REVIEW

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Promotion of cognitive health through

cognitive activity in the aging population
Tiffany F Hughes†
There is both popular and scientific interest in keeping the brain young and avoiding cognitive
impairment and dementia. Older adults may be able to modify their cognitive health status through
certain health behaviors. The aim of this review is to highlight the potential impact that cognitive
activity may have on cognitive health outcomes in late life. Evidence from observational studies
and randomized, controlled trials suggests that engagement in activities that are cognitively
stimulating is beneficial to cognitive functioning. There are many issues and questions that need
to be addressed before specific recommendations can be made at the population level or to
individual patients. However, older adults should be encouraged to stay active and to try new and
challenging activities in general to promote their cognitive and overall health.

The health of the brain, similar to that of the heart, participation in everyday life or specific preventa-
is increasingly being recognized as influenced by tive/intervention approaches may have on cogni-
our lifestyle and environment. The idea that older tive health. This section reviews the three levels of
adults can modify their risk for cognitive impair- cognitive functioning that are recognized in older
ment and dementia is quite appealing given the adults: normative cognitive aging, mild cognitive
looming public health crisis of dementia in the impairment (MCI) and dementia. It is of note
coming decades. The sale of books, computer that this delineation is somewhat arbitrary, with
programs and games claiming to increase ‘brain cognitive declines falling along a continuum.
fitness’ or to ‘keep the brain young’ has exploded
in recent years, demonstrating the public’s desire Normative cognitive aging
to maintain their brain and cognitive faculties as Although determining what changes can be
they age. However, empirical evidence supporting expected as part of the normal aging process is still
or refuting these claims is only emerging. an active area of inquiry, in general, two patterns
Several modifiable factors, including cogni- of change occur in cognitive functioning during
tive activity, exercise, vascular health and diet the course of adult development. Some abilities
and nutrition, are being studied regarding their remain relatively stable into old age, while others
potential to reduce the risk of cognitive impair- follow a trajectory of decline [4] . Verbal abilities,
ment and dementia [1,2] . The potential utility of including vocabulary, information and compre-
a cognitive activity approach is considered to be hension, are those that typically show minimal
under­appreciated since it may be the most direct decline until very old age. Abilities such as speed †
Department of Psychiatry,
pathway for improving cognitive health outcomes of processing, memory, spatial ability and reason- University of Pittsburgh School of
via a spectrum of biological changes in brain ing tend to decline more with aging. Importantly, Medicine, 3811 O’Hara St,
structure and function [3] . The purpose of this these declines do not substantially affect the abil- Pittsburgh, PA 15213, USA
review is to highlight cognitive activity as a �����
prom- ity of older adults to perform activities of daily Tel.: +1 412 647 6619
ising���������������������������������������
nonpharmacological method for maximiz- living. Older adults who experience normative Fax: +1 412 647 6555
ing cognitive health in old age. First, the spectrum cognitive changes are able to remain independent [email protected]
of cognitive health in old age is presented. Second, in the absence of any other conditions causing
the theoretical background supporting cognitive physical or mental disability. Keywords
activity is reviewed, followed by evidence from • cognitive activity • cognitive
select�������������������������������������������
observational studies and randomized, con- Mild cognitive impairment aging • cognitive impairment
trolled trials (RCTs) of cognitive activity. Finally, Mild cognitive impairment is an inter­mediate • cognitive intervention
• cognitive stimulation
a discussion of some important issues that should state between normal cognitive aging and
• cognitive training • dementia
be considered when evaluating this evidence and dementia, where individuals experience cogni- • mild cognitive impairment
designing future studies is presented. tive deficits that are greater than expected for • mental stimulation
their age but do not fulfill the diagnostic crite-
Spectrum of cognitive health in late life ria for dementia [5] . Other terms are also used
Where older adults are on the spectrum of cogni- to describe this state, such as age-associated part of
tive abilities in late life has important implications memory impairment [6] , age-related cognitive
with regard to the effect that cognitive activity decline [6] , age-associated cognitive decline [7]

