The future of cognitive remediation training in older adults.
Article Type: Report
Subject: Cognition in old age (Research)
Cognition disorders in old age (Diagnosis)
Cognition disorders in old age (Care and treatment)
Nurse and patient (Management)
Authors: Vance, David E.
Keltner, Norman L.
McGuinness, Teena
Umlauf, Mary Grace
Yuan, Yih-Ying
Pub Date: 10/01/2010
Publication: Name: Journal of Neuroscience Nursing Publisher: American Association of Neuroscience Nurses Audience: Professional Format: Magazine/Journal Subject: Health care industry Copyright: COPYRIGHT 2010 American Association of Neuroscience Nurses ISSN: 0888-0395
Issue: Date: Oct, 2010 Source Volume: 42 Source Issue: 5
Topic: Event Code: 310 Science & research; 200 Management dynamics Computer Subject: Company business management
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 238912116

With the growing population of older adults, nurses will need to address age- related cognitive declines. Evidence demonstrates that cognitive remediation training is effective in improving neuropsychological abilities in older adults, which can translate into improved functioning in instrumental activities of daily living. The future of cognitive remediation training will incorporate health promoting factors (e.g., sleep hygiene, physical exercise), which supports neuroplasticity and cognitive reserve. By approaching cognitive health holistically, the patient will be primed to receive the maximum benefit from cognitive remediation training. A model emphasizing this approach is provided as a didactic for nurses and other health professionals providing care to their older patients.


By 2030, there will be approximately 70 million adults 65 years or older (Administration on Aging, 2004). Accompanying this historic and unprecedented growth in the older population are subtle age-related cognitive declines. These declines are a normal aspect of nonpathological aging and can occur in a variety of cognitive domains, including memory, executive functioning, psychomotor ability, and speed of processing (Ball, Wadley, Vance, & Edwards, 2004).

A necessary component of successful aging requires maintenance of one's cognitive ability to preserve everyday functioning, to negotiate one's environment, and to actively engage in life. Even moderate declines in cognitive ability, without dementia, have been shown to impair one's ability to adhere to medications, to manage finances, to prepare food, to shop for groceries, and to perform household chores (McGuire, Ford, & Ajani, 2006), all of which can affect one's health, safety, and quality of life. Therefore, methods for improving or maintaining one's cognitive ability must be explored to promote successful aging and autonomy.

The purpose of this article was to examine the existing and future role of cognitive remediation training as an activity that encourages neuroplasticity and promotes efficient cognitive functioning. The efficacy of existing cognitive remediation training in improving cognitive functioning will be reviewed. Then, we propose that by combining cognitive remediation training with other practices that support neural health and cognitive reserve, this approach may yield an even larger boost in cognitive functioning than cognitive remediation training alone. Such practices that are proposed are physical exercise, mood, sleep, antioxidants, and neuroleptic medications. A model of how this may be conceptualized for examining the future of cognitive remediation training is provided. Implications for nursing research and practice are posited.

Neuroplasticity and Cognitive Reserve

Maintaining or improving cognitive ability depends on neurological processes, called neuroplasticity, that facilitate cognitive ability. Neuroplasticity refers to such a process by which morphological changes occur in the brain in response to novel sensory stimuli. These morphological changes, such as dendritic branching between neurons, support one's cognitive reserve (see Figure 1). Such cognitive reserve represents the billions of connections between neurons on which cognitive ability emerges; thus, the more extensive and sophisticated the connections among neurons, the more robust one's cognitive reserve is to insults that sever connections between neurons. As these neuronal connections are weakened because of disease or atrophy, the pathways in which neurons communicate information degrade, and the neurons are less able to transmit information to other areas of the brain, reducing the efficiency in which information is processed. The depletion in cognitive reserve translates into poorer overall cognitive ability.

