2013 reijndersa cognitive interventions in healthy older adults and mci

8/19/2019 2013 Reijndersa Cognitive Interventions in Healthy Older Adults and MCI

1/13

Ageing Research Reviews 12 (2013) 263–275

Contents lists available at SciVerse ScienceDirect

Ageing Research Reviews

j ournal homepage : www.elsevier .com/ locate /arr

Review

Cognitive interventions in healthy older adults and people with mild cognitiveimpairment: A systematic review

Jennifer Reijnders a,∗, Caroline van Heugten a,b, Martin van Boxtel a,b

a Department of Psychiatryand Neuropsychology, School for Mental Health and Neuroscience, Maastricht University Medical Centre, Maastricht, The Netherlandsb Department of Neuropsychologyand Psychopharmacology, Faculty of Psychology and Neurosciences, Maastricht University, Maastricht, The Netherlands

a r t i c l e i n f o

Article history:

Received 11 April 2012Received in revised form 13 July 2012Accepted 17 July 2012Available online 25 July 2012

Keywords:

Systematic reviewCognitive interventionsHealthy older adultsMild cognitive impairmentRandomized controlled trials

a b s t r a c t

Given that the research area of cognitive intervention studies in the aging population is growing rapidly,it is important to review and gauge more recent intervention studies, in order to determine the evidencefor the effectiveness of cognitive interventions. The purpose of the present review was to update therecent systematic reviews of Papp et al. (2009) and Martin et al. (2011), to evaluate the effectiveness of cognitive interventions in healthy older adults and people with MCI, by taking into account the method-ological quality of the interventions studies. A systematic review of randomized controlled trials (RCT)and clinical studies published between August 2007 and February 2012 in Pubmed and PsychINFO wasperformed. The quality of the included RCTs was assessed according to the CONSORT criteria for RCTs.A total of thirty-five studies were included; twenty-seven RTCs and eight clinical studies. The contentof the intervention studies differed widely, as did the methodological quality of the included RCTs, butwas considerably low with an average of 44% of the Consort items included. The results show evidencethat cognitive training can be effective in improving various aspects of objective cognitive functioning;memory performance, executive functioning, processing speed, attention, fluid intelligence, and subjec-tive cognitive performance. However, the issue whether the effects of cognitive interventions generalizeto improvement in everyday life activities is still unresolved and needs to be addressed more explicitlyin future research.

© 2012 Elsevier B.V. All rights reserved.

1. Introduction

The proportion of older individuals in our western society isgrowing rapidly (CBS, 2009). As a consequence a larger amountof people encounter difficulties in executive functioning, memory,and speed of information processing (Glisky, 2007). Itis anongoingdebatewhethersuch difficulties canbe postponedor even revertedin a normal aging population, but overall the general held opinionamong researchers in this field has been optimistic (Lustig et al.,2009; Valenzuelaand Sachdev, 2009). Cognitivetraining programs,involving guided practice of specific cognitive tasks, and cognitive

stimulation programs, aimed at enhancing general cognitive func-tioning, have been offered to prevent or minimize the effects of cognitive aging. The effects of such cognitive interventions wereinvestigatednot onlyin healthyolder adults, but alsoin people withcognitivedeterioration beyond thenormalage-dependentchanges,

∗ Corresponding author at: Maastricht University, School for Mental Health andNeuroscience, Department of Psychiatry and Neuropsychology, PO Box 616, 6200MD Maastricht, The Netherlands. Tel.: +31 43 3881029; fax: +31 43 3884092.

E-mail address: [email protected] (J. Reijnders).

for example people with mild cognitive impairment (MCI) (Lustiget al., 2009; Valenzuela and Sachdev, 2009).

In the last decade several reviews have been conducted into theeffects of cognitive interventions in healthy olderadults and peoplewith MCI (Valenzuela andSachdev, 2009; Jean et al., 2010a; Martinet al., 2011; Papp et al., 2009; Tardif and Simard, 2011; Teixeiraet al., 2012). Papp et al. (2009) performed a systematic review withmeta-analytic techniques to analyze randomized controlled trials(RCT) of cognitive interventions in healthy older adults. Ten RCTspublished between 1996 and 2007 were included and analyzedin their review. A mean effect size of 0.16 was found across all

outcome measures. Effect sizes were larger when outcome meas-ures were directly related to type of training. Their conclusionwas that training improves immediate performance on relatedtasks but there was no evidence for generalization effects to over-all cognitive functioning. They also stated that their review waslimited by small and heterogeneous studies with low methodolog-ically quality and more RCTs are needed with sufficient follow-uptime, matched active control groups and outcome measures thatcan show changes in more than one specific domain (Papp et al.,2009). The review of Martin et al. (2011) included, in compari-son to Papp et al. (2009), more studies from both healthy olderadultsandMCI populations.Atotalofthirty-sixRTCswereincluded,

1568-1637/$ – seefrontmatter © 2012 Elsevier B.V. All rights reserved.

