January/February 2019

Alzheimer's & Dementia: Brain Training and Cognitive Performance: Evidence From an Interventional Lifestyle Program
By Ian M. McDonough, PhD; Cynthia R. Green, PhD; and Sarah K. Letang, MS
Today's Geriatric Medicine
Vol. 12 No. 1 P. 5

With an increase in the average human life expectancy, our population faces new health challenges. Dementia, in particular, is affecting older adults' health more than ever. It's estimated that by 2050, $1.1 trillion will be spent on Alzheimer's disease and other forms of dementia in the United States alone.1

Of course, the economic impact does not compare to the devastation that persons with dementia face and the stress their caregivers experience. To help minimize issues stemming from dementia, scientific researchers around the world are thinking of new ways to prevent, delay, or at least better manage the disease and its impact on caregivers.

Current research suggests that many of the same factors that help improve general health, including heart health, might also improve brain health. What are these secrets to promoting a healthy body and mind? Habits people can start changing today include following a nutritious diet, keeping a healthy sleep schedule, engaging in physical activities, and keeping their brains stimulated.2

In a perfect world, people of all ages would engage in these healthful habits to reduce their risk of cognitive decline and push back any possible diagnosis of dementia. However, most of us are aware that knowing what's good for the body and mind is quite different from changing behavior, practicing new behaviors, and sustaining those practices throughout life. For these reasons, many programs have been developed to nudge people, particularly older adults, toward implementing such healthful practices.3,4

The Rise and Fall of Brain Training Programs
Of the many recommended health practices, keeping the brain mentally active and sharp has been a key focus that's increasingly of interest to both scientists and the community. From this interest, the term "brain training"—coined by companies that marketed cognitive games or interventions—has emerged. The idea is that training the brain through cognitive tasks or games can improve individuals' abilities, which in turn should improve their quality of life by allowing them to better remember people's names or what they need at the grocery store, react quickly and appropriately while driving, and perform other everyday tasks.

Furthermore, with the increased accessibility by all generations to smartphones and other mobile devices, the popularity of brain training has become apparent through the emergence of numerous easy-to-use apps such as Lumosity and CogniFit Brain Fitness that promise users can squeeze a brain workout simply and easily into their hectic lives.

In response to the increasing popularity of brain training, important questions have arisen: Do these activities actually aid in improving the brain in any way? Can practice in one skill truly enhance performance on an everyday skill that was not practiced? Will brain training help individuals as they age by lowering the risk for cognitive decline?

Companies that developed these apps have come under fire for falsely claiming the products benefitted aging brains by improving cognitive skills unrelated to the simple skills that could be practiced using the app.

In 2014, two respected groups of researchers published contradicting reviews on how previous research does or doesn't support the hypothesis that brain training aids in cognitive maintenance, enhancement, and development throughout life. Those researchers advocating for the brain training programs pointed to evidence that brain training results in cognitive improvement in the specific task the users were asked to perform. Improvements were found in processing speed, attention, and visual episodic memory, as well as subjective well-being.5,6

Advocates against brain training observe that it rarely generalizes to cognitive tasks other than those being trained and often doesn't contribute to improvement in the tasks of daily life.7

The New Model of Brain Engagement
With these mixed results for traditional brain training programs, a new approach or set of approaches are necessary. First, most brain training programs focus on cognition rather than on a well-rounded perspective that also includes improving social and emotional well-being. Second, many brain training programs are implemented on a computer, and some older adults might not have—or want—experience with computers.

To address these issues, TBH Brands LLC has been developing the Total Brain Health® programs and TBH Toolkits since 2015 (www.tbhtoolkits.com). These toolkits are a series of "out of the box" commercial programs on memory improvement and brain fitness designed especially to be used in active aging and fitness settings. The TBH Toolkits are founded on decades of research showing that cognitive function and long-term brain vitality are best supported by ongoing and robust engagement across physical, intellectual, and socio-economic aspects of well-being. In contrast to the old model of brain training programs, TBH's brain training philosophy draws from the following three evidence-based methods:

• training across the wellness spectrum;
• social-based brain training; and
• experiential learning.

