JMIR MEDICAL EDUCATION

Nakanishi et al

Original Paper

e-Learning and Web-Based Tools for Psychosocial Interventions
Addressing Neuropsychiatric Symptoms of Dementia During the
COVID-19 Pandemic in Tokyo, Japan: Quasi-Experimental Study
Miharu Nakanishi1,2, PhD; Syudo Yamasaki2, PhD; Kaori Endo2, PhD; Junko Niimura2, PhD; Canan Ziylan3, PhD;
Ton J E M Bakker3,4, MD, PhD; Eva Granvik5, MSc; Katarina Nägga6,7, MD, PhD; Atsushi Nishida2, PhD
1

Department of Psychiatric Nursing, Tohoku University Graduate School of Medicine, Sendai-shi, Japan

2

Research Center for Social Science & Medicine, Tokyo Metropolitan Institute of Medical Science, Setagaya-ku, Japan

3

Research Center Innovations in Care, Rotterdam University of Applied Sciences, Rotterdam, Netherlands

4

Stichting Wetenschap Balans, Rotterdam, Netherlands

5

Center for Excellence in Dementia, University Hospital, Malmö, Malmö, Sweden

6

Clinical Memory Research Unit, Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden

7

Department of Acute Internal Medicine and Geriatrics, Linköping University, Linköping, Sweden

Corresponding Author:
Miharu Nakanishi, PhD
Department of Psychiatric Nursing
Tohoku University Graduate School of Medicine
2-1 Seiryo-machi, Aoba-ku
Sendai-shi, 980-8575
Japan
Phone: 81 22 717 8179
Fax: 81 22 717 8179
Email: mnakanishi-tky@umin.ac.jp

Abstract
Background: Concern has been raised that the COVID-19 pandemic and consequent social distancing measures may increaseneuropsychiatric symptoms in people with dementia. Thus, we developed and delivered an e-learning training course to professional
caregivers on using a web-based tool for psychosocial interventions for people with dementia.
Objective: The aim of our study was to evaluate the feasibility and efficacy of an e-learning course in combination with a
web-based tool in addressing neuropsychiatric symptoms of dementia.
Methods: A quasi-experimental design was used in Tokyo, Japan. The e-learning course was delivered three times to professional
caregivers between July and December 2020. Caregivers who completed the course assessed the level of neuropsychiatric
symptoms in people with dementia using the total score from the Neuropsychiatric Inventory (NPI) via a web-based tool. The
primary outcome measures were the number of caregivers who implemented follow-up NPI evaluations by March 2021 and thechange in NPI scores from baseline to their most recent follow-up evaluations. As a control group, information was also obtained
from professional caregivers who completed a face-to-face training course using the same web-based tool between July 2019 andMarch 2020.
Results: A total of 268 caregivers completed the e-learning course in 2020. Of the 268 caregivers, 56 (20.9%) underwent
follow-up evaluations with 63 persons with dementia. The average NPI score was significantly reduced from baseline (mean20.4, SD 16.2) to the most recent follow-up evaluations (mean 14.3, SD 13.4). The effect size was assumed to be medium (Cohen
drm [repeated measures]=0.40). The control group consisted of 252 caregivers who completed a face-to-face training course. Of the 252
caregivers, 114 (45.2%) underwent follow-up evaluations. Compared to the control group, caregivers who completed the e-learning
course were significantly less likely to implement follow-up evaluations (χ21=52.0, P<.001). The change in NPI scores did not
differ according to the type of training course (baseline-adjusted difference=–0.61, P=.69).
Conclusions: The replacement of face-to-face training with e-learning may have provided professionals with an opportunity toparticipate in the dementia behavior analysis and support enhancement (DEMBASE) program who may not have participated in
the program otherwise. Although the program showed equal efficacy in terms of the two training courses, the feasibility was
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suboptimal with lower implementation levels for those receiving e-learning training. Thus, further strategies should be developed
to improve feasibility by providing motivational triggers for implementation and technical support for care professionals. Using
online communities in the program should also be investigated.
(JMIR Med Educ 2021;7(4):e30652) doi: 10.2196/30652
KEYWORDS
dementia; home care services; implementation science; nursing homes; web-based tool

