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The Effects of a Cognitive Training Program for Healthy Older
The Effects of a Cognitive Training Program for Healthy Older
Adults: A Program Evaluation Study
Adults: A Program Evaluation Study
Jacklyn Gehling
Minnesota State University, Mankato
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The Effects of a Cognitive Training Program for Healthy Older Adults: A Program
Evaluation Study
By
Jacklyn Gehling
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 2020
May 05, 2020
The Effects of a Cognitive Training Program for Healthy Older Adults: A Program Evaluation
Study
Jacklyn Gehling
This thesis has been examined and approved by the following members of the student’s
committee.
________________________________
Advisor
Jeffrey Buchanan, PhD
________________________________
Committee Member
Karla Lassonde, PhD
________________________________
Committee Member
Hsinhuei Sheen Chiou, PhD, CCC-SLP
Table of Contents
Introduction…………………………………………………………………………………………1
Method.……………………………………………………………………………………………5
Results……………………………………………………………………………………………14
Discussion………………………………………………………………………………………..17
References………………………………………………………………………………………..23
Appendix…………………………………………………………………………………………28
THE EFFECTS OF A COGNITIVE TRAINING PROGRAM FOR HEALTHY OLDER
ADULTS: A PROGRAM EVALUATION STUDY
JACKLYN GEHLING
A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE
REQUIREMENTS FOR THE DEGREE OF
MASTER OF ARTS IN CLINICAL PSYCHOLOGY
MINNESOTA STATE UNIVERSITY, MANKATO
MANKATO, MN
2020
ABSTRACT
As one ages, some degree of cognitive decline is expected. Despite this, declines in cognitive
abilities and the possibility of developing dementia are common concerns among older adults. In
response to these concerns, a variety of cognitive training programs have been developed that
aim to improve or maintain cognitive functioning. Previous literature has shown mixed or limited
findings on cognitive changes after implementation of cognitive training. This study evaluated
the effectiveness of a cognitive training program designed for older adults with no to minimal
cognitive decline. The current study included 19 participants who engaged in two, one-hour long
cognitive training classes each week for 12 weeks. Each class required participants to complete
activities that targeted the following cognitive domains: attention, visuospatial skills, memory,
processing speed, executive functioning, and language. These cognitive domains, along with
depression and memory self-efficacy, were assessed prior to and immediately following
completion of the program, and at a three-month follow-up. A moderate improvement on global
cognitive functioning was observed and small to large improvements were observed on other
measures of cognitive functioning. The findings of the current study provide preliminary support
for the use of a cognitive training program for healthy older adults.
1
Introduction
As adults age, many begin to notice declines in cognitive abilities such as memory and
problem solving, and report complaints that they are not as mentally capable as they once were.
These changes are a normal part of aging known as “age-related cognitive decline” (Deary et al.,
2009). Although these changes are normal, many older adults are interested in activities or
programs that help maximize cognitive functioning and minimize cognitive decline. Cognitive
training programs have been developed with this goal in mind and are designed to improve
cognitive abilities that decline with age or even prevent these abilities from declining.
Age-Related Cognitive Decline
Typically, older adults experience declines in domains of fluid intelligence that are
necessary in reasoning, problem-solving, abstract thinking, and decision making (Deary et al.,
2009). Skills that typically slow or decline with age include: processing speed and reaction time,
divided and sustained attention, various memory abilities (e.g., working, prospective, episodic),
verbal fluency, confrontation naming, visual construction, cognitive flexibility, and response
inhibition (Harada, Natelson-Love, & Triebel, 2013; Salthouse, 2012). In contrast, crystalized
intelligence, which involves knowledge from past experiences, facts, and vocabulary as a result
of learning, usually does not decline with age (Horn & Cattell, 1966).