Research shows that people must engage in activities across the multiple areas of health to fully boost their daily thinking and long-term brain vitality. Keeping physically fit helps sharpen intellectual performance and has been linked to lowered dementia risk. Cognitive training can revive skills that diminish with age, such as attention, quick thinking, multitasking, short-term memory, and reasoning. Strong, satisfying social ties, emotional balance, and a positive outlook are associated with better thinking and long-term brain vitality.

Training in groups has been shown to fast track the effects of brain training on cognitive abilities and can directly influence the cognitive skills most challenged by aging. This notion of social engagement was recently emphasized by the Global Council on Brain Health, which reported that "the weight of the evidence suggests that social engagement helps maintain thinking skills and slows cognitive decline in later life."8

All TBH courses and programs are built on a proprietary method that holds social-based brain training as a core tenet. People learn better by "doing," especially the types of activities that have been shown to boost brain fitness. In a TBH program, users are offered a "hands-on" opportunity to try out what they're learning, not just read about it or listen to a lecture.

Preliminary Evidence for the Toolkits
We recently presented findings at the Cognitive Aging Conference held every other year in Atlanta. In our study, two of the TBH programs, TBH MEMORY 1.0 and TBH BRAIN WORKOUT 1.0, were tested in a community-based sample of older adults. Fifty older adults participated in the TBH MEMORY 1.0 program consisting of one class per week for 16 weeks. Twenty older adults participated in the TBH BRAIN WORKOUT 1.0 program consisting of one class per week for 20 weeks. A trained community instructor led each.

Questionnaires were given to participants before and after the program. Participants in both TBH programs were given a brain health knowledge quiz and tested for depressive symptoms. In addition, participants in the TBH MEMORY 1.0 program were given questionnaires that focused on memory, including memory functioning and self-efficacy. Participants in the TBH BRAIN WORKOUT 1.0 program were given a daily habits questionnaire.

Both programs resulted in significant improvement in brain health knowledge, and this improvement did not significantly differ by group (see Figure 1). The TBH MEMORY group showed improvements in memory self-efficacy (see Figure 2). The TBH BRAIN WORKOUT group showed marginal improvements in health habits. No improvements were found for depression in either group. Overall, these pilot results show promise for both the TBH MEMORY and TBH BRAIN WORKOUT programs. Further research is needed to gather objective measures of cognition and should include both active and passive control groups.

Brain Health Research
We are currently expanding on the above findings by partnering with the Acts Center for Applied Research, which serves more than 8,500 independent living residents across the nation, to evaluate the TBH programs.

In participating communities, older adults are randomly assigned to one of six groups: TBH BRAIN WORKOUT 1.0, TBH BRAIN WORKOUT 2.0, TBH MEMORY 1.0, TBH MEMORY 2.0, a book club that will read and discuss a self-help book on cognitive health, and a wait-list control group. All groups other than the wait-list control group will meet for eight sessions over two months.

The older adults who agree to be a part of the research will be asked to fill out a survey at preintervention, postintervention 1 (immediate), and postintervention 2 (two months) that gathers information regarding demographics, depression, loneliness, social support, subjective memory, lifestyle factors, and healthy living knowledge. We've already collected data from more than 300 participants and plan to implement a new dementia risk scale in the next set of communities.

The Future of Brain Health Programs
To truly satisfy the goals of preventing, delaying, or at least better managing life-threatening neurocognitive disorders such as dementia, our research suggests that well-rounded programs offer the most promise for success. Such programs should target not only cognitive health but also eating, sleeping, and exercise to improve physical health. Furthermore, they should focus on social and emotional health by providing opportunities to engage with others.

