A game-based neurofeedback training system to enhance cognitive performance in healthy elderly subjects and in patients with amnestic mild cognitive impairment

Atrophy in the supramarginal gyrus associated with impaired cognitive inhibition in grieving Chinese Shidu parents

Background: The loss of an only child, known as Shidu in China, is a profoundly distressing experience, often leading to Prolonged Grief Disorder (PGD). Despite its impact, the structural brain alterations associated with PGD, potentially influencing cognitive impairments in Shidu parents, remain understudied.Objective: This study aims to identify brain structural abnormalities related to prolonged grief and their relation with cognitive inhibition in Shidu parents.Methods: The study included 40 Shidu parents and 42 non-bereaved participants. Prolonged grief was evaluated using the Prolonged Grief Questionnaire (PG-13). We employed voxel-based morphometry (VBM) and diffusion tensor imaging (DTI) to assess brain structural alterations and their correlation with cognitive inhibition, as measured by Stroop interference scores.Results: Findings suggest that greater prolonged grief intensity correlates with reduced grey matter volume in the right amygdala and the left supramarginal gyrus (SMG). Additionally, enhanced amygdala-to-whole-brain structural connectivity showed a marginal association with prolonged grief, particularly with emotional-related symptoms. Furthermore, a decrease in SMG volume was found to mediate the relation between prolonged grief and Stroop Time Inference (TI) score, indicating an indirect effect of prolonged grief on cognitive inhibition.Conclusions: The study provides insight into the neural correlates of prolonged grief in Shidu parents, highlighting the SMG's role in cognitive inhibition. These findings emphasise the need for comprehensive grief interventions to address the complex cognitive and emotional challenges faced by this unique bereaved population.

Applications of Alpha Neurofeedback Processes for Enhanced Mental Manipulation of Unfamiliar Molecular and Spatial Structures

This study explores a novel approach to enhancing cognitive proficiency by targeting neural mechanisms that facilitate science and math learning, especially mental rotation. The study specifically examines the relationship between upper alpha intensity and mental rotation skills. Although prior neurofeedback research for increasing upper alpha highlights this correlation, mostly with familiar objects, novel chemistry and math learning prompts envisioning unfamiliar objects which question the persistence of this correlation. This study revisits the upper alpha and mental rotation relationship in the context of unfamiliar objects with a single neurofeedback session and examines the efficiency of manual and automatic neurofeedback protocols. Results will provide a basis for integrating neurofeedback protocols into learning applications for enhanced learning. Our study encompassed three cohorts: Group 1 experienced an automatic neurofeedback protocol, Group 2 received a manual neurofeedback protocol, and the control group had no neurofeedback intervention. The experimental phases involved EEG measurement of individual upper alpha (frequency of maximal power + 2 Hz) intensity, mental rotation tasks featuring geometric and unfamiliar molecular stimuli, one neurofeedback session for applicable groups, post-treatment upper alpha level assessments, and a mental rotation retest. The neurofeedback groups exhibited increased levels of upper alpha power, which was correlated with improved response time in mental rotation, regardless of stimulus type, compared to the control group. Both neurofeedback protocols achieved comparable results. This study advocates integrating neurofeedback into learning software for optimal learning experiences, highlighting a single session's efficacy and the substantial neurofeedback protocol's impact in enhancing upper alpha oscillations.

Exploring the effects of combining health qigong and dance on working memory in middle-aged and elderly women: A preliminary investigation

OBJECTIVE

Cognitive decline represents a critical clinical and public health issue that adversely affects the quality of life for older patients and their families. This concern was exacerbated by the reduced engagement in outdoor activities among seniors during the COVID-19 pandemic, presenting substantial challenges to aging societies. The objective of this study was to investigate the impact of health qigong combined with Tibetan dance on working memory in middle-aged and elderly women, and to determine its potential as a preventive strategy against cognitive disorders.

METHODS

A pilot study was conducted to compare the effects of a Health Qigong exercise intervention with those of everyday life and sports routines. The primary outcome measure was working memory assessed using a 2-Back working memory task research paradigm. Between July and September 2021, a total of 33 women were divided into four groups: two middle-aged groups (N = 18, with 8 women in the experimental group and 10 in the control group) and two elderly groups (N = 15, with 7 in the experimental group and 8 in the control group). Participants in the experimental groups underwent a 10-week intervention, consisting of three 60-min sessions per week. Each session included a warm-up, Health Qigong combined with Tibetan dance, and a cool-down. Throughout the study, all participants continued their daily routines. Response times and error rates were analyzed using a mixed-design repeated-measures analysis of variance.

RESULTS

A simple effects analysis revealed that Health Qigong combined with Tibetan dance significantly enhanced 2-Back response time and error rate in the middle-aged group. In contrast, the 2-Back error rate significantly increased in the elderly control group that did not receive the intervention (p < 0.05).

CONCLUSION

Health Qigong demonstrates beneficial effects on middle-aged and elderly women. Combining Health Qigong with dance may serve as a preventive measure against cognitive disorders. This pioneering study conducted during the COVID-19 pandemic, assesses the new possibility of Health Qigong and dance, with the objective to offer more diverse indoor exercise options for middle-aged and elderly women.

Neurocognitive Features of Mild Cognitive Impairment and Distress Symptoms in Older Adults Without Major Depression

Background

Two distinct symptom dimensions were identified in older adults who did not have major depressive disorder (MDD): a) a dimension associated with mild cognitive dysfunction, and b) a dimension related to distress symptoms of old age (DSOA). It is uncertain whether previous findings regarding the features of amnestic mild cognitive impairment (aMCI) remain valid when patients with MDD are excluded.

Methods

To examine the neurocognitive features of aMCI (n = 61) versus controls (n=59) and the objective cognitive characteristics of DSOA in participants without MDD. Neurocognition was evaluated utilizing the Cambridge Neurological Test Automated Battery (CANTAB) and memory tests.

Results

This research demonstrated that CANTAB tests may differentiate between aMCI and controls. The One Touch Stockings of Cambridge, probability solved on first choice (OTS_PSFC), Rapid Visual Information Processing, A prime (RVP_ A´), and the Motor Screening Task, mean latency, were identified as the significant discriminatory CANTAB tests. 37.6% of the variance in the severity of aMCI was predicted by OTS_PSFC, RVP_ A´, word list recognition scores, and education years. Psychosocial stressors (adverse childhood experiences, negative life events), subjective feelings of cognitive impairment, and RVP, the probability of false alarm, account for 40.0% of the DSOA score.

Discussion

When MDD is ruled out, aMCI is linked to deficits in attention, executive functions, and memory. Psychosocial stressors did not have a statistically significant impact on aMCI or its severity. Enhanced false alarm response bias coupled with heightened psychological stress (including subjective perceptions of cognitive decline) may contribute to an increase in DSOA among older adults.

Efficacy of audiovisual neurofeedback training for attention enhancement: a multimodal approach

Attention is a cognitive process that involves focusing mental resources on specific stimuli and plays a fundamental role in perception, learning, memory, and decision-making. Neurofeedback (NF) is a useful technique for improving attention, providing real-time feedback on brain activity in the form of visual or auditory cues, and allowing users to learn to self-regulate their cognitive processes. This study compares the effectiveness of different cues in NF training for attention enhancement through a multimodal approach. We conducted neurological (Quantitative Electroencephalography), neuropsychological (Mindfulness Attention Awareness Scale-15), and behavioral (Stroop test) assessments before and after NF training on 36 healthy participants, divided into audiovisual (G1) and visual (G2) groups. Twelve NF training sessions were conducted on alternate days, each consisting of five subsessions, with pre- and post-NF baseline electroencephalographic evaluations using power spectral density. The pre-NF baseline was used for thresholding the NF session using the beta frequency band power. Two-way analysis of variance revealed a significant long-term effect of group (G1/G2) and state (before/after NF) on the behavioral and neuropsychological assessments, with G1 showing significantly higher Mindfulness Attention Awareness Scale-15 scores, higher Stroop scores, and lower Stroop reaction times for interaction effects. Moreover, unpaired t -tests to compare voxel-wise standardized low-resolution brain electromagnetic tomography images revealed higher activity of G1 in Brodmann area 40 due to NF training. Neurological assessments show that G1 had better improvement in immediate, short-, and long-term attention. The findings of this study offer a guide for the development of NF training protocols aimed at enhancing attention effectively.

