Meghan Kathleen Mattos

BACKGROUND As the number of US adults 65 years and older continues to grow, so does the need for sustainable, scalable approaches to cognitive assessment and support. Alzheimer’s disease (AD) affects over 6 million US adults, a number projected to reach 13 million by 2050, yet cognitive decline remains underdiagnosed and is often identified late in the disease course. Given older adults’ increasing access to and use of the Internet, Internet-based cognitive programs have emerged as a promising approach to cognitive assessment and monitoring. Building on previously successful approaches to cognitive enhancement program design, we developed LookAlikes, an easily accessible, interactive, and engaging cognitive assessment program that tracks multiple cognitive domains over time and provides instantaneous feedback. OBJECTIVE This 2-phase study aimed to (1) optimize the LookAlikes user interface and validate the accuracy of its speech-to-text and scoring systems (Phase 1) and (2) establish the feasibility and acceptability of LookAlikes among older adults with subjective memory concerns (Phase 2). We hypothesized that the program’s systems would achieve sufficient accuracy to support future longitudinal cognitive tracking and that LookAlikes would be feasible and acceptable to the target population. METHODS In both phases, participants (≥65 years of age) with subjective memory concerns were recruited from a convenience sample of older adults ineligible for an NIH-funded national randomized controlled trial (NCT05565833). All participants were asked to use LookAlikes daily for 12 days (<2 min/session) and complete an end-of-study online questionnaire assessing ease of use, program design, overall satisfaction, and likelihood of recommending the program, with open-ended questions to capture unanticipated feedback. In Phase 1 (N=40), we compared 480 audio files to processed speech-to-text results using word-by-word counts and calculated word error rate (WER) against a prespecified accuracy target of ≥85%. Phase 2 enrolled a separate, subsequent sample of 43 participants, and feasibility was measured by program use, duration of use, and frequency of use. Quantitative data were analyzed in SPSS Statistics (v.26); qualitative responses were analyzed using line-by-line coding and content analysis. RESULTS In Phase 1, all 40 participants completed the 12 LookAlikes activities (completion range 12-19 days) and the end-of-study questionnaire. Speech-to-text accuracy was 99.1% (WER=191/22,029) across 480 audio files, surpassing the 85% target. In Phase 2 (N=43), 97.7% of participants completed all 12 activities, with 74.4% completing them within 14 days; 1 participant withdrew. Acceptability was high: 92.7% reported playing LookAlikes every day, 75% indicated they would play for fun outside a study, and 85.3% liked the post-task scoring feedback. On a 5-point Likert scale, mean ratings for satisfaction (4.49), ease of use (4.61), and convenience (4.70) were consistently high. Participants reported low confusion (mean 1.54) and frustration (mean 1.59). The majority (87.8%) reported no privacy concerns. CONCLUSIONS The LookAlikes speech-to-text and scoring systems exceeded prespecified accuracy targets, and the program was feasible and highly acceptable to older adults with subjective memory concerns. Together, these complementary findings support progression to a longitudinal study evaluating LookAlikes to measure and track cognition over time.

Background: Informal caregivers of persons living with dementia experience high caregiver burden, with behavioral problems among care recipients being a significant contributing factor. Objective: This scoping review synthesized evidence on the effects of formal services on caregiver burden and care recipient behavioral problems. Methods: A literature search was conducted in PubMed, CINAHL, and EMBASE to identify relevant studies published from January 2014 to December 2025. Results: One hundred full-text articles were reviewed, and 15 met eligibility criteria. The review revealed four types of formal services: care management programs, caregiver education/training programs, support groups, and respite services. Most services associated with reducing caregiver burden and behavioral problems focused on educating or training caregivers. Findings suggest that various formal services, especially when delivered in person, may help reduce caregiver burden and behavioral problems among care recipients. Evidence-based dyadic interventions are needed to support caregivers and their care recipients in community settings.

Internet-based recruitment holds promise for Alzheimer's disease (AD) research, but its effectiveness for engaging rural older adults with cognitive concerns remains unclear. This review synthesized existing literature on internet-based recruitment for AD research targeting rural-dwelling older adults. After searching PubMed, CINAHL, Embase, and Web of Science, 670 non-duplicate records were screened, and only one eligible study was identified. The top two reasons for exclusion were internet-based recruitment was not used or rural recruitment outcomes were not measured. Despite the expansion of digital recruitment in AD research, rural populations remain overlooked, a critical gap given their disproportionate barriers to research participation.

