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Effects of working memory training on cognition in healthy older adults: A systematic review

EFEITOS DO TREINO DE MEMÓRIA OPERACIONAL NA COGNIÇÃO DE IDOSOS SAUDÁVEIS: UM ESTUDO DE REVISÃO SISTEMÁTICA

ABSTRACT.

The working memory (WM) training in older adults can benefit their cognition. However, there is a dearth of literature reviews on the subject.

Objective:

This study aimed to investigate and evaluate the effects of WM training on the cognition of healthy older adults, in individual and group interventions reported in the literature.

Methods:

This is a systematic review involving a qualitative analysis of publications on the SciELO, LILACS, and MEDLINE databases carried out between March and June 2021.

Results:

A total of 47 studies were identified and analyzed, comprising 40 in older adults only and 7 comparing older and younger adults, investigating individual or group WM training or other types of intervention focused on WM effects.

Conclusions:

Both individual and group intervention contributed to the maintenance and/or improvement of cognition in older adults exploiting brain plasticity to promote mental health and prevent cognitive problems that can negatively impact quality of life of this group.

Keywords:
Memory, Short-Term; Cognitive Aging; Executive Function; Spatial Memory; Mental Health

RESUMO.

O treino da memória operacional (WM) com idosos pode gerar benefícios em sua cognição. Entretanto, há escassez de revisões da literatura sobre o tema.

Objetivo:

Investigar e avaliar, na literatura, os efeitos do treino da WM na cognição de idosos saudáveis, em intervenções individuais e grupais.

Métodos:

Estudo de revisão sistemática realizado entre março e junho de 2021, utilizando-se as bases Scientific Electronic Library Online (SciELO), Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS) e Medical Literature Analysis and Retrieval System Online (MEDLINE).

Resultados:

Foram identificados e analisados 47 estudos, 40 apenas com idosos, e sete comparativos entre idosos e adultos mais jovens, que realizaram treino individual ou em grupo com foco nos efeitos na WM.

Conclusões:

Os trabalhos analisados mostraram que ambos os tipos de intervenções podem contribuir para a manutenção e/ou melhoria da cognição de pessoas idosas, aproveitando sua plasticidade cerebral e, portanto, para a promoção de sua saúde mental e para a prevenção de problemas cognitivos que podem interferir em sua qualidade de vida.

Palavras-chave:
Memória de Curto Prazo; Envelhecimento Cognitivo; Função Executiva; Memória Espacial; Saúde Mental

INTRODUCTION

The growth in the population of older people has led to a shift in epidemiological profile, changes that pose a major challenge to health systems worldwide. Multidisciplinary, preventive actions involving monitoring of the aging process are needed to reduce this burden11. Miranda GMD, Mendes ACG, Silva ALA. Population aging in Brazil: current and future social challenges and consequences. Rev Bras Geriatr Gerontol. 2016;19(3):507-19. https://doi.org/10.1590/1809-98232016019.150140
https://doi.org/https://doi.org/10.1590/...
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A prevalent health issue associated with aging is dementia. According to the World Health Organization22. World Health Organization. Dementia cases set to triple by 2050 but still largely ignored. Available from: https://www.who.int/news/item/11-04-2012-dementia-cases-set-to-triple-by-2050-but-still-largely-ignored
https://www.who.int/news/item/11-04-2012...
, the number of individuals presenting some degree of dementia syndrome may triple by 2050 compared with 2012 levels, with low- to middle-income countries set to be most affected33. Santos CS, Bessa TA, Xavier AJ. Fatores associados à demência em idosos. Ciênc Saúde Coletiva. 2020;25(2):603-11. https://doi.org/10.1590/1413-81232020252.02042018
https://doi.org/https://doi.org/10.1590/...
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Memory is a cognitive function that can be negatively impacted by different types of dementia or cognitive impairments that are precursors of a dementia syndrome diagnosis. Working memory (WM) is a type of short-term memory involved in the concurrent storage and processing of information before and during the execution of a given task44. Baddeley A. Working memory: theories, models, and controversies. Annu Rev Psychol. 2012;63:1-29. https://doi.org/10.1146/annurev-psych-120710-100422
https://doi.org/https://doi.org/10.1146/...
,55. Brum PS. Treino de memória operacional para idosos saudáveis: impacto do número de sessões e grau de escolaridade dos participantes na eficácia da intervenção [tese]. São Paulo: Faculdade de Medicina, Universidade de São Paulo, 2017. https://doi.org/10.11606/T.5.2018.tde-12012018-084240.
https://doi.org/https://doi.org/10.11606...
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Literature reveals that memory can be understood as long term or short term. The first is associated with the permanent storage of information, which can be retrieved and recalled at any time. The second, in turn, is related to the ability to memorize a limited amount of information over a short period of time. Long-term memory is subdivided into episodic, semantic, autobiographical, prospective, procedural, preactivation, and conditioning memory. While short-term memory refers to immediate memory and WM66. Cecchini MA, Cassimiro L, Barea KS, Yassuda MS Envelhecimento e cognição: memória, funções executivas e linguagem. In: Freita EV, Py L, eds. Tratado de Geriatria e Gerontologia. Rio de Janeiro: Guanabara Koogan; 2016. p. 2235-2240..

According to the literature review by Chai et al., different models describe the concept of WM, among which two stand out. The first is known as the multicomponent WM model, in which WM is seen as a system capable of providing information for the execution of more complex cognitive activities. In this model, there is a center that manages visuospatial skills, speech therapy, and multimodal information related to episodic memory, forming the WM. The second model highlights the influence of attentional cognitive ability in the formation of WM, in addition to identifying this subtype of memory as an integrated part of long-term memory77. Chai WJ, Hamid AIA, Abdullah JM. Working memory from the psychological and neurosciences perspectives: a review. Front Psychol. 2018;9:401. https://doi.org/10.3389/fpsyg.2018.00401
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Working memory is one of the most affected cognitive functions in the aging process. The literature explains that the areas of the prefrontal cortex, the region responsible for the functioning of WM, can suffer more significant impacts over time, which impairs the execution of tasks that require the processing and temporary storage of information, such as visuospatial information and verbal. Through visuospatial memory, the individual has the ability to understand their own spatial location, as well as the arrangement of objects in spaces and the identification of colors, textures, and shapes. Verbal memory is related to the skills of remembering, evoking, and understanding words, either written or verbal88. Santos FS, Silva TBL, Almeida EB, Oliveira EM. Estimulação cognitiva para idosos: ênfase em memória. São Paulo: Atheneu; 2018..

In this context, nonpharmacological interventions, including cognitive interventions, emerge as viable strategies for preventing cognitive decline and promoting mental health. Intervention strategies as a way of maintaining and improving the functioning of cognitive skills are possible due to the brain’s plasticity capacity. Neuroplasticity refers to the increase in the formation of the number of dendrites, axons, and synapses, from external events, which favor cognitive functionality99. Malloy-Diniz L, Fluentes D, Consenza RM. Neuropsicologia do envelhecimento: uma abordagem multidimensional. Porto Alegre: Artmed; 2013..

The deliberate practice of one or more cognitive skills via standardized activities is referred to as cognitive training (CT), which can be characterized as strategy-based cognitive training (SCT) or procedure-based cognitive training (PCT). The SCT is configured as an intervention with an emphasis on compensatory practices in which a facilitator provides instructions and resources that help in the execution of specific tasks and activities that present some commitment. The use of lists, calendars, and organization methods are some examples1010. Mowszowski L, Lampit A, Walton CC, Naismith SL. Strategy-based cognitive training for improving executive functions in older adults: a systematic review. Neuropsychol Rev. 2016;26(3):252-70. https://doi.org/10.1007/s11065-016-9329-x
https://doi.org/https://doi.org/10.1007/...
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In relation to PCT, this modality aims to achieve better functioning of specific cognitive functions, but does not provide compensatory strategies as in the model mentioned above. Due to this characteristic, the PCT presents a greater possibility of obtaining benefits for other skills in addition to the trained one1111. Karbach J, Verhaeghen P. Making working memory work: a meta-analysis of executive-control and working memory training in older adults. Psychol Sci. 2014;25(11):2027-37. https://doi.org/10.1177/0956797614548725
https://doi.org/https://doi.org/10.1177/...
. An example of this type of cognitive intervention is WM training, which aimed at stimulating cognition through exercises for enhancing attention, memory performance, and concentration55. Brum PS. Treino de memória operacional para idosos saudáveis: impacto do número de sessões e grau de escolaridade dos participantes na eficácia da intervenção [tese]. São Paulo: Faculdade de Medicina, Universidade de São Paulo, 2017. https://doi.org/10.11606/T.5.2018.tde-12012018-084240.
https://doi.org/https://doi.org/10.11606...
. Brum55. Brum PS. Treino de memória operacional para idosos saudáveis: impacto do número de sessões e grau de escolaridade dos participantes na eficácia da intervenção [tese]. São Paulo: Faculdade de Medicina, Universidade de São Paulo, 2017. https://doi.org/10.11606/T.5.2018.tde-12012018-084240.
https://doi.org/https://doi.org/10.11606...
demonstrated the effectiveness of WM training in cognitively healthy older adults, who showed performance gains on cognitive tests performed pre- and post-intervention.