10.2217/AHE.09.89 © 2010 Future Medicine Ltd Aging Health (2010) 6(1), 111–121 ISSN 1745-509X 111
REVIEW – Hughes

and cognitive impairment no dementia [8] . MCI and neurophysiologic (cognitive reserve) levels,
is associated with a heightened risk of progres- allowing individuals to compensate for age-
sion to dementia [9] , although many individu- related brain changes or disease pathology and
als with MCI remain stable or even revert back to not outwardly express symptoms of cognitive
to normal status [10] . The prevalence of MCI impairment or dementia [17] .
varies widely from 3 to 54% depending on the
criteria used to define it and how it is put into Environmental complexity
operation [11] . In addition, whether the study was Simply stated, the environmental complexity
conducted in a clinical or community-based set- hypothesis suggests that complex environments
ting can also affect the prevalence, with �����esti- have a positive effect on cognitive functioning
mates from community-based studies generally and simple environments have a negative effect
being lower [12] . Recent studies suggest that MCI on cognitive functioning. More specifically, the
patients experience subtle deficits in everyday complexity of an environment is a function of
functioning [13] and have mood disturbances [14] . the diversity of the stimuli, the number of deci-
sions required, the number of considerations
Dementia that need to be taken into account when mak-
Dementia is a chronic syndrome characterized ing decisions and the ill-defined and apparently
by acquired cognitive deficits in more than one contradictory contingencies resulting from these
cognitive domain, currently including memory, decisions. Accordingly, complex environments
that are severe enough to affect daily (social and are expected to reward cognitive effort, where
occupational) functioning, do not occur solely individuals should be motivated to develop
in the context of delirium and cannot be fully their intellectual capacities and to apply their
accounted for by another mental disorder  [15] . use to other situations. Continued exposure to
Alzheimer’s disease (AD) is the most common relatively simple environments may have the
subtype of dementia, followed by vascular demen- opposite effect, since the low level of environ-
tia and mixed dementias with both degener­ative mental demand does not foster the development
and vascular pathology. Approximately 35.6 mil- or maintenance of intellectual functioning [18] .
lion individuals are expected to be affected by
dementia worldwide in 2010, with the preva- Cognitive reserve
lence expected to double every 20 years to over The concept of cognitive reserve has been pro-
100 million in 2050 [101] . Dementia poses a large posed to explain the heterogeneity in clinical
burden for families and society owing to the level outcomes between individuals who have similar
of care that is necessary throughout the disease neural deficits related to disease pathology or
process. In the mild stage, those with dementia normal age-related brain changes. Two types of
may need supervision in order to prevent acci- cognitive reserve have been proposed to describe
dents (e.g.,  leaving the stove turned on) and this variation: passive and active [19] . The pas-
help with complex activities of daily living such sive model of reserve suggests that neuron and
as managing medication and finances. As the synapse number or brain size provide the basis
disease progresses, individuals lose the ability to for reserve, which is consequently determined
perform basic activities of daily living, includ- primarily by genetics but may be influenced,
ing dressing, bathing and toileting, are no lon- to some degree, by environmental influences.
ger able to speak or comprehend language, and The active model of reserve, more commonly
experience personality changes [16] . know as ‘cognitive reserve’, is more concerned
with neural processing and synaptic organiza-
Environmental complexity & tion than neuroanatomical differences. Neural
cognitive reserve processing and synaptic organization are more
Two theoretical perspectives, environmental sensitive to environmental influences; there-
complexity and cognitive reserve, may pro- fore, it is these changes that provide the greatest
vide explanations as to how cognitive activity potential for increasing reserve. It is likely to be
affects the expression of cognitive impairment. a combination of active and passive reserve that
Although they originated from different empiri- provides the most comprehensive explanation
cal roots  – the sociology of work and brain of the cognitive variation between individuals
injury, respectively  – together, they provide at the neurophysiologic level.
complimentary explanations of how cognitive Support for the cognitive reserve hypothesis at
activity may benefit the cognitive system at both the neural level has been demonstrated in animal
the psychosocial (environmental complexity) models and in humans [3] . Studies in rodents have

