Computerized cognitive training (CCT) can improve cognition in older adults. However, specific programs for this target group have rarely been developed, and predictors of training success are largely unclear. In a randomized controlled pilot trial, we examined effects of a six-week CCT, tailored to the cognitive profile of healthy older adults (EG, n = 21) as compared to a nonspecific CCT (CG, n = 18) matched in frequency and intensity. No interaction effects between Group and Time were found. However, within-group analysis showed significant gains in verbal and non-verbal memory, executive and visuospatial functions and subjective cognitive concerns (SCC) in the EG, while the CG only benefitted in non-verbal memory and set-shifting. Low cognitive performance and lower SCC at baseline were the most consistent predictors of cognitive gains in the EG. Thus, CCTs specifically tailored to older adults seem advantageous compared to non-specific CCT. Further, we conclude that SCC may be related to reduced cognitive plasticity.
Recently, cognitive interventions to enhance cognitive functions and attenuate cognitive decline in healthy elderly individuals have attracted increasing scientific attention. There is robust evidence that the aging brain is amenable to neuronal and cognitive plasticity [
Computerized cognitive trainings (CCT) have the advantage that they can be administered at home and are usually not cost-intensive. A systematic review of [
Remarkably, CCTs specifically tailored to the typical cognitive profile of healthy elderly individuals, which is characterized by decline in episodic memory, executive functions, attention and processing speed, but sometimes also visuospatial dysfunctions [
Predicting training response may be helpful to define which individuals will profit most from which type of CT. In studies examining effects of CT and combined interventions (e.g. CT with physical exercise) in healthy elderly people, cognitive baseline performance [
Indications that computer familiarity does not seem to be predictive for success of computer-based memory training [
On the basis of the noted considerations, the aims of this pilot study were (i) to investigate the effects of an adaptive CCT program specifically developed for aging people including psycho educational elements presented in videos on topics related to healthy cognitive aging, mechanisms of cognitive functions, as well as cognitive strategies, and (ii) to define predictors of intervention outcomes. For this purpose, we conducted a randomized controlled, single blind study, in which healthy elderly individuals received either a structured six week CCT specifically developed for this target group, or a less structured control CCT not tailored to this group, but comparable in frequency and intensity. Planning and reporting followed the recommendations of the CONSORT Statement for RCT [
The present study was conducted in compliance with the World Medical Association Declaration of Helsinki [
Healthy independent home dwelling participants aged between 55 and 100 years were recruited by the two study German centers Cologne and Vechta in the cities Cologne and Düsseldorf as well as Vechta, Bremen and Osnabrück, respectively. Individuals were recruited with flyers distributed via local pharmacies and through presentations at a Senior Service Center in Bremen. Participants did not receive monetary compensation. At first, individuals interested in the study were given standardized information either by telephone or, for those attending the presentations, on site. This information included the aims and the course of the study, inclusion and exclusion criteria, as well as a short description of the neuropsychological assessment. In case people were interested in participating in the study, personal information was collected and individuals were contacted later for the study.
The inclusion criteria were: male and female individuals aged 55 or older, native German language or very good German language, normal or sufficiently corrected vision and hearing ability, motor capacities that ensured an unimpaired work on a computer and written informed consent to participate in the study. Exclusion criteria were: psychiatric or neurological disorder, cognitive impairment operationalized by the Montreal Cognitive Assessment (MoCA; cut-off score < 26 points; [
The study was designed as a multicenter, single-blind RCT including a digital cognitive experimental and a digital cognitive control training intervention, which are described below. Participants were allotted randomly to one of these two interventions. The allocation of participants to one of the two interventions was conducted separately for each of the two study centers in Cologne and Vechta by using a computer-based Research Randomizer program (http://www.randomizer.org). For this purpose, random codes consisting of six letters and two digits were produced by a staff member and consecutively assigned to each participant. Furthermore, a random list for the allocation to the interventions was produced by a staff member not involved in the study and linked to the participants’ codes. However, if an individual failed the screening or discontinued training, the next recruited person was assigned to the intervention type which was originally planned for the person that had dropped out. By these means, a balanced number of participants was allocated to both types of interventions.
The screening and, in case of eligibility of the participant, the administration of the neuropsychological test battery, as well as the introduction to the training occurred within one visit―either at the participants’ home or at one of the study centers. It was performed by a staff member trained in neuropsychological testing. After written consent was obtained, the inclusion and exclusion criteria were checked via interview and MoCA cognitive screening. Afterwards, the neuropsychological test battery was conducted. After that, each participant received an introduction to the operation of the interventional program he or she was allocated to. If necessary, participants also received an introduction to the digital device of the intervention (computer or tablet, please see description of interventions below). Additionally, participants received a standardized study folder, containing contact details in the case of technical problems or other questions, the course of each training lesson including information on every module of this lesson, a formula in which a “school grade” could be given for each module, and finally, space for comments on each session. Furthermore, information on how to adapt the degree of difficulty of the exercises to participants’ personal performance level was provided.
The adaptation to the individual difficulty level was possible in all exercises of the experimental training, but only in two exercises of the control training. Participants were asked to start the training program within seven days after screening and pretest. During the first week of training, participants were contacted by telephone in order to assess possible problems with the device or the program. After three weeks (which represents 50% of the duration of intervention), a home visit was made to check whether the progress of the training and the training itself was running well. Regular telephone consultation hours were offered three times per week for the complete duration of the intervention period.
Neuropsychological assessment took place within one week prior and post intervention. One exception was a posttest 19 days after the end of the experimental training, in which earlier assessment was not possible due to organizational reasons. If available, counterbalanced parallel forms of the tests were used to reduce retest effects.
