Exploring the health benefits of a mobile-based multidomain lifestyle program for older adults living in assisted living facilities

Exploring the health benefits of a mobile-based multidomain lifestyle program for older adults living in assisted living facilities | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Exploring the health benefits of a mobile-based multidomain lifestyle program for older adults living in assisted living facilities Yongseop Kim, Junhyoung Kim, Marcia Ory, Myungjin Ko This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4355742/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 01 May, 2026 Read the published version in BMC Geriatrics → Version 1 posted 13 You are reading this latest preprint version Abstract Background Cognitive decline stands as a significant factor contributing to disability and dependency among older adults. Multi-domain lifestyle (MDL) interventions are widely recognized for their effectiveness in preserving cognitive functioning in older adults with dementia. However, little is known about MDL interventions using technology-based approaches in older adults residing in assisted living facilities. This qualitative study aims to explore the benefits of a mobile-based multidomain application, the Silvia Program, in enhancing the cognitive functioning of residents in assisted living facilities. Methods We conducted semi-structured, in-depth interviews to capture the health-related benefits and perspectives of the Silvia Program after a 12-week period. Ten participants (70% female; age range 66–93), all at risk of dementia (with MoCA scores between 18 and 25), were recruited from two local community assisted living facilities in the Midwestern area. Five steps of high-quality analysis of interview transcript was conducted. Results We identified three salient themes resulting from Silvia Program participation: (a) Cognitive benefits, (b) psychological wellbeing, (c) Health-related behavior management, (d) Technology anxiety, and (e) Content issues. Discussion The present study provides suggestive evidence for an overall positive effect of the use of the Silvia Program on the cognitive functioning among residents in ALFs. Practical implications and further discussion are addressed in this paper. dementia multidomain lifestyle intervention older adults Figures Figure 1 Figure 2 Introduction Cognitive decline is considered one of the major contributors to disability and dependency in older adults ( 1 – 5 ). It has been strongly linked with a decline in daily functioning, elevated health care expenses, and mental and behavioral challenges that result in a reduction in quality of life and a burden on family members or caregivers ( 6 , 7 ). In the United States, the number of people living with dementia is projected to increase by nearly 126%, from 6.1 million to 13.8 million over the same period ( 8 ). Given the current high and increasing proportion of the population in the United States living with dementia, its prevention has become a national priority for researchers, healthcare practitioners, and government entities as they strive to design and implement strategic plans that address the risk factors of dementia ( 9 , 10 ). Research demonstrates the efficacy of multi-domain lifestyle (MDL) interventions in maintaining and improving the cognitive function and healthy lifestyles of older adults who are at high risk for dementia ( 11 , 12 ). The Finnish Geriatric Intervention Study to Prevent Cognitive Impairment (FINGER) study was the first clinical trial to demonstrate the effectiveness of an MDL program in reducing the risk of dementia by improving cognitive functioning ( 13 , 14 ). The FINGER study includes multi-domain programs such as physical activity, dietary changes, cognitive training, and social activities, and reported that the intervention group experienced significant improvement in cognitive function and a reduced likelihood of developing dementia when compared to the control group ( 14 ). Clinical studies that have adopted the FINGER study approach have tested the effectiveness of multi-domain interventions to prevent or reduce cognitive decline in older adults in the United Kingdom, Japan, China, and South Korea ( 11 , 15 , 16 ). Systematic reviews and meta-analyses have provided evidence that short-term (< 1 year) multidomain (including two or more nonpharmacological factors including cognitive and physical exercise) interventions are associated with greater improvements in cognitive function when than single interventions in older adults( 17 , 18 ). While there are significant cognitive benefits that can be derived from MDL programs, traditional MDL interventions are affected by barriers in clinical trials that require face-to-face interaction, and intensive financial, time, and space resources that may negatively affect participant adherence and retention ( 19 , 20 ). Due to technology improvements and accessibility, there is a growing interest in the integration of mobile technology into clinical trials as it offers a cost-effective, accessible delivery modality that can be individualized, and is immersive and engaging for users ( 21 – 24 ). Prior studies have demonstrated that mobile technology is instrumental in improving access to healthcare ( 22 ), enhancing social connections ( 25 ), and increasing user safety, security, and independence( 26 ). The implementation of a technology-based, multi-domain approach aimed at enhancing cognitive and overall health through user-friendly and personalized mobile device-based activities represents an innovative approach. Our research team collaborated with Silvia Health, a digital health company specializing in dementia prevention that has designed the Silvia Program, a mobile device-based app that integrates evidence-based recommendations into a multidomain cognitive healthcare intervention ( 12 ) that can be individualized to meet the unique needs of older adults at high risk for dementia. The multi-dimensional components of this app include: (a) daily activity tracking including activity types and intensity, sleep quality and patterns, and daily nutrition, (b) participation in cognitive exercises, exercise programs, and mindfulness activities, and (c) provision of a weekly evaluation. Measures of the daily health management activity outcomes of each user are accessible at the end of each week of use. The evaluation gauges the difficulty of, and time invested in each task, and provides scores and information that can be used as feedback for selecting future activities. Studies that have tested the efficacy of the Silvia Program in older Korean adults who are at high risk of dementia demonstrate that Silvia Program users improved their cognitive functioning and suggest that this program is instrumental in reducing the risk of dementia by improving cognitive function ( 12 , 27 ) These previous studies tested the efficacy of the program that was implemented in the Korean language, so little information currently exists with regard to the potential health benefits of the Silvia Program as an MDL program among older adults living in an assisted living facility (ALF) who are at high risk of dementia in the United States (U.S.). This pilot study that addressed prior knowledge gaps was guided by two research questions: ( 1 ) What benefits do ALF residents accrue through participation in the Silvia Program? and ( 2 ) What challenges do ALF residents encounter while using the Silvia Program? The purpose of this qualitative investigation was to provide researchers with preliminary information on the health-related outcomes of Silvia Program use by ALF residents, and the identification of the challenges they encountered in their use of the program to provide the basis for the design of a follow-up experimental study to further explore the efficacy of the Silvia Program in affecting the health outcomes of ALF residents. Methodology Our research team used semi-structured, in-depth interviews to obtain a deep understanding of the perspectives of Silvia Program users and capture health-related benefits after use of the Silvia Program. Crabtree and Miller( 28 ) defined an in-depth interview as “a particular field research data-gathering process designed to generate narratives that focus on fairly specific research questions” (p. 93). This method enabled our research team to explore the experiences of Silvia Program users regarding their perception of the benefits, challenges, and their overall evaluation of the technology participation. Sample and Data Collection Our research team incorporated the purposeful criterion sampling strategy suggested by Patton( 29 ) that specifies participants must: (a) reside in ALFs, (b) have no history of diagnosis of Alzheimer’s Disease or its related dementia (ADRD) (MoCA score between 18 and 25, indicative of mild cognitive impairment), (c) have the ability to use a tablet, and (d) be capable of following verbal and written instructions in English. Participants were excluded if they had history of: (a) major psychiatric disorders (the Patient Health Questionnaire 9; score < 15), (b) degenerative brain disease (e.g., Alzheimer’s disease, Parkinson’s disease, Huntington’s disease etc.), (c) severe vision or hearing impairment, and (d) current participation in a cognitive training program. With cooperation from the directors of local ALFs, our research team provided a study flyer to potential participants, which enabled them to contact us with their interest in study participation. Potential participants were screened by our research team based on the study criterion, and eligible participants received informational sessions to explain the informed consent procedure, the safety protocol and guidelines, participant compensation, and the protection of their confidentiality and privacy related to study participation. With their agreement, we provided them with training sessions on how to use the Silvia Program. A total of 10 participants were recruited from two local community ALFs in the U.S. Midwest, of which seven were female (70%). The average age of participants was 79 (range = 67–93). Nine lived alone, and one participant lived with her spouse in the ALFs. Ten participants were older adults with mild cognitive functioning. This study gained approval from the Institutional Review Board (IRB) (#15198) of the sponsoring institution, and adhered to ethical research principles, using an approved research protocol, and working in accordance with the policies and processes at the research site. Each participant was assigned a pseudonym by researchers. Silvia Health Program Contents The Silvia Program was used by participants twice a week for 12 weeks, with each session lasting 40–50 minutes. The Silvia Program is a mobile health (mHealth) application that encompasses six domains: cognitive training, home-based exercise programs, mindfulness and relaxation activities, a daily diary feature, health-related educational content, and counseling. The development of the programs in the app was based on scientific evidence and designed to enhance brain health and reduce the risk of dementia. Participants participated in four activities including lifestyle management, cognitive training, a home-based exercise program, and mindfulness meditation. (See Fig. 1.) Figure 1. Features of the Silvia Program Daily Tracking Lifestyle Management: Lifestyle Management is a comprehensive system that enables participants to monitor and enhance their wellbeing and gain a holistic view of their lifestyle by tracking various health-related behaviors including physical activity levels, intensity, frequency, and types of activities, and detailed sleep patterns, noting times, perceived sleep quality, and disturbances. Nutritional