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4 Initial Application of Constraint-Induced Cognitive Therapy to Long COVID Brain Fog
- Gitendra Uswatte, Edward Taub, Karlene Ball, Kristine Lokken, Shruti P Agnihotri, Victor W Mark, Amy Knight, Brandon Mitchell, Jason Blake, Staci McKay, Terika Miller, Elizabeth Pollard, Piper Hempfling, Morgan Smith, Rebekah Chatfield, Erin Stanley, Cliff Lynam, Kyli Blagburn, Brooke Carroll, Gary Cutter
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- Journal:
- Journal of the International Neuropsychological Society / Volume 29 / Issue s1 / November 2023
- Published online by Cambridge University Press:
- 21 December 2023, pp. 598-599
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Objective:
Persistent brain fog is common in adults with Post-Acute Sequelae of SARS-CoV-2 infection (PASC), in whom it causes distress and in many cases interferes with performance of instrumental activities of daily living (IADL) and return-to-work. There are no interventions with rigorous evidence of efficacy for this new, often disabling condition. The purpose of this pilot is to evaluate the efficacy, on a preliminary basis, of a new intervention for this condition termed Constraint-Induced Cognitive therapy (CICT). CICT combines features of two established therapeutic approaches: cognitive speed of processing training (SOPT) developed by the laboratory of K. Ball and the Transfer Package and task-oriented training components of Constraint-Induced Movement therapy developed by the laboratory of E. Taub and G. Uswatte.
Participants and Methods:Participants were > 3 months after recovery from acute COVID symptoms and had substantial brain fog and impairment in IADL. Participants were randomized to CICT immediately or after a 3-month delay. CICT involved 36 hours of outpatient therapy distributed over 4-6 weeks. Sessions had three components: (a) videogamelike training designed to improve how quickly participants process sensory input (SOPT), (b) training on IADLs following shaping principles, and (c) a set of behavioral techniques designed to transfer gains from the treatment setting to daily life, i.e., the Transfer Package. The Transfer Package included (a) negotiating a behavioral contract with participants and one or more family members about the responsibilities of the participants, family members, and treatment team; (b) assigning homework during and after the treatment period; (c) monitoring participants’ out-of-session behavior; (d) supporting problem-solving by participants and family members about barriers to performance of IADL; and (e) making follow-up phone calls. IADL performance, brain fog severity, and cognitive impairment were assessed using validated, trans-diagnostic measures before and after treatment and three months afterwards in the immediate-CICT group and on parallel occasions in the delayed-CICT group (aka waitlist controls).
Results:To date, five were enrolled in the immediate-CICT group; four were enrolled in the wait-list group. All had mild cognitive impairment, except for one with moderate impairment in the immediate-CICT group. Immediate-CICT participants, on average, had large reductions in brain fog severity on the Mental Clutter Scale (MCS, range = 0 to 10 points, mean change = -3.7, SD = 2.0); wait-list participants had small increases (mean change = 1.0, SD = 1.4). Notably, all five in the immediate-CICT group had clinically meaningful improvements (i.e., changes > 2 points) in performance of IADL outside the treatment setting as measured by the Canadian Occupational Performance Measure (COPM) Performance scale; only one did in the wait-list group. The advantage for the immediate-CICT group was very large on both the MCS and COPM (d’s = 1.7, p’s < .05). In follow-up, immediate-CICT group gains were retained or built-upon.
Conclusions:These preliminary findings warrant confirmation by a large-scale randomized controlled trial. To date, CICT shows high promise as an efficacious therapy for brain fog due to PASC. CICT participants had large, meaningful improvements in IADL performance outside the treatment setting, in addition to large reductions in brain fog severity.