This neurological process is observed in animal studies. Using an enriched environmental paradigm, Kobayashi, Ohashi, and Ando (2002) demonstrated that cognitive performance in rats was related to morphological changes in the brain. Rats were placed in either a standard environmental condition or an enriched environmental condition. In the standard environmental condition, rats were placed in an ordinary-sized cage (33 x 40 x 18 cm high) with only wood shavings. There were three rats to a cage. In the enriched environmental condition, rats were placed in a large cage (120 x 50 x 40 cm high) with wood shavings and small constructions and a variety of toys to explore. Every week, the constructions and the toys were changed. There were 12 rats to a cage. It was hypothesized that rats placed in the enriched environmental condition would have more opportunities for socializing and learning. Because of this exposure, they would develop stronger and more neural connections that would produce morphological changes in the brain, resulting in greater cognitive reserve and corresponding cognitive functioning. Cognitive functioning was tested by using a Hebb-Williams Maze Task, which consists of the usual wood-constructed maze with a food treat at the end. These researchers found rats exposed to the enriched environmental condition displayed a higher level of learning the maze than the rats placed in the standard environmental condition. Interestingly, the cognitive benefits of living in the enriched environmental condition were found regardless of the age of the rats or how long they were exposed to the enriched environmental condition, even if exposure was as brief as 3 months. From such studies, the value of novel, stimulating activities in the environment is shown to be beneficial in changing the morphology of the brain at any age, which increases cognitive reserve and corresponding cognitive functioning (Yang et al., 2007). Likewise, we argue that cognitive remediation training, as does enriched environments in rats, alters underlying brain morphology, resulting in improved cognitive ability.


Types of Cognitive Remediation Training

Cognitive remediation training has been developed to improve functioning either in a particular cognitive domain, which can be referred to as domain-specific training, or in global cognition, which can be referred to as global cognitive training. The delivery of such training protocols varies widely from in-person training using pencil-and-paper strategies to group activities, to interactive videotapes, and to computerized training software. For this article, five types of cognitive remediation training protocols will be briefly reviewed to highlight the state of the literature; the first three come from the Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) study and represent domain-specific cognitive training protocols designed to improve cognition in a particular area (e.g., speed of processing, reasoning, and memory; Willis et al., 2006), and the last two (e.g., posit computer training and theater training) represent global cognitive training protocols designed to improve cognition in two or more cognitive domains at a time.

Speed of Processing Remediation Training

Speed of processing remediation training is based on the Speed of Processing Theory of Aging. This theory posits that as people age, the speed in which they process information slows. This slowing impacts the efficiency and function of other domains such as memory, executive functioning, and psychomotor ability (Ball et al., 2002).

Speed of processing remediation training is designed to accelerate the speed in which visual information is processed. It can be administered in a variety of ways: in a group format with a computer and a touch screen monitor (Vance & Crowe, 2006), at home with videotapes and a workbook (Wadley et al., 2006), or even over the Internet (Vance, McNees, & Meneses, 2009). The more well-known approach (e.g., ACTIVE study) is by using a computer to present visual information to older participants who respond and interact to such visual information using a touch screen monitor. Usually, a trainer, in tandem with the computer program, provides the participant feedback on their performance in 10 one-hour training sessions.

In this format, speed of processing training is very similar to the Useful Field of View subtests (Edwards et al., 2005). Useful Field of View is a computerized test of visual speed of processing that measures how quickly participants can detect visual information that is presented to them on a monitor, interpret the information, and respond appropriately. Because it is computer administered, the time of the presentations is determined automatically in milliseconds, allowing very exact measurements to occur. Similarly, in training, visual stimuli are presented in milliseconds so that if participants correctly respond to the presentation, the speed of the next presentation can be gradually increased. Identifying the participant's threshold of performance allows the presentation speed to be adjusted, which pushes the participant just beyond his or her ability level, making the task more challenging but not impossible. This approach promotes faster visual speed of processing. By using such a shaping paradigm, studies have shown that after training, this fluid ability is increased in older adults. For more information on the speed of processing training protocol, please see Willis et al. (2006).

As observed in the ACTIVE study, 637 community-dwelling older adults were administered this training protocol. In this sample, 87% exhibited reliable cognitive improvement on speed of processing because of the intervention. Although these findings are robust in showing that speed of processing training improved speed of processing, such cognitive gains did not generalize to other cognitive domains such as memory or reasoning.

