See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/307940176

Strategy-Based Cognitive Training for Improving Executive Functions in Older

Adults: a Systematic Review

Article  in  Neuropsychology Review · September 2016

DOI: 10.1007/s11065-016-9329-x

CITATIONS READS

10 533

4 authors:

Loren Mowszowski Amit Lampit

The University of Sydney University of Melbourne
40 PUBLICATIONS   660 CITATIONS    43 PUBLICATIONS   625 CITATIONS   

SEE PROFILE SEE PROFILE

Courtney C Walton Sharon L Naismith

The University of Queensland The University of Sydney
41 PUBLICATIONS   442 CITATIONS    285 PUBLICATIONS   7,305 CITATIONS   

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

HEROs 2.0 View project

All content following this page was uploaded by Amit Lampit on 24 June 2018.

The user has requested enhancement of the downloaded file.

Neuropsychol Rev (2016) 26:252–270
DOI 10.1007/s11065-016-9329-x

REVIEW

Strategy-Based Cognitive Training for Improving Executive

Functions in Older Adults: a Systematic Review
L. Mowszowski 1,2,3 & A. Lampit 2,3,4 & C. C. Walton 1,3 & S. L. Naismith 1,2,3,5

Received: 9 February 2016 / Accepted: 18 August 2016 / Published online: 9 September 2016
# Springer Science+Business Media New York 2016