3 CI Cognitive Therapy: Initial Application in a Pilot Study to Improve Cognitive Impairment in Chronic Stroke Survivors
- Edward Taub, Gitendra Uswatte, Karlene Ball, Victor W Mark, Staci McKay, Brandon Mitchell, Jason Blake, Amy Knight, Chen Lin, Gary Cutter
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- Journal:
- Journal of the International Neuropsychological Society / Volume 29 / Issue s1 / November 2023
- Published online by Cambridge University Press:
- 21 December 2023, pp. 597-598
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Objective:
CI Cognitive Therapy (CICT) is a combination of behavioral techniques derived from CI Movement Therapy (CIMT) modified to apply to the cognitive domain, and Speed of (Cognitive) Processing Training (SOPT). SOPT is effective in improving cognitive function in the treatment setting and driving ability in everyday situations. The data concerning the effect of SOPT on other cognition-based instrumental activities of daily living (IADL) in everyday situations is incomplete. The strengths of CIMT, based on its Transfer Package (TP), are to facilitate 1) transfer of improved function from the treatment setting to IADL in everyday settings, and 2) long-term retention of the improved performance of IADL. This study sought to determine in a preliminary case series whether the TP of CI Movement Therapy combined with SOPT would have the same effect on a wide range of impaired cognition-based ADL.
Participants and Methods:Participants were 6 adults with chronic stroke: mean chronicity = 36.2 months, (range, 16-56 months); mean age = 59.7 years, (range, 47-55); 1 female; 3 African American and 3 European American. Five had mild cognitive impairment, while one had moderate impairment. Participants received 35 hours of outpatient treatment in 10-15 sessions distributed over 2-6 weeks, depending on the participants’ availability. Sessions began with 1 hour of SOPT training followed by training of cognition-based ADL by the process of shaping, a common method in the behavior analysis field. Other behavior analysis methods employed in the TP of CI Movement Therapy were used, including: 1) behavior contracting, daily assignment of homework, participation of a family member in the training and monitoring process, daily administration of a structured interview assessing amount and quality of performance of 30 IADL, problem solving to overcome perceived (or real) barriers to performance of IADL. Participants were given daily homework assignments in follow-up and were contacted in periodic, pre-arranged phone calls to determine status, compliance and problem-solve.
Results:All six participants showed marked improvement on the SOPT test similar to that in the Ball et al studies. However, here transfer to IADL outside the treatment setting was substantial. On the main real-world outcome, the Canadian Occupational Performance Measure (COPM), there were increases of 2.7±1.3 and 2.1±1.6 on the two scales (d’s = 1.9 & 1.3, respectively). (Changes on the COPM > 2 points are considered clinically meaningful and changes in d’ >.8 are considered large). On two other real-word measures, the Cognitive Task Activity Log (CTAL) and inventory of Improved and New Cognitive Activities (INCA), there was a marked increase during the acquisition phase of training. There was no loss in retention over the 6-16 months (mean = 12.2) of follow-up to date. Instead, the INCA showed strong further improvement after the end of treatment-setting training, especially in the New Activities Not Performed Since Before Stroke Onset category, going from a mean of 8.2 after training to 14.6 at the end of follow-up.
Conclusions:These very preliminary results suggest that CICT may be an efficacious therapy for mild to moderate cognitive impairment in chronic stroke and possibly other disorders.
1 Benefits of Speed of Processing Training in Older Adults
- Karlene Ball, Katie Wheeler
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- Journal:
- Journal of the International Neuropsychological Society / Volume 29 / Issue s1 / November 2023
- Published online by Cambridge University Press:
- 21 December 2023, pp. 596-597
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Objective:
Physical, sensory, and cognitive function are all related to successful aging, quality of life, and independence in older age. Decline in cognitive function, in particular, can create difficulty in many Instrumental Activities of Daily Living such as driving and other aspects of everyday function. Loss of driving competence can subsequently lead to depression, isolation, loss of independence and reduced quality of life. Results from a large randomized controlled trial investigating the long-term impact of Speed of Processing Training will be presented demonstrating the impact of such training on cognitive and everyday function. Speed of Processing Training is an adaptive cognitive intervention administered on a computer that improves visual attention, and has been shown to enhance the connections needed for visual attention using task-driven and resting state fMRI.
