The term ‘neurotechnology’ is often used to collectively refer to the various technologies normally used within the field of neuroscience. Modern neurotechnology encompasses several types of tools and applications intended for neurological sensing and intervention. Among the sensing kinds stand out direct neuromonitoring tools, such as electroencephalography (EEG), to measure central nervous system electrical activity and to generate neurofeedback signals (Sitaram et al., 2017). More sophisticated brain monitoring tools that can be used for computer-aided diagnosis (CAD) systems (Ortiz et al., 2016) include advanced imaging and mapping technologies, such as radioactive isotope-based positron emission tomography (PET), single-photon emission computed tomography (SPECT), and functional magnetic resonance imaging (fMRI; Cohen et al., 2017).
On the intervention side of neurotechnology are several tools intended to enhance or suppress particular neurological activities. Important examples include invasive procedures, some of which may be grouped into what, according to the International Neuromodulation Society definition (http://www.neuromodulation.com/neuromodulation-defined), is generically known as neuromodulation. Invasive therapies, such as deep brain stimulation (DBS; Ponce et al., 2015), are typically used to treat serious disorders associated with chronic neural diseases, such as Parkinson’s disease (Shukla and Okun, 2016).
Other stimulation-type neurotechnological interventions that are considered only minimally invasive include focused ultrasound (FUS; Miller and O’Callaghan, 2017), transcranial direct current stimulation (tDCS; McKinley et al., 2017), or transcranial magnetic stimulation (tMS; Nguyen et al., 2017). They can be used as stand-alone interventions or in conjunction with electric neurofeedback to induce neuroplastic effects at specific brain locations, with the aim of modulating particular brain functions (Sitaram et al., 2017).
In addition to the above-mentioned direct types of more or less invasive neurotechnological intervention tools, there exist other indirect-type noninvasive neurotechnological tools and applications, based on information and communication technology (ICT), which operate through various kinds of human-computer interface (HCI) platforms (Kane and Parsons, 2017). These noninvasive indirect ICT-based interventions are also intended to produce an enhancing or suppressive effect on some brain functions. The most important type is referred to as neurocognitive training (see, for example, Sharpbrains; http://sharpbrains.com/pervasive-neurotechnology/) or simply as ‘cognitive training’.
The main intention of this analytic narrative review is to examine the use of advanced ICT-based tools for effectively applying nonpharmacological noninvasive cognitive interventions as a means to assess, maintain, or improve cognitive functions, or at least to mitigate the behavioral symptoms, of people affected by mild cognitive impairment (MCI; Alzheimer’s Association, 2017) and perhaps other age-related cognitive impairment-bearing neurodegenerative illnesses.
In addition, the intention of this analytic review is to scrutinize the subject without becoming a rigorous systematic meta-analytic review. Thus, it does not pretend to contain an exhaustive and systematic search of all existing literature. Rather, the choice of relevant works, studies, reports, and other documents mentioned here is the result of continuous literature survey and manual selection guided by accrued expertise on the subject. Besides the authors’ own growing topical knowledge base archive, sources of information included some of the more usual general scientific peer-reviewed journal databases, such as PubMed, Web of Knowledge, IEEExplore, Scopus, and Google Scholar. Other types of general and specific sources, such as science and professional magazines, news bulletins, and technical reports, have been routinely consulted whenever relevant to the subject. Web portals of pertinent governmental institutions and nongovernment organizations and associations, as well as those of some specific for-profit enterprises, were also monitored and accessed. Whenever wide-ranging searches were needed, they were conducted using topic-related keywords. Among other terms, the following were used: cognitive intervention, computer-based cognitive intervention, cognitive training, brain training, computerized cognitive training (CCT), cognitive impairment rehabilitation, MCI, and virtual reality (VR). Considering the relative novelty of the topic, most references are limited to recent years. For the sake of conciseness, only those that were deemed to be of particular relevance and significantly important for the specific purposes of highlighting, exemplifying, or emphasizing the arguments of the narrative were chosen and are cited in the text.
Cognitive training is based on the practice of certain guided mental exercises. Its intended purpose is to aid in preserving or improving specific cognitive abilities or functions of individuals, such as attention, memory, self-control and decision-making. Hopefully, the improvement will extend to other related but not specifically trained cognitive tasks (far transfer). Many different forms of cognitive training have been, and continue to be, proposed for use by people of all ages and health conditions. Such proliferation is turning this intervention into a potentially ubiquitous popular application. Cognitive training is commonly referred to as either ‘brain training’ or ‘mind training’ in popular literature, newspaper articles, self-help books, and commercial product advertisements (Simons et al., 2016).
Various cognitive training interventions are directly aimed at the elderly population. An important portion of them are those specifically developed for people who are affected by some kind of age-related mental impairment, including MCI (Mahncke et al., 2006; Magaro et al., 2015a,b; Regan et al., 2016). Encouraging results on the effects of cognitive training on both healthy and MCI elderly people have been reported. Cognitive training interventions for the aging population are widely viewed as effective and relatively inexpensive means of nonpharmacological therapy (Alzheimer’s Association, 2017) capable of improving, or at least preserving, cognition and memory and possibly even sensory and motor functions as well. Cognitive training can be useful as part of, or to complement, more comprehensive rehabilitation services within a goal-oriented re-enablement care strategy approach (Mishra and Barratt, 2016). Such strategies are meant to facilitate people with age-related cognitive impairment to maintain or enhance meaningful functioning, engagement, and participation in daily-life activities with their families and communities (Clare, 2017).