112 www.futuremedicine.com future science group

 Promotion of cognitive health through cognitive activity in the aging population – Review

shown that mental exercise induces neuro­genesis leads to less cognitive decline, rather than cog-
and synaptogenesis, increases hippo­campal syn- nitive decline leading to lower activity levels.
aptic reactivity, enhances cerebrovasculature and A life course approach was taken by Wilson
reduces brain b-amyloid deposition. Human and colleagues to examine how participation
studies have suggested that cognitive activity in cognitively stimulating activities measured
may lead to a reorganization of neurocognitive at 6, 12, 18 and 40 years of age, and current
networks, attenuate the adverse effects of stress age, was related to function in different cogni-
hormones on the brain and increase activity in tive systems [31] . They found that more frequent
brain regions (i.e., prefrontal cortical regions) participation in activities across the lifespan was
subserving executive functioning [20] . related to better perceptual speed, visuospatial
ability and semantic memory, but not to epi-
Empirical studies of cognitive activity & sodic memory or working memory. Additional
late-life cognitive health evidence from prospective studies using twin
The field of gerontology has long recognized the pairs discordant for dementia to assess participa-
importance of older adults remaining actively tion in leisure activities in midlife also supports
involved with the environment for a variety of a protective role of higher engagement against
health outcomes [21] . Activities that require cog- dementia [32] and AD [33] . There are studies that
nitive effort (e.g., reading, hobbies or learning a have reported no association between cognitive
new language) may be especially important for activities and cognition in older adults [34–36] ,
cognitive health. By increasing the complexity but methodological limitations may explain
of the environment, these activities may increase these null associations [17] .
cognitive reserve. In general, there appears to be
support for a positive association between cog- Randomized, controlled studies of
nitive activity and cognitive functioning in late cognitive activity
life. This section will review the �������������
most methodo- The benefits of engaging in a cognitively stimu-
logically sound observational studies and RCTs lating leisure activity seen in observational stud-
conducted in this area to date. ies has prompted cognitive intervention trials
that are designed to stimulate cognitive func-
Observational studies of tioning. One of the main objectives of these
cognitive activity RCTs is to establish whether there is a causal
Prospective studies of cognitive activity and risk relationship, since a major problem in the inter-
of cognitive impairment and dementia have gen- pretation of most observational study findings
erally found that more frequent participation in is the inability to distinguish cause from con-
cognitive activity is associated with a reduced sequence (i.e., does engagement in cognitively
rate of cognitive decline [22,23] and a reduced risk stimulating activity lead to better cognitive
of cognitive impairment [24,25] , dementia [26–28] health outcomes or does poor cognitive health
and AD [29,30] . The most informative data comes lead to less engagement in cognitive activity?).
from studies that used sophisticated techniques Three types of cognitive interventions have been
that allow for the direct assessment of the tem- described: cognitive stimulation, cognitive train-
poral order among the variables tested and stud- ing and cognitive rehabilitation  [37] . Cognitive
ies that assessed lifestyle activities across the life stimulation involves a broad range of activities,
course. For example, Ghisletta and colleagues typically in a group setting, with the goal of
examined whether changes in lifestyle activi- enhancing general cognitive and social func-
ties led to a change in cognitive functioning or tioning. Cognitive training is a more specific
whether changes in cognitive functioning led approach in which repeated training is carried
to a change in lifestyle activities using a bivari- out on a set of structured tasks that target one or
ate dual change score model approach [23] . The more specific cognitive domains (e.g., attention,
results of the study revealed that increased fre- memory and executive functioning). Cognitive
quency of participation in media- (e.g., listening rehabilitation has been broadly defined as ‘any
to the radio or watching television) and leisure- intervention strategy or technique that intends
(e.g., playing games or doing crossword puzzles) to enable clients or patients and their families
type activities was associated with less decline to live with, manage, bypass, reduce or come
in perceptual speed, ���������������������������
but that cognitive perform- to terms with deficits precipitated by injury to
ance did not influence change in cognitive activ- the brain’ [38] . Pathology-associated dementia
ity. This finding provides increased confidence would be considered injury to the brain. Since
that higher engagement in cognitive activities the primary goal of cognitive rehabilitation is

