Cognitive training with older adults: Intervention, rehabilitation, and engagement approaches

Cognitive training with older adults: Intervention, rehabilitation, and

engagement approachesMichael Marsiske

Department of Clinical and Health PsychologyUniversity of Florida

Review Summary and critical comparisons Demonstrations◦ Limited ability

Exposition of data needs and request for community input

Workshop

Review of the theoretical bases for much of the cognitive intervention research to date will be offered.

Differing approaches to intervention (intervention, rehabilitation, and engagement) will be compared.

Review of cognitive intervention findings will be offered, with an emphasis on the magnitude, durability, and transfer of training effects.

Brief process-oriented review of several common training approaches will be offered

Overview

By the end of the workshop, participants will be able to 1. describe the major theoretical underpinnings of

several approaches to cognitive enhancement with older adults, including intervention, rehabilitation, and engagement;

2. summarize the major findings of extant cognitive training studies; and

3. understand the content and process of several major training approaches currently available for older adults.

Objectives

The broad term linking much of what will be discussed today is either “enhancement” or “enrichment”◦ The idea is to unify a broad body of approaches (most still

confined to experimental proof of concept, rather than clinically validated or commercially available) that aim to improve cognitive performance in older adults These approaches have mostly been evaluated in adults free of

dementia (and usually free of MCI) They constitute, conceptually, more of a “prevention” and “early

intervention” approach rather than rehabilitation

Some definitions

Medical rehabilitation:◦ “The process of restoration of skills by a person who has had

an illness or injury so as to regain maximum self-sufficiency and function in a normal or as near normal manner as possible. For example, rehabilitation after a stroke may help the patient walk again and speak clearly again. “ (www.medterms.com)

Rehabilitation may not the right model for normal aging, or even for gradual-progressive onset disorders

Relatively scant evidence, from a rehabilitation perspective, for normal aging and MCI

Some definitions

Mayo’s notion of a “Cognitive Continuum”

Normal

Mild CognitiveImpairment

Dementia

Source: Peterson

Memory rehabilitation in MCI

Much of the other extant research has been focused on memory compensation (i.e., notebooks, calendars)

Feasibility study with 24 older individuals suggested that 20/24 participants could adhere to the curriculum

An RCT is under way. Intervention includes◦Multiple modules for different internal, external, and social

strategies◦Orientation, acquisition, practice with feedback, homework

using a workbook

Memory rehabilitation in MCI

A central premise here is that the goals of this research have evolved—as much for public health reasons as because of the goals of investigators—to examining cognitive interventions as prevention and rehabilitation approaches

The problem: The empirical research has not caught up with the rhetoric

The goals of cognitive training research have changed

If you work with adults, you have a steadily increasing probability of encountering clients in the second half of the life span

Cognitively, it is important to understand the backdrop of normal (cognitive) changes before conducting any cognitive assessment

Core premises

Cognitive issues also need be considered as one considers treatment plans, ways of communicating information with older clients

It is important to use information to work against stereotypical conceptions of cognitive aging

It is important to recognize the substantial plasticity of cognition, even into very old age

Core premises

Evolution of Research Trends Trend 1: Identifying declines/losses in function◦ Lasted until the mid 1950s

Trend 2: Establishing stability as well as decline◦Mid 1950s-1960s

Trend 3: Modifying age differences◦ 1970s◦ Establishing experiential & social influences

Trend 4: Modifiability of cognitive performance◦ Current◦New methods of measurement ◦ Expansion of definitions

Core questions of the field

Directionality◦Gains, losses, and/or maintenance

Universality◦Effects of individual differences

Reversibility◦Interventions & experiences promoting

improvement/recovery

Dixon & Cohen, 2003

Scaffolding Theory of Aging and Cognition

Protective mechanism for cognition in aging population Response to decline in normal function of fluid

mechanics/intelligence

Park & Reuter-Lorenz, 2009

Creation and utilization of supplemental neural pathwaysOr, reactivation of rudimentary pathways in response to

challenge May allow the aging adult to maintain high level of

functioning Illustrated by both loss of specificity and

lateralization of functional blood flow in the aging brain

A global model of enrichment of late life cognition

Hertzog et al, 2009

A global model of enrichment of late life cognition

Hertzog et al, 2009

Areas for consideration todayApproach Mediators Outcomes

Strategy training Let’s fill these cells in at the end

Education

Engagement: Social, complex activitiesEngagement: Video games and “brain training”Process training (recollection, varied emphasis, dual N-back)Physical exercise

Strategy training

Major foci: Reasoning Memory Attention/speed of processing

Since the 1970s, a large body of research has investigated the modifiability of several kinds of reasoning in adults aged 65 and older

Domains of focus

Figural Relations: Identify the pattern in the upper box, and pick which of the answer choices would best complete the question mark.

What is reasoning?

Inductive Reasoning: Identify the pattern among the series of letters, and then decide what would come next in the series

What is reasoning?

a m b a n b a o b a ?1. a2. b3. o4. p5. q

One common task: Episodic list recall

What is memory?

deskrangerbirdshoestovemountainglassestowelcloudsilverlambgunpencilchurchfish

There are many definitions One that we’ll consider today is ‘Useful Field of View’

What is “attention/speed of processing”?

