Cognitive care at your fingertips: A systematic review of telemedicine potential and barriers in rehabilitation for dementia

Abstract

Background

Dementia is characterized by a deterioration in cognitive functions that impacts everyday tasks and overall life quality, with Alzheimer's disease (AD) being the most prevalent form. As dementia progresses, cognitive rehabilitation, often utilized in conjunction with telemedicine, offers significant support via targeted interventions that enhance autonomy and overall quality of life (QoL).

Objective

This systematic review aims to explore the potential and barriers of telemedicine-based cognitive stimulation and training programs for individuals with dementia and mild cognitive impairment (MCI).

Methods

Studies were identified from an online search of PubMed, Web of Science, Embase, PsychINFO, and Scopus databases conducted up to 19 February 2025. This systematic review has been registered on PROSPERO under the following number: CRD42024615619.

Results

The studies establish that digital health interventions and telehealth approaches add to the improvement in cognitive rehabilitation among patients with dementia and MCI, by indicating striking improvements not only in cognitive functioning but also in increased support for caregivers. The higher adherence and satisfaction rates with such interventions can be attributed to telemedicine itself and newer technologies such as virtual reality (VR) and transcranial direct current stimulation, which can provide options for personalized and accessible care in neurodegenerative disease management.

Conclusions

Telemedicine-based cognitive rehabilitation in dementia patients, not only achieves improved cognitive functioning but also a better QoL and reduced caregiver burden. Further studies are needed to ensure equal implementation and long-term sustainability of these interventions, possibly with the inclusion of newer technologies such as VR and neuromodulation.

Keywords

Alzheimer's disease cognitive rehabilitation dementia neurorehabilitation telehealth telemedicine

Introduction

Globally, an estimated 55 million people currently live with dementia, and this figure is projected to rise to 78 million by 2030, increasing the public health burden.^1,2 The general symptoms of dementia include memory loss, impaired problem-solving, language difficulties, impaired judgment, and behavioral problems, affecting daily life activities and quality of life (QoL).^3,4 Alzheimer's disease (AD) is the most common form of dementia, characterized by progressive neurodegeneration leading to cognitive decline.^5–8 Mild cognitive impairment (MCI) is an intermediate clinical condition between normal aging and dementia, characterized by cognitive impairment that exceeds expected age-related changes but without significant impairment in daily functioning. MCI may represent a prodromal, preclinical stage of AD, termed “MCI due to AD,” in which AD pathology is detectable before overt dementia develops.^9–12 Therefore, while AD is a specific form of dementia, MCI due to AD may be considered a prodromal stage in the AD continuum.¹³ When considering the scenario in which the prevalence of the condition is still rising, experts have identified that cognitive rehabilitation plays an important part in managing and caring for people with dementia. It involves targeted, individualized strategies to address particular cognitive impairments, aiming to improve functional results. This type of intervention typically focuses on restoring lost cognitive abilities or compensating for existing deficits.¹⁴ Other cognitive approaches include cognitive training and cognitive stimulation. Cognitive training generally involves structured practice using standardized tasks specifically designed to target and enhance particular cognitive functions. These tasks are often adapted in difficulty to match the individual's current capabilities, allowing for a tailored and progressive training experience. In a broader sense, cognitive training may also include strategy training, which involves teaching individuals compensatory techniques or metacognitive strategies (e.g., use of mnemonic devices, self-monitoring, external aids) to support cognitive functioning in everyday life. Cognitive interventions can be delivered in individual or group formats, employing either traditional pencil-and-paper exercises or digital platforms.¹⁵ In contrast, cognitive stimulation typically involves participation in a variety of activities and group discussions designed to broadly enhance both cognitive and social functioning.¹⁶ Examples of cognitive interventions include memory training, problem-solving exercises, and the use of technologies to compensate for disabilities to promote independence in daily activities.^17,18 The goal is to support patients with impaired cognitive abilities, improving their QoL so they can be more involved in their care.¹⁹ Telemedicine is a way to furnish support, consultation, and rehabilitation at a distance. In recent years, telemedicine has emerged as a means to serve patients who have mobility issues or live in areas that are not easily accessible.²⁰ Additionally, teleconsultations have allowed healthcare providers to assess patients, conduct therapies, and monitor symptoms without making home visits.^21,22 This not only broadens care options but also eases the burden of caregivers, who often face many challenges in managing their loved ones.²³ Integrating cognitive stimulation and training, often via virtual reality (VR), into telemedicine enables ongoing support and lets clinicians adjust interventions in real time as the patient's condition evolves.²⁴ For example, patients can complete cognitive exercises online at home and receive instant feedback from their therapist.²⁵ Moreover, telehealth platforms have been designed to support group sessions that enhance social interaction among patients needed for psychosocial well-being.²⁶ Telemedicine has successfully delivered cognitive rehabilitation interventions, leading to improvements in cognitive skills and QoL, as supported by evidence.^27,28 By using technology, it is also possible to provide caregivers with training and education about the management of troublesome behaviors and offer appropriate support.^29–31 Most of these programs make use of interactive platforms that engage the patients in games and exercises that would improve their high-order cognitive skills, making the programs effective and enjoyable.³² By having regular virtual consultations, we can constantly update care plans as we address new challenges and provide continuous support to both the patients and the caregivers.³³ Many telehealth platforms indeed include components for caregiver education and support by equipping them with skills and strategies to handle behavioral issues and manage their well-being.^34,35 The COVID-19 pandemic hastened the adoption of telemedicine for dementia; this has resulted in a host of recent studies considering its long-term feasibility.³⁶ Most of such studies report convenience and flexibility associated with virtual appointments favored by the patients and caregivers.³⁷ They also showed that telemedicine could minimize the risk of catching communicable illnesses, an issue dear to at-risk populations.³⁸ Despite these findings, several barriers remain to the effective use of telemedicine in dementia care. Different levels of access to technology, as well as different digital competencies, along with demands for stable internet access, may prevent its extensive application, particularly among older adults population.³⁹ There are also concerns regarding how complete any functionality assessment via telehealth can be compared to one in person in the diagnosis and treatment of especially complex neurocognitive conditions.^40,41 While the potential of telemedicine in cognitive rehabilitation is increasingly recognized, a comprehensive synthesis of its implementation barriers and efficacy across dementia and MCI populations remains lacking. Therefore, this systematic review aims to address this critical gap by thoroughly examining the existing literature. Specifically, it aims to explore the potential and barriers of telemedicine-based stimulation and training programs for individuals with dementia and MCI. This systematic review is based on the theoretical framework of implementation science, specifically employing the Consolidated Framework for Implementation Research to steer the examination of obstacles and supports for the uptake of telemedicine-based cognitive rehabilitation.⁴² This framework facilitates a thorough evaluation of elements across various domains, such as intervention features, internal and external contexts, individual traits, and implementation procedures, resulting in a solid foundation for comprehending the intricacies of adapting telehealth interventions into clinical practice.

Methods

Search strategy

To ensure a comprehensive and up-to-date review of the literature, we initially conducted a systematic search covering publications up to 10 September 2024. This search was later extended to include studies published through 19 February 2025, allowing us to incorporate the most recent and relevant research findings. We performed an extensive literature search using the PubMed, Web of Science, Embase, PsychINFO, and Scopus databases, utilizing the keywords: ("telemedicine"[MeSH Terms] OR "telemedicine"[All Fields] OR "telemedicine s"[All Fields]) AND ("cognitive training"[MeSH Terms] OR ("cognitive"[All Fields] AND "training"[All Fields]) OR "cognitive training"[All Fields] OR ("cognitive"[All Fields] AND "rehabilitation"[All Fields]) OR "cognitive rehabilitation"[All Fields]) AND ("dementia"[MeSH Terms] OR "dementia"[All Fields] OR "dementias"[All Fields] OR "dementia s"[All Fields]). These databases were carefully selected to cover the broadest possible range of peer-reviewed literature in the fields relevant to this review.

Data extraction

Two reviewers (AC, MGM) performed independent searches to improve transparency and accuracy in locating pertinent studies. The search strategy was iteratively refined by testing different combinations of keywords, Boolean operators, and controlled vocabulary (e.g., MeSH terms) to maximize sensitivity and specificity. The PRISMA flowchart was employed to depict the process (identification, screening, eligibility, and inclusion) for choosing relevant studies, as shown in Figure 1.⁴³ The Cochrane Risk of Bias (RoB 2) framework was applied to assess bias risk in randomized controlled trials (RCTs), whereas the ROBINS-I tool was utilized for uncontrolled experimental studies included in this review. A detailed protocol for assessing bias, aligned with the Cochrane Handbook for Systematic Reviews of Interventions, was followed to maintain methodological rigor. Additionally, two researchers (AC, MGM) screened all articles based on titles, abstracts, and full texts, conducting independent data extraction, article gathering, and cross-validation to minimize bias risks (e.g., missing results bias, publication bias, time lag bias, language bias). The gathered data included study design, sample size, characteristics of participants, types of dementia, specifics of the cognitive rehabilitation intervention and duration, and assessed outcomes. The researchers (AC, MGM) reviewed complete text articles considered suitable for the study, and if there were disagreements regarding the inclusion and exclusion criteria, a final decision was reached by a third researcher (RSC). Discrepancies between reviewers during the screening or data extraction process were also resolved through discussion, with unresolved cases adjudicated by a third reviewer (RSC). Moreover, the concordance between the two evaluators (AC and MGM) was evaluated through the kappa statistic. The kappa score, which has a recognized threshold for significant agreement established at >0.61, was understood to indicate substantial alignment among the reviewers.⁴⁴ This standard guarantees a strong assessment of inter-rater reliability, highlighting the attainment of a significant degree of consensus in the data extraction procedure. Data extraction and organization were facilitated using Microsoft Excel, which streamlined the process and minimized human error. The software allowed for efficient management of large datasets, enabling reviewers to systematically record study characteristics, risk of bias assessments, and outcome data. Custom extraction sheets were designed within the software to ensure consistency and adherence to the predefined inclusion/exclusion criteria. Additionally, the software provided features such as tagging, filtering, and sorting, which facilitated the resolution of discrepancies and expedited the cross-validation process. This set of articles was subsequently refined for relevance, assessed, and summarized, with main topics highlighted from the summary according to the inclusion/exclusion standards.

Figure 1.

PRISMA 2020 flow diagram of evaluated studies.

This systematic review has been registered on PROSPERO under the number CRD42024615619 on 18 November 2024, with subsequent updates recorded on 21 May 2025 to reflect methodological refinements, such as the addition of further electronic databases and adjustments to our inclusion and exclusion criteria in response to reviewer feedback. Registration on PROSPERO ensures transparency and accountability by providing a publicly accessible record of the review protocol prior to its execution. This step minimizes the risk of selective reporting and allows for external validation of the review's methodology. By adhering to PROSPERO standards, this review aligns with best practices for systematic reviews and reinforces its methodological rigor.

Data synthesis

Data synthesis was conducted using narrative methods and quantitative analysis to tackle the variety of study designs and types of dementia included. This method allowed us to identify key themes, commonalities, and differences across the research landscape. By synthesizing qualitative observations, we provided a comprehensive understanding of the evidence related to different populations with various dementia diagnoses. Effect sizes and evidence certainty from diverse study types reflecting various dementia conditions were reported. Studies were grouped based on intervention types, patient characteristics, and reported outcomes to highlight consistencies and discrepancies. Throughout the synthesis process, the inclusion of a multidisciplinary team ensured a balanced interpretation of the data. Regular discussions and consensus meetings among reviewers helped mitigate potential biases in qualitative assessments and ensured consistency in categorizing and interpreting outcomes. This integrated approach combined qualitative insights with quantitative precision, offering a holistic understanding of the research landscape.

PICO evaluation

We applied the PICO model (Population, Intervention, Comparison, Outcome) to create our search terms. Our population included individuals diagnosed with either MCI or dementia. Regarding interventions, this review specifically focused on telemedicine-delivered cognitive training programs for individuals with MCI and cognitive stimulation interventions for those with dementia. Comparators comprised either traditional, face-to-face cognitive interventions or control groups receiving usual care or no intervention. The primary outcome was change in cognitive function, assessed via standardized and objective cognitive measures. Secondary outcomes included autonomy in activities of daily living, caregiver burden, and intervention feasibility and acceptability.

Inclusion criteria

This systematic review included studies evaluating the efficacy and feasibility of telemedicine-based cognitive interventions for individuals with MCI or dementia. Specifically, studies involving cognitive training delivered remotely to participants with MCI and cognitive stimulation provided to those with dementia were eligible. We acknowledged that cognitive rehabilitation could span across populations and intervention types; however, our inclusion criteria reflected the predominant focus observed in the literature and the available evidence. Eligible studies were required to clearly specify diagnostic criteria for MCI or dementia to ensure accurate participant classification. Interventions had to be administered via telemedicine platforms, including video conferencing, web-based applications, or tablet programs, focusing on cognitive rehabilitation components. Crucially, included studies were mandated to report at least one objective measure of cognitive function, such as performance on validated neuropsychological tests. We included primary research articles encompassing RCTs, uncontrolled experimental designs, observational studies, and retrospective analyses. Participants were adults aged 18 years or older, and only full-text articles published in English were considered to allow for thorough evaluation.

Exclusion criteria

To maintain methodological rigor and relevance, we applied strict exclusion criteria. Studies were excluded if they did not utilize telemedicine as the principal mode of cognitive intervention delivery, such as those relying exclusively on in-person interventions without a remote component. Research focusing on non-cognitive interventions, such as purely pharmacological treatments or physical therapy without a cognitive rehabilitation element, was excluded. Additionally, studies not reporting objective cognitive outcomes were omitted, as our review emphasized measurable cognitive changes. Telemedicine studies limited to consultations or assessments without rehabilitative intervention were outside our scope. Non-primary research articles, including reviews, protocols, and abstracts, were excluded, as were animal studies, given the human-centered focus of our review.

Results

A comprehensive literature search was carried out using five electronic databases. This initial search yielded a total of 4033 records. Before formal screening commenced, 182 duplicate records were identified and removed, along with 105 non-English articles. This left 3746 records for title and abstract screening. Following this initial screening phase, 1050 records were excluded based on inadequate study design, during the title and abstract screening phase, leaving 2696 reports for full-text retrieval. However, despite efforts to obtain these articles (e.g., emailing corresponding authors, consulting libraries, exploring open-access sources, checking institutional resources, and using research networks), 26 reports could not be retrieved. The remaining 2670 full-text articles were then assessed for eligibility: 2081 were excluded at title review, 342 at abstract review, and of the 247 articles subjected to detailed full-text screening, 232 were discarded for the following reasons: non-dementia population (n = 88), non-telemedicine intervention (n = 75), missing relevant outcomes (n = 40), or insufficient data (n = 29). Ultimately, 15 studies met our pre-defined inclusion criteria and were included in this systematic review.