Introduction
Dementia is a public health concern since people are living
longer and age increases the risk of dementia. Globally, the total
number of people with dementia was estimated to be 46.8
million in 2015 and is projected to rise to 131.5 million by 2050
[1]. Dementia is chronic and progressive in nature, caused bya variety of brain illnesses that affect memory, thinking,behavior, and ability to perform everyday activities. It isestimated that 5% to 8% of the general population aged 60 years
and over, at any given time, have dementia. Dementia affects
individuals, their families, and the economy, with global costs
estimated at approximately US $1 trillion annually [2]. Japan
also faces an expected increase in the number of people withdementia. This number is estimated to reach 10.2 million by
2050, accounting for 10% of the total population [3].
The COVID-19 pandemic has disproportionately impacted
people living with dementia [4]. The severity and mortality of
COVID-19 worsens with age [5] and in individuals withpre-existing illnesses, such as hypertension and diabetes [6,7],
which are common in people with dementia [8]. Furthermore,
people with dementia may not understand or remember therequired COVID-19 preventive measures, such as wearing afacial mask, physical distancing, and hygiene, because of their
cognitive impairment [9].
Concern has been raised that the COVID-19 pandemic andconsequent social distancing measures may increaseneuropsychiatric symptoms in people with dementia [10].
Neuropsychiatric symptoms, such as shouting, wandering,agitation, resistance to care, depression, anxiety, apathy, andother behaviors, are considered expressions of distress in people
with dementia. Neuropsychiatric symptoms are common inpeople with dementia both in the community [11] and in nursing
homes [12], resulting in higher psychotropic drug use [13] andincreased mortality [14]. Women are more likely to exhibit abroader range of symptoms compared to men [15]. Since
neuropsychiatric symptoms represent unmet needs and distress,
psychosocial interventions are globally recommended as
first-line treatments to target the underlying causes [4]. Social
distancing measures related to the COVID-19 pandemic, suchas home confinement and restrictions on visitors for nursing
home residents, imposed a risk for social isolation and/or
loneliness and they limited physical activity for people withdementia [16]. This has been shown to negatively impact
neuropsychiatric symptoms, such as anxiety and depression[17-19], in people with dementia and to cause further cognitiveand functional decline [17,20]. However, some nursing homehttps://mededu.jmir.org/2021/4/e30652

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residents in the Netherlands were reported to have decreased
neuropsychiatric symptoms, such as agitation and aggression,
due to a reduction in overstimulation [21]. Therefore, monitoring
the potential long-lasting effects of COVID-19 on
neuropsychiatric symptoms and the effectiveness ofinterventions delivered remotely through technology iswarranted [4,10].
To address neuropsychiatric symptoms, a face-to-face training
course was delivered with a web-based tool to professional
caregivers who participated in the psychosocial dementia
behavior analysis and support enhancement (DEMBASE)
program. The results of a cluster-randomized controlled study
indicated that DEMBASE is effective in reducing
neuropsychiatric symptoms in people with dementia [22]. Basedon these results, the Tokyo Metropolitan Government introduced
the DEMBASE program into the daily practice of professional
caregivers in 2018 [23].
Although the demand for e-learning platforms is emerging
among essential care workers, no evaluation exists that tests thefeasibility and efficacy of the digital transformation of thepsychosocial dementia care program for neuropsychiatric
symptoms. Therefore, we developed an e-learning training
course for professional caregivers using a web-based tool for
psychosocial interventions for people with dementia in Tokyo,
Japan. The e-learning course aimed to replace the face-to-facetraining course to avoid group gatherings during the COVID-19
pandemic in 2020. Furthermore, this study evaluated thefeasibility and efficacy of the e-learning course combined witha web-based tool in addressing neuropsychiatric symptoms ofdementia. We hypothesized that the e-learning course would
sustain the efficacy in reducing neuropsychiatric symptoms
because the interventions include discussions with amultidisciplinary discussion team. Feasibility, as measured by
the percentage implementation, was anticipated to be lower inthe e-learning training course due to reduced availability ofhuman resources during the COVID-19 pandemic.

Methods
DesignA quasi-experimental, longitudinal design was used (Figure 1).
The experimental group consisted of 268 professional caregivers
who completed the e-learning course and participated in the
DEMBASE program between July 2020 and March 2021. The
control group consisted of 252 professionals who completed aface-to-face training course and participated in the program
between May 2019 and March 2020.

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Figure 1. Flow of the psychosocial dementia care program in the experimental (e-learning course) and control (face-to-face training) groups.

