Vol. 16 nº 2 - Apr/May/Jun de 2022
Views & Reviews Pages 135 to 152
 

Long-term studies in cognitive training for older adults: a systematic review
Estudos de longa duração de treino cognitivo para idosos: uma revisão sistemática

Authors: Thais Bento Lima da Silva1,2; Jéssica Souza Bratkauskas1; Maurício Einstoss de Castro Barbosa1; Guilherme Alves da Silva1; Mariana Garcia Zumkeller1; Luiz Carlos de Moraes2; Patrícia Prata Lessa2; Neide Pereira Cardoso2; Tiago Nascimento Ordonez1; Sonia Maria Dozzi Brucki3

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Descriptors: Aging; Aged; Cognition; Cognitive Aging; Time.
Descritores:
Envelhecimento; Idoso; Cognição; Envelhecimento Cognitivo; Tempo.

ABSTRACT:
Studies show that aging is accompanied by losses in cognitive functions and that interventions can increase performance and/or support the maintenance of cognitive skills in the elderly.
OBJECTIVE: The objective of this study was to carry out a systematic review of long-term studies involving cognitive training (CT) in older adults without dementia and/or with mild cognitive impairment (MCI).
METHODS: A systematic review of controlled studies was published in scientific journals from 2000 onward, with duration ≥6 months, CT intervention, cognitively normal (CN) or MCI participants aged ≥60 years, and assessments using cognitive and/or neuropsychological tests.
RESULTS: A total of 32 studies were reviewed, comprising 10 on study protocols, 14 in CN older adults (no MCI and/or dementia), and 8 in older adults with MCI or at risk for dementia.
CONCLUSIONS: The studies reported improvements in cognitive performance for some motor abilities, among older participants of CT with or without booster sessions, including multimodal interventions or otherwise.

RESUMO:
Estudos mostram que o envelhecimento é acompanhado por perdas nas funções cognitivas, e que as intervenções podem gerar um aumento no desempenho e/ou apoiar a manutenção de habilidades cognitivas em idosos.
OBJETIVO: Realizar uma revisão sistemática de pesquisas com longa duração que ofereceram treino cognitivo (CT) em idosos sem demência e/ou com comprometimento cognitivo leve (MCI).
MÃ%TODOS: Revisão sistemática de estudos controlados, publicados em periódicos científicos a partir de 2000, com duração ≥6 meses, CT na intervenção, participantes ≥60 anos, saudáveis ou com MCI, avaliações por testes cognitivos e/ou neuropsicológicos.
RESULTADOS: Foram selecionados 32 estudos, sendo dez protocolos de pesquisa, 14 com idosos sem MCI e/ou sem demência e oito com idosos com MCI ou risco de demência.
CONCLUSÃES: Foram relatados benefícios no desempenho cognitivo, incluindo habilidades motoras, de idosos que participaram de CT, com ou sem sessões de reforço, incluindo ou não intervenções multimodais.

INTRODUCTION

According to the estimates of the United Nations 2019 Revision of World Population Prospects1, 17.8% of people in the world will be above age 65 by 2060, up from 9.6% in 2021. In Brazil, this proportion will increase from 9.9 to 27%. During the normal cognitive aging process, the organism undergoes periods of stability and change. These changes partially stem from physiological and anatomical components. Most notable of the normal changes accompanying healthy aging are the aspects relating to the brain and cognitive functioning2, which may affect more complex everyday tasks, such as driving, paying bills, and remembering dates and appointments3.

Studies show that aging is accompanied by losses in cognitive functions and that interventions can promote performance gains and/or support the maintenance of cognitive abilities in healthy older persons3,4. According to the literature, the existing cognitive interventions, such as cognitive training (CT), have the potential for promoting health by optimizing cognitive and neural plasticity. These effects may be increased by combining CT with other types of interventions, such as physical activities and a balanced diet, with the aim of improving the performance of the individual and neural reorganization as a result of the intervention5,6. Both neural and cognitive plasticity are an inherent part of the life course of an individual. Although diminishing with age, plasticity supports the learning of mnemonic techniques, as well as the expansion and integration of knowledge related to cognitive functions7.