information, focusing on balanced diet choices, is also documented. The system allows users to review weekly information that offers insights into the patterns of their behaviors. Participants are empowered to make informed decisions with systematic feedback based on gathered data that facilitates a proactive and personalized approach to health management. Cognitive Training: The cognitive training module offers more than 20 game programs that stimulate various cognitive functions such as memory, visuo-spatial abilities, language, executive function, and attention. Participants are free to choose their preferred program type and difficulty level (easy, medium, or hard) and can use the training program on a tablet device if available in the facility. During the session participants are encouraged to engage in at least 30 minutes of cognitive training twice a week to achieve the maximum benefit. Home-based Exercise: The exercise program module offers more than 25 visual instructions created by an exercise therapist that were designed to improve muscle strength, joint mobility, and balance. Participants can easily follow the movements step-by-step as demonstrated on the app by reading the instructions that accompany the images. Participants were advised to perform exercise programs for at least 15 minutes during each session. Mindfulness and Relaxation: The mindfulness and relaxation modules provide meditation programs that participants can follow with the guidance provided through both visual and audio instruction. This module also offers effective relaxation techniques such as deep breathing and mindfulness guidance. Interview Protocol Our research team developed an interview protocol based on previous technology-based studies ( 30 , 31 ) and adopted the content mapping and mining strategies suggested by Legard et al.( 32 ) to formulate interview questions. The purpose of the content mapping questions was to broadly explore the technology-based experiences of each participant, for example, “Could you tell me about your overall Silvia Program App experience?” and “Did you have any challenges using the tablet equipment and the Silvia Program App?” The content mining questions were asked to capture detailed evaluations of participant experiences, such as, “What benefits did you experience when participating in this Silvia Program?” Data collection and analysis were conducted concurrently, which enabled the incorporation of emerging themes into subsequent interviews. The interviews lasted between 30 to 90 minutes in duration and were audio recorded using an audio-recording app on a smartphone. While conducting each interview, the interviewer took field notes to document important contextual information ( 33 ). Data analysis and trustworthiness Audio recording was accomplished using Software Alice after which interviews were transcribed and coded. Qualitative data analysis in this study followed the five steps of high-quality analysis suggested by Creswell( 34 ). The first step involves creating raw data from interview transcripts and field notes. Next, each data set is organized, and a set of initial codes is created to represent the meanings of data from direct quotes. Then, themes and sub-themes are generated and articulated, followed by data interpretation. Two investigators (P and J) individually read each data set and created general themes and sub-themes that were then compared to reach a consensus. The constant comparative method was used to compare main and emerging themes and to strengthen consensus on data saturation and interpretation. To enhance credibility, two strategies were employed: Synthesized Member-Checking (SMC) ( 35 ) (see Fig. 2 ) and expert reviews. SMC is a validation technique used in research to ensure that the study’s findings align with participant experiences and perspectives. SMC involves five key steps: ( 1 ) preparing a synthesized summary of the emerging themes from interview data, ( 2 ) verifying participant eligibility to receive the SMC report, ( 3 ) distributing the SMC report with a cover letter and postpaid reply envelope, ( 4 ) gathering responses and additional data, and ( 5 ) integrating the findings. This process enhances the credibility of the research and reduces the risk of harm to participants. In addition to SMC, expert reviews were employed to strengthen the credibility of study findings. The research team was involved in the coding process to achieve consensus regarding the identification of key themes and interpretations of the data. Findings Based on the experiences and statements of the Silvia Program users, this exploratory qualitative study yielded findings related to the two research questions that were focused on the benefits and challenges experienced by ALF residents. Two core topics, five main themes and fourteen associated subthemes have been identified that are related to cognitive benefits, positive psychological experiences, health-related behavior management, and challenges associated with the Silvia Program use such as technology usability and content issues (See Table 1 ). Our findings suggest that the Silvia program can serve as a technology tool to improve the cognitive and psychological health and health management skills of ALF residents. The few challenges identified suggest further avenues of investigation for researchers in refining this approach. Table 1 Core Topics and Themes emerged from Qualitative Interview Core Topic Theme Subthemes Health benefits Cognitive benefits Attention and Concentration Calculation Memory Psychological wellbeing Recall positive life events Greater appreciation Practice mindfulness Health-related behavior management Self-awareness and monitoring Guidance and support Challenges Technology Anxiety Interface difficulties Technical glitches Content issues Lack of challenge Perceived lack of progress Overwhelming pace Health Benefits Cognitive Health . Improving cognitive function was identified as the most salient theme from the data. All participants identified several cognitive functions that they believed had improved including calculation, attention, and memory. In addition, cognitive training included activities for memory, visuo-spatial abilities, language, executive function, and attention and each activity provided participants with scores that enabled them to monitor their progress and encourage their participation. It appears that cognitive training can be instrumental in improving these cognitive domains by improving mathematical abilities and memory retention and strengthening critical thinking and attention skills. While some cognitive activities were found to be challenging for participants due to different degrees of difficulties in tasks, they mentioned that they adapted to the features, usage, and rules, and as a result improved their concentration and attention skills. Most participants experienced improvements in mathematical skills and recall of contents after engaging in cognitive exercises. Though they mentioned that they occasionally felt frustrated by challenging mathematical questions, they reported being determined to solve the questions to achieve higher scores on each activity. By engaging in different types of cognitive exercises, participants were actively involved with cognitive activities and felt that they improved their scores on algebraic calculations by improving their mathematical skills. For example, Lily said, I like the Farmers Market game. That really makes your brain think because you need to calculate how much all those things are together. I haven’t done math for a while, and I hate math, but in this game, I really enjoyed it. I think I like challenging myself with it, because it’s a fun way to practice my math skills. She also indicated that she improved her scores on the Farmers Market game and was able to proceed to levels of higher difficulty. Similarly, Mary shared how she used her mathematical skills to engage in cognitive activities. Among various cognitive activities, she stated that calculating the numbers through the activity was helpful to her cognitive function. Also, she stated, The second one I liked was the one where the vegetables were priced, and you had to add the prices. And if you wanted eggs and yeah . Participants believed that they enhanced attention and concentration on various activities. Especially, they identified some activities such as animal features in the 'Friends in the Woods' and “Finding Poppy” activities as a tool in enhancing attention and concentration because of different levels of difficulties in activities. They used similar expressions such as ‘I was fully focused on this activity’ ‘I was able to fully concentrate on them’ and ‘I enjoyed focusing and completing these activities. According to Amy, When I engaged in this activity, I concentrated solely on the task at hand. Engaging in activities such as solving puzzles and searching for puppies and kittens brought me a sense of pleasure. John who enjoyed animal-based activities stated, You should stay pretty fast because sometimes they just make those land there quick, and they'll you got to watch them because they'll sometimes do four and five at a time. Same thing. So, you got to just kind of keep getting that squirrel. These statements indicate that participants concentrated on their activities well and enhanced their attentive skills. Several participants reported that their memory was enhanced through Silvia Program participation. They indicated that various cognitive activities stimulated their brain to memorize numbers, colors, figures, objects, and language. As previously noted, participants embraced the challenges necessary to complete tasks related to memory, which resulted in memory enhancement. Paul who enjoyed color matching activities said, I struggled with selecting the correct colors, but I found that trying to recall the sequence and keep track of the colors was challenging and very fun. I believe it helped me improve my memory, and it's a positive and enjoyable challenge. Amy shared similar experiences by stating that the programs helped her refresh her mathematical skills and improve her memory. She also mentioned that practicing adding and subtracting numbers, matching colors, and recalling letters helped improve her memory. Several participants shared their memories with their family members and pets through cognitive activities that were designed with animals, nature, and locations. By engaging in cognitive activities, they shared their life stories by recalling personal events and thus contributed to strengthening their memory. Overall, these examples and statements provide qualitative evidence that participants benefited by engaging in the cognitive training activities of the Silvia Program such as calculation, attention, and memory. This finding suggests that the Silvia Program can be beneficial for cognitive health of users. Psychological Wellbeing . Most participants shared that they experienced mental relaxation and a sense of enjoyment and accomplishment while they participated in the Silvia Program. When they participated in the home-based exercise, relaxation/mindfulness, and cognitive training programs, they immersed themselves in each activity/program and felt relaxed and comfortable. They mentioned that these programs enabled them to experience a sense of happiness and enjoyment because there were fun, challenging components of each activity/program. For example, John stated, I found it (the activity) relaxing. I am always searching or looking for information, so to sit down and play games was very relaxing. Lily also mentioned that she felt excited when she played some star or animal-based cognitive exercises and followed some instructions