Brum et al.1212. Brum PS, Borella E, Carretti B, Yassuda MS. Working memory training format in older adults: individual versus group sessions. Aging Clin Exp Res. 2020;32(11):2357-66. https://doi.org/10.1007/s40520-019-01468-0
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carried out a study using individual WM training involving an adaptive scheme that allowed difficulty levels to be personalized. The results showed that three sessions of individual training promoted long-term gains in the cognitive skills trained plus a transfer effect to nontrained skills. The benefits, however, extended to include improvements in fluid intelligence, text comprehension, processing speed, and activities of daily living (ADLs).

From the research studies on the effects of WM training, those that present transfer results allow the association of this training modality to greater neuroplasticity, since the more cognitive regions are stimulated, the better performance of the respective functions is achieved, new skills are learned, and available cognitive resources are put to better use1313. Borella E, Carretti B, Zanoni G, Zavagnin M, De Beni R. Working memory training in old age: an examination of transfer and maintenance effects. Arch Clin Neuropsychol. 2013;28(4):331-47. https://doi.org/10.1093/arclin/act020
https://doi.org/https://doi.org/10.1093/...
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Although the results by Brum et al were positive, there are controversies in the literature about the benefits of close transference (for WM) and distant transference (for other cognitive skills) in WM training. The meta-analysis conducted by Sala et al, for example, aimed to investigate the effects of WM training on the cognitive abilities of the elderly. Only trained skills demonstrate significant improvement, indicating the absence of general benefits1414. Sala G, Aksayli ND, Tatlidil KS, Gondo Y, Gobet F. Working memory training does not enhance older adults’ cognitive skills: a comprehensive meta-analysis. Intelligence. 2019;77:101386. https://doi.org/10.1016/j.intell.2019.101386
https://doi.org/https://doi.org/10.1016/...
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Recent evidence suggests WM training interventions in healthy older adults can potentiate brain plasticity, leading to not only near-transfer effects in performance on tasks measured within the same CT construct but also nontrained and far-transfer effects, improving performance on tasks measured under constructs not targeted by the CT. Factors such as age and education level can influence the short- and long-term effects1515. Borella E, Carbone E, Pastore M, De Beni R, Carretti B. Working memory training for healthy older adults: the role of individual characteristics in explaining short- and long-term gains. Front Hum Neurosci. 2017;11:99. https://doi.org/10.3389/fnhum.2017.00099
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In the meta-analysis, Karbach and Verhaeghen1111. Karbach J, Verhaeghen P. Making working memory work: a meta-analysis of executive-control and working memory training in older adults. Psychol Sci. 2014;25(11):2027-37. https://doi.org/10.1177/0956797614548725
https://doi.org/https://doi.org/10.1177/...
analyzed the efficacy of WM training in enhancing the capacity and functioning of WM, and of executive functions training, focused on improving performance on dual-task, inhibitory and interference control, task switching, and general forms of attention, comparing the differences between young adults and older. The findings showed gains in the cognitive skills trained and small-to-moderate transfer effects to the global cognitive system. The authors concluded that training based on WM processes and executive functions was highly effective, suggesting that this type of cognitive intervention in older adults can help promote healthy aging1111. Karbach J, Verhaeghen P. Making working memory work: a meta-analysis of executive-control and working memory training in older adults. Psychol Sci. 2014;25(11):2027-37. https://doi.org/10.1177/0956797614548725
https://doi.org/https://doi.org/10.1177/...
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Other more recent meta-analyses have evaluated the results of WM training, considering transfer effects as well as long-term effects. However, unlike what the present review proposes to do, there was no comparison between effects in young and elderly adults1414. Sala G, Aksayli ND, Tatlidil KS, Gondo Y, Gobet F. Working memory training does not enhance older adults’ cognitive skills: a comprehensive meta-analysis. Intelligence. 2019;77:101386. https://doi.org/10.1016/j.intell.2019.101386
https://doi.org/https://doi.org/10.1016/...
,1616. Teixeira-Santos AC, Moreira CS, Magalhães R, Magalhães C, Pereira DR, Leite J, et al. Reviewing working memory training gains in healthy older adults: a meta-analytic review of transfer for cognitive outcomes. Neurosci Biobehav Rev. 2019;103:163-77. https://doi.org/10.1016/j.neubiorev.2019.05.009
https://doi.org/https://doi.org/10.1016/...
,1717. Nguyen L, Murphy K, Andrews G. Immediate and long-term efficacy of executive functions cognitive training in older adults: a systematic review and meta-analysis. Psychol Bull. 2019;145(7):698-733. https://doi.org/10.1037/bul0000196
https://doi.org/https://doi.org/10.1037/...
,1818. Hou J, Jiang T, Fu J, Su B, Wu H, Sun R, et al. The long-term efficacy of working memory training in healthy older adults: a systematic review and meta-analysis of 22 randomized controlled trials. J Gerontol B Psychol Sci Soc Sci. 2020;75(8):e174-e188, https://doi.org/10.1093/geronb/gbaa077
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, or samples with multiple age groups were included, or only computerized CT was considered1919. Schwaighofer M, Fischer F, Bühner M. Does working memory training transfer? A meta-analysis including training conditions as moderators. Educational Psychologist. 2015;50(2):138-66. https://doi.org/10.1080/00461520.2015.1036274
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The objective of this systematic review, involving a qualitative analysis, was to investigate and evaluate the effects of WM training on the cognition in healthy older adults, based on individual and group interventions reported in the literature.

METHODS

A systematic review involving a qualitative analysis was conducted between March and June 2021. All relevant articles published in Portuguese or English were selected according to predefined inclusion and exclusion criteria. The SciELO, LILACS, and MEDLINE electronic databases were searched using the following combination of keywords: (idosa OR idoso OR idosos OR idosas) OR (elder OR “older person” OR “older persons” OR “older people” OR “senior citizen” “senior citizens” OR elderly OR “aging people” OR “aging person” OR “aging persons” OR “older adult” OR “older adults”) AND (“intervenção cognitiva” OR “intervenções cognitivas” OR “treino cognitivo” OR “cognitive intervention” OR “cognitive interventions” OR “cognitive training”) AND (“memória operacional” OR “memória de trabalho” OR “working memory” OR “operational memory”) AND (envelhecimento OR aging).

Inclusion criteria were as follows: randomized clinically controlled trials published in Portuguese or English in scientific journals from 2011 onward; CT interventions focused on WM training, individual or group based; healthy participants aged over 60 years; and the use of cognitive and/or neuropsychological tests to determine the effects of the interventions.

The exclusion criteria adopted were as follows: publications of masters’ dissertations, book chapters, doctoral theses, letters to the editor, case studies, systematic and meta-analysis reviews, and research protocols; studies involving cognitive interventions combined with physical training, other types of intervention, and/or multimode intervention studies; participants aged <60 years (in studies of older adults only) presenting cognitive impairment or risk of developing dementia or cognitive decline; trials performed in residential care homes, such as Long-term Care Facilities (LTCFs); and studies that do not assess intervention effects on cognitive performance of participants.

To guide the stages of identifying, screening, and determining eligibility of studies, two independent reviewers performed the steps of the Statement of Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA)2020. Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(7):e1000097. https://doi.org/10.1371/journal.pmed.1000097.
https://doi.org/https://doi.org/10.1371/...
. The initial identification of studies entailed searches of the databases specified. During the screening stage, duplicate studies were removed and titles and abstracts analyzed by applying the predefined inclusion and exclusion criteria. For the eligibility stage, the selected studies were read in full and analyzed against the same criteria. The studies remaining after this stage were included in the review.