Reasoning Remediation Training

Like speed of processing training, reasoning training aims to improve executive functioning in older adults as measured by problem solving, logical pattern recognition, and decision-making abilities. Typically, reasoning training exercises focus on improving problem solving by teaching participants how to recognize logical patterns in a series of numbers and letters. Such reasoning techniques are then applied on everyday activities that require similar reasoning skills such as creating a medication adherence schedule or deciphering a bus schedule. In the ACTIVE study, 627 community-dwelling older adults were given 10 one-hour reasoning training sessions either in a group format or in a one-on-one format while being provided feedback on their performance. In this sample, 74% exhibited a reliable cognitive improvement on measures of reasoning skills in response to the intervention (Ball et al., 2002). As found with the speed of processing training, participants only experienced training gains in cognitive tests measuring reasoning and executive functioning, which did not translate into improvement in other cognitive domains such as memory or speed of processing.

Memory Remediation Training

Memory problems remain one of the most obvious cognitive changes associated with aging, and for that reason, more memory training techniques have been attempted than all other cognitive domain training protocols. Several types of memory cognitive remediation trainings attempt to ameliorate episodic memory by teaching and incorporating mnemonic strategies into everyday life (Ball et al., 2002; Floyd & Scogin, 1997). In the ACTIVE study, 620 community-dwelling older adults were given 10 one-hour memory training sessions either in a group format or in a one-on-one format while being provided feedback on their performance. Memory training consisted of learning mnemonics, which were practiced by learning word lists and recalling details from texts and narratives. In this sample, 26% exhibited a reliable cognitive improvement on memory skills in response to the intervention; this training gain is much lower than those found for speed of processing training (87%) and reasoning training (74%). This finding may suggest that memory is much more difficult to improve than other cognitive domains. As found with both speed of processing and reasoning training, participants only experienced training gains in cognitive tests measuring memory, which did not translate into improvement in other cognitive domains such as speed of processing or reasoning.

Posit Science Remediation Training

The Posit Science Corporation developed a computerized program designed to augment brain plasticity in older adults through six auditory and visual tasks that can be administered via home computers without the aid of trained staff. These tasks begin with fairly easy tasks and progressively become more difficult as the participants' abilities improve. All of these tasks use a combination of adaptive training procedures, acoustical and visual stimuli, engagement of attention, and novelty detection; as such, participants must process the information of the task in different neuromodulatory systems. The first task--"High or Low"--is a time-ordered judgment task that consists of reconstructing the sequence and identity (downward or upward) or frequency of auditory sweeps. The task becomes more challenging by changing the interstimulus interval and duration between the sweeps. The second task--"Tell Us Apart"--is a discrimination task that consists of participants identifying a computer-generated syllable (e.g.,/ha/) from a more ambiguous pair (e.g.,/ha/vs./da/). Again, the task is made more challenging by varying the duration and the intensity of the sweeps of the target consonant. The third task--"Match It"--is a spatial-match task that consists of participants matching short confusable words (e.g., had, bad) from a spatial grid presented on the computer. The task is made more challenging by altering the frequency of possible matches. The fourth task--"Sound Replay"--is a forward-span task that consists of participants reconstructing a sequence of short words, similar to those in task three. The fifth task--"Listen and Do"--is an instruction-following task that consists of participants reconstructing a series of spoken instructions, which is done by dragging icons on the computer screen. This task is made more challenging by altering the complexity and the number of the instructions and by modifying the level of pronunciation. The sixth task--"Story Teller"--is a narrative-memory task that consists of participants answering questions about short narratives. The task becomes more challenging on the basis of the length of the narrative and the level of pronunciation (Mahncke et al., 2006).

Using these challenging auditory cognitive tasks, 182 older adults were randomly assigned to an experimental training condition (n = 62), an active control group (n = 61) that received DVD-based educational lectures delivered on their computer that approximated the amount of computer exposure that the experimental participants received, or a no-contact control group (n = 59). Those in the experimental and active conditions were engaged 60 minutes a day, 5 days a week, for approximately 8 weeks. Neuropsychological tests showed that those participants who received the experimental treatment not only improved more than those participants in the other two conditions at posttest but also showed an increase on a number of cognitive tests, including speed of processing, spatial syllable match memory, forward word recognition span, working memory, and narrative memory (Mahncke, Bronstone, & Merzenich, 2006; Mahncke et al., 2006). Thus, the combination of progressively difficult visual and auditory tasks produced global cognitive training benefits as exhibited by improvement on the wide range of cognitive tasks.