Age-related cognitive decline is not pathological and typically does not cause significant
impairment in everyday functioning (Salthouse, 2012). Age-related cognitive decline can,
however, result in minor disturbances in daily functioning such as slight inconveniences (e.g.,
having difficulties finding car keys) or embarrassment (e.g., forgetting the name of an
acquaintance). It is common for older adults to worry about their cognitive health and report
subjective memory complaints related to these disturbances. Data from the United States of
2
Aging Survey conducted in 2015 revealed that 38 percent of adults over the age of 60 reported
subjective memory complaints and rated losing their memory as their top concern about aging
(National Council on Aging, 2015). Subjective memory complaints associated with age-related
cognitive decline are associated with increases in depression (Minett et al., 2008) and may cause
undue stress and anxiety. Older adults commonly worry about the implications of cognitive
decline, particularly the possibility of developing diseases that cause progressive and irreversible
cognitive impairment such as Alzheimer’s disease (Ostergren, 2017). Concerns about dementia
are certainly understandable given that approximately 5.8 million Americans have Alzheimer’s
disease (AD) and AD is projected to rise to nearly 14 million people by 2050 if no cure is found
(Alzheimer’s Association, 2019).
Cognitive Training
In response to older adults’ concerns about cognitive decline, academic researchers as
well as private businesses have developed cognitive training programs that have been created
with the goal of improving cognitive abilities or preventing declines in these abilities. Cognitive
training, sometimes marketed to the public as “brain training”, is a term used to describe
programs that provide guided practice on tasks requiring different cognitive abilities such as
memory or language (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). It is typically delivered via computer or other electronic devices, although
some programs are delivered to groups of participants by a live trainer. The assumption
underlying cognitive training is that the brain remains plastic as people age, so practicing
cognitive activities will improve or maintain functioning (Hertzog et al., 2008). Practice is
assumed to lead to what is known as transfer of training, which is essentially improvement on
3
tasks that are practiced as well as improvement on related tasks. Transfer depends on a similarity
between the content (e.g., knowledge, skill) learned initially and its later application (Simons et
al., 2016). It is assumed that regular practice of a cognitive domain (e.g., memory) will improve
or maintain functioning in that given domain and that these results will generalize beyond the
context of training.
Many “brain game” or “brain training” products on the market claim to improve
cognitive abilities, but many exaggerate the positive effects of their programs and can mislead
consumers (Simons et al., 2016). Simons and colleagues (2016) reviewed the “brain training”
literature and found evidence for improvements on trained tasks, but little evidence of benefits
on related cognitive tasks or everyday cognitive functioning. Conversely, recent reviews of the
empirical literature on cognitive training suggest that cognitive training programs can improve
cognitive functioning in older adults without dementia (Ball et al., 2002; Gross et al., 2012;
Rebok et al., 2014).
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 with
ages ranging from 65 to 94 years old were involved in the evaluation of three cognitive training
interventions. The three interventions targeted different cognitive abilities, which were: verbal
episodic memory, reasoning abilities, and speed of processing. Each intervention group
improved at the target cognitive ability compared to their baseline performance, and this
improvement sustained through a two-year observation period. However, the study did not find
that training effects generalized to everyday functioning.
4
A 10-year follow-up of the ACTIVE study was also completed (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 training group no longer maintained the effects in
memory performance. This long-term study provides support for the efficacy of cognitive
training in cognitively intact older adults.
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 treatment gains.
Overall, the literature has shown that improvements in cognitive functioning for healthy
older adults are typically observed only on measures of the specific domain for which someone
was trained. For example, individuals completing cognitive training that is focused on improving
memory skills often show improvements on measures of memory, but not on measures of other
important cognitive domains such as language or problem solving (Simons et al., 2016).
Additionally, there is little evidence that cognitive training enhances performance on distantly
related tasks or that training improves everyday cognitive functioning (Simons et al., 2016).
Purpose of Current Study
This study represents a program evaluation study in that the researchers were approached
by a community organization about evaluating the effects of a cognitive training program that
5
was being implemented with grant funding. Therefore, this research was conducted in the
context of program implementation in a real-world setting as opposed to being a traditional
experimental study conducted in a controlled setting.
