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Theses, Dissertations, and Other Capstone Projects
2018
The Effects of a Cognitive Training Program for
Cognitively Intact Older Adults
Caroline Kinskey
Minnesota State University, Mankato
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and Other Capstone Projects. 773.
https://cornerstone.lib.mnsu.edu/etds/773
Running head: COGNITIVE TRAINING FOR COGNITIVELY INTACT OLDER ADULTS
The Effects of a Cognitive Training Program for Cognitively Intact Older Adults
By
Caroline Kinskey
A Thesis Submitted in Partial Fulfillment of the
Requirements for the Degree of
Master of Arts
In
Clinical Psychology
Minnesota State University, Mankato
Mankato, Minnesota
May 2018
COGNITIVE TRAINING FOR COGNITIVELY INTACT OLDER ADULTS
March 27, 2018
The Effects of a Cognitive Training Program for Cognitively Intact Older Adults
Caroline Kinskey
This thesis has been examined and approved by the following members of the student’s
committee.
________________________________
Advisor
Jeffrey Buchanan, PhD
________________________________
Committee Member
Eric Sprankle, PsyD, LP
________________________________
Committee Member
Donald J. Ebel, PhD
COGNITIVE TRAINING FOR COGNITIVELY INTACT OLDER ADULTS
The Effects of a Cognitive Training Program for Cognitively Intact Older Adults
Caroline Kinskey
Master of Arts in Clinical Psychology Program
Minnesota State University, Mankato
2018
Abstract
Cognitive training is a term used to describe programs that provide guided practice on tasks
requiring different cognitive abilities such as memory or language. It is assumed that regular
practice will improve or maintain functioning in a particular cognitive domain (e.g., memory)
and those results will generalize beyond the context of training. Results have been mixed in the
existing literature that has evaluated the potential benefits of cognitive training on cognitive and
emotional functioning in cognitively intact older adults. This study investigated the effectiveness
of a cognitive training program for older adults with no to very minimal cognitive decline. Nine
individuals participated in the Mind Sharpener program developed by the New England
Cognitive Center. Two hour-long training sessions were completed each week for 12 weeks. In
each session, participants completed paper and pencil activities that targeted the following
cognitive domains: attention, language, perceptual speed, executive function, visual spatial skills,
verbal memory, and visual memory. Outcomes assessed included measures of cognitive abilities
targeted in the training program, depression, and memory self-efficacy. Measures were
completed prior to beginning the Mind Sharpener program and after completion of the program.
Across participants, ten measures improved following the Mind Sharpener program, six showed
stability, and one measure declined. The study provides promising results for the efficacy of
cognitive training programs.
COGNITIVE TRAINING FOR COGNITIVELY INTACT OLDER ADULTS
Table of Contents
Introduction…………………………………………………………………………………1
Method…….……………………………………………………………………………..10
Results…….………………………………………………………………………………18
Discussion….……………………………………………………………………………..22
References….………………………………………………………………………….….27
Tables….………………………………………………………………………………….35
Appendix….……………………………………………………………………………….45
COGNITIVE TRAINING FOR COGNITIVELY INTACT OLDER ADULTS
1
Introduction
A common fear adults have is the fear of developing dementia or Alzheimer’s disease
(Ostergren, 2017). Alzheimer’s disease is without a cure, which is often concerning for those
who are noticing cognitive decline in themselves or their loved ones. As adults age into older
adulthood, many adults begin to notice declines in their memory (e.g., difficulties recalling
names of people) and an increased difficulty with problem solving. Although these changes are
often a part of normal aging, many adults want to maintain their cognitive abilities for as long as
possible. Due to this, many older adults are interested in activities or programs that help
maximize cognitive functioning and minimize cognitive decline. To combat age-related
cognitive decline and potentially reduce the anxiety surrounding age-related cognitive decline,
cognitive training programs have been created that target various cognitive domains that decline
with age, with the goal of improving cognitive abilities or preventing them from declining.
Age-Related Cognitive Decline
As everyone ages, they experience “age-related cognitive decline.” Minor cognitive
decline as adults age is normal. Typically, older adults can expect to experience declines in
domains of fluid intelligence, which involves cognitive abilities that are necessary in reasoning,
problem-solving, abstract thinking, and decision making. In contrast, crystalized intelligence is a
result of learning, and does not usually decline with age. Crystalized intelligence involves
knowledge from past experiences, facts, and vocabulary (Horn & Cattell, 1966). Fluid abilities
that typically show decline with normal aging include some domains of memory (e.g., recall,
source, prospective, episodic memory) executive functions, and processing speed (Dreary et al.,
2009; Harada, Natelson Love, & Triebel, 2014).
