Winter 2010

Brain Fitness Games: The Real Deal?
By Jennifer Van Pelt, MA
Aging Well
Vol. 3 No. 1 P. 22

In “Sharpening the Aging Brain” (Summer 2008 issue), Aging Well first reported on the emerging brain fitness movement and the debate regarding the effectiveness of new computer technologies for improving older adult memory and possibly delaying the onset of dementia. More than one year later, the debate continues, but even in the face of uncertain effectiveness, the brain fitness market has continued to expand. Originally, products were designed specifically for older adult communities and elder assisted living facilities, but they have now expanded to serve the average aging adult.

What exactly is brain fitness? “Brain fitness is our brain’s ability to strengthen connections between neurons and even to promote new neurons in certain parts of the brain in order to maintain important brain functions,” according to Alvaro Fernandez, cofounder and CEO of San Francisco’s SharpBrains, an independent research and advisory company on brain fitness, and coauthor of The SharpBrains Guide to Brain Fitness. Neuropsychological and neuroscientific research has demonstrated that vigorous and regular mental activity can improve brain fitness, resulting in better memory and attention, as well as faster information-processing skills that deteriorate as the brain ages.

The fact that regular brain exercise improves cognitive function is not contested. Rather, the debate in the research community centers on whether exercising the brain can delay or even prevent the onset of dementia and exactly what types of brain exercise are most effective. This emphasis, says Fernandez, is interfering with a more important fact about brain fitness: Beginning and adhering to a regular brain exercise program can improve functionality today and tomorrow for people of all ages. “For example, insurance companies and AAA are now promoting computerized cognitive training for driving safety of older adults. This is about brain functionality today and tomorrow, not about developing Alzheimer’s disease 20 years from now,” he says.

The range of brain fitness products for both individuals and facilities serving older adults has grown substantially during the past two years. Many facilities and communities have implemented some type of brain fitness program. According to Fernandez, brain fitness is becoming a standard in older adult residential facilities, with more than 700 residential facilities in the United States alone installing computerized cognitive training programs since 2007. A SharpBrains market research report estimates that the market for brain fitness products, including consumers, facilities, health and insurance providers, and schools, will grow from $265 million in 2008 to $1 billion to $5 billion by 2015, depending on how consumer education, research, and marketing claims evolve.

Growing Interest
Dan Michel, founder and CEO of Dakim, Inc, says, “Over the past year, there has been a tremendous increase in the media exposure on brain health. This awareness building is helping seniors better understand the risks and rewards of cognitive exercise.” Aging consumers are now investigating brain fitness products for use at home. Dakim brain fitness technology is being used in more than 300 senior living communities across the country. According to Michel, it is the only brain fitness product designed for use over the long term to help seniors slow the development of dementia. Based on standard neurological tests and exercises, the Dakim product is configured to self-adjust as the user plays and ages, with new games automatically downloaded every night. Older adults, regardless of age or mental status, easily learn from the technology.

Michel notes that scientific research has fueled interest as well, with recent studies reporting the success of brain fitness activities in delaying the onset of memory decline and improving cognitive function. A report on 488 older adults in the Bronx Aging Study, a 10-year study of risk factors for cerebrovascular disease and dementia in adults aged 75 to 85, linked mentally stimulating leisure activities, such as playing cards, doing crossword puzzles, and doing artistic work with a delay in accelerated memory decline.1

Another study of more than 5,500 participants aged 65 and older reported that stimulating leisure activities were significantly associated with a reduced risk of dementia.2 These recent studies support earlier studies demonstrating that frequent brain exercise can reduce the likelihood of developing Alzheimer’s disease, as in the 2007 study of 700 older adults that found cognitively inactive older adults were 2.6 times more likely to develop Alzheimer’s than those who frequently participated in mentally stimulating activities.3

Another manufacturer, Posit Science, recently reported study results of its brain fitness product focusing on auditory processing. After daily one-hour sessions for eight weeks, participants aged 65 and older reported improvements in life tasks such as remembering names and numbers, as well as communication and overall memory.4 A new product from Posit Science called DriveSharp promotes safer driving for older adults by training speed-of-processing skills and useful field of view. The driving game is based on the brain fitness programs used in two large studies and has been shown to enhance real-life driving skills by improving reaction time to unexpected events and reducing the number of dangerous driving maneuvers on the road, according to Posit Science.  

Continuing Skepticism
Although many professionals in the aging field, as well as consumers, have enthusiastically received research on brain fitness games, others are more skeptical. Laura L. Carstensen, PhD, director of the Stanford Center on Longevity, says, “Fear of memory loss, mental impairment, and Alzheimer’s disease lead many consumers to search for products—from supplements to software—that claim to ward off such ailments. Such products are becoming more prolific, but this burgeoning industry is completely unregulated, and the claims can range from reasonable though untested to blatantly false. It is important for consumers to proceed with caution before buying into many of these product claims. There is no magic bullet solution for cognitive decline.”

