29 August 2016

Dementia? There’s not an app for that

Aged Care Clinical

 

As the baby boomer generation ages, the search intensifies for ways to prevent dementia

It’s been a rollercoaster year for the brain-training industry.

The company behind one of the most popular programs in the field, Luminosity, was forced to pull advertising that claimed its online program could help users perform better at work or school and prevent cognitive delay.

“Lumosity preyed on consumers’ fears about age-related cognitive decline, suggesting their games could stave off memory loss, dementia, and even Alzheimer’s disease,” said Jessica Rich, director of the consumer protection in the USA’s Federal Trade Commission.

“But Lumosity simply did not have the science to back up its ads.”

The company, which claims to have over 70 million users across 182 countries, agreed to pay US$2 million to the consumer protection agency for making deceptive claims.

The case was part of a wider crackdown on an increasingly profitable industry, with the agency targeting several other companies that claim they can improve cognitive function.

Concerns had been also mounting in the field, with nearly 70 cognitive psychologists and neuroscientists speaking out against brain training programs in a consensus statement in late 2014.

The time is ripe for such programs, with millions of baby boomers ageing, and worrying about the potential loss of their cognitive abilities. But the statement signatories said exaggerated and misleading claims made by providers of cognitive-training programs exploited the anxieties of older adults about impending cognitive decline.

There is “no compelling scientific evidence to date” that brain games could reduce or reverse cognitive decline, they conclude.

Indeed, this “magic bullet” approach detracts from what is known about cognitive health – that the influence we have on it comes from living a healthy and active lifestyle, they write.

And focussing on computer games diverts attention and resources away from other prevention efforts, they say.

EVIDENCE

Six months after Luminosity was forced to pull its advertising, the first positive results from a randomised trial of cognitive training in dementia were released. Finally, there was some evidence that cognitive training could help prevent dementia.

The ACTIVE study found that a decade after initial training, subjects performing one specific type of activity were 48% less likely to have developed dementia than those in the control group.

The US researchers randomised 2800 healthy people over the age of 65 into one of four groups: strategy-based memory training, strategy-based reasoning training, perceptual-based, computerised speed of processing training and a control group.

Participants underwent 10 hours of training over five weeks, and a subset in each group repeated the training sessions 11 and 35 months later. Participants were evaluated before training, at five weeks, and at one, two, three, five and 10 years, on outcomes relating to speed, memory, reasoning and functional performance. Mood, confidence, self-rated health, predicted healthcare costs and driving were also assessed.

While memory and reasoning training didn’t delay dementia compared to the control group, those who underwent 10 hours of speed-processing training had a 33% lower risk of developing dementia over the next decade.

If they also did four hours of “booster” sessions, their risk of getting dementia a decade later was reduced by 48%.

In short, at 10 years the incidence of dementia was around 8% in the speed training arm, compared with 14% in the control group.

“I think my exact words were ‘I knew it’,” study author Associate Professor Jerri Edwards says.

“Because I’ve been studying this training program for 20 years, and in our very early studies in 2002 and 2005 we showed it improved older adult everyday functional performance,” Professor Edwards, from the University of South Florida, says. “It’s been shown now that this computerised speed processing training program improves older adults’ everyday functional performance in more than four randomised clinical trials,” she says. “So to me it was just a matter of time before we could show that it delayed the onset of dementia – because dementia, by definition, involves functional impairment.”

The trial also found that training works for patients with lower cognitive abilities and educational attainment – both risk factors for dementia, says Professor Edwards.

And while there’s no evidence that this will benefit patients who pre-existing dementia, research does suggest it is effective in those with mild cognitive impairment.

So far, the findings have been presented at an international Alzheimer’s Association Conference, and have been submitted to a peer-reviewed journal for publication.

SPEED-PROCESSING TRAINING

A striking finding of this study was that a relatively small intervention could have such significant and long-term benefits.

The speed processing exercise performed in the study is now commercially available as part of Posit Science’s BrainHQ training program, under the name Double Decision.

Designed to improve the speed and accuracy that players process visual information, the online game tests the central and peripheral vision – known as “useful field of view” – performance.

It begins with two objects, such as a car and a road sign, flashed on a screen, and then the player attempts to identify the correct car and the location of the road sign.

As they identify more images correctly, the objects are flashed on screen for shorter periods.

Distractors are also added to the screen, the objects become more alike, and the peripheral objects move further towards the edge of the screen.

Professor Edwards says performing the activity results in very large improvements in the Useful Field of View performance as well as mental quickness.

“And we found that those improvements transfer directly to the everyday functional performance gains,” she says.

The company describes brain speed as the “signature deficit of aging”, which peaks in midlife and then declines.

“Processing speed is a key index of brain health status, akin, in its diagnostic value, to blood pressure measurements for cardiovascular health,” Dr Michael Merzenich, cofounder of Posit Science and early pioneer of the concept of brain plasticity, said in a statement.

A senior gentle man relaxing and doing the crossword

THE WILD WEST

While we now have some early evidence that one type of training may reduce the risk of dementia, the growing brain-training industry needs to be closely monitored, says Alzheimer’s Australia CEO Maree McCabe, so that people are not receiving “nefarious or inappropriate” information.

“People with dementia in the family are fearful of getting dementia,” she says. “They’ve seen the impact on their loved ones, and these people are then vulnerable to buying things or trying things that there may be no actual evidence for.”

