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REVIEW
Enhancing Cognitive Functioning in Healthly Older Adults:
a Systematic Review of the Clinical Significance of Commercially
Available Computerized Cognitive Training in Preventing
Cognitive Decline
Tejal M. Shah
1,2,3
&Michael Weinborn
1,2,4
&Giuseppe Verdile
1,2,3,5
&
Hamid R. Sohrabi
1,2,3
&Ralph N. Martins
1,2,3
Received: 6 September 2016 /Accepted: 7 December 2016
#Springer Science+Business Media New York 2017
Abstract Successfully assisting older adults to maintain or
improve cognitive function, particularly when they are dealing
with neurodegenerative disorders such as Alzheimer’sdisease
(AD), remains a major challenge. Cognitive training may
stimulate neuroplasticity thereby increasing cognitive and
brain reserve. Commercial brain training programs are com-
puterized, readily-available, easy-to-administer and adaptive
but often lack supportive data and their clinical validation
literature has not been previously reviewed. Therefore, in this
review, we report the characteristics of commercially available
brain training programs, critically assess the number and qual-
ity of studies evaluating the empirical evidence of these pro-
grams for promoting brain health in healthy older adults, and
discuss underlying causal mechanisms. We searched PubMed,
Google Scholar and each program’swebsiteforrelevantstud-
ies reporting the effects of computerized cognitive training on
cognitively healthy older adults. The evidence for each pro-
gram was assessed via the number and quality (PEDro score)
of studies, including Randomized Control Trials (RCTs).
Programs with clinical studies were subsequently classified
as possessing Level I, II or III evidence. Out of 18 identified
programs, 7 programs were investigated in 26 studies includ-
ing follow-ups. Two programs were identified as possessing
Level I evidence, three programs demonstrated Level II evi-
dence and an additional two programs demonstrated Level III
evidence. Overall, studies showed generally high methodo-
logical quality (average PEDro score = 7.05). Although cau-
tion must be taken regarding any potential bias due toselective
reporting, current evidence supports that at least some com-
mercially available computerized brain training products can
assist in promoting healthy brain aging.
Keywords Computerized cognitive training .Brain training .
Cognition .Dementia .Alzheimer’sdisease
Introduction
There has been a recent increase in interest in the maintenance
of brain function well into late life, yet helping older adults to
maintain or improve brain health and cognition remains a
challenge (Brayne 2007). High prevalence of age-related cog-
nitive decline and neurodegenerative disorders such as
Alzheimer’s disease (AD) add considerable difficulty to this
task (Schonknecht et al. 2005; Reitz et al. 2011). Current
treatment for AD is only palliative (Casey et al. 2010), and
clinical evidence to support prophylactic or delaying strategies
is minimal. Lifestyle strategies, including appropriate physical
and mental activities, good diet and social engagement for the
purposes of improving/maintaining cognition, functional in-
dependence and quality of life have been the focus of many
recent studies (Ruthirakuhan et al. 2012; Shah et al. 2014;
Ngandu et al. 2015). Concurrently, there has been increased
*Ralph N. Martins
r.martins@ecu.edu.au
1
McCusker Alzheimer’s Research Foundation, Hollywood Medical
Centre, Nedlands, WA, Australia 6009
2
Centre of Excellence for Alzheimer’s Disease Research & Care,
School of Medical Sciences, Edith Cowan University, 270 Joondalup
Drive, Joondalup, WA, Australia 6027
3
School of Psychiatry and Clinical Neurosciences, University of
Western Australia, Crawley, WA, Australia 6009
4
School of Psychology, University of Western Australia,
Crawley, WA, Australia 6009
5
School of Biomedical Sciences, CHIRI Biosciences, Curtin
University, Bentley, WA, Australia 6102
Neuropsychol Rev
DOI 10.1007/s11065-016-9338-9
interest amongst older adults in cognitive interventions and
activities to maintain and improve brain function. This is clear
from the estimated computer-based brain health and fitness
market in 2009, which was estimated to be $295 million
worldwide, representing a growth of nearly 35% compared
with 2008 (Fernandez 2010).
The concept of cognitive interventions for older adults is
not new, and evidence for neural plasticity, including brain
response to increasing cognitive activity has accumulated
(Johansson 2004; Pascual-Leone et al. 2005). Plasticity is
the brain’s lifelong ability for physical and functional change
in response to sensing, perceiving and learning; thus building
experience that in turn promotes learning throughout life
(Merzenich and Jenkins 1999;1993). Cognitive reserve or
behavioural brain reserve is the brain’s ability to respond or
compensate against brain injury/degeneration. Subjects with
high cognitive reserve exhibit more tolerance of AD patholo-
gy (Stern 2006,2012) and also show a 50% reduction in the
incidence of dementia (Valenzuela and Sachdev 2006).
Importantly, Stern has argued that engaging in mentally stim-
ulating activities may stimulate plasticity and thereby increase
cognitive reserve (Stern 2012).
Supporting this, observational studies have found that high
levels of cognitive activity appear to be beneficial in preserv-
ing cognition and reducing the risk of dementia amongst older
adults (Verghese et al. 2003). For example, healthy older peo-
ple with greater early and mid-life cognitive activity have
lower brain amyloid deposition, a hallmark of AD pathology,
as measured using carbon 11-labelled Pittsburgh compound-B
positron emission tomography (PiB-PET, Landau et al. 2012).
Further, cognitive training intervention studies using paper
and pencil as well as computer modalities have been found
to improve targeted cognitive domains of memory, processing
speed and reasoning in both typically and atypically aging
older adults (Ball et al. 2002a; Mahncke et al. 2006; Engvig
et al. 2010). These and other studies support the concept that
computer-based training can be beneficial to cognitively nor-
mal older adults, as well as those with mild cognitive impair-
ment (MCI) or AD (Günther et al. 2003; Barnes et al. 2009;
Tárraga et al. 2006; Galante et al. 2007). Although cognitive
training can maintain or promote neuroplasticity
(Mowszowski et al. 2010) and may provide benefits in
preventing/slowing progression of cognitive decline (Gates
et al. 2011; Woodward and Brodaty 2007), it may not neces-
sarily reverse the disease trajectory.
Cognitive training (and similar constructs, such as cogni-
tive stimulation and cognitive rehabilitation) typically involve
structured, frequent and repeated engagement in standardized
cognitively demanding tasks targeting specific cognitive do-
mains such as attention, memory and problem-solving (Bahar-
Fuchs et al. 2013; Gates et al. 2011). Previous reviews of the
literature evaluating the efficacy of computer-based commer-
cially available cognitive training programs for healthy older
adults have not systemically evaluated the quality of individ-
ual studies and did not review follow-up studies (Lampit et al.
2014;Shaoetal.2015; Kueider et al. 2012). Therefore, the
potential benefits of commercial computerized cognitive train-
ing in enhancing cognition in healthy older adults remains
unclear. This is important, as the extant literature includes
studies that vary in both methodological approach and quality.
Furthermore, the potentially differential benefits between the
many cognitive training programs available has not been sys-
tematically evaluated, leaving clinicians with inadequate in-
formation from which to base recommendations for their pa-
tients at risk of cognitive decline.
Until recently, there have been few randomized controlled
trials (RCTs) using commercial computerized cognitive train-
ing programs in cognitively healthy older adults. However,
there has been an increase in this research over the last five
years (Nouchi et al. 2012; Barnes et al. 2013; Ballesteros et al.
2015a). The time is therefore appropriate for a systematic
review of the evidence for efficacy of commercially available
computerized brain training programs in improving specific
cognitive domains in older adults. In this review, we rigorous-
ly categorized studies according to their scientific and meth-
odological merit. In addition, we discuss underlying mecha-
nisms in context of the potential benefits of cognitive training
in enhancing cognition in the elderly population.