Components of effective exergame-based training to improve cognitive functioning in middle-aged to older adults - A systematic review and meta-analysis

BACKGROUND

Exergame-based training is currently considered a more promising training approach than conventional physical and/or cognitive training.

OBJECTIVES

This study aimed to provide quantitative evidence on dose-response relationships of specific exercise and training variables (training components) of exergame-based training on cognitive functioning in middle-aged to older adults (MOA).

METHODS

We conducted a systematic review with meta-analysis including randomized controlled trials comparing the effects of exergame-based training to inactive control interventions on cognitive performance in MOA.

RESULTS

The systematic literature search identified 22,928 records of which 31 studies were included. The effectiveness of exergame-based training was significantly moderated by the following training components: body position for global cognitive functioning, the type of motor-cognitive training, training location, and training administration for complex attention, and exercise intensity for executive functions.

CONCLUSION

The effectiveness of exergame-based training was moderated by several training components that have in common that they enhance the ecological validity of the training (e.g., stepping movements in a standing position). Therefore, it seems paramount that future research focuses on developing innovative novel exergame-based training concepts that incorporate these (and other) training components to enhance their ecological validity and transferability to clinical practice. We provide specific evidence-based recommendations for the application of our research findings in research and practical settings and identified and discussed several areas of interest for future research.

PROSPERO REGISTRATION NUMBER

CRD42023418593; prospectively registered, date of registration: 1 May 2023.

Available rehabilitation technology with the potential to be incorporated into the clinical practice of physiotherapists: A systematic review

Background

The development of prototypes capable of intervening in the area of rehabilitation in physical therapy clinical practice activities that were previously carried out in a traditional way, that is, manually, demonstrates how technology is having an impact on professional careers such as physiotherapy.

Objective

The purpose of this study is to present a comprehensive examination of various technologies employed in the facilitation of patient rehabilitation, with a focus on their potential integration within the clinical practice of physical therapists.

Methods

We conducted a systematic search in four electronic databases (CINAHL, Embase, PEDro, and PubMed) for research on rehabilitation technologies. The eligible studies should demonstrate a clear utilization of technology in various aspects of the clinical approach to the rehabilitation process and have been published between 2000 and 2021 in either Portuguese or English.

Results

A total of 18 articles that satisfied the selection criteria were included in the study. The studies were classified into four distinct categories of rehabilitation technologies, which were determined by the specific characteristics of the technology employed and its integration with the therapeutic approach to rehabilitation. These categories include digital technologies, artificial intelligence and/or robotics, virtual technologies, and hybrid technologies.

Implications on Physiotherapy Practice

Rehabilitation technologies possess the capacity to effectively facilitate clinical activities performed by physical therapy professionals, including injury prevention, movement monitoring, and coordination of rehabilitation programs, with minimal or negligible intervention from the physical therapist. Further research is required to ascertain the precise capabilities of various technologies in collaborating with physiotherapists to deliver comprehensive care for patients' physical well-being, encompassing both therapeutic and preventive approaches.

Trial Registration

PROSPERO registration number CRD42020222288.

Computer gaming alters resting-state brain networks, enhancing cognitive and fluid intelligence in players: evidence from brain imaging-derived phenotypes-wide Mendelian randomization

The debate on whether computer gaming enhances players' cognitive function is an ongoing and contentious issue. Aiming to delve into the potential impacts of computer gaming on the players' cognitive function, we embarked on a brain imaging-derived phenotypes (IDPs)-wide Mendelian randomization (MR) study, utilizing publicly available data from a European population. Our findings indicate that computer gaming has a positive impact on fluid intelligence (odds ratio [OR] = 6.264, P = 4.361 × 10-10, 95% confidence interval [CI] 3.520-11.147) and cognitive function (OR = 3.322, P = 0.002, 95% CI 1.563-7.062). Out of the 3062 brain IDPs analyzed, only one phenotype, IDP NET100 0378, was significantly influenced by computer gaming (OR = 4.697, P = 1.10 × 10-5, 95% CI 2.357-9.361). Further MR analysis suggested that alterations in the IDP NET100 0378 caused by computer gaming may be a potential factor affecting fluid intelligence (OR = 1.076, P = 0.041, 95% CI 1.003-1.153). Our MR study lends support to the notion that computer gaming can facilitate the development of players' fluid intelligence by enhancing the connectivity between the motor cortex in the resting-state brain and key regions such as the left dorsolateral prefrontal cortex and the language center.

A review: effects of neurofeedback on patients with mild cognitive impairment (MCI), and Alzheimer's disease (AD)

Neurofeedback training (NFT) is a non-invasive method and has been shown to be effective for attention deficit/hyperactivity disorder (ADHD) and various psychiatric disorders. The aim of this paper is to evaluate the effectiveness of NFT for patients with Mild Cognitive Impairment (MCI) and Alzheimer's disease (AD) or Vascular Diseases (VD), so that we searched research articles from four databases, using the keywords neurofeedback, elderly, MCI, AD, VD, and dementia. As a result, 13 articles were identified regarding the effectiveness of NFT in patients with MCI and AD. Although each study differed in study design, training protocol, electroencephalogram (EEG) electrode placement, and reward and inhibition frequency bands, all were shown to enhance memory, attention, and other cognitive abilities. Additional well-designed, randomized studies with sufficient power are needed to further confirm the effectiveness of NFT.

Impact of Mobile Games-Aided Neurorehabilitation: A Systematic Literature Review

Neurological rehabilitation is a physician-supervised programme for individuals with nervous system diseases, injuries or disorders. Neurological rehabilitation, also known as neurorehabilitation, is part of the rehabilitation process that improves function, reduces severity and enhances a patient's well-being. Because neurological injuries occur in the brain, spine and nerves, affecting multiple body parts including organs, blood vessels, muscles and bones, rehabilitation requires a multidisciplinary approach. This study conducted a systematic literature review (SLR) on the use of mobile game in neurorehabilitation. The steps undertaken in the literature review included the collection, identification, categorisation, summarisation and synthesis of relevant studies in the research domain. A total of 50 related articles were reviewed. The study identified that the effects on cognitive skills, handgrip strength, memory, attention, visuospatial abilities, executive function tasks, motor functionality, and improvements in balance, visual perception, and functional mobility are impacts of the use of mobile games in neurological rehabilitation. Furthermore, several research challenges and recommendations for future research were identified.

Side of motor symptom onset predicts sustained attention deficits and motor improvements after attention training in Parkinson's disease

OBJECTIVE

Parkinson's disease (PD) side of motor symptom onset has been associated with distinct cognitive deficits; individuals with left-side onset (LPD) show more visuospatial impairments, whereas those with right-side onset (RPD) show more verbal impairments. Non-spatial attention is a critical cognitive ability associated with motor functioning that is right hemisphere lateralized but has not been characterized with regard to PD side of onset. We compared individuals with LPD and RPD on non-spatial attention tasks and examined differential responses to a 4-week sustained attention training program.

METHOD

Participants included 9 with LPD and 12 with RPD, who performed both brief and extended go/no-go continuous performance tasks and an attentional blink task. Participants also engaged in an at-home sustained attention training program, Tonic and Phasic Alertness Training (TAPAT), 5 days/week for 4 weeks. We assessed cognitive and motor symptoms before and after training, and after a 4-week no-contact period.

RESULTS

At baseline, participants with LPD exhibited worse performance than those with RPD on the extended continuous performance task, indicating specific deficits in sustaining attention. Poorer attention was associated with worse clinical motor scores. Notably, side of onset had a significant effect on clinical motor changes after sustained attention training, with only LPD participants improving after training, and 4/9 showing clinically meaningful improvements.

CONCLUSIONS

Compared to RPD, participants with LPD had poorer sustained attention pre-training and were more likely to improve on clinical motor functioning after sustained attention training. These findings support mechanistic differences between LPD and RPD and suggest potential differential treatment approaches.

Is it possible to prevent the progression of mild cognitive impairment through non-pharmacological treatments?

INTRODUCTION

Mild cognitive impairment produces slight cognitive and motor disturbances without affecting daily life during aging, however, if this symptomatology is not controlled, the speed of deterioration can increase, and even some cases of dementia can appear in the elderly population.

OBJECTIVE

To describe non-pharmacological therapies that seek to prevent, control and reduce the symptoms of mild cognitive impairment.

