Applying a Person-Centered Approach to Enhance Cognitive Training in Senior Living Community Residents With Mild Cognitive Impairment
Phase: NA
Conditions: Mild Cognitive Impairment
Sponsor: University of Rochester

Date: 2/26/2018 
 Applying a Person-Centered Approach to Enhance Cognitive 
Training in Senior Living Community Residents with Mild 
Cognitive Impairment (CogT-PACT study) 
 
 
Study Protocol 
 
NCT03292705 
 
Date: 2/26/2018 
 

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 Applying a Person-Centered Approach to Enhance Cognitive Training in Senior Living Community 
Residents with Mild Cognitive Impairment (CogT-PACT study) 
 
Principal Investigators: Feng (Vankee) Lin, RN, MB, PhD, School of Nursing; Benjamin Chapman, 
PhD, MPH, Department of Psychiatry 
Co-Investigators: Anton Porsteinsson, MD. 
 
1. STUDY OVERVIEW – PURPOSE AND BACKGROUND 
Computerized cognitive interventions (CCIs) have been increasingly widely implemented among older 
adults with mild cognitive impairment (MCI) (Jean, Bergeron, Thivierge, & Simard). Compared to 
traditional cognitive interventions, CCIs offer additional benefits including matching training content 
and difficulty with individual performance, visual appeal and variety, transportability, and scalability. 
However, the efficacy of CCIs in maintaining or improving older adults’ cognitive and functional 
health has been modest in an overall sense, and highly variable across individuals and studies. For 
example, in a recently completed RCT in older adults with MCI, we found similar to others (Rebok et 
al., 2014; Wolinsky, Vander Weg, Howren, Jones, & Dotson, 2013) that vision-based speed of 
processing (VSOP) training, a widely-applied CCI, was superior to an active control in improving both 
trained (i.e., attention and processing speed) and untrained (i.e., working memory and instrumental 
activities of daily living) outcomes (Lin et al., in press). However, considerable variability appeared 
around the main effects for the intervention. This variability was not explained by typical demographic 
or clinical factors, leading us to suspect other processes at play in older adults’ treatment response 
(Steinerman, 2011). Intriguingly, individuals’ attitudes toward technology use may help explain the 
variety in VSOP training effects (Lin et al., in press). Negative attitudes about computers—defined 
broadly by affective, cognitive, and behavioral-motivational components, may interfere with 
engagement with, and thus the efficacy of, CCIs (Steinerman, 2011). Negative attitudes toward 
computers may be even more common in older adults with MCI (Wild et al., 2012), underscoring the 
crucial need to address them if CCIs are to achieve their full potential. The goal of this R21 application 
is to generate proof of concept for a means to address negative attitudes towards computer technology. 
Importantly, we will then assess whether improved attitudes toward computers enhance engagement 
with and efficacy of CCIs in older adults with MCI.  
 
Person-centered care—that is, integrating individuals’ preferences throughout the process of 
intervention--has improved intervention engagement among older persons, including those with MCI 
(Kolanowski, Litaker, Buettner, Moeller, & Costa, 2011). A recent intervention predicated on this 
person-centered approach is called a “personalized engagement program” (PEP). PEP involves a 
database of individualized computer-led leisure activities. Our recent pilot data in assisted living 
facilities suggest that PEP promotes psychological well-being among older persons with MCI, and may 
shift computers from dauntingly complex or personally irrelevant devices to familiar, enjoyable 
technology. These results are consistent with a number of theories indicating that exposure to 
pleasurable experiences with an object or task improves several dimensions of attitudes, including 
affective and cognitive components, as well as behavior and motivation. Theories of attitude change 
and motivation (Cervone, Artistico, Berry, & Hoare, 2006; Harmon‐ Jones, Amodio, & Harmon‐
Jones, 2009) suggests that PEP may act as a “mastery experience”, pairing positive affect or better 
attention with successful goal-attainment in computer use, thereby reducing negative attitudes and 
increasing computer self-efficacy. If effective, this strategy would be the first to augment traditional 
CCIs with a non-cognitive psychological component (Lagana, Oliver, Ainsworth, & Edwards, 2011; 
Wild et al., 2012).  
 
Grounded in both our pilot data and the theory around it, we seek to take the next step in an arc of 
research ultimately intended to improve the efficacy of CCIs. Our Aim in this proposal is to conduct 
a small “proof-of-concept” randomized controlled trial (RCT) to assess whether an initial period 

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of PEP, followed by a standard CCI, improves a) attitudes toward computers, b) affective and 
attentional engagement with the CCI, and c) cognitive outcomes, compared to an attention control 
period followed by CCI. Our design involving stratified random assignment of 50 senior living 
community residents with MCI from several similar senior living communities to these two groups. 
The initial phase involves 4 weeks of either attention control or PEP, a “dose” suggested by prior work 
on attitude change and computers, followed by 6 weeks of CCI for both groups (a period our prior work 
indicates is sufficient for change in key cognitive domains among this population). We will assess the 
following outcomes: (1) attitudes toward computers at baseline, 4 week, post-training, and a 3-month 
follow-up, (2) affective and attentional engagement in CCI during intervention period, and (3) multiple 
cognitive domains at baseline, 4 week, post-training, and 3-month follow-up. Since the interventions 
will occur in the senior living communities (SLCs), our design eliminates the burden of special visits to 
study locations and seamlessly integrates the intervention into daily routines. Equally as importantly, 
assisted living facility residents with MCI are at higher risk for developing dementias (Hyde, Perez, & 
Forester, 2007; Kaufer et al., 2008) and a high priority in NIA’s mission to prevent Alzheimer’s disease 
(e.g., PA-15-015). We thus feel that the study’s impact upon the rapidly developing field of CCIs is 
potentially high, and ideal for the “high-risk high-reward” or proof-of-concept spirit of the exploratory, 
developmental R21 mechanism. Support for study hypotheses would form the foundation for a 
subsequent R01 taking the approach to full scale. 
 