future science group Aging Health (2010) 6(1) 113

REVIEW – Hughes

to provide support for everyday functioning in and dementia. In addition, there have been no
those who are already experiencing cognitive RCTs that have examined an everyday cogni-
deficits, the focus of this review is on cognitive tive stimulation intervention in older adults with
stimulation and training studies. The reader is MCI to examine whether the cognitive deficits
referred to a Cochrane review of cognitive reha- and associated impairments can be improved
bilitation and cognitive training for early-stage or stabilized.
AD and vascular dementia [37] .
Cognitive training
Cognitive stimulation The largest cognitive training study con-
Owing to the many methodological challenges ducted is the Advanced Cognitive Training
in testing the types of cognitively stimulating for Independent and Vital Elderly (ACTIVE)
activities measured in observational studies, only trial [42] . In this study, unimpaired, community-
a few large-scale RCTs have been conducted to dwelling older adults were trained in one of four
examine the efficacy of engaging in cognitively cognitive areas (i.e., memory, reasoning, speed of
stimulating leisure activities. The Experience processing and control) during ten group sessions
Corps (EC) [102] is the most well-known cog- over a period of 5–6 weeks, with four booster
nitive stimulation approach [39] . EC is a social sessions at 11 and 35  weeks postintervention
health promotion model that targets older adults in a subsample of participants. Assessment of
who are at a higher risk of poor health outcomes cognitive and functional measures at the 2- and
owing to their low educational attainment and 5‑year follow-ups revealed improvement in the
socioeconomic status (SES). Participants in EC domains trained and less self-reported decline
volunteer in the public school setting as tutors for in instrumental activities of daily living func-
elementary school-aged children. The activities tioning with reasoning training  [43] . Recently,
involved in EC are designed to enhance physi- computer-based cognitive training formats have
cal, social and cognitive activity simultaneously. started being tested. One such example is the
It has been demonstrated that EC participants Improvement in Memory with Plasticity-Based
show increased activity [38] , improved executive Adaptive Cognitive Training (IMPACT) study, a
function and memory [40] , and enhanced brain large RCT using the Brain Fitness Program from
activity in regions that are important for executive Posit Science (San Francisco, CA, USA) [44] . This
function [20] compared with their control coun- program consists of six computerized exercises
terparts. Another ‘everyday activity’ inter­vention designed to improve the speed and accuracy of
is the Senior Odyssey program (University of auditory information processing. Initial results
Illinois, IL, USA) [41,103] . This program was of this trial comparing pre- and postassessment
designed to be ‘a community-based program that scores suggest that the experimental program
takes advantage of existing social structures’ by improved performance in untrained tests of
being modeled, in part, on the Odyssey of the memory and attention relative to the active con-
Mind program (Creative Competitions, Inc., NJ, trol condition. The positive findings of these two
USA) for children and young adults. Participants examples of cognitive training studies are sup-
in the Senior Odyssey program work together in ported by a systematic review of the effect of cog-
teams to solve selected problems, exercising basic nitive training RCTs in healthy older adults over
cognitive processes, decision making, creativity time. Among seven trials meeting the inclusion
and evaluation of ideas in a friendly, competi- entry for the analyses, including the ACTIVE
tive environment. Postintervention assessments trial, a strong effect size for cognitive training
revealed that compared with controls, partici- was found compared with the control conditions,
pants who were randomly assigned to the pro- and this effect persisted in studies with more than
gram performed better on a composite measure 2 years of follow-up [45] .
of fluid ability and in the specific domains of Randomized, controlled cognitive train-
speed, inductive reasoning and divergent think- ing studies have also been conducted in older
ing, but not in working memory or visuospatial adults with MCI and dementia. In older adults
ability. Taken together, these two programs offer with MCI, the majority of these studies report
promise that an ‘everyday’ cognitive stimulation improvements in cognitive performance fol-
approach may improve cognitive health in older lowing training; for example, a 1‑year cognitive
adults that are cognitively unimpaired. motor intervention, consisting of cognitive exer-
Studies are needed to examine the efficacy of cise drills plus social and psychomotor activi-
everyday cognitive stimulation in decreasing the ties, was compared with a psychosocial support
likelihood of developing cognitive impairment control condition in individuals with MCI and