METHODS

An initial search was carried out in the databases of PubMed, Lilacs, EBSCO, ScienceDirect, Taylor & Francis and ProQuest. The results found were filtered through the PRISMA system and biases evaluated using the Cochrane Handbook for Systematic Reviews of Interventions.

RESULTS

Four categories of non-pharmacological therapies were created, using 50 articles found in the search, which contribute to controlling and improving cognitive and motor areas, in order to reduce the symptoms presented by mild cognitive impairment. The treatments have different methods, instruments and objectives, so that no meta-analysis of the studies could be performed. In addition, limitations related to the sample, the effectiveness of the results and the methodological quality were found.

CONCLUSIONS

It was found that non-pharmacological therapies prevent, improve and control the symptoms caused by mild cognitive impairment, however, it is necessary to carry out more studies with better methodologies to corroborate these results.

Feasibility, usability, and acceptance of "Brain-IT"-A newly developed exergame-based training concept for the secondary prevention of mild neurocognitive disorder: a pilot randomized controlled trial

Background

Exergames provide a promising new approach to implement simultaneous motor-cognitive training, which may support preventing the decline in cognitive functioning in older adults who have a mild neurocognitive disorder (mNCD).

Objectives

To evaluate feasibility, system usability, and acceptance of "Brain-IT", a newly developed training concept combining exergame-based motor-cognitive training and heart rate variability (HRV) guided resonance breathing for the secondary prevention of mNCD.

Methods

A pilot randomized controlled trial (RCT) with an allocation ratio of 2:1 (i.e., intervention:control) was conducted. The control group proceeded with usual care. The intervention group performed a 12-week training according to the "Brain-IT" training concept implemented with the "Senso Flex" (Dividat AG) exergaming system in addition to usual care. Feasibility and usability outcomes were analyzed using descriptive statistics. User acceptance was analyzed qualitatively and using Friedman analysis of variance (ANOVA), as well as Wilcoxon signed-rank tests.

Results

Eighteen participants (77.3 ± 9.8 years; 44.4% females) were included. On average, we recruited 2.2 participants per month, and 35.3% of the individuals contacted were included. The intervention group had an attrition rate of 20% and mean adherence and compliance rates of 85.0 and 84.1%, respectively. The mean system usability score, measured with the system usability scale, was 71.7. High levels of exergame enjoyment, an increase in exergame enjoyment, and internalization of training motivation with large effect sizes (p = 0.03, r = 0.75 and p = 0.03, r = 0.74, respectively), as well as acceptable perceived usefulness, were observed. Preliminary data on the effects of the "Brain-IT" training are promising.

Conclusion

The feasibility and usability of the "Brain-IT" training are acceptable. However, frequent occurrences of technical problems and difficulties in using the exergame training system were identified as barriers to performing the "Brain-IT" training. To optimize feasibility, either improvements or alternative solutions are required in the hardware and software of the exergame used to implement the "Brain-IT" training. The "Brain-IT" training itself was well-accepted by older adults who have mNCD. Therefore, the effectiveness of the "Brain-IT" training concept should be investigated in future studies.

Trial registration

clinicaltrials.gov/ct2/show/NCT04996654.

BCI-Walls: A robust methodology to predict if conscious EEG changes can be detected in the presence of artefacts

Brain computer interfaces (BCI) depend on reliable realtime detection of conscious EEG changes for example to control a video game. However, scalp recordings are contaminated with non-stationary noise, such as facial muscle activity and eye movements. This interferes with the detection process making it potentially unreliable or even impossible. We have developed a new methodology which provides a hard and measurable criterion if conscious EEG changes can be detected in the presence of non-stationary noise by requiring the signal-to-noise ratio of a scalp recording to be greater than the SNR-wall which in turn is based on the highest and lowest noise variances of the recording. As an instructional example, we have recorded signals from the central electrode Cz during eight different activities causing non-stationary noise such as playing a video game or reading out loud. The results show that facial muscle activity and eye-movements have a strong impact on the detectability of EEG and that minimising both eye-movement artefacts and muscle noise is essential to be able to detect conscious EEG changes.

The potential competency outcome of vigorous brain training game in the elderly: A systematic review

Background and Aims

The potential outcomes of vigorous brain training game in the elderly is questionable.

Methods

A systematic review of studies reporting the outcomes of brain training game under the PRISMA guideline was conducted using the PubMed database (1997-2022). The selection criteria were clinical studies published in English language.

Results

A total of 174 articles were identified by searching keywords. However, after screening the relation of the topic and methodology, 21 articles were included. The results of all studies showed positive outcomes after using the brain training game. Variation in the measurement tools were observed.

Conclusion

The brain training game showed a positive effect on the brain function. However, the confirmation studies with large populations and standard measurement tools are required for more validated results.

Effectiveness of an Individualized Exergame-Based Motor-Cognitive Training Concept Targeted to Improve Cognitive Functioning in Older Adults With Mild Neurocognitive Disorder: Study Protocol for a Randomized Controlled Trial

BACKGROUND

Simultaneous motor-cognitive training is considered promising for preventing the decline in cognitive functioning in older adults with mild neurocognitive disorder (mNCD) and can be highly motivating when applied in the form of exergaming. The literature points to opportunities for improvement in the application of exergames in individuals with mNCD by developing novel exergames and exergame-based training concepts that are specifically tailored to patients with mNCD and ensuring the implementation of effective training components.

OBJECTIVE

This study systematically explores the effectiveness of a newly developed exergame-based motor-cognitive training concept (called "Brain-IT") targeted to improve cognitive functioning in older adults with mNCD.

METHODS

A 2-arm, parallel-group, single-blinded randomized controlled trial with a 1:1 allocation ratio (ie, intervention: control), including 34 to 40 older adults with mNCD will be conducted between May 2022 and December 2023. The control group will proceed with the usual care provided by the (memory) clinics where the patients are recruited. The intervention group will perform a 12-week training intervention according to the "Brain-IT" training concept, in addition to usual care. Global cognitive functioning will be assessed as the primary outcome. As secondary outcomes, domain-specific cognitive functioning, brain structure and function, spatiotemporal parameters of gait, instrumental activities of daily living, psychosocial factors, and resting cardiac vagal modulation will be assessed. Pre- and postintervention measurements will take place within 2 weeks before starting and after completing the intervention. A 2-way analysis of covariance or the Quade nonparametric analysis of covariance will be computed for all primary and secondary outcomes, with the premeasurement value as a covariate for the predicting group factor and the postmeasurement value as the outcome variable. To determine whether the effects are substantive, partial eta-squared (η²_p) effect sizes will be calculated for all primary and secondary outcomes.

RESULTS

Upon the initial submission of this study protocol, 13 patients were contacted by the study team. Four patients were included in the study, 2 were excluded because they were not eligible, and 7 were being informed about the study in detail. Of the 4 included patients, 2 already completed all premeasurements and were in week 2 of the intervention period. Data collection is expected to be completed by December 2023. A manuscript of the results will be submitted for publication in a peer-reviewed open-access journal in 2024.

CONCLUSIONS

This study contributes to the evidence base in the highly relevant area of preventing disability because of cognitive impairment, which has been declared a public health priority by the World Health Organization.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05387057; https://clinicaltrials.gov/ct2/show/NCT05387057.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/41173.

Design Considerations for an Exergame-Based Training Intervention for Older Adults With Mild Neurocognitive Disorder: Qualitative Study Including Focus Groups With Experts and Health Care Professionals and Individual Semistructured In-depth Patient Interviews

BACKGROUND

Exergames have attracted growing interest in the prevention and treatment of neurocognitive disorders. The most effective exergame and training components (ie, exercise and training variables such as frequency, intensity, duration, or volume of training and type and content of specific exergame scenarios) however remain to be established for older adults with mild neurocognitive disorders (mNCDs). Regarding the design and development of novel exergame-based training concepts, it seems of crucial importance to explicitly include the intended users' perspective by adopting an interactive and participatory design that includes end users throughout different iterative cycles of development.

OBJECTIVE

This study aimed to determine the capabilities, treatment preferences, and motivators for the training of older adults with mNCD and the perspectives of individuals on training goals and settings and requirements for exergame and training components.

METHODS

A qualitative study including expert focus groups and individual semistructured in-depth patient interviews was conducted. Data were transcribed to a written format to perform qualitative content analysis using QCAmap software.

