In the current healthcare landscape, the standard paper-pencil rehabilitation approach is giving the floor to new interventions derived from technology and telemedicine (Burton and O'Connell, 2018; Ge et al., 2018; Bernini et al., 2023a,b). Manifold differences may be unveiled concerning the paper-pencil approach.

Firstly, trainings with computers or tablets have gained attention as they may take advantage of more catchy appealing stimuli, and more monitorable approach (Hu et al., 2021; Wilson et al., 2022), which enhance motivation and engagement in the patient with online multifaceted feedback (Irazoki et al., 2020; Wilson et al., 2022). A meta-analysis and comprehensive review of the research in this area revealed that older adults are highly satisfied related to the usage of tablets and other technology devices (Ramprasad et al., 2019). In particular, these people reported higher satisfaction for variables such as the availability, perceived helpfulness, online feedback on completion rates and usability of the technologies themselves. Indeed, technology allows for greater flexibility in modulating stimuli and provides immediate and contextualized feedback to the patient (Lorenz et al., 2019; Irazoki et al., 2020; Pappadà et al., 2021; Wilson et al., 2022).

Secondly, these novel interventions through technological devices enable reaching people at their homes, reducing costs and time, thus minimizing environmental constraints (Burton and O'Connell, 2018; Ge et al., 2018; Irazoki et al., 2020).

Moreover, in terms of effectiveness, validity, reliability, and patient satisfaction, there is early evidence that telemedicine and technological CT interventions are comparable to traditional face-to-face procedures (Ge et al., 2018; Georgopoulou et al., 2023). Again, Ramprasad et al. (2019) found no evidence of actual improvement in clinical or behavioral variables in patients using technology-based cognitive rehabilitation. Despite that a lot has been published on the advantages and disadvantages of different forms of rehabilitation (Bernini et al., 2023a,b; Mantovani et al., 2020), there is still an urgent necessity of further studies aiming to specifically compare standard versus technological CT. Tools and procedures of clinical and research rehabilitation protocols—both paper-pencil and technological—are not always clear and well-detailed, so preventing the reproducibility and, in turn, the scientific evaluation of these approaches (Ge et al., 2018; Sandoval-Lentisco et al., 2024). The detailed description of the procedure for creating and choosing technological items is pivotal to analyze possible involuntary confounding variables in the transition from interventions based on paper-pencil or computerized stimuli. Thus, to date, the lack of a reasonable amount of well conducted randomized controlled trials and longitudinal studies makes it difficult and incautious to draw firm conclusions (Ge et al., 2018; Mantovani et al., 2020; Maresca et al., 2020; Kang et al., 2022).

Regarding this point, the great variability of technological CT interventions may be partly responsible for the challenges in evaluating the efficacy of these treatments. Indeed, there are several types of technology-based cognitive rehabilitation approaches that are relevant discussing at this stage. The first is computer-based cognitive technology, which includes cognitive games that may be played on computers or mobile devices like tablets and smartphones (Irazoki et al., 2020; Wilson et al., 2022). The second one is virtual reality (VR), which is a computer simulation of a man-made setting where patients can engage in real time using both visual and non-visual modalities (such realistic noises). VR systems can be categorized by being non-immersive (monitor with a two-dimensional virtual environment and interaction via a controller like a mouse or joystick) or immersive (three-dimensional virtual world). Considering the two different VR modalities, the immersive approach offers a greater cognitive and motor challenge (Leung et al., 2022). At the same time, it is appropriate to note that, more generally, individuals with cognitive decline may experience confusion, exhibiting difficulty or inability to distinguish between reality and VR, or, conversely, developing dependence on excessive VR use (Leung et al., 2022).

Finaly, not much is known on why and how to pass from a standard approach based on paper-pencil to a technological one (Ge et al., 2018; Gates et al., 2019). Rarely, one solution fits all. Literature showed that technological interventions enable the rehabilitation of single- or multiple- domain(s), increasing the monitoring and control (Ge et al., 2018; Irazoki et al., 2020; Georgopoulou et al., 2023; Kang et al., 2022). The issue might be that, in some cases, a conventional approach may be less effective than a technological one in the rehabilitation of single specific domains, or vice versa. Indeed, the effectiveness of CT is linked to multiple variables of the patients' characteristics and their environment, so that the combination of these elements can function as facilitators or hindrances depending on the situation. For instance, relevant differences can be determined by environmental factors such as facility accessibility and related costs. For a patient living in a rural area, a technological CT can be more effective as it enables remote use and monitoring (Ramprasad et al., 2019; Irazoki et al., 2020). Similarly, technological CT could be appreciated by patients with physical disabilities who cannot undergo a face-to-face training section due to difficulties in reaching the clinic or by individuals with sensory deficits that technology can overcome (e.g., stronger visual and auditory feedback). In this sense, technological CT allows for full customization of treatment based on the individual's needs (Irazoki et al., 2020). On the contrary, some patients may be demotivated and lack adherence to technological CT, as they are not used to adopting technological devices such as computers or other smart devices, nor are they supported by a family caregiver (Irazoki et al., 2020; Grigorovich et al., 2021). In this case, lifestyle habits and sociodemographic factors may play a role in the preference of standard vs. technological approaches for CT, from both a clinical perspective and in terms of the patient's user experience (González-Fraile et al., 2021; Bernini et al., 2023a).

