through use of technology, volunteers, and provision of home-based services for community-dwelling people.

The objective of the current study is to evaluate the effectiveness of the tablet application of Lok Chi In-home Training on health outcomes among community-dwelling older adults with signs of cognitive impairment.

Overview of the Lok Chi In-Home Training

The current Lok Chi In-home Training program aims to provide holistic care and cognitive training to older adults with signs of cognitive impairment and/or depressive mood. The Lok Chi contains eight home-based training sessions and adopts principles of the BMS model, reminiscence therapy, and reality orientation (Chan, Chan, & Chan, 2014; Chan, Ho, & Chow, 2002).

Though the traditional Lok Chi invervention is effective in improving cognition, it is time-consuming, requiring planning and organization and variation in volunteers’ capacities, and volunteers need to bring materials such as books and media players during each training session. By using the tablet-based Lok Chi application, all the activities to be introduced to the participants were standardized and structured in sequence. For each training session, the sequence of activities begins with a warm-up exercise (10-hand movement), relaxation training (breathing method), and/or meditation training. Then, activities aimed at enhancing cognitive abilities are carried out, including games, quizes that promote attention, reminiscence that uses triggers to stimulate past memories, and reality orientation. Emotion- and spirit-targeting activities such as card matching games, stories, and experience sharing followed. Song sharing and motivational quotes were used to promote positive thinking. Finally, volunteers would review the session by inviting the participants to assess their emotional status before leaving (emotional thermometer) and reminding the participants of the date and time for their next visit. The materials were presented on a touch-screen interface that provided multisensory stimulation and provoked converstaion between volunteer and participants. Please see Figure 1 for an example of a Lok Chi training session.

Figure 1.

An example of activities in one training session.

The training intervention was provided by volunteers with the passion to serve those who were living in the same community. The volunteers were required to attend a four-session, standardized training for capacity building delivered by registered social workers and dementia care experts. The training included (1) knowledge of physical and mental health issues among older people, (2) communication skills with older people, (3) session-by-session description with illustrations on delivering of intervention using a tablet, and (4) practices on managing a tablet including power on/off, error fix, and so on. The training also imbedded content to nurture commitment and passion for serving seniors in the community. Volunteers who completed the entire training session were invited to join the program.

Trained volunteers worked in pairs to provide intervention to the participants using a tablet. The matching between volunteers and participants was carefully achieved by social workers reviewing the portfolios of both participants and volunteers. Support from social workers for volunteers and participants was continuous during the entire course of the program to empower volunteers and ensure quality of service delivery.

The primary research question addressed in this study is whether there would be improvement in terms of health outcomes (cognition and cognitive subdomain, depression, activities of daily life, and instrumental of daily living) after receiving the Lok Chi In-home Training among community-dwelling cognitively impaired older people. Additionally, we would like to investigate the users’ satisfaction with the intervention they received. This study has the following hypotheses:

Hypothesis 1: There will be a statistically significant pretest to posttest mean change in four main health outcomes (cognition and cognitive subdomains, depression, activities of daily life, and instrumental of daily living) after receiving Lok Chi intervention.

Hypothesis 2a: The change in pretest to posttest scores on cognition will not be significantly related to sample demographics.

Hypothesis 2b: The change in pretest to posttest scores on cognition will be significantly higher for those who have lower baseline scores in four main health outcomes.

Hypothesis 3: The participants will be satisfactory toward the Lok Chi intervention in the posttest.

