The Effectiveness of TECH: Tablet Enhancement of Cognition and Health, Cognitive Training Using Touchscreen Tablet Gaming Applications, for Older Adults With Mild Cognitive Impairment
Phase: NA
Conditions: Mild Cognitive Impairment
Sponsor: Assuta Hospital Systems

 
The Effectiveness of TECH: Tablet Enhancement of Cognition and Health 
NCT02955277 
March 2020 
 

OBJECTIVES  
To establish the effectiveness of the ‘Tablet Enhancement of Cognition and Health’ 
(TECH), a novel cognitive intervention for improving global cognition, specific cognitive 
components, and health-related quality of life (HRQoL) in older adults with Mild 
Cognitive Impairment (MCI), compared with a control group. 
METHODS 
Study design 
This is a single-blind randomized controlled trial (clinical trial number NCT02955277) 
with assessments administered pre and post the 5-week intervention, and at 6-month 
follow-up, by assessors blind to group allocation. 
Population 
Community dwelling older adults (>65 years) were recruited from two community 
geriatric clinics due to their memory problems, and were referred to the study by their 
family or geriatric physician. Inclusion criteria were as follows: a) a diagnosis of MCI, as 
determined by a score of 19-25 points on the Montreal Cognitive Assessment (MoCA), a 
valid and reliable tool,  subjective memory complaints supported by a family member, 
and independence in basic and instrumental activities of daily living (BADL, IAD), b) 
normal or corrected vision and hearing, c) written and spoken fluency of the language, 
and d) ability to use a touchscreen tablet after an initial demonstration. Individuals were 
excluded if they experienced severe depressive symptoms (Geriatric Depression Scale> 
10 points), and if they were diagnosed with dementia, or other neurological or psychiatric 
conditions. All participants signed informed consent forms before participating in the 
study. 

Tools 
Outcome measures 
The Primary outcome measure was MoCA (Nasreddine et al., 2005), for assessing 
global cognition, which was also used to screen for eligibility. Additional cognitive 
assessment included the WebNeuro assessment (Silverstein et al., 2007) which is A valid 
computerized assessment battery including the assessments of the following specific 
cognitive components/domain (subtests): Sustained attention (Continuous Performance 
Task), 22 controlled attention (Verbal Interference Task), flexibility (Switching of 
Attention Task), inhibition (Go-NoGo Task), working memory (Digit Span Task), 
memory recall (Memory Recall Task), problem solving (Maze Task). For each domain a 
raw score was calculated, and then converted to a z score, with a normative average of 0, 
and a standard deviation of 1. Higher scores for each domain indicates better 
performance. The secondary outcome measures included The Tower of Hanoi (ToH) task 
(Simon, 1975), a commonly used goal-directed measure assessing problem-solving, and 
specifically, planning. A computerized version of the task was used 
(http://vornlocher.de/tower). The participants completed the first three (out of six) levels 
of the task. the number of moves per level, and time for completion were recorded. the 
12-Item Short Form Health Survey (SF-12) (Ware, Snow, Koskinski, & Gandek, 1993) 
for measuring health-related quality of life; physical and mental composite summary 
scores (Wilson, Tucker, & Chittleborough, 2002), higher scores indicating better health 
measures (Ware et al., 1993). The General Self-Efficacy Scale (GSES) (Schwarzer& 
Jerusalem, 1995), which is highly reliable and valid scale for assessing optimistic self-
beliefs to cope with a variety of difficult demands in life. It consists 10 statements such as 

‘I can solve most problems if I invest the necessary effort’. The total score ranges from 
10 to 40. Higher scores represent higher levels of general self efficacy (Schwarzer 
&Jerusalem, 1995). In addition, demographic information and previous experience with 
technology use (computer, smartphone and tablet) were collected.  
The Intervention  
The TECH intervention (study group) included daily self-training facilitated by weekly 
group sessions. Participants received iPads to take home and were requested to play 
puzzle-game apps, which simultaneously provided practicing different cognitive 
components, 3-5 times a week X 30-60 minutes, for a total of 15-25 training sessions. 
Weekly one-hour sessions led by an occupational therapist (OT) took place in a small 
group setting (4-6 participants) over a five-week period. These sessions focused on 
teaching tablet operation, allowing participants to explore and practice new apps, and 
increasing their confidence and independence in using and activating the tablet. 
Standard care (control group). Participants received standard occupational therapy care 
for MCI including either a) a single consultation in a group setting (4-6 participants) to 
encourage participants to engage in activities such as solving crossword puzzles or 
playing board or card games in their leisure time to stimulate cognitive function; or b) 
participation in a social group (six one-hour sessions of 4-6 participants) of playing 
puzzle board games, with no recommendation to perform self-training at home. 
Procedure 
Participants were approached by phone and were provided with information about the 
study. Those who were willing to participate were invited to the geriatric clinic for the 
assessment session. After signing an informed consent form, the MoCA, GDS, BADL, 

and IADL questionnaires were administered to confirm eligibility. If the participants 
were found eligible, the remaining outcome measures were administered. Then 
participants were stratified according to low (19-22 points) or high (23-25 points) MoCA 
score and then randomly allocated to the TECH or control group using a 1:1 ratio. 
Allocation was concealed from the investigators and the enrolled participants. 
Participants were notified by phone about their allocation. The assessors, who were blind 
to group allocation, were OTs trained to assess the study. Participants who were invited 
to the post- and follow-up assessment sessions were asked not to discuss the intervention 
with the assessors.  
Data analysis 
'IBM SPSS Statistics 25' software was used for descriptive statistics to characterize the 
sample and outcome measures for the three assessments. Since the outcome measures 
were not normally distributed, non-parametric tests were performed. Intention-to-treat 
analysis was conducted with the last observation carried forward method, which is an 
acceptable data imputation method.26 The percentage change was calculated for MoCA, 
WebNeuro, and SF-12 measurements between pre and post and between pre and follow-
up using these formulas[(post-pre)/pre*100%], [(follow-up-pre)/pre*100%]. The 
difference between groups for the percentage change was tested using the Mann Whitney 
Test.  Since significance tests are highly dependent on the sample size, the effect size was 
also estimated by using the effect size formula for non-parametric tests: Cohen’s r=Z/√N. 
The Z value was retrieved from the Mann Whitney test U output. Cohen’s r effect size 
values were considered small (0.1), medium (0.3), and large (0.5). 

In each group, we calculated the percentage of participants who achieved the 
Minimal Clinically Important Difference (MCID) improvement in global cognition. 
MCID is defined as the smallest change in scores perceived by the patient as beneficial, 
which could lead to a change in the patient’s treatment. In this study, the MCID of the 
MoCA was considered an improvement of at least 1.22 points, as found in Stroke 
Rehabilitation (since MCID data for individuals with MCI, to the best of our knowledge, 
have not yet been established). 
 
The sample size was calculated using 'G*Power 3.1.9.4' software, according to a 
small effect size, based on previous studies assessing the effectiveness of computerized 
cognitive training for older adults with MCI, with 80% power and a significance level of 
0.05. A sample size of 68 participants was calculated. Taking into consideration a 20% 
drop-out rate, 80 participants were required.