A Randomized Controlled Trial Study of a Multimodal Intervention vs. Cognitive Training to Foster Cognitive and Affective Health in Older Adults

Research over the past few decades has shown the positive influence that cognitive, social, and physical activities have on older adults’ cognitive and affective health. Especially interventions in health-related behaviors, such as cognitive activation, physical activity, social activity, nutrition, mindfulness, and creativity, have shown to be particularly beneficial. Whereas most intervention studies apply unimodal interventions, such as cognitive training (CT), this study investigates the potential to foster cognitive and affective health factors of older adults by means of an autonomy-supportive multimodal intervention (MMI). The intervention integrates everyday life recommendations for six evidence-based areas combined with psychoeducational information. This randomized controlled trial study compares the effects of a MMI and CT on those of a waiting control group (WCG) on cognitive and affective factors, everyday life memory performance, and activity in everyday life. Three groups, including a total of 119 adults aged 65–86 years, attended a 5- or 10-week intervention. Specifically, one group completed a 10-week MMI, the second group completed 5-week of computer-based CT followed by a 5-week MMI, whereas the third group paused before completing the MMI for the last 5 weeks. All participants completed online surveys and cognitive tests at three test points. The findings showed an increase in the number and variability of activities in the everyday lives of all participants. Post hoc analysis on cognitive performance of MMI to CT indicate similar (classic memory and attention) or better (working memory) effects. Furthermore, results on far transfer variables showed interesting trends in favor of the MMI, such as increased well-being and attitude toward the aging brain. Also, the MMI group showed the biggest perceived improvements out of all groups for all self-reported personal variables (memory in everyday life and stress). The results implicate a positive trend toward MMI on cognitive and affective factors of older adults. These tendencies show the potential of a multimodal approach compared to training a specific cognitive function. Moreover, the findings suggest that information about MMI motivates participants to increase activity variability and frequency in everyday life. Finally, the results could also have implications for the primary prevention of neurocognitive deficits and degenerative diseases.

Memory Compensation Strategies in Older People with Mild Cognitive Impairment

OBJECTIVES

With the rapid growth of the older population worldwide, understanding how older adults with mild cognitive impairment (MCI) use memory strategies to mitigate cognitive decline is important. This study investigates differences between amnestic and nonamnestic MCI subtypes in memory strategy use in daily life, and how factors associated with cognition, general health, and psychological well-being might relate to strategy use.

METHODS

One hundred forty-eight participants with MCI (mean age = 67.9 years, SD = 8.9) completed comprehensive neuropsychological, medical, and psychological assessments, and the self-report 'Memory Compensation Questionnaire'. Correlational and linear regression analyses were used to explore relationships between memory strategy use and cognition, general health, and psychological well-being.

RESULTS

Memory strategy use does not differ between MCI subtypes (p > .007) despite higher subjective everyday memory complaints in those with amnestic MCI (p = .03). The most marked finding showed that increased reliance-type strategy use was significantly correlated with more subjective memory complaints and poorer verbal learning and memory (p < .01) in individuals with MCI. Moreover, fewer subjective memory complaints and better working memory significantly predicted (p < .05) less reliance strategy use, respectively, accounting for 10.6% and 5.3% of the variance in the model.

CONCLUSIONS

In general, the type of strategy use in older adults with MCI is related to cognitive functioning. By examining an individual's profile of cognitive dysfunction, a clinician can provide more personalized clinical recommendations regarding strategy use to individuals with MCI, with the aim of maintaining their day-to-day functioning and self-efficacy in daily life.

Cognitive Aging: Activity Patterns and Maintenance Intentions

This study examined relationships between cognitive functioning in older people and 1) levels of mental, physical and social activities, and 2) intentions regarding maintenance of cognitive functioning. Participants ( N = 145) were 70–91 years of age, varied in health status and socio-economic backgrounds. Current cognitive functioning was assessed by psychometric tests and real world problem solving tasks. Crystallized ability was indexed by the National Adult Reading Test (NART). Degree of involvement in mentally demanding activities was positively related to a fluid cognitive factor after effects of age, prior functioning, gender, health, and socio-economic status were accounted for. Social and physical activities were not related to the cognitive measures. Age effects on cognitive functioning were reduced among participants who reported undertaking activities intentionally to maintain cognitive functioning.