The chief underlying principles upon which all cognitive training paradigms are based evolved from the concept of functional or structural neuroplasticity (Draganski et al., 2004; Guidolin et al., 2017; Lindenberger et al., 2017; Román et al., 2017). The neuroplasticity concept is called upon to justify cognitive training, alleging the hypothesis that cognitive abilities, akin to physical fitness, can be maintained or improved by the practice of exercise, which in this case means by properly exercising the brain (Mahncke et al., 2006; Shah et al., 2017). Furthermore, this idea is vindicated in the case of the elderly population based on the widely held view that the potential for neuroplasticity continues until old age (Leung et al., 2015).
Modern neurotechnological cognitive interventions are the result of the convergence of ICT and mental healthcare. Most cognitive training nowadays entail the engagement of individuals (normal or patients) through HCI platforms in the practice of computer-generated mentally demanding exercises, such as mazes, geometric and mathematical challenges, and many other kinds of so-called serious video games (Anguera et al., 2013; Wang, 2016). Accordingly, this type of cognitive training interventions is frequently referred to as CCT. Conceptually, CCT could be thought of as belonging to a broader class of intelligent computer-based assistive applications with the ability to communicate information through data networks, commonly referred to as intelligent assistive technologies (IATs), which encompass those specifically aimed at dementia care (Ienca et al., 2017).
CCT is nowadays viewed by most as the preferred and most effective type of tool to use for nonpharmacological cognitive interventions (Alzheimer’s Association, 2017), especially for those intended to help preserve cognitive function or delay the onset of age-related cognitive decline symptoms in people affected by MCI and other early stages of Alzheimer’s disease (AD; Alzheimer’s Association, 2017). According to a 2016 systematic literature review and meta-analysis conducted to study the efficacy of published computer-based cognitive interventions for improving cognition in people with dementia, CCT interventions may be classified according to their intended purpose into four categories: recreation, rehabilitation, stimulation, and training (García-Casal et al., 2016). Although CCT continues to be researched and developed, it is already being recommended and adopted as an effective intervention for the elderly population in general. An illustrative example of current widespread application of CCT is the cognitive training program aimed at older people with MCI implemented in Thailand in the framework of the concept of living in healthy cities (Chaikham et al., 2016).
A synergic application of multicomponent neurotechnological interventions of different modalities seems to be a promising approach for enhancing effectiveness. For example, a minimally invasive direct intervention used tMS combined with a noninvasive indirect CCT intervention to improve cognitive performance, locomotor activity, apathy, caregiver burden, and dependence of patients with AD (Nguyen et al., 2017). Likewise, the combination of neurocognitive-type and non-cognitive-type interventions, such as physical exercise, diet, and lifestyle, allows to configure simultaneous multidomain enhanced effectiveness strategies (Darviri et al., 2016; Shah and Martins, 2017). A representative example of the effectiveness of multidomain interventions is a recent randomized trial study called ‘The Brain Train Study’ about combined cognitive and physical training interventions in aged MCI subjects (Maffei et al., 2017), proving the effectiveness of this type of intervention in improving cognitive status and other indicators of brain health in MCI subjects.
Commercial brain training products
Coinciding with the presently rising scientific attention and renewed research interest in CCT development, there is also a growing popular awareness of brain training applications available in the open market. People in general seem to hold optimistic notions and have enthusiastic expectations about brain training. This perception is apparently rooted on some tacit belief that cognitive functioning can be improved by training. However, such conviction has been found to depend on factors such as age and awareness level (Rabipour and Davidson, 2015). Commercial brain training products come in different presentations, usually as stand-alone applications or as services delivered through the Internet. Most are being offered in the form of CCT programs capable of boosting attention, processing speed, memory, and other cognitive skills (Fitzgerald, 2017). Consumer CCT applications provide mind-challenging interactive exercises in the form of various types of cognitive activities, such as puzzles and mazes, as well as in the form of serious games (Anguera et al., 2013; Wang, 2016). The expansion of pervasive and ubiquitous computing, driven by an ever-growing availability of all kinds of personal ICT devices, such as tablets and smart mobile phones, is a strong enabling factor for the current quick proliferation of brain training applications. A recent Internet survey about the use, experience, and perception of CCT consumer applications among the US population indicates that there is a high level of interest in those applications that are smartphone based (apps), especially on the part of those under age 30 years (Torous et al., 2016).
A considerable business sector dedicated to CCT products has been growing over the years, maturing into what today may be referred to as the ‘brain training industry’. Companies in this sector market their products to healthcare professionals, educators, and the general public. Many CCT commercial applications that may be accessed through a web page, played in a PC, tablet, or smartphone, have been developed in different parts of the world. Some representative examples of such products are listed in Table 1.
CCT tools are commonly advertised as being capable of boosting or rehabilitating some cognitive abilities, such as memory, attention, and reasoning speed, and consequently capable of improving certain aspects of life activities that require the use of those abilities. As any commercial merchant would do, companies in this sector release publicity that includes appealing claims that emphasize the potential benefits of their products.
The nature of the claims made by different companies is diverse. Claims are usually said to be underwritten not only by various kinds of evidence but also by their creators’ professional reputation. For example, Cogmed’s developer Pearson Education, Inc. (see Table 1) identifies its founders as neuroscientists at the Karolinska Institute in Stockholm and portrays itself as a leader in the field of CCT. The company publicizes several claims about the effectiveness of their product regarding working memory (WM) and lasting improvements in attention. In this case, the claims are comprehensively described in an online document, written on this company’s behalf, and based on previously published scientific articles (Söderqvist and Nutley, 2017).