This study aims to contribute to the current literature in two ways. First, the cognitive
training program utilized in this study was a comprehensive training program targeting all six
primary cognitive domains (i.e., processing speed, memory, language, attention/concentration,
visuospatial skills, and problem solving/executive functioning). Few existing studies have
examined the effects of comprehensive cognitive training programs, particularly those delivered
in community-based organizations as opposed to research settings. Second, many studies have
investigated computer-based cognitive training programs (Simons et al., 2016), whereas the
current study investigated a socially based cognitive training program delivered to a group of
individuals with a live facilitator/trainer.
The purpose of the current study was to determine the effects of a cognitive training
program on cognitive and emotional functioning for healthy, community-dwelling older adults
who reported subjective cognitive impairment. Based on previous literature, it was hypothesized
that there would not be robust changes in memory, however, there would be meaningful
improvements in executive functioning, processing speed, and self-reports of memory self-
efficacy. Additionally, it was hypothesized that there would be a decline in depressive
symptoms.
Method
Participants and Setting
Participants were recruited from a non-profit organization serving community-dwelling
older adults in a small Midwestern metropolitan area in the United States. Staff at the facility
6
were asked to recruit individuals who were interested in participating in a cognitive training
program and who reported subjective changes in cognitive functioning. To be included in the
study, participants were required to achieve a score of 78 or above on the Modified Mini-Mental
Status Examination (3MS; Teng & Chui, 1987), indicating mild cognitive decline to intact
cognitive abilities. 3MS scores ranged from 90-99 (M = 95.26, SD = 3.25) for participants,
indicating intact cognitive abilities. Exclusion criteria included a 3MS score below 78, a
diagnosis or condition that causes progressive dementia, or the presence of a significant visual,
hearing, or motor impairment that could prevent successful participation in the program. No
individuals were excluded from the study based on these criteria.
A sample of 31 individuals initially consented to participate in the study. To be included
in data analysis, participants were required to complete at least 75% of all cognitive training
classes. Twenty-six participants met this criterion of completing at least 75% of the classes,
while five participants dropped out of the study prior to completing the program due to various
reasons. One participant obtained a job and could no longer attend classes, one participant
became ill, and the other three stopped coming to class due to unknown reasons. To be included
in the final analysis, participants needed to complete testing at the three-month follow-up in
addition to having already completed the pre-test and post-test. Seven participants were unable to
complete follow-up testing due to various reasons. Three participants were out of the state, two
participants could not be reached, one participant had a medical emergency, and one participant
was ill. Nineteen participants completed all testing that was required to be included in the final
analysis. Participants in the final analysis included 13 Caucasian females and 6 Caucasian males
whose ages ranged from 61-92 years old (M = 75.26, SD = 8.43). The amount of education
7
completed ranged from high school degree to doctoral degree. A full summary of participant
demographics can be found in Table 1 of the Appendix.
Materials
Cognitive training program.
The program evaluated in this study was created by a non-profit organization devoted to
the development of cognitive training programs. The program, Mind Sharpener, developed by
the New England Cognitive Center (NECC), is designed for older adults who report subjective
cognitive decline that does not interfere with completing daily activities and have little to no
objective cognitive decline.
Prior to the start of the study, a master trainer from NECC trained three staff members at
the adult community center to deliver the program. A manual that included detailed instructions
about how to deliver the program was also provided. Throughout the study, NECC staff were
available for consultation or further training if necessary. The cognitive training program was
delivered to four separate groups of participants at different times. The program included 24,
one-hour classes delivered twice a week over a twelve-week period. Each class included a
sequence of paper-and-pencil activities related to six cognitive domains: processing speed,
visuospatial skills, attention and concentration, memory, language, and problem
solving/executive functioning. Each class was structured such that there was a 5-minute warm-
up, then 5-7 minutes on activities involving processing speed, 10-12 minutes on visuospatial
activities, 5-7 minutes on attention and concentration, 12-14 minutes on memory, 8-10 minutes
on language, 8-10 minutes on problem solving, and then a 3-5 minute wrap-up at the end.
