Cognitive training with older adults: Intervention, rehabilitation, and engagement approaches

1. Cognitive training with older adults: Intervention, rehabilitation, and engagement approaches Michael Marsiske Department of Clinical and Health Psychology University of Florida

2. Workshop • Review • Summary and critical comparisons • Demonstrations • Limited ability • Exposition of data needs and request for community input

3. Overview • Review of the theoretical bases for much of the cognitive intervention research to date will be offered.  • Differing approaches to intervention (intervention, rehabilitation, and engagement) will be compared. • Review of cognitive intervention findings will be offered, with an emphasis on the magnitude, durability, and transfer of training effects. • Brief process-oriented review of several common training approaches will be offered

4. Objectives By the end of the workshop, participants will be able to • describe the major theoretical underpinnings of several approaches to cognitive enhancement with older adults, including intervention, rehabilitation, and engagement; • summarize the major findings of extant cognitive training studies; and • understand the content and process of several major training approaches currently available for older adults. 

5. Some definitions • The broad term linking much of what will be discussed today is either “enhancement” or “enrichment” • The idea is to unify a broad body of approaches (most still confined to experimental proof of concept, rather than clinically validated or commercially available) that aim to improve cognitive performance in older adults • These approaches have mostly been evaluated in adults free of dementia (and usually free of MCI) • They constitute, conceptually, more of a “prevention” and “early intervention” approach rather than rehabilitation

6. Some definitions • Medical rehabilitation: • “The process of restoration of skills by a person who has had an illness or injury so as to regain maximum self-sufficiency and function in a normal or as near normal manner as possible. For example, rehabilitation after a stroke may help the patient walk again and speak clearly again. “ (www.medterms.com) • Rehabilitation may not the right model for normal aging, or even for gradual-progressive onset disorders • Relatively scant evidence, from a rehabilitation perspective, for normal aging and MCI

7. Normal Mild Cognitive Impairment Dementia Mayo’s notion of a “Cognitive Continuum” Source: Peterson

8. Memory rehabilitation in MCI Much of the other extant research has been focused on memory compensation (i.e., notebooks, calendars)

9. Memory rehabilitation in MCI • Feasibility study with 24 older individuals suggested that 20/24 participants could adhere to the curriculum • An RCT is under way. Intervention includes • Multiple modules for different internal, external, and social strategies • Orientation, acquisition, practice with feedback, homework using a workbook

10. The goals of cognitive training research have changed • A central premise here is that the goals of this research have evolved—as much for public health reasons as because of the goals of investigators—to examining cognitive interventions as prevention and rehabilitation approaches • The problem: The empirical research has not caught up with the rhetoric

11. Core premises • If you work with adults, you have a steadily increasing probability of encountering clients in the second half of the life span • Cognitively, it is important to understand the backdrop of normal (cognitive) changes before conducting any cognitive assessment

12. Core premises • Cognitive issues also need be considered as one considers treatment plans, ways of communicating information with older clients • It is important to use information to work against stereotypical conceptions of cognitive aging • It is important to recognize the substantial plasticity of cognition, even into very old age

13. Evolution of Research Trends • Trend 1: Identifying declines/losses in function • Lasted until the mid 1950s • Trend 2: Establishing stability as well as decline • Mid 1950s-1960s • Trend 3: Modifying age differences • 1970s • Establishing experiential & social influences • Trend 4: Modifiability of cognitive performance • Current • New methods of measurement • Expansion of definitions

14. Core questions of the field • Directionality • Gains, losses, and/or maintenance • Universality • Effects of individual differences • Reversibility • Interventions & experiences promoting improvement/recovery Dixon & Cohen, 2003

15. Scaffolding Theory of Aging and Cognition • Protective mechanism for cognition in aging population • Response to decline in normal function of fluid mechanics/intelligence Park & Reuter-Lorenz, 2009

16. Scaffolding Theory of Aging and Cognition • Creation and utilization of supplemental neural pathways • Or, reactivation of rudimentary pathways in response to challenge • May allow the aging adult to maintain high level of functioning • Illustrated by both loss of specificity and lateralization of functional blood flow in the aging brain Park & Reuter-Lorenz, 2009

17. Scaffolding Theory of Aging and Cognition Park & Reuter-Lorenz, 2009

18. A global model of enrichment of late life cognition

19. A global model of enrichment of late life cognition Hertzog et al, 2009

20. A global model of enrichment of late life cognition Hertzog et al, 2009

21. Areas for consideration today

22. Strategy training

23. Domains of focus • Major foci: • Reasoning • Memory • Attention/speed of processing • Since the 1970s, a large body of research has investigated the modifiability of several kinds of reasoning in adults aged 65 and older

24. 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.

25. 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. q

26. What is memory? • One common task: Episodic list recall desk ranger bird shoe stove mountain glasses towel cloud silver lamb gun pencil church fish

27. What is “attention/speed of processing”? • There are many definitions • One that we’ll consider today is ‘Useful Field of View’

28. Restriction of the Useful Field of View

29. Useful Field of View

30. Useful Field of View “Speed”. This test determines the fastest speed at which you can identify whether the central target (which flashes quickly) is a car or a truck. The minimum (best) score is 16 ms; the maximum score is 500 ms—because the system TIMES OUT. If it takes you longer than half a second, the system quits on you.

