Verbal prompting to improve everyday cognition in MCI and unimpaired older adults.

As rates of cognitive impairment and degenerative neurological diseases increase with population aging, there are concomitant increases in functional disability and healthcare costs (Alzheimer’s Association, 2011). This has spurred a broad gerontological literature on ways to support independent functioning. One method investigated for providing cognitive and functional support is prompting. Prompting, defined here as reminding, persuading, pointing out possible actions or cognitions to an individual, represents one external strategy that may be used when individuals encounter cognitive failures (i.e., unsure what to do next in a sequence of actions; unable to remember a fact or action). When used with individuals with high levels of impairment (e.g., persons with frank dementia, usually in the moderate to severe range), prompting has been shown to be effective in terms of supporting basic activities of daily living (e.g., Mihailidis, Boger, Craig & Hoey, 2008). Prompting has received relatively little attention in less impaired populations, including those who are cognitively normal or who have mild cognitive impairment (MCI). Providing external cognitive support has been shown to be effective with several older, impaired populations. Some forms of such cognitive support that have been investigated include external automated devices that provide pre-programmed reminders or alarms for complex behaviors such as hand washing (Bharucha et al., 2009; Gillespie, Best, & O’Neill, 2011), social support that provides reminders or spousal support for generating shared problem solutions in the context of collaborative cognition (e.g., Baltes & Staudinger, 1996; Dixon & Gould, 1996; Margrett & Marsiske, 2002), and environmental support through the use of “cues” (e.g., depth-of-processing encoding instructions; cued recall or recognition) to improve memory performance (Craik, 1986; Kirchhoff, Anderson, Barch, & Jacoby, 2012; Park & Shaw, 1992). In the majority of these studies, the additional support through reminders, collaboration, or environmental cues improved the performance on the task. The outcomes measured in studies of cognitive support provision have included performance on basic activities of daily living (e.g., hand washing, Mihailidis et al., 2008), complex problem solving and errand planning (e.g., Berg, Johnson, Meegan, & Strough, 2003), and verbal memory performance (e.g, Johansson, Andersson, & Ronnberg, 2005; Park & Shaw, 1992). The current study investigated verbal prompting as a form of cognitive support for older adults. In persons with advanced dementia, previous studies of external prompting mostly used step-by-step prompting (e.g., “turn on the water, now wet your hands, get some soap, rub, rinse, etc.”). The current study used a more global prompting approach among elders who were cognitively normal or who met criteria for mild cognitive impairment. In contrast to the previous prompting studies, prompts used in this investigation were relatively “minimal”, and did not offer the step-by-step instructions used in assistive technology dementia studies (e.g., Bewernitz, Mann, Dasler, & Belchior, 2009; LoPresti, Mihailidis & Kirsch, 2004). The current study also sought to compare the effectiveness of these prompts among elders who were generally less impaired than in most previous research. Given that other forms of cognitive support (collaborative cognition, encoding and retrieval support) benefitted cognition even in unimpaired elders, it followed that prompting might also be beneficial for a broad cross-section of older adults. The current study compared older adults with and without mild cognitive impairment on a performance-based measure of everyday cognition; the administration strategy of the task permitted a comparison of performance under prompted and unprompted conditions. An individual was determined to exhibit Mild Cognitive Impairment (MCI) when they demonstrate cognitive impairment in one or more domains, but do not meet criteria for dementia and have largely intact independent functioning (e.g., Albert et al., 2011; Jak et al., 2009; Petersen, 2004). There is no single classification method for defining MCI, but Cook and colleagues (2013) recently developed an MCI classification method for use in this sample. Several studies have shown that adults with MCI may in fact evince some functional impairment on tasks assessing complex Instrumental Activities of Daily Living (IADL; e.g., medication use, financial management, food preparation; Lawton & Brody, 1969). Specifically, cross-sectional studies have demonstrated that being classified as MCI resulted in more difficulty with IADLs based on self- or informant-report (Perneczky et al., 2006; Teng, Becker, Woo, Cummings, & Lu, 2010; Tuokko, Morris, & Ebert, 2005). In studies of performance-based IADL functioning, persons with MCI or with low levels of executive functioning have also displayed reduced functioning (Cahn-Weiner, Malloy, Bole, Marran, & Salloway, 2000; Goldberg et al., 2010). Reduced performance-based functioning in MCI has also been confirmed longitudinally (e.g., Allaire & Willis, 2006; Gross, Rebok, Unverzagt, Willis, & Brandt, 2011). Wadley and colleagues (2007) demonstrated that having MCI predicted greater three-year decline in self-reported activities of daily living (ADLs; e.g., feeding, hygiene, dressing) and IADL perceived difficulty and performance relative to their unimpaired peers. The current study sought to determine whether MCI-related functional impairment might extend to measures of functional cognition, or everyday cognition. Everyday cognition has been conceptualized by some investigators as the cognitive performance demonstrated when encountering natural (ecological) stimuli (e.g., read food package labels or official documents; Allaire & Marsiske, 1999). Indeed, measures of everyday cognition and other ways of measuring functioning and everyday task performance have tended to be moderately-to-strongly related. For example, the Observed Tasks of Daily Living (OTDL), which is a performance-based everyday cognition measure (participant behaviorally completes tasks related to medication use, telephone use, and financial management), has demonstrated a strong, positive correlation with IADL scores (r = 0.5; Diehl, Willis, & Schaie, 1995). Domains of the OTDL also demonstrate convergent validity with scales from the Everyday Problems Test (EPT; Diehl, Willis & Schaie, 1995; Willis & Marsiske, 1993) as well as a strong bivariate correlation (r=0.64; Diehl et al., 2005), suggesting that the OTDL is quite similar in scope to other, well-known measures of everyday cognition. There is a growing body of literature that highlights the predictive utility of measures of everyday cognition. Allaire and colleagues (2009) demonstrated that performance on the Everyday Cognition Battery (ECB; Allaire & Marsiske, 1999) was different between healthy and mild cognitively impaired older adults. The ECB Knowledge Test is also a significant predictor of mortality, above and beyond basic cognitive abilities, self-reported health, and demographic variables (Weatherbee & Allaire, 2008). Additionally, a measure of everyday cognition was found to predict self-reported medication adherence following a kidney transplant (Gelb, Shapiro, & Thornton, 2010). The current study investigated the effectiveness of verbal prompting during a performance-based task of daily activities (OTDL; e.g., medication, financial management, and telephone use). The performance trajectory of unimpaired elders and those who met criteria for mild impairment was examined, both with and without prompting support, over ten years. Overall, the purpose of the study was to investigate whether responsive verbal prompting (i.e., when participants gave behavioral signs of not knowing what do next in problem solving, or being unwilling to proceed) could improve performance on a measure of everyday cognition for elders with and without MCI. A secondary question was whether such prompting modified the ten-year trajectory of observed everyday cognition performance. Specifically, the primary aims of this investigation were to: (1) to compare prompted and unprompted performance on the Observed Tasks of Daily Living (OTDL) (2) to investigate whether there are MCI-related performance decrements on the OTDL, and (3) to examine whether prompting modified the ten-year trajectory of OTDL performance (compared to unprompted performance), and whether the longitudinal effects of prompting were moderated by participant cognitive status.