Abstract
Introduction: Due to the fact that individuals reach a higher age, mild cognitive impairment and Alzheimer’s disease will occur more and more. The aim of this literature review is to show how much research is done in online interventions by Mild Cognitive Impairment or Alzheimer’s’ disease, and what the results are of these interventions.
Materials and Methods: PubMed was searched for studies that examined the results of different online interventions for mild cognitive impairment and Alzheimer’s disease.
Results: Seventeen studies met this literature review’s criteria. Ten studies applied an online intervention in middle-aged healthy adults, adults with MCI, adults with AD or health care givers. Lifestyle changes by setting new goals, due to several online interventions, show a decrease of risk factors and an increase of protective factors. Home-based online interventions as smartphone applications show an increase in self-management and motivation. Besides lifestyle changes, increase in self-management and motivation, results show also improvements in different domains of cognition. These improvements caused by online interventions increased social interaction and therefore resulted in higher protection on developing AD. Also AD knowledge in health care givers was increased by a visiting Alzheimer’s associated website.
Conclusion: Main finding of this literature review include that there is not enough research done towards online interventions for MCI and AD. Nevertheless this small amount of studies using online interventions, show interesting diverse outcomes on all kinds of scales and various in scores.
Keywords: Alzheimer’s disease (AD), mild cognitive impairment (MCI), quality of life, online intervention(s), web-based, multimedia, online, website and training.
Introduction
Mild Cognitive Impairments, Dementia and Alzheimer’s disease
The process of becoming old is a natural process and happens to every individual. Healthy cognitive aging is a slow declining process; the brain has the capacity to compensate different declining processes. This capacity is depending on specialized networks between parts of the brain and the brain reserves. Forgetfulness can occur at different ages, but is increasing when individuals get older. Sometimes forgetfulness can be a pre-developing stage of cognitive disorders. If cognitive tests show a loss of brain functions and if a loss of brain functions have a negatively influence on daily life, it relates to dementia (5De Cano van de Gerontologie, van Boxtel, M., 2016)
27.000 individuals in the Netherlands are suffering from dementia. The chance to develop dementia is around 20% (4Leven met Alzheimer, 2016). The biggest risk factor to develop dementia is increasing age and the most common form of dementia is Alzheimer; 60-70% of patients with dementia have Alzheimer (4Leven met Alzheimer, 2016; Holford, P., 2011). In the Alzheimer’s disease accumulation of proteins take place in neurons in the brain (2Alzheimer Nederland, 2016). Each part of the brain has his own function and show clinical symptoms if affected. Alzheimer disease evolves gradually, where the complaints increase in small steps. It frequently occurs when patients reach the year of 70, due to increased risk factors during lifetime. Nevertheless it can also start at an earlier age (6The DANA foundation, Schnabel, J., 2013; Anstey et al., 2013). The cause of Alzheimer is unknown and there is still a lack of scientific evidence to substantiate the cause.
A pre-phase of Alzheimer’s disease (AD) is Mild Cognitive Impairment (MCI), since patients with MCI face a higher risk of developing AD. However it is also possible to have a steady state MCI, where patients will not develop AD at all. MCI are brain dysfunctions and causes memory dysfunctions (amnestic MCI) and thought process dysfunctions (non-amnestic MCI) (8Alzheimer’s Association, 2016). Some individuals that face cognitive dysfunctions can still function normally when executing tasks on a daily basis (2Alzheimer Nederland, 2016; 7VUmv Alzheimer centrum, 2016; Holford, P., 2011).