Abstract Given projected increases in dementia prevalence,
emphasising earlier stages of cognitive impairment in older
adults enables targeted early intervention strategies. Strategy-
based cognitive training (SCT) is a remedial approach involv-
ing guidance and practice in compensatory techniques to im-
prove cognition, including memory and attention. It may also
be effective for improving executive functions (EF) integral to
everyday tasks. This review systematically evaluates SCT ef-
fects on EF in older adults without dementia. Following
PRISMA guidelines, we reviewed eligible trials according to
pre-defined criteria, differentiating SCT from other cognitive
interventions and stipulating total EF-focused intervention
time, study design and target population (healthy older adults
or mild cognitive decline). We then evaluated trials according to
design, methodological quality and outcomes. Unfortunately,
with too few studies in mild cognitive impairment, we
refocused our review only on healthy older adults. Thirteen
studies with 4120 participants in total were included, pri-
marily targeting inductive reasoning. Despite heteroge-
neous study designs and SCT programs, 11/13 trials re-
ported significant EF improvements, generally of
* L. Mowszowski
loren.mowszowski@sydney.edu.au
1
Healthy Brain Ageing Program, University of Sydney,
Sydney, Australia
2
School of Psychology, University of Sydney, Sydney, Australia
3
Brain and Mind Centre, University of Sydney, Sydney, Australia
4
Regenerative Neuroscience Group, University of Sydney,
Sydney, Australia
5
Charles Perkins Centre, University of Sydney, Sydney, Australia
moderate effect size (Hedges’ g > 0.3). Four studies re-
ported sustained benefits from one month to 10 years.
There was some evidence of far transfer. We conclude that
there is promising evidence for SCT as a targeted inter-
vention for EF in healthy older adults and preliminary
evidence for maintaining effects over time. Fewer trials
have investigated far transfer (e.g. improved everyday
functioning) or capacity to delay/prevent dementia, which
are most relevant to clinical utility. Limitations include
the inability to calculate effect sizes for four studies and
absence of statistical meta-analysis.
Keywords Cognitive training . Strategy training . Executive
functions . Older adults . Mild cognitive impairment
Introduction
Dementia is associated with enormous financial, healthcare and
community costs. These are projected to escalate with an
expanding ageing population and associated increases in de-
mentia incidence. Indeed, global dementia prevalence is expect-
ed to rise to >115 million people by 2050 (Prince et al. 2013). In
light of these projections, over the last decade, substantial ad-
vances have occurred in understanding the pathophysiological
progression of dementia. It is now well recognised that the
trajectory of cognitive decline in ageing ranges from normal
age-related change through to asymptomatic ‘preclinical’ dis-
ease (associated with research-based biomarkers of neuropa-
thology), subjective cognitive decline, Mild Cognitive
Impairment (MCI) and finally dementia (see Dubois et al.
2014; Sperling et al. 2011). Importantly, increased appreciation
for the significance of these earlier stages of cognitive decline
presents an opportunity to validate early intervention strategies,
to ultimately prevent or slow the progression of cognitive
Neuropsychol Rev (2016) 26:252–270
decline (particularly when this leads to dementia) (Mowszowski
et al. 2010; Naismith et al. 2009).
Whilst currently there are no available drugs to treat neu-
rodegenerative disease, non-pharmacological or behavioural
early intervention strategies targeting cognition and/or psy-
chosocial functions are appealing, as they have no known
side-effects, they require active engagement, and they foster
empowerment for older adults. Of significance, such strategies
enable individuals to adapt to and/or compensate for cognitive
changes and thus support functional independence. Cognitive
Training (CT) is one such behavioural intervention, referring
to programs which remediate cognition by providing
theoretically-driven strategies and/or skills, usually involving
guided or supervised practice on tasks reflecting a variety of
cognitive domains (Mowszowski et al. 2010). In terms of
efficacy in older adults, some Cochrane reviews published
within the last five years have been inconclusive (e.g. Bahar-
Fuchs et al. 2013; Martin et al. 2011). However, this has po-
tentially related to the broad nature of these reviews, which
have tended to include vastly heterogeneous studies with re-
spect to severity of cognitive impairment, CT program meth-
odology (often spanning both CT as well as broader cognitive
rehabilitation techniques) and study design. However, more
recent reviews have tended to focus on specific cohorts or
CT methodologies and therefore perhaps provide a more fo-
cused evaluation. Such distinctions are important, since under
the broad umbrella of CT, both computer-based and strategy-
based techniques are available.
Anecdotally, it would appear that CT is most commonly
perceived to be that based on repetitive, drill-and-practice
computer-based exercises, which take a ‘restorative’ ap-
proach. Such techniques aim to improve functioning in spe-
cific cognitive domains and thus aim to recover impaired
skills (Sitzer et al. 2006). The popularity of this field may be
partly attributed to the interest of consumers in several
commercialised products such as the Lumosity or BrainHQ
websites, hand-held computer games such as Nintendo’s
Brain Trainer and apps such as Fit Brains. However, there
are in fact a wide variety of computerised CT programs avail-
able and empiric research surrounding these have evaluated
their efficacy in various healthy and clinical groups. Indeed,
several recent reviews and meta-analyses have focused on the
efficacy of computer-based CT and have demonstrated gener-
ally positive effects for improving episodic memory, attention,
working memory, processing speed, visuospatial skills and
aspects of executive functioning in healthy older adults and
those with MCI (for examples, see Gates and Valenzuela
2010; Kueider et al. 2012; Lampit et al. 2014). These reviews
have in general posited that when delivered as part of con-
trolled research studies, computer-based CT may be effica-
cious as a multi-modal, engaging, incrementally challenging
and widely accessible intervention strategy. However, Lampit
et al. (2014) also noted some caveats in that computer-based
253
CT appears to be less effective when completed by individuals
at home using online programs, compared to a group- or cen-
tre-based, facilitated approach; additionally, benefits are opti-
mal at a ‘dosage’ of up to three sessions per week for at least
30 min at a time. Given these parameters, a more structured,
facilitated or supervised program of computerised CT appears
to be favourable to ensure adherence.
The other more longstanding approach to CT is strategy-
based CT (SCT). In our experience, this technique inherently
involves a heavier emphasis on guided facilitation and super-
vision (see Diamond et al. 2015; Mowszowski et al. 2010). It
focuses more heavily on ‘compensatory’ rather than restor-
ative methods, aiming to bypass deficient cognitive processes
and teach alternative approaches to achieving goals (Sitzer
et al. 2006). SCT typically encourages both internal tech-
niques (e.g. visual imagery, categorisation, structured heuris-
tics for problem-solving or goal directed behaviour, etc.) and
external techniques (e.g. using calendars, checklists or envi-
ronmental cues) to strengthen relevant cognitive functions and
adapt to areas of weakness or decline by recruiting additional
cognitive networks. SCT therefore involves active teaching,
modelling and guidance in adaptive techniques by a facilitator,
and we assert that it should be interactive, engaging and con-
textually relevant to practical activities (e.g. remembering ap-
pointments, conversational details or names/faces; carrying
out complex tasks such as travel arrangements, medication
management or bill paying). Recent systematic reviews and
meta-analyses in healthy older adults and MCI have generally
shown consistent and significant improvements particularly in
the domain of memory following SCT, although benefits for
attention, processing speed and working memory have also
been demonstrated (see Gates et al. 2011; Jean et al. 2010;
Reijnders et al. 2013; Valenzuela and Sachdev 2009). There is
also some evidence for positive SCT-related effects on psy-
chosocial functioning, such as subjective memory, quality of
life, depression and even sleep quality (for example, see
Diamond et al. 2015; Kinsella et al. 2009; Kurz et al. 2009;
Naismith et al. 2011).
In addition to the abovementioned studies and reviews,
recent critical appraisals by Gates and Sachdev (2015);
Lampit et al. (2015) and indeed our own group (Walton
et al. 2014) have also supported reports from individual stud-
ies regarding the sustainability of effects over time, as well as
the ability of computer-based and SCT effects to transfer to
untrained cognitive domains (although all have highlighted
the need to include further measures of real-world functioning
such as activities of daily living). Importantly, one consistent
finding across studies is the excellent tolerance and lack of
negative effects of SCT (Bahar-Fuchs et al. 2013).
As such, we propose that the focus should now shift to
translating research findings to clinical (as opposed to re-
search) contexts, where improving a person’s ‘real-world’
functioning is usually a major goal of treatment. In this regard,
254
research has shown that the cognitive domain of executive
functioning (EF) is most important for effective and efficient
engagement in daily life (see Royall et al. 2007). EF refers to
multidimensional cognitive processes including working
memory, planning, reasoning, problem-solving, judgement,
self-monitoring, maintaining goal-directed or purposeful be-
haviour, etc. and these abilities are particularly important for
effective functioning in daily life, especially in novel, complex
or demanding situations (Strauss et al. 2006). The relevance of
EF for real-world functioning has frequently been demonstrat-
ed by the integral relationship between instrumental activities
of daily living (IADLs; e.g. financial management, driving,
work-related tasks etc.) and many components of EF includ-
ing inhibitory control, planning, attention regulation (e.g. at-
tentional switching) and working memory (Jefferson et al.
2006; Vaughan and Giovanello 2010). Additionally, across
the ageing, neuropsychiatric and neurodegenerative disease
literature, it is clear that poor EF significantly and robustly
predicts IADL impairment (Aretouli and Brandt 2010;
Duara et al. 2011; Grigsby et al. 1998). Indeed, such relation-
ships are evident even in older adults with ‘subclinical’ cog-
nitive impairment (Royall et al. 2000).
Despite these well-established links with functional capac-
ity, there is a relative paucity in the number of CT studies
addressing EF when compared to those targeting other do-
mains, such as memory. This is apparent in both CT content
as well as in the choice of primary outcome measures
(Reijnders et al. 2013). Where some CT studies have targeted
EF (see reviews by Kueider et al. 2012; Lampit et al. 2014),
this has typically either occurred within a multi-domain or
multi-faceted CT program (e.g. Diamond et al. 2015;
Naismith et al. 2011), or utilising computer-based methods
focusing on very discrete aspects, such as n-back tasks to train
working memory (e.g. Jaeggi et al. 2008) or rapid serial pre-
sentation tasks to train attentional switching (e.g. Brom and
Kliegel 2014), but without facilitated coaching or guidance in
adaptive strategies.
However, it may be that process-based higher-level EFs such
as planning, inhibition, attentional switching, problem-solving
and goal-directed behaviour are particularly amenable to simi-
larly process-based SCT, involving guided practice alongside
teaching of adaptive techniques, such as problem-solving train-
ing, goal management training or reasoning skills training.
Certainly it is conceivable that such techniques could be easily
transferred or generalised to everyday situations and functional
activities (Chapman and Mudar 2014); indeed, they have been
recommended in the Practice Guidelines for treatment of defi-
cits in EF in traumatic brain injury (Cicerone et al. 2011).
However, as noted above, in healthy older adults and those with
MCI, those SCT studies that have incorporated EF techniques
have tended to do so as part of a broader program, and EF and
functional outcomes have been secondary or tertiary. Moreover,
to our knowledge these findings have not been systematically
Neuropsychol Rev (2016) 26:252–270
synthesised or summarised, thus potentially limiting apprecia-
tion for potential benefits or application among clinicians and
researchers alike. The exception to this is the expanding litera-
ture on working memory computer-based CT, which has been
reviewed elsewhere (e.g., see Spencer-Smith and Klingberg
2015) – in any case, this refers to computer-based rather than
SCT, and relates to just one discrete aspect of EF.
As such, we aimed to conduct a systematic review of the
CT literature to determine the nature, quality and extent of the
evidence base for interactive, facilitated SCT for specifically
improving EF in healthy older adults and/or those with MCI.
From this evidence base, we aimed to determine whether there
is any evidence that such techniques are effective in improv-
ing EFs and other ‘markers’ of EFs, such as functional
outcomes.
Methods
This systematic review adheres to the Preferred Reporting
Items for Systematic Reviews and Meta-Analyses
(PRISMA; Moher et al. 2009).
Eligibility Criteria
Participants
Eligible studies included older adults (i.e. mean participant
age > 50 years), without dementia or neurological/
neuropsychiatric illness, i.e. cognitively intact (i.e. healthy
older adults) or those with MCI. Studies that preferentially
recruited people with dementia (of any aetiology) or a specific
neuropsychiatric population (e.g., stroke) or where more than
50 % of the sample was recorded to have any such condition at
baseline, were excluded. Studies that included both younger
and older adults in separate groups were considered eligible,
but only the older adult data was included in the review.
Interventions
Eligible studies were those that provided SCT, defined as ex-
plicit instruction and/or guided practice provided in group
format or at home, specifically targeting EF (including plan-
ning, reasoning, cognitive flexibility, problem-solving, phone-
mic verbal fluency, inhibition or related constructs. As noted
previously, working memory training was excluded in light of
existing systematic reviews targeting this sub-domain).
Interventions that included training in EF alongside other cog-
nitive domains were included only where the EF component
was provided over at least 50 % of the total intervention time.
Computerised interventions were included only where this
served as a platform for strategy instruction or practice and
where EF was targeted.
Neuropsychol Rev (2016) 26:252–270
Control Conditions
Eligible studies included only those with a designated control
condition, comprising either a passive (i.e., no-contact or
waitlist) or active control arm. Eligible active control condi-
tions included interventions solely targeting other cognitive
domains or those involving cognitive stimulation, general ac-
tivities (e.g. watching educational videos) or treatment-
as-usual. Multi-modal interventions such as those in-
volving physical exercise as a control condition were consid-
ered eligible only where the CT group received comparable
physical exercise intervention (thereby isolating CT as the
active ingredient). Studies comparing older adults solely to
younger adults or to clinical groups (e.g., studies comparing
healthy people to those with MCI or comparing MCI with
dementia) but without a suitable control intervention were
excluded.
Outcomes
Outcome measures included pre- and post-intervention scores
on at least one objective test of EF as defined above (i.e.
including planning, reasoning, cognitive flexibility, problem-
solving, phonemic verbal fluency, response inhibition or re-
lated constructs) and/or functional measures of far transfer
(e.g. IADLs, driving, finance management) as long as they
were measured in both groups. Measures of other cognitive
domains or physiological outcomes (e.g., balance, gait, neu-
roimaging) were excluded from this review.
Types of Studies
Eligible studies included randomised or non-randomised trials
involving at least two groups of eligible participants, or parts
of such trials (where appropriate data was available).
Observational studies, pre-post designs without control
groups or other non-controlled designs were excluded.
Search Strategy and Study Selection
One reviewer (AL) searched Medline, PsycINFO, CENTRAL
and CINAHL using the search strategy (‘cognitive training’ or
‘brain training’ or ‘neurocognitive training’ or ‘reasoning
training’ or ‘mental training’ or ‘strategy training’ or ‘cogni-
tive stimulation’ or ‘cognitive intervention’ or ‘cognitive stim-
ulation’ or ‘cognitive remediation’ or ‘cognitive rehabilita-
tion’ or ‘cognitive practice’) AND (‘aged’ or ‘older adults’