http://dx.doi.org/10.1016/j.arr.2012.07.003

http://localhost/var/www/apps/conversion/tmp/scratch_5/dx.doi.org/10.1016/j.arr.2012.07.003http://localhost/var/www/apps/conversion/tmp/scratch_5/dx.doi.org/10.1016/j.arr.2012.07.003http://www.sciencedirect.com/science/journal/15681637http://www.elsevier.com/locate/arrmailto:[email protected]://localhost/var/www/apps/conversion/tmp/scratch_5/dx.doi.org/10.1016/j.arr.2012.07.003http://localhost/var/www/apps/conversion/tmp/scratch_5/dx.doi.org/10.1016/j.arr.2012.07.003mailto:[email protected]://www.elsevier.com/locate/arrhttp://www.sciencedirect.com/science/journal/15681637http://localhost/var/www/apps/conversion/tmp/scratch_5/dx.doi.org/10.1016/j.arr.2012.07.003


2/13

264 J. Reijnders et al. / AgeingResearch Reviews 12 (2013) 263–275

Fig. 1. Selection process of the systematic review.

published between 1985 and 2007. Only data on memory train-ing could be pooled. Results showed that, for healthy olderadults, immediate and delayed verbal recall improved significantlythrough training compared to a no-treatment control group. When

compared to an active control condition, the improvements wereno longer significant. For individuals withMCI, theanalysisdemon-strated the same pattern (Martin et al., 2011). Only quite recently,a review of Tardif and Simard (2011) was published, who reviewedcognitive interventions in healthy older adults and included four-teen studies, published between 2001 and March 2011. Theirconclusion was that improvements were observed on at least oneoutcome measure in each study. They also noted that the qualityand content of the studies included were very heterogeneous anddifficult to compare which made generalization to everyday liferather difficult (Tardif and Simard, 2011).

Given that the research area of cognitive intervention studies isgrowing rapidly, it is important to review and gauge more recentintervention studies in both healthy older adults and people withMCI, in order to determine the evidence for the effectiveness of

cognitive interventions. In doing so, it is important to recognizethat one should consider the heterogeneity in quality and contentof the studies and interventions and to include not only objectiveoutcome measures (e.g. test performance) but also the subjec-

tive outcome of such interventions (e.g. cognitive complaints).The purpose of the present review was therefore to evaluate theeffectiveness of cognitive interventions in healthy older adults andpeople with MCI, by taking into account the content and method-ological quality of the interventions studies.

2. Methods

A systematic literature search for cognitive intervention studieswas done in two databases: Pubmed and PsychINFO. Our searchincluded studies that were performed between August 1, 2007 andFebruary 14, 2012, as we wanted to build on the results of two ear-lier performed systematic reviews (Martin et al., 2011; Papp et al.,2009). Our initial search strategy included the intersection of the

followingterms:[‘cognitiveintervention’ OR‘cognitive training’OR


3/13


4/13

http://www.consort-statement.org/


5/13

J. Reijnders et al. / Ageing Research Reviews 12 (2013) 263–275 267

Table 2

Intervention characteristics of studies in MCI population (n =6).

Study Aim of intervention Intervention Duration Total hours of intervention

Control group

Barneset al. (2009) To improve auditoryprocessing speed and accuracy

Computer-based cognitivetraining developed by PositScience Corporation

100min/day5 days/week6 weeks

50 h More passive computeractivities

Jean et al. (2010b) To re-learn face-nameassociations

Training in face-nameassociations using both

errorless learning and spacedretrieval paradigm andpsycho-educational sessionson memory

6 sessions of 45min

4.5 h Training in face-nameassociations using errorless

learning paradigm andpsycho-educational sessionson memory

Kinsella et al. (2009) Memory rehabilitation, topractice memory strategies foreveryday problems

Practice in memory strategies(internal and external),strategies for improvingorganisational and attentionalskills and general copingstrategies

1.5h/week5 weeks

7.5 h Waiting list

Troyeret al. (2008) Multidisciplinary group-basedintervention to changeeveryday memory behavior

Practice and application of memory strategies andeducation about lifestyle:nutrition, recreation andrelaxation

10 sessions of 120min

20 h Waiting list

Tsolaki et al. (2011) Holistic cognitiverehabilitation program to covertheneeds and deficiencies of patients with MCI

Practice of attention andparameters of executivefunction; enhancement of mental imagery, episodic,semantic, autobiographical andvisual memory;relaxation techniques

60 sessions of 90min3 session/week

90 h Waiting list

Wagner et al. (2008) To analyze everyday situationswith memoryproblem andtrain specific strategies

Practicing prospective memoryand structured processing of new information related toreal-life situations

7 sessions of 90min

10.5 h No training

and Noice, 2009; Talib et al., 2008; West et al., 2008), the samenumber of studies used an individually based intervention (Baileyet al., 2010; Basak et al., 2008; Berry et al., 2010;Borella et al., 2010;Fairchild and Scogin, 2010; Mozolic et al., 2011; Richmond et al.,2011; Slegers et al., 2008; Smith et al., 2009; Tranter and Koutstaal,

2008) and one study used both (Hastings and West, 2009). Fivestudies included follow-up data, up till one year after the inter-vention (Borella et al., 2010; Buschkuehl et al., 2008; Hastings andWest, 2009; Slegers et al., 2008; Smith et al., 2009).