As concluded by the Lancet Commission, effective programs must not only teach how to improve brain health through all these factors but also give older adults the tools to implement that knowledge throughout their lives and maybe have some fun in the process.3

The Total Brain Health Toolkits aim to cover all of these bases and thus provide such a solution. However, it's also important that we don't fall into the traps that brain training programs found themselves in—that is, we need to provide evidence proactively that these programs do what they claim to do, and if not, adjust them accordingly.

— Ian M. McDonough, PhD, is an assistant professor in the psychology department at the University of Alabama and an associate of the Alabama Research Institute on Aging. In his first year as faculty, he received the Matilda White Riley Early Stage Investigator Honors from the National Institutes of Health and was accepted into the highly competitive Butler-Williams Scholars Program at the National Institute on Aging. His current research focuses on the neural correlates of memory and how they differ with old age. He's recently begun investigating how the brain differs in middle-aged and older adults at risk for Alzheimer's disease, with a particular focus on racial/ethnic health disparities. This work has garnered him the 2017 Charles Barkley Health Disparities Research Investigator Award.

— Cynthia R. Green, PhD, is a clinical psychologist and a leading expert and author in the field of brain health. She's CEO of TBH Brands, the parent company of Total Brain Health. A member of the department of psychiatry faculty at the Mount Sinai School of Medicine since 1990, Green is the author of five books on brain health, both on her own and in collaboration with major brands such as Prevention and National Geographic. Her book with National Geographic, Your Best Brain Ever, was named a "2013 Top Guide to Life After 50" by The Wall Street Journal. In addition, Green frequently serves as a consultant to companies on memory and brain fitness and is a highly regarded keynote speaker for organizational, corporate, and association events.

— Sarah K. Letang, MS, is a clinical graduate student in the psychology department at the University of Alabama. She's amassed an impressive amount of clinical assessment experience with all age ranges at the University of Michigan's Physical Medicine and Rehabilitation and Beaumont Hospital's Physical Medicine and Rehabilitation. Her current research focuses on the aging population, primarily examining how the brains of middle-aged individuals differ from those of older adults at risk for Alzheimer's disease. Her recent clinical training at the Mary Starke Harper Geriatric Psychiatry Center in Tuscaloosa, Alabama, has allowed her to gain comprehensive experience in clinical therapy for the aging population.

References
1. Alzheimer's Association. 2018 Alzheimer's disease facts and figures. https://www.alz.org/media/HomeOffice/Facts%20and%20Figures/facts-and-figures.pdf. Published 2018.

2. Deckers K, van Boxtel MP, Schiepers OJ, et al. Target risk factors for dementia prevention: a systematic review and Delphi consensus study on the evidence from observational studies. Int J Geriatr Psychiatry. 2015;30(3):234-246.

3. Livingston G, Sommerlad A, Orgeta V, et al. Dementia prevention, intervention, and care. Lancet. 2017;390(10113):2673-2734.

4. Ngandu T, Lehtisalo J, Solomon A, et al. A 2 year multidomain intervention of diet, exercise, cognitive training, and vascular risk monitoring versus control to prevent cognitive decline in at-risk elderly people (FINGER): a randomised controlled trial. Lancet. 2015;385(9984):2255-2263.

5. Ballesteros S, Mayas J, Prieto A, et al. A randomized controlled trial of brain training with non-action video games in older adults: results of the 3-month follow-up. Front Aging Neurosci. 2015;7:45.

6. Basak C, Qin S. Virtual cognitive training in healthy aging and mild cognitive impairment. In: Pak R, Collins McLaughlin A, eds. Aging, Technology and Health. Academic Press; 2018:215-235.

7. Simons DJ, Boot WR, Charness N, et al. Do "brain-training" programs work? Psychol Sci Public Interest. 2016;17(3):103-186.

8. Global Council on Brain Health. The brain and social connectedness: GCBH recommendations on social engagement and brain health. https://www.aarp.org/content/dam/aarp/health/brain_health/2017/02/gcbh-social-engagement-report-english-aarp.doi.10.26419%252Fpia.00015.001.pdf. Published 2017.