Both the experimental and the control training were comparable with regard to frequency and intensity in order to warrant comparability. Both trainings consisted of eighteen lessons, with an average training period of 40 to 45 minutes each. Training sessions were performed three times per week over a period of six weeks. Every session contained two exercises (one 20 and one 10 minutes), a video (10 - 15 minutes), and an “advice of the day”. An overview on the structure of both interventions with examples of the exercises is given in
The “NeuroVitAALis” Software which has been designed on the basis of the paper and pencil multidomain cognitive group training program “NEUROvitalis” (for a detailed description, see [
The first exercise (20 minutes) of each session targets either memory or executive functions. The second exercise (10 minutes) could be chosen by the user and either trained spatial cognition, attention, language, or, if not already practiced during the session, either memory or executive function. All exercises had different levels of difficulty (with three to twenty-four levels). Each session also contained a psychoeducational video (10 - 15 minutes) on topics related to healthy cognitive aging or to cognitive functions and cognitive strategies. Finally, an “advice of the day” was given which aimed at the stimulation of cognitive, mnestic, and social activities as well as structuring the day. One example would be the following: “Do you plan to buy groceries today? Try to memorize your shopping list and do your groceries without using it. Check the list after you have gathered all products in order to review that you did not forget something.” The tasks were designed to autonomously adapt to the performance level of the user. However, as the program was still in a pilot phase, the automatic adjustment of difficulty levels was not implemented during the study period yet. In order to approximate comparability to a fully structured automated program, the study protocol included concrete instructions on how to adapt the degree of difficulty of the exercises to participants’ personal performance level.
After thirteen lessons, two individuals reported that the exercise for the training of executive functions had an undemanding degree of difficulty on its highest level. After consultation with the research group, a modification of the study protocol was administered in these cases, and the exercise was replaced by the exercise for spatial cognition on level ten, which is highly demanding and also requires executive functions in its operation.
The control training was conducted on computers. Exercises were taken from the German dyslexia software “Tintenklex” (http://www.legasthenie-software.de) and did not specifically aim at the amelioration of age-sensitive functions. Ten different tasks were chosen training reading abilities, orthography, perception, concentration, visual-spatial perception as well as visual-motor skills. In each session, two tasks defined in the study protocol were trained 20 and 10 minutes, respectively. Videos of 10 - 15 minutes that do not belong to the software were chosen from freely available sources from the internet and included topics like doing sports and exercise, nutrition, relaxation, stress and sleep. Participants watched one video per training lesson. The “advices of the day” (one per training lesson) focused on healthy aging and achievement of well-being in a more general way than in the experimental intervention. They did not focus on cognition.
Verbal memory was assessed with the German verbal learning and memory test “Verbaler Lern- und Merkfähigkeitstest” (VLMT; [
To assess Subjective Cognitive Concerns (SCC) a modified and extended version of the Subjective Memory Impairement Questionnaie (SMI-Q) proposed by [
Further variables used for the predictor analysis of training success were technology commitment (consisting of technology acceptance, technology competence and technology control) as assessed using the technology commitment scale [
Statistical analyses were performed using IBM SPSS Statistics 23 for Windows (2015). Post-hoc power analysis was performed using the software G * Power 3.1.7 [
Baseline data of experimental and control group were compared between groups, using t-tests for independent samples to compare the age, years of education (including both school and professional education), cognitive state (MoCA), depression score (BDI-II), technology commitment, self-efficacy (SWE) and motivation assessed via an average grade, and chi-square test for the comparison of sex distribution. As Kolmogorov-Smirnov test for normality indicated that neuropsychological data could not be assumed to be normally distributed (0.086 ³ D £ 0.275 with pre- and/or posttest scores at p < 0.05 in 69.23% of the tests), non-parametric analyses were performed. To quantify the gains achieved within the experimental and control training, we calculated reliable change indices (RCIs; [
Predictors of training success within the EG were estimated using backwards multiple regressions to ensure achievement of best model fit while taking into account each relevant predictor. The significance level was set at α = 0.10. Based on the current literature outlined above, the following predictors were integrated in the regression models: baseline level of the cognitive tests, depression score, motivation, SCC, technology commitment, age, years of education, sex, and self-efficacy. For the analyses, the SCC SMI-Q extended version total score of subjectively impaired cognitive domains (0 - 5 points) was used, as only the perceived number of subjectively impaired cognitive domains has a predictive value, but not the intensity of worries about the perceived worsening. The assumptions for multiple regression were checked according to the suggestions of [
Data assessment took place between March 2015 and October 2015. N = 54 persons were assessed for eligibility and randomized, of which a total of N = 49 engaged in the training conditions EG (n = 28) and CG (n = 21). During the study, n = 10 (20.4%) persons dropped out due to technical issues with the software and/or hardware issues and, consequently, deviations from the training protocol (EG: n = 3; CG: n = 1), discontinuation of the training (EG: n = 4; CG: n = 1), and non-compliance with the training protocol (CG: n = 1). Thus, a total of N = 39 datasets (EG: n = 21; CG: n = 18) were included for statistical analysis. The flow of participants during the study including information for the flow of participants per study center is presented in
Baseline data, including sociodemographic characteristics, the overall cognitive state as assessed with the MoCA, BDI-II score, technology commitment, SWE self-efficacy, as well as motivation during the intervention assessed via an average grade, are presented in
For the analysis of pre- and posttest group comparisons (N = 39, 2-tailed α = 0.05) the power to detect small effects (Cohen’s d ≥ 0.2) was 9.2%, the power to detect moderate effects (Cohen’s d ≥ 0.5) was 32.3% and the power to detect
Experimental Condition n = 21 | Control Condition n = 18 | |||||
---|---|---|---|---|---|---|
Max. | M | (SD) | M | (SD) | ||
Age | - | 66.14 | (6.17) | 68.50 | (6.97) | |
Education | - | 16 | (2.57) | 14.72 | (2.72) | |
Sex | - | ♀ = 15 | ♂ = 6 | ♀ = 15 | ♂ = 3 | |
Cognitive Screening: MoCA | 30 | 27.43 | (1.17) | 27.78 | (1.35) | |
Depression: BDI-II | 63 | 4.90 | (3.89) | 5.33 | (3.14) | |
Technology commitment | 5 | 3.44 | (0.60) | 3.36 | (0.60) | |
Self-efficacy: SWE | 40 | 30.57 | (4.04) | 30.28 | (4.24) | |
Motivation | 6 | 2.23 | (0.62) | 1.92 | (0.53) |
Note. BDI-II = Beck Depression Inventory. MoCA = Montreal Cognitive Assessment. SWE = Self-Efficacy Expectation.