The number of people with MCI in the intervention groups var-ied from 11 ( Jean et al., 2010b) to 104 (Tsolaki et al., 2011). Themean age of thestudypopulationsranged from 53.7 (Wagneret al.,2008) to 78 years (Kinsella et al., 2009). In four (out of six) stud-ies, the interventions were carried out in a clinical setting (Barneset al., 2009; Kinsella et al., 2009; Tsolaki et al., 2011; Wagneret al., 2008). A group-based intervention was used in four studies(Kinsellaet al., 2009;Troyer etal., 2008;Tsolakiet al., 2011;Wagneret al., 2008), whereas two studies used an individually based inter-vention (Barnes et al., 2009; Jean et al., 2010b). In two studies the

effectiveness of the intervention was not only assessed immedi-ately after the intervention but also after three or four months(Kinsella et al., 2009; Troyer et al., 2008). In one study a follow-upassessment was planned (Wagner et al., 2008).

The total hours of intervention varied widely between studies,as can be seenin Tables 1 and 2. We performed a linear regressionanalysisto investigatewhetherthe effectivenessof theinterventioncould be predicted by the total hours of intervention. The effec-tiveness of an intervention was calculated by dividing the numberof significant outcome measures by the total number of outcomemeasures. We found no significant effect between total hours of intervention and intervention effect (R2: 0.016, p = 0.54), indicatingthat in the included studies there was no dose response relation-ship between total hours of intervention and the effectiveness of the intervention.

3.3. Description of interventions

Table 1 shows the characteristics of the interventions that wereperformedin healthy older adults. Elevenstudies aimed at improv-ingmemory performance; fourstudies addressedworkingmemory

by computerized training (Berry et al., 2010; Buschkuehl et al.,2008; Richmond et al., 2011) or training of the categorization spantask (Borella et al., 2010); four studies provided training of the useof memory strategies (Bottiroli and Cavallini, 2009; Cavallini et al.,2010; Talib et al., 2008), accompanied with psycho-educationallessons (Fairchild and Scogin, 2010) and the other three stud-ies aimed at improving memory self-efficacy by a multifactorialtraining program (Hastings and West, 2009; West et al., 2008) ora memory training program derived from Bandura’s self-efficacytheory (McDougall et al., 2010). Six studies aimed at improvingcognitive functioning in general by providing a computer course(Klusmannet al., 2010;Slegerset al., 2008), a plasticity-based adap-tivecognitive training(Smithetal.,2009), a multifactorialcognitivetraining (Buiza et al., 2008), a community-based program (Carlson

et al., 2008) or an acting course (Noice and Noice, 2009). Besidesthis, single studies aimed at improving learning abilities by train-ing metacognitive skills (Bailey et al., 2010), executive functioningby a real-time strategy game (Basak et al., 2008), attentional skillsby training a selectiveattention task (Mozolic et al., 2011) and fluidintelligence by novel stimulating activities (Tranter and Koutstaal,2008). Tenstudies usedan active control condition, where theothereleven used a waiting list or no training control group. The dura-tion of an interventionvaried between 3 hourly sessions up till 180sessions (Borella et al., 2010; Buiza et al., 2008).

Table 2 shows the characteristics of the interventions assessedin people with MCI. Most interventions aimed at improving mem-ory performance by training memory strategies ( Jean et al., 2010b;Kinsella et al., 2009;Troyer et al., 2008;Tsolaki et al., 2011; Wagneret al., 2008), accompanied with psycho-education on memory


6/13

Table 3

Study characteristics of intervention studies in healthy older adults (n =21).

Study Sample size(EG/CG)

Mean age(year)

Intervention Follow-up Outcome measures of intere

Baileyet al. (2010) 29/27 Range 60–89 Metacognitive trainingat home

Post-intervention Self-paced m emory t askExperimenter-paced memor

Basak et al. (2008) 20/20 69.1/70.0 Strategy-basedreal-time videogame

Post-intervention Operation spanTask switchingN-back taskVisual short-term memory

Raven’s Advanced ProgressivStopping taskFunctional field of viewAttentional blinkEnumerationMental rotation

Berry et al. (2010) 15/15 71.9 Perceptualdiscrimination training

Post-intervention Trained p erceptual t askUntrained perceptual taskWM/delayed recognition paWM/delayed recognition pa

Borella et al. (2010) 20/20 69.0/69.2 Verbal WM training Post-interventionand8 monthsfollow up