Procedure
Data were collected in naturalistic long-term care settings from
April 2019 to March 2020 for the control group, and from April
2020 to March 2021 for the experimental group. Each municipal
government independently decided whether to apply for thefund, which was approved for use in the recruitment of careproviders and other professionals and in conducting a training
course among all participating professionals.
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All professionals were informed of their voluntary participation
during the recruitment process, and their application toparticipate was regarded as consent. Participating professionals
acquired informed consent from persons with dementia and/or
their family members prior to providing care.
Since the e-learning training course was introduced by thegovernment in response to the COVID-19 pandemic, we could
not determine the sampling process and sample size a priori forthis study. We anticipated that the rate of implementation would
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be 15% lower in the experimental group compared to the control
group. The rate of implementation in the control group was
expected to be equal to that in our previous study (46.4%) [23].
Therefore, the desired sample size of professionals was 283 pergroup, which was calculated using G*Power software (version
3.1.9.7; Heinrich-Heine-Universität Düsseldorf) [24,25].

ParticipantsCare professionals working as long-term service providers wereinvited to participate in the DEMBASE program. Potential
participants included care managers, nurses, and other directcare workers who worked for providers that were accredited by
the public long-term care insurance program. We included all
the professionals who applied to participate in the program.
Participant recruitment was conducted by each municipalitythat applied to the program. In 2019, 10 municipalities
participated in the face-to-face training course. The number ofparticipating municipalities increased to 23 in 2020; this wasdue to the availability of e-learning.
The approaches for the recruitment process, therefore, varied
according to municipality-based choices (eg, an application
form on a website, an oral invitation sent to 3-4 providers, andNakanishi et alholding a seminar for the directors of the providers). Under thefunding rule established by the Tokyo Metropolitan
Government, the DEMBASE program was made available forin-home care management agencies, in-home care services, andresidential care services. In-home care management agencies
handle monthly care plans for in-home care recipients and are
independent from the providers of in-home care services.
In-home care service providers offer direct care to individuals
who live in their houses. Residential care service providers offer
a residential care package to individuals who reside in facilities,
and they handle the monthly care plans for their care recipients.

Intervention
Overview
The DEMBASE program was comprised of (1) a training course,(2) an interdisciplinary discussion meeting (analysis), (3) aweb-based tool for ongoing behavioral assessments (dementia
behavior), and (4) a debriefing meeting (support enhancement).
The timing of the training course and debriefing meetings varied
by municipality (Figure 1). The characteristics of the programsin both groups are summarized in Table 1.

Table 1. Characteristics of the dementia behavior analysis and support enhancement (DEMBASE) program in the experimental group (e-learning) andcontrol group (face-to-face training course).
Program characteristic

Experimental group

Control group

Time period•

July 21, 2020-March 31, 2021•

May 30, 2019-March 31, 2020

Training course details••

e-Learning delivery
5.5 hours on average••

Face-to-face delivery
1-day course at venue

Evaluation of neuropsychiatric symptoms
Specification of unmet needs
Establishment of an interdisciplinary action plan•••

Evaluation of neuropsychiatric symptoms
Specification of unmet needs
Establishment of an interdisciplinary action plan

Neuropsychiatric Inventory (NPI)
Basic physical needs and environmental sources of
discomfort
Prescribed medication for the nervous system•••

Neuropsychiatric Inventory (NPI)
Basic physical needs and environmental sources of
discomfort
Prescribed medication for the nervous system

Zoom meeting
Two meetings, 90 minutes eachFirst meeting: review of learning and setting a task
Second meeting: sharing the experience of the program•••

Face-to-face meeting
1 day, 3 hours at venue
Sharing the experience of the program

Interdisciplinary discussion •meeting: action items••
Web-based tool: contents•••

Debriefing meeting details

•
•
•
•

Training Course
Overview
The training course guided (1) the process of an interdisciplinary
meeting to evaluate neuropsychiatric symptoms, specify unmet
needs using a 23-item checklist, and establish an action planusing an interdisciplinary approach; (2) the implementation of
the action plan; and (3) the use of the web-based tool.

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The training course was based on the consideration ofneuropsychiatric symptoms as communicating unmet needs[26-28]. Based on global evidence, psychosocial interventions
including goal setting, such as providing pleasant activities,
providing outdoor activities, and removal of environmental
triggers, were recommended to address these unmet needs [29].
The web-based tool was explained to each participating
professional during the training course (Figure 2). Further details
regarding the training components and topics of discussion fromdebriefing meetings are reported elsewhere [23].