RESULTS

In total, 10 experts and health care professionals (80% females) and 8 older adults with mNCD (38% females; mean age 82.4, SD 6.2 years) were recruited until data saturation was observed.

CONCLUSIONS

The psychosocial consequences of patients' self-perceived cognitive deterioration might be more burdensome than the cognitive changes themselves. Older adults with mNCD prefer integrative forms of training (such as exergaming) and are primarily motivated by enjoyment or fun in exercising and the effectiveness of the training. Putting the synthesized perspectives of training goals, settings, and requirements for exergames and training components into context, our considerations point to opportunities for improvement in research and rehabilitation, either by adapting existing exergames to patients with mNCDs or by developing novel exergames and exergame-based training concepts specifically tailored to meet patient requirements and needs.

Real-time noise cancellation with deep learning

Biological measurements are often contaminated with large amounts of non-stationary noise which require effective noise reduction techniques. We present a new real-time deep learning algorithm which produces adaptively a signal opposing the noise so that destructive interference occurs. As a proof of concept, we demonstrate the algorithm's performance by reducing electromyogram noise in electroencephalograms with the usage of a custom, flexible, 3D-printed, compound electrode. With this setup, an average of 4dB and a maximum of 10dB improvement of the signal-to-noise ratio of the EEG was achieved by removing wide band muscle noise. This concept has the potential to not only adaptively improve the signal-to-noise ratio of EEG but can be applied to a wide range of biological, industrial and consumer applications such as industrial sensing or noise cancelling headphones.

Efficacy of Neuro-Feedback Training for PTSD Symptoms: A Systematic Review and Meta-Analysis

If the negative emotions experienced in life become trauma, they affect daily life. Neuro-feedback technology has recently been introduced as a treatment, but many different neuro-feedback protocols and methods exits. This study conducted a meta-analysis of neuro-feedback training for post-traumatic stress disorder (PTSD) symptoms to evaluate the effects of functional magnetic resonance imaging (fMRI) and electroencephalogram (EEG)-based neuro-feedback training. A search of PubMed, the Cochrane Library, Web of Science, Science Direct, and ClinicalTrials.gov was conducted from January 2011 to December 2021. The studies' quality was assessed using the Cochrane risk of bias tool and publication bias was assessed by Egger's regression test. Seven studies that met the inclusion criteria were used for the systematic review and meta-analysis. EEG was more effective than fMRI for PTSD symptoms, and the effect on PTSD symptoms was higher than on anxiety and depression. There was no difference in the effectiveness of the training sessions. Our findings showed that EEG-based neuro-feedback training was more helpful for training PTSD symptoms. Additionally, the methods were also shown to be valid for evaluating clinical PTSD diagnoses. Further research is needed to establish a gold standard protocol for the EEG-based neuro-feedback training (EEG-NFT) method for PTSD symptoms.

COVID-19 Long-Term Effects: Is There an Impact on the Simple Reaction Time and Alternative-Forced Choice on Recovered Patients?

A comparative single-evaluation cross-sectional study was performed to evaluate cognitive damage in post-COVID-19 patients. The psychophysics tests of Two-Alternative Forced Choice (2AFC) and Simple Reaction Time (SRT), under a designed virtual environment, were used to evaluate the cognitive processes of decision-making, visual attention, and information processing speed. The population under study consisted of 147 individuals, 38 controls, and 109 post-COVID patients. During the 2AFC test, an Emotiv EPOC+® headset was used to obtain EEG signals to evaluate their Focus, Interest, and Engagement metrics. Results indicate that compared to healthy patients or recovered patients from mild-moderate COVID-19 infection, patients who recovered from a severe-critical COVID infection showed a poor performance in different cognitive tests: decision-making tasks required higher visual sensitivity (p = 0.002), Focus (p = 0.01) and information processing speed (p < 0.001). These results signal that the damage caused by the coronavirus on the central nervous and visual systems significantly reduces the cognitive processes capabilities, resulting in a prevalent deficit of 42.42% in information processing speed for mild-moderate cases, 46.15% for decision-making based on visual sensitivity, and 62.16% in information processing speed for severe-critical cases. A psychological follow-up for patients recovering from COVID-19 is recommended based on our findings.

New treatment strategy for chronic low back pain with alpha wave neurofeedback

The lifetime prevalence of low back pain is 83%. Since there is a lack of evidence for therapeutic effect by cognitive behavioral therapy (CBT) or physical therapy (PT), it is necessary to develop objective physiological indexes and effective treatments. We conducted a prospective longitudinal study to evaluate the treatment effects of CBT, PT, and neurofeedback training (NFT) during alpha wave NFT. The early-chronic cases within 1 year and late-chronic cases over 1 year after the diagnosis of chronic low back pain were classified into six groups: Controls, CBTs, PTs, NFTs, CBT-NFTs, PT-NFTs. We evaluated the difference in EEG, psychosocial factors, scores of low back pain before/after the intervention. Therapeutic effect was clearly more effective in the early-chronic cases. We found that the intensity of alpha waves increased significantly after therapeutic intervention in the NFT groups, but did not have the main effect of reducing low back pain; the interaction between CBT and NFT reduced low back pain. Factors that enhance therapeutic effect are early intervention, increased alpha waves, and self-efficacy due to parallel implementation of CBT/PT and NFT. A treatment protocol in which alpha wave neurofeedback training is subsidiarily used with CBT or PT should be developed in the future.

Methodology and preliminary data on feasibility of a neurofeedback protocol to improve visual attention to letters in mild Alzheimer's disease

Background

Brain-computer interface (BCI) systems are controlled by users through neurophysiological input for a variety of applications, including communication, environmental control, and motor rehabilitation. Although individuals with severe speech and physical impairment are the primary users of this technology, BCIs have emerged as a potential tool for broader populations, including delivering cognitive training/interventions with neurofeedback (NFB).

Methods

This paper describes the development and preliminary testing of a protocol for use of a BCI system with NFB as an intervention for people with mild Alzheimer's disease (AD). The intervention focused on training visual attention and language skills, as AD is often associated with functional impairments in both. This funded pilot study called for enrolling five participants with mild AD in a six-week BCI EEG-based NFB intervention that followed a four-to-seven-week baseline phase. While two participants completed the study, the remaining three participants could not complete the intervention phase because of COVID-19 restrictions.

Results

Preliminary pilot results suggested: (1) participants with mild AD were able to participate in a study with multiple assessments per week and complete all outcome measures, (2) most outcome measures were reliable during the baseline phase, and (3) all participants with mild AD learned to operate a BCI spelling system with training.

Conclusions

Although preliminary results demonstrate practical feasibility to deliver NFB intervention using a BCI to adults with AD, completion of the protocol in its entirety with more participants is needed to further assess whether implementing NFB-based cognitive intervention is justified by functional treatment outcomes.

Trial registration

This study was registered with ClinicalTrials.gov (NCT03790774).

Application of Serious Games in Health Care: Scoping Review and Bibliometric Analysis

Background

Serious games (SGs) as one kind of intervention that can improve the level of knowledge and change behavior to affect health outcomes has been increasingly applied in health care.

Objective

Analyze hotspots and trends of the application of SGs in health care and provide reference and direction for further research in the future.

Methods

The Web of Science (WoS) Core Collection database was used for extracting the literature on SGs in health care for the period from the database established to 11 October, 2021. Scoping review and bibliometric analysis were used to deeply analyze and visualize countries, categories of studies, annual study output, cited authors, cited journals, cited articles, and keywords of healthcare field.

Results

A total of 1,322 articles were retrieved, then every articles' title and abstract were read one by one, and 795 articles were included after screening with an exponential increase in publication volume. The United States of America made the greatest contribution to global publications regarding SGs in health care. From the total, 20.8% of articles fall under the category of health care sciences services. The target groups were mainly concentrated in children (18.0%), youth (13.8%), the elderly (10.9%), adolescents (9.1%), and adults (3.4%). Baranowski T (n = 103 citations) is the most influential author, followed by Kato PM (n = 73 citations) and Desmet A (n = 58 citations). The top three cited journals were "Plos One" (n = 268 citations), "Games for Health Journal" (n = 209 citations), and "Journal of Medical Internet Research" (n = 197 citations), and the top three cited articles were "A meta-analysis of serious digital games for healthy lifestyle promotion," "A Systematic Review of Serious Games in Training Health Care Professionals," and "Video game training enhances cognitive control in older adults." More and more studies focus on specific age groups, such as children, adolescents, and the elderly. The research hotspots and trends included "rehabilitation," "medical education," and "design."

