Cognitive exercise and its role in cognitive function in older adults.
ABSTRACT Converging lines of research indicate that complex mental activity is associated with reduced dementia risk. Thus, intense interest exists in whether different forms of cognitive exercise can help protect against cognitive decline and dementia. However, there is considerable confusion in terminology that is hindering progress in the field. We therefore introduce a concrete definition of cognitive training (CT) and make this the focus of our article. Clinical research that has evaluated CT in normal aging, mild cognitive impairment, and dementia is then critically reviewed. Despite many methodological shortcomings, the overall findings indicate that multidomain CT has the potential to improve cognitive function in healthy older adults and slow decline in affected individuals. Finally, practical issues, including the strengths and weaknesses of commercial products, are explored, and recommendations for further research and clinical implementation are made.
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ABSTRACT: Cognitive training, a safe non-pharmacological intervention, may help mitigate cognitive decline and prevent the development of dementia in elderly individuals.Shanghai archives of psychiatry. 02/2014; 26(1):30-41.
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ABSTRACT: The aim of this study was to assess the efficacy of cognitive training, specifically computerized cognitive training (CCT) and virtual reality cognitive training (VRCT), programs for individuals living with mild cognitive impairment (MCI) or dementia and therefore at high risk of cognitive decline. After searching a range of academic databases (CINHAL, PSYCinfo, and Web of Science), the studies evaluated (N = 16) were categorized as CCT (N = 10), VRCT (N = 3), and multimodal interventions (N = 3). Effect sizes were calculated, but a meta-analysis was not possible because of the large variability of study design and outcome measures adopted. The cognitive domains of attention, executive function, and memory (visual and verbal) showed the most consistent improvements. The positive effects on psychological outcomes (N = 6) were significant reductions on depressive symptoms (N = 3) and anxiety (N = 2) and improved perceived use of memory strategy (N = 1). Assessments of activities of daily living demonstrated no significant improvements (N = 8). Follow-up studies (N = 5) demonstrated long-term improvements in cognitive and psychological outcomes (N = 3), and the intervention groups showed a plateau effect of cognitive functioning compared with the cognitive decline experienced by control groups (N = 2). CCT and VRCT were moderately effective in long-term improvement of cognition for those at high risk of cognitive decline. Total intervention time did not mediate efficacy. Future research needs to improve study design by including larger samples, longitudinal designs, and a greater range of outcome measures, including functional and quality of life measures, to assess the wider effect of cognitive training on individuals at high risk of cognitive decline.The American journal of geriatric psychiatry: official journal of the American Association for Geriatric Psychiatry 05/2014; · 3.35 Impact Factor
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ABSTRACT: Cognitive training is an emergent approach that has begun to receive increased attention in recent years as a non-pharmacological, cost-effective intervention for Alzheimer's disease (AD). There has been increasing behavioral evidence regarding training-related improvement in cognitive performance in early stages of AD. Although these studies provide important insight about the efficacy of cognitive training, neuroimaging studies are crucial to pinpoint changes in brain structure and function associated with training and to examine their overlap with pathology in AD. In this study, we reviewed the existing neuroimaging studies on cognitive training in persons at risk of developing AD to provide an overview of the overlap between neural networks rehabilitated by the current training methods and those affected in AD. The data suggest a consistent training-related increase in brain activity in medial temporal, prefrontal, and posterior default mode networks, as well as increase in gray matter structure in frontoparietal and entorhinal regions. This pattern differs from the observed pattern in healthy older adults that shows a combination of increased and decreased activity in response to training. Detailed investigation of the data suggests that training in persons at risk of developing AD mainly improves compensatory mechanisms and partly restores the affected functions. While current neuroimaging studies are quite helpful in identifying the mechanisms underlying cognitive training, the data calls for future multi-modal neuroimaging studies with focus on multi-domain cognitive training, network level connectivity, and individual differences in response to training.Frontiers in Aging Neuroscience 08/2014; 6(231). · 2.84 Impact Factor
Cognitive Exercise and Its Role in Cognitive Function
in Older Adults
Nicola Gates & Michael Valenzuela
Published online: 8 January 2010
# Springer Science+Business Media, LLC 2010
Abstract Converging lines of research indicate that complex
intense interest exists in whether different forms of cognitive
exercise can help protect against cognitive decline and
dementia. However, there is considerable confusion in
terminology that is hindering progress in the field. We
therefore introduce a concrete definition of cognitive training
(CT) and make this the focus of our article. Clinical research
that has evaluated CT in normal aging, mild cognitive
impairment, and dementia is then critically reviewed. Despite
many methodological shortcomings, the overall findings
indicate that multidomain CT has the potential to improve
cognitive function in healthy older adults and slow decline in
affected individuals. Finally, practical issues, including the
strengths and weaknesses of commercial products, are
explored, and recommendations for further research and
clinical implementation are made.