The effects of CT can extend to other domains, such as health promotion8,9, as well as functioning10. A plethora of cognitive modalities have been tested in both healthy and cognitively impaired elderly, displaying similar positive effects on cognitive performance and other variables, such as psychological well-being. According to Ngandu et al.6, intervention might not be too late for presymptomatic and predementia disease stages and also for at-risk states, such as in mild cognitive impairment (MCI). For example, recent studies by Peng et al.11, Valdés et al.12, Lee et al.13, and Djabelkhir et al.14. reported cognitive gains in older adults with MCI. The research by Lee et al.13 indicated benefits even for mild dementia.

One of the first CT studies of the long-term type, i.e., lasting 6 consecutive months or longer, was the multicenter study conducted by Ball et al.15, involving a large number of participants: 2,832 subjects aged 65â?"94 years. Participants received one of the following types of cognitive intervention: (a) verbal episodic memory training (group 1), (b) logical reasoning training (group 2), (c) processing speed training (group 3), or (d) control group without training (group 4). A total of 10 training sessions were given and 60% of the sample received 4 booster sessions after 11 months. The results showed that 87% of participants from group 3 improved performance on processing speed, 74% from group 2 improved logical reasoning, and 26% from group 1 improved memory. Booster sessions were effective for maintaining processing speed and logical reasoning, but not for episodic memory. The positive effects of training were not detected during the daily routine of participants, but persisted after 2 years, suggesting that the intervention effects can remain consistent over the long term.

Ngandu et al.6, in a study involving a multidomain intervention of nutritional diet, physical exercise, CT, and vascular risk monitoring, reported this to be more effective and efficient, showing 20â?"150% of improvement in cognitive performance of participants. The Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability (FINGER) described the effects of this approach, showing that the intensity of the intervention, the target public, the type of approach, and the fact of being long-term training explained the beneficial effects for cognition observed in participants. These results reveal the importance of healthy dietary habits and regular physical exercise in conjunction with cognitive interventions.

Training studies differ not only in duration but also in strategies trained and methodology employed. Results reported in the literature varied widely regarding the strength of effects, generalization to untrained tasks, and long-term maintenance of improvements16. This heterogeneity justifies an analysis of the literature on long-term cognitive interventions with the aim of adding to the knowledge on CT and providing consistent, in-depth information on the cognitive benefits associated with long-term interventions and the strategies they employ. The objective of this study was to carry out a systematic review of long-term studies involving CT in older adults without dementia and/or with MCI.


METHODS

This systematic review had its protocol registered in the International Prospective Register of Systematic Reviews (PROSPERO) in April 2021 (submitted in February 2021) under registration number CRD42021239130. The protocol can be assessed at https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021239130.

Eligibility criteria were as follows: clinical trial studies with a 6-month duration or longer, intervention involving CT and a control group, cognitively normal (CN) or MCI participants aged ≥60 years, articles published in 2000 or later in scientific journals, and follow-up assessments of intervention effects using cognitive and/or neuropsychological tests. The criterion used for CT studies to be considered long term was to have a duration of 6 consecutive months or more.

Publications of masterâ?Ts dissertations, book chapters, doctoral theses, letters to the editor and case studies, studies whose samples included individuals aged <60 years or with dementia, studies performed at long-term care institutions, and studies failing to report the effects of intervention on cognitive performance were excluded.

The systematic review was conducted between February and April 2021. All manuscripts in Portuguese and English were revised for eligibility criteria. The Scielo, LILACS, and PubMed/MEDLINE scientific databases were searched using the following combinations of the key words: ((idoso OR idosos OR idosa OR idosas) OR (elder OR â?oolder personâ?? OR â?oolder personsâ?? OR â?oolder peopleâ?? OR â?osenior citizenâ?? OR â?osenior citizensâ?? OR elderly OR â?oaging peopleâ?? OR â?oaging personâ?? OR â?oaging personsâ??)) AND (â?otreino cognitivoâ?? OR â?ocognitive trainingâ??) AND (â?olonga duraçãoâ?? OR â?olong termâ?? OR longitudinal OR â?ofollow upâ??) AND (envelhecimento OR aging).

