Mom and dad may be getting on in years and aren’t as sharp as they used to be. A loved one or family member returns home from military service suffering from post-traumatic stress disorder (PTSD) or traumatic brain injury (TBI), or a friend has debilitating effects from past trauma. Substance abuse, with or without a co-occurring mental health disorder, may result in difficulties in decision-making, memory, learning and concentration.
What can be done to help these individuals? In addition to professional therapy, privately or at a residential or outpatient facility, could brain training games, or cognitive training (CT) programs, help?
To gain some perspective on the subject we turned to Larry Brooks, PhD., a clinical neuropsychologist in private practice in Miami and Hollywood, Florida, as well as a consulting neuropsychologist at Lucida Treatment Center. Dr. Brooks specializes in the assessment and cognitive rehabilitation of individuals with neurological disorders. He is also a voluntary assistant professor of research in the Department of Physical Medicine and Rehabilitation at the Miller School of Medicine, University of Miami.
Are cognitive training programs available on the Web useful for seniors or parents of adult children getting on in years to help them retain cognitive abilities, to potentially keep them sharper and more engaged?
In a single word…yes. In a 2010 state of the science review on preventing cognitive decline conducted by the National Institutes of Health (NIH), computerized brain training was found to have better evidence to support it in terms of decreasing risk for cognitive decline than medications and physical exercise. Some other studies have also shown long-term effects of brain training. That being said, it matters which program is used. The Brain HQ program by Posit Science has the best evidence in terms of enhancing cognitive function in seniors.
Note: Dr. Brooks currently participates in research on the development of brain training software but has no financial interest in any brain training products.
Additionally, not all cognitive abilities are equally affected by these brain training games. Concentration, information processing speed and visual scanning all can improve with the use of these games. On the other hand, there is no strong evidence that memory (defined as recall of information after a delay) improves. Though most people worry about memory, problems with attention and processing speed actually underlie a lot of memory issues by affecting learning. If one does not learn well, one does not remember well. Thus, memory can be improved, but indirectly by enhancing one’s ability to learn.
Since CT games would also keep people occupied and competitive, it may be good for social reasons as well, do you agree?
Brain training games are only one small component of what people can do if they want to stay sharp. There is considerable evidence that people with more extensive social networks do better in terms of quality of life and retaining cognitive abilities. I would encourage people to get out of the house, visit family, take a class, exercise, and be social. The area of mindfulness meditation is also very popular right now and has an increasing base of research support.
Can you report on any studies you know of that have shown good results with CT programs for individuals with certain disabilities or disorders?
This is an important issue as many of the brain training games have been developed with the aim of reducing age-related cognitive decline. At this time, the research literature on the effectiveness of these programs for individuals with brain injuries, strokes, substance abuse, or Alzheimer’s disease is in its early phases, but multiple trials are underway for these and other disorders. One exception is that there have been some studies to suggest that Cogmedmay be effective in improving inattention in Attention Deficit Hyperactivity Disorder (ADHD). Altogether, we should expect a lot of exciting new studies to be published soon.
Unlike most of the other computer programs, Attention Process Training-3 (APT-3) has been developed to target the cognitive deficits frequently seen in individuals with stroke or brain injury. The exercises are usually much simpler than the ones used in the more commercially oriented products. APT-3 should also be used under the supervision of someone with training in cognitive rehabilitation, as much of the gains come from increasing a patient’s awareness of his or her deficits and then helping the patient learn strategies to overcome the deficits. The goal is for the patient to learn strategies that will help him succeed at life, not at brain training games.
An additional problem is that patients with stroke often have aphasia, which can involve difficulty in speaking, understanding speech or reading. This renders many computer games totally useless. Cataracts, glaucoma, paralysis, or a Parkinson’s-related tremor can also make many of the computer games fairly unhelpful for certain patients.
Are you involved with one of the programs you reviewed, as in did you help them develop and/or test it?