Introduction: Family caregivers frequently experience sleep challenges that impact their own health and ability to provide care for a care recipient (i.e., the person a caregiver supports). Cognitive-behavioral therapy for insomnia (CBT-I) effectively treats insomnia, but there is limited evidence regarding caregivers’ perceived impacts of this intervention. The current study evaluated caregivers’ experiences using Sleep Healthy Using The Internet (SHUTi), an Internet-delivered CBT-I intervention. Method: The sample comprised caregivers with insomnia who supported care recipients requiring medium- or high-intensity care for any condition, including Alzheimer’s disease/dementia (21%), cancer (11%), or a mobility problem (11%). Participating caregivers who used SHUTi ( n = 82; age M = 53.20, 85% female, 59% lived with the care recipient) provided open-ended feedback about their experience. Responses were analyzed using a rapid content analysis approach. Results: Responses revealed that caregivers perceived benefits of SHUTi to their functioning and their understanding of sleep . Caregivers described how the intervention improved their overall daytime abilities, mood, and caregiving capacity. They also shared how the intervention helped them prioritize sleep and self-care, gave them insight into their sleep, and increased their knowledge of healthy sleep. Discussion: Caregivers reported wide-ranging benefits from CBT-I beyond improved sleep. Despite the untailored nature of this intervention, several caregivers described positive impacts on their caregiving capabilities and outlook, resulting from the program helping them to improve their sleep and self-care more broadly. These results suggest that framing caregiver-focused health interventions as important to both caregivers and care recipients may increase caregivers’ uptake of such resources.

Background: Ongoing capacity‐to‐consent (CTC) assessments are essential in long‐term studies with cognitively impaired adults to protect research participants, uphold ethical research standards, and ensure the validity of study findings. This study describes the development, implementation, and benefits of repeated CTC assessments in a two‐year, Internet‐based randomized controlled trial (RCT) involving older adults living with cognitive concerns. Method: SHUTi MIND is an RCT evaluating an online insomnia intervention in older adults with cognitive concerns, using rolling recruitment. CTC is assessed via phone at baseline and every six months (6, 12, 18, and 24 months) using a standardized, IRB‐approved protocol. The protocol was developed based on current literature, study‐specific considerations, and input from neuropsychologists. A trained staff member conducts semi‐structured interviews that include (1) assessing participants’ understanding of recent, past, and upcoming events and (2) reviewing and evaluating their comprehension of the study’s purpose, risks, benefits, voluntariness, and decision‐making rationale. Up to three phone calls and three emails are made. If participants cannot demonstrate CTC, they are deemed to lack capacity, and surrogate consent is attempted. CTC completion rates and contact attempts were analyzed at the 6‐ and 12‐month assessments. Result: Of the total study participants ( N =176), 80 had enrolled for at least 6 months and were eligible for the 6‐month CTC assessment. Sixty‐one participants (76.25%) completed the 6‐month CTC assessment, with 183 total contact attempts (mean = 2.29 contacts/participant). At 12 months, 43 were eligible for the 12‐month CTC check, and 32 (74.42%) completed the CTC assessment with 103 contact attempts (mean = 2.40 contacts/participant). One participant was determined to lack CTC, and surrogate consent was successfully obtained. Conclusion: The structured CTC protocol, including proactive follow‐up by phone and email, yielded high completion rates and allowed for consistent monitoring of decisional capacity over time. These findings suggest that routine CTC assessments in remote clinical trials involving cognitively impaired participants are both feasible and effective for identifying participants who may require additional ethical safeguards.