The scope of the study’s systematic review was registered on the International Prospective Register of Systematic Reviews (PROSPERO)2121. Silva TBL, Barbosa MEC, Brucki SMD, Yassuda MS, Lessa PP, Verga CER, et al. Effects of working memory training on cognition in healthy older adults: a systematic review. PROSPERO 2021. Available from: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=245439
https://www.crd.york.ac.uk/prospero/disp...
under registration number CRD42021245439. In addition, the included studies were rated for quality according to the Downs and Black Checklist2222. Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health. 1998;52(6):377-84. https://doi.org/10.1136/jech.52.6.377
https://doi.org/https://doi.org/10.1136/...
. This evaluation tool devised by Downs and Black comprises 27 items distributed between 5 sub-scales: reporting or assessment (10 items), external validity (3), internal validity of the measurements described and outcome bias (7), Confounding factors (6), and Power (1). Checklist items were scored 0 or 1, except for the item assessing the reporting of confounding factors, which score 0-2 points, and the item on power (item 27) modified as per other studies2222. Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health. 1998;52(6):377-84. https://doi.org/10.1136/jech.52.6.377
https://doi.org/https://doi.org/10.1136/...
,2323. Ratcliffe E, Pickering S, McLean S, Lewis J. Is there a relationship between subacromial impingement syndrome and scapular orientation? A systematic review. Br J Sports Med. 2014;48(16):1251-6. https://doi.org/10.1136/bjsports-2013-092389.
https://doi.org/https://doi.org/10.1136/...
, whose original scoring of 0-5 points was changed to score 0 or 1 point, with a score of 1 given if the article reported calculation of power and/or sample size and 0 if these calculations had not been performed. Thus, the total scores on the Checklist ranged from 0 to 28 points. To improve the reading of the data obtained, scores were converted into percentages for each domain and an overall mean total score for all domains was calculated. A system for classifying the quality of articles was defined as follows: ≤0.39 poor, 0.40-0.69 regular, 0.70-0.79 good, and ≥0.80 excellent.

RESULTS

A total of 229 studies were retrieved in the initial search, 6 of which were subsequently excluded because they were duplicates. Titles and abstracts of the remaining 223 studies were read and screened for relevance to the review and selected according to the inclusion and exclusion criteria. Thus, 71 articles were read in full and, after rigorous application of the criteria, a further 24 were excluded, of which 4 did not have a control group and a training group, 3 did not evaluate the effects of the intervention, 9 did not use a strategy directed to WM, 5 included elderly and nonelderly in the same groups, 2 had a group of elderly people with mild cognitive impairment (MCI), and 1 was published in Spanish. The study selection process is shown in the flow diagram2020. Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(7):e1000097. https://doi.org/10.1371/journal.pmed.1000097.
https://doi.org/https://doi.org/10.1371/...
depicted in Figure 1.

Figure 1.
Flowchart of study search and review process.

