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Tech Revolution: Behavioral and Cognitive Interventions

Series - Will Technology Revolutionize Dementia Diagnosis and Care?:

Could playing a computer game or video chatting with friends help you ward off Alzheimer’s disease? This sounds like a tall order, though epidemiological evidence consistently links high lifetime levels of cognitive and social stimulation to a lower risk of getting AD (see, e.g., ARF related news story; ARF news story; ARF news story; and ARF news story). Such lifestyle findings have made researchers wonder if mental training or social activity in late life could protect the brain. The boom in computer and personal technology use makes this approach appealing, as technology provides tools for reaching homebound older adults. Such interventions have the advantage of being safe and relatively cheap compared to most pharmacological agents. But do they work? Studies of specific approaches have often come up short (see, e.g., ARF related news story; ARF news story), leaving unanswered the question of whether late-life mental stimulation can slow cognitive decline.

“There has never been a really good test of cognitive remediation,” John Harrison at Metis Cognition, Warminster, Wiltshire, U.K., told Alzforum. Still, he believes the strategy could work. “We have a sense we can still help patients in the very early stages by tutoring them on cognitive tasks, in the hope that it will preserve cognition for a little longer.”

Although many groups have developed brain-training software and cognitive interventions, often these approaches do not get validated in clinical trials due to the high costs of testing. For example, the European-based HERMES project, an EU-funded collaboration between organizations in six countries that ran from 2008 to 2011, developed a technology to assist older adults with daily life and support cognitive functions. The hope was that this would allow people to maintain their independence longer. Specifically, the system helps people with mild memory problems remember past events and keep track of future plans. A mobile phone and a home computer with two webcams allow users to record portions of their day and later play them back to refresh their memories of events. A calendar and personal data assistant (PDA) help seniors remember upcoming events. The computer also contains several cognitive games: mazes, jigsaw puzzles, and a program that trains users how to remember people’s names. Over three years, the HERMES team built and refined a prototype using input from older adults who were either cognitively healthy or had age-related memory loss. They also tested the system in a handful of user homes.

“The elderly [participants] were able to learn how to use the system, and were happy with it,” said Mari Feli Gonzalez at INGEMA Foundation, Spain, who worked on the project. She added that the team learned about designing interfaces for older adults, as well as the difficulties involved in taking a computer system from the lab to a real-world home environment. In the home, the system sometimes broke down due to the users’ unfamiliarity with technology, which led them to push the wrong buttons and freeze the programs. Gonzalez noted that the system would need to be made more robust for home use. However, the HERMES project has ended and the team has no current plans to market the technology, Gonzalez said. The project also had insufficient funding to test whether using the system long term prevented cognitive decline.

Some commercial brain-training companies have raised millions of dollars to test cognitive interventions. One example is Lumosity, a seven-year-old company based in San Francisco, California, that provides online cognitive training through a suite of games and boasts 30 million users worldwide. Lumosity conducts studies based on its enormous dataset of users, who agree to provide anonymous demographic information and game play data to the company. The company has presented findings from its database at neuroscience conferences. Lumosity was co-founded by a Stanford neuroscience PhD candidate and consults a scientific advisory board to help develop its interventions. In its Human Cognition Project, Lumosity partners with more than 1,500 researchers worldwide to test the efficacy of its games in various populations, said program manager Elizabeth Ricker. Researchers gain access to Lumosity’s cognitive tools, its assessments, and its database on human cognitive performance. In order to maintain objectivity, the company does not currently fund researchers directly, Ricker added.

However, to date, few published studies have looked at whether Lumosity’s training programs slow cognitive decline in older adults. One study on people with mild cognitive impairment, led by Maurice Finn at the University of New South Wales, Australia, found that 16 participants who completed 30 cognitive training sessions developed better visual sustained attention compared to a control group. The intervention did not improve everyday memory abilities or mood, Finn reported (see Finn and McDonald, 2011). Lumosity is currently pursuing MCI and aging studies with independent researchers in four different countries. One such ongoing clinical trial at University College London, U.K., tests a combination of Lumosity cognitive training with physical and social interventions in 128 people with MCI to see if the treatment delays dementia onset.

