Mild neurocognitive disorder (mNCD) (1) is defined as a transitional status between normal aging and possible development of early dementia. It is characterized by subjective cognitive complaints and objective cognitive decline greater than expected for individual’s age and education levels, but not interfering with activities of daily life. Subjective cognitive decline (SCD) is a condition referring to the self-perception of worsening cognitive abilities relative to a previous level of performance (2). Existing literature suggests that SCD individuals are at greater risk for dementia than older adults without SCD, as their subjective cognitive decline would in part reflect subtle impairment that has not yet reached the criteria for mNCD diagnosis (3). Given the limited effectiveness of pharmacological treatments in slowing cognitive symptoms in all these “at risk” individuals, cognitive rehabilitation techniques have gained increasing attention in recent years (4–6).

Cognitive rehabilitation can be delivered using traditional paper-and-pencil techniques or by means of more innovative computer-based solutions (7), this thanks to the development of Information and Communication Technologies. Computer-based solutions overcome some limits of traditional approaches, such as time, costs, and individuals’ accessibility, to name a few (8–11). In fact, computerized rehabilitation uses engaging motivational cues and provides real-time feedback; task complexity and response time demands may change frequently during and across sessions, in accordance with individual performance. This allows avoiding over- or under-stimulation and providing more training time in areas of relative weakness. Computer support also saves time for therapists in the preparation of the exercises and allows to record all session parameters for further statistics (12). Telerehabilitation (TR) represents a further development of computer-based rehabilitation, providing assistance to individuals at risk of dementia on a large scale and directly at home (13, 14). In this regard, it is of particular importance that TR tools have a person-centered design, involving final users into the creation, design, and refinement of the software (15). To the best of our knowledge, the available evidence about usability and user experience (UX) associated to cognitive TR in the field of neurodegenerative diseases is still poor and heterogeneous (16–22). For instance, Isernia and colleagues (23) evaluated participants’ experience with iHEAD, which is a telerehabilitation program for both motor and cognitive abilities in Chronic Neurological Diseases (e.g., Parkinson’s disease, multiple sclerosis, and stroke). Jelcic (24) explored the feasibility of a lexical-semantic stimulation via TR in early Alzheimer disease.

Usability is defined as the degree to which a particular system can be used with effectiveness, efficiency, and satisfaction by users (25). It can be measured with objective parameters, such as number of completed tasks, time to complete the tasks, number of interventions made by the therapist, and number of errors (26). UX refers to the perceptions, beliefs, emotions, and preferences related to the utilization of the TR system (25). UX can be considered as a subjective dimension assessed by means of validated questionnaires and scales or by non-standardized tools (26). Taken together, usability and UX are used to evaluate the effectiveness of TR system and they should be preliminary assessed (27). A major issue in the field of normal and pathological aging is the lack of familiarity/life experience with advanced technology, which could determine difficulties in the autonomous management of digital devices (28–30). Therefore, it has been stressed the need of accessible and user-friendly TR platforms in aged populations. As consequence, duration and frequency of cognitive rehabilitation sessions need to be adjusted according to participant’s characteristics (31) as well as adherence to treatment and outcome measures must be monitored by the therapist remotely (32).

In the last years, a cognitive rehabilitation (CoRe) software was implemented for an in-person cognitive training (33, 34). CoRe has been shown to be effective in restoring lost brain function and slowing degenerative diseases in early cognitive decline, compared with traditional interventions (35–37). In view of the willingness of treated participants to start/continue CoRe program at distance (38), we have recently developed a “home” version (i.e., HomeCoRe), able to provide a cognitive intervention directly at home (39, 40).

In the present study, we aimed at determining the usability and UX of the HomeCoRe system in individuals at risk of dementia. To this end, we recruited a sample of 14 individuals with SCD or mNCD. Treatment adherence and performances across the treatment sessions were used as usability indicators; UX was evaluated by means of both self-reported quantitative questionnaires and a qualitative session diary exploring personal experience while using the system. In particular, we considered the percentage of completed sessions as primary outcome, while the other usability and UX scores as secondary outcomes. The association between participants’ technological skills and main outcome measures was evaluated as well.

TR represents a unique opportunity to guarantee constancy and continuity to cognitive rehabilitation at distance. Therefore, the proper development of TR programs and software in neurodegenerative diseases should result from an integrated view of their usability and UX. Unfortunately, in this field, these issues are poorly considered and rarely assessed (16–22). In the present pilot study, we aimed at measuring usability and UX of a cognitive TR intervention in individuals at risk of dementia. Preliminary assessment of their technological skills was performed in order to evaluate its correlation with usability and UX scores. This is because aging may be associated to difficulties in managing technological devices autonomously (28–30).

