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Working memory training with technological innovation in older adults with mild neurocognitive disorder: a systematic review using ToS (Tree of Science) methodology

Authors:

Abstract

Objective: Working memory training has shown both physical and cognitive benefits in aging population. However, these gains are not clear after brain injury and mild cognitive disorder. Thus, the aim of this study is to identify the current state of the scientific literature on technology-mediated working memory training in adults with mild neurocognitive impairment. Methods: A systematic review was performed, following the PRISMA guidelines in English language in the Scopus, Web of Science and Pubmed databases. We included articles that were experimental studies, from the last 7 years, with older adults, in English language and studies related to working memory training in patients with minor neurocognitive disorder, and excluded those that had a different methodological design, were studies with incomplete information, were subjective and not interpretable and studies in patients with severe neurological diseases and psychiatric diseases. Results: A total of 745 articles were identified, 675 were eliminated after reading the title, abstract and keywords because they did not fit the specificity of the research topic or the population, and after applying inclusion and exclusion criteria, 1334 articles were eliminated, and 70 were evaluated for eligibility, and of these only 30 met the quality criteria. Conclusion: Neurological changes in mild neurocognitive impairment reduce the ability to simultaneously maintain and process information to perform complex tasks. The findings of the systematic review support the sensitivity and ecological validity of neuropsychological rehabilitation mediated by virtual reality, computerized training, video games and robotics in working memory training in adults with mild neurocognitive disorder because it represents a protective factor for mental health, allowing brain stimulation and the development of skills that favor social interaction, problem solving and maintenance of cognitive reserve.
Mediterranean Journal
of Clinical Psychology
ISSN 2282-1619
1
Volume 11, n 3, 2023
Articles
Working memory training with technological innovation in older adults with
mild neurocognitive disorder: a systematic review using ToS (Tree of Science)
methodology
Danicza Martínez Morales 1 *, Andrés David Montoya Arenas 2, 3, Daniel Landínez
Martínez 4
Abstract
Objective: Working memory training has shown both physical and cognitive benefits in aging
population. However, these gains are not clear after brain injury and mild cognitive disorder. Thus,
the aim of this study is to identify the current state of the scientific literature on technology-mediated
working memory training in adults with mild neurocognitive impairment.
Methods: A systematic review was performed, following the PRISMA guidelines in English language in
the Scopus, Web of Science and Pubmed databases. We included articles that were experimental
studies, from the last 7 years, with older adults, in English language and studies related to working
memory training in patients with minor neurocognitive disorder, and excluded those that had a
different methodological design, were studies with incomplete information, were subjective and not
interpretable and studies in patients with severe neurological diseases and psychiatric diseases.
Results: A total of 745 articles were identified, 675 were eliminated after reading the title, abstract and
keywords because they did not fit the specificity of the research topic or the population, and after
applying inclusion and exclusion criteria, 1334 articles were eliminated, and 70 were evaluated for
eligibility, and of these only 30 met the quality criteria.
Conclusion: Neurological changes in mild neurocognitive impairment reduce the ability to
simultaneously maintain and process information to perform complex tasks. The findings of the
systematic review support the sensitivity and ecological validity of neuropsychological rehabilitation
mediated by virtual reality, computerized training, video games and robotics in working memory
training in adults with mild neurocognitive disorder because it represents a protective factor for mental
health, allowing brain stimulation and the development of skills that favor social interaction, problem
solving and maintenance of cognitive reserve.
1 School of Neuropsychology, Neurological Institute of Colombia, San Buenaventura University,
Medellín, Colombia
2 School of Neuropsychology, San Buenaventura University, Medellín, Colombia
3 Bolivarian Pontifical University, Medellín, Colombia
4 Health Science Faculty, School of Medicine, University of Manizales, Manizales, Colombia
E-mail corresponding author: danicza.neuropsicologa@gmail.com
Keywords:
Mild neurocognitive disorder; Cognitive rehabilitation; Working memory; Innovation;
Technology.
Received: 5 July 2023
Accepted: 1 December 2023
Published: 28 December 2023
Citation: Martínez Morales, D., Montoya Arenas, A.D., Landínez Martínez, D.
(2023). Working memory training with technological innovation in older adults
with mild neurocognitive disorder: a systematic review using ToS (Tree of
Science) methodology. Mediterranean Journal of Clinical Psychology 11(3).
https://doi.org/10.13129/2282-1619/mjcp-3884
MJCP|11, 3, 2023 Martínez Morales et al.
2
1. Introduction
The aging process entails a series of morphological, physiological, social, and psychological
modifications that are a direct consequence of the passage of time. Two significant changes that
have occurred in recent decades are a considerable increase in life expectancy and a reduction
in birth rates. This has led to a significant aging of the population, and globally, the older adult
population is growing rapidly, which subsequently reflects in the prevalence of age-related
diseases, such as neuropsychiatric disorders, which are the leading causes of disability in older
adults worldwide. The growing study of changes and characteristics within this population
segment has allowed us to conclude that aging-related diseases are diverse and result in a
deterioration in the quality of life for those affected and their families (Cancino et al., 2016).
Therefore, it is important to note that one of the main effects of this dramatic demographic
change is that many older individuals lack access to the basic resources necessary to enjoy a
dignified life, and many others face multiple obstacles to fully participate in society.
Consequently, healthcare attention generates a high economic cost for accessing services
worldwide, with 23% of healthcare expenditure dedicated to the care of individuals over 60
years old, and 7% of that expenditure corresponds to neurological and mental disorders (Prince
et al., 2015).
However, one of the main strategies for building an inclusive society for all ages is the global
initiative of the Decade of Healthy Aging 2021-2030, declared by the General Assembly of the
United Nations (UNGA). This global initiative brings together the efforts of governments,
international organizations, professional groups, academia, civil society, media, and the private
sector to improve the lives of families, communities, and older individuals.
