Definition of Cognitive Training

Question:

Discuss About The Cognitive Training Treatment Of Dementia?

Cognitive training (CT) is a guided practice in which a patient is guided on a set of standardised activities aimed at reflecting given cognitive functions that include memory, attention and problem-solving. The definition of cognitive training is “a structured practice of complex mental activity aimed at enhancing cognitive function” (Takeda, Tanaka, Okochi, & Kazui, 2012). To delineate cognitive training from other interventions, an operational definition is adopted. As per the operational definition, cognitive training involves repeated activities on identified problematic areas, with the use of tests that are standardises, and also targeting specific cognitive domains” (Gates, Sachdev, Fiatarone, & Valenzuela, 2011). The tasks are tailored based on the patient’s individual performance capacity and adaptive training. The tasks taken under cognitive training involve analogues of activities of daily living and their availability is evolving and they are now available through computerised packages is now possible alongside the traditional paper-and-pencil (Bahar-Fuchs, Clare, & Woods, 2013).

The primary assumption that underlies the practice is that practice has the potential of improving or maintaining an individual’s functioning in a particular domain. One more postulation is that any accrued effect from the practice translates generally past just the context of the training. The last assumption has however been debated and argued otherwise (Owen, Hampshire, Grahn, Stenton, & Dajani, 2010), but this contradiction of failure of transferability is as a result of problems in task design (Jaeggi, Studer-Luethi, Buschkuehl, Su, & Jonides, 2010). Evidence from the last decades has shown cognitive training to be quite an effective therapy for dementia. Cognitive training has shown to produce modest substantial benefits in the treatment of dementia to produce primary positive cognitive outcomes (Kallio, Öhman, Kautiainen, Hietanen, & Pitkälä, 2017). This paper is a critical analysis of cognitive training as a treatment modality for dementia. It reviews literature for- and against- it with an aim of justifying its application.

Cognitive training is often promoted as an effective modality for the treatment of dementia. It is often considered as an effective alternative intervention for a number of reasons, notably, it has minimal risk and contradiction compared to other strategies do, and it is also preferred by the elderly (Rodakowski, Saghafi, Butters, & Skidmore, 2015). The impacts of the intervention in dementia patients have been studied for the last several decades, with a majority indicating it having a desirable cognitive rehabilitation and enhancement training and constructive effect on patients presenting with dementia and other forms of cognitive diseases. Study findings have further demonstrated that some elements of cognitive training in seniors is associated with the improvement in neuropsychological and neurophysiological dimensions (Mowszowski, et al., 2014). Likewise, there is evidence of the therapy having positive effects on well-being, mood and stress, in persons presenting with the condition and also those without any cognitive condition but take specialised cognitive exercises. Regardless of the minimal evidence on the efficacy of the intervention in delaying problems in an individual’s daily functioning, some studies such as a randomised trial by ACTIVE established that advanced cognitive training produces positive effects, with minimal decline in instrumental activities of daily living (IADL), alongside preventing and reducing the risk of the development of decline in functioning among dementia patients during their old age (Rebok, et al., 2014).

Assumptions underlying Cognitive Training

Drawing on evidence from a number of studies, the effectiveness of cognitive training can be established. For the purposes of this paper, reference is drawn to two research studies. One is a 2013 review by Bahar-Fuchs and fellows and another study from 2016. The aim of the 2013 review was to appraise the existing evidence on the efficacy of the therapy on persons with Alzheimer’s disease (Bahar-Fuchs, Clare, & Woods, 2013). The researchers identified eleven studies which met the inclusion criteria. The meta-analysis did not detect any adverse effects of the modality. This finding counteracts earlier proposals from other commentators such as Small, et al., (1997) who claim that there is a likelihood of the process to have negative impacts such as on mood.  The review identified both short and long term positive benefits of cognitive training which include improved memory capacity, satisfaction in the attainment of personal goals, and the general quality of life (Bahar-Fuchs, Clare, & Woods, 2013).

The aim of the 2016 study by Giuli, Papa, Lattanzio, and Postacchin was to examine the impacts of CT as a nonpharmacological intervention among elderly persons who exhibit one of 3 unlike cognitive statuses. The results of the analysis showed that the participants accrued positive immediate outcomes compared to the controls who had been recruited for the study. The results from the study supported the statement that cognitive training could be used as an operative intervention in the treatment of dementia in the elderly with/without cognitive decline, as reported in other studies which include Huckans, et al., (2013) and Choi & Twamley, (2013). However, some others claim that there is a lack of theoretical rehabilitation model to serve as a guide in assessing cognitive training, as a result, it is recommended to take into consideration various aspects when managing patients with cognitive deficits, precisely those with dementia (Huckans, et al., 2013). As a result, it is always indicated to use comprehensive multi-modal cognitive training which also incorporates compensatory and restorative approaches to the elements of psychological support for the disorders and advice for lifestyle intervention (Buschert, et al., 2011).