Complex mental activity can promote several neuroplastic
mechanisms, a phenomenon that is conserved well into
advanced age  and hence may be exploited for the
mitigation of age-related changes in cognition. For example,
meta-analyses have shown that individuals with higher levels
of mental activity are at only about half the risk of
developing dementia  and have a reduced rate of incident
cognitive decline , and that late-life mental exercise
exhibits a dose-dependent relationship with dementia risk
reduction independent of early life experiences . Inter-
ventions based on augmenting complex mental activity
therefore represent a promising new approach to combating
age-related cognitive decline and to dementia prevention. In
this review, we discuss important definitions, summarize the
results of recent clinical trials, and finally introduce some of
the major commercial products in this burgeoning field.
Mental activity, cognitive exercise, and cognitive intervention
are commonly used nonspecific terms that encompass
disparate interventions based on different theoretical con-
structs. Although the review of Clare and Woods 
provided a taxonomy of cognitive interventions into “cogni-
tive rehabilitation,” “cognitive stimulation,” or “cognitive
training” (CT) and hence the basis for differentiation,
significant confusion remains. Similar interventions have,
for example, been labelled differently: computer-based
repetitive training has been referred to as “cognitive
intervention”  and “cognitive rehabilitation” [6-8]. Qual-
itatively different interventions have also been given the
same label, with “cognitive stimulation” being used to refer
to generic discussion topics , training in memory strategies
, and CT exercises . In our opinion, this ongoing
confusion has hampered the development and validation of
cognitive interventions in general and may have contributed
to the mixed findings to date. Consequently, this article
focuses on one form of cognitive intervention: CT.
CT, defined under the Cochrane protocol of Martin et al. ,
is “an intervention providing structured practice on tasks
N. Gates (*):M. Valenzuela
Neuropsychiatric Institute, Prince of Wales Hospital,
Randwick, Sydney, NSW 2031, Australia
Curr Psychiatry Rep (2010) 12:20–27
relevant to aspects of cognitive functioning, using standard-
ized tasks” and “intended to address cognitive function and/
or cognitive impairment directly.” Based on this and similar
definitions , we have developed an operational definition
of CT that includes four components: 1) repeated practice, 2)
on tasks with an inherent problem, 3) using standardized
tasks, and 4) that target specific cognitive domains. CT
programs adhering to this definition have been studied across
the age and clinical spectrum, from healthy older adults [14-
19] to those with preclinical dementia or mild cognitive
impairment (MCI) [7•, 8, 20-23] to those diagnosed with
Alzheimer’s disease (AD) [5, 11, 24-30].
Reviews across the population groups identified above agree
that the field continues to face many challenges, primarily a
lack of randomized clinical trials and methodological issues
[4, 13, 22, 31-34••]. The most prominent design issues
include small sample sizes, lack of randomization, absence of
active or placebo controls, limiting of outcome measures due
to combined treatment interventions, and lack of longitudinal
follow-up. Despite these important limitations, there is
promising evidence that CT may be an effective cognitive
and functional intervention for the aged. A summary of
results from randomized controlled trials of CT in this area is
presented in Table 1 and in more detail subsequently.
