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Technology-based Neurocognitive Assessment of the Elderly: a Mini Review

Neurocognitive disorders in the elderly are on the rise all over the world. Neuropsychological assessment is vital to monitoring the progress of cognitive deficits. Over the years, there has been significant development in neuropsychological assessment to predict the development and progression of MCI and dementia. One such area of recent advancement in the field of neuropsychology is technology-based assessment. There are several types of technology-based assessments available based on the type of usage, site of the assessment, type of administration, type of device used for assessment, etc. Virtual reality-based assessments and digital assessments of neurocognitions for early identification of subtle cognitive deficits in patients with mild cognitive impairment (MCI) and major neurocognitive disorders (MND) represent two newly developed technologies. A few studies have demonstrated their efficacy; however, there remain several limitations and drawbacks to their usage within the elderly population. In this review, we have briefly discussed technology-based neuropsychological assessment, along with their usage and limitations.


INTRODUCTION
Aging is an inherent process that accompanies changes in the cognitive competencies and functionality of an individual. It is also now a well-known fact that, worldwide, the pace of population aging is much faster than in the past, and neuropsychiatric conditions have become a leading contributor of disability in the ageing population [1]. Neurocognitive disorders form the bulk of the neuropsychiatric conditions affecting the elderly, of which Alzheimer's dementia is the most common.
Dementia is an umbrella term used to describe the various symptoms associated with cognitive impairment.
There is a gradual progression of neurocognitive impairment in the elderly, starting from the preclinical stage to mild cognitive impairment (MCIs) and, finally, major neurocognitive disorders (MND). Therefore, it is necessary that there should be appropriate assessment of cognitive functions for early identification of neurocognitive disorders in the elderly to develop strategies to slow down the progression of cognitive impairment and develop proper management strategies for early intervention [2]. The to January 2021. Keywords included "technology", "digital", "neurocognition", "assessment", "elderly", "dementia", and "mild cognitive impairment" in various combinations.
Only original articles (abstract and full text) and review articles published in English prior to January 2021 were reviewed and checked thoroughly. More than 300 articles related to the topic were found, out of which those relevant to technology-based neurocognitive assessment methods for the elderly have been included.

Commentaries, viewpoints, and letters to editors related
to the topic were excluded.

NEUROPSYCHOLOGICAL TESTING METHODS
There are several significant limitations to traditional neuropsychological tests and testing methods [3]. Some of these include: (1) findings cannot be correlated with real-time brain functioning in functional imaging studies; (2) traditional tests require the patient to travel to the hospital; (3) the scoring process can be complex; (4) many times, it depends on the administrator to decide alternative forms to avoid practice effect; (5) there can be an impact due to the 'white coat effect' while testing; and (6) there is occasionally a need to perform multiple tests in longitudinal studies, which can be quite cumbersome for the patient.
Another issue with the traditional neuropsychological tests is that they usually compare the findings of cognitively challenged individuals with normative data, i.e., those who are cognitively normal in the same age group, who themselves may not actually be entirely free of the markers of dementia.
Therefore, there is a need to validate such tests with the biomarkers of dementia. There is also a need to explore the correlation of cognitive functioning with amyloid plaques over time [4]. For this, we need to have sensitive tests to pick up early cognitive changes associated with biomarker evidence of preclinical Alzheimer's dementia. To overcome these issues and for better assessment, technology-based assessments have come to the fore in recent times.

TECHNOLOGY-BASED ASSESSMENTS
Any instrument or method that utilizes a computer/ digital tablet/ handheld device, or other digital interface instead of a human examiner to administer, score, or interpret tests of brain function and related factors relevant to neurologic health and illness questions is understood to represent a form of technology-based assessment [5].
For neuropsychological assessment purposes, these can be broadly categorized as computer-based, tablet-based (mostly touchscreen devices), and mobile/smart phonebased assessments, and wearable devices. The number of tests based on digital cognitive assessments had increased exponentially in last few years.  [7].

Types of technology-based assessment
Different types of immersions have been used in VR-based assessments. These are non-immersive three-dimensional computer screens with mouse/joystick or sensor-based gloves, or semi-immersive large screen displays using shutter glasses or full immersive environments with a "green screen" and head-mounted display [7].
There can be two types of exploration within VR environments: active exploration, or passive exploration.
In active exploration, participants are immersed within and navigate a virtual environment guided by a research assistant, or otherwise navigate and move around by themselves using a joystick. There is 360-degree 'first person view' of the environment in active exploration.
In passive exploration, participants immersed in the virtual world do not move around or explore it. They • Web-based apps that can be either completed on personal computers or on tablets are designed to be completed without active participation or the presence of an examiner [6].