Processing speed activities targeted speed, accuracy and automaticity of response and involved
almost no processing. Visuospatial activities targeted location, position, composition,
8
relationship, direction and perspective of objects in the environment. Attending to tasks and
maintaining focus are the primary targets for activities of attention and concentration. Memory
activities targeted short-term recall and working memory, as well as provided strategies to
facilitate information storage. The memory exercises attempted to stimulate multiple types of
memory, including short-term and long-term, verbal, visual, and auditory memories. Language
activities targeted language fluency, focusing on word recognition and word retrieval. Problem
solving activities may have involved identification, sorting, classifying, comparing/contrasting,
connecting, computing, sequencing, manipulating, decoding, and/or evaluating. All activities
involved repetition and positive reinforcement (i.e., praise) to promote learning. Activities within
each domain gradually increased in difficulty as the program progressed. The activities required
minimal instruction, therefore allowing the class time to be primarily dedicated to having the
participants engage in the activities. Feedback about performance was provided; however,
participants were never graded on activities and never directly compared their answers to others
given that the goal of the program was to engage participants in cognitively stimulating
activities.
Measures of cognition.
Modified Mini-Mental Status Examination (3MS). The 3MS (Teng & Chui, 1987) is a
measure of global cognitive functioning that was used to screen for dementia and determine
appropriateness for the Mind Sharpener program. It is a standardized assessment that is widely
used to evaluate individuals with cognitive impairment. The 3MS measures multiple cognitive
domains such as attention, orientation, short-term memory, and verbal reasoning. The measure is
highly reliable for assessing individuals with dementia (α = .88) and has high sensitivity (.93) in
9
differentiating between individuals with and without dementia (Tombaugh et al., 1996). Scores
can range from 0 to 100 with lower scores indicative of greater cognitive impairment.
Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). The
RBANS is a multi-component assessment that measures the cognitive domains of immediate
memory, visuospatial and constructional abilities, attention and concentration, language, and
delayed memory (Randolph, 1998). The cognitive domains assessed on the RBANS are
represented as index scores. The measurement of each cognitive domain, or index, includes two
subtests except for the delayed memory domain that includes four subtests, resulting in 12
subtests and five indexes that comprise the RBANS. A composite, total scaled index score of all
cognitive domains is calculated as well and is a measure of global cognitive functioning. In the
present analysis, index scores from the RBANS were reported rather than subtest scores as these
provide a more accurate assessment of performance. The primary focus of RBANS interpretation
is at the index level as index scores have the highest level of internal consistency and stability
(Randolph, 1998). An index score of 100 on any given cognitive domain is considered average
and is at the 50th percentile, while the standard deviation for all scales is 15.
The RBANS takes approximately 30 minutes to administer. Four alternate forms can be
used to evaluate cognitive functioning over time and minimize practice effects. Participants were
randomly assigned to complete either Form A or Form B first. Participants then completed the
other form at post-testing and finally completed the first form at follow-up testing. When
comparing performance over time on the same form, it is necessary to control for practice
effects; however, using alternate forms limits the impact of these effects and no adjustments need
to be made to account for increased performance due to previous exposure to the items
(Randolph, 1998).
10
The immediate memory domain of the RBANS includes the list-learning subtest and the
story memory subtest. During the list-learning subtest, participants were read a list of ten words
and then asked to recall the words. This was done four times, with each trial involving the
examiner reading the same list of words and asking the participant to recall the words. The story
memory subtest involved the examiner reading a short story and then asking the participant to
recall as much of the story as they could. This procedure was done two times.
The visuospatial and constructional domain of the RBANS includes the figure copy
subtest and the line orientation subtest. During the figure copy subtest, participants were asked to
copy a complex geometric figure from a model. Each different shape was scored separately to
comprise a score on the overall figure. During the line orientation subtest, participants were
shown a series of ten line-orientation cards and were asked to determine which two numbers
corresponded with the angles of the lines shown on each card.