Interventions
Interventions of MCI and Alzheimer are limited. Various drug interventions, face-to-face helping interventions and caregiver interventions (medical interventions) are available. Nevertheless, the interventions available cannot eliminate underlying pathology, but can only alternate symptoms (5De Cano van de Gerontologie, van Boxtel, M., 2016; 7VUmv Alzheimer centrum, 2016). Results of recent studies indicate a focus on clinical symptoms reduction, alternation or risk factors reduction. The interventions are based on changing these symptoms or factors. Interventions on patients already diagnosed with AD or MCI will effect the clinical symptoms, whereas interventions on patients at risk will effect risk factors which have a higher risk on developing AD or MCI (6The DANA foundation, Schnabel, J.,2013; Norton C.M. et al, 2015). Face-to-face interventions include developing a (personalized) health care program to provide assistance with the basic needs, such as physical activities, lifestyle, nutrition and cognitive activities. Additionally, caregiver interventions facilitate these personalized patient intervention programs and provide assistance with daily tasks with a focus on psychosocial, social and physical activities (3Alzheimer Nederland, 2016)
Online Interventions
Nowadays, medical institutions provide interventions online to help patients and caregivers more easily and efficiently. Online interventions are a method to support the traditional interventions (e.g. drug, interventions, face-to-face interventions, caregiver interventions) and are used for informative, preventive and treatment approaches. For caregivers that help diagnosed patients, online interventions are focusing on providing knowledge about the disease and how to help the patients correctly in different situations (Hughes M.L et al, 2015). The use of online interventions for threating patients that are diagnosed with MCI or Alzheimer’s disease is a main topic in the medical world. There is a lack of research that study what online interventions are and what the effectiveness is of using online interventions compared to using traditional interventions on diagnosed patients with MCI or AD. Additionally, there is still a big gap surrounding the subject of online interventions for MCI and AD. This literature research brings all relevant articles together to see what kind of studies and how many studies where completed on online interventions for MCI and AD. Online interventions is a very important tool in the process of therapy, since it is more time efficient and cost efficient to facilitate patients in this manner. Additionally, online interventions will reduce the burden of people executing the interventions (Hughes M.L et al, 2015)
Methods
Inclusion criteria
Due to de difference in all studies, there were almost no corresponding inclusion or exclusion criteria (see appendix, All different inclusion and exclusion criteria for each study). Studies need to have specific keywords (search procedure) in title or abstract. The selected studies need to eligibility/comply to the inclusion criteria of this literature review. Inclusion criteria’s are: written in English, studies published after 2012 (except one study), participants need to have MCI or AD or had to be healthy, scientific articles, online intervention, measurable outcomes.
Search procedure
Using the electronic PubMed database, reference lists and citations of articles (see appendix, Figure 1,2,3 Search history). The following MeSh terms were used: “Alzheimer’s disease”, “Mild cognitive impairment”, website, online and “Quality of Life”. The following Tiab terms were used: “Alzheimer’s disease”, “Mild cognitive impairment”, “online intervention(s)”, web-based, cancer, website, e-health, “Quality of Life”, online, “web-based intervention”, “online help”, nutrition, exercise, training, multimedia, support, “cognition, tests” and “computer-assisted instruction”. For this systematic review Cochrane library, Elsevier Journals, Google scholar, JMIR publications have also been used.
Keywords: Alzheimer’s disease (AD), mild cognitive impairment (MCI), quality of life, online intervention(s), web-based, multimedia, online, website and training (last search was 21th of June 2016).
Study procedure
Different combinations of the selected keywords(see appendix, Figure 1,2,3 Search history). Gave a total of 46 articles. At first, the titles were read and needed to comply to this literature reviews criteria. 28 articles remained and the abstracts were read. Only 4 articles met this literature review criteria and were found by the snowball method (citations and reference lists) and were additionally added to the selection. After that, studies were excluded due to the fact that the interventions were not focused on online interventions and the abstracts did not match this research. The remaining 20 articles were fully read and after that still 3 studies were excluded. At the end 17 studies were included to this literature review, since they complied with the inclusion criteria’s. These articles focused on online interventions for middle-aged (healthy) adults, or adults with AD, or adults with MCI and showed outcomes with different measurements (see appendix, Figure 4. Flowchart).
Measures
The studies that were used in this literature review did not have corresponding online interventions and did not have corresponding outcome measurement tools. The measurement tools varied from simple risk and protective factor lists, to intermediate memory and verbal tests, to complex tests were different domains derive a score. For example tests such as AD knowledge scales, ADAS-cog, MMSE, ANU-ADRI and many more (see appendix, Measurements for each).
Results
The selected studies used in this literature review had multifarious results and differed from each other in online interventions. Multiple studies showed increasing outcomes due to online interventions. A part of the outcomes were expressed in different scales (see appendix, Tabel 1.). Two studies used participants with MCI, two studies used participants with AD, three studies used participants at risk developing AD and five studies used healthy adults. A part of these studies used healthy adults compared to participants having MCI or AD. Due to big differences between the studies it was hard to get clear overall results, therefore the results are divided into a few categories. For a quick overview of the different results see appendix, Table 1.