The primary scope of the study (Giuli, Papa, Lattanzio, & Postacchin, 2016) was to demonstrate that comprehensive cognitive training had the potential of producing positive effect among elderly people presenting with various cognitive statuses. To eliminate any biases, Giuli and fellows adopted a multidisciplinary approach whose main strength is to facilitate the analysis of the role played by various actors that come into play in the management of rehabilitation and enhancing the cognitive functions in elderly persons. Another notable set of results from the study were evidenced in the dimensions of memory, metamemory, self-efficacy, and “confidence of own memory”. The subject’s level of complaints on difficulties on carrying out activities of daily living was diminished, owing to improved performance in the perception of mnemonics (Giuli, Papa, Lattanzio, & Postacchin, 2016).

Effectiveness of Cognitive Training on dementia patients

Findings from various studies coupled with the most recent by Giuli and fellows have demonstrated improvements in the patients’ cognitive performance and psychological status, which are often observed in the immediate of the training. Likewise, patients without any form of cognitive deficit who have also undergone cognitive intervention have also shown to improved performance especially in memory and learning processes. This conclusion is not only made by Giuli and others (2016) but by another very recent study by Rahe, Petrelli, Kaesberg, Fink, Kessler and Kalbe, (2015) who concluded that cognitive training or cognitive training combined with protective factors such as physical activity (CPT) produces stronger long-term effects on attention.

The findings of these two papers, however, contradict with the findings of a study conducted in 2013 whose aim was to analyze the effectiveness of CT in patients who had Alzheimer’s disease and also to provide an also estimate its feasibility (Alves, et al., 2013). The findings of the review showed the effect of the intervention on the subjects was only in global cognitive functions (which were assessed using a Mini-Mental State Examination (MMSE)), and not in other cognitive functions. However, it was observed that the subjects recorded a reduced level of perceived psychological stress. This is a confirmation of an observation made by various authors who have made conclusions in their studies that cognitive training has a beneficial impact on the psychological status of those receiving it (Reijnders, van Heugten, & van Boxtel, 2013).

Most of the studies often obtain results which illustrate improvements in different memory and learning cognitive tests, alongside selective attentive processes and verbal fluency, which is not in the case in those not treated with the intervention. These conclusions are strong indicators that cognitive training can produce positive impacts on cognitive performance in patients with a mild cognitive decline, or early dementia before conversion to full-blown dementia (Valenzuela & Sachdev, 2009). An additional observation made by Valenzuela and Sachdev is that cognitive training confers a protective effect on longitudinal neuropsychological performance in patients with any form of dementia.

Supported by evidence from Giuli, Papa, Lattanzio, and Postacchin, (2016), subjects subjected to cognitive training improve in cognitive functions (memory, attention) and also in the degree of dementia. These patients also show a better mood status compared to those not treated with the intervention. The effect of cognitive training is also supported by findings in other studies, which have shown an evidenced improvement in mood status in dementia patients treated with the intervention (Rodakowski, Saghafi, Butters, & Skidmore, 2015).

Studies supporting the Effectiveness of Cognitive Training

It is also advisable to discuss how the intervention generally impacts a dementia patient in his or her daily living. This can be assessed using the Instrumental Activities of Daily Living Scale (IADL). Study findings have also shown that a large intervention effect in subjects with Alzheimer’s disease and also an intermediate effect in persons with mild cognitive impairment (MCI) (Giuli, Papa, Lattanzio, & Postacchin, 2016). This effect could be related to numerous variables which undoubtedly cause a complex relationship. Regardless, it is possible to point out some possible explanations, which according to Rebok, et al., (2014) includes the possibility that cognitive training produces changes in both behavior and social interactions, and this supports a patient’s engagement in functional activities. Further, there is also the likelihood that the patient’s improvement in his/her psychological characteristics, awareness and confidence in their abilities confers a positive effect on their capacity to plan and master activities of daily living. One of the hypotheses made with regard to an individual’s sense of control (even in the diseased status ) in aspects of daily living activities and setbacks plays a role in the delay of the onset of functional disabilities (Cooper, Huisman, Kuh, & Deeg, 2011).