for home-based exercise programs. She felt physically and mentally stronger after doing these activities. In a similar manner, Susan stated, But just about all of those games were fascinating. I really enjoyed those. They were all good mentally and really exciting. I had a really great time. Some participants shared personally meaningful stories related to their participation in specific activities within the program such as memories of spending time with family members and beloved pets from the past. They mentioned that these program activities undeniably had a profound and positive impact on their psychological wellbeing. Frank, who enjoyed playing with animals mentioned that he felt a sense of enjoyment and connection with his past with some activities. Also, according to Ashley, That (Finding My Puppy) was my favorite activity of all the games… a dog like mine. Unfortunately, mine was gone, but those dogs are like my dog. She shared that she cherished her memory with her pet through this activity and mentioned that she enjoyed playing this activity. Paul also stated, I like the games, and I liked putting in our meals and all that kind of stuff too. That made me relive today, it was like a blast from the past because I felt like I was back in my childhood, enjoying simple pleasures and spending time with loved ones. A few participants mentioned that they experienced a sense of accomplishment by improving their scores on cognitive activities and participating in exercise programs and mindfulness. While they encountered some challenges, they developed the perseverance necessary to persist in various programs that led to a sense of achievement and accomplishment. Thus, based on these examples and statements, participants experienced enhanced psychological wellbeing that resulted in an enhanced sense of enjoyment, accomplishment, and feelings of relaxation and reward. Health-related Behavior Management . Most participants indicated that the lifestyle management aspect of the Silvia Program helped them pursue a much healthier lifestyle. They identified their daily routines, sleep patterns, dietary habits and nutritional information as the main benefits of the lifestyle management program that contributed to a heightened awareness of their overall health management. By tracking this information and monitoring their lifestyle related behaviors, they reported that they modified their behaviors when needed. They shared that these changes not only enhanced their perception of managing health behaviors but also empowered them to monitor and regulate these behaviors. For example, Tina stated that monitoring her life routines helped her to make better choices for food and exercise and prioritized her health. Similarly, Tiffany stated, It is good that the app encourages us to think about what we eat and the importance of getting enough protein. And it's not just about eating; it also tracks our sleeping habits. She also indicated that she was determined to pursue a healthier lifestyle in terms of eating and sleeping. Several participants also modified their sleep patterns based on data from the Silvia Program sleep tracking system. According to Mary, she maintained and improved her sleep pattern and quality by monitoring her sleep and mentioned that she decided to restrict the use of her own electronic devices to promote better sleep. Also, Mary said, At first, I didn't think it would make a difference, whether I slept for a certain number of hours or ate a specific way. But now I understand the importance of finding a balance in life. These examples indicate that the lifestyle management programs offered by the Silvia Program helped participants to make a better choice for their health and pursue a healthier lifestyle. Challenges In addition to the positive outcomes of the use of the Silvia Program, participants identified two main challenges: ( 1 ) technology anxiety and challenging content. The identification of these challenges can provide practical suggestions for efficacy investigations that involve the technology developer. One primary challenge that most participants experienced in the first two weeks was technological anxiety caused by unfamiliarity with mobile technologies. Although it took a short time to adjust to and understand how to use the Silvia Program on a tablet device, participants expressed concerns and apprehensions related to technology use, and several participants mentioned that technology anxiety impeded their ability to fully engage with each program in the early stages of their participation. For instance, Velvet stated, Initially, I was uncertain and apprehensive as I had no prior experience with this type of thing and was concerned about making mistakes or breaking it. Some participants experienced frustration when they experienced technical glitches (screen frozen), especially in the middle of engaging in activities. Tina indicated that he lost interest in redoing the activities when the program stopped unexpectedly. Tiffany also mentioned that she was frustrated and uneasy when she was not able to continue doing the activities due to technical errors. She said, I've been frustrated when it didn't work properly, it continuously stopped in the middle of the game. For example, I just did the rainbow melody, and it didn't work, I was worried if I had done something wrong. While most participants found the programs enjoyable, it is worth noting that some individuals exhibited a reluctance to engage in some activities because of the complexity of the instructions and repetitive program contents. They mentioned that found some activities less than challenging and some instructions too complex (home-based exercises). For example, Frank shared that some activities within the program were so fast paced that at times he was overwhelmed, reporting, “Sometimes I can't read the instructions because it goes too fast.” Also, John mentioned, “ Because you had to look at the animals. You saw what's coming down. Then you had to change the animal, and sometimes there were three animals, and sometimes there were four, and if I, if you go too fast. Participants frequently expressed that they became easily bored when they encountered monotonous or overly simplistic activities that failed to challenge and engage them for a sustained period. Additionally, when they perceived limited improvement in their performance over time, they were more prone to lose interest. Consequently, the provision of tangible and meaningful results at the conclusion of each activity emerged as a critical factor in sustaining participant motivation and engagement with these activities. Discussion This pilot study explored the health benefits and challenges associated with the use of the Silvia Program by ALF residents. Our findings show that participants reported potential health benefits, including cognitive health, psychological wellbeing, and health-related behavior management, but that participants also reported challenges including technology use anxiety and content related challenges. These findings suggest that Silvia Program use can be instrumental in promoting improved cognitive function and psychological wellbeing and enhance the ability of users to manage their health-related behaviors and that the challenges experienced by participants can be successfully addressed through further development of the contents of the program. Research has provided evidence that MDL programs targeting modifiable risk factors hold promise in preserving specific cognitive and physical functioning domains for older adults with MCI or at high risk of dementia( 5 , 27 ). However, some studies have suggested that MDL interventions may not have an immediate effect on cognitive performance after 24 months of intervention ( 4 ). A systematic review noted that approximately two-thirds of ongoing MDL interventions are effective in improving cognitive function, particularly among studies targeting MCI( 3 ). Our findings suggest that the Silvia program can serve as a technology tool to improve the cognitive and psychological health and health management skills of ALF residents. The minor challenges identified suggest further avenues of investigation for researchers in refining this approach. Prior research has provided evidence that the use of technology-based cognitive games is associated with positive mood and relaxation ( 36 , 37 ). These studies suggest that game users can experience positive emotions and a sense of enjoyment. Based on these reported benefits of technology-based games, our findings suggest that cognitive activities provided on a mobile device can offer can provide triggering of positive emotions for ALF residents. This indicates that MLD programs can serve as useful tools for cognitive enhancement and produce emotional and psychological benefits. In addition, participants in our study mentioned that the Silvia program played a particularly important role in tracking their health behaviors, including sleep patterns, dietary habits, and physical activities. These activities, and the feedback they provided to participants, contributed to an increased awareness of their overall health and enhanced management skills. This finding aligns closely with previous research indicating that the integration of MDL into mobile technology provides personalized engagement ( 24 ), improved access to healthcare ( 22 ), and increased independence for users ( 26 ). This is crucial, as caregiving for this population demands a high level of health care management. An empirical study that investigated the efficacy of the Silvia Program with the sample of older Korean adults demonstrate that Silvia Program users (healthy aging adults) reported improved cognitive function ( 27 ). The English language version of the program evaluated in this study was implemented in ALF settings in United States. With this new population, our findings extend the existing knowledge that the Silvia Program can be effective in improving cognitive function among users living with mild cognitive impairment. This study provides qualitative evidence that will provide a foundation upon which future clinical trials can be designed to test the efficacy of the program in improving cognitive function and mental health of ALF residents. Studies have suggested there is high prevalence of technology anxiety (fear, apprehension, and phobia) associated with the use of electronic devices by older adults ( 5 ). In the present study, it appears that ALF residents have experienced technology anxiety at the beginning of their participation, and that these negative feelings and reluctance decreased when participants gained a level of comfort with the technology used in this study. This suggests that understanding and acknowledging potential technology related barriers that participants may encounter prior to a clinical trial is a priority, and that any use of technology-based program applications with geriatric populations must be accompanied with technology training and assessment of perceptions of technology complexity in future studies. In addition, mobile technology developers must create customized, individualized content for users so that their engagement with the program can be sustained. Limitations and Conclusion There are several limitations inherent to this study. First, this pilot study focused on ALF residents who were not diagnosed with ADRD but did not differentiate the impact of Silvia Program use related to different levels of cognitive functions. Future experimental designs should be pursued to evaluate differences in health outcomes between healthy aging adults and residents with mild cognitive impairments. A comparison of the outcomes for treatment and control groups is recommended for a