Visuospatial WM (dot matrixShort-term memory (digit spInhibition (stroop color taskProcessing speed (pattern cotask)Fluid intelligence (Catell’s Cu

Bottiroli and Cavallini(2009)

21/23 66.2/66.1 Computer-basedmemory training

Post-intervention Figure l ist r ecognitionWord list recognitionFace-name learningPlace-word learningPaired associated recall

Buiza et al. (2008) 85/68/85a 74.4 Cognitive therapyEG1: Cognitiveintervention andwell-beingEG2: cognitive therapy

Post-intervention Immediate memoryRecent logic execution memShort-term memoryWorking memoryLearning potentialVisomanual coordinationMotor executionPhonetic fluencyCapacity for abstractionPraxis

Buschkuehl et al.(2008)

13/19 80.1 Computerized WMtraining

Post-interventionand 1 yearFU

Visual free recallVerbal free recallDigit span

Block spanCarlson et al. (2008) 70/58 70.1/68.4 Community-based

programAt 4 and 8 months Word list memory

Trail Making TestRey-Osterrieth Complex figuPsychomotor speed

Cavallini et al. (2010) 27/24/29a 65.8/63.566.0

Memory trainingEG1: training inmnemonicsEG2: training inmnemonics andinstructions

Post-interv ention Associate learning (practicedList learning (practiced task)Text learningPlace learningName-face learningGrocery list learning


7/13

Fairchild and Scogin(2010)

28/25 72.4 Memory enhancementprogram

Post-intervention Names and Faces taskAppointment Keeping taskMultifactorial Memory QuesObject Misplacement taskTarget Complaints Methodo

Hastings andWest(2009)

99/45/41a 70.9 Memory trainingEG1: group-based EG2:self help

Post-intervention(only performancemeasures)and 1month FU

Memory Self-Efficacy QuestiMetamemory in Adulthood (-locus of control-anxiety-achievementName recallStory recallShopping list recall

Klusmann et al. (2010)e 92/91/76a 73.6 Computer course (EG1)and physical exercisecourse (EG2)

Post-interv ention Rivermead Behavioral MemoFree and Cued Selective RemVerbal fluencyStroop testTrail Making TestSubjective ratings of -memory-concentration-flexibility-physical health-physical well-being

McDougall et al. (2010) 135/130 75 Memory training At 2, 6, 14 and 26months

Mini-Mental State ExamHopkins Verbal Learning Tes

Brief Visuospatial Memory TRivermead Behavioral MemoDirect Assessment of FunctioMemory Self-Efficacy QuestiSpielberger State-Trait AnxieCenters for Epidemiologic StMetamemory in Adulthood

Mozolic et al. (2011) 33/33 69.4 Modality specificattention training

Post-interv ention Selective attention task (crosSelective attention task (witMultisensory integration tasSymbol Digit Modalities TesWalk and talk paradigmLetter n-back testStroop testTrail Making TestHopkins verbal learning testProfile of Mood States

Health status QuestionnaireNoice and Noice (2009) 42/40/40b 80.2/8 2.7/81.6 Multi-moda l a ctivities

in college acting classesEG:acting courseCG1: no interventionCG2: singing course

Post-intervention Word list recallDelayed word list recallCategory FluencyDigit SpanStory Recall TaskProblem SolvingSelf-reported Personal Grow

Memory Controllability InveLifestyle Activities Question


8/13


9/13


Table 4

Study characteristics of intervention studies in MCI population (n =6).

Study Sample size(EG/CG)

Mean age(year)

Intervention Follow-up Outcome measures of interest Significant effect forexperimental groupa

Barneset al. (2009) 22/25 74 Computer-basedauditoryprocessing speedtraining

Post-interv ention RBANSCalifornia verbal learning testBoston naming testTrial making testVerbal fluency

Design fluencySpatial span

00000

00 Jean et al. (2010b) 11/11 68.5 Training in

face-nameassociations

Post-interventionat 1 and 4 weeks

Face-name associationsCalifornia verbal learning testDementia Rating ScaleMini Mental State ExaminationRivermead Behavioral Memory TestSelf-esteem scaleMultifactorial Memory Questionnaire

0b

000000b

Kinsella et al. (2009) 22/22 78 Strategy training(memory,attention, andorganisationalskills)

Post-interventionat2 weeks and 4months

Prospective memoryMMQ-abilityMMQ-strategyMMQ-contentmentStrategy knowledge repertoire

+000+

Troyeret al. (2008) 24/24 75.4 Memory strategiestraining andlifestyle education

Post-interventionand 3 months

Memory ToolboxMultifactorial Memory QuestionnaireImpact rating scaleLifestyle importanceName recallNumber recallWordlist recall

+000000

Tsolaki et al. (2011) 104/72 67 Cognitiverehabilitationprogram

Post-intervention MiniMental State ExaminationMontreal Cognitive AssessmentFunctional Cognitive Assessment ScaleMoCA (verbal memory)Rey-Österrieth Complex Figure TestMoCA (Clock drawing)Functional Rating Scale of Symptomsof Dementia

