Revisiting Brain Exercises

Last week, I highlighted some research by the HABIT team evaluating the comparative impact of the 5 components of the HABIT program: Cognitive rehabilitation, cognitive training, yoga, support group, and wellness. We concluded that the topic is complicated and that no one intervention is "best." Multi-component interventions are likely to continue to be most helpful for patients with MCI. I did, however, mention that in evaluating the outcomes of quality of life, mood, anxiety, and self-efficacy, eliminating cognitive training did not negatively impact those outcomes.

Does this mean we think you can stop doing those brain games? Not so fast. I noted that we have not yet evaluated our cognitive outcome data to see if cognitive training may make a difference there.  Because of this, I thought it an opportune time to highlight another recent study, this time from researchers in China, specifically evaluating the cognitive impact of cognitive training. Here are some details and summary, but you can read the study here if you like.

THE STUDY POPULATION:

This study was conducted in patients diagnosed with "vascular cognitive impairment no dementia". This is essentially another way of saying Mild Cognitive Impairment (MCI) but with a known underlying etiology (cause) of vascular disease. As we discuss in HABIT, MCI is a syndrome that describes the loss of cognitive ability (memory, word finding, or executive functioning for example) but with relatively good day-to-day functioning. There are many diseases that may cause MCI. Alzheimer's disease is one, but vascular disease (i.e., small strokes or impaired blood flow in blood vessels of the brain) is another. In HABIT, we see patients with MCI with all etiologies and we may not even be sure of the disease. However, in this specific study, researchers limited the sample to patients with evidence of cognitive impairment (but not dementia) with evidence significant small vessel ischemic disease (i.e., vascular disease, primarily based on MRI scan--taking a picture of the brain and seeing evidence of small strokes).

THE INTERVENTION:

Patients were randomly assigned to one of two possible interventions. The training group received a computerized, multidomain, adaptive training program for 7 weeks. They completed 30 minutes of training per day 5 days per week. When patients completed tasks with high accuracy, they upgraded to a higher difficulty level. The active control group received speed and attention tasks, also 30 minutes per day, 5 days per week for 7 weeks. In this group, they completed tasks at the same difficulty level throughout the study. This is a key difference between the interventions--the exercises got progressively more difficult as the participants got better at them in the training group.

OUTCOME MEASURES:

The researchers collected data on measures of cognitive functioning (pencil and paper cognitive measurements) as well as measurements of brain functioning on brain scans (MRI and functional MRI). These measures are mean to evaluate changes in size of memory-important areas of the brain and evaluate the integrity and efficiency of the connections in the brain. They conducted these measurements prior to the intervention, at the end of the interventions, and 6 months later.

RESULTS AND CONCLUSIONS:

The found a significant improvement on pencil and paper cognitive measurements in the training group compared to the active control group. Unfortunately, this effect went away by 6 months after stopping the intervention. They did not find any change in the size of various brain structures with training compared to the active control, but the did see an increase in brain connections. Again, this improvement went away by 6 months after stopping the intervention.

What are the take home message?

1. This study shows improvements in cognitive functioning and brain efficiency with a specific type of cognitive exercise: adaptive computerized cognitive training.  It is important that the control group--also doing cognitive exercise but without consistent adjustment of the challenge level--did not show the same benefit. So, this suggests that not all cognitive exercises are equal, and that the most benefit on cognitive measures and brain connection efficiency is likely to come from exercises that continue to adapt and provide challenge, even as you get better at the exercises.
2. However, there is another outcome I would like to see evaluated in these studies, which is lacking here--do the benefits on cognitive outcomes and brain connections from training exercises result in improvements in other outcomes, such as how a person with MCI is functioning and coping day to day?  Or, do these improvements help slow any progression of MCI over the long term? I certainly think these cognitive and brain outcomes are exciting, but our patients want to know more--reasonably so. If I do these brain games, will it slow any decline I might have down the road or will it actually improve how I am able to function and living independently in day-to-day activities? So, I think these results are an exciting start, but I hope we can eventually see longer term funding of these studies to really support evaluating long term outcomes.
3. This study was done with patients with a specific type of MCI related to vascular disease. The results may not be equally applicable to all other types of MCI (such as MCI thought to be related to Alzheimer's disease or Parkinson's disease). However, this study is still of interest in my mind as it is a study with individuals with an abnormal process rather than a study of normal cognitive aging (which many other studies in the area are and are less relevant to our patients with MCI).
4. It is also very relevant that the benefits of the adaptive cognitive exercises dissipated over time when the participants stopped doing them. By 6 months, they had lost all the benefits they'd gain. This is why we emphasizing creating HABITS in our program--keep doing the exercises to maintain the benefits.

Overall, I usually emphasize to my patients that we need to understand the benefits of cognitive exercise more. Ongoing research seems to suggest that cognitive exercises are not all created equal, and any potential benefits are only sustained with ongoing exercise.  I'm optimistic enough about the benefits given studies like these, that we do routinely recommend brain exercise and help our patients create a habit during our treatment program. If you've been successful in creating a cognitive exercise habit, I'd love to hear more about what you are doing and how you maintain the habit!