Does Online Cognitive Training Work?

Online cognitive training programs promise to boost memory and attention, and they're popping up at a rapid pace. According to one dementia expert, the online cognitive training business has grown from about $200 million annually 6 or 7 years ago to an estimated $2 billion a year today.

But are these companies truly giving patients an edge when it comes to warding off dementia, or are they cashing in on the worried well and an often vulnerable aging population?

Cognitive training is loosely defined as regularly engaging in a cognitive task, for example, learning a list of words, a set of pictures, or a certain route to a particular target.

Online cognitive training programs typically involve buying a monthly or annual subscription that allows users access to various cognitive tasks. These users sit at a computer to do these tasks on a regular basis. They usually have to pay more to get upgraded applications.

"It's a huge industry," says Peter Snyder, PhD, professor, neurology, Alpert Medical School, Brown University, and chief research officer, Lifespan Hospital System, Providence, Rhode Island, and editor, Alzheimer's & Dementia: Diagnosis, Assessment & Disease Monitoring, the Alzheimer's Association's online, open-access journal.

Not surprisingly, many of these brain training companies target the aging baby boomer market. For the next 15 years, 10,000 people per day, every day, will turn age 65 in the United States, Dr Snyder said.

Many of them are worried about their memory. The issue of how to prevent dementia ''actually comes up almost every time I see a patient," says David Knopman, MD, professor, neurology, Mayo Clinic College of Medicine, and an investigator in the Mayo Clinic Alzheimer Research Center, Rochester, Minnesota.

If they still have a job, Dr Knopman advises patients that they probably get enough stimulation in the work environment. ''Certainly the computer can't be as good for mental stimulation as the challenges you face in the work environment, even if you're not in an executive position.''

And if the patient is retired but reads newspapers, belongs to a book club, or does volunteer work, "what would the computer testing offer that this socially engaging and mentally stimulating activity doesn't provide?'' asks Dr Knopman.

The benefits of cognitive activity aren't in question. It's clear from the literature, says Dr Snyder, that engaging cognitively with challenging and varied tasks may help slow the rate of progression of Alzheimer's disease.

Sylvie Belleville, PhD, professor, neuropsychology, University of Montreal, Quebec, Canada, and director of the research center there, also stresses the importance of living a cognitively demanding life.

"It's amazing the effect that lifetime stimulating cognitive activities have on the brain," she says "People who have been cognitively engaged have less amyloid burden in their brain; they have a larger brain and more activation in the brain when they do a task."

Eric Reiman, MD, executive director, Banner Alzheimer's Institute, director, PET Center, Banner Good Samaritan Medical Center, and director, Arizona Alzheimer's Disease Consortium, Phoenix, emphasizes the importance of cognitive stimulation in the form of higher education — either through the "use it or lose it" hypothesis or the "cognitive reserve" hypothesis, where the educated seem to be able to compensate for cognitive loss.

He points out that many highly educated people don't exhibit manifestations of dementia until it's relatively severe, although he says that at that stage, such people seem to decline at a relatively fast rate.

In addition to cognitively stimulating activities and higher education, lifestyle habits play a huge role in preserving mental power. For example, being socially engaged — getting out, gardening, seeing family — reduces stress, depression, and loneliness, which in turn can help maintain brain function, according to Dr Snyder.

Dr Reiman adds that treating diabetes, high blood pressure, and high cholesterol levels; losing excess weight; and not smoking also help retain cognitive ability.

He notes that such healthy lifestyle interventions may be the reason behind reports that the expected increase in the prevalence of Alzheimer disease isn't materializing.

Rock Solid Evidence

The lifestyle factor that has the most credible evidence for protecting against dementia to date is not cognitive training but physical activity. "The evidence is absolutely rock solid; it's incontrovertible," says Dr Snyder.

He worries that patients will play online cognitive games three times a week in the hopes of protecting their brain instead of taking a brisk walk three times a week.

And Dr Knopman is concerned that those playing brain games may not be socially active. Online cognitive training is 'the opposite of being socially engaged," he notes. "They force people to bury themselves in the computer for a certain period of time."

It's not clear whether pursuing cognitive training online adds any further benefits to physical and cognitive pursuits offline. That's because to date there's scant literature on the subject.

One study published earlier this year in The Lancet looked at the effect of healthy eating and exercise in addition to brain training in 1260 people aged 60 to 77 years who were at risk for dementia. Researchers found that an intensive program incorporating all three approaches, plus management of metabolic and vascular risk factors, slowed cognitive decline over 2 years.

Overall scores on the Neuropsychological Test Battery in the intervention group were 25% higher than those in a control group that received only regular health advice. The results were particularly striking in the areas of executive function and processing speed.

But how much brain training contributes to the mix remains to be seen.

Literature a "Wreck"

The literature in this area leaves a lot to be desired, Dr Snyder said. Most of the published literature is a "wreck," he says, partly because the outcome measures are confounded, the follow-up period isn't long enough, or proper comparisons aren't in place.

A randomized controlled trial of cognitive training would have to compare this training to an appropriate placebo, he points out. "In this case, what's the placebo? Is it absolutely nothing at all, which in most cases is what has been done?"

The question, says Dr Snyder, should be whether the online tasks are more effective than freely accessible pursuits doctors might routinely recommend to older adults, which in addition to regular physical activity might be things like learning a new language or practicing the piano.

Learning a language or an instrument is a complex process that involves several cognitive functions. In contrast, many of the online cognitive games being marketed focus on very specific cognitive functions, for example, remembering word lists.