Restriction of the Useful Field of View

Useful Field of View

“Speed”. This test determines the fastest speed at which you can identify whether the central target (which flashes quickly) is a car or a truck. The minimum (best) score is 16 ms; the maximum score is 500 ms—because the system TIMES OUT. If it takes you longer than half a second, the system quits on you.

“Divided attention”. This test determines the fastest speed at which you can identify whether the central target (here: car) AND identify the location of a “peripheral” target (here: say 2 o’clock). Again, scores reflect the fastest speed at which you achieve 75% accuracy, and will range from 16 ms (limits of the system) to 500 ms (time out).

“Selective attention”. This test determines the fastest speed at which you can identify whether the central target (here: car) AND identify the location of a “peripheral” target (here: say 2 o’clock) in visual clutter. Again, scores reflect the fastest speed at which you achieve 75% accuracy, and will range from 16 ms (limits of the system) to 500 ms (time out).

Reasoning training

Prototypical design of reasoning training studies

Baseline“Pretest”

Assessment

5-10 strategy sessions, 2x week

No contact

Immediate“Posttest”

Assessment

Additional delayed

posttests

randomization

Ranging from•1 wk•1 month •6 months•7 years

We typically evaluate these studies by three criteria Magnitude of effect Breadth of effect (training transfer) Durability of effect

Evaluative criteria

Participants have tended, at enrollment, to be young, healthy older adults

Reasoning training

Study Year Mean Age (Range)

Plemons, Willis & Baltes 1978 69.5 (59-85) Willis, Blieszner & Baltes 1981 69.8 (61-81) Blieszner, Willis & Baltes 1981 70.3 (60-85) Willis, Cornelius, Blow & Baltes 1983 70.5 (62-84) Willis & Schaie; Schaie & Willis 1991 72.8 (64-95) Baltes, Dittmann-Kohli & Kliegl 1986 72.0 (60-86) Baltes, Kliegl, & Dittmann-Kohli 1988 73.0 (63-89) Baltes, Sowarka, & Kliegl 1989 72.0 (63-90) Hofland 1981 69.2 (60-80)

The outcome battery is typically constructed in a transfer hierarchy, with “nearest” transfer measures closest to the content of training (and therefore most likely to show effects)

Example: Figural Relations Near-near transfer: ADEPT Figural Relations Near-fluid transfer: Culture Fair Test Far-fluid transfer: Letter Sets, Letter Series,… Far non-fluid transfer: Vocabulary, Identical Pictures,

everything else

Defining “breadth” (transfer)W

The earliest studies showed significant improvement due to training, although effects were quite narrow.

Reasoning training: Magnitude and breadth

Target of training: Figural Relations

Source: Plemons, Willis, & Baltes, 1978

Training effects are usually highly specific (i.e. seen only for tests of the specific ability trained)

Target of training: Figural Relations

Source: Willis, Blieszner, & Baltes, 1978

The earliest studies showed significant improvement due to training, although effects were quite narrow.

Target of training: Inductive Reasoning or Spatial Orientation

Source: Willis & Schaie, 1994

In most studies, the obtained training effects, though highly specific, appear to last for very long times

Reasoning studies: Durability

Study Year Breadth of transfer Durability of effects

Plemons, Willis & Baltes

1978 Near-near (ADEPT Figural Relations) only

6 months

Willis, Blieszner & Baltes

1981 Both trained (Figural Relations) and far-fluid (Inductive Reasoning) abilities show transfer

6 months

Blieszner, Willis & Baltes

1981 Near-near (Inductive Reasoning) only

1 month

Baltes, Dittmann-Kohli & Kliegl

1986 Near-fluid and far-fluid transfer

Improvement to 1 month; drop by 6 months, but still above immediate posttest levels

Willis and Nesselroade found that pre-post gains were similar when subjects were, on average, 70 years old and again 7 years later. Moreover, there appeared to be some “residual” benefit (about 0.4 S.D.) of training 7 years later

Willis and Schaie revisited their Seattle Longitudinal Study subjects seven years after their first training

Reasoning studies: Durability and “booster” interventions

Other interventions

Memory◦ This line of research tends to be more age comparative, and to

feature a wide diversity of tasks and mnemonic strategies to be trained

◦Many examples of training effectiveness (Rebok, Rasmusson & Brandt, 1996; Greenberg & Powers, 1987; Scogin, Storandt, & Lott, 1985; Yesavage, 1985; Kliegl, Smith & Baltes, 1990)

◦ Verhaeghen, Marcoen & Goosens (1992) meta-analysis: Pretest to posttest effect size for mnemonic training groups (0.73 SD units) was twice that of placebo groups (0.37 SD units) or control groups (0.38 SD units).

Other targets of intervention: Memory

Memory (continued)◦ Verhaeghen, Marcoen & Goosens (1992) meta-analysis:

Treatment gains were largest when training was conducted in a group additional memory–related intervention (such as using external

memory aids or motivation enhancement) was provided sessions were relatively short participants were younger

Other targets of intervention: Memory

Substantial word recall gains for older adults: But age-related limits as well

Berlin Method of Loci studies; Baltes, Kliegl, Smith, Lindenberger

Memory (continued)◦ Durability results mixed

Maintained effects have been detected from 1 week to six months (Scogin, Storandt, & Lott, 1985; Flynn & Storand, 1990; Sheikh, Hill & Yesavage, 1986; Stigsdotter & Backman, 1989; Stigsdotter Neely, & Backman, 1993; West & Crook, 1992)

Other studies have failed to find maintenance (Scogin & Bienias, 1988; Schmitt, Murphy & Sanders, 1981; Wood & Pratt, 1987)

Neely and Backman (1995), using a more complex “multifactorial” memory training program, found that trained subjects showed maintenance gains extending to 3.5 years.

