Brain Training to Keep Dementia at Bay: Buyer Beware

Deborah Brauser

November 21, 2014

Growing evidence suggests brain training may help maintain cognition and lower dementia risk, resulting in the rise of a billion dollar brain training industry. However, new research examining the efficacy of such programs suggests not all are created equal and that it may be a case of buyer beware.

A meta-analysis of 51 randomized clinical trials (RCTs) that included more than 4800 older participants showed that group-based brain training under the supervision of a trainer was significantly more effective for overall cognition, memory, and processing speed than self-directed, home-based training programs.

"Our results send a key message to the public. They show that brain training carried out in a center can improve cognition in older adults, but commercial products promoted for solo training use at home just don't work. There are better ways to spend your time and money," senior author Michael Valenzuala, PhD, associate professor and leader of the Regenerative Neuroscience Group at the Brain and Mind Research Institute (BMRI) at the University of Sydney, Australia, said in a release.

In addition, training one to three times per week was effective, but more than that appeared to neutralize benefits.

"The brain's plastic mechanisms may saturate if training is too frequent. Like strenuous physical exercise, we recommend at least one rest day between training sessions," lead author Amit Lampit, postdoctoral research fellow at BMRI, said in the same release.

"The brain may need a rest day between rigorous exercise, much like the body," Dr Lampit told Medscape Medical News.

The study was published online November 18 in PLoS Medicine.

Pop-up "Industry"

It is estimated that by 2050, 100 million individuals worldwide will have developed dementia. With new research suggesting that brain training can help maintain cognition and lower dementia risk, a whole "brain training industry" has popped up, investigators note.

"There has been a lot of controversy about cognitive training and whether it can improve cognition in older adults," said Dr Lampit.

"We felt that both the public and scientific discussion was not well informed enough and based more on opinions than hard evidence. As a result, the marketing had got ahead of the science. And we felt scientific discussion was becoming reactionary," he added.

The researchers sought to "quantitatively assess" whether computerized cognitive training (CCT) can improve cognition in a systematic analysis.

They examined data on 51 RCTs published through July 2014, which included 4885 adults aged 60 years or older (60% women) who did not have dementia or other impairments. All studies assessed effects of at least 4 hours of CCT on cognitive performance (n = 2527) vs a control group (n = 2358).

CCT consisted of standardized computer tasks or video games on personal computers, mobile devices, or gaming consoles in a home (n = 19) or group setting (n = 32).

The RCTs were conducted in the United States (n = 25), Europe (n = 16), Canada (n = 3), and Australia (n = 2), as well as Israel, China, Taiwan, the Republic of Korea, and Japan (n = 1 each).

Dr Lampit noted that he was surprised to have found so many RCTs on this topic. "This allowed us to investigate many questions that have not been addressed before."

Results showed a "small but significant" overall effect on cognition for CCT vs control interventions (P < .001).

In addition, "small to moderate effect sizes" were shown for improved nonverbal and verbal memory (P = .002 and .02, respectively), working memory (P < .001), processing speed (P = .002), and visuospatial skills (P = .01).

There was no significant association between CCT and improvements in executive function or attention.

Not a Magic Bullet

When examining CCT delivery modes, group-based training was significantly more effective for overall cognitive performance compared with home-based administration (Hedges g, 0.29 vs .09, respectively; P < .001).

Group-based training was also more effective for processing speed, nonverbal memory, visuospatial skills (all, P < .01), and working memory (P < .05).

Training in which one (P < .001) or two to three sessions per week (P < .001) were administered showed a significant effect, but those in which more than three sessions per week were administered did not.

"It is possible there is a maximal dose for CCT, after which factors such as cognitive fatigue may interfere with training gains," write the investigators.

The 25 studies that examined both frequency and delivery mode showed a significant improvement in cognitive performance for patients who underwent group-based CCT for two or three sessions per week (P < .001).

Finally, there was no significant efficacy for training that specifically focused on working memory and only weak evidence for training that lasted less than 30 minutes per session.

"We now understand how to prescribe brain training based on the highest standards of medical evidence," said Dr Valenzuela.

However, "this is not a magic bullet. We still don't know if this type of activity can prevent or delay dementia. Much more research is needed," he added.

Uncertain Evidence Base

Druin Burch, from the Public Library of Science in Cambridge, United Kingdom, writes in an accompanying editorial that the findings show that CCT is "modestly effective" in this patient population, which is a valuable conclusion to both academics and to companies who sell these types of training programs.

"CCT has a market approaching a billion dollars a year and an uncertain evidence base," writes Dr Burch.

He notes, however, that although improvement from group-based CCT "may approximate an average relative improvement of 1 point on the Mini–Mental State Examination," none of the outcome measures were based on actual daily living activities.

Dr Burch adds that the meta-analysis was also limited by the time frame used to assess for changes and that the investigators could not evaluate whether these changes persisted.

"Valenzuela and colleagues show effects that are statistically significant but uncertain in their impact on human capacity and performance," he writes.

"Does a billion-dollar gap exist between our knowledge about 'standardized computerized tasks with clear cognitive rationale' and the industry selling them? Valenzuela and colleagues' overview of the evidence for CCT...suggests it does," writes Dr Burch.

"It makes clear what remains to be discovered and suggests promising lines of inquiry. Their paper is of use to those planning thoughtful research in the field."

Dr Valenzuela has reported receiving research funding and honoraria from the Brain Department LLC for a project unrelated to the current meta-analysis and that the Regenerative Neuroscience Group receives "in-kind research support in the form of no-cost software" from BrainTrain Inc. Dr Burch reported no relevant financial relationships other than being a consulting editor for PLoS Medicine.

PLoS Med. Published online November 18, 2014. Article, Editorial

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