Conclusions

The application of SGs in health care remains important areas for future research. "Rehabilitation," "medical education," and "design" reflected the latest research hotpots and future trends.

Sharpening Working Memory With Real-Time Electrophysiological Brain Signals: Which Neurofeedback Paradigms Work?

Growing evidence supports the idea that the ultimate biofeedback is to reward sensory pleasure (e.g., enhanced visual clarity) in real-time to neural circuits that are associated with a desired performance, such as excellent memory retrieval. Neurofeedback is biofeedback that uses real-time sensory reward to brain activity associated with a certain performance (e.g., accurate and fast recall). Working memory is a key component of human intelligence. The challenges are in our current limited understanding of neurocognitive dysfunctions as well as in technical difficulties for closed-loop feedback in true real-time. Here we review recent advancements of real time neurofeedback to improve memory training in healthy young and older adults. With new advancements in neuromarkers of specific neurophysiological functions, neurofeedback training should be better targeted beyond a single frequency approach to include frequency interactions and event-related potentials. Our review confirms the positive trend that neurofeedback training mostly works to improve memory and cognition to some extent in most studies. Yet, the training typically takes multiple weeks with 2-3 sessions per week. We review various neurofeedback reward strategies and outcome measures. A well-known issue in such training is that some people simply do not respond to neurofeedback. Thus, we also review the literature of individual differences in psychological factors e.g., placebo effects and so-called "BCI illiteracy" (Brain Computer Interface illiteracy). We recommend the use of Neural modulation sensitivity or BCI insensitivity in the neurofeedback literature. Future directions include much needed research in mild cognitive impairment, in non-Alzheimer's dementia populations, and neurofeedback using EEG features during resting and sleep for memory enhancement and as sensitive outcome measures.

One-Year Follow-Up of Healthy Older Adults with Electroencephalographic Risk for Neurocognitive Disorder After Neurofeedback Training

Background:

In healthy older adults, excess theta activity is an electroencephalographic (EEG) predictor of cognitive impairment. In a previous study, neurofeedback (NFB) treatment reinforcing reductions theta activity resulted in EEG reorganization and cognitive improvement.

Objective:

To explore the clinical applicability of this NFB treatment, the present study performed a 1-year follow-up to determine its lasting effects.

Methods:

Twenty seniors with excessive theta activity in their EEG were randomly assigned to the experimental or control group. The experimental group received an auditory reward when the theta absolute power (AP) was reduced. The control group received the reward randomly.

Results:

Both groups showed a significant decrease in theta activity at the training electrode. However, the EEG results showed that only the experimental group underwent global changes after treatment. These changes consisted of delta and theta decreases and beta increases. Although no changes were found in any group during the period between the posttreatment evaluation and follow-up, more pronounced theta decreases and beta increases were observed in the experimental group when the follow-up and pretreatment measures were compared. Executive functions showed a tendency to improve two months after treatment which became significant one year later.

Conclusion:

These results suggest that the EEG and behavioral benefits of this NFB treatment persist for at least one year, which adds up to the available evidence contributing to identifying factors that increase its efficacy level. The relevance of this study lies in its prophylactic features of addressing a clinically healthy population with EEG risk of cognitive decline.

[Effectiveness of brain-computer interfaces and cognitive training using computer technologies in restoring cognitive functions in patients after stroke]

OBJECTIVE

To study the effectiveness of brain-computer interfaces (BCI) and cognitive training using computer technologies in restoring cognitive functions in poststroke patients.

MATERIAL AND METHODS

Thirty-four stroke patients (mean age 59.3±10.8 years) with stroke duration of 5.1±4.7 months, were included. To assess the effectiveness of treatment, patients before and after treatment were tested using memorization of words according to the method of Luria A.R. «10 words», the Montreal Cognitive Assessment Scale (MoCA), the Clock Drawing Test (CDT). All patients received standard rehabilitation therapy (exercise therapy, physiotherapy, sessions with a speech therapist-neuropsychologist). Patients of the first group additionally received training on the «Neurochat» complex, patients of the second group - on the «Exokist-2» complex, patients of the third group - cognitive training according to standard programs using computer technology and visual material.

RESULTS

Patients of the three groups showed a significant improvement in the total MoCA score: in the 1^st and 2^nd groups - p<0.01, in the 3^rd group - p<0.05. According to CDT, there was a significant change in the 2^nd group (p=0.018). The Luria method «10 words» revealed an improvement in memory in all groups (p<0.01, p<0.05), being more pronounced in the 1^st and 2^nd groups.

CONCLUSION

The effectiveness of BCI in restoring cognitive functions in patients after a stroke in comparison with cognitive training without BCI has been demonstrated. However, there are reasons to believe that various BCIs have a specific effect on cognitive functions and have their own target group.

Effects and Feasibility of a Memory Exergame Training in Older Adults: A Randomized Controlled Trial

Objective: The aim of the study is to assess the feasibility, sustainability, and effectiveness of task-specific memory exergame training on motor-cognitive performance in older adults. Materials and Methods: Fifty older adults (age: 78.8 ± 7.0 years) participated in a randomized controlled trial with a 10-week intervention and 3-month follow-up period. Both the intervention group (IG: n = 29) and control group (CG: n = 21) underwent a once-weekly exercise program, including strength and balance exercises, while the IG performed an additional exergame training, combining dynamic balance with visuospatial memory tasks. Outcome measures were completion time for distinct levels of memory exergame tasks without (condition 1) and with procedural support (condition 2) and (sub)-total game scores documented by a game-specific assessment strategy. Results: Significant improvements in the IG compared with the CG over the intervention period were found for completion times in most of the analyzed levels of condition 1 (P < 0.001-0.047; η_p² = 0.238-0.335) and one level of condition 2 (P < 0.001, η_p² = 0.267), for the subtotal game score of condition 1 (P = 0.002; η_p² = 0.186), and for the total game score (P = 0.005; η_p² = 0.162). Improvements were partially sustained 3 months after training cessation (P = 0.008-0.039, η_p² = 0.095-0.174). Completion rates for initial levels were 86%-98%. No clinical events or safety issues were observed during the training. Conclusion: The study demonstrates that additional memory exergame training effectively, and sustainably, improves performance in complex motor-cognitive tasks involving dynamic balance and visuospatial memory in older adults.

A Novel Game-Based Intelligent Test for Detecting Elderly Cognitive Function Impairment

PURPOSES

This research explores the game-based intelligent test (GBIT), predicts the possibilities of Mini-Mental State Examination (MMSE) scores and the risk of cognitive impairment, and then verifies GBIT as one of the reliable and valid cognitive assessment tools.

METHODS

This study recruited 117 elderly subjects in Taiwan (average age is 79.92 ± 8.68, average height is 156.91 ± 8.01, average weight is 59.14 ± 9.67, and average MMSE score is 23.33 ± 6.16). A multiple regression model was used to analyze the GBIT parameters of the elderly's reaction, attention, coordination, and memory to predict their MMSE performance. The binary logistic regression was then utilized to predict their risk of cognitive impairment. The statistical significance level was set as α = 0.05.

RESULTS

Multiple regression analysis showed that gender, the correct number of reactions, and the correct number of memory have a significantly positive predictive power on MMSE of the elderly (F = 37.60, R 2 = 0.69, and p < 0.05). Binary logistic regression analysis noted that the correct average number of reactions falls by one question, and the ratio of cognitive dysfunction risk increases 1.09 times (p < 0.05); the correct average number of memory drops by one question, the ratio of cognitive dysfunction risk increases 3.76 times (p < 0.05), and the overall model predictive power is 88.20% (sensitivity: 84.00%; specificity: 92.30%).

CONCLUSIONS

This study verifies that GBIT is reliable and can effectively predict the cognitive function and risk of cognitive impairment in the elderly. Therefore, GBIT can be used as one of the feasible tools for evaluating older people's cognitive function.

Effectiveness of psychosocial interventions among older adults with mild cognitive impairment: a systematic review and meta-analysis

OBJECTIVES

This review aimed to examine available evidence concerning the effectiveness of psychosocial interventions in improving memory, executive function, depression and activities of daily living (ADL) in older adults with MCI.

