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Cognitive Training for Older Adults: What Is It and Does It Work? Alexandra Kueider, Krystal Bichay, and George Rebok

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Cognitive Training for Older Adults: What Is It and Does It Work? Alexandra Kueider, Krystal Bichay, and George Rebok Issue Brief OCTOBER 2014 Cognitive Training for Older Adults: What Is It and Does It Work? Alexandra Kueider, Krystal Bichay, and George Rebok Older adults are more likely to fear losing their mental abilities than their physical abilities.1 But a growing body of research suggests that, for most people, mental decline isn’t inevitable and may even be reversible. It is now becoming clear that cognitive health and dementia prevention must be lifelong pursuits, and the new approaches springing from a better understanding of the risk factors for cognitive impairment are far more promising than current drug therapies. Key points from our analysis of the current evidence What Is Known About Cognitive Training Now? include the following: Aggressive marketing notwithstanding, drugs mar- ■■ Cognitive training can improve cognitive abilities. keted for dementias such as AD do little to maintain Dementia drugs cannot. cognitive and functional abilities or slow the prog- ress of the disease. In contrast to drugs are mental ■■ No single cognitive training program stands out exercises to improve cognitive abilities. Dr. Richard as superior to others, but a group format based Suzman, Director of the Division of Behavioral and on multiple cognitive strategies seems the most Social Research at the National Institute on Aging promising. (NIA), states, “These sorts of interventions are poten- tially enormously important. The effects [of cogni- ■■ Research comparing cognitive exercise tive training interventions] were substantial. There approaches is still thin. Rigorous evaluation stan- isn’t a drug that will do that yet, and if there were, it dards are needed. would probably have to be administered with mental exercises.”2 ■■ Cognitive training could reduce health care costs by helping older individuals maintain a healthy Controversy and confusion still surround the efficacy and active lifestyle. of cognitive training in older adults. A common mis- conception is that loss of cognitive abilities — mem- ■■ No scientific evidence exists that cognitive train- ory, attention, and the other faculties that enable one ing can prevent Alzheimer’s disease (AD) or other to think clearly, maintain social relationships, recover forms of dementia or predementia, and more from disease, and cope with normal age-related research is needed before firm conclusions can decline — is inevitable and unalterable as we age. be drawn. But human and animal studies suggest that the brain AMERICAN INSTITUTES FOR RESEARCH | MAKING RESEARCH RELEVANT ISSUE BRIEF is malleable, even late in life. Although no conclusive tasks become very hard or impossible to perform, evidence points to any particular cognitive train- AD or another type of dementia is diagnosed, in ing program as the most effective way to maintain which case cognitive training may be in order. The current cognitive abilities or delay dementia’s onset, key question here is whether training basic cognitive participation in mentally stimulating activities is abilities will transfer to everyday abilities, such as associated with lowered risk for developing AD and managing one’s finances or medicines. related dementias. Cognitive training is based on the idea that the brain, There is an urgent need to lower the risk of develop- even in old age, can change for the better. What we ing AD and related dementias quickly, effectively, know about the brain suggests that it resembles and at a low cost. According to the NIA, 87 percent muscles: In the same way that physical training of individuals remain cognitively healthy well into old improves physical abilities, cognitive training (or age, while one in seven develop more severe cogni- brain training) improves cognitive (or mental) abili- tive impairments, including dementia.3 One in nine ties. Cognitive training uses guided practice on a adults over the age of 65 has AD, and one in three set of tasks related to memory, attention, or other over the age of 85 has AD.4 And the aging population brain functions. This training can take many shapes. is growing rapidly. In 2010, 40 million people aged For instance, it can be conducted on the computer 65 and older accounted for 13 percent of the total or delivered in person, either individually or in small U.S. population. In 2030, the number of people in the groups. But it typically involves using repetitive United States over the age of 65 is expected to grow exercises designed to improve single (e.g., memory) to 72 million, accounting for almost 20 percent of the or multiple (e.g., memory and reasoning) cognitive U.S. population.5 abilities. What Is Cognition, and What