Another example of the type of publicity that resorts to the developers’ reputation is that from Posit Science Corporation. Their commercial product BrainHQ (see Table 1) is explicitly publicized as having been designed by an international team of neuroscientists led by a renowned researcher, described as a member of the National Academy of Sciences, co-inventor of the cochlear implant, and Kavli Prize laureate. The publicity also mentions that more than 100 published scientific papers, conducted by scientists at respected universities, attest to the benefits of their product.
Similarly, the makers of CogniFit (see Table 1) not only publicize their product as being clinically proven but also assert that it is recognized by the scientific community. To support that claim, they provide a list of published scientific articles where CogniFit has been reviewed and validated (see https://www.cognifit.com/neuroscience).
One of the best-known commercial brain training products is Luminosity by Lumos Labs, Inc. (see Table 1). Luminosity’s claims are also apparently backed up by scientific evidence. For example, a trial study, funded by this company, proved that comprehensive training with this product resulted in significant improvements in cognitive skills compared to the control group and observed evidence of transfer effectiveness to other untrained measures of cognitive performance (Hardy et al., 2015).
Because of the many possible CCT paradigms, and the various promising ICT-based supporting methods available for their delivery, it is essential to ensure that patients are exclusively subjected to totally proven and worthwhile procedures (Gooding et al., 2015). To that end, it is of paramount importance to scrupulously establish the extent of any potential beneficial effects that may be derived from the use of any method, instrument, or platform that is eventually used either by professional clinical practitioners or by the general public.
The brain training debate
Regardless of the more or less substantiated evidence of the effectiveness of commercial CCT products, certain claims made by a few companies that market CCT products at times might have exaggerated, overstated, or misrepresented their products in ways that could have misled costumers. Such claims, or rather the way how they were presented, have been harshly questioned by consumer advocates (Yong, 2016). In 2016, the US Federal Trade Commission (FTC) of the US Department of Commerce indicted some commercial companies for supposedly making insufficiently substantiated claims in their publicity. In one notorious case, where the courts found defendants responsible of misleading customers, they were ordered to refrain from making such claims in the future unless they could provide scientifically solid evidence to back up their claims (FTC vs. LUMOS Labs, Inc., 2016).
From then on, external interests vigorously entered the already complex academic debate about cognitive training. These new interests were no longer only those normally associated with research funding’s competitive procurement but others directly related to commercial consumer market profits. The legal actions undertaken by the US FTC, although probably warranted, contributed to heating up the debate by bringing the issue of brain training effectiveness out of the realm of scientific research rigor into the world of mass media exposure and public opinion controversy.
Notwithstanding such legal mishaps, supporting evidence of the effectiveness of some commercial CCTs continued to emerge. A recent systematic review study (Shah et al., 2017) involving seven representative commercially available CCT programs for cognitive decline indicates that there is clinically significant evidence that supports the notion that some commercially available CCT products can help promote healthy brain aging. In another CCT randomized controlled study (Cavallo et al., 2016) conducted using the Brainer platform (see Table 1) with a large group of patients affected by early-stage AD, it was shown that significant performance improvements are possible at individual and group levels in the domains of memory, language, and executive function. The fact that those improvements remained stable after 6 months indicates that intense CCT, when specifically designed for each patient’s needs, as was done in that study, can be a feasible and effective therapy for early-stage AD.
Still, a significant number of reputed researchers question the scientific soundness of certain claims made about brain training’s effectiveness for maintaining, restoring, or improving cognitive functions (Fitzgerald, 2017). The fact that sometimes claims have been presented in embellished statements intended for commercial promotion has contributed to blot the discussion. However, claims are often truly based on research conclusions and opinions of other equally qualified researchers who advocate the use of this type of brain training interventions. Thus, a pungent controversy has evolved between advocates and skeptics, at times not exempt of strong bias connotations (van Heugten et al., 2016).
However, it is also undeniable that short- and long-term benefits of brain training products had been questioned for quite some time (Jaeggi et al., 2011). Scientists from around the world have expressed doubts about the effectiveness of brain training in general. In an attempt to clarify the issue, the Max Planck Institute for Human Development together with the Stanford Center on Longevity gathered in 2014 a number of leading cognitive psychologists and neuroscientists so that they could share their views about commercial brain games. The product was a consensus document about the brain training industry (Allaire et al., 2014). Their concluding opinion maintained that claims that were being alleged at the time in commercial advertisements of brain games were often overstated and occasionally deceiving. Two years later, a group of seven psychologists reviewed and analyzed published papers that had been used to support some commercial products allegations (Yong, 2016). They found the evidence supporting existing commercial claims to be weak.
Unfortunately, the legitimate questions raised by different scientists in this debate have been simplistically bundled together in many public opinion scenarios and have ended up being perceived as summarized by the question: Do the so-called ‘brain training’ programs work or not?
The present situation is far from being that simple. It is important to emphasize that most, if not all, of the review and meta-analysis studies that to date have found cognitive training to be relatively ineffective place the blame for reaching such conclusion on the weakness of the reported evidence about their effectiveness. Some studies express disappointment that the present evidence is not stronger (Simons et al., 2016).
Another important question is the issue of ‘far transfer’. Little evidence has been found to date that existing CCT can produce significant long-term change in the execution of cognitive tasks under real-world situations or conditions different from those tasks that were trained by repeated exercise (McCabe et al., 2016). Studies on WM training have noted gains within the WM domain but no clear evidence of broad generalized far transfer and maintenance effects to other cognitive domains (Vermeij et al., 2016). Nevertheless, the lack of enough evidence of successful far transfer in published studies could originate mostly from common methodological deficiencies, such as small sample sizes, absence of passive control groups, improper measures, and other significant procedural shortcomings, as judiciously suggested by McCabe et al. (2016).