To guide the stages of identification, screening, and eligibility of studies, two pairs of reviewers working independently screened all records retrieved, following the steps of the Statement of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)17. The initial identification of studies was performed by searching the abovementioned databases. In the screening stage, duplicate studies were excluded, and titles and abstracts were read for the first selection, according to the preestablished inclusion and exclusion criteria. In the eligibility stage, the remaining studies were read in full in order to be selected according to the same criteria. The remaining studies after this stage were the studies included in the review.

The following data were extracted from the articles: study title, authorsâ?T name, summary, results, methods, justification, objectives, and conclusion. Excel spreadsheets were used as support tools in this process.

The studies were assessed for quality according to Downs and Blackâ?Ts18 checklist. This assessment tool consists of 27 questions, which are divided into 5 subscales: report or assessment of adequate information (10 items), external validity (3 items), internal validity of detailed measurements and result bias (7 items), confounding factors (6 items), and power (1 item). Each item that makes up the checklist assigns a score from 0 to 1, except for the item that assesses the description of confounding factors, which can assign up to 2 points, and the item that assesses the description of the studyâ?Ts power (27), which originally assigned from 0 to 5 points, but was modified to assign from 0 to 1 point, as in other studies19-21 so that a score of 1 was given if the article presented power calculation and/or sample size calculation and a score of 0 if it did not present any of these calculations. Thus, the checklist has total scores ranging from 0 to 28 points. For a better understanding of the data obtained, the score was converted into a percentage for each domain, and a final average of the total score of all domains was calculated. Next, the quality of the articles was classified as follows: up to 0.39 was considered bad, 0.40â?"0.69 considered regular, 0.70â?"0.79 considered good, and 0.80 or above was considered excellent.


RESULTS

The initial search led to the retrieval of 83 studies, of which 1 was subsequently excluded owing to duplication. Titles and abstracts of the remaining 82 studies were read and screened for relevance to the review topic. After applying inclusion and exclusion criteria, a total of 27 studies were excluded. Thus, 56 articles were read in full; of these, 24 studies that did not meet the eligibility criteria were excluded. The process of study selection for inclusion in the review is shown in Figure 1. The final 32 studies included in the review for analysis are listed in Tables 1â?"3.


Figure 1. Flowchart showing study selection process.17








Publications of study protocols

Ten of the studies included were protocols, i.e., publications of study methods and planning, but not results22-38. Study protocols are regularly published before the intervention is carried out so that its originality and authorship are assured, thus enabling its application by other researchers in different research centers.

Eight of the study protocols22-29 had innovative methods and objectives, which, in general, sought to investigate the effects of multiple domain interventions focusing on a range of aspects, such as preventing cognitive impairment, cognitive functions, physical fitness, activities of daily living (ADL), quality of life, gait speed, incidence of falls, and executive functions. For these studies, participants were categorized into CN older adults, elderly at risk for cognitive impairment, subjects with aging-related cognitive impairment, and older patients diagnosed with MCI. Interventions used a variety of resources, such as tablets, computers, physical training (PT), walking, health advice, software such as Fit Brains and Tonic and Phasic Alertness Training (TAPAT), electrostimulation, and vitamins.

Two other studies included in this review were publications of study protocols. Jobe et al.31 presented the design of the long-term Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) study, based on a sample of 2,802 older adults. The participants were randomized into a control group, speed of processing training (SOPT) group, a reasoning training group, and a memory group. The intervention consisted of 10 sessions of 60â?"75 min over a period of 56 weeks, plus booster sessions for 11 months after the primary training. To determine the long-term effects, assessments were carried out after 1 and 2 years. Similarly, Rebok et al.10 applied booster sessions for 35 months after the primary intervention, with data collected 3, 5, and 10 years after the pre-intervention assessment. Due to the magnitude of the ACTIVE study, many studies recruited its data, of which 11 were selected for inclusion in this review.