Is Cognitive Cognitive training programs seem more likely to Training? work if they are delivered in a group format, contain multiple cognitive strategies (e.g., the use of imagery Cognition is a combination of processes, including to aid memory and repetition), and grow more chal- paying attention, learning and reacting to objects in lenging as performance improves.6 Table 1 compares the environment, and using language and memory. some cognitive training programs to cognitive stimu- If cognition becomes impaired, an individual may lation and cognitive rehabilitation, all of which aim to have difficulty performing everyday tasks. If those increase general cognitive and social function. Table 1. Three Approaches to Improve Cognitive Abilities Cognitive Training Cognitive Stimulation Cognitive Rehabilitation Description Uses repetitive exercises keyed to specific Engagement with activities involving some mental Tailored to the individual and involves cognitive abilities. May be computer-as- processing in a social context. Aims to be enjoyable. working on personal goals, often using ex- sisted or delivered in person individually ternal cognitive aids. Usually implemented or in small groups. in real-world settings. Example 1 The ACTIVE study trained one of three Experience Corps uses the time, skills, and experience A personalized memory notebook system, abilities: of older adult volunteers to improve the health and well- much like a Daytimer, is tailored to an Memory being of the volunteers and the educational outcomes of individual’s memory deficits. Sections may Reasoning disadvantaged elementary-school children. Volunteers include: Information processing speed7 are trained for 30 hours in literacy support, violence Orientation (personal and medical info) prevention and other skills.9 Names of emergency contacts Example 2 The IMPACT study used six computerized Senior Odyssey is a community-based intervention: Rehabilitation may also cover specific exercises to improve the speed and accu- older adults tackle a program of problem solving and everyday tasks, such as making change or racy of auditory information processing.8 brain teasers. Teams meet weekly for 16 weeks to de- balancing a checkbook. velop and test solutions for a long-term problem and to practice working as a group on spontaneous problems.10 2 ISSUE BRIEF Throughout the past 15 years, cognitive training “[ACTIVE] found that community-dwelling seniors who received interventions have been used to improve cognitive cognitive training had less of a decline in certain thinking skills performance in healthy older adults. To date, the than [those] who did not have training. The study addresses a largest trial of cognitive training in cognitively healthy very important hypothesis — interventions can be designed to older adults is the Advanced Cognitive Training for maintain cognitive function.” Independent and Vital Elderly (ACTIVE) study. Its - Richard J. Hodes, M.D., NIA Director participants were assigned to one of three interven- tion groups (i.e., memory, reasoning or information processing speed) or to a no-contact control group. The memory training intervention aimed to cre- Can the training effects of ACTIVE and other cog- nitive training trials be compared to the treatment ate multiple ways to make the to-be-remembered effects of drug trials with dementia patients? The information more meaningful, such as remembering short answer is that it’s difficult. Both the primary it by categorizing, visualizing and associating it with outcome measures used in these studies and the something familiar or well-known. The reasoning approach to quantifying treatment differ from those training intervention aimed to improve the ability to used in drug trials. Even more important, the partici- identify patterns from a series of letters, numbers pants differ. All ACTIVE participants were healthy el- and words that act as an aid to organizing daily derly whose cognitive trajectory was assumed to be activities, such as following a medication regimen relatively stable over the study period, whereas AD and thus reducing the burden on memory. (If one drug study participants are amid progressive brain knows how to read a bus schedule, one doesn’t degeneration so their cognitive skills are on a steep have to remember when the bus comes.) The downhill trajectory, such that even 6 to 12 months information processing speed training intervention makes a big difference in their cognitive abilities. aimed to improve mental processing speed so that That said, an earlier AD intervention trial found that the most effective current treatment available for the increasingly complex information could be under- disorder improved cognitive scores between 0.24 stood increasingly fast. How quickly could someone, and 0.31 standard deviation units over a 6-month for instance, identify whether an object in the middle treatment period.13
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