[Do practices of learning activities improve the cognitive functioning of healthy elderly adults? From the viewpoint of a transfer effect]

The present study examined influences of reading aloud and performing simple calculation on the cognitive functioning of healthy elderly adults, based on the findings that these tasks activated the prefrontal lobe. The elderly adults' memory and inhibitory functions were assesed by Short-Term memory, CST, Stroop, and SRC tasks, before and after intervention for 18 months. The study found that the learning group had significant improvement from the pre- to the post-test for the short-term memory, STM, CST, and Stroop tasks. On the other hand, there was significant decline over the 18 months in the control group which was given only the assessment tasks. These results are discussed in terms of the effectiveness of cognitive training.

Reasoning training in the ACTIVE study: how much is needed and who benefits?

OBJECTIVE

To characterize change through 5-year follow-up, associated with training, booster, adherence, and other characteristics.

METHODS

Sample included all individuals randomly assigned to reasoning training (N = 699). Piecewise latent growth modeling was used to examine trajectory of performance on outcome measures.

RESULTS

Training resulted in improved reasoning performance through Year 5. A significant third annual booster effect was one-half the size of the training effect. Training adherence resulted in greater training effects. Higher education, Mini-Mental State Exam (MMSE), better health, and younger age related to higher baseline performance. Higher MMSE was related to larger training effects, larger linear slopes, and smaller booster effects. Significant functional outcomes included a training effect for complex reaction time (CRT), and first annual booster effects for the CRT and observed tasks of daily living.

DISCUSSION

Initial training gain was comparable with magnitude of age-related cognitive decline over 5 years with no training. Neither age nor gender predicted training or booster effects, indicating the generality of training effects across age (65-90 years).

Individual differences in cognitive plasticity: an investigation of training curves in younger and older adults

To date, cognitive intervention research has provided mixed but nevertheless promising evidence with respect to the effects of cognitive training on untrained tasks (transfer). However, the mechanisms behind learning, training effects and their predictors are not fully understood. Moreover, individual differences, which may constitute an important factor impacting training outcome, are usually neglected. We suggest investigating individual training performance across training sessions in order to gain finer-grained knowledge of training gains, on the one hand, and assessing the potential impact of predictors such as age and fluid intelligence on learning rate, on the other hand. To this aim, we propose to model individual learning curves to examine the intra-individual change in training as well as inter-individual differences in intra-individual change. We recommend introducing a latent growth curve model (LGCM) analysis, a method frequently applied to learning data but rarely used in cognitive training research. Such advanced analyses of the training phase allow identifying factors to be respected when designing effective tailor-made training interventions. To illustrate the proposed approach, a LGCM analysis using data of a 10-day working memory training study in younger and older adults is reported.

Memory intervention: the value of a clinical holistic program for older adults with memory impairments

OBJECTIVES

Increasingly, cognitive training appears an asset in improving attention and working memory for older adults. We conducted a study involving a 'holistic' training program for several cohorts of older adults (N = 112), targeting community residents with a spectrum of memory complaints ranging from Age Associated Memory Impairment to mild dementia.

METHOD

We developed a 7-session, manualized program targeting concentration, as well as mindfulness, exercise, stress reduction, socialization, diet, and values/identity techniques. We applied this model to 11 cohorts and conducted pre- and post-testing on memory (List Learning, Story Memory, Coding, Digit Span, Recall, and Recognition) and function (Functional Assessment Questionnaire). We also divided the Memory Group by Risk Status - Low, Medium, and High.

RESULTS

Results showed that the Memory Clinic Group as a whole improved on this training on most scales. When broken down by risk status, the Low and Medium Risk Groups were statistically superior to the High Risk Group on cognitive measures.

CONCLUSION

There were differences also on adjustment, this time favoring only the Low Risk Groups. Holistic memory training seems to be impactful for older adults.

Longitudinal Differences in Cognitive Functioning Among Older Adults With and Without Heart Failure

Objective: Secondary data analyses were conducted to examine cognitive function and longitudinal cognitive decline among older adults with and without heart failure (HF). Method: Data from the Advanced Cognitive Training for Independent and Vital Elderly study were used to compare baseline ( N = 2,790) and longitudinal ( n = 692) changes in memory, reasoning, and speed of processing performance among participants ( M age = 73.61, SD = 5.89) who self-reported HF at baseline, developed HF over time, or never reported HF. Results: At baseline, there were differences in memory and speed of processing with participants who never reported HF performing better than those who reported developing HF over time, and those who reported HF at baseline performing the worst ( ps < .05). Longitudinally, participants with self-reported HF at baseline showed declines in reasoning over time. Discussion: The results indicate that cognitive difficulties in memory and speed may occur prior to a HF diagnosis, while those with HF may experience steeper declines in reasoning as measured by word series test.