Methodology
The search process was completed in two steps. In step one,
relevant commercial cognitive training programs were identi-
fied and in step two, studies related to the programs were
identified and subsequently reviewed systematically. Briefly,
information regarding the availability of brain training soft-
ware programs was originally obtained using World Wide
Web search engines. Search terms initially used were commer-
cial brain/cognitive training programs, computerized brain/
cognitive training programs and software for brain/cognitive
training. In the next step, for the scientific validation literature
of identified programs, we searched for human clinical trials
in PubMed and Google Scholar (using exact phrase as article
title) along with the following search terms: Bcognitive
stimulation^OR Bbrain training^OR Bcognitive
rehabilitation^OR Bcognitive enhancement^OR Bbrain fit-
ness software^OR Bcognitive retention therapy^OR
Bcomputerized cognitive behavioural therapy^with and with-
out the related software programs. Exclusion criteria were
reviewed manually in final eligible studies. In addition, we
searched each product’s website for relevant software infor-
mation and any published clinical studies including internal
white paper studies eligible for this review. The search was
performed and updated through September 2015.
Neuropsychol Rev
Study Selection
Eligible studies were published in English, peer reviewed re-
ports of clinical trials evaluating the effects of previously iden-
tified computerized brain training on formal outcome mea-
sures of specific cognitive domains in cognitively intact,
healthy older adults, aged ≥50 years. Internal white paper
studies were also eligible for inclusion. Relevant follow-up
studies were included to identify maintained/long term effica-
cy of any observed cognitive benefits. Articles for detailed
review were excluded if they were: (1) conference abstracts
(2) studies of populations other than cognitively healthy older
adults (3) studies on rehabilitation for psychiatric or any other
neurodegenerative ailments including dementia (4) articles in-
volving training using video games (5) review articles and (6)
studies without cognition as primary outcome measure.
Moreover, if studies already satisfied the criteria for providing
a higher level of evidence, then trials of the same commercial
program providing a lower evidence level were not reviewed.
Data Extraction
Two reviewers (TS and MW) independently screened the ti-
tles and abstracts along with the relevant websites to identify
eligible articles. Disagreements between the reviewers about
study inclusion were resolved through discussion.
Specifically, the following data were extracted onto a template
(see Table 2): study source, sample size, age and intervention
duration, intensity and frequency with main study outcomes at
post-intervention and follow-up. We included the significance
levels (p value) and effect sizes [eta-squared (η
2
)/partial eta-
squared (pη
2
)/Cohen’sd] for immediate post-intervention data
including the cognitive outcome measures of processing
speed, attention, reasoning, language, memory, executive
functions and working memory. For studies that did not report
effect sizes but where the required data were available,
Cohen’sdvalues were calculated (Cohen 1988).
Risk of Bias
The risk of bias was assessed along with the overall method-
ological quality using the Physiotherapy Evidence Database
(PEDro) scale. The PEDro scale has a maximum score of 10
and interpretive guidelines for study quality are as follows:
>6 = high; 5–6 = moderate and <5 = poor quality (Maher
et al. 2003; Walser et al. 2009). The trials were initially rated
by TS and independently evaluated by MW and HRS. Any
disagreements on the assessments among the authors were
resolved through discussion. Besides collecting systematic
evidence of publication bias, we additionally documented
the role of company or authors who designed the cognitive
training programs used in reviewed articles or relevant study
funding by the companies that designed respective programs.
Data Synthesis and Analysis
For the current review, we assessed 1) the number of pub-
lished clinical trials for each program and 2) the methodolog-
ical quality of each study in an approach adapted from a series
of systematic reviews of the efficacy of cognitive intervention
for acquired brain injury by Cicerone et al. (for a review please
see Cicerone et al. 2011). Cicerone et al. (2011) classified
interventions as demonstrating Level I evidence if there was
at least one supportive RCT or quasi-randomized study, re-
gardless of blinding. Interventions were classified as having
Level II evidence if there were supportive non-randomized
studies, and interventions with Level III evidence included
studies without control conditions or absence of direct statis-
tical comparison of treatment conditions. Overall, the inclu-
sion of non-randomized, retrospective and baseline studies,
studies without control group or single-subject designs and
lack of discussion on the quality of the study methodology
were some of the limitations of the criteria by Cicerone et al.
(2011). For the present study, therefore we adapted this ap-
proach to be more stringent and include information on both
the quantity and quality of each study (provided by the PEDro
scale).
Specifically, we required at least two well-designed RCTs
or quasi-randomized studies, one of which must be of high
quality (PEDro score in the high range) and second at least of
moderate quality (PEDro score in the moderate range) for
classification as Level I evidence. Programs with clinical trials
providing Level II evidence required only one well-designed
RCT of high quality (PEDro score in the high range).
Programs with one or more moderate/poorly designed RCT
(Pedro score in the moderate to poor range) and other meth-
odological approaches (e.g., internal Bwhite paper^studies)
were classified as providing Level III evidence. Randomized
trials without a formally identified control group (active/inac-
tive) were excluded. Follow-up studies were not considered as
independently contributing to Level classification, but were
reviewed to assess whether the observed cognitive benefits
were sustained over time. Finally, in order to assess the meth-
odological quality of each RCT, we used the PEDro scale.
Results
Figure 1illustrates the flow of studies into review. In step one,
32 commercial brain training programs were identified, out of
which 14 programs were found to be recommended for youn-
ger population, rehabilitation, cognitively declined or other
neurological conditions or were paper and pencil based and
Neuropsychol Rev
hence, excluded. Step two was then conducted to identify
studies that used each of the remaining 18 programs identified
for cognitive training. A total of 7985 studies were retrieved
after removing duplicates. In total, 244 full text publications
were identified and assessed for eligibility. Based on the
inclusion/exclusion criteria, 26 supporting studies including
follow-ups were reviewed.
Evidence of Quality and Characteristics
The characteristics of all clinical trials relevant for each pro-
gram are summarized in Table 1. Out of the 18 programs
initially identified, relevant articles were retrieved for only
seven programs. Programs with no clinical trials, i.e. without
any empirical evidence (n= 11) were removed from assess-
ment. Twenty-six eligible articles including follow-up studies
were reviewed and all subsequent studies without follow-ups
(n= 18) evaluated. The mean PEDro score for all studies
(n= 18) was 7.05 indicating high methodological quality
overall, with most studies classified as high (n= 12) or mod-
erate (n= 6) quality and no studies classified as poor quality.
Twelve studies were either conducted or funded by the
program’s respective company. Two studies were allowed free
access to respective programs to conduct the research, and
four studies were conducted independently of the product
company. We scored the ratings of independent funding
(n= 6, includes 2 studies in which companies allowed pro-
gram access) versus company funded (n= 12) studies. When
compared, the PEDro ratings showed moderate to high quality
studies in both categories (average PEDro score for indepen-
dently funded studies = 6.3 and average PEDro score for com-
pany funded studies = 7.4).
Study Characteristics
Study characteristics and program features are summarized in
Table 2and 3respectively. The products described below are
listed as per the classification Levels.
Programs With Clinical Trials Providing Level I
Evidence
Studies classified as delivering Level I evidence (at least two
well-designed RCTs or quasi-randomized studies, one with
high quality and second at least of moderate quality as rated
on the PEDro score) were available for programs from Posit
Fig. 1 Flow of studies into
review
Neuropsychol Rev
science and Cognifit. These programs are discussed in the
section below.
Posit Science®
Posit science was evaluated in 10 studies, including 8 high
quality RCTs. The interventions include a number of cognitive
training programs, including modules for memory, processing
speed and reasoning. Posit also produces the Brain Fitness
Program (BFP, six exercises), which was developed to im-
prove auditory processing and memory. The principle behind
the BFP is based on the SAAGE™(Speed, Accuracy,
Adaptivity, Generalizability, Engagement) design protocol
(Brainhq.com) for spanned acoustic stimuli (Mahncke et al.
2006) including engaging mechanisms promoting brain plas-
ticity (Recanzone et al. 1992,1993; Xerri et al. 1999). Another
Posit program is the Cortex –Insight program (IP, 5 exer-
cises), which focuses on visual processing and memory. The
IP is based on the principle of BUseful Field of View^
(UFOV), defined as the area over which the participant can
see details quickly and accurately without moving one’seyes
or head (Ball and Owsley 1993; Owsley et al. 1998;Sanders
1970). Interventions based on UFOVare designed to improve
driving and visual processing and attention skills (Ball et al.