strong effects (Cohen’s d ≥ 0.8) was 67.1%. Outcome data for pre- and posttest are presented in
Experimental Condition (n = 21) | Control Condition (n = 18) | ||||||
---|---|---|---|---|---|---|---|
M (SD) Md (Range) | Tb | M (SD) Md (Range) | Tb | ||||
Max. | Pretest | Posttest | Pretest | Posttest | |||
COGNITIVE STATUS | |||||||
MoCA | 30 | 27.29 (1.27) 27 (4) | 27.72 (1.79) 28 (6) | 88.5 | 27.50 (1.54) 28 (4) | 27.28 (2.24) 28 (7) | 42 |
MEMORY | |||||||
Verbal Memory | |||||||
Immediate recall VLMT 1 - 5 | 75 | 49.57 (6.06) 48 (23) | 54.29 (7.35) 54 (23) | 163.5** | 53.17 (10.88) 56.5 (32) | 55.94 (9.59) 57.5 (32) | 121 |
Delayed recall VLMT 7 | 15 | 10.24 (2.12) 11 (9) | 11.90 (2.17) 12 (9) | 152.5** | 10.94 (3.82) 12.5 (12) | 12.11 (2.65) 12 (10) | 91.5 |
Figural Memory | |||||||
Direct recall WMS VR | 42 | 34.43 (5.64) 34 (24) | 37.33 (5.58) 39 (22) | 162** | 35.5 (4.96) 34.5 (18) | 37.28 (3.79) 37.5 (13) | 71 |
Delayed Recall WMS VR | 42 | 27.05 (7.60) 28 (28) | 31.90 (8.66) 34 (35) | 186** | 28.33 (7.81) 28 (27) | 32.33 (8.88) 34 (26) | 118.5** |
ATTENTION | |||||||
BTA | 20 | 17.10 (2.21) 18 (8) | 17.95 (1.75) 18 (8) | 100.5 | 16.94 (2.04) 17 (7) | 17.44 (1.85) 18 (7) | 77 |
Processing Speed | |||||||
TMT Aa | ? | 38.32 (22.08) 31.3 (103.2) | 34.24 (11.86) 31 (47.57) | 85.5 | 36.95 (9.12) 35 (42.9) | 34.68 (8.54) 34.91 (31.24) | 63.5 |
EXECUTIVE FUNCTIONS | |||||||
Key Search | 16 | 11.90 (2.93) 11 (9) | 12.62(3.28) 13 (12) | 74 | 13.72 (2.52) 14.5 (7) | 12.78 (3.06) 12.5 (9) | 16.5 |
Verbal Fluency | |||||||
Verbal letter | ? | 19.57 (5.92) 20 (23) | 19.14 (6.19) 19 (28) | 64 | 21.78 (6.92) 20 (26) | 21.50 (7.45) 21.5 (26) | 64.5 |
Semantic-alternating | 23.67 (4.96) 24 (19) | 22.43 (4.49) 22 (17) | 74 | 25.28 (6.31) 23.5 (28) | 22.22 (4.49) 22.5 (15) | 37.5* | |
Set Shifting | |||||||
TMT Ba | ? | 79.96 (31.19) 73 (115.15) | 71.52 (24.72) 68 (76.36) | 52* | 78.10 (22.51) 72.4 (78.4) | 68.29 (24.72) 65.28 (76.61) | 28* |
Visual Spatial Abilities | |||||||
LPS 50+ | 40 | 19.48 (4.96) 20 (18) | 21.43 (4.52) 21 (16) | 186.5* | 20.44 (5.75) 20 (22) | 19.78 (5.29) 20 (18) | 74.5 |
SUBJECTIVE COGNITIVE CONCERN | |||||||
SMI-Qa | 5 | 2.05 (1.43) 2 (5) | 1.86 (1.80) 1 (5) | 23.5 | 1.83 (1.79) 1.5 (5) | 1.61 (1.50) 1 (4) | 28 |
SMI-Q extendeda | 20 | 7.90 (2.21) 8 (7) | 7.19 (2.14) 6 (6) | 18* | 7.67 (2.57) 7 (7) | 6.72 (1.99) 6 (7) | 23 |
Note. BTA = Brief Test of Attention.LPS 50+ = Leistungsprüfsystem für 50 - 90 jährige. MoCA = Montreal Cognitive Assessment. SMI-Q = Subjective Memory Impairment Questionnaire. TMT = Trail Making Test. VLMT = Verbaler Lern- und Merkfähigkeitstest. WMS VR = Wechsler Memory Scale (German version) subtest Visual Reproduction. a. Low scores indicate better performance. b. Statistical Value for the Wilcoxon Signed Rank Test for dependent samples. *p ≤ 0.05; **p ≤ 0.01; ***p ≤ 0.001.