Demographic and etiological characteristics: age, sex, and contributing factors in dementia populations and their geographic distribution

An extensive examination of research from various worldwide locations, such as Italy, Australia, Canada, Hong Kong, Argentina, Turkey, South Korea, and rural areas of the United States, shows considerable diversity in demographic characteristics and diagnostic classifications among individuals facing cognitive deterioration. In Italy, the studies covered a range of diagnoses, including MCI, AD, vascular cognitive impairment (VCI), and subjective/mild neurocognitive disorders (SCD/mNCD). Rossetto et al.⁴⁵ noted an even sex distribution in MCI/AD, with an average age in the late 70s, whereas Jelcic et al.⁴⁶ found a largely female demographic with AD, with older age averages. Mosca et al.⁴⁷ underscored a gender-specific difference in dropout rates among MCI/VCI participants, where females showed greater attrition, indicating possible sex-related factors in adherence.⁴⁷ Manenti et al.^48,49 and Bernini et al.⁵⁰ investigated MCI and SCD/mNCD, respectively, revealing different sex ratios and average ages,^47,48,50 whereas Corallo et al.⁵¹ concentrated on AD/MCI during COVID-19, highlighting a predominance of female patients and unique age characteristics for patients and caregivers.⁵¹ Beyond Italy, research showed similarly varied demographics and diagnoses. Australian study examined MCI associated with mood-related neuropsychiatric symptoms (MrNPS), uncovering a primarily female group, indicating possible sex-based vulnerabilities.⁵² Canadian research explored various diagnoses, such as subjective cognitive impairment, MCI, and dementia,^53,54 highlighting predominantly female samples and age groups spanning from the mid-60s to 80.^53,54 In Hong Kong, Poon et al.⁵⁵ and Lai et al.⁵⁶ explored MCI/dementia and neurocognitive disorders (NCD), respectively, noting differences in age and sex reporting.^55,56 In Argentina, Canyazo et al.,⁵⁷ examined MCI with an equal sex ratio,⁵⁷ whereas Torpil et al.,⁵⁸ in Turkey presented a primarily male group with amnestic MCI.⁵⁸ Jung et al.,⁵⁹ in South Korea, concentrated on AD, highlighting a predominance of females. Etiological factors leading to cognitive decline were diverse, including AD, VCI, MrNPS, and SCD, and the worsening impact of isolation due to COVID-19. Mosca et al.⁴⁷ focused on vascular contributions, whereas Bahar-Fuchs et al.⁵² emphasized factors related to mood. Contextual elements like social isolation and the burden of caregiving,⁵⁶ isolation due to COVID-19,⁵¹ digital literacy,⁵⁰ and geographic isolation⁵⁴ were also recognized as important factors. Table 1 contains a summary of the demographics and etiological characteristics of the included studies.

Table 1.

Summary of clinical studies: aim of the study, study design, participants, demographics, and diagnostic criteria.

Author/Location/Country	Aim	Study Design	Sample Size	Demographics	Diagnosis and Clinical Criteria Assessment
Rossetto et al. (2023)⁴⁵ Location: IRCCS Don Gnocchi Foundation center Country: Italy	The main goal of this research was to assess the efficiency and effectiveness of the ABILITY telerehabilitation model, provided asynchronously, for individuals with MCI or mild dementia in the AD continuum.	RCT	30 participants	Age: Mean approximately 78 years (ABILITY: 78.2 ± 3.95; TAU: 77.13 ± 6.38) Sex: ABILITY group 40% male (6/15); TAU group 53.3% male (8/15) Education: ABILITY mean 9.33 ± 4.01 years; TAU mean 7.60 ± 2.67 years Cognitive Level at baseline: MMSE ∼25; MoCA ∼18 in both groups Diagnosis Distribution: Within AD continuum—Mild Cognitive Impairment (MCI) and mild Alzheimer's Disease (MCI: ABILITY 9, TAU 10; mild AD: ABILITY 6, TAU 5)	Inclusion: Diagnosis of mild AD or MCI due to AD according to established criteria ([17,18]); MMSE > 18; minimum 3 years of schooling; age > 65 years; stable pharmacological treatment for at least 3 months; ability to participate in rehabilitation trial. Exclusion: Dysmetria, visual/auditory/communication deficits affecting testing or rehab performance. Diagnosis established by neurologists at a memory clinic during periodic medical screening.
Jelcic et al. (2014)⁴⁶ Location: San Camillo Hospital in Venice Country: Italy	To evaluate the feasibility and efficacy of LSS-tele compared with LSS-direct and UCS in patients with early AD, focusing on changes in global cognition, language, memory, attention, executive functions, and visual-spatial abilities.	RCT	27 participants	Age (mean ± SD): LSS-tele 86 ± 5.1 years; LSS-direct 82.7 ± 6 years; UCS 82.3 ± 5.9 years. Sex (M/F): LSS-tele 2/5; LSS-direct 3/7; UCS 1/9. Education (mean ± SD): LSS-tele 6 ± 3.5 years; LSS-direct 6.7 ± 3.3 years; UCS 8.7 ± 3.7 years. Baseline MMSE (mean ± SD): LSS-tele 23.7 ± 2.8; LSS-direct 24.9 ± 2.5; UCS 24.8 ± 2.7.	Diagnosis: Probable AD according to National Institute of Neurological and Communicative Disorders and Stroke–AD and Related Disorders Association criteria. Disease stage: Early AD, CDR score 0.5–1. Inclusion: Stable psychoactive medication (≥3 months); no antidementia drug therapy due to contraindications or compliance issues. Exclusion: Brain lesions on imaging, severe systemic illness or depression, severe behavioral symptoms (assessed by Neuropsychiatric Inventory), severe lexical-semantic deficits (naming test score ≤ 2 SD below norm). Baseline evaluation by multidisciplinary team (neurologist, neuropsychologist, speech therapist, social worker).
Mosca et al. (2020)⁴⁷ Location: Memory Clinic of University Hospital of Careggi and the Don Carlo Gnocchi Foundation in Florence Country: Italy	The research sought to assess the feasibility, compliance, and patient satisfaction of the GOAL, Tele-R system, a multifaceted intervention that integrates cognitive, physical, and social activities, in those with MCI or VCI.	RCT	86 patients were initially approached, and 61 enrolled and randomized: Tele-R group: 29 patients; standard care group: 32 patients. Dropouts: 30 total (higher in standard care group), 31 patients completed the study (19 tele-R, 12 standard care).	Age: Mean ∼74 years (completed study 74.2 ± 4.1; dropouts 73.6 ± 3.9). Sex: Female drop-out rate significantly higher (66%) than male (27%). Education: ∼10 years (completed 10.3 ± 4.6; dropouts 9.8 ± 4.6). Baseline cognitive status (MoCA): completed 20.9 ± 3.3; dropouts 22.6 ± 3.7. Balanced distribution of MCI and VCI subtypes between groups and dropouts.	Diagnosis of MCI or VCI based on clinical, neuroimaging, and neuropsychological data.
Manenti et al. (2020)⁴⁸ Location: IRCCS Istituto Centro San Giovanni di Dio Fatebenefratelli of Brescia, IRCCS Centro Neurolesi Bonino-Pulejo, Messina, and IRCCS Fondazione Don Carlo Gnocchi Onlus of Milan Country: Italy	To evaluate the efficacy of a face-to-face cognitive VRRS compared to face-to-face cognitive treatment as usual in individuals with MCI. To assess whether home-based cognitive telerehabilitation using VRRS prolongs treatment effects versus unstructured cognitive stimulation or no additional treatment.	RCT	79 screened; 30 excluded (27 did not meet inclusion criteria, 3 declined). 49 participants randomized: Clinic-VRRS + Tele@H-VRRS group: 18 participants; Clinic-VRRS + Tele@H-UCS group: 14 participants; Clinic-TAU group: 17 participants.	Mean age: 76.5 years (SD 4.2); Mean education: 10.7 years (SD 4.4); Sex distribution: 24 males (49%); Group specifics: Clinic-VRRS + Tele@H-VRRS: 13 males, 5 females; mean age 75.3 (SD 3.3); education 11.8 (SD 4.8); Clinic-VRRS + Tele@H-UCS: 4 males, 10 females; mean age 76.3 (SD 4.9); education 10.5 (SD 4.8); Clinic-TAU: 7 males, 10 females; mean age 78.1 (SD 4.1); education 9.8 (SD 3.7). No significant difference in age or education between groups; significant difference in sex distribution (p = 0.036).	Participants were selected based on Petersen's criteria for MCI, including memory complaints, independent living, MMSE scores between 30, CDR of 0.5, and preserved daily functioning. Those diagnosed with dementia (DSM-V), mood or anxiety disorders, major neurological or psychiatric conditions, sensory impairments, a history of brain injury, stroke, tumor, or alcohol abuse were excluded. The sample included 42 amnestic MCI cases (20 single-domain, 22 multiple-domain) and 7 non-amnestic MCI cases (single and multiple-domain), reflecting a range of cognitive profiles within the MCI spectrum.
Manenti et al. (2024)⁴⁹ Location: IRCCS Istituto Centro San Giovanni di Dio Fatebenefratelli of Brescia, IRCCS Fondazione Don Carlo Gnocchi Onlus of Milan, and IRCCS Centro Neurolesi Bonino-Pulejo of Messina Country: Italy	To evaluate the efficacy of the cognitive VRRS combined with anodal tDCS applied to the DLPFC compared to placebo tDCS combined with VRRS and to face-to-face cognitive treatment as usual. To assess whether cognitive telerehabilitation prolongs the beneficial effects of these treatments in subjects with MCI.	RCT	A total of 109 participants with MCI were randomized into five groups: Clinic-atDCS-VRRS+Tele@H-VRRS (n = 23); Clinic-ptDCS-VRRS+Tele@H-VRRS (n = 21); Clinic-VRRS+Tele@H-VRRS (n = 20); Clinic-VRRS+@H-UCS (n = 23); Clinic-TAU (treatment as usual) (n = 22).	Mean age: approximately 76.5 years (range not explicitly reported). Education: mean ∼10 years. Sex distribution: 52 males and 57 females overall; significant difference in sex distribution across groups (p = 0.013). Cognitive status: MMSE mean ∼27 (range 24–30). Handedness (EHI) and cognitive reserve (CRI) measured. Clinical Dementia Rating (CDR): mean ∼0.5.	Inclusion: Petersen criteria for MCI (2011), including subjective cognitive complaints (patient, informant, or clinician); defective performance in at least one cognitive domain; MMSE score 24/30; CDR ≤ 1. Preserved functional autonomy (basic and instrumental activities of daily living). No diagnosis of dementia (DSM-5 criteria). Absence of depressive or anxiety symptoms. Exclusion: Other neurological or major psychiatric disorders, visual/auditory impairments, history of traumatic brain injury, stroke, brain tumor, alcohol abuse, contraindications to tDCS (seizures, major head trauma, brain surgery, implants, pacemaker). MCI subtypes in sample: aMCI: 72 subjects (36 single-domain, 36 multiple-domain). naMCI: 37 subjects (26 single-domain, 11 multiple-domain).
Bahar-Fuchs et al. (2017)⁵² Location: Canberra Country: Australia	To evaluate the effects of home-based, adaptive, and individually tailored CCT versus an active control condition on cognitive and non-cognitive outcomes in older adults with MCI, MrNPS, or both. To determine whether tailored and adaptive CCT is superior to generic training. To assess cognitive (global and domain-specific) and non-cognitive outcomes, including metacognition, mood, activities of daily living, and caregiver burden. To explore differential benefits across diagnostic groups (MCI, MrNPS, MCI+MrNPS).	RCT	Total participants screened for eligibility: 188 expressed interests; 88 met basic criteria; 76 completed baseline assessment. Eligible and randomized: 45 participants (MCI = 8, MrNPS = 12, MCI+MrNPS = 25). Intervention commenced by 43 participants (CCT = 20, AC = 23).	Age: Mean ∼74.6 years (range not explicitly stated, SD ∼6.8). Sex distribution: 24 males / 21 females overall. Education: Mean ∼14.4 years. Residency: Australian Capital Territory and surrounding New South Wales regions. Additionally, participants required home computer/internet access and English fluency.	MCI diagnosis based on NIA-AA clinical criteria: Subjective concern reported by participant, informant, or clinician. Objective cognitive impairment in 1 or 2+ domains (1.5 SD below age/education norms). Preserved functional independence verified by the BADL ≤8 excluded. MrNPS diagnosis based on informant ratings using the NPI-Q: Presence of ≥1 moderate symptom in depression, anxiety, apathy, or irritability. Exclusion if psychosis spectrum symptoms (delusions, hallucinations) are present. Screening excluded individuals with a dementia diagnosis, major neurological/psychiatric illness (excluding depression/anxiety), sensory impairments, less than 6 years of education, recent mood- or cognition-stabilizing medications, or prior cognitive training participation.
Canyazo et al. (2023)⁵⁷ Location: Cognitive Neurology Service of Fleni, Argentina Country: Buenos Aires	To measure the effects of CTR on cognition, neuropsychiatric symptoms, memory strategies, and daily functioning in patients with MCI.	RCT	60 participants. Treatment group: n = 30 Control group (waiting list): n = 30	Inclusion: Age > 60 years Mean age: Treatment group 71.1 years (SD 8.43); Control group 72.7 years (SD 5.15) Sex distribution: Treatment group: 50% female, 50% male; control group: 60% female, 40% male. Groups matched by age, sex, and MoCA score. Exclusion: Alcohol/drug abuse, visual or auditory deficits impeding cognition, major psychiatric disorders	Diagnosis of MCI based on Petersen's criteria: Subjective cognitive complaints Objective cognitive impairment (as assessed by neuropsychological tests). Preservation of functional independence. Cognitive screening: Argentine version of MoCA.
Torpil et al. (2023)⁵⁸ Location: occupational therapy department of a public university Country: Turkey	To compare the effectiveness of CR delivered via FF versus TR methods on cognitive functions in older adults diagnosed with amnestic-MCI.	RCT	Initial screened participants: 72 older adults. Final analyzed sample: 68 (34 in FF group; 34 in TR group) after two exclusions and two dropouts.	Age range: 65 to 75 years. Mean age: FF group 70.26 ± 2.62 years; TR group 69.79 ± 2.74 years (no significant difference). Sex distribution: FF group: 29.4% female, 70.6% male. TR group: 35.3% female, 64.7% male (no significant difference). Education: balanced between groups with ∼44% high school, ∼56% bachelor's degree.	Diagnosis of amnestic-MCI established by clinical neuropsychologist and physician according to Albert et al. core clinical criteria (2011) involving: Concern regarding cognitive change (self/informant/clinician). Objective impairment in one or more cognitive domains. Preservation of independence in functional abilities. Absence of dementia or other neurodegenerative diseases.
Jung et al. (2023)⁵⁹ Location: Myongji Hospital in Goyang and Cheongpungho Geriatric Hospital Country: Republic of Korea	To investigate the effects of internet-based versus in-person multimodal cognitive interventions on cognition, mood (depression and anxiety), and ADL in patients with mild to moderate AD. To determine whether internet-based cognitive intervention is as effective as in-person intervention.	RCT	52 patients with probable mild to moderate AD initially enrolled. 42 patients completed the study (21 intervention, 21 control). The intervention group was subdivided into Intervention A (n = 13): internet-based first, then in-person; and Intervention B (n = 13): in-person first, then internet-based.	Mean age: 77.4 ± 8.4 years overall (intervention: 79.3 ± 8.1; control: 75.4 ± 8.4). Sex: 66.7% female overall (balanced between groups). Education: mean 8.4 ± 5.1 years (balanced between groups). Comorbidities included hypertension, diabetes mellitus, dyslipidemia, cardiac disease, and stroke (no significant differences between groups). Medication use was balanced except SSRIs higher in the control group (p = 0.014). Baseline cognitive and mood scores (MMSE, GDS, BAI, S-IADL) comparable between groups.	Diagnosis of probable AD based on NINCDS-ADRDA criteria. Mild to moderate AD defined as CDR 0.5 to 1 (Korean version). Exclusion: metabolic diseases affecting cognition, chronic alcoholism, stroke, seizure, brain surgery, psychotic/mood disorders (DSM-5 criteria).
Burton et al. (2018)⁵³ Location: University of Saskatchewan Country: Canada	To investigate the feasibility and acceptability of delivering goal-oriented cognitive rehabilitation to individuals with SCI, MCI, and early-stage dementia due to AD using telehealth videoconferencing compared to in-person delivery. To determine whether telehealth cognitive rehabilitation is a viable alternative to in-person cognitive rehabilitation.	RCT	8 participants were recruited and randomly assigned (4 in-person, 4 telehealth). 2 telehealth participants withdrew before the intervention phase. Final sample completing intervention: 6 participants (3 in-person, 3 telehealth).	Age range: 66 to 80 years. Education range: 12 to 18 years. Sex: 5 females, 1 male. Recruitment sources: community organizations, hospital geriatric assessment program. Support person involvement varied: 1 attended all sessions, others participated in interviews/questionnaires or not at all.	Diagnoses among participants: SCI: 4 participants; MCI: 1 participant; dementia due to AD: 1 participant. Diagnosis and Clinical Criteria Assessment: Diagnosis largely self-reported but confirmed consistent with clinical interview, neuropsychological testing, and questionnaires. Cognitive impairment confirmed via MMSE at initial assessment and neuropsychological battery including RBMT-III, D-KEFS, TEA.
Poon et al. (2005)⁵⁵ Location: Shatin Hospital Country: Hong Kong	To compare the feasibility, acceptability, and clinical outcomes of a cognitive intervention program delivered via telemedicine (videoconferencing) versus conventional FTF methods in community-dwelling older adults with MCI or mild dementia.	RCT	22 participants	Community-dwelling older adults recruited from a neighborhood social center. Baseline cognitive function: C-MMSE scores ranged 14 to 22. No statistically significant baseline differences in demographic or clinical characteristics between groups reported.	Participants were screened initially using the C-MMSE, adjusting cutoffs for educational level. Those below the cut-off were referred to a geriatrician for diagnostic confirmation of mild dementia or MCI. Neuropsychological outcome measures included: C-MMSE (cognitive screening); C-RBMT; HDS.
Lai et al. (2020)⁵⁶ Location: Activity Center Country: Hong Kong	This study examined whether adding video-conferencing telehealth to routine telephone calls offers additional benefits over phone calls alone for home-cared older adults with neurocognitive disorders and their spousal caregivers during COVID-19 social distancing. It focused on effects on patients’ cognition, behavioral symptoms, and quality of life, as well as caregiver health, burden, and self-efficacy.	Controlled Experimental Study	Total of 60 dyads (person with NCD + spousal caregiver) 30 dyads per group (intervention versus control)	Care recipients with NCD: age range 64–80 years (mean ∼72.7 years); caregivers: age range 66–82 years (mean ∼72 years). Sex distribution: Care-recipients: Control 12 females/18 males; Intervention 13 females/17 males; Caregivers: Control 18 females/12 males; Intervention 17 females/13 males. Years of education (care recipients): Control group mean ∼7.0 years (range 5–9); intervention group mean ∼8.0 years (range 5–11), statistically higher (p = 0.035). Caregiver education comparable between groups (∼8 years).	Inclusion: Home-cared persons aged 65–80 diagnosed with NCD according to DSM-5 criteria. Exclusion: Major physical disabilities (e.g., stroke). Diagnosis confirmed via center records and clinical interview.
Bernini et al. (2023)⁵⁰ Location: IRCCS Mondino Foundation of Pavia Country: Italy	To determine the usability and UX of the HomeCoRe telerehabilitation system in individuals at risk of dementia (with subjective cognitive decline or mild neurocognitive disorder) and their family members. To evaluate the association between participants’ technological skills and main usability and UX outcomes.	Uncontrolled Experimental Study	14 participant's total: 4 with SCD; 10 with mNCD.	Mean age: 68.2 years (range >50 years). SCD group mean age: 61.5 years. mNCD group mean age: 71.0 years. Gender: 65% female overall (100% female in the SCD group, 50% female in mNCD group). Mean years of education: 12.2 years. Technological skills (self-rated, scale 0–4): mean 2.3 (moderate). Family members were involved for support in most cases (11 out of 14 participants).	Inclusion: Diagnosis of SCD or mNCD based on clinical history, neurological and neuropsychological assessment. CDR ≤ 0.5. MMSE adjusted score ≥ 23.8. Age > 50 years, education > 5 years. Exclusion: Sensory impairments. Motor deficits in dominant upper limb.
Corallo et al. (2023)⁵¹ Location: IRCCS Centro Neurolesi Bonino Pulejo, Messina Country: Italy	To assess the impact of structured video call telemedicine interventions on cognitive and behavioral symptoms in hospitalized patients with dementia during COVID-19 quarantine, and on the psychological well-being and burden of their caregivers.	Uncontrolled Experimental Study	28 patients with mild to moderate neurocognitive impairment and their caregivers; 21 diagnosed with AD, 7 with MCI.	Patients: Mean age: 83.7 ± 10.2 years; Gender: 5 males (18%), 23 females (82%); Mean education: 6.3 ± 3.4 years. Caregivers: Mean age: 51.7 ± 9.5 years; Gender: 12 males (43%), 16 females (57%); Mean education: 12.9 ± 3.6 years; Relationship: 25% sons, 54% daughters, 18% husbands, 4% wives.	Confirmed dementia diagnosis (AD or MCI) via clinical history, neurological and neuropsychological evaluation. Cognitive assessment by MMSE, with inclusion MMSE > 12 (range 13–16).
Park et al. (2022)⁵⁴ Location: Baylor College of Medicine Country: United States	To evaluate the feasibility, acceptability, and preliminary effectiveness of a telemedicine-based, self-administered interactive exercise program (“tele-Exergame”) on cognition and anxiety in older adults with MCI or dementia.	Uncontrolled Experimental Study	14 participants.	Mean age: 68.1 ± 5.4 years. Sex: 12 females (85.7%). Mean BMI: 31.5 ± 7.2 kg/m². Clinical comorbidities included high blood pressure (85.7%), musculoskeletal problems (35.7%), depression (35.7%), sleep problems (50%), diabetes (35.7%), among others. 28.6% used walking assistance, 35.7% had high concern for falling, and 28.6% were at risk for clinical depression.	Inclusion: clinically diagnosed MCI or dementia, or MoCA score ≤ 25. Exclusion: severe cognitive impairment (MoCA < 16), major mobility disorders, other neurological or psychiatric conditions interfering with participation, and major sensory impairments. Diagnosis confirmed by clinical psychologist via MoCA and clinical interview.