2. CHARACTERISTICS OF THE RESEARCH POPULATION 
 
2.1. Subject Characteristics 
 
a) Number of Subjects:  A single-blinded, multi-site, randomized controlled trial will be 
conducted. A total of 50 participants will be recruited from several similar SLCs in the New 
York State. Randomization will be stratified by size of SLC (11 participants randomized to 2 
groups in SLCs with 60-80 beds, 14 in SLCs with >100 beds).  
 
b) Gender and Age of Subjects:  aged 60 years or older. \ Most of the literature reports an 
equal gender representation in MCI population (although one or two regional studies 
reported higher incident rate of MCI in males from the Mayo Clinic). However, the 
proportion of female is significantly higher among SLCs (> 65%). We thus expect our 
sample to represent a balance between typical SLC composition and MCI distribution, and 
expect roughly 1/3 to 1/2 men (n = 17-25) and 1/2 to 2/3 women (n = 25-33). 
 
 
c) Racial and Ethnic Origin: We plan to recruit 8% of minority (4 African American 
participants) from the SLCs. The percentage is higher than the 4% minority population in the 
Monroe County. 
 
 
d) Vulnerable Subjects: All subjects will have the capacity to provide consent by assessing 
their comprehension and capacity of decision making. 
 
2.2. Inclusion and Exclusion Criteria 
 
 
a) Inclusion Criteria: (1) in-screening results which fall within the cutoff range of scores seen 
in ‘mild cognitive impairment’ 
i. 18 ≤ MoCA ≤ 26 
ii. RAVLT Delayed Recall Total Score ≤ 6 (or 1.5 SD below age-corrected 

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norms) 
iii. GDS Total Score ≤ 6 
iv. ADL-PI-self Total Score ≤ 30 
v. UBACC an intact score (score 2 on items 1, 2, 4, 7, & 9)  
vi. if on AD medication (i.e., Memantine or cholinesterase inhibitors), 
antidepressant, or anxiolytics, no changes of doses in the 3 months prior to 
recruitment;  
vii. others: age ≥60 years, English-speaking, adequate visual and hearing acuity 
for testing, resident of senior living community.   
b. A board-certified geriatric psychiatrist (Dr. Porsteinsson, co-I) will review 
individual cases to ensure the validity of the MCI diagnosis (amnestic single- or 
multiple-domain phenotypes);  
 
b) Exclusion Criteria: (1) current enrollment in another cognitive improvement study; (2) 
uncontrollable major depression: or other psychopathology identified by staff or medical 
records;  (3) having active legal guardian (indicating impaired capacity for decision making); 
(4) medical history of AD or other types of dementia; (5) Not a resident of a collaborating 
senior living community 
 
Eligibility will be determined after the screenings. 
 
 
3. SUBJECT IDENTIFICATION, RECRUITMENT AND CONSENT 
 
3.1.  Method Of Subject Identification And Recruitment 
Each SLC provides case management, at least one meal a day, housekeeping services, social and 
recreational activities. Randomization will be stratified by size of SLC (11 participants 
randomized to 2 groups in SLCs with 60-80 beds, 14 in SLCs with >100 beds). Staff at the SLCs 
will briefly introduce the study to the residents using the flyer. Residents who are interested in 
screening and learning more about study can leave their info on the flyer and the staff there will 
collect the information for the research team. The flyer includes a brief description of the study 
and space for individuals to leave their name, phone number, and e-mail address. SLC staff will 
secure the collected flyers in a locked cabinet in their management office specifically for the 
study purpose. Our research team will gather those periodically. Screening will be conducted at 
SLCs by our research team independently to avoid any potential perceptions of coercion by 
facility staff. 
 
3.1.1. This study has also been registered on clinicaltrials.gov (NCT 03292705). 
 
3.2.  Process of Consent 
After the initial phone screening process to determine interest and eligibility, any possible 
participants who wish to continue with an in-person screening assessment will be asked for their 
verbal consent to participate in the in-person screening. If verbal consent is provided, the 
interviewer will sign and date the verbal consent form and schedule the in-person screening 
appointment. An appointment letter can be mailed or e-mailed to the subject, if they wish, to 
confirm the appointment day and time. 
 
At the end of the in-person screening stage, our research team will go over the main study consent 
form. Each possible participants’ decision-making capacity will be assessed using UCSD Brief 
Assessment of Capacity to Consent (UBACC), based on the information given to them about the 
main study consent, to ensure older adults who attend the proposed study have adequate capacity 

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for giving consent and making decision. Subjects will not sign the consent form at this time – it is 
merely meant as a measure of decision making capacity to ensure eligibility. 
 
A copy of main study consent form will be provided to potential participants for further 
consideration. They can read through the information before their first study visit. 
 
At the first study visit, our research team will again describe the nature of the study and its risks 
and benefits and answer any questions and complete all additional elements of an informed 
consent process. The information included in the informed consent document includes: (1) the 
objective of the project as it relates to the examination of an intervention that addresses cognitive 
capacity; (2) description of timeline, the assessment and intervention procedure and components; 
(3) description of the environment where the assessments are conducted; (4) description of how 
the confidentiality regarding participant data will be protected; (5) description of the potential 
risk, relevant protections, and benefits of participating in the study. Each participant will sign the 
study-specific consent form. Participants are asked to answer five questions that assess their 
comprehension and decisional capacity to participate in research (ability to understand, 
appreciate, reason, and express opinions). The five questions were developed by Resnick et al’s 
that specifically addressed the informed consent process among cognitively impaired patients. 
They are (1) “what are two potential risks?” (2) “what is expected from you?” (3) “what if you 
don’t want to continue?” (4) “what if you experience discomfort?” (5) “how is it decided who 
gets the study intervention?” The health project coordinator will determine whether the 
participant’s responses are adequate based on the criteria provided in Resnick et al’s work. Each 
participant will sign the study-specific consent form. Note: If a participant fails to answer all 
questions correctly, the health project coordinator will re-explain relevant parts in the consent 
form. Participants are required to answer all questions correctly to continue the study. In our 
previous feasibility study, all participants succeeded in answering these questions. Participants 
will be compensated up to $70 for all study sessions they complete. The amount of compensation 
is considered appropriate for the intense and complexity of the study procedure. 
 