1988,2002b; Edwards et al. 2005,2006). At present, Posit
Science have replaced its programs by an online training sys-
tem known as BrainHQ (Brainhq.com).
Multiple peer-reviewed articles evaluating Posit Science
programs have fulfilled the gold standard for clinical trials
(Ball et al. 2002a; Mahncke et al. 2006; Smith et al. 2009;
Brainhq.com). The landmark study BThe Advanced Cognitive
Training for Independent and Vital Elderly^(Balletal.
2002a), ACTIVE trial is one of the largest, multicentre, RCT
on cognitive training in healthy older adults. Besides cogni-
tion, this trial also examined the long-term benefits of cogni-
tive interventions on the daily functioning of older individuals
who were living independently. The study recruited 2832 par-
ticipants aged 65 years or older and randomly assigned them
into one of three intervention groups targeting memory, rea-
soning or speed of processing, as well as a control group that
did not receive any training. The intervention consisted of 10
one-hour training sessions over six weeks. Memory training
focused on improving verbal episodic memory through the
use of mnemonic strategies. Reasoning training consisted of
working with trainers to learn and practice skills related to
inductive reasoning and problem solving. Speed of processing
training included a computer-based training procedure that
required the participants to identify a central visual target
and locate another peripheral stimulus. Results indicated that
training resulted in improved memory, reasoning and process-
ing speed, with maximum benefits observed in the speed of
Tabl e 1 Evidence quality and characteristics for studies included in this review
Program identified
with eligible trials
Level of evidence Study PEDro score
a
Author/s designed
program/company
employee
Study funded by company
Posit science I Mahncke et al. (2006)8 Yes Yes
Smith et al. (2009)9 Yes Yes
Ball et al. (2002a)9 Yes NA
Wol i ns k y e t al. ( 2013)9 Yes NA
Berry et al. (2010)8 Yes Yes
Edwards et al. (2013)5 Yes NA
O’Brien et al. (2013)7 Yes NA
Barnes et al. (2013) 7 Allowed program access
Anderson et al. (2013) 7 NA not funded by company
Leung et al. (2015) 5 NA not funded by company
Peretz et al. (2011)9 Yes Yes
Cognifit Shatil (2013)5 Yes NA
Shatil et al. (2014)6 Yes NA
Cogmed Brehmer et al. (2011) 7 Allowed program access
Brain age II Nouchi et al. (2012)9 Yes NA
My brain trainer Simpson et al. (2012) 7 NA not funded by company
Dakim III Miller et al. (2013)5 Yes Yes
Lumosity Ballesteros et al. (2014) 5 NA not funded by company
PEDro Physiotherapy Evidence Database, NA not available
a
PEDro score: >6 = high; 5–6 = moderate and <5 = poor methodological quality
Neuropsychol Rev
Tab l e 2 Published randomized clinical trials that have tested computerized software programs to enhance cognition/memory in cognitively intact older adults
Program/Company,
study (References)
n, Age Groups Cognitive training sessions Duration Control condition Reported results
BFP/Posit Science,
(Mahncke et al. 2006)
n=182,60–87 years 1. Experimental
2. Active control
3. No contact control
40 sessions, one hour/day,
5 days/week
8-10 weeks Educational DVDs
or
no contact
Training improved processing speed: p< 0.001,
d= 0.25; RBANS: p= 0.019, d=0.25and
word recognition: p= 0.022, d=0.25.
Sustained benefits at 3 months follow-up.
BFP/Posit Science,
IMPACT trial (Smith
et al. 2009)
n=487,65–80 years 1. Experimental
2. Active control
40 sessions, one hour/day,
5 days/week
8-10 weeks Educational DVDs Training improved processing speed: p< 0.001,
d= 0.87; RBANS: p=0.02,d=0.23;word
recall: p< 0.05, d= 0.28; delayed word
recall: p< 0.05, d= 0.20; digit span: p< 0.05,
d= 0.26; letter number sequencing: p<0.05,
d=0.23and CSRQ: p= 0.001, d=0.33.
BFP/Posit Science,
IMPACT trial (Zelinski
et al. 2011)
n= 415, >65 years 3-month follow-up study –––Training gains declined over the 3-month
no-contact period.
Insight/Posit Science,
ACTIVE trial (Ball et
al. 2002a)
n= 2832, 64–94 years 1.Reasoning training
2.Processing speed
training (Insight not
completely developed)
3.Memory training
4. Control
10 sessions, 60–75
min/session
4-5 weeks No contact Each intervention significantly improved the
targeted cognitive domain, sustained
benefits until 2 years.Training improved
memory: p< 0.001, d= 0.25; reasoning:
p<0.001,d= 0.48 and processing speed:
p<0.001,d=−1.46.
Posit Science, ACTIVE
trial (Wolinsky et
al. 2006b)
n= 2147, >65 years 2-year follow-up study –––Only the speed of processing training
protected against extensive clinically
relevant decline in HRQoL.
Posit Science, ACTIVE
trial (Wolinsky et
al. 2006a)
n= 1804, >65 years 2 and 5 year follow-up
study
–––At 2 years post-training, processing speed
intervention showed less decline in
HRQoL; at 5 year post-training all
three intervention groups were protective
at a lower threshold of age related
extensive declines in HRQoL.
Posit Science, ACTIVE
trial (Willis et al. 2006)
n= 67% retention from
ACTIVE study
5-year follow-up study –––Maintained cognitive benefits at 5 years
of the ACTIVE trial intervention;
reasoning training showed less
functional decline in IADL.
Posit Science, ACTIVE
Trial (Rebok et
al. 2014)
n= 44% retention from
ACTIVE study
10-year follow-up study –––All three interventions showed less
difficulty with IADL; reasoning and
processing speed interventions maintained
their effects on their targeted cognitive
domains; memory training intervention
did not maintain memory performance at
10 years follow-up.
Insight-Road tour
module/Posit Science,
(Wolinsky et al. 2013)
n=681,50–64 years
and ≥65 years
1.Processing speed
training
2. Active control
10 h 1.5 months Computerised
crossword puzzles
Training improved UFOV: d=−0.322 to −0.579;
Trails A: d=−0.204 to −0.265; Trails B:
d=−0.225 to −0.320; SDMT: d=0.263 to
0.351 and Stroop Word: d= 0.240 to 0.271.
All intervention groups had p< 0.05.
Insight-Sweep seeker
module/Posit Science,
n=32,60–89 years 1. Cognitive training
2. Control
10 h; 40 min sessions,
3–5 sessions/week
3-5 weeks No training Training improved perception-medium:
d= 0.85; perception-high: d=0.88;
Neuropsychol Rev
Tab l e 2 (continued)
Program/Company,
study (References)
n, Age Groups Cognitive training sessions Duration Control condition Reported results
(Berry et al. 2010)discrimination: p< 0.01, d=0.91and working
memory: p<0.05,d= 0.81. Transfer of
benefits from perceptual discrimination
training to working memory; EEG-early
visual processing during stimulus encoding
predicted working memory accuracy
improvements.
Insight/Posit Science,
(Edwards et al. 2013)
n=75,59–95 years 1. Insight training
2. Control
20 sessions, twice/week 12 week No training Training improved performance in the UFOV:
p = 0.043, d= 0.63.
Insight/Posit Science,
(O’Brien et al. 2013)
n=22,65–82 years 1. Speed of processing
training
2. Control
Upto 20 h; 70 min
twice/week
10 weeks No training Training improved attention: p=0.01, pη
2
=0.31
with changes in event related potentials in
the form of increased N2pc amplitude:
p = 0.025; pη
2
= 0.227 and P3b amplitude
p = 0.023; pη
2
=0.419.
BFP & Insight/Posit
Science, (Barnes et
al. 2013)
n= 126, >65 years 1. MA-I/EX-I
2. MA-I/EX-C
3. MA-C/EX-I
4. MA-C/EX-C
36 sessions, Insight for the
first 6 weeks–18 sessions;
BFP for the last
6weeks–18
sessions; 1 h three
times/week
3 months MA-C: educational
DVDs; EX-C:
stretching and toning
Global cognitive scores improved significantly
over time: p< 0.001; no significant differences
between the intervention and the active control
group.