As far as we know, regardless of the standard or technological approach, there is currently no agreement on the duration of CT to be effective in both the short and long term. Specifically, there is heterogeneity in duration and frequency of CT, respectively ranging from 4 to 26 weeks, and from two to three times per week for <1 h (Irazoki et al., 2020; Contreras-Somoza et al., 2021). While considering the need to make different treatment protocols comparable in order to study their effectiveness, the fact that modern medicine is becoming more and more patient-oriented should not be ignored. In fact, it clearly appears that developing individualized treatment plans that are tailored to each patient's unique requirements may be advantageous. Thus, it is crucial in clinical practice to avoid standardizing frequency and duration of treatment. Conversely, it is recommended to calibrate these aspects through a constant discussion between the healthcare professionals involved in the treatment and a regular reassessment of the patient's individual therapeutic goals, taking into account both short- and long-term objectives (Fleeman et al., 2015).

Even without a clear guideline, it seems that CT must be frequent and prolonged to be effective (Mantovani et al., 2020; Bahar-Fuchs et al., 2013). From a broader perspective, CT can be part of an active lifestyle that is a protective factor against dementia (Ownby and Waldrop, 2023). However, literature and clinical practice suggest that cognitive impairment can affect non-adherence, in particular the unintentional one caused by forgetfulness or cognitive deficits that prevent the correct implementation of therapies (Bahar-Fuchs et al., 2013; Dequanter et al., 2022; Nahas et al., 2024). Besides this, it is necessary that the patient is fully engaged in the CT, that should be considered a pivotal non-pharmacological intervention for preventing cognitive decline and maintaining cognitive resources (Dequanter et al., 2022). Indeed, modern conceptualization of adherence is intended as a complex and broader process referring to “the extent to which a person's behaviour-taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a healthcare provider” (Sabaté, 2003, p. 3). That is, independently from the approach—standard or technological—the success of the intervention is likewise given by the patient's adherence in terms of persistence and correct implementation of the proposed CT (El-Saifi et al., 2018). Thus, it is essential to identify all potential obstacles and enablers for adherence in order to stay persistent over time.

For instance, interventions based on telehealth home monitoring may improve adherence in the elderly because they solve the problem of travel to reach healthcare facilities (El-Saifi et al., 2018). The literature recommends also the adoption of a patient-centered approach, in which CT is a shared decision (Ranzini et al., 2020). In their study, Fleeman et al. (2015) proposed an interdisciplinary approach to cognitive rehabilitation known as the Integrative Cognitive Rehabilitation Programme Theoretical Model (ICRP) that takes its cue from the theory of Distributed Cognition. The latter conceives cognition as a socio-technical system in which individuals, objects, processes and contexts interact in such a way that, from a rehabilitation perspective, cognitive support technology and formal and informal caregivers act as compensatory tools to improve cognitive functioning in the individual's environment (Hutchins, 1995). Consequently, the ICRP is based on the idea that the integration of compensatory rehabilitation strategies, which consider the uniqueness of the individual according to the biopsychosocial model and the Distributed Cognition theory, allows for the development of a rehabilitation plan that maximizes the individual's potential, thus facilitating the personalization of the intervention for each patient (Fleeman et al., 2015). In this way, the already patient-centered treatment can benefit from the specific competences of a multidisciplinary team, favoring a continuous exchange and comparison between the different professionals involved.

Moreover, sociodemographic and lifestyle habits may push the patient to prefer and, in turn, to easily adhere to, standard or technological CT (Kerkhof et al., 2022; Bernini et al., 2023a). These aspects should be carefully considered as they may help foster the patient's engagement and motivation. For example, today's older individuals may have discomfort with unfamiliar technological devices, but this condition may reverse in tomorrow's seniors who may instead be less accustomed to paper and pencil (Garcia Reyes et al., 2023). It is essential to consider and implement supportive factors in the rehabilitation process that can enhance the perceived effectiveness of CT, such as external support, the therapist-patient relationship, satisfaction, and self-perceived efficacy regarding the intervention. These elements may improve patient motivation and the usability experience of the tools, ultimately supporting adherence to rehabilitation and generalizing the skills acquired (Nahas et al., 2024).

Lastly, we have to consider cognitive impairment as a family condition. Consequently, it is crucial for adherence to pay attention to the patient-caregiver dyad (Giardini et al., 2018; Torlaschi et al., 2022). Indeed, CT should be supportive without being a further burden for the caregiver (Giardini et al., 2018). Moreover, the caregiver role may be played by different people, such as wives or husbands, sons or daughters, as well as homecare assistants (Bremer et al., 2017). Considering everyone is a child of his time, choosing the more functional approach depends also on the caregivers' characteristics and, in turn, on the patient-caregiver dyad needs (Cunnah et al., 2021).