CT in Healthy Older Adults
Whether older cognitively intact individuals can benefit from
different conclusions [33, 34••]. However, different clinical
trials were identified within each review. Examination of
longitudinal randomized controlled trials of training adhering
to our definition demonstrated that CTcan help slow the rate
of age-related cognitive decline on a range of cognitive tasks,
with on average a moderate effect size (ES) of 0.6 [34••].
The largest randomized trial to date, the ACTIVE
(Advanced Cognitive Training for Independent and Vital
Elderly) study, which involved 2802 older Americans,
compared three training programs (memory strategy, rea-
soning, and speed of processing) and a no-contact control
and measured performance immediately after training and
at 1- and 2-year follow-up. Results indicated that domain-
specific training led to improvement in the targeted
cognitive functions, with computer-based speed training
resulting in the greatest gains compared with pen-and-paper
reasoning and memory strategy training . Although the
transfer of gains to functional measures was not evident at
2 years, subsequent investigation revealed that the positive
functional benefits were manifest at 5-year follow-up .
Training relying specifically on computer delivery was
investigated in the randomized trial of Mahncke et al.
 using the commercially available Posit Science (San
Francisco, CA) program. Training exercises designed to
improve aural language processing resulted in improvements
in both targeted cognitive function and nontrained cognitive
function in the experimental group compared with control
participants. In addition, memory performance remained
enhanced at 3-month follow-up.
Although the limited number of well-designed random-
ized trials of training in healthy older adults limits the
extent to which conclusions can be drawn, both these
studies indicate that CT can result in the generalization of
benefit to nontrained functions, and that such benefits
persist. Furthermore, there are indications that computer-
delivered training is efficacious and potentially associated
with better outcomes (Gates, unpublished data).
CT in MCI and At-Risk Groups
The opportunity to intervene at the preclinical dementia
stage with nonpharmacologic strategies that are safe and
engaging carries enormous potential for helping prevent
dementia. However, to date, few studies have been
conducted. Trials of memory strategy training have resulted
in limited improvement on objective memory and cognitive
function [20, 23], suggesting that impaired memory
function may be resistant to the benefits of a unimodal
memory intervention. For example, a randomized trial of
memory strategy training within a larger memory interven-
tion, including cueing, categorization, chunking, and
method of loci, found no difference between trained and
wait-list control participants on objective measures of
memory at the end of training or at 3-month follow-up .
In contrast, trials of multidomain CT in MCI have shown
positive effects [6-8, 21]. The Rozzini et al. [7•] random-
ized study of 59 independently living individuals diagnosed
with MCI used TNP computer software  to train
multiple cognitive functions with modulated complexity.
At 3-month follow-up, episodic memory was significantly
improved in the combined CT and medication treatment
group compared with the medication-only and no treatment
control groups. Furthermore, the CT and medication
treatment group had a greater reduction in depressive
symptoms and behavioral and neuropsychiatric disturbance
than the group receiving pharmacologic treatment alone.
This single trial suggests that in the context of MCI,
multidomain CT can potentially lead to enduring positive
effects on memory as well as generalized benefit in
neuropsychiatric symptoms. However, the paucity of
randomized controlled trials makes it difficult to make
Curr Psychiatry Rep (2010) 12:20–2721
Table 1 Cognitive training characteristics and cognitive outcomes in randomized controlled trials of healthy older adults and those with mild cognitive impairment and Alzheimer’s disease
Primary cognitive outcome
completion ofa 92-page
Cognitive specific: immediate
and delayed recall of 20 nouns,
15 names and faces, 15 shopping
items; Benton Visual Retention
Test; Digit Span Test
strategy training and
problem-solving andvisuospatial tasks
Buschke Selective Reminding
Heiss et al.
perceptual, and motor
tasks); computer drill CT
Global: MMSE; domain specific:
Corsi Blocks, selective
reminding test, fragmented
pictures test, token test,
supermarket test, orientation
test, Praxis test, reaction timetest, tapping task
Davis et al.