Notwithstanding all potential and real deficiencies of presently available evidence of CCT’s effectiveness or success, it is essential to insist on the fact that, for the most part, none of the reservations that are brought up by skeptics arise from the existence of any solid disproving counterevidence that unmistakably demonstrates that cognitive training does not work or cannot work. Rather, as already mentioned, the core of this still unresolved controversy rests solely upon the alleged absence of sufficient, bona fide, well-substantiated, and rigorous scientific evidence that can prove in an unquestionable way that CCT can indeed become an effective neurocognitive intervention tool. In short, the potential effectiveness of CCT is yet to be unquestionably proven, because the scientific evidence that exists up to now is still weak due mainly to methodological shortcomings.
Other factors that further complicate this debate include the doubts of some skeptics and critics about the possible influence of commercial business interests that fund or sponsor research whose findings are then reported in articles published in specialized journals. Similarly, there are worries about possible publication bias and selective reporting practices (Simons et al., 2016) that could be inadvertently contaminating some of the meta-analyses. The possible presence of placebo effects could also alter the results of cognitive intervention trials, as apparently happened, because of enticing recruiting advertising, in a cognitive training study (Foroughi et al., 2016). Thus, future studies of trial cases must incorporate measures to prevent or correct possible bias and placebo effects.
As we have mentioned, skeptics’ allegations are being tenaciously disputed by many reputed advocates of cognitive training. Consequent with their convictions, numerous proponents continue to do more extensive quality testing to further corroborate that cognitive training can indeed work. Meanwhile, the ongoing debate continues to cause a negative impact on the evolution of CCT paradigms in general. Particularly troublesome is the detrimental influence that the public exposure of the debate has on potential support for research and development (R&D) activities needed to bolster CCT.
The present reality of this still unresolved debate is that the available published meta-analyses on this subject generate promising but still insufficient results that lead to diverse, and at times conflicting, conclusions (Makin, 2016). In such a state of affairs, it seems reasonable to ask a fundamental question regarding the immediate future of R&D activities in the field of CCT interventions in general and more specifically those aimed at MCI and other neurodegenerative age-related cognitive impairments. The question may be enunciated as ‘Given the context of the ongoing brain training debate, should R&D of CCT interventions continue to be pursued?’ or alternatively ‘Should such activities be promoted, supported, or funded?’
Considering the existing literature on the subject, and in view of the quick evolution of emerging ICT-based platforms, the answer to this crucial question must be certainly affirmative. This straightforward assertion is by no means in conflict with acknowledging that the effectiveness of many of today’s commercially available CCT products has yet to be rigorously proven. However, we reject the contentions that all CCT interventions are ineffective or that cognitive functions in general cannot be trained. Accordingly, in the following sections, we will substantiate our viewpoint and argue the reasons why, in our opinion, R&D activities to improve the effectiveness of CCT interventions in general, and those for MCI in particular, should continue to be decidedly pursued and supported.
ICT-based therapeutic cognitive training
Videogames, serious games, and computerized cognitive training applications may have various features in common but in principle belong to different categories. They are all based on computerized platforms (mainframe, PC, smartphone, etc.) with 2D or 3D image display devices [monitor screen and VR head-mounted display (HMD) goggles] that are operated through user interfaces (game controller) and generate at least visual and audio responses but eventually also kinetic and other sensations. Videogames are designed primarily for entertainment, whereas serious games are usually meant to convey information or learning experiences beyond genuine entertainment, for job training or skills improvement, and for educational and remote learning purposes. On the contrary, CCT provides cognitively challenging tasks to exercise various cognitive domains of the human mind.
Interactive CCT applications can be presented to the user through the traditional 2D video displays of game consoles (Wang, 2016) or smart mobile devices. However, more sophisticated alternatives for CCT, such as 3D immersive VR (García-Betances et al., 2015a,b), are available. VR also can be combined and enhanced with augmented reality (AR) capabilities (Chicchi Giglioli et al., 2015) to create more interactive and mixed reality (MR) environments. There are also other promising ICT-based next-generation ideas, such as multisensory feedback and holographic 3D vision, which are constantly being developed, improved, and made available.
A recent quality assessment review and meta-analysis of 12 CCT interventions (García-Casal et al., 2016) confirms that although CCT can produce moderate beneficial effects on cognition and anxiety and small effects on depression there seems to be still insufficient evidence to demonstrate that these interventions can significantly improve the activities of daily living. Nevertheless, the study does indicate that results produced by CCT interventions are significantly more beneficial than those obtained from non-computer-based interventions (García-Casal et al., 2016).
Another systematic review and meta-analysis investigated the efficacy of using CCT in depressive disorders (Motter et al., 2016). The study’s search from 2007 to 2014 found a total of nine randomized controlled trials (RCTs) that met PRISMA’s high-quality guidelines for systematic reviews and meta-analyses (Moher et al., 2009). The evaluation of those trials indicates that CCT produces positive effects of diverse significance on domains related to depressive symptoms, daily functioning, attention, WM, and global functioning, whereas executive functioning and verbal memory do not appear to have experienced significant improvement. A more recent systematic review and meta-analysis (Smart et al., 2017) analyzed nine trials on older adults with self-perceived cognitive decline but clinically normal function. A small but significant effect was found that could benefit objective cognitive functioning.