The objectives, methods, and results of the 47 studies selected for analysis are listed in Tables 1 and 2. Regarding the sample profiles, 40 studies involved older adults only, of which 34 performed WM training. Of this total, 25 applied individual interventions1313. Borella E, Carretti B, Zanoni G, Zavagnin M, De Beni R. Working memory training in old age: an examination of transfer and maintenance effects. Arch Clin Neuropsychol. 2013;28(4):331-47. https://doi.org/10.1093/arclin/act020
https://doi.org/https://doi.org/10.1093/...
,2424. Anguera JA, Boccanfuso J, Rintoul JL, Al-Hashimi O, Faraji F, Janowich J, et al. Video game training enhances cognitive control in older adults. Nature. 2013;501(7465):97-101. https://doi.org/10.1038/nature12486
https://doi.org/https://doi.org/10.1038/...
,2525. Benjamin DR, van de Water ATM, Peiris CL. Effects of exercise on diastasis of the rectus abdominis muscle in the antenatal and postnatal periods: a systematic review. Physiotherapy. 2014;100(1):1-8. https://doi.org/10.1016/j.physio.2013.08.005
https://doi.org/https://doi.org/10.1016/...
,2626. Engers PB, Rombaldi AJ, Portella EG, Silva MC. The effects of the Pilates method in the elderly: a systematic review. Rev Bras Reumatol. 2016;56(4):352-65. https://doi.org/10.1016/j.rbre.2016.05.005
https://doi.org/https://doi.org/10.1016/...
,2727. Basak C, O’Connell MA. To switch or not to switch: role of cognitive control in working memory training in older adults. Front Psychol. 2016;7:230. https://doi.org/10.3389/fpsyg.2016.00230
https://doi.org/https://doi.org/10.3389/...
,2828. Binder JC, Martin M, Zöllig J, Röcke C, Mérillat S, Eschen A, et al. Multi-domain training enhances attentional control. Psychol Aging. 2016;31(4):390-408. https://doi.org/10.1037/pag0000081
https://doi.org/https://doi.org/10.1037/...
,2929. Borella E, Carretti B, Cantarella A, Riboldi F, Zavagnin M, De Beni R. Benefits of training visuospatial working memory in young-old and old-old. Dev Psychol. 2014;50(3):714-27. https://doi.org/10.1037/a0034293
https://doi.org/https://doi.org/10.1037/...
,3030. Borella E, Cantarella A, Carretti B, De Lucia A, De Beni R. Improving everyday functioning in the old-old with working memory training. Am J Geriatr Psychiatry. 2019;27(9):975-83. https://doi.org/10.1016/j.jagp.2019.01.210
https://doi.org/https://doi.org/10.1016/...
,3131. Borella E, Carretti B, Meneghetti C, Carbone E, Vincenzi M, Madonna JC, et al. Is working memory training in older adults sensitive to music? Psychol Res. 2019;83(6):1107-23. https://doi.org/10.1007/s00426-017-0961-8.
https://doi.org/https://doi.org/10.1007/...
,3232. Borella E, Carretti B, Sciore R, Capotosto E, Taconnat L, Cornoldi C, et al. Training working memory in older adults: is there an advantage of using strategies? Psychol Aging. 2017;32(2):178-91. https://doi.org/10.1037/pag0000155
https://doi.org/https://doi.org/10.1037/...
,3333. Cantarella A, Borella E, Carretti B, Kliegel M, de Beni R. Benefits in tasks related to everyday life competences after a working memory training in older adults. Int J Geriatr Psychiatry. 2017;32(1):86-93. https://doi.org/10.1002/gps.4448
https://doi.org/https://doi.org/10.1002/...
,3434. Ghavidel F, Fadardi JS, Gatto NM, Sedaghat F, Tabibi Z. Feasibility of using a computer-assisted working memory training program for healthy older women. Cogn Process. 2020;21(3):383-90. https://doi.org/10.1007/s10339-020-00975-7
https://doi.org/https://doi.org/10.1007/...
,3535. Guye S, von Bastian CC. Working memory training in older adults: Bayesian evidence supporting the absence of transfer. Psychol Aging. 2017;32(8):732-46. https://doi.org/10.1037/pag0000206
https://doi.org/https://doi.org/10.1037/...
,3636. Heinzel S, Rimpel J, Stelzel C, Rapp MA. Transfer effects to a multimodal dual-task after working memory training and associated neural correlates in older adults - a pilot study. Front Hum Neurosci. 2017;11:85. https://doi.org/10.3389/fnhum.2017.00085
https://doi.org/https://doi.org/10.3389/...
,3737. Lebedev AV, Nilsson J, Lövdén M. Working memory and reasoning benefit from different modes of large-scale brain dynamics in healthy older adults. J Cogn Neurosci. 2018;30(7):1033-46. https://doi.org/10.1162/jocn_a_01260
https://doi.org/https://doi.org/10.1162/...
,3838. Maraver MJ, Gómez-Ariza CJ, Borella E, Bajo MT. Baseline capacities and motivation in executive control training of healthy older adults. Aging Ment Health. 2022;26(3):595-603. https://doi.org/10.1080/13607863.2020.1858755
https://doi.org/https://doi.org/10.1080/...
,3939. Matysiak O, Kroemeke A, Brzezicka A. Working memory capacity as a predictor of cognitive training efficacy in the elderly population. Front Aging Neurosci. 2019;11:126. https://doi.org/10.3389/fnagi.2019.00126
https://doi.org/https://doi.org/10.3389/...
,4040. McAvinue LP, Golemme M, Castorina M, Tatti E, Pigni FM, Salomone S, et al. An evaluation of a working memory training scheme in older adults. Front Aging Neurosci. 2013;5:20. https://doi.org/10.3389/fnagi.2013.00020
https://doi.org/https://doi.org/10.3389/...
,4141. Payne BR, Stine-Morrow EAL. The effects of home-based cognitive training on verbal working memory and language comprehension in older adulthood. Front Aging Neurosci. 2017;9:256. https://doi.org/10.3389/fnagi.2017.00256
https://doi.org/https://doi.org/10.3389/...
,4242. Richmond LL, Morrison AB, Chein JM, Olson IR. Working memory training and transfer in older adults. Psychol Aging. 2011;26(4):813-22. https://doi.org/10.1037/a0023631
https://doi.org/https://doi.org/10.1037/...
,4343. Schmicker M, Menze I, Koch D, Rumpf U, Müller P, Pelzer L, et al. Decision-making deficits in elderly can be alleviated by attention training. J Clin Med. 2019;8(8):1131. https://doi.org/10.3390/jcm8081131
https://doi.org/https://doi.org/10.3390/...
,4444. Simon SS, Tusch ES, Feng NC, Håkansson K, Mohammed AH, Daffner KR. Is computerized working memory training effective in healthy older adults? Evidence from a multi-site, randomized controlled trial. J Alzheimers Dis. 2018;65(3):931-49. https://doi.org/10.3233/JAD-180455
https://doi.org/https://doi.org/10.3233/...
,4545. Stamenova V, Jennings JM, Cook SP, Walker LAS, Smith AM, Davidson PSR. Training recollection in healthy older adults: clear improvements on the training task, but little evidence of transfer. Front Hum Neurosci. 2014;8:898. https://doi.org/10.3389/fnhum.2014.00898.
https://doi.org/https://doi.org/10.3389/...
,4646. Stepankova H, Lukavsky J, Buschkuehl M, Kopecek M, Ripova D, Jaeggi SM. The malleability of working memory and visuospatial skills: a randomized controlled study in older adults. Dev Psychol. 2014;50(4):1049-59. https://doi.org/10.1037/a0034913
https://doi.org/https://doi.org/10.1037/...
,4747. Strenziok M, Parasuraman R, Clarke E, Cisler DS, Thompson JC, Greenwood PM. Neurocognitive enhancement in older adults: comparison of three cognitive training tasks to test a hypothesis of training transfer in brain connectivity. Neuroimage. 2014;85 Pt:1027-39. https://doi.org/10.1016/j.neuroimage.2013.07.069.
https://doi.org/https://doi.org/10.1016/...
,4848. Wilkinson AJ, Yang L. Long-term maintenance of inhibition training effects in older adults: 1- and 3-year follow-up. J Gerontol B Psychol Sci Soc Sci. 2016;71(4):622-9. https://doi.org/10.1093/geronb/gbu179
https://doi.org/https://doi.org/10.1093/...
,4949. Zinke K, Zeintl M, Rose NS, Putzmann J, Pydde A, Kliegel M. Working memory training and transfer in older adults: effects of age, baseline performance, and training gains. Dev Psychol. 2014;50(1):304-15. https://doi.org/10.1037/a0032982
https://doi.org/https://doi.org/10.1037/...
,5050. Irigaray TQ, Gomes Filho I, Schneider RH. Efeitos de um treino de atenção, memória e funções executivas na cognição de idosos saudáveis. Psicol Reflex Crít. 2012;25(1):188-202. https://doi.org/10.1590/S0102-79722012000100023
https://doi.org/https://doi.org/10.1590/...
,5151. Ji Y, Wang J, Chen T, Du X, Zhan Y. Plasticity of inhibitory processes and associated far-transfer effects in older adults. Psychol Aging. 2016;31(5):415-29. https://doi.org/10.1037/pag0000102
https://doi.org/https://doi.org/10.1037/...
,5252. Kazazi L, Shati M, Mortazavi SS, Nejati V, Foroughan M. The impact of computer-based cognitive training intervention on the quality of life among elderly people: a randomized clinical trial. Trials. 2021;22(1):51. https://doi.org/10.1186/s13063-020-05008-4
https://doi.org/https://doi.org/10.1186/...
,5353. Loosli SV, Falquez R, Unterrainer JM, Weiller C, Rahm B, Kaller CP. Training of resistance to proactive interference and working memory in older adults: a randomized double-blind study. Int Psychogeriatr. 2016;28(3):453-67. https://doi.org/10.1017/S1041610215001519
https://doi.org/https://doi.org/10.1017/...
,5454. Netto TM, Greca DV, Zimmermann N, Oliveira CR, Teixeira-Leite HM, Fonseca RP, et al. Efeito de um programa de treinamento da memória de trabalho em adultos idosos. Psicol Reflex Crit. 2013;26(1):122-35. https://doi.org/10.1590/S0102-79722013000100014
https://doi.org/https://doi.org/10.1590/...
,5555. Weicker J, Hudl N, Frisch S, Lepsien J, Mueller K, Villringer A, et al. WOME: theory-based working memory training - a placebo-controlled, double-blind evaluation in older adults. Front Aging Neurosci. 2018;10:247. https://doi.org/10.3389/fnagi.2018.00247
https://doi.org/https://doi.org/10.3389/...
,5656. van Muijden J, Band GPH, Hommel B. Online games training aging brains: limited transfer to cognitive control functions. Front Hum Neurosci. 2012;6:221. https://doi.org/10.3389/fnhum.2012.00221
https://doi.org/https://doi.org/10.3389/...
,5757. Zimmermann N, Netto TM, Amodeo MT, Ska B, Fonseca RP. Working memory training and poetry-based stimulation programs: are there differences in cognitive outcome in healthy older adults? NeuroRehabilitation. 2014;35(1):159-70. https://doi.org/10.3233/NRE-141104
https://doi.org/https://doi.org/10.3233/...
. Seven studies of older adults performed a variety of interventions centered on WM effects, comprising two with individual training5858. Cujzek M, Vranic A. Computerized tabletop games as a form of a video game training for old-old. Neuropsychol Dev Cogn B Aging Neuropsychol Cogn. 2017;24(6):631-48. https://doi.org/10.1080/13825585.2016.1246649
https://doi.org/https://doi.org/10.1080/...
,5959. Toril P, Reales JM, Mayas J, Ballesteros S. Video game training enhances visuospatial working memory and episodic memory in older adults. Front Hum Neurosci. 2016;10:206. https://doi.org/10.3389/fnhum.2016.00206.
https://doi.org/https://doi.org/10.3389/...
and five with group training6060. Berggren R, Nilsson J, Brehmer Y, Schmiedek F, Lövdén M. Foreign language learning in older age does not improve memory or intelligence: evidence from a randomized controlled study. Psychol Aging. 2020;35(2):212-9. https://doi.org/10.1037/pag0000439
https://doi.org/https://doi.org/10.1037/...
,6161. Degé F, Kerkovius K. The effects of drumming on working memory in older adults. Ann N Y Acad Sci. 2018;1423(1):242-50. https://doi.org/10.1111/nyas.13685
https://doi.org/https://doi.org/10.1111/...
,6262. Guo X, Yamashita M, Suzuki M, Ohsawa C, Asano K, Abe N, et al. Musical instrument training program improves verbal memory and neural efficiency in novice older adults. Hum Brain Mapp. 2021;42(5):1359-75. https://doi.org/10.1002/hbm.25298
https://doi.org/https://doi.org/10.1002/...
,6363. Wong PCM, Ou J, Pang CWY, Zhang L, Tse CS, Lam LCW, et al. Language training leads to global cognitive improvement in older adults: a preliminary study. J Speech Lang Hear Res. 2019;62(7):2411-24. https://doi.org/10.1044/2019_JSLHR-L-18-0321
https://doi.org/https://doi.org/10.1044/...
. The other seven studies analyzed involved young and older adults who underwent individual WM training, comparing the performance of the two age groups6464. Brehmer Y, Westerberg H, Bäckman L. Working-memory training in younger and older adults: training gains, transfer, and maintenance. Front Hum Neurosci. 2012;6:63. https://doi.org/10.3389/fnhum.2012.00063
https://doi.org/https://doi.org/10.3389/...
,6565. Chan JSY, Wu Q, Liang D, Yan JH. Visuospatial working memory training facilitates visually-aided explicit sequence learning. Acta Psychol (Amst). 2015;161:145-53. https://doi.org/10.1016/j.actpsy.2015.09.008
https://doi.org/https://doi.org/10.1016/...
,6666. Heinzel S, Schulte S, Onken J, Duong QL, Riemer TG, Heinz A, et al. Working memory training improvements and gains in non-trained cognitive tasks in young and older adults. Neuropsychol Dev Cogn B Aging Neuropsychol Cogn. 2014;21(2):146-73. https://doi.org/10.1080/13825585.2013.790338
https://doi.org/https://doi.org/10.1080/...
,6767. Rolle CE, Anguera JA, Skinner SN, Voytek B, Gazzaley A. Enhancing spatial attention and working memory in younger and older adults. J Cogn Neurosci. 2017;29(9):1483-97. https://doi.org/10.1162/jocn_a_01159
https://doi.org/https://doi.org/10.1162/...
,6868. Sandberg P, Rönnlund M, Nyberg L, Neely AS. Executive process training in young and old adults. Neuropsychol Dev Cogn B Aging Neuropsychol Cogn. 2014;21(5):577-605. https://doi.org/10.1080/13825585.2013.839777
https://doi.org/https://doi.org/10.1080/...
,6969. Sandberg P, Neely AS. Long-term effects of executive process training in young and old adults. Neuropsychol Rehabil. 2016;26(5-6):761-82. https://doi.org/10.1080/09602011.2015.1108205
https://doi.org/https://doi.org/10.1080/...
,7070. von Bastian CC, Langer N, Jäncke L, Oberauer K. Effects of working memory training in young and old adults. Mem Cognit. 2013;41(4):611-24. https://doi.org/10.3758/s13421-012-0280-7
https://doi.org/https://doi.org/10.3758/...
.

