An evaluation of alertness training for older adults

Lost in Time: Temporal Monitoring Elicits Clinical Decrements in Sustained Attention Post-Stroke

OBJECTIVES

Mental fatigue, 'brain fog', and difficulties maintaining engagement are commonly reported issues in a range of neurological and psychiatric conditions. Traditional sustained attention tasks commonly measure this capacity as the ability to detect target stimuli based on sensory features in the auditory or visual domains. However, with this approach, discrete target stimuli may exogenously capture attention to aid detection, thereby masking deficits in the ability to endogenously sustain attention over time.

METHODS

To address this, we developed the Continuous Temporal Expectancy Task (CTET) where individuals continuously monitor a stream of patterned stimuli alternating at a fixed temporal interval (690 ms) and detect an infrequently occurring target stimulus defined by a prolonged temporal duration (1020 ms or longer). As such, sensory properties of target and non-target stimuli are perceptually identical and differ only in temporal duration. Using the CTET, we assessed stroke survivors with unilateral right hemisphere damage (N = 14), a cohort in which sustained attention deficits have been extensively reported.

RESULTS

Stroke survivors had overall lower target detection accuracy compared with neurologically healthy age-matched older controls (N = 18). Critically, stroke survivors performance was characterised by significantly steeper within-block performance decrements, which occurred within short temporal windows (˜3 ½ min), and were restored by the break periods between blocks.

CONCLUSIONS

These findings suggest that continuous temporal monitoring taxes sustained attention processes to capture clinical deficits in this capacity over time, and outline a precise measure of the endogenous processes hypothesised to underpin sustained attention deficits following right hemisphere stroke.

How can technology support ageing in place in healthy older adults? A systematic review

Background

Ageing in place has recently gained visibility in healthcare policies and services. Technology has the potential to facilitate independence at home. The objective of this systematic review is to identify technologies that have been rigorously evaluated for supporting the ageing in place of healthy older adults. As well we explored the methods in engagement with technology in healthy older adults.

Methods

Databases Pubmed, Scopus, PsycInfo and Cinahl were consulted for clinical controlled trials or randomised controlled trials between 2014 and 2019. Studies were included if they contained a technological intervention and focussed on supporting healthy older adults’ independent living. PRISMA guidelines and the risk of bias tool of the Cochrane Collaboration were applied.

Results

The search identified 3662 articles of which only 7 made the final analysis. Through narrative analysis, technologies were categorised into three groups: accessible communication, emergency assistance and physical and mental well-being. Patient-centredness was extensively addressed by exploring how the participants engaged in the development and evaluation of the technology and how they were trained and monitored.

Conclusions

Literature concerning technology to support ageing, based on controlled trials and research performed in authentic home situations, is scarce. Thus, there is a need to investigate the subject in depth. The use of a neurofeedback headband, an accessible computer system, a wristband with pedometer, a biofeedback device and an online video platform can bring added value to ageing in place for healthy older adults. A patient-centred approach for developing, implementing and evaluating technology benefits ageing in place.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40985-020-00143-4.

Psychometric evaluation of the Chinese version of the Toronto Hospital Alertness Test

Background

Alertness is an important part of attention which is different from the opposite of sleepiness. This study aimed to translate and assess the measurement properties of the Toronto Hospital Alertness Test (THAT) in Hong Kong Chinese population.

Methods

The standard forward-backward translation procedure and cognitive debriefing were conducted to obtain the Chinese THAT. One hundred Chinese adults completed the Chinese THAT, the Center for Epidemiological Studies Depression Scale (CES-D), the Pittsburgh Sleep Quality Index (PSQI), and the Athens Insomnia Scale (AIS) by telephone interviews.

Results

The factorial validity was assessed by confirmatory factor analysis, and the internal reliability was examined by coefficient omega. The two negatively worded items of the THAT had low factor loadings and were removed. One more item was removed based on the modification indices of the eight-item model. The remaining seven-item THAT showed satisfactory unidimensionality with root mean square error of approximation (RMSEA) = 0.06, standardized root mean square residual (SRMR) = 0.08, and comparative fit index (CFI) = 1.00. The coefficient omega of the seven-item Chinese THAT was 0.80 (95% CI: 0.74–0.86). Convergent validity was demonstrated with THAT moderately associated with CES-D (r = − 0.45, P < 0.01), PSQI (r = − 0.40, P < 0.01), and AIS (r = − 0.45, P < 0.01).

Conclusions

The Chinese version of THAT demonstrated acceptable reliability and validity in a Chinese population.

Construction and evaluation of multidomain attention training to improve alertness attention, sustained attention, and visual-spatial attention in older adults with mild cognitive impairment: A randomized controlled trial

OBJECTIVES

We aimed to analyze the effects of multidomain attention training on alertness, sustained attention, and visual-spatial attention in older adults with mild cognitive impairment (MCI).

DESIGN

The design used in this study was a two-arm, parallel group, double-blind randomized controlled trial.

SETTING AND PARTICIPANTS

The participants of the study were seventy-eight older adults with MCI (mean age: 79.5 ± 7.9 years) from retirement centers and community housing for the elderly.