Even so, according to the estimation from the multinational study Global Burden of Disease,
there is international concern because worldwide cases of dementia will triple from the estimated
57 million in 2019 to 153 million in 2050 unless public health education is strengthened and
modifiable risk factors are addressed in a timely manner (Nichols et al., 2022). In the case of
Colombia, the study estimated 369,422 cases in 2019 and projected 1,375,881 cases for 2050, an
increase of 272 percent, the highest in the world, significantly higher than the expected increase
(166 percent), and above that of Central Latin America (239 percent) and most countries in the
region (Nichols et al., 2022). For that reason, the efforts of researchers and clinicians must focus
on identifying risk factors to generate inclusive and effective preventive measures that
contribute to improving the quality of life of older adults, their families, and communities.
In the population of Latin America and the Caribbean, estimates for the prevalence of mild
neurocognitive disorders ranged from 6.8% to 25.5%, and mild amnestic neurocognitive
disorder ranged from 3.1% to 10.5% (Ribeiro, 2022). According to the systematic review
conducted by Pais et al. (2020), the global prevalence of mild neurocognitive disorder ranged
MJCP|11, 3, 2023 Working memory training in older adults with MND
3
from 5.1% to 41%, with a median of 19.0%. On the other hand, the incidence of mild
neurocognitive disorder ranged from 22 to 76.8 per 1000 person-years, with a median of 53.97
per 1000 person-years, which is alarming and requires intervention from both clinical and
research perspectives.
Mild neurocognitive disorder is considered the transitional stage between normal cognitive
decline in healthy aging and dementia, affecting 10 to 15% of the population over 65 years old
(Anderson, 2019). Thus, 7.1% of individuals aged 60 and above present mild neurocognitive
disorder. This cognitive decline increases exponentially, reaching 13% in individuals between 75
and 79 years old and 36.2% in those over 85 years old (González, 2009).
On that account, it is of utmost importance to understand that mild neurocognitive disorder is
one of the most common clinical neurological manifestations in the elderly and represents a
heterogeneous clinical syndrome that can be associated with different etiologies. In the DSM-
5, the proposed diagnostic criteria for mild neurocognitive disorder are as follows: Criterion A
demonstrates cognitive decline in one or more cognitive domains compared to a previously
higher level of performance, or when there are memory complaints reported by the individuals,
which are corroborated by a family member or informant in an objective assessment by a
healthcare professional. Additionally, from a neuropsychological perspective, there is a
performance decline on tests by one or two standard deviations below the required performance
for neuropsychological evaluation (American Psychiatric Association, 2013).
Criterion B states that cognitive deficits do not impair functional independence related to the
ability to perform instrumental activities of daily living, which are complex tasks such as
managing finances, medication use, running errands, and using public transportation. Criterion
C indicates that cognitive deficits do not occur exclusively during delirium, and Criterion D
states that cognitive deficits are not primarily due to the presence of other mental disorders
(American Psychiatric Association, 2013).
The international working group on mild neurocognitive disorder of Winblad et al. (2004), in
an extension of the initial term, identified four subtypes: single-domain amnestic, multiple-
domain amnestic, single-domain non-amnestic, and multiple-domain non-amnestic, which are
explained as follows. The amnestic subtype involves exclusive impairment of memory, while
the multiple-domain amnestic subtype includes impairment of functions beyond memory, such
as attention, language, executive functions, gnosis, and praxis. The non-amnestic subtype refers
to the impairment of a function other than memory, and the multiple-domain non-amnestic
subtype involves impairment of more than one function other than memory (Ocaña et al., 2019).
Furthermore, in older individuals, the component of working memory known as the central
executive appears to be most affected, while the functioning of the verbal component of this
memory system, known as the phonological loop, seems to be preserved. However, the most
MJCP|11, 3, 2023 Martínez Morales et al.
4
common clinical symptom of mild neurocognitive disorder is the loss of episodic memory, with
a particularly rapid rate of forgetting and deterioration of delayed recall. Still, deficits in working
memory and executive functions are also frequently observed in populations with mild
neurocognitive disorder (Huntley & Howard, 2010), especially in the multidomain subtype
(Klekociuk & Summers, 2014).
Having said that, working memory is a construct that involves the temporary maintenance and
manipulation of recently acquired or retrieved information from long-term memory (Baddeley,
2017). Baddeley's model is one of the most recognized among several models that seek to
describe the operating principles of working memory (Osaka et al., 2012). Working memory
encompasses interacting subsystems, including two unimodal subsystems (the phonological
loop for verbal information and the visuospatial sketchpad for visual and spatial information),
a flexible system (the central executive) responsible for controlling and regulating the storage
subsystems, and a limited-capacity multimodal system (the episodic buffer) that allows
interaction between the components of working memory and communication with long-term
memory (Baddeley, 2017).
Working memory is crucial for the selection and attention to relevant information, as well as for
filtering out distracting stimuli, functions also known as attentional control. Also, working
memory involves processes related to dividing attention across multiple tasks, updating and
monitoring verbal and visuospatial information, and inhibiting impulsive responses (Landínez
& Montoya, 2021). In the involvement of working memory is involved not only in basic
cognitive processes but also in higher order cognitive processes such as executive function,
therefore, working memory deficits can lead to a general impairment of cognitive function and
have a negative impact on the individual's daily life (Quintero-López et al., 2023). Therefore,
among health care alternatives cognitive training interventions have attracted increasing
scientific interest as a non-pharmacological intervention and prevention method. In the meta-
analysis by Chiu et al., (2017) cognitive intervention in adults was found to be a potential to
combat cognitive decline.
Given the above, it is essential to understand that cognitive training has as its premise that brain
functioning is modifiable even in old age (López-Higes et al., 2018). Currently, there are
different techniques and cognitive training programs. According to Villalba and Tortajada
(2014), the first technique is the traditional one, focused on working with paper and pencil
exercises. The second type of technique is based on the use of computerized devices, such as
brain training games, online programs, or digital media. Finally, there are techniques that seek
to create innovative programs mediated by technology, involving several types of functionalities,
such as computerization and movement (Villalba and Tortajada, 2014). In this way, healthcare
MJCP|11, 3, 2023 Working memory training in older adults with MND
5
professionals have sought to develop and innovate various cognitive training programs for older
adults to improve cognitive function (Villalba and Tortajada, 2014).