+++++++

Wagner et al. (2008) 33/40 53.7 Behavioral analysisand memorystrategy training

Post-interventionand follow upplanned

Appointment testLogicalmemory ILogicalmemory IIMemory assessment clinicsquestionnaire

+0++

MCI, mild cognitive impairment; EG,experimental group; CG, control group;N , number of patients;RBANS, RepeatableBattery for Assessment of Neuropsychological Status;MMQ, Multifactorial Memory Questionnaire; MoCA, Montreal Cognitive Assessment.

a +, positive effect forexperimental group; 0, no difference between groups; −, negative effectfor experimental group.b Improved in both groups.

( Jean et al., 2010b), lifestyle(Troyer et al.,2008), orpracticeofatten-tional skills (Kinsella et al., 2009; Tsolaki et al., 2011). One studyaimed at improving processing speed by using a computer-basedcognitive training program (Barnes et al., 2009). Two studies usedan active control condition, where the other four used a waitinglist or no training control group. The duration of an interventionvaried between 5 and 20 weeks (Kinsella et al., 2009; Tsolaki et al.,2011).

3.4. Outcome measures and effects

In the twenty-one RCTs in healthy older adults included inour analysis, the most commonly used outcome measure wasobjective memory performance (twenty studies) (Table 3). In sev-enteen studies, memory performance was significantly improvedafter the intervention. Significant differences were observed on thefollowingtasks; self-paced memory task(Baileyet al., 2010), work-ing memory tasks (Basak et al., 2008; Berry et al., 2010; Borellaet al., 2010; Buiza et al., 2008; Buschkuehl et al., 2008; Richmondet al., 2011; Smith et al., 2009; Talib et al., 2008), recognition task(Bottiroli and Cavallini, 2009), face-name learning tasks (Bottiroliand Cavallini, 2009; Fairchild and Scogin, 2010), immediate mem-ory and learning potential (Buiza et al., 2008), word list recall

(Carlson et al., 2008; Cavallini et al., 2010; Noice and Noice, 2009),

name recall(Hastings andWest,2009; West et al., 2008), story/textrecall (Cavallini et al., 2010; Hastings and West, 2009; Noice andNoice, 2009;Talibet al., 2008; West et al., 2008), Rivermead Behav-ioral Memory Test (Klusmann et al., 2010), Repeatable Battery forthe Assessment of Neuropsychological Status (Smith et al., 2009),Rey Auditory Verbal Learning Test (Smith et al., 2009), memorystrategy use (Talib et al., 2008; West et al., 2008). In eight stud-ies, measures of executive functioning were included, of whichfive studies showed significant effects on the following tasks; task

switching (Basak et al., 2008), Stroop Color Word Task (Borellaet al., 2010), Trail MakingTest (Carlson et al., 2008), Rey-ÖsterriethComplex Figure Test (Carlson et al., 2008), Symbol Digit Modali-ties Test (Mozolic et al., 2011), walk and talk paradigm (Mozolicet al., 2011), fluency and problem solving (Noice and Noice, 2009).In three studies,significant improvement on (fluid) intelligence testwere observed; Catell’s Culture Fair (Bottiroli and Cavallini, 2009;Tranter and Koutstaal, 2008), Raven’s Advanced Progressive Matri-ces (Basak et al., 2008). In two studies, significant improvementon attentional tasks were observed; selective attention task, multi-sensory integration task (Mozolic et al., 2011), Repeatable Batteryfor Assessment of Neuropsychological Status (Smith et al., 2009).In two studies, significant improvement in speed of processingwas observed (Borella et al., 2010; Smith et al., 2009). In one

study a measure of general cognitive functioning (Mini Mental


10/13

272 J. Reijnders et al. / AgeingResearch Reviews 12 (2013) 263–275

State Examination) was included as an outcome measure and sig-nificantly improved by the intervention (McDougall et al., 2010).Subjective measures of cognitive performance were included infive studies. Significant effects were observed for the Multifacto-rial Memory Questionnaire (Fairchild and Scogin, 2010), ObjectMisplacement task (Fairchild and Scogin, 2010), Memory Self-Efficacy Questionnaire (Hastingsand West,2009; West etal., 2008),Metamemory in Adulthood (Hastings and West, 2009; McDougallet al., 2010; West et al., 2008), and Cognitive Self-Report Ques-tionnaire (Smith et al., 2009). In two studies, measures of dailyfunctioning (Direct Assessment of Functional Status (McDougallet al., 2010) and Instrumental Activities of Daily Living (Slegerset al., 2008)) wereincluded,but no significant effectwere observed.