The study by Kivipelto et al.30 described the protocol of the FINGER study, with 1,200 older persons at risk for cognitive impairment. Participants were randomized into two groups. One group received CT combined with nutritional counseling, PT, social activity, and management of metabolic and vascular risk factors, for two 6-month periods, three times a week, totaling 72 sessions of 10â?"15 min each. The other group consisted of control and was given regular health advice. Long-term effects were to be measured by assessments planned 1 and 2 years after the intervention. One of the studies derived from the FINGER was also included in this review.

Complete clinical trials

Of the 22 studies whose results were analyzed in this review, 14 involved samples comprising CN older adults, i.e., without MCI and/or early dementia10,32-44, whereas 8 involved subjects with MCI or at risk for dementia6,45-51.

Ten10,37-44,51 of 22 studies drew on data from the ACTIVE study. Besides, a number of studies included employed multimodal interventions, also referred to as multifactorial, namely, FINGER, with nutritional interventions based on a specific diet, physical fitness training programs, and cognitive interventions, such as CT, and also with vascular risk monitoring6,30; AgeWell, which includes nutritional counseling, physical activity, CT, optimization of medication, management of vascular risk factors, social activity, and further specific interventions targeting grief and depression33; other studies whose interventions include combined CT and PT22,23,28,32,34,35; and a study with training of memory, reasoning, problem resolution strategies, visuospatial map reading skills, and handicraft making34.

Objectives

The objectives of the studies varied widely, in which those involving CN subjects tended to investigate the long-term effects of programs for SOPT, reasoning and/or episodic memory on everyday functioning and cognition10,41,43, on the trajectory of cognitive aging42, increase in cognitive function of older people33, impact of CT on objective measures of physical functioning38, on use of cognitive strategies40,44, on initial recall and learning37, on memory for prose39, on performance of working memory (WM), and on untrained tasks36. Studies with interventions involving combined CT and PT investigated the long-term effects on cognition32 and fluid cognitive abilities sensitive to age35. Finally, the study by Li et al.34 examined the relationship between changes in brain activity and cognitive performance after a multimodal or multifactorial intervention.

The studies with samples comprising older adults with MCI focused on investigating the longitudinal effects of SOPT on processing speed51 and examining longitudinal efficacy for cognitive performance of different types of intervention: a program using episodic memory coding strategies48, a neuropsychological training (NPT) program in patients treated with cholinesterase inhibitors (ChEIs)49, a creative expression therapy (CrExp)45, CT plus psychosocial intervention47, a computerized cognitive training (CCT) program46, and a program of simulated functional tasks (FcTSim)50.

With regard to the study in older adults with some cognitive impairment but no MCI diagnosis, the objective was to investigate the longitudinal effects on cognitive functions of a multidomain intervention, combined CT, diet, physical exercise, and cardiovascular risk monitoring6.

Main interventions with cognitively normal older adults

Of the 14 studies conducted in CN samples, 4 studies10,38,41,42 analyzed data from the three intervention groups of the ACTIVE study31. Based on the protocol of this study, Kwok et al.33 conducted a trial in 223 older people with subjective cognitive complaints who received an intervention of 12 sessions of 90 min given weekly, also entailing SOPT, besides memory and reasoning training.

Five studies involving CN elderly were specific interventions for training memory. Three studies analyzed data from memory, training, and control groups in the ACTIVE study, involving a total of 1,401 participants37,40,44. The studies of by Gross and Rebok40 and Gross et al.44 assessed the impact of the memory training program from the ACTIVE study on the use of strategies. In a specific learning intervention involving the memorizing of short stories, the study by Sisco et al.39 assessed the impacts of the memory training program from the ACTIVE study in conjunction with the booster intervention, including a total of 1,902 participants39. Borella et al.36 carried out WM training with 36 older adults who underwent a 2-week intervention of 60-min sessions.

The study by Ball et al.43 analyzed the data from the primary SOPT program plus booster sessions of the ACTIVE study, in which 1,400 and 633 older adults participated, respectively, including control groups.

