Dementia Care and Prevention

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17 Νοε 2013 (πριν από 3 χρόνια και 4 μήνες)

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Cognitive Training for

Dementia Care and Prevention


Ryuta Kawashima

Smart Ageing International Research Center

IDAC, Tohoku University

Sendai JAPAN

http://www.fbi.idac.tohoku.ac.jp/fbi/

Smart Ageing


~ A new concept toward super
-
ageing society ~

Implication of Smart Ageing

Traditional view of
Ageing


Ageing is loss


Ageing is deterioration


Grey Dawn, etc…

Anti
-
aging: wrong
view of ageing


Ageing is disease


Ageing is ugly


Younger is better than older

View of

Smart Ageing


Ageing
-
related challenges
are opportunities for


-

mutual growth


-

smarter solution


Ageing is gain


Ageing is human
development

Concept of Smart Ageing from

14
th

Century

「時分の花」

Flower at season

All young actors have this flower (beauty).


「まことの花」

True flower

Only actors who has been devoting
themselves can have this flower in their
later stage of life.


世阿弥

Ze/a/mi (1363~1443)

He brought Noh to what is essentially its present
-
day.

He wrote the first known treatise on drama named
Fushikaden
.

「能」

:Noh is a major form of classical
Japanese musical drama that has
been performed since the 14th century.

Anti
-
ageing:

to cling to flower at season


Smart ageing:

to gain true flower

Four Principles to Achieve Smart Ageing


Cognitive Stimulation


Physical Exercise


Well Balanced Nutrition


Socialization

Today’s Main Topics


The Prefrontal Cortex

The most important part of our brain


Cognitive Functions of the Prefrontal Cortex

7

The prefrontal cortex plays extremely important roles
in keeping our daily life healthy and happy.

1.
Verbal and non
-
verbal communication

2.
Logical thinking

3.
Working memory

4.
Control, especially inhibition of behavior

5.
Control of emotion

6.
Intention

7.
Attention

8.
Initiation

9.
Learning

PFC

Functions of the Prefrontal Cortex

Changes in Neuropsychological
Measures during Ageing

Chronological Age


Z
-
score

Modified from Park et al. 2002; Salthouse 2006

Cognitive tasks requiring

prefrontal functions

Cognitive tasks requiring

semantic knowledge

Relation between the

Prefrontal Function and Age

0

2

4

6

8

10

12

14

16

18

60

65

70

75

80

85

90

95

100

365 healthy elders

118 people with dementia

Age

FAB score

Normal adults

5 years old

6 years old

7 years old

We assessed the prefrontal function by the FAB (Frontal Assessment Battery at Bedside)

Dysfunction of the Prefrontal Cortex


Patients with PFC lesions







Psychological states


Feelings of guilt or remorse


Changes in interpretations of reality


Increase in lying or untruthful behavior


Planning

Controlling
Emotions

Language

Episodic

Memory

Sensory


Neural Basis of Cognitive Training


Working Memory

Working

memory

is

a

system

for

temporarily

storing

and

managing

the

information

required

to

carry

out

complex

cognitive

tasks

such

as

learning,

reasoning,

and

comprehension
.

Working

memory

is

involved

in

the

selection,

initiation,

and

termination

of

information
-
processing

functions

such

as

encoding,

storing,

and

retrieving

data
.

Working Memory training

Improve WM function

Learning effects

Improve non
-
trained
cognitive functions

Improve fluid intelligence

Transfer effect

To the ability to reason quickly and to think
abstractly. This type of intelligence tends to
decline during late adulthood.

Working Memory Training

Visuospatial Span Task

N
-
back Dual Task

3+2

1+1

6+1

1+2

Memorize 5

Memorize 2

Memorize 7

&

Answer 5

Daily intervention by working memory tasks (computer basis)















Memorize 3

&

Answer 2

A part of this study is published inTakeuchi et al., J Neurosci 2010

Visuospatial Span Task

N
-
back Dual Task

3 + 2




1 + 1





5 + 1 =>
5





1 + 2


=>
2






….

7 + 1

2 + 3

3 + 4 =>

5 + 3 =>

1 + 1 =>

3 + 3 =>

Beneficial Effects by Working Memory Training

RCT; Intervention group (41 healthy young) vs. Control group (20 healthy young)

Increase resting rCBF

Pre
-
test

One Month Intervention

Post
-
test

20~ 60 min a day,

5 days a week

Found improvement of non
-
trained cognitive tests

(general intelligence, inhibition, creativity etc.)