The Stanford Center on Longevity convened 30 cognitive and brain scientists to release a statement providing public guidance on products claiming to improve mental fitness and the science behind them. In the May 2009 statement, the expert consensus stated that “software-based cognitive training and brain games have been shown to improve users’ performance on trained tasks. The important caveat is that very few training programs have shown evidence that such gains translate into improved performance in the complex realm of everyday life. A program might train you to memorize lists of words, for example, but this particular skill is not likely to help you remember where you left your car keys or the time of an upcoming appointment. We strongly support research on software-based training and encourage interested people to participate in clinical trials investigating its potential.”

While research results continue to meet with mixed reviews, anecdotal reports and testimonials from older adult users and caregivers in elder care facilities are positive, according to Michel and Fernandez. This positive feedback, combined with results of earlier research studies, laid the foundation for the development of brain fitness products such as Dakim’s and their success in the elder care market. Expansion into the at-home consumer market has quickly followed. Nintendo and other gaming companies offer games designed specifically for brain fitness, and the Internet offers similar older adult games. Much like a specific physical fitness regimen works particular muscles, a computerized brain fitness program can be used as a customized workout, according to Fernandez.

But games specifically dubbed “brain games” may not be the only ones that can improve brain fitness. Emerging research suggests that some standard computer games can provide brain benefits, too. According to the findings of the Mind Research Network, the popular video game Tetris can create positive changes in the brain—most notably in the areas believed to play a role in critical thinking, language processing, and the planning of coordinated movements. The researchers, led by California neuroscientist Richard Haier, PhD, studied the effects of Tetris on brain activity in adolescent girls using MRI. The girls who played Tetris for 30 minutes daily for three months demonstrated improved efficiency in parts of the brain associated with reasoning, critical thinking, language, and processing.

Research findings relating brain fitness games to increased thickness of the brain’s cortex are of interest for aging adults, since the cortex naturally deteriorates as we age. “We have no research on how Tetris may change the brains of older adults. Nonetheless, most researchers who study aging believe in the axiom ‘use it or lose it.’ Although Tetris is a very simple game to learn and play, from the brain’s perspective, it is quite complex. We think playing Tetris is a good workout for many brain areas. I suspect that there are brain changes in older adults who play regularly. Personally, I try to play every day,” says Haier.

One study concluded that playing a strategy video game improved working memory, visual short-term memory, and reasoning in adults over the age of 60.5 Future studies may examine whether playing Tetris and other standard computer games can lead to improvements in other cognitive function areas.

Varying Options
Media coverage of brain games and their growing presence in elder care facilities may give the impression that such games are the only option for improving older adults’ brain fitness. But just as there are many different types of physical exercise, there are many types of brain exercise, and different people will like different activities. Brain games may appeal to many older adults but should not be viewed as the sole activity for improving brain fitness, says Fernandez. The most effective brain exercise is one that keeps elders engaged long term, says Michel. Computerized brain fitness programs should fit into an overall lifestyle that includes regular mental stimulation involving a variety of activities, including those that one may not be good at, to induce learning. “A critical aspect for consumers and professionals to understand is that simply doing one more crossword puzzle after you have done 10,000 is not enough brain exercise. True brain exercise requires novelty, variety, and increasing levels of challenge,” Fernandez states.

An active proponent of lifelong learning, especially to maintain brain health, Nancy Merz Nordstrom, MEd, is author of Learning Later, Living Greater: The Secret for Making the Most of Your After-50 Years and director of the Elderhostel Institute Network. “Although brain fitness programs certainly have their place, I really feel it’s all about staying engaged and connected with society, and you do that by being involved in life,” she says. But older adults should not dismiss the latest technology just because they think they don’t need it, she says. In older adult communities, these programs certainly help residents and get their attention, but the need to keep brains engaged all day, every day, in ordinary tasks should also be stressed, Nordstrom advises.

She suggests looking for simple ways to keep older adults’ brains challenged and engaged all day, not just for a certain time period, such as when they are playing a “brain game.” She recommends a variety of easily accessible activities to keep older brains challenged and engaged, including the following:

• playing board games such as Scrabble, Risk, Pictionary, or Monopoly with friends to combine mental stimulation with social interaction;

• doing Sudoku, crossword, or jigsaw puzzles; and

• playing card games or chess.

The Stanford Center on Longevity’s guidance statement on cognitive fitness notes, “Learning stimulates the brain and contributes to one’s general sense of competence. However, there is no evidence that any particular formal training or practice regime is required. Before settling on a particular method and investing time and sometimes money in a particular product, consumers need to consider hidden costs beyond dollars and cents. Every hour spent doing solo software drills is an hour not spent hiking, learning Italian, making a new recipe, or playing with your grandchildren. Other avenues for cognitive enhancement, such as participating in your community and exploring your passions, may also stimulate your mind while producing socially meaningful outcomes.”

“New learning and integration of new information, not retrieval of old information, is required if you want to create new neurons and synapses to build ‘cognitive reserve,’” Michel notes. So this suggests that while trivia- and memory-based games may be fun and improve retrieval, they may not be as effective in preventing memory loss. Cognitive reserve, or brain resilience, is built up by daily mental stimulation and helps provide a buffer against age-related deterioration. Lifelong learning, brain fitness games, and stimulating leisure activities can all help aging adults build cognitive reserve.