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 Promotion of cognitive health through cognitive activity in the aging population – Review

early AD who were taking cholinesterase inhibi- and inconsistencies, and the findings from
tors (ChEIs). The authors found that those in RCTs are generally more robust compared with
the intervention group maintained their cogni- observational studies. Second, there may be
tive status after 6 months, whereas the control differences in the protective effects of cognitive
group showed declines in cognitive status [46] . activity����������������������������������������
depending on the etiology of the cogni-
Two computer-based cognitive training studies tive impairment, the current level of cognitive
have also demonstrated improved cognitive abili- functioning or the stage of life. Finally, other
ties in individuals with MCI. The first study was characteristics (e.g.,  educational attainment,
designed to stimulate memory, language, abstract SES, apolipoprotein E [APOE] genotype and
reasoning and visuospatial abilities in those with personality) may influence the potential for
MCI taking ChEIs. The findings revealed that cognitive activity to improve cognitive health
memory and abstract reasoning improved more as well as other secondary outcomes such as
in the cognitive training plus ChEI treatment everyday functioning.
group compared with those on ChEI treatment
alone [47] . The second computer-based program Interpreting observational studies
was designed to improve auditory processing & randomized, controlled trials
speed and found promising preliminary results, The drive to confirm the findings of observa-
where those in the intervention group demon- tional studies through RCTs necessitates that
strated greater, although not statistically signifi- the basic strengths and limitations of each
cant, improvements in the Repeatable Battery study design be reviewed. First, the strengths of
for Assessment of Neuropsychological Status observational study designs are the large num-
total score compared with the control group [48] . ber of participants (and clinical events) that can
Each of these described RCTs was conducted be included, that exposure–disease associations
with less than a total of 100 participants, so addi- are studied under real-life conditions and that
tional large-scale RCTs are necessary before the they are generally lower in cost. The major limi-
efficacy of cognitive training in MCI patients tation is that risk estimates from observational
can be determined. Evidence in favor of cogni- studies do not necessarily imply a direct causal
tive training benefiting older adults with AD is relationship. This is particularly problematic
mixed. A meta‑analysis of 17 controlled stud- when studying cognitive health outcomes since
ies revealed a medium overall effect size across observational studies cannot generally (except
the cognitive training strategies and cognitive with very long follow-ups or sophisticated sta-
domains tested. A medium effect size was also tistical analyses) distinguish whether higher
observed for other secondary outcomes includ- engagement in cognitive activities actually pre-
ing activities of daily living, depression and vented or lowered the risk of cognitive decline
self-rated general functioning [49] . Conversely, or dementia, or if lower engagement in cogni-
a Cochrane review of cognitive training in AD tive activities resulted from declining cognition
came to the conclusion that there is ‘no evidence owing to aging or preclinical dementia. For this
for the efficacy of cognitive training in improv- reason, the observed association should only be
ing cognitive functioning for people with mild- interpreted as a signal that suggests where there
to-moderate AD’ [37] . Thus, it seems that those is an underlying mechanism to be explored.
with MCI, and possibly AD, may benefit from RCTs are conducted after there is sufficient
cognitive training strategies, although additional evidence from observational studies to warrant
studies are needed in these populations. the randomization of individuals to a treatment
(e.g., drug or behavioral intervention) or con-
Considerations in the study of trol condition. Because causal associations can
cognitive activity be tested, RCTs are considered the gold stan-
While the studies conducted thus far seem to dard for testing the efficacy of treatments or
point to a beneficial effect of cognitive activity interventions in health research. A limitation of
for cognitive health in later life, especially for RCTs is that they can often not be generalized
healthy individuals, there are certain issues that to the population.
should be considered when interpreting these While the findings of RCTs are stronger
results, as well as additional questions that need than those of observational studies, the role
to be answered before specific recommenda- of observational studies in discovering the
tions can be made at the population level or to what, when and how much, as well as gener-
individual patients. First, limitations of obser- ating hypotheses regarding potential biologi-
vational studies can lead to misinterpretation cal mechanisms of certain behaviors that may

