REACT MCI - Repeated Advanced Cognitive Training in Mild Cognitive Impairment (REACT MCI)

Repeated Advanced Cognitive Training in Mild Cognitive Impairment (The REACT MCI Study). A Randomized, Controlled Trial.

Oslo University Hospital, NKS Olaviken, St. Olavs Hospital, NKS Kloverasen, Barrow Neurological Institute, University of Maryland

Background: Dementia is a debilitating and devastating disease impacting the individuals, their families, and the health care system. According to the World Health Organization the dementia epidemic could overwhelm the global health care system and undermine social and economic development. Currently, no curative treatment for dementia exists despite immense research activity. The cognitive and functional impairment in dementia, especially Alzheimer's disease (AD), develop slowly decades before clinical signs emerge. This knowledge has led to the recognition of a prodromal period of mild cognitive impairment (MCI), between normal cognition and dementia. This is at present the earliest stage for intervention in dementia; even a short delay in dementia progression will have a large impact on global economy and health care. Objectives: In this clinical multicenter study, we aim to investigate the efficiency and cost-effectiveness of working memory training in MCI. To identify high responders to training analysis of genetic markers, relative's stress and craniospinal clearance will be performed. Participants and methods: This study is a blinded, randomized and controlled trail that will include 213 participants, diagnosed with MCI, included from five Norwegian Memory clinics in four health care regions. The groups will be randomized to either two training periods, one training period or active control. The intervention is computerized working memory training. Neuropsychological status, activities of daily living (ADL), and relative stress and quality of life will be assessed at baseline and 3, 6, 12 ,24 and 48 months after training. Structural MRI will be performed at baseline, and 3 and 6 months after training. For participants in the REACT MCI glymphatics substudy craniospinal clearance will be measured at baseline. A cost-utility analysis will be performed to evaluate if the working memory training is more cost-effective compared to the active control group in the MCI phase, taking a societal perspective.

Randomization in blocks of six to eight will be performed by the regional research support statistics service to either two training periods, one training period or generalized brain training/active control.

All study personnel except for the PI, coaches and Study secretary will be blinded for group allocation regarding types of memory training.

One training period of 30 minutes of daily adaptive training for 4-5 days a week up for 20- 25 trainings using computerized cognitive training.

Two training periods of 30 minutes of daily adaptive training for 4-5 days a week up for 20- 25 trainings using computerized cognitive training.

The generalized brain training group (Active control) will play solitaire 30 minutes daily for 25 sessions

Reduced function in the glymphatic system is associated with reduced working memory training effect measured by CT evaluated craniospinal clearance

Craniospinal clearance will be evaluated with a single CT image scan at level with the foramen magnum.

Working memory training impact quality of life measure in the participants as compared to active control measured by EuroQOL5D-5L after 12 months.

We consider the participants as having dementia when they no longer rapport intact activities of daily living and in addition display reduction of 1.5 standard deviation on test score on two tests on three or more cognitive domains.

The effect of working memory training is dose related measured by spatial span backwards after 6 months

Allelic variations in predefined genetic markes influence training effects after 3 months measured by spatial span backwards.

Allelic variations of LMX1a, APOE, AQP4 and/or COMT have in previous publications shown variable impact on working memory training. A statistical model combining these genes will be fitted for this investigation

Workin memory training reduces relatives stress scores as compared to relatives stress scores in the active control group after 12 months

The generic outcome in the analysis is QALYs (Quality adjusted life years) derived from the instrument EQ-5D 5L. The second outcome is production loss of the relatives and patients associated with MCI through the progression of dementia The health economic analysis will include following costs: 1) intervention related costs 2) direct costs/health care costs, mainly related to use of health care services, including primary, secondary and tertiary care and health services 3) indirect costs, including work absence for the patients and the relatives of the patients (i.e., productivity loss). Data will be collected through a self-report measures (EQ-5D 5L), and from the Norwegian patient registry.

The generic outcome in the analysis is QALYs (Quality adjusted life years) derived from the instrument EQ-5D 5L. The second outcome is production loss of the relatives and patients associated with MCI through the progression of dementia The health economic analysis will include following costs: 1) intervention related costs 2) direct costs/health care costs, mainly related to use of health care services, including primary, secondary and tertiary care and health services 3) indirect costs, including work absence for the patients and the relatives of the patients (i.e., productivity loss). Data will be collected through a self-report measures (EQ-5D 5L), and from the Norwegian patient registry.

Inclusion Criteria for the REACT MCI study: Diagnosis of MCI, based on the Mayo/winblad criteria or confirmation of current MCI status within the last 6 months before study enrollment. The ability to use and accessibility to an iPad or computer. Fluent in Norwegian. Spinal tap performed and results available Exclusion Criteria for the REACT MCI study: Patients unable to undergo a MRI investigation based on claustrophobia or metal foreign bodies are excluded from the study. Major psychiatric illness and current substance abuse Recent stroke Inclusion Criteria for the REACT MCI Glymphatics substudy: Enrollment in the REACT MCI study Participant allocated to Sorlandet Hospital or Oslo University Hospital Exclusion Criteria for the REACT MCI Glymphatics substudy: Individuals with known allergy against contrast solutions Individuals with other serious allergies Individuals with kidney failure or glomerular filtration rate < 30 Individuals younger than 18 or older than 80 Pregnant or lactating women For individuals >70 years or with medications affecting kidney function the glomerular filtration rate needs to be less than week old.