Method

Participants and Inclusion Criteria

Participants were community-dwelling adults aged over 60, living in a public housing estate in Hong Kong. The cognitive functioning level of the older adults was screened using the Cantonese Chinese version of Montreal Cognitive Assessment (MoCA) administrated by trained social workers. The MoCA is a valid, reliable, and feasible assessment tool for detecting MCI and dementia among older Chinese adults (Chu, Ng, Law, Lee, & Kwan, 2015; Yeung, Wong, Chan, Leung, & Yung, 2014). The full score of MoCA is 30, with higher scores indicating better cognitive capability. For identification of MCI, the optimal cutoff score was below 22/23 (for people with no more than 6 years of education, one extra point is added; Wong et al., 2009; Yeung et al., 2014). The MoCA is also a useful tool to differentiate between mild dementia and moderate dementia, whereby a cutoff score lower than13/14 after the adjustment of education indicates moderate dementia (You et al., 2011). In the current study, a MoCA score between 13 and 22, indicative of MCI and mild dementia, was adopted for participant screening. We assume interventions may offer the possibility of maintaining or improving cognitive function and perhaps delay progression from MCI to clinical dementia among these high-risk individuals. In addition, all participants did not have neuropsychiatric behavioral problem.

Measures

The health outcomes were assessed by social workers at baseline (4–6 weeks before the intervention) and after completion of the intervention at the home of the participants.

Cognitive functioning

MoCA was used for cognitive screening because of its higher sensitivity and specificity in detecting MCI and dementia comparing with other tools (Chu et al., 2015; Nasreddine et al., 2005). MoCA is an 8-item measure with a maximum score of 30. A score below 22/23 with correction in education suggests MCI, while score below 13/14 indicates mild dementia in Hong Kong population.

To measure the changes in cognitive functioning of the participants, the Hong Kong MoCA 5-Minute Protocol (MoCA 5-Min) was used in the pretest and posttest. MoCA 5-Min performed equally well as MoCA in cognitive screening but is less time-consuming. It includes four subtests examining the cognitive subdomains of attention, verbal learning and memory, executive functions/language, and orientation. The total score is calculated by summing up the item scores and ranging between 0 and 30, with higher scores indicating better cognitive capability. The validity of the MoCA 5-Min has been reported in the Hong Kong population (Wong et al., 2015). Participants were assessed with the MoCA 5-Min 4–6 weeks prior to the intervention in the pretest and after the intervention in the posttest.

Depressive symptoms

The 15-item Geriatric Depression Scale (GDS) was used as one of the primary measurements for emotional health changes in the pre- and post-tests (Sheikh & Yesavage, 1986). The items were scored on a dichotomous scale, with 0 indicating the absence of the described situation and 1 indicating the presence of the described situation. Higher scale scores suggest more depressive symptoms, the theoretical range being 0–15. The Chinese version has been validated among older Chinese people (Chan, 1996; Liu, Lu, Yu, & Yang, 1998).

Functional health

The Barthel Index of Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) were adopted to assess the functional performance of all participants before and after receiving the intervention. The Barthel Index of ADL measures the level of dependency in activities of daily living among older people in the past 3 months (Mahoney & Barthel, 1965). It contains 10 daily living activities (feeding, grooming, bathing, dressing, bowel and bladder care, toilet use, mobility, ambulation, transfers, and stair climbing) using two to four response options ranging from 0 to a maximum of 1, 2, or 3. The theoretical range of the total scale score was 0–20, with a higher score indicating higher independence.

The IADL measure adopted here was modified from the Lawton IADL Scale (Lawton & Brody, 1969). It was a 9-item scale used to assess the level of independency in more complex daily living activities among community-dwelling older people. In each item, the respondent was asked to rate on a 3-point scale (0 = totally independent, 1 = need some help in any task; either verbal or physical help, 2 = unable to do, dependent) to what extent he/she has needed assistance in performing specific daily living tasks in the past week and earlier. The total score of IADL ranges from 0 to 18. Higher scores mean lower level of independence in the instrumental activities of daily living.

Satisfaction with the service

In the posttest, the participants who completed all the sessions were asked to indicate their satisfaction with each activity carried out during the intervention. Responses were based on a 5-point Likert-type scale, from 0 = do not like at all to 4 = like very much. In addition, eight questions rated on a 10-point Likert-type scale with 1 = least agree to 10 = most agree were used to assess overall satisfaction with the intervention as well as with volunteers, usefulness of the activities, and long-term planning regarding the program such as the possibility of referring the service to other people and continuing to use the program.

