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November 11, 2008

Sharpening the Aging Brain
By Jennifer Van Pelt, MA
For The Record
Vol. 20 No. 23 P. 20

Experts disagree on exactly which brain exercises are most effective, but all agree that challenging the aging mind benefits older adults. From sudoku to software, brain agility in older adults means use it or lose it.

Experts disagree about the value and effectiveness of currently marketed brain fitness programs such as computerized games and activities designed to stimulate the brain and improve its function. So does exercising the brain really postpone age-related memory lapses or the onset of dementia?

Lifestyle and behaviors that support good cerebrovascular health, such as exercising regularly and not smoking, will help prevent age-related memory loss. “What is good for the heart is also good for the brain,” says Aaron Philip Nelson, PhD, ABPP, director of neuropsychology at Boston’s Brigham and Women’s Hospital and author of the Harvard Medical School Guide to Achieving Optimal Memory.

Nelson advocates a problem-focused approach to memory issues. “Neuropsychological testing of individuals who believe they have memory problems often reveals that the problem really is related to attention and ability to focus. Memory is normal, but they are not absorbing the information properly and therefore cannot remember it,” he explains.

Nelson cites the example of one of his patients, a 72-year-old retired university professor who became concerned when she could no longer remember what she read, a skill she had formerly considered an academic strength. “Actually, her attention was drifting while she was reading, so we worked to devise a strategy to help her become more engaged in the reading process to guarantee information processing,” he says. Taking notes, making a written summary after reading a chapter, and rereading notes periodically made reading a more interactive process and created a more durable “memory trace.”

Nelson believes practical strategies designed to address specific cognitive functions will improve functionality in daily life more significantly than brain fitness software whose effectiveness and applicability to daily activities remain unproven. Marketing such brain fitness games may be misleading consumers, according to Nelson. “Currently, there is little evidence to support these memory games,” he says. “No data have been published supporting that playing a memory game on a computer will help overall memory in daily life.”

Contrasting Viewpoints
Proponents of brain fitness programs disagree. Posit Science, a San Francisco-based company that markets two brain health programs, the Brain Fitness Program Classic and Insight, has installed its brain fitness products in more than 200 residential and long-term care communities in the United States and Canada. Joe Hardy, PhD, a neuroscientist and the company’s director of research and development, cites a study by researchers at the Mayo Clinic and the University of Southern California indicating that programs such as Brain Fitness and Insight can significantly improve memory. “Basically, they [the games] roll back the clock by 10 years in terms of memory performance in healthy adults,” he says.

The Brain Fitness Program is auditory based and is designed to improve attention and memory, such as remembering phone numbers or new names. Insight trains visual processing to improve visual memory. A 2002 study of the Insight technology showed that users’ visual speed of processing not only improved but also transferred to daily activities, such as locating phone numbers in a telephone directory or reading a recipe. “Health-related quality of life also declined more slowly in those doing the training,” Hardy says.

 Alvaro Fernandez, cofounder and CEO of San Francisco’s SharpBrains, a research and consulting company that recently published the 2008 report, “The State of the Brain Fitness Software Market,” predicts, “Within the next few years, we think the same thing that has happened for physical fitness—increasing numbers of health clubs, trainers, coaches, and equipment variety—will also happen for the field of brain fitness. Cognitive training will be conducted much like physical fitness training.”

Based on its market research, SharpBrains estimates that approximately 400 to 500 facilities for older adults in the United States now offer some type of computerized brain fitness program to complement recreational and therapeutic activities. Direct purchases by consumers for at-home use are increasing rapidly as well. “There is growing evidence that these brain fitness activities can be helpful in improving specific cognitive skills,” says Fernandez.

However, since brain fitness products vary in their user interface, skills trained, hardware and software requirements, and cost, choosing the right product may be difficult for both consumers and facility directors. “Different programs address different cognitive skills or skill sets,” Fernandez says. For instance, a program focusing on auditory processing helps users discern and process information they hear, such as asking for instructions from the pharmacist. Other programs address short-term memory, general information processing, or decision-making and problem-solving abilities.