Experimental Condition | Control Condition | p | Ub | ||
---|---|---|---|---|---|
Md (Range) | Md (Range) | ||||
COGNITIVE STATUS | |||||
MoCA RCI | 0 (8.23) | 0 (9.6) | 0.294 | 151 | |
MEMORY | |||||
Verbal Memory | |||||
Immediate recall VLMT 1 - 5 RCI | 0.77 (5.56) | 0.58 (7.1) | 0.587 | 169.5 | |
Delayed recall VLMT 7 RCI | 1.08 (4.33) | 0.27 (80.12) | 0.233 | 145 | |
Figural Memory | |||||
Direct recall WMS VR RCI | 6.17 (37.48) | 4.11 (39.75) | 0.646 | 172.5 | |
Delayed Recall WMS VR RCI | 1.08 (4.33) | 0.27 (80.12) | 0.233 | 145 | |
ATTENTION | |||||
BTA PC | 5.26 (48.57) | 5.41 (55) | 0.967 | 191 | |
Processing Speed | |||||
TMT Aa PC | −7.19 (78.99) | −5.2 (80.14) | 0.900 | 184 | |
EXECUTIVE FUNCTIONS | |||||
Key Search PC | 0 (120.63) | 0 (88.31) | 0.156 | 138.5 | |
Verbal Fluency | |||||
Verbal letter PC | −5 (110) | −4.11 (79.44) | 0.900 | 193.5 | |
Semantic-alternating PC | −4.55 (61) | −9.55 (80.18) | 0.257 | 148 | |
Set Shifting | |||||
TMT Ba PC | −11.11 (75.73) | −9.73 (75.94) | 0.477 | 163 | |
Visual Spatial Abilities | |||||
LPS 50+ RCI | 1.34 (9.35) | 1 (18.03) | 0.174 | 140 | |
SUBJECTIVE COGNITIVE CONCERN | |||||
SMI-Q extendeda PC | 0 (4) | 0 (4) | 0.813 | 180.5 |
Note. BTA = Brief Test of Attention. LPS 50+ = Leistungsprüfsystem für 50 - 90 jährige. MoCA = Montreal Cognitive Assessment. PC = percentage change score. SMI-Q = Subjective Memory Impairment Questionnaire. RCI = reliable change index. TMT = Trail Making Test. VLMT = Verbaler Lern- und Merkfähigkeits test. WMS VR = Wechsler Memory Scale (German version) subtest Visual Reproduction. a. Low scores indicate positive direction. b. Statistical Value for the Mann-Whitney-U test with independent samples.
measure (all p > 0.05). However, note that the power to detect group differences even for strong effects was generally low.
For the detection of effects from pre- to posttest (experimental group n = 21, control group n = 18, 2-tailed α = 0.05), post-hoc power analysis revealed a power of 13.6% in the experimental and 12.2% in the control condition to detect small effects (Cohen’s dz ≥ 0.2), a power of 56.6% in the experimental and 49.6% in the control condition to detect moderate effects (Cohen’s dz ≥ 0.5) and a power of 92.5% in the experimental and 87.6% in the control condition to detect strong effects (Cohen’s dz ≥ 0.8).
The results of the outcome measures pre- and post-intervention for both groups are presented in
Within the domain of executive functions, both groups significantly improved in set shifting with moderate effects as indicated by the TMT B [EG: T(21) = 52, p = 0.027, dz = 0.526; CG: T(18) = 28, p = 0.012, dz = 0.669]. However, the CG showed lower scores at posttest in verbal fluency [RWT semantic alternating fluency; T(18) = 37.5, p = 0.036, dz = 0.536]. Furthermore, only the EG significantly improved in visual-spatial functioning [LPS50+, subtest 9: T(21) = 186.5, p = 0.013, dz = 0.605], and SCC decreased [SMI-Q extended version: T(21) = 18, p = 0.027, dz = 0.526]―both with moderate effects. No other significant results were found.
Assuming a maximum of nine predictors per model (based on n = 21 participants in the EG), this study had 62% power to detect predictors of a model with at least R2 = 0.50 (α = 0.05). The results of the predictor analyses are shown in
1) Low baseline performance in the particular tests were predictors for training gains in verbal intermediate (VLMT 1 - 5, β = −0.453) and long term memory (VLMT 7, β = −0.595) as well as figural short (WMS VR direct recall, β = −0.711) and long-term memory (WMS VR delayed recall, β = −0.626), executive functions as indicated by verbal fluency tasks (RWT letter fluency, β = −0.467), semantic-alternating fluency, β = −0.476) and set-shifting (TMT B, β = −0.466), attention (BTA (β = −0.889) and processing speed (TMT A: β = −0.72), and visuospatial functioning (LPS 50+, subtest 9, β = −0.461).
2) Low SCC as measured with the SMI-Q extended version score was a predictor for gains in verbal intermediate memory (VLMT 1 - 5; β = −0.281), executive functions as indicated by verbal fluency (RWT letter fluency, β = −0.546), and attention (BTA, β = −0.372).
3) A good average grade for the intervention predicted gains in verbal intermediate (VLMT 1 - 5, β = −0.546) and long term memory (VLMT 7, β = −0.513).
4) High self-efficacy scores predicted improvement of figural memory (WMS VR direct recall, β = 0.355).
5) High depression scores were predictive for better performance post training in processing speed (TMT A, β = −0.368).
6) Higher age was a negative predictor―in other words: younger age was a positive predictor―for gains in figural memory (WMS VR direct recall, β = −0.774), and attention (BTA, β = −0.246).
7) Years of education did not have a predictive value in any of the analyses.
8) Female sex predicted gains in long-term figural memory (WMS VR delayed recall, β = 0.461) and attention (BTA, β = 0.293), while male sex predicted losses in set shifting (TMT B, β = −0.351).
9) Technology commitment led to inconsistent results. On the one hand, high technology commitment predicted gains in figural long term memory (WMS VR delayed recall, β = 0.623). On the other hand, it predicted a negative influence on executive functions (TMT B, β = 0.400; RWT letter fluency, β = −0.406), and speed of processing (TMT A, β = 0.275).
This study aimed at examining the effects of a CCT especially designed for older adults compared to an unspecific CCT in a group of healthy older adults. The main findings of the study are that (1) no Group × Time interaction effects were found for the CG versus the EG when RCIs and change scores from pre- to posttest were compared, but that (2) in within-group comparisons, the EG showed significant gains in verbal short and long-term memory, non-verbal short and long-term memory, set-shifting, visuospatial functions, and SCC, while the CG only benefitted in non-verbal long-term memory and set-shifting and even worsened in an alternating fluency task. Finally, (3) low cognitive baseline performance as well as lower SCC at baseline were the most consistent predictors of cognitive gains in the EG.