Memory strategy and
60 (180 for
Global: MMSE; domain
specific: logical memory
test, visual reproduction test,
Digit Span Test, Verbal SeriesAttention Test, COWAT,
category fluency test,
Quality of Life
Ball et al.
3 training groups:
speed of processing
Composite scores from
Rapp et al.
Memory strategy training
chunking, method of loci)
within a larger, multifaceted
Domain specific: Memory
Questionnaire, word list
(immediate and delayed recall), story paragraph(immediate and delayedrecall), grocery list (immediate and delayed recall), names and faces(immediate and delayed recall)
Profile of Mood
et al. 
Memory strategy training
Domain specific: Hopkins
Verbal Learning Test-revised,
Brief Visuospatial Memory
Test-revised, BNT, COWAT,
Judgment of Line Orientation,
22Curr Psychiatry Rep (2010) 12:20–27
Table 1 (continued)
Primary cognitive outcome
et al. 
Domain specific: face-name
object memory, change
(for purchase), balancing
et al. 
12 MCI patients
(pen and paper)
et al. 
Memory strategy training
Recall of number sequences
et al. 
Posit Science (San
and no contact
Global and specific: RBANS
et al. 
Composite cognitive score
et al. 
Global: MMSE, ADAS-Cog
Willis et al.
et al. 
training, NPT [36, 49]
Global: MMSE; domain
specific: prose memory,
word repetition test,
Corsi Blocks, Raven’s
Matrices, digit cancelation,
semantic and phonemic
and ideomotor apraxia
et al. [7•]
ChEI and multidomain
(attention, abstractreasoning, visuospatial
abilities with the NPT)
and ChEI alone
Global: MMSE; domain
specific: story paragraph,
letter verbal fluency,
semantic verbal fluency,
Coloured Matrices, RCFT copy and
GDS (15 items),
et al. 
gnosis language, memory, orientation, calculation),
Internet based program
within a multifactorial
Global: ADAS-Cog, MMSE;
domain specific: BNT, verbal fluency, story recall
et al. 
Memory strategy training
(spaced retrieval, memory
book, semantic association,
logical location) within alarger mixed intervention
Domain specific: word list
of 2-syllable nouns, digit
span, memory strategy
Curr Psychiatry Rep (2010) 12:20–27 23
conclusive statements in this area; further research of this
type must be a top international priority.
CT in Dementia
Although the number of published studies investigating CT
in dementia exceeds those with normative and preclinical
groups, findings have been mixed. A 2003 Cochrane
review concluded that there were no significant positive
benefits from CT in this population . However, the
nature of the training programs included in the review were
highly variable, ranging from multidomain computerized
exercises to memory strategy training and training in
compensatory devices. As mentioned, this confusion of
intervention type creates significant issues when attempting
to interpret and integrate results across trials. A subsequent
review and meta-analysis separated training in compensa-
tion strategies from CT, and CT was found to have a greater
benefit (ES, 0.54) compared with restorative techniques
(ES, 0.36) .
The separation of memory strategy training from CT as
defined here can also provide further insights. Studies of
memory strategy training have demonstrated no effect on
general cognitive measures [25, 26, 37]. In contrast,
randomized trials of multidomain CT in AD have demon-
strated positive effects on global cognitive measures [5, 11]
and functional measures . Tarraga et al.  randomly
assigned individuals with mild AD to computer-based CT
in combination with an integrated psycho-stimulation
program or to one of two control groups (integrated
psycho-stimulation program alone or no intervention).
Following high-volume training, the CT group demonstrat-
ed better performance on the primary global cognitive
measure (AD Assessment Scale, cognitive subscale) and on
secondary neuropsychological tests at 24-week follow-up
compared with both control groups. Another randomized
investigation of multidomain CT demonstrated delay of
clinical progression by the end of training and at 3-month
follow-up compared with a control group . Consequent-
ly, some evidence suggests that multidomain CT may
benefit those with AD by slowing the disease’s progression.