In summary, cognitive training has shown positive effects of some outcomes immediately following the intervention. The intervention enables patients to learn new strategies in the use of memory and cognitive functions, and this presents a benefit to the patient, evidently in the dimensions of improving personal self-esteem and reducing psychological diseases. This generally improves the patient’s wellbeing and quality of life and may enable him or her life independently for a long period of time. The positive impact of cognitive training as a preventive and intervention for dementia permits its usage as a non-pharmacological intervention in reducing costs associated with the treatment of dementia especially in elderly persons, alongside the costs incurred in caregivers, and this has a positive impact on health systems of any country. Multidimensional cognitive training also serves as an important instrument in the secondary prevention of dementia-related symptoms, alongside improving the quality of life of those affected. Based on a review of literature in 2017 by Kallioa, Ohman, Kautiainen, Hietanenb, and Pitkala, cognitive training has evidenced positive effect on the following dimensions of dementia patients. The best performance is in the domain of memory in which 5 of the studies reviewed by the authors showed significant improvement in episodic, semantic and episodic autobiographical memory. In the domain of executive functioning, three studies reported that cognitive training had a positive impact on executive function and abstract. With regard to the domain of attention, only one study had reported a significant improvement in processing speed. In language, four studies have shown that the intervention improves both verbal functions, episodic memory, and working memory. On the contrary, in the performance in the domain of visual perception, there is only one study that has documented a positive result (Kallioa, Ohman, Kautiainen, Hietanenb, & Pitkala, 2017). Generally, cognitive training is a viable intervention.

Studies contradicting the Effectiveness of Cognitive Training

Specific types and doses of cognitive training have the ability to delay the onset of dementia. This claim was provided by a randomised controlled trial known as The Advanced Cognitive Training in Vital Elderly study (ACTIVE) conducted between 1998 and 2004. ACTIVE is the largest study carried so far that has demonstrated that cognitive training improves cognitive functioning in elderly adults (Willis, et al., 2017). The authors demonstrated that cognitive training could confer the effects over a period of five years with evidence that improved cognitive function significantly improves daily functioning. Notable findings from the ACTIVE study with regard to the prevention of dementia, the study established that in elderly persons, the risk of dementia is reduced by forty-eight percent within a decade when the subjects undertook a total of ten or more sessions of cognitive training (Willis, et al., 2017). According to Willis and fellows, the risk of dementia is reduced by eight percent for each session of cognitive training.

This evidence especially reinforces modern cognitive training which is basically computerised, diverting from the earlier form of pencil-and-paper. There is no other drug or device with the ability to change the incidence of dementia. Mental activity, on the other hand, provides a greater “brain reserve” which reduces the risk of dementia by forty-six percent (Valenzuela & Sachdev, 2009). Continued participation in mentally stimulating activities can delay the development of cognitive and functional decline, especially in elderly persons. Overall, cognitive training programs have generated evidence to indicate that they boost both memory, speed of processing, problem-solving and reasoning. At the moment when “it is fiendishly complicated to do randomized controlled trials on more than one intervention at a time” (Begley, 2017), the multifaceted approach in preventing dementia is not feasible, hence leaving cognitive training as the online option.

The literature review above investigates on the significance of cognitive training as a treatment modality for dementia. It is evident that cognitive training can improve cognitive functions of persons with or without dementia. Some of the domains that cognitive training has shown to improve include immediate and delayed memory, executive functioning, attention, cognition, processing speed, neuropsychological status and visuospatial construction.

Thus, the ability of the modality to improve cognitive function can be regarded as a useful, affordable and easily accessible tool that can be used in the management of dementia, and also as a preventive tool to prevent age-associated cognitive decline in ageing individuals. Cognitive training can also be improved by combining with other modalities such as physical training and pharmacological approaches.

As recommended by some authors, cognitive training alone or combined with other intervention methods (pharmacological or non-pharmacological) can improve some aspects of cognition in patients presenting with dementia.

This paper offers evidence supporting the efficacy of the intervention. Based on the reported studies and reviews, there is evidence of gains resulting from cognitive training. This, however, does not completely ignore the doubts raised in the scientific community for the lack of a large-scale randomised controlled trial which can test the efficacy of cognitive training alongside other interventions. This is owed to the neurobiology of dementia which calls for a multifaceted approach in the dimension of prevention

References

Alves, J., Magalhães, R., Thomas, R., Gonçalves, O., Petrosyan, A., & Sampaio, A. (2013). Is there evidence for cognitive intervention in Alzheimer disease? A systematic review of efficacy, feasibility, and cost-effectiveness. Alzheimer Dis Assoc Disor, 195-203.

Bahar-Fuchs, A., Clare, L., & Woods, B. (2013). Cognitive training and cognitive rehabilitation for mild to moderate Alzheimer’s disease and vascular dementia (Review). The Cochrane Library, 1-73.

