1. Cognitive Enhancement in Older Adults Michael Marsiske Monday, May 6th, 2013, from 12:00 PM – 1:00 PM HPNP Building - Classroom 1101

2. Objectives Learning Objectives: At the conclusion of this presentation, participants should be able to: 1.Understand the trajectories of normal cognitive aging, and various approaches to cognitive enhancement in older adults 2.Appreciate the current state of knowledge regarding the effectiveness of various intervention approaches 3.Recognize critical data needs for next-generation cognitive enhancement research and clinical practice

3. Disclosure Dr. Marsiske has received research support from Posit Science, Inc., in the form of site licenses for cognitive training programs for different research projects. Relevant research slides will be flagged

4. Normal cognitive aging Horn, J. L., & Cattell, R. B. (1967). Age differences in fluid and crystallized intelligence. Acta psychologica, 26, 107-129.

5. Normal cognitive aging Park, D. C., Lautenschlager, G., Hedden, T., Davidson, N. S., Smith, A. D., & Smith, P. K. (2002). Models of visuospatial and verbal memory across the adult life span. Psychology and aging, 17(2), 299-320.

6. Normal cognitive aging Park et al infographic retrieved from http://gizmodo.com/5495086/this-is-your-faulty- brain-on-a-microchip

7. Normal cognitive aging Schaie, K. W. (1996). Intellectual development in adulthood: The Seattle longitudinal study. Cambridge University Press.

8. Normal cognitive aging Baltes, P. B., Staudinger, U. M., & Lindenberger, U. (1999). Lifespan Psychology: Theory and Application to Intellectual Functioning. Annual Review of Psychology, 50, 471-507.

9. Normal cognitive decline Marsiske, Dzierzewski, Thomas et al., under review Adults aged 65-96 (n=692), observation only, five-year longitudinal change

10. Nancy Denney’s concept of optimal exercise Hertzog, C., Kramer, A. F., Wilson, R. S., & Lindenberger, U. (2008). Enrichment Effects on Adult Cognitive Development Can the Functional Capacity of Older Adults Be Preserved and Enhanced?. Psychological Science in the Public Interest, 9(1), 1-65.

11. Normal cognitive aging Characterized by losses and gains Also characterized by wide individual differences Intervention goals may be varied – Reduce the rate of decline (alter brain health) – Restore impaired functioning (rebuilt synaptic circuits – rehabilitation approach) – Compensate for impaired functioning (especially using that strong semantic system; teach new procedural and declarative approaches)

12. Normal cognitive decline Compensate for impaired functioning (especially using that strong semantic system; teach new procedural and declarative approaches)

13. Two recent “news” stories

16. The fictitious approach

18. So what do we know? In the next few slides, I’m going to offer a few summary propositions drawn from my work, although similar findings have emerged from labs all around the world The bottom line is that durable cognitive gains are relatively easy to achieve, even in advanced age and with mildly impaired elders The problem we face is generalization of training to actually affect (a) everyday functioning and (b) conversion to dementia

19. 1. The easiest thing to do is to provide practice

20. 3-year retest-gain in several Reasoning measures (ACTIVE control sample)

21. 2. More practice means more gain…but, practice provides very narrow gains

22. Daily Mental Exercise  Participants complete 120 Daily Mental Exercise Workbooks on their own in their homes  twice a day (morning and night)  for 60 consecutive days Allaire, J. C., & Marsiske, M. (2005). Intraindividual variability may not always indicate vulnerability in elders' cognitive performance. Psychology and Aging, 20, 390-401

23. Daily Practice Effects: Reasoning Allaire, J. C., & Marsiske, M. (2005). Intraindividual variability may not always indicate vulnerability in elders' cognitive performance. Psychology and Aging, 20, 390-401

24. Daily Practice Effects: Speed Allaire, J. C., & Marsiske, M. (2005). Intraindividual variability may not always indicate vulnerability in elders' cognitive performance. Psychology and Aging, 20, 390-401

25. Daily Practice Effects: Memory Allaire, J. C., & Marsiske, M. (2005). Intraindividual variability may not always indicate vulnerability in elders' cognitive performance. Psychology and Aging, 20, 390-401

26. Headlines like this refer to the lack of transfer

27. 3. More practice is even helpful in persons with early memory loss

28.  With Karin McCoy  68 adults with a mean age of 75 years  49 were cognitively intact; 17 had amnestic Mild Cognitive Impairment (MCI)  Focus was again intra-individual variability  All participants received  31 daily trials with measures of list memory (3 repetitions of AVLT-type lists daily), as well as working memory (forward and backward digit span) and perceptual speed/attention (digit- symbols) FitMind Study

29. Equivalent practice related gain, regardless of cognitive status Source: Marsiske & McCoy, in preparation

30. Equivalent practice related gain, regardless of cognitive status Source: Marsiske & McCoy, in preparation

31. Equivalent practice related gain, regardless of cognitive status Source: Marsiske & McCoy, in preparation

32. 4. Training can produce strong and durable cognitive improvements in the target of intervention

34.  We typically evaluate these studies by three criteria  Magnitude of effect  Breadth of effect (training transfer)  Durability of effect  In the slides that follow, I’m going to focus not on immediate gains, but what was still left after five years. THAT is the true test of durability. Evaluative criteria for training studies

35. ACTIVE Findings Memory outcome Reasoning outcome Speed of Processing outcome Each intervention produced significant and durable effects that were still detectable five years after training Source: Willis et al 2006

36. 5. And more training is generally better Memory outcome Reasoning outcome Speed of Processing outcome Source: Willis et al 2006

37. 6. Training even seems to affect functioning; less self-reported IADL decline Source: Willis et al 2006

38. 7. Persons with extended training even show improved everyday performance in behavioral observations Everyday Problem Solving Everyday Speed Source: Willis et al 2006

39. 8. Training also seems to improve the “self-system”: locus of control, self- rated health, etc.