Motivated to enter the field of brain fitness following his father’s diagnosis of Alzheimer’s disease, Dan Michel, founder and CEO of Dakim, Inc, based in Santa Monica, Calif., says, “I believe that medical research has shown that cognitive stimulation can significantly reduce the risk of dementia. Dakim’s [m]Power program is so named because we hope to empower older adults and their caregivers to prevent or slow the onset of dementia.” [m]Power’s SeniorCentric interface utilizes a touch screen with no mouse or keyboard.

Because many older adults are unfamiliar with computers, Dakim’s integral hardware and software product is designed to be easy for them to use, even with limited hand-eye coordination or fine motor skills. “We want to make this experience fun and compelling for seniors, so they look forward to using [m]Power,” he says. The program requires neither training nor facilitators, removing related costs from its implementation in a facilitywide brain fitness program. Users’ pictures and names appear on the screen to start the program after they simply enter their initials.

Dakim downloads rich content and new exercises almost daily, preventing tedium and repetition. Multimedia activities include music and visual content designed to stimulate cognitive function and socialization.
Brain fitness product supporters believe their benefits extend beyond cognitive training. Brain fitness classes can serve as social activities for participants in a supportive environment, resulting in benefits beyond improvement in memory for older adults who frequently isolate themselves. Programs help introduce computers to older adults who may never have used them before. “We have seen this lead to an increased comfort level with computer use to e-mailing and Internet use. After brain fitness classes, grandparents are now e-mailing friends and family and viewing family photos on the Internet,” Hardy says.

Although there may be benefits related to social interaction and computer use, Nelson remains unconvinced that commercial brain fitness products alone can result in memory improvements applicable to daily situations. At best, he believes, brain fitness games may help indirectly, since memory capabilities and other cognitive functions are “use it or lose it” skills. Nelson suggests that activities such as visiting theaters and museums, volunteering, participating in book discussion groups or a chess or bridge club, surfing the Internet, and taking courses to learn new skills can keep the brain stimulated and may be more interesting for older adults than just playing brain fitness games.

“People who stay mentally active on a daily basis have better preserved cognitive skills as they age,” says Cynthia R. Green, PhD, an assistant clinical professor at New York’s Mount Sinai School of Medicine and president of Memory Arts LLC, a provider of scientifically based memory fitness training for individuals, corporations, and organizations.

Green cites the Stern cognitive reserve study, as well as the large, 30-year Seattle Longitudinal Study by psychologist K. Warner Schaie, PhD, indicating that predictors of good mental function in aging include a high level of reading comprehension or verbal fluency, a successful career or other active involvement throughout life, and a continuing interest in mental activities after retirement. The Schaie study found less mental decline in older adults who liked learning new things, enjoyed visiting new places, and adapted easily to change than in those who didn’t.

Published long before the advent of today’s brain fitness software, these studies suggest that older adults do not necessarily need to participate in computerized brain training to fight age-related decline in cognitive functions. Green notes, “While there is no evidence that brain games will prevent brain changes, practicing certain skills during these games may help with some skills related to memory.”

With brain fitness games, Nelson says, an individual may become better at playing the game but no better in terms of daily functioning. For instance, he questions whether brain fitness software can help older adults remember where they put their car keys or the dates of their grandchildren’s birthdays. Just as functional fitness exercises are now considered more appropriate to improve elders’ physical fitness, functional strategies to address individual memory problems will better help older adults improve daily cognitive functioning. For older adults who can’t remember the birthdays of their grandchildren or their doctors’ appointments, keeping a calendar with birthdays and appointments noted in a visible place will be much more helpful in daily life than playing games that test memory skills, Nelson says.

Testing the Waters
Tempering an interest in keeping up with the latest trends in brain fitness with a bit of skepticism about their effectiveness, administrators at older adult communities and facilities may consider their implementation as only one part of an overall program designed to enhance body and brain health. Westcott Lakes, sponsored by Tallahassee’s Florida State University, is an upscale continuing care retirement community (CCRC) focusing on preventive healthcare and lifelong learning for community members. “As a nation, we have been pretty successful at keeping people alive a lot longer, but we haven’t focused on the quality of life for those years. If there is a chance that brain fitness programs can delay memory loss and improve quality of life, then we should try them,” says G. Richard Ambrosius, vice president of communications, coaching, and culture for PRAXEIS, a Jacksonville, Fla.-based company that develops, markets, and manages Life Fulfilling Communities for adults aged 62 and older.