A recently published systematic review and meta-analysis examined 17 CCT research trials conducted over the last 20 years on older adults with MCI or dementia (Hill et al., 2017). The study proves that CCT can lead to significant improvement in global cognition, memory, learning, and attention and psychosocial functioning, including mood, self-perceived quality of life, and depressive symptoms. However, effects on other domains, such as executive function and processing speed, were not found to be significant. The study provides a noteworthy hint by revealing that the effectiveness of CCT is weak in people who already have been diagnosed with dementia. Another very important finding is that the evidence of treatment effectiveness that does exist comes mostly from those trials that were done using immersive-type technologies. Results of this meta-analysis suggest that there is sufficient evidence to warrant proceeding to clinical implementation of CCT. Meanwhile, research should continue on ways to improve its effectiveness, so that CCT may be able to provide substantial help in the global fight against dementia (University of Sydney, 2016).
A strong motivation to maintain treatment engagement seems to be of crucial importance for the success of CCT as has been demonstrated by experience. CCT provides the best benefit when it incorporates motivational strategies to enhance treatment engagement in the cognitive therapeutic environment. This was corroborated, among others, by a study about CCT for older adults with subclinical cognitive decline (Gooding et al., 2015).
The combination of noninvasive ICT-based interventions, such as CCT, with other types of neurotechnological tools or direct interventions is an effective strategy to enhance the effectiveness of ICT-based therapeutic cognitive applications. For example, a minimally invasive direct intervention, using tMS, was recently applied in combination with CCT to a small group of AD patients (Nguyen et al., 2017). Results of that experience indicate that patients can clearly benefit from such combined procedures in the domains of cognitive performance, apathy, and dependence and that the effects persist in the long term.
Perception and acceptance by older patients of new ICT-based interventions for ailment treatment have been frequent subjects of study. Contrary to the common assumption that older people tend to be fearful or anxious of using new or unknown technology, most studies indicate a high rate of acceptance of such new techniques by older people (Kujawska et al., 2016). Nonetheless, it is still important to consider acceptance aspects when designing accessible ICT-based applications. A study about ICT usage by people with aging- and disability-derived functional impairments analyzed ICT-based applications to identify relevant cognitive functions involved in accessibility (García-Betances et al., 2016). Results showed that using cognitive virtual user models allows to integrate cognitive and perceptual aspects during the design and testing process of accessible ICT-based applications and services.
VR is a relatively new branch of ICT that can be useful in medical specialties as part of a rehabilitation strategy. VR has been already explored in various medical areas, such as traumatic brain injury, poststroke intervention (Lledó et al., 2016; Mazzoli Moraes et al., 2016), and musculoskeletal recovery. A recent systematic review of RCTs has evaluated the utility and efficacy of innovative VR-based interventions in pain management, eating disorders, and cognitive and motor rehabilitation in patients admitted to hospitals or rehabilitation centers (Dascal et al., 2017). VR has been proven to be a promising technology for improving the feasibility and effectiveness of attention bias and executive function cognitive training in the treatment of appetitive behavior disorders (Forman et al., 2017). Likewise, VR can be advantageously used in neuropsychology because it strives to engage one or more of the psychophysical systems that are vital for cognition: the visual, auditory, haptic, kinesthetic, and eventually even olfactory sensory perceptions (Riva, 1998; García-Betances et al., 2015a). VR-based neurotechnology can be used with both allocentric and idocentric points of view in nonimmersive as well as immersive modalities.
VR applications for cognitive intervention may be classified according to different categories: (a) the intended purpose (e.g. cognitive impairment assessment and early diagnosis, patient cognitive training or rehabilitation, and caregivers’ education), (b) the domain focus (e.g. spatial impairment and memory deficit), (c) the type of methodology used (e.g. tasks, games, and mazes), (d) the immersion level, (e) the sensorial modalities used (e.g. visual, auditory, and kinesthetic), and (f) the type of interaction (passive or active; García-Betances et al., 2015b).
Early studies examined the potential of using nonimmersive VR environments for CCT applications. An example of such early technology is a VR system used to improve the functional cooking autonomy of AD patients (Foloppe et al., 2015). Although it was a single case study, it was enough to demonstrate that even such nonimmersive VR can be useful to improve a patient’s functional ability.
A more advanced type of HCI for VR CCT is the modern HMD. Present and forthcoming advanced VR capabilities offer the possibility of simulating immersive and interactive life-like scenarios to produce in the user a sensation of ‘being there’. Fully immersive 3D interactive VR and AR environments allow to perform tests and exercises within dynamically adaptive real life-like settings that can be adjusted according to various needs. Such advanced HCIs are constantly being improved and have been used for neuropsychological assessment and in therapies for phobias, stress, anxiety, exercise and memory problems (Rizzo et al., 2000; Riva, 2005; García et al., 2012; García-Betances et al., 2015a).
Innovative CCT to meet the needs of the elderly population could benefit from a more intensive use of the value added by VR-based platforms to better address the specific requirements of cognitive impairment mitigation within a comprehensive cognitive rehabilitation scenario. Such tools can be of great assistance to the medical personnel, healthcare workers, and caregivers in general for enhancing the quality of life of elderly people with MCI. In that respect, we have suggested criteria and strategies for the effective design and development of VR tools for MCI (García-Betances et al., 2015a). Such tools, once equipped with adequate protocols and procedures, and making use of the immersive and interactive capabilities of emerging and next-generation advanced VR technology, represent the future of CCT interventions, as we have suggested in a brief review of VR technology for possible use in AD-related diseases (García-Betances et al., 2015b).
