Cognitive Interventions in Healthy Older Adults and People With Mild Cognitive

Ageing Research Reviews 12 (2013) 263 275

Contents lists available at SciVerse ScienceDirect

Ageing Research Reviews

j ourna l ho mepage: www.elsev ier .c

Review

Cognitive interventions in healthy older adults animpair

Jennifer Boxa Department o icht Ub Department o , Maa

a r t i c l

Article history:Received 11 AReceived in reAccepted 17 JuAvailable onlin

Keywords:Systematic revCognitive interventionsHealthy older adultsMild cognitive impairmentRandomized controlled trials

ive inore rervenal. (2er adtudien Aud RC

A total of thirty-ve studies were included; twenty-seven RTCs and eight clinical studies. The contentof the intervention studies differed widely, as did the methodological quality of the included RCTs, butwas considerably low with an average of 44% of the Consort items included. The results show evidencethat cognitive training can be effective in improving various aspects of objective cognitive functioning;memory performance, executive functioning, processing speed, attention, uid intelligence, and subjec-

1. Introdu

The progrowing raof people enand speed odebate whein a normalamong rese2009; Valeninvolving gstimulationtioning, havcognitive ainvestigatedcognitive de

CorresponNeuroscience,MD Maastrich

E-mail add

1568-1637/$ http://dx.doi.otive cognitive performance. However, the issue whether the effects of cognitive interventions generalizeto improvement in everyday life activities is still unresolved and needs to be addressed more explicitlyin future research.

2012 Elsevier B.V. All rights reserved.

ction

portion of older individuals in our western society ispidly (CBS, 2009). As a consequence a larger amountcounter difculties in executive functioning, memory,f information processing (Glisky, 2007). It is an ongoingther such difculties can be postponed or even reverted

aging population, but overall the general held opinionarchers in this eld has been optimistic (Lustig et al.,zuela and Sachdev, 2009). Cognitive training programs,uided practice of specic cognitive tasks, and cognitive

programs, aimed at enhancing general cognitive func-e been offered to prevent or minimize the effects of

ging. The effects of such cognitive interventions were not only in healthy older adults, but also in people withterioration beyond the normal age-dependent changes,

ding author at: Maastricht University, School for Mental Health and Department of Psychiatry and Neuropsychology, PO Box 616, 6200t, The Netherlands. Tel.: +31 43 3881029; fax: +31 43 3884092.ress: [email protected] (J. Reijnders).

for example people with mild cognitive impairment (MCI) (Lustiget al., 2009; Valenzuela and Sachdev, 2009).

In the last decade several reviews have been conducted into theeffects of cognitive interventions in healthy older adults and peoplewith MCI (Valenzuela and Sachdev, 2009; Jean et al., 2010a; Martinet al., 2011; Papp et al., 2009; Tardif and Simard, 2011; Teixeiraet al., 2012). Papp et al. (2009) performed a systematic review withmeta-analytic techniques to analyze randomized controlled trials(RCT) of cognitive interventions in healthy older adults. Ten RCTspublished between 1996 and 2007 were included and analyzedin their review. A mean effect size of 0.16 was found across alloutcome measures. Effect sizes were larger when outcome meas-ures were directly related to type of training. Their conclusionwas that training improves immediate performance on relatedtasks but there was no evidence for generalization effects to over-all cognitive functioning. They also stated that their review waslimited by small and heterogeneous studies with low methodolog-ically quality and more RCTs are needed with sufcient follow-uptime, matched active control groups and outcome measures thatcan show changes in more than one specic domain (Papp et al.,2009). The review of Martin et al. (2011) included, in compari-son to Papp et al. (2009), more studies from both healthy olderadults and MCI populations. A total of thirty-six RTCs were included,

see front matter 2012 Elsevier B.V. All rights reserved.rg/10.1016/j.arr.2012.07.003ment: A systematic review

Reijndersa,, Caroline van Heugtena,b, Martin van f Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastrf Neuropsychology and Psychopharmacology, Faculty of Psychology and Neurosciences

e i n f o

pril 2012vised form 13 July 2012ly 2012e 25 July 2012

iew

a b s t r a c t

Given that the research area of cognitit is important to review and gauge mfor the effectiveness of cognitive interecent systematic reviews of Papp et cognitive interventions in healthy oldological quality of the interventions sand clinical studies published betweeperformed. The quality of the includeom/ locate /ar r

d people with mild cognitive

tela,b

niversity Medical Centre, Maastricht, The Netherlandsstricht University, Maastricht, The Netherlands

tervention studies in the aging population is growing rapidly,cent intervention studies, in order to determine the evidencetions. The purpose of the present review was to update the009) and Martin et al. (2011), to evaluate the effectiveness ofults and people with MCI, by taking into account the method-s. A systematic review of randomized controlled trials (RCT)gust 2007 and February 2012 in Pubmed and PsychINFO wasTs was assessed according to the CONSORT criteria for RCTs.

264 J. Reijnders et al. / Ageing Research Reviews 12 (2013) 263 275

published bing could adults, immthrough tracompared tno longer sistrated the a review of cognitive inteen studieconclusion outcome mand contendifcult to rather difc

Given thgrowing rapinterventioMCI, in ordFig. 1. Selection process of the systematic

etween 1985 and 2007. Only data on memory train-be pooled. Results showed that, for healthy olderediate and delayed verbal recall improved signicantlyining compared to a no-treatment control group. Wheno an active control condition, the improvements weregnicant. For individuals with MCI, the analysis demon-same pattern (Martin et al., 2011). Only quite recently,Tardif and Simard (2011) was published, who reviewedterventions in healthy older adults and included four-s, published between 2001 and March 2011. Theirwas that improvements were observed on at least oneeasure in each study. They also noted that the qualityt of the studies included were very heterogeneous andcompare which made generalization to everyday lifeult (Tardif and Simard, 2011).at the research area of cognitive intervention studies isidly, it is important to review and gauge more recent

n studies in both healthy older adults and people wither to determine the evidence for the effectiveness of

cognitive inthat one shof the studioutcome mtive outcomThe purposeffectivenepeople withological qua

2. Method

A systemwas done iincluded stFebruary 14lier perform2009). Our following te review.

terventions. In doing so, it is important to recognizeould consider the heterogeneity in quality and contentes and interventions and to include not only objectiveeasures (e.g. test performance) but also the subjec-e of such interventions (e.g. cognitive complaints).

e of the present review was therefore to evaluate thess of cognitive interventions in healthy older adults and

MCI, by taking into account the content and method-lity of the interventions studies.

s

atic literature search for cognitive intervention studiesn two databases: Pubmed and PsychINFO. Our searchudies that were performed between August 1, 2007 and, 2012, as we wanted to build on the results of two ear-ed systematic reviews (Martin et al., 2011; Papp et al.,initial search strategy included the intersection of therms: [cognitive intervention OR cognitive training OR

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265Table 1Intervention characteristics of studies in healthy older adults (n = 21).