Procedure

A single-group, pretest–posttest design was employed to evaluate the effectiveness of the Lok Chi intervention. Eligible participants were recruited and introduced to the program by social workers from the public housing estate. After obtaining written consent from the eligible participants, the social worker administrated a pre-assessment to obtain baseline health information at the home of participants. Prior to intervention, social workers reviewed the portfolio of both participants and trained volunteers, then paired them up, and scheduled time for delivering the tablet-based in-home service. Accommodating the mutual availability of both participants and volunteer was time-consuming because of unexpected circumstances like health problems and family concerns. The entire period of the intervention was around 2 months (eight weekly training sessions). Once the volunteers reported to the social workers that they had finished the service, social workers went to the living place of the participants to conduct the posttest assessment. Ethical approval was obtained from the Human Research Ethics Committee of the University of Hong Kong before the commencement of the study.

Data Analysis

Descriptive statistics (frequencies, proportion distributions, mean, and standard deviation) were used to summarize the data. Internal consistency of the measures was assessed using Cronbach’s α. Paired t tests were conducted to compare the health outcomes before and after the intervention. Cohen’s d were calculated to measure the effect size for paired samples with 0.20 as small, 0.50 as medium, and 0.80 as large effects, respectively. The variables related to the improvement of the outcome measures were identified by using one-way analysis of variance for the categorical variables and Spearman’s correlation analysis for the continuous variables. For all of the analyses, two-tailed p values of <.05 indicate statistical significance. Data were analyzed using SPSS 24.0.

Results

A total of 63 seniors were recruited from nine public rental housing estates located in Hong Kong Island, Kowloon, and New Territory in Hong Kong. However, two of them did not meet the inclusion criteria (MoCA score between 13 and 22) and were excluded. The remaining 61 older adults agreed to join the program and started to receive the weekly training provided by the trained volunteers. Among them, four participants withdrew from the program. A total of 57 participants received the entire eight-session training and completed the posttest. The effectiveness evaluation was only done in the cases in which the services, as well the completed pre- and post-tests (n = 57), were completed. Figure 2 illustrates the flow of participants through each stage of the study.

Figure 2.

Flow chart of participations through the study.

Characteristics of Participants

Table 1 provides the demographics data of the participants. The average age of the participants was 86.68 years (SD = 5.40). The majority of them were females (77.2%, n = 44), walking unsteadily (49.1%, n = 28), and receiving services from Day Care Centre and Enhanced Home and Community Care. Among the participants, 29.8% (n = 17) were living with family members, 29.8% (n = 17) were living alone, and 17.5% (n = 8) were living with spouse only.

Table 1.

Demographic Characteristics of Participants in the Pretest–Posttest Study.

Characteristics	n (%)
Gender
Male	13 (22.8)
Female	44 (77.2)
Living with
Family members	17 (29.8)
Alone	17 (29.8)
Spouse only	8 (17.5)
Family members and domestic helpers	10 (14.0)
Domestic helper only	4 (7.0)
Spouse and domestic helper	1 (1.8)
Mobility
Act freely	21 (36.8)
Walk unsteadily	28 (49.1)
Need assistance	6 (10.5)
Rely on others	2 (3.5)
Levels of supporting networks
Community services	4 (7.0)
Care services	30 (52.6)
Indoor call services	16 (28.1)
Informal supports from neighbor/friends/family/religion	7 (12.3)

The participants had a mean MoCA 5-Min score of 17.04 (SD = 3.15) and a mean GDS score of 3.44 (SD = 3.43), with 13.3% (n = 9) assessed as indicating clinical depression (GDS score ≥ 8).