or ‘elder$’ or ‘senior$’ or ‘aging’ or ‘ageing’ or ‘geriatric’ or
‘older adults’; ‘mild cognitive impairment’ or ‘mci’) AND
(‘executive function$’ or ‘reasoning’ or ‘planning’ or ‘cogni-
tive flexibility’ or ‘problem-solving’). Databases were
searched from inception to 30 November 2015 and no limits
were applied, including on publication language.
255
The title and abstract of identified papers were initially
screened by AL. The full-text versions of remaining papers
were assessed against the inclusion criteria by two indepen-
dent reviewers (AL and LM). Where necessary to enable
judgement of eligibility, study authors were contacted by
LM for further detail, e.g. requesting full-text papers, regard-
ing availability of EF outcome data or to clarify the extent of
guided instruction/facilitation provided during CT sessions.
Additionally, reference lists of the retrieved studies were ex-
amined and studies known to LM and AL were also identified
and assessed for inclusion.
Data Collection and Analysis
In order to describe and evaluate this body of research, study
characteristics (e.g. sample demographics, format of the CT
and control interventions, outcome measures) were extracted
by LM and key outcome data were extracted by CCW, using
templates prepared by LM and AL. Where a study included
multiple intervention conditions, only data relating to the
strategy-based intervention targeting EF was included for the
purposes of this review. Outcome data preferably included
pre- and post-intervention means and standard deviations;
however in the absence of such data, other test statistics such
effect sizes with 95 % confidence interval (CI) were accepted
if available. Analysis included calculation of standardized
mean difference (calculated as Hedges’ g with 95 % CI) of
change from baseline to each follow-up. Hedges’ g (Hedges
1981) is an estimation of standardized mean difference with a
correction for small sample sizes. Hedges’ g values of <0.30
were considered small, 0.30–0.60 were considered moderate,
and >0.60 were considered large effect sizes. We did not plan
to pool results into a meta-analysis here as we considered our
range of studies too broad – that is, we included both healthy
older adults and those with MCI and we accepted several sub-
domains of EF as targets for CT. Given the novelty of this
systematic review, we considered a broad approach to be ap-
propriate. However, calculated effect sizes were plotted
against their standard error and formally assessed using
Egger’s Test of the Intercepts in order to examine small study
effect (publication bias) across studies (Sterne et al. 2011).
Methodological Quality
Individual studies were assessed for quality using the PEDro
scale, developed by the Physiotherapy Evidence Database and
utilised previously in other reviews of cognitive intervention
(e.g. Lampit et al. 2014; Leung et al. 2015). This scale in-
cludes 11 items designed to assess the methodological quality
and reporting of clinical trials and has been shown to be reli-
able for rating non-pharmacological intervention trials (Maher
et al. 2003). We abbreviated the PEDro scale for the purpose
of this review by omitting items #5 (blinding of participants)
256
and #6 (blinding of therapists), as such blinding is impractical
in SCT studies. Thus, the total obtainable quality score was
9/9. Quality ratings were independently completed by LM and
CCW with consultation to reconcile any discrepancies, in-
cluding consultation with a Clinical Trials specialist where
necessary.
Results
Study Selection
Figure 1 illustrates the flow of studies during the selection
process. As illustrated, a total of 499 articles were identified
from the literature search once duplicates were removed and
this was supplemented by ten additional studies known to the
authors or identified on review of study reference lists. Of
these, 93 full-text articles were then independently reviewed
by AL and LM for eligibility, with 19 studies confirmed as
eligible for inclusion. As outlined in Fig. 1, 55 % of the ex-
cluded studies were omitted because the intervention did not
specifically target EF (i.e. <50 % of the total intervention
duration was devoted to EF; for example, Levine et al. 2007;
Rojas et al. 2013), or because the intervention, upon close
review, did not constitute SCT as per our definition (i.e. these
studies typically involved paper-and-pencil or computerised
repetitive exercises in reasoning, but without explicit guid-
ance, facilitation or teaching of adaptive approaches for in-
creased effectiveness or efficiency). We note that of the 19
eligible studies, four reported outcomes from the same trial
(Advanced Cognitive Training for Independent and Vital
Elderly, or ACTIVE; Ball et al. 2002; Ball et al. 2010;
Rebok et al. 2014; Willis et al. 2006); hence while all out-
comes will be considered in relation to intervention effects,
from a methodology and design perspective the four reports
will be considered as one trial. This reduces the total number
of eligible studies to 16.
The majority (n = 13) of these studies included healthy
older adults with no overt cognitive decline and no history
of neurological or neuropsychiatric illness. Only three studies
targeting older adults with some degree of cognitive decline
were identified (Boron et al. 2007; Moro et al. 2015; Williams
et al. 2014). Additionally, these three studies varied widely in
terms of design, sample size, setting, SCT program, and per-
haps most importantly, with respect to operationalizing ‘cog-
nitive impairment’. Only one of the three studies (Moro et al.
2015) stipulated the use of formal criteria to define MCI
(Petersen et al. 2009) and this trial employed a non-
randomised, cross-over design with 30 community dwelling
elders. The other two trials utilised broader definitions of
‘mild impairment’ or ‘decline’ which were not specifically
aligned with established criteria for MCI. For example,
Boron et al. (2007) carried out a non-randomised, controlled
Neuropsychol Rev (2016) 26:252–270
study sampling a mixed group of 335 apparently healthy el-
ders as well as ‘decliners’, identified as those from an existing
cohort who demonstrated >1 standard error of measurement
decline on cognitive tests over 14 years since initial
testing – however, the degree of decline and global
cognitive status were not provided, making it difficult
to characterise this subsample. The third study included
a mixed group of 89 participants living in one of 13
low-care hostel settings, either with cognitive concerns,
mild impairments in cognition (criteria unspecified), or
documented cognitive decline, but still with Bsufficient
cognitive abilities to benefit from the intervention^
(Williams et al. 2014, p.983). This was the only study of the
three to utilise a randomised design, although even so, partic-
ipants were randomised in clusters according to residential
facility rather than individually.
After lengthy consideration, in light of a) the paucity of
studies identified as targeting older adults with MCI; and b)
the vast differences in operationalization of ‘mild cog-
nitive impairment’ with only one study utilising
established or even well-defined criteria, it was decided
that there is currently insufficient literature satisfying
our specified inclusion criteria to warrant a useful or
informative evaluation of SCT for EF within this popu-
lation. As such, these three studies will no longer be
considered within this review but will rather serve to empha-
sise the need for further research in this subgroup. The follow-
ing evaluation therefore refers only to the 13 studies focusing
on healthy older adults.
Characteristics of Included Studies
Design and Sample Size
Characteristics of each included study are detailed in Table 1.
As mentioned above, all 13 studies included healthy older
adults with no overt cognitive decline and no history of neu-
rological or neuropsychiatric illness. Of these, 11 were
randomised controlled trials (RCTs) and two were quasi-
randomised whereby couples or small groups were allo-
cated together if requested and the remainder were
randomised (Klauer 1992), or only those participants
who committed to attend all sessions were randomised
while the remainder were allocated to the control con-
dition (Hasselhorn et al. 1995). Across the studies, sam-
ple size varied considerably, ranging from the smallest
at 19 participants (Dawson et al. 2014) to the largest at
2832 participants (ACTIVE; Ball et al. 2002). Average sample
size was 316.9 participants, although this is perhaps mislead-
ing as three studies included ≥270 participants (Ball et al.
2002; Cheng et al. 2012; Stine-Morrow et al. 2014) whilst
the other ten studies reported data from fewer than 100 partic-
ipants (median sample size =69).
Neuropsychol Rev (2016) 26:252–270
Fig. 1 Summary of study
Identificcation
identification and selection
process 623 records identified through
database searching
509 records after duplicates removed
Screening
Eligibility
Included
16 healthy older adult studies
included in qualitative synthesis
Sample Demographics
Sample demographics were broadly comparable across all 13
studies. All recruited volunteers living independently in the
community and all but one recruited participants from urban
areas; the remaining study recruited rural-dwelling partici-
pants (Blieszner et al. 1981). Most of the studies recruited
through advertising via local community or seniors’ groups,
newspapers and flyers, while one trial utilised participants
sourced from an existing research centre database (Dawson
et al. 2014) and one study did not specify their recruitment
strategy (Chapman et al. 2015). Five studies were conducted
in the USA (Ball et al. 2002; Blieszner et al. 1981; Margrett
and Willis 2006; Stine-Morrow et al. 2014; Chapman et al.
2015), three in Germany (Baltes et al. 1989; Hasselhorn et al.
1995; Klauer 1992), two in Spain (Calero and Garcia-Berben
1997; Fernandez-Ballesteros and Calero 1995) and one each
257
10 additional records identified
through other sources
509 records screened 416 records excluded
93 full-text articles
assessed for eligibility
74 full-text articles excluded:
Not strategy-based training (n=21)
Executive functioning component <50% total intervention (n=20)
Not pre-post design (n=9)
Inappropriate control armor no control (n=8)
Multiple exclusionary issues (n=6)
No executive functioning outcome measure (n=4)
Data superseded by a later study included in the review (n=2)
Full text report unavailable for assessment (n=2; both dissertations)
Primarily dementia / neuropsychiatric sample (n=1)
Authors did not provide additional detail when requested, unable to
assess eligibility (n=1)
19 studies included in
qualitative synthesis
3 ‘mild cognitive impairment’
studies removed from review
in Canada (Dawson et al. 2014), China (Cheng et al. 2012)
and the Netherlands (van Hooren et al. 2007). In terms of
demographics, one study (Blieszner et al. 1981) did not spec-
ify the gender breakdown of the sample; however the remain-
der were more commonly female (total mean = 69.4 % fe-
male; SD = 16.3). Mean age across the studies was 70.0 years
(SD = 3.7; range = 62.8–85.0). The average level of partici-
pant education tended to be higher among studies conducted
in the USA and Canada (mean = 14.2 years; SD = 2.2) com-
pared to those conducted in Europe or China (mean = 7.9 years,
SD = 3.3), although one Spanish study specifically targeted
older adults with low education (<4 years; Fernandez-
Ballesteros and Calero 1995), citing this as a common occur-
rence in the older adult Spanish population for whom school-
ing was not compulsory at the time. One American study
(Chapman et al. 2015) and one German study (Klauer 1992)
did not provide information regarding education. Somewhat
258
surprisingly, less than half of the studies provided an estima-
tion of global cognitive functioning at baseline. Three studies
(Ball et al. 2002; Cheng et al. 2012; van Hooren et al. 2007)
provided a Mini-Mental State Examination (MMSE) score
(mean = 27.7, SD = 0.9) and three (Chapman et al. 2015;
Dawson et al. 2014; Stine-Morrow et al. 2014) provided a
Montreal Cognitive Assessment (MOCA) score (mean = 27.3,
SD = 1.2), both averages falling within the accepted cut-offs
for normal functioning.
Control Conditions
All 13 studies included at least some form of control arm. As
shown in Table 1, seven studies utilised a passive control
condition with no contact between assessments (four of which
were waitlist-controlled, i.e. participants were offered the
treatment at a later point). The remaining six studies utilised
active control conditions, comprising psychoeducation and/or
non-specific cognitively stimulating activities (e.g. crossword
and Sudoku puzzles (Dawson et al. 2014; Klauer 1992),
discussion of current events (Fernandez-Ballesteros and
Calero 1995) or completing questionnaires (Margrett and
Willis 2006)). Two studies utilised an active ‘self-guid-
ed’ EF training condition in comparison to facilitated,
strategy-based EF training (Baltes et al. 1989; Calero
and Garcia-Berben 1997). This type of active control
was considered eligible as it directly compares a strategy-
based to a non-strategy-based approach, and in one of these
studies (Baltes and colleagues) a no-contact control was also
compared, which is additionally useful for determining effica-
cy overall.
SCT Program Characteristics
All 13 studies utilised the same basic format of explicit strat-
egy provision with examples and modelling, followed by
guided practice predominantly on paper-and-pencil tasks and
then feedback regarding performance accuracy and strategy
use. In 11 studies, a specialist trainer provided face-to-face
facilitation whilst in the remaining two studies (Margrett and
Willis 2006; Stine-Morrow et al. 2014), participants were pro-
vided with the same manualised workbook containing de-
tailed written and pictorial strategy instructions, adapted by
Margrett and Willis from a program originally delivered in a
face-to-face format.
As illustrated in Table 1, aside from this consistent basic
format, there were broad differences amongst the studies in
other SCT characteristics. In terms of EF subdomain, the ma-
jority of the studies (n = 11) targeted inductive reasoning (typ-
ically relating to deducing serial patterns in letter / number /
picture sequences, which are then related to everyday exam-
ples such as transportation schedules or medication prescrip-
tions), although one of these trials also included a second
Neuropsychol Rev (2016) 26:252–270
experimental group targeting problem-solving (Fernandez-
Ballesteros and Calero 1995). Two studies targeted goal-
directed behaviour relating to everyday problems or tasks,
one utilising a well-known structured heuristic known as the
‘Goal-Plan-Do-Review’ process (Dawson et al. 2014) and the
other describing a ‘stop-state-check’ sequence of strategies
(van Hooren et al. 2007).
In relation to CT dosage, as illustrated in Table 1, the total
number of sessions ranged from five to 24, with an average of
10.4 total sessions across the studies (median = 10). Sessions
were typically around one hour in duration (mean = 64.0 min).
In terms of intensity, four studies included twice weekly ses-
sions; two included weekly sessions; and seven studies (i.e.
over half of the sample) did not specify the frequency of train-
ing at all. The length of treatment ranged from two weeks to
16 weeks (mean = 7.9; median = 6), with four studies omitting
information regarding treatment length. Nine studies required
participants to attend a training site (e.g. research centre) while
three studies included training in the participants’ home and
one study did not specify location. Eight studies included
group-based training; three completed individualised training
and two studies’ programs comprised a mix of both group and
individualised sessions. Group size ranged from two through
to 15 participants across the trials. Three of the studies includ-
ed additional practice tasks given as homework in between
training sessions; all homework tasks were designed to pro-
vide extra exposure to the strategies as well as emphasise their
application to real-world examples (such as locating a tele-
phone number for a service) (Chapman et al. 2015; Cheng
et al. 2012; van Hooren et al. 2007). Only two of the studies
included booster training sessions prior to long-term follow
up. In both cases, booster sessions were offered to a random
subset of 60 % of the study sample (Ball et al. 2002 - four
booster sessions over a two- to three-week period, 11 months
post-training; and Cheng et al. 2012 – three booster sessions
over three months, six months post-training). None of the
studies included systematic or regular contact with study per-
sonnel (e.g. trainers) in between formal training sessions, and
none of the studies involved adjunctive treatments concurrent-
ly to SCT.
Outcome Measures and Reporting
In total, 33 post-treatment EF outcomes were reported across
the 13 trials, equating to 2.5 outcomes per trial on average.
Eight of the trials reported an incomplete dataset at follow-up,
in most cases following withdrawals due to illness, death or
change of mind during the course of the trial, although one
trial (ACTIVE; Ball et al. 2002) also noted drop-outs due to
protocol violations such as inappropriate randomisation. Of
the eight trials reporting drop-outs, only five reportedly
accounted for this using statistical methods (e.g. intention-to-
treat analyses).
Table 1 Characteristics of included studies