Reasoning studies: Durability and “booster” interventions

An exception to “limited transfer” may be the Useful Field of View, a measure of speeded visual attention

Participants must perform both central perceptual tasks (identify an object) and note the location of an eccentric/peripheral visual target

Here, we seem to see transfer to driving related outcomes

Visual attention training

The literature has been very clear that cognitive training with older adults, when that training is focused on the enhancement of specific intellectual abilities, produces effects of substantial magnitude, that generalize to multiple markers of the trained ability, that can be very durable, and are typically very specific to the ability trained

Summary of pre-1996 findings

Are findings laboratory specific? Are positive benefits most likely for European

American, advantaged older adults? Does participant status, especially mental status, matter?

Is the durability of different cognitive interventions non-equivalent?

Do these interventions matter? Is there any way we might see transfer to everyday life?

What we didn’t know

A multi-site, longitudinal trial of cognitive interventions with diverse elders

Advanced Cognitive Training with Independent and Vital Elders

The design of the ACTIVE trial was largely pre-specified by the National Institute on Aging and the National Institute of Nursing Research in RFA-AG-96-001.

Three major emphases of the request for applications were 1. common multi-site intervention protocols2. a focus on everyday independence and the cognitive components of functional

competence as primary outcome measures3. interventions on proximal outcomes at the level of basic cognitive abilities, rather

than directly at the level of the primary outcome measures.

The resultant ACTIVE study differed from prior cognitive training research in several ways: 1. multisite, randomized controlled, single-blind trial2. analytical approach is intent-to-treat, thereby including all randomized participants

rather than only those compliant with the intervention, as in prior research in this field

3. it includes primary outcome measures of everyday functioning 4. the study sample is more socioeconomically and racially diverse than in prior

intervention studies

ACTIVE Sites and Principal Investigators

University of Alabama-BirminghamKarlene Ball, Ph.D.

Hebrew Rehabilitation Center for Aged, Boston

John Morris, Ph.D. Indiana University

Fred Unverzagt, Ph.D. Johns Hopkins University

George Rebok, Ph.D.

Pennsylvania State UniversitySherry Willis, Ph.D.

University of FloridaMichael Marsiske,

Ph.D. New England Research

Institutes, Coordinating CenterSharon Tennstedt, Ph.D.

Demographic characteristicsIneligible Not-Randomized Randomized

N 855 1,312 2,832

Women 77% 79% 76%

Age, years: mean (sd) 75 (9) 75 (7) 74 (6)

Oldest old, age 85+ 15% 9% 5%

Non-white 42% 40% 27%

Mental Status: Randomized Participants

23 24 25 26 27 28 29 30

MMSE Score

mean (sd) = 27.3 (2.0)Source: Morris et al., 2000

Age Distribution: Randomized Participants

-40 -30 -20 -10 0 10 20 30 40

1 %U.S. 65+, 1998ACTIVE

Source: Morris et al., 2000

Does intervening on basic abilities transfer to real-world tasks?

So what does training look like?

Reasoning training

Source: Willis, 1997

Reasoning training

Memory training

Source: Rebok, 1997

Memory training

Source: Rebok, 1997

Memory training

Source: Rebok, 1997

Memory training

Source: Rebok, 1997

Memory training

Source: Rebok, 1997

Memory training

Source: Rebok, 1997

Memory training

Source: Rebok, 1997

Memory training

Source: Rebok, 1997

Memory training

Source: Rebok, 1997

Memory training

Source: Rebok, 1997

Memory training

Source: Rebok, 1997

Memory training

Source: Rebok, 1997

Trained

Untrained

Overall, this large-scale intervention study (2,802 persons aged 65-96) demonstrated that cognitive interventions helped normal elderly perform better on multiple measures of the specific ability for which they were trained It did not demonstrate generalization to everyday performance, at least in the initial 2 years Although training impact dissipated over the two-year period of followup, it remained statistically significant, a durability which has not been reported in many other studies

Take skill acquisition from one context or set of stimuli, and show that this yields improved performance in some other context or set of stimuli This is the classic goal of education This is the vexing challenge of skill training research

Optimized by similarity between trained and transfer task, lots of practice, situated learning

Transfer of training

The trial pre-specified that “real world” functioning (e.g., IADLs) should be the primary outcome

Knowing, from a century of research (e.g, Thorndike, 1905), that this would be difficult, following the terms of the RFA, the outcome battery included multiple measures in two domains of everyday cognition that (a) had been shown to be related to trained abilities (often r = 0.70 or higher), and (b) had been shown to be related to traditionally measured IADLs

Training did not demonstrate generalization to everyday performance, at least in the initial 2 years

Optimizing transfer?

Everyday transferEveryday Problem Solving: Net Training Effects

Pretest A1 A2

Occasion

Memory

Reasoning

Control

Data from: Ball et al. 2002

Everyday transfer

Data from: Ball et al. 2002

Everyday Speed: Net Training Effects

Pretest Posttest A1 A2

Occasion

Memory

Reasoning

Control

5-year effect of training on cognitive abilities

Memory trained Reasoning trained Speed trained

Training Group

Memory compositeReasoning compositeSpeed composite

ACTIVE Cognitive Results

Intervention Arm Result

Memory training Participants outperformed on the memory task those who were receiving other training

Reasoning training After year 5, participants outperformed on the reasoning task compared to those in the controls.