BFP/Posit Science,
(Anderson et al. 2013)
n=104,55–75 years 1. Cognitive training
2. Active control
40 sessions; 1-h/day, 5
days/week
8 weeks Educational DVD’s Training improved memory: p< 0.001, d=0.79;
processing speed: p = 0.021, d=0.68and
speech-in-noise perception: p < 0.01, d=0.72.
BFP/Posit Science,
(Anderson et al. 2014)
n=62,55–70 years 6-month follow-up study –––Maintained gains in processing speed but not
memory and speech-in-noise recognition.
BFP/Posit Science,
(Leung et al. 2015)
n= 209, >60 years 1. Cognitive training
2. Active control
39 sessions, 1-h per sessions,
3 times/week
13 weeks Educational video
programs
Training improved attention: p=0.026, d=0.31
and working memory: p= 0.012, d=0.35.
Personal Coach/Cognifit,
(Peretz et al. 2011)
n= 155, >50 years 1. Cognitive training
2. Computer games
36 sessions, 20–30 min/session;
3 sessions/week
3 months Played conventional
computer games
Training-specific improvement in visuospatial
working memory: p= 0.0001, d=0.43;
learning: p = 0.0012, d= 0.51 and attention:
p = 0.0019, d=0.63.
Cognifit, (Shatil 2013)n=118, 65–93 years 1.Physical activity
2.Cognitive training
3. Combined
4. Active Control
Cognitive training –32 h,
48 min sessions, three
times/week
4 months Book reading The cognitive training and the combined group
improved on: hand-eye coordination:
p<0.001,d= 0.80; processing speed:
p < 0.001, d= 0.71; visual scanning: p = 0.021,
d= 0.77; global visual memory: p =0.003;
d= 0.64 and naming: p < 0.05, d=0.82.
Cognifit, (Shatil et al. 2014)n=140,60–87 years 1. Television based
cognitive training
2. Active control
24 sessions, 20 min sessions,
three times per week
8 weeks Non-cognitive
applications
Improvement in working memory and executive
functions in the training group. Digit Span
Forward: p<0.01; d= 0.58. Digit Span
Reverse: p< 0.01; d= 0.58. Digit Span Total:
p<0.001;d= 0.70. Trail Making Test
Part B: p < 0.05; d=−0.40. Trail Making Test
Total: p < 0.05; d=−0.40.
Cogmed QM/Cogmed,
(Brehmer et al. 2011)
n=23,60–70 years 1. Adaptive training
2. Active control
25 sessions, 25 min/day,
5 days/week
5 weeks Improved working memory, attention, episodic
memory, less everyday cognitive problems;
Neuropsychol Rev
Tab l e 2 (continued)
Program/Company,
study (References)
n, Age Groups Cognitive training sessions Duration Control condition Reported results
Fixed, low level
cognitive training
practice
BOLD decrease in frontal, parietal and
temporal regions, higher neural efficiency.
Span Board Backward: p=0.04;pη
2
= 0.18.
Paced Auditory Serial Addition Task:
p=0.02;pη
2
= 0.22.
Brain Fitness/Dakim,
(Miller et al. 2013)
n= 69, 81.8 ± 6.1 years 1. Intervention
2. Control
20-25 min/day, 5 days/week,
43 sessions at 2 months
and81sessionsat6months
6months Wait–list Training improved delayed memory: p=0.01,
d= 0.67; 40 sessions over 6 months resulted
in improved immediate memory: p=0.001;
delayed memory: p= 0.004 and language:
p=0.03.
Brain age/Nintendo,
(Nouchi et al. 2012)
n= 32, 69.1 ± 0.31 years 1. Brain age
2. Tetris
15 min/day, 5 days/week 1 month Played Tetris Improved executive functions and processing
speed assessed using Frontal Assessment
Battery at Bedside: p=0.001,η
2
=0.13;Trail
Making Test Type B: p= 0.006, η
2
=0.13;
Symbol Search: p= 0.014, η
2
=0.12and
Digit Symbol Coding: p= 0.005, η
2
=0.19.
My brain trainer,
(Simpson et
al. 2012)
n=34,53–75 years 1. My brain trainer
2. Active Control
20 min daily 21 days Played Solitaire Improved processing speed at post - training and
at three weeks follow-up as assessed on
Simple Reaction Time: p = 0.024, pη
2
= 0.154
and Complex Reaction Time:
p = 0.007, pη
2
= 0.170.
Lumosity, (Ballesteros
et al. 2014)
n=60,57–80 years 1. Experimental group
2. Control
20 sessions; 1-h sessions 10-12 weeks Three meetings; 2-h in
duration discussing
aging and interests
Training improved processing speed: p< 0.001,
pη
2
= 0.83; Cross-Modal Oddball Attention
Task: p<0.05, pη
2
= 0.05; immediate
memory: p<0.05,pη
2
= 0.14 and delayed
memory: p< 0.001, pη
2
= 0.45.
Lumosity, (Mayas
et al. 2014)
n=27,57–77 years 1. Experimental group
2. Control
20 sessions; 1-h sessions 10-12 weeks Three meetings; 2-h in
duration discussing
aging and interests
Improved alertness: p=0.04,d=0.9and
reduced distraction: p=0.05,d=0.43inthe
exercise group
Lumosity, (Ballesteros
et al. 2015a)
n=40,57–80 years 3-month follow-up study –––No sustained cognitive benefits; maintained
benefits in subjective wellbeing only
BFP Brain Fitness Program, DVD Digital Video Disc, dCohen’sd,RBANS Repeatable Battery for the Assessment of Neuropsychological Status, IMPACT The Improvement in Memory with Plasticity-
Based Adaptive Cognitive Training, CSRQ Cognitive Self Report Questionnaire-25, ACTIVE The Advanced Cognitive Training For Independent And Vital Elderly, HRQoL Health-Related Quality of Life,
IADL Instrumental Activities Of Daily Living, UFOV Useful Field Of View, SDMT Symbol Digit Modalities Test, EEG Electroencephalogram, pη
2
Partial eta squared, MA-I Mental Activity-Intervention,
EX-I Exercise-Intervention, EX-C Exercise-Control, MA-C Mental Activity-Control, BOLD Blood-Oxygen-Level-Dependent, η
2
Eta squared
Neuropsychol Rev
processing training group. The IP was originally developed as
part of this ACTIVE trial for training of processing speed and
was later revised to include additional tasks (Jobe et al. 2001;
Ball et al. 2013). Thus, the program was not fully developed in
the ACTIVE trial.
Following the initial validation trial, ACTIVE participants
were reassessed on multiple occasions over 10 years. Initially
they received a booster training of 4 hours after 11 and
35 months post-baseline, and displayed additional improve-
ments in the reasoning and speed of processing intervention
groups. However, the memory group participants did not
show further benefit. Notably, however, a five-year follow-
up on 67% of ACTIVE participants demonstrated persistence
of the benefits obtained in all three intervention groups.
Further, these participants displayed a slower decline in instru-
mental activities of daily living {IADL, (Willis et al. 2006)}
with the reasoning group showing the greatest resistance to
IADL loss. It was additionally noted thatthe speed of process-
ing training was protective against clinical decline in health-
related quality of life at two and five years post-training
(Wolinsky et al. 2006a,b). More recently, a 10-year follow-
up study of the ACTIVE trial participants found that each of the
cognitive intervention groups reported less decline in self-
reported IADL when compared to the control group.
However, reasoning and speed, but not memory training, result-
ed in improved targeted cognitive abilities (Rebok et al. 2014).