Hypothesis 1: Changes in Health Outcome Measures

Table 2 summarizes the changes in four major health outcomes before and after receiving the tablet Lok Chi In-home Training. The Cronbach’s α value for all measures were above 0.60, indicating adequate internal consistency. The results of paired t tests indicate that after receiving the Lok Chi intervention, the participants showed a significant improvement in MoCA 5-Min scores, from 17.04 (SD = 3.15) to 19.85 (SD = 4.32; paired t = −0.679, p < .001; 95% CI [−3.744, −1.888]), with a strong effect size (Cohen’s d = −0.805). In regard to specific cognitive domains, it was found that the changes in scores of attention (paired t = −5.134, p < .001; 95% CI [−1.122, −0.492]), Cohen’s d = −0.680), delayed memory (paired t = −3.953, p < .001; 95% CI [−1.850, −0.606]), Cohen’s d = −0.524), and verbal fluency (paired t = −3.529; p = .001; 95% CI [−1.815, −0.501], Cohen’s d = −0.467) were significant with moderate effect size. However, the changes in orientation scores were not statistically significant.

Table 2.

Comparison of Pre- and Post-Service Tests.

Variables	Pretest	Posttest	Cronbach’s α	Paired t (p)	95% CI of the change score	Cohen’s d
Variables	M (SD)	M (SD)	Cronbach’s α	Paired t (p)	95% CI of the change score	Cohen’s d
ADL	18.63 (2.51)	18.49 (2.31)	.83	0.789 (.433)	[−0.216, 0.497]	.105
IADL	13.91 (3.65)	13.28 (3.82)	.89	2.278 (.027)	[0.076, 1.187]	.302
GDS	3.44 (3.43)	2.33 (2.82)	.60	4.234 (.000)	[0.583, 1.628]	.561
MoCA 5-Min	17.04 (3.15)	19.85 (4.32)	.61	−6.079 (.000)	[−3.744, −1.888]	−.805
Attention	3.54 (1.20)	4.35 (1.06)		−5.134 (.000)	[−1.122, −0.492]	−.680
Delayed memory	7.03 (1.74)	8.26 (2.12)		−3.953 (.000)	−1.850, −0.606	−.524
Verbal fluency	10.28 (3.33)	11.44 (3.25)		−3.529 (.001)	[−1.815, −0.501]	−.467
Orientation	5.83 (1.24)	6.00 (1.31)		−1.322 (.192)	[−0.441, 0.091]	−.175

Note. n = 57. ADL = Activity of daily living; IADL = Instrumental activity of daily living; GDS = Geriatric Depression Scale; MoCA 5-Min = Hong Kong Montreal Cognitive Assessment 5-Minute Protocol; SD = Standard deviation.

There was also a significant reduction in depression, the GDS score dropping from 3.44 (SD = 3.43) to 2.33 (SD = 2.82; paired t = 4.234, p < .001; CI [0.583, 1.628]) with moderate effect (Cohen’s d = 0.561). Dependent level in IADL was significantly decreased from 13.91 (SD = 3.65) to 13.28 (SD = 3.82; paired t = 2.278, p = .027; CI [0.076, 1.187]) with a small effect size (Cohen’s d = 0.302). However, the participants did not show any significant change in ADL scores.

Hypotheses 2 and 3: Variables Related to Change in MoCA 5-Min Score

Table 3 shows the variables related to the improvement in MoCA 5-Min score (ΔMoCA 5-Min). The results reveal that the ΔMoCA 5-Min score was not varied among any of the demographic variables including age, gender, living arrangement, mobility, and level of supporting networks. Rather, the ΔMoCA 5-Min score was positively related to baseline ADL score (ρ = 0.203, p = .05) and negatively related to GDS score (ρ = −0.268, p = .006).

Table 3.

Correlation Between Demographics and Outcome Variables.

