Developing a music-based digital therapeutic to help manage the neuropsychiatric symptoms of dementia.

The greying of the world is leading to a rapid acceleration in both the healthcare costs and caregiver burden that are associated with dementia. There is an urgent need to develop new, easily scalable modalities of support. This perspective paper presents the theoretical background, rationale, and development plans for a music-based digital therapeutic to manage the neuropsychiatric symptoms of dementia, particularly agitation and anxiety. We begin by presenting the findings of a survey we conducted with key opinion leaders. The findings highlight the value of a music-based digital therapeutic for treating neuropsychiatric symptoms, particularly agitation and anxiety. We then consider the neural substrates of these neuropsychiatric symptoms before going on to evaluate randomized control trials on the efficacy of music-based interventions in their treatment. Finally, we present our development plans for the adaptation of an existing music-based digital therapeutic that was previously shown to be efficacious in the treatment of adult anxiety symptoms.

Implementation of a Virtual Reality recreation program in long-term care.

Introduction: This manuscript describes the implementation of a Virtual Reality (VR) recreation program at long-term care sites across Ontario, Canada, using the RE-AIM Framework to guide the implementation and its evaluation. Methods: We developed a VR recreation program to enhance the lives of long-term care residents, through 3 sequential phases. In Phase 1, we learned about resident and staff needs through focus groups, staff surveys and observations. In Phase 2, we developed 10 VR experiences, based on the data from Phase 1. In Phase 3, we implemented the VR experiences and supporting manual and measured their implementation, using the RE-AIM Framework. Results: We found the VR program to be highly (but not consistently) implementable across all sites. Factors that supported implementation were the following: resident interest in the content and technology, relative ease of use for staff to implement and formally integrating VR into the recreation calendar. Factors that impeded implementation were the following: the size of the headset, inability for the headset to cast given the sites' Information Technology infrastructure and some content that was not engaging. Conclusions: VR programs are highly implementable and this implementation is enhanced by integration of the program into existing recreational systems, ease of use and resident engagement.

Virtual reality and well-being in older adults: Results from a pilot implementation of virtual reality in long-term care.

INTRODUCTION: This paper describes the findings of a pilot implementation project that explored the potential of virtual reality (VR) technology in recreational programming to support the well-being of older adults in long-term care (LTC) homes. METHODS: 32 Adults in four LTC homes participated in a pilot implementation project where they viewed VR experiences of popular locations in Canada created especially for this project. Data in this paper are based on multiple viewing experiences (n = 102) over a two-week period. RESULTS: VR appeared to be an effective distraction from pain for the participants. Participants of this study found the VR experiences to be enjoyable and were relaxed and happy while viewing them. Most participants were attentive or focused while viewing the VR experiences, and the experiences were found to be a source of reminiscence for some of the participants. Participants related well to others around them during a majority of the experiences and the VR experiences were a point of conversation between the staff and the participants. CONCLUSION: The findings from this pilot implementation reveal that VR shows potential to enhance the physical, emotional, cognitive, and social well-being of older adults living in LTC, including those living with cognitive impairment.

In Their Own Words: How COVID-19 Has Impacted the Well-Being of Persons Living with Dementia in the Community.

COVID-19 has had a devasting impact on older adults in Canada, including persons living with dementia. This intrinsic case study sought to understand the perceptions of persons living with dementia regarding how COVID-19 has impacted their well-being. Ten persons living with dementia participated in in-depth qualitative interviews about their experience with COVID-19. Using thematic analysis, four themes were identified: (1) expressing current and future concerns; (2) social connections and isolation; (3) adapting to change and resilience through engagement and hope; and (4) we're not all the same: reflecting individual experiences of the pandemic. Results highlight that while COVID-19 contributed to isolation, concerns, and frustrations, persons with dementia also demonstrated adaptation and resilience. This study reinforced that persons with dementia and their responses to challenges are unique. Therefore, interventions to support persons with dementia must also be individualized to each person's abilities and circumstances.

Hearing Screening for Residents in Long-Term Care Homes Who Live with Dementia: A Scoping Review.