 
4. METHODS AND STUDY PROCEDURES 
 
4.1. Study Procedures and Assessments 
Procedure: 
A single-blinded, multi-site, randomized controlled trial of PEP+CCI, vs. control + CCI is involved. 
For PEP+CCI group, PEP will be implemented for the first 4 weeks, and CCI for the following 6 weeks. 
For the control + CCI group, an inert control condition, consisting of nothing outside of the ordinary, 
will be implemented for the first 4 weeks, and CCI for 6 more weeks. While we considered active 
control conditions, a reviewer pointed out that they pose challenges here if they share any computer or 
leisure components. As PEP is a solitary activity with a computer rather than a human-based 
intervention like psychotherapy, there is no “attention” (beyond that of the computer) to control. 
Research assistants provide the same set of assessments in each arm of the trial. Finally, at the 
developmental phase of an intervention design, an inert control is a sound starting point against which 
to test the new intervention. If proof of concept is achieved at this phase, subsequent trials will examine 
other types of control conditions. We will assess outcomes at the following time points: (1) computer 
attitudes at baseline, 4 week (the end of implementing PEP in the treatment arm), post-CCI training, 
and a 3-month follow-up, (2) engagement in CCI during intervention period, and (3) multiple cognitive 
domains at baseline, post-training, and follow-up. Assessments will be conducted by our research team. 
Separate staff blind to group assignment will conduct post-training and follow-up assessments. All 
intervention and assessments will occur in private rooms in relevant SLCs. 
 

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Interventions: 
CCI. VSOP training will use the INSIGHT online program (Posit Science), which includes five 
training paradigms (Eye for detail, Peripheral challenge, Visual sweep, Double decision, Target 
tracker) that practice processing speed and attention. All exercises share visual components and focus 
on accuracy and fast reaction times. Participants respond either by identifying what object they see or 
where they see it on the screen. The training will automatically adjust the difficulty of each task based 
on the participant’s performance, ensuring that the participants always operate near their optimal 
capacity. The training programs will automatically record the percentage of completion of each game 
and scores.  
PEP. The PEP system is built on a picture-based touch-screen interface on tablet computers. PEP 
allows users to explore and participate in entertainment, educational, spiritual, and other recreational 
activities and content personalized according to their interests and preferences. It provides easy access 
to the Internet and communication applications, and has hundreds of modules spanning music, travel, 
trivia, games, and religious and inspirational domains. For instance, if music is among a person’s 
lifelong interests, the PEP system provides access to multiple music genres through jukebox, karaoke 
and therapeutic music applications that can be tailored to a particular activity and by individual interest 
(for instance, a preference for classic jazz). As another example, for someone who likes travel or 
visiting new places, the interface offers access to Google Earth, guided tours, slide shows and regional 
facts and history. We will track the amount and type of particular usage (e.g., religion, travel, music, 
etc.) for each individual in the PEP+CCI group.  
 
Intervention format and fidelity The PEP+CCI group will practice PEP for the first 4 weeks and VSOP 
for the following 6 weeks, and control + CCI group will receive attention control for the first 4 weeks, 
and VSOP for the following 6 weeks. Computer exposure interventions effecting attitude change have 
varied from a few days or a week 25,26 to 6 weeks10; we choose a median point as 4 weeks. The 6-week 
VSOP training duration is typical in the field, and similar to our prior work (Lin et al., in press). 
Orientations to PEP and VSOP will be provided using structured manuals developed from pilot studies 
and an on-going R01 VSOP project (see Appendix for training manuals). PEP will be individual based 
for 5 hours per week for 4 weeks, while VSOP will be delivered individually or based on small groups 
(3-5 persons), depending on a participant’s preference, for 4 one-hour sessions per week for 6 weeks.. 
There will be sessions training and orienting the research team and staff of SLC on different aspects of 
the study. 
 
Standardized fidelity assessments for both data collection and intervention modality will be used across 
multiple assisted living facilities. PI or project coordinator will observe a random 10% of the data 
collection and CCI sessions at each SLC. Competence (i.e., adhering to protocol measures and rules, 
consistency in administration, competency with measures and interpersonal skills with subject) will be 
assessed and feedback will be provided to individual assessors. 
 
Measures:  
Cognitive screening (T0): The cognitive screening battery will take approximately 30 minutes to 
complete. General cognitive functioning will be measured using the (a) Montreal Cognitive 
Assessment (MoCA) version 2, a common cognitive screening measure with high sensitivity to MCI 
and easily administrable. (b) The Rey Auditory Verbal Learning Test, lists C&D (RAVLT) is a 
measure of verbal learning and memory with high reliability and validity. Depression will be measured 
with the (c) Geriatric Depression Scale (GDS) – a series of yes or no questions concerning feelings of 
depression often seen in older adults. Subjective ability to perform everyday activities will be based on 
responses to all 15-items in the (d) Activities of Daily Living – Prevention Instrument (ADL-PI-self) 
questionnaire. Questions about demographic information, subjective memory complaints, family and 

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personal health history will also be asked during screening (K. Ball, Beard, Roenker, Miller, & Griggs, 
2000; McGwin & Ball, 2002). Use of a cholinesterase inhibitor agent or Memantine and other 
medications and medical conditions will be confirmed after screening, with the subject’s verbal 
permission, with their physician. 
 
