An estimated 6.9 million US older adults are living with Alzheimer disease and related dementias (ADRD) and the incidence increases with age [1]. ADRD is characterized by a progressive loss of cognition and function that eventually results in loss of independence and mortality. Currently, there are no curative treatments for ADRD. Thus, there is increased focus on nonpharmacological interventions that target modifiable risk factors for cognitive decline and dementia in older adults.

Apathy is a psychological syndrome characterized by a lack of motivation and interest, flattening of affect, and social withdrawal that predicts cognitive decline and increases the risk of ADRD by 20%-70% [2-10]. The prevalence of apathy ranges between 20% and 30% in community-dwelling older adults [11]. Apathy predicts the incidence of predementia syndromes mild cognitive impairment (MCI) and motoric cognitive risk syndrome, which is characterized by subjective cognitive complaints and slow gait [12,13]. Apathy is associated with social isolation related to a lack of interest in engagement [14]. Similarly, loneliness is highly prevalent in community-dwelling older adults (up to 43% [15]) and is associated with an increased risk of cognitive decline and ADRD [16,17]. Apathy and loneliness both represent potentially modifiable risk factors for cognitive decline and dementia and reminiscence therapy (RT) has been studied to target both these risk factors [18-20].

RT is a noninvasive, nonpharmacological intervention that has been shown to improve cognition, mood, functional status, quality of life, and apathy in older adults [18-24]. RT uses life story recollection in individual or group settings to improve psychological well-being. Prompts, photos, or music are all techniques used to trigger reminiscence, and the intervention can be delivered in person or virtually. Mechanisms for RT for apathy work through structured socialization with prompting from facilitators that stimulate motivation to engage. In addition, social stimuli lead to positive emotions through the sharing of personal stories. Sharing personal stories and a structured social environment that provides opportunities for meaningful engagement that may not happen in a casual social context address loneliness as well. A conceptual model of RT to address loneliness and apathy and how reminiscence may work as an intervention is visually depicted in Figure 1.

Cognitive decline in aging is multifactorial with multiple possible causes and there is significant variability in cognition based on the presence or absence of risk factors such as social factors (eg, loneliness) and apathy. In addition, the multiple aspects of social relationships (eg, meaning and purpose in life and social support) and psychological well-being (eg, depression) influence cognition via multiple possible paths. Meaning and purpose in life were associated with cognitive decline, and incident MCI and Alzheimer disease in prior studies [25]. In addition, studies investigating volunteering interventions to provide meaningful social, physical, and cognitive activities for older adults reduced brain aging [26]. RT is similarly organized to provide structured social engagement and stimulate cognitive activity through exercising autobiographical memory [27] and improvements in cognition may be mediated through improved life meaning and purpose. Depression is a well-known risk factor for cognitive decline [28] and loneliness and the relationship between loneliness and depression may be bidirectional [29]. In addition, apathy and depression are distinct neuropsychiatric conditions that often co-occur and symptoms may overlap [30]. Given the mechanisms of RT are not well understood, multiple aspects of social relationships and psychological well-being may be considered as mediators of the relationship between RT and health outcomes.

A growing body of research on RT for older adults targets individuals with ADRD and older adults in long-term care, as well as healthy older adults living in the community [18,20,21,31]. In addition, individual RT applied using virtual reality was shown to improve cognition and psychological well-being in institutionalized older adults, compared to traditional RT [32]. Studies on the effects of a virtually delivered group reminiscence therapy intervention that combines the benefits of a group intervention and is delivered virtually using communication technologies are scarce. The novelty of this proposal is that the intervention is designed, developed, and delivered via an established community-based organization by nonclinicians and has not been formally studied.

Life Story Club (LSC) is an established, nonprofit organization founded in Brooklyn, New York, in 2019. The organization is dedicated to reducing loneliness in older adults through RT and has already successfully served more than 1500 older adults. LSCs are virtual, no-cost RT clubs that meet weekly. The clubs are led by trained facilitators who propose 2 story prompts per meeting to invite participants to share their stories (eg, “As a child, what did you say you wanted to be when you grew up?” Or, “Tell a story about a time you or your loved one didn’t accept defeat.”). Participants alternate responding to prompts and sharing their stories. Facilitators are nonclinicians with teaching, arts, or social science backgrounds. Facilitators undergo comprehensive training including shadowing, on-the-job learning, and certification in Mental Health First Aid and SAFECare LGBTQ+ (lesbian, gay, bisexual, transgender, queer/questioning, and others) Cultural Competency Training prior to leading a club. LSC serves roughly 400 older adults per year and clubs are offered in English, Spanish, Mandarin, or Cantonese. In addition, groups can be phone or video-based to provide for broader access. Clubs can also be tailored based on particular interests such as LGBTQ+ clubs or cooking clubs.