more objective measurement of the efficacy of the use of an MDL program by ALF residents. Second, considering the inherent limitations of qualitative studies, a randomized clinical trial with an experimental study design is needed to objectively assess the efficacy of the program in improving the cognitive function and wellbeing of ALF residents using standardized assessment tools validated in AD populations. Lastly, as our sample consisted of only ALF residents, future studies should seek to involve community-dwelling older adults or older adults residing in nursing homes who have the potential to gain benefit from using the Silvia Program and its activities. Despite these limitations, this qualitative study of the use of the Silvia Program by ALF residents allowed us to identify the potential beneficial health outcomes, and challenges related to its use such as technology anxiety and glitches and needed content improvements. Our findings provide evidence of the positive health outcomes that MDL program use can provide for ALF residents, and strategies that can be used to minimize the challenges that may pose barriers or impede user engagement with the program. Overall, the results of our study provide qualitative evidence that the Silvia Program can be instrumental in reducing the risk of dementia, improving psychological wellbeing, and enhancing the management of health-related behaviors. Declarations i. Ethics approval and consent to participate This study obtained ethics approval from Indiana University’s Institutional Review Board (IRB) (#15198) and adhered to ethical research principles, using an approved research protocol. Participants, staff, and caregiver provided specific informed consent for participation in the qualitative components of the interview. All methods were carried out in accordance with relevant guidelines and regulations of Indiana University. ii. Consent for publication Not applicable. iii. Availability of data and materials The data that support the findings of this study are available from the corresponding author, YSK, upon reasonable request. iv. Competing interests The authors declare no competing interests. v. Funding Not applicable. vi. Authors' contributions YSK led the study design, led the ethics approval applications, provided oversight over implementation planning and data collection, and drafted the manuscript. JHK provided oversight over the study design, ethics approvals, consulted on implementation planning, provided oversight over data analysis, and edited the final manuscript. MO consulted during ethics approvals, led implementation planning, and edited the final manuscript. MJK provided oversight over data analysis and edited the final manuscript. All authors read and approved the final manuscript. vii. Acknowledgement We would like to thank all the residents and professional staff from Bell Trace Assisted Living and Evergreen Village at Bloomington for their participation in the study. References Rivan NFM, Singh DKA, Shahar S, Wen GJ, Rajab NF, Din NC, et al. Cognitive frailty is a robust predictor of falls, injuries, and disability among community-dwelling older adults. BMC Geriatr. 2021;21:1–13. Kim J, Angel JL, Rote SM. A longitudinal study of cognitive and instrumental activities of daily living disablement among the oldest Mexican Americans. J Aging Health. 2022;34(2):196–205. Castro CB, Costa LM, Dias CB, Chen J, Hillebrandt H, Gardener SL, et al. Multi-domain interventions for dementia prevention–a systematic review. 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JAMA Netw Open. 2022;5(5):e226744–e226744. Meng X, Fang S, Zhang S, Li H, Ma D, Ye Y, et al. Multidomain lifestyle interventions for cognition and the risk of dementia: A systematic review and meta-analysis. Int J Nurs Stud. 2022;130:104236. Montero-Odasso M, Zou GY, Kamkar N, Feldman HH, Belleville S, Chertkow H, et al. Multidomain trials to prevent dementia: addressing methodological challenges. Alzheimers Res Ther. 2022;14(1):94. Röhr S, Kivipelto M, Mangialasche F, Ngandu T, Riedel-Heller SG. Multidomain interventions for risk reduction and prevention of cognitive decline and dementia: current developments. Curr Opin Psychiatry. 2022;35(4):285–92. Akin-Sari B, Inozu M, Haciomeroglu AB, Cekci BC, Uzumcu E, Doron G. Cognitive training via a mobile application to reduce obsessive-compulsive-related distress and cognitions during the COVID-19 outbreaks: a randomized controlled trial using a subclinical cohort. Behav Ther. 2022;53(5):776–92. Elbaz S, Cinalioglu K, Sekhon K, Gruber J, Rigas C, Bodenstein K, et al. A systematic review of telemedicine for older adults with dementia during COVID-19: an alternative to in-person health services? Front Neurol. 2021;12:761965. Pothier K, Soriano G, Lussier M, Naudin A, Costa N, Guyonnet S, et al. A web-based multidomain lifestyle intervention with connected devices for older adults: research protocol of the eMIND pilot randomized controlled trial. Aging Clin Exp Res. 2018;30:1127–35. Jiang X, Ming WK, You JHS. The cost-effectiveness of digital health interventions on the management of cardiovascular diseases: systematic review. J Med Internet Res. 2019;21(6):e13166. Waycott J, Vetere F, Ozanne E. Building social connections: a framework for enriching older adults’ social connectedness through information and communication technologies. Ageing and digital technology: Designing and evaluating emerging technologies for older adults. 2019;65–82. Wang S, Bolling K, Mao W, Reichstadt J, Jeste D, Kim HC, et al. Technology to support aging in place: Older adults’ perspectives. In: Healthcare. MDPI; 2019. p. 60. Lee J, Kim J, Park A, Hong R kyeun, Ko M, Heo M, et al. Efficacy of a mobile-based multidomain intervention to improve cognitive function and health-related outcomes among older Korean adults with subjective cognitive decline. Journal of Alzheimer’s Disease. 2023;(Preprint):1–12. Crabtree BF, Miller WL. Doing qualitative research. Sage publications; 2023. Patton MQ. Two decades of developments in qualitative inquiry: A personal, experiential perspective. Qualitative social work. 2002;1(3):261–83. Kim Y, Junhyoung Kim P, Kim R, Yoon S. A pilot study of a nature-based virtual reality program on mental health among Korean immigrants during the COVID-19 pandemic. Gerontechnology. 2023;22(1). Kim J, Kim Y, Chang PS, Min Oh S, Han S. A pilot study of virtual reality (VR) Tai Chi program on mental health among older adults during the COVID-19 pandemic. Am J Health Behav. 2022;46(5):576–85. Legard R, Keegan J, Ward K. In-depth interviews. Qualitative research practice: A guide for social science students and researchers. 2003;6(1):138–69. Phillippi J, Lauderdale J. A guide to field notes for qualitative research: Context and conversation. Qual Health Res. 2018;28(3):381–8. Creswell JW, Poth CN. Qualitative inquiry and research design: Choosing among five approaches. Sage publications; 2016. Birt L, Scott S, Cavers D, Campbell C, Walter F. Member checking: a tool to enhance trustworthiness or merely a nod to validation? Qual Health Res. 2016;26(13):1802–11. Zhong D, Chen L, Feng Y, Song R, Huang L, Liu J, et al. Effects of virtual reality cognitive training in individuals with mild cognitive impairment: a systematic review and meta‐analysis. Int J Geriatr Psychiatry. 2021;36(12):1829–47. Pallavicini F, Pepe A. Virtual reality games and the role of body involvement in enhancing positive emotions and decreasing anxiety: within-subjects pilot study. JMIR Serious Games. 2020;8(2):e15635. Additional Declarations No competing interests reported. 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It has been strongly linked with a decline in daily functioning, elevated health care expenses, and mental and behavioral challenges that result in a reduction in quality of life and a burden on family members or caregivers (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). In the United States, the number of people living with dementia is projected to increase by nearly 126%, from 6.1\u0026nbsp;million to 13.8\u0026nbsp;million over the same period (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Given the current high and increasing proportion of the population in the United States living with dementia, its prevention has become a national priority for researchers, healthcare practitioners, and government entities as they strive to design and implement strategic plans that address the risk factors of dementia (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eResearch demonstrates the efficacy of multi-domain lifestyle (MDL) interventions in maintaining and improving the cognitive function and healthy lifestyles of older adults who are at high risk for dementia (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). The Finnish Geriatric Intervention Study to Prevent Cognitive Impairment (FINGER) study was the first clinical trial to demonstrate the effectiveness of an MDL program in reducing the risk of dementia by improving cognitive functioning (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). The FINGER study includes multi-domain programs such as physical activity, dietary changes, cognitive training, and social activities, and reported that the intervention group experienced significant improvement in cognitive function and a reduced likelihood of developing dementia when compared to the control group (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Clinical studies that have adopted the FINGER study approach have tested the effectiveness of multi-domain interventions to prevent or reduce cognitive decline in older adults in the United Kingdom, Japan, China, and South Korea (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Systematic reviews and meta-analyses have provided evidence that short-term (\u0026lt;\u0026thinsp;1 year) multidomain (including two or more nonpharmacological factors including cognitive and physical exercise) interventions are associated with greater improvements in cognitive function when than single interventions in older adults(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWhile there are significant cognitive benefits that can be derived from MDL programs, traditional MDL interventions are affected by barriers in clinical trials that require face-to-face interaction, and intensive financial, time, and space resources that may negatively affect participant adherence and retention (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Due to technology improvements and accessibility, there is a growing interest in the integration of mobile technology into clinical trials as it offers a cost-effective, accessible delivery modality that can be individualized, and is immersive and engaging for users (\u003cspan additionalcitationids=\"CR22 CR23\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Prior studies have demonstrated that mobile technology is instrumental in improving access to healthcare (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e), enhancing social connections (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e), and increasing user safety, security, and independence(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe implementation of a technology-based, multi-domain approach aimed at enhancing cognitive and overall health through user-friendly and personalized mobile device-based activities represents an innovative approach. Our research team collaborated with Silvia Health, a digital health company specializing in dementia prevention that has designed the Silvia Program, a mobile device-based app that integrates evidence-based recommendations into a multidomain cognitive healthcare intervention (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) that can be individualized to meet the unique needs of older adults at high risk for dementia. The multi-dimensional components of this app include: (a) daily activity tracking including activity types and intensity, sleep quality and patterns, and daily nutrition, (b) participation in cognitive exercises, exercise programs, and mindfulness activities, and (c) provision of a weekly evaluation. Measures of the daily health management activity outcomes of each user are accessible at the end of each week of use. The evaluation gauges the difficulty of, and time invested in each task, and provides scores and information that can be used as feedback for selecting future activities.