Cognitive exercises based on VR tools are well suited to assess and stimulate functional abilities associated with cognitive and motor activities of daily life in domains such as spatial memory, executive functions, and cognitive flexibility in patients with MCI. VR offers the possibility of dynamically modulating and self-pacing interventions according to the characteristics and individual needs of participants. VR can also serve to enhance engagement using motivational techniques, such as reward feedback, which allow producing a competitive spirit in the participants. Emerging 3D stereovision fully immersive features of today’s advanced VRs, coupled with MR scenarios and other imbedded interactive and sensorial next-generation capabilities, can play an essential role in generating realistic stimuli to provide vivid egocentric point-of-view sensations.
The validity and reliability of a VR system of this type were recently positively assessed for motor training of balance and postural control tasks in groups of aged healthy and MCI subjects (Bourrelier et al., 2016). Other feasibility studies have been conducted about the use of highly realistic image-based rendered VR with MCI and dementia patients. One study (Manera et al., 2016) suggests that VR-based CCT can be useful to improve the adherence of elderly people with cognitive impairment to the training. On the contrary, simpler semi-immersive VR technology could still be useful. A recent study used VR-based active navigation to improve the visuospatial orientation ability of people with cognitive and physical disabilities (de la Torre-Luque et al., 2017).
There are current efforts to develop more objective performance-based and observational assessments of cognitive and functional capacity deficits to be used as tools to detect early stages of the AD (preclinical, pre-MCI, and MCI; Harvey et al., 2017). The requirements for these assessments clearly favor the use of the latest advanced computerized strategies, such as the quickly evolving VR technologies, which can vividly simulate daily-life functional conditions.
It is already known that VR can provide an effective means for objective and well-controlled assessment of episodic memory (Plancher and Piolino, 2017). However, VR may be also helpful to assess aspects of cognition other than episodic memory. Advanced VR environments could provide an ideal platform for implementing novel tests of metacognition, social cognition, and prospective memory as has been recently recommended by the Working Group on Cognitive Assessment of Early AD in Clinical Trials of the International Society for Clinical Trials and Methods (ISCTM; Harvey et al., 2017). VR’s dynamic navigation capacity with high levels of immersion and interaction should help the challenging processes of diagnosing MCI and early AD. VR technology represents one of today’s most promising tools for providing nonpharmacological interventions for dementia (Raggi et al., 2017).
In addition to VR’s usefulness for CCT and cognitive assessment interventions, VR environments also can be used as an effective research tool. An example is a recent study that explored the potential of using an HMD-based immersive VR driving simulator to investigate how age affects the driving ability of aging adults (Bennett et al., 2016). In this regard, VR could be a decisive tool for advancing spatial memory research needed to empower the development of potential neurorehabilitation tools for topographical disorientation in AD (Raggi et al., 2017). Additionally, the use of evolving advanced VR-based tools for assessment interventions could facilitate opening up yet unexplored avenues of research, for example, to understand fundamental neurological mechanisms, such as episodic and other types of memory associated with cognitive functions (García-Betances et al., 2016; Plancher and Piolino, 2017; Raggi et al., 2017).
Most research studies about cognitive training conducted during the last two decades or so suggested that it could be beneficial for elderly people (Ball et al., 2002) as well as for patients with MCI and dementia (Jean et al., 2010). The Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) study of the U.S. National Institutes of Health (https://clinicaltrials.gov/ct2/show/NCT00298558) established that the application of cognitive training for memory, reasoning, and speed of processing results in a reduced decline of self-reported independent activities of daily living (IADL) and that training of reasoning and processing speed, but not memory, produced improved cognitive abilities retention for 10 years (Rebok et al., 2014). Although the use of CCT is a promising beneficial noninvasive neurocognitive intervention for older adults, its effectiveness probably declines slightly with age (Motter et al., 2016).
Not all studies conducted on the subject report positive results. Some fail to discover significant evidence after training of the sought for improvement. For example, a recent study of cognitive training trials with 97 healthy older adults aged 65 and over (Goghari and Lawlor-Savage, 2017) could not find any after-training noticeable improvement of near or far transfer of WM, planning, reasoning, verbal fluency, cognitive flexibility, creativity, and processing speed. However, the lack of evidence in this study does not necessarily mean that the training protocol used is ineffective. A very plausible explanation in this case could be that the healthy elders that comprised this study’s cohort were already before training at or around their maximum cognitive level for their age, so that no significant improvement should have been expected. Of course, there might have been other instrumental reasons for having failed to observe change in this case, for instance, that the assessment tools used for comparison were not acute enough to perceive very small changes. This example serves to underscore the importance of precise conceptual definition and methodological rigor when performing meaningful cognitive training trial studies.
In contrast to trials that predictably yield marginally noticeable changes, there are others that in principle should be expected to produce evident changes. That is the case of a study of cognitive training for a large number of older MCI patients with low education level living in Chinese rural areas (Liu et al., 2016). In this case, 2 months of training did produce, as expected, observable beneficial and long-term cognitive changes on attention, language, orientation, visual perception, organization of visual movement and logical questioning.
Methodological deficiencies unfortunately plague many cognitive training studies. A recent systematic review of cognitive training interventions to improve or stabilize cognition and everyday functioning in patients with AD (Kallio et al., 2017) uncovered several types of such shortcomings in many of the studied trials. Most prominent were inaccurate descriptions of training exercises, inadequate statistical procedures, and incomplete follow-ups. These findings emphasize the need for well-designed RCTs to corroborate that cognitive training indeed can become an effective treatment. Additionally, including both active (fake training) and passive (no training) control groups in the design of any RCT study is a vital requirement to be able to accurately analyze resulting evidence. The capital importance of including such control groups was recently illustrated by the intriguing results reported in a study about CCT use to improve executive functioning after stroke (van de Ven et al., 2017).