Weekly sessions follow a structured format to ensure consistency and engagement. Weekly prompts are sent to participants via email, text, or phone 1-2 days before the meeting. Sessions begin with greetings and icebreakers. The facilitator then introduces the prompt and shares an example story. Each participant shares a 5-minute story related to one of the prompts and participants are encouraged to engage with the storyteller’s experience. Sessions conclude with final thoughts. LSC prompts are drawn from a library designed to evoke a range of autobiographical memories and reflections. Each week, prompts rotate across categories for broad depth and variety in storytelling experiences. LSC structure and prompt categories are detailed in Table 1.

Individuals are referred to LSC via primary care providers and through community outreach via naturally occurring retirement communities, public libraries, and older adult centers. Caregivers, family members, or individuals can also self-refer via the LSC website. RT as delivered by LSC can potentially improve accessibility and equity given its virtual delivery in multiple languages and can extend the reach of the intervention to homebound and rural older adults—the population who are at the highest risk for cognitive decline, tend to be hard to reach, and often not included in research for those reasons. LSC is a well-established community-based organization with a formalized infrastructure to serve community-based older adults.

The purpose of this study will be to explore the feasibility of a virtual group reminiscence therapy (vGRT) intervention delivered by LSC to improve loneliness and apathy in community-dwelling older adults. Rather than developing a new intervention, we propose to capitalize on an existing community-based resource to deliver a novel, virtual RT intervention directly to individuals in the community. We hypothesize that a virtual, group RT intervention will be feasible and acceptable for community-dwelling older adults.

This study is a prospective, nonrandomized, mixed methods feasibility study testing the impact of the LSC intervention. The purpose of the proposed study design is to test the feasibility of the intervention and provide preliminary data for a larger randomized controlled trial (RCT).

Participants will be recruited via partnerships with local community-based organizations serving older adults, home care agencies, as well as referrals from health care teams within the health system (eg, post-acute care managers, primary care social workers, and providers). Retention will be maximized by using preintervention counseling, regular opportunities for questions and feedback from participants, and compensation for completing pretest assessments, posttest assessments, and qualitative interviews at costs consistent with Institutional Review Board guidelines. All participants who participated in the LSC intervention will be invited to participate in qualitative interviews and we will enroll up to 30 participants or until saturation is reached.

Assessments will be collected via telephone at baseline, 3 months, and 6 months post RT. Participants will receive a gift card for each completed assessment. Qualitative interviews will be conducted with a subset of 30 participants to assess satisfaction with the intervention, what aspects can be improved, and explore barriers and facilitators of participation, including digital literacy. A semistructured interview guide is included in Multimedia Appendix 1. Interviews will take place at an agreed-upon location over 60 minutes and will be conducted by the primary investigator or coinvestigator. We will collect data on the following outcome measures and covariates:

Our primary outcomes will be loneliness and apathy. This is based on our hypothesis that targeting these cognitive decline and dementia risk factors will result in improved cognition in the longer term. Given this is a feasibility study and 3- and 6-month intervals may be too short of a time frame to see a difference in cognition and that the study will not be powered to detect differences in cognition, we propose to examine differences in loneliness and apathy, risk factors for cognitive decline, which can plausibly change in this short interval.

Secondary outcomes will be examined as potential mediators of effects between RT, loneliness, and apathy.

The primary purpose of this exploratory project is to test the feasibility of an LSC intervention and to provide estimates of the efficacy of the LSC intervention to inform a future RCT. We will enroll a total sample size of 50 participants and expect an estimated 15% dropout rate. This sample size follows guidelines for pilot studies and is appropriate for exploring feasibility [51]. Descriptive statistics will be used to report sample characteristics, feasibility markers, and measures. Statistical analyses will be conducted using Stata (version 18.5; StataCorp LLC). Repeated-measures ANOVA will be applied to test for overall differences in loneliness and apathy at baseline, 3 months, and 6 months. Secondary outcomes will be analyzed for differences in trends before and after the intervention and associations with changes in loneliness and apathy. We will test whether these measures mediate changes in loneliness and apathy from baseline using linear regression models.

We will use field notes and memos throughout the qualitative interview process to explore qualitative data. Data will be deductively analyzed using NVivo 15 software.

Data will be entered and stored in a secure, HIPAA (Health Insurance Portability and Accountability Act)-compliant REDCap (Research Electronic Data Capture; Vanderbilt University) database. Only study staff tasked with data entry and analysis will have access to the data. No identifying information will be written or transcribed for this study.

This study is being conducted in accordance with the Declaration of Helsinki ethics code. The protocol will be reviewed by the Albert Einstein College of Medicine institution review board. Because the intervention poses no more than minimal risk, a waiver of written consent was requested. Oral informed consent will be sought via telephone prior to study enrollment and prior to qualitative interviews.