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Figure 2. Web-based tool and training course of the program. DEMBASE: dementia behavior analysis and support enhancement.

e-Learning Training Course and Web-Based Debriefing
Meeting
The e-learning training course was delivered thrice to 298
professional caregivers between July and December 2020. Of
the 298 caregivers, 268 (89.9%) completed the course. On
average, professionals spent a total of 331.1 (SD 262.3) minutes
to complete the course. The e-learning system was developed
based on the framework provided by the Ginger App Company.
The course included learning about interdisciplinary discussion
meetings and virtual point-by-point operation of the web-based
tool (Figure 2). Every text and direction on the screen was
followed by voices that were developed using Amazon Polly(Amazon Web Services). The e-learning course was designed
and developed by the Tokyo Metropolitan Institute of Medical
Science, in collaboration with the face-to-face training course’s
instructors and the Tokyo Metropolitan Government. A
prototype of the course was completed by four professionals
who had not participated in the face-to-face training. Based on
their feedback, revisions were made to the course, after which
it was finalized.
A debriefing meeting was delivered via a Zoom meeting (Zoom
Video Communications) and divided into two parts. The first90-minute debriefing meeting was within 4 weeks after thee-learning course was completed and was aimed at reviewing
what participants had learned during the course, motivating useof the DEMBASE program, and setting a task by the next
debriefing meeting. Hereafter, a 90-minute debriefing meeting
was set 4 weeks later to share participant experiences related
to the program. The first debriefing meetings were held 21 times
between September 2020 and February 2021. The second
debriefing meetings were held 14 times between November
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2020 and March 2021. Both debriefing meetings were organized
by instructors who had completed the face-to-face training
course and the train-the-trainer program offered by the Tokyo
Metropolitan Institute of Medical Science.
Face-to-Face Training Course and Debriefing Meeting
A 1-day, face-to-face training course was delivered 12 times to
274 professional caregivers between May 2019 and February
2020. Of the 274 caregivers who intended to participate in thecourse, 252 (92.0%) attended and completed it. The course
included learning about, and role-play of, interdisciplinary
discussion meetings and real point-by-point operation of the
web-based tool (Figure 2).
Face-to-face, 3-hour debriefing meetings were held nine times,
4 to 6 weeks after the face-to-face training, which was conducted
between July 2019 and February 2020. Debriefing meetings
were organized by instructors who had completed theface-to-face training course and the train-the-trainer program,offered by the Tokyo Metropolitan Institute of Medical Science.

Interdisciplinary Discussion Meeting
Once the training course was completed, the professionals held
an interdisciplinary discussion meeting with other care
professionals to evaluate the neuropsychiatric symptoms of eachparticipant with dementia, to specify their unmet needs, and toestablish an interdisciplinary action plan to meet those needs.
The medications prescribed to each participant with dementia
were also assessed.
These components were included to promote a plan-do-study-act(PDSA) cycle, developed according to the team-based dementia
case management model. The PDSA cycle is widely used as a
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quality improvement method in health care settings [30]. If thelevel of neuropsychiatric symptoms assessed was not reduced
during follow-up evaluations, care professionals reviewed unmet
needs and revised the action plan during the discussion meeting.
Unmet needs, content of the action plan, and types of caregivers
involved in the meeting were categorized and recorded using
the web-based tool. The categories of unmet needs weredeveloped by referring to the findings on associations between
neuropsychiatric symptoms and basic physical needs [31] aswell as environmental sources of discomfort [32,33].

Web-Based Tool
The web-based tool provided a visualization of longitudinalchanges in neuropsychiatric symptoms measured by the
Neuropsychiatric Inventory (NPI) to inform interdisciplinary
decision making. Professionals input the information collectedduring the discussion meeting into the web-based tool. The
individual characteristics of persons with dementia wererecorded at registration, including birth year and month, sex,
and type of dementia. Participating professionals performed abaseline evaluation and follow-up evaluations to assess
neuropsychiatric symptoms at each time point for each personwith dementia until the end of the fiscal year.

Debriefing Meeting
The participating professionals attended a debriefing meeting
after training where they were divided into groups of 4 to 6
members to share their experiences about the program.