31. Useful Field of View “Divided attention”. This test determines the fastest speed at which you can identify whether the central target (here: car) AND identify the location of a “peripheral” target (here: say 2 o’clock). Again, scores reflect the fastest speed at which you achieve 75% accuracy, and will range from 16 ms (limits of the system) to 500 ms (time out).

32. Useful Field of View “Selective attention”. This test determines the fastest speed at which you can identify whether the central target (here: car) AND identify the location of a “peripheral” target (here: say 2 o’clock) in visual clutter. Again, scores reflect the fastest speed at which you achieve 75% accuracy, and will range from 16 ms (limits of the system) to 500 ms (time out).

33. Reasoning training

34. 5-10 strategy sessions, 2x week Immediate “Posttest” Assessment Additional delayed posttests Baseline “Pretest” Assessment No contact • Ranging from • 1 wk • 1 month • 6 months • 7 years randomization Prototypical design of reasoning training studies

35. Evaluative criteria • We typically evaluate these studies by three criteria • Magnitude of effect • Breadth of effect (training transfer) • Durability of effect

36. Reasoning training • Participants have tended, at enrollment, to be young, healthy older adults

37. Defining “breadth” (transfer) • The outcome battery is typically constructed in a transfer hierarchy, with “nearest” transfer measures closest to the content of training (and therefore most likely to show effects) • Example: Figural Relations • Near-near transfer: ADEPT Figural Relations • Near-fluid transfer: Culture Fair Test • Far-fluid transfer: Letter Sets, Letter Series,… • Far non-fluid transfer: Vocabulary, Identical Pictures, everything else Waning effects expected

38. Reasoning training: Magnitude and breadth • The earliest studies showed significant improvement due to training, although effects were quite narrow. Target of training: Figural Relations Source: Plemons, Willis, & Baltes, 1978

39. Reasoning training: Magnitude and breadth • Training effects are usually highly specific (i.e. seen only for tests of the specific ability trained) Target of training: Figural Relations Source: Willis, Blieszner, & Baltes, 1978

40. Reasoning training: Magnitude and breadth • The earliest studies showed significant improvement due to training, although effects were quite narrow. Target of training: Inductive Reasoning or Spatial Orientation Source: Willis & Schaie, 1994

41. Reasoning studies: Durability • In most studies, the obtained training effects, though highly specific, appear to last for very long times

42. Reasoning studies: Durability and “booster” interventions • Willis and Nesselroade found that pre-post gains were similar when subjects were, on average, 70 years old and again 7 years later. Moreover, there appeared to be some “residual” benefit (about 0.4 S.D.) of training 7 years later • Willis and Schaie revisited their Seattle Longitudinal Study subjects seven years after their first training

43. Other interventions

44. Other targets of intervention: Memory • Memory • This line of research tends to be more age comparative, and to feature a wide diversity of tasks and mnemonic strategies to be trained • Many examples of training effectiveness (Rebok, Rasmusson & Brandt, 1996; Greenberg & Powers, 1987; Scogin, Storandt, & Lott, 1985; Yesavage, 1985; Kliegl, Smith & Baltes, 1990) • Verhaeghen, Marcoen & Goosens (1992) meta-analysis: Pretest to posttest effect size for mnemonic training groups (0.73 SD units) was twice that of placebo groups (0.37 SD units) or control groups (0.38 SD units).

45. Other targets of intervention: Memory • Memory (continued) • Verhaeghen, Marcoen & Goosens (1992) meta-analysis: Treatment gains were largest when • training was conducted in a group • additional memory–related intervention (such as using external memory aids or motivation enhancement) was provided • sessions were relatively short • participants were younger

46. Substantial word recall gains for older adults: But age-related limits as well Berlin Method of Loci studies; Baltes, Kliegl, Smith, Lindenberger

47. Reasoning studies: Durability and “booster” interventions • Memory (continued) • Durability results mixed • Maintained effects have been detected from 1 week to six months (Scogin, Storandt, & Lott, 1985; Flynn & Storand, 1990; Sheikh, Hill & Yesavage, 1986; Stigsdotter & Backman, 1989; Stigsdotter Neely, & Backman, 1993; West & Crook, 1992) • Other studies have failed to find maintenance (Scogin & Bienias, 1988; Schmitt, Murphy & Sanders, 1981; Wood & Pratt, 1987) • Neely and Backman (1995), using a more complex “multifactorial” memory training program, found that trained subjects showed maintenance gains extending to 3.5 years.

48. Visual attention training • An exception to “limited transfer” may be the Useful Field of View, a measure of speeded visual attention • Participants must perform both central perceptual tasks (identify an object) and note the location of an eccentric/peripheral visual target • Here, we seem to see transfer to driving related outcomes

49. Summary of pre-1996 findings • The literature has been very clear that cognitive training with older adults, when that training is focused on the enhancement of specific intellectual abilities, produces effects • of substantial magnitude, • that generalize to multiple markers of the trained ability, • that can be very durable, and • are typically very specific to the ability trained

50. What we didn’t know • Are findings laboratory specific? • Are positive benefits most likely for European American, advantaged older adults? • Does participant status, especially mental status, matter? • Is the durability of different cognitive interventions non-equivalent? • Do these interventions matter? Is there any way we might see transfer to everyday life?