Journal of Neuroscience Nursing:
Then & Now
Mental Stimulation, Neural Plasticity, and Aging: Directions for Nursing Research and Practice
Vance, David E.; Webb, Nicole M.; Marceaux, Janice C.; Viamonte, Sarah M.; Foote, Anne W.; Ball, Karlene K.
Questions or comments about this article may be directed to David E. Vance, PhD MGS, at firstname.lastname@example.org. He is an assistant professor at the School of Nursing at the University of Alabama‐Birmingham.
Nicole M. Webb, MA, is a doctoral candidate in the department of psychology at the University of Alabama‐Birmingham.
Janice C. Marceaux, MA, is a doctoral candidate in the department of psychology at the University of Alabama‐Birmingham.
Sarah M. Viamonte, MA, is a doctoral candidate at the Edward R. Roybal Center for Translational Research in Aging and Mobility at the University of Alabama‐Birmingham.
Anne W. Foote, DSN CRNP, is an associate professor at the School of Nursing at the University of Alabama‐Birmingham.
Karlene K. Ball, PhD, is a professor and director at the Edward R. Roybal Center for Translational Research in Aging and Mobility at the University of Alabama‐Birmingham.
An unprecedented increase in the number of older adults and consequent age‐related cognitive declines may negatively contribute to an already overwhelmed healthcare system. Many older adults report cognitive changes and express interest in methods to maintain cognitive functioning. Mental stimulation that consists of cognitively challenging activities is a means to facilitate neural plasticity, which can increase cognitive reserve and result in maintained or improved cognitive functioning. In addition, compensatory activities may provide mental stimulation that can improve cognitive functioning and increase cognitive reserve. Several mental stimulation (e.g., education, cognitive remediation therapy) and mental compensation (e.g., spaced retrieval method, method of loci) strategies are described in this article. Because nurses have a significant amount of direct contact with older adults, these strategies have important implications for nursing practice and research.
In 2006, there were approximately 500 million people age 65 and older worldwide. This number is expected to increase to 1 billion within 25 years (National Institute on Aging, 2007). In the United States alone, the number of individuals over 65 years of age is expected to double within the next 25 years to approximately 72 million, or 1 out of every 5 people (National Institute on Aging, 2006). Although increased longevity is in many ways to be celebrated, the exponential growth of the older population creates many challenges on an individual and global basis.
Primary areas of focus regarding older adults include independence, functionality, and quality of life. Each of these areas is compromised by cognitive impairment, which is particularly prevalent among the fastest‐growing segment of the population: the “oldest old,” those over the age of 85 (National Institute on Aging, 2006, 2007). Cognitive impairment can occur without dementia; both are on a continuum of mental functioning. Cognitive impairment is a loss of mental abilities that interferes with normal thinking, while dementia is a progressive loss of cognitive abilities resulting in a total loss of autonomy and ability to function. Between 11% and 27% of older adults exhibit some level of cognitive impairment without dementia (Busse, Bischkopf, Riedel‐Heller, & Angermeyer, 2003; DiCarlo et al., 2000; Graham et al., 1997; Hanninen et al., 1996; Schroder et al., 1998). Likewise, Cigolle, Langa, Kabeto, Tian, and Blaum (2007) found nearly 32% of individuals older than age 90 reported cognitive impairment. These estimates of cognitive impairment exclude adults who meet the criteria for a dementia diagnosis; consequently, the percentage of older adults with a cognitive condition is much higher. The oldest‐old population is at a much higher risk for cognitive impairment and dementia and the resulting complications and disabilities. For that reason, finding ways to improve or compensate for cognitive impairment remains a challenge for research and practice.