COGNITIVE TRAINING FOR COGNITIVELY INTACT OLDER ADULTS
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Processing speed is one of the first and most noticeable cognitive domains to decline
during the aging process (Salthouse, 1993; Schiae, 1989, 1994). Processing speed encompasses
the time it takes for someone to solve a problem and reaction time (Salthouse, 2000). A decline
in speed of processing affects many day-to-day activities. Older drivers with slower speed of
processing are more than twice as likely as older adults with intact speed of processing to cause a
car crash in the following three to four years (Ball et al., 2006). Furthermore, a decline in
processing speed is related to an increased risk of falls, difficulty with balance, and difficulty
transitioning from sitting to standing (Owsley & McGwin, 2004; Sims, McGwin, Pulley, &
Roseman, 2001; Syaplin, Gish, & Wagner, 2003). The slowing of processing speed can affect
other cognitive domains as well, such as verbal fluency (Harada et al., 2014).
Attention is the ability to selectively concentrate on relevant information or specific
stimuli, while ignoring irrelevant stimuli. Previous research has found that selective and divided
attention decline the most as we age (Carlson, Hasher, Connelly, & Zacks, 1995; Salthouse,
Fristoe, Lineweaver, & Coon, 1995). Selective attention is the ability to attend to specific stimuli
while ignoring irrelevant stimuli. Divided attention, which involves executive functioning,
allows us to process information from different sources at one time and shift our attention
accordingly. Divided attention is necessary to multitask. Working memory, a construct related to
attention, requires the ability to remember and hold information in the mind, and manipulate that
information. Working memory has also been reliably found to decline with age (Salthouse et al.,
1989).
There are multiple domains of memory that are impacted at different times in the aging
process. For example, declarative memory, which is the ability to recall facts and events, can be
divided into semantic and episodic memory. Semantic memory involves facts, information, and
COGNITIVE TRAINING FOR COGNITIVELY INTACT OLDER ADULTS
3
common knowledge. Episodic memory is the memory of past events and their details. Episodic
memory declines throughout life, while semantic memory has late-life declines (Harada et al.,
2014). Nondeclarative memory, also known as implicit memory, is the memory outside of one’s
awareness. Nondeclarative memory includes procedural memory, which is responsible for
knowing how to do things, such as knowing how to tie shoes or how to ride a bike. Unlike
declarative memory, nondeclarative memory is not affected by normal aging (Lezak, Howieson,
Bigler, & Tranel, 2012).
Another area of memory that declines with age is the ability to complete delayed recall
tasks, which is the ability to retrieve information from memory without a cue (Whiting & Smith,
1997). For example, if someone wrote a grocery list and then left it at home, their ability to
remember what items were on the list would involve delayed free recall. On the other hand,
recognition memory, which is the ability to remember information when given a cue, does not
decline with age. Recognition memory could be tested by asking the person who left their
grocery list at home, “Were eggs on your grocery list?” which would provide the person with a
cue regarding the items on their grocery list. The ability to remember where you learned
information is known as source memory, which also declines with age. Additionally, prospective
memory, which involves being able to remember to perform an intended task in the future, also
declines with age. This may result in an older adult forgetting to take medication, forgetting why
they walked into a room, etc. (Craik & Salthouse, 2008).
The cognitive domain of language consists of both fluid and crystallized abilities, so there
is a less noticeable decline in language during the aging process. Since vocabulary is a
crystallized ability, it tends to increase with age (Hayden & Welsh-Bohmer, 2011; Salthouse,
2009). Some domains of language do decrease with age, such as confrontation naming (i.e. the
COGNITIVE TRAINING FOR COGNITIVELY INTACT OLDER ADULTS
4
ability to see an object and know the name for it) and verbal fluency (i.e., the ability to think of
words that belong to a certain category, such as animals or words that begin with a specific
letter). The declines in language usually have minimal impact in an older adult’s ability to
function in their day-to-day life (Harada et al., 2014).
Visuospatial abilities and construction abilities are necessary to understand space in two
and three dimensions. The ability to take parts of something and put them together to make a
coherent whole, like a puzzle, involves visual construction abilities. Visual construction abilities
decline with age (Howieson, Holm, Kaye, Oken, & Howieson, 1993). Visual spatial abilities
remain intact with age, which include spatial awareness and the ability to recognize familiar
objects and faces (Harada et al., 2014).