Although we were not able to find Group × Time interaction effects, the fact that substantially more gains were achieved in the CCT target intervention as elicited in the within-group comparisons allow the (tentative) conclusion that it was indeed more effective than the active control intervention. When interpreting these results one has to keep in mind that the effects of our target intervention might be underestimated for two reasons: first, an active control group was used. Although [
The fact that low cognitive baseline performance was predictive for gains in various cognitive domains including verbal and non-verbal memory, executive functions, processing speed and visuospatial functioning is consistent with most, though not all [
Our result that also lower SCC is predictive for cognitive gains in relevant domains (verbal memory, verbal fluency, and attention), is intriguing. SCC is regarded as a predictor for dementia development [
Consistent with our hypothesis, motivation and self-efficacy were identified as positive predictors of training success in verbal and figural memory, respectively. Metacognitive and motivational measures were already identified as predictors for gains in objective memory measures in a strategic memory training in older adults [
The other results of our predictor analysis are less clear-cut. Regarding depression, the result that higher depression scores predicted better outcome in verbal memory and speed of processing was unexpected, as depression is regarded to reduce brain and cognitive plasticity [
Regarding the influence of sociodemographic factors, the fact that female gender predicts gains in memory corroborates previous findings that women profit more from CT programs especially in the memory domain, although [
The inconsistent results regarding technology commitment as a predictor for gains in figural memory, but losses in executive functions and speed of processing are hard to interpret―even more so when the results of [
Some limitations have to be kept in mind when interpreting the results. First, the small sample size in our pilot study limited the power to detect interaction effects between the two training groups and generally limit clear conclusions. Thus, further studies with larger samples are needed and might be able to demonstrate the possible favour of cognitive training programs that are tailored to the specific needs of healthy older adults. Second, the fact that a pilot version of the training program was used in which the automatic adjustment of difficulty levels had not been implemented yet and in which individuals had to follow concrete instructions to choose the adequate training levels, might have influenced the results. Thus, future studies will have to show whether the expectation that fully adaptive programs which lead the individual smoothly through the program will be more effective. Third, our study was only single-blind. While individuals who performed the training were blind to the program, the person who administered the neuropsychological test battery was not. Thus, although test battery was fully standardized, a bias is possible and should clearly be avoided in further studies. Fourth, it is not possible to define the specific efficacious elements in a multidomain training program and, in our case, differentiate the impact of the direct training from the psychoeducational elements. One important difference between the groups was that the experimental group included a video that explained effects of cognitive training, which might have promoted expectations and corresponding effects. Therefore, for future studies and to extract the effects of the direct training, the psychoeducational elements should be designed more similar between groups, especially regarding contents that could directly influence the training outcome via a placebo effect as for example information on the effectiveness of cognitive trainings. Another control group that only differs in the nature of the psychoeducational elements could further disentangle effects of the specifically targeted cognitive training intervention from psychoeducational effects. With regard to the fact that effects of specific cognitive training tasks in the programs cannot be derived, it is important to note that multidomain trainings rather than interventions focused on only one domain have been recommended for inducing lasting improvement in cognition in healthy older adults [
The specific strength of our study is that, to our knowledge, this is the first RCT with CCT that was specifically developed for healthy older adults. Such programs which contain both training elements for those domains that are particularly vulnerable in higher age and psychoeducational elements promoting a lifestyle supporting healthy cognitive aging seem very important in an aging society with an increasing prevalence of dementia. A further strength that planning and reporting followed the recommendations of the CONSORT Statement for RCT [
In conclusion, although our hypothesis that a CCT especially tailored to the profile of healthy older adults would lead to better cognitive outcome compared to a non-tailored CCT in terms of significant interaction effects could not be verified, benefits in more cognitive domains in within-comparisons for the CCT indicate that this type of intervention may be a fruitful approach to support older adults in sustaining their cognitive level. More studies are needed to corroborate this notion and also to further specify which individuals have a high probability to benefit from such programs. SCC as a possible predictor for future cognitive decline will have to be considered in this research.
This research was conducted at the University of Vechta und the University Hospital of Cologne. We thank all participants for their interest in the study. We thank Tintenklex Legasthenie Software, Damp, Germany for providing the software for study purposes. We thank Kay Paluszak for his help with data collection. Furthermore, we gratefully acknowledge the support of Ann-Kristin Folkerts, Bernd-Josef Leisen, Mandy Roheger, Sabrina Blawath and the Senior Service Office in Bremen, Germany.
This work was supported by the Federal Ministry of Education and Research under Grant 16SV5917.
Kalbe, E., Bintener, C., Ophey, A., Reuter, C., Göbel, S., Klöters, S., Baller, G. and Kessler, J. (2018) Computerized Cognitive Training in Healthy Older Adults: Baseline Cognitive Level and Subjective Cognitive Concerns Predict Training Outcome. Health, 10, 20-55. https://doi.org/10.4236/health.2018.101003
Manuscript “Computerized cognitive training in healthy older adults: baseline cognitive level and subjective cognitive concerns predict training outcome” by Kalbe et al.