future science group Aging Health (2010) 6(1) 115

REVIEW – Hughes

enhance cognitive health in old age, should not Timing of cognitive activity engagement
be overlooked. In some cases, such as the life- The cognitive activities reviewed here primarily
course study of cognitive activity, the findings fall into the categories of primary and secondary
from observational studies cannot be tested in prevention. Briefly, primary prevention meth-
RCTs owing to practical or ethical reasons, and ods aim to keep older adults’ levels of cogni-
alternatives to the RCT may therefore be the tive functioning within the ‘normal’ or ‘mildly
gold standard [50] . It is also important to note impaired’ range and avoid the development of
that when there is a discrepancy between obser- clinically expressed dementia. Secondary preven-
vational and interventional studies, it may not tion would then identify those with early cog-
always be that the observational study results nitive impairment (e.g., MCI) so interventions
are incorrect. It may be that the experimental could be targeted in order to prevent further
intervention was undertaken with the wrong deterioration to dementia. Among the studies
exposure, the exposure may be in the causal of cognitive activity that have been conducted,
pathway but may not be modifiable or the tim- only the ACTIVE trial has shown benefits
ing and duration of the exposure may have been in both healthy participants and those with
critical in determining whether it leads to dis- MCI  [51] . Additional studies of cognitive activ-
ease and when it may be modifiable. However, ity are needed that include older adults across the
with that said, the findings of RCTs should cognitive continuum in order to determine if the
take precedence over observational studies same or similar strategies can be used in healthy,
since the methodological strengths of RCTs mildly impaired and dementia populations.
better delineate the true causal risk factors from Another issue related to timing is that the
factors that may be a marker of the disease or extent to which cognitive activity benefits cogni-
moderate or mediate the association between tive health outcomes may be specific to the stage
a causal risk factor and cognitive health out- of the life course. This is because the underlying
comes. Thus, researchers and clinicians should pathological process of degenerative dementias
evaluate each type of study for its strengths and probably begins many years before the clinical
limitations when drawing conclusions regard- symptoms are expressed. Thus, whether cogni-
ing the utility of a particular cognitive activity tive activity is a true risk factor or a preclinical
strategy, noting that factors that are demon- symptom (i.e., a contributing cause or an effect)
strated to be protective in observational studies of cognitive impairment or dementia can often
may not necessarily have a preventative effect be confusing, especially if there is insufficient
when tested in RCTs. time between the assessment of the cognitive
activity and the onset of symptoms [52] . This is
Etiology of MCI & response evidenced by the nonlinear or time-dependent
to intervention association between hyper­tension in obser-
Efforts to better understand the syndrome vational studies  [53] and hormone therapy in
of MCI are primarily related to its associa- RCTs  [54,55] . Thus, it is important to consider
tion with an increased rate of progression to that the results of both observational and RCTs
AD. However, different etiologies are likely to may be influenced by the stage of life at which
explain symptoms associated with MCI, includ- the study was conducted. The general assump-
ing mood disorders (e.g., major depression) and tion is that cognitive stimulation across the
vascular disorders as well as other degenerative entire life course is likely to be most beneficial
(e.g., frontotemporal dementia and Lewy body and will follow a linear pattern, although this
dementia) or comorbid conditions [5] . No studies has not been empirically supported as of yet.
have examined whether, for example, cognitive
impairment associated with major depression Other characteristics
responds differently to intervention therapies The goal is to develop recommendations for
compared with cognitive impairment owing to a cognitive activity that can be disseminated at
progressive brain disorder such as AD����������
. The gen- the population level, but a more patient-centered
eral assumption is that the latter would show less approach may also be needed. Certain character­
benefit. Future large RCTs need to test whether istics known to be associated with the likelihood
the efficacy of cognitive interventions target- of engaging in cognitive activities and with the
ing MCI vary as a function of etiology. At this risk of cognitive impairment and dementia
time, physicians should be aware of the fact that will need to be considered. The characteris-
patients with MCI may respond differently to tics include, but are not limited to, educational
cognitive intervention. attainment [56] , SES [56] , APOE genotype [57]

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 Promotion of cognitive health through cognitive activity in the aging population – Review