Participants and Methods:The ACTIVE clinical trial recruited a volunteer sample of 2,832 community dwelling older adults between the ages of 65 and 94 years at six different field sites in six different states. This study evaluated the impact of three cognitive interventions targeted at improving cognitive and everyday function which served as contract control conditions for each other. Participants were randomly assigned to speed of processing training, reasoning training, memory training, or a no-contact control group. Follow-up testing was collected in person for ten years, and at twenty years final archival data was collected from the Departments of Motor Vehicles at each of the six field sites, as well as the Medicare/Medicaid data across the twenty years since enrollment. Outcomes included measures of cognitive function, measures of IADL (including crash involvement and driving cessation), and secondary outcomes of mobility (falls, driving habits, life space), quality of life, mortality and health conditions (from Medicare Records).
Results:Results will be presented with respect to everyday function including several longitudinal measures of mobility: number of miles driven per year and driving difficulty, rates of driving cessation, and crash involvement. Random effects modelling, cox proportional hazards, and rate ratios will be presented illustrating the positive impact of cognitive training on these outcome measures. In particular, Speed of Processing Training was found to sustain driving competence with respect to continued driving relative to other types of training, and to reduce the risk of crash involvement over ten years. Furthermore, decline in Speed of Processing was the only cognitive measure predictive of crash involvement longitudinally in the no-contact control group. Positive benefits were also observed for Health Related Quality of Life (HRQoL), and depression.
Conclusions:The ACTIVE clinical trial, among other studies, has demonstrated that cognitive training can have long-term positive benefit on the everyday abilities, quality of life, and continued independence of older adults.
Longitudinal relationships between subjective fatigue, cognitive function, and everyday functioning in old age
- Feng Lin, Ding-Geng Chen, David E. Vance, Karlene K. Ball, Mark Mapstone
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- International Psychogeriatrics / Volume 25 / Issue 2 / February 2013
- Published online by Cambridge University Press:
- 19 October 2012, pp. 275-285
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Background: The present study examined the prospective relationships between subjective fatigue, cognitive function, and everyday functioning.
Methods: A cohort study with secondary data analysis was conducted using data from 2,781 community-dwelling older adults without dementia who were enrolled to participate in the Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) randomized intervention trial. Measures included demographic and health information at baseline, and annual assessments of subjective fatigue, cognitive function (i.e. speed of processing, memory, and reasoning), and everyday functioning (i.e. everyday speed and everyday problem-solving) over five years.
Results: Four distinct classes of subjective fatigue were identified using growth mixture modeling: one group complaining fatigue “some of the time” at baseline but “most of the time” at five-year follow-up (increased fatigue), one complaining fatigue “a good bit of the time” constantly over time (persistent fatigue), one complaining fatigue “most of the time” at baseline but “some of the time” at five-year follow-up (decreased fatigue), and the fourth complaining fatigue “some of the time” constantly over time (persistent energy). All domains of cognitive function and everyday functioning declined significantly over five years; and the decline rates, but not the baseline levels, differed by the latent class of subjective fatigue. Except for the decreased fatigue class, there were different degrees of significant associations between the decline rates of subjective fatigue and all domains of cognitive function and everyday functioning in other classes of subjective fatigue.
Conclusion: Future interventions should address subjective fatigue when managing cognitive and functional abilities in community-dwelling older adults.
Speed of processing training protects self-rated health in older adults: enduring effects observed in the multi-site ACTIVE randomized controlled trial
- Fredric D. Wolinsky, Henry Mahncke, Mark W. Vander Weg, Rene Martin, Frederick W. Unverzagt, Karlene K. Ball, Richard N. Jones, Sharon L. Tennstedt
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- International Psychogeriatrics / Volume 22 / Issue 3 / May 2010
- Published online by Cambridge University Press:
- 15 December 2009, pp. 470-478
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Background: We evaluated the effects of cognitive training on self-rated health at 1, 2, 3, and 5 years post-baseline.
Methods: In the ACTIVE (Advanced Cognitive Training for Independent and Vital Elderly) randomized controlled trial, 2,802 older adults (≥65 years) were randomly assigned to memory, reasoning, speed of processing, or no-contact control intervention groups. Complete data were available for 1,804 (64%) of the 2,802 participants at five years. A propensity score model was adjusted for attrition bias. The self-rated health question was coded using the Diehr et al. (2001) transformation (E = 95/VG = 90/G = 80/F = 30/P = 15), and analyzed with change-score regression models.