The term mental stimulation often is used to refer to any activity that requires cognitive processing. This article defines mental stimulation as the explicit use of activities that stimulate the connections between neurons (i.e., neural plasticity) to augment cognitive functioning. The use of mental stimulation to facilitate neural plasticity is vital to maximize cognitive functioning in older adults. Principles of mental stimulation and neural plasticity will be presented through evidence‐based studies that demonstrate their effectiveness in improving cognitive reserve and functioning. Methods to mentally stimulate the brain to increase, maintain, or compensate for such damage are posited. Such methods are highlighted in a flowchart for ease of interpretation and quick referencing. Implications for nursing practice are identified to help nurses provide mental stimulation to older adults who wish to improve or maintain their cognitive functioning. We conclude by providing suggestions for nursing research to further incorporate these psychological concepts into nursing practice.
Neural Plasticity and Cognitive Reserve
Mental stimulation requires explicit engagement in cognitive activities with the intent to stimulate connections between neurons; as a result, the concept is closely associated with neural plasticity. Developmental theories of mental stimulation and neural plasticity in humans typically conceptualize the process as initial exposure to novel stimuli, neuronal expansion, and establishment of new “connections” between neurons (i.e., synapses). As experiences are repeated, neural pathways and connections are strengthened (i.e., learning takes place). This process probably is best summarized by the familiar phrase “Neurons that fire together wire together” (Löwell & Singer, 1992, p. 211). However, if experiences are not particularly salient or neuronal connections are not strengthened via repeated exposure, “synaptic pruning” occurs.
Diamond (1993) and other researchers further explored this concept using a rat model by systematically controlling for various components of environmental stimulation, including social interaction with other rats, exercise opportunities, and novel stimuli in the cage (e.g., toys, bridges, opportunities for exploration). This research avenue has revealed that rats exposed to more stimulating environments had increased thickness of the cerebral cortex, presumably as the result of greater and more complex neuronal pathways. Likewise, demanding mental functions in humans are presumed to require more complex neural circuitry and more dense and complex synaptic connections. Consistent with animal research, postmortem research by Arendt, Bruckner, Gertz, and Marcova (1998) noted the association between neuronal loss and premortem cognitive function in the absence of clinical dementia; in other words, neuronal loss and cognitive function are correlated even in patients who do not have dementia.
Both anatomical and neuroimaging research on neural plasticity (Stern et al., 2003; Whalley, Deary, Appleton, & Starr, 2004) have begun to clarify the construct of cognitive reserve. Cognitive reserve is believed to mediate the relationship between pathology and the onset of cognitive impairment (Stern, 2002). The importance of this hypothesis is that adults with greater cognitive reserve can sustain more neuronal loss or pathology before exhibiting signs of mild cognitive impairment or dementia. Consequently, if older adults engage in mentally stimulating activities, neural plasticity will be promoted, and, theoretically, their cognitive reserve will increase.
Successful Aging Through Cognitive Strategies
Figure 1 illustrates that successful aging requires sufficient cognitive ability to negotiate and enjoy one's environment. With age‐related cognitive declines, however, the ability to successfully age may be compromised, and mental stimulation and cognitive strategies are needed to maintain or compensate for such losses. In Figure 1, mental stimulation refers to methods that promote brain health through learning. Cognitive strategies are specific techniques that help people remember information; these techniques are useful when one is experiencing cognitive impairment. These mental stimulation and cognitive strategies can improve cognitive reserve, which supports cognition or can help compensate for loss of cognitive reserve. In Figure 1, cognitive reserve is represented as a dotted line to signify that it is somewhat malleable.
Baltes and Baltes (1990) proposed a model of successful aging developed from a theory of adaptive development and effective life management through selective optimization with compensation (SOC; Baltes & Carstensen, 2003; Baltes & Smith, 2003). The theory describes the life course as having changes in both resources and goals. As humans, our course begins with a focus on personal gain and growth early in adulthood, and, as we age, the focus shifts toward minimizing declines. The three components of SOC are selection, optimization, and compensation.