Results from other studies using Posit software have gen-
erally supported findings from the ACTIVE trial. For exam-
ple, Edwards and colleagues studied 97 adults (61–95 years),
and found thatwhile speed of processing training produced no
immediate transfer effects to other cognitive domains, it may
have contributed to enhanced speed in performing IADLs
(Edwards et al. 2002). In addition, studies using the IP and
BFP programs have produced promising results. For example,
a study of 32 healthy older adults using the Bsweep seeker^
module from the IP for 40 min, 3–5 sessions/week for 3–5
weeks reported direct transfer of benefits from perceptual dis-
crimination training to working memory performance in older
adults. The study also used electroencephalography and re-
ported that early visual processing during stimulus encoding
predicted improved working memory (Berry et al. 2010). In
another study of 22 participants, an increase in the amplitudes
of event related potentials related to selective attentional pro-
cessing were reported following speed of processing training
for 10 weeks (O’Brien et al. 2013). Finally, in yet another study
using IP on 75 older adults, the UFOV performance was en-
hanced after 3 months of training with 20 sessions (Edwards
et al. 2013). The Broad tour^module of IP also showed improved
processing speed and executive functions (Wolinsky et al. 2013).
Mahncke and colleagues administered the BFP to 187 par-
ticipants randomized into a training group, a contact control
group or a no-contact control group, and found training pro-
duced gains in independent measures of cognition (Mahncke
et al. 2006). Briefly, the intervention group was given intensive
training on the BFP with a duration and frequency of 60 min
sessions for 5 days per week (total 40 sessions) for 8 to
12 weeks. The contact control group were given an educational
DVD whereas the no-contact control group did not receive any
intervention. The study showed significant improvements in
directly trained tasks underlying speed of processing and for-
ward recognition memory span. An obtained effect size of 0.25
suggested significant generalization of improvements to non-
related standardised memory tests from the Repeatable Battery
for the Assessment of Neuropsychological Status. Memory en-
hancement was found to be sustained after 3 months of no
contact at a follow-up assessment. The study also reported that
older adults had no difficulty in using the program on the com-
puter. Based on this study, Smith and colleagues carried out
another landmark study, BThe Improvement In Memory With
Plasticity Based Adaptive Cognitive Training^{(Smith et al.
2009), IMPACT study}. The cohort included 487 healthy
community-dwelling adults aged 65 years and older, and used
a similar training approach to the initial study led by Mahncke
and colleagues. The study found improved neuropsychological
function broadly, but with the greatest benefits observed in
auditory memory/attention. However, training gains declined
at 3-month follow-up which indicated that booster training ses-
sions may be required to maintain training-induced benefits
(Zelinskietal.2011). Recent studies support the above findings
in the form of improved attention, working memory, processing
speed and transfer of training benefits to everyday problem
solving and reasoning with altered occipital-temporal white
matter integrity (Strenziok et al. 2014; Leung et al. 2015;
Anderson et al. 2013,2014).
Of interest, one RCT study evaluated the utility of Posit
Science programs in combination with physical activity. The
mental activity and exercise (MAX) trial used a 2x2 factorial
design and 126 older adults with cognitive complaints were
divided into four groups, and underwent intensive physical
and/or cognitive training. All groups including the control
group underwent 12 weeks of home-based mental activity
(1 h/day, 3 days/week) plus class-based physical activity 1 h/
day, 3 days/week, (Barnes et al. 2013). Cognitive training
comprised of 18 sessions of IP (visual stimulation) for the first
6 weeks followed by 18 sessions of BFP (auditory stimula-
tion) for the last 6 weeks. Thus each group had 36 sessions of
mental training (as just described, whereas the control group
watched educational DVDs 3 times a week) and 36sessions of
physical training; either active (aerobic) or control (stretching
and toning), giving a total of 72 sessions. Improved global
cognition was found in all the groups including the control
group, and there were no intervention-specific benefits, a pos-
sible reason being that the amount of activity may be more
important than the type i.e. more training sessions may be
required to see an effect when used in combination. Details
for three non-randomized studies that used Posit Science
Neuropsychol Rev
softwares in combination with physical activity were not in-
cluded in the review (Frantzidis et al. 2014;Shahetal.2014;
Bamidis et al. 2015).
Cognifit™
Cognifit™interventions were evaluated in 3 studies including
1 high and 2 moderate quality studies. Its software includes
four different versions: Cognifit personal coach for brain
health, Mindfit which is a CD-ROM version, Cognifit senior
driver for maintaining driving skills of seniors and the Mindfit
Bback on track^version. Mindfit aims to train 14 cognitive
skills through 21 exercises. Feedback is provided by progres-
sion charts and personal coaching via an individualised train-
ing system (ITS™) and is recommended for rehabilitation. A
study using the Mindfit program for cognitive remediation on
gait performance reported improved processing speed in the
sedentary elderly (Verghese et al. 2010). As attention and ex-
ecutive functions are associated with slow gait and falls in the
elderly, this study showed that the benefits of cognitive train-
ing can be transferred to untrained domain of mobility. RCTs
have been conducted using ITS™on individuals with multi-
ple sclerosis, dyslexia and other disorders showing improved
cognition. Mindfit has also been reported to enhance memory,
attention, executive functions and processing speed in chronic
insomnia patients (Haimov et al. 2008).
A study by Peretz and colleagues in 155 healthy older
adults using the Cognifit personal coach reported that al-
though both the training and an active control condition im-
proved cognition per se, the training was more effective for
visuospatial working memory, learning and attention (Peretz
et al. 2011). Another randomized double-blind study was con-
ducted using Cognifit along with a physical activity interven-
tion, using a four-condition design on 118 healthy older adults
(Shatil 2013). Participants were randomized into physical ac-
tivity, brain training, a combination ofboth, or a control group.
The brain training and combined groups displayed enhanced
memory, processing speed including hand-eye coordination,
the authors concluded that the mechanism of action behind the
benefits observed in the combined group was likely due to the
brain training rather than the physical activity component. For
older adults without computer facilities, Cognifit’s television
compatible software version showed improved working mem-
ory and executive functions in healthy older adults (Shatil
et al. 2014).
Programs with Clinical Trials Providing Level II
Evidence
Studies providing Level II (that is, only a single relevant well-
designed RCT with PEDro score in the high range) evidence
used brain training programs from Cogmed, Brain age 2 and
My brain trainer.
Cogmed
Cogmed (Cogmed.com) was evaluated in one RCT of high
quality. The Cogmed coach version initially trains for 30 ses-
sions with assistance and motivation. There is a six-month
follow-up interview and training with another 100 sessions
over a year. In a RCT of 23 healthy older adults Cogmed
training resulted in improved memory performance
(Brehmer et al. 2011). The study administered 25 sessions of
adaptive training (individually adjusted task difficulty to bring
individuals to their performance maximum) within five
weeks, and included an active control group that performed
low-level fixed cognitive training. Specifically, improvements
were observed in the adaptive training group for working
memory, but also in the untrained cognitive domains of atten-
tion and episodic memory. In addition, functional magnetic
resonance imaging [blood-oxygen-level-dependent (BOLD)
fMRI] was performed to assess in-scanner task-associated
neural activations seen during working memory performance.
No significant group differences in brain activation patterns at
baseline or post-intervention were seen, in the low-task diffi-
culty condition. However, greater decreases in neocortical
brain activity and greater increases in subcortical activity were
found in the adaptive training group under high-task difficulty
conditions, post-intervention. This was interpreted as indicat-
ing that the high-load task was less executively demanding
and required less neural activity to attain the same baseline
performance level in the adaptive training group. Overall, the
study findings showed behavioural training gains as a result of
adaptive cognitive training which was associated with chang-
es in neural activity while performing a challenging working
memory task.
Brain Age 2
Brain Age 2 from Nintendo® (Brainage.com) was evaluated
in one high quality RCT. It trains individuals to solve simple
maths problems, count currency, draw pictures and unscram-
ble letters. It is administered via a handheld device and has a
touch screen with a pen. This product is extremely popular in
the market and its most appealing feature is considered to be
its portability. Brain age 2 has been tested in healthy elderly
and young adults (Nouchi et al. 2012,2013). An RCT on 32
healthy older adults using brain age versus another popular
game BTetris ^for 15 min/day for 5 days/week for 4 weeks
reported improved executive functions and processing speed
(Nouchi et al. 2012). However, no transfer effects were
Neuropsychol Rev
observed in other outcome measures of global cognition or
attention.