Field of view training Outperformed everyone else after 5 years.

Is more training better? We have conducted booster training (4 additional

training sessions at 1 year, and again 3 years, after initial training)

About 50% of those initially trained were randomized to receive extra booster training

Effects of Booster Training

Memory boosted Reasoning boosted Speed boosted

Training Group

Memory compositeReasoning compositeSpeed composite

IADLs and Booster Training

Booster Training Result

Speed of Processing Training Improved in the ability to do everyday tasks. Reacting to road signs, looking up numbers in the phone book, understanding medical labels

Reasoning training Improved everyday problem solving: understand directions, charts, forms

Does training matter? What is the breadth of training effects?

This is one way to examine the “transfer” question

Training Effects on Daily Function All trained participants reported less difficulty with

IADLs compared to control group; this reached significance for our Reasoning training.

The basic ten sessions of training had no effect on performance-based measures of function. However, a subsample received booster training. Booster speed training improved performance in Everyday Speed tasks. Training effects were modest

There was a similar trend for booster reasoning training to improve Everyday Problem Solving.

Training Effects on Self-reported IADLS

Memory Reasoning Speed Control

Baseline Year 1 Year 2 Year 3 Year 4 Year 5(N=2802) (N=2325) (N=2234) (N=2101) (N=1877)

ACTIVE Functional Status Patterns (IADLS)

Third-year mark

Control group were significantly lower

All four groups reported some degree of decline Training groups declined at similar,

shallower rates

Participants who received training, especially Speed of Processing/Useful Field of View, reported better◦ IADL functioning◦ Self-reported health◦ Internal Locus of Control◦ Depressive symptomatology

(multiple studies; Fred Wolinsky et al)

ACTIVE Study: Broad self-believe transfer

Can training be used in persons with mental impairment?

No difference in training for Reasoning & Speed, …but low memory group showed no gain in Memory

Persons trained in reasoning

Immediate 1-Year 2-Year

Occasion

Memory normal

Memory impaired

Persons trained in speed

Occasion

Memory normal

Memory impaired

Persons trained in memory

Occasion

Memory normal

Memory impaired

Does training affect the rate of cognitive impairment?

In the first three years, we could detect not detect training group differences in cognitive or functional decline rates

…but initial level did predict the rate of perceived functional decline

Cognitive Status

Cognitive status

Trained Healthy

Control Healthy

Control At RiskTrained At Risk

PosttestPretest

t of F

M. Baltes, Sowarka & Kuhl (1989) reported that persons at risk for dementia did not show typical training effects in a figural relations training study. Subsequent work showed that posttest gain in inductive reasoning and figural relations rivaled free recall in the prediction of cognitive status.

Two groups of participants (those with and without reliable longitudinal decline) received training; gain slopes were roughly parallel, suggesting that training could constitute either “remediation” or “enhancement”

Reasoning studies: Cognitive status

Inductive Reasoning Training

Source: Willis & Schaie, 1994

Do we need training? What other strategies might work?

The effects of practice have been well documented for younger adults (e.g., ETS studies), but there is also a body of evidence suggesting that practice (without training) is beneficial for older adults Digit symbol

Linear gain after 10 practice trails (Erber, 1976) and 20 practice trails (Grant, Storandt, & Botwinick, 1978), with some evidence of asymptote after 100 trials (Beres & Baron, 1981).

Perceptual speed gain after two 30-minute sessions (Hoyer, Labouvie & Baltes, 1973)

Reasoning studies: Training/self-training/practice

Some research has questioned the need for a trainer/tutor, and even for a structured training program.Baltes, Kliegl, & Dittmann-Kohli (1988) found few differences between subjects who received 10 hours of training in Inductive Reasoning and Figural Relations, and those who received 10 hours of no-feedback practice.

There were only subtle differences between practice and training subjects. For Figural Relations, practice effects were largest on items of medium difficulty, while trained subjects appeared to have had largest accuracy gain on Inductive Reasoning measures. (Baltes, Kliegl, & Dittmann-Kohli, 1988)

Self-administered training is as good as tutor-guided training (Baltes, Sowarka, & Kliegl, 1989)Indeed, self-administered training may be more durable than tutor-guided training (Blackburn, Papalia-Finlay, Foye & Serlin, 1988)Practice on as few as six Raven’s Progressive Matrices items may yield significant improvements, relative to controls (Denney & Heidrich, 1990)

Practice Social Contact “Engagement”

Decomposing cognitive intervention effects

Practice

In the reasoning domain, Hofland (1981; and Hofland, Willis & Baltes, 1981) found little evidence of asymptote, and consistent gain in both Inductive Reasoning and Figural Relations after 8-10 no-feedback practice sessions

Practice is highly effective

Source: Hofland, Willis & Baltes, 1981

3-year retest-gain in several Reasoning measures (ACTIVE control sample)

Participants Participants

72 participants enrolled at pretest; 58 (14 male, 44 female) remained at posttest, about 36 of whom did twice-daily diaries for 60 days

independently living Mean age of survivors = 74 years (range = 60-87 years) Mean education of survivors = 16 years (range = 12 –