\u003c/p\u003e \u003cp\u003eStudies that have tested the efficacy of the Silvia Program in older Korean adults who are at high risk of dementia demonstrate that Silvia Program users improved their cognitive functioning and suggest that this program is instrumental in reducing the risk of dementia by improving cognitive function (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e) These previous studies tested the efficacy of the program that was implemented in the Korean language, so little information currently exists with regard to the potential health benefits of the Silvia Program as an MDL program among older adults living in an assisted living facility (ALF) who are at high risk of dementia in the United States (U.S.).\u003c/p\u003e \u003cp\u003eThis pilot study that addressed prior knowledge gaps was guided by two research questions: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) What benefits do ALF residents accrue through participation in the Silvia Program? and (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) What challenges do ALF residents encounter while using the Silvia Program? The purpose of this qualitative investigation was to provide researchers with preliminary information on the health-related outcomes of Silvia Program use by ALF residents, and the identification of the challenges they encountered in their use of the program to provide the basis for the design of a follow-up experimental study to further explore the efficacy of the Silvia Program in affecting the health outcomes of ALF residents.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cp\u003eOur research team used semi-structured, in-depth interviews to obtain a deep understanding of the perspectives of Silvia Program users and capture health-related benefits after use of the Silvia Program. Crabtree and Miller(\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e) defined an in-depth interview as \u0026ldquo;a particular field research data-gathering process designed to generate narratives that focus on fairly specific research questions\u0026rdquo; (p. 93). This method enabled our research team to explore the experiences of Silvia Program users regarding their perception of the benefits, challenges, and their overall evaluation of the technology participation.\u003c/p\u003e\n\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n\u003ch2\u003eSample and Data Collection\u003c/h2\u003e\n\u003cp\u003eOur research team incorporated the purposeful criterion sampling strategy suggested by Patton(\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e) that specifies participants must: (a) reside in ALFs, (b) have no history of diagnosis of Alzheimer\u0026rsquo;s Disease or its related dementia (ADRD) (MoCA score between 18 and 25, indicative of mild cognitive impairment), (c) have the ability to use a tablet, and (d) be capable of following verbal and written instructions in English. Participants were excluded if they had history of: (a) major psychiatric disorders (the Patient Health Questionnaire 9; score\u0026thinsp;\u0026lt;\u0026thinsp;15), (b) degenerative brain disease (e.g., Alzheimer\u0026rsquo;s disease, Parkinson\u0026rsquo;s disease, Huntington\u0026rsquo;s disease etc.), (c) severe vision or hearing impairment, and (d) current participation in a cognitive training program.\u003c/p\u003e\n\u003cp\u003eWith cooperation from the directors of local ALFs, our research team provided a study flyer to potential participants, which enabled them to contact us with their interest in study participation. Potential participants were screened by our research team based on the study criterion, and eligible participants received informational sessions to explain the informed consent procedure, the safety protocol and guidelines, participant compensation, and the protection of their confidentiality and privacy related to study participation. With their agreement, we provided them with training sessions on how to use the Silvia Program. A total of 10 participants were recruited from two local community ALFs in the U.S. Midwest, of which seven were female (70%). The average age of participants was 79 (range\u0026thinsp;=\u0026thinsp;67\u0026ndash;93). Nine lived alone, and one participant lived with her spouse in the ALFs. Ten participants were older adults with mild cognitive functioning. This study gained approval from the Institutional Review Board (IRB) (#15198) of the sponsoring institution, and adhered to ethical research principles, using an approved research protocol, and working in accordance with the policies and processes at the research site. Each participant was assigned a pseudonym by researchers.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n\u003ch2\u003eSilvia Health Program Contents\u003c/h2\u003e\n\u003cp\u003eThe Silvia Program was used by participants twice a week for 12 weeks, with each session lasting 40\u0026ndash;50 minutes. The Silvia Program is a mobile health (mHealth) application that encompasses six domains: cognitive training, home-based exercise programs, mindfulness and relaxation activities, a daily diary feature, health-related educational content, and counseling. The development of the programs in the app was based on scientific evidence and designed to enhance brain health and reduce the risk of dementia. Participants participated in four activities including lifestyle management, cognitive training, a home-based exercise program, and mindfulness meditation. (See Fig.\u0026nbsp;1.)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 1.\u003c/strong\u003e Features of the Silvia Program\u003c/p\u003e\n\u003cp\u003eDaily Tracking Lifestyle Management: Lifestyle Management is a comprehensive system that enables participants to monitor and enhance their wellbeing and gain a holistic view of their lifestyle by tracking various health-related behaviors including physical activity levels, intensity, frequency, and types of activities, and detailed sleep patterns, noting times, perceived sleep quality, and disturbances. Nutritional information, focusing on balanced diet choices, is also documented. The system allows users to review weekly information that offers insights into the patterns of their behaviors. Participants are empowered to make informed decisions with systematic feedback based on gathered data that facilitates a proactive and personalized approach to health management.\u003c/p\u003e\n\u003cp\u003eCognitive Training: The cognitive training module offers more than 20 game programs that stimulate various cognitive functions such as memory, visuo-spatial abilities, language, executive function, and attention. Participants are free to choose their preferred program type and difficulty level (easy, medium, or hard) and can use the training program on a tablet device if available in the facility. During the session participants are encouraged to engage in at least 30 minutes of cognitive training twice a week to achieve the maximum benefit.\u003c/p\u003e\n\u003cp\u003eHome-based Exercise: The exercise program module offers more than 25 visual instructions created by an exercise therapist that were designed to improve muscle strength, joint mobility, and balance. Participants can easily follow the movements step-by-step as demonstrated on the app by reading the instructions that accompany the images. Participants were advised to perform exercise programs for at least 15 minutes during each session.\u003c/p\u003e\n\u003cp\u003eMindfulness and Relaxation: The mindfulness and relaxation modules provide meditation programs that participants can follow with the guidance provided through both visual and audio instruction. This module also offers effective relaxation techniques such as deep breathing and mindfulness guidance.\u003c/p\u003e\n\u003ch2\u003eInterview Protocol\u003c/h2\u003e\n\u003cp\u003eOur research team developed an interview protocol based on previous technology-based studies (\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e) and adopted the content mapping and mining strategies suggested by Legard et al.(\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e) to formulate interview questions. The purpose of the content mapping questions was to broadly explore the technology-based experiences of each participant, for example, \u0026ldquo;Could you tell me about your overall Silvia Program App experience?\u0026rdquo; and \u0026ldquo;Did you have any challenges using the tablet equipment and the Silvia Program App?\u0026rdquo; The content mining questions were asked to capture detailed evaluations of participant experiences, such as, \u0026ldquo;What benefits did you experience when participating in this Silvia Program?\u0026rdquo; Data collection and analysis were conducted concurrently, which enabled the incorporation of emerging themes into subsequent interviews. The interviews lasted between 30 to 90 minutes in duration and were audio recorded using an audio-recording app on a smartphone. While conducting each interview, the interviewer took field notes to document important contextual information (\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e).\u003c/p\u003e\n\u003ch2\u003eData analysis and trustworthiness\u003c/h2\u003e\n\u003cp\u003eAudio recording was accomplished using Software Alice after which interviews were transcribed and coded. Qualitative data analysis in this study followed the five steps of high-quality analysis suggested by Creswell(\u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e). The first step involves creating raw data from interview transcripts and field notes. Next, each data set is organized, and a set of initial codes is created to represent the meanings of data from direct quotes. Then, themes and sub-themes are generated and articulated, followed by data interpretation. Two investigators (P and J) individually read each data set and created general themes and sub-themes that were then compared to reach a consensus. The constant comparative method was used to compare main and emerging themes and to strengthen consensus on data saturation and interpretation.\u003c/p\u003e\n\u003cp\u003eTo enhance credibility, two strategies were employed: Synthesized Member-Checking (SMC) (\u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e) (see Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e) and expert reviews. SMC is a validation technique used in research to ensure that the study\u0026rsquo;s findings align with participant experiences and perspectives. SMC involves five key steps: (\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e) preparing a synthesized summary of the emerging themes from interview data, (\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e) verifying participant eligibility to receive the SMC report, (\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e) distributing the SMC report with a cover letter and postpaid reply envelope, (\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e) gathering responses and additional data, and (\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e) integrating the findings. This process enhances the credibility of the research and reduces the risk of harm to participants. In addition to SMC, expert reviews were employed to strengthen the credibility of study findings. The research team was involved in the coding process to achieve consensus regarding the identification of key themes and interpretations of the data.