Theatre Training

Other global cognitive training protocols do not rely on technology at all. Noice, Noice, and Staines (2004) recognized that acting is a highly complex skill that requires a full range of physiological, affective, and especially cognitive resources. From this insight, these researchers developed a "theater training" training protocol that consisted of nine 90-minute training sessions administered over a month. The sessions were composed of progressively challenging acting exercises. Older adults in this group were compared with other older adults randomly assigned to a visual art group and a no-contact control group. Compared with these two groups, those older adults assigned to the theater training group showed improvement in several cognitive domains. Besides being innovative and fun, this training protocol was successful in promoting adherence to the treatment and in improving functioning beyond one cognitive domain.

Facilitating Factors of Cognitive Remediation

Given the efficacy of such cognitive remediation training, the cognitive gains may be increased further by factors that facilitate neural health such as physical exercise, mood, sleep hygiene, nutrition and antioxidants, and neuroleptic medications. Although this list of factors is by no means exhaustive, by considering their impact on cognitive functioning, manipulating such factors into training protocols can augment the health and viability of neurons, which may help older adults to receive additional benefit from cognitive remediation training. Thus, the combined influence of all of these factors with cognitive remediation training may yield even larger cognitive gains for older adults. The contribution of each of these factors on cognition and neural health is discussed in the following sections.

Physical Exercise

Multiple studies have shown that physical activity alone can improve cognitive ability (e.g., Lochbaum, Karoly, & Lander, 2002). In a structural equation model study examining the combined influence of sedentary behavior, social networks, and depression on cognition in a sample of 158 community-dwelling older adults, Vance, Wadley, Ball, Roenker, and Rizzo (2005) found that elevated levels of sedentary behavior were independently associated with higher levels of depression and poorer cognitive functioning. Moreover, Colcombe and Kramer (2003) reported that sedentary older adults who were enrolled into an aerobic exercise program and adhered to it for at least 6 months experienced significant cognitive gains in speed of processing, memory, and executive functioning.

Taking this a step further, at the University of Alabama at Birmingham, Ball et al. (2002) (NIH/NIA grant no. 5 R37 AG05739-16) are now conducting a study (the Physical Activities and Cognitive Exercise Study) designed to examine the cognitive benefits of four training conditions: speed of processing training with physical exercise, speed of processing only, physical exercise only, and mental stimulation only. The speed of processing training is similar as mentioned previously. The physical exercise component consists of 10 supervised one-hour training sessions in the laboratory and then self-administered physical exercises in the home. The mental stimulation only group receives a workbook of crossword puzzles, word jumbles, and sudoko tasks that the participants are encouraged to do on their own; this condition serves as the no-contact control group. Although the study is ongoing and the results are not yet available, this approach represents the future of cognitive remediation training by combining physical exercise with cognitive remediation training. It will be interesting to observe whether older adults will experience additional cognitive benefit from receiving both speed of processing training and physical exercise than from either approach alone.


For many older adults, aging signifies a time marked by loss of family and friends, declines in physical functioning, and a reduction in productivity and energy. Not surprisingly, depression and dysthymic disorders affect 5% to 10% of older adults (Lyness, Caine, King, Cox, & Yoedinono, 1999). Comijs, Jonker, Beekman, and Deeg (2001) found that depressive symptoms were positively associated with declines in speed of processing over a 3-year period. In community-dwelling older adults, Bassuk, Berkman, and Wypij (1998) also found that depressive symptoms were predictive of future declines in cognition. Many researchers have suggested that reducing depression and facilitating positive mood in older adults through antidepressants may facilitate neuroplasticity and promote more optimal cognitive functioning (Fuchs, Czeh, Kole, Michaelis, & Lucassen, 2004; Reid & Stewart, 2001). Combined with cognitive remediation training, augmenting mood through antidepressants or cognitive-behavioral treatments for mood problems may prove to support neuroplasticity and improve cognitive gains even further.

Sleep Hygiene

Older adults experience poorer sleep hygiene compared with younger and middle-aged adults (Redline et al., 2004). Such poor sleep hygiene may contribute to poor memory consolidation and poorer cognitive functioning; therefore, improving sleep may improve overall cognitive functioning (Blackwell et al., 2006). Both short sleep duration (<5 hours/night) and difficulty falling asleep or staying asleep on a regular basis have been associated with declines in global measures of cognition over a 2-year period (Tworoger, Lee, Schemhammer, & Grodstein, 2006). Sleep disordered breathing, typically characterized by snoring and/or excessive daytime sleepiness symptoms, is also associated with cognitive impairment in elders (Cohen-Zion, Stepnowsky, Marler, Kripke, & Ancoli-Israel, 2001; Rao et al., 2005; Spira et al., 2008). Confounding the presence of sleep problems, many older adults self-medicate using alcohol or over-the-counter medications that can produce harmful side effects and exacerbate the underlying sleep disorder (Johnson, 1997; Roehrs, Hollebeek, Drake, & Roth, 2002), which further contributes to declines in cognitive functioning.