BACKGROUND: Hearing loss is highly prevalent in older adults, particularly among those living with dementia and residing in long-term care homes (LTCHs). Sensory declines can have deleterious effects on functioning and contribute to frailty, but the hearing needs of residents are often unrecognized or unaddressed. OBJECTIVE: To identify valid and reliable screening measures that are effective for the identification of hearing loss and are suitable for use by nursing staff providing care to residents with dementia in LTCHs. METHODS: Electronic databases (Embase, Medline, PsycINFO, CENTRAL, and CINAHL) were searched using comprehensive search strategies, and a stepwise approach based on Arksey & O'Malley's scoping review and appraisal process was followed. RESULTS: There were 193 scientific papers included in the review. Pure-tone audiometry was the most frequently reported measure to test hearing in older adults living with dementia. However, measures including self- or other-reports and questionnaires, review of medical records, otoscopy, and the whisper test were found to be most suitable for use by nurses working with older adults living with dementia in LTCHs. CONCLUSION: Although frequently used, the suitability of pure-tone audiometry for use by nursing staff in LTCHs is limited, as standardized audiometry presents challenges for many residents, and specific training is needed to successfully adapt test administration procedures and interpret results. The whisper test was considered to be more suitable for use by staff in LTCH; however, it yields a limited characterization of hearing loss. There remains an urgent need to develop new approaches to screen hearing in LTCHs.

Accessible Virtual Arts Recreation for Wellbeing Promotion in Long-Term Care Residents.

The efficacy of a technology-driven visual arts recreation activity, delivered virtually, was evaluated for its potential to achieve positive impacts, similar to traditional arts-interventions, on wellbeing in long-term care residents. Thirty-one residents (average age 86.8 years; SD = 9.4) engaged with the arts-intervention for 30-minutes, twice weekly, for 6 weeks with either a partner or as part of a group. Wellbeing indicators included self-reported psychological and health-related wellness, and attention capacity. Binomial tests of postintervention change revealed a significant above-chance probability of improvement in one or more wellbeing indicators (p < .05). Postparticipation feedback survey scores were positive (p < .05). Cognitive status did not influence outcome; however, other participant characteristics such as younger age, higher openness-to-experience (personality trait), and lower baseline mood were significantly associated with positive response to the intervention (p < .05). Findings demonstrate technology may be an effective platform for promoting accessibility to beneficial arts-interventions for older adults.

The Circle of Care for Older Adults With Hearing Loss and Comorbidities: A Case Study of a Geriatric Audiology Clinic.

Purpose Older adults seeking audiologic rehabilitation often present with medical comorbidities, yet these realities of practice are poorly understood. Study aims were to examine (a) the frequency of identification of selected comorbidities in clients of a geriatric audiology clinic, (b) the influence of comorbidities on audiology practice, and (c) the effect of comorbidities on rehabilitation outcomes. Method The records of 135 clients ( M age = 86 years) were examined. Information about comorbidities came from audiology charts (physical paper files) and hospital electronic health records (EHRs). Data about rehabilitation recommendations and outcomes came from the charts. Focus groups with audiologists probed their views of how comorbidities influenced their practice. Results The frequency of identification was 68% for visual, 50% for cognitive, and 42% for manual dexterity issues; 84% had more than one comorbidity. Also noted were hypertension (43%), falls (33%), diabetes (13%), and depression (16%). Integrating information from the audiology chart and EHR provided a more complete understanding of comorbidities. Information about hearing in the EHR included logs of outpatient audiology visits (75% of 135 cases), audiologists' care notes for inpatients and long-term care residents (25%), and entries by other health professionals (60%). Modifications to audiology practice were common and varied depending on comorbidity. High rates of success were achieved regardless of comorbidities. Conclusions In this clinic, successful outcomes were achieved by modifying audiology practice for clients with comorbidities. Increased interprofessional communication among clinicians in the circle of care could improve care planning and outcomes for older adults with hearing loss.

Considering Age-Related Hearing Loss in Neuropsychological Practice: Findings from a Feasibility Study.

ABSTRACTHearing loss is highly prevalent in older adults and can pose challenges for neuropsychologists, as assessment and intervention procedures often involve orally presented information which must be accurately heard. This project examined the hearing status of 20 clients (mean age = 71 years) in a hospital-based outpatient neuropsychology clinic, and explored whether information about hearing loss informed neuropsychologists' clinical practice. A research assistant administered a brief hearing screening test to each participant. Four treating neuropsychologists were asked to comment on their client's hearing status before and after being shown their client's hearing screen test results. Screening revealed that the majority of participants had at least mild hearing loss, and that the neuropsychologists were relatively accurate (60%) at estimating their clients' hearing status. Neuropsychologists used information about a client's hearing status to make recommendations that clients pursue audiologic services, and to educate clients and family members about hearing loss and communication.

Hearing and vision screening tools for long-term care residents with dementia: protocol for a scoping review.