Executive functioning involves higher-order thinking, abstract thinking, problem-solving
skills, reasoning skills, self-control, and other cognitive abilities that allow people to be mentally
flexible and use their resources to achieve a goal. Some types of executive functioning decline
with age while others remain stable throughout life. Cognitive flexibility falls under executive
functioning, and is defined as the ability to think about something in more than one way.
Cognitive flexibility declines with age, and older adults have more concrete thinking compared
to younger adults (Harada et al., 2014; Weckner, Kramer, Hallam, & Dellis, 2005). Response
inhibition, which is the ability to inhibit a more automatic response for a more novel response,
also tends to decline with age (Wecker, Kramer, Wisniewski, Delis, & Kaplan, 2000). Types of
executive functioning that do not decline with age include the ability to understand similarities,
proverbs, and reason with familiar material (Harada et al., 2014).
COGNITIVE TRAINING FOR COGNITIVELY INTACT OLDER ADULTS
5
Cognitive Impairment
As mentioned previously, age-related cognitive decline is not pathological. Mild
cognitive impairment (MCI) is a stage between normal aging and dementia. Those with MCI are
at a high risk for developing dementia, with 10-15% of people with MCI receiving diagnoses of
Alzheimer’s disease each year (Peterson et al., 2009). In comparison, only 1-2% of cognitively
intact older adults will receive a diagnosis of Alzheimer’s the following year (Petersen et al.,
1999). Some people with MCI remain stable or improve cognitively, but over half progress to
developing dementia within 5 years (Gauthier et al., 2006). Unlike with normal age-related
cognitive decline, the changes that occur are more noticeable to the family and friends of the
person with MCI. However, unlike with a more serious form of decline, such as dementia, the
changes are usually not severe enough to significantly negatively impact someone’s life and
ability to function.
Need for Interventions Targeting Cognitive Decline
The older adult population is rapidly increasing each year. The number of Americans that
are 65 years of age or older is predicted to double from 46 million today to 98 million in 2060
(Mather, Jacobson, & Pollard, 2015). Currently, the 65-and-older group comprises
approximately 14 percent of the United States population, and by 2060 older adults will account
for about 24 percent of the population (Mather et al., 2015). Given the fact that there is no cure
for Alzheimer’s disease and similar forms of dementia, we can expect to also see growth in the
number of people diagnosed with these progressive cognitive diseases. With the growing aging
population, the need for interventions for cognitive decline and cognitive disorders will continue
to increase. More than 5 million Americans currently live with Alzheimer’s disease, and this
number is estimated to triple to 16 million by 2050 (Alzheimer’s Association, 2017).
COGNITIVE TRAINING FOR COGNITIVELY INTACT OLDER ADULTS
6
Currently, there are medications that have been approved by the U.S. Food and Drug
Administration (FDA) to treat symptoms of Alzheimer’s disease, but none of these medications
prevent the progression of cognitive decline (Alzheimer’s Association, 2017). Additionally,
many of these medications have unwanted side effects. Due to the limited effectiveness of
pharmacological treatments, there is an increased interest in non-pharmacological treatments in
preventing or slowing the progression of cognitive decline.
Cognitive Training
Cognitive training, sometimes marketed to the public as “brain training,” is a type of non-
pharmacological intervention that uses guided practice on a set of standardized tasks that are
meant to target and improve particular cognitive functions (Bahar-Fuchs, Clare, & Woods,
2013). Cognitive training typically takes place in small groups and is comprised of a
standardized, structured program of activities (Belleville, 2008). The goal of cognitive training is
to improve cognitive functioning, sustain functioning, or slow cognitive decline. The concept of
cognitive training assumes that the brain remains plastic as adults age, and that practice can
potentially improve or maintain functioning in a specific cognitive domain (Hertzog, Kramer,
Wilson, & Lindenberger, 2008). Additionally, it is assumed that improvements or maintenance
will generalize to daily life. In previous research, there has not been evidence that the benefits of
cognitive training generalize to daily life (Owen, 2010; Papp, 2009; Ball et al., 2002).