All six RCTs in the MCI population included in our analysisused objective memory performance as an outcome measure: infour studies memory performance significantly improved after theintervention (Table 4). Significant improvements were observedon the following tasks; prospective memory (Kinsella et al., 2009),memory strategy knowledge (Kinsella et al., 2009; Troyer et al.,2008), verbal memory (Montreal Cognitive Assessment) (Tsolakiet al., 2011), appointment test (Wagner et al., 2008) and logicalmemory(Wagneret al., 2008). Intwostudiesmeasuresofexecutivefunctioning were included; the functional cognitive assessment

scale was significantly improved by the intervention in one study(Tsolakietal.,2011 ). In three studies, a measure of general cognitivefunctioning was included. In only one study general cognitive per-formance, measured with the Mini Mental State Examination andthe Montreal Cognitive Assessment was significantly improved bythe intervention (Tsolaki et al., 2011). In three studies, a subjectivemeasure of cognitive performance was included, the MultifactorialMemory Questionnaire, although no significant effects were foundon this scale. In one study a significant improvement on a mea-sure of daily functioning (Functional Rating Scale of Symptoms of Dementia) was observed (Tsolaki et al., 2011).

3.5. Methodological quality of study

The methodological quality of the twenty-seven RCTs wasassessed. The percentage of the Consort items reported in theincluded studies ranged from 16% to 73%, with an average of 44%(Table 5). The study of Smith et al. (2009) had the highest method-ological quality (73%), while the study of Wagner et al. (2008) hadthe lowestquality (16%). The Consort statementcan be divided intoseven categories: ‘title/abstract’; ‘introduction’; ‘methods-trial’;methods-randomization’; ‘results’; ‘discussion’; and ‘other infor-mation.’ In five of these categories (‘title/abstract,’ ‘methods-trial,’‘methods-randomization,’ ‘results,’ and ‘other information’) lessthan 50% of the items was reported.

3.6. Non-randomized controlled trials

Eight non-RCTs were included; three clinical studies in healthyolder adults (Ackerman et al., 2010;Li et al., 2008;Schmiedek et al.,2010) andfive clinical studies in peoplewithMCI (Greenawayet al.,2008; Hampstead et al., 2008; Joosten-WeynBanningh et al., 2008;Londos et al., 2008; Ozgis et al., 2009).

In healthy older adults, one study aimed at improving workingmemory performance by computerized training. The workingmemory training showed improvements on practiced and neartransfer tasks but no effects on far transfer tasks (Li et al., 2008).Two studies aimed at improving cognitive functioning in general.Schmiedek et al. (2010) provided an internet-based training envi-ronment including tasks of perceptual speed, episodic memory,and working memory. They used only self-report evaluationreports as outcome measures. Ackerman et al. (2010) provided a

brain training environment including training sessions with the

Nintendo Wii and reading sessions which showed practice-relatedimprovement but no significant transfer effects.

In people with MCI, two studies focused on improving adap-tive behavior and functional ability. Greenaway et al. (2008)showed improvement in functional ability by the use of a ‘mem-ory support system’ and Joosten-Weyn Banningh et al. (2008)provided cognitive behavioral group therapy which resulted inincreased acceptance and marital satisfaction in people with MCIand increased awareness in their caregivers. The results of twostudies focusing on memory improvement (by memory strategytraining or spaced retrieval memory training) showed practice-relatedeffects(Hampsteadet al., 2008;Ozgis etal., 2009). Thestudyof Londos et al. (2008) examined the effect of an established reha-bilitation program designed to improve cognitive performance,occupational performance, and quality of life. The results showedimprovements in cognitive processing speed, occupational perfor-mance, and some domains of quality of life (Londos et al., 2008).

4. Discussion

This systematic review, evaluating the effectiveness of cogni-tive interventions in healthy older adults and people with MCI,

showed that cognitive interventions can be effective in improvingvarious aspects of objective cognitive functioning; memory per-formance, executive functioning, processing speed, attention, fluidintelligence, and subjective cognitive performance. A critical com-parison between different intervention studies is difficult becauseof the heterogeneity of the intervention programs and the chosenoutcome measures. Most intervention studies used memory per-formance as the primary outcome measure, but only few studiesused similar tests to measure memory functioning which frus-trated a morequantitative meta-analysison these studies. Differentintervention programs proved to be effective in improving eitherobjective or subjective memory performance; training of mem-ory strategies (Bottiroli and Cavallini, 2009; Cavallini et al., 2010;Talib et al., 2008; Wagner et al., 2008), accompanied with practice

of attentional skills (Kinsella et al., 2009; Tsolaki et al., 2011),psycho-educational lessons on memory and/or lifestyle (Fairchildand Scogin, 2010; Troyer et al., 2008); computerized training of working memory task (Berry et al., 2010; Borella et al., 2010;Buschkuehl et al., 2008; Richmond et al., 2011); and training pro-gramsfocusingonmemoryself-efficacyormetacognition(Hastingsand West, 2009; McDougall et al., 2010; West et al., 2008). Exec-utive functioning was mostly included as a secondary outcomemeasure, and only two intervention programs aimed directly atimproving executive functioning (Basak et al., 2008; Carlson et al.,2008).