My Brain Trainer
My brain trainer (Mybraintrainer.com) was evaluated in a
single RCT of high quality. It is a program that includes exer-
cises for neuronal stimulation that aims to increase cerebral
blood flow and the number of neural receptors, and to enhance
the synthesis and uptake of neurotransmitters. A randomized
single blind trial have been conducted using my brain trainer’s
21-day online exercises on 34 participants between 53–75
years of age with an active control group that played solitaire
card game. The study reported improved processing speed
(Simpson et al. 2012).
Programs With Clinical Trials Providing Level III
Evidence
Studies providing Level III evidence (that is one or more
moderate/poorly designed RCT with Pedro score in the mod-
erate to poor range and other methodological approaches)
used brain training programs from Dakim and Lumosity.
Dakim
Dakim (Dakim.com) was evaluated in a single trial of relative-
ly moderate quality (PEDro score = 5). It comes as software or
as a plug in and play touch screen system with five levels of
challenging exercises. Individual 25-min sessions includes
exercises from each of the following domains: memory, crit-
ical thinking, visuospatial, calculation and language. It has
over 100 exercises lasting for over 300 h with regular updates.
In a RCT of 69 healthy older adults using this program, the
intervention group showed improved memory and language
after completing 40 sessions in two months (Miller et al.
2013). The study also reported benefits at six months fol-
low-up. In addition, an unpublished clinical trial on more than
100 participants reported improved memory retention and de-
layed recall (Dakim.com).
Lumosity
Lumosity (Lumosity.com) was evaluated ina single RCTclas-
sified in the moderate range of the PEDro scale. It is based on
the principle of neuroplasticity and recommends 15 min of
daily training. The website has online neuropsychological as-
sessments for various cognitive domains with about 10 mil-
lion members in its community. It includes a brain grade test
for speed, memory, attention, flexibility and problem solving.
While not yet the subject of an RCT, a white paper reported a
study of 23 healthy adults who trained with lumosity for
20 min per day for five weeks reported improved working
memory, visual attention and executive functions (Scanlon
et al. 2007; Hardy and Scanlon 2009). Later, a RCT using
lumosity reported cognitive gains, increased alertness and
wellbeing in healthy older adults (Ballesteros et al. 2014;
Mayas et al. 2014). A follow-up study three months later
Tabl e 3 List of computerized brain fitness programs and their features (in alphabetical order)
Program Website Specifications Training exposure Web references
BFP/Insight www.positscience.com
www.brainhq.com
NP, BFP - SAAGE™design
protocol, Insight - UFOV
technology/web based
BFP - 60 min for 5 days/week for
8–10 weeks, total 40 sessions;
Insight - 60–90 min of 10
sessions for 2–3 times/week
(Brainhq.com)
Brain Age 2 www.brainage.com
www.brainage2.com
Increases blood flow to the
prefrontal cortex/played
on a palm device
Few minutes per day (Brainage.com; Brainage2.com)
Cogmed www.cogmed.com NP/CD-ROM/web based 30-45 min, 1 session for
5 days/week for 5 weeks
(Cogmed.com)
Cognifit www.Cognifit.com, NP/web based 20 min, 3 times/week (Cognifit.com)
Dakim (m) Power www.dakim.com Use it or lose it?/web based 20-25 min, 3–5 times/week (Dakim.com)
Lumosity www.lumosity.com NP/web based Full workout in 10 min/day/daily
30 min sessions
(Lumosity.com)
My Brain Trainer www.mybraintrainer.com Elementary cognitive tasks
to stimulate neurons,
increases blood flow to the
brain/web based
10 min twice per day, daily (Mybraintrainer.com)
BFP Brain Fitness Program, NP Neuroplasticity, SAAGE Speed, Accuracy, Adaptability, Generalizability and Engagement, UFOV Useful Field of View,
CD-ROM Compact Disc-Read Only Memory
Neuropsychol Rev
showed that only subjective well-being was maintained, indi-
cating that booster sessions of brain training may be required
for the maintenance of cognitive benefits (Ballesteros et al.
2015a). Moreover, lumosity’s online brain exercises involving
visual working memory when used as an assessment parame-
ter for cognition, identified subjects at risk of cognitive decline
(Geyer et al. 2015). A web-based RCT (n= 4715, 18–80
years) reported improved processing speed, memory, problem
solving abilities and concentration after participants complet-
ed lumosity exercises for 15 min, 5 days per week for 10 weeks
(Hardy et al. 2015). However, the study also included younger
participants. Only one study was validated for lumosity as
separate articles reported findings from the data of a single
RCT (Ballesteros et al. 2014,2015a,b; Mayas et al. 2014).
Discussion
This review gives details of 7 commercial computerized brain
training programs and summarizes 26 clinical trials including
follow-up studies conducted in healthy older adults. Overall,
most studies had at least adequate methodological quality
(67% of studies were rated as high quality using PEDro clas-
sification, see Table 1). In addition to classifying the method-
ological quality of individual studies, this review also classi-
fied the overall level of research evidence found for each
training program. Results indicated that two programs (Posit
science and Cognifit) met criteria for Level I evidence (mul-
tiple well-designed RCTs). Three additional programs
(Cogmed, Brain age 2 and My brain trainer) met criteria for
Level II evidence (at least one high quality, well-designed
RCT). Finally two products (Dakim and Lumosity) were clas-
sified as possessing Level III evidence (some supportive re-
search, but moderately designed RCT).
Programs with clinical trials providing Level I evidence (13
studies, see Table 1) administered training sessions that ranged
from 4 weeks to 16 weeks. Briefly, seven studies reported
improved processing speed, 3 studies reported improved at-
tention with either small, medium or large effect sizes and five
studies reported improved memory/working memory with
small to medium effect size. One study reported improved
reasoning with small effect size whereas only two studies
reported significantly improved executive functions with a
small effect size.
Programs with clinical trials providing Level II evidence (3
studies, see Table 1) administered training sessions that ranged
from 21 days to 5 weeks. Results from all three studies report-
ed improved processing speed with a medium to large effect
size whereas one study reported improved memory with large
effect size. One study also reported improved attention with a
large effect size. Only one study reported improvement in
executive functions with medium effect size.
Programs with clinical trials providing Level III evidence
(2 studies, see Table 1) administered training sessions that
ranged from 10 weeks to six months. Results from one study
reported improved processing speed with a large effect size
whereas two studies reported improved memory with medium
to large effect size. One study reported improved attention
with small effect size.
The RCTs conducted using Posit Science interventions (IP
and BFP) include large sample sizes. According to the
ACTIVE trial, the benefits of cognitive training for even a
relatively short period of time appear to be sustained over 2,
5 and possibly 10 years post-intervention when occasional
booster sessions were included. The ACTIVE trial is the larg-
est and most frequently cited RCT reporting cognitive bene-
fits, following 10 sessions of training. The ACTIVE trial re-
ported generalisation of benefits to health-related quality of
life and IADLs, with the follow-up study at 10 years post-
intervention showing sustained benefits, including resistance
to IADL decline. Thus, although it is difficult to compare
any two programs side by side, there is evidence that at
least some of these programs enhance memory, process-
ing speed, executive functions and reasoning capabilities
in older adults.
When used in combination with physical activity, comput-
erized brain training have shown mixed results. The MAX trial
(Barnes et al. 2013) used both physical and mental training but
did not demonstrate intervention specific benefits. One of the
reasons for this may be that the training conditions used for the
control group may have provided similar benefits to the inter-
vention training program. Moreover, the cognitive training ses-
sions shown to be effective are 10 sessions for the IP and 40
sessions for the BFP. The cognitive training thus differed (i.e.,
36 sessions in the MAX trial) from the recommended sessions
and this could have led to undetected training benefits. On the
other hand, the study led by Evelyn Shatil (Shatil 2013)using
Cognifit program together with physical activity showed im-
proved hand-eye coordination, global visual memory and pro-
cessing speed in the cognitive training and the combined group.