INTRODUCTION: Hearing and vision loss among long-term care (LTC) residents with dementia frequently goes unnoticed and untreated. Despite negative consequences for these residents, there is little information available about their sensory abilities and care assessments and practices seldom take these abilities or accessibility needs into account. Without adequate knowledge regarding such sensory loss, it is difficult for LTC staff to determine the level of an individual's residual basic competence for communication and independent functioning. We will conduct a scoping review to identify the screening measures used in research and clinical contexts that test hearing and vision in adults aged over 65 years with dementia, aiming to: (1) provide an overview of hearing and vision screening in older adults with dementia; and (2) evaluate the sensibility of the screening tools. METHODS AND ANALYSIS: This scoping review will be conducted using the framework by Arksey and O'Malley and furthered by methodological enhancements from cited researchers. We will conduct electronic database searches in CENTRAL, CINAHL, EMBASE, MEDLINE and PsycINFO. We will also carry out a 'grey literature' search for studies or materials not formally published, both online and through interview discussions with healthcare professionals and research clinicians working in the field. Our aim is to find new and existing hearing and vision screening measures used in research and by clinical professionals of optometry and audiology. Abstracts will be independently reviewed twice for acceptance by a multidisciplinary team of researchers and research clinicians. ETHICS AND DISSEMINATION: This review will inform health professionals working with this growing population. With the review findings, we aim to develop a toolkit and an algorithmic process to select the most appropriate hearing and vision screening assessments for LTC residents with dementia that will facilitate accurate testing and can inform care planning, thereby improving residents' quality of life.

Noise Affects Performance on the Montreal Cognitive Assessment.

We investigated the effect of background noise on performance on the Montreal Cognitive Assessment (MoCA). Two groups of older adults (one with clinically normal hearing, one with hearing loss) and a younger adult group with clinically normal hearing were administered two versions of the MoCA under headphones in low and high levels of background noise. Intensity levels used to present the test were customized based on the hearing abilities of participants with hearing loss to yield a uniform level of difficulty across listeners in the high-level noise condition. Both older groups had poorer MoCA scores in noise than the younger group. Importantly, all participants had poorer MoCA scores in the high-noise (M = 22.7/30) compared to the low-noise condition (M = 25.7/30, p < .001). Results suggest that background noise in the test environment should be considered when cognitive tests are conducted and results interpreted, especially when testing older adults.

Effects of Vocal Emotion on Memory in Younger and Older Adults.

BACKGROUND/STUDY CONTEXT: Emotional content can enhance memory for visual stimuli, and older adults often perform better if stimuli portray positive emotion. Vocal emotion can enhance the accuracy of word repetition in noise when vocal prosody portrays attention-capturing emotions such as fear and pleasant surprise. In the present study, the authors examined the effect of vocal emotion on the accuracy of repetition and recall in younger and older adults when words are presented in quiet or in a background of competing babble. METHODS: Younger and older adults (Mage = 20 and 72 years, respectively) participated. Lists of 100 items (carrier phrase plus target word) were presented in recall sets of increasing size. Word repetition accuracy was tested after each item and recall after each trial in each set size. In Experiment 1, one list spoken in a neutral voice and another with emotion (fear, pleasant surprise, sad, neutral) were presented in quiet (n = 24 per group). In Experiment 2, participants (n = 12 per group) were presented the emotional list in noise. RESULTS: In quiet, word repetition accuracy was near perfect for both groups and did not vary systematically with set size for the list spoken in a neutral voice; however, for the emotional list, repetition was less accurate, especially for the older group. Recall in quiet was higher for younger than older adults; collapsed over groups, recall was higher for the neutral than for the emotional list and it decreased with increasing set size. In noise, emotion-specific effects emerged; word repetition for the older group and word recall for both groups (more for younger than older) was best for fear or pleasant surprise and worst for sad. CONCLUSION: In quiet, vocal emotion reduced the word repetition accuracy of the older group and recall accuracy for both groups. In noise, there were emotion-specific effects on the repetition accuracy of older adults and the recall accuracy of both groups. Both groups, but especially the younger group, performed better for items portraying fear or pleasant surprise and worse for items portraying sadness or neutral emotion. The emotion-specific effects on word repetition cascade to recall, especially in older listeners.

Do negative views of aging influence memory and auditory performance through self-perceived abilities?