22 years) 52 European American, 6 African American

Daily Mental Exercise

Participants complete 120 Daily Mental Exercise Workbooks on their own in their homes twice a day (morning and night) for 60 consecutive days

• Workbooks include self-administered, timed tests of three cognitive abilities– Inductive Reasoning--Letter Series– Speed of Processing--Number

Comparison– Memory--AVLT

Content of Daily Mental Exercise Workbooks

Design

Pretest

Pretest Session 2/ Workbook

Instruction

Pretest Session 2 No Contact

Daily Mental Exercise

Post-Test

Daily Practice Effects: Reasoning

Daily Practice Effects: Speed

Daily Practice Effects: Memory

Huge effects of retest, with little evidence of asymptote (except for Reasoning, and that is likely a ceiling effect problem) after 120 occasions!

However, the band of transfer is narrower than that reported in any other training or practice study, given these effects

Simple routine engagement may actually “over-crystallize” task-specific skills

MEDLI Study

Another study of ours looked more formally at mild cognitive impairment, (MCI) using clinical consensus criteria for identification of these cases

One question the study asked was: How does extensive practice (31 occasions) improve performance in those with, and without, MCI?

FitMind Study

With Karin McCoy 68 adults with a mean age of 75 years 49 were cognitively intact; 17 had amnestic Mild Cognitive

Impairment (MCI) Focus was again intra-individual variability All participants received 31 daily trials with measures of list memory (3 repetitions of

AVLT-type lists daily), as well as working memory (forward and backward digit span) and perceptual speed/attention (digit-symbols)

FitMind Study

Equivalent practice related gain, regardless of cognitive status

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30Occasion

cog stat:Non-MCIMCI

Growth Curves for AVLT Total Recall

Source: Marsiske & McCoy, in preparation

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30

Occasion

cog stat:Non-MCIMCI

Growth Curves for Symbol Digit Score

Retest effects are large, even for persons with probable incipient cognitive pathology

Interestingly, however, practice does not appear to help persons with MCI “catch up” in memory

Again, practice effects are highly specific. Transfer is elusive

FitMind Study

Education

STAC Model: Education

STAC Model: Education and Engagement3343 adults aged 32-84MIDUS Study

Engagement: Social, complex activities

Is any mental stimulation good? Does the age of onset matter?

Controversy regarding whether an intellectually rich life delays decline (Salthouse, 2006)

The work of Wilson and Schooler has suggested that demanding work and challenging leisure could aid in resistance to decline

The cognitive reserve hypothesis (Scarmeas & Stern, 2003) suggests that education and complex life could produce enhanced neural circuits

Might the late-life engagement in novel contexts, ill-defined problems, and non-routine activities produce broad intellectual gains? (Stine-Morrow, 2007)

What about learning a new instrument? Crossword puzzles?

Bugos et al., reported that six-months of piano instruction, in novices, boosted attention and working memory relative to untrained controls

Salthouse, however, reported that crossword puzzlers, while showing benefits of their hobby, did not show attenuated rates of decline.

Experimental study of complex activity

•150 older adults randomized to receive either • “Senior Odyssey”

• (n=87; teams solve long-term ill structured problems from the disciplines of literature, science and technology, civil engineering, and history, like building a structure out of balsa wood) or

• testing-only control (n=63)

Experimental study of complex activity

Source: Stine-Morrow et al, 2008

Typically draw on self-reports of specific activities deemed to be cognitively stimulating, like reading a book, attending a play, or playing chess, and asking people to indicate whether or not or how frequently they participated. These frequency reports are then typically summed into a general activity scale or into activity subscales.

In multiple studies, more cognitive activity is associated with a slower rate of decline Bosma et al., 2002; Hultsch et al., 1999; Schooler& Mulatu, 2001; Wilson, Bennett, et al., 2003; Wilson, Mendes de Leon, et al., 2002; Wilson, Scherr, Schneider, Li, & Bennett, 2007).

Complex activity engagement as enrichment (source: Hertzog et al, 2009)

A higher level of cognitive activity has been associated with reduced risk of developing incident dementia (Crowe et al., 2003; Scarmeas, Albert, Manly,&Stern, 2001;Verghese et al., 2003;Wang, Karp, Winblad, & Fratiglioni, 2002; Wilson, Bennett, Bienias, et al., 2002; Wilson, Mendes de Leon, et al., 2002; Wilson, Scherr, et al., 2007), or incident cognitive impairment (Verghese et al., 2006; Wang et al., 2006).

Complex activity engagement as enrichment (source: Hertzog et al, 2009)

Engagement: Video games

Useful Field of View is improved by first-person shooter video games in college-aged players (but not by Tetris)

Tetris

Medal of Honor

Rise of Nations (Video Game)

Basak, Boot, Voss & Kramer (2009)

Video game group: 23.5 hours of training (n=20) No contact control group Trained participants improved more than the control

participants in executive control functions, such as task switching, working memory, visual short-term memory, and reasoning.

Basak, Boot, Voss & Kramer (2009)

Task Switching

N-back focus switch costs

Example: Brain Age

Is there value in commercially available mental training programs?