The type of sleep one receives is also of importance. Several studies show (Stickgold & Walker, 2007; Vendette et al., 2008) that rapid eye movement (REM) sleep is important for memory consolidation; in other words, REM sleep is an important resource in memory formation. In fact, Stickgold (2005) found that different types of sleep (i.e., REM sleep, slow-wave sleep, non-REM sleep) are associated with cognitive performance in a number of cognitive domains.

Given these issues, screening for sleep problems or poor sleep habits is an important first step in planning interventions with cognitive remediation training. For example, the Sleep-50 instrument can efficiently screen for the most common sleep problems older adults experience (sleep apnea, insomnia, restless leg syndrome); it is easily scored (Spoormaker, Verbeek, van den Bout, & Klip, 2005). In addition, nurses can use these data to complement assessment of comorbidities, medication side effects, and health status that may affect sleep quality or validate the need for a medical referral.

As with other facilitating factors, improving sleep hygiene may be used in concert with cognitive remediation training to improve cognitive functioning. Furthermore, the timing of cognitive remediation training, such as an hour or two before going to sleep to facilitate memory consolidation or an hour or two after waking up during the most alert hours of the day, may prove to bolster the training effects and improve the generalization of cognitive gain even more.

Nutrition and Antioxidants

Proper nutrition and antioxidants are an obvious consideration for improving neural health and for supplementing cognitive remediation training. Studies show that malnutrition in older adults is correlated with poorer cognitive functioning (Fillit et al., 2002; Gonzalez-Gross, Marcos, & Pietrzik, 2001). Examining the nutritional intake of 168 community-dwelling older adults, Requejo et al. (2003) found that moderate alcohol use, greater consumption of fish and total food, and less intake of sweets were associated with overall cognitive functioning. Likewise, food rich in antioxidants such as spinach and blueberries may prevent free radicals from damaging neurons and reducing cognitive reserve. Solfrizzi, Panza, and Capurso (2003) reported that antioxidant deficiencies in vitamins C and E have been associated with an elevated risk of cognitive decline. As with other supporting factors, combining proper nutrition along with cognitive remediation training may result in more optimal improvements and generalization of cognitive training gains.

Neuroleptic Medications

Neuroleptic medications are used to improve cognitive functioning in older patients with cognitive impairment (Meyer et al., 2002) and may be used in conjunction with cognitive remediation training. These neuroleptic medications can be grouped into two overarching categories: the acetylcholine (ACh)enhancing agents and the putative neuroprotective agents. Beyond these primarily psychotropic agents, nonpsychotropic drugs such as the nonsteroidal anti-inflammatory drugs and the statins may also contribute to improved cognitive performance.

The most consistently treatable biological change in Alzheimer's disease is the diminished bioavailability of ACh in the brain. Most brain ACh is synthesized in the nucleus basalis of Meynert and distributed throughout the cerebrum by efferents from those nuclei (Keltner, Schwecke, & Bostrom, 2007). The reduction of nucleus basalis of Meynert tissue is readily apparent with available imaging technology. Pharmacologic efforts to counter this endogenous reduction in ACh have been moderately successful by inhibiting the enzymes responsible for the breakdown of ACh (i.e., the cholinesterase [ChE] inhibitors). Unfortunately, improvements associated with ChE inhibitors are modest for many individuals and are transient. There is no indication that the disease process is slowed by these agents, although behavioral improvements are noted. However, when combined with the various other strategies discussed in this article, it is hoped that cognitive improvement will prove to be longer lasting.