The attention and concentration domain of the RBANS is comprised of the digit span
subtest and the coding subtest. The digit span subtest involved the examiner reading a series of
digits to the participant and then asking the participant to repeat the digits back in the exact order
they heard them. The number of digits increases by one each trial, for eight trials, or is
discontinued once the participant can no longer recall digits correctly for two consecutive
attempts. During the coding subtest, participants were asked to write down numbers in boxes that
were associated with specific simple shapes as quickly as they could. Participants had 90 seconds
to fill in as many boxes as they could.
The language domain of the RBANS includes the picture-naming subtest and the
semantic fluency subtest. During the picture-naming subtest, participants were shown ten
drawings of common objects and asked to name each one. The picture-naming subtest measures
11
confrontation naming skills. During the semantic fluency subtest, participants were asked to say
as many words associated with a specific category of objects as they could in 60 seconds.
The final domain assessed in the RBANS is the delayed memory domain. It is
administered after a delay of 20 minutes and it assesses rate of forgetting over time. The delayed
memory domain of the RBANS includes the list recall subtest, the list recognition subtest, the
story recall subtest, and the figure recall subtest. During the list recall subtest, participants were
asked to recall any words that they remembered from the list of ten words presented during the
list learning subtest. Immediately following free recall, participants were read a list of 20 words
during the list recognition subtest and were asked to say “yes” to a word if they thought it was on
the original list and “no” if they thought it was not. Ten were on the list and ten were not. During
the story recall subtest, participants were asked to recall any details from the story that was read
to them during the story memory subtest. Finally, during the figure recall subtest, participants
were presented with a blank sheet of paper and asked to draw the complex geometric figure that
was shown during the figure copy subtest as they remembered it.
The RBANS demonstrates respectable psychometric properties. The reliability
coefficients of the five domains and total scaled score range from .83-.94 for ages 60-89, and
test-retest correlations range from .62-.81 for ages 20-89. Additionally, the internal consistency
demonstrates correlations of .81-.94 for ages 60-89. When examining the alternate-form
comparison between Form A and Form B, the calculated differences for all ages from Form A to
B range from .46-.82 (Randolph, 1998).
Visual Puzzles. Although the RBANS assesses visuospatial skills, Visual Puzzles, which
is part of the Perceptual Reasoning Index on the WAIS-IV (Wechsler, 2008), was also
administered as it provided a more challenging assessment of visuospatial skills for the
12
cognitively intact participants in this study. This test assesses visuospatial reasoning and requires
mental transformation, manipulation, and the ability to analyze dimensional objects. Participants
were shown a completed puzzle with a display of six figures. Participants were then asked to
select three of the six possible figures that could create the completed puzzle. Participants
continued the test until they answered three consecutive items incorrectly.
Trail Making Test Part A. Trail Making Test Part A assesses cognitive processing speed
(Trail Making Test; Armitage; 1946, Reitan & Davison, 1974). Participants were given a piece
of paper with the numbers 1 through 25 contained in circles scattered across the paper.
Participants were asked to connect the numbers as fast as they could in numerical order.
Participants were instructed 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 B. Trail Making Test Part B is used to examine executive
functioning (Trail Making Test; Armitage, 1946; Reitan & Davison, 1974). Part B is similar to
Trail Making Test Part A, but Part B requires participants to alternate between numbers and
letters in order as fast as they can. They were 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.” Trail Making Test Part A and Part B are sensitive to
detecting brain damage and cognitive impairment (Reitan & Davison, 1974; Aschendorf et al.,
2008). However, 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 et al., 1998).
Non-cognitive measures.
The Patient Health Questionnaire-9 (PHQ-9). The PHQ-9 is a 9-item self-report
instrument, which assesses the frequency and severity of depressive symptoms (PHQ-9;
Kroenke, Spitzer, & Williams, 2001). It has high internal reliability (α = .89), sensitivity of 88%,
13
and specificity of 88% for major depression (Kroenke, Spitzer, & Williams, 2001). The PHQ-9
has been validated for use with older adults (Ell et al., 2005), including those with cognitive
impairment (Boyle et al., 2011).