Measurement
The primary outcome measure for feasibility was the percentage
of professionals with “full implementation” of the DEMBASE
program. Full implementation was defined as the completionof a follow-up evaluation of neuropsychiatric symptoms for atleast one person with dementia.
The primary outcome measure for efficacy was the change inthe level of neuropsychiatric symptoms in persons with dementia
who received full implementation of the program. The secondary
outcome measure was the change in the percentage ofpsychotropic prescriptions. We collected this information onneuropsychiatric symptoms and prescribed medications, which
was available via the web-based tool.
The NPI–Nursing Home version (NPI-NH) was used to assess
the incidence, frequency, and severity of neuropsychiatric
symptoms. The original NPI-NH was comprised of 12 items torate the frequency and severity of neuropsychiatric symptoms
in persons with dementia [34-37]. Scores for each item ranged
from 0 to 12, with higher scores indicating more severe
symptoms. Frequency and severity scores were multiplied todetermine a total score ranging from 0 to 144. The Japaneseversion of the NPI-NH had good validity and reliability [38].

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Nakanishi et al
Drug names and daily dosage were recorded for each prescribed
medication. In this study, the presence of prescribed medication
for the nervous system was used for analysis based on the
Anatomical Therapeutic Chemical classification system:
percentages of the prescriptions were calculated for analgesics(N02), antipsychotics (N05A), anxiolytics (N05B), hypnotics
and sedatives (N05C), antidepressants (N06A), and antidementia
drugs (N06D).

Statistical Analysis
The percentage of professionals who implemented follow-up
evaluations was compared between the experimental and control
groups using a chi-square test.
The change in the level of neuropsychiatric symptoms in persons
with dementia from baseline to the most recent follow-up wascompared between the two groups. Multiple linear regression
analysis was used, including the NPI score at the most recent
follow-up evaluation as a dependent variable and group as anindependent variable. The NPI score at baseline was entered asa covariate.
The within-subject effect size was calculated using the Cohen
formula for the NPI score. The effect size was assumed to be
low if d values varied by approximately 0.20, medium if d values
varied by approximately 0.50, and large if d values were greaterthan 0.80 [39,40].
Between-group differences were also examined for changes in
psychotropic prescriptions using binomial logistic regression
analysis. The model included the rate of prescription at the mostrecent follow-up evaluation as a dependent variable, group as
an independent variable, and rate of prescription at baseline asa covariate.
Statistical significance was considered at an overall α value of.05. All statistical analyses were conducted using Stata software(version 16.1; StataCorp LLC).

EthicsThis project was approved by the Ethics Review Board of theTokyo Metropolitan Institute of Medical Science (No. 20-41)
and Tohoku University (2021-1-293). This project wascompleted in accordance with the Helsinki Declaration of 1975
(as revised in 2013).

Results
Characteristics of Care Professionals
The experimental group (ie, e-learning) included professionals
from in-home care management (131/268, 48.9%), in-homecare services (93/268, 34.7%), and residential care services(44/268, 16.4%) (Table 2). The distribution of types of service
did not significantly differ between the experimental group andthe control group (ie, face-to-face) (χ22=4.1, P=.13).

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Table 2. Types of service of professional caregivers who completed the training course to use a web-based tool of psychosocial interventions forneuropsychiatric symptoms of dementia.
Professionals in e-learning group, 2020
(n=268), n (%)

Professionals in face-to-face training group,2019 (n=252), n (%)

Community general support center

50 (18.7)

8 (3.2)

Initial phase intensive support team

12 (4.5)

1 (0.4)Care management agency

69 (25.7)

101 (40.1)

Day care at center

41 (15.3)

52 (20.6)

Rehabilitation at center

3 (1.1)2 (0.8)Rehabilitation at home

2 (0.7)0 (0)Home-visiting nursing care

32 (11.9)

2 (0.8)Personal care at home

10 (3.7)

16 (6.3)

In-home multiple service

5 (1.9)11 (4.4)

Group home

19 (7.1)

31 (12.3)

Housing with care

3 (1.1)4 (1.6)

Geriatric intermediate care facility

4 (1.5)3 (1.2)

Nursing home

17 (6.3)

21 (8.3)

Long-term sanatorium

1 (0.4)0 (0)Type of service
In-home care management

In-home care service

Residential care service

Feasibility: Full Implementation
Of the 268 professionals who completed the e-learning course,
56 (20.9%) implemented follow-up evaluations ofneuropsychiatric symptoms by the end of March 2021 (Table3). The percentage of full implementation in the experimentalgroup was significantly lower than that of professionals whocompleted the face-to-face training course in 2019.

Table 3. Percentage of professionals who implemented follow-up evaluations of neuropsychiatric symptoms.

aFollow-up evaluation

Professionals in the e-learning group, Professionals in the face-to-face2020 (n=268), n (%)
training group, 2019 (n=252)

Chi-square (df)

P value

Implemented

56 (20.9)

114 (45.2)

52.0 (1)<.001

Did not implement

212 (79.1)

138 (54.8)—a—Chi-square and P values are reported in the top row of compared items.