I have not participated in the testing or development of any of the computer games. I use Posit Science’s Brain HQ and APT-3 with some of my patients. I pay Posit Science a fee so I can monitor my patients’ performances remotely.
What do you believe is the outlook for CT programs in the near future? Is it five years or less down the road before a mass of evidence will be in, or is there a shorter window for review/evaluation?
These programs are getting better all the time. Take Lumosity. Right now, Lumosity does not have much evidence of its effectiveness published in peer-reviewed journals. However, it has tens of millions of users. In a few years, the vast data Lumosity will have gathered and analyzed should dramatically enhance its effectiveness. Lumosity will be performing research on a scale of which academic institutions can only dream. The same goes for the other brain training companies, but Lumosity’s scale almost assures that it will be a significant player in the near future.
What about for shut-ins? Are CT programs good for them?
For people who have difficulty getting out of the house due to age-related physical decline or disability, computerized brain training is a boon. We know that more training equals better results, so now patients can see their clinician less frequently and still get work in at home.
What else would you like to say about these types of Web-based brain training games?
There are three key points to remember:
- If your goal is to stay sharp as you age, be careful about which program you purchase. Not all programs have the same scientific support for their effectiveness.
- This is just the beginning, and it will only get bigger. More companies are coming online, and there is serious money behind some of these ventures. Some of the players will change over the next few years, and the games will only become more effective. Technological advances in cloud computing and web conferencing will further facilitate a therapeutic interaction between expert clinicians and a patient in his or her own home.
- If you have noticed a decline in your memory, get a neuropsychological evaluation to objectively measure your cognitive abilities. If they are below expectations, then a treatment plan should be developed. The most important part of the treatment plan is for the patient to set goals and work with someone who has an understanding of how cognitive problems may interfere with life goals. Brain training games should only be one part, albeit an important part, of a comprehensive plan.
How do these training programs compare with clinical cognitive behavioral therapy for treating people with Alzheimer’s disease or other cognitive disabilities?
Importantly, these computerized brain training games are not a substitute for a comprehensive cognitive rehabilitation program for an individual who has a neurological disorder. However, these games provide a useful supplement to the cognitive rehabilitation programs because people can keep working at home and not just in the clinician’s office. A comprehensive cognitive rehabilitation program for a neurological disorder has to focus on improving functioning in real life activities as its centerpiece. Psychotherapy, including cognitive-behavioral or psychodynamic therapies, is important to help individuals cope with changes in function and identity. Learning to use strategies to overcome areas of weakness is one of the most important components. This may include using an iPad to take notes or set reminders.
Alzheimer’s disease is particularly challenging because there is not much that can be done to improve cognition or even function once the illness has progressed past a certain point. Recent scientific focus has been on developing treatments targeted for early stages of Alzheimer’s to help slow the progression. Exciting work is being done at several centers nationally in this area.
CT Program Comparison
|Brain HQ||$96 a year||Optional. Clinician can monitor progress remotely.||Strong evidence base. Designed for use with healthy aging population.Addresses multiple cognitive domains (e.g., attention, working memory, processing speed).||Some difficulties when using with specific disabled populations, i.e., difficulty with vision, speech, or hand tremors.|
|Cogmed||Varies by clinician. Likely to be much more expensive than Brain HQ or Lumosity.||Visits take place in according to specified schedule with direct supervision by clinician.||Fairly strong evidence base. Oversight by clinician ensures quality of intervention.||Focuses primarily on only one cognitive domain (working memory). While working memory is important, other cognitive skills are also very important.|
|Attention Process Training-3||Varies by clinician, but it will likely be a part of a broader treatment program.||Brain training games assigned by clinician. Challenge level determined by clinician.||Strong evidence base. Best program for people who have had neurological problems, such as a stroke or brain injury. Allows the clinician to get details about types of errors, which is critical for treatment planning.||Not intended for a healthy aging population.Has to be used with involvement of a clinician.|
|Lumosity||$79.95 a year||No clinician involvement.||Easy access. Engaging games.||Weak evidence base compared to the other programs.|