“Posit Science’s Brain Fitness Program will be used to kick off the community’s lifelong learning program called Life College,” says Ambrosius. “Initially, we will have computers in our welcome center classroom with brain fitness classes offered three to five days a week.” Because member-driven programs are more likely to succeed, program officials explain the science behind brain fitness programs to current and prospective community members who evaluate this and other programs.
Implementing brain fitness programs in older adult residential communities and CCRCs is an expensive undertaking, although some brain games are available free online where individuals can also purchase affordable online games or software for home use.

Commercial brain fitness games are not the only option to train the brain, says Green. Timed activities that require paying attention, focusing, working quickly, and thinking flexibly are ideal for training skills required for daily memory challenges, she says. In cases where finances create a barrier to purchasing brain fitness programs, Green suggests inexpensive activities organized around games that have been available for years. “Boggle, a timed word game, and Simon, a nonverbal game with an auditory and visual component, could easily be offered in a recreation room much like bingo is. Or older adults can borrow their grandkids’ Nintendo or Wii games, which offer brain challenges,” she says.

 There is no question that exercising the brain imparts benefits as we age and certain brain training exercises can improve specific cognitive skills. However, whether brain fitness programs prevent Alzheimer’s disease continues to be evaluated. “There is a need for better and more widely accessible cognitive assessments that can provide a good baseline, identify priorities, and measure progress,” Fernandez says. Information from manufacturers and clinicians involved in brain training is often confusing and conflicting, and health professionals need better education and information about how the brain works with regard to cognitive skills in order to make well-informed decisions, he says.

It is likely that the debate among researchers, brain fitness program suppliers, and practitioners will continue, given the emerging developments in this new and evolving field of brain health. Should consumers and organizations for older adults invest in these tools and methods? Ambrosius sums it up: “While brain fitness programs may not prevent Alzheimer’s disease or dementia, they certainly do no harm and may be one way to counter the self-fulfilling prophecies of aging that do so much harm.”

— Jennifer Van Pelt, MA, is a freelance writer based in Reading, PA, and a certified fitness instructor with experience teaching older adults.


Training Sensory Attention
Advanced brain imaging techniques are helping to reveal how the brain is affected by cognitive training. Paul J. Laurienti, MD, PhD, an associate professor in the radiology department at Wake Forest University, recently presented preliminary data from a pilot study of 66 healthy adults aged 65 to 75 who underwent multiple types of MRI before and after cognitive training sessions. The cognitive training program was devised specifically for the study and targeted sensory attention.

During functional MRI (fMRI), the participants were imaged while performing specific tasks related to hearing, vision, and attention to assess how distracting background information affects the ability to process sounds or visual images. Initial results showed improvements in attention, as well as working memory and speed-of-information processing, with eight weekly sessions of cognitive training. Laurienti believes this combination of anatomical and fMRI is the most extensive imaging study assessing a cognitive training program and plans to expand it to multicenter clinical trials.

“Evidence shows that older adults are more distractible across sensory modalities. In a world where we are constantly bombarded with sensory information, it is very important to be able to filter information that is important,” he says. “If we can train attention, older adults will be able to take in information more efficiently, resulting in cognitive improvements at all levels. Improving attention leads to improving information processing, which in turn can lead to better memory comprehension.”

He believes none of the commercially available brain fitness products addresses this type of sensory attention. The value of attention training lies in teaching older adults to focus on one sense and ignore the others—for instance, reading a book while a television or radio is playing in the background.

Another important practical application, Laurienti believes, may be help with fall prevention. For older adults, a fall can be devastating, causing broken bones, loss of mobility, and even death (from complications). “There is growing evidence that falls aren’t simply a physical process, but that cognition is involved,” he says. Further studies may show how sounds and other distractions contribute to falling, which Laurienti says results from multisensory interactions. “Ultimately, attention training could apply to everyday fall prevention,” he says.