Brain Age I and II Big Brain Academy Positscience M*Power Lumos Labs Happy Neuron Brain Trainer Mind Habits Brain Builder Vigorous Mind AARP

Example: Positscience IMPACT

RBANS Auditory Memory

Pretest Posttest

Occasion

e Training

Control

AVLT Memory

Pretest Posttest

Occasion

e Training

Control

Processing speed

Pretest Posttest

Occasion

e Training

Control

Smith, Housen, Yaffe, Ruff, Kennison, Mahncke, & Zelinski (2009)

PositScience Memory Training

Positscience Insight Training

Road Tour = Useful Field of View training

Study (16-500 ms) Test (center task: car or truck?)

(peripheral: Location of sign)

Increase difficulty viaCenter task complexityPeripheral target eccentricityPresentation time

Sweep Seeker = Dynamic contrast sensitivity training

Study Test

Increase difficulty viaTightness of resolution

Process training

Cognitive control◦ Dual task; multi-tasking◦ Task switching

Kramer and colleagues (Kramer, Larish & Strayer, 1995; Kramer, Larish, Weber & Bardell, 1999) trained younger and older adults in dual-task performance◦ Some participants were trained in “variable priority”, which

meant dynamically shifting the attention to be paid to a particular task Older adults showed faster rates of dual-task acquisition under

variable priority, higher rates of retention after 2 months, and better transfer to novel dual tasks

Training at the generalizable process level

Li et al. trained spatial N-back in adults aged 20-30 and 70-80◦ Both age groups gained, and showed transfer to closely

related other spatial n-back task, as well as to a numerical n-back task

◦Older adults, but not younger adults, maintained some spatial n-back gains over 3-months, but there was decrement

◦ No evidence for far transfer to more complex working memory tasks

Jennings and colleagues used recollection training◦Older adults often rely on habit rather than recollection in

contexts requiring controlled processing Joint consequence of poorer initial encoding and non-selective

retrieval evaluations◦ Using a shaping paradigm (repetition-lag), train improved

discrimination between originally encoded words and familiarity induced by probe-word repetitions Transfer seen to n-back task, self-ordered pointing, source recall,

and digit-symbol substitition Bissig & Lustig suggest what is trained is “attention to detail”—

more time is spent encoding target information

Dual N-back training

Dual N-back demo (source: Soakyourhead.com)

A square is shown (remember location)

A letter is said (remember what it is)

Arrow points to the “2”. This means that you should remember if the current target(s) match what occurred two trials ago

This square appears in upper left, and the letter “K” is said

In this second trial, a new square appears (upper right), and a new letter (“M”)

In successive trials, one must both match to two trials back, and remember for going forward.

This square again appears in upper left, so hit “A” for matched location

If the letter was also again “K”, hit “L” for matched sound

Physical exercise

Physical Exercise training

Combinatorial treatments

In press

Community dwelling elders aged 62 and older

A 14-day plan based on a proprietary book (Small & Vorgan, The Memory Prescription, 2004, Hyperion, New York)◦ Stress reduction◦ Physical exercise◦Memory training◦ Nutritional changes and supplements

immediate memory (WMS–III, VPA I: total learning, and HVLT-R total learning),

Delayed memory (WMS–III, VPA II, delayed recall, and HVLT-R delayed recall),

memory retention (WMS– III, VPA, and HVLT-R), memory recognition (WMS–III, VPA, and HVLT-R), and verbal fluency (COWAT, animals, fruits, or vegetables)—were assessed. Four factor scores from the MFQ were used to evaluate changes in

subjective memory following the intervention; “retrospective function scale” showed improvement

Underlined values improved significantly from pre-to-post intervention, although control for practice effects may not have been adequately established

For best evaluations◦ True pre-post designs◦With true control groups◦ Ideally, groups receiving individual components◦ Ideally, a broad outcome battery to show specificity of effects

A review of intervention approachesApproach Mediators Outcomes

Physical exercise Perfusion, CNS trophic factors, negative affect

Generally improved cognition, especially executive/controlled processing

Education Generally, cognitive reserve (larger, better connected semantic system)

Entrance in older adulthood at a higher level; typically longer time course to reach an impaired threshhold

Engagement: Social, complex activities

Affect, social functioning, specific leisure product

Improvement in aspects of speed, reasoning

Engagement: Video games Specific trained skill; speed, general meta-cognitive habits

Improvement specifically in visual attention skills, task switching working memory

Strategy training Specific trained skill; general meta-cognitive habits, self-beliefs

Improvement on specific tasks trained; everyday tasks with high saturation of trained ability; self-rated function

Process training (recollection, varied emphasis, dual N-back)

Specific trained skill, general meta-cognitive habits

Improvements, broadly, in detail oriented/elaborative processing (recollection), working memory and reasoning (dual task training)

Thinking about the bigger issues

Prevention Rehabilitation ◦ Cognitive impairment◦Older drivers

The Road Ahead

“Nationally, clinical neuropsychology has not developed data-driven prescriptive treatment programs … [w]hile neuropsychology’s “strong suit” is assessment, this information often is not fully utilized and integrated with treatment. “

“Clinical neuropsychology has to demonstrate its effectiveness in the healthcare market and that means it needs to focus more on treatment and outcome. … Clinical neuropsychology has been defined, in large part, as a neurodiagnostic discipline. But with functional neuroimaging and other neurodiagnostic methods competing with traditional assessment, this aspect likely will not maintain the same level of relevance as it has in the past. “

Quotes from an anonymous reviewer on the “State of Neuropsychology”, 2005.