Study demographics Intervention design Study Quality

Study Cohort N Mean Age % Female Design CT Target CT Durationc Group size Control Type Shortened
PEDro rating

Ball et al. 2002 Healthy T = 2832 T = 73.6a T = 76a RCT Inductive reasoning Sessions: 10 2–4 Passive (no contact) 8
I = 705 Mins/session: 67.5
C = 704 Weeks: 5.5

Baltes et al. 1989 Healthy T = 72 T = 72a T = 72a RCT Inductive reasoning Sessions: 5 5–10 Passive (no contact) 2
I = 24 Mins/session: 60 & Active
Neuropsychol Rev (2016) 26:252–270

C = 24 Weeks: US (self-guided training)

Blieszner et al. 1981 Healthy T = 52b T = 70.3 US RCT Inductive reasoning Sessions: 5 3–8 Passive (no contact) 4
I = 26b I = 26 Mins/session: 60
C = 26 C = 26 Weeks: 2

Calero and Garcia-Berben 1997 Healthy T = 25 68.3a 80a RCT Inductive reasoning Sessions: 5 6–8 Active (self-guided training) 6
I = 13 Mins/session: 60
C = 12 Weeks: 4

Chapman et al. 2015 Healthy T = 37 T = 62.9 T = 65 RCT Gist reasoning Sessions: 12 5 Passive (waitlist control) 7
I = 18 I = 61.8 I = 74 Mins/session: 60
C = 19 C = 64 C = 56 Weeks: 12