The exercise group alone did not show cognitive gains.
Another study on 224 elderly participants showed that a com-
bination of physical activity in the form of walking and resis-
tance training along with auditory and visual stimulation using
the BPF and IP programs (total 160 combined sessions in four
months) improved verbal episodic memory in healthy older
adults (Shah et al. 2014). Furthermore, improved verbal mem-
ory in the combined group was associated with increased brain
glucose metabolism in the left primary sensorimotor cortex at
16 weeks post-intervention. In addition, a study using the
Greek version of BFP together with exercise reported increased
neuropsychological synchronisation in the intervention group
(Frantzidis et al. 2014). This study used 24–40 training sessions
of the BFP. Although the exercise component and the study
design differed in these studies, it is possible that all observed
Neuropsychol Rev
benefits could be the result of the greater number of training
sessions. Some studies lack the inclusion of stand-alone train-
ing such as that in the study by Franzidis and colleagues
(Frantzidis et al. 2014), which means that the combined effects
cannot be compared with isolated training effects. Overall, fur-
ther evidence is required to determine if computerized brain
training programs show synergistic benefits when used in com-
bination with exercise.
Despite the positive cognitive outcomes reviewed here,
there are still significant limitations to the current evidence
and areas needing further study. One such limitation is the fact
that the measurement of cognition remains limited in many
studies, with little or no measurement of cognitive domains
with demonstrated promise in predicting real-world function-
ing in older adults {e.g. prospective memory; (Woods et al.
2012)}. Assessments of executive functions considered as one
of the reliable predictors of IADL in older adults (Lewis and
Miller 2007) is also lacking in majority of the studies.
Inclusion of assessments testing a broad array of cognitive
domains would enhance our understanding regarding the po-
tential transfer of effects to untrained cognitive domains.
Additionally, although brain training has been tested in com-
bination with exercise as discussed above, more studies are
required that also consider combination with other lifestyle
factors such as social engagement and diet.
Another major limitation is the lack of measuring candidate
blood, cerebrospinal fluid (CSF) or brain imaging AD bio-
markers in many of the studies providing Level I and Level II
evidence. The inclusion of such parameters could have helped
to elucidate the possible mechanisms of action behind the ben-
efits observed using such neuroplasticity-based tailored pro-
grams. In a study testing the BFP on 6 MCI patients versus 6
controls using fMRI, it was shown that activation in the left
hippocampus increased significantly in the training MCI group
(Rosen et al. 2011). One could speculate that similar brain
changes happen in trials involving cognitively intact healthy
older adults. The trial by Cogmed QM targeted working mem-
ory and used fMRI to measure brain activity under two difficult
conditions (Brehmer et al. 2011). The study showed that al-
though there were no training related changes in working mem-
ory, a pattern of increased neural efficiency in the form of
decreased neocortical brain activity and increased subcortical
activity was observed in the intervention group. Moreover, the
gains were transferred to non-targeted tasks of attention and
episodic memory. Performance gains in the training group in-
creased from week 1 through week 4 and remained stable
thereafter. The active control group received the same training
as the experimental group, with the main difference being that
of task difficulty was fixed at a lower level. This would indicate
that the intensity of the training is also important in addition to
the type of training performed. However, the results are limited
by a small sample size, and replication in a larger cohort is
needed. The use of brain imaging in future clinical studies of
cognitive training would help indicate its mechanism(s) of ac-
tion, thus paving a way for investigating strategies for the ther-
apeutic management of AD. Studies providing relevant evi-
dence to the significant question yet to be adequately addressed
regarding the mechanism(s) by which the cognitive training
interventions reviewed here may produce positive cognitive
effects is further discussed below.
Potential Mechanisms Underlying Cognitive Benefits
of Cognitive Training
Animal studies show that cognitive stimulation can result in
molecular, synaptic and neural alterations in the brain
(reviewed in Buonomano and Merzenich 1998). Virtual real-
ity based games can alter neurochemical levels in the brain
(Koepp et al. 1998), suggesting potential mechanisms for cog-
nitive rehabilitation by these programs (Cameirão et al. 2010).
For example, intervention studies incorporating brain training
have reported increased levels of serum brain derived neuro-
tropic factor (Anderson-Hanley et al. 2012; Vinogradov et al.
2009). The brain derived neurotropic factor plays an important
role in memory processing. However, as mentioned in the
discussion above, in humans, the most powerful and common-
ly used measure to assess the effects of brain training is neu-
roimaging. Brain imaging conducted after training has shown
changes in activity in certain brain regions while performing
specific tasks, along with long-term global changes (Buschert
et al. 2010). Engvig and colleagues showed that 8 weeks of
training with the Method of Loci (paper and pencil based
memory training) resulted in improvements in memory
(Engvig et al. 2010). These improvements correlated positive-
ly with increases in the cortical thickness of the lateral
orbitofrontal cortex bilaterally, as well as the right fusiform
cortex. The same group found that the training caused changes
in white matter microstructure: diffuse tensor imaging was
used to show higher levels of fractional anisotropy in the fron-
tal cortex of the older adults who had undergone the intensive
memory training, compared to the control group. This indicat-
ed that training may protect against age-related decreases in
myelination (Engvig et al. 2012). Other studies of the same
Method of Loci training found that training increased brain
activity in the occipito-parietal and frontal cortex as assessed
using PET (Nyberg et al. 2003), and that memory improve-
ments after 5 weeks of training correlated with increases in
choline and creatine signals in the hippocampus, as measured
using magnetic resonance spectroscopy (Valenzuela et al.
2003).
Computer based games also appear to influence changes
seen in brain activity. For example, a PET study (n=8,males,
19–32 years of age in the training group) measuring regional
cerebral glucose metabolic rate after 4–8 weeks of playing the
computer game Tetris for 30–45 min, 5 times/week reported a
Neuropsychol Rev
decrease in glucose metabolic rate in cortical surface regions,
alongside a 7-fold increase in performance in the game (Haier
et al. 1992). Another study using fMRI reported increased
brain activity in the middle frontal gyrus and superior and
inferior parietal cortices after practicing working memory
tasks (Olesen et al. 2003). A recent study using manual Bgist
reasoning^cognitive training on 37 cognitively normal elder-
ly individuals for 1 h sessions, 3 times/week for 12 weeks
reported increased global and cerebral blood flow in the de-
fault mode and central executive network, with increased
white matter integrity in the left uncinate region (Anand
et al. 2011; Chapman et al. 2013). The study used 3 MRI-
based measurements namely arterial spin labelling MRI, func-
tional connectivity and diffusion tensor imaging. Using simi-
lar neuroimaging techniques, it will be interesting to deter-
mine whether the use of computerized brain training exercises
results in similar or greater training benefits than those obtain-
ed with the paper and pencil/video games based training.
Considering that the brain is adaptive in nature, a computer-
ized brain training program that is adaptable and challenging
may alter neural activity involving the specific targeted cogni-
tive domains to be trained, as well as the brain regions involved
in executing the tasks. One possible explanation is that, as the
training becomes adaptive and the brain becomes accustomed
to performing the trained tasks, neural activity in these regions
would eventually decrease. It is also possible that if the training
is too challenging, other brain regions may be involved as a
compensatory mechanism resulting in increased neural activity
in these regions. Another explanation to this mechanism is that
decreased neural activity may demonstrate that the subjects are
performing well in the trained tasks thus using a limited (min-
imum necessary) number of neural circuits. In contrast, subjects
finding the training difficult, i.e. Bpoor performers^may display
increased neural activity (Haier et al. 1992). A study (n= 17) by
Small and colleagues (Small et al. 2006) investigated the bene-
fits of a combination of memory training, exercise, stress reduc-
tion and diet on cognition and cerebral glucose metabolism
using PET scan. The study reported a 5% decrease in activity
in the left dorsolateral prefrontal cortex and improvement in
word fluency in the intervention group. It is possible that the
changes observed in the brain’s left hemisphere could be due to
the verbal emphasis in the program’s memory training exercises
as explained by the study authors. However, inclusion of com-
parative single intervention groups would further help to con-
clusively determine whether all and/or any one component of
the program resulted in training benefits. In summary, it has
been hypothesised that processes requiring attention show de-
creased brain activity and task specific brain regions are associ-
ated with increased brain activity after training (Buschert et al.