Scientific Institute for Research, Hospitalization and Healthcare (IRCCS); Mild Cognitive Impairment (MCI); Alzheimer's Disease (AD); Randomized Controlled Trial (RCT); Control Group (CG); Intervention Group (IG); Lexical-Semantic Stimulation via teleconference (LSS-tele); Face-to-Face Lexical-Semantic Stimulation (LSS-direct); Unstructured Cognitive Stimulation (UCS); Games for Older Adults’ Active Life (GOAL); Tele-Rehabilitation (Tele-R); Vascular Cognitive Impairment (VCI); Virtual Reality Rehabilitation System (VRRS); Transcranial Direct Current Stimulation (tDCS); Dorsolateral Prefrontal Cortex (DLPFC); Computerized Cognitive Training (CCT); Mood-related Neuropsychiatric Symptoms (MrNPS); Cognitive Telerehabilitation (CTR); Subjective Cognitive Impairment (SCI); Neurocognitive Disorder (NCD); Subjective Cognitive Decline (SCD); Minor Neurocognitive Disorder (mNCD); User Experience (UX); Montreal Cognitive Assessment (MoCA); Mini-Mental State Examination (MMSE); Clinical Dementia Rating (CDR); Falls Efficacy Scale-International (FES-I); Center for Epidemiologic Studies-Depression (CES-D); Beck Anxiety Inventory (BAI); Clinical Dementia Rating Scale (CDRS); Neuropsychiatric Inventory Questionnaire (NPI); Hamilton Anxiety Rating Scale (HAM-A); Geriatric Depression Scale (GDS); Zarit Burden Inventory (ZBI); Beck Depression Inventory (BDI); National Institute of Neurological and Communicative Disorders and Stroke-Alzheimer Disease and Related Disorders Association (NINCDS-ADRDA); Neuropsychiatric Inventory (NPI); Activities of Daily Living (ADL); Clinical Dementia Rating (CDR); Neuropsychological Inventory Questionnaire (NPI-Q); Hong Kong Mini-Mental State Examination (C-MMSE); Rivermead Behavioural Memory Test (RBMT); Rivermead Behavioural Memory Test III (RBMT-III); Delis-Kaplan Executive Function System (D-KEFS); Test of Everyday Attention (TEA); Mini-Mental State Examination, Cantonese version (C-MMSE); Center for Epidemiologic Studies-Depression questionnaire (CES-D); Clinical Dementia Rating (CDR); Center for Epidemiologic Studies-Depression (CES-D); Neuropsychiatric Inventory Questionnaire (NPI-Q).

Study design, research methods, type of interventions, and data collection tools

A review of studies of cognitive treatments showed a generalized dependency on designs using RCTs,^{45–49,52,53,55,57–59} which reflected a preference for stringent method expectations. In other geographic regions, all these studies used a different set of neuropsychological tests in an alike process for cognitive functions, such as, though not all, Montreal Cognitive Assessment (MoCA), Mini-Mental State Examination (MMSE), and Free and Cued Selective Reminding Test (FCSRT). Such measurements rendered cognitive change after various treatments measurable in an unprejudicial manner. Intervention methods ranged between cognitive stimulation (dementia) and cognitive training strategies (MCI). Different studies have analyzed the efficiency of systems of telerehabilitation, such as ABILITY platform,⁴⁵ and GOAL Tele-Rehabilitation,⁴⁷ which comprised adaptive cognitive exercises and online monitoring. Virtual reality rehabilitation systems (VRRS), as examined by Manenti et al.,^47,48 also emerged as a prominent intervention strategy, demonstrating potential for enhancing memory and executive functions. Computerized cognitive training (CCT), along with multimodal treatments, which comprise cognitive, music, and arts therapies, have been employed for rehabilitating different cognitive aspects.

The weight of evidence: Analyzing effect sizes and certainty. The analyzed studies exhibited a diversity of effect sizes and different degrees of certainty. Research utilizing strong RCT methodologies, like those by Manenti et al.,^47,48 showed considerable advancements in cognitive areas with moderate to high confidence, frequently backed by large effect sizes. In contrast, research with limited sample sizes or uncontrolled experimental frameworks, such as Burton et al.,⁵³ and Corallo et al.,⁵¹ demonstrated reduced certainty of evidence, even while noting considerable effects. Significantly, telerehabilitation measures, as demonstrated in Rossetto et al.,⁴⁵ and Mosca et al.,⁴⁷ exhibited considerable adherence and cognitive advantages with moderate confidence, frequently linked to medium to large effect sizes. In general, the quality of evidence fluctuated according to methodological robustness and sample size, affecting the applicability of results. Table 2 contains a summary of the studies methodologies.

Table 2.

Summary of studies methodologies.

