July 15, 2017

Feasibility of Using App-based Technology in High Stress Older Adult Caregivers

Alexandra Crosswell

Pilot Study Report

Introduction

Chronically stressed caregivers are at increased risk for health problems compared to age-matched low stress non-caregivers, including problems with cognitive functioning. Being a caregiver for a loved one with a chronic illness is associated with decreased cognitive control, including diminished selective attention (Caswell et al., 2003). The psychological stress of caregiving may lead directly to attentional deficits (potentially through accelerated age-related cognitive decline and/or through increased cognitive demands). In a cyclical pattern, these decreases in attentional abilities may lead to increased distress in caregivers as they become less efficient at redirecting their attention away from negative thoughts and emotions (a core component of effective emotion regulation is selective attention; Gross, 1998). Cognitive training interventions have been shown to enhance sustained attention (Anguera et al., 2013) though have yet to be tested in high stress older adult caregivers, a group at risk for declining cognitive health. In this study, we test the feasibility of a app-based daily attention training program in high stress family caregivers of patients with neurodegenerative disease, and examined initial evidence for improvements in psychological distress and attentional abilities as a result of the training.

Purpose

The purpose of this pilot study was to test the feasibility of using an app-based attentional training program in high stress older adult caregivers of neurodegenerative patients in preparation for the submission of an R01 grant.

Procedures

High stress older adult caregivers were recruited locally and consented to the study. Participants came to our research lab at UCSF Laurel Heights to complete computer-based cognitive and psychosocial questionnaires before receiving an iPad and learning to use the MediTrain app. Participants were then loaned an iPad and asked to engage with the app for 20-30 minutes a day, 5 days a week, for 6 weeks. After the 6 weeks, participants returned for a follow-up clinic visit. At each visit, participants completed cognitive tasks using the POSIT and Adaptive Cognitive Evaluation (ACE) app per protocol from collaborator David Zeigler, and psychosocial questionnaires including caregiving burden and caregiving satisfaction, general perceived stress, depressive symptoms, sleep quality, physical symptoms, and mindfulness.

Participant Recruitment

N=55 screened for eligibility, n=20 were eligible, n=18 consented, n=14 completed study (defined as completing both pre and post visits), n=4 were non-completers.

Feasibility Summary

The initial goal of the study was to recruit 20 participants and assign 10 to the active MediTrain condition and 10 to the control condition. We changed the plans midway through the study and decided to only run the MediTrain group due to difficulty recruiting and technical problems leading to data loss. Recruitment of this sensitive population was difficult. Technical difficulties with the new software apps (MediTrain and ACE) took significant staff time, and led to data loss. Participants were able to come in for the in-person sessions, and reported fatigue for visits that lasted longer than 2 hours. Fatigue from study-related tasks was more common in this population than we have seen in previous populations in our work. MediTrain was acceptable to participants, with participants reporting liking the app and able to complete 20-30 minutes per day of training. Potential improvements to the app suggested by the participants included more guided meditation and the addition of music. Participants were also frustrated by the app crashing and it miscalculating the amount of time they had spent meditating. The POSIT cognitive tasks were not appropriate for this sample as the adaptive aspect made them take a long time to complete (in some cases >60 minutes, which fatigued and frustrated participants), a score was given to participants based on norms data not controlling for age, and the data produced is not of research quality. After the first 10 participants, we stopped using the POSIT tasks because of these issues.

Results

Participants completed psychosocial questionnaires before and after 6 weeks of training, including measures of perceived stress (PSS), depressive symptoms (CESD), mindfulness (MAAS), and sleep quality (PSQI). We hypothesized that participants who competed the training would show decreases in psychological distress, and increases in mindfulness and sleep quality. Participants reported a significant decrease in perceived stress (p= .014), a marginally significant increase in mindfulness (p=.15), and no significant changes in depressive symptoms (p=.88) or sleep quality (p=.88).

The cognitive data from the ACE tasks has been processed and is currently being analyzed.

How can other researchers use these findings to inform their own work exploring the concept of ‘stress’?

Researchers considering working with older adult high stress caregivers need to limit the number of tasks asked of the participants due to issues of fatigue. Participants came in to our lab already fatigued and were fatigued by the tasks/ engaging in the study procedures. Future researchers should examine the specific aspects of cognitive control that are impacted by the stress of caregiving (e.g. is it alerting, orienting, or executive control?; Posner and Rothbart, 2007) and whether cognitive training indeed improves those specific aspects.

How will this experience alter the way in which you approach studying and measuring ‘stress’?

I will incorporate fatigue and energy/ vitality in to my models of how chronic stress impacts cognitive health, especially in the context of caregiving in which the participants is rarely ‘off the clock.’ One pathway by which a brief daily intervention may exert its positive effects may be through giving caregivers a brief ‘respite’ from the activities and negative cognitive thought patterns associated with daily caregiving. This can be explored in future research.