Practice-oriented retest learning as the basic form of cognitive plasticity of the aging brain

It has been well documented that aging is associated with declines in a variety of cognitive functions. A growing body of research shows that the age-related cognitive declines are reversible through cognitive training programs, suggesting maintained cognitive plasticity of the aging brain. Retest learning represents a basic form of cognitive plasticity. It has been consistently demonstrated for adults in young-old and old-old ages. Accumulated research indicates that retest learning is effective, robust, endurable and could occur at a more conceptual level beyond item-specific memorization. Recent studies also demonstrate promisingly broader transfer effects from retest practice of activities involving complex executive functioning to other untrained tasks. The results shed light on the development of self-guided mental exercise programs to improve cognitive performance and efficiency of the aging brain. The relevant studies were reviewed, and the findings were discussed in light of their limitations, implications, and future directions.

Cognition-focused interventions for older adults: the state of play

OBJECTIVE

The aim of this study was to review and discuss the evidence supporting the use of cognition-focused interventions to enhance mental function and decrease the risk of dementia.

METHOD

A non-quantitative review was made of existing evidence supporting the use of cognitive stimulation, rehabilitation and training in enhancing mental function and decreasing the risk of dementia in later life.

RESULTS

Despite growing popularity, there is limited evidence from randomized trials to support the use of cognition-focused interventions to decrease the rate of cognitive decline associated with increasing age or with dementia. There is currently no evidence available from randomized trials to support the use of cognition-focused interventions to prevent dementia.

CONCLUSIONS

Sufficiently powered randomized trials of cognition-focused interventions designed to prevent dementia and limit the progression of cognitive decline in later life are needed before these programs are adopted in normal routine clinical practice.

Cognition-based interventions for healthy older people and people with mild cognitive impairment

BACKGROUND

Evidence from some, but not all non-randomised studies suggest the possibility that cognitive training may influence cognitive functioning in older people. Due to the differences among cognitive training interventions reported in the literature, giving a general overview of the current literature remains difficult.

OBJECTIVES

To systematically review the literature and summarize the effect of cognitive training interventions on various domains of cognitive function (ie memory, executive function, attention and speed) in healthy older people and in people with mild cognitive impairment.

SEARCH STRATEGY

The CDCIG Specialized Register was searched on 30 September 2007 for all years up to December 2005. The Cochrane Library, MEDLINE, EMBASE, PsycINFO and CINAHL were searched separately on 30 September 2007 to find trials with healthy people. These results were supplemented by searches from January 1970 to September 2007 in PsychInfo/Psyndex, ISI Web of Knowledge and PubMed.

SELECTION CRITERIA

RCTs of interventions evaluating the effectiveness of cognitive training for healthy older people and people with mild cognitive impairment from 1970 to 2007 that met inclusion criteria were selected.

DATA COLLECTION AND ANALYSIS

Authors independently extracted data and assessed trial quality. Meta-analysis was performed when appropriate.

MAIN RESULTS

Only data on memory training could be pooled for analysis. Within this domain, training interventions were grouped according to several outcome variables. Results showed that for healthy older adults, immediate and delayed verbal recall improved significantly through training compared to a no-treatment control condition. We did not find any specific memory training effects though as the improvements observed did not exceed the improvement in the active control condition. For individuals with mild cognitive impairment, our analyses demonstrate the same pattern. Thus, there is currently little evidence on the effectiveness and specificity of memory interventions for healthy older adults and individuals with mild cognitive impairment.

AUTHORS' CONCLUSIONS

There is evidence that cognitive interventions do lead to performance gains but none of the effects observed could be attributable specifically to cognitive training, as the improvements observed did not exceed the improvement in active control conditions. This does not mean that longer, more intense or different interventions might not be effective, but that those which have been reported thus far have only limited effect. We therefore suggest more standardized study protocols in order to maximize comparability of studies and to maximize the possibility of data pooling - also in other cognitive domains than memory.