Many products on the market designed to improve cognitive abilities, often referred to as
“brain games,” exaggerate the positive effects of their programs, and sometimes mislead
consumers (Simons et al., 2016). Lumosity, a popular online program that consists of games that
target various cognitive domains, was charged by the U.S. Federal Trade Commission for
deceptive advertising (FTC, 2016). The FTC stated that Lumosity did not have the scientific
COGNITIVE TRAINING FOR COGNITIVELY INTACT OLDER ADULTS
7
evidence to support the claims their advertisements made, and that Lumosity “preyed on
consumers’ fears of age-related cognitive decline, suggesting their games could stave off
memory loss, dementia, and even Alzheimer’s disease.” Following the suit, FTC and Lumos
Labs, the creators of Lumosity, agreed in a settlement that randomized, controlled, blinded trials
were the standard to provide evidence for the efficacy of products.
The demand for products that claim to aid in cognitive functioning continues to grow
each year. The research firm SharpBrains (sharpbrains.com) tracks all companies in the “digital
brain health market” and publishes market reports. SharpBrains reported that there was an
estimated total market sales of $210 million in 2005, $600 million in 2009, and $1.3 billion in
2013. The firm predicts that cognitive training and brain assessment software will have yearly
sales of $3.38 billion by 2020 (SharpBrains, 2013, 2015). The brain training industry is large, but
how much evidence is there for the efficacy of these cognitive training programs?
The largest and most notable study evaluating the effectiveness of cognitive training for
independent older adults began in 1998 and is known as the ACTIVE study (Advanced
Cognitive Training for Independent and Vital Elderly; Ball et al., 2002). The study was
randomized, single-blind, and had a control group. A volunteer sample of 2,832 older adults in
six metropolitan areas in the United States, with ages ranging from 65 to 94 years old, was used
to evaluate three cognitive training interventions. Participants were randomly assigned to one of
four groups. One group took part in a 10-session group training designed to target verbal
episodic memory. The second cognitive training group targeted reasoning abilities, and the third
group targeted speed of processing. Additionally, there was a no-contact control group. A
random sample of 60% of the three treatment groups received booster training 11 months after
the initial intervention. The primary outcomes were aspects of functional activities, both
COGNITIVE TRAINING FOR COGNITIVELY INTACT OLDER ADULTS
8
performance-based and self-reported. Each intervention group improved at the target cognitive
ability compared to their baseline performance, and this improvement sustained through the two-
year observation period. Those who received booster training in the speed of processing group
improved speed, as did the reasoning group. However, the study did not find that training effects
generalized to everyday functioning.
A five-year follow-up of the previously mentioned study was also completed (Willis et
al., 2006). Booster training was provided to a random subsample at 11 and 35 months after the
initial training sessions. The booster training consisted of four 75-minute sessions which were
meant to help maintain the initial improvement of the targeted cognitive ability. At the five-year
follow-up, the reasoning group reported significantly less difficulty in ADLs compared to the
control group. A nonsignificant difference in self-reported difficulty with ADLs was found in the
speed of processing and memory training group compared to the control group. The booster
training for the speed of processing group had a significant effect on a performance-based
functional measure of everyday speed of processing. The other two groups did not have any
significant booster effects regarding everyday problem-solving or self-reported difficulties with
completing ADLs. However, the booster training resulted in significant improvement for the
reasoning group on reasoning performance, and the speed of processing group on processing
speed performance. The effects of the interventions were maintained through the five years since
the beginning of the initial study.
Additionally, there was a 10-year follow-up of the ACTIVE study (Rebok et al., 2014).
The reasoning and speed of processing group maintained their effects from the interventions at
the 10-year follow-up. However, the memory cognitive training group no longer maintained the
COGNITIVE TRAINING FOR COGNITIVELY INTACT OLDER ADULTS
9
effects in memory performance. This long-term study provides support for the efficacy of
cognitive training in cognitively intact older adults.
Another randomized controlled study examined the effects of a six-week memory
training program involving education on dementia, memory, memory performance, relaxation
skills, and specific memory skills (Rapp, Brenes, & Marsh, 2002). The control condition did not
receive any education or memory training. The participants met criteria for mild cognitive
impairment (Petersen et al., 1999), and did not have any difficulties in completing ADLs.
Following completion of the memory training program, the treatment group perceived their
memory to be better compared to the control group. Additionally, the treatment group perceived
that their memory had improved since prior to the training. At the six-month follow-up, the
treatment group still reported higher memory appraisals than the control group. However, the
groups did not differ on quantitative measurements of memory performance.