Interventional Neuropsychology

There is not much consensus on what the critical domains are, and how they should be measured

Can we identify some core outcomes that are (a) meaningful, and (b) plausibly influenced by cognitive training◦ The ACTIVE group selected everyday problem solving,

driving and ADL/IADL ratings

Challenge #1: What is the acceptable transfer outcome?

If the outcome of interest is everyday functioning, are we looking for an immediate transfer? What is the time course?◦ Most healthy community-dwelling elders may be performing

close to ceiling on many typical everyday tasks◦ Are we building a “reserve” of maintained cognitive ability,

which may be drawn upon in the future to attenuate the rate of decline?

◦ This implies that real-world transfer should not be immediate, and may not be seen in terms of heightened performance, but in terms of protected performance (I.e., prevention)

Challenge #2: What is the time course of expected transfer?

So we think of our interventions, instead, as building cognitive reserve? Keeping the underlying skills strong, or even enhancing

them, so that they are available when needed? If reserve-building is the goal,

can single-ability interventions ever work? can short-term interventions ever work? do we need “long-haul” follow-up studies? Are formal tutor-guided programs feasible?

Strategies for prevention

Ample work suggests that retest gains can be almost as great as training-related gains, when testing exposure is equated

There may be qualitative differences in accuracy of responding, especially to items of greater difficulty, following training

Challenge #3: Do we need training at all?

High-road versus low-road transfer?◦ Salomon & Perkins, 1989:◦ Transfer: documenting the effect of learning something on a

different performance or context◦ Low-road transfer: “Transfer of a well mastered skill appears to

take care of itself when an appropriate situation is encountered. It happens automatically…. No far transfer takes place via the low road, but the transfer that does take place is easy and automatic. Sometimes it is even too automatic: your tendency to drive in London on the right despite your knowledge that the right is the wrong side is an example of low road negative transfer.”

Challenge #4: “Bottom-up” or “top-down” interventions? “High road” or “low road”?

High-road versus low-road transfer?◦High-road transfer: Transfer to new situations is not easy and it

does not happen on its own; it requires the mindful abstraction of a principle, the effortful search in one's memory, the selection of the appropriate principle and, finally, its application to a new instance.

Arguably, everything we know about older adults is that teaching for low road transfer (training as close to the criterion task as possible) will maximize outcomes

Gibson’s Top-Down & Bottom-Up

ComplexActivity

BasicAbility

ComplexActivity

The extreme “low road” position would be to train at the level of complex activities, and not at the level of basic abilities◦ Through planful, deliberate exercise of complex tasks, we may

simultaneously exercise the underlying constituent abilities on which those tasks depend, and their coordination. This is the implied mechanism from correlational data suggesting that complex activity as a protective mechanism for late life cognition (e.g., Wilson et al. 2002, Arbuckle, Schooler, Mulatu & Oates, 1999; Schaie, 1983; but see Hertzog, Hultsch & Dixon, 1999)

◦ Do our cognitive interventions need to be “activity prescriptions”? (Denise Park, Liz Stine-Morrow, and Michelle Carlson, among others, all think so).

The problem of intervening at the level of complex activity is that we do not yet have a good understanding of which activities, at which intensity, exercise particular abilities◦What we need is the equivalent of understanding which

“muscle groups” are moved by particular physical exercises

Careful experimental work needs to be done to link particular abilities to particular activities…

Key principles guiding neurorehabilitation over the past 20 years include “Hebbian learning” (i.e., many, many repetitions of tasks to build synaptic circuits), a tailored focus on individual areas of need, and “contextualized learning” (e.g., Ylvisaker et al., 2005; Rehabilitation of Persons With Traumatic Brain Injury. NIH Consensus Statement 1998 Oct 26-28; 16: 1-41.)

So, too, the formal education is designed to provide years of instruction and practice

A challenge, then, is to move beyond the two-week program in training with older adults.

Challenge #5: Lessons from neuro-rehabilitation (and education science)

Cognitive impairment◦ Conventional models have said nothing can be done

That sounds a lot like beliefs about normal aging prior to the 1970s

Pharmacological windows are opening ((e.g., Donepezil; Yesavage et al., 2002; Peterson et al., 2004)

Older drivers

Rehabilitation

1) encourage spontaneous recovery; 2) attempt to retrain areas of impairment; 3) compensate for residual impairments; 4) modify the environment to maximize performance;

and 5) increase self-awareness of performance and behavior.

Farmer & Muhlenbruck (2000)

Basic rehabilitation principles

Key principles guiding neurorehabilitation over the past 20 years include “Hebbian learning” (i.e., many, many repetitions of tasks to build synaptic circuits), a tailored focus on individual areas of need, and “contextualized learning” (e.g., Ylvisaker et al., 2005; Rehabilitation of Persons With Traumatic Brain Injury. NIH Consensus Statement 1998 Oct 26-28; 16: 1-41.)

Basic rehabilitation principles

The challenges to encouraging adults to exercise physically are well documented (e.g., Reeves & Rafferty, 2005), and have been touched on at this conference.

This non-compliance occurs despite (a) documented health benefits; and (b) growing public health messages about exercise

There is not yet a public health culture of “mental exercise”, something P. Baltes has discussed as a “culture of old age”

Cognitive interventionists need to take a page from physical exercise research to maximize compliance (e.g., accountability, logging, cross-training and preferred activities/intensity to boost motivation, “coaching”/monitoring). Like Joan McDowd, there is value in collaborating with our rehabilitation and exercise science colleagues.