Study Aim of intervention Intervention Duration Total hours ofintervention

Control group

Bailey et al. (2010) Improving ability to regulatelearning

Training metacognitive skills at home such asself-testing and efcient time allocation

2 weeks manual with lessonsand 4 assignments

NC Waiting list

Basak et al. (2008) To improve executive functions A real-time strategy game (rise of nation) thatcombines the speed of real-time gaming and thecomplexity of strategy games

15 training sessions of 1.5 h45 weeks

22.5 h No training and nocontact

Berry et al. (2010) To improve perceptual abilities Visual cognitive training using the Sweep Seekerprogram (Posit science)

35 sessions per week. Total of10 h training

10 h No training

Borella et al. (2010) To improve performance onWM tasks and generalizationto untrained task

Verbal WM training using the categorization workingmemory span task

3 sessions of 60 min 3 h Active control

Bottiroli and Cavallini (2009) Improve the use of memorystrategies and transfer effectsto non-practiced tasks

Teaching 2 memory strategies and practicing on 3computerized memory tasks which were adapted fromthe neuropsychological training software

3 sessions of 2 h 6 h Waiting list

Buiza et al. (2008) To improve cognitive functionsand quality of life

Cognitive therapy based on Braak and Braaks model ofAlzheimers staging addressing memory, attention,language, visuoconstructive ability, executivefunctions, visuo-motor coordination, and praxis (EG1and 2). In EG1 issues related to well-being werediscussed

2 years, total of 180 session 270 h No training

Buschkuehl et al. (2008) To improve memoryperformance in oldold adults

Computerized WM training 3 months2 sessions per week of 45 min

18 h Active control(physicalintervention)

Carlson et al. (2008) To enhance physical, social,and cognitive activity and, indoing so, exercise memory andexecutive functions

Community-based program Experience Corps to helpelementary school children with reading achievement,library support and classroom behavior

1 year15 h per week

630 h Waiting list

Cavallini et al. (2010) Instruction-based memorytraining to promote transfereffects to other memory tasks

Training in mnemonics (EG1) and in EG2: alsoinstructions how to apply these to other tasks, imageryand sentence generation were practiced

4 sessions of 2 h 8 h No training

Fairchild and Scogin (2010) To improve both objective andsubjective memory

Memory enhancement program addressing objectiveand subjective memory; information about agingprocess; nutrition; mood; controllability of memoryand teaching mnemonics

6 weeks1 session per week of3060 min

6 h Minimal socialsupport

Hastings and West (2009) To improve self-efcacy andmemory performance

Multi-factorial training program centred on increasingself-efcacy, including strategy training, classdiscussions, homework reading and practice exercisesSelf help participants used a manual containing thesame strategy training material and practice exercises

6 sessions of 2 h 12 h Waiting list

Klusmann et al. (2010) To increase cognitiveperformance

Computer course (EG1): creative, coordinative, andmemory tasksPhysical exercise course (EG2): aerobic endurance,strength, and exibility training

6 months75 session of 90 min

112.5 h No contact

McDougall et al. (2010) To increase memoryself-efcacy

Memory training based on cognitive behavioral modelof everyday memory derived from Bandurasself-efcacy theory (SeniorWISE study)

8 sessions and 4 boostersessions

18 h Health promotiontraining

Mozolic et al. (2011) To help people suppressirrelevant auditory and visualstimuli

Individual training program focused on visual andauditory selective attention

8 sessions of 1 h per week 8 h Educational lecture

Noice and Noice (2009) To improve cognitive functionand affective measures

Offering a specic type of novel, stimulating,multi-modal activity: acting course

8 sessions of 1 h2 sessions per week

8 h Waiting listAdditional controlgroup (CG2):singing course

Richmond et al. (2011) To improve performance onWM tasks and generalizationto untrained task

Complex WM training using both a verbal and a spatialWM tasks

45 weeks5 days per week2030 min per day

12.5 h Active control


Tabl

e

1

(Con

tinu

ed)

Study

Aim

of

inte

rven

tion

Inte

rven

tion

Dura

tion

Tota

l hou

rs

ofin

terv

ention

Con

trol

grou

p

Sleg

ers

et

al. (

2008

)

To

impro

ve

the

qual

ity

of

life

ofol

der

adults

Firs

t

trai

nin

g

in

com

pute

r

use

;

during

inte

rven

tion

assign

men

ts

on

the

com

pute

r

and

inte

rnet

Trai

nin

g:

3

sess

ions

of

4

hIn

terv

ention

:

16

assign

men

tsduring

1

year

431

h

CG1:

trai

nin

g,

no

inte

rven

tion

CG2:

no

trai

nin

g,no

inte

rven

tion

CG3:

no

conta

ctSm

ith

et

al. (

2009

)

To

impro

ve

spee

d

and

accu

racy

of

auditor

y

info

rmat

ion

pro

cess

ing

Plas

ticity

-bas

ed

Adap

tive

Cog

nitiv

e

Trai

nin

g

(IM

PACT)

:6

exer

cise

s

with

adju

stin

g

difcu

lty

8

wee

ks5

day

s

per

wee

k1

h

per

day

40

h

Act

ive

control

conditio

n

(gen

eral

cogn

itiv

est

imula

tion

pro

gram

)Ta

lib

et

al. (

2008

)

To

impro

ve

cogn

itiv

eper

form

ance

and

PLA

2ac

tivi

tyM

emor

y

trai

nin

g:

educa

tion

, mnem

onic

stra

tegi

es,

atte

ntion

and, w

orki

ng

mem

ory

exer

cise

s4

sess

ions

of

90

min

6 h

Stan

dar

dou

tpat

ient

care

Tran

ter

and

Kou

tsta

al

(200

8)

