Providing a Purposeful and Stimulating Volunteer Opportunity for Older Adults With Mild Cognitive Impairment

Abstract

Social interactions have cognitive and emotional benefits for older adults with mild cognitive impairment (MCI). The prevalence of loneliness and isolation in this population has been repeatedly noted, but interventions remain limited. We designed a program to connect older adults with MCI with an engaging volunteering opportunity, through videoconferencing conversations with another adult practicing English (English language learner). Ten MCI-English language learner pairs had conversation sessions over 6 weeks. We tracked session engagement, monitored conversations, and interviewed participants at follow-up. Pairs completed 78% of scheduled sessions; only 7% were missed because the MCI participant canceled or failed to appear. Qualitative interviews suggested that participants felt comfortable and engaged. No negative experiences were observed or reported. This program is feasible and potentially desirable for older adults with MCI. This model is interesting given the concern about in-person volunteering risks, and the millions of people motivated to improve English fluency.

Poor psychological wellbeing and social withdrawal have been causally implicated in cognitive decline and are commonly recognized features of mild cognitive impairment (MCI). As more older adults live alone, strategies are needed to increase meaningful social engagement to prevent mood problems, preserve cognitive functioning, and enhance quality of life. The COVID-19 pandemic has increased the urgency of supporting meaningful interactions while minimizing the risk of infection.

Volunteering can protect against cognitive decline through both neurological and psychological mechanisms.1 Volunteerism and cultivating a sense of “mattering” are especially important, because purpose is one of the dimensions of wellbeing that decreases the most with age.2 Community-dwelling older adults with greater purpose in life have a substantially decreased risk of developing Alzheimer’s disease.3

We developed an intervention designed to increase meaningful social interactions among older adults with MCI. The Seniors Promoting English Acquisition and Knowledge (SPEAK)! program enables semistructured webcam conversations between older adults with MCI and adults who want to improve their English fluency, that is, English language learners (ELLs). Prior work indicates that people with MCI actively engage in web-enabled conversations and that such conversations may improve depressive symptoms and cognition.4,5 Here, we present results from the initial user-centered design, which included 10 MCI-ELL pairs with up to 6 possible hour-long conversation sessions each, and semistructured interviews at follow-up.

METHODS

Eligibility and Screening

Our primary source of participants with MCI was the Michigan Alzheimer’s Disease Research Center (MADRC), which hosts a research registry of individuals with cognitive concerns, some of whom having undergone detailed neuropsychological evaluations and received a diagnosis of MCI. Potential recruits were eligible if they had a montreal cognitive assessment (MoCA) score between 12 and 25,6 and were: 55+ years of age, fluent speakers of English, and able to participate in videoconferencing. We used a modified version of the University of California, San Diego Brief Assessment of Capacity to Consent (UBACC) to ensure that participants were able to provide informed consent.7,8

Most ELLs were identified through a social media campaign that ran for 1 week. A total of 549 potential ELL participants clicked the ad and were directed to our university’s research portal (a 5.36% click-through rate, 549/10,248). Additional ELLs were identified by the University of Michigan English Language Institute, which serves non-native English students and staff. To be eligible, ELLs had to be 18+ years of age and able to participate in videoconferencing.

The SPEAK! Intervention

We developed an online platform that allowed communication through: the program’s videoconferencing website, e-mail and text reminders, live text chat, and asynchronous messaging. Staff facilitated participant pair enrollment and conversation session scheduling. Participant pairs were coupled with a staff liaison, who was present in all sessions for introductions and troubleshooting technical problems. The platform facilitated session recordings and retained system engagement logs (eg, logons, messaging, and material review).

Participants with MCI and ELLs participated separately in an orientation with staff, conducted through videoconferencing. Orientation for participants with MCI emphasized strategies to ensure that they were comfortable communicating using their webcam, and strategies for handling possible difficulties understanding their partner. For ELLs, orientation emphasized strategies to be more effectively understood, and how to manage instances where their partner might get nervous or frustrated. All orientations included a discussion of topics to avoid, such as finances and potentially contentious political or religious differences.

Pairs were assigned based on their scheduling availability. Once paired, they participated in up to 6, hour-long conversation sessions. All participants were sent reminders 24 hours before each session through telephone, e-mail, or text message according to their preference. Each session was facilitated by staff who introduced the session and assisted with any technical issues. A suggested session outline and potential session topics were available through the program’s website.

Data Collection and Analysis

For participants with MCI, we collected sex, race/ethnicity, age, level of education, and MoCA score. For ELLs, we collected basic sociodemographic descriptors and their primary language. Staff maintained records regarding completed and missed sessions. Staff took notes during all sessions and assessed factors such as the extent to which participants used materials and the proportion of time in which each person was listening versus speaking. Key utterances such as statements by the ELL giving appreciation and framing requests in a positive manner were also noted. Semistructured interviews were conducted separately after the pair reached at least week 5. Detailed notes were taken and responses were summarized by theme.

RESULTS

Five of the 10 participants with MCI were male and 5 were female; 6 were White, and 4 were Black/African American. The average age of participants with MCI was 72.8 years (range: 61 to 89 y). Nine of the 10 participants with MCI had MoCA scores between 20 and 25, and 1 had a MoCA score of 12. All participants with MCI reported at least some college education. ELLs came from a variety of countries outside of the United States, including South Korea (2), Chile (1), Brazil (1), Colombia (1), China (2), Japan (1), and India (2). Six of the 10 ELLs were male and 4 were female. Six ELLs were employed, 3 were postdoctoral fellows, and 1 was a stay-at-home caregiver.