A further two studies in CN older adults applied interventions involving combined CT plus PT32,35. The study by Linde et al.35, involving 70 senior citizens, applied an intervention comprising weekly 30- to 90-min sessions of PT, CT, and combined PT plus CT, given over a 16-week period. Eggenberger et al.32 conducted an intervention with 89 older adults comprising 52 sessions for 1 h, given twice weekly over 26 weeks, consisting of a virtual reality (VR) videogame dancing and treadmill walking with and without simultaneous verbal memory training.

Finally, Li et al.34 recruited 270 CN older persons and performed a CT intervention for 12 weeks, twice a week with 1-h sessions, consisting of training of memory, reasoning, problem resolution strategies, visuospatial map reading skills, and production of handcraft.

Main interventions with older adults with mild cognitive impairment or at risk for dementia

Seven of the eight studies with cognitively impaired individuals examined the effects of a variety of forms of CT in older adults with MCI45-51 and one in participants at risk for dementia, but not diagnosed with MCI6.

Among the investigations in samples of older subjects with MCI, the study by Valdes et al.51 assessed the data of 1,298 participants of the SOPT and control groups of the ACTIVE study. Belleville et al.47 carried out an 8-week intervention of eight 2-h sessions. A total of 145 older adults participated in memory training, psychosocial intervention, and a control group. A booster session of the same duration was performed 3 months after the intervention. In the study by Rojas et al.48, 46 MCI participants were randomized and the intervention group participated in a 6-month intervention in sessions of 2 h, twice weekly, of CT and cognitive stimulation, including episodic memory training and executive control training techniques. Rozzini et al.49 carried out an intervention with 59 participants and 20 sessions of 1 h, five times a week. The investigation groups were divided into a group receiving ChEIs only, a group receiving ChEIs plus NPT (software training memory, language, attention, abstract reasoning, and visuospatial abilities), and a control group. In their study, Bahar-Fuchs et al.46 applied an intervention lasting 8â?"12 weeks with two sessions of 20â?"30 min/ day, three times a week. Notably, 68 participants were randomized into CCT and active control conditions. In the study by Law et al.50, 83 older adults were randomized to receive 13 sessions of functional task exercises (FcTSim) with PT or to an active CT group for 10 weeks. In the study by Zhao et al.45, an intervention was performed, comprising 25 sessions of 1 h each over 16 weeks with 93 participants, who were randomized into a CrExp group or a standard CT control group.

With regard to the study in older adults at risk for developing dementia6, a multidomain intervention combining PT, diet, cardiovascular risk monitoring, and CT with the use of technology was performed. The authors carried out the intervention based on the protocol of the FINGER study30.

Risk of bias

Regarding the categories of the methodological quality checklist, according to the scores, no articles obtained less than 0.71 points and 23 reached more than 0.80, which corresponds to a high score, excellent quality in the studies analyzed, and low risk of bias. The total average of articles for all categories was 0.84 out of a total of 1.0, meeting the methodological quality requirements of Downs and Black18. When divided by domains, the scores achieved were as follows: report 0.84, external validity 0.77, internal validity 0.74, confusion 1.0, and power 0.75 (Table 4).




DISCUSSION

The aim of this study was to carry out a systematic review of studies investigating the long-term effects of CT programs in older adults without dementia. A total of 32 studies were reviewed, comprising 14 in CN older adults, 8 in older adults with MCI and/or at risk of developing dementia, and 10 on study protocols.

Cognitive training long-term studies with cognitively normal older adults

With regard to the CT long-term studies with CN older adults, and among the studies analyzing data from the three intervention groups of the ACTIVE study, Willis et al.41 and Rebok et al.10. found less decline in self-reported IADL, particularly in the reasoning training group41. Regarding this finding in the functionality of the elderly, Carvalho et al.52 highlighted the importance of cognitive interventions, with an emphasis on memory training, to improve the performance on mnemonic tasks.

The results from the studies by Willis et al.41 and Rebok et al.10. also showed improvements in trained cognitive abilities, with benefits sustained for 5 years after the start of the intervention in all three CT groups41 and for 10 years in the reasoning training and SOPT groups.10. The study by Rebok et al.10 also revealed a medium-to-large effect of the SOPT on processing speed after 10 years. This finding, which represents highly effective maintenance of gains of this type of CT over time, highlights the importance of performing longer follow-up of the effects of CT interventions. In previous year, the study by Ball et al.43, also derived from the ACTIVE study, confirmed the maintenance of positive effects of SOPT for 5 years after the intervention, corroborating the results of the study by Willis et al.41.