and personality [58] . These characteristics may make any specific recommendations. Questions
affect the overall efficacy of cognitive activity remain concerning which particular activi-
by providing a baseline level of brain/cognitive ties (i.e.,  what), timings (i.e.,  when), dosages
reserve (e.g., educational attainment), determin- (i.e., how much) and durations (i.e., how long)
ing access to cognitively stimulating activities are most effective. Furthermore, this is likely
(e.g., SES), limiting or enhancing the extent to to be highly individualized and to depend on
which cognitive activity can increase reserve and a number of factors. However,
�������������������������
the current evi-
cognitive functioning (e.g., APOE genotype) and dence does support the general recommendation
influencing motivation and adherence to cogni- of encouraging adults to engage in activities that
tive activity recommendations (e.g., personal- are new and challenging�����������������������
. This means that indi-
ity). Further understanding of the role that these viduals who frequently engage in activities that
characteristics play will be an important step in are considered to be of high cognitive demand
tailoring cognitive activity recommendations. (e.g., reading or playing bridge) will need to do
different activities that are novel and require
Conclusion active learning. With that said, until definitive
Many older adults are at an increased risk of cog- studies have been conducted, physicians should
nitive impairment and dementia owing to their avoid creating the false hope in their patients that
genetic make-up or early life environment [59,60] . they can avoid MCI and dementia by increasing
Since these influences cannot be modified, the their cognitive activity or, even worse, creating
search is on for effective strategies to prevent or the misperception that patients are to blame for
slow the onset of cognitive impairments in these their cognitive problems.
individuals. In addition, it is also important to
find ways of keeping the cognition functioning Future perspective
of all older adults at an optimal level, regard- In the future, large, well-designed RCTs based
less of whether or not they are at a high risk for on a number of observational studies will need
cognitive decline. Engagement in activities that to be conducted in order to make evidence-
stimulate cognitive functioning, be it through based recommendations to the pubic and to
leisure or structured training tasks, is emerg- individual patients about ways in which they
ing as one of the most promising approaches to can maintain their cognitive health with aging
promote cognitive health with aging [61] . The through cognitive activity. Observational stud-
environmental complexity and brain/cogni- ies will need to take advantage of existing longi-
tive reserve hypotheses offer explanations at tudinal data and collect more detailed informa-
the psychosocial and neurophysiologic levels tion in order to address questions related to the
for the effect of cognitive activity on cogni- timing of cognitive activities, dosage, duration,
tive functioning. Based on this review of select specific types of activities, interactions between
observational studies and RCTs, healthy and activities and level of cognitive demand. At the
cognitively impaired older adults are likely to same time, the design and conduct of RCTs will
benefit from engaging in activities that ‘exercise need to be improved to tackle a number of chal-
the brain’. A number of considerations should lenges in this field, including those described in
be taken into account when evaluating studies this review, and other issues such as increasing
of cognitive activity, including the study design the sample size in order to achieve adequate
(observational vs RCT), the underlying etiol- power, more precisely defining the cognitive
ogy of the cognitive impairment (e.g., degen- outcome, using active control conditions, add-
erative, vascular, psychiatric or other illness), ing sensitive performance or informant-based
whether the cognitive activity strategy has been measures of everyday functioning, and includ-
examined in older adults across the cognitive ing other secondary outcomes such as mood,
spectrum, the timing between the assessment perceived cognitive performance and quality
of cognitive activity or intervention in relation of life measures [45] .
to the cognitive outcome and other partici- A burgeoning area of investigation is related
pant/patient characteristics such as education, to the use of video games and other technologies
SES, APOE genotype and personality that may by older adults. Given the increasing importance
influence the impact of cognitive activity on of using technology in everyday life (e.g., using
cognitive health. the automated teller machine [ATM] or navi-
So what recommendations can be made at this gating websites for health information), cogni-
time regarding cognitive activity? The simple tive stimulation strategies using technology may
answer is that there is inadequate evidence to prove to be beneficial on a number of fronts [62] .

