Titolo della tesi: Information and Communication Technology procedures for eHealth in patients with Alzheimer's disease and related dementias: a point-of-care personalised approach.
The present Ph.D. dissertation was developed in the research and technological innovation framework of the European Marie S. Curie Action International Training Network and European Training Network titled ‘Blood Biomarker-based Diagnostic Tools for Early-stage Alzheimer’s Disease’ (BBDiag; https://cordis.europa.eu/project/id/721281/). The activities were focused on the development and testing of new information and communication technologies (ICT) for the point-of-care (PoC) (e.g., home, residency home, and pharmacy) assessment of patients with Alzheimer’s disease (AD) and related dementing disorders.
My Ph.D. work aimed to develop and test smart ICT point-of-care applications (apps) for patients with AD and related dementing disorders (e.g., Parkinson’s disease (PD) with cognitive deficits). To this aim,
(1) I interviewed potential users (i.e., patients, relative carers, and medical staff) about familiarity and needs concerning mobile and computerised technologies to guide the design of the new apps (Study one).
(2) Based on the data, I designed a mobile app for managing and visualising the values derived from graphene-based biosensors of blood-biomarkers associated with AD, which were developed in the BBDiag project. To mitigate the risk factor of smoking for dementing disorders, I designed and developed a mobile app, and then used it to perform a preliminary beta test. The app was designed to monitor and visualise the number of cigarettes that an individual smokes per day to reduce smoking towards complete cessation (Study two).
(3) Finally, I collaborated with colleagues at Sapienza University of Rome and other partners to test the effects of an app for computerised cognitive training at point of care (homes) in patients with AD and Parkinson’s disease with cognitive deficits (Study three).
The details of the three studies are summarised in the following sections.
Study one
This study used semistructured interviews to ascertain the views of patients with cognitive deficits, relative careers, and medical personnel on the use of mobile applications. We questioned patients and careers about the assistance in daily life needed as well as the assistance necessary to organize the activities of daily life. Notably, we asked them about the current use of ICT devices (i.e., smartphones, tablets, personal computers), mobile apps, and their difficulties in the use of these technologies. We also enquired about their openness and fears concerning those technologies, possible benefit they perceived in them, obstacles to its use, areas of use they thought most promising, ideas for new ICT services useful for health care as well as concerns about data security and their willingness to allow their information to be used for research. The interviews were analysed using qualitative content analysis according to Mayring (Mayring 2015). Technology openness and fear were quantified, due to the nature of the answers given. The medical personnel were most open to the use of mobile apps to support and monitor patients at their homes, especially if it would help them to prevent harm to the patient. 50% of the patients used smartphones and 50% used mobile phones. 70% of the careers used smart phones, about 10% mobile phones. In contrast, 90% of the medical personnel used smartphones.
Study two
In this part of the PhD work, we developed an application to help persons with AD to cease smoking, since smoking contributes to the development of AD. The smartphone app consists of a counter that is connected to a data base. The user is able to enter cigarettes smoked simply, and the mobile app can generate graphs to show how many cigarettes were smoked over a day, a week and a month. The app uses notifications to positively reinforce the reduction of the smoked cigarettes.
We tested this mobile app in a small user group to get user feedback and find possible bugs. The users were globally happy with the app, and their feedback resulted in minor changes to the application to improve user experience. Based on this test, the mobile app will be used in a clinical trial in AD and PD patients with cognitive deficits (ADCD and PDCD, respectively) to be carried out at the Sapienza University of Rome in 2022 (after a stabilisation of the coronavirus pandemic).
Moreover, two mobile apps for the analysis of blood-biomarkers were designed primarily for the use on tablets. One application primarily geared towards medical use allows for the generation of a patient’s profile to continuously monitor patients in longitudinal studies measuring blood biomarkers of AD. The other application is geared towards home use and monitoring at PoC if patients or relative carers have the necessary skills. This application contains fewer options and is easier to use. Both apps connect a central cloud set up at the University of Plymouth (Beneficiary of the BBDiag Consortium) and a point-of-care graphene-based device to be developed in the BBDiag project to measure multiple blood biomarkers of AD. The mobile app also serves a local storage and analysis of the collected data.
Since the mentioned PoC graphene-based device was not completed by the personnel of Swansea University and Plymouth University (Beneficiaries of the BBDiag Consortium) due to delays caused by coronavirus pandemic, the prototype of the application is not fully functional. The design of the mobile apps was performed taking the inputs of study one into account. Most patients with cognitive deficits and relative careers advocated a simple to use solution. Also, some of the medical personnel were concerned of an increase in workload if such applications were to be added to their daily routines.
Study three
In this study, we investigated the effect of two weeks of computerised cognitive training (CCT) on the resting-state electroencephalographic (rsEEG) source activity estimated in ADCD and PDCD patients. We also included a control group of normal healthy elderly people (Nold) to define the abnormalities in the rsEEG measures derived by the EEG study. The ADCD and PDCD groups underwent clinical-neuropsychological assessment and a rsEEG recording at baseline and after two weeks of CCT or sham treatment (i.e., watching favourite videos). Both ADCD and PDCD patients showed an improvement in the performance accuracy after two weeks of CCT. The PDCD patients also exhibited an improvement in the rsEEG source activity after the CCT. A reduction in the abnormalities was observed in the posterior delta and theta cortical source activities. The CCT was not able to produce statistically significant beneficial effects in the rsEEG source activities in the ADCD patients, possibly due to more pronounced cholinergic deficits in relation to PDCD patients.
Overview of the significance of the findings
Patients with cognitive deficits and their caregivers were interested in mobile apps for clinical applications even if there were misalignments between patients and caregivers’ views that need to be explored further to design appropriate interventions using of those technologies. The medical personnel interviewed was especially interested in mobile apps for clinical application that would prevent harm to the patients. However, they added the caveat that the use of new technologies should not increase the workload in patients’ clinical management. Those findings were used to optimize the design of the mobile apps of my Ph.D. work.
Study two developed one application to support patients to cease smoking and two blood-biomarker detection apps of which one is intended for PoC (i.e., home) use and the other for professional use by medical personnel using the results from study one to align better with the needs of potential users. Testing in a small user group of the application to support the cessation of smoking demonstrated that it is a feasible way to support smokers willing to stop. The feedback from the testers resulted in minor changes to the application. The smoking application prototype can now be tested in a wider population. Due to unavailability of the BBDiag PoC device the prototypes of the BBDiag applications are not fully functional, but they could be used to confirm the design concept with users in a small exploratory study.
Study three demonstrated the feasibility of the use of mobile apps by patients with cognitive deficits and caregivers at PoC (i.e., patients’ homes). Indeed, patients and caregivers were able to face the stress associated with the use of mobile apps when they were simple and promised to be beneficial for the clinical management of the disease. Furthermore, study three demonstrated that mobile apps can be successfully used for diagnostic and training purposes. Both ADCD and PDCD groups were able to manage the CCT for two weeks and showed the effects of the cognitive training in the performance of the serious videogames used. Some positive effects of the CCT were observed in the reduction of the abnormalities in rsEEG source activities in PDCD patients, possibly due to a partially preserved brain ascending cholinergic systems.
All three studies at the basis of this Ph.D. dissertation showed that patients with cognitive deficits are interested in and would use PoC mobile apps related to the collection of relevant data for brain health assessment and training of brain functions. This outcome encourages further investments in educational and scientific activities to develop and test new mobile apps for clinical management of patients with cognitive deficits.