Characteristics of Persons With Dementia
There were 63 persons with dementia who received follow-up
evaluations by professionals who completed the e-learning
course (Table 4). The distribution of types of service did not
significantly differ between the experimental group and thecontrol group (ie, face-to-face) (χ22=1.4, P=.51). There was no
significant between-group difference in sex (χ22=0.1, P=.81)
or age (t145.72=0.42, P=.68).

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Some people in the experimental group (n=63) were identified
to have unmet needs at baseline related to the following: social
isolation (n=30, 48%), sleepiness or tiredness (n=27, 43%),
urination (n=27, 43%), hydration (n=27, 43%), and evacuation(n=24, 38%). Some people in the control group (n=132)
presented with needs related to sleepiness or tiredness (n=65,
49.2%), evacuation (n=56, 42.4%), feeling uncomfortable (n=53,
40.2%), and pain (n=52, 39.4%) (Table S1 in Multimedia
Appendix 1).

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Table 4. Baseline characteristics of persons with full implementation of the psychosocial dementia care program in Tokyo.
Characteristic

Persons with dementia in e-learning group, Persons with dementia in face-to-face2020 (n=63), n (%)
training group, 2019 (n=132), n (%)

Age in years
≤64

0 (0)

4 (3.0)65-74

6 (9.5)12 (9.1)

75-84

21 (33.3)

38 (28.8)

85-94

32 (50.8)

69 (52.3)≥95

4 (6.3)9 (6.8)Male

18 (28.6)

40 (30.3)

Female45 (71.4)

92 (69.7)

Community general support center

12 (19.0)

1 (0.8)Initial phase intensive support team1 (1.6)0 (0)Care management agency

16 (2.5)

49 (37.1)

Day care at center

8 (12.7)

36 (27.3)

Rehabilitation at center

3 (4.8)0 (0)Rehabilitation at home

1 (1.6)0 (0)Personal care at home

1 (1.6)5 (3.8)Home-visiting nursing care

7 (11.1)

2 (1.5)In-home multiple service

3 (4.8)9 (6.8)Group home

3 (4.8)14 (10.6)

Housing with care

0 (0)4 (3.0)Geriatric intermediate care facility

2 (3.2)3 (2.3)

Nursing home

6 (9.5)9 (6.8)Sex

In-home care management

In-home care

Residential care

Efficacy: Neuropsychiatric Symptoms
The 63 persons with dementia in the experimental group had amean NPI score of 20.4 (SD 16.2) at baseline. The symptoms
that were frequently observed in the experimental group atbaseline included agitation or aggression (n=48, 76%), anxiety(n=35, 56%), delusion (n=32, 51%), irritability or lability (n=30,48%), and depression or dysphoria (n=26, 41%). These

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symptoms were also observed in the control group at baseline(Table S2 in Multimedia Appendix 1). The mean NPI score wassignificantly reduced to 14.3 (SD 13.4) at the most recent
follow-up (paired t62=4.10, P<.001). The level of reduction was
not significantly different from that in the control group (Table5). The effect size was assumed to be medium for both theexperimental group (drm [repeated measures]=0.40) and the control
group (drm=0.36).

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Table 5. Change in level of neuropsychiatric symptoms from baseline to the most recent follow-up evaluation.
Persons with dementia in e- Persons with dementia in face-to- Baseline-adjusted
learning group, 2020 (n=63) face training group, 2019 (n=132) differencea

MeasureP value

NPI scoreb, mean (SD)
Baseline

20.4 (16.2)

23.8 (18.1)

N/Ac

N/A

Follow-up

14.3 (13.4)

17.4 (17.2)

N/A

N/A

Difference

6.1 (11.8)

6.4 (10.6)

–0.61

.69

0.40

0.36

N/A

N/A

Effect size: Cohen drm (repeated measures)a

The baseline-adjusted difference was examined using multiple linear regression analysis with the Neuropsychiatric Inventory (NPI) score at baseline
as a covariate.
b

Levels of neuropsychiatric symptoms were assessed using the total NPI score, which ranged from 0 to 144.

c

N/A: not applicable; these values were only calculated for the NPI score difference.