Cheng et al. 2012 Healthy T = 270 T = 70.3 T = 49 RCT Inductive reasoning Sessions: 24 15 Passive (waitlist control) 7
I = 90 I = 69.8 I = 54 Mins/session: 60
C = 90 C = 70.2 C = 50 Weeks: 12

Dawson et al. 2014 Healthy T = 19 T = 73.9 T = 84 RCT Problem solving Sessions: 12 US Active (psycho-education 9
I = 10 I = 74.1 I = 90 & goal-directed Mins/session: 90 with cognitive stimulation)
C=9 C = 73.7 C = 78 behavior Weeks: 8

Fernandez-Ballesteros Healthy T = 90a T = 68.9 T = 36 RCT Inductive reasoning Sessions: 7.5 5–7 Active (discussion 4
and Calero 1995 I1 = 69.6 I1 = 30 ( I1) & problem Mins/session: 60 of current affairs)
I2 = 68.9 I2 = 23 solving (I2) Weeks: 10 (I1) & 5 (I2)
C = 68.7 C = 57

Margrett and Willis 2006 Healthy T = 98 T = 71.4 T = 50 RCT Inductive reasoning Sessions: 10 1 Active (questionnaires) 6
I1 = 30 I1 = 71.7 I1 = 50 Mins/session: 67.5
I2 = 34 I2 = 71.8 I2 = 50 Weeks: 5.5
C = 34 C = 70.9 C = 50

Stine-Morrow et al. 2014 Healthy T = 461 T = 72.6 T = 75 RCT Inductive reasoning Sessions: 16 1 Passive (waitlist control) 6
I = 130 I = 73.4 I = 77 Mins/session: 67.5
C = 143 C = 72.9 C = 76 Weeks: 16

Klauer 1992 Healthy T = 36 a T = 68.4 a T = 75 a QR Inductive reasoning Sessions: 6 US Active (cognitive stimulation) 3
Mins/session: 52.5
Weeks: US
259
260 Neuropsychol Rev (2016) 26:252–270

T Total (including participants from interventions not of interest in this review); I Intervention group of interest, C Control group of interest, RCT Randomized controlled trial; QR Quasi-randomized; US =
Study Quality

PEDro rating
All but one study included EF (whether trained or un-

Shortened
trained subdomains) as a primary outcome. Chapman et al.
(2015) alone reported EF as a secondary outcome, as the focus

7
4
of this trial was on neuroimaging outcomes of CT.
As per our methods and as shown in Table 2, all 13 studies
included at least one objective cognitive outcome (subjective

Passive (waitlist control)

measures were also used in some studies, but as noted in the
Passive (no contact)

methods section, these were not reviewed here). None of the

Control Type

studies utilised test measures with identical tasks or items to

those used during training. Eleven studies used the cognitive
tests of EF to assess near transfer (i.e. benefits directly related
to the trained tasks, typically within the same EF subdomain)
and in most cases, to also assess far transfer to untrained EF
Group size

subdomains. For example, if the SCT program had focused on

inductive reasoning, a study would have included an inductive
7
1

reasoning task for near transfer as well as one or more working

memory, cognitive flexibility or problem-solving tasks for far
transfer. Two studies (Dawson et al. 2014; van Hooren et al.
Mins/session: 52.5

Mins/session: 75

2007) used subjective measures including questionnaires or

CT Durationc

Sessions: 12
Sessions: 10

semi-structured interview to assess near transfer and therefore

Weeks: US

Weeks: 6

used the objective cognitive tasks only to measure far transfer.

Across the studies, the cognitive tests primarily comprised
measures of inductive or abstract reasoning such as Raven’s
Inductive reasoning

Progressive Matrices (Raven and Court 1998), Letter Series

(Thurstone and Thurstone 1949), Word Series (Gonda and
Goal-directed
behaviour
CT Target

Schaie 1985) and Letter Sets (Ekstrom et al. 1976), but also
Intervention design

included tests of cognitive flexibility such as the Trail Making

Test (Reitan 1979) or inhibitory control such as the DKEFS
Colour-Word Interference Test (Delis et al. 2001). In addition
Design

to cognitive tests, three studies (Ball et al. 2002; Ball et al.

RCT
QR

2010; Dawson et al. 2014) also included functional measures

of far transfer (i.e. relating to generalisability of training to
% Female

IADLs). These measures ranged from performance-based

T = 82.5
T = 89 a

C = 83
I = 82

simulated or actual real-life tasks, to paper-and-pencil based

everyday problem-solving tasks (see Table 2).
Overall, outcome data reporting varied widely, with some
Mean Age

T = 74.3 a

Calculated as mean value when range provided in study report

C = 63.3
T = 62.8

studies providing pre- and post-intervention means and stan-

I = 62.4

dard deviations, some studies providing standardized scores

referenced to the control group, some studies providing effect
Study demographics

Data from 4 participants dropped after intervention

size data (with and without confidence intervals), some stud-

T = 59 a

C = 31
T = 69
I = 38

ies reporting post-treatment gain scores and one study provid-

N

ing latent change score modelling to determine the interven-

Breakdown between groups not specified

tion effect. We did not have access to sufficient or appropriate

Cohort

Healthy

Healthy

follow up data to calculate effect sizes for outcomes reported

by Baltes et al. (1989); Fernandez-Ballesteros and Calero
(1995); Cheng et al. (2012) or Stine-Morrow et al. (2014)
and therefore can only describe the results of these trials as
reported by the study authors.
Table 1 (continued)

van Hooren et al., 2007

Hasselhorn et al. 1995

Importantly, eight of the 13 trials included longitudinal

follow-up beyond the immediate post-intervention assess-
Unspecified

ment. As shown in Table 2, five trials included one longitudi-

nal follow up; two trials included two longitudinal assess-
Study

ments; and the ACTIVE study included the longest follow-

b
a

c
Table 2 Study outcomes and calculated Hedges’ g effect sizes*
Study
Healthy older adults
Ball et al. 2002a (ACTIVE)
Willis et al. 2006 (ACTIVE)
Ball et al. 2010c (ACTIVE)
Rebok et al. 2014(ACTIVE)
Blieszner et al. 1981
Calero and
Garcia-Berben 1997
Outcome Post-training Follow Up 1 Follow Up 2 Comparison of interest
Reasoning Composite Score 0.48 1 year: 0.40 2 years: 0.26 Strategy-based training
(Word Series, Letter vs no-contact control
Series, Letter Sets)
IADLs (Minimum Data n/a -0.13b -0.06b
Set – Home Care)
Everyday Problems Test n/a 0.03 -0.03
Neuropsychol Rev (2016) 26:252–270
Reasoning Composite Score n/a 5 years: 0.26 (0.19, 0.33) n/a Strategy-based training
(Word Series, Letter vs no-contact control
Series, Letter Sets)
IADLs (Minimum Data n/a 0.29 (0.09, 0.49) n/a
Set – Home Care)
Everyday Problems Test n/a -0.08 (−0.18, 0.02) n/a
Motor Vehicle Collisions n/a 6 years: 0.50 (0.27, 0.92) n/a Strategy-based training
(per person-miles) vs no-contact control
Reasoning Composite Score n/a 10 years: 0.23 (0.12, 0.34) n/a Strategy-based training
(Word Series, Letter vs no-contact control
Series, Letter Sets)
IADLs (Minimum Data n/a 0.38 (0.11, 0.65) n/a
Set – Home Care)
Everyday Problems Test n/a -0.02 (−0.20, 0.16) n/a
ADEPT Figure Relations 0.22 (−0.32, 0.75) 1 month: 0.12 (−0.41, 0.66) 6 months: 0.08 (−0.45, 0.62) Strategy-based training
ADEPT Induction 0.39 (−0.15, 0.93) 0.36 (−0.18, 0.90) -0.02 (−0.56, 0.51) vs no-contact control
Culture Fair Test -0.08 (−0.62, 0.46) 0.02 (−0.52, 0.55) -0.08 (−0.62, 0.46)
Induction Composite (Number 0.22 (−0.32, 0.76) 0.17 (−0.36, 0.71) 0.05 (−0.49, 0.59)
Series, Letter Series, Letter Sets)
Raven’s Progressive Matrices -0.28 (−0.82, 0.26) 0.05 (−0.48, 0.59) 0.18 (−0.35, 0.72)
Cattell domain score -0.11 (−0.87, 0.65) 3 months: −0.05 (−0.85, 0.75) n/a Tutor guided vs self-guided
Cattell Series subtest -0.11 (−0.87, 0.65) -0.64 (−1.47, 0.18) n/a strategy-based training
Classification subtest 0.11 (−0.65, 0.87) 0.00 (−0.80, 0.80) n/a
Conditions subtest -0.36 (−1.13, 0.40) 0.00 (−0.80, 0.80) n/a
Matrices subtest -0.04 (−0.80, 0.72) 0.51 (−0.31, 1.33) n/a
Raven’s Progressive Matrices -0.11 (−0.87, 0.65) 0.14 (−0.67, 0.95) n/a
261
Table 2 (continued)
262

Study Outcome Post-training Follow Up 1 Follow Up 2 Comparison of interest

Chapman et al. 2015 Daneman and Carpenter -0.11 (−0.74, 0.52) n/a n/a Strategy-based training vs
Working Memory waitlist control
Test of Strategic Learning 1.52 (0.80, 2.24) n/a n/a
Trails B-A 0.35 (−0.28, 0.99) n/a n/a
WAIS III Similarities 0.74 (0.09, 1.39) n/a n/a

Dawson et al. 2014d
DKEFS - First move Tower Test 0.02 (−0.84, 0.88) 3 months: 0.97 (0.05, 1.88) n/a Strategy-based training vs
DKEFS –Tower test -0.61 (−1.50, 0.27) 0.17 (−0.69, 1.03) n/a psycho-education control
achievement score
DKEFS – Trail Making Test -0.20 (−1.06, 0.67) -0.11 (−0.97, 0.75) n/a
DKEFS – Word Fluency -0.04 (−0.90, 0.82) 0.04 (−0.82, 0.90) n/a

Margrett and Willis 2006 Letter Series Test 1.14 (0.61, 1.66) n/a n/a Strategy-based individual
Letter Sets Test 0.50 (−0.19, 1.19) n/a n/a training vs cognitive
Word Series Test 0.38 (−0.11, 0.87) n/a n/a stimulation control
Letter Series Test 1.41 (0.88, 1.93) n/a n/a Strategy-based collaborative
Letter Sets Test 0.55 (−0.12, 1.22) n/a n/a training vs cognitive
Word Series Test 0.41 (−0.06, 0.89) n/a n/a stimulation control

Klauer 1992 Raven’s Progressive Matrices 0.05 (−0.59, 0.68) n/a n/a Strategy-based vs cognitive
stimulation control

Hasselhorn et al. 1995 Raven’s Progressive Matrices: 1.21 (0.54, 1.88) 11 months: 0.28 (−0.41, 0.97) n/a Strategy-based training vs
Inductive reasoning no-contact control
Raven’s Progressive 0.51 (−0.12, 1.14) 0.01 (−0.68, 0.69) n/a
Matrices: Perception

van Hooren et al., 2007 Stroop Color Word Interference 0.20 (−0.28, 0.67) 7 weeks: −0.12 (−0.60, 0.35) Strategy-based training vs
waitlist control