Table 1.
Studies with older adults.
Table 2.
Studies comparing older and younger adults.

The number of participants in the studies involving older adults only ranged from 14 to 235 subjects and maximum age was 95 years. Intervention duration ranged from 1 to 26 weeks, with a minimum of 5 and maximum of 50 sessions, and session length of 20-150 min each. Follow-up assessments took place within a period of 3 years post-intervention.

In studies comparing younger and older adults, the number of participants ranged from 43 to 123, mean age of older adults was 60-77 years, age of younger adults was 19-36 years, intervention duration was 2-5 weeks, and the number of sessions ranged from 10 to 25, with session duration of 10-60 min. Follow-up assessments were carried out within a period of 18 months post-intervention.

Finally, according to the scores for the categories of the methodological quality Checklist, none of the articles scored <0.68 points and 43 scored >0.70, attaining moderate-to-high score and good-to-excellent quality rating for the articles reviewed. Mean overall score for articles across all categories was 0.81 out of 1.0 in fulfilling Down and Black methodological quality requirements. The breakdown of scores by domain was as follows: reporting 0.95, external validity 0.51, bias/internal validity 0.62, confounding 0.99, and power 0.56 (Table 3).

Table 3.
Results of the downs and black checklist for the present systematic review.

DISCUSSION

The aim of this study was to investigate and evaluate the effects of WM training on the cognition of healthy elderly people, based on individual and group interventions reported in the literature. A total of 47 eligible studies with a wide range of objectives were selected for review.

As can be seen, the analyzed studies presented a variety of research methods and objectives related to WM training, among which the evaluation of the intervention effects on trained and untrained cognitive skills stands out2828. Binder JC, Martin M, Zöllig J, Röcke C, Mérillat S, Eschen A, et al. Multi-domain training enhances attentional control. Psychol Aging. 2016;31(4):390-408. https://doi.org/10.1037/pag0000081
https://doi.org/https://doi.org/10.1037/...
,2929. Borella E, Carretti B, Cantarella A, Riboldi F, Zavagnin M, De Beni R. Benefits of training visuospatial working memory in young-old and old-old. Dev Psychol. 2014;50(3):714-27. https://doi.org/10.1037/a0034293
https://doi.org/https://doi.org/10.1037/...
,3030. Borella E, Cantarella A, Carretti B, De Lucia A, De Beni R. Improving everyday functioning in the old-old with working memory training. Am J Geriatr Psychiatry. 2019;27(9):975-83. https://doi.org/10.1016/j.jagp.2019.01.210
https://doi.org/https://doi.org/10.1016/...
,3131. Borella E, Carretti B, Meneghetti C, Carbone E, Vincenzi M, Madonna JC, et al. Is working memory training in older adults sensitive to music? Psychol Res. 2019;83(6):1107-23. https://doi.org/10.1007/s00426-017-0961-8.
https://doi.org/https://doi.org/10.1007/...
,3232. Borella E, Carretti B, Sciore R, Capotosto E, Taconnat L, Cornoldi C, et al. Training working memory in older adults: is there an advantage of using strategies? Psychol Aging. 2017;32(2):178-91. https://doi.org/10.1037/pag0000155
https://doi.org/https://doi.org/10.1037/...
,3333. Cantarella A, Borella E, Carretti B, Kliegel M, de Beni R. Benefits in tasks related to everyday life competences after a working memory training in older adults. Int J Geriatr Psychiatry. 2017;32(1):86-93. https://doi.org/10.1002/gps.4448
https://doi.org/https://doi.org/10.1002/...
,3535. Guye S, von Bastian CC. Working memory training in older adults: Bayesian evidence supporting the absence of transfer. Psychol Aging. 2017;32(8):732-46. https://doi.org/10.1037/pag0000206
https://doi.org/https://doi.org/10.1037/...
,3939. Matysiak O, Kroemeke A, Brzezicka A. Working memory capacity as a predictor of cognitive training efficacy in the elderly population. Front Aging Neurosci. 2019;11:126. https://doi.org/10.3389/fnagi.2019.00126
https://doi.org/https://doi.org/10.3389/...
,4242. Richmond LL, Morrison AB, Chein JM, Olson IR. Working memory training and transfer in older adults. Psychol Aging. 2011;26(4):813-22. https://doi.org/10.1037/a0023631
https://doi.org/https://doi.org/10.1037/...
,4949. Zinke K, Zeintl M, Rose NS, Putzmann J, Pydde A, Kliegel M. Working memory training and transfer in older adults: effects of age, baseline performance, and training gains. Dev Psychol. 2014;50(1):304-15. https://doi.org/10.1037/a0032982
https://doi.org/https://doi.org/10.1037/...
,5050. Irigaray TQ, Gomes Filho I, Schneider RH. Efeitos de um treino de atenção, memória e funções executivas na cognição de idosos saudáveis. Psicol Reflex Crít. 2012;25(1):188-202. https://doi.org/10.1590/S0102-79722012000100023
https://doi.org/https://doi.org/10.1590/...
,5151. Ji Y, Wang J, Chen T, Du X, Zhan Y. Plasticity of inhibitory processes and associated far-transfer effects in older adults. Psychol Aging. 2016;31(5):415-29. https://doi.org/10.1037/pag0000102
https://doi.org/https://doi.org/10.1037/...
,5252. Kazazi L, Shati M, Mortazavi SS, Nejati V, Foroughan M. The impact of computer-based cognitive training intervention on the quality of life among elderly people: a randomized clinical trial. Trials. 2021;22(1):51. https://doi.org/10.1186/s13063-020-05008-4
https://doi.org/https://doi.org/10.1186/...
,5454. Netto TM, Greca DV, Zimmermann N, Oliveira CR, Teixeira-Leite HM, Fonseca RP, et al. Efeito de um programa de treinamento da memória de trabalho em adultos idosos. Psicol Reflex Crit. 2013;26(1):122-35. https://doi.org/10.1590/S0102-79722013000100014
https://doi.org/https://doi.org/10.1590/...
,5656. van Muijden J, Band GPH, Hommel B. Online games training aging brains: limited transfer to cognitive control functions. Front Hum Neurosci. 2012;6:221. https://doi.org/10.3389/fnhum.2012.00221
https://doi.org/https://doi.org/10.3389/...
,7171. Heinzel S, Lorenz RC, Pelz P, Heinz A, Walter H, Kathmann N, et al. Neural correlates of training and transfer effects in working memory in older adults. Neuroimage. 2016;134:236-49. https://doi.org/10.1016/j.neuroimage.2016.03.068
https://doi.org/https://doi.org/10.1016/...
,7272. Goghari VM, Lawlor-Savage L. Comparison of cognitive change after working memory training and logic and planning training in healthy older adults. Front Aging Neurosci. 2017;9:39. https://doi.org/10.3389/fnagi.2017.00039
https://doi.org/https://doi.org/10.3389/...
. Transfer effects were mentioned in 36 articles, representing a significance related to the benefits of WM training.