2010). Interestingly, a lifetime of cognitive activity has been
showntoresultinlowerAβdeposition levels in the human
brain (Landau et al. 2012). It would be tempting to speculate
that besides alterations in neural activity, computerized brain
training may alter levels of brain and/or blood Aβpeptide in
humans; high levels of which are thought to form toxic oligo-
mers that have key roles in promoting neurodegeneration in
AD.
The studies discussed above indicates that mentally chal-
lenging activities may trigger brain changes beneficial for en-
hancing cognition. Out of the many cognitive domains
assessed, many studies on computerized brain training inter-
ventions have reported an improvement in the targeted cogni-
tive domain of verbal episodic memory. Of note, this is a
major domain that is affected in MCI and AD (Petersen
et al. 2001). However, one of the greatest challenges faced
by brain training programs is to prove the claims that the
benefits extend to other non-targeted and untrained cognitive
domains. The controversial study by Owen and colleagues
challenged the support behind the widely held belief that com-
mercially available computerized brain training programs im-
prove general cognition (Owen et al. 2010). The six-week
web-based study included 11,430 participants trained to im-
prove reasoning, memory, planning, visuospatial skills and
attention. The study reported improvements in the targeted
domains, yet there were no transfer effects to other cognitive
domains. Although the study received global focus, it was
criticised due to its training duration which was only 10 min/
day, three times/week for six weeks and the lack of face to face
cognitive training. The study cohort also included younger
people (age range 18–69). Further clinical trials need to be
carried out to address the transfer effect query which may also
be answered more definitively by inclusion of brain imaging
biomarkers in such studies.
Mental Activities versus Computerized Cognitive
Trainin g
The concept of benefits to cognition being obtained from
leisure-time mentally stimulating activities was initially obtain-
ed from observational studies based on self-reported question-
naires (Verghese et al. 2003;Wilsonetal.2007; Scarmeas et al.
2001; Fratiglioni et al. 2004). Recent studies (such as many of
those listed in Table 2) have shown that computerized programs
could result in superior benefits when compared to activities
carried out by control groups. An active control group usually
engages in routine leisure activities like book reading, puzzles,
surfing the internet or watching YouTube documentaries on a
computer. The study by Mahncke and colleagues (Mahncke
et al. 2006) included an Bactive computer^control group as
well as a Bno contact^control group versus the intervention
group. Besides demonstrating the cognitive benefits in the in-
tervention group, the study also showed that the control groups
did not differ statistically from one another, in other words, no
placebo effect was found. On the other hand, the study by Peretz
and colleagues (Peretz et al. 2011) included a computer games
Neuropsychol Rev
group versus the computerized cognitive training group, and
demonstrated cognitive benefits in both groups compared to
baseline cognitive performance, with superior benefits in the
cognitive training group (Peretz et al. 2011). Another one year
RCT involving 191 healthy older adults aged 65–75 years re-
ported that intensive use of personal computers with standard
software applications did not result in any cognitive benefits
when compared to three types of control groups (Slegers et al.
2009). These findings support the concept that simple mental
activities do not provide the cognitive benefits of the specialised
software based brain training exercises. Therefore, a tailored
program which is adaptable, continuously challenging and not
monotonous, with fixed intensity, duration and frequency is
more beneficial than routine mental activities. Most of the train-
ing programs follow the same design principle of targeting,
adaptivity, novelty, engagement and completeness in their exer-
cises. Such an approach is usually absent in routine mental
activities. Tasks that have been performed many times in the
past simply revitalize the existing circuits and do not challenge
the brain to work in new ways. Thus, in order for the brain to be
exercised effectively, the activities are required to be novel,
well-tailored to the individual, and continually challenging. A
total of 11 programs initially selected did not show clinical
significance as there were no studies to provide any Levels of
evidence. While it is possible that these other programs are
equally effective, given that they are mostly based on the same
neuroplasticity principle, they could differ/target specific cogni-
tive domains only, and thus need to be empirically validated in
independent clinical studies.
The limitations of this review need to be acknowledged.
Studies evaluating cognitively impaired older adults with a
comparative study control group were not reviewed. Thus, it
is unknown whether the results reviewed for healthy older
adultscanalsobeextendedtocognitivelyimpairedsub-
groups. Furthermore, it was also difficult to extract informa-
tion solely concerning those programs recommended for older
adults as most of these programs are recommended to be used
by all age groups. Additionally, differences between on-line
brain training games and software designed exercises still
needs to be clearly demarcated. However, this is only possible
if each brain training component comes with particular spec-
ifications. Most important and as discussed earlier, findings of
company funded/affiliated studies should be further validated
in more independent studies. Lastly, although we did not in-
clude video games in the review, some of the programs may
utilise a similar format, however it was not possible to verify
the contents of each of the programs.
Future Directions
Cognitive training interventions show the potential to enhance
brain health. The majority of the programs discussed here
support the notion that the human brain is plastic in later life,
and can benefit from specifically designed brain training pro-
grams (Baltes et al. 1988; Baltes and Lindenberger 1988;
Schaie and Willis 1986; Willis 1987). Level 1 clinical trials
and their programs identified in this review have been clini-
cally endorsed for their ability in enhancing memory, process-
ing speed, reasoning and executive functions. However, the
molecular evidence concerning how or where these software
programs alter neuronal or synaptic plasticity is lacking.
Assessments using blood, CSF and brain imaging biomarkers
of AD would considerably enhance clinical validation of such
brain training programs. This would also enable greater un-
derstanding of the connection between computerized brain
exercises and human cognition. The Stanford Centre on
Longevity and the Max Planck Institute for Human
Development, Berlin produced a consensus statement for the
public concerning the state of science of such programs in
May 2009. It states that Bsoftware based cognitive training
and brain games have been shown to improve users’perfor-
mance on trained tasks. The important caveat is that very few
training programs have shown evidence that such gains trans-
late into improved performance in the complex realm of ev-
eryday life. A program might train in memorizing lists of
words, for example, but this particular skill is not likely to
help you remember where you left your car keys or the time
of an upcoming appointment. We strongly support research on
software-based training and encourage interested people to
participate in clinical trials investigating its potential.^This
statement indicates that clinical research needs to determine
whether the benefits measured by neuropsychological testing
translate into cognitive benefits in day to day real life situation.
The statement also mentions that Blearning stimulates the
brain and contributes to one’s general sense of competence.^
Finally, other avenues of cognitive enhancement such as
social engagement must also be explored: as many elderly
people are not motivated to learn new technology and follow
complex commands while spending their time in front of com-
puters. However, even if such brain training programs are
scientifically validated and people are keen to use them, there
are questions that still need to be addressed, such as how much
time needs to be spent on such programs, how much time is
practical or necessary to obtain optimum benefits in old age?
Elderly people are encouraged to be active both physically
and mentally as this will surely enhance their quality of life
and assist in retaining their independence as they age. Due to
the expanding interest in such programs, yet without any de-
bate or validation studies concerning whether these programs
are effective in preventing/delaying AD onset, the choice on
the market continues to expand with the launching of more
and more new programs. Economically, a delay of AD onset
by 5 years can save$13.5 billion by 2020 and $67.5 billion by
2040 in Australia alone (AccessEconomics 2004). Therefore
there is an urgent need for further clinical validation studies of
Neuropsychol Rev
such programs, particularly those with clinical trials that have
already shown cognitive benefits and are described as provid-
ing Level I and II evidence in this article.
Acknowledgements TS is supported by the Australian Postgraduate
Award from the University of Western Australia, the Research
Excellence Award from Edith Cowan University and the Freemasons of
Western Australia Education Grant 2010 and 2011. TS and MWreviewed
the study abstracts and program relevant websites. All authors reviewed
and approved the final manuscript. The McCusker Alzheimer’s Research
Foundation Inc. contributed financial and in kind support.
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