Interestingly, when considering the objective measurement of usability, including treatment adherence and WS values, we found a generalized good compliance to HomeCoRe coupled with a satisfactory efficiency of this system, which was not related to participants’ level of technological skills. This result may stem from the fact that HomeCoRe was developed by clinicians based on the characteristics of individuals at risk of dementia (not healthy users) to provide a tool to be used in clinical practice. We also found that the total time for the treatment was about 14 h, which means that participants spent about 45 min per session. This result is in line with our previous experience with CoRe (35–37) in which we highlighted a very good adherence to the treatment when administered in hospital setting, where the dropouts were due to participants’ medical conditions and not to the treatment itself. The adherence rate is a crucial issue for the home-based rehabilitation protocols (63). Individuals with neurodegenerative disorders that could benefit from rehabilitation often do not adhere to a prescribed protocol once it is home-based due to the lack of familiarization with technology and computers (64–66) and to the loss of human interaction (67). The distinctiveness of TR systems such as HomeCoRe, by providing objective measures of the progress of the intervention and allowing remote monitoring and contact with the therapist, could be helpful in overcoming these limitations.

The UX was overall positive for both participants and family members. As regards participants, they expressed a good impression and satisfaction toward the product (data from the UEQ) and perceived usability of the HomeCoRe system (data from the SUS), which was also confirmed by their family members. In addition, feedbacks from the HUXQ suggested that participants considered HomeCoRe as particularly useful and enjoyable, were highly motivated, included the system in their routine, and were able to perform TR activities in autonomy without finding technical problems. From the family member side, some slight differences emerged at the HUXQ with respect to their relatives’ answers. In particular, family members reported more technical problems while using HomeCoRe. However, they agreed in perceiving their relatives as motivated and autonomous and had no difficulty in including the treatment in their daily routines. Even if our UX data could be impacted by the risk of courtesy bias, we believe that the integration of these findings with those concerning the objective measurement of usability could support HomeCoRe as a satisfactory tool and then encourage its use for TR.

Correlation analysis highlighted a significant association between technological skills and the fact of being autonomous in performing HomeCoRe activities. This finding highlights the important role of the family member in supporting those individuals less skilled with technologies. In the future, it could be interesting to evaluate perceived technological skills across the intervention sessions in order to understand if they change while participants become more confident with the system.

Finally, we found that all participants reported a good perception of cognitive changes immediately after HomeCoRe intervention, as resulted from the PGIC, regardless of their technological skills. For what concerns the session diary, participants reported issues in performing some tasks and in the corresponding difficulty levels. Concerning this specific issue, it should be noticed that tasks duration and difficulty level were set as the same duration and level we generally used in the clinical setting (35–37). Consequently, it suggests that some little adjustments (e.g., extra time for training and performing some exercises) could be relevant in the TR session due to the lack of therapist feedbacks generally provided during in-person treatment. In addition, future studies exploring also the point of view of health care figures while using HomeCoRe may provide further insight into their experience. Despite the small sample size, the present results suggest that HomeCoRe could represent a useful and acceptable TR system for individuals at risk of dementia. This is important given the crucial role that technologies will play in future neurorehabilitation models. The availability of effective and feasible TR modalities is indeed critical to address the paucity of healthcare personnel dedicated to cognitive rehabilitation within the neuropsychology services, thus allowing to increase the offer to a wider number of participants. It should be noted that we enrolled participants aged above 50 years. This is because, in some cases, dementia-related impairment manifests prior to older adulthood and such a situation may underline different pathological processes (68, 69). The next step will consist in performing a RCT to explore the effectiveness of HomeCoRe in a broader context of neurocognitive disorders.

This study has some limitations. While the sample size is adequate for a usability study (41, 42), it is too small to draw definitive conclusions about the association of technological skills with outcome measures. Participants with poor familiarity with technological devices and without a compliant family member could be excluded by the use of TR, representing a selection bias for this kind of intervention (70). However, there is evidence about the possibility of using telemedicine devices in individuals with early cognitive impairment living alone, given that the compliance is strictly related to the level of monitoring remotely received (71). Our sample consisted of individuals with SCD and MCI who may have had memory problems that impaired their ability to provide a report about something that happened in the past (i.e., user experience indices). In this regard, it should be noted that we integrated UX measures with those provided directly by the system (i.e., usability indices) that could not suffer from this issue. Finally, our intervention lasted for 6 weeks. There are some evidences (66, 72, 73) showing that the level of adherence and compliance drop significantly after the first 3 months of TR. In any case, we believe that such a length of the intervention could be useful in order to avoid to stress participants and family members. In addition, it is important to consider the HomeCoRe architecture allows to customize and extend the treatment duration according to participants’ characteristics.

The datasets presented in this study can be found in online repositories. The names of the repository/repositories and accession number(s) can be found at: Zenodo; https://doi.org/10.5281/zenodo.7595576.

The studies involving human participants were reviewed and approved by San Matteo Hospital, Pavia. The patients/participants provided their written informed consent to participate in this study.

SBe and SBo: study concept and design, acquisition of data, analysis and interpretation of data, and drafting of the manuscript. SP and SQ: analysis and interpretation of data. AC, MP, and CC: participants’ recruitment and data interpretation. SC, TV, and CT: critical revision of the manuscript for important intellectual content. All authors contributed to the article and approved the submitted version.

This work was supported by a grant from the Italian Ministry of Health (Ricerca Corrente 2020).

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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