A novel training program targeting executive functioning in the elderly used a
multitasking cooking task (Wang, Chang, & Su, 2011). Participants in the study were all healthy
older adults who lived in the community. The treatment group cooked four to six foods while
setting as many tables as possible. The task gradually increased in speed and difficulty. The
intervention was brief, with only five sessions lasting an hour each. The training resulted in a
short-term increase in executive control processing, as measured by WAIS sub-tests. This study
is unique in how the training involved a real-world task, and the researchers conducted
quantitative measures of cognitive domains to determine if there was a transfer of skills. Most
other studies do the opposite, where the cognitive training involves structured paper and pencil
activities, and then based on self-report, the researchers look to see if the skills acquired
transferred outside of the structured training activities.
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A meta-analysis conducted in 2012 examined the results of memory training
interventions for community-dwelling, cognitively intact older adults (Gross et al., 2012). The
review identified 402 publications, but only 35 met inclusion criteria for the review. To be
included in the review, the publications had to report original data on memory training, involve
randomization, all participants had to be at least 60 years of age, and the intervention had to be
non-pharmacological and target memory. The review found that memory gains in treatment
groups were larger than retest effects in the control groups. Additionally, training multiple
strategies resulted in larger training gains. Treatment gains did not appear to be influenced by
training of a particular strategy, the ages of the participants, or session length.
Purpose of Current Study
The purpose of the current study is to add to the literature examining the effectiveness of
cognitive training programs for cognitively intact older adults. Based on previous literature, we
expected to see significant improvements in executive functioning, processing speed, and self-
reports of memory self-efficacy. Minimal improvement in memory was expected. Additionally,
it was hypothesized that there would be a decline in depressive symptoms (Brum, Forlenza, &
Yassuda, 2009).
Method
Subjects
Participants for this study were recruited by administrators and staff at a convent located
in a small Midwestern metropolitan area. Staff were asked to identify and approach residents that
had minimal or no cognitive decline and may be interested in taking part of a cognitive training
program. To meet inclusion criteria for the study, participants had to have a score of 78 or above
on the Modified Mini-Mental State Exam (3MS; E. L. Teng & H. C. Chui, 1987) indicating mild
COGNITIVE TRAINING FOR COGNITIVELY INTACT OLDER ADULTS
11
cognitive decline to intact cognitive abilities. Potential participants were excluded from the study
based on the following criteria, which were assessed via self-report, report of facility staff, or
cognitive testing:
1) The presence of a serious health problem that could compromise their ability to
participate in the cognitive training classes.
2) Significant disabilities that could prevent the individual from participating (e.g., visual
or hearing deficits, impaired motor skills, significant language impairment).
3) An individual’s level of cognitive decline was too severe based on the 3MS (i.e., a
score below 78).
Ten women met criteria and consented to participate in the study (see Appendix for the
full consent form). One participant dropped out prior to completing the program; staff reported
that she was having difficulty with the activities and requested to drop out. All of the participants
were Caucasian women with at least a bachelor’s degree. Ages of the subjects ranged from 72 to
93 years old (M = 82.22, SD = 7.53). The average 3MS score prior to beginning the program was
92.00 (SD = 4.92), and scores ranged from 81 to 96 (out of a possible score of 100).
Additionally, each participant’s face sheet in their medical chart was reviewed with a
nurse or staff member present. Information collected from medical charts included medical
diagnoses and medications taken by the participant for anxiety, depression, or pain. These
variables were tracked because these conditions and medication could affect the ability of
participants to engage in the Mind Sharpener program.
Six of the nine participants that completed the study had a diagnosis of depression. Four
of the six participants took at least one antidepressant. One participant with depression took 50
mg of Zoloft and another participant took 30 mg of Cymbalta daily. One of the participants with
COGNITIVE TRAINING FOR COGNITIVELY INTACT OLDER ADULTS
12
a diagnosis of depression also had a diagnosis of Alzheimer’s disease, and took 300 mg of
Wellbutrin and 15 mg of Remeron for depression, and 21 mg of Namenda for Alzheimer’s
disease. Another participant with depression also had a diagnosis of dementia, and took 50 mg of
Trazadone and 1 mL of cyanocobalamin. Two of the participants with depression did not take an
antidepressant; one of the participants was prescribed 1.0 mg of Lorazepam and the other took no
medications. One participant had Parkinson’s disease and was prescribed 1mL of
cyanocobalamin. Another participant had a diagnosis of mild cognitive impairment and took
Lexapro. One of the nine participants did not have any diagnosis nor took any medications that
may have impacted her ability to complete the study. Despite some of the participants having a
diagnosis of dementia and MCI, the participants still scored above a 78 on the 3MS and met
inclusion criteria for the study. The participant who dropped out of the study passed away
following the study and we were unable to access her medical information.