Cognitive Failures Questionnaire (CFQ). The CFQ is a 25-item measure that assesses
participants’ perception of their memory (Broadbent et al., 1982). Participants were asked to
estimate how frequently they experience common memory problems (e.g., forgetting
appointments, forgetting names of people, forgetting if a light was turned off or if a door was
locked, etc.). The measure is positively correlated with other self-report measures of memory,
absentmindedness, and slips of action (Broadbent et al., 1982).
Frequency of Forgetting-10 Scale. The Frequency of Forgetting-10 Scale is a 10-item
measure that assesses participants’ judgement about their cognitive capabilities (Zelinski &
Gilewski, 2004). Participants were asked to rate how confident they were in their memory
abilities (e.g., how distressing memory problems were, overall confidence in memory, etc.).
Experimental Design and Procedure
A pre-post plus quasi-experimental design with a three-month follow-up was employed
to evaluate the potential benefits of the cognitive training program. After signing a consent form
(approved by the Institutional Review Board), the researchers administered a battery of
neuropsychological tests to assess the six cognitive domains targeted by the program. Tests were
administered one week prior to starting the program, within one week following the completion
of the program, and then again at the three-month follow-up. At each testing period, participants
also completed measures of memory self-efficacy and mood. The measures took approximately
60 minutes to administer.
14
Results
A within-subjects repeated measures analysis of variance (ANOVA) was conducted on
each individual measure. This was done to determine if there were meaningful differences
between pre-, post-, or follow-up testing for each given measure. If a main effect was discovered
in the overall model of the repeated measures ANOVA, then pairwise comparisons were
examined to determine where significant differences were. If a significant difference was found
from one testing period to another on a given measure, then an effect size statistic (Cohen’s d)
was computed to determine the magnitude of the difference. According to Cohen, d ≥ 0.20 is a
small effect size, d ≥ 0.50 is a moderate effect size, and d ≥ 0.80 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). Results are explained for each of the six
cognitive domains that were targeted in the cognitive training program. A full summary of
results can be found in Table 2 of the Appendix.
Attention.
RBANS Attention and Concentration Index Score. Results from the repeated measures
ANOVA revealed no main effect, F(1.49, 26.74) = 0.63, p = 0.50, indicating no significant
differences between any of the three testing periods for the domain of attention. A Greenhouse-
Geisser adjustment of the degrees of freedom was performed due to a violation of the assumption
of sphericity.
Visuospatial skills.
RBANS Visuospatial and Constructional Index Score. A main effect was discovered for
the domain of visuospatial skills, F(2, 36) = 5.03, p = 0.01. There was a significant difference (p
15
= 0.03) between pre-test (M = 101.95, SD = 17.55) and post-test (M = 111.21, SD = 13.55). In
addition, a moderate effect (d = 0.60) from pre-test to post-test was found.
WAIS-IV Visual Puzzles. A main effect was not found for this additional measure of
visuospatial skills, F(2, 36) = 1.82, p = 0.18, indicating no significant differences between pre-,
post-, or follow-up testing periods on this measure.
Memory.
RBANS Immediate Memory Index Score. Results revealed a main effect for the domain
of immediate memory, F(2,36) = 4.15, p = 0.02. There was a significant difference (p = 0.03)
between post-test (M = 103.53, SD = 15.77) and follow-up test (M = 110.53, SD = 15.78). In
addition, a moderate effect (d = 0.67) from post-test to follow-up test was found.
RBANS Delayed Memory Index Score. A main effect was discovered for the domain of
delayed memory, F(2, 36) = 15.46, p = 0.00. There was a significant difference (p = 0.02) from
post-test (M = 102.95, SD = 17.15) to follow-up test (M = 108.79, SD = 14.87). In addition, a
moderate effect (d = 0.67) from post-test to follow-up test found. There was also a significant
difference (p = 0.00) from pre-test (M = 98.16, SD = 16.31) to follow-up test (M = 108.79, SD =
14.87). In addition, a large effect (d = 1.39) from pre-test to follow-up test was found.
