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Clinician Article

Computerised cognitive training for preventing dementia in people with mild cognitive impairment.



  • Gates NJ
  • Vernooij RW
  • Di Nisio M
  • Karim S
  • March E
  • Martinez G, et al.
Cochrane Database Syst Rev. 2019 Mar 13;3:CD012279. doi: 10.1002/14651858.CD012279.pub2. (Review)
PMID: 30864747
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Disciplines
  • Geriatrics
    Relevance - 6/7
    Newsworthiness - 6/7
  • Psychiatry
    Relevance - 6/7
    Newsworthiness - 5/7
  • FM/GP/Mental Health
    Relevance - 6/7
    Newsworthiness - 4/7
  • Family Medicine (FM)/General Practice (GP)
    Relevance - 5/7
    Newsworthiness - 4/7
  • General Internal Medicine-Primary Care(US)
    Relevance - 5/7
    Newsworthiness - 4/7
  • Internal Medicine
    Relevance - 4/7
    Newsworthiness - 4/7

Abstract

BACKGROUND: The number of people living with dementia is increasing rapidly. Clinical dementia does not develop suddenly, but rather is preceded by a period of cognitive decline beyond normal age-related change. People at this intermediate stage between normal cognitive function and clinical dementia are often described as having mild cognitive impairment (MCI). Considerable research and clinical efforts have been directed toward finding disease-modifying interventions that may prevent or delay progression from MCI to clinical dementia.

OBJECTIVES: To evaluate the effects of at least 12 weeks of computerised cognitive training (CCT) on maintaining or improving cognitive function and preventing dementia in people with mild cognitive impairment.

SEARCH METHODS: We searched to 31 May 2018 in ALOIS (www.medicine.ox.ac.uk/alois) and ran additional searches in MEDLINE, Embase, PsycINFO, CINAHL, ClinicalTrials.gov, and the WHO portal/ICTRP (www.apps.who.int/trialsearch) to identify published, unpublished, and ongoing trials.

SELECTION CRITERIA: We included randomised controlled trials (RCTs) and quasi-RCTs in which cognitive training via interactive computerised technology was compared with an active or inactive control intervention. Experimental computerised cognitive training (CCT) interventions had to adhere to the following criteria: minimum intervention duration of 12 weeks; any form of interactive computerised cognitive training, including computer exercises, computer games, mobile devices, gaming console, and virtual reality. Participants were adults with a diagnosis of mild cognitive impairment (MCI) or mild neurocognitive disorder (MND), or otherwise at high risk of cognitive decline.

DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data and assessed risk of bias of the included RCTs. We expressed treatment effects as mean differences (MDs) or standardised mean differences (SMDs) for continuous outcomes and as risk ratios (RRs) for dichotomous outcomes. We used the GRADE approach to describe the overall quality of evidence for each outcome.

MAIN RESULTS: Eight RCTs with a total of 660 participants met review inclusion criteria. Duration of the included trials varied from 12 weeks to 18 months. Only one trial used an inactive control. Most studies were at unclear or high risk of bias in several domains. Overall, our ability to draw conclusions was hampered by very low-quality evidence. Almost all results were very imprecise; there were also problems related to risk of bias, inconsistency between trials, and indirectness of the evidence.No trial provided data on incident dementia. For comparisons of CCT with both active and inactive controls, the quality of evidence on our other primary outcome of global cognitive function immediately after the intervention period was very low. Therefore, we were unable to draw any conclusions about this outcome.Due to very low quality of evidence, we were also unable to determine whether there was any effect of CCT compared to active control on our secondary outcomes of episodic memory, working memory, executive function, depression, functional performance, and mortality. We found low-quality evidence suggesting that there is probably no effect on speed of processing (SMD 0.20, 95% confidence interval (CI) -0.16 to 0.56; 2 studies; 119 participants), verbal fluency (SMD -0.16, 95% CI -0.76 to 0.44; 3 studies; 150 participants), or quality of life (mean difference (MD) 0.40, 95% CI -1.85 to 2.65; 1 study; 19 participants).When CCT was compared with inactive control, we obtained data on five secondary outcomes, including episodic memory, executive function, verbal fluency, depression, and functional performance. We found very low-quality evidence; therefore, we were unable to draw any conclusions about these outcomes.

AUTHORS' CONCLUSIONS: Currently available evidence does not allow us to determine whether or not computerised cognitive training will prevent clinical dementia or improve or maintain cognitive function in those who already have evidence of cognitive impairment. Small numbers of trials, small samples, risk of bias, inconsistency between trials, and highly imprecise results mean that it is not possible to derive any implications for clinical practice, despite some observed large effect sizes from individual studies. Direct adverse events are unlikely to occur, although the time and sometimes the money involved in computerised cognitive training programmes may represent significant burdens. Further research is necessary and should concentrate on improving methodological rigour, selecting suitable outcomes measures, and assessing generalisability and persistence of any effects. Trials with long-term follow-up are needed to determine the potential of this intervention to reduce the risk of dementia.


Clinical Comments

FM/GP/Mental Health

The bottom line is that the variability of the studies available prevent drawing any conclusions either way as to whether computerized cognitive training is beneficial in mild cognitive impairment. Noteworthy, however, is that some individual studies showed a large positive benefit, so further study is indeed warranted.

FM/GP/Mental Health

There is still no evidence that cognitive training makes a difference; this is not news.

Geriatrics

The same conclusion was reached in another recent Cochrane systematic review exploring the efficacy of computerised cognitive training (CCT) for maintaining cognitive function in cognitively healthy older persons. It seems plausible that CCT does not have any role in cognitive function, either in healthy elderly individuals or in a cognitively impaired older population.

Internal Medicine

The major concern is that the study did not provide evidence or refuted the implications of a computerized cognitive training to prevent clinical dementia owing to very low quality of evidence and high risk of bias.

Psychiatry

The development of interventions to slow or prevent the progression of mild cognitive impairment to dementia is of great interest to psychiatrists and other providers. Computer-based interventions would appear to be easily distributed at low cost. The article points to the need for more rigorous research in this area.

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