Author	Treatment Period	Intervention Group	Control Group	Research Methods	Data Collections Tools/Outcome Measures
Rossetto et al. (2023)⁴⁵	6 weeks of intervention, with assessments at baseline (T0), post-treatment (8 weeks, T1), and 12-month follow-up (T2).	ABILITY telerehabilitation group n = 15 participants (6 males), mean age 78.2 ± 3.95 years; performed cognitive and physical activities at home via a digital platform with adaptive difficulty, telemonitoring of vital signs, and weekly feedback.	TAU group n = 15 participants (8 males), mean age 77.13 ± 6.38 years; performed standard paper-and-pencil cognitive exercises and written physical activity instructions at home, with a fixed difficulty progression and diary monitoring of vital signs.	RCT. Single-blinded outcome assessors; 1:1 randomization; adherence and usability monitored; statistical analysis including period effect, treatment effect, follow-up effect, carry-over effect; sample size powered for pilot trial.	SUS for technology usability (patients and caregivers). Adherence rates (% sessions completed) and perceived difficulty balancing (6-point scale). Neuropsychological assessments: MoCA, Verbal Fluency Tests (FAS, CAT), TMT parts A and B, Free and Cued Selective Reminding Test (FCSRT: IFR, ITR, DFR, DTR). Autonomy in daily living: ADCS/ADL. Behavioral symptoms: NPI reported by caregivers. Safety monitored via weekly calls and adverse event reporting.
Jelcic et al. (2014)⁴⁶	3 months, with two weekly 1-h sessions.	LSS-tele group: 7 participants with early-stage AD (mean age 86 ± 5.1 years; 2 males, 5 females). Received lexical-semantic stimulation (LSS) via telecommunication technology (teleconference). Exercises focused on enhancing semantic verbal processing through remote interactive sessions.	LSS-direct group: 10 participants (mean age 82.7 ± 6 years; 3 males, 7 females). Received same lexical-semantic stimulation delivered face-to-face by therapist. UCS group (Unstructured Cognitive Stimulation): 10 participants (mean age 82.3 ± 5.9 years; 1 male, 9 females).	Pilot RCT with three arms (LSS-tele, LSS-direct, UCS). Observer-blinded neuropsychological assessments at baseline and post-intervention. Random assignment with some reallocation based on participant preferences.	Global cognitive performance: MMSE; Lexical-semantic abilities: Verbal Naming Test, phonemic and semantic fluency tests; Episodic verbal memory: Brief Story Recall, RAVL; Working memory: Forward Digit Span Test; Visual-spatial memory: ROCF Delayed Recall; Attention and executive functions: Digit Cancellation Test, Trail Making Test (Parts A and B); Visual-spatial abilities: ROCF Copy Test. Patient satisfaction questionnaire for LSS-tele group assessing perceived utility and feasibility (10-point Likert scale).
Mosca et al. (2020)⁴⁷	8 weeks of intervention, followed by 12-month follow-up assessments.	Tele-rehabilitation group (Tele-R) = 19 patients.	Standard care group: 12 patients completed the study. Received usual care without Tele-R intervention. The 12-month follow-up visit included similar evaluations.	RCT. Randomization via computer algorithm. Baseline and post-intervention evaluations including cognitive, behavioral, functional, and quality-of-life measures. Attrition and adherence analyses using chi-square and Mann-Whitney U-tests. Satisfaction assessed via ad hoc questionnaire.	MoCA; FCSRT; Digit Span (forward and backward); Corsi Span (forward and backward); Rey Complex Figure Test (copy and delayed recall); Modified Card Sorting Test; TMT Part A and B; Stroop Test; Phonemic and Semantic Fluency tests; ADCS/ADL; Mood and quality of life: CESD; SF-36 physical and mental component summaries; drop-out rates. Rehabilitation adherence score (activities completed). Satisfaction questionnaire assessing: Experience appreciation (scale 1–5). Usability (yes/no). Perceived physical, cognitive, and emotional benefits (yes/no). Satisfaction with exercise variety (yes/no).
Manenti et al. (2020)⁴⁸	Face-to-face cognitive VRRS treatment: 12 sessions over 4 weeks (3 sessions/week). Followed by a home-based treatment phase: 36 sessions over 12 weeks (3 sessions/week) for two groups (telerehabilitation or unstructured cognitive stimulation).	clinic-VRRS + Tele@H-VRRS (Face-to-face VRRS + home-based VRRS telerehabilitation) = 18 participants. clinic-VRRS + Tele@H-UCS (Face-to-face VRRS + home-based unstructured cognitive stimulation) = 14 participants.	clinic-TAU (Face-to-face cognitive treatment as usual) = 17 participants. acts as active control with usual care cognitive treatment (12 face-to-face sessions over 4 weeks), no home-based follow-up treatment.	Multicenter RCT with rater-blinded outcome assessment. Participants were randomized by stratified randomization (age and MMSE performance) into 3 groups. Blinded neuropsychologists conducted evaluations. Statistical analysis: GLMMs comparing groups across four time points (baseline, post-treatment, 4-month, and 7-month follow-ups).	EMQ; BADL/IADL scales; GDS; NPI; QOL-AD. MMSE; Raven's Colored Progressive Matrices; Verbal Fluency (phonemic and semantic); BADA, action and object naming; ROCF (copy and recall); CDT; TMT Part A and B; RAVLT immediate and delayed recall; FCSRT.
Manenti et al. (2024)⁴⁹	FTF treatment: 12 sessions over 4 weeks (one session per day, total 12 sessions). Home-based treatment (telerehabilitation or unstructured cognitive stimulation): 36 sessions over 3 months (3 sessions per week). Follow-up assessments were conducted at baseline (T0), post-treatment (T1, 1 month), 4 months (T2), and 7 months (T3) from baseline.	Clinic-atDCS-VRRS+Tele@H-VRRS n = 23. Face-to-face cognitive training using the Virtual Reality Rehabilitation System (VRRS) combined with anodal tDCS applied to the left dorsolateral prefrontal cortex (DLPFC) during training. Followed by cognitive telerehabilitation (home-based VRRS training on tablet). Clinic-VRRS+Tele@H-VRRS n = 20. Face-to-face VRRS only (no tDCS). Followed by cognitive telerehabilitation (home-based VRRS). Clinic-VRRS+@H-UCS n = 23. Face-to-face VRRS only. Followed by at-home unstructured cognitive stimulation (paper-pencil, puzzles, reading, etc.).	Clinic-ptDCS-VRRS+Tele@H-VRRS n = 21. Face-to-face VRRS combined with placebo (sham) tDCS during training. Followed by cognitive telerehabilitation (home-based VRRS). Clinic-TAU (Treatment As Usual) n = 22. Face-to-face cognitive treatment as usual: 12 group sessions of metacognitive training, reminiscence therapy, orientation, paper-pencil exercises. No home-based treatment.	Multicenter RCT, active-controlled, double-blinded (investigators and outcome assessors blinded) clinical trial. Randomization: Stratified by age and MMSE score using opaque sealed envelopes. Statistical analyses: GLMMs for repeated measures; beta regression for long-term effects; intention-to-treat with handling of missing data via GLMM.	MMSE; CDR; CRIq; Episodic memory (primary focus): RAVLT; immediate and delayed recall; FCSRT; IFR, ITR, DFR, DTR, and ISC. ROCF, delayed recall and copy. Language: Verbal fluency (phonemic and semantic). BADA, object and action naming. Attention and executive function: TMT parts A and B. EMQ for subjective memory complaints. BADL and IADL. GDS. NPI. QOL-AD scale. SUS to assess usability of VRRS system (clinic and home-based). tDCS perceptual sensations questionnaire: assessment of sensations (burning, itching, tingling) during stimulation.
Bahar-Fuchs et al. (2017)⁵²	Intervention duration: 8 to 12 weeks (flexible training period). Follow-up assessment conducted 3 months (12 weeks) post-intervention.	Home-based, computerized, multi-domain cognitive training using CogniFit™ platform. Individually tailored training tasks based on baseline cognitive profile. Adaptive task difficulty was adjusted according to participant performance. Delivered as two sessions/day (∼20–30 min total), 3 days/week. Behavioral change techniques employed to support adherence (goal setting, commitment, social support, monitoring). Participants received feedback on performance after each session (21 participants initially randomized; 20 commenced intervention).	Same CogniFit™ platform and same 33 cognitive training tasks. Training tasks are allocated in a non-tailored, random sequence (not adapted to cognitive profile). Fixed difficulty level throughout training (no adaptation). No feedback on performance after training sessions. Behavioral change techniques were matched to the intervention group to control for engagement and adherence factors (23 participants initially randomized; 23 commenced intervention).	Participants were stratified by diagnosis (MCI, MrNPS, MCI+) before randomization. Blinding: Participants unaware of group allocation and study hypotheses; assessors blinded to condition. ITT analysis was employed. Primary outcome: Change in global cognitive ability immediately post-intervention. Secondary outcomes: cognitive domain-specific abilities, metacognition, mood, ADLs, and caregiver burden at post-intervention and 3-month follow-up.	ACE-III; baseline screening only. Sydney Language Battery (SydBat). Logical Memory (Immediate and Delayed Recall). RAVLT. RCFT. Verbal Fluency (Letter, Category, Switching). Digit Span (Forward and Backward). Digit-Symbol Coding. Trail Making Task (A and B). Sniffin Sticks (Olfactory Discrimination and Identification). Memory Awareness Rating Scale (MARS; self and informant). MMQ. CDR. informant/clinician. GDS. GAI. Apathy Evaluation Scale (AES; informant). NPI-Q; informant. ZBI; caregiver burden. BADL; informant-rated functional independence).
Canyazo et al. (2023)⁵⁷	10 weeks (10 sessions of 45 min each, once per week). Pre-treatment assessment at week 0 and post-treatment assessment at week 10.	30 patients with MCI. Received CTR via the AgeWise program. Intervention included multi-domain cognitive training (orientation, attention, memory, executive function, visuospatial skills, language, and social cognition). Included psychoeducation on healthy aging and neuroplasticity. Use of compensatory memory strategies and training on protective factors (nutrition, physical exercise, social activities, and cardiovascular risk control). Home-based, asynchronous, remote sessions guided by neuropsychologists.	30 patients with MCI. Waiting list group (no treatment during study period) Matched by age, sex, and MoCA scores.	RCT. Random allocation to treatment or control groups. Intention-to-treat analysis. Statistical approach: Linear mixed-effects models with group (control/treatment) and time (pre/post) as fixed factors and participant ID as a random effect. Controlled for diagnosis, age, and sex.	MoCA. RAVLT. Learning trials, delayed recall). Verbal Fluency Test (phonological fluency). FAQ. MMQ. satisfaction and strategy use). GDS. NPI-Q. EDO-10. Depression, Anxiety and Stress Scale (DASS-21; stress subscale).
Torpil et al. (2023)⁵⁸	12 weeks total. Intervention sessions: Twice weekly, 45 min each session. Pre-intervention assessment at baseline and post-intervention assessment after 12 weeks.	34 older adults with aMCI. Access to and use of telecommunication technology (Zoom, WhatsApp, Skype) at home. Intervention delivered remotely by occupational therapist in participants' home environment. Structured CR program targeting multiple cognitive domains (attention/concentration, orientation, memory, visual perception, spatial perception, praxis, visuomotor organization, and thinking operations). Pre-intervention home visits for technological adaptation and environment optimization. Individualized sessions, delivered by experienced therapist with 9 years CR experience.	34 older adults with amnestic MCI. Same diagnostic criteria and demographic matching as the TR group. Received the same structured CR program delivered in clinical occupational therapy practice units. Individualized sessions with the same therapist as the TR group.	Random assignment to TR or FF groups via computer-generated randomization. Evaluators were blinded to group allocation and intervention type. Design following CONSORT guidelines for RCTs. Sample size was determined via power analysis targeting 30 subjects/group with allowance for dropout (final analyzed N = 68). Non-parametric statistical methods were used (Mann–Whitney U test, Wilcoxon signed-rank test, Chi-square) due to non-normal distribution. Effect sizes calculated (Cohen's d). Outcome assessor blinded to group and intervention.	Primary cognitive outcome: LOTCA-G. Items were scored on an ordered scale of 1–4 (orientation 1–8); higher scores indicate better cognitive function. Administered pre- and post-intervention by a blinded occupational therapist. Demographic data recorded (age, sex, education level, marital status).
Jung et al. (2023)⁵⁹	Total duration: 8 weeks (two consecutive 4-week intervention periods). Participants were assigned to either 4 weeks of internet-based intervention followed by 4 weeks of in-person intervention or vice versa. Neuropsychological assessments at baseline, week 4, and week 8.	This study involved 26 participants split evenly into two groups for a crossover design. The intervention combined multiple non-pharmacological therapies over 8 weeks, including cognitive training twice weekly (30 min each), music therapy weekly, and art therapy weekly, with each modality equally divided between internet-based Zoom sessions and in-person delivery. Internet sessions featured real-time therapist interaction and both group and individual activities, while in-person sessions were conducted in clinical or group settings.	26 participants. Received pharmacological treatment only (acetylcholine esterase inhibitors, NMDA antagonists, SSRIs, benzodiazepines) with no cognitive/multimodal intervention. Matched in demographics and baseline clinical characteristics with intervention group.	Initial randomization to intervention or control (1:1 ratio). The intervention group was further randomized to order of delivery (internet-based then in-person or vice versa). Blinding: Not possible due to intervention nature (open-label), but assessors blinded to group allocation. Statistical analysis: ANCOVA controlling for education years and baseline CDR-SOB.	K-MMSE. KDSQ-C. GDS. BAI. ADL. S-IADL. CDR for dementia staging. Satisfaction with intervention assessed by a structured questionnaire (6 items, 5-point Likert scale).
Burton et al. (2018)⁵³	Total duration: 8 weeks of cognitive rehabilitation intervention following a 3-week baseline phase. Weekly 1-h sessions (total of 8 sessions) after baseline. Baseline measurement: 3 weeks (weekly measurement) before intervention start. Intervention structured to target new goals every 3 weeks (Goal 1 targeted after baseline, Goal 2 after 3 weeks of intervention).	3 participants. Intervention: goal-oriented cognitive rehabilitation delivered via telehealth videoconferencing. Participants received individualized, person-centered cognitive rehabilitation focused on functional goals (e.g., memory, organization, sleep, and concentration). Intervention included strategies such as spaced retrieval, cuing and fading, errorless learning, cognitive behavioral techniques for mood/sleep, and external memory aids. Caregiver involvement variable (some present for initial interview/questionnaires; some absent).	3 participants. Similar individualized cognitive rehabilitation as the telehealth group, targeting personal goals. Caregiver involvement variable: one participant attended all sessions with spouse support.	This small-scale randomized controlled trial used a combined between-subjects and multiple baseline single-case design. Participants were randomly assigned to in-person or telehealth interventions. Initial assessments and baseline goal measurements were conducted before the intervention. Targeted goals were introduced sequentially every 3 weeks to enable within-subject comparisons.	COPM. MMSE. RBMT-III. D-KEFS, Verbal Fluency Subtest. TEA. QoL-AD, patient and caregiver report. Bristol Activities of Daily Living Scale. HADS. WHOQOL-BREF, caregiver report. ZBI, caregiver burden. Weekly observational performance and satisfaction ratings on each goal using COPM throughout baseline and intervention phases. Qualitative data collected via therapist's research journal reflecting adaptations, challenges, and therapeutic process during intervention delivery.
Poon et al. (2005)⁵⁵	Duration: 6 weeks Timeline: 12 cognitive intervention sessions delivered twice weekly over this 6-week period.	The telemedicine group consisted of 11 community-dwelling older adults diagnosed with mild cognitive impairment or mild dementia. At baseline, their C-MMSE scores ranged from 14 to 22, and there were no significant differences in these scores compared to the control group. The intervention was delivered remotely through a broadband videoconferencing system that connected a community center with a hospital. A high-resolution document camera was used to facilitate the sessions.	The face-to-face intervention group included 11 participants who met the same criteria as those in the videoconferencing group, that is, community-dwelling older adults with mild cognitive impairment or mild dementia. Unlike the remote sessions, the intervention for this group was delivered in person at the community center.	The study employed a RCT design, with participants randomly assigned to either the videoconferencing or face-to-face group following an initial cognitive screening and diagnosis confirmation by a geriatrician. Baseline assessments were conducted in a blinded manner to reduce bias, and cognitive outcomes were compared before and after the intervention. The trial took place at a community social center for seniors and an affiliated hospital in Hong Kong.	C-MMSE; C-RBMT; HDS. Additional measure: User satisfaction questionnaire for the videoconfering group, consisting of 11 Likert-scale questions (1–5) assessing acceptability of telemedicine delivery.
Lai et al. (2020)⁵⁶	Duration: 4 weeks. Timeline: Weekly sessions conducted during the social distancing period of the COVID-19 pandemic (March–mid-May 2020).	This study involved 30 dyads of community-dwelling older adults with neurocognitive disorder and their spousal caregivers, aged 65 to 80. Telehealth support was provided via video-conferencing platforms like Zoom, WhatsApp, and FaceTime, engaging both care recipients and caregivers. Participants had similar demographics to controls, with slightly higher education levels among care recipients, and excluded those with major physical disabilities to ensure full participation. This telehealth model aimed to enhance care delivery by directly involving both members of the caregiving pair.	30 care-recipient and spousal caregiver dyads. Telehealth targeted at caregivers only via weekly telephone calls (30 min each).	This non-randomized controlled study used alternate group allocation and blinded baseline and follow-up assessments to reduce bias. Statistical analyses involved mixed ANOVAs and ANCOVAs controlling for age and education, with effect sizes reported as partial eta squared. The study was ethically approved by the Hong Kong Polytechnic University Human Research Ethics Committee and was conducted at an activity day center and participants’ homes, reflecting a community-centered approach.	MoCA, Chinese version of cognitive function; RMBPC, behavioral and psychological symptoms, rated by caregiver. QoL-AD, Chinese version quality of life, reported by caregiver. For caregivers: SF-36v2, physical and mental health status. ZBI, perceived caregiver burden. RCSES, caregiving self-efficacy in managing care-recipient behavior and obtaining support.
Bernini et al. (2023)⁵⁰	Duration: 6 weeks. Timeline: 18 remote sessions (3 sessions per week), each lasting approximately 45 min.	This pilot study included 14 individuals at risk of dementia (4 with Subjective Cognitive Decline and 10 with mild Neurocognitive Disorder), averaging 68 years old and 12 years of education. All met mild cognitive impairment criteria (MMSE > 23.8, CDR ≤ 0.5). Most had family support, while a few were independent. Participants engaged in personalized, adaptive cognitive exercises via a touchscreen laptop, remotely monitored by therapists.	None (pilot usability and user experience study without control group).	This non-randomized pilot study assessed usability and user experience through pre- and post-intervention measures, focusing on adherence, performance, and subjective feedback. Quantitative data included adherence rates, performance scores, and validated questionnaires, complemented by qualitative analysis of session diaries.	MMSE; MoCA; DGS; CBTT; Verbal Span; RAVLT; Immediate and Delayed Recall; Logical Memory Immediate and Delayed Recall; ROCF delayed recall and copy; RPM; FAB; TMT Parts A and B; Attentive Matrices; FAS and Semantic (CAT) Verbal Fluency; IADL; BDI; SF-36 physical and mental subscales; CRIq; Self-reported Technological Skills: UEQ; SUS; PGIC; HUXQ. Descriptive session diary capturing qualitative feedback on tasks, difficulty, execution time, and technical issues.
Corallo et al. (2023)⁵¹	Duration: Approximately 25 days (mean 24.28 ± 2.69 days). Timeline: Video call intervention provided during hospitalization in a COVID-19 ward from admission (T0) to discharge (T1).	28 patients (21 AD, 7 MCI and their caregivers.	None (quasi-experimental single-arm study without separate control).	This quasi-experimental pre-post study assessed patients face-to-face at admission and discharge, while caregivers were evaluated remotely via telemedicine. Daily psychological interviews and structured video calls with the care team provided ongoing support. Clinical and psychometric measures were collected at both time points. Nonparametric statistical analyses were conducted with significance at p < 0.05 to evaluate outcomes.	MMSE, FIM, CDR, NPI, BPSD, HAM-A, GDS, EQ-5D. Caregiver Assessments: ZBI, BDI, HAM-A, EQ-5D.
Park et al. (2023)⁵⁴	Duration: 6 weeks. Timeline: Participants performed tele-Exergame exercises twice weekly, with daily leg raising or foot flexion exercises (∼30 min/day) at home.	14 older adults with MCI or dementia. Cognitive status confirmed by MoCA score ≤25 (excluded if MoCA <16).	None (no separate control or comparison group; feasibility/proof-of-concept single-arm study).	This Phase I feasibility study used a pre-post design to evaluate a remote, self-administered tele-Exergame involving leg exercises with real-time feedback via wearable sensors and a tablet app. Participants received initial device training and were remotely monitored and coached. Paired t-tests and Cohen's d assessed pre-post changes, with significance at p < 0.05.	TAM questionnaire, MoCA, BAI, Demographic and Clinical Data (Age, gender, BMI, comorbidities, fear of falling (FES-I), (CES-D).