INTERVENTION

The participants were randomly assigned to an experimental group (multidomain attention training, n = 39) or an active control group (n = 39). Both groups underwent training sessions for 45 minutes three times per week for 6 weeks (18 sessions in total).

MEASURES

The main efficacy indicator was alertness (Trail Making Test Part B), sustained attention (Digit Vigilance Test), and visual-spatial attention (Trail Making Test Part A). The secondary outcome indicators were other cognitive functions (Mini-Mental State Examination [MMSE] and Montreal Cognitive Assessment [MoCA] subscales). Measurements were obtained at pretest, posttest, and 3 and 6 months after training.

RESULTS

The results were analyzed by a generalized estimating equation (GEE), which indicated that attention outcomes (alertness, sustained attention, and visual-spatial attention) of the experimental group did not improve after training. However, the experimental group displayed a significant improvement in the attention, memory, and orientation of MMSE and MoCA subscales over a period of 6 months and also showed superior results compared with the control group.

CONCLUSIONS

Multidomain attention training demonstrated improved alertness and visual-spatial attention for posttest after 6 months. We also outline potential future advances in attention training for improving attention in older adults with MCI.

Brain-computer interfaces in neurologic rehabilitation practice

The brain-computer interfaces (BCIs) for neurologic rehabilitation are based on the assumption that by retraining the brain to specific activities, an ultimate improvement of function can be expected. In this chapter, we review the present status, key determinants, and future directions of the clinical use of BCI in neurorehabilitation. The recent advancements in noninvasive BCIs as a therapeutic tool to promote functional motor recovery by inducing neuroplasticity are described, focusing on stroke as it represents the major cause of long-term motor disability. The relevance of recent findings on BCI use in spinal cord injury beyond the control of neuroprosthetic devices to restore motor function is briefly discussed. In a dedicated section, we examine the potential role of BCI technology in the domain of cognitive function recovery by instantiating BCIs in the long history of neurofeedback and some emerging BCI paradigms to address cognitive rehabilitation are highlighted. Despite the knowledge acquired over the last decade and the growing number of studies providing evidence for clinical efficacy of BCI in motor rehabilitation, an exhaustive deployment of this technology in clinical practice is still on its way. The pipeline to translate BCI to clinical practice in neurorehabilitation is the subject of this chapter.

Plasticity of the Right-Lateralized Cognitive Reserve Network in Ageing

Cognitive reserve (CR) is the phenomenon where older adults with more cognitively stimulating environments show less age-related cognitive decline. The right-lateralized fronto-parietal network has been proposed to significantly contribute to CR and visual attention in ageing. In this study we tested whether plasticity of this network may be harnessed in ageing.We assessed CR and parameters of visual attention capacity in older adults. Transcranial direct current stimulation (tDCS) was employed to increase right fronto-parietal activity during a lateralized whole-report task. At baseline, older adults with greater CR showed a stronger hemifield asymmetry in processing speed towards the left visual-field, indicative of stronger involvement of the right hemisphere in these individuals. Correspondingly, processing speed improved during right prefrontal tDCS. Older adults with lower levels of CR showed tDCS-related improvements in processing speed in the left but not right hemifield: thus tDCS temporarily altered their processing speed asymmetry to resemble that of their high reserve peers.The finding that stronger right hemisphere involvement is related to CR supports Robertson's theory. Furthermore, preserved plasticity within the right prefrontal cortex in older adults suggests this is a viable target area to improve visual processing speed, a hallmark of age-related decline.

Effect of cognitive training on episodic memory retrieval in amnestic mild cognitive impairment patients: study protocol for a clinical randomized controlled trial

BACKGROUND

Mild cognitive impairment (MCI) is a transition state between asymptomatic stage and dementia. Amnestic MCI (aMCI) patients who mainly present with memory deficits are highly likely to progress to Alzheimer's disease (AD). At present, no broadly effective drug therapy is available to prevent the progression from memory deficit to dementia. Cognitive control training, which has transfer effects on multiple cognitive capacities including memory function in healthy old adults, has not yet been applied to aMCI.

METHODS/DESIGN

In this single-center, randomized double-blind placebo-controlled study, 70 aMCI patients will be recruited and randomly assigned to the training and control groups. The intervention is an Internet-based cognitive control training program performed for 30 min daily, five days per week, for 12 consecutive weeks. Neuropsychological assessment and structural and functional magnetic resonance imaging (MRI) will be performed at baseline and outcome. Primary outcomes are changes of episodic memory retrieval function. Secondary outcome measures are neuroplasticity changes measured by functional and structural MRI.

DISCUSSION

In this study, an Internet-based cognitive control training program is adopted to investigate whether cognitive control training can enhance the retrieval of episodic memory in aMCI patients. The combination of multi-modal MRI and neuropsychological tests could have a good sensitivity in evaluating the effects of cognitive control training and could also uncover the underlying neural underpinning.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03133052 . Registered on 21 April 2017.