Traditional pen-and-pencil CT exercises are being increas-
ingly replaced by computer-based programs. This trend
seems to be driven by several factors, including greater
community access to computers, commercialization of
computerized products, and research interest. Computer-
based CT has been successfully delivered to healthy older
Table 1 (continued)
Primary cognitive outcome
et al. 
Global: RBANS; domain
specific: BNT, California
Verbal Learning Test,
aControl of multidomain computer exercises, termed mental stimulation training
AD Alzheimer’s disease, ADAS-Cog Alzheimer’s Disease Assessment Scale, cognitive subscale, ADL activities of daily living, BADL basic activities of daily living, BNT Boston Naming Test,
ChEI cholinesterase inhibitor, COWAT Controlled Oral Word Association Test, CT cognitive training, GDS Geriatric Depression Scale, IADL instrumental activities of daily living, MCI mild
cognitive impairment, MMSE Mini-Mental State Examination, NPI Neuropsychiatry Inventory, NPT neuropsychological training, NR not reported, RBANS Repeatable Battery of Assessment of
Neuropsychological Status, RCFT Rey-Osterrieth Complex Figure Test, TMT Trail Making Test
24Curr Psychiatry Rep (2010) 12:20–27
adult [15, 35], MCI [6-8, 21, 39] and AD populations [5,
11], and as an implementation strategy, it is likely superior
for several reasons. First, computer delivery facilitates
multimodal and multidomain training, which seems to be
a key factor for functional efficacy. The magnitude of the
ES may be stronger when exercises are implemented via
computer. Within the ACTIVE study, for example, 5-year
post ES were 0.76 for computer-based information speed
training, compared with 0.23 to 0.26 for traditional memory
and reasoning training , although this result may also be
due to a domain-specific effect.
Second, computer-based interventions enable algorithms
to set the initial level of task difficulty with reference to the
individual’s baseline competency and then gradually in-
crease task difficulty in a customized fashion, in effect
providing an individualized intervention. These features
also allow effective control of ceiling and floor effects,
which theoretically may be a key ingredient for successful
cognitive exercise regimes, as individuals are continually
cognitively challenged. In addition, computer-based inter-
ventions enable the unobtrusive real time monitoring of
cognitive performance, the standardization of intervention,
and potentially the reduction of personnel and implemen-
tation costs, making this an attractive research option.
Our definition of CT is compatible with the form of training
provided by several commercial products, some of which
are listed in Table 2. Despite the current limited empiric or
independent research, commercial claims abound regarding
the enhancement of cognitive function through training
. These claims and the proliferation of commercial
products seem to be outpacing clinical research, although
many companies are increasingly undertaking direct re-
search [35, 41] or sponsoring academic research [39, 42]. In
general, investigation of commercial products should be of
the same standard as that of pharmacologic studies [33, 40]
and hence should inform widespread community imple-
mentation. The main risks of irresponsible marketing of CT
products are that users may develop unrealistic expectations
and that an exciting new research option may be prema-
Role of CT in the Cognitive Function of Older Adults
Current research suggests that the clinical role and type of
CT intervention may differ depending on the older adult
population and AD prevention stage. Three stages of AD
prevention have been identified: primary prevention to
reduce disease incidence in cognitively healthy individuals;
secondary prevention to slow progression of preclinical
disease to clinical disease (often translating to reduction of
MCI “conversion” to dementia); and tertiary prevention, the
reduction of disability due to cognitive symptoms in
diagnosed patients .
