Merits of late life cognitive training: Findings, controver - PowerPoint Presentation

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Merits of late life cognitive training: Findings, controversies, and a way forward

Michael Marsiske

Department of Clinical & Health Psychology

University of Florida

February 7, 2017Slide2

With thanksSlide3

The premise

Cognitive training with older adults

started

as a “proof of concept”Challenge the notion of irreversible decline in information processing abilities Strong evidence of durable effects led to an interest in whether training gains could matter

Can we boost independence? Well being?There have been some misstepsSlide4

The story

With whom are we intervening?

What is fueling the growth?

What are the historical findings?

What is the controversy?Is there no evidence of transfer?The way forwardSlide5

With whom are we intervening?Slide6

Normal aging

Normal

Mild Cognitive

Impairment

Dementia

Source: PetersonSlide7

Normal aging

Park et al

infographic

retrieved from http://gizmodo.com/5495086/this-is-your-faulty-brain-on-a-microchipSlide8

Why intervene?

Hertzog et al, 2009Slide9

What is fueling the growth?Slide10

Popular interestSlide11

Emergence of the “brain training” industry

By 2010!

Brain

Age I and IIBig Brain Academy

PositscienceM*PowerLumosityHappy NeuronBrain TrainerMind Habits

Brain BuilderVigorous MindAARPSlide12

Emergence of the “brain training” industry

Research was actually not the proximal stimulus for the emergence of many “brain training” programs

Demographic change, and the emergence of a (computer-savvy) “Baby Boomer” market, along the ability to offer web-delivered adaptive training, were chief drivers.

But when the marketing of health-related claims outstrips research….Slide13

What are the historical findings?Slide14

How did we get here? Origin story…

Trend 1

: Identifying declines/losses in function

Lasted until the mid 1950sTrend 2: Establishing stability as well as declineMid 1950s-1960s

Trend 3: Modifying age differences1970sEstablishing experiential & social influencesTrend 4: Modifiability of cognitive performanceCurrentNew methods of measurement Expansion of definitionsSlide15

How did we get here? Origin story…

Major foci:

Reasoning

Memory

Attention/speed of processingSince the 1970s, a large body of research has investigated the modifiability of several kinds of reasoning in adults aged 65 and olderSlide16

What is reasoning?

Figural Relations

: Identify the pattern in the upper box, and pick which of the answer choices would best complete the question mark.Slide17

What is reasoning?

Inductive Reasoning

: Identify the pattern among the series of letters, and then decide what would come next in the series

a m b a n b a o b a

?

1. a

2. b

3. o

4. p

5. qSlide18

What is memory?

One common task: Episodic list recall

desk

ranger

bird

shoe

stove

mountain

glasses

towel

cloud

silver

lamb

gun

pencil

church

fishSlide19

What is attention/speed of processing?

There are many definitions

One that we’ll consider today is ‘Useful Field of View’Slide20

Restriction of the Useful Field of ViewSlide21

Useful Field of ViewSlide22

Prototypical design of cognitive training studies

Baseline

“Pretest”

Assessment

5-10 strategy sessions, 2x week

No contact

Immediate

“Posttest”

Assessment

Additional delayed posttests

randomization

Ranging from

1 wk

1 month

6 months

7 yearsSlide23

Pre-ACTIVE studies, in a nutshell

They worked!

Reasoning gains strong (about 0.5 SD more improvement than untrained controls), and lasted up to 7 years – no “transfer” though

Memory training widely found to be successful, especially in small group format, but seldom lasted even 2 years – no “transfer” though

UFOV training very strong, with evidence of transfer to other complex visual attention tasks, self-reported and simulated drivingSlide24

ACTIVE 1996 and paradigm shift

The design of the ACTIVE trial was largely pre-specified by the National Institute on Aging and the National Institute of Nursing Research in RFA-AG-96-001.

Three major emphases of the request for applications were

common multi-site intervention protocolsa focus on everyday independence and the cognitive components of functional competence as primary outcome measuresinterventions

on proximal outcomes at the level of basic cognitive abilities, rather than directly at the level of the primary outcome measures. Slide25

ACTIVE 1996 and paradigm shift

The resultant ACTIVE study differed from prior cognitive training research in several ways:

multisite, randomized controlled, single-blind trial

analytical approach is intent-to-treat, thereby including all randomized participants rather than only those compliant with the intervention, as in prior research in this fieldit includes primary outcome measures of everyday functioning the study sample is more socioeconomically and racially diverse than in prior intervention studiesSlide26

ACTIVE

University of Alabama-Birmingham

Karlene Ball PhD

Hebrew SeniorLife Boston

John Morris PhDRichard Jones ScD

Indiana UniversityFredrick Unverzagt PhDJohns Hopkins UniversityGeorge Rebok PhDPennsylvania State University

Sherry Willis PhD

University of Florida/Wayne State UniversityMichael Marsiske PhDNew England Research Institutes, Coordinating CenterSharon Tennstedt PhDNational Institute on Aging