Attitudes toward technology use (Baseline [T1], End of Week 4 [T2], End of Week 10 [T3], & 
Week 23 [T4]): The Attitudes Towards Computers Questionnaire (ATCQ) will be used, one of the 
most common instruments assessing attitudes related to computer/internet. The ATCQ is a 35-item 
scale with 5-point Likert response options, assessing seven dimensions of attitudes toward computers: 
comfort (feelings of comfort with computers and their use); efficacy (feelings of competence with the 
computer); gender equality (the belief that computers are important to both men and women); control 
(the belief that people control computers); interest (the extent to which one is interested in learning 
about and using computers); dehumanization (the belief that computers are dehumanizing); and utility 
(the belief that computers are useful). It forms a single sum score, and can be broken down into subscale 
scores as well; our primary outcome is the former, although secondary analyses will examine the latter. 
The ATCQ has been used in prior research with elderly samples25,26 including those MCI persons53 with 
good internal consistency and test-retest reliability (both > .85) and validity. (Choi & Dinitto, 2013; 
Czaja et al., 2006; Czaja & Sharit, 1998)    
Engagement in CCI (throughout VSOP training): The completion percentage and score of each of 
the five tasks in the VSOP training will be recorded automatically by the program by training session 
and as total. Training performance is calculated relative to the normative data in Posit Science database 
that have completed these same configurations and expressed as a percentile.  
Cognitive and psychological measures (Assessment points: T1 -T4): The following assessments 
will take approximately 1.5 hours at each assessment period with breaks as needed, established 
durations acceptable for persons with MCI (Jack et al., 2008). a) Useful Field of View (UFOV) is a 
computerized test assessing visual processing speed and attention. This measure will not be 
administered at T2 to avoid practice effects (and we do not expect this measure to change after the 
engagement intervention).(K. K. Ball, Beard, Roenker, Miller, & Griggs, 1988; Deary, Johnson, & Starr, 2010; Melnick, Harrison, Park, Bennetto, 
& Tadin, 2013) b) EXAMINER, developed by the National Institute of Neurological Disorders, is a 
computerized test designed for clinical trials, measuring several executive function domains that are 
used to develop composite scores (verbal fluency, cognitive control and working memory). The test has 
been validated to detect cognitive function related to the prefrontal cortex (Possin et al., 2013). 
EXAMINER uses comparable assessment packages that are slightly different at each assessment point 
to avoid practice effects. For our purposes, only the following EXAMINER measures will be used to 
reduce subject burden while still assessing functioning: Category Fluency, Flanker, Set-Shifting, 
Dot-Counting, 1-Back, and Anti-Saccades. c) Brief Visuospatial Memory Test (BVMT-R) is a 
well-validated battery of long-term visual memory in terms of learning and delayed recall, which also 
includes alternate versions of the test to avoid practice effects. To reduce subject burden, the optional 
copy trial of this measure will not be used. (Benedict, Schretlen, Groninger, Dobraski, & Shpritz, 
1996). These measures are commonly used and reliable and valid for patients with MCI, (Lin, Vance, 
Gleason, & Heidrich, 2012) and used in our previous work. d) Everyday Problems for Cognitive 
Challenged Elderly Test (EPCCE) is a variation of the well-validated Everyday Problems Test which 
uses printed information to measure the degree of functioning in instrumental activities of daily living 
in older adults with some degree of cognitive impairment. The EPCCE is made up of 32 open-ended 
questions (scored binomially & summed for total score or percentage correct) about 16 printed stimuli 
cards involving seven instrumental living domains (finances, medications, phone, shopping, 
transportation, household, and meals/nutrition), with high test-retest reliability (r = .94) (Willis, 1993) 
As each activity domain of the EPCCE is assessed twice throughout the measure, the test will be split 
into two versions (v1 & v2, used at alternating time points) with each domain being measured once in 
each version. This will be done to reduce subject burden and practice effects. e) Activities of Daily 

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Living – Prevention Instrument (ADL-PI-self) is a 15-item self-report questionnaire measuring overall 
functional ability over the past 3 months on a four-point Likert scale (from 1 – 4), where responses to 
each item are summed for a total performance score (higher scores indicate more impaired functioning) 
(Galasko et al., 2006). As the scale refers to functioning in the last 3 months, it will only be 
administered at screening, and T3 and T4. f) UCLA Loneliness Scale is a 20-item self-report measure 
of perceived feelings of social isolation and loneliness on a four-point Likert scale (from 1-4) resulting 
in a total score (higher scores for this measure indicate more feelings of loneliness and isolation, both of 
which relate to depression)(Russel, 1996). We will also note any medication or other health changes 
which occur during the trial. 
Additonal information (Assessment point: Baseline): Self-report physical activities during the last 
year will be recorded with responses to the Victoria Longitudinal Study Leisure Activity Questionnaire 
(VLS) physical activity sections, and corroborated with SLC staff who observe the residents on a daily 
basis. To assess expectancy of change in attitudes toward computers, all participants will complete a set 
of items asking “How much do you expect your X to change in the next 4 weeks?” where X is one of the 
seven components of the ATCQ, and the response scale is a five-point Likert ranging from “Not at all” 
to “Quite a bit”. At the suggestion of a reviewer, a four additional constructs known be associated with 
cognitive function will also be assessed by questionnaire: the Perceived Stress Scale (PSS),(Cohen, 
Kamarck, & Mermelstein, 1983) the NEO-Five Factor Inventory (NEO-FFI),(Costa & MacCrae, 1992) 
the Life Orientation Test (LOT),(Scheier, Carver, & Bridges, 1994) and the General Self-Efficacy scale 
(GSES)(Schwarzer & Jerusalem, 2010). These questionnaires as a set average about 25 minutes. They 
will be used in tertiary, exploratory moderator analysis intended to generate future hypotheses (rather 
than test current ones) about who might benefit most and least from PEPs. Future studies can then tailor 
or target PEP if indicated, to enhance its possible impact. The goal is not a formal qualitative analysis of 
these hypotheses, but rather to allow for the emergence of information that might “slip through the 
cracks” of questionnaires and which could be useful in refining the intervention in subsequent phases.  
 
Outcome Measures 
Assesses 
Time-point Used 
ATCQ Total Score 
Attitudes towards technology 
T1-T4 
Engagement in CCI (% complete) 
Engagement with VSOP intervention 
During phase 2 
EXAMINER (Forms A-C) 
Executive functioning (cognition) 
T1 (Form A), T2 (Form B), T3 
(Form C), T4 (Form A) 
UFOV 
Visual speed of processing 
T1, T3, T4 
BVMT-R (Forms 1-4) 
Visuospatial memory 
T1 (Form 1), T2 (Form 2), T3 
(Form 3), T4 (Form 4) 
EPCCE (Versions 1 & 2) 
Functioning in instrumental daily living 
activities 
T1 (V1), T2 (V2), T3 (V1), T4 (V2) 
ADL-PI-self 
Self-perceived functioning in daily living 
activities 
T0, T3, -T4 
UCLA Loneliness 3 
Self-perceived feelings of loneliness 
T1-T4 
Background/Tertiary Outcomes 
Assesses 
Time-point Used 
VLS Physical Activity  
Physical activity 
T1 
ATCQ Beliefs 
Expected changes in attitude towards 
technology 
T1 
PSS 
Self-perceived level of stress 
T1 
Neo-FFI 
‘Big 5’ personality traits 
T1 

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LOT 
Optimism vs. pessimism 
T1 
GSES 
Perceived self-efficacy 
T1 
Medication/Health update 
Medication/health changes 
T1-T4 
Screening Measures 
Assesses 
Time-point Used 
MoCA (v2) 
General cognitive ability 
T0 
RAVLT (Lists C&D) 
Verbal  memory & learning 
T0 
GDS 
Current depressive symptoms 
T0 
ADL-PI-self 
Self-perceived functioning in daily living 
activities 
T0 
Demographic & health history 
Anamneses 
T0 
UBACC 
Capacity to consent 
T0 
 
As the living communities working with us on this study have other activities or research studies their 
residents participate in, we will also ask about whether they have participated in any other kind of 
cognitive intervention at 10 and 23 week follow-up appointments. This will allow to control for any 
confounding effects from other intervention programs or mentally stimulating activities in our later 
analysis. In addition, at the end of the study, we will send out a summary letter to all participants, will 
provide a summary of overall findings from the study. 
 