These results corroborate the outcomes identified in the meta-analysis by Karbach and Verhaeghen. The analyses presented by these authors showed that 100% of the evaluated studies whose focus was on WM training presented close or distant transference effects. In this systematic review, 76.5% described at least one observed effect. It should be noted that eight studies did not investigate transfer effects3434. Ghavidel F, Fadardi JS, Gatto NM, Sedaghat F, Tabibi Z. Feasibility of using a computer-assisted working memory training program for healthy older women. Cogn Process. 2020;21(3):383-90. https://doi.org/10.1007/s10339-020-00975-7
https://doi.org/https://doi.org/10.1007/...
,4848. Wilkinson AJ, Yang L. Long-term maintenance of inhibition training effects in older adults: 1- and 3-year follow-up. J Gerontol B Psychol Sci Soc Sci. 2016;71(4):622-9. https://doi.org/10.1093/geronb/gbu179
https://doi.org/https://doi.org/10.1093/...
,5050. Irigaray TQ, Gomes Filho I, Schneider RH. Efeitos de um treino de atenção, memória e funções executivas na cognição de idosos saudáveis. Psicol Reflex Crít. 2012;25(1):188-202. https://doi.org/10.1590/S0102-79722012000100023
https://doi.org/https://doi.org/10.1590/...
,5353. Loosli SV, Falquez R, Unterrainer JM, Weiller C, Rahm B, Kaller CP. Training of resistance to proactive interference and working memory in older adults: a randomized double-blind study. Int Psychogeriatr. 2016;28(3):453-67. https://doi.org/10.1017/S1041610215001519
https://doi.org/https://doi.org/10.1017/...
,5858. Cujzek M, Vranic A. Computerized tabletop games as a form of a video game training for old-old. Neuropsychol Dev Cogn B Aging Neuropsychol Cogn. 2017;24(6):631-48. https://doi.org/10.1080/13825585.2016.1246649
https://doi.org/https://doi.org/10.1080/...
,6060. Berggren R, Nilsson J, Brehmer Y, Schmiedek F, Lövdén M. Foreign language learning in older age does not improve memory or intelligence: evidence from a randomized controlled study. Psychol Aging. 2020;35(2):212-9. https://doi.org/10.1037/pag0000439
https://doi.org/https://doi.org/10.1037/...
,6161. Degé F, Kerkovius K. The effects of drumming on working memory in older adults. Ann N Y Acad Sci. 2018;1423(1):242-50. https://doi.org/10.1111/nyas.13685
https://doi.org/https://doi.org/10.1111/...
,6363. Wong PCM, Ou J, Pang CWY, Zhang L, Tse CS, Lam LCW, et al. Language training leads to global cognitive improvement in older adults: a preliminary study. J Speech Lang Hear Res. 2019;62(7):2411-24. https://doi.org/10.1044/2019_JSLHR-L-18-0321
https://doi.org/https://doi.org/10.1044/...
.

In contrast, three reviewed articles found no transfer effect from WM training3535. Guye S, von Bastian CC. Working memory training in older adults: Bayesian evidence supporting the absence of transfer. Psychol Aging. 2017;32(8):732-46. https://doi.org/10.1037/pag0000206
https://doi.org/https://doi.org/10.1037/...
,3737. Lebedev AV, Nilsson J, Lövdén M. Working memory and reasoning benefit from different modes of large-scale brain dynamics in healthy older adults. J Cogn Neurosci. 2018;30(7):1033-46. https://doi.org/10.1162/jocn_a_01260
https://doi.org/https://doi.org/10.1162/...
,4343. Schmicker M, Menze I, Koch D, Rumpf U, Müller P, Pelzer L, et al. Decision-making deficits in elderly can be alleviated by attention training. J Clin Med. 2019;8(8):1131. https://doi.org/10.3390/jcm8081131
https://doi.org/https://doi.org/10.3390/...
. This outcome was also found in other studies, such as the one by Goghari and Lawlor-Savage7272. Goghari VM, Lawlor-Savage L. Comparison of cognitive change after working memory training and logic and planning training in healthy older adults. Front Aging Neurosci. 2017;9:39. https://doi.org/10.3389/fnagi.2017.00039
https://doi.org/https://doi.org/10.3389/...
. When comparing the effects of WM training with logic and planning training in groups of healthy elderly, the authors found that there was an improvement in the cognitive functions of both groups; however, transfer effects were not observed even in the training focused on WM. As described, the conclusions suggest that some variables interfered in the results, for example, the participants’ high cognitive reserve7373. Stern Y, Barnes CA, Grady C, Jones RN, Raz N. Brain reserve, cognitive reserve, compensation, and maintenance: operationalization, validity, and mechanisms of cognitive resilience. Neurobiol Aging. 2019;83:124-9. https://doi.org/10.1016/j.neurobiolaging.2019.03.022
https://doi.org/https://doi.org/10.1016/...
.

Cognitive reserve is understood as the use of mechanisms for adaptation and flexibility of cognitive functions in the face of changes caused by the natural or pathological process of cognitive aging. Despite being a characteristic common to all people, some have greater cognitive reserve compared to others. This is due to different variables, the high level of education, and greater involvement in leisure activities, for example, which are associated with greater capacity for cognitive reserve.

Other important factors related to cognitive performance refer to neurogenesis (capacity to form new neurons) and neuroplasticity (formation of new synaptic connections). Like cognitive reserve, both depend on exposure to stimulating factors, such as CT99. Malloy-Diniz L, Fluentes D, Consenza RM. Neuropsicologia do envelhecimento: uma abordagem multidimensional. Porto Alegre: Artmed; 2013..

The improvement in the performance of certain cognitive functions observed in the studies included in this review validates the hypotheses related to cognitive plasticity from training, since healthy elderly people achieved better results in performing activities after undergoing interventions. In this sense, some researchers highlighted the cognitive plasticity observed at the conclusion of their studies, including prefrontal neuroplasticity1313. Borella E, Carretti B, Zanoni G, Zavagnin M, De Beni R. Working memory training in old age: an examination of transfer and maintenance effects. Arch Clin Neuropsychol. 2013;28(4):331-47. https://doi.org/10.1093/arclin/act020
https://doi.org/https://doi.org/10.1093/...
,2424. Anguera JA, Boccanfuso J, Rintoul JL, Al-Hashimi O, Faraji F, Janowich J, et al. Video game training enhances cognitive control in older adults. Nature. 2013;501(7465):97-101. https://doi.org/10.1038/nature12486
https://doi.org/https://doi.org/10.1038/...
,3434. Ghavidel F, Fadardi JS, Gatto NM, Sedaghat F, Tabibi Z. Feasibility of using a computer-assisted working memory training program for healthy older women. Cogn Process. 2020;21(3):383-90. https://doi.org/10.1007/s10339-020-00975-7
https://doi.org/https://doi.org/10.1007/...
,4141. Payne BR, Stine-Morrow EAL. The effects of home-based cognitive training on verbal working memory and language comprehension in older adulthood. Front Aging Neurosci. 2017;9:256. https://doi.org/10.3389/fnagi.2017.00256
https://doi.org/https://doi.org/10.3389/...
,4646. Stepankova H, Lukavsky J, Buschkuehl M, Kopecek M, Ripova D, Jaeggi SM. The malleability of working memory and visuospatial skills: a randomized controlled study in older adults. Dev Psychol. 2014;50(4):1049-59. https://doi.org/10.1037/a0034913
https://doi.org/https://doi.org/10.1037/...
,4949. Zinke K, Zeintl M, Rose NS, Putzmann J, Pydde A, Kliegel M. Working memory training and transfer in older adults: effects of age, baseline performance, and training gains. Dev Psychol. 2014;50(1):304-15. https://doi.org/10.1037/a0032982
https://doi.org/https://doi.org/10.1037/...
,5151. Ji Y, Wang J, Chen T, Du X, Zhan Y. Plasticity of inhibitory processes and associated far-transfer effects in older adults. Psychol Aging. 2016;31(5):415-29. https://doi.org/10.1037/pag0000102
https://doi.org/https://doi.org/10.1037/...
,5959. Toril P, Reales JM, Mayas J, Ballesteros S. Video game training enhances visuospatial working memory and episodic memory in older adults. Front Hum Neurosci. 2016;10:206. https://doi.org/10.3389/fnhum.2016.00206.
https://doi.org/https://doi.org/10.3389/...