METHODS

Eight electronic databases were used to conduct a comprehensive literature search for published and unpublished studies. A primary outcome was cognitive function, including memory and executive function. Secondary outcomes were depression and ADL. Two researchers independently appraised quality of included studies and extracted data. Meta-analysis, heterogeneity test, subgroup analysis and sensitivity analyses were performed.

RESULTS

Ten studies (out of 1,265 records) were included in this review. Psychosocial interventions contributed to a significant improvement in memory, not executive function, depression and ADL. Subgroup analyses suggested that interventions with a longer duration, more therapeutic sessions, and individual format had larger effect sizes. Strategies found to enhance memory entailed behavior modification and activation, memory training, visual imagery, storytelling, memory aids, journaling, and exercise.

CONCLUSION

Healthcare providers may offer psychosocial interventions to client with MCI in clinical settings. Higher quality trials should be conducted to increase solid evidence in this domain.

Investigation of combined treatment of acupuncture and neurofeedback for improving cognitive function in mild neurocognitive disorder: A randomized, assessor-blind, pilot study

BACKGROUND

Mild neurocognitive disorder (MND) is an intermediate state that can progress to dementia, and the cognitive reserve of MND is an important task in preventing dementia. Acupuncture and neurofeedback (NF) training have been used to improve cognitive function and treat MND or dementia, but their effectiveness remains controversial. In this trial, we will evaluate the efficacy and safety of combined NF-acupuncture treatment in comparison with single acupuncture treatment.

METHODS AND DESIGN

This study is a randomized, assessor-blind, pilot trial. It is designed in accordance with the Standards for Reporting Interventions in Controlled Trials of Acupuncture. A total of 44 MND participants who meet the inclusion and exclusion criteria will be enrolled, and each will be randomly assigned to 1 of 2 groups of 22 subjects. Each subject will visit 24 times over 12 weeks and receive either acupuncture or NF-acupuncture combined treatment. At visit 25 (week 13), a follow-up evaluation will be performed, and then the investigator will analyze the results. The primary outcome is defined by the Korean version of the Montreal Cognitive Assessment score from screening to visit 25. The secondary outcome includes the following: change in Alzheimer Disease Assessment Scale-Cognitive, the Korean version of the Beck Depression Inventory, Body Awareness Questionnaire, delayed matching to sample task scores, and functional near-infrared spectroscopy values, from visit 1 to visit 25; heart rate variability values from visit 1 to visit 5, visit 9, visit 13, visit 21, visit 25; breath per minute values from visit 1 to visit 1 to 25.

DISCUSSION

We will evaluate the effectiveness and safety of combined NF-acupuncture therapy, and expect that it will serve as the basis for the use of NF together with acupuncture in the clinical setting.

TRIAL REGISTRATION NUMBER

KCT0004972 (registered in Clinical Research Information Service of the Republic of Korea, https://cris.nih.go.kr/cris/search/detailSearch.do/16239).

EEG-neurofeedback and executive function enhancement in healthy adults: A systematic review

Electroencephalographic (EEG)-neurofeedback training (NFT) is a promising technique that supports individuals in learning to modulate their brain activity to obtain cognitive and behavioral improvements. EEG-NFT is gaining increasing attention for its potential "peak performance" applications on healthy individuals. However, evidence for clear cognitive performance enhancements with healthy adults is still lacking. In particular, whether EEG-NFT represents an effective technique for enhancing healthy adults' executive functions is still controversial. Therefore, the main objective of this systematic review is to assess whether the existing EEG-NFT studies targeting executive functions have provided reliable evidence for NFT effectiveness. To this end, we conducted a qualitative analysis of the literature since the limited number of retrieved studies did not allow us meta-analytical comparisons. Moreover, a second aim was to identify optimal frequencies as NFT targets for specifically improving executive functions. Overall, our systematic review provides promising evidence for NFT effectiveness in boosting healthy adults' executive functions. However, more rigorous NFT studies are required in order to overcome the methodological weaknesses that we encountered in our qualitative analysis.

Is It Possible to Prevent the Progression of Mild Cognitive Impairment Through Non-Pharmacological Treatments?

INTRODUCTION

Mild cognitive impairment produces slight cognitive and motor disturbances without affecting daily life during aging, however, if this symptomatology is not controlled, the speed of deterioration can increase, and even some cases of dementia can appear in the elderly population.

OBJECTIVE

To describe non-pharmacological therapies that seek to prevent, control and reduce the symptoms of mild cognitive impairment.

METHODS

An initial search was carried out in the databases of PubMed, Lilacs, EBSCO, ScienceDirect, Taylor & Francis and ProQuest. The results found were filtered through the PRISMA system and biases evaluated using the Cochrane Handbook for Systematic Reviews of Interventions.

RESULTS

Four categories of non-pharmacological therapies were created, using 50 articles found in the search, which contribute to controlling and improving cognitive and motor areas, in order to reduce the symptoms presented by mild cognitive impairment. The treatments have different methods, instruments and objectives, so that no meta-analysis of the studies could be performed. In addition, limitations related to the sample, the effectiveness of the results and the methodological quality were found.

CONCLUSIONS

It was found that non-pharmacological therapies prevent, improve and control the symptoms caused by mild cognitive impairment, however, it is necessary to carry out more studies with better methodologies to corroborate these results.

Evidence for a Specific Association Between Sustained Attention and Gait Speed in Middle-to-Older-Aged Adults

Although cognitive decline has previously been associated with mobility limitations and frailty, the relationship between sustained attention and gait speed is incompletely characterized. To better quantify the specificity of the sustained attention and gait speed association, we examined the extent to which this relationship is unique rather than accounted for by executive functioning and physical health characteristics. 58 middle-to-older-aged community-dwelling adults without overt evidence of cognitive impairment (45-90 years old; 21 females) participated in the study. Each participant completed a 4-meter gait speed assessment and validated neuropsychological tests to examine various domains of executive functioning including working memory (i.e., Digit Span), inhibitory control (i.e., D-KEFS Color-Word Interference), and task switching (i.e., D-KEFS Number/Letter Switching). Multiple physical and vascular risk factors were also evaluated. Sustained attention was assessed using the gradual onset continuous performance task (gradCPT), a well-validated go/no-go sustained attention task. A series of linear regression models were used to examine how different aspects of cognition, including sustained attention and traditional measures of executive functioning, related to gait speed while controlling for a variety of physical and vascular risk factors. Among all predictors, gradCPT accuracy explained the most variance in gait speed (R 2 = 0.19, p < 0.001) and was the only significant predictor (β = 0.35, p = 0.01) when accounting for executive functioning and other physical and vascular risk factors. The present results indicate that sustained attention may be uniquely sensitive and mechanistically linked to mobility limitations in middle-to-older adults.

Brain Exercising Games With Consumer-Grade Single-Channel Electroencephalogram Neurofeedback: Pre-Post Intervention Study

Background

The aging population is one of the major challenges affecting societies worldwide. As the proportion of older people grows dramatically, so does the number of age-related illnesses such as dementia-related illnesses. Preventive care should be emphasized as an effective tool to combat and manage this situation.

Objective

The aim of this pilot project was to study the benefits of using neurofeedback-based brain training games for enhancing cognitive performance in the elderly population. In particular, aiming for practicality, the training games were designed to operate with a low-cost consumer-grade single-channel electroencephalogram (EEG) headset that should make the service scalable and more accessible for wider adoption such as for home use.

Methods

Our training system, which consisted of five brain exercise games using neurofeedback, was serviced at 5 hospitals in Thailand. Participants were screened for cognitive levels using the Thai Mental State Examination and Montreal Cognitive Assessment. Those who passed the criteria were further assessed with the Cambridge Neuropsychological Test Automated Battery (CANTAB) computerized cognitive assessment battery. The physiological state of the brain was also assessed using 16-channel EEG. After 20 sessions of training, cognitive performance and EEG were assessed again to compare pretraining and posttraining results.

Results

Thirty-five participants completed the training. CANTAB results showed positive and significant effects in the visual memory (delayed matching to sample [percent correct] P=.04), attention (median latency P=.009), and visual recognition (spatial working memory [between errors] P=.03) domains. EEG also showed improvement in upper alpha activity in a resting state (open-eyed) measured from the occipital area (P=.04), which similarly indicated improvement in the cognitive domain (attention).