Variables	ΔMoCA 5-Min
Variables	F	p value
Gender	−0.009	.993
Living arrangement	0.441	.778
Mobility	1.198	.319
Level of supporting networks	0.459	.712
	ρ	p value
Age	−0.102	.281
ADL	0.203	.050*
IADL	0.074	.444
MoCA 5-min	−0.120	.204
GDS	−0.268	.006**
ΔGDS	−0.108	.278

Notes. n = 57. F = One-way analysis of variance; ρ = Spearman’s rho; ADL = Activity of daily living; IADL = Instrumental activity of daily living; GDS = Geriatric Depression Scale; MoCA 5-Min = HK Montreal Cognitive Assessment 5-Minute Protocol; ΔGDS = Changes in GDS from pretest to posttest; ΔMoCA 5-Min = Changes in MoCA 5-Min from pretest to posttest.

*Significant at p < .05. **Significant at p < .01.

Hypothesis 4: Satisfaction With the Service

Participants were asked in the posttest to rate their level of satisfaction with the service. Table 4 shows that participants were satisfied with all the activities using a 0-4 point scale. Satisfaction with volunteers and overall satisfaction scores were both above 8.71 of 10. Participants also found the service beneficial to their body–mind–spiritual well-being and would like to continue to use the service and refer it to others.

Table 4.

Users’ Satisfaction on the Service.

Variables	M	SD
User satisfaction toward each activity
Warm-up games	3.24	0.67
Breathing method	2.89	0.63
Meditation training	2.43	0.73
Emotional activities	2.75	0.71
Cognitive activities	2.98	0.54
Positive thinking	2.98	0.84
Emotional thermometer	2.76	0.64
Overall satisfaction	9.13	1.07
Satisfaction toward volunteers	8.71	1.24
Users perceived usefulness
Physical and mental activities make you feel filled with vitality	7.82	1.73
Physical and mental activities make you feel relaxed	7.50	1.65
Mind training activity can improve your memory performance	6.96	1.78
Training activity can enhance your daily life abilities	6.75	1.83
Long-term planning toward the program
Willingness to join the service again	7.73	2.53
Willingness to recommend the service to your friends or neighbors	6.71	2.15

Note. n = 57.

Discussion and Applications to Practice

The primary purpose of the study was to assess the potential effectiveness of a tablet-based, volunteer-mediated intervention for older people with cognitive impairment. The findings show that after completion of an eight-session Lok Chi intervention, participants showed significant change over time in health outcome measures. As compared to baseline, cognitive ability was improved based on the results of the MoCA 5-Min with large effect size. In particular, the most significant outcome benefits were found in attention, verbal fluency, and delayed memory. Also, participants showed significant mitigation of depressive symptoms as measured by the GDS with moderate effect size after receiving the intervention. Instrumental activity of daily life of participants also improved significantly.

Compared with other conventional or computerized cognitive interventions, the Lok Chi intervention is encouraging in improving cognitive functioning and depression (García-Casal et al., 2017; Kueider et al., 2012; Li et al., 2011; Reijnders et al., 2013). These results support the feasibility and potential effectiveness of the Lok Chi intervention that innovatively uses tech-supported, multimedia channels to facilitate active engagement of both participants and volunteers and integrates volunteer support with standardized intervention protocol. The change in ADL after intervention was not significant, which might be due to that for most of the people with MCI and mild dementia, their activities of daily life are largely intact or minimally impaired (Cooper et al., 2015; Gauthier et al., 2006).

Tablet-based cognitive intervention has many advantages. Computerized cognitive training intervention has been proved to be comparable to or better than traditional, paper-and-pencil health outcomes for older people with dementia (García-Casal et al., 2017; Livingston et al., 2017). With the utilization of computerized tablets and App, the intervention protocol that shapes activity sequences is standardized, interactive, and easy for volunteers to implement (Chan & Holosko, 2016; Kueider et al., 2012). The current Lok Chi intervention offers a range of enjoyable activities providing stimulation for concentration and memory. For example, with the tablet, the participants can follow the songs in App and repeat the songs they like. The tablet itself provides visual, auditory, and tactile stimuli, raising the participants’ interest and awareness levels to enhance their comprehensive well-being. Findings revealed participants were positive toward tablet use and perceived it as useful. The tablets are portable and combine features of many materials used previously such as books, posters, and media players. By employing tablet-based intervention, implementation and administration costs could be saved. It has high availability and accessibility as well the ability to reach home-bound older people.