The neuroprotective agents discussed next are those drugs that purportedly diminish brain degeneration. In contrast to ChE inhibitors that seem to mask the progressive assault on the brain, these agents hold promise of actually inhibiting deterioration. There are two drugs subsumed under this category, an N-methyl-D-aspartate (NMDA) inhibitor and a monoamine oxidase B inhibitor. The NMDA antagonist is memantine (Namenda). Memantine's mechanism of action differs from the ChE inhibitors significantly. Memantine blocks abnormal and sustained signaling by glutamate but does not apparently interfere with normal glutamate neuron activation (Keltner, 2004). To appreciate this effect, one must consider that glutamate is the most abundant excitatory neurotransmitter in the brain; hence, aberrations in function of this chemical have potential for global influence. The term neuronal exeitotoxicity typically refers to the overabundance of glutamate coupling with NMDA receptors that leads to neuronal death. Hippocampal excitotoxicity is directly linked to memory deficits and can be caused by various insults (e.g., prolonged seizures, Alzheimer's disease). By blocking NMDA receptors, memantine is thought to retard neurodegenerative processes such as those that occur in Alzheimer's disease. That said, such a mechanism supports the maintenance of cognitive reserve.

Selegiline (Eldepryl) is a monoamine oxidase B inhibitor, which means it conserves dopamine, and has been considered as a method for improving cognitive functioning in certain clinical populations (Sacktor et al., 2000). It is not clear if its antioxidant properties or a more fundamental mechanism contributes to its neuroprotective potential. Selegiline has demonstrated both cognitive and noncognitive improvements in five double-blind randomized trials (American Psychiatric Association, 1997). Selegiline is both an energizing drug (due to preservation of catecholamines) and can cause significant orthostatic hypotension. The former can be positive for some patients but evolves into agitation and irritation in others.

Nonpsychotropic agents can also delay dementia and be beneficial for cognitive reserve. Cyclooxygenase synthesizes prostaglandins that in turn cause inflammation. Nonsteroidal anti-inflammatory drugs inhibit cyclooxygenase, thus interfering with the production of prostaglandins. Because Alzheimer's disease is thought by many clinicians to be a "low-burner" inflammatory process, agents such as ibuprofen (e.g., Motrin, Advil) and aspirin (because they are cyclooxygenase inhibitors) have the potential to reduce the neuronal loss associated with this degenerative process. Other researchers have long suspected a relationship between high cholesterol levels and Alzheimer's disease. One study suggests statins (e.g., Lipitor, Zocor, Pravachol) reduce the risk of Alzheimer's disease by approximately 40% (Green, Bachman, Benke, Cupples, & Farrer, 2003).

Neuroleptics and other drugs that improve cognition and/or reduce cognitive decline obviously add to cognitive reserve, enabling older patients to fend off the advances of nonpathological and pathological aging. To that end, drug therapy is an important dimension of efforts to maintain cognitive competence. Hence, combining cognitive remediation training with such neuroleptic medications may further improve cognitive training effects.


Cognitive Remediation Training Model

Figure 2 is presented as a didactic to highlight the role that cognitive remediation training plays in increasing cognitive functioning and everyday performance, such as the Instrumental Activities of Daily Living (IADLs) and the Activities of Daily Living (ADLs). In this model, domain-specific cognitive training generally improves functioning only within the domain for which training occurred (i.e., speed of processing training improves speed of processing functioning). However, the idea behind improving functioning in a certain cognitive domain is that it may generalize to other cognitive domains or to everyday functioning. For example, Edwards et al. (2005) improved speed of processing in 63 community-dwelling older adults after being trained; furthermore, they found that improvement in training generalized to improve functioning on the Timed Instrumental Activities of Daily Living measure. Likewise, as implied by the Speed of Processing Theory of Aging (Ball et al., 2004), improvement in speed of processing should support other cognitive domains that rely on it. One important caveat is that, as yet, such findings have not been observed, perhaps because speed of processing training has focused more on increasing speed of visual attention rather than overall neural speed.

Meanwhile, global cognitive training, such as seen with Posit Science and theater training, offers techniques that focus on improving cognitive functioning beyond a single cognitive domain. As such, they may be more likely to improve everyday functioning as well; however, to our knowledge, an examination of how global cognitive training generalizes to everyday functioning has yet to be conducted. Regardless, both global cognitive training and domain-specific cognitive training are needed. Although global cognitive training could have more generalized effects toward everyday functioning, domain-specific cognitive training may be more advantageous in changing a particular cognitive ability that impacts a specific everyday functioning task. For example, Roenker, Cissell, Ball, Wadley, and Edwards (2003) used speed of processing training with 48 community-dwelling older adults and found that by increasing the speed of visual attention in these participants, participants improved on driving simulator measures and exhibited fewer dangerous maneuvers during a driving evaluation. Such targeted domain-specific cognitive training may be more useful in changing specific behaviors, such as driving, than by using global cognitive training techniques.