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Findings","content":"\u003cp\u003eBased on the experiences and statements of the Silvia Program users, this exploratory qualitative study yielded findings related to the two research questions that were focused on the benefits and challenges experienced by ALF residents. Two core topics, five main themes and fourteen associated subthemes have been identified that are related to cognitive benefits, positive psychological experiences, health-related behavior management, and challenges associated with the Silvia Program use such as technology usability and content issues (See Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). Our findings suggest that the Silvia program can serve as a technology tool to improve the cognitive and psychological health and health management skills of ALF residents. The few challenges identified suggest further avenues of investigation for researchers in refining this approach.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eCore Topics and Themes emerged from Qualitative Interview\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eCore Topic\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eTheme\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eSubthemes\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"8\" align=\"left\"\u003e\n\u003cp\u003eHealth benefits\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"3\" align=\"left\"\u003e\n\u003cp\u003eCognitive benefits\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAttention and Concentration\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCalculation\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMemory\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"3\" align=\"left\"\u003e\n\u003cp\u003ePsychological wellbeing\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRecall positive life events\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGreater appreciation\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePractice mindfulness\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eHealth-related behavior management\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSelf-awareness and monitoring\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGuidance and support\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"5\" align=\"left\"\u003e\n\u003cp\u003eChallenges\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eTechnology Anxiety\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eInterface difficulties\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTechnical glitches\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"3\" align=\"left\"\u003e\n\u003cp\u003eContent issues\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLack of challenge\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePerceived lack of progress\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOverwhelming pace\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n\u003ch2\u003eHealth Benefits\u003c/h2\u003e\n\u003cp\u003e\u003cstrong\u003eCognitive Health\u003c/strong\u003e. Improving cognitive function\u003c/p\u003e\n\u003cp\u003ewas identified as the most salient theme from the data. All participants identified several cognitive functions that they believed had improved including calculation, attention, and memory. In addition, cognitive training included activities for memory, visuo-spatial abilities, language, executive function, and attention and each activity provided participants with scores that enabled them to monitor their progress and encourage their participation. It appears that cognitive training can be instrumental in improving these cognitive domains by improving mathematical abilities and memory retention and strengthening critical thinking and attention skills. While some cognitive activities were found to be challenging for participants due to different degrees of difficulties in tasks, they mentioned that they adapted to the features, usage, and rules, and as a result improved their concentration and attention skills.\u003c/p\u003e\n\u003cp\u003eMost participants experienced improvements in mathematical skills and recall of contents after engaging in cognitive exercises. Though they mentioned that they occasionally felt frustrated by challenging mathematical questions, they reported being determined to solve the questions to achieve higher scores on each activity. By engaging in different types of cognitive exercises, participants were actively involved with cognitive activities and felt that they improved their scores on algebraic calculations by improving their mathematical skills. For example, Lily said,\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n\u003cp\u003e\u003cem\u003eI like the Farmers Market game. That really makes your brain think because you need to calculate how much all those things are together. I haven\u0026rsquo;t done math for a while, and I hate math, but in this game, I really enjoyed it. I think I like challenging myself with it, because it\u0026rsquo;s a fun way to practice my math skills.\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eShe also indicated that she improved her scores on the Farmers Market game and was able to proceed to levels of higher difficulty.\u003c/p\u003e\n\u003cp\u003eSimilarly, Mary shared how she used her mathematical skills to engage in cognitive activities. Among various cognitive activities, she stated that calculating the numbers through the activity was helpful to her cognitive function. Also, she stated,\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n\u003cp\u003e\u003cem\u003eThe second one I liked was the one where the vegetables were priced, and you had to add the prices. And if you wanted eggs and yeah\u003c/em\u003e.\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eParticipants believed that they enhanced attention and concentration on various activities. Especially, they identified some activities such as animal features in the 'Friends in the Woods' and \u0026ldquo;Finding Poppy\u0026rdquo; activities as a tool in enhancing attention and concentration because of different levels of difficulties in activities. They used similar expressions such as \u0026lsquo;I was fully focused on this activity\u0026rsquo; \u0026lsquo;I was able to fully concentrate on them\u0026rsquo; and \u0026lsquo;I enjoyed focusing and completing these activities. According to Amy,\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n\u003cp\u003e\u003cem\u003eWhen I engaged in this activity, I concentrated solely on the task at hand. Engaging in activities such as solving puzzles and searching for puppies and kittens brought me a sense of pleasure.\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eJohn who enjoyed animal-based activities stated,\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n\u003cp\u003e\u003cem\u003eYou should stay pretty fast because sometimes they just make those land there quick, and they'll you got to watch them because they'll sometimes do four and five at a time. Same thing. So, you got to just kind of keep getting that squirrel.\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eThese statements indicate that participants concentrated on their activities well and enhanced their attentive skills.\u003c/p\u003e\n\u003cp\u003eSeveral participants reported that their memory was enhanced through Silvia Program participation. They indicated that various cognitive activities stimulated their brain to memorize numbers, colors, figures, objects, and language. As previously noted, participants embraced the challenges necessary to complete tasks related to memory, which resulted in memory enhancement. Paul who enjoyed color matching activities said,\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n\u003cp\u003e\u003cem\u003eI struggled with selecting the correct colors, but I found that trying to recall the sequence and keep track of the colors was challenging and very fun. I believe it helped me improve my memory, and it's a positive and enjoyable challenge.\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eAmy shared similar experiences by stating that the programs helped her refresh her mathematical skills and improve her memory. She also mentioned that practicing adding and subtracting numbers, matching colors, and recalling letters helped improve her memory.\u003c/p\u003e\n\u003cp\u003eSeveral participants shared their memories with their family members and pets through cognitive activities that were designed with animals, nature, and locations. By engaging in cognitive activities, they shared their life stories by recalling personal events and thus contributed to strengthening their memory.\u003c/p\u003e\n\u003cp\u003eOverall, these examples and statements provide qualitative evidence that participants benefited by engaging in the cognitive training activities of the Silvia Program such as calculation, attention, and memory. This finding suggests that the Silvia Program can be beneficial for cognitive health of users.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePsychological Wellbeing\u003c/strong\u003e. Most participants shared that they experienced mental relaxation and a sense of enjoyment and accomplishment while they participated in the Silvia Program. When they participated in the home-based exercise, relaxation/mindfulness, and cognitive training programs, they immersed themselves in each activity/program and felt relaxed and comfortable. They mentioned that these programs enabled them to experience a sense of happiness and enjoyment because there were fun, challenging components of each activity/program. For example, John stated,\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n\u003cp\u003e\u003cem\u003eI found it (the activity) relaxing. I am always searching or looking for information, so to sit down and play games was very relaxing.\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eLily also mentioned that she felt excited when she played some star or animal-based cognitive exercises and followed some instructions for home-based exercise programs. She felt physically and mentally stronger after doing these activities. In a similar manner, Susan stated,\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n\u003cp\u003e\u003cem\u003eBut just about all of those games were fascinating. I really enjoyed those. They were all good mentally and really exciting. I had a really great time.\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eSome participants shared personally meaningful stories related to their participation in specific activities within the program such as memories of spending time with family members and beloved pets from the past. They mentioned that these program activities undeniably had a profound and positive impact on their psychological wellbeing. Frank, who enjoyed playing with animals mentioned that he felt a sense of enjoyment and connection with his past with some activities. Also, according to Ashley,\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n\u003cp\u003e\u003cem\u003eThat (Finding My Puppy) was my favorite activity of all the games\u0026hellip; a dog like mine. Unfortunately, mine was gone, but those dogs are like my dog.\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eShe shared that she cherished her memory with her pet through this activity and mentioned that she enjoyed playing this activity.