Running head: INTERVENTIONS FOR PREVENTING COGNITIVE DECLINE: SEPARATING FACTS FROM WISHFUL THINKING

Anyone who stops learning is old, whether at twenty or eighty. Anyone who keeps learning stays young. The greatest thing in life is to keep your mind young. Henry Ford

Interventions for preventing cognitive decline: separating facts from wishful thinking Karen A. Basso Colorado State University Adult Education and Training 18 March 2012

INTERVENTIONS FOR PREVENTING COGNITIVE DECLINE: SEPARATING FACTS FROM WISHFUL THINKING Introduction

Memory is an odd thing. Memory is the ability to retain learned information and knowledge and to retrieve that information and knowledge but it is also so much more. It is part of who we are, a repository of history, and what remains of family and friends when they have departed. What and how the brain remembers is influenced by myriad external distractions and internal workings of the mind and body. The Rashomon effect gives a name to how a group having the same experience will come away with completely different takes on what they saw, heard, or felt about any given situation. In my home, this sometimes causes arguments and while my maternal grandmother was living, I used to marvel at how she could have nonfactual recall of past events. Despite Grandmas faulty recall, she observed, my mind has outlived my body. outlive our mind. Losing ones memories provokes more fear than thoughts of physical decline as we age. A recent Medscape article paints an alarming picture. As our world ages, the worldwide incidence of dementia (cognitive and intellectual deterioration) is expected to increase from 35 million to 115 million by 2050 (Buschert, 2010). The cost of caring for those who cannot care for themselves is astronomical in terms of dollars and stress to elderly and their caregivers. A multidisciplinary approach is required to combat this trend. psychology, and medicine all have a role. Science gives us hope and a growing body of evidence that cognitive decline is far from inevitable. This hopefulness is beginning to extend to those who are on the path to cognitive Neuroscience, education, If we are lucky, our body does not

INTERVENTIONS FOR PREVENTING COGNITIVE DECLINE: SEPARATING FACTS FROM WISHFUL THINKING

impairment and Alzheimers disease (AD) - the most feared and prevalent form of dementia afflicting the elderly. Newer imaging techniques such as Positron Emission Tomography (PET)

scanning, and Functional Magnetic Resonance Imaging (FMRI) allows researchers to observe the brain at work and offers proof of the brains plasticity a capacity to replace and reorder injured or defective portions of the brain. Research in cognitive interventions seeks to delay the onset or possibly even reverse early signs of cognitive decline. It is posited that if cognitive interventions can delay the onset of AD by five years, the prevalence of the disease could decrease by as much as 50% worldwide (Buschert, 2010). In these instances, one may have the disease but outlive the symptoms that rob one of memories and eventually the ability to do even the most fundamental activities of daily living. Nascent research in cognitive intervention has spurred an avalanche of self-help books, websites, blogs, brain games, motivational speakers, and all manner of others seeking to spread the good news and in many cases exploit those fearful of losing memory and function. Organizations such as American Association of Retired People (AARP) and Alzheimers Association have joined the cause and offer abundant articles on age proofing ones brain and brain health. This paper examines the science and sometimes-inflated claims about cognitive interventions, the market for brain training games and their validity as a cognitive intervention, and seeks to inform the practice of adult educators working with an increasingly older population.

INTERVENTIONS FOR PREVENTING COGNITIVE DECLINE: SEPARATING FACTS FROM WISHFUL THINKING Cognitive intervention and brain training