Conclusions

Outcomes of this study show the potential use of practical neurofeedback-based training games for brain exercise to enhance cognitive performance in the elderly population.

EEG-Based Closed-Loop Neurofeedback for Attention Monitoring and Training in Young Adults

Attention is an important mechanism for young adults, whose lives largely involve interacting with media and performing technology multitasking. Nevertheless, the existing studies related to attention are characterized by low accuracy and poor attention levels in terms of attention monitoring and inefficiency during attention training. In this paper, we propose an improved random forest- (IRF-) algorithm-based attention monitoring and training method with closed-loop neurofeedback. For attention monitoring, an IRF classifier that uses grid search optimization and multiple cross-validation to improve monitoring accuracy and performance is utilized, and five attention levels are proposed. For attention training, we develop three training modes with neurofeedback corresponding to sustained attention, selective attention, and focus attention and apply a self-control method with four indicators to validate the resulting training effect. An offline experiment based on the Personal EEG Concentration Tasks dataset and an online experiment involving 10 young adults are conducted. The results show that our proposed IRF-algorithm-based attention monitoring approach achieves an average accuracy of 79.34%, thereby outperforming the current state-of-the-art algorithms. Furthermore, when excluding familiarity with the game environment, statistically significant performance improvements (p < 0.05) are achieved by the 10 young adults after attention training, which demonstrates the effectiveness of the proposed serious games. Our work involving the proposed method of attention monitoring and training proves to be reliable and efficient.

Neurofeedback and the Aging Brain: A Systematic Review of Training Protocols for Dementia and Mild Cognitive Impairment

Dementia describes a set of symptoms that occur in neurodegenerative disorders and that is characterized by gradual loss of cognitive and behavioral functions. Recently, non-invasive neurofeedback training has been explored as a potential complementary treatment for patients suffering from dementia or mild cognitive impairment. Here we systematically reviewed studies that explored neurofeedback training protocols based on electroencephalography or functional magnetic resonance imaging for these groups of patients. From a total of 1,912 screened studies, 10 were included in our final sample (N = 208 independent participants in experimental and N = 81 in the control groups completing the primary endpoint). We compared the clinical efficacy across studies, and evaluated their experimental designs and reporting quality. In most studies, patients showed improved scores in different cognitive tests. However, data from randomized controlled trials remains scarce, and clinical evidence based on standardized metrics is still inconclusive. In light of recent meta-research developments in the neurofeedback field and beyond, quality and reporting practices of individual studies are reviewed. We conclude with recommendations on best practices for future studies that investigate the effects of neurofeedback training in dementia and cognitive impairment.

The utility and cultural specificity of cognitive-based interventions in preventing cognitive decline among healthy older adults in Asia: A systematic review

BACKGROUND

The effects of aging and its associated cognitive decline is particularly acute in Asia given the exponential growth of older adults as a proportion of the population as a whole. Many structured cognitive interventions have been proposed to prevent the cognitive decline typically seen in older age, but their utility as a viable means of achieving these goals is questionable.

OBJECTIVES

To summarize and synthesize evidence on the utility and methodological quality of cognitive-based interventions on cognitive performance and associated secondary outcomes among healthy older adults in Asia, as well as novel, culture-specific components of cognitive interventions across the region.

DATA SOURCES

The PubMed/Medline, Web of Science, Scopus, and ScienceDirect databases were searched through May 2020.

ELIGIBILITY

Studies including individuals aged 60 years and above, who had no previous history of physical and/or mental illness. Few restrictions placed on intervention design, duration and mode of delivery, provided that participants were randomized to study conditions, and intervention included components addressing at least one cognitive domain.

RESULTS

A total of 17 studies from six countries met the eligibility criteria and were included in the final review. Evidence from those studies indicated that cognitive interventions may be most effective when the design and aims were directed towards improvement in specific cognitive domains, but evidence regarding long-term effectiveness in preventing progression to clinical-level cognitive deficits is still unclear. Several studies highlighted culture-specific activities as components of their interventions, though these will need to be further outlined and standardized clearly in future research.

Musical Auditory Alpha Wave Neurofeedback: Validation and Cognitive Perspectives

Neurofeedback through visual, auditory, or tactile sensations improves cognitive functions and alters the activities of daily living. However, some people, such as children and the elderly, have difficulty concentrating on neurofeedback for a long time. Constant stressless neurofeedback for a long time may be achieved with auditory neurofeedback using music. The primary purpose of this study was to clarify whether music-based auditory neurofeedback increases the power of the alpha wave in healthy subjects. During neurofeedback, white noise was superimposed on classical music, with the noise level inversely correlating with normalized alpha wave power. This was a single-blind, randomized control crossover trial in which 10 healthy subjects underwent, in an assigned order, normal and random feedback (NF and RF), either of which was at least 4 weeks long. Cognitive functions were evaluated before, between, and after each neurofeedback period. The secondary purpose was to assess neurofeedback-induced changes in cognitive functions. A crossover analysis showed that normalized alpha-power was significantly higher in NF than in RF; therefore, music-based auditory neurofeedback facilitated alpha wave induction. A composite category-based analysis of cognitive functions revealed greater improvements in short-term memory in subjects whose alpha-power increased in response to NF. The present study employed a long period of auditory alpha neurofeedback and achieved successful alpha wave induction and subsequent improvements in cognitive functions. Although this was a pilot study that validated a music-based alpha neurofeedback system for healthy subjects, the results obtained are encouraging for those with difficulty in concentrating on conventional alpha neurofeedback.

Trial registration: 2018077NI, date of registration: 2018/11/27

Do Older and Young Adults Learn to Integrate Geometry While Navigating in an Environment of a Serious Game?

We evaluated the outcomes of an intervention using a serious game designed to be played on iPads for improving spatial reorientation by training users to integrate geometry of the environment, instead of relying solely on featural cues. Using data logged online through a clinical study of using this game, the effect of training among 16 older adults (69.3 ± 6.4 years, 4 males), who played the game repeatedly (self-administered) over a period of 8 weeks, was investigated. The game contains a hexagonal room with 3 objects, textured walls, and grids on the floor, which are removed one by one as the participant played the game. In each level, the room also rotates such that the viewpoint of the user is different from that of the previous level. Participants cannot play a higher level unless they make no mistake during the trials of the lower test level. In addition to data of older adults available from that clinical trial, we recruited 16 young adults (27.3 ± 5.6 years, 4 males) to play the game for 5 sessions and compared their results with those of the older adults. We evaluated the error type made in each test level and the scores for each session among older adults. Further, we compared the frequency of each error type between young and older adults during the test levels that a landmark adjacent to the target was removed over the first 5 sessions. The results of older adults’ performance suggest they learned to make fewer mistakes over the sessions. Also, both young and older adults learned to integrate the geometrical cues rather than relying on the landmark cue adjacent to the target to find the target. Overall, the results indicate the designed hexagonal room game can enhance spatial cognition among all age groups of adults.

Visual-Electrotactile Stimulation Feedback to Improve Immersive Brain-Computer Interface Based on Hand Motor Imagery

In the aging society, the number of people suffering from vascular disorders is rapidly increasing and has become a social problem. The death rate due to stroke, which is the second leading cause of global mortality, has increased by 40% in the last two decades. Stroke can also cause paralysis. Of late, brain-computer interfaces (BCIs) have been garnering attention in the rehabilitation field as assistive technology. A BCI for the motor rehabilitation of patients with paralysis promotes neural plasticity, when subjects perform motor imagery (MI). Feedback, such as visual and proprioceptive, influences brain rhythm modulation to contribute to MI learning and motor function restoration. Also, virtual reality (VR) can provide powerful graphical options to enhance feedback visualization. This work aimed to improve immersive VR-BCI based on hand MI, using visual-electrotactile stimulation feedback instead of visual feedback. The MI tasks include grasping, flexion/extension, and their random combination. Moreover, the subjects answered a system perception questionnaire after the experiments. The proposed system was evaluated with twenty able-bodied subjects. Visual-electrotactile feedback improved the mean classification accuracy for the grasping (93.00%  $\pm$  3.50%) and flexion/extension (95.00%  $\pm$  5.27%) MI tasks. Additionally, the subjects achieved an acceptable mean classification accuracy (maximum of 86.5%  $\pm$  5.80%) for the random MI task, which required more concentration. The proprioceptive feedback maintained lower mean power spectral density in all channels and higher attention levels than those of visual feedback during the test trials for the grasping and flexion/extension MI tasks. Also, this feedback generated greater relative power in the $\mu$ -band for the premotor cortex, which indicated better MI preparation. Thus, electrotactile stimulation along with visual feedback enhanced the immersive VR-BCI classification accuracy by 5.5% and 4.5% for the grasping and flexion/extension MI tasks, respectively, retained the subject’s attention, and eased MI better than visual feedback alone.