To

enhan

ce

uid

inte

llig

ence

per

form

ance

Div

erse

and

nov

el

men

tally

stim

ula

ting

activi

ties

101

2

wee

ks2

h

per

wee

k24

h

Social

grou

pm

eetings

Wes

t

et

al. (

2008

)To

impro

ve

self-e

fca

cy

and

mem

ory

per

form

ance

Multi-fa

ctor

ial t

rain

ing

pro

gram

centred

on

incr

easing

self-e

fca

cy, includin

g

stra

tegy

trai

nin

g,

clas

sdiscu

ssio

ns,

hom

ewor

k

read

ing,

and

pra

ctice

exer

cise

s

6

sess

ions

of

2

h

12

h

Wai

ting

list

NC, n

ot

calcula

ble;

EG, e

xper

imen

tal g

roup;

CG, c

ontrol

grou

p;

WM

, wor

king

mem

ory.

cognitive stimulation OR cognitive rehabilitation OR brain train-ing OR memory training OR mnemonic training] AND [healthyelderly OR older adults OR aging OR mild cognitive impairmentOR MCI]. This search was supplemented by manual search fromthe referenof missing rPapp et al. (used by two

The folloas eligible:study popuMCI, (3) antive and/orif the langusame studywas found original stuassessmentthe original

After thedata indepestudies usinfor random(Schulz et aconsensus wity of the stConsort staheterogenecally pool thmeta-analy

3. Results

3.1. Studies

In Fig. 1 thirty-ve sRTCs and eiseparately. studies incl2010; BasaBottiroli an2008; CarlsScogin, 201McDougall 2009; Rich2009; Talib2008) and ple with Met al., 20092008). Tabltion prograTables 3 anincluding o

3.2. Study c

The numvaried fromThe mean aet al., 2010)carried outtion was uset al., 2008et al., 2010ces of selected articles. In order to minimize the chanceelevant studies we extended the search terms used by2009) and also used a combination of the search terms

earlier reviews (Martin et al., 2011; Papp et al., 2009).wing inclusion criteria were used to identify studies

(1) randomized controlled trial or clinical study, (2)lation consisting of healthy older adults or people withy type of cognitive intervention, and (4) use of objec-

subjective outcome measures. Studies were excludedage was not English. Furthermore, papers based on the

population were excluded. When more than one paperabout a specic data set, only the main paper on thedy data was included for further analysis and quality. If the original study was published before 2007 then

study was also not included. nal selection, two reviewers (JR and MvB) extractedndently and assessed the methodological quality of theg a standardized form of the Consort statement 2010ized controlled trials (www.consort-statement.org)

l., 2010). In case of discrepancies between the two raters,as achieved after discussion. The methodological qual-udies was indicated by the percentage of items of thetement reported in the articles. Given the considerableity of the interventions it was decided not to statisti-e data of the studies in order to perform a quantitativesis.

included

the results of the selection process are shown. A total oftudies were selected for further analysis; twenty-sevenght clinical studies. The clinical studies will be discussedOf the twenty-seven RCTs, twenty-one interventionuded a population of healthy older adults (Bailey et al.,k et al., 2008; Berry et al., 2010; Borella et al., 2010;d Cavallini, 2009; Buiza et al., 2008; Buschkuehl et al.,on et al., 2008; Cavallini et al., 2010; Fairchild and0; Hastings and West, 2009; Klusmann et al., 2010;et al., 2010; Mozolic et al., 2011; Noice and Noice,mond et al., 2011; Slegers et al., 2008; Smith et al.,

et al., 2008; Tranter and Koutstaal, 2008; West et al.,six intervention studies included a population of peo-CI (Barnes et al., 2009; Jean et al., 2010b; Kinsella

; Troyer et al., 2008; Tsolaki et al., 2011; Wagner et al.,es 1 and 2 present the characteristics of the interven-ms (for healthy older adults population and MCI) andd 4 present the characteristics of the included RCTs,utcome measures and effects.

haracteristics

ber of healthy older adults in the experimental groups 13 (Buschkuehl et al., 2008) to 242 (Smith et al., 2009).ge of the study populations ranged from 63.5 (Cavallini

to 80.2 years (Noice and Noice, 2009). All studies were in an experimental setting. A group-based interven-ed in ten studies (Bottiroli and Cavallini, 2009; Buiza; Buschkuehl et al., 2008; Carlson et al., 2008; Cavallini; Klusmann et al., 2010; McDougall et al., 2010; Noice

J. Reijnders et al. / Ageing Research Reviews 12 (2013) 263 275 267

Table 2Intervention characteristics of studies in MCI population (n = 6).

Study Aim of intervention Intervention Duration Total hours ofintervention

Control group

Barnes et al. 1005 da6 w

Jean et al. (2 6 se45 m

Kinsella et a 1.5 5 w

Troyer et al. 10 s120

Tsolaki et al. 60 s90 m3 se

Wagner et a 7 se90 m

and Noice, number of set al., 2010;Fairchild an2011; Slege2008) and studies inclvention (BoWest, 2009

The numied from 11mean age o2008) to 78ies, the inteet al., 2009et al., 2008)(Kinsella et et al., 2008)vention (Baeffectivenesately after (Kinsella etassessment

The totaas can be seanalysis to icould be prtiveness of of signicanmeasures. Winterventiothat in the ship betwethe interven

scrip

le 1 sed

moryput (2009) To improve auditoryprocessing speed and accuracy

Computer-based cognitivetraining developed by PositScience Corporation

010b) To re-learn face-nameassociations

Training in face-nameassociations using botherrorless learning and spacedretrieval paradigm andpsycho-educational sessionson memory

l. (2009) Memory rehabilitation, topractice memory strategies foreveryday problems

Practice in memory strategies(internal and external),strategies for improvingorganisational and attentionalskills and general copingstrategies

(2008) Multidisciplinary group-basedintervention to changeeveryday memory behavior

Practice and application ofmemory strategies andeducation about lifestyle:nutrition, recreation andrelaxation

(2011) Holistic cognitiverehabilitation program to coverthe needs and deciencies ofpatients with MCI

Practice of attention andparameters of executivefunction; enhancement ofmental imagery, episodic,semantic, autobiographical andvisual memory;relaxation techniques

l. (2008) To analyze everyday situationswith memory problem andtrain specic strategies

Practicing prospective memoryand structured processing ofnew information related toreal-life situations

2009; Talib et al., 2008; West et al., 2008), the sametudies used an individually based intervention (Bailey