Language.
RBANS Language Index Score. No main effect was discovered for the domain of
language, F(2, 36) = 0.58, p = 0.56, indicating no meaningful differences between any of the
three testing periods for the domain of language.
Processing speed.
16
Trail Making Test Part A. Scores were very similar between all three testing periods on
Trail Making Test Part A and no main effect was discovered, F(2, 36) = 0.44, p = 0.65,
indicating no significant improvement on this measure of processing speed.
Problem solving.
Trail Making Test Part B. There were slight differences between pre-, post-, and follow-
up test scores on Trail Making Test Part B, however, no main effect was discovered, F(2, 36) =
1.02, p = 0.37, indicating no significant improvement on this measure of executive
functioning/problem solving.
Global cognitive functioning.
RBANS Total Scaled Score. Results from the repeated measures ANOVA revealed a
main effect for the Total Scaled Score on the RBANS, F(2, 36) = 9.23, p = 0.00. This is a
composite measure of all index scores on the RBANS and is a measure of global cognitive
functioning. There was a significant improvement (p = 0.01) from pre-test (M = 100.16, SD =
16.54) to follow-up test (M = 111.11, SD = 11.82). In addition, a moderate effect (d = 0.76) from
pre-test to follow-up test was found.
Non-cognitive measures.
Patient Health Questionnaire-9 (PHQ-9). All scores were in the healthy range (0-5) on
the PHQ-9 at pre-, post- and follow-up assessment. There was no main effect for this measure of
depressive symptoms, F(2, 36) = 0.04, p = 0.96, indicating no significant differences between
testing periods.
Cognitive Failures Questionnaire (CFQ). All scores were in the average range on the
CFQ at pre-, post- and follow-up test. A main effect was not discovered for this measure of
17
minor cognitive errors occurring in everyday life, F(2, 36) = 0.76, p = 0.47, indicating no
significant differences between testing periods.
Frequency of Forgetting-10 Scale. All scores were in the average range on the
Frequency of Forgetting-10 Scale at pre-, post- and follow-up test. There was no main effect for
this measure of memory self-efficacy, F(2,36) = 1.82, p = 0.18, indicating no significant
differences between testing periods.
Discussion
The results of this study provide preliminary support for the use of the Mind Sharpener
cognitive training program with healthy older adults. In general, there was improvement in the
domains of global cognitive functioning, visuospatial skills, immediate memory and delayed
memory. When examining the domain of global cognitive functioning, significant improvement
from pre-test to follow-up test was discovered, suggesting improvement over time and
maintenance of gains three months after the class was completed. This finding is consistent with
the results of a recent meta-analysis that showed multi-component cognitive training programs
that focused on improving global cognitive functioning for healthy older adults produced
improvements over time (Basak, Qin, & O’Connell, 2020). This finding is particularly promising
given that participants in the current study had global cognitive functioning scores in the average
range at baseline, so there presumably was little room for improvement in the overall sample.
Additionally, this study found improvements in visuospatial skills, immediate memory,
and delayed memory. This is consistent with previous research on cognitive training programs
for healthy older adults (Ball et al., 2002; Gross et al., 2012). For the domain of visuospatial
skills, significant improvement from pre-test to post-test was found, indicating short-term
improvement. This result could be related to the content of the cognitive training program.
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Classes included a variety of visuospatial tasks that required mental rotation or reversal of visual
stimuli. For the domain of delayed memory, significant improvement was discovered from post-
test to follow-up test and from pre-test to follow-up test, indicating sustained improvement in
this domain following the cognitive training program. Sustained improvement was also
discovered in the domain of immediate memory, as there was a significant improvement from
post-test to follow-up test. These results could be related to the content of the cognitive training
program as there is a heavy emphasis on memory tasks in the program. Approximately 25% of
each class focuses on tasks involving immediate and delayed verbal memory skills similar to
those assessed on the RBANS. These findings are particularly relevant to older adults
experiencing age-related cognitive decline as many report subjective memory complaints and are
most concerned about improving the cognitive domain of memory in improving their overall
cognitive health.