The study by Jones et al.42, who drew data from the ACTIVE study, except those related to the booster intervention, showed that memory gains were maintained for 5 years, akin to Willis et al.41 and Ball et al.43, and that reasoning training significantly attenuated the aging-related limitations in this cognitive ability. The results of the study by Li et al.34, included in this review, were consistent with this finding. The authors reported, based on neuroimaging analyses, that CT can promote plastic gains in intrinsic activity patterns, particularly through improvements in functional connectivity and in brain structure which, according to the researchers, are probably part of the neural mechanisms underlying the effects of CT. In other words, according to these findings, CT can slow the pace of cognitive aging.

The results of the study by Ross et al.38, however, showed that more training sessions in all intervention groups of the ACTIVE study, i.e., SOPT, memory, and reasoning training, enhanced the performance on tests evaluating fine motor coordination (abilities such as drawing and painting) and gross motor coordination (running, jumping, and walking up and down the stairs), visuomotor coordination (observe, recognize, and use of visual information on shapes, figures, and objects), and also motor speed. However, these results suggested that greater training on reasoning increased hand-grip strength, closely associated with ADL. Effects on cognitive-motor abilities were also observed by Theill et al.53, although in this case through simultaneous performance of PT and CT, as opposed to the use of CT alone by Ross et al.38. Theill et al.53 found that simultaneous training can promote specific improvement in both cognitive performance and dual-task motor-cognitive performance, providing greater potential for performing ADLs.

In a study based on the ACTIVE protocol, Kwok et al.33 showed an improvement in general cognitive functioning of low-educated individuals, with effects maintained for at least 9 months in the cognitive areas of conceptualization and memory. The authors proposed this finding might be explained by the ceiling effect, i.e., a tendency of the CT to promote greater gains among subjects with below normal cognition prior to the training and in individuals who received no simultaneous training. In contrast, the results of the study by Teixeira-Fabrício et al.54 showed that a higher educational level can lead to greater use of strategies, higher self-efficacy for memory, and larger performance gain post-training. In addition, Casemiro et al.55 emphasized that greater education can be directly associated with ease of learning. The researchers reported that high-educated individuals perform visual search tasks more effectively than subjects with a lower educational level.

The studies by Gross and Rebok40 and Gross et al.44 . assessed the impact of the memory training program from the ACTIVE study on the use of strategies. The results of the first of these two studies40 indicated that memory training improved the levels of use of strategies and can assist older adults who deploy them in appropriate situations. The authors reported that the effects of training persisted for up to 5 years and that strategies are positively associated with memory performance and daily functioning. The results of the study by Gross et al.44 suggested that the method of loci (MoL) (post-training) was used by up to 25% of older adults and immediately improved memory, with effects sustained throughout the follow-up period. These results corroborate the notion that a balance occurs between complexity and novelty in strategy selection by the elderly and that the memory training produces, by promoting changes in the strategies used, observable qualitative and quantitative differences in memory performance. Other studies assessing the effects of memory training on the use of strategies in CN older persons are also available in the literature. In contrast to the findings of Gross and Rebok40 and Gross et al.44, the results of the study by Yassuda et al.16 suggested that the more intense use of memory strategies resulting from training does not necessarily guarantee better performance. Carvalho et al.52, however, showed that categorization strategy training led to greater use of the trained strategy and significantly improved the performance on the episodic memory task.

Another study by Gross et al.37, also derived from the ACTIVE study, reported an association of memory training with significant long-term gains in learning, stemming from both the highly significant training effect and slower memory decline for up to 5 years. The study by Sisco et al.9, which assessed the impacts of the memory training program from the ACTIVE study in conjunction with the booster intervention, suggested in their results that, when carried out in a multifactorial manner together with the booster intervention, the training can improve literal recall for stories.