Jonathan King PhDNational Institute of Nursing Research Susan Marden PhDSlide27

ACTIVESlide28

ACTIVE

Ineligible Not-Randomized Randomized

N 855 1,312 2,832

Women 77% 79% 76%

Age, years: mean (sd

) 75 (9) 75 (7) 74 (6)Oldest old, age 85+ 15% 9% 5%Non-white 42% 40% 27%Slide29

ACTIVE

mean (sd) = 27.3 (2.0)Slide30

ACTIVE

Source:

Morris et al., 2000Slide31

ACTIVESlide32

ACTIVE

10-year Trajectory of Memory, Separately by Training GroupSlide33

ACTIVE

10-year Trajectory of Reasoning, Separately by Training GroupSlide34

ACTIVE

10-year Trajectory of Speed of Processing , Separately by Training GroupSlide35

Corpus on 2/6/2017, 333 articles

Exploding fieldSlide36

What is the controversy?Slide37

The controversySlide38

The controversySlide39

The FTC fineSlide40

Important concept: Transfer (breadth)

A key issue of shared interest in both the Stanford Statement and the rebuttal was the issue of

transfer

Does cognitive training generalize to important real world outcomes?Is the generalization from cognitive training as strong as from other intervention approaches (e.g., exercise)?Slide41

Important concept: Transfer (breadth)

Transfer of training?Slide42

Brain training as a vehicle for specificity/depth, not breadth?

For well over a century, we have know that training effects tend to be narrow and specific,

not

general

Woodworth, R. S., & Thorndike, E. L. (1901). The influence of improvement in one mental function upon the efficiency of other functions.(I).

Psychological review, 8(3), 247.Slide43

Thurstone’s Law of Identical ElementsSlide44

Brain training as a vehicle for specificity/depth, not breadth?

It’s a ubiquitous problem

School trained mathematics do not automatically generalize to real-world financial or consumer competence

Physical skill learning (e.g., strength training) does not automatically generalize to improved everyday functioning in older adults (Manini)Slide45

OwensSlide46

Transfer: Educational theory

First principles of education (demonstration, application, integration)

Part/whole

instructional models (start simple, build in complexity, practice out of school)

Cognitive flexibility (use many, different, real world scenarios; switch things up)Situated learning, cognitive apprenticeship, anchored instruction.Reflection and metacognitionT

hreshold concepts (“you can’t unsee after that”)Slide47

Transfer: High road vs. low road

Salomon & Perkins,

1988

Low-road transfer Develop some skills to automaticity (typing, driving); you don’t have to think about them

High-road transfer Engage in analysis and identification of strategies that cut across situations; e.g., using a highlighter when readingEmphasizes key informationTrains a habit of mind to look for key ideas or main conceptsSlide48

Transfer: What does it mean in a declining population? Time course?

Since the transfer concept was really developed in educational and occupational contexts, the idea was that training would have

short term payoff

in terms of improved performance on meaningful outcomesBut with older adults, do we

really expect that improving your memory, for example, will quickly yield improved everyday performance?Is the expectation even improvement? Or is it maintenance or reduced decline?Slide49

Is there no

evidence of transfer?Slide50

Build on successes

Plus, there is evidence that

If we conceptualize transfer as reduced decline, not gain, and

We are willing to wait a really long time (no less than three years, and up to ten years)we may actually see transfer to real world outcomes we care aboutSlide51

ACTIVE

10-year Trajectory of Self-Reported IADL Difficulty, Separately by Training GroupSlide52

ACTIVE

State reported crashes over 10 years

Ross, Edwards & Ball, 2013Slide53

The way forwardSlide54

The way forward

Improve the design of training studies

Leverage the specificity of training

Training dosages need to be adequate for transfer

Focus on the “right” outcomesAugment cognitive trainingSlide55

1. Improve the design of training studies

Simons, D. J., Boot, W. R., Charness, N.,

Gathercole

, S. E., Chabris, C. F., Hambrick

, D. Z., & Stine-Morrow, E. A. (2016). Do “brain-training” programs work?. Psychological Science in the Public Interest, 17(3), 103-186.Slide56

1. Improve the design of training studies

“Based on this examination, we find extensive evidence that brain-training interventions improve performance on the trained tasks, less evidence that such interventions improve performance on closely related tasks, and little evidence that training enhances performance on distantly related tasks or that training improves everyday cognitive performance.