Cognitive interventions are any behavioral or learning based activities that promote or restore brain function and prevent mental decline. Interventions are either compensatory or restorative. Any reading on adult education techniques focus almost exclusively on

compensatory interventions (techniques to work with declining capacity) as seen in Learning in Adulthood which claims memory capacity and skills are key to how adults learn, formal memory training helps older adults cope with memory deficits, and adult educators should integrate memory skills into learning programs for adults (Merriam, 2010). Occupational

therapists, psychologists, and others assist recovery from traumatic brain injuries, stroke, and other disorders using restorative interventions (techniques to correct memory and other cognitive deficits). Brain training as a cognitive intervention is relatively new and has shown some promise. The self-help market capitalizes on this limited research and peoples desire to remain mentally sharp. There is no shortage of excitement about the potential of brain training and the ability of the brain to retain and even recover function after grievous insults. Evidence of excitement includes abundant books, websites, lectures, blogs, and media coverage promoting the ability to save the brain from the effects of aging, autism, ADHD, PTSD, Alzheimers, and other problems. It is difficult to ignore success stories like Sharon Stones recovery from a brain bleed and Bob Woodruff and Gabriel Giffords recovery from traumatic brain injury. There are books and more to help you think like the Buddha, use your brain to change your body, or change your brain to improve your life. There is material dedicated to brain based education offering solutions to all the challenges of teaching and learning.

INTERVENTIONS FOR PREVENTING COGNITIVE DECLINE: SEPARATING FACTS FROM WISHFUL THINKING

Hollywood, many scientists, and the media have joined an apparent brain training revolution. Companies such as Nintendo, Posit Science, Lumosity and others claim their products can improve or restore brain function and prevent cognitive decline. Detractors and the cautious warn there is little evidence for these claims while promoters of brain training as a cognitive intervention seem to have won the hearts and minds of an aging population (Katnelson, 2010&Telegraph, 2009). One article in The Telegraph warns brain training may do more harm than good, especially if persons choose the games over physical activity. The article describes an exponential increase in money spent for such games from a low of 1.5 million euro in 2005 to 55 million euro or approximately 72 million U.S. dollars four years later (Telegraph, 2009). Companies feed on fear of an aging population and in some instances appear to stretch science to sell products. For example, I signed up for a trial membership with Lumosity, an online brain training site that promises to increase reasoning, processing speed, and prevent cognitive decline. The games are entertaining and the Lumosity site; Lumosity.com, provides bits of information about research on the site and via email. An example of helpful

information from Lumosity email is follows: Our openness to new experiences is another personality trait that may lead to relationship success Openness may be trainable, according to new research from the University of Illinois published in Psychology and Aging. Out of 183 older adults, those who underwent cognitive training increased their openness to new experiences. After the training, which featured pattern-recognition and problem solving, these same participants also improved inductive reasoning skills.

INTERVENTIONS FOR PREVENTING COGNITIVE DECLINE: SEPARATING FACTS FROM WISHFUL THINKING

There are many more examples of trainable traits, behaviors, or other activities that promise to improve almost every

conceivable aspect of life. If you decide to end your relationship with Lumosity, they continue to send positive motivation and research results via email but are also not above using scare tactics. The photo is a

screen capture of an email I received several weeks after my trial period ended

(Lumosity.com, personal communication, February 1, 2012). The study is real and the results are factual; however, Lumosity like many others cherry pick information to support their claims. People, who are desperate, scared, or selling something have grabbed onto a limited number of studies showing promise of preventing mental decline. Hollywood, the media, and authors (many with scientific backgrounds) are reluctant or simply fail to tell the whole story. It is up to science to determine if and what cognitive interventions work and educators to stay abreast of research and help people make informed choices about how to maintain cognitive function plus seek ways to help prevent decline and work with those who are in a state of decline.

INTERVENTIONS FOR PREVENTING COGNITIVE DECLINE: SEPARATING FACTS FROM WISHFUL THINKING Science offers cautious optimism for cognitive intervention

Most research on cognitive intervention is conducted with an end goal of preventing age related cognitive decline, Alzheimers disease, and loss of ability to live and function independently. There is growing evidence the brain has reserve capacity as those with larger brain mass and/or higher educational attainment seem to suffer less from cognitive decline than their cohorts. Brain reserve is the term dealing with brain size while cognitive reserve deals with function. Cognitive reserve is thought to be modifiable, the basis for cognitive intervention.