In addition to focusing on neuropsychological aspects directly related to cognitive abilities, it would be worthwhile that future studies also consider daily functioning, self-efficacy, and quality of life, as was also recently suggested (van Heugten et al., 2016). A relevant example of the kind is the study about three cognitive training programs on automobile driving cessation for older adults at risk for mobility decline due to cognitive impairment (Ross et al., 2016).
The integration of motivational strategies into cognitive intervention protocols to stimulate engagement could prove to be of vital importance (Gooding et al., 2015). The introduction of the latest immersive VR technologies into CCT, coupled with realistic multisensorial interaction devices and neurophysiological feedback capacities, are perhaps the most impacting improvements that can be made to CCT for MCI.
To be able to produce solid evidence of cognitive training effectiveness, specific measures of objective evaluation must be instrumented. Long-term follow-ups are needed to appraise the retention potential of the intervention effects (García-Casal et al., 2016). As we already mentioned, a crucial desirable aspect of CCT interventions is the ability to transfer the potential effects to other not-trained activity domains (far transfer capacity). Although not yet fully demonstrated, it is expected from other experiences that the use of VR in CCT can in fact increase the probability of far transfer to real daily-life situations.
There is evidence that training can also yield improvements of sensory perceptual abilities in both young and older people. It has been demonstrated that experience and training result in long-term visual perceptual learning (VPL; Sasaki and Watanabe, 2017). In this context, VR might turn out to be the ideal supporting platform for sensory perceptual training of complex stimuli. Coupled with other analytic neurotechnologies, such as neuroimaging, VR may also be helpful for understanding plasticity at the sensory and decision phases in the normal as well as the cognitively impaired human brain. The synergic use of advanced CCT tools, such as VR, together with sophisticated brain monitoring tools, should help in advancing the growing field of model-based cognitive neuroscience (Palmeri et al., 2017). Combined multimodality interventions could 1 day facilitate testing model hypotheses about cognitive mechanisms of human perception, learning, remembering and deciding within a mathematical psychology framework.
A recent editorial article (van Heugten et al., 2016) stated that brain training studies in general have shown up to now only promising signs of being effective in healthy persons and patients with cognitive deficits. Therefore, it advised to consider those studies only as proof-of-concept evidence that suggest that cognitive improvement may be possible through training. In spite of the mounting optimistic evidence, as of today, it is still unknown how much VR and other advanced computer technologies may be able to slow down the course of age-related degenerative cognitive impairment such as incipient dementia. Much less certain is whether such ICT tools will eventually help to arrest their course and, if so, under what conditions and circumstances. It is therefore evident that, if we pretend to ever answer these important questions in an undisputable manner, more and better systematic research is still needed on the subject.
As most early studies do show promising results, further systematic research is indeed warranted to explain, reproduce, and expand the initial results (Allaire et al., 2014). Most researchers agree that the cognitive training field needs more, larger, and methodologically sounder studies as well as revisiting the pertinent basic science (Makin, 2016). The application of adequate and proven learning strategies based on existing knowledge about memory phenomena, as suggested by McCabe et al. (2016), should lead to more effective CCT procedures, at least in the important domain of WM. Further research is needed to ascertain the effectiveness of CCT interventions in general but especially in the categories of cognitive recreation, rehabilitation, stimulation and training interventions for people with dementia (García-Casal et al., 2016).
R&D and design activities on advanced forms of CCT, based on emerging ICT such as VR, should be encouraged together with careful analysis and validation of their effectiveness. Considering the growing promising evidence and a reasonable expectation of the potential benefits, the question to ask in the present context is no longer whether or not CCT works but rather ‘What characteristics and conditions are required by advanced CCT platforms, such as VR and other emerging ICT, to be able to induce significant, transferable, and lasting beneficial effects in patients with MCI?’
We have sought to shed some light on the repercussions of the ongoing debate regarding the effectiveness of some of today’s consumer-oriented commercial brain training products. In that course, we have drawn attention to one crucial fact: that the most relevant reservations that have been brought up in this debate refer only to the alleged lack of sufficient methodologically rigorous scientific evidence to unquestionably support advertised claims of commercial products. The emphasis is placed on the term ‘sufficient’. We have argued that the persistence of this debate does not imply by any means that CCT paradigms have been found to be essentially ineffective. Much less that cognitive functions in general have been proven to be untrainable. Quite on the contrary, given the very promising evidence published about CCT, and in view of the good prospects for substantial near-term advances in emerging ICT-based technological tools, such as VR, we strongly advocate the continued pursuit of further research efforts in the field of CCT. We propose that particular attention be given to developing novel neurocognitive intervention VR-based platforms aimed at mitigating the symptoms of cognitive impairment afflictions. Advanced ICT-based platforms’ immersive characteristics and interactive functions are of particular relevance for treating many of the main symptoms of MCI and other neurodegenerative age-related cognitive decline illnesses, especially in the domains of memory, sustained attention, executive ability to make decisions, spatial orientation and time and visual perception.
There is no doubt that more RCTs of CCT must be carried out in a scientifically rigorous manner and that their results should be subjected to methodically scrupulous analyses. However, it is also clear that it is not enough to just do better experimental validations of existing neurocognitive training paradigms, most of which are based on antiquated neurotechnological tools. If this promising and potentially important field is to make further progress, it is essential to undertake new CCT platform design initiatives. Better and more resourceful platforms based on advanced ICT, especially those capable of multidomain and multimodality operation, are necessary to support the delivery of future CCT interventions.