This study has several strengths. The conventional Lok Chi intervention was implemented and tested before it was transformed into a tablet-based version. The Lok Chi intervention protocol is theory-based with local and realist content. It adopted the concept of whole-person and BMS integrative health using a multilevel strategy. Concerning the body aspect, relaxation and breathing exercises were embedded to promote positive body feelings that would in turn affect participants’ emotions (Chan et al., 2014). As for the mind aspect, volunteers played and shared inspiring stories, songs, and memories with participants to encourage their positive thinking (Cheung et al., 2019). In regard to the feeling aspect, volunteers played interactive games with the participants to stimulate moments of happiness (Chow et al., 2017). The meditation exercise helped the participants restore peacefulness. Lok Chi intervention greatly improved memory and mood, consistent with previous studies adopting this Eastern holistic care approach (Cheung et al., 2019; Chow et al., 2017; Young et al., 2017).

Elements of reminiscence therapy and reality orientation were integrated into the Lok Chi tablet and delivered in the form of story sharing, quotation sharing, positive song sharing, and singing, which was successful in encouraging positive thinking. The design of the cognitive games, such as card and table block games that were composed of training on multiple cognitive domains in a relaxing way, drew the participants’ interest in joining the service and kept up their interest in the exercise (Cotelli et al., 2012; Subramaniam & Woods, 2012). Retelling of Hong Kong history was also promising in training their cognitive abilities in the domain of memory. The feedback concerning satisfaction indicated that the participants enjoyed the games and that the games were attractive to them.

The implementation of Lok Chi intervention is carried out by nonprofessionals, that is, volunteers living in the community. Involving trained volunteers in provision of dementia care services might be promising and of considerable importance in the community. In recent years, there has been increasing interest in Western countries in volunteer-facilitated, activity-based training programs for people with cognitive impairments (Han, Brown, & Richardson, 2018; Söderhamn, Landmark, Aasgaard, Eide, & Söderhamn, 2012; Van der Ploeg, Walker, & O’Connor, 2014). Chung (2009) found that the reminiscence program facilitated by volunteers greatly improved the quality of life and mood of dementia patients.

Involving volunteers in cognitive training might also be challenging. Previous study has pinpointed the importance of structured training, demonstrations at the outset, and ongoing support for volunteers (Han et al., 2018; Söderhamn et al., 2012; Van der Ploeg et al., 2014). In the current study, volunteers completed a structured, capability building training, and the trained volunteers and participants were carefully matched by social workers. The social worker also accompanied the volunteers during the first one or two home visits to ensure the success of rapport building. Advice from social workers was offered before the home visit, and debriefing sessions were held after the visit when necessary. The continuous support from social workers further empowered and motivated the volunteers: mobilizing volunteers is essential and desirable. Our results warrant a proper cognitive intervention for community-dwelling, cognitively impaired older people. The positive changes in mental health and cognitive ability among participants demonstrate that this approach is feasible and practical. These findings are promising to social worker practice and open new opportunities for extending and adjusting the conventional cognitive intervention delivery model.

Technology is shaping social work practice. There has been an emergence of technology-based cognitive interventnions such as video games and computer-assisted training. However, a recent Cochrane review found contradictory results regarding computerized cognitive training for preventing dementia in people with MCI (Gates et al., 2019). For a cognitive intervention to be useful, researches have been increasingly focusing on the generalization of benefits from trained cognitive tasks to other untrained cognitive activities, global cognitive funtion, then independent functioning in daily activities. The Cochrane review found that computerized cognitive training appeared to have potential effects on improving global cognition, cognitive subdomains of episodic memory and working memory, but no evidence supported the effects on functional performance and depression. In several review studies, the effects of computerized cognitive intervention on cognition (overall cognition, attention, and memory) and depression showed the most consistent results, but the effects on IADL and ADL have not been observed (Chandler, Parks, Marsiske, Rotblatt, & Smith, 2016; Coyle, Traynor, & Solowij, 2015; Hill et al., 2016). The result of our research is in line with these findings. Improvements in cognition might be successfully transferred to psychological improvements (reducing depression) and IADL, but might not to ADL. This is expected because most of the computerized interventions are remediation-based rather than compenstaion-based; remediation-based intervention usually results in larger impacts on cognitive outcomes rather than everyday functioning outcomes (Chandler et al., 2016).