Scientific Institute for Research, Hospitalization and Healthcare (IRCCS); Mild Cognitive Impairment (MCI); Alzheimer's Disease (AD); Randomized Controlled Trial (RCT); Treatment As Usual (TAU); System Usability Scale (SUS); Montreal Cognitive Assessment (MoCA); Phonemic Verbal Fluency Test (FAS); Category Verbal Fluency Test (CAT); Trail Making Test (TMT); Free and Cued Selective Reminding Test (FCSRT); Activities of Daily Living Inventory (ADCS/ADL); Neuropsychiatric Inventory (NPI); Lexical-Semantic Stimulation via teleconference (LSS-tele); Face-to-Face Lexical-Semantic Stimulation (LSS-direct); Unstructured Cognitive Stimulation (UCS); Mini-Mental State Examination (MMSE); Clinical Dementia Rating (CDR); Games for Older Adults’ Active Life (GOAL); Tele-Rehabilitation (Tele-R); Vascular Cognitive Impairment (VCI); face-to-face (FTF), Virtual Reality Rehabilitation System (VRRS); Transcranial Direct Current Stimulation (tDCS); Dorsolateral Prefrontal Cortex (DLPFC); Mood-related Neuropsychiatric Symptoms (MrNPS); Addenbrooke Cognitive Examination-III (ACE-III); Sydney Language Battery (SydBat); intention-to-treat (ITT), Memory Awareness Rating Scale (MARS); Meta-Memory Questionnaire (MMQ); Geriatric Depression Scale (GDS); Geriatric Anxiety Inventory (GAI); Apathy Evaluation Scale (AES); N-Methyl-D-Aspartate antagonists (NMDA), Selective Serotonin Reuptake Inhibitors (SSRI), Neuropsychiatric Inventory Questionnaire (NPI-Q); Clinical Dementia Rating – Sum of Boxes (CDR-SOB), Zarit Burden Interview (ZBI); Bristol Activities of Daily Living Scale (BADL); Cognitive Telerehabilitation (CTR); Functional Activities Questionnaire (FAQ); Depression, Anxiety and Stress Scale (DASS-21); Loewenstein Occupational Therapy Cognitive Assessment – Geriatric Version (LOTCA-G); Korean Mini-Mental State Examination (K-MMSE); Korean Dementia Screening Questionnaire – Cognition (KDSQ-C); Beck Anxiety Inventory (BAI); Seoul Instrumental Activities of Daily Living (S-IADL); Canadian Occupational Performance Measure (COPM); Rivermead Behavioral Memory Test III (RBMT-III); Delis-Kaplan Executive Function System (D-KEFS); Test of Everyday Attention (TEA); Quality of Life in Alzheimer's Disease (QoL-AD); Hospital Anxiety and Depression Scale (HADS); World Health Organization Quality of Life Assessment (WHOQOL-BREF); Clinical Dementia Rating Sum of Boxes (CDR-SOB); Rey Auditory Verbal Learning Test (RAVLT); Rey Complex Figure Test (RCFT); Battery for the Analysis of Aphasia Deficits (BADA), Cognitive Reserve Index questionnaire (CRIq); Patient Global Impression of Change (PGIC); User Experience Questionnaire (UEQ); HomeCoRe User Experience Questionnaire (HUXQ); Functional Independence Measure (FIM); Behavioral and Psychological Symptoms of Dementia (BPSD); Hamilton Anxiety Rating Scale (HAM-A); Beck Depression Inventory (BDI); EuroQol 5-Dimension questionnaire (EQ-5D); Falls Efficacy Scale-International (FES-I); Center for Epidemiologic Studies-Depression (CES-D); Body Mass Index (BMI), Technology Acceptance Model (TAM).

Cognitive domains and assessment matching

In reviewing these trials, it became clear that the most frequently targeted and assessed domain was global cognition, typically measured with the MMSE or MoCA.^45,46 Whenever a study included memory-focused exercises, whether through spaced retrieval, errorless learning, or structured recall practice, those participants showed some of the largest gains on memory tests like the RAVLT, FCSRT, or RBMT.^47,48 Language skills were next in line: only some studies trained naming or fluency explicitly, and it was precisely in those trials (for example, the lexical-semantic telerehab protocols) that meaningful improvements in verbal fluency and naming tasks were observed.^45,46 By contrast, when language exercises were absent, performance on the CAT or letter-fluency drills barely budged.⁵³ For executive function and attention, studies often relied on the Trail Making Test (A and B) or the Frontal Assessment Battery. Interventions that wove in dual-task balance challenges or adaptive problem-solving games consistently produced moderate improvements, think shorter TMT-B times or fewer errors, suggesting that pairing a mental challenge with movement fires up those frontal networks.^47,54 Studies that tackled visuospatial abilities directly, typically using VR-based figure copying or tablet-drawn planning tasks, showed patients improved their accuracy and organizational strategies.^48,49 If a rehabilitation program did not explicitly include a visuospatial component, though, performance on the Rey–Osterrieth or clock-drawing tended to stay flat.⁵³

Safety and adverse events

In the studies examined, the explicit documentation of safety and adverse events was significantly limited, indicating a generally positive safety profile for telerehabilitation and digital cognitive therapies. The main focus was on feasibility, compliance, and effectiveness, with an underlying assumption of limited safety issues. When recorded, negative events were mainly confined to technical difficulties or temporary exhaustion among participants, rather than serious medical issues.^45,46 When examined, drop-out rates were often linked to unrelated factors like existing comorbidities or individual situations, instead of being due to negative effects from the intervention itself.⁴⁷ Research utilizing VR and tDCS highlighted the necessity for regulated settings and skilled operators; however, they did not document notable negative occurrences, suggesting that these techniques are safe when implemented properly.^48,49 Telerehabilitation and digital cognitive interventions for MCI and dementia are generally safe and well-tolerated, with a focus on optimizing accessibility and adherence, and the mitigation of technological hurdles.^53,55

Quality of included studies: risk of bias

To ensure a thorough evaluation of methodological quality, we conducted a detailed assessment of bias risk using established and recognized tools specifically designed for the study design of the included papers.^45–59 This systematic approach provided a robust framework for identifying potential limitations and inconsistencies in research methods, enabling a transparent and reliable comprehension of the findings within the broader context of evidence.

Cochrane risk-of-bias tool for randomized trials (Rob 2)

Of the fifteen studies, eleven were RCTs.^{45–49,52,53,55,57–59} We used the updated Cochrane Risk of Bias (RoB 2) tool, which covers five domains: i) bias arising from the randomization process, ii) bias due to deviations from the intended intervention, iii) bias due to missing data on the results, iv) bias in the measurement of the outcome, and v) bias in the selection of the reported result (Figure 2).⁶⁰

Figure 2.

Risk of Bias (RoB) of included RCT studies.

The bias risk evaluation performed with the RoB 2 tool shows subtle differences in methodological strictness among the studies included. Instead of merely listing the areas showing possible bias, this conversation seeks to clarify the reasoning behind these evaluations, following the reviewer's astute recommendation.

Domain 2, dealing with bias caused by variability in planned interventions, proved to be a major source of concern. Studies undertaken by Jelcic et al.,⁴⁶ Mosca et al.,⁴⁷ Canyazo et al.,⁵⁷ and Jung et al.⁵⁹ have been recognized as having “High” or “Some concerns” in this context. The main reason for this concern remained the lack of thorough and extensive descriptions about how fidelity in planned interventions had been checked and confirmed. As can be seen in the research undertaken by Jelcic et al.,⁴⁶ complexity in interventions coupled with a lack of specified protocols related to fidelity created doubts about possible discrepancies. Likewise, Mosca et al.⁴⁷ had concerns about the application of interventions in different setups, adding to variations. Moreover, Canyazo et al.,⁵⁷ and Jung et al.⁴⁶ emphasized the need for consistency in implementing interventions in avoiding bias. Domain 3 (bias caused by absent outcome data) also posed significant difficulties. Mosca et al.,⁴⁷ and Burton et al.⁵³ were evaluated as presenting a “High” risk in this area. In Mosca et al.,⁴⁷ the lack of clear reporting regarding participant attrition and the management of missing data complicated the evaluation of its possible effects on the study's results. Burton et al.⁵³ demonstrated a comparable trend, indicating that the disclosure of absent data was inadequate to dismiss bias. On the other hand, Domains 1 (bias in randomization process), 4 (bias in outcome measure), and 5 (bias in selection of outcome reported) had lower risks for bias. Studies such as Rossetto et al.,⁴⁵ Manenti et al.,^48,49 and Torpil et al.⁵⁸ had routine ratings as “Low” or “Some concerns” in these domains. However, in these domains too, in several research have been observed as “Some concerns,” for lack of specificity in reportage. For instance, Poon et al.,⁵⁵ and Burton et al.⁵³ had “Some concerns” in domain 4, for lack of specificity in reportage in outcome measure. Overall general risk for bias represents findings for each domain as well. Studies such as Mosca et al.,⁴⁷ and Canyazo et al.⁵⁷ had a “High” general risk designation for reasons for serious problems in multiple domains.

The risk of bias in non-randomized studies–of interventions (ROBINS-I)

For the four non-randomized studies—one was controlled experimental study⁵⁶ and three were uncontrolled experimental studies^50,51,54—we applied the ROBINS-I tool. ROBINS-I assesses bias in seven areas: i) bias due to confounding, ii) bias in participant selection, iii) bias in classification of interventions, iv) bias due to deviations from intended interventions, v) bias due to missing data, vi) bias in outcome measurement, and vii) bias in selection of the reported outcome (Figure 3).⁶¹

Figure 3.

Cochrane Risk of Bias in non-randomized studies of interventions (ROBINS-I).

The ROBINS-I evaluation emphasizes significant heterogeneity in methodological quality among the studies included. Lai et al.⁵⁶ had a moderate total risk, mainly contributed by serious confounding bias (D2). This was due to poor control of potential confounders, particularly the lack of randomization and significant baseline differences in education levels between groups, which may have influenced cognitive outcomes. Additionally, differences in intervention exposure (video-conferencing plus phone versus phone alone) introduced a possible dose effect, making it difficult to isolate the effect of the video modality itself. These unadjusted variables likely impacted both cognitive and caregiver-related outcomes. Furthermore, a moderate risk of bias in participant selection (D1) was present due to non-random, convenience sampling and alternate allocation, which limits generalizability and increases the chance of group imbalances. On the other hand, Bernini et al.⁵⁰ presented a low risk of bias in all domains, indicating a robust study design and conduct. In contrast, Corallo et al.⁵¹ presented a high overall risk, especially in participant selection (D1) and intervention classification (D6). Strong bias in D1 was due to selection bias stemming from the recruitment of patients from a single frail population hospitalized for COVID-19, most of whom were transferred from a nursing home following an outbreak. This context-specific sampling may have led to a non-representative and highly specific cohort, thus limiting external validity. Strong bias in D6 was due to possible misclassification of the intervention, as the study combined telepsychological support, video calls, and caregiver updates under a single undefined intervention label, complicating the assessment of its core components and efficacy. Finally, Park et al.⁵⁴ identified a high overall risk, with very high biases in participant selection (D1), confounding variables (D2), and deviations from planned interventions (D5). The significant bias in D1 was probably a result of a selection bias, whereas that in D2 was a result of poor control of confounders. In D5, inconsistencies in the implementation of the planned intervention were emphasized.

Telemedicine cognitive rehabilitation: efficacy, feasibility, and impact across diverse dementia/MCI populations

Studies reviewed demonstrate that cognitive rehabilitation through telemedicine care is practical and advantageous to many populations suffering from MCI and dementia. Evidence indicates that telerehabilitation platforms, through the combination of adaptive cognitive training tasks and remote monitoring, significantly enhance cognitive functions, including MoCA scores, verbal fluency, memory, and executive functions, in many cases equaling or exceeding those of face-to-face therapies.^45,46,48,58 Adherence to telemedicine interventions tends to be solid, with diminished dropout rates and high completion percentages of cognitive and physical modules evidenced.^47,50 Telemedicine can manage difficulties in terms of geographical access and social isolation to a considerable extent, particularly when circumstances such as the COVID-19 pandemic have occurred.^51,56,57 From a clinical outcomes point of view, telehealth interventions have demonstrated improvement in mood, QoL, and caregiver stress.^56,57,59 While there are some studies that suggest that face-to-face interventions may yield slightly improved outcomes in some domains, like memory under certain conditions. Telemedicine is generally as effective as individual rehabilitation.^46,53,55,58 Reported barriers were technical skills concerns, primarily for the women participants, as well as the need for personalized modifications to enhance involvement.^47,50 Integrating telerehabilitation with additional therapies like tDCS proved more useful in improving cognitive performance.⁴⁹ Moreover, rural populations are interested in telehealth cognitive rehabilitation and emphasize its capacity to overcome geographical distances.⁵⁴

The impact of telemedicine on cognitive decline: benefits in early-stage dementia

The success of telerehabilitation appears particularly clear in early dementia cases, when cognitive reserves can more readily be called on. Studies continually demonstrate significant cognitive improvement in patients with MCI and mild AD using telemedicine systems. For example, Rossetto et al.⁴⁵ showed that the ABILITY telerehabilitation system presented statistically significant differences in MoCA scores, verbal fluency, memory, and executive functions (p<0.05) in MCI or mild dementia patients.⁴⁵ Similarly, Jelcic et al.⁴⁶ reported the recovery of MMSE scores and language function in patients with mild AD that received lexical-semantic stimulation through teleconference.⁴⁶ Further, Manenti et al.⁴⁸ found that telerehabilitation maintained gains in memory and executive functions in patients with MCI following face-to-face VR rehabilitation.⁴⁸ The GOAL Tele-R system also evidenced robust compliance (84% for cognitive and physical modules) and low dropout (34.5% compared with 62.5%, p = 0.029) in patients with MCI and VCI, demonstrating the acceptability and feasibility of telerehabilitation during the early stages of cognitive deterioration.⁴⁷ The effectiveness of multimodal face-to-face and web-based interventions, with significant improvement in cognitive function (K-MMSE) in mild to moderate AD, also supports telemedicine as a viable tool for the management of early dementia.⁵⁹

Comparative effectiveness: control conditions and differential benefits in MCI versus dementia

Across the RCTs we reviewed, telemedicine-delivered cognitive rehabilitation was most often benchmarked against either face-to-face interventions or treatment-as-usual controls. For example, Rossetto et al.⁴⁵ directly compared their six-week ABILITY platform to TAU and found significantly larger improvements in global cognition, language, memory retention, and executive function, with effect sizes often exceeding 0.80, while demonstrating higher adherence (81% versus 62%) and no safety concerns.⁴⁵ Similarly, Jelčić et al.,⁴⁶ randomized mild AD patients to either lexical-semantic telerehabilitation or unstructured stimulation and observed equivalent MMSE gains in both tele- and face-to-face arms (p = 0.01–0.03) but uniquely preserved delayed recall and boosted verbal fluency only under the remote protocol.⁴⁶ GOAL Tele-R showed lower drop-out (34% versus 62%, p = 0.029) and high satisfaction compared with standard care in MCI/VCI,⁴⁷ while VRRS trials reported that home-based telerehab almost entirely maintained post-clinic memory gains over seven months versus unstructured home exercises or TAU.^48,49 When we stratify by diagnosis, individuals with MCI consistently achieved larger standardized gains, particularly in episodic memory and executive/dual-task performance, whereas those with mild dementia experienced more modest but still significant improvements in attention, language fluency, and QoL. This pattern suggests that telerehabilitation could be especially potent in the prodromal stage yet remain beneficial and scalable even after clinical dementia onset. Table 3 contains a summary of the studies’ interventions and main findings while Figure 4 presents the main results of the research.

Figure 4.

Key findings of the studies.

Table 3.

Summary of studies interventions and main findings.