Procedure
A pre-post quasi-experimental design was employed. After recruitment and receiving
consent from the participants, the author and research assistants administered the cognitive tests
and other measures with each participant individually. Shortly after pretesting, the participants
began the Mind Sharpener program, which was developed by the New England Cognitive Center
(NECC). Mind Sharpener is designed for older adults that are cognitively intact or have minimal
cognitive decline. The program consists of 24 classes, with two 1-hour sessions occurring per
week. Activity staff at the convent who were trained by the NECC implemented the program.
Throughout the study, NECC staff were available to consult for questions or if further training
appeared necessary.
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The cognitive training classes consisted of varied pencil and paper activities that targeted
the following specific cognitive domains: reaction time/psychomotor speed,
attention/concentration, memory (with emphasis on short-term memory), visual spatial acuity,
language, and problem solving/executive function. Mind Sharpener is designed to be appropriate
for adults, challenging, enjoyable, and the activities increase in difficulty over time. The
activities involved repetition and reinforcement to promote learning. The activities required
minimal instruction, therefore allowing the class time to be primarily dedicated to having the
participants engage in the activities. In order to be included in data analysis, a participant needed
to complete 75% of the classes. Overall, nine individuals completed over 75% of the classes,
excluding the aforementioned participant that dropped out of the study.
Materials
The measures used in this study evaluated various cognitive domains that are targeted by
the Mind Sharpener program. In addition, participants completed measures regarding subjective
complaints of memory functioning and mood. Participants were tested within one week prior to
beginning the Mind Sharpener program, with half of the tests being completed on one day and
the rest of the tests completed on a different day. Assessment was also completed within one
week of completing the program, which was approximately 12 weeks later. The measures took
approximately 60 minutes to complete.
Global Functioning
Modified Mini-Mental State Exam (3MS; E. L. Teng & H. C. Chui, 1987)
The 3MS is a measure of global cognitive functioning that is used to screen for dementia.
It is a standardized assessment that is widely used to evaluate individuals with cognitive
impairment. The 3MS measures multiple cognitive domains (e.g., attention, orientation, short-
COGNITIVE TRAINING FOR COGNITIVELY INTACT OLDER ADULTS
14
term memory, verbal reasoning, etc.). The measure is highly reliable for assessing individuals
with dementia (α = .88), and has high sensitivity (.93) in differentiating between individuals with
and without dementia. (Tombaugh, McDowell, Kristjansson, & Hubley, 1996). Scores can range
from 0 to 100 with lower scores indicative of greater cognitive impairment.
Attention
The Forward and Backward Digit Span (Wechsler, 2008)
These two tests measure simple attention (forward digit span) and working memory
(backward digit span). This test requires participants to listen to a list of numbers read aloud, and
then repeat them exactly as heard or in reverse order. Two digits are presented on the first trial,
and the length of digit strings increases as the trials progress until the participant is unable to
successfully complete two trials of the same length.
This is a subtest in the Wechsler Adult Intelligence Scale- Fourth Edition (WAIS-IV; Wechsler,
2008) and correlates highly with the WAIS-III digit span.
Brief Test of Attention (BTA; Schretlen, 1997)
The BTA is a measure of auditory divided attention. Participants listen to a voice
recording of numbers and letters being read aloud. The participant is to keep track of only how
many numbers (or letters) they heard in each string. To prevent participants from counting on
their fingers, they are asked to place their hands on the table where the researcher can see them.
The BTA has good reliability, equivalence of forms, and construct validity (α = .82-.91)
(Schretlen, Bobholz, & Brandt, 1996).
Language
Controlled Oral Word Association Test (COWAT; Benton & Hamsher, 1989)
COGNITIVE TRAINING FOR COGNITIVELY INTACT OLDER ADULTS
15
The COWAT is designed to measure verbal fluency. Participants are given one minute to
say as many words that begin with a specific letter. Proper nouns and variations of the same
word do not count (e.g., bed, beds, bedding). In the pretest, the letters are F and S. In the posttest,
participants must name as many words that begin with the letters A and P. The COWAT
correlates with other neuropsychological tests and has good test-retest reliability (Benton &
Hamsher, 1989; Ruff, Light, Parker, & Levin, 1996).