The Lok Chi In-home Training is promising because it adopts principles from validated theories with localized content, and the tablet version is introduced after implementation of conventional practices. Another concern regarding implementation of technology in cognitive care is the reduction of social contact (Livingston et al., 2017). The tablet-based Lok Chi intervention is led by volunteers, and the tablet itself is used to promote social interactions between volunteer and participants. Participants do not need to be technologically savvy to benefit from the training.

Given the accessible, safe, and practical advantages of technology-assisted intervention, the utilization of tablets and App in service delivery is recommended. We think it is crucial that the computerized intervention be theory-driven and evidence-based. This tablet-based intervention could also be used by service providers and caregivers in the community or institutions without replacing or reducing human contact. Moreover, volunteer-supported, home-based intervention is considered to be an empowerment approach for volunteers, participants, and social service teams. In this study, volunteers are from the same living community as the participants. It is suggested that volunteers from the younger generation could be recruited as well. Capacity building and continuous support from social workers and health-care professionals are essential in this intervention delivery model.

It is found that participants with higher ADL and less depressive symptoms (higher GDS score) achieved greater cognitive improvements. These people seem to be most likely to benefit from Lok Chi intervention. Therefore, for older adults with MCI and early dementia without onset of depressive symptoms nor impaired daily functioning would be the primary targets for this intervention.

There are several limitations to the study. First, the research is based on a self-controlled pre- and post-test design. The absence of a control group and randomization left us unable to attribute the observed effects specifically to the tablet-based intervention. More rigorous study design, such as a randomized control trial, should be conducted to evaluate the effectiveness of the intervention. Additionally, given the degenerative nature of dementia, a longitudinal design with more waves of posttest data should be used to track the long-term effects of the intervention and whether these may reduce conversion to dementia. Second, in this study, the intervention is facilitated by volunteers. Further study may want to explore the motivation, competency, and benefits of the volunteering experience. Third, although older adults are increasingly using information and communication technologies, the usage rate is still low. Their acceptance and long-term adherence to tablet-based intervention may be limited. Future study should investigate this aspect of computerized intervention.

Footnotes

Acknowledgments

The authors wish to acknowledge invaluable contributions of the volunteer team members of the service. Special thanks to Ms. Wong Wing Lam, Patsy, managers of the rental housing estates for their support; Miss Fu Yin Qi, Joyce of the research team for her contributions to research activities. Last but not the least, we would like to thank all dementia older adults and their families for their participation.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study is funded by the Hong Kong Housing Society.

ORCID iD

Ke Chen

Vivian Wei Qun Lou

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A Tablet-Based Volunteer-Mediated Intervention for Cognitively Impaired Older People: A Pretest–Posttest

Abstract

Purpose:

Method:

Results:

Conclusions:

Keywords

Overview of the Lok Chi In-Home Training

Method

Participants and Inclusion Criteria

Measures

Cognitive functioning

Depressive symptoms

Functional health

Satisfaction with the service

Procedure

Data Analysis

Results

Characteristics of Participants

Hypothesis 1: Changes in Health Outcome Measures

Hypotheses 2 and 3: Variables Related to Change in MoCA 5-Min Score

Hypothesis 4: Satisfaction With the Service

Discussion and Applications to Practice

Footnotes

Acknowledgments

Declaration of Conflicting Interests

Funding

ORCID iD

References