Efficacy: Psychotropic Prescriptions
The percentage of psychotropic prescriptions was not
significantly different between the experimental and control
groups (Table 6).
Table 6. Change in psychotropic prescriptions from baseline to the most recent follow-up evaluation.
Persons with dementia in e-learning Persons with dementia in face-to-facegroup, 2020 (n=63), n (%)
training group, 2019 (n=132), n (%)

Baseline-adjusted
differencea

P value

Baseline

10 (15.9)

20 (15.2)—b—Follow-up

9 (14.3)

19 (14.4)

0.68

.72

Baseline

10 (15.9)23 (17.4)——

Follow-up

12 (19.0)

27 (20.5)

1.03

.97

Baseline

7 (11.1)

7 (5.3)——

Follow-up

7 (11.1)

7 (5.3)

1.52.78

Baseline

7 (11.1)

14 (10.6)——

Follow-up

6 (9.5)13 (9.8)

0.46

.61

Baseline

2 (3.2)4 (3.0)——

Follow-up

3 (4.8)6 (4.5)

1.05.97

Baseline21 (33.3)

59 (44.7)——

Follow-up

24 (38.1)

64 (48.5)

0.99

.99

Prescription
Analgesics

Antipsychotics

Anxiolytics

Hypnotics and sedatives

AntidepressantsAntidementia drugsaThe baseline-adjusted difference was examined using binomial logistic regression analysis with psychotropic prescription at baseline as a covariate.

bBaseline-adjusted differences and P values are reported in the bottom row of compared items.

Discussion
Overview
With an increasing demand for e-learning platforms for essential
workers, it is vital that the feasibility and efficacy of the digitally
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transformed DEMBASE program be assessed. Thus, this study
aimed to test the feasibility and efficacy of the e-learning
training course, distributed to 268 professionals between Julyand December 2020 during the COVID-19 pandemic, bycomparing it to the face-to-face training course and assessing

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which program more effectively addressed neuropsychiatric
symptoms of dementia.

Principal Findings
By replacing the face-to-face training course with the e-learning
course, professionals who may not have participated in the
program otherwise were provided the opportunity to participate
in the DEMBASE program. This may explain the reduction inneuropsychiatric symptoms, which was significant with amedium effect size in this study. Similarly, the natural reductionof NPI scores was –0.8 over 6 months in a randomized
controlled study [22]; thus, the program with e-learning training
in this study appeared to be clinically effective. The efficacy ofthe program was not significantly different between the twogroups. However, the percentage of full implementation was
significantly lower among professionals who completed thee-learning course than among those who completed theface-to-face training course. Therefore, replacing face-to-facetraining courses with e-learning training courses appeared to beless effective in encouraging professionals to implement the
program.
Compared to the face-to-face training course, the e-learning
course may have lacked motivational triggers for implementation
for professionals. Unlike e-learning, face-to-face training courses
involved role-play in an interdisciplinary discussion meetingthat may have yielded human interactions among participating
professionals and between instructors and participants. Although
we divided debriefing meetings into two parts and intended forthe first meeting to offer interactions between participants, the90-minute Zoom meeting may have been suboptimal tosubstitute the motivational triggers that emerged in theface-to-face training course. In addition, facilitating such aninteraction can be complemented by using online communities,
such as Facebook and LinkedIn; however, these online platforms
are not often used by professional caregivers [41]. Therefore,
the use of online communities in the DEMBASE program,which has not yet been introduced because of privacy concernswith social networks, is encouraged and should be further
investigated.
The reduced implementation could also have been because of
the increased workload of professionals due to the COVID-19
pandemic. This pandemic may have had a negative impact on
the feasibility of the DEMBASE program among professionals.
As preventive measures against COVID-19 were added to their
daily practice, professionals had less time to implement the
program. Furthermore, face-to-face contact was avoided, evenfor communication between professionals, under the lockdown
and other public health and social measures that were
implemented. In this study, we replaced a face-to-face debriefing
meeting with a Zoom meeting, thus providing professionals
with an opportunity to participant in a web-based meeting.
Furthermore, we proposed to the participants that aninterdisciplinary discussion meeting also be held via a Zoom
meeting. Municipal governments also provided financial support
to long-term care providers to refund the costs of purchasing
tablet devices for program implementation. However, long-termcare service providers generally have several barriers tohttps://mededu.jmir.org/2021/4/e30652