Exercises: Experimental intervention “Neuro VitAALis”
Exercise “Category memory” (Example in
Mainly trained domain: Memory
Experimental intervention | Control intervention | |
---|---|---|
Frequency, intensity | For both trainings: 18 units à 40 - 45 minutes (3 x/week) | |
Elements | For both trainings: ・ digitalized exercises ・ psychoeducational videos ・ advice of the day | |
Main domains trained | Memory Executive functions Complex attention Spatial cognition Language | Reading Spelling Attention Visual-spatial perception Visual-motor skills |
Typical session | 1) Exercise either memory or executive functions (20 min) 2) Psychoeducational video (10 - 15 min) 3) Exercise: complex attention, spatial cognition, or language (10 min) 4) Advice of the day (5 min) | 1) Exercise (20 min) 2) Psychoeducational video (10 - 15 min) 3) Exercise (10 min) 4) Advice of the day (5 min) |
Topics of the psychoeducational videos per session | 1) Introduction 2) Effectiveness of cognitive training 3) The aging brain from a biological perspective 4) Cognition in ageing 5) Memory and age 6) Attention and memory 7) External mnemonic strategies 8) Internal mnemonic strategies 9) Memorizing names and faces 10) Working memory 11) Planning aids for everyday life 12) Successful aging 13) Risk factors of cognitive reduction 14) Protective factor: Nutrition 15) Protective factor: Exercise 16) Protective factor: Lifestyle 17) The importance of the image of old age 18) Outlook to my further NeuroCare training | 1) Good sleep 2) Myths about sports 3) Extinction learning 4) Weight regulation I 5) Good resolutions 6) Sleep 7) Romantic relationships 8) Risk factor: Overweight 9) Health applications 10) Myths about sleep 11) Nutrition 12) Drinking 13) Memory traces 14) Sitting 15) Relationships 16) Weight regulation II 17) Sleeping pills 18) Time management |
The presented visual stimuli consist of eight umbrella term cards (e.g. profession) and 80 picture cards. The exercise sequence follows the same principle as a classic memory game. In the middle lies a card pile with an umbrella term. The top card is disclosed; around this card lie hidden picture cards. The first picture card is then to be uncovered/turned over and examined to see whether it matches the umbrella term. In the case of a match, both cards are laid aside and a new umbrella term is revealed. If the uncovered card does not match the umbrella term, the card is turned upside down again and the umbrella term stays unchanged. At higher difficulty levels, individual or combined parameters of difficulty increase: Duration of the game, number of hidden cards, frequency of changing the umbrella card, specification of the search request of a category towards a single concrete picture card. There are 24 difficulty levels for this exercise.
Exercise “Daily plan” (Example in
Mainly trained domain: executive functions
At the beginning of the task a daily calendar with time categories is presented. On the right side, there are different activities displayed that should be classified into the daily schedule following specific rules. The classification of activities not only depends on a predefined time schedule but also on an order of succession of activities that needs to be considered. Difficulty variations result from the following conditions: Individual timeslots in the schedule are blocked, while others may be occupied twice, appointments are subject to a fixed duration, appointments are only shown once and then must be kept in mind/remembered until they are processed. There are 14 difficulty variations/levels for this exercise.
Exercise “Lateral thinking” (Example in
Mainly trained domain: Complex attention
The exercise is composed of varying stimuli in different colors and shapes moving from the left to the right side of the screen. If a stimuli fits the displayed rule/criteria (color and shape) it has to be selected before reaching a red marked area on the right side of the screen. At higher levels, attention must also be given to the patterns of the stimuli. Difficulty variations result from the following conditions: Density of stimuli, number (and combination) of features that have to be considered before selection, number and speed of the change of rules/criteria, presentation speed of the stimuli. There are 14 difficulty variations for this exercise.
Exercise “City map” (Example in
Mainly trained domain: Spatial cognition
The task is composed of two parts: The first part of the task consists in the completion of a map by inserting matching parts. The cards have to be selected and aligned in order to fit the layout of a street map. In the second part it is required to determine the shortest possible distance from a certain starting point,
through various intermediate stations, to a destination point. The task difficulty is simultaneously increased in both conditions. The variations of the first tasks are: number of cards that need to be inserted and correctly aligned prior to insertion, completion of the map after a memorizing phase. The difficulty parameters of the second part change as follows: Number of intermediate stations, impairment of the feasible direction induced by one-way streets. There are 16 difficulty variations for this exercise.
Exercise: “Word fluency” (Example in
Mainly trained domain: Language
Language is trained through three different exercises of increasing complexity. There are three difficulty variations for each exercise. The first task requires the user to match terms to defined categories. The difficulty of the task is increased
through specification of the categories (e.g. insect instead of animal). During the next task, the user has to contrive words matching a specific category, the number of clues given decreases alongside the increase of task difficulty. The third and most complex exercise is a blank field of a crossword puzzle in which the user has to fill in all cases with a term without contradictions. Each task has a specific amount of letters that the participant is required to use. Task difficulty increases by number of the blank fields to fill and number of compulsory letters.
Exercises: Control intervention “Tintenklex”
Example: Exercise “Word rain” (Example in
Mainly trained domain: Spelling, speed of processing
The word that is initially displayed is to be composed with letters, moving from the top of the screen to the bottom. The user solves the exercise by moving each letter into the right column before it reaches the bottom. The user has the possibility to adapt the speed.
Exercise: “Griddle” (Example in
Mainly trained domain: Reading/attention
Words which can be displayed diagonally, vertically and horizontally, forwards and backwards have to be found.
Exercise: “Klexsklick” (Example in
Mainly trained domain: Visuo-spatial processing, reading
At the right eight words are displayed. In the middle of the screen is a grid of 5 × 6 fields, and one field after the other is revealed until the user recognizes the symbol and clicks the field with the matching word.
Exercise: “Labyrinth” (Example in
Mainly trained domain: Visual-motor processing
The task is part of three exercise-units with a duration of ten minutes. The user has to solve a labyrinth by moving the red dot via the exit.
Exercise: “Different pictures” (Example in
Mainly trained domain: visuospatial processing, attention
The task is part of three exercise-units with a duration of ten minutes. The user has to compare the two images, find 10 differences and click on the appropriate places on one of the fields.