Serious video games and virtual reality for prevention and neurorehabilitation of cognitive decline because of aging and neurodegeneration

PURPOSE OF REVIEW

Cognitive decline because of aging and neurodegeneration has become increasingly prevalent. This calls for the implementation of efficacious, motivating, standardized and widely available cognitive interventions for the elderly. In this context, serious video games and virtual reality may represent promising approaches. Here, we review recent research on their potential for cognitive prevention and neurorehabilitation of age-related cognitive decline and mild cognitive impairment (MCI).

RECENT FINDINGS

The majority of currently available data in this evolving domain lacks the methodological quality to draw reliable conclusions on the potential of novel technology for cognitive training in older people. However, single well designed randomized controlled trials have reported promising effects of cognitive interventions involving serious video games and virtual reality. The cognitive benefits of exergames promoting physical exercise with and without combined cognitive training remain unclear.

SUMMARY

The immersion into stimulating and motivating environments along with training content based on neuroscientific and neuropsychological models may represent a significant advance as compared with conventional computerized cognitive training. Additional research with sound methodology including sufficient sample sizes, active control groups and meaningful outcome measures of everyday function is needed to elucidate the potential of serious video games and virtual reality in multifactorial neurorehabilitation of cognitive decline in aging and neurodegeneration.

Z-score neurofeedback, heart rate variability biofeedback, and brain coaching for older adults with memory concerns

BACKGROUND

The three-month, multi-domain Memory Boot Camp program incorporates z-score neurofeedback (NFB), heart rate variability (HRV) biofeedback, and one-on-one coaching to teach memory skills and encourage behavior change in diet, sleep, physical fitness, and stress reduction.

OBJECTIVE

This prospective trial evaluates the Memory Boot Camp program for adults ages 55 to 85 with symptoms of Mild Cognitive Impairment (MCI) and subjective memory complaints.

METHODS

Participants were evaluated via the Montreal Cognitive Assessment (MoCA), NeuroTrax Global Cognitive Score, measures of anxiety, depression, sleep, quality of life, quantitative electroencephalography (QEEG), and HRV parameters at four timepoints: baseline, pre-program, post-program, and follow-up. The trial included a three-month waiting period between baseline and pre-program, such that each participant acted as their own control, and follow-up took place six months after completion of the program.

RESULTS

Participants' MoCA scores and self-reported measures of anxiety, depression, sleep quality, and quality of life improved after treatment, and these changes were maintained at follow-up. Physiological changes in HRV parameters after treatment were not significant, however, breathing rate and QEEG parameters were improved at post-program and maintained at follow-up. Finally, participants' improvement in MoCA score over the treatment period was correlated with their improvement in two brain oscillation parameters targeted by the z-score NFB protocol: relative power of delta and relative power of theta.

CONCLUSIONS

Trial results suggest that the Memory Boot Camp program is a promising treatment strategy for older adults with symptoms of MCI and subjective memory complaints.

Brain Computer Interfaces for Improving the Quality of Life of Older Adults and Elderly Patients

All people experience aging, and the related physical and health changes, including changes in memory and brain function. These changes may become debilitating leading to an increase in dependence as people get older. Many external aids and tools have been developed to allow older adults and elderly patients to continue to live normal and comfortable lives. This mini-review describes some of the recent studies on cognitive decline and motor control impairment with the goal of advancing non-invasive brain computer interface (BCI) technologies to improve health and wellness of older adults and elderly patients. First, we describe the state of the art in cognitive prosthetics for psychiatric diseases. Then, we describe the state of the art of possible assistive BCI applications for controlling an exoskeleton, a wheelchair and smart home for elderly people with motor control impairments. The basic age-related brain and body changes, the effects of age on cognitive and motor abilities, and several BCI paradigms with typical tasks and outcomes are thoroughly described. We also discuss likely future trends and technologies to assist healthy older adults and elderly patients using innovative BCI applications with minimal technical oversight.

SMR/Theta Neurofeedback Training Improves Cognitive Performance and EEG Activity in Elderly With Mild Cognitive Impairment: A Pilot Study

Background: Neurofeedback (NF) training, as a method of self-regulation of brain activity, may be beneficial in elderly patients with mild cognitive impairment (MCI). In this pilot study, we investigated whether a sensorimotor (SMR)/theta NF training could improve cognitive performance and brain electrical activity in elderly patients with MCI. Methods: Twenty elderly patients with MCI were assigned to 20 consecutive sessions of sensorimotor (SMR)/theta NF training, during 10 weeks, on a basis of two sessions each week. Neuropsychological assessments and questionnaires, as well as electroencephalogram (EEG), were performed and compared between baseline (T0), after the last NF training session at 10 weeks (T1), and 1-month follow-up (T2). Results: Repeated measures ANOVA revealed that from baseline to post-intervention, participants showed significant improvement in the Montreal cognitive assessment (MoCa, F = 4.78; p = 0.012), the delayed recall of the Rey auditory verbal learning test (RAVLT, F = 3.675; p = 0.032), the Forward digit span (F = 13.82; p < 0.0001), the Anxiety Goldberg Scale (F = 4.54; p = 0.015), the Wechsler Adult Intelligence Score-Fourth Edition (WAIS-IV; F = 24.75; p < 0.0001), and the Mac Nair score (F = 4.47; p = 0.016). EEG theta power (F = 4.44; p = 0.016) and alpha power (F = 3.84; p = 0.027) during eyes-closed resting-state significantly increased after the NF training and showed sustained improvement at a 1-month follow-up. Conclusion: Our results suggest that NF training could be effective to reduce cognitive deficits in elderly patients with MCI and improve their EEG activity. If these findings are confirmed by randomized controlled studies with larger samples of patients, NF could be seen as a useful non-invasive, non-pharmacological tool for preventing further decline, rehabilitation of cognitive function in the elderly. Clinical Trial Registration: This pilot study was a preliminary step before the trial registered in www.ClinicalTrials.gov, under the number of NCT03526692.

Beta wave enhancement neurofeedback improves cognitive functions in patients with mild cognitive impairment: A preliminary pilot study

BACKGROUND

Mild cognitive impairment (MCI) is a symptom characterizing cognitive decline and a transitional state between normal aging and dementia; however, there is no definitive diagnosis and treatment for MCI. Neurofeedback (NF), which is a training mechanism that employs operant conditioning to regulate brain activity, has been increasingly investigated concerning its beneficial effects for dementia and MCI.

METHODS

This study investigated cognitive improvement and hemodynamic changes in the prefrontal cortex (PFC) following NF training in patients with MCI. Five patients with MCI received NF training for enhanced beta band activity in the dorsolateral PFC-16 sessions for 8 weeks-with each session divided into 9 5-minute trials. The primary outcome measure was a cognitive assessment tool: the Korean version of the Montreal Cognitive Assessment. The secondary outcome measures were the Central Nervous System Vital Signs for neurocognitive testing, hemodynamic changes using functional near-infrared spectroscopy in the PFC during a working-memory task, and Beck Depression Inventory scores.

RESULTS

After completing the training, patients' cognitive function significantly improved in domains such as composite memory, cognitive flexibility, complex attention, reaction time, and executive function. Increased electroencephalogram beta power was observed over NF training sessions (Spearman rank correlation test: r = 0.746, P = .001). The threshold value for gaining positive feedback from pre-NF baseline on beta power significantly increased (Spearman rank correlation test: r = 0.805, P = .001). Hemodynamic response in PFC changed after NF training, and individual differences were identified. Specifically, hypoactivation of the hemodynamic response by emotional distraction recovered following NF training.

CONCLUSION

We suggest that patients' cognitive processing efficiency was improved by the NF training. These beneficial results suggest that NF training may have potential therapeutic applications to prevent the progression from MCI to dementia.

TRIAL REGISTRATION NUMBER

Clinical Research Information Service (KCT0003433).