 
4.2.  Payment for Participation 
Participants will be paid $20 at baseline, $10 at week 4 intermediate assessment, $20 at week 10 
post training assessment, and $20 at week 23 follow-up. Together, participants will be paid $70. 
If a participant does not complete all sessions, he/she will be paid for the completed portion. The 
entire study procedure will occur in relevant SLCs, so no need for transportation. 
 
 
4.3. Return of Individual Research Results   
For newly diagnosed MCI, we will emphasize the screening is for research purpose, not a clinical 
diagnosis. We will suggest the participant schedule an appointment with their PCP or the 
clinician taking charge of relevant SLC to discuss the test results, and we will also refer the 
participant to the local memory clinics if the participant prefers. We will send a final summary of 
the study findings assembling de-identified information from all participants. 
 
5. SUBJECT WITHDRAWALS   
Participants will be advised during the consent process and the actual study process that they have the 
right to withdraw from the study at any time without prejudice. 
 
 
6. RISK/BENEFIT ASSESSMENT 
Risks to participants for this study are expected to be minimal.  
 
6.1. Risks to Subjects 
Some assessments carry the potential risk of being perceived as burdensome by some 
participants, although no sustained negative effects from assessments are expected.  
 

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Although the assessments involved in the study have been regularly used in clinical diagnosis, 
the challenges and potential failures from completing the assessments may produce frustration 
to the participants.  
 
Participants will be instructed that they can take a break or discontinue the assessment or 
training at any time during the assessment or training session.  
 
The alternative to PEP+CCI intervention is to participate in a CCI alone intervention, which has 
been demonstrated to improve a broad range of cognitive functions in patients with MCI. All 
participants will be reminded of the voluntary nature of study participation.  
 
Concern about identification of depression and suicide intention during the screening via the 
research team: We exclude participants with major depressive disorder who have currently (<3 
months ago) changed their dosage or type of antidepressant or anxiolytic medication, or have a 
total Geriatric Depression Scale score of 7 or higher (with scored between 5 and 6 to be further 
clarified by the clinicians), so as to avoid patients with unstable major depression or psychiatric 
disorders. We do not expect the PEP or CCI induce any depressive or anxious symptoms from 
the training. In fact, cognitive training programs have been constantly used to reduce psychiatric 
symptoms among older adults in previous studies. Also, we do not expect to observe any suicide 
intention from this group of participants. The literature does not suggest the diagnosis of MCI is 
attributed to the likelihood of suicide. Regardless, one of the co-Is, Dr. Porsteinsson is a board 
certified geriatric psychiatrist. He will provide immediate care to any participants at risk of 
suicide or clinically unstable. If a participant is judged to be at immediate high risk and leaves 
study venue against the advice of Dr. Porsteinsson, we will contact the clinician taking charge of 
the relevant SLC.  
 
Protection against risks: During informed consent procedures, individuals will be told about 
possible risks and benefits of participation. This will include questions or tests that may cause 
them to feel uncomfortable or upset. They will be informed that should they feel upset they 
should tell the interviewer, and he/she will provide a break. They will be informed that: they 
may withdraw from an assessment at any time for any reason and receive full reimbursement for 
that assessment; and, they may withdraw from the research study at any time without negative 
consequences. Of note, except providing a brief introduction of the study, the SLC staff will not 
be involved in the study procedure. Residents’ direct health care provided by the SLC will not 
affected by their decision on participating in, or later, withdrawing from the study. 
 
Psychological distress: Potential interviewers will be trained to detect distress and take 
immediate action to reduce the participant's distress. This may mean having the participant take 
a break, get something to eat, or finish for the day. The interviewer will be taught to intervene in 
a calm fashion and give the participant time to talk and become more relaxed. If these measures 
do not alleviate the problem, the interviewer will be instructed to contact the research team (Dr. 
Porsteinsson, a geriatric psychiatrist) for additional assistance. With the participant’s 
permission, we will also contact the relevant staff and physician working at the SLC. 
 
Ongoing monitoring of medical changes. We will monitor cognitive assessments across all 
assessment points. If we find any participant’s assessments fall below the range of scores for 
MCI, we will notify their SLC staff and physician with permission for further follow up and 
clinical assessments. 

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Confidentiality and privacy: All hard-copy based materials and data will be kept in a locked 
research office in a locked file cabinet.  No one other than the research team will have access to 
the data.  The list of affiliated SLC address, and the study ID numbers associated participants’ 
confidential information (i.e., names, gender, age, unique identification code in the affiliated 
SLC) will only be stored in study management software (e.g., Filemaker Pro) in a secure 
manner.  In separate data management software (e.g., Excel, SPSS), there will only be the study 
ID number associated with individuals’ responses to the questionnaires. All computer-based 
materials and data will be kept in password-protected server at School of Nursing. Servers at the 
School of Nursing are routinely audited for vulnerabilities or improper configurations by 
relevant Information Security team.  
 
Note. In the two intervention platforms (PEP and VSOP), participants are asked to enter the ID 
they get assigned. Despite no private health information will be provided on the intervention 
platform, we will still address the protection of participants’ activities in the platform, including: 
(1) in conjunction with the PI, the highly experienced IT staff will secure the intervention site 
and its operations; (2) the intervention platform, where individual training (both PEP and 
VSOP) data will be housed, will be accessed through secure password protected processes; (3) 
Online data from PEP and VSOP training will only be accessed by the participant and 
investigators and study staff directly involved in this study through secure password protected 
processes. The PEP and Posit Science which own the training programs, have constructed data 
transport and storage systems to be HIPAA and FIPS-140 compliant. 
 