Based on the site of assessment, technology-
based assessments can be divided into office-based assessment and remote location assessment. However, there are certain problems with remote location assessments such as difficulty in maintaining participant engagement, issues related to data privacy, digital unsupervised evaluations, and frequent changes in the versions/updates to web-based apps, which often pose challenges to the administrator as well as the participant, etc. [6].

Based on type of administration, technology-based
assessments can be categorized as either selfadministered or clinically administered assessments • BYOD-based cognitive assessment -These are primarily smartphone-and browser-based tests.
These have the added an advantage of having a wider audience without the added expense of a managed device, and smartphones offer novel data collection

Digital assessments
Some of the instruments developed for digital applications and that have also been validated [6] include (1)  However, there are a few additional non-card-playing tasks (e.g., a paired associative learning task and a maze learning task). The Cogstate system was designed to be administered by an examiner, but there have been recent efforts to effect remote administration; additionally, once logged into the platform, the tasks are easy to progress through independently.
More recently, the CBB has been made available for unsupervised testing using a web browser.
It is being used in the Healthy Brain Project in Australia with a high acceptability and usability and low rates of missing data. The psychometric characteristics of the CBB were similar to those collected from supervised testing [6]. Additionally, Cogstate C3 battery's memory tasks were found to be best at identifying individuals' subtle cognitive impairments, as defined by paper and pencil measures (PACC) performance. It has been found to correlate well with paper and pencil measures of performance. •

Computerized National Institutes of Health
Toolbox Cognition Battery (NIH-TB): This was designed as an easily accessible and low-cost stay in a fixed location and are exposed to stimuli but can look around and can have a 360-degree 'first person' view of the environment [8].

Cognitive assessment via wearable devices
In recent years, mobile and wearable technologies (such as smartphones, tablets, smartwatches and rings, smart suits) present a unique opportunity to massively detect

STRENGTHS OF DIGITAL ASSESSMENTS
Digital assessments are more accessible and cost-effective due to self-administration. These tests automatically generate alternative forms which may help minimize practice and version effects. They have automatic scoring recording and give immediate access to results.
These tests utilize artificial intelligence (AI) methods and hence are faster, novel, and provide more sensitive cognitive data analysis [7]. These tests are highly scalable, and therefore can be used for remote assessment in a much larger population. These can be used for more frequent assessment with potentially more sensitive cognitive paradigms. Moreover, as these are performed in a familiar environment, they may accordingly increase the ecological validity. Another major advantage of digital assessments is that they provide cognitive assessment outside clinics with rapid data transfer to healthcare providers. Certain time-sensitive parameters, such as reaction time or inspection time, can be measured more accurately with digital tests [19].
In some tests, there are algorithmically defined approaches to a particular test (e.g., organization, planning), evaluation of pauses, perseverations, domain-specific errors, and/or response times in very specific measurements that add value to neuropsychological assessment data [7,20].
Added advantages of smartphone-based assessments include reduced risk of the "white-coat effect". They

CONCLUSIONS AND THE WAY FORWARD
It is essential to establish a neuropsychology data archive as an Open-Access Global Resource and develop a global collaborative network. It is also necessary to specify the latent traits assessed by each test and identify each trait's most efficient measurement models [24]. There should be constant efforts to improve the reliability and validity of mobile assessments and attempts to incorporate

CRITIQUE OF TECHNOLOGY-BASED ASSESSMENTS
There is lack of consistent, consensual definitions of key neuropsychological concepts, which poses an ongoing challenge to the profession and researchers, resulting in problems in communication within and outside the field. Neuropsychologists tend to be molecular in their approach, dividing behaviors into abilities such as language, memory, and the like. In fact, behavior in the environment rarely involves using these abilities in isolation [22]. In addition to the above-mentioned, there are also issues related to patients' preferences and it is frequently seen that patients use devices less often due to cumbersome procedures related to wearing them or difficulty in logging in and out from their systems. Additionally, many of the elderly do not want to be dependent on caregivers or assessors to help them to use these devices daily.
Among all such devices, cognitive tests based on tablets are most acceptable. Studies have suggested that adults of more than 55 years of age have a greater preference for the use of touchscreen devices, as these devices have more direct and intuitive interaction, lower motor demands, and are relatively easy to use. Moreover, tablets offer greater mobility than personal computers and are more user-friendly than smartphones for older adults owing to the larger screen sizes and better response field views. In recent years, there had been a growing interest in developing and validating tablet-based cognitive assessment tools.
Many neuro-cognitive tests have been validated for use with tablets [5].
Further, there are emerging legal and ethical issues related to technology-based monitoring. Some authors have raised privacy concerns with trackable wearable devices and the feeling of constantly being monitored