Basak et al., 2008; Berry et al., 2010; Borella et al., 2010;d Scogin, 2010; Mozolic et al., 2011; Richmond et al.,rs et al., 2008; Smith et al., 2009; Tranter and Koutstaal,one study used both (Hastings and West, 2009). Five

3.3. De

Tabperforming meby comuded follow-up data, up till one year after the inter-rella et al., 2010; Buschkuehl et al., 2008; Hastings and; Slegers et al., 2008; Smith et al., 2009).ber of people with MCI in the intervention groups var-

(Jean et al., 2010b) to 104 (Tsolaki et al., 2011). Thef the study populations ranged from 53.7 (Wagner et al.,

years (Kinsella et al., 2009). In four (out of six) stud-rventions were carried out in a clinical setting (Barnes; Kinsella et al., 2009; Tsolaki et al., 2011; Wagner. A group-based intervention was used in four studiesal., 2009; Troyer et al., 2008; Tsolaki et al., 2011; Wagner, whereas two studies used an individually based inter-rnes et al., 2009; Jean et al., 2010b). In two studies thes of the intervention was not only assessed immedi-the intervention but also after three or four months

al., 2009; Troyer et al., 2008). In one study a follow-up was planned (Wagner et al., 2008).l hours of intervention varied widely between studies,en in Tables 1 and 2. We performed a linear regressionnvestigate whether the effectiveness of the interventionedicted by the total hours of intervention. The effec-an intervention was calculated by dividing the numbert outcome measures by the total number of outcomee found no signicant effect between total hours of

n and intervention effect (R2: 0.016, p = 0.54), indicatingincluded studies there was no dose response relation-en total hours of intervention and the effectiveness oftion.

2008; Richmtask (Borellof memory2010; Taliblessons (Faies aimed atraining proa memory theory (Mccognitive fu(Klusmann tive cognititraining (Buet al., 2008this, single ing metacoby a real-timby training intelligence2008). Ten seleven usedtion of an insessions (Bo

Table 2 in people wory performKinsella et aet al., 2008 min/dayys/weekeeks

50 h More passive computeractivities

ssions ofin

4.5 h Training in face-nameassociations using errorlesslearning paradigm andpsycho-educational sessionson memory

h/weekeeks

7.5 h Waiting list

essions of min

20 h Waiting list

essions ofin

ssion/week

90 h Waiting list

ssions ofin

10.5 h No training

tion of interventions

hows the characteristics of the interventions that werein healthy older adults. Eleven studies aimed at improv-

performance; four studies addressed working memoryerized training (Berry et al., 2010; Buschkuehl et al.,

ond et al., 2011) or training of the categorization span

a et al., 2010); four studies provided training of the use strategies (Bottiroli and Cavallini, 2009; Cavallini et al.,

et al., 2008), accompanied with psycho-educationalirchild and Scogin, 2010) and the other three stud-t improving memory self-efcacy by a multifactorialgram (Hastings and West, 2009; West et al., 2008) or

training program derived from Banduras self-efcacyDougall et al., 2010). Six studies aimed at improvingnctioning in general by providing a computer courseet al., 2010; Slegers et al., 2008), a plasticity-based adap-ve training (Smith et al., 2009), a multifactorial cognitiveiza et al., 2008), a community-based program (Carlson) or an acting course (Noice and Noice, 2009). Besidesstudies aimed at improving learning abilities by train-gnitive skills (Bailey et al., 2010), executive functioning

e strategy game (Basak et al., 2008), attentional skillsa selective attention task (Mozolic et al., 2011) and uid

by novel stimulating activities (Tranter and Koutstaal,tudies used an active control condition, where the other

a waiting list or no training control group. The dura-tervention varied between 3 hourly sessions up till 180rella et al., 2010; Buiza et al., 2008).

shows the characteristics of the interventions assessedith MCI. Most interventions aimed at improving mem-ance by training memory strategies (Jean et al., 2010b;l., 2009; Troyer et al., 2008; Tsolaki et al., 2011; Wagner), accompanied with psycho-education on memory

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Table 3Study characteristics of intervention studies in healthy older adults (n = 21).

Study Sample size(EG/CG)

Mean age(year)

Intervention Follow-up Outcome measures of interest Signicant effect forexperimental groupd

Bailey et al. (2010) 29/27 Range 6089 Metacognitive trainingat home

Post-intervention Self-paced memory taskExperimenter-paced memory task

+0

Basak et al. (2008) 20/20 69.1/70.0 Strategy-basedreal-time videogame

Post-intervention Operation spanTask switchingN-back taskVisual short-term memoryRavens Advanced Progressive MatricesStopping taskFunctional eld of viewAttentional blinkEnumerationMental rotation

0++++0000+

Berry et al. (2010) 15/15 71.9 Perceptualdiscrimination training

Post-intervention Trained perceptual taskUntrained perceptual taskWM/delayed recognition paradigm NIWM/delayed recognition paradigm IS

+++0

Borella et al. (2010) 20/20 69.0/69.2 Verbal WM training Post-interventionand 8 monthsfollow up

Visuospatial WM (dot matrix task)Short-term memory (digit span)Inhibition (stroop color task)Processing speed (pattern comparisontask)Fluid intelligence (Catells Culture Fair)

++++ (also at FU)+ (also at FU)

Bottiroli and Cavallini(2009)

21/23 66.2/66.1 Computer-basedmemory training

Post-intervention Figure list recognitionWord list recognitionFace-name learningPlace-word learningPaired associated recall

+++++

Buiza et al. (2008) 85/68/85a 74.4 Cognitive therapyEG1: Cognitiveintervention andwell-beingEG2: cognitive therapy

Post-intervention Immediate memoryRecent logic execution memoryShort-term memoryWorking memoryLearning potentialVisomanual coordinationMotor executionPhonetic uencyCapacity for abstractionPraxis

+ (for EG1)00+ (for EG1)+ (for EG1)0000+ (for EG1)

Buschkuehl et al.(2008)

13/19 80.1 Computerized WMtraining

Post-interventionand 1 year FU

Visual free recallVerbal free recallDigit spanBlock span

+00+

Carlson et al. (2008) 70/58 70.1/68.4 Community-basedprogram

At 4 and 8 months Word list memoryTrail Making TestRey-Osterrieth Complex gure testPsychomotor speed

+++0

Cavallini et al. (2010) 27/24/29a 65.8/63.566.0

Memory trainingEG1: training inmnemonicsEG2: training inmnemonics andinstructions