In addition to the heterogeneity of the included interventionstudies, the methodological quality of the studies differed vastly:only between 16% and 73% of the quality criteria items were

addressed in the studies. When assessing studies with a high qual-ity rating (>60% of the Consort quality criteria), we observed bothpositive and negative results. The study of Smith et al. (2009)showed that computerized cognitive training led to improvementof performance generalizing to untrained measures of memoryand attention and subjective everyday functioning. The study of Klusmann et al. (2010) showed that a 6-month computer coursehad a positive affect on memory performance (measured withthe Rivermead Behavioral Memory Test) in healthy older adults.However, the same improvement was achieved with a 6-monthphysical exercise course (Klusmann et al., 2010). In people withMCI, a computer-based auditory processing speed training showedno improvements on memory, executive, or general cognitiveperformance (Barnes et al., 2009). However, a 5-week memory

rehabilitation program focusing on practicing memory strategies


11/13


Table 5

Quality assessment of included studies using theConsort statement 2010.

Title, abstract(max. 2)

Introduction(max. 2)

Methods-trial(max. 9)

Methods-randomization(max. 8)

Results(max. 10)

Discussion(max. 3)

Other information(max. 3)

Total (%) score(max. 37)

Barneset al. (2009) 2 2 5 5 5 3 2 24 (65%) Jean et al. (2010a) 1 2 5 4 5 2 1 20 (54%)Kinsella et al. (2009) 2 2 5 5 6 3 1 24 (65%)Troyeret al. (2008) 1 2 4 4 6 2 0 19 (51%)Tsolaki et al. (2011) 1 2 2 2 2 1 0 10 (27%)

Wagner et al. (2008) 0 2 3 0 1 0 0 6 (16%)Bailey et al. (2010) 0 1 4 1 3 3 1 13 (35%)Basak et al. (2008) 0 2 5 1 6 3 1 18 (49%)Berry et al. (2010) 0 1 4 2 4 1 1 13 (35%)Borella et al. (2010) 0 2 4 2 3 3 0 14 (38%)Bottiroli and Cavallini

(2009)1 1 4 2 4 1 0 13 (35%)

Buiza et al. (2008) 1 1 3 0 0 2 1 8 (22%)Buschkuehl et al.

(2008)0 2 3 1 4 3 1 14 (38%)

Carlson et al. (2008) 1 2 5 2 5 3 1 19 (51%)Cavallini et al. (2010) 0 1 3 2 2 2 1 11 (30%)Fairchild and Scogin

(2010)0 2 1 3 6 3 1 16 (43%)

Hastings and West(2009)

0 2 4 1 3 3 1 14 (38%)

Klusmann et al. (2010) 2 2 6 6 6 3 1 26 (70%)McDougall et al. (2010) 0 2 4 3 5 2 2 18 (49%)Mozolic et al. (2011) 1 2 4 4 4 3 1 19 (51%)Noice andNoice (2009) 0 2 4 2 6 2 1 17 (46%)Richmond et al. (2011) 0 2 4 2 3 3 1 15 (41%)Slegers et al. (2008) 1 2 5 4 5 3 1 21 (57%)Smith et al. (2009) 1 2 5 7 8 3 1 27 (73%)Talib et al. (2008) 0 2 3 1 3 1 1 11 (30%)Tranter and Koutstaal

(2008)0 2 3 1 5 3 1 15 (41%)

West et al. (2008) 0 2 2 1 3 3 1 12 (32%)

Total for category (%)15 (28%) 49 (91%) 104 (43%) 68 (31%) 113 (42%) 64 (79%) 24 (30%) 44%

did show improvements on prospective memory task and strategyknowledge repertoire (Kinsella et al., 2009).

Another aspect of methodological quality, not specifically

addressed in the Consort Statement items, is whether the controlgroup received an active control intervention or no intervention.With an active control condition the effects of, for example, socialattention as part of group meetings can be controlled for. Whenlooking at the RCTs in the healthy older adults, ten RCTs includedan active control condition. These studies did show an effect onmeasures of cognitive functioning, more specifically executivefunctioning, speed, attention, and subjective memory functioning(Borella et al., 2010; Buschkuehl et al., 2008; Fairchild and Scogin,2010; McDougallet al., 2010; Mozolic et al., 2011; Noice andNoice,2009; Richmond et al., 2011; Slegers et al., 2008; Smith et al., 2009;Tranter and Koutstaal, 2008). In the MCI population, two studiesincluded an active control group. The interventions executed inthese two studies did not show any significant effect (Barnes et al.,2009; Jean et al., 2010b). In conclusion, evaluating the results of intervention studies with an active control condition, it may beconcluded that cognitive interventions can have a positive effecton various aspects of both objective and subjective cognitive func-tioning in healthy older adults, but not in people with MCI.