The London-based brain-training company My-Cog is also starting clinical trials of its intervention. Similar to the HERMES project, My-Cog has developed a three-pronged approach to keeping older people cognitively active and living at home. An online virtual assistant helps people remember appointments and tasks, while a computerized “memory box” will include photos of important people and places in the user’s life, as well as linking the participant to an online community of close friends and relatives who share those memories, said CEO Claire Mitchell. Cognitive games make up the third aspect of the intervention. To keep the games interesting enough to hold people’s attention over months of play, the company has partnered with gaming companies to develop a game with a full graphic interface in which participants control an avatar and have to complete various tasks. Clinicians, neurologists, and psychologists helped design the tasks to exercise working memory, executive function, and attention, Mitchell said. Users will take cognitive pre-tests that will assign a gaming “prescription,” as well as occasional ongoing tests to track people’s status and flag problems. (See also Wall Street Journal blog, in which Harrison, who consults for the company, describes a prototype of the game.)

A 12-week pilot trial of the game starts in January 2013. It will include 450 junior high and high school students (300 who will play the game and 150 controls), as well as 60 people with AD and 20 people with Parkinson’s disease. Hugo de Waal at Norfolk and Waveney Mental Health Trust, Norwich, U.K., and Bastiaan Bloem at Radboud University Nijmegen Medical Centre, the Netherlands, lead the trial. This pilot will test whether the system is easy to use and keeps people engaged, Mitchell said. A full Phase 1 trial of 300 people with AD and PD is currently recruiting for a planned start in summer 2013.

While many groups have tried to devise cognitive interventions, few studies have examined the cognitive effect of promoting social engagement in the elderly with technology. One such project is the pilot video chatting study run by Hiroko Dodge at the Oregon Center for Aging and Technology (ORCATECH) in Portland. Dodge plans to enroll 100 participants with normal cognition or mild memory problems into a clinical trial. All participants will take the CAMCI and CogState computerized cognitive tests, as well as standard neuropsychological exams, before and after the study. Half the participants will receive a social intervention every day for six weeks, in the form of a 30-minute video phone call from a researcher. The calls will use a standardized protocol that includes quizzes, picture descriptions, and a chat about what the participant did the day before.

Dodge is currently recruiting participants, and expects to begin collecting data next year. She noted that one reason to try social stimulation instead of cognitive is because computer games can require a high level of cognitive ability. “We thought conversation, which anyone can do, might be more accepted by people with cognitive decline or impairment,” Dodge said. People with mild cognitive impairment tend to dread cognitive testing, in part because it is difficult and shows them their impairment. If Dodge sees improved scores on cognitive post-tests in this trial, she will test a larger group of people to investigate whether cognitively normal people or those with mild cognitive impairment benefit more from the intervention.

Since epidemiological evidence suggests that cognitive, social, and physical activity all slow cognitive decline and lower the risk for AD, would combining these three types of intervention give more bang for the buck? Another study at ORCATECH addresses that question. Led by Holly Jimison, the study follows 33 cognitively healthy adults, average age 85, who live at home. “We focus on building cognitive reserve and delaying decline,” Jimison said. Participants play a range of computer games that allow the researchers to monitor memory, attention, planning, and verbal fluency over time. The researchers enrolled family members who live far away and encouraged them to make Skype video calls to their elders. Often, the older adults in the study would log in to the system and not see a family member available, but would find other people in the study online. Participants began chatting with each other and formed close friendships, Jimison said. “We lean now toward including participants as part of their own social network.” In addition, the study monitors participants’ physical activity, sleep, and general health. A “health coach” receives the data and works with the participant on behavioral interventions, for example, setting up an exercise program, suggesting ways to improve sleep, and teaching relaxation techniques.