Objectives: Cognitive disorders are common in older persons with seizures (PWS). Cognitive disorders are often associated with impaired Instrumental Activities of Daily Living (IADLs). However, the effects of seizures on IADLs remain unexplored. This study (9/2005–3/2024) from 42 US Alzheimer's Disease Research Centers examined baseline and longitudinal IADL decline in cognitively normal and cognitively impaired participants grouped as active seizures (past 12 months), remote seizures (history but none in 12 months), and controls (no seizures).Methods: Pfeffer Functional Activities Questionnaire (FAQ) measured IADLs. ANOVA compared individual and total FAQ by seizure and cognitive status. Multivariable linear regression adjusted FAQ for seizure status, age, sex, and education. ANOVA compared the rate of longitudinal FAQ decline across seizure groups. Post hoc analyses identified group differences.Results: Among 20,486 cognitively normal participants (average age = 69.7 years, female = 65% [N = 13,370]), IADLs were worse among 114 active seizure participants (adjusted‐mean‐difference [95% confidence interval (CI)]: active vs. remote = 0.69 (0.23, 1.14), p = 0.0011, active vs. controls = 0.85 (0.46, 1.24), p < 0.001). Among 30,238 cognitively impaired participants (average age = 72.2 years, female = 52% [N = 15,632]), IADLs were worse among 735 active seizure participants (adjusted‐mean‐difference (95% CI): active vs. remote = 6.85 (5.59, 8.10), p < 0.001, active vs. controls = 8.93 (8.06, 9.80), p < 0.001). Longitudinally, IADLs in cognitively normal adults declined faster in active seizure participants than in controls (p = 0.0396). Active seizure participants struggled most with managing taxes, traveling, paying bills, and remembering appointments.Interpretation: Active seizures are associated with worse baseline IADLs and a faster rate of longitudinal decline in IADLs. These findings highlight the significant need to assess IADLs in routine clinical care in older PWS regardless of their cognition to identify those needing assistance.

Background/Objectives: Frailty assessments in older adults are an important prognostic indicator for predicting health-related outcomes. The purpose of this study was to determine the feasibility and acceptability of using a wrist-worn actigraphy device to measure frailty in homebound older adults. Methods: In this US single-site cohort study, older adult participants were asked to continuously wear an actigraphy device on their wrist for three weeks. Caregivers were asked to complete short descriptive surveys. Surveys collected demographic and subjective frailty measures; sleep and activity data were collected via Actiwatch. Descriptive statistics were performed for quantitative data; qualitative analyses were conducted for open-ended survey questions. Results: Twelve of the thirteen dyads completed all study activities, participants demonstrated feasibility and acceptability of device use, and dyads reported overall positive experiences. Conclusion: Findings suggest that wearing a wrist-worn actigraphy device is feasible and acceptable in homebound older adults and can potentially measure objective frailty over time.

Seizures are common in dementia and associated with accelerated cognitive decline. However, the impact of active vs remote seizures on cognition remains understudied. This study aimed to investigate the impact of active vs remote seizures on cognition in people with normal cognition and mild cognitive impairment (MCI). This longitudinal, multicenter cohort is based on National Alzheimer's Coordinating Center data of participants recruited from 39 Alzheimer's Disease Centers in the United States from September 2005 to December 2021. All participants with normal cognition and MCI and at least 2 visits were included. Primary outcome, that is, cognitive decline, was determined using Clinical Dementia Rating (CDR) from (1) normal-to-impaired (CDR ≥0.5) and (2) MCI-to-dementia (CDR ≥1) groups. The effect of active seizures (over the preceding 12 months), remote seizures (previous seizures but none over the preceding 12 months), and no seizures (controls) on cognition was assessed. Subgroups of chronic seizures at enrollment and new-onset seizures were further analyzed. Cox regression models assessed the risk of all-cause MCI and/or dementia. All models were adjusted for age, sex, education, race, hypertension, and diabetes. Of the 13,726 participants with normal cognition at enrollment (9,002 [66%] female; median age 71 years), 118 had active seizures and 226 had remote seizures. Of the 11,372 participants with MCI at enrollment (5,605 [49%] female; median age 73 years), 197 had active seizures and 226 had remote seizures. Active seizures were associated with 2.1 times higher risk of cognitive impairment (adjusted hazard ratio [aHR] 2.13, 95% CI 1.60-2.84, p < 0.001) in cognitively healthy adults (median years to decline: active seizures = ∼1, remote seizures = ∼3, no seizures = ∼3) and 1.6 times higher risk of dementia (aHR 1.58, 95% CI 1.24-2.01, p < 0.001) in those with MCI (median years to decline: active seizures = ∼1, remote seizures = ∼2, controls = ∼2). This risk was not observed with remote seizures. In this study, active seizures but not remote seizures were associated with earlier cognitive decline in both cognitively normal adults and those with MCI, independent of other dementia risk factors. Therefore, early identification and management of seizures may present a path to mitigation of cognitive decline in the aging epileptic population. A limitation is that causality cannot be confirmed in our observational longitudinal study.