A frequent question in memory disorder clinics is, “Should I do crossword puzzles?” Personally, I love crossword puzzles and think they are lots of fun. However, this question is not asked by those looking for a new form of entertainment. The people who ask this question in a memory clinic are often in the early stages of dementia, or perhaps the children of individuals with advanced dementia. They are looking for ways to feel healthier, safer, or more hopeful despite experiencing or witnessing the devastating effects of cognitive decline. My usual answer to this question is, “Do the crossword puzzle when you come back from your walk.” That is the beginning of one of my favorite pieces of clinical advice, my mini-lecture on how brain games are only part of a brain-healthy lifestyle.
Two Important Questions
Brain game providers have vigorously marketed their wares to consumers eager to preserve optimal cognitive functioning in later years. TV, the internet, and radio, including public radio programs, frequently promote brain games, which listeners experience as highly credible.
The value of cognitive stimulation or brain training, however, have not been consistently supported by research. Much of the doubt about brain games focuses on whether they achieve two important cognitive goals: persistence of gains and do the gains generalize across tasks.
Do the Gains Persist Over Time?
In the famous ACTIVE study, it took only ten sessions of cognitive training to produce benefits measured a decade later.1 Other studies, however, have questioned whether gains demonstrated after cognitive exercises will endure over time. Persistence of gains is an important goal for any cognitive exercise.
Do Improvements Help with Other Similar Tasks?
Generalizability, the other important goal, refers to the translation of improvement gained while practicing one task to better performance on other cognitively-demanding tasks. If I can remember a sequence of moves in a video game puzzle, for example, will I also have an easier time finding my car at the mall? Task-specific improvement is a recognized benefit of brain games, but evidence of generalizability has been limited and inconsistent.
An Important Lesson
I have nothing against crossword puzzles. Even more, I like the animated, interactive brain games that you can access on the internet. However, I agree with Daniel Simons of the University of Illinois, the lead author of a recently published analysis of the research on brain games.2 He and his colleagues set out to learn whether there is enough evidence to show that these cognitive exercises strengthen the brain and prevent dementia. Sadly, Simons concluded that there is not sufficient support for claims that brain games can prevent dementia or significantly improve mental functioning beyond the task that the game presents.
Some of my colleagues were disappointed to see Simons’ thoughtful assessment and blunt criticism of products developed by an industry that brings in billions of dollars per year from aging Baby Boomers hoping to outwit normal aging and the effects of neurodegenerative diseases. However, a more important lesson, to my thinking, is that it is time for us to re-evaluate our focus on brain exercise and turn our attention back to the body in which the brain lives. The brain, after all, functions best when supplied by nutrients in the blood that is pumped by a healthy heart; oxygen absorbed through healthy lungs; and the biochemical support promoted by a nutritious diet and healthy metabolic environment.
A Golden Opportunity for Prevention
The enthusiasm about brain games, of course, is part of a growing interest in shifting our approach to helping people with dementia. At present, the treatment system is more reactive, waiting until cognitive difficulty interferes with independence before engaging supports. There is growing interest in developing a more proactive, preventive, wellness-based approach, focused on general physical health to support optimal cognitive functioning.
Even without improved dementia-specific medical treatments, we can adopt simple and powerful lifestyle changes that hold a promise of delaying or preventing cognitive decline. The value of a preventive approach is all the more believable in the light of findings from biomarker studies that show the appearance of dementia to be preceded by two or three decades of metabolic change.3 Those decades provide a golden opportunity for prevention.
A recent population-based analysis estimated that about 40% of cases of dementia might be delayed or prevented by attention to lifestyle factors including exercise, diet, disease management, and remediation of hearing loss.4 Recognition of the importance of these risk factors has fueled enthusiasm for the encouragement of a prevention-oriented “brain-healthy lifestyle.” Such a lifestyle includes detection and attentive care for established diseases such as hypertension or diabetes mellitus, promotion of physical activity and cognitive stimulation, improvement of nutrition, encouragement of social engagement, and optimization of stress management and restorative sleep. “Brain Games” are neither the only nor the most important component of this brain-healthy lifestyle.
I want to highlight the importance, in particular, of physical activity. In the United States, physical inactivity, defined as engaging in less than 20 minutes of vigorous activity on 3 or more days per week or moderate activity for 30 minutes on 5 or more days per week, appears to be responsible for a significant portion of the risk of developing Alzheimer’s disease.
