George Rebok, PhD, conducted one of the largest studies to date looking at how cognitive training affects older adults. Rebok, a professor at the Center on Aging and Health at Johns Hopkins School of Public Health, talks about the study findings, commercially available brain training, and what he recommends for brain health.Q: You conducted a large study that looked at brain training in older adults. What was the impact of the training?
The study you refer to is the ACTIVE study, which is an acronym for Advanced Cognitive Training for Independent Vital Elderly. It is the largest cognitive intervention study that’s ever been done here in the U.S., or anywhere else from what I know.
We targeted three different abilities – memory, reasoning and speed of processing — that are known to decline with age, and that we also know underlie a lot of the everyday activities that we carry out. So the idea with ACTIVE was to target these different abilities to see if we could improve them, and by improving them, then if your everyday abilities skills would improve.
We had over 2,800 participants nationwide at six different sites around the country, and they were randomized into one of four conditions: either one of the interventions –memory, reasoning or speed – or to a control condition, where all they got was measurements over time. They did not receive any training.
What we found was I think very encouraging and also somewhat surprising … all three intervention groups showed significant improvement, both immediately after training, and it lasted up through 5 years for all three groups. We did a 10-year post-training assessment, and (improvements in) two of the three conditions – reasoning and speed of processing — were still significant after 10 years. People who had this modest amount of training – the training only lasted over 10 sessions over a 5 to 6- week period– produced these long-term benefits. It seemed like there was a protective effect there, that it helped people from declining cognitively.
People who did the memory training were doing better, but it wasn’t significant at 10 years. So that was the first major finding, that we had the effects for the training on these cognitive skills.
The second thing is that the training generalized to everyday skills and abilities. At 10 years, all three groups reported less difficulties carrying out their everyday activities of daily living — for example, managing their medications, or managing their finances, or preparing meals – these kinds of everyday activities that help us remain independent .
The average age to begin with at baseline was about 74 years. At 10 year follow up, these people were well into their 80s, so everybody was experiencing more difficulty carrying out everyday activities of daily living, but the intervention groups reported less difficulty relative to the controls. There was some kind of protection there from having had this kind of training.
Q: You mentioned there was a more modest effect on memory. Can you talk about that?
The reason for that is a bit unclear. It could just be we needed more than 10 sessions to really train all of these multiple strategies to a point where people were able to use them automatically and well. But that said, memory still resulted in a significant effect even at 5 years post-intervention, which is in itself pretty remarkable. Even at 10 years, the memory group still reported less difficulty carrying out their everyday activities. So even though the effects on memory per se at 10 years weren’t significant, people still felt that something that they had gained from training and maybe strategies they learned that they then applied after the training.
Q: Is the training you studied in this trial similar to products people might find on the commercial market?
There may be some similarities – there have not been head to head comparisons between training programs like Lumosity and the types of training that we did. The training we did in ACTIVE was based on a theory of cognitive aging, and we had these carefully sequenced steps in terms of learning different strategies, and being able to practice the strategies. It was a highly structured program carried out over a series of sessions.
What we don’t know about Lumosity and other commercial training programs is how long-lasting these effects are that they claim to get with these training programs, and they haven’t been able to show that the training makes you better at any skills that really matter other than getting better on the specific skills you’re being trained on.
So that’s a problem with a lot of cognitive training and cognitive exercises where if you do crossword puzzles all the time, what you get good at is doing crossword puzzles. You may become an expert, but that doesn’t necessarily mean it’s going to affect other areas of functioning that might be important to you.
I think you have to look at these commercial training programs in the context of how people are using them. Are they going to continue to use them? Will they tire of them after a while? How do you keep them interested in doing these programs? It’s like physical exercise where you sign up for a training program and you’re all gung ho to begin with, but your enthusiasm tends to wane over time. I think there are also opportunity costs. People think that if they do these things for hours and hours on end every day, that somehow they’re going to improve their cognition, become more intelligent or whatever. Well, it’s probably not quite that simple, and what aren’t you doing when you’re doing all of these exercises online? You might not be exercising, socializing – doing other things that could also benefit your cognition.
And frankly, a lot of the commercial programs – some of them are very good, some of them probably not so good. There’s a lot of variation and a lot of hype and claims being made about their effects, and for most of them there’s just not a lot of solid evidence that they work, that they work for everyone, that their effects last a long time and that they generalize outside the actual training that’s being done.
Q: Have you tried a lot of these commercially available products that are out there, and what do you think?
I have tried some of them. The exercises in some way are similar to what’s being done in the scientific literature, but I think a lot of them train on a very limited set of skills. In terms of really engaging my interest for the long run, they really don’t do that. I tend to think of cognitive improvement more contextually in that you have to think of the whole context of improvement — not only doing cognitive training, but getting enough exercise, eating a balanced diet, getting enough sleep, maintaining social relationships. All of those things are very important to being able to maintain in our cognitive vitality as you get older.
