Cognitive Interventions for Older Adults: Does Approach Matter?

Abstract

Assisted living (AL) is the fastest growing option for residential care that is designed to provide older adults with needed supports while promoting independence1. Nevertheless, AL residents typically experience progressive decline in cognitive ability and self-care that necessitates more intensive nursing care, and typically, most AL residents will transfer to a nursing home (NH) within one to three years1–4. Older adults require a variety of cognitive abilities to meet every day self-care challenges needed to remain in AL. Cognitive decline is key predictor of disability and NH placement for AL residents 5. Someone in the US is diagnosed with Alzheimer’s disease (AD) every 68 seconds, and the number of dementia sufferers will double by 2050, reaching 16 million6. Therefore, the development of new interventions to decrease cognitive decline is critical. Cognitive training programs are gaining popularity based on the notion that “use it or lose it” applies to cognition7,8. Research demonstrates that training in specific cognitive skills can improve memory, cognitive processing speed, spatial orientation, reasoning, and executive function in community dwelling older adults 7,9. Cognitive training can also benefit persons with dementia and mild cognitive decline. A meta-analysis of cognitive training research involving persons with early-stage AD reported overall effect sizes of 0.47 for interventions targeting learning, memory, and executive function, with improvements in activities of daily living (ADLs), problem solving, depression, and self-rated functioning10. A cognitive training intervention called Reasoning Exercises in Assisted Living (REAL) was developed to teach reasoning and problem solving skills to AL residents who are at risk for cognitive and functional decline. The intervention was modeled after the inductive reasoning skills found to improve cognition and maintain self-care over 5 years in healthy, independent older adults11. The REAL program includes six, hour-long, sessions in which providers work individually with AL residents12. The goal of this intervention is to improve older adults’ everyday problem-solving skills so they can maintain their ability to care for themselves and “age in place” in AL. REAL successfully improved problem solving scores of AL residents in a preliminary study12. Results from a subsequent cluster randomized clinical trial (reported elsewhere) also show potential for this intervention13. REAL is provided to AL residents in a one-to-one format. This approach has been successful. However, having adequate interventionists to provide REAL to individual AL residents is a challenge and is costly. Considering that cost is one predictor of successful dissemination of interventions in real-world settings, more efficient ways to provide REAL to large numbers of AL residents are needed14. Thus, the purpose of this pilot study was to examine feasibility and compare costs and outcomes for REAL provided in individual versus small group formats.