Author	Type of Cognitive Intervention	Intervention Execution	Barriers Overcome	Main Findings	Effect Size and Certainty of Evidence.
Rossetto et al. (2023)⁴⁵	Multidimensional digital-health home intervention combining: Cognitive activities (attention, reasoning, procedural, semantic, autobiographical memory, executive functions, visual-spatial skills); Motor exercises (home-based motor exercises and aerobic activities outside the home); Delivered via an asynchronous telerehabilitation platform (ABILITY Telerehabilitation Platform); Adaptive cognitive training with incremental difficulty based on performance and self-reported difficulty.	Frequency: Cognitive activities 5 days/week (∼20–30 min/day), motor activities 3 days/week (∼15–25 min/day). ABILITY group received activities via a digital platform with therapist monitoring and adaptive difficulty. TAU group received paper-and-pencil cognitive activities and written instructions for motor tasks with fixed incremental difficulty. Telemonitoring of vital parameters (blood pressure, oxygen level, heart rate, weight) in ABILITY group via biometric devices integrated into platform. Weekly reminders and ongoing therapist feedback. Assessments at baseline, post-treatment (8 weeks), and 1-year follow-up. Patients and caregivers received initial training and motivational strategies.	Addressed limited access to institutional face-to-face rehabilitation by enabling home-based treatment via telehealth. Overcame technology usability challenges in cognitively impaired elderly through caregiver involvement and user-centered design. Maintained adherence by providing adaptive difficulty tailored to patient performance and perception of task difficulty. Ensured safety and privacy with a certified medical-grade digital platform. Enabled asynchronous communication to bypass the need for real-time therapist presence, increasing scalability. Minimize disengagement common in traditional paper-pencil approaches via engaging digital content and continuous monitoring.	The ABILITY group showed significantly higher adherence to the rehabilitation, fulfilling 81% of the prescribed sessions, compared to 62% from the control group, who received traditional cognitive paper-and-pencil exercises and written physical activity recommendations. Crucially, those patients who underwent the ABILITY telerehabilitation program showed significant changes in key cognitive domains such as overall cognition (MoCA), verbal fluency (CAT), and executive function (TMT-A) at p < 0.05. These cognitive advantages were not just temporary one-year effects; they persisted for at least 12 months following intervention, and the long-term benefits to global cognitive functioning and language skills were emphasized. By contrast, participants in the control condition experienced a progressive worsening of behavioral symptoms and increased caregiver distress, thus demonstrating the broader psychosocial impact of the ABILITY intervention beyond cognitive functioning.	Effect sizes for significant outcomes ranged from moderate to large: MoCA: Cohen's d = 0.784 (treatment effect), d = 0.845 (carry-over effect). CAT: Cohen's d = 0.658 (treatment effect), d = 0.737 (carry-over effect). TMT-A: Cohen's d = 0.838 (treatment effect). Memory ITR: Rank biserial correlation = 0.448 (treatment effect). Behavioral symptoms and caregiver distress: Cohen's d up to 0.812. Statistical significance was achieved at p < 0.05 for these measures. Certainty of evidence: Due to the small sample size, the certainty of evidence is considered low to moderate.
Jelcic et al. (2014)⁴⁶	LSS: a domain-specific cognitive training targeting semantic verbal processing. Delivered in two formats: LSS-tele: via telecommunication technology (teleconference) and LSS-direct: face-to-face, in-person cognitive stimulation. Control condition: UCS, non-specific cognitive activities such as creative work, reading, and discussion.	The intervention took place in small groups of 3–4 participants at elderly day care centers twice a week for three months, with one-hour morning sessions. The LSS included exercises targeting word meaning, relationships, and comprehension, supported by group discussions to enhance verbal skills. The LSS-tele group received the intervention remotely via a customized Skype^®-based system, with a therapist leading sessions from a distance and a trained operator assisting onsite. The LSS-direct group had face-to-face sessions with the therapist present throughout. The control group engaged in unstructured cognitive activities focused on creativity and communication. Caregivers provided informal cognitive support between sessions.	Overcame geographic and mobility barriers by using telecommunication technology to deliver therapy remotely to patients on islands and in remote areas. Addressed challenges of elderly patients’ unfamiliarity with technology via on-site operator assistance and a user-friendly videoconferencing interface. Managed potential sensory limitations (hearing and vision impairments), though these may have partially affected LSS-tele efficacy. Balanced patients’ preferences and technological acceptance (two patients switched from tele to direct due to discomfort with technology). Therapist supervision ensured quality and safety despite remote delivery. Small group format and caregiver involvement enhanced engagement and adherence.	Both the LSS-tele and LSS-direct groups demonstrated marked enhancements in MMSE scores, indicating beneficial cognitive outcomes from the interventions. Moreover, language skills, such as phonemic and semantic fluency, showed enhancement in the LSS-tele group. Memory functions differed, with delayed verbal memory becoming stable in the LSS-tele group and enhancing in the LSS-direct group. Performance in working memory revealed varied outcomes, remaining stable in the LSS-tele group, enhancing in the LSS-direct group, and deteriorating in the UCS group, whereas attention skills showed improvement in the LSS-tele group.	MMSE improvements: statistically significant with p = 0.03 (LSS-tele) and p = 0.01 (LSS-direct). Language and memory domain improvements reached significance (e.g., verbal naming test p = 0.003 between groups, phonemic/semantic fluency p<0.05 within LSS-tele). Working memory and attention showed significant within-group improvements/stabilization in LSS groups compared to decline in UCS (p = 0.009 for working memory). No explicit Cohen's d or effect size metrics reported; significance inferred via p-values and mean score changes. The study had a relatively small sample size (n = 27), and some imbalance in group numbers, which limits the generalizability of the findings. Therefore, the certainty of evidence is considered low to moderate.
Mosca et al. (2020)⁴⁷	Multidimensional, multi-domain tele-rehabilitation program combining: Cognitive training (using computerized cognitive exercises), Adapted Physical Activities; Social activities. Delivered via a web-based application (“GOAL Tele-R” system).	The intervention was delivered as a home-based program, remotely supervised through a tablet equipped with a dedicated web application. It lasted eight weeks, with patients engaging in cognitive exercises three times per week, physical exercises twice weekly, and social activities once a week. Cognitive training was provided via computerized exercises integrated into the app through the BrainHQ platform, while physical activities were guided by instructional videos. Social activities were supported by caregivers to encourage engagement. Before starting, patients received training to use the tablets independently. Throughout the program, the clinical team monitored progress and personalized the activity schedule remotely using an administrative interface, with adherence and completion of activities tracked electronically.	Addressed technological unfamiliarity in elderly MCI/VCI patients through multidisciplinary training and a user-friendly, co-designed web app; Overcame geographical and logistic limitations by delivering multidimensional rehabilitation remotely; Mitigated potential low adherence by combining cognitive, physical, and social modules to maintain engagement; Controlled for systematic biases due to technology-related drop-outs; managed attrition with personalized follow-up; Despite a high drop-out rate, adherence within the treatment group was high (∼84%). Female participants showed higher drop-out, possibly due to gender-specific social/family roles, highlighting the need for tailored support.	The control group had a significantly greater drop-out rate than the Tele-R group, indicating improved retention with remote rehabilitation. The baseline characteristics were comparable for those who withdrew and those who finished the study, except for sex, as females had a higher rate of dropping out. Patients exhibited high compliance with the Tele-R program, emphasizing its practicality for sustained application. Moreover, overall satisfaction levels were elevated, as the majority of participants valued the diverse exercises and considered the platform user-friendly, highlighting the program's promise for enhancing engagement and accessibility in rehabilitation.	Statistically significant difference in drop-out rates between treatment and control groups (χ² = 4.778, p = 0.029). No explicit effect sizes (e.g., Cohen's d) reported for cognitive or physical outcomes in this paper. High internal validity through randomization and comprehensive baseline assessment; limited by drop-out rates and lack of reported efficacy data. Certainty of evidence: Moderate: Although it was a RCT, the study experienced a fairly high overall dropout rate. Nevertheless, the research offered definitive information regarding feasibility and adherence. The results regarding satisfaction and adherence were quite robust.
Manenti et al. (2020)⁴⁸	Face-to-face individualized cognitive rehabilitation using a VRRS; Home-based cognitive telerehabilitation using the same VRRS system; Control conditions included face-to-face cognitive treatment as usual and home-based unstructured cognitive stimulation.	The study compared a VRRS with traditional cognitive treatment and unstructured stimulation in MCI patients. The intervention included 12 weekly face-to-face VRRS sessions (60 min each) followed by 36 home-based VRRS telerehabilitation sessions over 12 weeks, delivered via tablet with therapist support. Control groups received either standard face-to-face cognitive training or home-based unstructured activities with similar frequency and duration. The program combined personalized, adaptive cognitive exercises with remote monitoring to enhance and maintain cognitive functions.	Technical familiarity: Participants and caregivers were trained to use tablets before starting home-based treatment. Remote monitoring: The therapist continuously adjusted and monitored treatment remotely via telerehabilitation functionalities. Accessibility: Overcame geographical and mobility barriers by providing home-based intervention. Engagement: Used individualized and adaptive protocols to maintain participant adherence. Usability challenges are addressed by providing manuals, diaries, and technical support.	In-person VRRS demonstrated greater efficacy compared to conventional cognitive therapy in improving memory, language, attention, and visuoconstructional skills. The group that integrated clinic-VRRS with Tele@H-VRRS exhibited superior memory performance over time compared to individuals who received unstructured stimulation. Furthermore, the computerized cognitive tasks in the VRRS system revealed distinctions between the telerehabilitation and unstructured stimulation groups, with both VRRS methods exhibiting strong usability.	Effect size for MMSE improvement in prior related study: Cohen's d = 0.85 (used for sample size calculation). Statistical significance: Interaction terms for cognitive outcomes (e.g., FCSRT IFR, semantic fluency, CDT) showed p-values between 0.01 and 0.03, indicating significant differential improvement. Certainty of evidence: Moderate to High. The study was a multicenter, RCT with rater blinding, which strengthens the evidence. However, the sample size, while adequate, could have been larger.
Manenti et al. (2024)⁴⁹	Cognitive rehabilitation using a VRRS combined with anodal tDCS targeting the DLPFC. Followed by cognitive telerehabilitation (home-based VRRS). Control interventions included VRRS combined with placebo tDCS and VRRS alone (without tDCS). Face-to-face cognitive treatment as usual (group cognitive stimulation, metacognitive strategy training, reminiscence therapy, paper-pencil tasks). Home-based unstructured cognitive stimulation (creative manual activities, reading, crosswords, sudoku).	Initial cognitive training and tDCS sessions were delivered face-to-face over 12 one-hour sessions across 4 weeks. This was followed by a 12-week home-based telerehabilitation program using tablets with the VRRS app, consisting of three one-hour sessions per week. The VRRS training included 12 adaptive exercises targeting memory, visuospatial skills, attention, and executive functions. During face-to-face sessions, tDCS was applied at 2 mA for 25 min over the left DLPFC (F3) with the cathode on the right supraorbital area; placebo stimulation involved brief initial current for blinding. Home telerehabilitation featured personalized VRRS modules, manuals, and diaries, with weekly remote support and adjustments by therapists. Control treatments included group reality orientation, metacognitive strategies, and paper-pencil tasks, while unstructured stimulation involved everyday cognitive activities without adaptive training.	Feasibility of delivering intensive cognitive rehabilitation combined with tDCS in older adults with MCI. Maintaining treatment adherence and engagement during home-based telerehabilitation. Technical challenges are addressed by providing initial training on tablet use and ongoing remote assistance. Blinding of participants and researchers to active versus placebo tDCS conditions. Overcoming limitations of cost and accessibility for intensive face-to-face rehabilitation by implementing telerehabilitation. Mitigation of potential COVID-19 pandemic-related recruitment and participation difficulties (41 declined participation mainly due to the pandemic). Ensuring usability and acceptance of VRRS technology in both clinical and home settings, confirmed via System Usability Scale (SUS) scores.	Significant improvement in episodic memory, measured by Immediate Free Recall on the Free and Cued Selective Reminding Test (FCSRT), was observed exclusively in the group that received VRRS combined with anodal tDCS followed by home-based telerehabilitation (clinic-atDCS-VRRS + Tele@H-VRRS). Neither the placebo tDCS + VRRS group nor the cognitive treatment as usual group showed meaningful gains in episodic memory. Importantly, the combined treatment group sustained these cognitive improvements at the 7-month follow-up, indicating lasting benefits. Other cognitive domains, such as RAVLT Immediate Recall and BADA Object Naming, did not show significant changes, except for a decline in RAVLT Immediate Recall within the placebo group. The VRRS system was well tolerated and demonstrated good usability both in clinical and home settings. Side effects related to tDCS were minimal and similar across active and placebo groups. Overall, the combination of VRRS cognitive rehabilitation with anodal tDCS and telerehabilitation proved to be feasible and well accepted and showed promise for supporting long-term cognitive improvement in patients with mild cognitive impairment.	Statistical significance: FCSRT Immediate Free Recall showed significant group*time interaction (p = 0.002) favoring the clinic-atDCS-VRRS+Tele@H-VRRS group. Improvement from baseline to post-treatment (T0 to T1): p = 1.03 × 10⁻⁵ (adjusted p = 0.00037). Maintenance of improvement at 7-month follow-up (T3): p = 1.06 × 10⁻⁵ (adjusted p = 0.00037). Odds ratios from beta regression analysis: Clinic-ptDCS-VRRS+Tele@H-VRRS versus clinic-atDCS-VRRS+Tele@H-VRRS: OR = 0.56, p = 0.047 (significant reduced effect). Clinic-VRRS+Tele@H-VRRS versus clinic-atDCS-VRRS+Tele@H-VRRS: OR = 0.59, p = 0.06 (trend-level). Pseudo R² for the model explaining variability in memory outcome: 0.088 (approximately 8.8%). Evidence level: Preliminary but randomized controlled, multicenter trial with blinding and adequate sample size (N = 109). Certainty of evidence: Moderate to High: The research is a RCT that provides blinding for both assessors and investigators, enhancing the evidence. The multicenter approach enhances generalizability as well.
Bahar-Fuchs et al. (2017)⁵²	CCT. Home-based, multi-domain, adaptive, quasi-individually tailored computerized cognitive training using the CogniFit™ platform.	The home-based, unsupervised training lasted 8 to 12 weeks, with participants completing two 20–30-min sessions three days per week. The minimum prescribed dose was 24 sessions (50% of the program), with adherence tracked at 20%, 50%, and 80% levels. Training used the CogniFit™ platform, featuring 33 game-like tasks targeting multiple cognitive domains. Tasks were personalized based on a baseline assessment, with difficulty adaptively adjusted throughout. Participants received performance feedback after each training block. A research assistant provided a face-to-face orientation at participants’ homes to set up the program, explain procedures, and introduce behavior-change techniques.	Addressed adherence challenges inherent in home-based interventions by implementing behavior-change techniques such as goal setting, reminders, social support, environmental control, and regular monitoring calls. Providing a detailed intervention manual and participant diaries for self-monitoring and motivation. Ensured blinding to group allocation to reduce bias and expectancy effects. Used an active control condition to control for non-specific intervention effects and participant engagement. Provided ergonomic guidance and technical support to facilitate use of the computer platform at home. Overcame challenges of heterogeneous participant profiles by tailoring tasks based on individual cognitive profiles.	Participants in the CCT group showed significant improvements in global cognition, learning, and delayed memory at the 3-month follow-up compared to controls. Gains in global cognition and non-memory functions were also evident immediately post-intervention. Benefits were similar across those with MCI, mood-related neuropsychiatric symptoms (MrNPS), or both. Participants with MrNPS experienced mood improvements and fewer depressive symptoms. Both groups reported increased memory satisfaction, but MrNPS participants in the CCT group relied less on memory strategies and underestimated their performance compared to informants. Functional independence tended to improve, and caregiver burden decreased in the CCT group, except for caregivers of MrNPS-only participants, who reported increased burden. Adherence was strong, with most completing at least 80% of the training, which was linked to better follow-up participation.	Global cognition: Large effect post-intervention (d = 0.80), maintained at 3-month follow-up (d = 0.79). Composite delayed memory: small effect post-intervention (d = 0.25), large effect at follow-up (d = 0.92). Composite learning and memory: medium effect post-intervention (d = 0.50), medium-large effect at follow-up (d = 0.83). Composite non-memory: Small effect post-intervention (d = 0.09), medium effect at follow-up (d = 0.67). Meta-memory and mood outcomes: No significant effects or small effects with wide confidence intervals. Caregiver burden: Small to medium effect at follow-up (d = 0.62). Relative Risk of clinically meaningful improvement (≥0.5 SD). Global cognition post-intervention: RR = 7.4 (7.4 times greater likelihood of improvement in CCT). Global cognition at follow-up: Relative Risk = 3.0. Moderate certainty due to well-conducted double-blind RCT design, use of active control, appropriate statistical modeling (Linear Mixed Models), and reporting according to CONSORT guidelines.
Canyazo et al. (2023)⁵⁷	CTR. Multicomponent cognitive rehabilitation program delivered remotely via teleneuropsychology. Intervention program: AgeWise program.	The intervention was delivered remotely through a teleneuropsychology platform over 10 weekly sessions, each lasting 45 min. Sessions focused on cognitive stimulation across multiple domains, including orientation, attention, memory, executive function, visuospatial skills, language, and social cognition, alongside psychoeducation about healthy aging, neuroplasticity, and strategies to compensate for memory difficulties. Participants also completed homework assignments to reinforce cognitive exercises and memory strategies. The program emphasized five key protective factors against cognitive decline: cognitive stimulation, nutrition, physical activity, social engagement, and cardiovascular risk management. All sessions were conducted by neuropsychologists trained in the AgeWise program, with assessments carried out before treatment began and immediately after its conclusion.	COVID-19 pandemic and related social distancing measures limiting access to traditional face-to-face cognitive rehabilitation. Vulnerability of older adults and need to avoid exposure to the virus via travel or clinic visits. Use of teleneuropsychology enabled continuity of cognitive rehabilitation during pandemic-related restrictions. Addressed accessibility challenges such as geographical distance, physical limitations, and lack of caregiver availability. The asynchronous model allowed patient flexibility in scheduling sessions. Cultural adaptation: First study to evaluate CTR effects in Latin America, promoting region-specific evidence and treatment guidelines.	The treatment group showed significant improvements in various cognitive and functional parameters with higher scores in RAVLT learning trials, delayed recall, and phonological fluency. Significant reductions were also observed in depression, neuropsychiatric symptoms, and stress, along with improvements in memory satisfaction and the use of memory strategies.	RAVLT learning trials β = 0.7 (p = 0.030). RAVLT delayed recall β = 0.48 (p = 0.029). Phonological fluency β = 0.72 (p = 0.001). FAQ β = -3.16 (p = 0.001). MMQ satisfaction β = 10.3 (p = 0.004). MMQ strategy β = 4.4 (p = 0.000). GDS depression β = -2.68 (p = 0.000). NPI-Q β = -1.46 (p = 0.045). EDO-10 β = -1.5 (p = 0.000). DASS-21 stress β = -6.0 (p = 0.000). Certainty of evidence: Moderate: Although the research is an RCT, the non-blinded approach and limited sample size somewhat diminish the reliability of the findings. The use of a waiting list control group also decreases the confidence.
Torpil et al. (2023)⁵⁸	Cognitive Rehabilitation. Delivered via two methods: Face-to-face (FF) cognitive rehabilitation. Telerehabilitation (TR) cognitive rehabilitation via teleconference.	The face-to-face group received occupational therapy in clinical settings, while the telerehabilitation group participated from home via platforms like Zoom, WhatsApp, or Skype. The 12-week program included two 45-min individualized sessions per week led by an experienced occupational therapist. Early weeks focused on attention, orientation, and memory exercises, progressing to visual-spatial tasks, praxis, and thinking operations. The final weeks integrated cognitive skills with metacognitive strategies such as self-monitoring and goal setting. For telerehabilitation, pre-intervention home visits ensured participants’ environments and technology were properly set up using their existing devices.	COVID-19 pandemic restrictions limiting face-to-face rehabilitation. Accessibility challenges for older adults include transportation, health risks, and social distancing requirements. Adaptation to home environment for telerehabilitation, including technology setup and caregiver involvement. Variability of teleconference platforms and connection issues. Potential attention and compliance challenges in non-standardized home settings.	Both the face-to-face and telehealth groups showed clear cognitive gains across the board. Everyone improved significantly, with strong effects seen in all areas tested. However, the face-to-face group showed a slight edge in visual, spatial, and motor skills, as well as overall cognitive performance, after the intervention.	Effect sizes (Cohen's d) for within-group pre-to-post changes ranged from moderate to strong across cognitive domains in both groups: Orientation: FF d = 1.71, TR d = 2.18; Visual perception: FF d = 1.87, TR d = 1.40; Spatial perception: FF d = 2.29, TR d = 1.75; Motor praxis: FF d = 2.44, TR d = 1.94; Visuomotor: FF d = 1.33, TR d = 1.40; Thinking operation: FF d = 1.16, TR d = 1.24; Memory: FF d = 1.57, TR d = 1.80; Attention/concentration: FF d = 1.70, TR d = 1.89; Total LOTCA-G: FF d = 3.79, TR d = 2.39. Between-group effect sizes for post-intervention differences favoring FF: Visual perception: d = -1.405; Spatial perception: d = -0.958; Motor praxis: d = -1.159. Total test: d = -0.743 Statistical significance for group differences reported at p < 0.01. Power analysis indicated 90% power to detect large effect size (d = 0.8) with n = 30 per group. Certainty of evidence: Moderate, supported by RCT design but limited by small sample size, potential variability in TR environment, and feasibility nature of study.
Jung et al. (2023)⁵⁹	Multimodal cognitive intervention combining cognitive training, music therapy, and art therapy. Delivered via two modes: Internet-based intervention (real-time Zoom videoconferencing). In-person intervention.	The study involved patients with mild to moderate Alzheimer's disease who participated in an 8-week intervention combining twice-weekly 30-min cognitive training with weekly 30-min music and art therapy sessions. Cognitive training included education and structured activities, while music therapy focused on singing and improvisation, and art therapy involved creative exercises like painting and memory box creation. Sessions were delivered both online via Zoom and in-person, with participants randomized to start in either setting for four weeks before crossing over to the other.	COVID-19 pandemic restrictions limiting in-person therapy access. Mobility and transportation challenges for elderly patients. Adaptation of music and art therapies to online environments while maintaining therapeutic engagement. Use of existing ICT tools (Zoom) to ensure real-time interaction and group dynamics remotely. Ensured technological accessibility and participant comfort with remote interventions.	The intervention group exhibited significant enhancements in cognitive function, daily living skills, mood, and anxiety in comparison to the control group. Both face-to-face and virtual interventions enhanced cognitive performance and mood similarly, yet the in-person method resulted in more significant improvements in daily living skills and decreased anxiety. Significantly, both types of interventions were met with the same level of satisfaction.	No significant difference between internet-based and in-person interventions in improving cognition (p = 0.918) or depression (p = 0.282). In-person intervention was significantly more effective than internet-based intervention in improving anxiety (p = 0.009) and activities of daily living (p = 0.023). Certainty of evidence: Moderate. RCT with crossover design but limited by sample size and some methodological constraints.
Burton et al. (2018)⁵³	Goal-oriented CR: person-centered, functional goal setting with individualized intervention. Techniques include: Spaced retrieval, Errorless learning (cuing and fading), External memory aids, CBT for mood and sleep goals, Goal management training, Preview Question Read State Test (a hierarchical text organization strategy). Relaxation exercises (for mood regulation).	Over 8 weeks following a 3-week baseline, six participants with SCI, MCI, or AD dementia engaged in weekly one-hour sessions delivered either in-person or via telehealth at the University of Saskatchewan's Video Therapy Analysis Lab. Participants set personalized goals updated every three weeks. Progress was tracked using the COPM and neuropsychological assessments before and after the intervention. Sessions were led by a senior doctoral student supervised by a neuropsychologist. Telehealth sessions involved adaptations such as verbal coaching and guiding remote material use. Caregiver involvement varied across participants.	Low participant recruitment, leading to expanded inclusion criteria (SCI, MCI, early dementia). Limited support persons available for some participants. Modifications required for remote delivery: More verbal description due to inability to physically interact with materials. Technological challenges and adapting cognitive techniques (e.g., spaced retrieval, external aids) to videoconferencing. Participants’ initial apprehension or disappointment about telehealth modality, which improved over time (“different but not worse”).	Cognitive rehabilitation via in-person and telehealth was feasible and well received by older adults with cognitive impairment or early AD. All in-person participants completed eight sessions; telehealth participants completed six to eight sessions. Most goals improved, fully in-person and mostly via telehealth, with sleep and concentration goals showing less change remotely. Neuropsychological outcomes were mixed but indicated some cognitive and mood benefits, particularly in the telehealth group. Therapeutic rapport was strong across both modes, and participants adapted well to telehealth, finding it an acceptable alternative. Generalization of strategies across goals limited strict experimental interpretation but offered valuable clinical gains.	Quantitative analysis relied primarily on visual inspection of single-case experimental design data rather than statistical effect sizes. SED, and MCID were used for secondary neuropsychological and mood measures when available. Improvement of 2+ points on COPM considered clinically significant; this was achieved in the majority of goals. Low. The research involves a notably limited sample size, which constrains the applicability of the results. The single-case design, although beneficial for personal assessment, lacks robust evidence for wider implementation.
Poon et al. (2005)⁵⁵	Cognitive intervention program comprising cognitive assessment, cognitive training, and psychosocial support. Delivered via two modalities: telemedicine (videoconferencing, VC) and conventional face-to-face (FTF) treatment.	The study was conducted over a six-week period at a community social center for seniors, with the videoconferencing group also connected to a hospital. Participants attended a total of 12 sessions, averaging about two sessions per week. The intervention was delivered either via videoconferencing using a broadband connection (1.5 Mbps) and a high-resolution document camera to project images during assessments and training or through face-to-face sessions held directly at the community center. A social worker at the community center coordinated the program. Importantly, the assessment and training methods were consistent across both groups, with no significant modifications made based on the mode of delivery.	The telemedicine delivery effectively overcame geographical barriers as well as travel time and cost constraints, making the intervention more accessible. Both clients and community center staff showed high acceptance of the videoconferencing format, with over 90% expressing satisfaction with the audio and visual quality. Participant compliance was also excellent, remaining above 95% in both the videoconferencing and face-to-face groups. However, some limitations were noted, particularly regarding the need for physical guidance during spatial construction training, which was less effective when delivered remotely. These challenges were acknowledged as inherent to the telemedicine approach.	Both the videoconferencing and face-to-face groups showed significant and comparable improvements in global cognition and memory-related functions, as assessed by the C-MMSE, C-RBMT, and HDS. Notably, spatial construction skills improved only in the face-to-face group, likely due to the need for physical guidance. High satisfaction rates and over 95% compliance in both groups demonstrate the feasibility and acceptability of remote cognitive intervention in community settings. Additionally, psychosocial factors such as peer support may have contributed to the observed cognitive gains, highlighting the value of social engagement alongside cognitive training.	C-MMSE: VC group improved from 18.73 ± 2.15 to 21.91 ± 2.95; FTF from 18.27 ± 2.41 to 22.09 ± 3.53 C-RBMT-profile: VC 5.64 ± 2.29 to 8.81 ± 3.12; FTF 7.45 ± 2.16 to 10.36 ± 2.73 HDS: VC 154.82 ± 24.99 to 169.27 ± 26.06; FTF 156.09 ± 17.1 to 170.64 ± 15.95 Certainty of evidence: Moderate, limited by small sample size (n = 22) and short follow-up period; findings are promising but require larger trials for confirmation
Lai et al. (2020)⁵⁶	Supplementary telehealth cognitive intervention delivered via video conferencing platforms (Zoom, WhatsApp, FaceTime). Combined cognitive and psychosocial support, including health education and engagement, beyond telephone calls alone.	This four-week study involved community-dwelling older adults with neurocognitive disorder and their caregivers, recruited from an activity center. Weekly 30-min phone calls were provided to caregivers in both groups, while the intervention group also received an additional 30-min video session including both care recipient and caregiver. Video-conferencing was conducted on caregivers’ mobile devices, with care recipients present for direct interaction. Outcomes were assessed at baseline and after four weeks under blinded conditions.	COVID-19 social distancing restricted face-to-face services, limiting engagement and social interaction via phone-only telehealth. Video conferencing overcame these barriers by enabling immersive, face-to-face-like communication, including non-verbal cues. Older adults and caregivers found the mobile apps easy to use, with strong acceptance and engagement. This approach helped reduce loneliness and routine disruption for home-bound neurocognitive disorder patients and maintained their active participation despite pandemic isolation.	Supplementary video-conferencing telehealth effectively prevented the cognitive decline observed in the telephone-only control group, with MoCA scores remaining stable in the intervention group while significantly declining in controls, as shown by a robust Group × Time interaction. Quality of life, measured by the QoL-AD, improved or was maintained in the intervention group but declined among controls. Behavioral and psychological symptoms remained stable across both groups, with no significant differences. Importantly, caregivers in the intervention group experienced meaningful improvements in both physical and mental health (SF-36v2), reported reduced perceived burden (Zarit Burden Interview), and demonstrated increased caregiving self-efficacy (RCSES). Notably, positive correlations between improvements in care recipients and caregivers suggest a synergistic effect within these dyads. These benefits emerged after just four weeks of supplementary video-conferencing, which was also perceived as more engaging and user-centered compared to telephone-only calls, highlighting the added value of this telehealth approach.	Significant Group × Time interactions with large effect sizes reported (partial eta squared, hp²): MoCA cognitive function: hp² = 0.50, p < 0.001; QoL-AD quality of life: hp² = 0.23, p < 0.001; SF-36v2 physical health: hp² = 0.51, p < 0.001; SF-36v2 mental health: hp² = 0.46, p < 0.001; Zarit Burden Interview (caregiver burden): hp² = 0.25, p < 0.001; Caregiving Self-Efficacy Scale: hp² = 0.23, p < 0.001. Certainty of Evidence: Moderate, promising initial results pending confirmation in larger randomized controlled trials.
Bernini et al. (2023)⁵⁰	Computerized cognitive rehabilitation delivered via a telerehabilitation system named HomeCoRe. Patient-tailored adaptive cognitive exercises targeting multiple domains: logical-executive functions, attention/processing speed, working memory, and episodic memory.	This six-week home-based telerehabilitation program used touchscreen laptops for three 45-min sessions per week. Adaptive exercises adjusted difficulty based on performance, while therapists remotely monitored progress and managed treatment plans. Family support and remote technical assistance facilitated use. Usability was measured by adherence and performance scores, and user experience assessed through validated questionnaires and session diaries, offering comprehensive insight into engagement and satisfaction.	Remote delivery of cognitive rehabilitation effectively overcame the limited accessibility and logistical challenges often associated with in-person sessions. To address potential technological unfamiliarity among older adults, participants received initial in-person training and ongoing support from family members. The adaptive software was carefully designed to prevent both over- and under-stimulation, helping to maintain engagement and motivation throughout the program. Therapists remotely monitored progress and communicated asynchronously, allowing personalized oversight without the need for physical presence.	Treatment adherence was remarkably high, with participants completing 96.1% of sessions and 94.5% of exercises. Performance improved significantly over time, with weighted scores rising from an average of 50.4 in the first session to 59.2 by session 18 (p = 0.002). User experience was rated exceptionally well across all UEQ dimensions, including attractiveness, clarity, efficiency, reliability, stimulation, and novelty. System Usability Scale scores exceeded expectations, averaging around 86 for participants and 88 for family members. Participants also reported mild to moderate cognitive improvements based on Patient Global Impression of Change scores. The HomeCoRe program was seamlessly integrated into daily routines, supported by high levels of motivation and autonomy. Interestingly, participants’ technological skills correlated only with their sense of autonomy in using the system, not with adherence or performance outcomes. While some exercises, such as Learning of Couples and Span Backward, were perceived as more challenging, concerns about timing and difficulty were minor. Family members noted slightly more technical difficulties but generally agreed on the program's usability and the motivation it fostered.	Significant increase in weighted performance score with Wilcoxon signed-rank test (Z = -3.11, p = 0.002) indicating medium effect size. Certainty of evidence: moderate. Preliminary (pilot) usability and acceptability study; moderate certainty on usability, no efficacy data yet.
Corallo et al. (2023)⁵¹	Telemedicine-supported psychological support and cognitive rehabilitation for hospitalized patients with dementia. Structured video call interventions involving patients, caregivers, and healthcare professionals. Psychological well-being and caregiver burden addressed through remote communication and support. Use of telepsychotherapy elements embedded within the intervention.	15 The study took place in a COVID-19 hospital ward specializing in low-intensity care for frail elderly patients with mild to moderate dementia. Hospitalization lasted around 25 days, during which the intervention was delivered continuously from admission (T0) to discharge (T1). Patients participated in daily psychological interviews and scheduled video calls lasting about an hour, involving themselves, their caregivers, psychologists, and the medical team. Electronic devices were provided to patients, enabling video calls through a secure telematic platform integrated within the hospital network. Sessions typically included video calls between patients and family caregivers at the bedside, always facilitated by a psychologist; teleconferences where the medical team updated caregivers on the patient's condition; and private psychological support meetings for caregivers to address clinical concerns and caregiver burden. Cognitive and psychological assessments were conducted face-to-face for patients and remotely for caregivers at both time points, ensuring comprehensive evaluation of outcomes.	During COVID-19 hospitalization, social isolation and visitor restrictions posed significant challenges to maintaining patient-family connections. These barriers were effectively addressed through remote video communication, which helped preserve meaningful interaction despite physical separation. Caregivers’ anxiety and distress, rooted in the lack of physical contact and uncertainty about their loved ones’ health, were alleviated by a structured telemedicine support system. Employing a telepsychotherapeutic approach, the team was able to overcome the absence of in-person presence by facilitating rich verbal and nonverbal communication via video calls. Both technical and emotional challenges related to hospital quarantine and pandemic restrictions were carefully managed, ensuring continuity of care and emotional support despite the unprecedented separation imposed by social distancing measures.	Following the intervention, caregivers experienced significant improvements in psychological well-being and quality of life, with all measured clinical variables showing statistically meaningful change. Notably, a strong positive correlation emerged between the quality of life scores of patients and their caregivers (Spearman's R = 0.52, p = 0.002), highlighting the interconnected nature of their experiences. Patients demonstrated meaningful gains in functional independence, as measured by the FIM, as well as improvements in cognitive status (MMSE) and reductions in behavioral symptoms (NPI), anxiety (HAM-A), and depression (GDS). Their overall quality of life (EQ-5D) also improved by discharge compared to admission. Caregivers similarly showed significant reductions in burden (Zarit Burden Interview), anxiety (HAM-A), and depression (Beck Depression Inventory), alongside enhanced quality of life. Telemedicine-based psychological support played a crucial role in sustaining the patient-caregiver relationship throughout hospitalization, helping to alleviate the distress and anxiety that arose from both the hospitalization itself and the added challenges of COVID-19 restrictions.	Correlation between patient and caregiver quality of life was moderate (R = 0.52) and significant (p = 0.002). Certainty of evidence: Moderate to low due to lack of control group, small sample size, and quasi-experimental design.
Park et al. (2022)⁵⁴	Telemedicine-based, self-administered interactive physical-cognitive exercise program (tele-Exergame). Gamified balance and motor-cognitive training exercises (leg raising, foot flexion) with explicit augmented visual feedback. Physical-cognitive dual-task training designed to improve balance and cognition during distractive conditioning.	Conducted remotely in participants’ homes over six weeks, this study used the Tele-FootX™ system wearable sensors paired with a tablet app offering real-time feedback and remote coaching during twice-weekly supervised exergaming sessions plus daily exercises. Participants received initial training and ongoing technical support. Assessments included technology acceptance, cognitive function, and anxiety at baseline and study end, evaluating both usability and clinical outcomes.	To improve adherence to balance training in cognitively impaired older adults, the program combined gamification with immediate feedback to enhance motivation. Remote supervision ensured correct exercise performance without clinic visits, while a simple, user-friendly interface minimized cognitive barriers. Home-based delivery overcame access challenges, with tailored exercise difficulty and ongoing coaching addressing memory and attention issues. Anxiety and low motivation were countered through interactive design features like rewards and progress tracking.	After six weeks, participants showed high acceptability and positive attitudes toward the tele-Exergame system, with significant gains in ease of use and perceived benefit. Cognitive function improved by nearly 10%, and anxiety decreased by 28%. Large effect sizes supported strong user engagement, while cognitive and anxiety improvements were modest but meaningful. Positive feedback from participants and caregivers underscored usability and motivation, demonstrating the feasibility and effectiveness of this self-administered, telemedicine-supervised exercise program for older adults with MCI or dementia.	TAM questionnaire: Large (Cohen's d 0.84–1.46) indicating strong increases in acceptability, perceived benefit, and satisfaction. MoCA (cognition) and BAI (anxiety): Small effect sizes (Cohen's d 0.29–0.38) indicating modest but significant clinical improvements. Certainty of evidence: Preliminary, moderate to low certainty due to small sample size, lack of control group, and short intervention duration.