Exercise drills in healthy older adults produce positive
effects [34••] and are commensurate with the definition of
primary prevention. Similarly, CT has been shown to help
maintain and enhance function in MCI [6-8, 21]—consis-
tent with secondary prevention—and may therefore slow
disease progression in at-risk individuals. Two studies
demonstrated that multidomain CT is beneficial in AD
groups, with training leading to improved global cognitive
function [5, 11], suggesting that CT can provide secondary
prevention in the diagnosed population. Although memory
strategy training to date has demonstrated limited benefit on
cognitive function—and therefore has no impact at primary
and secondary stages—it may be beneficial at tertiary
prevention when aimed at improving impaired memory
Table 2 Summary of commercially available cognitive training products
ProductManufacturerProduct description Published
Nintendo DS (Redmond, WA)
Advanced Brain Technologies
Lumos Labs (San Francisco, CA)
Posit Science (San Francisco, CA)
Scientific Brain Training
(Palo Alto, CA)
CogniFit (Yoqneam, Israel)
MyBrainTrainer (Los Angeles, CA)
Dakim (Santa Monica, CA)
Brain fitness program 2.0
CD, requires Internet
CD, requires Internet
CD or downloads, requires Internet
Software and touch screen
CD compact disc
Curr Psychiatry Rep (2010) 12:20–27 25
function and reducing disability. Several clinical trials have
also investigated the benefit of combining CT with
medication [7•, 27, 44], with results indicating that
combination CT treatment provided greater benefit than
medication alone. These findings suggest that CT may play
an important adjunctive and synergistic role with traditional
pharmacologic treatment at different disease stages.
Research suggests that CT may have therapeutic benefit,
and there have been no reports of adverse outcomes .
Clinicians therefore may wish to consider CT as a treatment
option. Our reviews of the area suggest that computerized
multidomain brain training, or cross-training, is most likely
to lead to meaningful benefits, and several products are
available. There are, however, issues that should be
considered in consultation with patients. The straightfor-
ward issues of access and feasibility should be reviewed
initially. Economic resources and computer access need to
be taken into account, as do prerequisite skills such as
literacy and numeracy levels, sensory acuity, and motor
dexterity and coordination. We recommend that clinicians
become familiar with using a range of products themselves
and develop specific knowledge about level of supporting
scientific research, nature of instruction and structure with
the program, and whether training is domain specific or
multidomain. In addition to the content of the exercises,
their adaptability, feedback of results, and support systems
also vary considerably between products. Matching patients
to training programs may require exploration of several
options. Fortunately, several programs offer free initial
trials to facilitate this process. Clinicians interested in
accessing a consumer information sheet about CT devel-
oped by the authors can find it at http://www.brainage.med.
Finally, it is important to emphasize to patients and to
cognitively intact individuals interested in embarking on
CT that there is no guarantee that any such training will
eliminate the risk for dementia or cognitive impairment. CT
is therefore best viewed as only part of a wider strategy of
maximal risk reduction and maintenance of optimal brain
health. CT complements and should be combined with
other risk reduction strategies, including participation in
cognitive, social, and physical leisure activities [45, 46], as
well as careful control of vascular risk factors .
CT is a specific form of cognitive intervention that aims to
stimulate residual neuroplastic pathways in the aged brain.
Research suggests that CT can be beneficial across the aged
spectrum, including in healthy adults and those at risk with
MCI and AD. Training exercises seem to have greater
efficacy than memory strategy training, and training in
multiple cognitive domains seems to have greater benefit
than unimodal training. In addition, increasingly popular
computer-based programs may produce more effective
outcomes on global and domain-specific cognitive mea-
sures. More rigorous research is required to adequately
determine “dose,” frequency, and duration of optimal
intervention. CT is therefore a promising new intervention
that can contribute to maintaining optimal cognition in
older adults and potentially help prevent dementia as part of
a comprehensive risk reduction strategy.
New South Wales Vice Chancellor’s Fellowship.
Dr. Valenzuela is supported by a University of
Fitness, Australia, a commercial, Internet-based CT enterprise, and
maintains a financial interest. No other potential conflicts of interest
relevant to this article were reported.
Miss Gates is a former director of HeadStrong Cognitive
Papers of particular interest, published recently, have been
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