One of the foremost concerns of elderly individuals is the possibility of cognitive decline or worse, dementia. The awareness of the devastating mental losses wrought by Alzheimer’s Disease and other forms of dementia have created the urgency to find activities to prevent or slow cognitive decline. One of many such activities is the use of computerized brain training exercises to achieve this goal. This is the topic of my blog.
Background – Changes in Cognition with Age
Even in the absence of disease, some aspects of brain function such as information processing speed (basically the response speed to a mental stimulus), some types of memory such as encoding and retrieval, executive function (basically global decision making) and reward-based behavior tend to decline with age. In contrast, functions such as semantic memory (facts/knowledge), most aspects of language, emotional processing, autobiographical memory (about self) and automatic memory processes (rote memory such as riding a bike) remain unchanged with age but are affected by disease. See (Insight 6 – More longevity building: Ways to minimize brain aging) for a more in depth discussion of aspects of cognition that change or remain stable and their consequences.
Several approaches to minimize age-associated cognitive decline have already gained convincing clinical support (reviewed in Insight 6 – More longevity building: Ways to minimize brain aging). They are:
a) a program of aerobic exercise (Insight 4: Anti-aging benefits of aerobic and stretch exercises)
b) continued engagement in serious mental stimulation
c) mastery of new skills
d) optimizing vision and hearing.
The data indicate that commitment to these 4 pursuits maintains cognition and slows cognitive decline. These pursuits work because they physically change the brain’s neural networks for the better. This is termed neuroplasticity. Thanks to this mechanism, our nerves and connections are strengthened.
Is it reasonable to engage in computerized brain training to prevent cognitive decline?
Computerized brain training
There are now hundreds of companies worldwide that sell computerized brain training exercises. These exercises are referred to as computerized cognitive training (CCT). Another name for computerized brain training or CCT is computerized brain games. The idea behind CCT is that hours of repetitive practice on standardized exercises will improve the function of the exercise-targeted brain domain. For example, cognitive training in processing speed should improve reaction time or cognitive training in memory for encoding and retrieval should produce better recall of a list of items. This training could possibly translate into more global cognitive function and enhance every day activities called instrumental activities of daily living, such as handling finances, shopping, meal preparation.
There are three forms of cognitive intervention: cognitive training, cognitive stimulation, and cognitive rehabilitation (Gates et al., 2019). Cognitive training serves to prevent cognitive decline. In contrast, cognitive stimulation and rehabilitation restore reduced cognitive function, and compensate for cognitive impairment, respectively. This blog will discuss the science of cognitive training only.
The efficacy of computerized brain training is unsettled.
Analysis of Computerized Brain Training
There exist hundreds of clinical trials that studied the merits of computerized brain training. Many of these trials tested a small number of participants which reduces confidence in the results. Additionally, in some trials, control participants were “passive controls” who were not exposed to any type of computerized exercise, also reducing confidence in the results. Considering these issues, it seemed reasonable to focus on critical reviews of the computerized brain training trials. A review or summary of a large number of trials is called a systematic review. A statistical analysis of a select number of trials that meet strict criteria is called a meta-analysis. Both review types provide important information.
Early Findings
One of the earliest reports on CCT was a systematic review by Kueider et al., (2012). The authors reviewed the top 38 studies (out of 115) covering the prior 25 years. These select studies trained elderly (55 years and older) who were without mild cognitive impairment or dementia. The training included CCT as well as neuropsychological software and video games. The authors concluded that there were cognitive benefits regardless of the training venue and that “computerized training is effective”. Use of CCTs produced higher scores in processing speed, memory, attention and executive function.
Several years later, in contrast, an extensive list of eminent professors of gerontology, psychology, neuroscience, neurology, cognitive sciences and related fields submitted a position paper on computerized cognitive training. See (https://longevity.stanford.edu)for details. “The strong consensus of this group is that the scientific literature does not support claims that the use of software-based “brain games” alters neural functioning in ways that improve general cognitive performance in everyday life, or prevent cognitive slowing and brain disease”. That was in 2014. Since then, several excellent reviews appeared.
Recent Findings
Efficacy supported by meta-analysis
Bonnechère et al., (2020) published a meta-analysis of clinical trials in which participants practiced with commercially available brain training exercises. Specifically, the goal was to demonstrate maintenance of cognitive function in people, 60 years and older, without any known cognitive difficulties. The analysis statistically assessed 16 studies which together totaled 1500 patients. Independent of the participants’ age and time devoted to training, the authors conclude that these commercially available exercises improve memory, executive function and processing speed with the greatest improvement in processing speed. There was no improvement in attention or visuospatial skills.
This is an interesting review in that it provides for each analyzed study, the name of the cognitive exercise, the company producing the exercise and examples of the “workings” of the exercise. Unfortunately, some studies enrolled small numbers of participants with about a 10% or so drop-out rate to boot. Importantly, the relation to global function or instrumental activities of daily living was not studied.
Efficacy unsupported by meta-analysis
With a different view, Gates et al., (2019; 2020) reviewed nearly 8000 clinical trial reports (including quasi clinical trials, published and unpublished trials). Their criteria accepted only trials of computerized cognitive training that lasted for 12 weeks of more, in individuals, 65 years and older with the goal of improvement in cognition of cognitively healthy elderly. Eight randomized clinical trials with a total of 1183 participants met these criteria.
Gates et al., (2019) concluded that outcomes of these trials were in the range of low to very low confidence. In short this means that more research is required before one can confidently conclude that computerized brain training improves cognition of cognitively healthy elderly. This supports the 2014 conclusion of numerous experts in the field (see above). Gates et al., (2019) also points out that there are no long term studies on cognitive brain exercises (beyond 12 weeks or so). Additionally, there is a paucity of data on the harmful effects (such as anxiety, frustration) of computerized brain exercises.
Summary – Computerized brain training needs more research
Today, the development and sales of computerized cognitive training, stimulation and rehabilitation is a multi-billion dollar industry. Findings of major critical reviews in the field of computerized cognitive training indicate that test scores increase with specific training in multiple brain domains. Importantly, one gets a higher score with repetitive practice using computerized brain training. Unfortunately, there is no data at present to confirm that spending hours on computerized brain exercises will translate into a more effective ability to carry out daily cognitive challenges.
Select References
Gates NJ, et al., Computerized cognitive training for maintaining cognitive function in
cognitively healthy people in late life. Cochran Database Syst Rev. 13: 1-94, 2019
Kueider et al., Computerized Cognitive Training with Older Adults: A Systematic Review. PLoS ONE 7: 2012 e40588
Bonnechère, B et al, The use of commercial computerised cognitive games in older adults: a meta‑analysis. Sci Rep. 2020 Sep 17;10(1):15276
Gates NJ et al., Computerized cognitive training for 12 or more weeks for maintaining cognitive function cognitively healthy in late life (review) Cochrane Database of Systematic Reviews 2020, Issue 2. Art. No.: CD012277.