Post-intervention Associate learning (practiced task)List learning (practiced task)Text learningPlace learningName-face learningGrocery list learning

+ (EG1 = EG2)+ (EG1 = EG2)+ (EG2 > EG1)000

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269

Fairchild and Scogin(2010)

28/25 72.4 Memory enhancementprogram

Post-intervention Names and Faces taskAppointment Keeping taskMultifactorial Memory QuestionnaireObject Misplacement taskTarget Complaints Methodology

+0+++

Hastings and West(2009)

99/45/41a 70.9 Memory trainingEG1: group-based EG2:self help

Post-intervention(only performancemeasures) and 1month FU

Memory Self-Efcacy QuestionnaireMetamemory in Adulthood (3 subscales)-locus of control-anxiety-achievementName recallStory recallShopping list recall

+ (for EG1 at FU)

+ (EG1 and EG2, at FU)00+ (EG1 and EG2, also at FU)+ (EG1 and EG2, also at FU)0

Klusmann et al. (2010)e 92/91/76a 73.6 Computer course (EG1)and physical exercisecourse (EG2)

Post-intervention Rivermead Behavioral Memory TestFree and Cued Selective Reminding TestVerbal uencyStroop testTrail Making TestSubjective ratings of-memory-concentration-exibility-physical health-physical well-being

+ (EG1 and EG2)+ (due to worsening in CG)00+ (due to worsening in CG)

+ (EG1)+ (EG1)0+ (EG2)0

McDougall et al. (2010) 135/130 75 Memory training At 2, 6, 14 and 26months

Mini-Mental State ExamHopkins Verbal Learning Test revisedBrief Visuospatial Memory TestRivermead Behavioral Memory TestDirect Assessment of Functional StatusMemory Self-Efcacy QuestionnaireSpielberger State-Trait Anxiety InventoryCenters for Epidemiologic Studies ScaleMetamemory in Adulthood

+ (only at 2 months)0000000+

Mozolic et al. (2011) 33/33 69.4 Modality specicattention training

Post-intervention Selective attention task (cross-modal)Selective attention task (within-modality)Multisensory integration taskSymbol Digit Modalities TestWalk and talk paradigmLetter n-back testStroop testTrail Making TestHopkins verbal learning testProle of Mood StatesHealth status Questionnaire

+0+++000000

Noice and Noice (2009) 42/40/40b 80.2/82.7/81.6 Multi-modal activitiesin college acting classesEG: acting courseCG1: no interventionCG2: singing course

Post-intervention Word list recallDelayed word list recallCategory FluencyDigit SpanStory Recall TaskProblem SolvingSelf-reported Personal Growth

Memory Controllability InventoryLifestyle Activities Questionnaire

++0+ (only EG compared toCG1)+0 (improved in EG andCG2)00

270J.

Reijnders

et al.

/ A

geing Research

Review

s 12 (2013) 263 275

Table 3 (Continued)


Mean age(year)

Intervention Follow-up Outcome measures of interest Signicant effect forexperimental groupd

Richmond et al. (2011) 21/19 66 Verbal and spatial WM training Post-intervention Reading spanDigit span forwardDigit span backwardRavens Advanced Progressive MatricesTest of everyday attentionCVLT: total correctCVLT: repetitionsCVLT: intrusionsSelf-reports: memorySelf-reports: attention

+00000+0++

Slegers et al. (2008)f 60/49/55/40c Range 6475 Computer training and InternetUsageEG: training and interventionCG1: training, no interventionCG2: no training, no interventionCG3: no contact

Post-intervention and 12 monthsFU

Short-Form Health Survey (SF-36)Loneliness questionnaireSymptom Check List 90Development and activity (self-report)Instrumental Activities of Daily LivingBelief in External Control ScaleMastery ScaleComputer useVisual verbal learning testMotor choice reaction time testLetter digit substitution testConcept shifting testStroop color word testCognitive Failure Questionnaire

00000000000000

Smith et al. (2009) 242/245 75.6/75.0 Computerized cognitive training Post-intervention and 3 months FU RBANS (auditory memory and attention)Rey Auditory Verbal Learning TestRivermead Behavioral Memory TestDigit span backwards testLetter-number sequencingProcessing speedCognitive Self-Report Questionnaire

++ (also at FU)0++ (also at FU)+ (also at FU)+

Talib et al. (2008) 11/12 67.8/67.3 Memory training Post-intervention Prose recallList recallWAIS digit symbolNumber of underlined words in short textCategorization measure

+0+0+

Tranter and Koutstaal(2008)

22/22 67.8 Mentally stimulating activities Post-intervention Catells Culture Fair (uid intelligence)WAIS-R blocks (Spatial perceptual test)

++

West et al. (2008) 42/42 69.9 Group-based memory training Post-intervention at week 6 andweek 9

Memory Self-Efcacy QuestionnaireMetamemory in Adulthood (3 subscales)-locus of control-anxiety-achievementName recallStory recallShopping list recallDigit symbol substitution testStrategy checklisteffective strategy use

+

+00++00+

EG, experimental group; CG, control group; N, number of patients; FU, follow-up; WM, working memory; NI, no interference task; IS, interrupting stimulus task; RBANS, Repeatable Battery for the Assessment of NeuropsychologicalStatus; CVLT, California Verbal Learning Test.

a Two experimental groups.b Two control groups.c Three control groups.d +, positive effect for experimental group; 0, no difference between groups; , negative effect for experimental group.e Subjective measures reported in Klusmann et al. (2011).f Objective outcome measures reported in Slegers et al. (2009).


Table 4Study characteristics of intervention studies in MCI population (n = 6).


Mean age(year)

Intervention Follow-up Outcome measures of interest Signicant effect forexperimental groupa

Barnes et al.

Jean et al. (2

Kinsella et a

Troyer et al.

Tsolaki et al.

Wagner et a

MCI, mild cognMMQ, Multifa

a +, positiveb Improved

(Jean et al., 2tional skillsaimed at imcognitive tran active colist or no trvaried betw2011).