IADLs Instrumental Activities of Daily Living, ADEPT Adult Development and Enrichment Project, WAIS Wechsler Adult Intelligence Scale, DKEFS Delis-Kaplan Executive Function System
a
Effect sizes provided in published study report without confidence intervals;
b
Score combines IADLs and ADLs;
c
Rate Ratio (95 % CI) taken directly from published study report;
d
An additional test assessing functional outcomes (Canadian Occupational Performance Measure) was also used, however effect sizes could not be computed as sufficient data were unavailable. Results of
this test are discussed in-text as reported by study authors
*Effect sizes in bold indicate that the study authors reported this outcome as statistically significant
Neuropsychol Rev (2016) 26:252–270
Neuropsychol Rev (2016) 26:252–270
up period, reporting outcomes at one and two years (Ball et al.
2002) as well as five years (Willis et al. 2006) and even ten
years (Rebok et al. 2014) post-intervention.
Methodological Quality
As shown in Table 1, the 13 studies were rated as being of
varying methodological quality overall. Two studies scored at
or below 3/9 possible points on the shortened PEDro rating
scale, suggesting poor methodological quality, whilst only
five studies scored at least 7/9. Figure 2 illustrates the spread
of scores across individual PEDro criteria, showing that over-
all, more studies adhered to standards around appropriate
reporting of results and randomised design, followed by en-
suring similar group characteristics at baseline, obtaining key
outcome data from a majority of the enrolled sample and
specification of eligibility criteria, compared to other (perhaps
more intricate) methodological issues such as concealment of
allocation, blinding of assessors or accounting for incomplete
datasets at follow-up (e.g. by using an intention-to-treat anal-
ysis). This distribution is important to note, as the latter issues
are perhaps more concerning when considering potential risk
of bias (i.e. under- or overestimating results due to flaws in
study design, implementation or analysis). We note that it is
certainly possible that some trials may have accounted for
these issues during the course of the study. However, as meth-
odological quality ratings can only be completed on the basis
of information provided in study reports, when relevant details
were not explicitly documented it had to be assumed that the
study design was lacking in that particular feature.
Intervention Effects within Studies
Table 2 displays outcome measures, effect sizes with 95 %
confidence intervals (calculated as per our methods section)
and comparisons of interest for each study, along with an
indication of whether the comparison was significant accord-
ing to the study authors. As mentioned above, appropriate
Fig. 2 Percentage of trials
(N = 13) meeting individual
(shortened) PEDro criteria for
methodological quality, based on
information provided in
study reports
263
outcome data from four studies was not available for our effect
size calculations; hence we can only refer to the significance
of outcomes as reported for these four trials (Baltes et al. 1989;
Cheng et al. 2012; Fernandez-Ballesteros and Calero 1995;
Stine-Morrow et al. 2014).
Effect Size Calculations
In terms of our calculated effect sizes, across all EF outcomes,
statistically significant moderate to large effect sizes (ranging
from g = 0.45 to g = 0.99) were found in studies with N ≥ 39
(Ball et al. 2002; Hasselhorn et al. 1995; Margrett and Willis
2006) with the exception of two studies (Blieszner et al. 1981;
van Hooren et al. 2007), and there was no evidence of publi-
cation bias (Egger’s Intercept =0.37, p = 0.40).
Near Transfer Outcomes
In terms of reported study outcomes, 10 out of the 11 studies
using objective measures of near transfer (i.e. within the same
EF subdomain as that trained, using non-identical or untrained
tasks) demonstrated significant improvements on at least one
such outcome measure immediately post-training, and these
were generally of at least moderate effect size (i.e. Hedge’s
g > 0.3) according to our calculations. Whilst the remaining
study by Calero and Garcia-Berben (1997) did report an im-
provement following SCT; this finding was also evident in the
self-guided training (i.e. non-strategy based) control group,
indicating a more generalised effect of CT on reasoning.
Incidentally, the other study (Baltes et al. 1989) directly
comparing SCT and self-guided reasoning training sim-
ilarly reported improvements on near transfer outcomes
in both groups; however this study also included a no-contact
control condition, where the benefits of SCT were more clear-
ly apparent.
Of the eight studies that measured longitudinal near trans-
fer outcomes in addition to immediate post-training compari-
sons, four reported sustained improvements over time.
264
Specifically, benefits were maintained on inductive reasoning
tasks following reasoning training after one month (Blieszner
et al. 1981), three months (Fernandez-Ballesteros and Calero
1995), six months (Cheng et al. 2012) as well as one, two, five
and ten years (ACTIVE trials; Ball et al. 2002; Rebok et al.
2014; Willis et al. 2006) post SCT cessation. Both of the
studies that included booster training within 12 months for a
subset of participants reported significant improvements in the
trained EF subdomain among those receiving booster training
(Ball et al. 2002; Cheng et al. 2012). Sustained effects of
booster training were also apparent five years (Willis et al.
2006) and ten years (Rebok et al. 2014) post-training.
Calculated effect sizes at longitudinal follow up tended to vary
more widely, ranging from small (0.23) to moderate (0.50).
Far Transfer Outcomes
In terms of far transfer to untrained EF subdomains or IADLs,
immediate post-training comparisons indicated that only one of
the six studies that included such outcome measures reported
significant post-SCT improvements. Interestingly, this study
(Dawson et al. 2014) included a broader program of SCT
targeting problem-solving, goal-directed behaviour and abstract
reasoning skills (e.g. as compared to targeting inductive reason-
ing alone) and the reported improvements were seen on a semi-
structured interview measure of everyday problem-solving and
performance in relation to real-world tasks (e.g. managing fi-
nances, meal preparation). Longitudinal far transfer benefits,
however, were more variable. The abovementioned improve-
ment in everyday problem-solving was not sustained three
months after training (Dawson et al. 2014). However, two other
trials that did not initially report generalisability immediately
post-training, reported improvements at longitudinal follow-up
- possibly suggesting some delay in transfer to far-reaching
domains or everyday functioning. This included improvements
in untrained EF subdomains such as inhibitory control at one-
year following reasoning training (Cheng et al. 2012), as well as
improvements in self-reported and simulated IADLs at five-year
follow-up (Willis et al. 2006; we calculated a small effect size of
0.29) and ten-year follow-up (Rebok et al. 2014, we calculated a
moderate effect size of 0.38) and reduced number of at-fault
motor vehicle collisions (as a measure of driving safety) six
years (Ball et al. 2010, we calculated a moderate effect size of
0.50) following reasoning training in the ACTIVE trial. In the
two trials that included booster training, unfortunately far trans-
fer effects were not investigated in this subgroup.
Discussion
This systematic review aimed to evaluate whether SCT is
effective for improving EF in healthy older adults or those
with mild cognitive impairment. Ninety-three articles were
Neuropsychol Rev (2016) 26:252–270
identified as addressing EF using SCT, indicating the value
in utilising this behavioural intervention for this purpose.
However, application of our specific criteria defining the pa-
rameters of SCT and stipulating that programs needed to focus
on EF for at least 50 % of the total intervention time in order to
truly target EF, reduced this number down to just 16 trials.
This suggests that whilst many CT trials across the literature
intend to use strategy training to address EF, when examined
closely many of them do not provide a truly facilitative, guid-
ed approach (often favouring drill-and-practice repetitive ex-
ercises without teaching adaptive techniques) or do not spend
sufficient time addressing EF, rather focusing on broad or
multi-domain interventions. Multi-faceted interventions (such
as those involving relevant psychoeducation, for example)
may indeed be advantageous in targeting multiple dementia
risk factors simultaneously in older adults (see Mowszowski
et al. 2010; Naismith et al. 2009); however in relation to syn-
thesising findings to enable an objective review of the evi-
dence base for improving EF, it was imperative to increase
the specificity of interventions considered here.
Somewhat surprisingly, the study selection process identi-
fied only three studies investigating SCT in older adults with
mild cognitive change, and of these, only one study formally
operationalized participants as having MCI according to
standardised, established criteria. The other two studies did
not sufficiently characterise their sample with respect to the
nature or severity of cognitive decline to enable a clear under-
standing of how SCT might benefit this subgroup. Moreover,
only one trial followed a randomised controlled design, and
the three studies varied so widely with respect to methodology
and SCT parameters that we determined that a valid synthesis
of the findings was not feasible. This is somewhat unfortunate,
as this group might be expected to have an increased need for
remediation of subtle cognitive deficits. Indeed, although the
distinction between MCI and established dementia essentially
lies in the absence of frank functional impairment, more recent
iterations of MCI diagnostic guidelines (e.g. Winblad et al.
2004) have noted that even those with MCI may experience
a small degree of subtle functional change, and this is typically
related to slightly reduced efficiency or effectiveness in com-
pleting complex daily tasks such as paying bills or preparing
meals, despite maintained overall independence (also see
Albert et al. 2011). The focus on improving EF in healthy
older adults has therefore been explained as taking a preven-
tative rather than a treatment-based approach, positing SCT to
have a protective effect by delaying or preventing cognitive
and functional difficulties associated with normal ageing or
neurodegeneration (see Ball et al. 2010). However, it is well-
established that older adults with MCI are at a greater risk of
developing dementia (Sperling et al. 2011) and we have pre-
viously proposed that CT may be especially relevant and ef-
ficacious as a secondary prevention strategy in this group
(Mowszowski et al. 2010). As such, one of the first lessons
Neuropsychol Rev (2016) 26:252–270
of this systematic review is the great need for further research
in this area, to more accurately evaluate the utility of SCT
programs for improving even mild cognitive or functional
changes in MCI. Additionally, we propose that such research
should be more stringent with respect to defining these
groups, by incorporating well-defined and preferably validat-
ed criteria for MCI, as well as potentially differentiating be-
tween subgroups with amnestic versus non-amnestic forms of
MCI, to better target those with specific difficulties in EF from
the outset.
Removing the three ‘mild cognitive impairment’ studies
reduced the final number of trials reviewed here to 13, focus-
ing on healthy older adults. Of these 13 studies, despite our
stringent inclusion criteria there were still considerable varia-
tions in study design, CT program methodology and outcome
measures. This is certainly consistent with previously identi-
fied limitations across the field, namely the heterogeneity in
methodology and content across studies and the resul-
tant barrier to integrating findings stemming from such
disparate trials (Walton et al. 2014). Indeed, this finding
underscores our initial decision not to undertake a meta-
analytical approach. Nonetheless, this review has revealed
some informative trends.
Analysis of intervention effects revealed that significant
SCT-related improvements were demonstrated in 11/13 stud-
ies post-treatment and/or longitudinally, with no apparent dif-
ferences between studies utilising group vs. individual train-
ing or between programs of varying length and intensity. Of
these significant findings, effect sizes ranged from small (e.g.
Hedges’ g = 0.05; Klauer 1992) to large (e.g. Hedges’
g = 1.52; Chapman et al. 2015). These findings are generally
consistent with those reported in another systematic review of
cognitive interventions (albeit combining both SCT and
computer-based or multi-modal interventions; Reijnders
et al. 2013) but differ from those reported in a meta-analysis
of computer-based interventions alone (Lampit et al. 2014),
where effect sizes were reported as negligible for EF.
The predominance of positive effects, primarily shown in
the trained EF subdomain but also generalised in some studies
to other cognitive domains or functional outcomes, suggests
that SCT targeting EF has some promise as a remedial tech-
nique. Moreover, evidence of sustained benefit over months
and even years following training suggests that this approach
has potential for lasting impact, particularly when booster ses-
sions are provided within 12 months. Although few trials have
investigated capacity for dementia prevention as an ‘ideal’
outcome of CT, this has at least been explored in a five-year
follow up of the ACTIVE trial (Unverzagt et al. 2012). This
secondary analysis indicated that whilst reasoning training (or
indeed, memory or processing speed training) did not result in
a significant reduction in dementia incidence, larger,
population-based trials would be required to uncover such
effects. In any case, despite the optimistic results reported
265
above, caution should be taken in interpreting the findings
for several reasons.
Firstly, the assessment of EF is notoriously difficult, as EF
is inherently multi-faceted and relies on elements of novelty,
creativity and application of abstract skills and concepts to
varying scenarios. However, tasks measuring EF require the
participant to respond to very specific situations, often in
structured environments, effectively reducing the ‘executive’
load on participants from the outset (see discussion by Lezak
1982). As such, tests of EF are by nature, artificial and possi-
bly limited in how well they truly assess EF abilities.
Moreover, it is often difficult to derive appropriate alternative
forms of these somewhat abstract tests, such that practice ef-
fects are difficult to avoid. In the absence of suitable alternate
forms, inclusion of appropriate control conditions are
imperative to determine with any confidence whether
changes in outcomes are due to intervention effects
rather than practice or prior exposure. This is one of
the reasons that we included such stringent inclusion criteria
around the nature of control conditions, and indeed, as shown
in Fig. 1, eight studies were excluded solely on the basis of an