An important question that was raised in earlier reviews iswhether observed training effects on various aspects of cognitivefunctioning generalize to untrained tasks or overall cognitive func-tioning, or lead to functional improvement in daily life situations.A number of studies specifically addressed the question of gener-alization to untrained task or to subjective experience of cognitivefunctioning (Berry et al., 2010; Borella et al., 2010; Bottiroli andCavallini, 2009; Buschkuehlet al., 2008; Fairchild and Scogin, 2010;Richmond et al., 2011; Smith et al., 2009). Activities of Daily Living(ADL) measures were included in three intervention studies and a

significant effect on ADL was observed in one study (Smith et al.,2009). From these data it can be concluded that there is very littleevidence for generalization effects to overall cognitive functioning

and daily life situations. The issue whether the effects of cognitiveinterventions generalize to improvement in everyday life activitiesstill needs to be addressed more explicitly in future research.

Another important question is whether there is evidence of the rooting of training effect after the training period has ended.Follow-up data were available in seven out of twenty-six RCTs.They showed that positive effects on memory strategy knowledgeremainedafter 3/4 months (Kinsellaet al., 2009;Troyer etal., 2008),positive effects on memory self-efficacy and recall tasks preservedafter 1 month (Hastings and West, 2009), positive effects on mem-ory and speed preserved after 3 months (Smith et al., 2009), andpositive effects on speed and fluid intelligence preserved after 8months (Borella et al., 2010). Two studies including a 1-year followup did not find any significant effects (Buschkuehl et al., 2008;Slegers et al., 2008). From these data it canbe concludedthat train-ing effects can be preserved at least for a couple of months.

In comparison to theearlier reviews of Papp et al.(2009), Martinet al.(2011) and Tardif and Simard (2011), more intervention stud-ies were included in this review. This could be the results of usingmore elaborated search terms or an increase in studies investi-gating the effect of cognitive interventions in the last few years.However, our conclusions are in line with the conclusions of theseearlier reviews (Martin et al., 2011; Papp et al., 2009; Tardif andSimard, 2011). A strength of this study, in comparison with earlierreviews, is themethodologicalquality rating we performed accord-ing to the Consort Statement 2010 for RCTs. The methodologicalquality of the twenty-seven RCTs differed considerably. Takinginto account that some items (such as blinding, serious harms,and interim analysis) are less applicable for non-pharmacological


12/13


13/13


Slegers, K., van Boxtel, M., Jolles, J., 2009. Effects of computer training and internetusageon cognitiveabilitiesin olderadults:a randomizedcontrolledstudy.AgingClinical and Experimental Research 21 (1), 43–54.

Smith, G.E., et al., 2009. A cognitive training program based on principles of brainplasticity:results fromtheImprovementin Memory withPlasticity-basedAdap-tive Cognitive Training (IMPACT) study. Journal of the American GeriatricsSociety 57 (4), 594–603.

Talib, L.L., et al., 2008. Cognitive training increasesplatelet PLA2 activity in healthyelderly subjects.ProstaglandinsLeukotrienesand EssentialFatty Acids78 (4–5),265–269.

Tardif, S., Simard, M., 2011. Cognitive stimulation programs in healthy elderly: a

review. International Journal of Alzheimers Disease, Article ID: 378934.Teixeira,C.V., etal., 2012.Non-pharmacological interventionson cognitivefunctions

in older people with mild cognitive impairment (MCI). Archives of Gerontologyand Geriatrics 54 (1), 175–180.

Tranter, L.J.,Koutstaal, W., 2008.Age and flexible thinking:an experimental demon-stration of the beneficial effects of increased cognitivelystimulating activity on

fluid intelligence in healthy older adults. Neuropsychology, Development, andCognition. Section B, Aging, Neuropsychology and Cognition 15 (2), 184–207.

Troyer, A.K., et al., 2008. Changing everyday memory behaviour in amnestic mildcognitive impairment: a randomisedcontrolled trial.NeuropsychologicalReha-bilitation 18 (1), 65–88.

Tsolaki, M., et al., 2011. Effectiveness of nonpharmacological approachesin patientswith mild cognitive impairment. Neurodegenerative Diseases 8 (3), 138–145.

Valenzuela, M., Sachdev,P., 2009.Can cognitiveexercise preventthe onset ofdemen-tia? Systematic review of randomized clinical trialswith longitudinal follow-up.American Journal of Geriatric Psychiatry 17 (3), 179–187.

Wagner, S., et al., 2008. Does a cognitive-training programme improve the per-

formance of middle-aged employees undergoing in-patient psychosomatictreatment? Disability and Rehabilitation 30 (23), 1786–1793.

West, R.L.,Bagwell,D.K.,Dark-Freudeman, A.,2008. Self-efficacyand memory aging:the impact of a memory intervention based on self-efficacy. Neuropsychology,Development, and Cognition. Section B, Aging, Neuropsychology and Cognition15 (3), 302–329.

2013 reijndersa cognitive interventions in healthy older adults and mci

Documents