Computerized working memory training has significant potential as it allows for the generation
of situations related to daily activities such as physical, intellectual, and occupational activities.
In these training, working memory acts as a moderator between cognitive tasks and functional
abilities, as active storage, information manipulation, and integration of signals are required in
daily life, which are central processes in working memory (Landínez & Montoya, 2021). In
neuropsychological intervention processes, computer-based technological tools have
demonstrated their effectiveness in cognitive training of individuals with neurological disorders
and have been shown to help this population to acquire crucial social and personal skills to
integrate into the different scenarios of their lives being more autonomous and independent
(Mezzalira et al., 2021).
Rehabilitation interventions involving virtual reality technology, computerized training, video
games, and robotics have been developed to promote functional independence in patients.
Virtual reality encompasses a range of technologies that can artificially generate sensory
information in the form of an interactive virtual environment that is perceived as like the real
world (Rand et al., 2008). Since virtual environments are interactive and game-like, they promote
active exploration, enhance engagement, and provide motivation and enjoyment, enabling
longer exercise sessions and better treatment adherence (Holden, 2005). Therapists providing
virtual reality-based therapy must make decisions regarding appropriate games that match the
individual patient's abilities and treatment goals (Glegg et al., 2014). This decision-making
process can be complex and relies on understanding the functioning of the virtual reality system
and game requirements.
Virtual reality technology is gaining recognition as a useful tool for cognitive research,
assessment, and rehabilitation. Still, while virtual reality-based applications can potentially offer
more versatile, comprehensive, and safe function assessments, they can also be more expensive,
complex, and challenging to use for older patients. Side effects of head-mounted visual displays
include nausea and disorientation, although specific reports in older subjects are lacking
(Cherniack, 2011). One application of virtual reality for the treatment of neuropsychological
conditions is the Vlad 3D semi-immersive software, where emotions are generated through the
manipulation of images, which are recognized with the recording of narrative experiences, and
with quantitative and qualitative monitoring (Pappalardo, 2020).
Brain training games have gained popularity over the past decade, with increasingly solid
findings and claims that computerized working memory and attention tasks can improve
cognition (Morrison & Chein, 2011). Moreover, rehabilitation robotics has provided promising
approaches for training and assistance to mitigate cognitive deficits. Yet, there are still
MJCP|11, 3, 2023 Martínez Morales et al.
6
multifaceted challenges in this field, including ethical issues, user-centered design, reliability,
trust, cost-effectiveness, and personalization of the robot-assisted cognitive training system
(Yuan et al., 2021).
Cognitive training utilizes repeated practice of standardized exercises targeting one or more
cognitive domains and may aim to improve or maintain optimal cognitive function (Gates et al.,
2019). In spite of that, currently available evidence does not allow us to determine whether
computerized cognitive training will prevent clinical dementia or improve/maintain cognitive
function in those already showing evidence of cognitive decline. The small number of trials,
small sample sizes, risk of bias, inconsistency among trials, and highly imprecise results mean
that no implications for clinical practice can be derived, despite some large effect sizes observed
in individual studies. Direct adverse events are unlikely to occur, although the time and
sometimes money involved in computerized cognitive training programs can represent
significant burdens (Gates et al., 2019).
Further research is needed and should focus on improving methodological rigor, selecting
appropriate outcome measures, and evaluating generalization and persistence of any effects.
Long-term follow-up trials are required to determine the potential of this intervention in
reducing dementia risk. In view of the above and the lack of consensus regarding technological
strategies, the aim of the study is to identify the current state of the scientific literature on
working memory training with technological innovation in older adults with mild
neurocognitive disorder. The research hypothesis is that cognitive training in working memory
mediated by technological innovation helps patients with mild neurocognitive disorder to obtain
cognitive improvement in their mental processes and activities of daily living.
2. Methodology
A systematic review was conducted following PRISMA guidelines in the English language using
Scopus, PubMed, and Web of Science databases. To identify articles on working memory
training with technological innovation in older adults with mild neurocognitive disorder, A
bibliometric analysis was conducted between January 2013 and April 2022. The following search
equations were used.
Table 1. Search Equations
Search Equations
1
2
("Mild neurocognitive disorders" AND "cognitive training" OR "online cognitive training" OR "Brain
training games" OR "virtual reality" OR "cognitive games" OR "rehabilitation cognitive" OR "memory
training" OR "memory" OR "working memory" AND "adults" )
MJCP|11, 3, 2023 Working memory training in older adults with MND
7
2.1 Inclusion Criteria
Articles were included if they met the following criteria: (1) publication date within the last 7
years, (2) full-text articles in English, (3) experimental studies, (4) elderly population, (5)
addressing the topic of neuropsychological rehabilitation therapy for patients with mild
neurocognitive disorder through working memory training using technological innovation tools.
2.2 Exclusion Criteria
Articles were excluded if they met the following criteria: (1) exploratory research with qualitative
methodologies, narrative reviews, and single-case studies; (2) studies with incomplete or
uninterpretable subjective information and lack of methodological clarity, (3) patients with
severe neurological diseases and psychiatric diseases.
Figure 1. Final Citation Network (Research Communities)
MJCP|11, 3, 2023 Martínez Morales et al.
8
PRISMA Flow Diagram Showing Selection Methodology
3. Results
A total of 745 articles were identified, and 675 were eliminated after reviewing the title, abstract,
and keywords due to their lack of relevance to the specific research topic or population. After
applying inclusion and exclusion criteria, 1334 articles were removed, and 70 were assessed for
eligibility. Out of these, only 30 met the criteria for quality and were related to working memory
training and technological innovation in older adults with mild neurocognitive disorder. Please
refer to Table 2 for the included articles in the review.
Records eliminated after reading the title,
abstract and keywords because they did not fit
the specificity of the research topic or
population (n=675).