Regarding the long-term effects after the interventions, 12 studies showed associated results. Effects were noticed after 35151. Ji Y, Wang J, Chen T, Du X, Zhan Y. Plasticity of inhibitory processes and associated far-transfer effects in older adults. Psychol Aging. 2016;31(5):415-29. https://doi.org/10.1037/pag0000102
https://doi.org/https://doi.org/10.1037/...
,5959. Toril P, Reales JM, Mayas J, Ballesteros S. Video game training enhances visuospatial working memory and episodic memory in older adults. Front Hum Neurosci. 2016;10:206. https://doi.org/10.3389/fnhum.2016.00206.
https://doi.org/https://doi.org/10.3389/...
,6363. Wong PCM, Ou J, Pang CWY, Zhang L, Tse CS, Lam LCW, et al. Language training leads to global cognitive improvement in older adults: a preliminary study. J Speech Lang Hear Res. 2019;62(7):2411-24. https://doi.org/10.1044/2019_JSLHR-L-18-0321
https://doi.org/https://doi.org/10.1044/...
,6464. Brehmer Y, Westerberg H, Bäckman L. Working-memory training in younger and older adults: training gains, transfer, and maintenance. Front Hum Neurosci. 2012;6:63. https://doi.org/10.3389/fnhum.2012.00063
https://doi.org/https://doi.org/10.3389/...
, 45858. Cujzek M, Vranic A. Computerized tabletop games as a form of a video game training for old-old. Neuropsychol Dev Cogn B Aging Neuropsychol Cogn. 2017;24(6):631-48. https://doi.org/10.1080/13825585.2016.1246649
https://doi.org/https://doi.org/10.1080/...
, 62424. Anguera JA, Boccanfuso J, Rintoul JL, Al-Hashimi O, Faraji F, Janowich J, et al. Video game training enhances cognitive control in older adults. Nature. 2013;501(7465):97-101. https://doi.org/10.1038/nature12486
https://doi.org/https://doi.org/10.1038/...
,2828. Binder JC, Martin M, Zöllig J, Röcke C, Mérillat S, Eschen A, et al. Multi-domain training enhances attentional control. Psychol Aging. 2016;31(4):390-408. https://doi.org/10.1037/pag0000081
https://doi.org/https://doi.org/10.1037/...
,3232. Borella E, Carretti B, Sciore R, Capotosto E, Taconnat L, Cornoldi C, et al. Training working memory in older adults: is there an advantage of using strategies? Psychol Aging. 2017;32(2):178-91. https://doi.org/10.1037/pag0000155
https://doi.org/https://doi.org/10.1037/...
,4040. McAvinue LP, Golemme M, Castorina M, Tatti E, Pigni FM, Salomone S, et al. An evaluation of a working memory training scheme in older adults. Front Aging Neurosci. 2013;5:20. https://doi.org/10.3389/fnagi.2013.00020
https://doi.org/https://doi.org/10.3389/...
, 81313. Borella E, Carretti B, Zanoni G, Zavagnin M, De Beni R. Working memory training in old age: an examination of transfer and maintenance effects. Arch Clin Neuropsychol. 2013;28(4):331-47. https://doi.org/10.1093/arclin/act020
https://doi.org/https://doi.org/10.1093/...
, 94949. Zinke K, Zeintl M, Rose NS, Putzmann J, Pydde A, Kliegel M. Working memory training and transfer in older adults: effects of age, baseline performance, and training gains. Dev Psychol. 2014;50(1):304-15. https://doi.org/10.1037/a0032982
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, and 36 months4848. Wilkinson AJ, Yang L. Long-term maintenance of inhibition training effects in older adults: 1- and 3-year follow-up. J Gerontol B Psychol Sci Soc Sci. 2016;71(4):622-9. https://doi.org/10.1093/geronb/gbu179
https://doi.org/https://doi.org/10.1093/...
. While two studies did not identify long-term effects after 82929. Borella E, Carretti B, Cantarella A, Riboldi F, Zavagnin M, De Beni R. Benefits of training visuospatial working memory in young-old and old-old. Dev Psychol. 2014;50(3):714-27. https://doi.org/10.1037/a0034293
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and 35555. Weicker J, Hudl N, Frisch S, Lepsien J, Mueller K, Villringer A, et al. WOME: theory-based working memory training - a placebo-controlled, double-blind evaluation in older adults. Front Aging Neurosci. 2018;10:247. https://doi.org/10.3389/fnagi.2018.00247
https://doi.org/https://doi.org/10.3389/...
months of follow-up. The remaining studies included did not investigate the long-term effects of training.

Five recently published meta-analyses investigated the long-term effects of memory training in healthy older adults1414. Sala G, Aksayli ND, Tatlidil KS, Gondo Y, Gobet F. Working memory training does not enhance older adults’ cognitive skills: a comprehensive meta-analysis. Intelligence. 2019;77:101386. https://doi.org/10.1016/j.intell.2019.101386
https://doi.org/https://doi.org/10.1016/...
,1616. Teixeira-Santos AC, Moreira CS, Magalhães R, Magalhães C, Pereira DR, Leite J, et al. Reviewing working memory training gains in healthy older adults: a meta-analytic review of transfer for cognitive outcomes. Neurosci Biobehav Rev. 2019;103:163-77. https://doi.org/10.1016/j.neubiorev.2019.05.009
https://doi.org/https://doi.org/10.1016/...
,1717. Nguyen L, Murphy K, Andrews G. Immediate and long-term efficacy of executive functions cognitive training in older adults: a systematic review and meta-analysis. Psychol Bull. 2019;145(7):698-733. https://doi.org/10.1037/bul0000196
https://doi.org/https://doi.org/10.1037/...
,1818. Hou J, Jiang T, Fu J, Su B, Wu H, Sun R, et al. The long-term efficacy of working memory training in healthy older adults: a systematic review and meta-analysis of 22 randomized controlled trials. J Gerontol B Psychol Sci Soc Sci. 2020;75(8):e174-e188, https://doi.org/10.1093/geronb/gbaa077
https://doi.org/https://doi.org/10.1093/...
,1919. Schwaighofer M, Fischer F, Bühner M. Does working memory training transfer? A meta-analysis including training conditions as moderators. Educational Psychologist. 2015;50(2):138-66. https://doi.org/10.1080/00461520.2015.1036274
https://doi.org/https://doi.org/10.1080/...
, but Hou et al.1818. Hou J, Jiang T, Fu J, Su B, Wu H, Sun R, et al. The long-term efficacy of working memory training in healthy older adults: a systematic review and meta-analysis of 22 randomized controlled trials. J Gerontol B Psychol Sci Soc Sci. 2020;75(8):e174-e188, https://doi.org/10.1093/geronb/gbaa077
https://doi.org/https://doi.org/10.1093/...
reported that four of these reviews present important inconsistencies that prevent a specific conclusion on these effects, for example, with the absence of a methodological standard and limitations regarding the reporting of follow-up time of the analyzed studies, which represents a lack of clarity regarding the effects to be long term.

The most recent meta-analysis1818. Hou J, Jiang T, Fu J, Su B, Wu H, Sun R, et al. The long-term efficacy of working memory training in healthy older adults: a systematic review and meta-analysis of 22 randomized controlled trials. J Gerontol B Psychol Sci Soc Sci. 2020;75(8):e174-e188, https://doi.org/10.1093/geronb/gbaa077
https://doi.org/https://doi.org/10.1093/...
, exploring the objectives, methods, and results of 22 studies, concluded that there was maintenance of long-term effects after WM training, both for shorter periods (<6 months) and for longer periods (>6 months), showing similarities in the observed effects.

In short, the literature is not consistent in reporting transfer effects and long-term effects of WM training in elderly individuals. This literature review, as well as studies by Karbach and Verhaeghen1111. Karbach J, Verhaeghen P. Making working memory work: a meta-analysis of executive-control and working memory training in older adults. Psychol Sci. 2014;25(11):2027-37. https://doi.org/10.1177/0956797614548725
https://doi.org/https://doi.org/10.1177/...
and Hou et al.1818. Hou J, Jiang T, Fu J, Su B, Wu H, Sun R, et al. The long-term efficacy of working memory training in healthy older adults: a systematic review and meta-analysis of 22 randomized controlled trials. J Gerontol B Psychol Sci Soc Sci. 2020;75(8):e174-e188, https://doi.org/10.1093/geronb/gbaa077
https://doi.org/https://doi.org/10.1093/...
, reported both follow-up effects and untrained skills, while studies by Schwaighofer et al.1919. Schwaighofer M, Fischer F, Bühner M. Does working memory training transfer? A meta-analysis including training conditions as moderators. Educational Psychologist. 2015;50(2):138-66. https://doi.org/10.1080/00461520.2015.1036274
https://doi.org/https://doi.org/10.1080/...
, Teixeira-Santos et al.1616. Teixeira-Santos AC, Moreira CS, Magalhães R, Magalhães C, Pereira DR, Leite J, et al. Reviewing working memory training gains in healthy older adults: a meta-analytic review of transfer for cognitive outcomes. Neurosci Biobehav Rev. 2019;103:163-77. https://doi.org/10.1016/j.neubiorev.2019.05.009
https://doi.org/https://doi.org/10.1016/...
, Sala et al.1414. Sala G, Aksayli ND, Tatlidil KS, Gondo Y, Gobet F. Working memory training does not enhance older adults’ cognitive skills: a comprehensive meta-analysis. Intelligence. 2019;77:101386. https://doi.org/10.1016/j.intell.2019.101386
https://doi.org/https://doi.org/10.1016/...
, and Nguyen et al.1717. Nguyen L, Murphy K, Andrews G. Immediate and long-term efficacy of executive functions cognitive training in older adults: a systematic review and meta-analysis. Psychol Bull. 2019;145(7):698-733. https://doi.org/10.1037/bul0000196
https://doi.org/https://doi.org/10.1037/...
showed no significant long-term benefits and close or distant transfer effects.