Selection is described as voluntary and loss‐based; it involves selecting or narrowing the range of domains (e.g., relationships, health, or personal identity) and specific goals (e.g., spending time with family, exercising regularly, or participating in cultural activities) to what is within our reach while sacrificing goals beyond our reach. For example, later in life when attention and memory may not be as keen as in young adulthood, the selection of cognitive tasks may be limited to daily living tasks such as self‐care and managing a home instead of more esoteric goals such as pursuing a degree or learning a foreign language. Daily living tasks may be chosen because maintaining independence often is of primary importance for many older people (Marsiske, Lang, Baltes, & Baltes, 1995).
Optimization refers to the resources that can be used to achieve goals to attain a higher level of functioning. For example, an older adult may use mnemonic strategies to learn and retain information so he or she can pursue meaningful activities that require memory demands, such as coursework. In this sense, the older adult is optimizing his or her existing memory ability to retain its best‐possible functioning.
Compensation refers to establishing or attaining new resources to counteract declines that threaten current levels of functioning. Older adults must optimize their independence or abilities by compensating in areas in which ability is lacking. An older adult with mild memory problems, for example, may devote memory resources to performing certain tasks, such as remembering to take medications. The adult may use mnemonic strategies such as pill dispensers and a watch alarm to facilitate medication adherence; these aids compensate for declining memory ability so he or she can reallocate attention to more worthwhile pursuits and interests. Such compensation strategies emphasize the role of adaptation in the process of successful aging, especially successful cognitive aging.
SOC is a developmental construct that explains the variety of common behaviors that serve as situation‐specific processes used to obtain the most advantageous result through adaptation. This model helps to identify the behavioral, motivational, and cognitive processes involved in successful aging. As cognitive abilities become less efficient, adaptation strategies suggested through SOC to maintain and adjust to limitations are necessary for successful aging. Although minimizing physical disabilities and maintaining social networks are important components of successful aging (Rowe & Kahn, 1997), intact cognitive functioning also is a critical component of successful aging that may work to maintain capacity in other areas important for overall successful aging (Vance, Ball, Moore, & Benz, 2007).
Using successful aging and cognitive reserve as a guide to increase cognitive quality of life, Table 1 and Figure 1 represent a general taxonomy through which maintaining or compensating for cognitive loss can facilitate successful aging. Although these strategies are by no means exhaustive, they demonstrate how mental stimulation may be used to expand cognitive reserve or compensate when cognitive reserve declines.
Maintaining or Improving Cognitive Abilities
Successful cognitive aging entails either improving or maintaining cognitive reserve to support overall cognition. Vance and Crowe (2006) proposed a model of neural plasticity and cognitive reserve in older adults that posited several steps to maintain or limit age‐related loss, including a healthy lifestyle and engaging in mentally stimulating activities such as educational pursuits, novel experiences, and participating in cognitive remediation.
A healthy lifestyle likely provides the physiological foundation upon which neuronal health is supported, which in turn helps maintain or improve cognitive functioning. Avoiding conditions such as hypertension, pulmonary diseases, and diabetes has protective effects against subtle cognitive decline (Anstey & Low, 2004; Emery, Schein, Hauck, & MacIntyre, 1998). Also, higher levels of antioxidants have been associated with better cognitive functioning in older adults (Solfrizzi, Panza, & Capurso, 2003). Furthermore, several studies have shown the positive benefits of physical exercise on cognitive ability in older adults (Kramer, Hahn, & McAuley, 2000; Vance, Wadley, Ball, Roenker, & Rizzo, 2005).
Beyond maintaining a healthy lifestyle, mental stimulation also has been shown to help maintain or improve cognitive functioning either through education, a lifestyle of novel experiences, or cognitive remediation. Education remains one of the most salient predictors of cognitive functioning in later life. Several studies indicate that those who acquire more formal education experience a lower rate of developing cognitive impairments and dementia in later life (Milan et al., 2004; Whalley et al., 2004). Based upon neurological principles, these findings suggest that as more neural connections are made while learning, cognitive reserve and resistance to age‐related changes increase. Likewise, those who pursue educational goals may be the same people who develop lifestyles of engaging novel experiences.