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Nakanishi et al
implementing digital transformation in dementia care, including
information technology infrastructure instability and a reluctanceto change established practices and routines [42]. Thus,
additional technical support is warranted to enable long-termcare providers to have essential communication between
professionals and with people with dementia amid the
COVID-19 pandemic.
The reduced rate of full program implementation in thee-learning course may also be attributed to possible misdirectionin the recruitment process phrased as “participation in e-learning
course.” Some professionals confessed in the debriefing meetingthat they recognized the DEMBASE program as an e-learning
course rather than the PDSA cycle combining aninterdisciplinary discussion meeting with a web-based tool.
Therefore, a video message from “peer” professionals who have
implemented the program and recognized its effectiveness may
improve the readiness of applicants for participation. Such peer
messages can also be integrated into the content of the e-learning
training course. Additionally, recruiting two or more
professionals from the same provider could encourage program
implementation, as they may be able to commence the programwith a small discussion meeting with those who have completed
the course.

Strengths and Limitations
A strength of this study was that the efficacy and feasibility of
replacing a face-to-face course with an e-learning training course
was tested using a quasi-experimental design, thus addressing
a gap in the literature. A limitation was the lack of informationon the characteristics of professionals. That is, differences in
the gender and age of the professionals in the experimental (ie,e-learning) and control (ie, face-to-face) groups may haveinfluenced the level of resistance to technology usage [43].
Based on the agreement for this study with the Tokyo
Metropolitan Government, we were not allowed to access suchinformation. In addition, the small number of persons withfollow-up evaluations in the experimental group may havecaused insufficient statistical power to examine the differencesin changes in neuropsychiatric symptoms.

Conclusions
The e-learning training course provided the opportunity for
professionals to participate in the psychosocial dementia careprogram during the COVID-19 pandemic. Following completionof the e-learning course, the program sustained an equal levelof efficacy in reducing neuropsychiatric symptoms comparedto the face-to-face training course. However, the feasibility
appeared to be suboptimal as the rate of implementation was
low among professionals who completed the e-learning course.
Further strategies to encourage implementation of the program
should, thus, be developed to provide motivational triggers for
implementation, such as distribution of a video message frompeer professionals in the recruitment process and the e-learning
training course as well as technical support for care professionals
who work for people with dementia. Additionally, the use of
online communities by the professionals in the program should
be further investigated.

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JMIR MEDICAL EDUCATION

Nakanishi et al

Acknowledgments
This study was funded by the Policy-Based Medical Services Foundation and the Japan Society for the Promotion of Science,
KAKENHI (grant JP21H03281). This work was also supported by the Research Center for Social Science and Medicine, Tokyo
Metropolitan Institute of Medical Science. None of these funding sources were involved in the design or conduct of this study.
These funders had no input in data collection, management, analysis, or interpretation, and were not able to monitor the manuscriptfor presentation, review, or approval.

Authors' Contributions
MN, SY, KE, JN, and AN collected the data, analyzed and interpreted the data, and prepared the manuscript draft. CZ, TJEMB,
EG, and KN were involved in the study design and setup, supervised the data analysis, and contributed to finalizing the manuscript.

Conflicts of Interest
None declared.

Multimedia Appendix 1
Unmet needs identified and presence of neuropsychiatric symptoms evaluated during the interdisciplinary discussion meeting atbaseline.
[DOCX File , 24 KB-Multimedia Appendix 1]

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Abbreviations
DEMBASE: dementia behavior analysis and support enhancement
NPI: Neuropsychiatric Inventory
NPI-NH: Neuropsychiatric Inventory–Nursing Home version
PDSA: plan-do-study-act

Edited by G Eysenbach; submitted 31.05.21; peer-reviewed by K Koly; comments to author 27.06.21; revised version received 19.07.21;
accepted 19.09.21; published 12.10.21
Please cite as:
Nakanishi M, Yamasaki S, Endo K, Niimura J, Ziylan C, Bakker TJEM, Granvik E, Nägga K, Nishida A
e-Learning and Web-Based Tools for Psychosocial Interventions Addressing Neuropsychiatric Symptoms of Dementia During the
COVID-19 Pandemic in Tokyo, Japan: Quasi-Experimental StudyJMIR Med Educ 2021;7(4):e30652
URL: https://mededu.jmir.org/2021/4/e30652
doi: 10.2196/30652
PMID: 34543224©Miharu Nakanishi, Syudo Yamasaki, Kaori Endo, Junko Niimura, Canan Ziylan, Ton J E M Bakker, Eva Granvik, Katarina
Nägga, Atsushi Nishida. Originally published in JMIR Medical Education (https://mededu.jmir.org), 12.10.2021. This is an
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