Online interventions and risk reduction
Anstey et al. (2015) shows that middle-aged adults had a significant decline in the Australian National University Alzheimer’s Disease Risk Index (ANU-ADRI) score after a Body Brain Life (BBL) online intervention for 26 weeks, compared with the control group without BBL online interventions. The BBL group and the BBL + Face-to-Face (FF) group showed an increase of protective factors. Participants will make lifestyle changes after and during these online interventions. These lifestyle changes will increase protective factors and decrease risk factors (Anstey K.J. et al, 2013). Positive alterations in lifestyle in both groups (BBL and BBL + FF) resulted in improvements of the ANU-ADRI score over a period of 12 and 26 weeks (Anstey K.J. et al, 2015). The improvement of the ANU-ADRI score gives a reduction on the overall risk of developing AD (Anstey K.J. et al, 2013). Norton et al. (2015) indicates that custom smartphone applications among middle-aged adults could be useful as an intervention to implement changes in lifestyle behaviour. Positive lifestyle changes cause a prevention of AD and are associated with a lower risk on developing AD. Additionally, E-health lifestyle interventions are useful to set up goals and to realize these goals. These goals are leading to changes in lifestyle behaviour. E-health interventions showed improvements especially on overall lifestyle and weight loss. Changes in risk factors associated with cognitive decline, due to lifestyle alterations, showed an improvement and lasted for one year. This tool can be helpful by preventing early stage cognitive decline and is a perfect tool to increase self-management of risk factors for middle-aged adults (Aalbers T. et al, 2016). The research of Van Osch et al. (2015) shows that the use of online interventions, such as IVitality, motivates patients (at risk) to monitor their health at home.
Online interventions and cognition
Computerized Cognitive Training (CCT) and Virtual Reality Cognitive Training (VRCT) as an online intervention showed consistent improvements on different cognitive domains (attention, executive functions, memory) of participants that are facing high risk of cognitive decline. Beside the positive results on cognition, depressive symptoms and anxiety were significant reduced. CCT and VRCT are interventions showing long-term improvement of cognition (Coyle H. et al, 2015). Additionally, Dodge et al. (2015) specifies that web-enabled conversational interaction interventions showed improvements for cognitive healthy adults and for adults with MCI. Cognitive healthy adults improved their language and executive functions and adults with MCI had improvements in psychomotoric speed. Participants using web-enabled conversations showed an increase in social contacts/activities (Dodge H.H. et al, 2015). Hughes et al. (2013) point out that increased social interactions and social networks results in to higher protective function on developing AD.
The study of Tarranga et al. (2016) shows that interventions with interactive multimedia internet-based system (IMIS) and with the integrated psychostimulation program (IPP) showed higher outcomes on the Alzheimer’s Disease Assessment Scale- Cognitive Subscale (ADAS cog) and the Mini-Mental State Examination (MMSE). We can conclude out of these measures that AD patients improved cognition in both groups. Outcomes on the ADAS cog and MMSE scale were unchanged after a 24 weeks follow up. Participants using IPP had also better results compared to participants getting the Choline Esterase Inhibitor treatment (ChEIs), these results were declining after 24 weeks. The IMIS intervention showed improvement, for all individual patients on all individual tasks, above and beyond IPP alone and lasted for 24 weeks (Tárranga L. et al, 2016).
Vermeij et al (2015) researched the influence of online training on patients with MCI and showed that healthy older adults and adults with MCI showed improvement on digit span and spatal span after online working-memory training. Improvements in working memory functioning are related to less ageing related decline (Vermeij A. et al, 2015).
Online interventions and Knowledge
Alzheimer’s associated website (www.alz.org) was used to improve knowledge of AD for health care provides. After visiting the website, participants had higher scores on the Alzheimer’s Disease Knowledge Scale (ADKS). However, Hughes et al. (2015) indicates that healthcare workers benefit more from the website than non-healthcare workers.