A lot of these programs are starting to claim – and there’s just not a shred of evidence that I know (of) for this – is that they somehow prevent dementia, or that they stop you from getting Alzheimer’s disease. I don’t think that there’s any evidence for that out there, and I think that they’re really overstating their data by even suggesting that somehow if you do these programs that you’re going to prevent dementia. There’s just no evidence for that at this point.
Q: Where do you think cognitive training holds the most promise?
We’re going to see continued interest in developing other cognitive training programs, and refining the ones that have already been developed. This has become a multi-million dollar industry, and I don’t see any change to that. I think that the research is going to become more refined, and we need better designed studies to really draw definitive conclusions. There’s a lot of confusion out there on the part of consumers of these programs, and even within the research community. How well do these programs work? How long do these effects last? Does this training matter in any meaningful way to my life? Do these programs prevent dementia? I think a lot of these questions are still unanswered, and I think we’re going to see more research directed at these questions, and hopefully we’ll soon start seeing some answers.
There’s no doubt that this area is just a boom area right now, and by every indication, it’s going to continue to increase, and not just training with older people. Up and down the lifespan you see interest in cognitive training now with children, and (in) young and middle adulthood. Training isn’t just for old people worried about Alzheimer’s disease. It’s not just for certain age groups. I think it’s something for all people.
I think it’s going to go the way of personalized medicine, where training becomes more individualized. It’s not one size fits all, it’s going to be more sort of personalized programs that are really matched to your level of ability and motivation and personality. We’re really going to be able to much better fit the cognitive training to individuals or groups of individuals instead of saying, ‘Go out and buy this program and hope it works for you.’
Q: What do you think the next big area of study is for cognitive training for older adults?
We need to understand how training done over months and years is going to affect people. Most of the interventions that are done now are small-dose interventions.
I don’t think we really know yet what the upper bounds of training are. How much will people tolerate if they do this training over a year or two years or whatever? What difference will it make ultimately? I think that’s going to be one big area, sort of seeing what the limits of this training are, and can we push those limits?
It gets into this notion of plasticity and elasticity and how much is really potentially possible with this kind of training, and I don’t think we really know that yet. We see some improvements, sometimes they’re fairly modest, but the training has been modest too.
The other big area is what we might call multi-modal training. So we combine training modalities. So rather than just doing cognitive training, we combine cognitive training with physical exercise, or pharmacotherapy, or nutraceuticals, or some kind of combined intervention where we’re not just training or targeting a specific cognitive skill or set of skills, but we’re really kind of coming at it from kind of a systems levels.
I think that’s really going to be the wave of the future – these kinds of combined interventions or multi-modal interventions. It’s very complex, it’s hard to design studies to test those, you need a lot of people, it’s very expensive, but I think more and more, you’re going to see that just one type of training approach alone isn’t going to really do it. It’s got to be looked at as a package.
Q: Are there proven steps we can take to either prevent memory loss or improve cognitive abilities? What sort of programs are out there that consumers can take advantage of?
People have to educate themselves about what’s out there. When you’re looking at any cognitive training program, if it’s commercially available, you have to look to see who developed it, what their credentials are, is there an evidence base for that program. Have the results been replicated several times?
A lot of times when they make claims about these programs it’s based on one single study, or the people who developed the program have very few credentials in that area. Just being a knowledgeable consumer, looking at the background and really digging into the training program will be very helpful.
Thinking about more broadly how you can continue to challenge yourself cognitively and physically and socially as you get older to maintain your health is going to be very important, and not just relying on training programs to undo decades and decades of poor eating habits or lack of exercise.
Thinking of what you can do, not just in terms of training, but in terms of developing an exercise routine, maintaining your friendship network, challenging yourself daily cognitively. Rather than reaching for the calculator all the time to maybe do some calculations – trying to do those things mentally. Or trying to memorize the names of clerks at stores you shop at as kind of a cognitive exercise, trying to remember your license plates.
There’s just a number of ways on a daily basis we can challenge ourselves, and I think that becomes very important, particularly as we get older and our abilities do change.
Finding opportunities to stay meaningfully engaged as we get old — if we’ve retired, OK, what’s going to replace the cognitive stimulation you got with work?
We have this program that we’ve done research on called Experience Corps that has older volunteers working with school children for 15 or more hours per week over a school year and we found that that kind of very high impact volunteering can really improve people’s cognition and well-being. They’re not getting specific brain-training exercises, but they are very stimulated, they’re engaged with the curriculum, they’re engaged with the children, and that’s very mentally stimulating for people. They seem to do better.
Seeking out opportunities like that, volunteer opportunities that might offer that degree of challenge, I think is also very important.
Q: Any final thoughts?
I think the jury is still out on a lot of these questions. There’s not strong evidence that behavioral interventions prevent dementia at this point. That’s going to be a high-priority area for the future. I think you’re going to see some really rapid developments over the next few years in this area, and it’ll be interesting to see what happens.
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