Challenge #6: Lessons from physical exercise

Exercise interventions for sedentary elders complete fitness evaluation identification of deficit areas and levels of fitness multi-factorial program to intervene in deficit areas; cross-training adaptive structure (start easy, get harder); increase challenge incorporation of real-world context where possible (e.g., resistance

bands in the apartment; walking 30 minutes a day) no short-term solutions; ongoing monitoring and compliance logging expect high rates of non-compliance

Exercise Science models

So far, for reasons of experimental control, most training studies have intervened on single abilities at a time

Given that most everyday problems studied to date seem to be related to multiple abilities, it seems likely that intervening with multiple abilities would be more successful.

Challenge #7: Single-component or multi-component interventions?

However, if we can extrapolate from studies involving massed versus distributed practice with older adults, ◦ In low-dosage studies, gain in single abilities may be

optimized by massed practice of a single ability◦ In higher-dosage studies, distributed practice (i.e., multiple

components, intermingled) may yield better performance (Kausler, Wiley & Phillips, 1990) and superior transfer (e.g., from a focal ATM to a novel ATM task; Jamieson & Rogers, 2000)

Challenge #7: Single-component or multi-component interventions?

If we are moving beyond relatively brief, laboratory-based, single-ability interventions, tutor-guided individual and group sessions are not feasible for most organizations

How do we disseminate and encourage training program participation?◦We can’t send elders back to school, can we?

Challenge #8: What is the delivery mechanism?

Elderhostel, Institute for Learning in Retirement, etc.◦ Elderhostel servers 200,000 older adults each year, and

offers over 10,000 programs a year in more than 90 countries

◦ The Institute for Learning in Retirement offers university-affiliated programs for elders; there are over 250 such institutes in the US

◦ Thus, in at least a subset of elders, there is hunger for life long learning opportunities. However, by preference, these will be for knowledge domains (e.g., history, art, computers), and not necessarily challenging “fluid” abilities

Computer-based modules◦ E.g., Hermann, Rebok & Plude; Rasmusson, Rebok,

Bylsma, & Brandt, 1999 Videotape based modules◦ E.g., Ball, Owsley, Roenker

Peer and couple modules◦ E.g., Margrett, Saczynski & Willis, 2004;◦ Blackburn, Papalia-Finlay, Foye & Serlin,

Transfer of learning is the influence of prior learning on performance in a new situation.

Conventional wisdom in educational psychology Practicing on a variety of tasks will enhance and quicken the

learning process as compared to practicing on the same category or class.

To produce positive transfer of learning, we need to practice under a variety of conditions.

Transfer is heightened when there is a similarity between the practice context and the real-world context

Thorndike and Woodward in 1901

Transfer of training

Reconsidering the transfer question

The difficulty of achieving transfer of learning is accepted as fact in educational and industrial/organizational literatures

Thorndike (1924): “…the intellectual values of studies should be determined largely by

the special information, habits, interests, attitudes, and ideals which they demonstrably produce. The expectation of any large differences in general improvement of the mind from one study rather than another seems doomed to disappointment…when the good thinkers studied Greek and Latin, these studies seemed to make good thinking. Now that the good thinkers study Physics and Trigonometry, these

seem to make good thinkers.”

Reconsidering the transfer question

Multi-ability training may maximize the “paths” to influencing everyday functioning

Training should directly emphasize transfer, using principles like encoding specificity, organization (Sternberg & Frensch, 1993) or the kind of problem-based successive approximation with individualized feedback proposed by Singley (1995)

So we think of our interventions, instead, as building cognitive reserve? Keeping the underlying skills strong, or even enhancing

them, so that they are available when needed? If reserve-building is the goal,

can single-ability interventions ever work? can short-term interventions ever work? do we need “long-haul” follow-up studies? Are formal tutor-guided programs feasible?

Is transfer the wrong goal?

Is boosting cognition even likely to be helpful in the normal range?

Under normal conditions, individuals may not draw upon all of their “intellectual resources” in the solution of common problems.

In this view, cognitive interventions increase “ability surplus”, and would not be expected to have a direct or immediate effect on everyday cognitive tasks

Transfer may not be seen at time of training, but (under the assumption of preserved training benefits), at the time when normative intellectual decline would begin to compromise everyday task performance. At this time, trained persons would have higher levels of the “resources” needed to support maintained everyday competence.

Some concluding thoughts Plasticity is demonstrated, even in those with initially at-risk status The “more is better” transfer findings suggest larger dosages will be

needed. This means we need to find ways to have people train on their own. The proliferating commercial products may be a step in this direction, but raise questions of empirical validation and quality control.

There is, so far, only modest evidence of transfer to real world function. While this is consistent with 100 years of skills training work, and reflects the complex multi-causal nature of functional ability, it also suggests that there may be room for skill-specific training too

Exciting findings in physical exercise studies, and hope for “engagement” studies, suggest that we may soon have a broad toolkit that we can suggest for cognitive prevention and remediation

Extension of these findings to those who are already impaired will be a major next step, but it will require more individualized, time-consuming and rehabilitative approaches

Questions? Thank you!

Cognitive training with older adults: Intervention, rehabilitation, and engagement approaches

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