Begley, S. (2017, June 22). Preventing Dementia: New Report Says Not Much Is Proved to Work. Retrieved from Scientific America: https://www.scientificamerican.com/article/preventing-dementia-new-report-says-not-much-is-proved-to-work/

Buschert, V., Friese, U., Teipel, S., Schneider, P., Merensky, W., Rujescu, D., . . . Buerger, K. (2011). Effects of a newly developed cognitive intervention in amnestic mild cognitive impairment and mild Alzheimer’s disease: a pilot study. J Alzheimers Dis., 679-94.

Choi, J., & Twamley, E. (2013). Cognitive rehabilitation therapies for Alzheimer’s disease: a review of methods to improve treatment engagement and self-efficacy. Neuropsychol Rev., 48-62.

Cooper, R., Huisman, M., Kuh, D., & Deeg, D. (2011). Do positive psychological characteristics modify the associations of physical performance with functional decline and institutionalization? Findings from the longitudinal aging study Amsterdam. J Gerontol B Psychol Sci Soc Sci., 468-77.

Gates, N., Sachdev, P., Fiatarone, S. M., & Valenzuela, M. (2011). Cognitive and memory training in adults at risk of dementia: a systematic review. BMC Geriatr., 55-69.

Giuli, C., Papa, R., Lattanzio, F., & Postacchin, D. (2016). The Effects of Cognitive Training for Elderly: Results from My Mind Project. Rejuvenation Res, 485-494.

Huckans, M., Hutson, L., Twamley, E., Jak, A., Kaye, J., & Storzbach, D. (2013). Efficacy of cognitive rehabilitation therapies for mild cognitive impairment (MCI) in older adults: working toward a theoretical model and evidence-based interventions. Neuropsychol Rev, 63-80.

Jaeggi, S., Studer-Luethi, B., Buschkuehl, M., Su, Y., & Jonides. (2010). The relationship between n-back performanceand matrix reasoning-implications for training and transfer. Intelligence, 625–35.

Kallio, E., Öhman, H., Kautiainen, H., Hietanen, M., & Pitkälä, K. (2017). Cognitive Training Interventions for Patients with Alzheimer’s Disease: A Systematic Review. J Alzheimers Dis, 1349-1372.

Kallioa, E.-L., Ohman, H., Kautiainen, H., Hietanenb, M., & Pitkala, K. (2017). Cognitive Training Interventions for Patients with Alzheimer’s Disease: A Systematic Review. Journal of Alzheimer’s Disease, 1349-1372.

Mowszowski, L., Hermens, F., K, D., Norrie, L., Cockayne, N., Ward, P., . . . Naismith, S. (2014). Cognitive training enhances pre-attentive neurophysiological responses in older adults ‘at risk’ of dementia. J Alzheimers Dis., 1095-108.

Owen, A., Hampshire, A., Grahn, J., Stenton, R., & Dajani, S. (2010). Putting brain training to the test. Nature, 775-8.

Rahe, J., Petrelli, A., Kaesberg, S., Fink, G., Kessler, J., & Kalbe, E. (2015). Effects of cognitive training with additional physical activity compared to pure cognitive training in healthy older adults. Clin Interv Aging, 297-310.

Rebok, G., Ball, K., Guey, L. J., Kim, H., King, J., Marsiske, M., . . . Willis, S. (2014). Ten-year effects of the advanced cognitive training for independent and vital elderly cognitive training trial on cognition and everyday functioning in older adults. J Am Geriatr Soc., 16-24.

Reijnders, J., van Heugten, C., & van Boxtel, M. (2013). Cognitive interventions in healthy older adults and people with mild cognitive impairment: a systematic review. Ageing Res Rev, 263-75.

Rodakowski, J., Saghafi, E., Butters, M., & Skidmore, E. (2015). Non-pharmacological interventions for adults with mild cognitive impairment and early stage dementia: An updated scoping review. Mol Aspects Med., 38-53.

Small, G., Rabins, P., Barry, P., Buckholtz, N., DeKosky, S., Ferris, S., . . . Khachaturian, Z. (1997). Diagnosis and treatment of Alzheimer disease and related disorders: consensus statement of the American Association for Geriatric Psychiatry, the Alzheimer’s Association and the American Geriatric Society. JAMA, 1363–1371.

Takeda, M., Tanaka, T., Okochi, M., & Kazui, H. (2012). Non-pharmacological intervention for dementia patients. Psychiatry and Clinical Neurosciences, 1-7.

Valenzuela, M., & Sachdev, P. (2009). Can cognitive exercise prevent the onset of dementia? Systematic review of randomized clinical trials with longitudinal follow-up. Am J Geriatr Psychiatry., 179-87.

Willis, S., Tennstedt, S., MArsiske, M., Ball, K., Elias, J., Koepke, K. M., . . . Wright, E. (2017). Long-term Effects of Cognitive Training on Everyday Functional Outcomes in Older Adults. JAMA, 2805-2815.