Asynchronous Telerehabilitation Platform (ABILITY); Treatment As Usual (TAU); Montreal Cognitive Assessment (MoCA); Controlled Oral Word Association Test (CAT); Trail Making Test Part A (TMT-A); Immediate Total Recall (ITR); Lexical-Semantic Stimulation (LSS); Teleconference (teleconference); Face-to-Face Lexical-Semantic Stimulation (LSS-direct); Unstructured Cognitive Stimulation (UCS); Mini-Mental State Examination (MMSE); Randomized Controlled Trial (RCT); Adapted Physical Activities (APA); GOAL Tele-Rehabilitation System (Tele-R); Virtual Reality Rehabilitation System (VRRS); Tele@Home (Tele@H); Free and Cued Selective Reminding Test (FCSRT); Trail Making Test (TMT); Cognitive Reserve Index questionnaire (CRIq); Transcranial Direct Current Stimulation (tDCS); Dorsolateral Prefrontal Cortex (DLPFC); Computerized Cognitive Training (CCT); Mood-related Neuropsychiatric Symptoms (MrNPS); Cognitive Telerehabilitation (CTR); Rey Auditory Verbal Learning Test (RAVLT); Functional Activities Questionnaire (FAQ); Multifactorial Memory Questionnaire (MMQ); Geriatric Depression Scale (GDS); EuroQol 5 Dimensions (EQ-5D); Neuropsychiatric Inventory Questionnaire (NPI-Q); Depression, Anxiety and Stress Scale (DASS-21); Face-to-Face (FF); Telerehabilitation (TR); Standard Error of Difference (SED), Loewenstein Occupational Therapy Cognitive Assessment—Geriatric Version (LOTCA-G); Minimum Clinically Important Differences (MCID), Goal-Oriented Cognitive Rehabilitation (CR); Cognitive Behavioral Therapy (CBT); Canadian Occupational Performance Measure (COPM); Subjective Cognitive Impairment (SCI); Mild Cognitive Impairment (MCI); Alzheimer's Disease (AD); Telemedicine (VC); Face-to-Face (FTF); Cantonese Mini-Mental State Examination (C-MMSE); Cantonese Rivermead Behavioral Memory Test (C-RBMT); Battery for the Analysis of Aphasia Deficits (BADA), Hierarchic Dementia Scale (HDS); Quality of Life in Alzheimer's Disease (QoL-AD); Short Form 36 version 2 (SF-36v2); Zarit Burden Interview (ZBI); Revised Caregiving Self-Efficacy Scale (RCSES); User Experience Questionnaire (UEQ); System Usability Scale (SUS); Patient Global Impression of Change (PGIC); Functional Independence Measure (FIM); Hamilton Anxiety Rating Scale (HAM-A); Beck Depression Inventory (BDI); Tele-Exergame (tele-Exergame); Technology Acceptance Model (TAM); Beck Anxiety Inventory (BAI).