Total number of records identified
in the analysis of the graphical
network of citations.
(n=745)
Records examined (n=745)
(Titles/Key words/Abstracts
examined)
Records identified in the database:
Web of science (n=414)
Scopus (n=48)
Pubmed (283)
Full-text articles evaluated for
eligibility.
(n=70)
Records eliminated after reading the full text
(n=40). They did not meet the statistical and
thematic criteria for inclusion.
Studies included in the analysis
(n=30)
Identification
Assessment
Eligibility
Included
MJCP|11, 3, 2023 Working memory training in older adults with MND
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Table 2. Studies Included in the Systematic Review
Study
Subject
(Sample size)
Female
%
Mean age
(years)
Type of
intervention
Evaluation instruments
(Fiatarone et
al., 2014)
MCI (100)
68%
70 yr..
Physical Training
Training
computerized
ADAS-Cog
List Learning Memory
Memory Domain
Attention/Speed SDMT
(Hughes et al.,
2014)
MCI (20)
70%
78 yr..
Interactive video
games
MMSE
CAMCI
(Styliadis et
al., 2015)
MCI (56)
45%
70 yr..
Physical Training
Training
computerized
MMSE
CDR
(Barban, et al.,
2016)
MCI (106)
Alzheimer (81)
CS (114)
57%
73 yr..
Training
computerized
Reminiscence
therapy
MMSE
RAVLT
FAS
(Gooding et
al., 2016)
MCI (74)
42%
76 yr..
Training
computerized
Cognitive Vitality
Training
MMSE
BSRT
LM
(Hyer et al.,
2016)
MCI (68)
52%
75 yr..
Training
computerized
RBANS
MMSE
CDR
CFQ
FAQ
WM Span Board, Letter
Number Sequencing
Trail Making A-B
(Manera et al.,
2016)
MCI (28)
Dementia (29)
43%
75 yr..
Virtual reality
MMSE
TA
MJCP|11, 3, 2023 Martínez Morales et al.
10
(Bahar-Fuchs
et al., 2017)
MCI (9)
MrNPS (11)
Ambos (25)
45%
66 yr..
Training
computerized
ACE-III
RAVLT
RCFT
MARS
MMQ
Digit Span
Digit-Symbol Coding
Logical Memory
(Djabelkhir,
2017)
MCI (19)
68%
75 yr..
Training
computerized
Computerized
cognitive
engagement
MMSE
Digit Span Wechsler
Trail Making A-B
(Savulich et
al., 2017)
aMCI (42)
40%
75 yr..
Training
computerized
MMSE
CANTAB PAL
BVMT-R
(Damirchi et
al., 2018)
MCI (33)
100%
67 yr..
Computerized
physical and
cognitive training
MMSE
Digits
Wechsler
(Hsieh et al.,
2018)
MCI (60)
72%
78 yr..
Virtual reality
Tai Chi
MMSE
CASI
(Amjad et al.,
2019).
MCI (38)
50%
60 yr..
Cognitive Games
Xbox 360 Kinect
MMSE
MOCA
(Flak et al.,
2019)
MCI (64)
34%
65 yr..
Training
computerized
WMS-III Digit Span
backward,
WMS-III Spatial Span
backward,
WMS-III Letter-Number
Sequencing,
CVLT-II
Trial Making B
MJCP|11, 3, 2023 Working memory training in older adults with MND
11
(Jirayucharoens
ak et al., 2019).
aMCI (65)
CS (54)
100%
71 yr..
Neurofeedback
training
MOCA
TMSE
CANTAB
(Li et al.,
2019)
MCI (141)
53%
70 yr..
Online cognitive
training
MMSE
ACER
AVLT
SDS
(Liao et al.,
2019)
MCI (34)
68%
73 yr..
Virtual reality
Traditional
physical and
cognitive training
MMSE
MOCA
(Park et al.,
2019).
MCI (20)
80%
70 yr..
Mixed reality
Computerized
training
CERAD
MMSE
(Yang et al.,
2019)
MCI (66)
52%
78 yr..
Virtual interactive
training
DS
MMQ
MMSE
MOCA
(Lee et al.,
2020)
MCI (46)
39%
74 yr..
Robotic cognitive
intervention
K-MMSE
SVLT
(Park et al.,
2020).
MCI (35)
48%
75 yr..
Virtual reality
MOCA
Digit Span Test
(Manenti et
al., 2020)
MCI (49)
51%
75 yr..
Virtual reality
RAVLT
(Thapa et al.,
2020)
MCI (68)
76%
72 yr..
Virtual reality
MMSE
(Torpil et al.,
2021)
MCI 61)
59%
70 yr..
Virtual reality
LOTCA-G
(Kim et al.,
2021)
MCI (22)
CS (22)
84%
74 yr..
Virtual reality
CERAD
(Maeng et al.,
2021)
MCI (31)
CS (25)
81%
73 yr..
Virtual reality
Digit span
Word list memory
CERAD
MJCP|11, 3, 2023 Martínez Morales et al.