Brain areas showing statistically significant increases in volume of grey matter compared
with control subjects after one month of intervention


Cognitive Training for People with Dementia

~ The
Learning Therapy ~


Principles


Create working memory training methods for
elder people including people with dementia


Therefore, tasks for cognitive intervention must


require working memory


be simple and easy


have sufficient cognitive load

18

Cognitive Load

Simple & Easy

Discovery by Chance

19

Simple arithmetic
operation

e.g. 2 + 3, 5 + 8

Right Hemisphere

Left Hemisphere

Read sentences
aloud


Quite unusual observation obtained from
our brain mapping database

Kawashima et al. Cognitive Brain Res 2004

Miura et al. Neuroimage 2005

Reading

Materials

Arithmetic Materials

Learning Therapy


Wide range of materials


10 ~ 15 min a day, 3 ~ 6 days a week





Assessment of Subjects

22

Diagnostic test

Appropriate degree of
difficulty and workload

Subjects could continue to perform the tasks with ease

Language
Problems

Arithmetic
Problems

Lowest level: read and write single syllables

Highest level: read aloud fairy tales.

Lowest level: counting practice

Highest level : three
-
digit division.

What is Learning Therapy?

23

Case 1: 94 years old woman

Dementia Alzheimer Type

24

Case2: 76 years old woman,

Vascular Dementia

25

26

Changes in

Neuropsychological Characteristics

15

16

17

18

19

20

21

22

FAB

MMSE

n.s.

p

< 0.05

Intervention


n =16


Baseline

6mo follow up

Control


渠n16


5

6

7

8

9

10

Baseline

6mo follow up

n.s.

p

< 0.05

Error bars indicate SEM

Source:
J Gerontology Series A, Biological Sciences and Medical Sciences
, 2005


*MMSE:
Mini
-
Mental State Examination

**FAB:
Frontal Assessment Battery at Bedside

Much improvement for the intervention group

compared to the control group on standard mental assessments

27

Changes in

Neuropsychological Characteristics

Error bars indicate SEM

*MMSE:
Mini
-
Mental State Examination

**FAB:
Frontal Assessment Battery at Bedside

The same results have been obtained from the USA trial

Baseline

6mo follow up

Baseline

6mo follow up

Intervention


n =20


Control


n =20


p

< 0.05

p

< 0.001

p

< 0.01

n.s.

FAB

MMSE

Changes in

NIRs* measurements

28

Prior to Intervention

One month after intervention

82 years old, Female, SDAT,
MMSE 15, FAB 7

NIRs*: Near Infra
-
Red Spectroscopy

Prefrontal cortex is much activated one
-
month after intervention

Changes in Neuropsychological
Characteristics

(two years follow up)


MMSE



Vascular dementia; n = 27

SDAT; n = 19

Vascular dementia; n = 27

SDAT; n = 19

Pre 6mo 12mo 18mo 24mo

Pre 6mo 12mo 18mo 24mo

Kawashima Jap J Clin Exp Med 2011

FAB

MMSE

Data for Donepezil and Control (placebo: projected data after 1.0 year ) were modified from
Winblad

et al.,
Demnt

Geriat

Cogn

Disord

2006.

Changes in Neuropsychological
Characteristics

(
SDAT
:
two

years follow up)

アリセプト

n=56 (Age 71.4; MMSE 19.9)

学習療法

n=19 (Age 81.1; MMSE 19.6)

対照(無治療)

n=58 (Age 71.2; MMSE 19.8)




MMSE score

Donepezil; n=56 (age 71.4 MMSE 19.9)

Learning Therapy; n=19 (age 81.1 MMSE 19.6)

Control (placebo); n=58 (age 71.2 MMSE 19.8)