Borella et al.36 showed in their study that WM training produced benefits that were maintained over time. The authors suggested that these findings confirmed there is still room for plasticity in the basic mechanisms of cognition in old age, congruent with other studies addressing CT in CN older adults in which these subjects were able to attain a level of current performance closer to their maximum possible performance56.

Ball et al.43 reported that positive initial SOPT effects were amplified by booster sessions. According to these authors, a single booster session counteracted around 5 months of age-related processing speed decline. In line with this finding, the results of the study by Aramaki and Yassuda57 showed that, besides stability in participantsâ?T cognitive performance between the two interventions, additional gains on episodic memory scales were observed after the booster intervention.

Linde et al.35 revealed in the results of their study that the three types of activities carried out by the participants, i.e., PT, CT, and combined PT plus CT, can be seen as cognition-enrichment behaviors. Eggenberger et al.32 reported that particular executive functions benefited from simultaneous CT and PT compared to exclusively physical multicomponent training, concluding that cognitive-physical training programs may counteract widespread cognitive impairments in the elderly. These findings are consistent with the recent study by McEwen et al.58, who carried out an intervention of simultaneous aerobic exercise and memory training and found that the intervention promoted improvements in memory, attention, and reasoning abilities.

Long-term studies on cognitive training in older adults with mild cognitive impairment or at risk for dementia

Of the eight studies involving cognitively impaired individuals, seven examined the longitudinal effects of a variety of forms of CT in older adults with MCI45-51, while one was a multidomain intervention in elderly people at risk for dementia, but not diagnosed with MCI6.

The study by Valdes et al.51 revealed that all MCI groups showed an immediate improvement relative to the control group, with an emphasis on the non-amnestic MCI group, in which no significant changes were observed during the 5-year follow-up. Belleville et al.47. suggested in their results an improvement on the memory task and strategy use in everyday life of participants of the CT. Consistent with the findings of both studies47,51, the study by Olchik59, in which older persons with MCI performed memory training, reported that CT can benefit participants in terms of acquisition of strategies for coping with and overcoming cognitive impairment, and even reverse MCI, allowing these individuals to attain a similar level of performance to CN subjects. In addition, the authors believe this training modality represents a cost-effective viable educational intervention that can benefit older persons with MCI.

Rojas et al.48 reported that CT in individuals with MCI can also represent a promising treatment option for optimizing performance, preventing cognitive decline, or delaying progression to dementia in this patient group. Brum et al.60 noted that CT in older adults with MCI constitutes a non-pharmacological alternative for preventing cognitive and functional decline and for promoting improvement in cognitive performance.

In the study by Rozzini et al.49, participants who received ChEIs plus NPT showed significant improvements in cognitive areas and in behavioral disturbances, confirming that a long-term NPT in ChEIs-treated MCI subjects induces additional cognitive and mood benefits. These results are in line with the findings of Olazarán et al.61, who reported that patients with MCI, mild Alzheimerâ?Ts disease (AD), or moderate AD treated with ChEIs and undergoing a long-term cognitive-motor intervention had greater mood and cognitive benefits compared to the control group.

Bahar-Fuchs et al.46 showed in their study that unsupervised home-based CCT with individual tailoring can lead to cognitive and non-cognitive benefits in older adults with MCI. Consistent with these results, the study by Hill et al.62 in older adults with MCI and dementia revealed the efficacy of CCT on global cognition, selected cognitive domains, and psychosocial functioning of individuals with MCI.

In the study by Law et al.50, the results showed that the FcTSim promoted improvements in general cognitive functions, particularly executive function and problem-solving ability, thereby serving as a cost-effective way of promoting brain plasticity, even in patients with MCI. These findings are consistent with the study by Liao et al.63, who randomized older adults with MCI into either a VR-based PT with CT group or a combined PT and CT group without VR. Results showed that the VR group improved global cognition, while both groups improved executive function and verbal memory.

Zhao et al.45 suggested in their study that the CrExp therapy promoted greater gains in general cognitive functioning, memory, executive functions, functional status, and everyday living ability among patients receiving the therapy compared to participants receiving standard CT. The authors reported that improvements were maintained at the 6-month follow-up and concluded that this therapy may serve as a cost-effective adjunct to standard interventions for older adults with MCI.