Bosting Naming Test (BNT; Kaplan, Goodglass, & Weintraub, 1983)
The BNT is a commonly used measure of confrontation naming. It is sensitive to early
cognitive changes in Alzheimer’s disease (Williams, Mack, & Henderson, 1989). In this test, a
series of 30 pictures of objects are displayed one at a time, and the participant is asked to name
what each picture represents. If the participant is unable to name the object, semantic and/or
phonemic cues are given by the person administering the test.
Perceptual speed
Trail Making Test Part A (Reitan & Davison, 1974)
Trail Making Test Part A assesses cognitive processing speed. Participants are given a
piece of paper with the number 1 through 25 contained in circles scattered across the paper.
Participants are asked to connect the numbers as fast as they can. Participants are told to “draw a
line from 1 to 2, 2 to 3, 3 to 4, and so on until you reach the end.” Trail Making Test Part A and
Part B are sensitive to detecting brain damage and cognitive impairment (Reitan & Davison,
1974; Aschendorf et al., 2008).
Executive functioning/Working memory/Cognitive flexibility
Trail Making Test Part B (Reitan & Davison, 1974)
COGNITIVE TRAINING FOR COGNITIVELY INTACT OLDER ADULTS
16
Trail Making Test Part B is used to examine executive functioning. Part B is similar to
Trail Making Test Part A, but Part B requires participants to alternate between numbers and
letters as fast as they can. They are told to “draw a line from 1 to A, A to 2, 2 to B, B to 3, and so
on until you reach the end.” Part B of the Trail Making Test has been found to have better
specificity and sensitivity to cognitive dysfunction at any level compared to Part A (Rasmusson,
Zonderman, Kawas, & Resnick, 1998).
Visual Spatial Skills
Visual Puzzles (Wechsler, 2008)
This test assesses visual spatial reasoning and requires mental transformation,
manipulation, and the ability to analyze dimensional objects. Participants are shown a completed
puzzle with a display of six figures, and asked to select three of six figures that could create the
completed puzzle. Visual puzzles are part of the Perceptual Reasoning Index in the WAIS-IV
(Wechsler, 2008).
Verbal Memory
Hopkins Verbal Learning Test – Revised (HVLT-R; Brandt & Benedict, 2001)
The HVLT-R is a measure of verbal memory. Participants are read a list of words and
then asked to say aloud as many of the words as they can remember from the list in any order.
This is done three times back-to-back to assess immediate recall abilities, and then 20 minutes
later to assess delayed verbal recall. Finally, there is a recognition trial where participants are
read a longer list of words, and asked to identify whether a word was on the original list. The
HVLT-R is highly correlated with other measures of verbal memory and is highly predictive at
classifying those with dementia versus controls (Shapiro, Benedict, Schretlen, & Brandt, 1999).
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Visual Memory
Brief Visuospatial Memory Test-Revised (BVMT-R; Benedict, 1997)
The BVMT-R is a measure of visual memory. Participants are shown a display of six
figures for 10 seconds, and then asked to draw as many of the figures as they can remember in
their correct location on the page. This is done three times back-to-back to assess immediate
visual recall, and then there is a delayed recall portion of the test 20 minutes later. Additionally,
there is a recognition trial where participants are shown figures and asked to identify if a figure
was on the original display. This measure has high construct and criterion-related validity
(Benedict, Schretlen, Groninger, Dobraski, & Shpritz 1996).
Additional Measures
The Patient Health Questionnaire-9 (PHQ-9; Kroenke, Spitzer, & Williams, 2001)
The PHQ-9 is a 9-item self-report instrument which assesses the frequency and severity
of depressive symptoms. It has high internal reliability (α = .89), and sensitivity of 88% and
specificity of 88% for major depression (Kroenke, Spitzer, & Williams, 2001). The PHQ-9 has
been validated with older adults (Ell et al., 2005), including those with cognitive impairment
(Boyle et al., 2011).
Cognitive Failures Questionnaire (CFQ; Broadbent, Cooper, FitzGerald, & Parkes, 1982)
The CFQ is 25-item measure that assesses the participant’s perception of their memory.
Participants were asked to estimate how frequently they have common memory problems (e.g.,
forgetting appointments, forgetting why you went from one part of the house to the other,
forgetting whether you have turned off a light or locked a door, etc.). The measure is positively
correlated with other self-report measures of memory, absentmindedness, or slips of action
(Broadbent, Cooper, FitzGerald, & Parkes, 1982).