0.5 1.0 1.5 2.0 years

LS mean change from week 0

Kawashima Jap J Clin Exp Med 2011

Case3: 86 years old women,

Senile Dementia Alzheimer Type

31

Case 3 (86 years old woman: SDAT


Showed major improvements after three
-
month intervention

32

Jan. 2005

Bedridden more than three years

Mar. 2005

Learning in a wheelchair

Beneficial Effects on Staffs of Day Centers

33

Responses and changes in staffs

1.
Increase in
deeper communication
with learners

2.
Deeper understanding
of the learners

3.
Enhanced understanding
that all elderly have
endless potential

4.
Acquir hints

to improve daily care in all learners

5.
Develop respect
for the learners

6.
Experience a heightened sense of pride
in their
work

Economic benefits of the Learning Therapy

35

Intervention

n = 116


Control

n = 105


Changes in Required Care Level
(RCL)


at two
-
year follow
-
up

about Tohoku University

Tokyo

Nagoya

Osaka

SENDAI

Tohoku

(
North East Region))

Kyoto

Tohoku University


Founded in 1907 as 3rd
Imperial University


An “Open
-
Door” admissions
policy


A “Research First” principle


Practice
-
Oriented Research
& Education

10 Undergraduate Schools

15 Graduate Schools

5 Research Institutes

About 850 Full Professors

About 18000 Students

38

“Green City” Sendai


Largest city in Tohoku District

3.11

39

We shall overcome!

40

2011.07.25


Videogame and Smart Ageing


The Brain training game could not affect


the cognitive functions
under
60 years old

Owen et al. (2010)

Age
: 18
-
60 years old

Training
:


1)
Reasoning (Game)

(
n
=4,678)


2)
Memory (Game)

(
n
=4,014)


3)
Control

(
n
=2,738)

Training Period
:


6weeks, 10mins, 3days a week

Outcome measures
:


reasoning, verbal short
-
term memory,


spatial working memory,


paired
-
associated learning


Brain activity during playing video games

Fighting game

fMRI


Shooting game

fMRI


Puzzle game

fMRI


Puzzle game

NIRs


The most videogames do not activate the prefrontal cortex.

Although,
theoretically, they should require prefrontal functions.

In addition, they often
deactivate

the prefrontal cortex.

43

R&D of video game that can
activate the prefrontal cortex

Seeds

Tohoku University

Measure brain activity






Needs

Company

(e.g. Nintendo)


Game soft

We evaluated and made
suggestions how to activate the
prefrontal cortex using brain
imaging techniques.

This evaluation (scientific proof)
added values to the game itself
and made it mega
-
hit!

44

45

What is Brain Training?


DS has hand
-
written letters and voice recognition capabilities
meaning it can make effective judgments, score and generate
graphs


-
> must be handy for smooth training


46

What is Brain Training?


Brain Training should be done everyday to become
effective


-
> Nintendo has know
-
how and expertise to encourage
our customers to play video games everyday


-
>Could be good way to train everyday?

Method

Parallel comparison, double masked






Randomized Controlled Trial


-
participants & tester were masked.

-
Cognitive Measures

-
Cognitive Measures

Pre

Intervention

Measures

Brain Age

Tetris

Post

Intervention

Measures

15 minutes, 5 sessions / week for 4 weeks

Nouchi et al. PLoS ONE 2012

Cognitive measures

General cognitive function


Mini
-
Mental State Examination (MMSE)

Executive function


Frontal Assessment Battery (FAB)


Trail Making Test (TMT), Random Number Generation (RNG)

Attention


Digit Cancellation task (D
-
CAT)

Working memory


Digit Span Backward (DS
-
B)

Processing speed


Digit Symbol Coding (DSC), Symbol Search (SS)

We used the statistical threshold (
p

< .01) for analyzing these cognitive measures and behavioral data.

Results: Behavior data

Training days, game performances

The change of game performance

in Tetris Group

The change of game performance

in Brain Age Group

Calculation 20

Calculation 100

Read Aloud

p
< .01

p
< .01

p
< .01

p
< .01

Results: Cognitive measures

General cognitive function, Executive function

General cognitive function

Executive function

Executive function

Executive function

p
< .01

p
< .01

p
< .01

p
< .01

p
< .01

p
< .01

Scores

Max

=

30

Number

Time (seconds)

Scores

Max

=

18

Trail Making Test

Random Number Generation

Results: Cognitive measures

Attention, Working Memory, Processing Speed

Attention

Working Memory

Processing Speed

Processing Speed

p
<.01

p
<.01

p
< .01

p
< .01

Number

Number

Number

Number

Digit Cancellation task

Digit Symbol Coding

Symbol Search

Digit Span Backward