Improvement in Verbal Memory Subtest VLMT 1 - 5 RCI | ||||||||
---|---|---|---|---|---|---|---|---|
β (standardized coefficients) | ||||||||
Predictor | Step 1 | Step 2 | Step 3 | Step 4 | Step 5 | Step 6 | Step 7 | |
Baseline Performance | −0.302 | −0.291 | −0.333 | −0.317 | −0.358+ | −0.439* | −0.453* | |
Depression (BDI-II) | −0.183 | −0.189 | −0.192 | −0.171 | x | x | x | |
Grade | −0.423 | −0.429+ | −0.477* | −0.402+ | −0.461* | −0.477* | −0.546** | |
SCC (SMI-Q) | −0.494+ | −0.498+ | −0.426+ | −0.371 | −0.434* | −0.321+ | −0.291+ | |
Technology Commitment | −0.211 | −0.236 | −0.238 | −0.232 | −0.208 | x | x | |
Age | 0.155 | 0.144 | x | x | x | x | x |
Education | −0.149 | −0.149 | −0.152 | −0.162 | −0.179 | x | x | |
---|---|---|---|---|---|---|---|---|
Sex | 0.042 | x | x | x | x | x | x | |
Self-efficacy (SWE) | −0.234 | −0.233 | −0.175 | x | x | x | x | |
R2adj | 0.420+ | 0.466* | 0.491* | 0.501* | 0.511** | 0.514** | 0.510* | |
n | 21 | |||||||
Improvement in Verbal Memory Subtest VLMT 7 RCI | ||||||||
β (standardized coefficients) | ||||||||
Predictor | Step 1 | Step 2 | Step 3 | Step 4 | Step 5 | Step 6 | Step 7 | Step 8 |
Baseline Performance | −0.628* | −0.629* | −0.624* | −0.626* | −0.670** | −0.682** | −0.614** | −0.595** |
Depression (BDI-II) | 0.254 | 0.255 | 0.254 | 0.250 | 0.242 | 0.240 | 0.136 | x |
Grade | −0.475 | −0.474 | −0.465 | −0.478+ | −0.561* | −0.591** | −0.573** | −0.513** |
SCC (SMI-Q) | −0.214 | −0.211 | −0.212 | −0.240 | −0.185 | −0.189 | x | x |
Technology Commitment | −0.007 | x | x | x | x | x | x | x |
Age | 0.134 | 0.136 | 0.136 | 0.157 | x | x | x | x |
Education | 0.019 | 0.019 | x | x | x | x | x | x |
Sex | 0.140 | 0.142 | 0.142 | 0.151 | 0.130 | x | x | x |
Self-efficacy (SWE) | 0.121 | 0.057 | 0.059 | x | x | x | x | x |
R2adj | 0.183 | 0.251 | 0.308+ | 0.355+ | 0.378* | 0.397* | 0.406** | 0.422** |
n | 21 | |||||||
Improvement in Figural Memory WMS VR Direct Recall RCI | ||||||||
β (standardized coefficients) | ||||||||
Predictor | Step 1 | Step 2 | Step 3 | Step 4 | Step 5 | Step 6 | Step7 | |
Baseline Performance | −0.673+ | −0.682.* | −0.751** | −0.781** | −0.834** | −0.761** | −0.711** | |
Depression (BDI-II) | −0.184 | −0.187 | −0.131 | x | x | x | x | |
Grade | −0.168 | −0.182 | −0.191 | −0.237 | −0.200 | x | x | |
SCC (SMI-Q) | 0.178 | 0.134 | x | x | x | x | x | |
Technology Commitment | 0.098 | x | x | x | x | x | x | |
Age | −0.769* | −0.801* | −0.785* | −0.821** | −0.878** | −0.783** | −0.774** | |
Education | 0.180 | 0.186 | 0.161 | 0.155 | x | x | x | |
Sex | 0.206 | 0.175 | 0.197 | 0.198 | 0.197 | 0.213 | x | |
Self-efficacy (SWE) | 0.222 | 0.226 | 0.162 | 0.202 | 0.217 | 0.300 | 0.355+ | |
R2adj | 0.301 | 0.351+ | 0.391* | 0.417* | 0.431* | 0.438* | 0.422** | |
n | 21 |
Improvement in Figural Memory WMS VR Delayed Recall RCI | ||||||||
---|---|---|---|---|---|---|---|---|
β (standardized coefficients) | ||||||||
Predictor | Step 1 | Step 2 | Step 3 | Step 4 | Step 5 | Step 6 | Step 7 | |
Baseline Performance | −0.944+ | −0.941* | −0.916* | −0.986** | −1.002** | −0.919** | −0.626* | |
Depression (BDI-II) | −0.111 | −0.112 | −0.136 | −0.108 | x | x | x | |
Grade | −0.134 | −0.138 | −0.135 | −0.131 | −0.172 | x | x | |
SCC (SMI-Q) | −0.073 | −0.071 | x | x | x | x | x | |
Technology Commitment | 0.537+ | 0.535+ | 0.555* | 0.545* | 0.580* | 0.610* | 0.623* | |
Age | −0.467 | −0.464 | −0.468 | −0.545 | −0.549+ | −0.417 | x | |
Education | −0.010 | x | x | x | x | x | x | |
Sex | 0.498+ | 0.498+ | 0.494+ | 0.491 | 0.509* | 0.534* | 0.461+ | |
Self-efficacy (SWE) | −0.115 | −0.117 | −0.102 | x | x | x | x | |
R2adj | 0.092 | 0.167 | 0.228 | 0.277+ | 0.314+ | 0.334* | 0.266* | |
n | 21 | |||||||
Improvement in Brief Test of Attention (BTA) PV | ||||||||
β (standardized coefficients) | ||||||||
Predictor | Step 1 | Step 2 | Step 3 | Step 4 | Step 5 | Step 6 | ||
Baseline Performance | −0.854*** | −0.869*** | −0.878*** | −0.566*** | −0.859*** | −0.889*** | ||
Depression (BDI-II) | 0.028 | x | x | x | x | x | ||