Figure 2 also shows that facilitating factors such as sleep hygiene and physical exercise may be used in conjunction with such cognitive remediation training to improve the range in which cognitive remediation training generalizes to other cognitive domains and everyday functioning. In fact, a combination of two or more of these factors may greatly facilitate neural functioning and support cognitive reserve, thus priming one to receive greater benefits from cognitive remediation training. Although not indicated explicitly, this model implies that harmful factors such as excessive alcohol or drug use, polypharmacy, and sedentary lifestyles may interfere with the cognitive gains that can occur through cognitive remediation training. Hence, both positive and negative factors can be examined in combination with cognitive remediation training.

Implications for Nursing Practice and Research

This article provides nurses and nurse researchers an overview of the role of cognitive remediation training. As such, nurses can use this information in three ways. First, given the direct contact nurses have with older patients, they are in a strategic position to recognize those who are concerned about their cognitive functioning or exhibiting cognitive problems. Such information can be derived from querying patients about their cognitive functioning. For example, nurses can ask if patients are experiencing difficulty remembering to pay bills, are more distractible, or are having trouble remembering information (Vance, Farr, & Stmzick, 2008). If such trouble is detected, nurses can explain that there are cognitive remediation programs available that have been shown to improve both global and domain-specific cognitive abilities. As such, referrals to neurologists or psychologists can be made to pursue this avenue of treatment further.

Second, nurses as health educators can instruct patients how to promote successful cognitive aging (Vance & Burrage, 2006). Many older adults are not aware that cognitive abilities can be sustained through nutrition, improved sleep hygiene, and enriched cognitive environments. Yet cognitive remediation training shows that cognitive exercises are important and effective in improving cognitive ability. Evidence suggests that even engaging in a mentally active lifestyle can promote successful cognitive aging and delay the onset of dementia in some people (Vance & Crowe, 2006; Wilson & Bennett, 2003). Furthermore, nurses can suggest other practical avenues for supporting cognitive reserve and for improving overall mental health, such as using a pedometer to increase physical activity, avoiding caffeine and naps to promote sleep hygiene, and developing new interests that will offer enriched cognitive stimuli. For many older adults, taking on a volunteer job is one feasible route to new routines that may offer mental stimulation that supports positively neuroplasticity and cognitive reserve.

Third, nurse researchers can examine this multimodal approach by investigating established cognitive training protocols, combining them with factors that facilitate cognitive reserve. In addition, the need to develop other types of cognitive remediation training that can be self-administered will be more important considering the cost of in-person training and the increasing number of older adults. For example, Wadley et al. (2006) developed a self-administered speed of processing training program that could be used at home with the aid of a workbook and videotapes. Such self-administered techniques could also be used in conjunction with other factors that enhance cognitive reserve. By developing such self-administered training techniques, nurses could provide such therapeutic materials to patients interested in ameliorating their cognitive abilities (Vance et al., 2009). Improvement of cognitive abilities will also improve overall functioning for older adults.


Dependency and declines in quality of life often accompany age-related cognitive loss (Schaie, 1996). However, cognitive remediation training has been shown to improve domain-specific and global cognitive functioning, which can translate into improved everyday functioning. Unfortunately, the full potential of such training protocols has only yet to be explored. Factors that facilitate cognitive reserve and support cognitive functioning can be combined with cognitive remediation training to form a multimodal approach for improving cognitive ability. This approach may be advantageous in improving functioning in other adults with cognitive difficulties such as those with traumatic brain injury or adults with HIV (Vance & Crowe, 2006). Finally, this multimodal approach with cognitive remediation training will be a more popular research trajectory in the foreseeable future.

DOI: 10.1097/JNN.0b013e3181ecb003

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The Future of Cognitive Remediation Training in Older Adults


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GENERAL PURPOSE STATEMENT: To provide the professional registered nurse with an overview of research related to cognitive changes and remediation in older adults.