“Slide57

1. Improve the design of training studies

Chief recommendations:

Double-blind controlled trial

Pre-registrationIntent-to-treat

Report on all measured outcomesMake trial data available for secondary analysisCost-effectiveness (“opportunity cost”Placebo controls; measure expectationsAcknowledge conflict of interestUse psychometrically sound distal outcomesSlide58

1. Improve the design of training studiesSlide59

1. Improve the design of training studies

Multiple concerns in the resulting systematic review

Concluded that cognitive training was the

only area of prevention science with even moderate quality evidenceConcerns about selective attrition in long-term studies

Concerns about limited “diffusion” of results (i.e., transfer)Slide60

1. Improve the design of training studies

ACTIVE conceptual model

0.5

0.5

0.5 x 0.5 = 0.25Slide61

1. Improve the design of training studies

ACTIVE conceptual model

0.2

0.2

0.2 x 0.2 = 0.04Slide62

2. Leverage the specificity of training

What is the way forward for training?

One important issue is re-framing

Rather than expect areas of skills training, like memory, to have broad and general effects, one important issue is to understand that perhaps memory training ought to be “prescribed” to help deal with focal memory concernsSlide63

2. Leverage the specificity of training

What is the way forward for training?

One important issue is re-framing

Rather than expect areas of skills training, like memory, to have broad and general effects, one important issue is to understand that perhaps memory training ought to be “prescribed” to help deal with focal memory concernsSlide64

3. Training dosages need to be adequate for transfer

A rationale for the computer- and home-based brain training programs is the idea of extending dosages.

When you think about the durability of ACTIVE findings, it is actually remarkable when we think about

how little we demanded of participantsSlide65

3. Training dosages need to be adequate for transfer

Nobody says “here are 10 hours of physical exercise, then stop”

In ACTIVE, over a 5 week period, participants in original training spent up to 900 minutes in training

That represents just 1.8% of the available time during that period.

Over the ten year period, even those who received booster spent just 0.003% of time in trainingEducation, rehabilitation science, and physical exercise science all tell us that dosages must be continuous, ongoing, protracted, and embedded into everyday lifeSlide66

3. Training dosages need to be adequate for transfer

But….

Just practicing for more time seems to potentially make gains

narrower (Allaire

& Marsiske; low road transfer makes you automatic at just one thing)Slide67

EngagementSlide68

EngagementSlide69

Engagement

150 older adults randomized to receive either

“Senior Odyssey”

(n=87; teams solve long-term ill structured problems from the disciplines of literature, science and technology, civil engineering, and history, like building a structure out of balsa wood) or

testing-only control

(n=63)Slide70

Engagement

Useful Field of View is improved by first-person shooter video games in college-aged players (but not by

Tetris

)Slide71

Engagement

Basak

, Boot, Voss & Kramer (2009)

Video game group: 23.5 hours of training (n=20)

No contact control group

Trained participants improved more than the control participants in executive control functions, such as task switching, working memory, visual short-term memory, and reasoning.Slide72

“The Videogame study”

Computerized training

Tetris

Medal of HonorSlide73

“The Videogame study”Slide74

“The Videogame study”Slide75

REVIVA

With Patricia

Belchior

Crazy Taxi

Computer training

Posit Science Road Tour

Funded by the Robert Wood Johnson Foundation

ControlSlide76

REVIVA

With Patricia

BelchiorSlide77

3. Training dosages need to be adequate for transfer

An exciting area for development comes from advances in neuroscience

If we can understand the functional activation patterns of an outcome task of interest, and

If we can understand the functional activation patterns associated with training related improvementWe can target training to focus on those skills and abilities that seem more germane to the outcome

A “modern” approach to trying to identify Thorndike’s “identical elements”Slide78

4. Focus on the “right” outcomes

Function

Mood

Quality of LifeMeta-cognition

Chandler, Park, Rotblatt, Marsiske, Smith (2016)Slide79

4. Focus on the “right” outcomes

Wolinksy

et al. (ACTIVE Study)

Locus of controlSubjective healthDepression symptoms

Health related quality of lifeSlide80

5. Augment cognitive training

Exercise and executive control

Mindfulness

Working memory training?

But, none of these studies have shown everyday transfer!Slide81

5. Augment cognitive trainingSlide82

5. Augment cognitive training

ACT Study

Augmenting Cognitive Training

Adam Woods, Ronald Cohen, Michael Marsiske

Univ. of Florida/Miami/ArizonaSlide83

5. Augment cognitive training

The ability to offer extended dosages and computer-based adaptive training includes:

Can do now

Train multiple thingsTrain each at their baseline level, and then adaptively ramp upNot yet available

At higher levels of mastery, include complex real world tasks that require the coordination of multiple trained skillsSlide84

In summarySlide85

In summary

Cognitive training interventions with healthy older adults have substantial and durable effects

on the targets of trainingEvidence for transfer has been limited so far, but so have dosages and training paradigmsSlide86

In summary

The next big goals for this field are to:

(

a) ground more heavily in the neuroscience implied by Thorndike; (b) generally improve design;

(c) extend the cognitive “diversity” of trained participants; (d) re-imagine training paradigms that are extended in dosage and situated in real-world tasksSlide87

Questions?

For further information, copies of reprints, or to request a copy of this talk

Michael Marsiske

marsiske@phhp.ufl.edu(352) 273-5097