Emerging evidence demonstrates that individuals who engage in mentally stimulating activities across the life span have cognitive advantages over those who do not. In a national birth cohort, Richards, Hardy, and Wadsworth (2003) examined the association between cognitive ability and engaging in an active leisure life (e.g., playing musical instruments, bridge, chess). Controlling for education, gender, intellectual quotient at adolescence, recurrent illnesses, mental illness, and occupational social class, these researchers found that those who engaged in more physical activity and spare‐time activities at 36 years of age had better memory performance at 43 years of age. Likewise, Grant and Brody (2004) discovered that older adults who had experience as a current or former orchestra member were less likely to develop or had delayed onset of Alzheimer disease. Similar to Diamond's (1993) experiments on an enriched environment for rats, these findings suggest that enriched participation helps to generate cognitive reserve to insulate people against age‐related and pathological neurological decline.
Cognitive remediation therapy is another strategy through which cognitive ability within a certain domain of functioning (e.g., reasoning) can be maintained or improved. Cognitive remediation therapy typically incorporates carefully selected cognitive exercises designed to gradually improve cognitive ability. In the literature, cognitive remediation therapy has focused primarily on improving reasoning, memory, and speed‐of‐processing training (Vance, 2006; Vance, Ball, et al., 2007).
In the ACTIVE study, participants were randomly assigned to one of three cognitive remediation therapies: reasoning, memory, or speed‐of‐processing training. Training for the three therapies consisted of 10 1‐hour sessions in which participants engaged in activities that required the use of a specific cognitive ability while being provided feedback. For the reasoning training, 620 community‐dwelling older adults were taught to identify patterns in a logical serial pattern and translate this skill into everyday functioning. For the memory training, 627 community‐dwelling older adults were provided training techniques and then practiced learning details using narratives, lists of words, and text materials. For the speed‐of‐processing training, 637 community‐dwelling older adults worked to identify objects on a computer screen at increasingly faster presentation speeds; this therapy was designed to improve visual information processing speed. Results from this training showed that 74%, 26%, and 87% of the reasoning, memory, and speed‐of‐processing participants, respectively, exhibited reliable cognitive improvement in the domain for which they were trained (Ball et al., 2002).
Other studies investigating these training techniques also have found marked improvement in cognitive functioning after training (Floyd & Scogin, 1997; Vance, Dawson, et al., 2007). In fact, using magnetic resonance spectroscopy, one study found changes in hippocampal neurochemistry (i.e., increased creatine and choline signaling) after older adults participated in 5 weeks of focused memory training (Valenzuela et al., 2003). The hippocampus is the primary brain structure that encodes information and memories; this structure begins to shrink early in Alzheimer disease (Mace & Rabins, 1991). These studies show that cognitive ability and cognitive reserve are malleable, at least within certain individual parameters, and capable of improvement in older adults.
Compensating for Loss or Limitation of Cognitive Ability
When cognitive reserve decreases, it is necessary to compensate for such losses, as Baltes and Baltes (1990) suggested in the SOC model. A review of the psychological and cognitive aging literature provides a variety of compensation strategies that older adults can use to counter poor cognitive functioning, including declines in memory functioning. Table 1 and Figure 1 feature some of the better known strategies that are easy to apply, including method of loci, spaced retrieval, chunking, levels of processing, and external cues.