Online interventions and Quality Of Life
Patients with AD are using the same quality of life scale as people in general; cognitive functioning, ability to perform activities of daily living, engage in meaningful time use and social behaviour, balance between positive emotion and absence of negative emotion (Lawton M.P. 1997). Lawton (1997) stated that several factors could improve the quality of live. Exercise can decrease the chance to develop different chronicle and non-chronicle diseases (e.g. diabetes, hypertension, stroke, cardiovascular diseases). These diseases may have an association with higher risk of AD. Exercise has positive effects on blood circulation including circulation in the brain, emotional health, stress release and joy. Besides normal exercise, mental exercises and therapeutic activities are also important. They are associated with preservation of cognitive function. Enjoyable activities may reduce stress or agitation and improves the quality of live. Activities on different levels and in different categories can support physical, mental and social states. Looking at nutrition, a varied diet can improve energy levels of everyday activities (2Alzheimer Nederland, 2016).
QOL has been researched after using online interventions in cancer patients or in patients after treated for cancer (see appendix, table 4.)
Overall, online interventions have positive effects on: lifestyle, cognition, knowledge and can result in a higher QOL in patients with MCI or AD.
Discussion
Unfortunately, not much research is done on online interventions, however it can be of great importance for facilitating the interventions of the future.
The aim of this study was to review the literature on online interventions for MCI or AD. The study of Anstey et al. (2015) shows lower rates on the ANU-ANDRI score caused by the BBL online intervention. The control group did not get the BBL and did not show a reduction of ANU-ADRI score. Due to the fact that the score declined, patients have less risk on developing AD. This online intervention has effect on different parts of risk factors and protective factors. This is a good randomized controlled trial to see whether there are studies done showing good outcomes of implementing online interventions (Anstey K.J. et al, 2015). Not only different online interventions can reduce risk factors, custom smartphone applications showed us that they can improve lifestyle and therefore lowering risk factors as well (Norton et al., 2015). Patients at risk are willing and highly motivated to contribute to home-based monitoring using smartphone applications (van Osch M. et al, 2015). These outcomes show that people at risk want to know what their personal risk is on developing AD and how they can affect their risk by attributing their lifestyle. This is a good and easy way to let patients self-monitor their health. It is really motivating if you can see changes after a while on an application, which you can consult any time. Besides using smartphone application, self-motivated e-health interventions where also implemented. Patients set goals and after implementing lifestyle changes that give positive results, goals were achieved (Aalbers T. et al, 2016). Self-monitoring lifestyle changes and risk factors lead to more motivation. The online interventions are requiring an active attitude through working with it on a daily basis or a few times in a week. This is a good way to let patients get more knowledge and higher consciousness level of the disease and their way of living.
The selected studies were not only showing effects on lifestyle and risk factors, but they additionally found out that online interventions have an effect on cognition. Virtual reality training increases different domains of cognition (Coyle H. et al, 2015). Increasing domains of cognition is important to keep the brain active and to lower risk of developing cognitive decline. Training the working-memory online gained trained and untrained tasks in healthy participants and patients with MCI. Conversational interactions using a webcam are giving positive results in cognitive healthy participants and patients with MCI. Improving the amount of conversations and conversation skills are great ways to improve social contacts. Higher social networks and social interactions are protective factors on developing AD (Dodge H.H. et al, 2015). Add up a multimedia tool to a drug intervention and greater outcomes in ADAS-cog and MMSE scores will be derived.
Distance education platforms are set up to give information and increase knowledge in an easy way. Health care workers and patients increased knowledge after visiting the website (Hughes, M.L et al 2015). Health care workers can be supported by these websites. This will result in a better way of helping patients with cognitive, functional and behavioural functions.
Strengths and limitations
This literature review presents the small amount of studies that are conducted in the field of online interventions for MCI or AD. Despite the fact that not much research is done, these studies show good outcomes, that can be seen as strengths. A limitation of this literature review is the use of different measurement tools to define the influences of various online interventions.
Clinical implications
Online interventions for MCI or AD have positive effects on reducing risk factors, increasing protective factors, changing lifestyle, different domains of cognition, knowledge, social interaction and more (see appendix Table 1.). This study presents that online interventions could be a enrichment in the therapy of patients with MCI or AD. There is no clear conclusion possible about specific online intervention leading to a specific outcome, due to the lack of studies regarding this manner. Future studies should examine more conform online interventions over a large period of time to say something about the prospective effects of online interventions. Bigger samples and better selection of participants are needed to generalize the outcomes over the population.
Conclusion
This literature review presents that there is not enough research done towards online interventions for MCI and AD. The small amount of studies that were found show interesting diverse outcomes on all kinds of scales and scores after using different online interventions in middle-ages healthy adults, adults at risk, adults with MCI, adults with AD and caregivers.