The Internet makes college-level courses and other subjects of interest available for elders who have difficulties traveling outside the home. Many colleges offer free classes for older adults. Nordstrom calls the Internet “a gold mine of stimulating games and brain exercises” and notes that in addition to online classes, older adults can join online discussion boards about virtually any topic of interest.

Questions Remain
Brain fitness activities may contribute to improved mental and physical health, and keeping the brain active may also help combat depression, which is common in older adults. A recent study reported brain tasks that improved processing speed, such as computerized brain games, reduced the risk of depression by 38% in older adults.6 Cognitive training results in slower decline in health-related quality of life and lowers annual medical care costs.7,8

Even as more studies report on the benefits of brain fitness games, skepticism remains, and criticism of their effectiveness is common. According to Fernandez, most of the confusion comes from the marketing claims and consumer perception that brain fitness products (or any other intervention, from supplements to meditation) are “magic pills” that will cure every brain ailment. “While there are very useful tools and some brain exercises are supported by evidence, consumers need to understand what they really need and how to find the right product for them,” he says. Specific computerized cognitive training and video games have been shown to improve brain functions, but the key questions are “Which specific product has shown what?” and “What do I need?” he emphasizes.

Ongoing research may address these issues. In the meantime, exercising the brain should be on every older adult’s daily to-do list. In response to the skepticism regarding brain fitness games, Michel says, “Even if we are not yet sure of [brain fitness games’] benefit, why not start playing them? The biggest difference, the greatest benefit, is between doing nothing and doing something.” The bottom line for the aging brain? Use it or lose it.

— Jennifer Van Pelt, MA, is a freelance writer based in Reading, Pa., and a certified fitness instructor with experience teaching older adults.

Harbinger of Health Plan Features to Come?
UPMC Health Plan in western Pennsylvania announced recently that it signed an agreement to offer brain fitness software at no cost to all UPMC for Life Medicare Advantage members. The brain training program is a new part of the UPMC Health Plan wellness services that focus on both mind and body fitness.

This particular brain fitness software is a suite of five gamelike computer exercises that make brain training challenging and effective. The program engages the brain’s natural plasticity (its ability to rewire itself) to improve basic brain function.

In addition to improving cognitive health, brain fitness exercise, much like physical exercise, can improve general health outcomes. Recent studies show specific brain fitness exercises improve functional independence, self-confidence, and health-related quality of life. A report funded by the National Institutes of Health indicates that use of such exercises is likely also to reduce healthcare costs.

“Brain health is important because it affects what matters most—quality of life, emotional health, relationships, everyday tasks, work, and hobbies,” says Cathy Batteer, UPMC Health Plan’s vice president of Medicare. “Fitness isn’t just about your body anymore. We care about overall mind-body wellness so we are thrilled to be the first health plan in this region to provide our members with this brain fitness software.”

Current or new UPMC for Life members who enroll in a Medicare Advantage plan can get the brain fitness software for no additional cost. Members who want the program will get a CD-ROM that can be easily loaded onto a home computer. No prior computer experience is needed to operate the program.

— Source: UPMC Health Plan

References
1. Hall CB, Lipton RB, Sliwinski M, et al. Cognitive activities delay onset of memory decline in persons who develop dementia. Neurology. 2009;73(5):356-361.

2. Akbaraly TN, Portet F, Fustinoni S, et al. Leisure activities and the risk of dementia in the elderly: Results from the Three-City Study. Neurology. 2009;73(11):854-861.

3. Wilson RS, Scherr PA, Schneider JA, Tang Y, Bennett DA. Relation of cognitive activity to risk of developing Alzheimer disease. Neurology. 2007;69(20):1911-1920.

4. Smith GE, Housen P, Yaffe K, et al. A cognitive training program based on principles of brain plasticity: Results from the Improvement in Memory with Plasticity-based Adaptive Cognitive Training (IMPACT) study. J Am Geriatr Soc. 2009;57(4),594-603.

5. Basak C, Boot WR, Voss MW, Kramer AF. Can training in a real-time strategy video game attenuate cognitive decline in older adults? Psychol Aging. 2008;23(4):765-777.

6. Wolinsky FD, Mahncke HW, Weg MW, et al. The ACTIVE cognitive training interventions and the onset of and recovery from suspected clinical depression. J Gerontol B Psychol Sci Soc Sci. 2009;64(5):577-585.

7. Wolinksy FD, Unverzagt FW, Smith DM, et al. The effects of the ACTIVE cognitive training trial on clinically relevant declines in health-related quality of life. J Gerontol B Psychol Sci Soc Sci. 2006;61(5):S281-S287.

8. Wolinksy FD, Mahncke HW, Kosinski M, et al. The ACTIVE cognitive training trial and predicted medical expenditures. BMC Health Serv Res. 2009;9:109.