Metacognitive monitoring and strategic behaviour in working memory performance

Research indicates that cognitive age differences can be influenced by metacognitive factors. This research has generally focused on simple memory tasks. Age differences in working memory (WM) performance are pronounced, but are typically attributed to basic cognitive deficits rather than metacognitive factors. However, WM performance can be influenced by strategic behaviour that might be driven by metacognitive monitoring. In the current project, we attempted to connect these lines of research by examining age differences in metacognitive WM monitoring and strategies. In Experiment 1, younger and older adult participants completed a computerized operation span task in conditions that either required or did not require monitoring reports. Participants in the monitoring condition predicted and postdicted global performance for each block and rated their responses following each trial within a block. In Experiment 2, participants also reported their trial-level strategic approach. In contrast to the age equivalence typically found for simple memory monitoring, results demonstrated age differences in WM monitoring accuracy. Overall age differences in strategy use were not found, but using effective strategies benefited older adults’ performance more than younger adults'. Furthermore, age-related differences in the WM task appear to be mediated by the accuracy of performance monitoring.

Predicting memory training response patterns: results from ACTIVE

Previous research suggests that there is a great deal of variability among older adults' response to memory training. Using latent class analysis, we examined data from the memory training arm of the Advanced Cognitive Training for Independent and Vital Elderly Trial (ACTIVE), a large randomized controlled cognitive training trial, to determine if there were distinct patterns of responsiveness to training. Additionally, we examined whether baseline demographic and cognitive factors were predictive of these response patterns. The results indicate that among memory-trained participants, there are 3 distinct response patterns, suggesting that participants gravitate toward specific mnemonic techniques. Furthermore, baseline memory and speed of processing abilities, age, and education are predictive of these distinct response patterns. Taken together, the findings suggest that we can characterize and predict older adults' response to memory training.

An arts intervention for older adults living in subsidized retirement homes

A theatrically based intervention was given to 122 older adults who took lessons twice a week for 4 weeks. The training consisted of multi-modal activities (cognitive-affective-physiological) typically employed in college acting classes. Comparison groups consisted of no-treatment controls and participants instructed in a different performing art, singing. Assessment of effectiveness was performed using a battery of 11 cognitive/affective test measures that included word recall, prose comprehension/recall, word generation, digit-span ability, and problem-solving. It was found that the acting group improved significantly from pretest to posttest over both other groups. Digit-span was the only measure that failed to improve. The gains were achieved despite the fact that no aspects of the intervention supplied specific training or practice on the test measures. Previous versions of the intervention with community-dwelling adults had produced similar findings but the current participants were older, less well-educated, and lived in subsidized, primarily low-income, retirement homes.

Reasoning Exercises in Assisted Living (REAL): a feasibility study

Assisted living facility residents are at risk of cognitive decline that can precipitate nursing home placement. Cognitive training protects cognition and leads to maintained self-care for community dwelling elders. This pilot study tested an intervention designed to improve reasoning and everyday problem solving for assisted living residents. Volunteers (N = 4) completed six Reasoning Exercises in Assisted Living (REAL) training sessions provided over one month. Pre-intervention, immediate post-intervention, and three-month follow-up assessments of problem solving were compared. Participants' scores on Everyday Problems for Cognitively Challenged Elderly (EPCCE) increased 20% from pre-(M = 11.00, SD = 8.83) to post-intervention (M = 19.5, SD = 8.35, t = -312, p = .05). After three months, participants showed sustained EPCCE score improvement (M = 21.75, SD = 4.57, t = -3.95, p = .03).

Spontaneous production and use of mnemonic strategies in older adults

Mnemonic strategy use in older adults has been measured a number of ways, and although strategy measurement has received considerable attention, little work has been done to compare various types of subjective strategy reporting. The authors compared self-generated and endorsed strategies for memory tasks in a sample of 85 African-American and Caucasian older adults and investigated demographic characteristics related to each strategy measurement and the relationship between strategy use and memory performance. Across memory measures, significantly more strategies were endorsed than self-generated. Race, favoring Caucasians, was the most salient demographic predictor of mnemonic strategy usage. Although strategic behavior was associated with ability performance on most memory measures, specific strategies for optimal performance were identified for number and story recall only. Findings highlight the importance of measuring both self-generated and endorsed strategies and confirm previous work on the relationship between strategy use and memory performance.

Effects of Cognitive Training on Change in Accuracy in Inductive Reasoning Ability

We investigated cognitive training effects on accuracy and number of items attempted in inductive reasoning performance in a sample of 335 older participants (M = 72.78 years) from the Seattle Longitudinal Study. We assessed the impact of individual characteristics, including chronic disease. The reasoning training group showed significantly greater gain in accuracy and number of attempted items than did the comparison group; gain was primarily due to enhanced accuracy. Reasoning training effects involved a complex interaction of gender, prior cognitive status, and chronic disease. Women with prior decline on reasoning but no heart disease showed the greatest accuracy increase. In addition, stable reasoning-trained women with heart disease demonstrated significant accuracy gain. Comorbidity was associated with less change in accuracy. The results support the effectiveness of cognitive training on improving the accuracy of reasoning performance.