inadequate control condition.
Secondly, methodological quality was rather variable
across the included studies. Most followed a RCT design
and (in accordance with our selection criteria for this review),
all included some form of control condition, demonstrating at
least a basic level of scientific quality. However, more sophis-
ticated aspects of experimental methodology were often
overlooked, including concealment of randomisation out-
comes, assessor blinding and accounting for drop-outs (with
statistical or other means), thus raising some concern regard-
ing the potential for performance, detection or attrition biases,
respectively, within those studies. Additionally, as noted
above, we abbreviated the PEDro scale to omit items relating
to participant and interventionist blinding, as this is impracti-
cal within the context of SCT studies. However, it is worth-
while noting that sham control conditions, whilst complex to
achieve optimally in this context (in terms of appropriately
matching for content, engagement and interventionist involve-
ment), may at least account for participant blinding. In gener-
al, this review therefore suggests a need to improve method-
ological quality and reduce the risk of bias in future research.
Consultation with guidelines or scales for methodological
quality and trial reporting (e.g. CONSORT guidelines) at the
early stages of trial design may be helpful to ensure that stud-
ies are designed and implemented to the highest quality, in
turn ensuring valid and useful comparisons and outcomes at
reporting. Additionally, recent calls to action for a coordinated
approach to CT research, possibly involving the establishment
of an international working/consensus group (see Gates and
Sachdev 2015; Walton et al. 2014), may help to resolve such
methodological issues across the field. Given that the studies
included in this review already reflect involvement of seven
266
countries across three continents, this topic is clearly of inter-
national interest. Indeed, successful collaborations have
already been demonstrated in the establishment of for-
mal guidelines for cognitive rehabilitation in other popula-
tions, such as traumatic and acquired brain injury (see
Bayley et al. 2014; Cicerone et al. 2011).
Third, it was somewhat disappointing to see that only three
of the trials investigated generalisability of intervention effects
with functional measures of far transfer, and this indicates a
vital need for replication and extension in this area of CT
research – particularly given that many studies claimed to
target EF because of its links with functional capacity.
Although the absence of a consistent or ‘gold standard’ mea-
sure of functional ability is often lamented throughout the
neuropsychological literature (see Gold 2012), despite their
abovementioned limitations, valid and useful functional mea-
sures have often been borrowed from occupational therapy
contexts, including performance-based simulations of func-
tional activities (e.g. balancing a check-book, arranging a trav-
el or medication schedule according to specific parameters,
preparing a meal etc.) as well as self/informant-report or struc-
tured interview relating to everyday functional abilities (e.g.
Canadian Occupational Performance Measure (Law et al.
1991), as used by one of the studies reviewed here (Dawson
et al. 2014), or the Lawton IADL Scale (Lawton and Brody
1969). Calls for the development of new measures including
those designed to detect subtle functional changes in complex
areas such as decision-making or social interactions (Sperling
et al. 2011) will thus be particularly relevant to SCT, in order
to better determine whether such programs are genuinely ef-
fective in eliciting ecologically-valid improvements as a result
of enhanced EF.
Interestingly, the majority of studies focused specifically on
the EF subdomain of inductive reasoning, which many of
these studies chose as representative of fluid intelligence,
known to gradually decline from early adulthood in compar-
ison to crystallised intelligence (see discussions by Blieszner
et al. 1981; Fernandez-Ballesteros and Calero 1995).
However, others appeared to select inductive reasoning as
such tasks were described as Bhighly structured, systematic
and purposeful^ (Margrett and Willis 2006), and therefore
conducive to training. In this regard, it may be viewed that
the structured nature of inductive reasoning tasks as well as
fairly discrete strategies that would be appropriate for these
tasks (e.g. increasing attention to repetitions within a stream;
verbalising schedules or written information to enhance pro-
cessing, chunking information into smaller components to aid
processing) lend particularly well to training programs com-
pared to other EF subdomains. For example, problem-solving
could perhaps be construed as a broader EF construct and
therefore more difficult to harness within an experimental set-
ting. However, this is mitigated by four studies which did
focus on remediating problem-solving skills, typically
Neuropsychol Rev (2016) 26:252–270
utilising structured heuristics with a step-wise approach to
focus goal selection, systematically examine alternative solu-
tions, and appropriately self-monitor to ensure adherence to
goals or task demands. Both formal heuristics (e.g. ‘Goal-
Plan-Do-Review’, as used by Dawson et al. 2014) and more
informal stepped approaches follow this general procedure
and were reported to be easily translatable to everyday tasks
such as planning a route or holiday, making financial deci-
sions, or even reorganising a cluttered living room. Thus, an
alternative explanation for the trend to focus on inductive
reasoning may simply relate to an historical continuation of
this research design.
It has already been noted that future research should strive
for higher methodological quality, should more specifically
target those with MCI, and should routinely include measures
of far transfer including appropriate functional outcomes.
Additionally, in line with current trends in the broader CT
literature, we propose that future research should also include
an investigation of neurobiological outcomes in relation to
EF-focused CT. Indeed, only one of the trials reviewed here
(Chapman et al. 2015) included neuroimaging outcomes.
These authors demonstrated both functional and structural al-
terations following SCT, in terms of both connectivity and
resting state cerebral blood flow. Crucially, the neural changes
observed across the central executive and default mode net-
works were correlated with the cognitive gains achieved
through training. These findings are certainly aligned with
other recent trials addressing neural mechanisms, with evi-
dence indicating that CT is associated with a variety of neu-
robiological changes including increased cortical thickness,
white matter connectivity and hippocampal volumes (see
review by Belleville and Bherer 2012) – in turn, suggesting
that such programs have the potential to alter disease trajecto-
ries. CT may also offer neuroprotection by promoting process-
es such as neuroplasticity and/or ‘cognitive reserve’.
Importantly, evidence suggests that neuroplasticity and en-
hancing cognitive reserve through life experiences and/or be-
havioural interventions can still occur later in life and that
substantial restoration is possible even in the ageing brain, to
delay or reverse the effects of normal ageing or even neuro-
degenerative pathology (e.g. Mahncke et al. 2006). Given that
functional/neuroanatomical links between EF and areas such
as the orbito-frontal, dorsomedial and dorsolateral prefrontal
cortices have been extensively established (see Stuss, 2011 for
discussion) and that CT-related structural and functional brain
changes have consistently been demonstrated within frontal
regions (Belleville and Bherer 2012), inclusion of neurobio-
logical outcomes in EF-focused CT research is certainly war-
ranted and will likely improve the standard of evidence.
Strengths of this review include a consistent, specific and
pre-determined definition of SCT which has been somewhat
lacking in other reviews. Additionally, many reviews have
included only English-language papers, thus potentially
Neuropsychol Rev (2016) 26:252–270
limiting the breadth of included research; however this
review included appraisal of seven full-text, non-
English papers. However, some limitations must also
be noted. We were unable to access librarian consulta-
tion services in developing the search strategy for this
review; additionally, it may have been advantageous for
more than one author to conduct the literature search. It
is also unfortunate that we were unable to calculate
effect sizes for four of the trials due to unavailability
of appropriate data. Additionally, whilst we have ex-
plained above our reasons for refraining from a meta-
analytical approach, future reviews may wish to under-
take this additional statistical analysis for a more in-
depth account of the literature to-date.
In conclusion, it is clear from the number of studies
identified and the consistent training-related gains across
included trials, that SCT is likely to be a viable and prom-
ising targeted treatment approach for improving EF in
healthy older adults. However, while also promising, re-
sults remain in preliminary stages with respect to the
generalisability of these improvements to untrained EF
subdomains as well as to functional or everyday out-
comes, primarily because few trials have specifically ex-
amined these far transfer effects. Additionally, whilst
there is certainly evidence to suggest that SCT effects on
EF are sustainable over time, follow up periods have not
been sufficiently lengthy so as to comment on whether
these programs have the capacity to delay the onset of
more significant cognitive or functional decline, or pre-
vent dementia. Moreover, there is currently insufficient
research to properly evaluate the utility of SCT pro-
grams for improving subtle EF changes in older adults with
MCI, who are at a higher risk of developing dementia com-
pared to healthy older adults. Further research in this subgroup
in particular is therefore urgently warranted in order to maxi-
mise the potential of this non-invasive, engaging and
empowering behavioural intervention.
Acknowledgments We would like to acknowledge the assistance of
Miss Stacey West in extracting descriptive study data as well as Mr.
Harry Hallock in completing effect size calculations.
Compliance with Ethical Standards
Funding Dr L. Mowszowski and Dr A. Lampit are each supported by a
National Health and Medical Research Council (NHMRC) – Australian
Research Council Dementia Research Development Fellowship. Mr C.C.
Walton is supported by an Australian Postgraduate Award from the
University of Sydney. Prof S.L. Naismith is supported by a NHMRC
Career Development Fellowship.
Conflict of Interest Dr A. Lampit receives in-kind research support in
the form of no-cost software from BrainTrain (USA) and Synaptikon
(Germany) for projects unrelated to this work. The other authors declare
that they have no conflicts of interest.
267
Ethical Approval This article does not contain any studies with human
participants or animals performed by any of the authors.
References
Albert, M. S., DeKosky, S. T., Dickson, D., Dubois, B., Feldman, H. H.,
Fox, N. C., et al. (2011). The diagnosis of mild cognitive impairment
due to Alzheimer’s disease: recommendations from the NIA-AA
workgroups on diagnostic guidelines for Alzheimer’s disease.
Alzheimer's & Dementia, 7(3), 270–279.
Aretouli, E., & Brandt, J. (2010). Everyday functioning in mild cognitive
impairment and its relationship with executive cognition.
International Journal of Geriatric Psychiatry, 25(3), 224–233.
Bahar-Fuchs, A., Clare, L., & Woods, B. (2013). Cognitive training and
cognitive rehabilitation for mild to moderate Alzheimer’s disease
and vascular dementia. Cochrane Database of Systematic Reviews,
6, CD003260, doi:10.1002/14651858.CD003260.pub2.
Ball, K., Berch, D. B., Helmers, K. F., Jobe, J. B., Leveck, M. D.,
Marsiske, M., et al. (2002). Effects of cognitive training interven-
tions with older adults: a randomized controlled trial. [clinical trial
randomized controlled trial research support, U.S. Gov’t, P.H.S.
JAMA, 288(18), 2271–2281.
Ball, K., Edwards, J. D., Ross, L. A., & McGwin Jr., G. (2010). Cognitive
training decreases motor vehicle collision involvement of older
drivers. [Multicenter Study Randomized Controlled Trial Research
Support, N.I.H., Extramural]. Journal of the American Geriatrics
Society, 58(11), 2107–2113. doi:10.1111/j.1532–5415.2010.03138.
x.
Baltes, P. B., Sowarka, D., & Kliegl, R. (1989). Cognitive training re-
search on fluid intelligence in old age: what can older adults achieve
by themselves? [Clinical Trial Randomized Controlled Trial].
Psychology and Aging, 4(2), 217–221.
Bayley, M. T., Tate, R., Douglas, J. M., Turkstra, L. S., Ponsford, J.,
Stergiou-Kita, M., Kua, A., Bragge, P., & Expert Panel, I. N. C. O.
G. (2014). INCOG guidelines for cognitive rehabilitation following
traumatic brain injury: methods and overview. The Journal of Head
Trauma Rehabilitation, 29(4), 290–306. doi:10.1097
/HTR.0000000000000070.
Belleville, S., & Bherer, L. (2012). Biomarkers of Cognitive Training
Effects in Aging. Curr Transl Geriatr Exp Gerontol Rep, 1(2),
104–110.
Blieszner, R., Willis, S. L., & Baltes, P. B. (1981). Training research in
aging on the fluid ability of inductive reasoning. Journal of Applied
Developmental Psychology, 2(3), 247–265, doi:10.1016/0193–
3973 %2881 %2990005–8.
Boron, J. B., Turiano, N. A., Willis, S. L., & Schaie, K. W. (2007). Effects
of cognitive training on change in accuracy in inductive reasoning
ability. [Research Support, N.I.H., Extramural]. The Journals of
Gerontology. Series B, Psychological Sciences and Social
Sciences, 62(3), P179–P186.
Brom, S. S., & Kliegel, M. (2014). Improving everyday prospective memory
performance in older adults: comparing cognitive process and strategy
training. [Comparative Study Research Support, Non-U.S. Gov’t].
Psychology and Aging, 29(3), 744–755, doi:10.1037/a0037181.
Calero, M., & Garcia-Berben, T. (1997). A self-training program in in-
ductive reasoning for low-education elderly: tutor-guided training
vs. self-training. [Empirical Study]. Archives of Gerontology and
Geriatrics, 24(3), 249–259, doi:10.1016/S0167–4943 %2896
%2900762–5.
Chapman, S. B., & Mudar, R. A. (2014). Enhancement of cognitive and
neural functions through complex reasoning training: evidence from
268
normal and clinical populations. Frontiers in Systems Neuroscience,
8, 69. doi:10.3389/fnsys.2014.00069.
Chapman, S. B., Aslan, S., Spence, J. S., Hart Jr., J. J., Bartz, E. K.,
Didehbani, N., et al. (2015). Neural mechanisms of brain plasticity
with complex cognitive training in healthy seniors. Cerebral Cortex,
25(2), 396–405. doi:10.1093/cercor/bht234.
Cheng, Y., Wu, W., Feng, W., Wang, J., Chen, Y., Shen, Y., et al. (2012).
The effects of multi-domain versus single-domain cognitive training
in non-demented older people: a randomized controlled trial. [ran-
domized controlled trial research support, non-U.S. Gov’t. BMC
Medicine, 10, 30. doi:10.1186/1741-7015-10-30.
