In my last post about memory training (that spilled into cognitive training issues), the experts quoted pointed to limitations in the research as well as existing programs tested. The indication was that programs were no better than normal activities that use cognitive abilities, such as discussion and learning. Many older people play word games online to charge up their brains. I have long suspected that much of the draw to American TV shows like The Price is Right (with Bob Barker talking so slowly and directing people so carefully) and Jeopardy (with constant memory testing) was for older folks wanting to challenge their minds even though they were home during the day. Now the older demographic is flooding onto the Internet for even more variety in games and intellectual stimulation.

Since there is such a loud collective “maybe” concerning the use of commercial brain games and clinical programs as preferred alternatives to what we might call “natural” activities, I’ll post some suggestions for enhancing such programs. This is based on the research and articles as well as my own experience with recovery and in working with clients. These are directed to full-blown programs with clinical abilities, but website designers for brain programs, therapists, and regular citizens concerned about their own brain health can use these items to trigger some brainstorming. How about posting what you do for your brain in the comments?

Of course, developers are already brainstorming. A brain-stimulation website called Lumosity.com has augmented it’s games with articles containing tips for enhancing brain health through means such as exercise and nutrition. But then, such articles are ubiquitous.

The Recommendations

1. Providers must get better at targeting specific functions that they determine to be most important to shore up each individual’s overall functioning. And for people without impairments, designer programs might prepare people for improved performance for other reasons. What about a waiter that is having difficulty remembering who ordered what, not because he or she is impaired, but because the waiter wants to excel or keep up with other staff that are better at it? Skills that are more sophisticated than brute force memory can be offered by such designer programs. There is already evidence that “reasoning” group training can have a good impact on daily living in the elderly.

Of the three types of training in the individual study cited in the first post, only reasoning training improved functioning in everyday activities (IADLs or instrumental activities of daily living). The other two trainings, speed of processing and memory, did not.

How about a staff person that wants to be more indispensable at work, and feels it will require better logical and synthetic analysis of problems that are discussed in staff meetings? I had a personal experience along these lines after brain injury. I spent roughly a year intensely studying hundreds clinical problems provided by a test-preparation organization (so the answers were actually available) and observed my ability to draw conclusions about subtle differences between viable clinical judgments improve markedly over that period). Note that the answers involved selecting from several groupings drawn from sixteen answer components (unique to each question). This meant that two or more answers would often be very close calls as to which was best. Further, the test for which I was preparing had a nearly 50% failure rate. (I passed.)

In exploring ways to improve effectiveness, says Medscape, Dr. Martin (from the previous post) is developing training that activates multiple skills through “goal-related cognitive activities” that include motor and cognitive tasks of diverse kinds. They measure “individual needs and goals for improvement” to customize their approach.

2. Providers should draw from real life to produce training activities as much as possible. I think this would help with motivation (choosing from various enjoyable activities would probably produce better compliance and engagement than being given something that seems artificial). But for many folks, the real kicker would be that they would be using their time productively in additional areas of life such as language learning, building social support, and cultivating artistic or musical skills. If there is resistance to this idea among any professionals, they should take inventory as to their motives. The subconscious can be very tricky in biasing us, and I’ve seen good professionals interfere with good ideas because of turf issues, all the while convinced of their purity.

3. Providers should think in terms of active ingredients, with a prime example being the social dimension. Research has been very supportive of social activity. If the training activities parallel (or actually are) normal life activities, many would be social, or could be converted into social activities. Since reasoning training is proving helpful, discussion is probably very helpful. In fact, it was one of the types of activities of the active controls (non-trained group that had improvement). Among the activities was an art discussion group.

