Training Foundational Skills to Enhance Cognition in Older Adults

摘要：到2030年，老年人的数量将超过儿童，占美国65岁或以上人口的25%。随着老年人口的规模和比例继续扩大，阿尔茨海默病(AD)和相关痴呆症的发病率也将增加。在过去的十年里，美国死于阿尔茨海默病的人数增加了120%以上，目前阿尔茨海默病是主要的死亡原因。增加对医疗和精神健康每况愈下的人的护理对公共卫生系统的影响是一个主要关切。另一个重要的问题是老年人的生活质量，他们通常在老龄化，但经历着记忆和认知功能的下降。轻度认知障碍(MCI)可从中年开始，并在整个一生中增加，影响日常功能的许多方面。到目前为止，还没有有效的治疗方法来减缓MCI或AD的进展。然而，随着最近的一些证据表明，认知功能的增强可能会减少影响并延迟MCI、AD和相关痴呆的发病，预防的可能性越来越大。目前提高认知能力的最有前途的方法之一是使用电子游戏。动作视频游戏可以提高选择性注意力、处理速度和工作记忆。基于游戏的认知训练的优势包括易于在家中使用，这提供了扩展的分布式练习和高参与度。我们提出了一个项目，该项目使用电子游戏来增强认知，这与目前使用的游戏有很大不同。我们的训练游戏使用凝视来训练注意力，这会迫使玩家保持持续的高参与度。此外，这些游戏的目标是特定的注意力技能，这些技能在典型的衰老过程中受到影响(分心和反应抑制)，影响执行和记忆功能，以及实际功能，如驾驶安全。这些游戏已经成功地用于训练注意力受损的青少年和患有发育障碍的年轻人，包括抵抗分心。我们预计，培训对老年人也同样有效。我们建议使用两年的规划期来进行一项临床试验，目的是：确定和解决适应老年人感觉能力下降所需的游戏修改；优化训练剂量和测试效果保留的时间；以及测试和完善结果评估组。随后对60-80岁的健康成年人进行的大样本随机对照试验将采用：4个参与者组(主动受训者、2个主动控制组、一个患有MCI的组)；4个水平的结果评估(1.主要的注意力测量；2.EEG、fMRI、结构和DTI生物标记物的变化(重点关注AD的大脑易感区域，如海马体、内侧颞叶)；3.认知/记忆功能的评估；以及4.实际功能和自我效能的评估)。长期的随访将评估训练样本与对照样本相比的MCI、AD和相关痴呆的发生率。我们的跨学科领导团队代表着AD/MCI研究、神经心理学、老年精神健康、临床试验方法、生物统计学以及健康相关评估和干预游戏的开发和使用方面的专业知识。

ABSTRACT: By 2030, older adults will outnumber children with 25% of the population of the United States age 65 or older. The rate of Alzheimer’s disease (AD) and related dementias will also increase as the size and proportion of the older adult population continues to expand. In the past decade, deaths from AD have increased more than 120% in the US and AD is currently a leading cause of death. The impact on public health systems from increased care for those with declining medical and mental health is a major concern. An additional important concern is for the quality of life in older adults who are aging typically but experiencing decline in memory and cognitive function. Mild cognitive impairment (MCI) can begin in middle age and increase throughout the lifespan affecting many aspects of daily function. To date there is no effective cure or treatment to slow progression of MCI or AD. Prevention, however, is a growing possibility with some recent evidence that enhancement of cognitive function may reduce effects and delay the onset of MCI, AD and related dementias. One of the more promising current approaches to enhancing cognitive performance is use of video-games. Action video games can improve selective attention, processing speed and working memory. Advantages of game-based cognitive training include the ease of use at home which provides for extended distributed practice and high engagement. We propose a project that uses video-games for cognitive enhancement that differ critically from those currently in use. Our training games use gaze to train attention which forces a constant high level of engagement. Additionally, these games target specific attentional skills that are affected in typical aging (distraction and response inhibition) and that affect executive and memory function as well as practical function such as driving safety. These games have been used successfully to train impaired attention including resistance to distraction in teens and young adults with developmental disorders. We expect training to be equally effective in older adults. We propose to use the 2-year planning period to conduct a clinical trial that aims: to identify and address any modifications of the games required for adaptation to diminished sensory abilities in older adults; to optimize training dosage and test timing of retention of effects; and to test and refine the battery of outcome assessments. A subsequent large sample randomized control trial of healthy adults aged 60-80 would employ: 4 participant groups (active trainees, 2 active control groups, a group with MCI); 4 levels of outcome assessment (1. primary measures of attention; 2. EEG, FMRI, structural and DTI biomarkers of change (with a focus on brain regions vulnerable in AD such as hippocampus, medial temporal lobe); 3. assessment of cognitive/memory function; and 4. assessment of practical function and perception of self-efficacy). A long-term follow-up would assess the rate of MCI, AD and related dementias in trained compared to control samples. Our cross-disciplinary leadership team represents expertise in AD/MCI research, neuropsychology, geriatric mental health, clinical trial methods, biostatistics and development and use of games for health-related assessment and intervention.