Cicerone, K. D., Langenbahn, D. M., Braden, C., Malec, J. F., Kalmar,
K., Fraas, M., et al. (2011). Evidence-based cognitive rehabilitation:
updated review of the literature from 2003 through 2008. Archives of
Physical Medicine and Rehabilitation, 92(4), 519–530. doi:10.1016
/j.apmr.2010.11.015.
Dawson, D., Richardson, J., Troyer, A., Binns, M., Clark, A., Polatajko,
H., et al. (2014). An occupation-based strategy training approach to
managing age-related executive changes: a pilot randomized con-
trolled trial. [randomized controlled trial research support, non-U.S.
Gov’t. Clinical Rehabilitation, 28(2), 118–127. doi:10.1177
/0269215513492541.
Delis, D., Kaplan, E., & Kramer, J. (2001). Delis-Kaplan Executive
Function System. San Antonio: TX: Harcourt Brace & Company.
Diamond, K., Mowszowski, L., Cockayne, N., Norrie, L., Paradise, M.,
Hermens, D. F., et al. (2015). Randomized controlled trial of a
healthy brain ageing cognitive training program: effects on memory,
mood, and sleep. Journal of Alzheimer's Disease, 44(4), 1181–1191.
doi:10.3233/JAD-142061.
Duara, R., Loewenstein, D. A., Potter, E., Barker, W., Raj, A.,
Schoenberg, M., et al. (2011). Pre-MCI and MCI: neuropsycholog-
ical, clinical, and imaging features and progression rates. The
American Journal of Geriatric Psychiatry, 19(11), 951–960.
Dubois, B., Feldman, H. H., Jacova, C., Hampel, H., Molinuevo, J. L.,
Blennow, K., et al. (2014). Advancing research diagnostic criteria
for Alzheimer’s disease: the IWG-2 criteria. Lancet Neurology,
13(6), 614–629. doi:10.1016/S1474-4422(14)70090-0.
Ekstrom, R. B., French, J. W., Harman, H., & Derman, D. (1976). Kit of
Factor Referenced Cognitive Tests (Revised (ed ed.). Princeton, NJ:
Educational Testing Service.
Fernandez-Ballesteros, R., & Calero, M. (1995). Training effects on in-
telligence of older persons. [Empirical Study]. Archives of
Gerontology and Geriatrics, 20(2), 135–148, doi:10.1016/0167–
4943%2894%2900591-T.
Gates, N. J., & Sachdev, P. (2015). Is cognitive training an effective treatment
for preclinical and early Alzheimer’s disease? Journal of Alzheimer's
Disease, 42 Suppl 4, S551–S559, doi:10.3233/JAD-141302.
Gates, N., & Valenzuela, M. (2010). Cognitive exercise and its role in
cognitive function in older adults. Current Psychiatry Reports,
12(1), 20–27. doi:10.1007/s11920–009-0085-y.
Gates, N. J., Sachdev, P. S., Fiatarone Singh, M. A., & Valenzuela, M.
(2011). Cognitive and memory training in adults at risk of dementia:
a systematic review. BMC Geriatrics, 11, 55, doi:10.1186/1471–
2318–11-55.
Gold, D. A. (2012). An examination of instrumental activities of daily
living assessment in older adults and mild cognitive impairment.
Journal of Clinical and Experimental Neuropsychology, 34(1), 11–
34. doi:10.1080/13803395.2011.614598.
Gonda, J., & Schaie, K. (1985). Schaie-Thurstone Mental Abilities
Test: Word Series Test. Palo Alto, California: Consulting
Psychologists Press.
Grigsby, J., Kaye, K., Baxter, J., Shetterly, S. M., & Hamman, R. F.
(1998). Executive cognitive abilities and functional status among
community-dwelling older persons in the San Luis Valley Health
and Aging Study. Journal of the American Geriatrics Society,
46(5), 590–596.
Neuropsychol Rev (2016) 26:252–270
Hasselhorn, M., Hager, W., Huber, M., & Godecke, D. (1995). Improving
intelligence and thinking in older adults: An evaluation of the Aachen
inductive reasoning training program for older adults. [Empirical
Study; Followup Study]. Zeitschrift fur Gerontopsychologie und -
psychiatrie, 8(3), 169–180.
Hedges, L. (1981). Distribution theory for Glass’s estimator of effect size
and related estimators. Journal of Educational Statistics, 6,
107–128.
Jaeggi, S. M., Buschkuehl, M., Jonides, J., & Perrig, W. J. (2008).
Improving fluid intelligence with training on working memory.
Proceedings of the National Academy of Sciences, 105(19), 6829–
6833. doi:10.1073/pnas.0801268105.
Jean, L., Bergeron, M. E., Thivierge, S., & Simard, M. (2010). Cognitive
intervention programs for individuals with mild cognitive impair-
ment: systematic review of the literature. The American Journal of
Geriatric Psychiatry, 18(4), 281–296. doi:10.1097/JGP.0b013
e3181c37ce9.
Jefferson, A. L., Paul, R. H., Ozonoff, A., & Cohen, R. A. (2006).
Evaluating elements of executive functioning as predictors of instru-
mental activities of daily living (IADLs). Archives of Clinical
Neuropsychology, 21(4), 311–320. doi:10.1016/j.acn.2006.03.007.
Kinsella, G. J., Mullaly, E., Rand, E., Ong, B., Burton, C., Price, S., et al.
(2009). Early intervention for mild cognitive impairment: a
randomised controlled trial. Journal of Neurology, Neurosurgery,
and Psychiatry, 80(7), 730–736. doi:10.1136/jnnp.2008.148346.
Klauer, K. J. (1992). How does cognitive training improve inductive
reasoning of the elderly as a function of amount of training?
[Empirical Study]. Zeitschrift fur Gerontopsychologie und -
psychiatrie, 5(3), 141–153.
Kueider, A. M., Parisi, J. M., Gross, A. L., & Rebok, G. W. (2012).
Computerized cognitive training with older adults: a systematic re-
view. PLoS ONE [Electronic Resource], 7(7), e40588. doi:10.1371
/journal.pone.0040588.
Kurz, A., Pohl, C., Ramsenthaler, M., & Sorg, C. (2009). Cognitive
rehabilitation in patients with mild cognitive impairment.
International Journal of Geriatric Psychiatry, 24(2), 163–168.
doi:10.1002/gps.2086.
Lampit, A., Hallock, H., & Valenzuela, M. (2014). Computerized
Cognitive Training in cognitively healthy older adults: A aystematic
review and meta-analysis of effect modifiers. PLoS Medicine,
11(11), e1001756.
Lampit, A., Valenzuela, M., & Gates, N. J. (2015). Computerized
Cognitive Training Is Beneficial for Older Adults. Journal of the
American Geriatrics Society, 63(12), 2610–2612, doi:10.1111
/jgs.13825.
Law, M., Baptiste, S., Carswell-Opzoomer, A., McColl, M. A., Polatajko,
H., & Pollock, N. (1991). Canadian Occupational Performance
Measure. Toronto, ON: CAOT Publications ACE.
Lawton, M. P., & Brody, E. M. (1969). Assessment of older people: self-
maintaining and instrumental activities of daily living.
Gerontologist, 9(3), 179–186.
Leung, I. H., Walton, C. C., Hallock, H., Lewis, S. J., Valenzuela, M., &
Lampit, A. (2015). Cognitive training in Parkinson disease: A sys-
tematic review and meta-analysis. Neurology, 85(21), 1843–1851.
doi:10.1212/WNL.0000000000002145.
Levine, B., et al. (2007). Cognitive rehabilitation in the elderly: effects on
strategic behavior in relation to goal management. Journal of the
International Neuropsychological Society, 13(1), 143–152.
Lezak, M. D. (1982). The problem of assessing executive functions.
International Journal of Psychology, 17(1–4), 281–297.
doi:10.1080/00207598208247445.
Maher, C. G., Sherrington, C., Herbert, R. D., Moseley, A. M., & Elkins,
M. (2003). Reliability of the PEDro scale for rating quality of ran-
domized controlled trials. Physical Therapy, 83(8), 713–721.
Mahncke, H. W., Bronstone, A., & Merzenich, M. M. (2006). Brain
plasticity and functional losses in the aged: scientific bases for a
Neuropsychol Rev (2016) 26:252–270
novel intervention. [Review]. Progress in Brain Research, 157, 81–
109, doi:10.1016/S0079–6123(06)57006–2.
Margrett, J. A., & Willis, S. L. (2006). In-home cognitive training with
older married couples: individual versus collaborative learning.
[Randomized Controlled Trial Research Support, N.I.H.,
Extramural Research Support, Non-U.S. Gov’t]. Aging,
Neuropsychology, and Cognition, 13(2), 173–195.
Martin, M., Clare, L., Altgassen, A. M., Cameron, M. H., & Zehnder, F.
(2011). Cognition-based interventions for healthy older people and
people with mild cognitive impairment. Cochrane Database of
Systematic Reviews, 1, CD006220. doi:10.1002/14651858.
CD006220.pub2.
Moher, D., Liberati, A., Tetzlaff, J., Altman, D. G., & Group, P. (2009).
Preferred reporting items for systematic reviews and meta-analyses:
the PRISMA statement. BMJ, 339, b2535. doi:10.1136/bmj.b2535.
Moro, V., Condoleo, M. T., Valbusa, V., Broggio, E., Moretto, G., &
Gambina, G. (2015). Cognitive stimulation of executive functions
in mild cognitive impairment: specific efficacy and impact in mem-
ory. [Research Support, Non-U.S. Gov’t]. American Journal of
Alzheimer’s Disease & Other Dementias, 30(2), 153–164,
doi:10.1177/1533317514539542.
Mowszowski, L., Batchelor, J., & Naismith, S. L. (2010). Early interven-
tion for cognitive decline: can cognitive training be used as a selec-
tive prevention technique? International Psychogeriatrics, 22(4),
537–548. doi:10.1017/S1041610209991748.
Naismith, S. L., Glozier, N., Burke, D., Carter, P. E., Scott, E., & Hickie, I.
B. (2009). Early intervention for cognitive decline: is there a role for
multiple medical or behavioural interventions? Early Intervention in
Psychiatry, 3(1), 19–27. doi:10.1111/j.1751–7893.2008.00102.x.
Naismith, S. L., Diamond, K., Carter, P. E., Norrie, L. M., Redoblado-
Hodge, M. A., Lewis, S. J., et al. (2011). Enhancing memory in late-
life depression: the effects of a combined psychoeducation and cog-
nitive training program. The American Journal of Geriatric
Psychiatry, 19(3), 240–248. doi:10.1097/JGP.0b013e3181dba587.
Petersen, R. C., Roberts, R. O., Knopman, D. S., Boeve, B. F., Geda, Y.
E., Ivnik, R. J., et al. (2009). Mild cognitive impairment: ten years
later. Archives of Neurology, 66(12), 1447–1455. doi:10.1001
/archneurol.2009.266.
Prince, M., Bryce, R., Albanese, E., Wimo, A., Ribeiro, W., & Ferri, C. P.
(2013). The global prevalence of dementia: a systematic review and
metaanalysis. Alzheimers Dement, 9(1), 63–75 e62. doi:10.1016/j.
jalz.2012.11.007.
Raven, J. C., & Court, J. H. (1998). Raven’s progressive matrices and
vocabulary scales: Oxford Psychologists Press Oxford, UK.
Rebok, G. W., Ball, K., Guey, L. T., Jones, R. N., Kim, H. Y., King, J. W.,
et al. (2014). Ten-year effects of the advanced cognitive training for
independent and vital elderly cognitive training trial on cognition
and everyday functioning in older adults. [randomized controlled
trial research support, N.I.H., extramural research support, non-
U.S. Gov’t. Journal of the American Geriatrics Society, 62(1), 16–
24. doi:10.1111/jgs.12607.
Reijnders, J., van Heugten, C., & van Boxtel, M. (2013). Cognitive in-
terventions in healthy older adults and people with mild cognitive
impairment: a systematic review. Ageing Research Reviews, 12(1),
263–275. doi:10.1016/j.arr.2012.07.003.
Reitan, R. M. (1979). Manual for administration for neuropsychological
test batteries for adults and children. Tucson, AZ: Reitan
Neuropsychological Laboratory.
Rojas, G. J., et al. (2013). Efficacy of a cognitive intervention program in
patients with mild cognitive impairment. International
Psychogeriatrics, 25(5), 825–831.
Royall, D. R., Chiodo, L. K., & Polk, M. J. (2000). Correlates of disability
among elderly retirees with "subclinical" cognitive impairment. The
269
Journals of Gerontology. Series A, Biological Sciences and Medical
Sciences, 55(9), M541–M546.
Royall, D. R., Lauterbach, E. C., Kaufer, D., Malloy, P., Coburn, K. L.,
Black, K. J., et al. (2007). The cognitive correlates of functional
status: a review from the committee on research of the American
neuropsychiatric association. The Journal of Neuropsychiatry and
Clinical Neurosciences, 19(3), 249–265. doi:10.1176
/jnp.2007.19.3.249.
Sitzer, D. I., Twamley, E. W., & Jeste, D. V. (2006). Cognitive training in
Alzheimer’s disease: a meta-analysis of the literature. Acta
Psychiatrica Scandinavica, 114(2), 75–90, doi:10.1111/j.1600–
0447.2006.00789.x.
Spencer-Smith, M., & Klingberg, T. (2015). Benefits of a working mem-
ory training program for inattention in daily life: a systematic review
and meta-analysis. PLoS ONE [Electronic Resource], 10(3),
e0119522. doi:10.1371/journal.pone.0119522.
Sperling, R. A., Aisen, P. S., Beckett, L. A., Bennett, D. A., Craft, S.,
Fagan, A. M., et al. (2011). Toward defining the preclinical stages of
Alzheimer’s disease: recommendations from the National Institute
on Aging-Alzheimer’s association workgroups on diagnostic guide-
lines for Alzheimer’s disease. Alzheimers Dement, 7(3), 280–292.
doi:10.1016/j.jalz.2011.03.003.
Sterne, J. A., Sutton, A. J., Ioannidis, J. P., et al. (2011). Recommendations
for examining and interpreting funnel plot asymmetry in meta-
analyses of randomised controlled trials. BMJ, 343, d4002.
Stine-Morrow, E. A., Payne, B. R., Roberts, B. W., Kramer, A. F.,
Morrow, D. G., Payne, L., et al. (2014). Training versus engagement
as paths to cognitive enrichment with aging. [Randomized
Controlled Trial Research Support, N.I.H., Extramural].
Psychology and Aging, 29(4), 891–906. doi:10.1037/a0038244.
Strauss, E., Sherman, E. M. S., & Spreen, O. (2006). A compendium of
neuropsychological tests: Administration, norms, and commentary
(3rd ed.): Oxford University Press.
Thurstone, L., & Thurstone, T. (1949). Examiner Manual for the SRA
Primary Mental Abilities Test (Form 10–14). Chicago, ILL.: Science
Research Associates.
Unverzagt, F. W., Guey, L. T., Jones, R. N., Marsiske, M., King, J. W.,
Wadley, V. G., et al. (2012). ACTIVE cognitive training and rates of
incident dementia. Journal of the International Neuropsychological
Society, 18(4), 669–677. doi:10.1017/s1355617711001470.
van Hooren, S. A. H., Valentijn, S. A. M., Bosma, H., Ponds, R. W. H. M.,
van Boxtel, M. P. J., Levine, B., Robertson, I., & Jolles, J. (2007)
Effect of a structured course involving goal management training in
older adults: A randomised controlled trial. Patient Education and
Counseling, 65(2), 205-213. doi:10.1016/j.pec.2006.07.010.
Valenzuela, M., & Sachdev, P. (2009). Can cognitive exercise prevent the
onset of dementia? Systematic review of randomized clinical trials
with longitudinal follow-up. The American Journal of Geriatric
Psychiatry, 17(3), 179–187. doi:10.1097/JGP.0b013e3181953b57.
Vaughan, L., & Giovanello, K. (2010). Executive function in daily life: Age-
related influences of executive processes on instrumental activities of
daily living. Psychology and Aging, 25(2), 343–355. doi:10.1037
/a0017729.
Walton, C. C., Mowszowski, L., Lewis, S. J., & Naismith, S. L. (2014).
Stuck in the mud: time for change in the implementation of cognitive
training research in ageing? Frontiers in Aging Neuroscience, 6, 43.
doi:10.3389/fnagi.2014.00043.
Williams, K., Herman, R., & Bontempo, D. (2014). Reasoning Exercises
in Assisted Living: a cluster randomized trial to improve reasoning
and everyday problem solving. [Comparative Study Multicenter
Study Randomized Controlled Trial Research Support, N.I.H.,
Extramural]. Clinical Interventions in Aging, 9, 981–996,
doi:10.2147/CIA.S62095.
270
Willis, S. L., Tennstedt, S. L., Marsiske, M., Ball, K., Elias, J., Koepke, K.
M., et al. (2006). Long-term effects of cognitive training on every-
day functional outcomes in older adults. [multicenter study random-
ized controlled trial research support, N.I.H., extramural. JAMA,
296(23), 2805–2814.
View publication stats
Neuropsychol Rev (2016) 26:252–270
Winblad, B., Palmer, K., Kivipelto, M., Jelic, V., Fratiglioni, L., Wahlund,
L.-O., et al. (2004). Mild cognitive impairment – beyond controver-
sies, towards a consensus: report of the international working group
on mild cognitive impairment. Journal of Internal Medicine, 256(3),
240–246. doi:10.1111/j.1365-2796.2004.01380.x.