Other important risk factors such as diabetes mellitus, midlife hypertension, midlife obesity, and depression, are exacerbated by inactivity and favorably affected by exercise. Analysis of multiple controlled studies of exercise supports claims of improved attention processing speed in cognitively healthy older adults.5 Furthermore, exercise improves cognitive functioning in older adults with established memory complaints6 and can even promote symptomatic and functional improvement in people already diagnosed with dementia.7
Large, objective, well-designed studies are currently assessing the effects of combined preventive interventions on cognitive aging. The results from these protocols are more impressive than those obtained in studies which relied on brain training alone. The FINGER study, for example, assigned a large population of aging Finnish adults, 60 to 77 years old, to one of two groups. The control group received only health advice, while the experimental group received a multi-modal intervention that included management of vascular risk factors, supervised physical activity, nutritional guidance, cognitive stimulation, and social engagement.8 Two years later, this healthy lifestyle group showed significantly less cognitive impairment as compared to the control group. Other studies are continuing to explore the benefits of similar multi-modal preventive strategies.
Anticipating stronger evidence of the cognitive benefits of a brain-healthy lifestyle, medical centers around the United States are setting up programs that promote optimal cognitive aging. UCLA’s Longevity Center programs include an immersive 1-day Brain Boot Camp experience as well as longer-term Brain Gym and Memory Maintenance programs.9
Boston’s Beth Israel Deaconess Hospital’s Brain Fit Club offers group lessons in Tai Chi, meditation, nutrition, sleep education, and cognitive stimulation.10 The University of Santa Barbara’s Cottage Center for Brain Fitness11 and Penn Memory Center’s Cognitive Fitness Program12 are additional leaders in providing older adults with the lifestyle tools they hope will assure optimal cognitive aging. As these programs evolve, we may learn more about which approaches yield the most beneficial outcomes.
Until disease-reversing treatments become available, early intervention will remain of critical importance in our battle with Alzheimer’s disease. New tools for earlier detection, such as amyloid PET scanning or less costly tests in development, will make earlier diagnosis and risk assessment increasingly possible. Even aging individuals in good health, however, can benefit from the components of a brain-healthy lifestyle: medical disease management, physical activity, education and cognitive stimulation, healthful nutrition, restorative sleep, stress management, and social engagement. The brain-healthy lifestyle, after all, is a way of life designed to nurture both brain and body.
- Alzheimer’s Disease Toolkit (Helpful Information to Understand and Manage Alzheimer's Disease)
- Expert Information on Alzheimer's Disease (Articles)
- Decreasing Your Risk of Alzheimer's Disease (Article)
- Risk Factors & Prevention (Article)
- Alzheimer's Prevention: Nutrition & Lifestyle (Fact Sheet)
- Q & A: Lowering Dementia Risk—What’s the Evidence? (Science News Q/A)
- Rebok GW, Ball K, Guey LT, et al. ACTIVE Study Group. Ten-year effects of the advanced cognitive training for independent and vital elderly cognitive training trial on cognition and everyday functioning in older adults. J Am Geriatr Soc. 2014;62:16-24.
- Simons DJ, Boot WR, Charness N, et al. Do "Brain-Training" Programs Work? Psychol Sci Public Interest 2016;17:103-186.
- Bateman RJ, Chengjie X, Benzinger TLS, et al. Clinical and Biomarker Changes in Dominantly Inherited Alzheimer's DiseaseNEJM 2012;367:795-804.
- Livingston G et al. Dementia prevention, intervention, and care: 2020 report of the Lancet Commission. .Lancet. 2020 Aug 8;396(10248):413-446. doi: 10.1016/S0140-6736(20)30367-6. Epub 2020 Jul 30.PMID: 32738937
- Smith PJ, Blumenthal JA, Hoffman BM, et al. Aerobic exercise and neurocognitive performance: a meta-analytic review of randomized controlled trials. Psychosom Med 2010;72: 239–252.
- Lautenschlager NT, Cox KL, Flicker L, et al. Effect of physical activity on cognitive function in older adults at risk for Alzheimer disease: a randomized trial. JAMA 2008;300:1027-37.
- Heyn P, Abreu BC, Ottenbacher KJ. The effects of exercise training on elderly persons with cognitive impairment and dementia: a meta-analysis. Arch Phys Med Rehabil 2004;95:1694- 1704.
- Ngandu T, Lehtisalo J, Solomon A, et al. A 2 year multidomain intervention of diet, exercise, cognitive training, and vascular risk monitoring versus control to prevent cognitive decline in at-risk elderly people (FINGER): a randomised controlled trial. Lancet 2015;385:2255-63.
- https://www.semel.ucla.edu/longevity, accessed 10/28/16
- http://www.bidmc.org/Centers-and-Departments/Departments/Neurology/Brain-Fit- Club.aspx, accessed 10/28/16
- https://www.cottagehealth.org/app/files/public/1185/Cottage-Magazine-Fall-2012.pdf, accessed 10/28/16
- https://pennmemorycenter.org/programs-services/cognitive-fitness/, accessed 10/28/16
This content was last updated on: November 9, 2020
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