40. 9. Training is even effective in improving the cognitive performance of impaired elders, at least in unimpaired domains

42. No difference in training for Reasoning & Speed, …but low memory group showed no gain in Memory Source: Unverzagt et al 2007

43. But training, as done in ACTIVE, is labor intensive and time consuming Remember those practice findings? Older adults can achieve a great deal on their own

44. 10. Maybe we don’t need training, just encouragement? Source: Thomas & Marsiske, under review, from the ACTIVE study

45. 11. Actual video games seem to produce measurable gains in visual attention

46. …but so does Tetris!? A first-person shooter game that improves selective visual attention in young adults does so for elders too… Belchior, Marsiske, et al (in press). Computers in human behavior)

47. In young adults, Useful Field of View is improved by first-person shooter video games in college-aged players (but not by Tetris)

48. Four intervention arms 1. UFOV 2. Medal of Honor 3. Tetris 4. No contact control

49. Implications for compliance? Maybe more importantly, older gamers are positively engaged by gaming more than they are by formal training programs Source: Belchior, Marsiske, Sisco, Yam & Mann, in press Belchior, P., Marsiske, M., Sisco, S. M., Yam, A., & Mann, W. (in press). Older adults’ engagement with a video game training program. Activities, Adapation and Aging.

50. Rise of Nations (Video Game) Basak, Boot, Voss & Kramer (2009)

51. 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. Basak, Boot, Voss & Kramer (2009)

52. Task Switching N-back focus switch costs

53. …and they appear to experience widespread gains in visual processing speed, some measures of everyday function, and affect. Belchior, Marsiske et al., REVIVA Study (Robert Wood Johnson Foundation, manuscript in preparation) Elders will be compliant with up to three- months of in-home computer based training/gaming…

54. 12. Moreover, video games seem to produce generalizable gain everyday function Timed Instrumental Activities of Daily Living Mental rotation (Yam dissertation) Positive affect

55. REVIVA Interim Findings: Gains on trained tasks

56. REVIVA Interim Findings: Transfer to other measures of visual attention / UFOV

57. REVIVA Interim Findings: Transfer to everyday activities Road Sign Test

58. REVIVA Interim Findings: Transfer to everyday activities Timed Instrumental Activities of Daily Living

59. What are these video games doing? Cognitive practice? Engagement (stimulation, arousal, emotional benefits?)

60. 13. Combinatorial interventions, especially video games PLUS cognitive training, offer intriguing results

61. Design Randomized parallel-group study of cognitive training combined with exercise

62. Design Wk 1: Exercise Wk 2: Exercise Wk 3: Exercise Wk 4: Exercise + COGNITIVE Monthly COGNITIVE PROBE Wk 1: nothing Wk 2: nothing Wk 3: nothing Wk 4: COGNITIVE Monthly PROBE 16-week protocol for Intervention (Aerobic) and Active Control (Wii-Sports) Passive Control

63. All Groups improved on INSIGHT Few between-group differences in gain Coded so that positive changes represent improvement Aerobic + INSIGHT Wii-Fit + INSIGHT INSIGHT only

64. Wii group showed consistently more improvement on multiple outcomes Group difference effect sizes were generally Cohen’s d=0.5 or better **** NOTE gains in delayed recall of 3 episodic memory tasks **** Group difference effect sizes were generally Cohen’s d=0.5 or better **** NOTE gains in delayed recall of 3 episodic memory tasks ****

65. Aerobic group showed the largest gains in Delayed Story Recall & Stroop CW Group difference effect sizes were generally Cohen’s d=0.5 or better

66. On a measure of perceived health-related quality of life, both treatment groups reported greater increases in physical functioning than Insight-only control

67. Note: The benefits of Wii are not due to aerobic training

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

69. Some Take Home Messages It is relatively easy to produce sizeable and durable cognitive gains in older adults Practice alone can produce substantial (if narrow) gains, even in those with incipient cognitive impairment Training produces highly durable gains, although still fairly narrow/specific There is clear evidence of a dose-response relationship

70. Some Take Home Messages The dose-response relationship suggests there is a need for ongoing, protracted training – The video game is one approach Elders can be highly compliant with home-based regimens, especially involving games – Here, too, there is some evidence of transfer/generalization In intact elders, there *may* be functional benefits of intervention, but they are not immmediate

71. Some Take Home Messages In ACTIVE, we saw generalization to – Self-reported IADLs and other self-rated outcomes only after 5 years, when normative decline had set in – Performance-based measures of everyday function only after extended (booster) dosages

72. Critical next steps Further evaluation of the extended home- based protocol Further evaluation of combinatorial treatments Better understanding of the mechanisms of gain – Functional reorganization of task performance? More focal recruitment? More compensatory recruitment Affective/arousal pathways

73. Critical next steps From exercise science: How to achieve prolonged, self-monitored engagement & high levels of adherence? From rehabilitation science: Which training activities move which cognitive abilities, which move which functional outcomes? – Taxonomy of intervention targets

75.  Major foci (training targets in ACTIVE):  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 Domains of focus

76.  Figural Relations: Identify the pattern in the upper box, and pick which of the answer choices would best complete the question mark. What is reasoning?

77.  Inductive Reasoning: Identify the pattern among the series of letters, and then decide what would come next in the series What is reasoning? a m b a n b a o b a ? 1. a 2. b 3. o 4. p 5. q

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

79. So what does training look like?

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

81. Restriction of the Useful Field of View

82. Useful Field of View

84. Exercise guidelines Fitness facilities Peer mentors Motivational interviewing Exercise guidelines Fitness facilities