Grade | −0.041 | −0.030 | x | x | x | x | ||
SCC (SMI-Q) | −0.415+ | −0.406* | −0.410* | −0.409* | −0.448** | −0.372** | ||
Technology Commitment | −0.178 | −0.175 | −0.169 | −0.167 | −0.161 | x | ||
Age | −0.307 | −0.311+ | −0.303+ | −0.311+ | −0.271* | −0.246+ | ||
Education | 0.057 | 0.060 | 0.053 | x | x | x | ||
Sex | 0.228 | 0.228 | 0.233 | 0.230 | 0.248+ | 0.293* | ||
Self-efficacy (SWE) | 0.068 | 0.069 | 0.079 | 0.076 | x | x | ||
R2adj | 0.651** | 0.679** | 0.703*** | 0.721*** | 0.735*** | 0.735*** | ||
n | 21 |
Improvement in Speed of Processing TMT-A PV | ||||||||
---|---|---|---|---|---|---|---|---|
β (standardized coefficients) | ||||||||
Predictor | Step 1 | Step 2 | Step 3 | Step 4 | Step 5 | Step 6 | Step 7 | |
Baseline Performance | −0.707* | −0.720** | −0.718* | −0.718** | −0.704** | −0.639*** | −0.720*** | |
Depression (BDI-II) | −0.358 | −0.350+ | −0.343+ | −0.338+ | −0.361* | −0.372* | −0.368* | |
Grade | 0.034 | 0.036 | x | x | x | x | x | |
SCC (SMI-Q) | 0.035 | X | x | x | x | x | x | |
Technology Commitment | 0.284 | 0.274 | −0.269 | 0.287 | 0.299 | 0.242 | 0.275+ | |
Age | 0.117 | 0.134 | 0.123 | 0.136 | 0.154 | x | x | |
Education | 0.181 | 0.175 | 0.184 | 0.186 | 0.191 | 0.194 | x | |
Sex | −0.036 | −0.036 | −0.042 | x | x | x | x | |
Self-efficacy (SWE) | 0.103 | 0.094 | 0.084 | 0.070 | x | x | x | |
R2adj | 0.430+ | 0.477* | 0.516* | 0.549** | 0.575** | 0.581*** | 0.570*** | |
n | 21 | |||||||
Improvement in Set Shifting TMT-B PV | ||||||||
β (standardized coefficients) | ||||||||
Predictor | Step 1 | Step 2 | Step 3 | Step 4 | Step 5 | Step 6 | Step 7 | |
Baseline Performance | −0.672+ | −0.664+ | −0.655* | −0.697* | −0.725* | −0.759** | −0.466* | |
Depression (BDI-II) | 0.193 | 0.196 | 0.188 | 0.181 | 0.151 | x | x | |
Grade | −0.129 | −0.124 | −0.130 | −0.092 | x | x | x | |
SCC (SMI-Q) | −0.044 | −0.027 | x | x | x | x | x | |
Technology Commitment | 0.529+ | 0.526 | 0.535* | 0.559* | 0.580** | 0.525 | 0.400* | |
Age | 0.363 | 0.343 | 0.329 | 0.362 | 0.423 | 0.413 | x | |
Education | 0.083 | 0.083 | 0.087 | x | x | x | x | |
Sex | −0.341 | −0.346 | −0.343+ | −0.344+ | −0.326+ | −0.367* | −0.351+ | |
Self-efficacy (SWE) | −0.034 | X | x | x | x | x | x | |
R2adj | 0.315 | 0.371+ | 0.419* | 0.452* | 0.482* | 0.491** | 0.444** | |
n | 21 |
Improvement in RWT Verbal Letter Fluency PV | ||||||||
---|---|---|---|---|---|---|---|---|
β (standardized coefficients) | ||||||||
Predictor | Step 1 | Step 2 | Step 3 | Step 4 | Step 5 | Step 6 | Step 7 | |
Baseline Performance | −0.409 | −0.409 | −0.409+ | −0.417+ | −0.413* | −0.467* | −0.467* | |
Depression (BDI-II) | −0.057 | −0.057 | −0.051 | −0.050 | x | x | x | |
Grade | 0.001 | X | x | x | x | x | x | |
SCC (SMI-Q) | −0.653+ | −0.653+ | −0.668* | −0.662* | −0.681* | −0.668* | −0.546* | |
Technology Commitment | −0.421 | −0.421 | −0.412 | −0.400 | −0.399 | −0.434+ | −0.406+ | |
Age | −0.033 | −0.033 | x | x | x | x | x | |
Education | −0.194 | −0.194 | −0.191 | −0.188 | −0.194 | x | x | |
Sex | −0.040 | −0.040 | −0.033 | x | x | x | x | |
Self-efficacy (SWE) | −0.254 | −0.254 | −0.271 | −0.277 | −0.264 | −0.238 | x | |
R2adj | 0.076 | 0.153 | 0.217 | 0.272+ | 0.318+ | 0.319* | 0.307* | |
n | 21 |
Note. BDI-II = Beck’s Depression Inventory. PC = percentage change score. RCI = reliable change index. RWT = Regensburger Wortflüssigkeits test. SCC = Subjective Cognitive Concerns. SMI-Q = Subjective Memory Impairment Questionnaire. SWE = self-efficacy expectation.TMT = Trail Making Test. VLMT = Verbaler Lern- und Merkfähigkeits test. WMS VR = Wechsler Memory Scale (German version) subtest Visual Reproduction. For RWT semantic-alternating fluency only baseline performance was a significant predictor (β = −0.476*; R2 = 0.186*). For improvement in visual-spatial functioning (LPS 50+ RCI) only baseline performance was a significant predictor (β = −0.461*; R2 = 0.171*). For improvement in planning abilities (Key Search PC) no significant predictors were identified. +p ≤ 0.10; *p ≤ 0.05; **p ≤ 0.01; ***p ≤ 0.001.