Overall, pairs completed 47 out of 60 possible 1-hour sessions (78%). There was no indication that missed sessions increased over time (ie, disengagement) or that missed sessions were related to the cognitive functioning of the participant with MCI. Only 4 sessions (6.7%) were missed because the participant with MCI canceled or failed to appear. Eight sessions were missed because the ELL canceled or failed to appear. One session was missed due to the participant with MCI experiencing technical problems. There was no indication that session completion was different for the participant with the lowest MoCA score (score of 12; 4 of 6 sessions completed).

Most participants with MCI (9 out of 10) needed some assistance with audio or video issues; and video issues occurred in 42.6% of sessions (Table 1). We observed no instance in which a participant with MCI expressed frustration or that the pair had a conflict or disagreement. Participants with MCI gave positive feedback to their ELL partner in more than half of all sessions and frequently expressed appreciation for the experience. ELL participants expressed appreciation to the participant with MCI in 64% of all sessions, and all 10 participants with MCI received expressions of appreciation from the ELLs. Although most pairs focused on language practice, pairs discussed a range of topics including family, culture, hobbies, and work.

TABLE 1.

Process Data From Completed Sessions

	Occurred in the Pair, N=10 Pairs	Occurred in Sessions, N=47 Sessions, N (%)
Experiences of older adults with MCI
Experienced audio problems	9/10	18/47 (38.3)
Experienced video problems	8/10	20/47 (42.6)
Experienced language problems*	3/10	3/47 (6.4)
Experienced frustration	0/10	0/47 (0.0)
Gave positive feedback	10/10	27/47 (57.4)
Expressed appreciation	10/10	22/47 (46.8)
Used chat feature	1/10	1/47 (2.1)
Experiences of ELLs
Experienced audio problems	3/10	3/47 (6.4)
Experienced video problems	3/10	4/47 (8.5)
Experienced language problems*	5/10	5/47 (10.6)
Experienced frustration	0/10	0/47 (0.0)
Gave positive feedback	10/10	25/47 (53.2)
Expressed appreciation	10/10	30/47 (63.8)
Used chat feature	4/10	5/47 (10.6)
Pair-level experiences
Pair had a conflict	0/10	0/47 (0.0)
Pair lacked topics to discuss	0/10	0/47 (0.0)
Staff member engaged†	10/10	20/47 (42.6)
Topics discussed
Family	10/10	30/47 (63.8)
Culture	9/10	22/47 (46.8)
Food	7/10	16/47 (34.0)
Home	10/10	22/47 (46.8)
Work	10/10	26/47 (55.3)
Hobbies	10/10	20/47 (42.6)
Sports	6/10	9/47 (19.1)
Vacation	6/10	13/47 (27.7)
Holidays	7/10	11/47 (23.4)
Idioms	6/10	13/47 (27.7)
Weather	10/10	25/47 (53.2)
Language practice	8/10	26/47 (55.3)

^*Issues such as confusion due to rapid speech, the person’s accent, pronunciation, or use of unknown words.

^†Staff engaged when the pair was struggling to understand one another and to help provide clarification to keep the conversation flowing.

ELL indicates English language learner; MCI, mild cognitive impairment.

Qualitative follow-up interviews suggested that participants with MCI felt comfortable in communicating with their partner and that they found it engaging (details available on request). Several commented that the conversations reminded them of their prior life experiences such as teaching or overcoming their own struggles as an immigrant to the United States. Several participants with MCI noted that the pair did encounter challenges (eg, understanding accents or technical problems) but that these were all resolvable. Participants with MCI were explicitly asked about any negative experiences with the program, but none were reported.

DISCUSSION

Few intervention studies have targeted social engagement among people with MCI, despite the role that loneliness and isolation play as risk factors for physical, emotional, and cognitive decline. Increasing numbers of individuals with cognitive impairment live alone, which increases their risk for under-treatment of psychiatric issues and self-neglect.9 These trends predate COVID-19, but have since been substantially exacerbated.

The SPEAK! model represents an opportunity for people with MCI to step out of the sick role, focus on activities that make life worth living, and feel useful again. Interventions focused on purposeful activities and achievements can improve multiple health outcomes. Feedback from the participants with MCI suggest that SPEAK! resonates with them precisely because it takes advantage of their decades of experience and addresses the need for English language practice.

The foreign-born population in the United States increased from 14 million in 1980 to 40 million in 2010. In 2012, 85% of these residents reported speaking a language other than English at home, and roughly 11.7 million spoke English either “not well” or “not at all.”10 SPEAK! provides a unique opportunity for ELLs to converse with a fluent English speaker and improve their confidence in speaking English.

The current study is limited in size and in the educational diversity of older adult participants. Future research, including randomized controlled trials, should focus on a broader range of people with MCI and examine impacts of participation on cognition, emotional wellbeing, and other outcomes. In the current study, all sessions were supervised by staff, both for the collection of evaluation metrics and to ensure participant safety in this novel intervention. To promote maximum program scalability, future research should determine when, how, and for which participants sessions can be unsupervised while maintaining program benefits and preventing possible harms. With those caveats in mind, this preliminary pilot study suggests that SPEAK! is a feasible and potentially desirable option for older adults with MCI interested in increasing their involvement in productive social relationships that may address their sense of isolation and loneliness.