Cognitive Remediation to Enhance Mobility in Older Adults: the Crem Study

Abstract

Mobility disabilities represent the most prevalent disability among seniors. Emerging evidence indicates that executive functions play an important role in maintaining mobility. However, the use of cognitive remediation programs to enhance mobility has not been investigated in a full-scale randomized control trial. The CREM study is a single-blind randomized control trial to examine the effect of computerized cognitive remediation versus computer-based health education training on mobility in 420 seniors. The primary outcome is change in gait speed during normal walking and walking-while-talking conditions from baseline to postintervention. Secondary outcomes are change in mobility, mobility-related cognitive processes and neuroplasticity. Results of this study will fill an important gap in the efficacy and feasibility of cognitive remediation to improve mobility in seniors. Mobility disability, defined as severe difficulty or inability to walk a quarter of a mile or climb stairs, is associated with loss of independence and is an independent predictor of mortality in older adults [1,2]. While exercise is recommended to prevent mobility disability and improve gait speed [3], <10% of US seniors exercise at recommended levels [4] and 25% are inactive [1], necessitating exploration of new approaches to improve mobility.Intact gait control requires efficient integration of many neural systems, namely motor, sensory and cognitive, including multiple cognitive subsystems (i.e., memory, attention and executive functions [EFs]). EFs are a set of higher cognitive processes that modulate behavior, facilitate allocation Practice points• Given the major medical and socioeconomic consequences of disability in seniors and the low compliance with recommended treatments such as physical exercise, investigation of alternate strategies to improve mobility is a vital need.• We present a randomized clinical trial to test the efficacy of a computerized cognitive remediation program on improving mobility in sedentary seniors, a group at an especially high risk for disability.• The primary outcome is postintervention change in gait speed measured during normal-pace walking (simple locomotion) and walking-while-talking (complex locomotion) conditions.• This novel approach to improving mobility has the potential to shift treatment paradigms in the field of disability by introducing cognitive approaches to mobility that can be applied to prevention and rehabilitation in diverse settings.

Cognitive-Based Interventions to Improve Mobility: A Systematic Review and Meta-analysis

“…8,11,12,17,21–24 It is hypothesized that specialized cognitive training, with a strong emphasis on executive control training, will provide beneficial effects on gait and executive functions through its impact on this frontosubcortical circuit. 35 Frontosubcortical circuits link specific regions of the frontal cortex (namely, prefrontal cortex) to the basal ganglia (motor control). 36 That is, given its plastic properties, the brain is able to continuously change in response to engagement in repeated sensory, motor, and/or cognitive activities.…”

Computerised cognitive remediation to enhance mobility in older adults: a single-blind, single-centre, randomised trial

“…CogniFit (CogniFit, San Francisco, CA, USA), a commercially available software, provides training across multiple cognitive domains, including executive functions and other related processes-such as speed of processing, divided attention, and visuospatial skills-that are relevant to walking performance. 3,11,18 Previous studies have suggested that training with CogniFit might improve walking speed. 3,12,18 For the intervention group, groups of up to eight participants attended three training days per week for 8 weeks.…”

“…3,11,18 Previous studies have suggested that training with CogniFit might improve walking speed. 3,12,18 For the intervention group, groups of up to eight participants attended three training days per week for 8 weeks. Each session was about 50 min (150 min weekly) and was split into three blocks.…”

“…We did a single-blind, single centre, randomised trial that compared cognitive remediation with an active control. The study design, intervention, and statistical analysis plan have been reported previously, 3,11 and the design was guided by feedback provided by participants in our pilot study. 3 Individuals who were 70 years or older; ambulatory; able to speak sufficient English to understand the cognitive assessment battery questionnaire; at high-risk for mobility disability, defined using a score of nine or less (frail range) on the Short Physical Performance Battery (SPPB); and had a walking speed of 100 cm/s or less were eligible for inclusion.…”

“…The study design, intervention, and statistical analysis plan have been reported previously, 3,11 and the design was guided by feedback provided by participants in our pilot study. 3 Individuals who were 70 years or older; ambulatory; able to speak sufficient English to understand the cognitive assessment battery questionnaire; at high-risk for mobility disability, defined using a score of nine or less (frail range) on the Short Physical Performance Battery (SPPB); and had a walking speed of 100 cm/s or less were eligible for inclusion. 3,11 Exclusion criteria were having dementia (previous diagnosis or diagnosed based on clinical and neuropsychological test performance at baseline); acute or terminal medical illnesses (eg, cancer [late stage or metastatic disease or receiving active treatment], chronic pulmonary disease on ventilator or continuous oxygen therapy, or active liver disease); recent or planned surgery or hospitalisation for a cause that might affect mobility; mobility limitations solely due to musculoskeletal limitations or pain that might prevent completion of mobility tests; any medical condition or chronic medication use (eg, neuroleptic) that would compromise safety or cognitive function; life expectancy of 12 months or less; severe auditory or visual loss; any active psychoses that would prevent completion of study protocol; having progressive, degenerative neurological disease (eg, Parkinson's disease or amyotrophic lateral sclerosis); and being resident in a nursing home.…”