\u003c/p\u003e\n\u003cp\u003ePaul also stated,\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n\u003cp\u003e\u003cem\u003eI like the games, and I liked putting in our meals and all that kind of stuff too. That made me relive today, it was like a blast from the past because I felt like I was back in my childhood, enjoying simple pleasures and spending time with loved ones.\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eA few participants mentioned that they experienced a sense of accomplishment by improving their scores on cognitive activities and participating in exercise programs and mindfulness. While they encountered some challenges, they developed the perseverance necessary to persist in various programs that led to a sense of achievement and accomplishment. Thus, based on these examples and statements, participants experienced enhanced psychological wellbeing that resulted in an enhanced sense of enjoyment, accomplishment, and feelings of relaxation and reward.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHealth-related Behavior Management\u003c/strong\u003e. Most participants indicated that the lifestyle management aspect of the Silvia Program helped them pursue a much healthier lifestyle. They identified their daily routines, sleep patterns, dietary habits and nutritional information as the main benefits of the lifestyle management program that contributed to a heightened awareness of their overall health management. By tracking this information and monitoring their lifestyle related behaviors, they reported that they modified their behaviors when needed. They shared that these changes not only enhanced their perception of managing health behaviors but also empowered them to monitor and regulate these behaviors. For example, Tina stated that monitoring her life routines helped her to make better choices for food and exercise and prioritized her health. Similarly, Tiffany stated,\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n\u003cp\u003e\u003cem\u003eIt is good that the app encourages us to think about what we eat and the importance of getting enough protein. And it's not just about eating; it also tracks our sleeping habits.\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eShe also indicated that she was determined to pursue a healthier lifestyle in terms of eating and sleeping.\u003c/p\u003e\n\u003cp\u003eSeveral participants also modified their sleep patterns based on data from the Silvia Program sleep tracking system. According to Mary, she maintained and improved her sleep pattern and quality by monitoring her sleep and mentioned that she decided to restrict the use of her own electronic devices to promote better sleep. Also, Mary said,\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n\u003cp\u003e\u003cem\u003eAt first, I didn't think it would make a difference, whether I slept for a certain number of hours or ate a specific way. But now I understand the importance of finding a balance in life.\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eThese examples indicate that the lifestyle management programs offered by the Silvia Program helped participants to make a better choice for their health and pursue a healthier lifestyle.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n\u003ch2\u003eChallenges\u003c/h2\u003e\n\u003cp\u003eIn addition to the positive outcomes of the use of the Silvia Program, participants identified two main challenges: (\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e) technology anxiety and challenging content. The identification of these challenges can provide practical suggestions for efficacy investigations that involve the technology developer.\u003c/p\u003e\n\u003cp\u003eOne primary challenge that most participants experienced in the first two weeks was technological anxiety caused by unfamiliarity with mobile technologies. Although it took a short time to adjust to and understand how to use the Silvia Program on a tablet device, participants expressed concerns and apprehensions related to technology use, and several participants mentioned that technology anxiety impeded their ability to fully engage with each program in the early stages of their participation. For instance, Velvet stated,\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n\u003cp\u003e\u003cem\u003eInitially, I was uncertain and apprehensive as I had no prior experience with this type of thing and was concerned about making mistakes or breaking it.\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eSome participants experienced frustration when they experienced technical glitches (screen frozen), especially in the middle of engaging in activities. Tina indicated that he lost interest in redoing the activities when the program stopped unexpectedly. Tiffany also mentioned that she was frustrated and uneasy when she was not able to continue doing the activities due to technical errors. She said,\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n\u003cp\u003e\u003cem\u003eI've been frustrated when it didn't work properly, it continuously stopped in the middle of the game. For example, I just did the rainbow melody, and it didn't work, I was worried if I had done something wrong.\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eWhile most participants found the programs enjoyable, it is worth noting that some individuals exhibited a reluctance to engage in some activities because of the complexity of the instructions and repetitive program contents. They mentioned that found some activities less than challenging and some instructions too complex (home-based exercises). For example, Frank shared that some activities within the program were so fast paced that at times he was overwhelmed, reporting, \u0026ldquo;Sometimes I can't read the instructions because it goes too fast.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eAlso, John mentioned,\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eBecause you had to look at the animals. You saw what's coming down. Then you had to change the animal, and sometimes there were three animals, and sometimes there were four, and if I, if you go too fast.\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eParticipants frequently expressed that they became easily bored when they encountered monotonous or overly simplistic activities that failed to challenge and engage them for a sustained period. Additionally, when they perceived limited improvement in their performance over time, they were more prone to lose interest. Consequently, the provision of tangible and meaningful results at the conclusion of each activity emerged as a critical factor in sustaining participant motivation and engagement with these activities.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis pilot study explored the health benefits and challenges associated with the use of the Silvia Program by ALF residents. Our findings show that participants reported potential health benefits, including cognitive health, psychological wellbeing, and health-related behavior management, but that participants also reported challenges including technology use anxiety and content related challenges. These findings suggest that Silvia Program use can be instrumental in promoting improved cognitive function and psychological wellbeing and enhance the ability of users to manage their health-related behaviors and that the challenges experienced by participants can be successfully addressed through further development of the contents of the program.\u003c/p\u003e \u003cp\u003eResearch has provided evidence that MDL programs targeting modifiable risk factors hold promise in preserving specific cognitive and physical functioning domains for older adults with MCI or at high risk of dementia(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). However, some studies have suggested that MDL interventions may not have an immediate effect on cognitive performance after 24 months of intervention (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). A systematic review noted that approximately two-thirds of ongoing MDL interventions are effective in improving cognitive function, particularly among studies targeting MCI(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Our findings suggest that the Silvia program can serve as a technology tool to improve the cognitive and psychological health and health management skills of ALF residents. The minor challenges identified suggest further avenues of investigation for researchers in refining this approach.\u003c/p\u003e \u003cp\u003ePrior research has provided evidence that the use of technology-based cognitive games is associated with positive mood and relaxation (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). These studies suggest that game users can experience positive emotions and a sense of enjoyment. Based on these reported benefits of technology-based games, our findings suggest that cognitive activities provided on a mobile device can offer can provide triggering of positive emotions for ALF residents. This indicates that MLD programs can serve as useful tools for cognitive enhancement and produce emotional and psychological benefits.\u003c/p\u003e \u003cp\u003eIn addition, participants in our study mentioned that the Silvia program played a particularly important role in tracking their health behaviors, including sleep patterns, dietary habits, and physical activities. These activities, and the feedback they provided to participants, contributed to an increased awareness of their overall health and enhanced management skills. This finding aligns closely with previous research indicating that the integration of MDL into mobile technology provides personalized engagement (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e), improved access to healthcare (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e), and increased independence for users (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). This is crucial, as caregiving for this population demands a high level of health care management.\u003c/p\u003e \u003cp\u003eAn empirical study that investigated the efficacy of the Silvia Program with the sample of older Korean adults demonstrate that Silvia Program users (healthy aging adults) reported improved cognitive function (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). The English language version of the program evaluated in this study was implemented in ALF settings in United States. With this new population, our findings extend the existing knowledge that the Silvia Program can be effective in improving cognitive function among users living with mild cognitive impairment. This study provides qualitative evidence that will provide a foundation upon which future clinical trials can be designed to test the efficacy of the program in improving cognitive function and mental health of ALF residents.\u003c/p\u003e \u003cp\u003eStudies have suggested there is high prevalence of technology anxiety (fear, apprehension, and phobia) associated with the use of electronic devices by older adults (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). In the present study, it appears that ALF residents have experienced technology anxiety at the beginning of their participation, and that these negative feelings and reluctance decreased when participants gained a level of comfort with the technology used in this study. This suggests that understanding and acknowledging potential technology related barriers that participants may encounter prior to a clinical trial is a priority, and that any use of technology-based program applications with geriatric populations must be accompanied with technology training and assessment of perceptions of technology complexity in future studies. In addition, mobile technology developers must create customized, individualized content for users so that their engagement with the program can be sustained.