One article from Medscape cites a meta-analysis including over 29,000 people who had a 46% reduced risk of developing dementia due to high cognitive reserve which was sustained over seven years and that mentally stimulating activities were shown to have the largest effect on reducing dementia risk (Buschert,2010). Several studies note educational attainment and other cognitive activities (not necessarily brain training) may increase cognitive reserve. A study by Tucker and Stern asserts cognitive reserve; presumed higher in educated and other higher functioning individuals, may offer protection even for those who have illnesses associated with cognitive decline (Columbia University, 2011). Tucker and Stern also state cognitive reserve is not fixed but evolving and interventions may work even if begun later in the process of diseases such as AD (Columbia University, 2011). Such research suggests intervention may prevent those with disease from becoming symptomatic or limit symptoms. A study by Spanish researchers suggests caution in stating a relationship between education and cognitive decline due to potential bias against illiterate and low literate individuals (Ardilla, 2000). The authors did find higher educational groups seem to have a slower decline with tasks such as word recall but found little other data suggesting education can prevent or

INTERVENTIONS FOR PREVENTING COGNITIVE DECLINE: SEPARATING FACTS FROM WISHFUL THINKING

slow decline. The Spanish study does agree more research is required to determine if cognitive intervention can decrease age or disease related cognitive decline. Though debate exists about whether educational attainment or cognitive interventions prevent or stall cognitive decline, there is initial promise that intervention works. Two major

studies and many smaller ones show potential benefits of cognitive training to prevent cognitive decline and possibly delay onset of MCI and AD. One of the first and largest studies (approximately 3000 participants) is the ACTIVE (Advanced Cognitive Training in

the Independent and Vital Elderly) study conducted for the National Institutes of Health (Willis, 2006). Subjects were tracked for five years. Groups either received no intervention, speed of processing training, memory training, or reasoning training. All training groups showed gains in the trained domains when compared to controls, but only the reasoning group reported benefits in instrumental activities of daily living that include driving, preparing meals, and other self-care activities. The results of the ACTIVE study are reinforced by data from the 2009 IMPACT (Improvement in Memory with Plasticity-based Adaptive Cognitive Training) study. IMPACT found that focused practice on perceptual speed, accuracy, adaptive algorithms, plus emphasizing attention and reward were associated with less serious risk of physical decline and may present a promising approach to counter cognitive decline (Smith, 2010). In the meantime, there is noticeable effort by organizations such as AARP, NIH, CDC, and others to educate the population about healthy brain behavior including mentally stimulating activities. Other modalities for preventing cognitive decline include genetic therapy (investigational), immune therapy (investigational), medication (ones in use are limited in effect), and healthy lifestyle (what is good for your heart is good for your brain). The

Alzheimers Association and Centers for Disease Control (CDC) authored The Healthy Brain

INTERVENTIONS FOR PREVENTING COGNITIVE DECLINE: SEPARATING FACTS FROM WISHFUL THINKING

Initiative: A National Public Health Road Map to Maintaining Cognitive Health (CDC, 2011). The Healthy Brain Initiative promotes collaborative efforts to fund, research, and promote efforts to maintain cognitive function throughout the lifespan. Information for adult educators As previously discussed, there is a great deal of information on strategies to assist older learners. These strategies are largely compensatory involving external memory aids, mnemonic devices, allowing extra time for processing information, providing material ahead of time, and building on students life experience. Occupational therapists, nurse educators, physicians, psychologists and other professionals involved with rehabilitation use restorative teaching strategies such as training on daily activities, reality orientation, and elimination of incorrect or inappropriate responses during learning (no effort is made in these instances to have the patient/student think through problems). Any educator working with students having a history of cognitive impairment due to trauma, illness, or aging is well advised to understand how and when to incorporate restorative techniques into their teaching. Adult educators can inform and assist organizations tasked with public health information in providing age appropriate and specific materials. Adult educators can also serve as agents for change and advocates for cognitive training and other brain healthy activities, which include promoting lifelong learning that may increase cognitive reserve and assist in preventing cognitive decline.