Jimison’s current goal is to show that the system is feasible. “We are first trying to show that we can keep people engaged and facilitate a coach in reaching a large number of clients. We want to make this scalable and cost effective.” Then she wants to test the system in a large clinical trial and adapt it for different cultural groups. Her ultimate goal is to slow cognitive and physical decline. “If we can delay symptoms, we can improve quality of life and influence cost and caregiver burden,” Jimison said.

Many older adults lose their independence due to a fall or accident. A broken hip or ankle can land a previously self-sufficient person in a nursing home, often for life. A study at the Technology Research for Independent Living (TRIL) Centre, based in Dublin, Ireland, looks at how technology might reduce this risk. Research suggests that elderly people are less mentally alert at certain times of the day, leaving them prone to accidents and falls, noted academic director Brian Caulfield. Therefore, participants in the “Training for Focused Living” project, led by Ian Robertson at Trinity College Dublin, receive in the mail an alertness training packet that consists of a booklet, a CD, and a biofeedback device. Over four weeks, participants read the booklet and learn specific exercises to sharpen their focus. For example, people will pick a “prime word” that helps them visualize something that gets them excited, such as a sporting event. Then participants use the biofeedback device to see if that increased their physiological arousal. The device consists of two finger-cuff electrodes that measure galvanic skin resistance as a surrogate measure of brain electrical activity. Users see visual feedback on an LCD screen embedded in a cushion they place in their lap. (Caulfield noted that during the design process, participants would typically place the screen on a lap cushion for viewing, so the researchers incorporated the device into such a cushion.)

 

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Measuring physiologic arousal with finger-cuff biofeedback device. © TRIL Centre

Once participants have learned to boost their alertness, they can apply the technique during low points in the day. For example, if a person has just eaten lunch and feels a bit sleepy, he or she can perform the exercise before standing up to walk to the bathroom. The researchers expect that being more alert will reduce a person’s risk of falls. As a side benefit, the training also seems to help with cognition. “We have done a prospective trial of this training program and found that it had positive effects on executive order functions,” Caulfield said, citing improvements on measures of category fluency and the Vigilant Auditory Attention Test. “Essentially, we are trying to tap into the cognitive reserve a person might have.” Robertson would like to scale up the technology and make it widely available, Caulfield noted.

Time will tell whether any of these strategies pan out. Even so, in the absence of effective pharmaceutical agents to treat AD, the field of tech-driven cognitive stimulation is likely to burgeon, Harrison said. Computers and personal electronics are also changing how scientists diagnose AD, and how people monitor and care for loved ones with dementia, as described in the earlier installments of this series. Altogether, technology appears poised to infiltrate the way we age.—Madolyn Bowman Rogers.

This is Part 4 and the final installment of this series. See also Part 1, Part 2, Part 3. Read a PDF of the entire series.

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References

News Citations

  1. Not Just Fun and Games—Cognitive Engagement Deters Amyloid
  2. Imaging Studies Support Cognitive Reserve Theory
  3. Chicago: Does Saying “I Do” Lower Late-life Dementia Risk?
  4. Add Mental Exercise to Potential AD Protection
  5. Brain Training Falls Short in Big Online Experiment
  6. The ACTIVE Trial—Long-Term Effects of Cognitive Training
  7. Will Technology Revolutionize Dementia Diagnosis and Care?
  8. Tech Revolution: Monitoring and the Power of Real-Time Data
  9. Tech Revolution: Help or Hal? Smart Homes to Ease Elder Care

Other Citations

External Citations

  1. HERMES project
  2. Lumosity
  3. Human Cognition Project
  4. Finn and McDonald, 2011
  5. ongoing clinical trial
  6. My-Cog
  7. Wall Street Journal blog
  8. pilot video chatting study
  9. Oregon Center for Aging and Technology
  10. clinical trial
  11. CAMCI
  12. Another study
  13. Technology Research for Independent Living (TRIL) Centre

Further Reading

This article also appears within the series: Brave New World? Technology in Dementia Diagnosis, Care

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