Method of loci is a paired associative strategy through which the learner links highly familiar places with information to be remembered. If an older adult wants to remember something like a phone number, for example, he or she can pair each number in sequence with a place with which he or she is familiar, such as a house, a neighborhood, or a walking trail (Fig 2). At the beginning of a walking trail, for example, an older adult could imagine a large number 9 standing on the path. Then, at a baseball field a few yards down the trail, he or she could envision a large number 3 standing on the grass. Further down the trail at the corner with the big tree, the person could imagine a large number 4, and so forth. This technique is effective because it draws upon well‐rehearsed visual information from one's personal history. The place or location must be highly salient for meaningful, associative learning to occur. Also, older adults must be capable of visualizing the environment in which items are to be paired in a sequence. This strategy remains a unique and, in some cases, an enjoyable strategy for learning new information (Solso, 1991).
Spaced retrieval is an easy‐to‐use technique through which an adult with a memory problem recalls a specific piece of information over progressively longer periods of time until it is firmly consolidated into his or her long‐term memory. Typically, the person starts out by first memorizing a piece of information, such as a phone number, and then recalling it immediately. The person is then instructed to recall the number after 30 seconds, 1 minute, 2 minutes, 4 minutes, 8 minutes, and 16 minutes (16 minutes is considered the amount of time needed for long‐term memory consolidation). If the older adult is unable to correctly recall the information at any point, it is reviewed once more, and then he or she is required to recall the information at the previous time duration at which the information was correctly recalled (Morrow & Fridriksson, 2006). Spaced retrieval has been shown to produce startling results in cognitively intact older adults as well as in adults aging with HIV, stroke, and dementia. Vance and Farr (2007) offer a worksheet and more details about this cognitive strategy.
Chunking is a simple technique whereby information is broken down into smaller and easier‐to‐remember parts or chunks. Again using the example of remembering a phone number, a local phone number is broken into two sections: the first three numbers and the last four numbers. It is easier to remember these two sections of the phone number separately and then put them together instead of trying to remember the entire seven‐number sequence. This strategy works effectively because it generally is easier to recall fewer items than many items (Gleitman, 1995). As a result, this strategy is useful when working memory is compromised by advanced age, disease, or both.
Levels of processing is a strategy through which information is remembered by thinking about it at a deeper level. More effort and energy are expended in thinking about information at this level, so neural connections are considered stronger, which helps a person retain information (Craik & Lockhart, 1972; Wood, 1983). Often this method works when the person pairs the information with bits of information already known so that new connections can be formed. A person can learn the phone number 325‐1787, for example, by processing the numbers at a deeper level. First, 325 (March 25) can be a friend's birthday, or history enthusiasts may know that 1787 was the year in which Western civilization switched to the Gregorian calendar. The phone number then becomes a combination of a birth date and the start of the Gregorian calendar. Tulving and Madigan (1970) refer to this as “elaboration coding.”
Use of external cues probably is the simplest and most straightforward strategy for retaining information. Calendars, desk organizers, notebooks, watches, cell phones, and a variety of other external aids are available. External cues work only if the person remembers to use them consistently, however. And some aids may be difficult to use, especially if they require knowledge of technology. The cognitive strategies discussed earlier, however, may prove most beneficial because information can be recalled if external cues are absent.
Combining cognitive strategies also is helpful. In a group of older adults with HIV and memory problems, Neundorfer and colleagues (2004) used both external cues and spaced retrieval strategies to help subjects perform certain goals such as remembering to go to doctors' appointments and taking medications. Researchers found that 90% of participants mastered their goals after four or five sessions. Likewise, Lekeu, Wojtasik, Van der Linden, and Salmon (2002) taught adults with early‐stage Alzheimer disease to use a mobile phone. Simple, easy‐to‐read instructions were printed on the back of the phones; the researchers successfully used spaced retrieval to help subjects remember to use the instructions.
Spaced retrieval also can be paired with chunking. For example, in remembering a phone number, spaced retrieval can be used to learn the first three numbers (i.e., the first chunk of the phone number), then to learn the last four numbers (i.e., the last chunk of the phone number), and then to learn to put both chunks together. Cognitive strategies can be combined in endless ways to work for adults compensating for memory problems.