3.4. Outcom

In the tour analysiobjective menteen studafter the intfollowing taing memoret al., 2010;et al., 2011;(Bottiroli anand Cavallinory and lea(Carlson et (2009) 22/25 74 Computer-basedauditoryprocessing speedtraining

Post-intervention

010b) 11/11 68.5 Training inface-nameassociations

Post-interventionat 1 and 4 weeks

l. (2009) 22/22 78 Strategy training(memory,attention, andorganisationalskills)

Post-interventionat 2 weeks and 4months

(2008) 24/24 75.4 Memory strategiestraining andlifestyle education

Post-interventionand 3 months

(2011) 104/72 67 Cognitiverehabilitation

Post-interventionprogram

l. (2008) 33/40 53.7 Behavioral analysisand memorystrategy training

Post-interventionand follow upplanned

itive impairment; EG, experimental group; CG, control group; N, number of patients; RBActorial Memory Questionnaire; MoCA, Montreal Cognitive Assessment.

effect for experimental group; 0, no difference between groups; , negative effect for exin both groups.

010b), lifestyle (Troyer et al., 2008), or practice of atten- (Kinsella et al., 2009; Tsolaki et al., 2011). One studyproving processing speed by using a computer-basedaining program (Barnes et al., 2009). Two studies usedntrol condition, where the other four used a waitingaining control group. The duration of an interventioneen 5 and 20 weeks (Kinsella et al., 2009; Tsolaki et al.,

e measures and effects

wenty-one RCTs in healthy older adults included ins, the most commonly used outcome measure wasemory performance (twenty studies) (Table 3). In sev-ies, memory performance was signicantly improvedervention. Signicant differences were observed on thesks; self-paced memory task (Bailey et al., 2010), work-y tasks (Basak et al., 2008; Berry et al., 2010; Borella

Buiza et al., 2008; Buschkuehl et al., 2008; Richmond Smith et al., 2009; Talib et al., 2008), recognition taskd Cavallini, 2009), face-name learning tasks (Bottirolii, 2009; Fairchild and Scogin, 2010), immediate mem-rning potential (Buiza et al., 2008), word list recallal., 2008; Cavallini et al., 2010; Noice and Noice, 2009),

name recallrecall (CavaNoice, 2009ioral Memothe AssessmRey Auditostrategy usies, measurve studiesswitching (et al., 2010)Complex Fities Test (Met al., 2011)In three stuwere obserTranter andces (Basak on attentionsensory intfor AssessmIn two studwas observstudy a meRBANSCalifornia verbal learning testBoston naming testTrial making testVerbal uencyDesign uencySpatial span

0000000

Face-name associationsCalifornia verbal learning testDementia Rating ScaleMini Mental State ExaminationRivermead Behavioral Memory TestSelf-esteem scaleMultifactorial Memory Questionnaire

0b

000000b

Prospective memoryMMQ-abilityMMQ-strategyMMQ-contentmentStrategy knowledge repertoire

+000+

Memory ToolboxMultifactorial Memory QuestionnaireImpact rating scaleLifestyle importanceName recallNumber recallWordlist recall

+000000

Mini Mental State ExaminationMontreal Cognitive Assessment

++Functional Cognitive Assessment ScaleMoCA (verbal memory)Rey-sterrieth Complex Figure TestMoCA (Clock drawing)Functional Rating Scale of Symptomsof Dementia

+++++

Appointment testLogical memory ILogical memory IIMemory assessment clinicsquestionnaire

+0++

NS, Repeatable Battery for Assessment of Neuropsychological Status;

perimental group.

(Hastings and West, 2009; West et al., 2008), story/textllini et al., 2010; Hastings and West, 2009; Noice and; Talib et al., 2008; West et al., 2008), Rivermead Behav-ry Test (Klusmann et al., 2010), Repeatable Battery forent of Neuropsychological Status (Smith et al., 2009),

ry Verbal Learning Test (Smith et al., 2009), memorye (Talib et al., 2008; West et al., 2008). In eight stud-es of executive functioning were included, of which

showed signicant effects on the following tasks; taskBasak et al., 2008), Stroop Color Word Task (Borella, Trail Making Test (Carlson et al., 2008), Rey-sterriethgure Test (Carlson et al., 2008), Symbol Digit Modali-ozolic et al., 2011), walk and talk paradigm (Mozolic, uency and problem solving (Noice and Noice, 2009).dies, signicant improvement on (uid) intelligence testved; Catells Culture Fair (Bottiroli and Cavallini, 2009;

Koutstaal, 2008), Ravens Advanced Progressive Matri-et al., 2008). In two studies, signicant improvemental tasks were observed; selective attention task, multi-

egration task (Mozolic et al., 2011), Repeatable Batteryent of Neuropsychological Status (Smith et al., 2009).ies, signicant improvement in speed of processinged (Borella et al., 2010; Smith et al., 2009). In oneasure of general cognitive functioning (Mini Mental


State Examination) was included as an outcome measure and sig-nicantly improved by the intervention (McDougall et al., 2010).Subjective measures of cognitive performance were included inve studies. Signicant effects were observed for the Multifacto-rial MemorMisplacemeEfcacy QueMetamemoet al., 2010tionnaire (Sfunctioninget al., 2010et al., 2008)

All six Rused objectfour studiesinterventioon the follomemory st2008), verbet al., 2011memory (Wfunctioningscale was s(Tsolaki et afunctioningformance, mthe Montrethe intervenmeasure of Memory Quon this scasure of dailDementia)

3.5. Method

The meassessed. Tincluded st(Table 5). Thological quathe lowest qseven catemethods-ramation. In methods-rthan 50% of

3.6. Non-ra

Eight noolder adults2010) and 2008; HampLondos et a

In healthmemory pmemory trtransfer tasTwo studieSchmiedek ronment inand workinreports as obrain traini

Nintendo Wii and reading sessions which showed practice-relatedimprovement but no signicant transfer effects.