Memory and hearing are critical domains that interact during older adults' daily communication and social encounters. To develop a more comprehensive picture of how aging influences performance in these domains, the roles of social variables such as views of aging and self-perceived abilities need greater examination. The present study investigates the linkages between views of aging, self-perceived abilities, and performance within and across the domains of memory and hearing, connections that have never been examined together within the same sample of older adults. For both domains, 301 older adults completed measures of their views of aging, their self-perceived abilities and behavioral tests. Using structural equation modeling, we tested a hypothesized model in which older adults' negative views of aging predicted their performance in the domains of memory and hearing through negatively affecting their self-perceived abilities in those domains. Although this model achieved adequate fit, an alternative model in which hearing performance predicted self-perceived hearing also was supported. Both models indicate that hearing influences memory with respect to both behavioral and self-perception measures and that negative views of aging influence self-perceptions in both domains. These results highlight the importance of views of aging and self-perceptions of abilities within and across these domains.

Aging Affects Identification of Vocal Emotions in Semantically Neutral Sentences.

PURPOSE: The authors determined the accuracy of younger and older adults in identifying vocal emotions using the Toronto Emotional Speech Set (TESS; Dupuis & Pichora-Fuller, 2010a) and investigated the possible contributions of auditory acuity and suprathreshold processing to emotion identification accuracy. METHOD: In 2 experiments, younger and older adults with normal hearing listened to and identified vocal emotions in the TESS stimuli. The TESS consists of phrases with controlled syntactic, lexical, and phonological properties spoken by an older female talker and a younger female talker to convey 7 emotion conditions (anger, disgust, fear, sadness, neutral, happiness, and pleasant surprise). Participants in both experiments completed audiometric testing; participants in Experiment 2 also completed 3 tests of suprathreshold auditory processing. RESULTS: Identification by both age groups was above chance for all emotions. Accuracy was lower for older adults in both experiments. The pattern of results was similar across age groups and experiments. Auditory acuity did not predict identification accuracy for either age group in either experiment, nor did performance on tests of auditory processing in Experiment 2. CONCLUSIONS: These results replicate and extend previous findings concerning age-related differences in ability to identify vocal emotions and suggest that older adults' auditory abilities do not explain their difficulties in identifying vocal emotions.

Effects of hearing and vision impairments on the Montreal Cognitive Assessment.

Many standardized measures of cognition include items that must be seen or heard. Nevertheless, it is not uncommon to overlook the possible effects of sensory impairment(s) on test scores. In the current study, we investigated whether sensory impairments could affect performance on a widely used screening tool, the Montreal Cognitive Assessment (MoCA). Three hundred and one older adults (mean age = 71 years) completed the MoCA and also hearing and vision tests. Half of the participants had normal hearing and vision, 38% impaired hearing, 5% impaired vision, and 7% had dual-sensory impairment. More participants with normal sensory acuity passed the MoCA compared to those with sensory loss, even after modifying scores to adjust for sensory factors. The results suggest that cognitive abilities may be underestimated if sensory problems are not considered and that people with sensory loss are at greater risk of cognitive decline.

Intelligibility of emotional speech in younger and older adults.

OBJECTIVES: Little is known about the influence of vocal emotions on speech understanding. Word recognition accuracy for stimuli spoken to portray seven emotions (anger, disgust, fear, sadness, neutral, happiness, and pleasant surprise) was tested in younger and older listeners. Emotions were presented in either mixed (heterogeneous emotions mixed in a list) or blocked (homogeneous emotion blocked in a list) conditions. Three main hypotheses were tested. First, vocal emotion affects word recognition accuracy; specifically, portrayals of fear enhance word recognition accuracy because listeners orient to threatening information and/or distinctive acoustical cues such as high pitch mean and variation. Second, older listeners recognize words less accurately than younger listeners, but the effects of different emotions on intelligibility are similar across age groups. Third, blocking emotions in list results in better word recognition accuracy, especially for older listeners, and reduces the effect of emotion on intelligibility because as listeners develop expectations about vocal emotion, the allocation of processing resources can shift from emotional to lexical processing. DESIGN: Emotion was the within-subjects variable: all participants heard speech stimuli consisting of a carrier phrase followed by a target word spoken by either a younger or an older talker, with an equal number of stimuli portraying each of seven vocal emotions. The speech was presented in multi-talker babble at signal to noise ratios adjusted for each talker and each listener age group. Listener age (younger, older), condition (mixed, blocked), and talker (younger, older) were the main between-subjects variables. Fifty-six students (Mage= 18.3 years) were recruited from an undergraduate psychology course; 56 older adults (Mage= 72.3 years) were recruited from a volunteer pool. All participants had clinically normal pure-tone audiometric thresholds at frequencies ≤3000 Hz. RESULTS: There were significant main effects of emotion, listener age group, and condition on the accuracy of word recognition in noise. Stimuli spoken in a fearful voice were the most intelligible, while those spoken in a sad voice were the least intelligible. Overall, word recognition accuracy was poorer for older than younger adults, but there was no main effect of talker, and the pattern of the effects of different emotions on intelligibility did not differ significantly across age groups. Acoustical analyses helped elucidate the effect of emotion and some intertalker differences. Finally, all participants performed better when emotions were blocked. For both groups, performance improved over repeated presentations of each emotion in both blocked and mixed conditions. CONCLUSIONS: These results are the first to demonstrate a relationship between vocal emotion and word recognition accuracy in noise for younger and older listeners. In particular, the enhancement of intelligibility by emotion is greatest for words spoken to portray fear and presented heterogeneously with other emotions. Fear may have a specialized role in orienting attention to words heard in noise. This finding may be an auditory counterpart to the enhanced detection of threat information in visual displays. The effect of vocal emotion on word recognition accuracy is preserved in older listeners with good audiograms and both age groups benefit from blocking and the repetition of emotions.