Results: The speed of processing (vs. no-contact control) group had statistically significant improvements (or protective effects) on changes in self-rated health at the 2, 3 and 5 year follow-ups. The 5-year improvement was 2.8 points (p = 0.03). No significant differences were observed in the memory or reasoning groups at any time.
Conclusion: The speed of processing intervention significantly protected self-rated health in ACTIVE, with the average benefit equivalent to half the difference between excellent vs. very good health.
Visual attention and self-regulation of driving among older adults
- Ozioma C. Okonkwo, Michael Crowe, Virginia G. Wadley, Karlene Ball
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- Journal:
- International Psychogeriatrics / Volume 20 / Issue 1 / February 2008
- Published online by Cambridge University Press:
- 01 February 2008, pp. 162-173
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Background: With the number of older drivers increasing, self-regulation of driving has been proposed as a viable means of balancing the autonomy of older adults against the sometimes competing demand of public safety. In this study, we investigate self-regulation of driving among a group of older adults with varying functional abilities.
Method: Participants in the study comprised 1,543 drivers aged 75 years or older. They completed an objective measure of visual attention from which crash risk was estimated, and self-report measures of driving avoidance, driving exposure, physical functioning, general health status, and vision. Crash records were obtained from the State Department of Public Safety.
Results: Overall, participants were most likely to avoid driving in bad weather followed by driving at night, driving on high traffic roads, driving in unfamiliar areas, and making left-hand turns across oncoming traffic. With the exception of driving at night, drivers at higher risk of crashes generally reported greater avoidance of these driving situations than lower risk drivers. However, across all driving situations a significant proportion of higher risk drivers did not restrict their driving. In general, self-regulation of driving did not result in reduced social engagement.
Conclusion: Some older drivers with visual attention impairments do not restrict their driving in difficult situations. There is a need for physicians and family members to discuss driving behaviors with older adults routinely to ensure their safety. The association between visual attention and driving restriction also has implications for interventions aimed at preserving mobility in the elderly.
Effect of memory impairment on training outcomes in ACTIVE
- FREDERICK W. UNVERZAGT, LINDA KASTEN, KATHY E. JOHNSON, GEORGE W. REBOK, MICHAEL MARSISKE, KATHY MANN KOEPKE, JEFFREY W. ELIAS, JOHN N. MORRIS, SHERRY L. WILLIS, KARLENE BALL, DANIEL F. REXROTH, DAVID M. SMITH, FREDRIC D. WOLINSKY, SHARON L. TENNSTEDT
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- Journal:
- Journal of the International Neuropsychological Society / Volume 13 / Issue 6 / November 2007
- Published online by Cambridge University Press:
- 18 October 2007, pp. 953-960
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Cognitive training improves mental abilities in older adults, but the trainability of persons with memory impairment is unclear. We conducted a subgroup analysis of subjects in the Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) trial to examine this issue. ACTIVE enrolled 2802 non-demented, community-dwelling adults aged 65 years and older and randomly assigned them to one of four groups: Memory training, reasoning training, speed-of-processing training, or no-contact control. For this study, participants were defined as memory-impaired if baseline Rey Auditory Verbal Learning Test (AVLT) sum recall score was 1.5 SD or more below predicted AVLT sum recall score from a regression-derived formula using age, education, ethnicity, and vocabulary from all subjects at baseline. Assessments were taken at baseline (BL), post-test, first annual (A1), and second annual (A2) follow-up. One hundred and ninety-three subjects were defined as memory-impaired and 2580 were memory-normal. Training gain as a function memory status (impaired vs. normal) was compared in a mixed effects model. Results indicated that memory-impaired participants failed to benefit from Memory training but did show normal training gains after reasoning and speed training. Memory function appears to mediate response to structured cognitive interventions in older adults. (JINS, 2007, 13, 953–960.)