In people with MCI, two studies focused on improving adap-tive behavior and functional ability. Greenaway et al. (2008)

d imppored ced acreas

focg or

effeos eon ptioneme, and

cussi

s systerved thas aspce, eence

bethetere mce aimilaa montiove oategt al., ntio-eduoging muehfocusest, 2unctre, aing

ddit, theetwesed ing (>e and thaformtentiann eposiermer, tal excompprov

anclitatiy Questionnaire (Fairchild and Scogin, 2010), Objectnt task (Fairchild and Scogin, 2010), Memory Self-stionnaire (Hastings and West, 2009; West et al., 2008),ry in Adulthood (Hastings and West, 2009; McDougall; West et al., 2008), and Cognitive Self-Report Ques-mith et al., 2009). In two studies, measures of daily

(Direct Assessment of Functional Status (McDougall) and Instrumental Activities of Daily Living (Slegers) were included, but no signicant effect were observed.CTs in the MCI population included in our analysisive memory performance as an outcome measure: in

memory performance signicantly improved after then (Table 4). Signicant improvements were observedwing tasks; prospective memory (Kinsella et al., 2009),rategy knowledge (Kinsella et al., 2009; Troyer et al.,al memory (Montreal Cognitive Assessment) (Tsolaki), appointment test (Wagner et al., 2008) and logicalagner et al., 2008). In two studies measures of executive

were included; the functional cognitive assessmentignicantly improved by the intervention in one studyl., 2011). In three studies, a measure of general cognitive

was included. In only one study general cognitive per-easured with the Mini Mental State Examination and

al Cognitive Assessment was signicantly improved bytion (Tsolaki et al., 2011). In three studies, a subjectivecognitive performance was included, the Multifactorialestionnaire, although no signicant effects were foundle. In one study a signicant improvement on a mea-y functioning (Functional Rating Scale of Symptoms ofwas observed (Tsolaki et al., 2011).

ological quality of study

thodological quality of the twenty-seven RCTs washe percentage of the Consort items reported in theudies ranged from 16% to 73%, with an average of 44%e study of Smith et al. (2009) had the highest method-lity (73%), while the study of Wagner et al. (2008) haduality (16%). The Consort statement can be divided into

gories: title/abstract; introduction; methods-trial;ndomization; results; discussion; and other infor-ve of these categories (title/abstract, methods-trial,andomization, results, and other information) less

the items was reported.

ndomized controlled trials

n-RCTs were included; three clinical studies in healthy (Ackerman et al., 2010; Li et al., 2008; Schmiedek et al.,ve clinical studies in people with MCI (Greenaway et al.,stead et al., 2008; Joosten-Weyn Banningh et al., 2008;

l., 2008; Ozgis et al., 2009).y older adults, one study aimed at improving working

erformance by computerized training. The workingaining showed improvements on practiced and nearks but no effects on far transfer tasks (Li et al., 2008).s aimed at improving cognitive functioning in general.et al. (2010) provided an internet-based training envi-cluding tasks of perceptual speed, episodic memory,g memory. They used only self-report evaluationutcome measures. Ackerman et al. (2010) provided ang environment including training sessions with the

showeory suprovidincreasand instudiestraininrelatedof Londbilitatioccupaimprovmance

4. Dis

Thitive inshowevariouformanintelligparisonof the outcomformanused strated interveobjectiory strTalib eof attepsychoand ScworkinBuschkgrams and Wutive fmeasuimprov2008).

In astudiesonly baddresity ratipositivshoweof perand atKlusmhad a the RivHowevphysicMCI, a no imperformrehabiprovement in functional ability by the use of a mem-t system and Joosten-Weyn Banningh et al. (2008)ognitive behavioral group therapy which resulted incceptance and marital satisfaction in people with MCIed awareness in their caregivers. The results of twousing on memory improvement (by memory strategy

spaced retrieval memory training) showed practice-cts (Hampstead et al., 2008; Ozgis et al., 2009). The studyt al. (2008) examined the effect of an established reha-rogram designed to improve cognitive performance,al performance, and quality of life. The results showednts in cognitive processing speed, occupational perfor-

some domains of quality of life (Londos et al., 2008).

on

tematic review, evaluating the effectiveness of cogni-ntions in healthy older adults and people with MCI,t cognitive interventions can be effective in improvingects of objective cognitive functioning; memory per-xecutive functioning, processing speed, attention, uid, and subjective cognitive performance. A critical com-ween different intervention studies is difcult becauseogeneity of the intervention programs and the choseneasures. Most intervention studies used memory per-s the primary outcome measure, but only few studiesr tests to measure memory functioning which frus-re quantitative meta-analysis on these studies. Differentn programs proved to be effective in improving eitherr subjective memory performance; training of mem-ies (Bottiroli and Cavallini, 2009; Cavallini et al., 2010;2008; Wagner et al., 2008), accompanied with practicenal skills (Kinsella et al., 2009; Tsolaki et al., 2011),cational lessons on memory and/or lifestyle (Fairchild, 2010; Troyer et al., 2008); computerized training ofemory task (Berry et al., 2010; Borella et al., 2010;l et al., 2008; Richmond et al., 2011); and training pro-ing on memory self-efcacy or metacognition (Hastings009; McDougall et al., 2010; West et al., 2008). Exec-ioning was mostly included as a secondary outcomend only two intervention programs aimed directly atexecutive functioning (Basak et al., 2008; Carlson et al.,

ion to the heterogeneity of the included intervention methodological quality of the studies differed vastly:en 16% and 73% of the quality criteria items weren the studies. When assessing studies with a high qual-60% of the Consort quality criteria), we observed bothd negative results. The study of Smith et al. (2009)t computerized cognitive training led to improvementance generalizing to untrained measures of memoryon and subjective everyday functioning. The study oft al. (2010) showed that a 6-month computer course

tive affect on memory performance (measured withead Behavioral Memory Test) in healthy older adults.he same improvement was achieved with a 6-monthercise course (Klusmann et al., 2010). In people withuter-based auditory processing speed training showed

ements on memory, executive, or general cognitivee (Barnes et al., 2009). However, a 5-week memoryon program focusing on practicing memory strategies


Table 5Quality assessment of included studies using the Consort statement 2010.

Title, abstract(max. 2)

Introduction(max. 2)

Methods-trial(max. 9)

Methods-randomization(max. 8)

Results(max. 10)

Discussion(max. 3)

Other information(max. 3)

Total (%) score(max. 37)

Barnes et al.Jean et al. (2Kinsella et aTroyer et al. Tsolaki et al.Wagner et aBailey et al. Basak et al. (Berry et al. (Borella et al.Bottiroli and

(2009)Buiza et al. (Buschkuehl

(2008)Carlson et alCavallini et aFairchild and

(2010)Hastings and

(2009)Klusmann etMcDougall eMozolic et aNoice and NRichmond eSlegers et alSmith et al. (Talib et al. (2Tranter and

(2008)West et al. (2

Total for cat 11

did show imknowledge

Anotheraddressed igroup receiWith an actattention alooking at tan active comeasures ofunctioning(Borella et a2010; McDo2009; RichmTranter andincluded anthese two s2009; Jean interventioconcluded ton various ationing in h