12
Note: MCI, Mild Neurocognitive Disorder Cluster; MrNPS, mood-related neuropsychiatric symptom
cluster; aMCI, amnestic mild neurocognitive disorder; CS, healthy control group; MCI-HIV, Human
Immunodeficiency Virus Associated Mild Neurocognitive Disorder Cluster; ADAS-Cog, Alzheimer's
Disease Assessment Scale-cognitive subscale; SDMT, Symbols and Digits Test; MMSE, Mini-Mental
State Examination; CAMCI, The Computerized Assessment of Mild Cognitive Impairment; RBANS,
Repeatable Battery for the Assessment of Neuropsychological State; CFQ, Cognitive Failure
Questionnaire; FAQ, Functional Activities Questionnaire; CDR, Clinical Dementia Rating Scale; WM
Span Board, Wechsler Memory Scale-Third Edition Span Board subtest; AT, attention tasks; ACE-III,
Addenbrooke Cognitive Examination; RAVLT, Rey Verbal Learning Test; FAS, phonological fluency
test; minimental state test, BSRT, Buschke selective recall test, LM, Logical Memory Subtests, , RCFT,
Rey Complex Figure Test; MARS, Memory Awareness Rating Scale; MMQ, Meta Memory
Questionnaire;, CANTAB PAL, The Cambridge Neuropsychological Test Automated Battery Paired
Associates Learning; BVMT-R, The Brief Visuospatial Memory Test-Revised; CASI, Screening
Instrument; WMS-III, Wechsler Memory Scale 3.ed; CVLT-II, California Verbal Learning Test Second
Edition; TMT A-B, Trail-Making Test for Screening, Part A and B; MoCA, Montreal Cognitive
Assessment; TMSE, Thai Mental State Examination; CANTAB, Cambridge Automated Battery of
Neuropsychological Tests; ACER, Addenbrooke's cognitive examination-revised; AVLT, the auditory
verbal learning test; SDS, symbol digit substitution test; CERAD, Consortium to Establish an
Alzheimer's Disease Registry; DS, Digit span; SVLT, Seoul Verbal Learning Test; LOTCA-G,
Loewenstein Occupational Therapy Cognitive Assessment-Geriatric; HVLT-R: Hopkins Verbal
Learning TestRevised; K-MMSE, Korean Mini-Mental State Exam; K-MoCA, the Montreal Korean
Cognitive Assessment; SVFT, the Semantic Verbal Fluency task; TMT B, the Tracing Test-B; N-Back,
working memory task.
(Ownby et al.,
2021).
MCI-VIH (46)
19%
57 yr..
Computerized
training
Digit Span Wechsler,
HVLT-R
(Ramnath et
al., 2021)
MCI (45)
50%
72 yr..
Interactive video
games
MMSE
Stroop
N-Back
(Duff et al.,
2022)
aMCI (113)
76%
77 yr..
Computerized
training
RBANS
(Lim et al.,
2023)
MCI (24)
70%
74 yr..
Interactive video
games
K-MMSE
K-MoCA
SVFT
TMT-B
N-Back
MJCP|11, 3, 2023 Working memory training in older adults with MND
13
The result of the analysis of the systematic review studies allowed finding three approaches:
computerized training, virtual reality and video games, and robotics, all related to working
memory training with technological innovation in older adults with mild neurocognitive
disorder.
3.1 Effect of computerized working memory cognitive training in patients with mild
neurocognitive disorder.
Fourteen studies were related to computerized cognitive training, involving a total of 1038
individuals with mild neurocognitive disorder, 81 with Alzheimer's disease, 46 with human
immunodeficiency virus (HIV), and 36 with mood-related neuropsychiatric symptoms. Of the
participants, 57% were female, with an average age of 71 years. In the study by Fiatarone et al.
(2014), the effects of resistance training and cognitive training on mild neurocognitive disorder
were assessed. They found that strength training significantly improved overall cognitive
function, with sustained executive and global benefits over 18 months, while cognitive training
alone attenuated the decline in the memory domain at 6 months. Besides, Ownby & Kim (2021)
investigated computerized training in patients with neurocognitive disorder associated with HIV
and found that participant ratings of the intervention were positive, with attention and
psychomotor speed measures suggesting positive effects of the intervention.
Moreover, Damirchi et al. (2018) investigated the mental, physical, and combined effects of
these two types of training on cognitive performance, serum levels of brain-derived
neurotrophic factor, and Irisin hormone in women diagnosed with mild neurocognitive
disorder. They found a positive effect of mental training on cognitive parameters, accompanied
by an elevation in serum neurotrophic levels, suggesting that mental training is a more useful,
safe, and persistent strategy to attenuate the progression of mild neurocognitive disorder.
Gooding et al. (2016) compared three methods of computerized cognitive training for older
adults with subclinical mild neurocognitive disorder and found no significant differences
between the computerized cognitive training groups and the cognitive vitality training group in
measures of verbal learning or memory. Thus, in the research conducted by Gooding et al.
(2016), they demonstrate that computerized cognitive training is more beneficial when
incorporated into a therapeutic environment rather than standalone, and the computerized
cognitive training group performed better than the active control group in a measure of verbal
learning and a measure of verbal memory.
Furthermore, Styliadis et al. (2015) evaluated the neuroplastic effects of combined physical and
computerized cognitive training in older adults at risk of dementia. They found that combined
physical and cognitive training showed indices of a positive effect on neuroplasticity in patients
MJCP|11, 3, 2023 Martínez Morales et al.
14
with mild neurocognitive disorder and that electroencephalogram (EEG) could serve as a
potential index of gains in cognitive impairments and neurodegeneration.
On the other hand, Hyer et al. (2016) developed a cognitive training program to improve
working memory in older adults with mild neurocognitive disorder, and both intervention
groups showed improvement over time. The Cogmed program was significantly superior to the
Sham programs in Span Board in spatial memory and subjective memory complaints as reported
with the Cognitive Failures Questionnaire (CFQ). The Cogmed group also demonstrated better
performance on the Functional Activities Questionnaire (FAQ). In view of the above, the
results suggest that working memory improved in both groups of older adults with mild
neurocognitive disorder.
However, Cogmed performed better in a central measure of working memory and obtained
higher satisfaction ratings (Hyer et al., 2016). Nonetheless, in the research conducted by Flak et
al. (2019), it was investigated whether an adaptive computerized working memory training
program based on Cogmed would be effective in improving working memory capacity and other
neuropsychological functions compared to a non-adaptive working memory training program
in older adult patients with mild neurocognitive disorder. Yet, no differences were found
between the two types of working memory training, nor in other domains of cognitive function.
Moreover, Li et al. (2019) demonstrated how multimodal cognitive training helps patients with
mild neurocognitive disorder obtain cognitive benefits, especially in memory, attention, and
executive function. Functional neuroimaging provided consistent evidence of neural activation.
Even so, after one year of follow-up and following the last training session, the effects were not
significant.