Implications for Nursing Research and Practice
Nurses and nurse researchers are in key positions to educate, detect and refer, intervene, and create new strategies for those at risk of developing cognitive impairment. As health educators, nurses can talk to patients, family members, and communities about ways to promote successful cognitive aging. Preventive health strategies to recommend include avoiding substance use, exercising, and eating well (Vance & Crowe, 2006; Vance et al., 2005), as well as staying cognitively viable through educational pursuits, mentally stimulating activities, and cognitive remediation therapy. A point to stress regarding mental stimulation is that such activities must be novel and challenging. Novelty encourages neural plasticity, which results in maintaining or improving cognitive reserve. The mental stimulation must make participants' “brains sweat”—a corollary to physical exercise. Nurses should encourage older adults to use a variety of cognitive strategies; relying on the same type of stimulation, such as crossword puzzles, is not mentally stimulating if this is the only type of cognitive exercise in which one engages.
Gerontological or adult nurses frequently see older adults in the primary care setting. To detect and refer patients who may be at risk for cognitive impairment, nurses need to assess patients for telltale signs of cognitive decline at each visit. Patients who forget their physician appointments or who are socially isolated and lack mental stimulation and those who comment about mental problems are at risk. Nurses can inquire about signs of decline and help initiate referrals to psychologists, psychiatrists, and neurologists. Vance, Farr, and Struzick (2008) designed a flowchart to educate nurses on how to detect and refer adults who are experiencing cognitive problems.
Nurses also can introduce simple approaches that can help patients compensate for cognitive decline. As suggested in Table 1 and Figure 1, spaced retrieval, external cues, and chunking are just a few of the strategies that nurses can teach to patients. These strategies can be combined and implemented on an individualized basis to make them more accessible and user‐friendly for older patients. Such techniques can help older adults compensate for age‐related cognitive losses, which can improve quality of life.
Finally, nurses can create and examine new strategies to improve or maintain cognitive functioning and compensate for cognitive impairment. New cognitive remediation strategies are in the works. Noice, Noice, and Staines (2004) developed a cognitive remediation therapy in which older participants were engaged in nine 90‐minute drama sessions during which they were taught how to act, memorize a script, respond emotionally, and spatially orient on stage. This training allowed for participation in the full continuum of the physical, cognitive, and affective components of a drama. Older adults who took part in this training experienced significant improvement on a number of cognitive domains compared to older adults assigned to visual art training and a no‐treatment control group. Other training paradigms, especially those that do not require a professional trainer, are needed to facilitate cognitive remediation therapy. Computer gaming as a strategy to improve cognitive functioning represents a novel area for exploration (Goldstein et al., 1997; Riesenhuber, 2004).
Mental stimulation, if it is to encourage neural plasticity, must be an activity that requires a significant amount of effort. Effective mentally stimulating activities should be novel, cognitively challenging, and preferably enjoyable so that older adults remain engaged. In those activities, the brain is forced to make new neural connections that increase cognitive reserve and improve cognitive functioning. Cognitive reserve and cognitive functioning decline significantly in some older adults, but compensatory activities can be employed to augment cognitive functioning. The dynamic action of learning and engaging in such compensatory activities has the potential to facilitate neural plasticity and improve cognitive functioning in older adults.
As primary care providers, nurses must assess older adult patients at each visit by inquiring about cognitive functioning; observing difficulty with attention, memory, and concentration; and making suggestions and referrals as needed. Conventional wisdom purports that doing the same activity repeatedly maintains cognitive function, but nurses must educate patients and their family members on the findings demonstrating that novel and cognitively challenging activities are needed to encourage the best possible cognitive functioning. Nurses also can suggest new ways to compensate for declines in cognitive functioning and help to implement these strategies. As the population continues to age, nurses and nurse researchers will undoubtedly increase their collaboration with psychologists, neurologists, and occupational therapists to develop new ways to encourage neural plasticity, improve cognitive functioning, and compensate for cognitive losses in older patients.
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