An impowhether obfunctioningtioning, or lA number oalization tofunctioningCavallini, 20Richmond e(ADL) meas

ant From (2009) 2 2 5 5 010a) 1 2 5 4 l. (2009) 2 2 5 5 (2008) 1 2 4 4

(2011) 1 2 2 2 l. (2008) 0 2 3 0 (2010) 0 1 4 12008) 0 2 5 1 2010) 0 1 4 2

(2010) 0 2 4 2 Cavallini 1 1 4 2

2008) 1 1 3 0et al. 0 2 3 1

. (2008) 1 2 5 2 l. (2010) 0 1 3 2

Scogin 0 2 1 3

West 0 2 4 1

al. (2010) 2 2 6 6t al. (2010) 0 2 4 3 l. (2011) 1 2 4 4 oice (2009) 0 2 4 2 t al. (2011) 0 2 4 2 . (2008) 1 2 5 4 2009) 1 2 5 7 008) 0 2 3 1 Koutstaal 0 2 3 1

008) 0 2 2 1

egory (%)15 (28%) 49 (91%) 104 (43%) 68 (31%)

provements on prospective memory task and strategyrepertoire (Kinsella et al., 2009).

signic2009). aspect of methodological quality, not specicallyn the Consort Statement items, is whether the controlved an active control intervention or no intervention.ive control condition the effects of, for example, socials part of group meetings can be controlled for. Whenhe RCTs in the healthy older adults, ten RCTs includedntrol condition. These studies did show an effect onf cognitive functioning, more specically executive, speed, attention, and subjective memory functioningl., 2010; Buschkuehl et al., 2008; Fairchild and Scogin,ugall et al., 2010; Mozolic et al., 2011; Noice and Noice,ond et al., 2011; Slegers et al., 2008; Smith et al., 2009;

Koutstaal, 2008). In the MCI population, two studies active control group. The interventions executed intudies did not show any signicant effect (Barnes et al.,et al., 2010b). In conclusion, evaluating the results ofn studies with an active control condition, it may behat cognitive interventions can have a positive effectspects of both objective and subjective cognitive func-ealthy older adults, but not in people with MCI.rtant question that was raised in earlier reviews isserved training effects on various aspects of cognitive

generalize to untrained tasks or overall cognitive func-ead to functional improvement in daily life situations.f studies specically addressed the question of gener-

untrained task or to subjective experience of cognitive (Berry et al., 2010; Borella et al., 2010; Bottiroli and09; Buschkuehl et al., 2008; Fairchild and Scogin, 2010;t al., 2011; Smith et al., 2009). Activities of Daily Livingures were included in three intervention studies and a

evidence foand daily liinterventiostill needs t

Anotherthe rootingFollow-up They showeremained apositive effafter 1 monory and spepositive effmonths (Boup did notSlegers et aing effects c

In compet al. (2011ies were incmore elabogating the However, oearlier reviSimard, 201reviews, is ting to the Cquality of into accounand interim5 3 2 24 (65%)5 2 1 20 (54%)6 3 1 24 (65%)6 2 0 19 (51%)2 1 0 10 (27%)1 0 0 6 (16%)3 3 1 13 (35%)6 3 1 18 (49%)4 1 1 13 (35%)3 3 0 14 (38%)4 1 0 13 (35%)

0 2 1 8 (22%)4 3 1 14 (38%)

5 3 1 19 (51%)2 2 1 11 (30%)6 3 1 16 (43%)

3 3 1 14 (38%)

6 3 1 26 (70%)5 2 2 18 (49%)4 3 1 19 (51%)6 2 1 17 (46%)3 3 1 15 (41%)5 3 1 21 (57%)8 3 1 27 (73%)3 1 1 11 (30%)5 3 1 15 (41%)

3 3 1 12 (32%)

3 (42%) 64 (79%) 24 (30%) 44%

effect on ADL was observed in one study (Smith et al., these data it can be concluded that there is very little

r generalization effects to overall cognitive functioningfe situations. The issue whether the effects of cognitivens generalize to improvement in everyday life activitieso be addressed more explicitly in future research.

important question is whether there is evidence of of training effect after the training period has ended.data were available in seven out of twenty-six RCTs.d that positive effects on memory strategy knowledge

fter 3/4 months (Kinsella et al., 2009; Troyer et al., 2008),ects on memory self-efcacy and recall tasks preservedth (Hastings and West, 2009), positive effects on mem-ed preserved after 3 months (Smith et al., 2009), andects on speed and uid intelligence preserved after 8rella et al., 2010). Two studies including a 1-year follow

nd any signicant effects (Buschkuehl et al., 2008;l., 2008). From these data it can be concluded that train-an be preserved at least for a couple of months.arison to the earlier reviews of Papp et al. (2009), Martin) and Tardif and Simard (2011), more intervention stud-luded in this review. This could be the results of usingrated search terms or an increase in studies investi-effect of cognitive interventions in the last few years.ur conclusions are in line with the conclusions of theseews (Martin et al., 2011; Papp et al., 2009; Tardif and1). A strength of this study, in comparison with earlierhe methodological quality rating we performed accord-onsort Statement 2010 for RCTs. The methodological

the twenty-seven RCTs differed considerably. Takingt that some items (such as blinding, serious harms,

analysis) are less applicable for non-pharmacological


interventions, it seems clear that substantial improvement in termsof study quality can still be made in future intervention studies. Inthis review we included intervention studies from both healthyolder adults and MCI populations. Although a clear differentiationbetween thmal versus cannot be cwith MCI bolder adultsis that due outcome mmeta-analyble publicathe results

4.1. Conclu

The reseffective intioning; mespeed, atteformance. Astudies is dtion prograthe heterogodological qthe effects oeveryday lifmore explica core set othe effectivobjective andomains (emeasures tshould be pthe methodimproved btained in thdesign and follow up a

Source of f

This stunition (NIBResearch (N

Conict of

We decl

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Cognitive interventions in healthy older adults and people with mild cognitive impairment: A systematic review1 Introduction2 Methods3 Results3.1 Studies included3.2 Study characteristics3.3 Description of interventions3.4 Outcome measures and effects3.5 Methodological quality of study3.6 Non-randomized controlled trials

4 Discussion4.1 Conclusions

Source of fundingConflict of interestReferences

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Cognitive Interventions in Healthy Older Adults and People With Mild Cognitive