On the other hand, according to the research conducted by Bahar-Fuchs et al. (2017),
computerized cognitive training showed greater improvement in composite measures of
memory, learning, and global cognition. Participants in the study who experienced mood-related
neuropsychiatric symptoms during the computerized cognitive training condition also reported
improved mood at 3-month follow-up and reported using fewer memory strategies in post-
intervention and follow-up assessments.
Similarly, Djabelkhir (2017) examined the feasibility of a computerized cognitive stimulation
(CCS) program and a computerized cognitive engagement (CCE) program, and then compared
their effects in older adults with mild neurocognitive disorder, demonstrating the benefits of
both cognitive intervention programs and suggesting their potential to improve episodic
memory, thus becoming a promising approach to slowing down cognitive symptoms associated
with dementia. In this way, computerized programs have the potential to improve processing
speed, providing new perspectives to bridge the digital divide and promote social inclusion for
MJCP|11, 3, 2023 Working memory training in older adults with MND
15
patients. Likewise, in the study by Yang et al. (2019), the development and effectiveness of
interactive virtual working memory training for older adults with mild neurocognitive disorder
were evaluated, and it was found that the applied program allowed older adults to maintain their
working memory and reduce the rate of cognitive decline.
In view of the above, Savulich et al. (2017) argued in their research studies that episodic memory
significantly improved in the cognitive training group. They observed how "gamified" cognitive
training can enhance visuospatial skills in individuals with mild amnestic neurocognitive
disorder. Gamification maximizes engagement with cognitive training by increasing motivation
and complements pharmacological treatments in mild amnestic neurocognitive disorder and
mild Alzheimer's disease. After all, larger controlled trials are needed to replicate and expand
these findings to further advance scientific knowledge.
From another perspective, Jirayucharoensak et al. (2019) examined the clinical efficacy of a
neurofeedback training system on cognitive performance in patients with mild amnestic
neurocognitive disorder and healthy older subjects, finding that neurofeedback significantly
improved rapid visual processing and spatial working memory. But, there was no significant
effect on pattern recognition memory and short-term visual memory, which are other features
of mild amnestic neurocognitive disorder. The study demonstrated that neurofeedback training
selectively enhances sustained attention, strategy, and executive functions but no other cognitive
deficits.
To further analyze computerized cognitive training in mild amnestic neurocognitive disorder,
the research study conducted by Duff et al. (2022) was found, which reveals how a parallel
clinical trial examines the short- and long-term efficacy of computerized cognitive plasticity
training. In the short term, participants in the active control group playing computer games
outperformed participants in the experimental group in the primary cognitive outcome of
composite scores of auditory attention and memory. Yet, there were no differences between the
groups in two secondary outcomes: composite global cognitive score and long-term daily
functioning rating.
3.2 Effect of Virtual Reality Strategies on Working Memory in Patients with Mild
Neurocognitive Disorder.
Ten studies related to virtual reality were found. There were 398 individuals with mild
neurocognitive disorder and 29 with dementia, with 71% of the participants being women, with
an average age of 73 years. Manera et al. (2016) demonstrated that participants with mild
neurocognitive disorder and dementia reported high satisfaction and interest in the task and
reported feelings of safety, low discomfort, anxiety, and fatigue. Additionally, participants
preferred the virtual reality condition compared to the pen-and-paper condition, even if the task
MJCP|11, 3, 2023 Martínez Morales et al.
16
was more difficult. Interestingly, apathetic participants showed a stronger preference for the
virtual reality condition than non-apathetic participants. These findings suggest that virtual
reality-based training can be considered a suitable tool for improving adherence to cognitive
training in older adults with mild neurocognitive disorder.
In the same line, Park et al. (2019) found in their research that individuals with mild
neurocognitive disorder who participated in mixed reality training showed significantly higher
performance in visuospatial working memory compared to those who participated in
conventional training. Moreover, Park et al. (2020) observed that cognitive-motor rehabilitation
based on virtual reality can help improve motivation for rehabilitation and cognitive function,
including memory and attention, in older adults with mild neurocognitive disorder more
effectively than conventional cognitive rehabilitation. Similarly, in the research conducted by
Manenti et al. (2020), improvement in memory, language, and visuoconstructional skills was
observed after completing an in-home cognitive virtual reality treatment, which identified a
higher rate of improvement compared to standard cognitive stimulation.
From the study by Hsieh et al. (2018), virtual reality-based Tai Chi exercise showed a protective
effect on some cognitive and physical functions in older adults with cognitive impairment. The
more appealing the program, the greater the improvement in cognitive performance. Similarly,
Liao et al. (2019) demonstrated that a twelve-week physical and cognitive training program
based on virtual reality led to significant improvements in dual-task walking performance in
older adults with mild neurocognitive disorder, which can be attributed to improvements in
executive function.
On the other hand, Thapa et al. (2020) assessed the effect of a virtual reality-based intervention
program on cognition in older adults with mild neurocognitive disorder, and analysis of the
group interactions revealed that the intervention group exhibited significantly improved
executive function and resting-state brain function. On top of that, gait speed and mobility also
significantly improved between and after the follow-up. The virtual reality training program
improved cognitive and physical function in patients with mild neurocognitive disorder
compared to controls. Encouraging patients to engage in virtual reality and game-based training
can be beneficial for preventing cognitive decline.
In line with the previously mentioned research, Torpil et al. (2021) argued that a virtual reality-
based intervention targeting cognitive functions in older adults with mild neurocognitive
disorder in a control and clinical group is effective, as they observed improvements in
orientation, visuospatial perception, visuomotor organization, thought processing, attention,
and concentration functions in the virtual reality group compared to the control group.
However, it is important to note that in the study conducted by Kim et al. (2021), they explored
the associations between cognitive reserve and the effects of cognitive training using virtual
MJCP|11, 3, 2023 Working memory training in older adults with MND
17
reality and observed that there was better performance in the total score of the Consortium to
Establish a Registry for Alzheimer's Disease Neuropsychological Battery (CERAD) in
cognitively normal participants with higher scores in the education subdomain of the cognitive
reserve questionnaire.