\u003c/p\u003e "},{"header":"Limitations and Conclusion","content":"\u003cp\u003eThere are several limitations inherent to this study. First, this pilot study focused on ALF residents who were not diagnosed with ADRD but did not differentiate the impact of Silvia Program use related to different levels of cognitive functions. Future experimental designs should be pursued to evaluate differences in health outcomes between healthy aging adults and residents with mild cognitive impairments. A comparison of the outcomes for treatment and control groups is recommended for a more objective measurement of the efficacy of the use of an MDL program by ALF residents. Second, considering the inherent limitations of qualitative studies, a randomized clinical trial with an experimental study design is needed to objectively assess the efficacy of the program in improving the cognitive function and wellbeing of ALF residents using standardized assessment tools validated in AD populations. Lastly, as our sample consisted of only ALF residents, future studies should seek to involve community-dwelling older adults or older adults residing in nursing homes who have the potential to gain benefit from using the Silvia Program and its activities.\u003c/p\u003e\u003cp\u003eDespite these limitations, this qualitative study of the use of the Silvia Program by ALF residents allowed us to identify the potential beneficial health outcomes, and challenges related to its use such as technology anxiety and glitches and needed content improvements. Our findings provide evidence of the positive health outcomes that MDL program use can provide for ALF residents, and strategies that can be used to minimize the challenges that may pose barriers or impede user engagement with the program. Overall, the results of our study provide qualitative evidence that the Silvia Program can be instrumental in reducing the risk of dementia, improving psychological wellbeing, and enhancing the management of health-related behaviors.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003ei. Ethics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study obtained ethics approval from Indiana University\u0026rsquo;s Institutional Review Board (IRB) (#15198) and adhered to ethical research principles, using an approved research protocol. Participants, staff, and caregiver provided specific informed consent for participation in the qualitative components of the interview. All methods were carried out in accordance with relevant guidelines and regulations of Indiana University.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eii. Consent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eiii. Availability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available from the corresponding author, YSK, upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eiv. Competing interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ev. Funding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003evi. Authors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYSK led the study design, led the ethics approval applications, provided oversight over implementation planning and data collection, and drafted the manuscript. JHK provided oversight over the study design, ethics approvals, consulted on implementation planning, provided oversight over data analysis, and edited the final manuscript. MO consulted during ethics approvals, led implementation planning, and edited the final manuscript. MJK provided oversight over data analysis and edited the final manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003evii. Acknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank all the residents and professional staff from Bell Trace Assisted Living and Evergreen Village at Bloomington for their participation in the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eRivan NFM, Singh DKA, Shahar S, Wen GJ, Rajab NF, Din NC, et al. Cognitive frailty is a robust predictor of falls, injuries, and disability among community-dwelling older adults. 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Alzheimer\u0026rsquo;s \u0026amp; Dementia. 2013;9(6):657\u0026ndash;65. \u003c/li\u003e\n\u003cli\u003eKivipelto M, Mangialasche F, Snyder HM, Allegri R, Andrieu S, Arai H, et al. World‐Wide FINGERS Network: a global approach to risk reduction and prevention of dementia. Alzheimer\u0026rsquo;s \u0026amp; dementia. 2020;16(7):1078\u0026ndash;94. \u003c/li\u003e\n\u003cli\u003eKivipelto M, Mangialasche F, Snyder HM, Allegri R, Andrieu S, Arai H, et al. World‐Wide FINGERS Network: a global approach to risk reduction and prevention of dementia. Alzheimer\u0026rsquo;s \u0026amp; dementia. 2020;16(7):1078\u0026ndash;94. \u003c/li\u003e\n\u003cli\u003eNgandu T, Lehtisalo J, Solomon A, Lev\u0026auml;lahti E, Ahtiluoto S, Antikainen R, et al. A 2 year multidomain intervention of diet, exercise, cognitive training, and vascular risk monitoring versus control to prevent cognitive decline in at-risk elderly people (FINGER): a randomised controlled trial. 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MDPI; 2019. p. 60. \u003c/li\u003e\n\u003cli\u003eLee J, Kim J, Park A, Hong R kyeun, Ko M, Heo M, et al. Efficacy of a mobile-based multidomain intervention to improve cognitive function and health-related outcomes among older Korean adults with subjective cognitive decline. Journal of Alzheimer\u0026rsquo;s Disease. 2023;(Preprint):1\u0026ndash;12. \u003c/li\u003e\n\u003cli\u003eCrabtree BF, Miller WL. Doing qualitative research. Sage publications; 2023. \u003c/li\u003e\n\u003cli\u003ePatton MQ. Two decades of developments in qualitative inquiry: A personal, experiential perspective. Qualitative social work. 2002;1(3):261\u0026ndash;83. \u003c/li\u003e\n\u003cli\u003eKim Y, Junhyoung Kim P, Kim R, Yoon S. A pilot study of a nature-based virtual reality program on mental health among Korean immigrants during the COVID-19 pandemic. Gerontechnology. 2023;22(1). \u003c/li\u003e\n\u003cli\u003eKim J, Kim Y, Chang PS, Min Oh S, Han S. A pilot study of virtual reality (VR) Tai Chi program on mental health among older adults during the COVID-19 pandemic. Am J Health Behav. 2022;46(5):576\u0026ndash;85. \u003c/li\u003e\n\u003cli\u003eLegard R, Keegan J, Ward K. In-depth interviews. Qualitative research practice: A guide for social science students and researchers. 2003;6(1):138\u0026ndash;69. \u003c/li\u003e\n\u003cli\u003ePhillippi J, Lauderdale J. A guide to field notes for qualitative research: Context and conversation. Qual Health Res. 2018;28(3):381\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eCreswell JW, Poth CN. Qualitative inquiry and research design: Choosing among five approaches. Sage publications; 2016. \u003c/li\u003e\n\u003cli\u003eBirt L, Scott S, Cavers D, Campbell C, Walter F. Member checking: a tool to enhance trustworthiness or merely a nod to validation? Qual Health Res. 2016;26(13):1802\u0026ndash;11. \u003c/li\u003e\n\u003cli\u003eZhong D, Chen L, Feng Y, Song R, Huang L, Liu J, et al. Effects of virtual reality cognitive training in individuals with mild cognitive impairment: a systematic review and meta‐analysis. Int J Geriatr Psychiatry. 2021;36(12):1829\u0026ndash;47. \u003c/li\u003e\n\u003cli\u003ePallavicini F, Pepe A. Virtual reality games and the role of body involvement in enhancing positive emotions and decreasing anxiety: within-subjects pilot study. JMIR Serious Games. 2020;8(2):e15635. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"dementia, multidomain lifestyle intervention, older adults","lastPublishedDoi":"10.21203/rs.3.rs-4355742/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4355742/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eCognitive decline stands as a significant factor contributing to disability and dependency among older adults. Multi-domain lifestyle (MDL) interventions are widely recognized for their effectiveness in preserving cognitive functioning in older adults with dementia. However, little is known about MDL interventions using technology-based approaches in older adults residing in assisted living facilities. This qualitative study aims to explore the benefits of a mobile-based multidomain application, the Silvia Program, in enhancing the cognitive functioning of residents in assisted living facilities.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe conducted semi-structured, in-depth interviews to capture the health-related benefits and perspectives of the Silvia Program after a 12-week period. Ten participants (70% female; age range 66\u0026ndash;93), all at risk of dementia (with MoCA scores between 18 and 25), were recruited from two local community assisted living facilities in the Midwestern area. Five steps of high-quality analysis of interview transcript was conducted.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eWe identified three salient themes resulting from Silvia Program participation: (a) Cognitive benefits, (b) psychological wellbeing, (c) Health-related behavior management, (d) Technology anxiety, and (e) Content issues.\u003c/p\u003e\u003ch2\u003eDiscussion\u003c/h2\u003e \u003cp\u003eThe present study provides suggestive evidence for an overall positive effect of the use of the Silvia Program on the cognitive functioning among residents in ALFs. Practical implications and further discussion are addressed in this paper.\u003c/p\u003e","manuscriptTitle":"Exploring the health benefits of a mobile-based multidomain lifestyle program for older adults living in assisted living facilities","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-05-31 20:27:48","doi":"10.21203/rs.3.rs-4355742/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-02-18T04:55:32+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-02-16T03:02:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"210194569044340052173028045088202016651","date":"2025-02-15T01:35:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"307406967567600621250574367379888094860","date":"2025-02-15T00:21:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"103300668768026899486812581078032456788","date":"2025-02-13T12:21:16+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-01-12T09:19:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"229006544641499401389612291259281266160","date":"2025-01-06T16:19:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"239498716448838225734198416140874534720","date":"2025-01-05T05:15:19+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-01-02T15:52:06+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-12-17T16:36:05+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-05-16T14:54:59+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-05-16T14:53:30+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Geriatrics","date":"2024-05-01T19:16:45+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ea028f71-4439-485b-ab71-d93f06e0a0b4","owner":[],"postedDate":"May 31st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-05-04T15:59:44+00:00","versionOfRecord":{"articleIdentity":"rs-4355742","link":"https://doi.org/10.1186/s12877-026-07291-3","journal":{"identity":"bmc-geriatrics","isVorOnly":false,"title":"BMC Geriatrics"},"publishedOn":"2026-05-01 15:57:01","publishedOnDateReadable":"May 1st, 2026"},"versionCreatedAt":"2024-05-31 20:27:48","video":"","vorDoi":"10.1186/s12877-026-07291-3","vorDoiUrl":"https://doi.org/10.1186/s12877-026-07291-3","workflowStages":[]},"version":"v1","identity":"rs-4355742","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4355742","identity":"rs-4355742","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}