future science group Aging Health (2010) 6(1) 117

REVIEW – Hughes

Executive summary
Introduction
• There is both popular and scientific interest in strategies to maximize cognitive health with aging.
• Several modifiable factors (e.g., cognitive activity, physical exercise, diet and nutrition, and social engagement) are being studied for
their potential to reduce the risk of cognitive impairment and dementia.
• Activities that are cognitively stimulating may be the most direct way to enhance cognitive health via structural and functional
brain changes.
Spectrum of cognitive change with aging
• Declines in processing speed, memory and reasoning are typical with aging, with verbal abilities and comprehension generally being
preserved into old age.
• Mild cognitive impairment (MCI) is an intermediate state between normal cognitive decline owing to aging and dementia. It is
associated with an increased risk of dementia, but many older adults with MCI do not progress to dementia and may even improve
their cognitive functioning over time.
• Dementia is a degenerative condition characterized by cognitive decline interfering with work, social and everyday functioning.
Environmental complexity & brain/cognitive reserve
• The environmental complexity hypothesis posits that complex environments have a positive effect on cognitive functioning and simple
environments have a negative effect on cognitive functioning.
• The cognitive reserve theory suggests that complex environments benefit cognitive systems by increasing the efficiency of neural
networks and producing redundancy within the network.
• The greater one’s reserve is, the more neuropathology associated with aging or brain disease can be tolerated without producing
outward cognitive symptoms.
Empirical studies of cognitive activity
• Observational studies focusing on leisure activities, such as reading, hobbies, learning a new language or taking a course, support a
positive association between cognitive activity and cognitive health.
• Cognitive interventions promoting cognitive health can be divided into the categories of cognitive stimulation and cognitive training.
• Cognitive stimulation involves a broad range of activities, typically in a group setting, with the goal to enhance general cognitive and
social functioning. Experience Corps and Senior Odyssey (University of Illinois, IL, USA) are examples of cognitive stimulation programs.
Each has observed improved cognitive functioning in program participants compared with control participants.
• Cognitive training is a more specific approach that includes repeated training on a set of structured tasks that target one or more
specific cognitive domains. Results from the Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) trial, the largest
cognitive training trial to date, and other computer-based programs suggest that cognitive training can improve performance on
trained and untrained cognitive tasks.
Considerations in the study of cognitive activity
• Observational studies and randomized controlled trials (RCTs) have strengths and weaknesses that should be considered when
evaluating studies of cognitive activity and cognitive health. RCTs are considered the gold standard in testing the efficacy of
interventions and treatments in health research since causal relations can be examined.
• MCI is a heterogeneous condition in which symptoms can result from degenerative, psychiatric, vascular and other illnesses. It is
unclear how different etiologies of MCI respond to cognitive interventions.
• The insidious development of dementia can lead to confusion as to whether cognitive activity is a true risk factor or a preclinical
symptom (i.e., a contributing cause or an effect) of cognitive impairment or dementia.
• Studies are needed that assess the efficacy and effectiveness of cognitive interventions across the cognitive continuum.
• Other participant/patient characteristics, such as educational attainment, socioeconomic status, APOE genotype and personality, should
be considered when studying cognitive activity in research studies or making recommendations about cognitive activity to patients.
Conclusion
• Engagement in cognitively stimulating activities has demonstrated promise in the promotion of cognitive health with aging.
• At this time, there is inadequate evidence to make specific recommendations. In general, older adults should be encouraged to engage
in new and challenging activities.
• Physicians should communicate to their patients that there is no guarantee that engaging in cognitive activities will prevent or delay
MCI or dementia.
Future perspective
• Both observational studies and RCTs are needed to establish a definitive connection between cognitive activity and cognitive health in
late life.
• Studying video games and technology is a new area that may demonstrate positive effects on cognitive health outcomes with aging.
• Including neuroimaging in studies of cognitive activity will provide new knowledge of the underlying mechanisms and help target
intervention approaches.

118 www.futuremedicine.com future science group

 Promotion of cognitive health through cognitive activity in the aging population – Review

Interactive video game play using the Nintendo targeted cognitive interventions. In these neu-
Wii™ (Nintendo, WA, USA) is occuring across roimaging studies, as well as in all future stud-
the country in senior centers, public libraries ies, a multidisciplinary collaborative effort will
and retirement communities. Researchers are be necessary.
now beginning to explore how video games
can contribute to improvement in cognitive Financial & competing interests disclosure
functioning [104] . Tiffany F Hughes is supported by T32 award no. MH019986
A more complete picture of the role of cog- from the National Institute of Mental Health, National
nitive activity in cognitive health will also be Institutes of Health and United States Department of
drawn using neuroimaging techniques such Health and Human Services. The ����������������������������
author has no other rel�
as functional MRI. Measuring changes in the evant affiliations or financial involvement with any organi�
brain in response to cognitive interventions zation or entity with a financial interest in or financial
is already being carried out in studies such conflict with the subject matter or materials discussed in the
as EC  [20] . Knowledge of the correspondence manuscript apart from those disclosed.
between cognitive activity and patterns of brain No writing assistance was utilized in the production of
activation will permit the development of more this manuscript.

7. Levy R: Aging-associated cognitive decline. 16. Sloane PD, Zimmerman S, Suchindran C

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