Unlike previous research on cognitive training programs for cognitively healthy older
adults (Ball et al., 2002), significant improvements in the domains of processing speed, as
measured by Trail Making Test Part A, and executive functioning/problem solving, as measured
by Trail Making Test Part B, were not discovered. It is possible that the classes did not
adequately target these skills. There was relatively little time devoted to processing speed
exercises (about five minutes per class). For the domain of executive functioning/problem
solving, it is possible that the content of the exercises in the class did not translate to
improvements on Trail Making Test Part B, and/or it is possible that this domain is too broad of
a construct to influence through a comprehensive cognitive training class like Mind Sharpener.
Exploratory analyses were conducted on the cognitive domains of attention and language
for which there is little existing empirical research. Results revealed no significant changes in
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these cognitive domains. It is possible that the tests used to measure these domains did not
accurately assess the specific skills taught in the class. For example, “language” is a very broad
construct that consists of a variety of abilities. The program includes several language exercises
and there was relatively little practice devoted to the specific skills that were on the assessment
(i.e., confrontation naming and semantic fluency). Therefore, the test used to measure language
abilities may not have accurately assessed the language skills that were targeted in the class. The
same reasoning can be applied to the domain of attention, since this is also a very broad domain
consisting of a variety of abilities. Additionally, for the domain of language, since this domain is
considered an ability of crystallized intelligence as opposed to an ability of fluid intelligence,
improvement in this domain may be less likely.
No significant differences were discovered on non-cognitive domains. Previous research
has suggested that cognitive training might have a beneficial effect on mood (Brum, Forlenza, &
Yassuda, 2009), and so it was predicted that there would be an improvement on scores on the
PHQ-9. Scores on the PHQ-9 did not significantly improve over time, although, baseline scores
were very low (i.e., in the very healthy range) so there was little room for improvement. Based
on previous literature (Rapp et al., 2002), we had also hypothesized that there would be a
decrease in the subjective cognitive failures that participants reported. However, there was no
change in the Cognitive Failures Questionnaire or the Memory Self-Efficacy Scale (Frequency of
Forgetting Scale) following the program. It is possible that using a measure of self-efficacy
related to broader cognitive functioning, as opposed to memory only, would produce different
results. Additionally, the Cognitive Failures Questionnaire is an outdated instrument, and thus
the content may no longer be relevant. Future researchers should consider using newer measures
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such as the Multifactorial Memory Questionnaire (MMQ; Troyer & Rich, 2002), which includes
three subscales regarding memory ability, memory satisfaction and the use of memory strategies.
Limitations and Future Directions
The current study found tentative support for the effectiveness of cognitive training
programs for healthy older adults. Although several positive results were found in important
cognitive domains, these positive results need to be considered in the context of several
limitations. One significant limitation is that there was no control group. The purpose of this
study was to assess the effects of a cognitive training program that was already established at an
adult community center. Therefore, the researchers were required to conduct the best possible
evaluation of a grant-funded program being implemented in a community-based setting as
opposed to the community center being required to adhere to the procedures necessary for an
internally consistent experimental research study. In addition, a control group was not included
due to the high community interest in the cognitive training program and to the needs of the adult
community center to maximize utilization of the program because of grant requirements. Future
studies will need to incorporate no-intervention control groups as well as active control groups
(e.g., book clubs) to determine if the cognitive training program is responsible for changes in
cognitive functioning observed in this study.
Another limitation is the relatively small sample size and lack of heterogeneity of the
sample, which can be a threat to generalization. Future researchers should look to expand the
sample size and include an equal number of males and females from diverse cultural
backgrounds.
Some aspects of the assessment process also limit conclusions that can be drawn from
this study. For example, pre-, post- and follow-up testing were not always conducted at the same