Discussion

This review of 15 studies illustrates that telemedicine-delivered cognitive rehabilitation offers both promising and nuanced benefits for MCI, and early dementia. Although fifteen studies represent a solid foundation for a nascent field, they also raise several critical questions. First, the comparatively recent advent of widely available digital interventions for cognitive decline may partly explain this gap. Clinical adoption is often constrained by infrastructure deficits, variable digital literacy, and regulatory hurdles, which in turn limit the proliferation of rigorous trials.^62,63 Second, the variability in study, participant characteristics, and intervention strategies highlights the challenge of standardizing research in this area. Every study, though valuable, is particular in its focus on populations or interventions, which limits the possibility of synthesizing across studies to a unified body of evidence. Qualitatively, the studies reveal a consistent pattern: with scrupulous execution, telemedicine-based cognitive treatments have marked advantages. Platforms like ABILITY⁴⁵ and GOAL Tele-R⁴⁷ exemplify a shift toward personalized, adaptive training with remote clinician oversight, enabling real-time tailoring to individual cognitive profiles and thereby enhancing both efficacy and user engagement.⁶⁴ Yet, the differences in technological development and usability across these platforms underscore the need for human-centered design in telemedicine. The success of the interventions depends not only on their clinical efficacy but also on their usability and accessibility for older adults, who can have different levels of digital literacy.⁵⁰ However, it is important to qualify these observations: only one high-quality RCT⁴⁸ reported higher attrition and technical difficulties among female participants, suggesting that these findings may reflect study-specific demographics or device familiarity rather than a universal gender barrier. Across the seven moderate- to high-quality RCTs, adherence rates were consistently robust (81–85%), and usability was rated “good” to “excellent,” with direct comparisons against face-to-face or treatment-as-usual controls confirming equivalent, or in some cases superior, cognitive gains in remote arms.^45,46,48,59 By contrast, the smaller, uncontrolled pilots,^51,54 offered promising feasibility and safety data but carry low certainty due to limited sample sizes and the absence of rigorous control groups. Furthermore, while digital literacy was flagged as a barrier in two studies,^50,53 the majority did not systematically assess participants’ prior technology experience, leaving open the question of how generalizable ease-of-use findings are across less tech-savvy populations. Notably, a minority of trials combining VR with tDCS,^48,49 point toward increasingly sophisticated, technology-driven rehabilitation.⁶⁵ Yet, such approaches, while promising for memory and executive gains, raise valid concerns about cost, scalability, and required technical expertise.⁶⁶ Wider implementation will demand specialized equipment and skilled operators-resources that may be scarce in many settings.⁶⁷ The importance of caregivers in the effectiveness of telemedicine initiatives is stressed in the research.⁶⁸ The positive effect of video conferencing on caregiver burden and self-efficacy, as shown by the Hong Kong trial,⁵⁶ indicates the bidirectional relationship between patient and caregiver well-being. This highlights the importance of using an integrated method of cognitive rehabilitation, which considers the needs of both the individual with cognitive impairment and their care network.⁶⁹ Additionally, geographical variation of the research, such as Italy, Australia, Canada, etc., highlights global applicability of telemedicine for addressing cognitive impairment. At the same time, it emphasizes the necessity for culturally tailored and contextually sound interventions.⁷⁰ The efficacy of telemedicine can be subject to variability based on cultural perceptions of technology, the condition of healthcare facilities, and availability of digital services.⁵⁴ In summary, while fifteen studies confirm that telemedicine in remains an emerging discipline, they collectively demonstrate its transformative potential for delivering personalized, accessible care in MCI and dementia. To fully realize this, future research must employ robust designs, larger samples, and explicitly address current gaps in usability, equity of access, and long-term outcomes.

Synergies in telemedicine: combining cognitive stimulation and training for optimal outcomes

Expanding on the incorporation of cognitive stimulation and training in telemedicine, it's important to differentiate their functions and possible synergies.⁷¹ Cognitive training, typically organized and repetitive, seeks to enhance particular cognitive areas such as memory or executive function via focused exercises.⁷² Research, exemplified by VRRS and CCT, demonstrates its effectiveness in improving quantifiable cognitive results.⁷³ Nevertheless, the application of these benefits to tangible enhancements in the real world continues to be a topic of debate. Cognitive stimulation, on the other hand, takes a wider approach, involving individuals in various activities that foster cognitive and social involvement, including conversations, games, and creative endeavors.⁷⁴ This method, although possibly less concentrated on particular cognitive areas, can enhance feelings of well-being and social ties, which are vital for those experiencing cognitive decline.⁷⁵ In telemedicine, the difficulty is in successfully providing both methods. Can online platforms mimic the lively, engaging quality of in-person cognitive stimulation? Additionally, how can we customize cognitive training to suit individual learning rates and varying cognitive capacities in a remote environment? The examined studies indicate that both outcomes are achievable, yet the ideal combination remains uncertain. For instance, although the ABILITY platform showed effectiveness with adaptive cognitive training exercises, the wider social and psychological advantages of unstructured cognitive stimulation (similar to what was applied in some control groups) should not be disregarded.⁴⁵ Additionally, the timing and order of these interventions are essential. Should cognitive training come before stimulation to establish a base, or the other way around to boost motivation and involvement? The available literature indicates that a flexible, individual-focused method is essential, yet additional research is necessary to identify the most effective tactics.^76,77 We should also take into account the influence of technology in enabling these interventions. Can artificial intelligence-driven platforms modify exercises instantly according to user performance, or can VR settings offer immersive and engaging stimulation experiences?.⁷⁸ In the end, the aim is to utilize telemedicine to develop a holistic cognitive rehabilitation system that combines the advantages of training and stimulation, guaranteeing that those experiencing cognitive decline obtain tailored, effective, and interactive care.

Strength and limitations

This systematic review has various strong points and weaknesses that should be addressed. One of the key aspects is the thorough examination of the literature, which includes searching various trustworthy databases to find relevant studies. This methodology ensures the study is comprehensive, making its outcomes more trustworthy by accurately portraying the status of telemedicine in dementia care. Additionally, the use of the PICO model made the screening process easier by guaranteeing that the review centered on interventions and outcomes suitable for those with dementia. This review emphasized an important aspect of dementia care with the increasing global prevalence by focusing on cognitive rehabilitation and utilizing telemedicine. It also efficiently combines findings from RCTs and other research designs on different telemedicine treatments and their beneficial effects on cognitive function, QoL, and caregiver assistance. It indicates that utilizing digital health interventions may enhance compliance, resulting in cognitive improvements, especially in those with MCI, AD, and early-stage dementia. There are also certain critical constraints of this evaluation. The evaluation of bias risk indicates certain concerns regarding the methodological quality of the studies analyzed in the review. The benefits of telehealth were emphasized, but it also mentioned the difficulties arising from differences in technology access and digital skills among older adults. These elements may decrease the overall utilization of telehealth services, especially within at-risk communities. Another constraint is that only fifteen studies in English were identified for analysis. Despite these constraints, this systematic review is a valuable contribution to the research on cognitive rehabilitation using telemedicine in dementia care. While it acknowledges the positive impact of technology in enhancing patient results, it recognizes obstacles that must be addressed regarding fairness in access and successful execution. This suggests that upcoming studies should focus on removing these obstacles (limited digital literacy among older adults, uneven access to reliable broadband and devices, and varying levels of caregiver support) and continuing to explore the potential long-term impacts that telemedicine interventions could have on cognitive function and QoL for patients with dementia. New research should therefore embed structured digital literacy training for both patients and caregivers, evaluate device loan or subsidy programs to close hardware and connectivity gaps, and apply human-centered design principles to simplify user interfaces.

Conclusions and future directions

This review highlights that telemedicine cognitive rehabilitation programs can be beneficial for dementia patients, enhancing cognitive abilities and QoL, and lowering caregiver stress. There is evidence that suggests technology use in rehabilitation can substantially improve results, particularly for AD, MCI, and early-stage dementia patients. These results show that these programs boost involvement and availability of treatment when in-person interventions are not an option, like during the COVID-19 outbreak. Barriers such as unequal access to technology, availability, and digital literacy still exist, which could hinder the widespread use of telehealth solutions. Thus, the main focus should be on implementing strategies to address these barriers and ensure equal access to telemedicine for all populations. Research should also examine the long-term viability of interventions and how telemedicine can complement traditional care methods. Additional value may also be found by combining telehealth with new technologies like VR and neuromodulation techniques. Ultimately, upcoming studies should also focus on improving telemedicine techniques to cater more to individual patients, and to evaluate the impact of this method on cognition and support for caregivers.

Footnotes

Acknowledgments

The authors have no acknowledgments to report.

ORCID iD

Maria Grazia Maggio

Author contributions

Andrea Calderone: Conceptualization; Investigation; Methodology; Validation; Visualization; Writing – original draft.

Angela Marra: Conceptualization; Methodology; Resources; Validation; Visualization; Writing – review & editing.

Desirèe Latella: Data curation; Validation; Visualization; Writing – original draft.

Paolo De Pasquale: Data curation; Validation; Visualization; Writing – original draft.

Loris Pignolo: Validation; Visualization; Writing – original draft; Writing – review & editing.

Maria Grazia Maggio: Supervision; Validation; Visualization; Writing – original draft; Writing – review & editing.

Rocco Salvatore Calabrò: Conceptualization; Formal analysis; Methodology; Project administration; Resources; Supervision; Validation; Visualization; Writing – review & editing.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by Current Research Funds 2025, Ministry of Health, Italy.

Declaration of conflicting interests

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

Data availability statement

The data supporting the findings of this study are available within the article.

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