Cognitive behavior therapy after acquired brain injury: maintenance of therapeutic benefits at 6 months posttreatment.

OBJECTIVES: To examine whether 6-month posttreatment acquired brain injury (ABI) patients receiving cognitive behavior therapy (CBT) adapted for ABI would demonstrate (1) maintenance of psychological benefits, (2) better community integration, and (3) commensurate benefits for both teletherapy and face-to-face group therapy. A secondary objective was to examine the relationship between coping strategies and mood and community integration. PARTICIPANTS: Seventeen chronic ABI patients with elevated psychological distress. OUTCOME MEASURES: Symptom Checklist-90-Revised (SCL-90-R), Depression Anxiety Stress Scales-21 (DASS-21), Community Integration Questionnaire, and the Ways of Coping questionnaire, revised. PROCEDURES: Eleven CBT sessions provided either in a face-to-face group format or individually by telephone with outcomes measured pretreatment, posttreatment, and at 6-month follow-up. RESULTS: At 6-month follow-up, full-group scores were significantly better than pretreatment for psychological distress (t(16) = 6.22, P < .01, SCL-90-R; t(16) = 7.32, P < .01, DASS-21) and for community integration (t(16) = -6.15, P < .01), with negligible decrements from immediately posttreatment. Subgroup scores were comparable. Coping also improved but was uncorrelated with mood or community integration. CONCLUSION: The CBT adapted for ABI shows enduring benefits for mood and community integration. The efficacy of teletherapy obviates service access problems related to geographical remoteness and mobility restrictions. A larger, randomized, control trial that examines underlying mechanisms of efficacy is needed.

Use of affective prosody by young and older adults.

Emotion is conveyed in speech by semantic content (what is said) and by prosody (how it is said). Prior research suggests that older adults benefit from linguistic prosody when comprehending language but that they have difficulty understanding affective prosody. In a series of 3 experiments, young and older adults listened to sentences in which the emotional cues conveyed by semantic content and affective prosody were either congruent or incongruent and then indicated whether the talker sounded happy or sad. When judging the emotion of the talker, young adults were more attentive to the affective prosodic cues than to the semantic cues, whereas older adults performed less consistently when these cues conflicted. Participants' reading and repetition of the sentences were recorded so that age- and emotion-related changes in the production of emotional speech cues could be examined. Both young and older adults were able to produce affective prosody. The age-related difference in perceiving emotion was eliminated when listeners repeated the sentences before responding, consistent with previous findings regarding the beneficial role of repetition in conversation. The results of these experiments suggest that there are age-related differences in interpreting affective prosody but that repeating may be a compensatory strategy that could minimize the everyday consequences of these differences.

Attentional switching in the sequential flanker task: age, location, and time course effects.

The sequential flanker task was developed to study sequential performance using methodology borrowed from studies of task switching. We investigated age differences in backward inhibition [BI: Mayr, U., & Keele, S. W. (2000). Changing internal constraints on action: The role of backward inhibition. Journal of Experimental Psychology: General, 129, 4-26] during a sequential category search task. Participants learned four animal categories in a fixed order, and then searched for exemplars from those categories in runs of mis-ordered exemplars. Across three experiments, we observed robust BI facilitation effects. However, the magnitude of BI effects did not differ across age groups. This age-invariance held despite manipulations of distractibility (Experiment 2), and interstimulus interval (Experiment 3), suggesting that BI processes may be relatively automatic and obligatory in the context of sequential tasks. The findings are discussed in terms of the attentional mechanisms that underlie task set switching and sequential performance.