But up until a few years ago, the industry was like the “wild west”, Posit Science CEO Henry Mahncke says. “Anyone has been able to start a ‘brain training’ company and say, ‘Here’s this game that trains your memory’ and there’s been really no regulatory enforcement around that.”

“So that’s been crazy, and I think that’s been incredibly confusing for consumers and for doctors both over the last couple of years,” he says.

The industry is now in the process of sifting the wheat from the chaff though, Mahncke says. And one analogy is the early days of antibiotic discovery.

“There was mouldy fruit, oil from snakes, and it was hard to figure out what was helpful or not. Then eventually we figured out that mouldy fruit was penicillin and that it was incredibly helpful, and we figured out that snake oil had no particular medicinal properties.”

“So that was an incredible revolution when it happened, and that feels like where we are with brain training now.”

“We’re just starting to figure out what the things are that have been shown to improve brain function and cognitive health, and what are just ways to spend time.”

While it’s common for people to be concerned they are slowing down as they age, there have been few evidence-based interventions to prevent dementia, Mahncke says. Exercise is one, but people already know that this is good for them.

Mahncke says the company and the researchers are so confident in the findings of the ACTIVE study they are making the dataset publicly available to anyone who wants to do their own prodding of the data.

If people want to re-analyse the data, or change certain thresholds, then they will be able to, he says.

Until then, we have to be cautious, says leading dementia expert Professor Henry Brodaty, an audience member at the conference.

“It was very impressive, but we haven’t seen the details,” he says. “We don’t know what the attrition rate was, and you need to see the actual methodology first. But to have that decrease in dementia incidence was quite exciting.”

Another possible benefit of speed processing training is road safety. Ten years down the track, fewer participants had been involved in car accidents, and more people were still driving, the Scientia Professor at UNSW’s Centre for Healthy Brain Ageing notes.

At the memory clinic at the Prince of Wales Hospital, Professor Brodaty and colleagues recommend programs such as Luminosity and Posit Science to patients concerned about their memory.

This hasn’t changed since Luminosity’s bad press. “We’re not confident, but we don’t think it does any harm.”

OTHER OPTIONS

Professor Anthony Hannan, head of the Neural Plasticity Laboratory at The Florey Institute of Neuroscience and Mental Health, places more stock in lifestyle interventions than speed processing training.

Often something is presented at a conference, but it turns out not to be reproducible, he says.

“That’s the nature of science, you need a build-up of evidence, which is why they have Cochrane databases and meta-analyses.”

One of the problems with the industry is that these commercial companies can’t or won’t do the type of trials that pharmaceutical companies do to test their products, Professor Hannan says.

As well as being incredibly expensive to do a large randomised, double blind, placebo-controlled trial, it’s actually very difficult to find the right placebo, he says. The control group for the ACTIVE trial was no contact, which could have meant that they missed some other benefit of computer activity or researcher engagement.

To this end, a group of US psychologists evaluated the placebo effect of brain training on cognitive outcomes.

The vast majority of previously published studies on brain training had recruited subjects with posters using positive phrases such as ‘brain training’ and ‘cognitive enhancement’, suggesting the proven efficacy of such activities.

The study, published in the Proceedings of the National Academy of Sciences 1 in June this year, compared participants recruited using this “overt” recruitment strategy with those recruited with a neutral-language flyer that had no positive associations.

Participants in the “overt” recruitment group were more likely to score highly on fluid intelligence after only an hour of the brain-training game.

They had a 5-10 point IQ score increase after the test, compared to those recruited with a similar, but neutral-language flyer.

The authors concluded there was “clear evidence of a placebo effect after a brief cognitive training routine that led to significant fluid intelligence gains”.

So in future research, possible placebo effects need to be ruled out before claims can be made about treatment benefits, they say.

WHAT WE KNOW WORKS

Meanwhile, we know of five key factors that have a substantial impact on brain health, Professor Hannan says – physical exercise, diet, cognitive stimulation, chronic stress and sleep.

“Body health impacts on brain health,” he says. “Rather than thinking of the brain as a separate entity, we know that there’s dynamic cross-talk between the two.”

Chronic stress and sleep are often overlooked, but there’s growing evidence that high levels of stress and sleep disruption can lead to brain ageing and cognitive problems, Professor Hannan says.

“Epidemiology studies suggest that people who stay more mentally active have protection against Alzheimer’s disease and other forms of dementia,” he says. “And we think of that, together with physical activity, as building up a ‘brain reserve’.”

But studies into cognitive stimulation often find that effective interventions also include a physical or social component, he says.

“Rather than being prescriptive, it has to be something that people enjoy, not only for the quality of life, but something they will continue doing for months and years – not just give up after a week.

“A lot of things that don’t require screen devices, that don’t require hardware and software, provide cognitive stimulation, like playing cards, doing gardening, making music or learning languages,” says Professor Hannan.

Which was a point echoed in the 2014 consensus statement, where the researchers highlighted the opportunity costs of the brain-training activities.

“Time spent playing the games is time not spent reading, socialising, gardening, exercising, or engaging in many other activities that may benefit cognitive and physical health of older adults.”

The key message?

“Don’t pin all your hopes on one thing,” says McCabe.

Professor Jerri Edwards acted as a consultant to Posit Science in 2008. She has no other financial ties

References:

1: PNAS 2016; online 20 June http://www.pnas.org/ent/113/27/7470.abstract

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