So after some practice, you may get good at remembering those word lists — the so-called training effect — but how that translates into everyday life is unclear. "Is learning word lists over and over again on a computer going to generalize to being able to find your car in a crowded parking lot at a shopping mall?" asks Dr Snyder.

But forgetting where you parked your car, or the name of your grandson, can be a scary experience. More and more patients are looking for ways to prevent their descent into mental fog.

And so they're increasingly turning to online cognitive games. "This is an industry that I worry preys on the elderly, preys on a vulnerable population," says Dr Snyder.

Sweet Spot

William Mansbach, PhD, from Mansbach Health Tools LLC, Simpsonville, Maryland, agrees that the "sweet spot" for the at-home brain training industry is the "worried well" and that in general the industry's claims far exceed the evidence.

But this may not be the case for those already experiencing memory impairment. His company has developed programs that he says can improve global cognition in these patients in as little as 3 weeks if they practice for 20 minutes, three times a week.

One of his programs — Memory Match — is a cognitive training task that exercises working memory and attention using themed cards. A study discussed at the Alzheimer's Association International Conference earlier this year found that those with mild cognitive impairment and mild dementia improved significantly on this test compared to a control group that didn't receive it. Importantly, says Dr Mansbach, those with more severe dementia did not improve.

In structured interviews following this study, participants in the treatment group pointed to the intervention as a reason their memory improved, according to Dr Mansbach.

He's proud of the "clear evidence" and "large effect sizes" from the study that suggest that this approach is legitimate.

Patients using his brain training tasks first do a self-assessment to determine at what level to start in order to get maximum benefit, he says. One of his criticisms of other programs is that there are no real assessment of the person doing the training and no concrete idea of what needs improving.

However, while he's convinced his program works in the short run, long-term benefits are unclear. "We have no idea, and no one does."

There could well be an important role for cognitive training outside industry, though. Jens Pruessner, PhD, professor, psychiatry, McGill University, Montreal, thinks that using this training may help pinpoint patterns that might be clues to the onset of dementia.

In a research project, he and his colleagues are testing PONDER (Prevention of Neurodegenerative Disease in Everyone at Risk), a free online cognitive training program aimed at those aged 40 years and up. Using neuropsychological assessments, researchers are tracking the progress of users to see whether the frequency, intensity, and duration of cognitive training leads to observable changes over time.

"Let's say that in general, the training effect is such that you improve by 20% over time when you have been doing this task every other week for 6 months," said Dr Pruessner. "Are those people who only improve by 10% or 5% at risk of developing mild cognitive impairment and eventually dementia?"

So far, the mean age of users is 57 years, which is exactly when age-related cognitive decline begins in those destined to develop dementia. Dr Pruessner notes that dementia begins some 20 years before clinical symptoms become significant.

Perhaps the most well-known of these companies is Lumos Labs in San Francisco, California, whose brain training site, Lumosity, is used by more than 70 million "brain trainers" in 182 countries, the company's website notes.

The company has a collaborative research initiative, called the Human Cognition Project (HCP), that it says partners with more than 90 collaborators from 40 universities. "Through the HCP, we grant qualified researchers free access to Lumosity's cognitive training tasks, assessments, research tools, and in some cases, limited access to data on cognitive task performance — helping them conduct larger, faster, and more efficient studies," the website notes.

Lumosity also has in-house researchers to develop new cognitive training tasks and assessments, provide administration of controlled studies, and study Lumosity gameplay information to enhance the experience, the site notes.

Several publications in peer-reviewed journals have used Lumosity data. Earlier this year, researchers published a paper in Alzheimer's & Dementia using data from Lumosity's Memory Match game, which requires visual working memory, to look at individual differences in age-related changes in working memory. They found significant effects of age on baseline scores and lower learning rates. "Online memory games have the potential to identify age-related decline in cognition and to identify subjects at risk for cognitive decline with smaller sample sizes and lower cost than traditional recruitment methods," the authors concluded.

A randomized trial of nonaction video games from the Lumosity site reported in 2014 in Frontiers in Aging Neuroscience showed improvements with training in processing speed, attention, and immediate and delayed visual recognition memory in the trained group, but no variation in the control group. Neither group improved in visuospatial working memory or executive control, the researchers report.

"Overall, the current results support the idea that training healthy older adults with non-action video games will enhance some cognitive abilities but not others," the researchers, with first author Soledad Ballesteros, PhD, Studies on Aging and Neurodegenerative Diseases Research Group, Universidad Nacional de Educación a Distancia, Madrid, Spain, concluded.

Multiple emails and telephone messages to Lumosity requesting an interview for this article, sent over several weeks, were not returned.

Personal Trainer for the Brain?

So, at the end of the day, should that 57-year-old patient who is worried about his forgetfulness fork out subscription fees every month to play cognitive games? If it keeps someone mentally active, "why not?" says Dr Belleville.

She points out that people pay a lot of money to join a gym when they could jog for free in the park. "If you have to pay a gym to continue to do your exercises, then pay; it's worth the money."

However, she acknowledges that while there's a good deal of evidence that a certain amount and intensity of physical activity is good for the brain, "when you look at cognitive training, it's all over the place."

And she agrees that it's not clear whether the training effect goes beyond the task being practiced — or whether it has the same impact as informal training, such as doing crossword puzzles several times a week.

On the other hand, "it's probably better than doing nothing at all and looking at silly programs on television," she says. "I think there's something there, but we need to understand better what the active ingredient is so we can provide good advice to people."

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Cite this: Does Online Cognitive Training Work? - Medscape - Dec 17, 2015.