6.2. Benefits to Subjects 
According to the Alzheimer’s Association report, there are 5.4 million persons who have 
Alzheimer’s disease (AD), whose care cost 200 billion dollars in 2012 and affected 10.9 million 
informal caregivers. To develop strategies that can prevent or slow the progression of AD is the 
highest priority of AD research. If the intervention is efficacious, and more importantly, if the 
underlying mechanism is fully understood, it will provide the basis for a larger, more definitive 
trial where its efficacy can be determined. Long term participants may benefit from an 
improvement in cognitive abilities. Given the risks to participants, and the scientific importance 
of the proposed investigation, the risk/benefit ratio is highly favorable and supports the ethical 
reasonableness. As will be noted in the consent form, some subjects may benefit from the 
interventions, but others may not have any direct benefit from study participation. 
 
If the intervention is successful at improving cognitive abilities, then there may be a benefit to 
future patients. The study may also provide important information on the role of PEP+CCI 
training in contributing to health and well-being and the importance of suggesting a mentally 
active lifestyle in patient-health care provider interactions, further informing health practices. 
 
6.3. Alternatives to Participation 
All participants will be informed that their participation is voluntary. They can choose not to 
participate and they may withdraw from participation at any time without affecting their care. 
Also, participants will be informed that if they feel undue burden and/or become tired with 
participation that they may stop the interview at any time, reschedule, or withdraw from the study 
if desired. Participation in the study does not preclude participants from using resources that are 
usually available to patients with cognitive deficits. 
 
7. CONFIDENTIALIATY OF DATA AND INFORMATION STORAGE  

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In School of Nursing (SON), we have a confidential data storage system called MIS system, which is 
protected by password and SON computer/internet security system per HIPPA regulation. Only 
members of the research team have access to the MIS system that is related to the study. 
 
All screening information will be assigned a "Screening ID" once the permission to contact information 
is received and stored in locked drawer in study file. Information from the screening information will 
also be entered to the MIS system. In the MIS system, if a patient is screened and not eligible or not 
interested, then no identifying information (names, etc.) will be kept in MIS. The information from 
these forms will be used to monitor reasons for exclusion. If a patient is interested in enrolling – we 
keep name/address (for appointment letters) – and then assign ID after consented.   
 
All patient data collected for research purposes will be obtained with the written consent of the patient. 
After written informed consent has been obtained, participants will be given an actual "ID number". 
Questionnaires and demographic information will be recorded only with ID numbers. This actual ID 
number will also be entered into the MIS system. All hardcopies of questionnaires and demographic 
information will be kept in a secure file in a research office at the School of Nursing and saved for seven 
years. At the completion of the subject's participation or coding of data the data would be de-identified 
to further protect the subject's privacy and confidentiality of the data. All of the data will be entered 
electronically by the PI or the data management team from the School of Nursing in the investigator’s 
computer at the SON and saved as a back up to the University main server. All electronic data from 
questionnaire, biomarkers, and demographic information will be stored on the School of Nursing 
network drive, which is password and firewall protected per HIPPA regulation, so that the PI can 
oversee the process. Access will be given only to those persons directly involved with the research. 
Individual data will not be available to anyone outside the proposed research team without the written 
consent of a participant. Confidentiality will be assured by the maintenance of the data in locked offices 
at the School of Nursing and by restricted access to computerized data. Participants will be assured that 
all data will be reported without identifiers and reported in the aggregate.  
 
The only place that link the "Screening ID" and "Actual ID" is the MIS system and the blue envelope 
utilized to randomize the participant (kept in the study file). We will use MIS system to contact 
participants for any follow-up contact (e.g., phone interview, schedule appointments). 
 
8. RESEARCH INFORMATION IN MEDICAL RECORDS 
N/A 
 
9. DATA ANALYSIS AND DATA MONITORING 
 
9.1. Planned Statistical Analysis 
The general modeling strategy will implement Generalized Mixed Effects (GLMMs) models 
with random effects for subject and site. The latter (i.e., random effects), if non-significant given 
the small number and similarity of sites, can be dropped. GLMMs yield valid estimates if data are 
Missing at Random (i.e., predictable from observed covariates) and offer the flexibility to deal 
with any distribution of outcome within the exponential family. Most outcomes are likely to be 
normal, but appropriate links and distributions will be used as needed. Given the smaller sample 
size of the trial, rather than relying on large sample theory standard error estimates, we will use 
clustered bootstrap standard errors (Field & Welsh, 2007). Power analyses. Sample size 
estimates are based on effects in our (Lin et al., in press) and others’ (Valdes, O'Connor, & 
Edwards, 2012; Wolinsky et al., 2013) previous work. Using a two-sided alpha = .05, this study 
has 80% power to detect medium effects (≥ 0.5) for the group effect on attitudes toward 
technology (H1), engagement in VSOP training (H2), and cognitive outcomes (H3). 
Preliminary Analyses. Distributions will be visually inspected for outliers, and determine the 

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best link and distribution combination for each outcome using the Quasi Information Criteria 
(Pan, 2001). The groups will be compared to determine systematic differences (failure of 
randomization) on potential covariates using Chi-square, T-tests or nonparametric analyses, as 
appropriate. Those found to significantly differ between groups will be included in models. For 
each hypothesized outcome (H1: attitudes toward computer use, H2: engagement in VSOP 
training, H3: 5 cognitive outcomes), model specification will include time, group, and their 
interaction as predictors (and controls as needed). Linear contrasts will test intervention effects at 
post-intervention. A separate model will also verify that ATCQ scores show significantly greater 
improvement at 4 weeks in the PEPs group as expected. Secondary analyses will examine the 
association between ATCQ scores at 4 weeks and CCI outcomes. ATCQ scores are intended to 
be systematically higher in the MCI+CCI group by design, but considering then on a continuous 
scale provides additional information about the “dose response” or slope of the association 
between attitudes and CCI improvements. Secondary analyses will also consider different 
domains of attitude change, explore gender moderation, and correlations between amount of 
attitude change and engagement/cognitive change. A set of tertiary, hypothesis-generating 
analyses for future intervention refinements will examine the optimism, stress, general 
self-efficacy, and the Big 5 as potential moderators. Finally, sensitivity analyses will employ 
multiple imputation to further probe the impact of any drop-out, and multiple comparisons will 
be conducted under False Discovery Rate control. 
 