Thus, among patients with mild neurocognitive disorder, none of the scores for the education,
work activity, and leisure time subdomains were related to a change in the total CERAD scores.
The total score of the questionnaire did not predict global cognitive improvement in either
group. On the other hand, in the research conducted by Maeng et al. (2021), a virtual reality-
based cognitive training program was designed for older adults with mild neurocognitive
disorder and normal cognition, and cognitive improvement was observed in the ability to learn
new information, visuospatial construction ability, and frontal lobe function in both groups. In
the initial evaluation based on a simulated illness questionnaire, the clinical group reported
significantly more disorientation and nausea than the cognitively normal elderly group. Even so,
both groups showed a reduction in discomfort as the virtual reality-based cognitive training
program progressed.
3.3 Effect of Video Game and Robotics Strategies on Working Memory in Patients with
Mild Neurocognitive Disorder.
Five studies related to video games and robotics were found. There were 173 individuals with
mild neurocognitive disorder, with 60% of the participants being women, with an average age
of 71 years. In the studies from Hughes et al. (2014), the feasibility and potential efficacy of an
interactive Wii video game test to improve cognitive function were evaluated compared to
health education in a community sample of older adults with mild neurocognitive disorder.
Interactive video games showed moderate effects in favor of the Wii group, and a larger-scale
trial is needed. Similarly, Amjad et al. (2019) found beneficial effects of Xbox 360 Kinect games
after short- and long-term interventions in subjects with mild neurocognitive disorder.
Therefore, these games can serve as potential therapeutic candidates for mild neurocognitive
disorder.
On the other hand, Ramnath et al. (2021) demonstrated that an active intervention using
interactive video games was more effective than conventional multimodal exercise in improving
executive and global cognitive performance and functional capacity in older adults with
subjective memory complaints. Likewise, Lim et al. (2023) confirmed the efficacy and safety of
cognitive rehabilitation training using a serious game for older adults with mild neurocognitive
disorder, and the results indicated that the study group participating in home-based serious game
training showed immediate improvement in scores on the Korean version of the Mini-Mental
State Exam, the Montreal Korean Cognitive Assessment, and the Semantic Verbal Fluency task
compared to the control group, and the effects of home-based serious game training continued
MJCP|11, 3, 2023 Martínez Morales et al.
18
after one month. Thus, serious brain training games are considered useful for improving
cognitive function.
The last finding was from the research study proposed by Lee et al. (2020), which evaluated a
four-week home-based robotic cognitive intervention for patients with mild neurocognitive
disorder. They found that there were no significant baseline clinical or demographic differences
between the robot and control groups after the cognitive intervention. However, the robot
group showed greater improvement in working memory, but further studies with larger sample
sizes and longer study periods are needed to demonstrate the effects of these programs on other
cognitive domains in patients with mild neurocognitive disorder.
4. Discussion
This systematic review presents three perspectives that dominate the study of working memory
training with technological innovation in older adults with mild neurocognitive disorder. The
findings support the sensitivity and ecological validity of neuropsychological rehabilitation
mediated by virtual reality, computerized training, video games, and robotics, demonstrating
that the use of technology in therapies versus traditional approaches helps achieve better results.
It effectively promotes cognitive skills, basic and instrumental abilities, and social
communication through safe, controllable, and repeatable training modes, making the
development of such tools increasingly attractive for healthcare professionals.
Understanding that as individuals age, the demands of the environment significantly decrease,
leading to a process of "untraining" of cognitive skills. Consequently, there is a reduction in the
performance of daily activities, resulting in insufficient stimulation of cognitive functions
(Calero & Navarro, 2006). Additionally, other factors come into play, such as level of education,
level of physical activity, dietary habits, emotional well-being, social and affective support,
among others (Blasco & Meléndez, 2006). These factors serve as protective factors, defined as
personal characteristics or environmental factors that increase the likelihood of individuals
maintaining good health and acquiring beneficial physical and mental capabilities for the aging
process.
It is also important to consider cognitive neuroplasticity when stimulating cognitive function.
Cognitive neuroplasticity refers to the capacity of the nervous system to generate new dendrites
and synapses from remaining neurons, thus maintaining the efficiency of neural circuits. This
process occurs when appropriate and sustained stimulation through practice leads to beneficial
changes in the structure and function of the brain (Vega et al., 2016). Hence, the significant
development of technology in recent years arises from the need to personalize and improve
specialized care for individuals with cognitive difficulties due to neurological conditions. The
MJCP|11, 3, 2023 Working memory training in older adults with MND
19
incorporation of technology into interventions represents a therapeutic innovation, making
them more didactic, creative, and flexible.
Cognitive assessment, neuropsychological rehabilitation, and research on non-pharmacological
interventions in patients with mild neurocognitive disorder have become the focus of dementia
prevention in recent years. Cognitive training and stimulation provided through digital devices
are promising strategies to maintain cognitive function in healthy older adults and rehabilitate
individuals with mild neurocognitive disorder (Zhang et al., 2019). Computerized cognitive
interventions are not only useful for improving cognition, memory, and attention, but they also
have a positive influence on the psychosocial functioning of older adults with mild
neurocognitive disorder by enhancing functionality in daily activities and enabling the use of
compensatory strategies (Hill et al., 2017). Similarly, it has been demonstrated that the beneficial
effects of computerized cognitive training are maintained in both the short and long term in
individuals with preserved cognitive function (Ten Brinke et al., 2018).
Given the above, it is important to consider that the combination of physical exercise with
cognitive training is a popular intervention in dementia prevention trials and guidelines. Gavelin
et al. (2021) suggest that simultaneously combined interventions are effective in promoting
cognitive and physical health in older adults and, consequently, should be preferred over single-
domain training implementation. In the same vein, Meng et al. (2022) also found combined
interventions to be effective in improving cognition in older adults with mild neurocognitive
disorder.