Prefrontal Modulation of Visual Processing and Sustained Attention in Aging, a tDCS–EEG Coregistration Approach

The ability to sustain attention is integral to healthy cognition in aging. The right PFC (rPFC) is critical for maintaining high levels of attentional focus. Whether plasticity of this region can be harnessed to support sustained attention in older adults is unknown. We used transcranial direct current stimulation to increase cortical excitability of the rPFC, while monitoring behavioral and electrophysiological markers of sustained attention in older adults with suboptimal sustained attention capacity. During rPFC transcranial direct current stimulation, fewer lapses of attention occurred and electroencephalography signals of frontal engagement and early visual attention were enhanced. To further verify these results, we repeated the experiment in an independent cohort of cognitively typical older adults using a different sustained attention paradigm. Again, prefrontal stimulation was associated with fewer attentional lapses. These experiments suggest the rPFC can be manipulated in later years to increase top–down modulation over early sensory processing and improve sustained attention performance. This holds valuable information for the development of neurorehabilitation protocols to ameliorate age-related deficits in this capacity.

Randomized control trial of computer-based training targeting alertness in older adults: the ALERT trial protocol

Background

Healthy aging is associated with a decline in multiple functional domains including perception, attention, short and long-term memory, reasoning, decision-making, as well as cognitive and motor control functions; all of which are significantly modulated by an individual’s level of alertness. The control of alertness also significantly declines with age and contributes to increased lapses of attention in everyday life, ranging from minor memory slips to a lack of vigilance and increased risk of falls or motor-vehicle accidents. Several experimental behavioral therapies designed to remediate age-related cognitive decline have been developed, but differ widely in content, method and dose. Preliminary studies demonstrate that Tonic and Phasic Alertness Training (TAPAT) can improve executive functions in older adults and may be a useful adjunct treatment to enhance benefits gained in other clinically validated treatments. The purpose of the current trial (referred to as the Attention training for Learning Enhancement and Resilience Trial or ALERT) is to compare TAPAT to an active control training condition, include a larger sample of patients, and assess both cognitive and functional outcomes.

Methods/design

We will employ a multi-site, longitudinal, blinded randomized controlled trial (RCT) design with a target sample of 120 patients with age-related cognitive decline. Patients will be asked to complete 36 training sessions remotely (30 min/day, 5 days a week, over 3 months) of either the experimental TAPAT training program or an active control computer games condition. Patients will be assessed on a battery of cognitive and functional outcomes at four time points, including: a) immediately before training, b) halfway through training, c) within forty-eight hours post completion of total training, and d) after a three-month no-contact period post completion of total training, to assess the longevity of potential training effects.

Discussion

The strengths of this protocol are that it tests an innovative, in-home administered treatment that targets a fundamental deficit in adults with age-related cognitive decline; employs highly sensitive computer-based assessments of cognition as well as functional abilities, and incorporates a large sample size in an RCT design.

Trial registration

ClinicalTrials.gov identifier: NCT02416401.

Interfacing brain with computer to improve communication and rehabilitation after brain damage

Communication and control of the external environment can be provided via brain-computer interfaces (BCIs) to replace a lost function in persons with severe diseases and little or no chance of recovery of motor abilities (ie, amyotrophic lateral sclerosis, brainstem stroke). BCIs allow to intentionally modulate brain activity, to train specific brain functions, and to control prosthetic devices, and thus, this technology can also improve the outcome of rehabilitation programs in persons who have suffered from a central nervous system injury (ie, stroke leading to motor or cognitive impairment). Overall, the BCI researcher is challenged to interact with people with severe disabilities and professionals in the field of neurorehabilitation. This implies a deep understanding of the disabled condition on the one hand, and it requires extensive knowledge on the physiology and function of the human brain on the other. For these reasons, a multidisciplinary approach and the continuous involvement of BCI users in the design, development, and testing of new systems are desirable. In this chapter, we will focus on noninvasive EEG-based systems and their clinical applications, highlighting crucial issues to foster BCI translation outside laboratories to eventually become a technology usable in real-life realm.

Targeting alertness to improve cognition in older adults: A preliminary report of benefits in executive function and skill acquisition

Efficient self-regulation of alertness declines with age exacerbating normal declines in performance across multiple cognitive domains, including learning and skill acquisition. Previous cognitive intervention studies have shown that it is possible to enhance alertness in patients with acquired brain injury and marked attention impairments, and that this benefit generalizes to improvements in more global cognitive functions. In the current preliminary studies, we sought to test whether this approach, that targets both tonic (over a period of minutes) and phasic (moment-to-moment) alertness, can improve key executive functioning declines in older adults, and enhance the rate of skill acquisition. The results of both Experiments 1 and 2 demonstrate that, compared to active control (AC) training, alertness training significantly enhanced performance in several validated executive function measures. In Experiment 2, alertness training significantly improved skill acquisition compared to AC training in a well-characterized speed of processing (SOP) task, with the largest benefits shown in the most challenging SOP blocks. The results of the current study suggest that targeting intrinsic alertness through cognitive training provides a novel approach to improve executive functions in older adults and may be a useful adjunct treatment to enhance benefits gained in other clinically validated treatments.