Conclusion Having a medical background and appreciation for education, I cannot help but come away from researching this topic with a sense of optimism about what the future holds. One sure

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thing in life is each person has a finite amount of time. Maintaining cognitive function is paramount to a quality life and independence. Mild cognitive impairment and diseases such as Alzheimers jeopardize cognition, which decreases quality and eventually leads to dependence. Time is critical as even five years of deferred decline may keep a person from exhibiting disease symptoms and reduce the occurrence of AD by up to 50% (Buschert, 2010). Research on cognitive intervention suggests cautious optimism about the ability to increase cognitive reserves while the media, brain training companies, and aging advocacy groups are promoting cognitive stimulation along with more traditional interventions like diet and exercise as sure means to age proof your brain. Adult educators should be informed by and participate in brain health initiatives. In the meantime, despite conflicting evidence that brain training works and questionable tactics of companies selling brain games I do not personally see the harm in adding some games and other mental stimulation to a brain healthy lifestyle.

That is my major preoccupation, memory, the kingdom of memory. I want to protect and enrich that kingdom, glorify that kingdom and serve it. Elie Wiesel

INTERVENTIONS FOR PREVENTING COGNITIVE DECLINE: SEPARATING FACTS FROM WISHFUL THINKING References

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Ardilla, A.; Ostrosky-Solis. (2000). Age-Related Cognitive Decline during Normal Aging: The Complex Effect of Education. Archives of Clinical Neuropsychology, 15(6), 495-513. Retrieved March 15, 2012, from Science Direct Web site: http://www.sciencedirect.com/ science/article/pii/S0887617799000402 Brain training games 'do more harm than good'. (2009, February 11). The Telegraph. Retrieved March 15, 2012, from The Telegraph Web site: http://www.telegraph.co.uk/health/ healthnews/4586419/Brain-training-games-do-more-harm-than-good.html Buschert, V. (2010). In Heather Wood (Ed.), Cognitive Intervention in Alzheimer Disease [Continuing Medical Education Article Review]. Retrieved March 15, 2012, from Medscape Web site: http://www.medscape.org/viewarticle/726725 Centers for Disease Control. (2011). The CDC Healthy Brain Initiative Progress 2006-2011 [Data File]. Available March 15, 2012, from CDC.gov Web site: http://www.cdc.gov/ aging/pdf/HBIBook_508.pdf Columbia University Medical College. (2011, August). Cognitive Reserve in Aging [Research Study]. Available March 15, 2012, from CUMC Web site: http:// www.cumc.columbia.edu/dept/sergievsky/pdfs/cognitivereserveinaging.pdf Katnelson, A. (2010). No gain from brain training. Nature International Weekly Journal of Science, 464(1111). Retrieved March 15, 2012, from Nature Web site: http:// www.nature.com/news/2010/100421/full/4641111a.html Merriam, S., Caffarella, R., & Baumgartner, L. (2007). Learning in adulthood: a comprehensive guide (3rd ed.). San Francisco: Jossey-Bass.

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Smith, G.; Housen, P (2009). A Cognitive Training Program Based on Principles of Brain Plasticity: Results from the Improvement in Memory with Plasticity-based Adaptive Cognitive Training (IMPACT) Study. Journal for the American Geriatrics Society, 57(4), 594-603. Retrieved March 16, 2012, from Wiley On Line Library Web site: http:// onlinelibrary.wiley.com/doi/10.1111/j.1532-5415.2008.02167.x/pdf Willis, S.; Tennstedt, S. (2006). Long-term Effects of Cognitive Training on Everyday Functional Outcomes in Older Adults. Journal of the American Medical Association, 296(23), 2805-2814. Retrieved March 16, 2012, from JAMA Web site: http://jama.amaassn.org/content/296/23/2805.full#sec-11