It is also essential that future novel methodologies and strategies be based on a correct knowledge of human brain functionality as well as on a better understanding of the structural, physiological, functional and neurochemical basis of brain plasticity. As cognitive training might unequally affect different brain regions and modify the spatial distribution of functionally relevant subnetworks (Taya et al., 2015), monitoring and studying the brain’s structural connectome (Guidolin et al., 2017), through image analysis, can supply vital information about cognitive training-induced structural connectivity and plasticity changes within specific subnetworks in the brain (Román et al., 2017). Other important aspects of interest for CCT could be selective plasticity stabilization, its trained-skills specificity, and the individual differences present among specific domains (Lindenberger et al., 2017). In the long run, the ever-growing corpus of knowledge related to neurological functionality and plasticity will undoubtedly benefit from the information to be gathered from the feedback that future CCT interventions will provide.
Regardless of the course of the public brain training debate, CCT tools have already demonstrated their feasibility as a promising neurotechnological therapeutic option for ameliorating cognitive deficit symptoms. Thus, CCT ought to be further explored through emerging ICT to fully reveal and develop its potential capacities as well as to be able to reliably appraise the real implications of its possible benefits. We have mentioned important factors that need to be considered for improving the significance, rigor, reproducibility, and reliability of any future research on this topic. We recall three of them: proper selection of samples of broadly and narrowly defined target populations, precise specification of the intervention’s possibly multiple active ingredients, and the assessment of the intervention’s effectiveness through rigorous patient-centered outcome measurements. The assessment factor should be focused not only on traditional clinical measures of impairment’s symptoms reduction but also on innovative measurement of improvements in daily-life functions (Rodakowski and Skidmore, 2017).
Future work should concentrate on the use of present and future advanced forms of ICT-based CCT platforms, especially the latest-generation VR and several other emerging or yet to emerge high-tech resources. There are already sufficient reasons to believe that increasing the levels of immersion and interaction of the CCT environments through the use of advanced VR technologies could notably improve the efficacy of the interventions by enhancing their potential to induce larger effects.
Prof. Sophia Vinogradov, Head of the Department of Psychiatry at the University of Minnesota Medical School, in a recently published comment (Vinogradov, 2017), heralded an imminent change of paradigm centered on ICT-based tools, based on the understanding that computational neuroscience and neuroplasticity-based treatments together represent the future of psychiatry.
Summing up, the question today no longer is whether to use ICT-based neurocognitive intervention but how to do it. Pursuing further R&D, if conducted within appropriate frameworks, is not only warranted but also necessary and should be decidedly encouraged and supported. Progress in this direction can greatly enhance our ability to preserve older people’s cognitive health (Medalia and Erlich, 2017), the single major factor that conditions their personal independence and quality of life, as well as that of their relatives and care-keepers. In today’s scenario of increasing human life expectancy, longer lifespans must be matched by similarly long ‘health-spans’ of the aging population (Kaeberlein et al., 2015). An essential requirement for promoting healthy aging is safeguarding older people’s cognitive health, an urgent task that today represents a challenge with human, societal, and economic repercussions.
This work has been partially supported by the European Union’s Horizon 2020 SMART4MD project (GA no. 643399) and City4Age project (GA no. 689731).
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About the article
Rebeca Isabel García-Betances
Rebeca Isabel García-Betances is a telecommunications engineer with an MSc in biomedical engineering and is presently a biomedical engineering PhD candidate at UPM. She is a senior researcher at the LifeSTech Group, where she works on e-Health, e-Inclusion, self-management of chronic diseases, and VR in Ambient Intelligence applications. She currently manages activities for three EU’s Horizon 2020 Programme projects related to dementia self-management, brain-computer interfaces, and smart home technologies. She has authored 12 articles in refereed specialized journals in areas of communications infrastructure for rural telemedicine, automatic patient identification, patient engagement in diabetes self-management, affective and persuasive computer-mediated healthcare, ICT use for aging- and disability-derived functional impairments, and VR environments for cognitive training of the elderly and AD patients.
María Fernanda Cabrera-Umpiérrez
María Fernanda Cabrera-Umpiérrez is a telecommunications engineer with a PhD in biomedical engineering. She is an associate professor at ETSIT, UPM, and the CTO of the LifeSTech Group. She has been responsible for the concept development and coordination of large multidisciplinary national and international projects and has been the project coordinator and technical manager of more than 30 national and EU projects. She has authored more than 100 articles in national and international journals and conferences in the fields of e-Health, adaptive interfaces and decision support, and integrated care.
María T. Arredondo
María T. Arredondo is an Electrical Engineer with a PhD in Telecommunications Engineering. She is a full Professor of Bioengineering at UPM’s ETSIT. She is the CEO of LifeSTech, an international research group at UPM’s ETSIT, which she founded in 1995, dedicated to development of ICT applications to support people’s health care, welfare, quality of life, social inclusion and independent living. She has been a Principal Researcher in more than 50 EU-funded granted scientific and technical projects dealing with a variety of issues in the areas of Ambient Assisted Living and Ambient Intelligence applied to the social and healthcare sectors. She has published more than 200 papers and several books, and has served or serves on numerous committees and editorial boards.
Published Online: 2017-08-19
Published in Print: 2017-12-20
Conflict of interest statement: The authors declare no competing interests. The corresponding author had full control of all the parts of the article and has final responsibility in the decision to submit it for publication.