Over and above that, in analyzing other studies, it was found that virtual reality technology is
an emerging intervention and has gradually become a complementary therapy for various
conditions such as cerebral palsy, depression, Parkinson's disease, and mild neurocognitive
disorder (Roosink et al., 2016). Virtual reality utilizes human senses such as sight, touch, and
movement to control a virtually created environment. Its advantage lies in simulating real-life
experiences (Rizzo et al., 2000) and providing short-term feedback (Liao Y. et al., 2019) based
on the individual's performance through the creation of a virtual environment.
In view of the above, virtual reality technology allows patients to exercise within a limited space,
thereby reducing healthcare costs as it does not require the presence of a neuropsychologist like
more traditional therapies but can also be utilized at home. Compared to traditional treatment,
virtual reality improves patient motivation and engagement (Kim et al., 2017). Also, virtual
reality technology not only allows precise control of the environment but also enables adjusting
the difficulty level according to the patient's skill level. Due to its accessibility and safety, it is
convenient for patients to use it temporarily at home, which is beneficial for rehabilitation
implementation (Hwang & Park, 2018).
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20
Considering the advantages of virtual reality usage, it is imperative to understand that the
compensatory model of brain plasticity shows that an aging brain can better maintain or
conserve cognitive functions by increasing activation in frontal, temporal, and parietal brain
regions (Lustig et al., 2009). The advantage of virtual reality is that it provides timely feedback
to patients with mild neurocognitive disorder and increases stimulation in their cognitive and
motor areas, thereby improving cognitive functions and activities of daily living (Coyle et al.,
2015).
On the other hand, information and communication technologies can also play a key role in the
treatment, stimulation, and rehabilitation of patients (Robert et al., 2014). This is the underlying
idea behind the current use of serious games, which are a broader replication of video game
resources that integrate games and serious purposes. In fact, recently, some studies have started
employing serious games with individuals with mild and major neurocognitive disorder as a
cutting-edge intervention, focused on non-pharmacological approaches, and can be defined as
interventions that directly or indirectly target cognition, as opposed to interventions primarily
focusing on behavior, mood, or physical function (Bahar-Fuchs et al., 2017).
Therefore, these interventions are often designed to promote intellectual stimulation and
minimize cognitive decline. The progressive decline in cognitive functions is indeed a clinical
feature of major neurocognitive disorder, and it has been found to be associated with
impairment in activities of daily living (Tomaszewski et al., 2020. Thus, intervention aimed at
preventing and rehabilitating such decline can promote longer independent living at home and
reduce the burden on patients and their families.
On the other hand, robotics in cognitive rehabilitation offers promising training and assistance
methods to mitigate cognitive deficits, and recent advancements in robotics and information
and communication technology are expected to enhance human healthcare and aid patients with
cognitive impairment in exercise and therapy. Faced with a severe shortage of healthcare
personnel and a heavy caregiver burden, robots can help and care without incurring physical
and emotional strain (Taheri et al., 2018).
In view of the above, the goal of cognitive rehabilitation with robotics is to provide cognitive
training to vulnerable individuals with cognitive disabilities that can complement their caregivers
or therapists (Doraiswamy et al., 2020). Nevertheless, robotics poses significant ethical
challenges for cognitive rehabilitation or training, and ethical considerations regarding human
dignity, safety, legality, and social factors need to be considered (Villaronga, 2016).
Lastly, memory training rehabilitation with technological innovation in older adults with mild
neurocognitive disorder mediated by virtual reality, computerized training, video games, and
robotics holds significant potential as it allows the generation of situations related to activities
MJCP|11, 3, 2023 Working memory training in older adults with MND
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of daily living and functional skills such as physical, intellectual, and occupational activity.
However, to maintain or improve working memory functioning, it is important for individuals
to face new learning experiences with constant challenges, such as cognitive training targeting a
specific cognitive function (Binotti et al., 2009). Cognitive training alone represents a protective
factor for mental health, allowing for stimulation and development of skills that promote social
interaction, problem-solving, and the maintenance of cognitive reserve.
5. Strengths and limitations
The systematic review of the literature made it possible to identify the main works on working
memory training with technological innovation in older adults with mild neurocognitive
disorder, presenting a wide range of possibilities with experimental methodological designs of
high scientific rigor to establish clinical strategies for intervention and rehabilitation, but there
were limitations given that studies published only in English were included, given that the
databases where the search was conducted include research published in that language, and it is
recommended that future research include databases with publications in Spanish so that the
Latin American population can be included.
6. Conclusion
This review has shown support for the hypothesis of improved cognitive performance in older
adults with mild neurocognitive impairment with working memory training mediated by
technological innovation through virtual reality, computerized training, video games and
robotics, demonstrating sensitivity and ecological validity of neuropsychological rehabilitation.
However, longitudinal studies on the interventions are required to assess long-term transfer and
relevance in reducing the prevalence of major neurocognitive disorder.
Additionally, the exercise carried out constitutes a valuable exploratory input for health
professionals interested in technological innovation in neuropsychological rehabilitation
processes, and allows identifying the opportunity to delve deeper into this research topic given
that there are few publications for the Latin American case, according to the high quality
standards in scientific publications; taking into account that the main studies are published in
the main neuroscience journals of the world. Finally, it is recommended for future studies to
aim for a larger sample size, to reduce variability in intervention design and measures applied,
and to strive to clarify whether there are additional benefits to implementing multimodal
interventions.
Conflict of interest statement
The authors declare that the research was conducted in the absence of any potential conflict of
interest.
MJCP|11, 3, 2023 Martínez Morales et al.
22
Authors’ contribution
DMM, DMA, and DLM worked on the conceptualization of the systematic review, analysis,
methodology, supervision, validation, visualization, writing, editing, and preparation of the
manuscript.
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23
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©2023 by the Author(s); licensee Mediterranean Journal of Clinical
Psychology, Messina, Italy. This article is an open access article, licensed
under a Creative Commons Attribution 4.0 Unported License.
Mediterranean Journal of Clinical Psychology, Vol. 11, No. 3 (2023).
International License (https://creativecommons.org/licenses/by/4.0/).
DOI: 10.13129/2282-1619/mjcp-3884
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