LEARNING OBJECTIVES: After reading the preceding article and taking the following test you should be able to:

1. Describe research findings related to retraining for improvement of both domain specific and global cognitive functioning in older adults.

2. Discuss how lifestyle changes and medications can be used to improve cognitive functioning.

1. Neuroplasticity refers to a process by which

a. the brain becomes more pliable and porous with aging and dementia.

b. changes in the brain occur with sudden dehydration or fluid overload.

c. the neurons in the brain harden with aging.

d. morphological changes occur in the brain in response to novel sensory stimuli.

2. Kobayashi, Ohashi, and Ando (2002) demonstrated increased cognitive performance in rats related to

a. an enriched environment.

b. the size of the brain.

c. the weight of the brain.

d. the age of the rat,

3. Two types of global cognitive training protocols are theatre training and

a. speed of processing training.

b. Posit computer training.

c. reasoning training,

d. memory training.

4. Remediation training in speed of processing is designed to accelerate

a. memory retention.

b. converting thoughts to speech.

c. voluntary motor functioning,

d. processing visual information.

5. Responding by touch screen to visual information on a computer screen has resulted in robust improvement in

a. memory skills.

b. reasoning skills.

c. speed of processing.

d. all areas of cognitive functioning.

6. Reasoning remediation training in older adults also improved performance in

a. memory.

c. speed of processing.

b. mood.

d. executive functioning.

7. Which cognitive domain seems to be the most difficult to improve?

a. memory

b. reasoning

c. speed of processing

d. executive functioning

8. The Posit Science remediation training

a. uses auditory and visual tasks administered via home computers without trained staff.

b. uses a computerized program with a trained aid.

c. consists of learning mnemonics with word lists and details from texts and narratives.

d. is measured by problem solving and logical pattern recognition abilities,

9. Which Posit Science remediation training task consists of participants reconstructing a sequence of short words?

a. Sound Replay

b. Tell Us Apart

c. High or Low

d. Listen and Do

10. Results of the Posit remediation training study showed

a. no difference between experimental training and DVD-based educational lectures.

b. global cognitive training benefits with progressively difficult visual and auditory tasks.

c. no benefits beyond improvement in auditory cognitive tasks.

d. greater improvement using the DVD-based lectures.

11. Which statement about theater retraining is not true?

a. It is an example of global retraining.

b. It represents a highly complex skill.

c. Older adults have difficulty adhering to this treatment,

d. It does not rely on technology at all,

12. Which statement about the effects of physical activity on cognitive functioning is true?

a. It is beneficial only in combination with other types of retraining.

b. It can benefit cognitive functioning on its own.

c. It does not benefit cognitive functioning,

d. It is equally effective as mental stimulation.

13. All of the following sleep issues are associated with poor cognitive functioning except

a. sleeping 6 to 7 hours at night.

b. sleep disordered breathing.

c. over the counter sleep aids,

d. alcohol use,

14. Which evidence-based nutritional intervention might be recommended to improve cognitive function?

a. weight loss

b. eliminate alcohol use

c. increase intake of blueberries

d. Vitamin A supplementation

15. Which is an N-methyl-D-aspartate (NMDA) inhibitor thought to retard neurodegenerative processes?

a. memantine (Namenda)

b. pravastatin sodium (Pravachol)

c. selegiline (Eldepryl)

d. ibuprofen (e.g. Motrin, Advil)

16. Selegiline (Eldepryl) promotes cognitive function by

a. blocking abnormal glutamate signaling.

b. conserving dopamine,

c. reducing neuronal loss.

d. synthesizing prostaglandins.


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Questions or comments about this article may be directed to David E. Vance, PhD MGS, at He is an associate professor at the School of Nursing, University of Alabama at Birmingham (UAB), Birmingham, AL.

Norman L. Keltner, EdD RN, is a professor, School of Nursing, University of Alabama at Birmingham (UAB), Birmingham, AL.

Teena McGuinness, PhD PMH-NP BC, is a professor, School of Nursing, University of Alabama at Birmingham (UAB), Birmingham, AL.

Mary Grace Umlaut PhD RN FAAN, is a professor, School of Nursing, Capstone College of Nursing, University of Alabama, Tuscaloosa, AL.

Yih-Ying Yuan, BS, University of Alabama at Birmingham (UAB), Birmingham, AL.
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