Individual or group interventions

Regarding the methods adopted, there was a prevalence of individual interventions, among which 27 had only elderly people as participants and 7 compared young adults and elderly people. The other studies (13) conducted strategies in groups. No significant differences were observed in the results of the two intervention modalities, with transfer effects and long-term effects in both individual and group interventions.

The benefits associated with individual cognitive intervention are described by Justo-Henriques et al.7474. Justo-Henriques SI, Pérez-Sáez E, Apóstolo JLA. Protocolo de intervenção individual baseado na terapia de reminiscência em idosos com perturbação neurocognitiva. Rev Enf Ref. 2020;5(3):1-10. https://doi.org/10.12707/RV20043
https://doi.org/https://doi.org/10.12707...
. According to the authors, individual sessions allow the customization of activities and a greater approach to the participant, which promotes greater engagement. In addition, when performing an individual intervention, the facilitator is able to recognize the specific demands of the individual and focus on training the most compromised skills, favoring the achievement of benefits after the intervention.

Cognitive group training allows for social interactions, which, as mentioned by Ordonez et al.7575. Ordonez TN, Borges F, Kanashiro CS, Santos CCN, Hora SS, Lima-Silva TB. Actively station: effects on global cognition of mature adults and healthy elderly program using eletronic games. Dement Neuropsychol. 2017;11(2):186-97. https://doi.org/10.1590/1980-57642016dn11-020011
https://doi.org/https://doi.org/10.1590/...
, can alleviate social isolation and the perception of loneliness. Engaging in group activities generates benefits for quality of life, well-being, and mental and cognitive health and is even capable of reducing the chances of developing or worsening dementia7676. Silva TBL, Santos G, Zumkeller MG, Barbosa MEC, Moreira APB, Ordonez TN, et al. Efeitos das intervenções cognitivas na cognição e em variáveis sociais de adultos maduros e em idosos: uma revisão sistemática. Revista Kairós-Gerontologia. 2021;24(Especial 29):297-317. http://dx.doi.org/10.23925/2176-901X.2021v24iEspecial29p297-317
https://doi.org/http://dx.doi.org/10.239...
.

Comparison between young adults and seniors

Seven individual WM training studies compared the performance of younger and older adults. The benefits of memory training for both younger and older subjects were reported across all studies; however, training in various executive processes induced fewer transfer effects to the untrained cognitive abilities of older participants.

Although, as already mentioned, based on the results obtained by other studies, the elderly benefit from transfer effects to untrained cognitive skills, theories explain why these effects are more expressive in younger people7777. Dias CA. Reservas cognitivas no envelhecimento típico e com declínio cognitivo: ênfase na leitura e na escolaridade [dissertação]. Rio Grande do Sul: Programa de Pós-Graduação em Letras, Pontifícia Universidade Católica do Rio Grande do Sul; 2020.. The concepts of brain reserve and cognitive reserve are part of this explanation.

While the cognitive reserve is intended for functional adaptations and flexibilities, the brain reserve is related to individual anatomical characteristics. It is these reserves that allow the elderly to compensate for the deficits caused by the aging process or a pathology. When recruiting neural resources, the elderly person may be able to perform tasks in the same way as a young person; however, in tasks that require greater neuronal activation, due to high complexity, compensatory resources tend not to be sufficient, causing differences in performance of young and old7777. Dias CA. Reservas cognitivas no envelhecimento típico e com declínio cognitivo: ênfase na leitura e na escolaridade [dissertação]. Rio Grande do Sul: Programa de Pós-Graduação em Letras, Pontifícia Universidade Católica do Rio Grande do Sul; 2020..

It is also possible to find in the literature hypotheses that the elderly show more significant improvements in cognitive performance after training compared to younger adults7878. Bherer L, Kramer AF, Peterson MS, Colcombe S, Erickson K, Becic E. Transfer effects in task-set cost and dual-task cost after dual-task training in older and younger adults: further evidence for cognitive plasticity in attentional control in late adulthood. Exp Aging Res. 2008;34(3):188-219. https://doi.org/10.1080/03610730802070068
https://doi.org/https://doi.org/10.1080/...
,7979. Kray J, Eber J, Karbach J. Verbal self-instructions in task switching: a compensatory tool for action-control deficits in childhood and old age? Dev Sci. 2008;11(2):223-36. http://doi.org/10.1111/j.1467-7687.2008.00673.x
https://doi.org/http://doi.org/10.1111/j...
,8080. Karbach J, Kray J. How useful is executive control training? Age differences in near and far transfer of task-switching training. Dev Sci. 2009;12(6):978-90. https://doi.org/10.1111/j.1467-7687.2009.00846.x
https://doi.org/https://doi.org/10.1111/...
. The researchers attribute this outcome to the already existing high-performance capacity of young people, which limits the expansion and achievement of even better results.

The differences in the intensity of the transference effects for young and old submitted to WM training found in this review corroborate most of the reviews and meta-analyses carried out with this theme7878. Bherer L, Kramer AF, Peterson MS, Colcombe S, Erickson K, Becic E. Transfer effects in task-set cost and dual-task cost after dual-task training in older and younger adults: further evidence for cognitive plasticity in attentional control in late adulthood. Exp Aging Res. 2008;34(3):188-219. https://doi.org/10.1080/03610730802070068
https://doi.org/https://doi.org/10.1080/...
,7979. Kray J, Eber J, Karbach J. Verbal self-instructions in task switching: a compensatory tool for action-control deficits in childhood and old age? Dev Sci. 2008;11(2):223-36. http://doi.org/10.1111/j.1467-7687.2008.00673.x
https://doi.org/http://doi.org/10.1111/j...
,8080. Karbach J, Kray J. How useful is executive control training? Age differences in near and far transfer of task-switching training. Dev Sci. 2009;12(6):978-90. https://doi.org/10.1111/j.1467-7687.2009.00846.x
https://doi.org/https://doi.org/10.1111/...
. However, a difference was found with the results of the most recent meta-analysis, in which significant transfer effects were found in the elderly compared to the younger ones1111. Karbach J, Verhaeghen P. Making working memory work: a meta-analysis of executive-control and working memory training in older adults. Psychol Sci. 2014;25(11):2027-37. https://doi.org/10.1177/0956797614548725
https://doi.org/https://doi.org/10.1177/...
.

Overall, the interventions involving older adults only showed positive effects on cognitive performance, albeit in the form of WM training gains for the target cognitive ability or transfer effects of this type of training, as well as other types of WM-related CT. The studies also reported transfer effects of the training performed to everyday functions in older adults, with consequent improvements in quality of life.

Positive effects were also reported by the studies comparing the performance of older adults with young adults, including the possibility of promoting far-transfer effects in older adults, although contrasting with reported difficulty inducing these effects through training of different executive processes.

Thus, it was concluded that WM training, as well as different types of WM-related CT, can contribute to the maintenance and/or improvement of cognition in older people, recruiting their brain plasticity to promote mental health and prevent cognitive problems which can negatively impact their quality of life.

Limitations of the study include the difficulty performing a more comprehensive review of the wide variety of studies, published within the time window, investigating WM training and directly or indirectly related cognitive skills to determine the efficacy of nonpharmacological interventions aimed at enhancing cognitive performance of older adults.

Therefore, future studies with interventions focusing on specific aspects of WM and executive functions should be conducted in both healthy and cognitively impaired young-old and old-old.

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  • 1
    This study was conducted by the Group of Cognitive and Behavioral Neurology, School of Medicine, Universidade de São Paulo, São Paulo SP, Brazil.
  • Funding: none.

Publication Dates

  • Publication in this collection
    15 Aug 2022
  • Date of issue
    Dec 2022

History

  • Received
    16 Dec 2021
  • Reviewed
    01 Mar 2022
  • Accepted
    29 Mar 2022
Academia Brasileira de Neurologia, Departamento de Neurologia Cognitiva e Envelhecimento R. Vergueiro, 1353 sl.1404 - Ed. Top Towers Offices, Torre Norte, São Paulo, SP, Brazil, CEP 04101-000, Tel.: +55 11 5084-9463 | +55 11 5083-3876 - São Paulo - SP - Brazil
E-mail: revistadementia@abneuro.org.br | demneuropsy@uol.com.br