9.2. Data and Safety Monitoring 
This is a pilot randomized controlled trial study (Phase I). The MPI (Dr. Lin and Dr. Chapman) 
will oversee the project, and hold regular monthly conference call with the research team, 
including SLC staff members. For each monthly meeting, the PIs will present an overall progress 
statement. The issues/concerns related to the safety of participants will include 
(1) the evidence of safety issues that should be addressed; 
(2) all serious adverse events, determine whether individual patients should be removed from the 
protocol. We acknowledge that there may be rare instances where some emergent situation 
occurs that was unanticipated regarding the welfare of the participant. In these situations, the UR 
IRB may be contacted to help resolve the situation. 
In addition, the following steps will be taken to protect the confidentiality of data and 
computer records and participant safety: 
1) 
Confidentiality will be assured by the maintenance of the data forms in locked offices, and 
by restricted access to computerized data. Only core research team members will have access to 
the name, address, telephone number, and other information corresponding to each identification 
number. Participants will be fully informed of the study requirements throughout the conduct of 
the study and will be allowed the opportunity to withdraw from participation if they cannot, or do 
not comply with the rigors of the research protocol. Handling of data will be limited to the 
numerical values and statistical summaries. 
2) 
Identifiers linking identification codes with individual names will only be available to the 
PI and study staff who contacts participants. 
3) 
The MPI have obtained the policies of the UR IRB specifically regarding adverse events 
associated with the study. The MPI will adhere to those policies, and maintain a copy of the 
policies in the study file. 
4) 
The investigators will protect the health and safety of participants, inform them of 
information relevant to their continued participation (e.g., newsletters) and pursue the research 
objective with scientific diligence. 
5) 
The following policies required by our IRB and NIH will be adhered to: (1) any adverse 
events that are serious and unexpected and are related (possibly or probably) to the study will be 
reported to the IRB and NIH within 15 calendar days; (2) adverse events that are both unexpected 

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and related that are either life threatening or result in death will be reported to IRB and NIH 
immediately; and (3) for adverse events that do not meet the criteria above will be documented in 
the summary report submitted to the IRB and NIH annually at the time of the study’s continuing 
review. Because the proposed study is minimal risk, we do not anticipate any serious adverse 
effects as described in the first two categories from a result of participating in this study. 
6) 
The MPI will ensure that the NIH (funding Institute and Center) is informed of actions, if 
any, taken by the IRB as a result of its continuing review, and recommendations that emanate 
from the monitoring activities. 
7) 
The MPI will be responsible for monitoring of this plan throughout the life of this study. 
 
10. REFERENCES 
 
Albert, M. S., DeKosky, S. T., Dickson, D., Dubois, B., Feldman, H. H., Fox, N. C., . . . Phelps, C. H. 
(2011). The diagnosis of mild cognitive impairment due to Alzheimer's disease: recommendations 
from the National Institute on Aging-Alzheimer's Association workgroups on diagnostic guidelines 
for Alzheimer's disease. Alzheimers Dement, 7(3), 270-279. doi:S1552-5260(11)00104-X [pii] 
10.1016/j.jalz.2011.03.008 [doi] 
Ball, K., Beard, B., Roenker, D., Miller, R., & Griggs, D. (2000). Increasing mobility and reducing 
accidents of older drivers. . In K. Schaie & M. Pietrucha (Eds.), Mobility and Transportation in the 
Elderly (pp. 213–251). New York, NY: Springer Publishing Co Inc. 
Ball, K. K., Beard, B. L., Roenker, D. L., Miller, R. L., & Griggs, D. S. (1988). Age and visual search: 
Expanding the useful field of view. JOSA A, 5(12), 2210-2219.  
Benedict, R. H. B., Schretlen, D., Groninger, L., Dobraski, M., & Shpritz, B. (1996). Revision of the Brief 
Visuospatial Memory Test: studies of normal performance, reliability, and validity. Psychological 
Assessment, 8(2), 145.  
Cervone, D., Artistico, D., Berry, J. M., & Hoare, C. (2006). Self-efficacy and adult development. 
Handbook of adult development and learning, 169-195.  
Choi, N. G., & Dinitto, D. M. (2013). The digital divide among low-income homebound older adults: 
Internet use patterns, eHealth literacy, and attitudes toward computer/Internet use. J Med Internet 
Res, 15(5), e93. doi:10.2196/jmir.2645 
Cohen, S., Kamarck, T., & Mermelstein, R. (1983). A global measure of perceived stress. J Health Soc 
Behav, 24(4), 385-396.  
Costa, P. T., & MacCrae, R. R. (1992). Revised NEO personality inventory (NEO PI-R) and NEO 
five-factor inventory (NEO-FFI): Professional manual: Psychological Assessment Resources, 
Incorporated. 
Czaja, S. J., Charness, N., Fisk, A. D., Hertzog, C., Nair, S. N., Rogers, W. A., & Sharit, J. (2006). Factors 
predicting the use of technology: findings from the Center for Research and Education on Aging 
and 
Technology 
Enhancement 
(CREATE). 
Psychol 
Aging, 
21(2), 
333-352. 
doi:10.1037/0882-7974.21.2.333 
Czaja, S. J., & Sharit, J. (1998). Age differences in attitudes toward computers. J Gerontol B Psychol Sci 
Soc Sci, 53(5), P329-340.  
Deary, I. J., Johnson, W., & Starr, J. M. (2010). Are processing speed tasks biomarkers of cognitive aging? 
Psychol Aging, 25(1), 219-228. doi:2010-04859-019 [pii] 
10.1037/a0017750 [doi] 
Field, C., & Welsh, A. (2007). Bootstrapping clustered data. Journal of the Royal Statistical Society: Series 
B (Statistical Methodology, 69, 369-390.  
Galasko, D., Bennett, D.A., Sano, M., Marson, D., Kaye, J., Edland, S.D. (2006). ADCS Prevention 
Instrument 
Project: 
Assessment 
of 
Instrumental 
Activities 
of 
Daily 
Living 
for 
Community-dwelling Elderly Individuals in Dementia Prevention Clinical Trials. Alzheimer Dis 
Assoc Disord, 20, S152-S169. 

