Towards a smartphone-based and conversational agent delivered just-in-time adaptive intervention for seniors affected by cognitive decline: Single-arm feasibility study (Preprint)
Authors: Brill Esther , Vinay Rasita , Joshi Priyam , Klöppel Stefan , Kowatsch Tobias 
Published: September 2024

BACKGROUND

Dementia is projected to impact 152 million people by 2050, making it one of the most pressing global health challenges. The neurodegenerative process initiates well before clinical symptoms manifest, advancing from subjective cognitive decline (SCD) to mild cognitive impairment (MCI) and ultimately to dementia. Despite the growing prevalence, awareness of dementia prevention is limited, and many individuals express a desire to cease living upon diagnosis. Lifestyle interventions can mitigate cognitive decline, but there is a need for effective, scalable approaches to deliver these interventions to older adults. Digital health interventions, such as app-based just-in-time adaptive interventions (JITAIs), offer a promising solution, but their application in cognitively impaired older populations remains underexplored.

OBJECTIVE

This study evaluated the feasibility, acceptability, and adherence to a smartphone-based JITAI delivered by a rule-based conversational agent (CA) among older adults with SCD or MCI. The primary focus was on adherence to the CA-initiated conversational turns (measured objectively via interaction logs), with secondary objectives including the perceptions of technology acceptance, the working alliance with the CA, self-reported adherence to the suggested health-promoting activity, and feedback for future improvements (through a questionnaire and short interview).

METHODS

This monocentric study investigated 15 participants (mean age = 70.3 years; 66.7% female and 33.3% male) with SCD (n=12) or MCI (n=3). Participants used the study app that delivered daily health-promoting activities through a CA over two weeks. Participants received notifications to engage in seven health-related activities, and adherence to the activity was self-reported. Post-intervention, participants rated their experience with the app and assessed their working alliance with the CA through the 6-item session alliance inventory. Data on smartphone usage, demographic information, and cognitive performance (via MoCA) were collected during a pre-intervention visit.

RESULTS

Participants rated the study app positively, especially regarding ease of use and a subset of the working alliance. Adherence to the CA-initiated conversational turn was measured at an average of 80.95% across 14 days. 27.14% of participants indicated as being vulnerable and 100% then responded with their state of receptivity, of which 82.65% were receptive to completing the activity, and 69.13% self-reporting adherence to the activity. There was no significant decline in adherence across the study period. Qualitative results support these findings and present two emerging themes: app enjoyment and enhancing engagement.

CONCLUSIONS

This study demonstrates that smartphone-based JITAIs are feasible and generally well-accepted by older adults with SCD or MCI. However, the findings underscore the need for robust technological infrastructure and potential personal assistance to optimize adherence. Future interventions could benefit from integrating wearables to improve real-time engagement and accurately monitor adherence, ultimately supporting healthy aging and cognitive health in older populations.