4. Programs should address more variables, such as mood, psychosocial support and psychosocial problems. Many clinicians fall too easily into the “brain in a jar” syndrome of thinking that their job is done because they conformed to a limited definition of the outcome or job they are performing. It is very important that programs addressing cognitive impairment look at the other issues that often arise. For example, even a “small” level of cognitive impairment makes many people experience difficulties managing their lives. The resulting stress can be part of a spiral affecting mood, finances, and relationships. Conversely, mood problems such as depression can contribute to cognitive problems. Assessment should include financial difficulties and whether the person is being conned or manipulated by anyone, including family members. Finances are among the first areas to go out of whack with mounting cognitive issues because of mismanagement, forgetting, or being manipulated. Many con artists specialize in manipulating elderly people or anyone they size up as having cognitive problems. Even the Readers Digest Sweepstakes has been accused of being manipulative of this demographic. For example, they have sent money requests that look like bills. I reported them to the authorities for this. I feel very protective of our elders. I hope you do, too.

5. Programs should have more hours and longer duration. At least this is one factor that researchers speculate may make the difference. Most research has involved rather limited time periods for intervention. The fact that they have demonstrated effectiveness parallel to related life activities despite this limitation is a very good reason to include a “more is better” hypothesis. However, in some conditions, booster sessions were not helpful, so we clearly have a lot to learn.

6. Programs should incorporate the forms of training that have been proven to be effective, even if they are mainly gung-ho about training that has yet to be proven. However, note that a complaint about the available data was that there was not enough diversity in the programs to be very enlightening. (Too much “heterogeneity.”)

7. Programs should include lifestyle factors as programmed activities (or at least as activities promoted through education). Exercise has a great deal of support in cognitive enhancement and maintenance. Safe practices for exercise should be included. I’m a big fan of myofascial conditioning (such as through trigger point therapy and massage, which can be self-applied with body tools). Nutritional factors such as avoiding trans-fatty acids are coming to the fore as well.

8. It can be very helpful to desensitize and reprocess losses and other issues associated with cognitive decline, such as stigma. Cognitive abilities comprise a tremendous share of what people feel makes them “who” they are, even how human they are. The stigma associated with cognitive issues is harsh and unconscious. People apply it to themselves unconsciously. Treatments such as coherence therapy and eye movement desensitization and reprocessing (EMDR) should be available or at least recommended and explained. In the spirit of draining the swamp to find out where the alligators are, using a treatment like EMDR for desensitization may remove some symptoms of cognitive decline that were based in trauma. With this handled, it is clearer what cognitive problems need to be addressed in their own right.

9. Programs should help to identify and habituate self-management behaviors that will aid people in staying safe and organized. People with cognitive problems are very dependent on external structure and input for success. I have seen people make the same mistake over and over (like not being able to find their medication) until someone helped them focus and establish a special place for it. Even for someone still living at home, input that helps them see the importance of adapting to their changing needs as they age can be very valuable. I have helped families hire “success coaches” to drop in on people who had such difficulties. They helped the person structure their lives. I got this idea from working with developmentally disabled people as an independent living skills training about a million years ago, give or take.

References

Johnson, K. (2011). Cognitive training to improve memory just as effective as other intellectual activities. Medscape Medical News, January 25.

Martin M, Clare L, Altgassen AM, Cameron MH, & Zehnder F (2011). Cognition-based interventions for healthy older people and people with mild cognitive impairment. Cochrane database of systematic reviews (Online), 1 PMID: 21249675

Willis, S., Tennstedt, S., Marsiske, M., Ball, K., Elias, J., Koepke, K., Morris, J., Rebok, G., Unverzagt, F., Stoddard, A., Wright, E., & , . (2006). Long-term Effects of Cognitive Training on Everyday Functional Outcomes in Older Adults JAMA: The Journal of the American Medical Association, 296 (23), 2805-2814 DOI: 10.1001/jama.296.23.2805

Example Programs (This does not constitute any kind of endorsement)

UCSF Memory and Aging Center: Emphasizing evaluation, treatment and research.

Memory Training Centers of America: A commercial/clinical program that integrates into living situations for the elderly.

CSEP: Vocational rehab for cognitively impaired (example of a type of program that contracts with states).

PACE: Example of a program for children.