Effects of environmental support and strategy training on older adults' use of context

Age-related cognitive differences may be due, in part, to difficulties using task-relevant context in a proactive manner. Two studies evaluated different methods for increasing older adults' use of context in the AX-Continuous Performance Task (H. E. Rosvold, A. F. Mirsky, I. Sarason, E. D. Bransome, & L. H. Beck, 1956), which evaluates components of context processing. The results suggest that (a) age differences in the use of context are not due to reduced access to cue information, (b) directed strategy training made older adults' context processing performance more like that of young adults, and (c) similar performance changes could be observed with less directed instruction and extended practice. These results suggest that age-related differences in context processing can be ameliorated by directed strategy training or extended practice.

Differential effects of single versus combined cognitive and physical training with older adults: the SimA study in a 5-year perspective

The present study evaluates the effect of cognitive training, of psychoeducational training and of physical training on cognitive functioning, physical functioning, physical health, independent living and well-being in older people. Also the combination of physical training with cognitive training or psychoeducational training, respectively, was evaluated. In contrast to most training studies with older people, training effects were evaluated in a longitudinal perspective over 5 years to analyse long-term-results of cognitive and physical activity on older adults. Training effects were evaluated compared to a no-treatment-control group. Subjects were 375 community residents aged 75-93 years. Up to 5 years after baseline examination, significant training effects were observed in the group exposed to the combined cognitive and physical training. The physical and cognitive status in the participants of this group could be preserved on a higher level compared to baseline, and the participants displayed fewer depressive symptoms than the no-treatment-control group. The results are discussed in the light of recent research regarding the effects of mental and physical activity on brain function in older adults.

Intraindividual variability may not always indicate vulnerability in elders' cognitive performance

This study examined consistency of performance, or intraindividual variability, in older adults' performance on 3 measures of cognitive functioning: inductive reasoning, memory, and perceptual speed. Theoretical speculation has suggested that such intraindividual variability may signal underlying vulnerability or neurologic compromise. Thirty-six participants aged 60 and older completed self-administered cognitive assessments twice a day for 60 consecutive days. Intraindividual variability was not strongly correlated among the 3 cognitive measures, but, over the course of the study, intraindividual variability was strongly intercorrelated within a task. Higher average performance on a measure was associated with greater performance variability, and follow-up analyses revealed that a higher level of intraindividual variability is positively associated with the magnitude of a person's practice-related gain on a particular measure. The authors argue that both adaptive (practice-related) and maladaptive (inconsistency-related) intraindividual variability may exist within the same individuals over time.

Neuromodulation of associative and organizational plasticity across the life span: Empirical evidence and neurocomputational modeling

Developmental plasticity is the key mechanism that allows humans and other organisms to modify and adapt to contextual and experiential influences. Thus, reciprocal co-constructive interactions between behavioral and neuronal plasticity play important roles in regulating neurobehavioral development across the life span. This review focuses on behavioral and neuronal evidence of lifespan differences in associative memory plasticity and plasticity of the functional organization of cognitive and cortical processes, as well as the role of the dopaminergic system in modulating such plasticity. Special attention is given to neurocomputational models that help exploring lifespan differences in neuromodulation of neuronal and behavioral plasticity. Simulation results from these models suggest that lifespan changes in the efficacy of neuromodulatory mechanisms may shape associative memory plasticity and the functional organization of neurocognitive processes by affecting the fidelity of neuronal signal transmission, which has consequences for the distinctiveness of neurocognitive representations and the efficacy of distributed neural coding.

Environmental Influences on Cognitive and Brain Plasticity During Aging

In the current article, we provide a critical review of the extant literature that has focused on environmental influences on cognitive and brain plasticity over the adult life span. The review includes both human epidemiological, and human and nonhuman cross-sectional and longitudinal research. We review a number of factors that have been suggested to reduce age-related cognitive decline including both formal and informal education, leisure pursuits, intellectual engagement, and expertise in different skill domains. We also examine the literature on cognitive and physical fitness training. We conclude with a discussion of the gaps in the literature and suggestions for future research.