Page 14 of 15 
 
Version Date: 2/26/2018 
Harmon‐Jones, E., Amodio, D. M., & Harmon‐Jones, C. (2009). Action‐Based Model of Dissonance: A 
Review, Integration, and Expansion of Conceptions of Cognitive Conflict. Advances in 
experimental social psychology, 41, 119-166.  
Hyde, J., Perez, R., & Forester, B. (2007). Dementia and assisted living. Gerontologist, 47 Spec No 3, 
51-67.  
Jack, C. R., Jr., Bernstein, M. A., Fox, N. C., Thompson, P., Alexander, G., Harvey, D., . . . Weiner, M. W. 
(2008). The Alzheimer's Disease Neuroimaging Initiative (ADNI): MRI methods. J Magn Reson 
Imaging, 27(4), 685-691. doi:10.1002/jmri.21049 [doi] 
Jean, L., Bergeron, M. E., Thivierge, S., & Simard, M. Cognitive intervention programs for individuals 
with mild cognitive impairment: systematic review of the literature. Am J Geriatr Psychiatry, 
18(4), 281-296. doi:10.1097/JGP.0b013e3181c37ce9 [doi] 
Kaufer, D. I., Williams, C. S., Braaten, A. J., Gill, K., Zimmerman, S., & Sloane, P. D. (2008). Cognitive 
screening for dementia and mild cognitive impairment in assisted living: comparison of 3 tests. J 
Am Med Dir Assoc, 9(8), 586-593. doi:10.1016/j.jamda.2008.05.006 
Kolanowski, A., Litaker, M., Buettner, L., Moeller, J., & Costa, P. T., Jr. (2011). A randomized clinical trial 
of theory-based activities for the behavioral symptoms of dementia in nursing home residents. J Am 
Geriatr Soc, 59(6), 1032-1041. doi:10.1111/j.1532-5415.2011.03449.x 
Lagana, L., Oliver, T., Ainsworth, A., & Edwards, M. (2011). Enhancing computer self-efficacy and 
attitudes in multi-ethnic older adults: a randomised controlled study. Ageing Soc, 31(6), 911-933. 
doi:10.1017/s0144686x10001340 
Lin, F., Heffner, K., Ren, P., Tivarus, M., Brasch, J., Chen, D., . . . Tadin, D. (in press). Cognitive and 
Neural Effects of Vision-Based Speed of Processing Training in Older Adults with Amnestic Mild 
Cognitive Impairment: A Pilot Study. . J Am Geriatr Soc.  
Lin, F., Vance, D. E., Gleason, C. E., & Heidrich, S. M. (2012). Taking care of older adults with mild 
cognitive impairment: An update for nurses. Journal of Gerontological Nursing, 38(12), 22-35.  
McGwin, C. O. M. S. G., & Ball, J. K. (2002). Timed instrumental activities of daily living tasks: 
Relationship to cognitive function and everyday performance assessments in older adults. 
Gerontology, 48, 254-265.  
Melnick, M. D., Harrison, B. R., Park, S., Bennetto, L., & Tadin, D. (2013). A strong interactive link 
between 
sensory 
discriminations 
and 
intelligence. 
Curr 
Biol, 
23(11), 
1013-1017. 
doi:S0960-9822(13)00494-6 [pii] 
10.1016/j.cub.2013.04.053 [doi] 
Pan, W. (2001). Akaike's information criterion in generalized estimating equations. Biometrics, 57(1), 
120-125.  
Possin, K. L., Feigenbaum, D., Rankin, K. P., Smith, G. E., Boxer, A. L., Wood, K., . . . Kramer, J. H. 
(2013). Dissociable executive functions in behavioral variant frontotemporal and Alzheimer 
dementias. Neurology. doi:WNL.0b013e318296e940 [pii] 
10.1212/WNL.0b013e318296e940 [doi] 
Rebok, G. W., Ball, K., Guey, L. T., Jones, R. N., Kim, H. Y., King, J. W., . . . Willis, S. L. (2014). 
Ten-Year Effects of the Advanced Cognitive Training for Independent and Vital Elderly Cognitive 
Training Trial on Cognition and Everyday Functioning in Older Adults. J Am Geriatr Soc. 
doi:10.1111/jgs.12607 [doi] 
Russel, D. (1996). UCLA Loneliness Scale (Version 3): Reliability, validity, and factor structure. Journal 
of Personality Assessment, 66¸ 20-40. 
Scheier, M. F., Carver, C. S., & Bridges, M. W. (1994). Distinguishing optimism from neuroticism (and 
trait anxiety, self-mastery, and self-esteem): A reevaluation of the Life Orientation Test. Journal of 
Personality and Social Psychology, 67(6), 1063-1078.  
Schwarzer, R., & Jerusalem, M. (2010). The general self-efficacy scale (GSE). Anxiety, Stress, and Coping, 
12, 329-345.  
Sheikh, J. I., & Yesavage, J. A. (1986). Geriatric Depression Scale (GDS): Recent evidence and 
development of a shorter version. Clinical gerontologist, 5(1-2), 165-173.  

Page 15 of 15 
 
Version Date: 2/26/2018 
Steinerman, J. R. (2011). Minding the aging brain: technology-enabled cognitive training for healthy 
elders. Curr Neurol Neurosci Rep, 10(5), 374-380. doi:10.1007/s11910-010-0124-4 [doi] 
Valdes, E. G., O'Connor, M. L., & Edwards, J. D. (2012). The effects of cognitive speed of processing 
training among older adults with psychometrically- defined mild cognitive impairment. Curr 
Alzheimer Res, 9(9), 999-1009. doi:CAR-EPUB-20120515-001 [pii] 
Wild, K. V., Mattek, N. C., Maxwell, S. A., Dodge, H. H., Jimison, H. B., & Kaye, J. A. (2012). 
Computer-related self-efficacy and anxiety in older adults with and without mild cognitive 
impairment. Alzheimer's & Dementia, 8(6), 544-552.  
Willis, S. (1993). Test Manual for Everyday Problems Test for Cognitively Challenged Elderly. Retrieved 
from 
https://sharepoint.washington.edu/uwsom/sls/Documents/Manual%20EPT%20Cgn%20Chal%20
Elderly%20copy.pdf.  
Wolinsky, F. D., Vander Weg, M. W., Howren, M. B., Jones, M. P., & Dotson, M. M. (2013). A 
randomized controlled trial of cognitive training using a visual speed of processing intervention in 
middle aged and older adults. PLoS One, 8(5), e61624. doi:10.1371/journal.pone.0061624 [doi] 
PONE-D-12-40242 [pii]