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Results
Due to the small sample size, inferential statistics were not used to detect differences
between pre-treatment and post-treatment measures. Instead, the effect size statistic (Cohen’s d)
was used to estimate the magnitude of difference between pre- and post-treatment measures.
According to Cohen, d = 0.2 is a small effect size, 0.5 is a medium effect size, and anything over
0.8 is a large effect size (Cohen, 1988). Effect sizes provide a measure of clinical significance as
opposed to evaluating solely the statistical significance (i.e., rareness of a result).
Global Functioning
Modified Mini-Mental State Exam
There was a small effect size indicating improvement in global cognitive functioning
from pretesting (M = 92.0, SD = 4.92) to posttesting (M = 94.0, SD = 4.09), d = .30, CI 95%
[-.63, 1.23].
Attention
Forward Digit Span
The Forward Digit Span requires participants to listen to a series of numbers, and repeat
the numbers in the same order. There was a negligible difference between pretesting (M = 8.33,
SD = 2.00) and posttesting (M = 8.44, SD = 2.60), d = .11, CI 95% [ -.81, 1.04] indicating
stability (i.e., no change) in this measure of simple attention.
Backward Digit Span
The Backward Digit Span requires participants to listen to a series of numbers, and say the
numbers they heard in reverse order. There was a small positive effect size in this measure of
working memory from prior to beginning the cognitive training program (M = 7.89, SD = 2.52)
to after completing the program (M = 8.22, SD = 2.05), d = .22, CI 95% [-.70, 1.15].
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Brief Test of Attention
The BTA measures selective attention by requiring participants to keep track of how
many numbers are presented in a list of both letters and numbers. There was a negligible
difference between pretesting (M = 6.22, SD = 2.28) and posttesting (M = 6.44, SD = 2.07), d =
.12, CI 95% [ -.81, .1.04] indicating stability in this measure.
Language
Controlled Oral Word Association Test
Verbal fluency was measured by the COWAT. The test requires participants to state as
many words that begin with a specific letter in one minute. A medium negative effect size was
observed from pretesting (M = 27.44, SD = 7.53) to posttesting (M = 24.0, SD = 8.37), d = -.48.
CI 95% [ -1.41, .46], indicating decline occurred in this specific cognitive ability.
Bosting Naming Test
The BNT is a measure of confrontational word retrieval. Participants are shown pictures
one at a time and asked to name the object in each picture. Stability was observed in the BNT
from pretesting (M = 24.44, SD = 2.92) to posttesting (M = 24.11, SD = 2.98), d = -.13, CI 95%
[-1.05, .80].
Perceptual speed
Trail Making Test Part A
Trail Making Test Part A measures perceptual speed by requiring participants to connect
the numbers 1-25 on a piece of paper as quickly as they can. It is measured in the seconds it
takes for the participant to complete the task. A small improvement was observed from
pretesting (M = 46.89, SD = 14.39) to posttesting (M = 42.22, SD = 16.35), d = -.32, CI 95%
[-1.25, .91].
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Executive functioning/Working memory/Cognitive flexibility
Trail Making Test Part B
Trail Making Test B requires participants to alternate between connecting letters and
numbers on a piece of paper as quickly as they can. Stability in scores was observed from
pretesting (M = 115.0, SD = 42.24) to posttesting (M = 113.11, SD = 60.40), d = -.10, CI 95%
[-1.02, .83].
Visual Spatial Skills
Visual Puzzles
Visual puzzles measure visual spatial skills by requiring participants to select three
figures from an array of six figures that can make the completed puzzle presented. There was a
small positive effect size from pretesting (M = 10.44, SD = 1.74) to posttesting (M = 11.22, SD =
3.02), d = .43, CI 95% [-.52, .1.35].
Verbal Memory
Hopkins Verbal Learning Test
Immediate Recall
Immediate verbal recall abilities were measured by the HVLT. Participants are read aloud
a list of words and then asked to list as many words as they can remember. This is done three
times consecutively. There was a large improvement from pretesting (M = 19.56, SD = 5.03) to
posttesting (M = 23.56, SD = 4.64), d = 1.03, CI 95% [.05, 2.02].
Delayed Recall
The HVLT has a delayed recall trial approximately 20 minutes after the initial trials.
There was a small improvement from pretesting (M = 6.78, SD = 2.44) to posttesting (M = 7.56,
SD = 2.01), d = .27, CI 95% [ -.66, 1.20].