Law et al.50 and Zhao et al.45 showed that these interventions can serve as cost-effective strategies for older adults with MCI, satisfying the premises of the World Health Organization (WHO), which holds that CT should be provided and applied to both CN older adults and individuals with MCI as a preventive action for cognitive decline and development of dementia, irrespective of social class64. This is also guaranteed by the Active Aging policy, which highlights the necessity of incentive for care and development of cognitive abilities to maintain the autonomy of an individual64.

With regard to the study in older adults at risk for developing dementia but not diagnosed with MCI6, results showed that multidomain intervention can improve cognitive functioning in older adults at risk of cognitive decline6.

To sum up, the studies reviewed reported a number of cognitive performance benefits, including a role in improving some motor abilities, among older adults without dementia who participated in CT programs with or without booster sessions and who received multimodal interventions or otherwise.

A total of 14 long-term studies were gathered in which cognitively healthy elderly people, without any type of cognitive impairment, were followed up. In view of this, it was possible to report several cognitive performance benefits. Furthermore, the results of these studies documented that such cognitive benefits lasted up to 5 years after starting the intervention. Eight long-term studies were also gathered in which elderly with MCI or at risk for dementia were followed up. Studies have indicated significant sustained improvements in general cognitive function, executive function, and problem-solving ability, in addition to an increase in brain plasticity. Furthermore, it has also been observed that computerized cognitive interventions at the MCI can prevent cognitive decline or slow conversion to dementia. Finally, 10 publications of protocols were analyzed, studies that will describe their methods and plans. Among them, one protocol has demonstrated the potential to significantly improve efforts to ameliorate cognitive decline, providing important information about the feasibility and intervention effects of a combination of exercise and CT for older adults with MCI.

It is important to highlight that the studies with methodology models included in this review were mostly interventions characterized as multicomponent cognitive stimulation and allow the replication of their methods to other research centers, to verify in a contemporary way to the original authors, if the models of proposed interventions can generate cognitive gains in healthy elderly and in elderly people with MCI.

Therefore, different types of CT programs appear to represent highly applicable cost-effective strategies for promoting health and quality of life in older age. There were a vast number of studies addressing the theme and a wide variety of objectives related to the specific subthemes, with consequent heterogeneity in study results. Generally, however, all findings showed positive effects on the cognition of participants.

The limitations of this study included the selection and inclusion of multimodal CT research; the comparison of CT studies whose participants were CN elderly with studies in which older adults with MCI participated; and the citing of cognitive improvements measured using cognitive screening tests as opposed to more specific tests, such as neuropsychological assessment scales.

As presented in this article, some of the studies employed original, innovative methods incorporating a long-term follow-up. Thus, the methodology of these studies should be replicated in different cultures, given some have been published without results, providing fertile ground for future studies. It is also suggested to carry out future systematic review studies of CT only with a focus on multimodal studies and with samples focused on CN elderly and older adults with MCI.

Authorsâ?T contributions. TBLS, JSB, MECB, GAS, MGZ, LCM, PPL, NPC, TNO, SMDB: conceptualization, investigation, methodology, visualization, writing â?" original draft, and writing â?" review & editing. TBLS, LCM, PPL, SMDB: funding acquisition. TBLS, TNO, SMDB: project administration, supervision, and writing â?" review & editing.


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This study was conducted by the Group of Cognitive and Behavioral Neurology, School of Medicine, Universidade de São Paulo, São Paulo, SP, Brazil

1. Universidade de São Paulo, Escola de Artes, Ciências e Humanidades, São Paulo SP, Brazil
2. Instituto Supera de Educação, São José dos Campos SP, Brazil
3. Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Grupo de Neurologia Cognitiva e Comportamental, São Paulo SP, Brazil

Correspondence:

Thais Bento Lima-Silva
Email: gerontologathais@gmail.com

Received on June 29, 2021
Received in its final form on October 25, 2021
Accepted on October 30, 2021

Disclosure: The authors report no conflicts of interest

Funding: none

 

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