Aging, Healthy
Conditions
Keywords
cognition disorder, cognitive behavior therapy, functional ability
Brief summary
The purpose of the ACTIVE study was to test if cognitive training interventions could maintain functional independence in elders by improving basic mental abilities, with follow-up assessments through five years.
Detailed description
ACTIVE was a 4-arm, single-blind, randomized controlled trial. The primary objective of ACTIVE was to test the effectiveness and durability of three distinct cognitive interventions in improving elders' performance on basic measures of cognition and measures of cognitively demanding daily activities (e.g., food preparation, driving, medication use, financial management). These interventions previously had been found successful in improving cognitive abilities under laboratory or small-scale field conditions. The three interventions shared common design features: 1) equivalent intensity and duration; 2) small group settings in ten 60-75 minute sessions; 3) focus on strategies for solving problems, remembering, or responding quickly to information; 4) modeling and demonstration of strategy usage; 5) practice on exemplar problems; 6) individual and group exercises; 7) feedback on performance; 8) fostering of self-efficacy regarding performance; 9) applying strategies to real-world tasks; 10) individualized training experiences, and 11) social interaction activities. In all three interventions, Sessions 1-5 focused on strategy instruction and exercises to practice the strategy. Sessions 6-10 provided additional practice exercises, but no new strategies were introduced. Content for each of the 10 sessions was scripted in a trainer's manual. Interventions: 1. Reasoning training focused on inductive reasoning, the ability to solve problems that follow a serial pattern and manifest in executive functioning. Participants were taught strategies to identify the pattern or sequence required to solve a problem. Training exercises involved identifying patterns in both laboratory-type reasoning tasks and in everyday activities, e.g., understanding the pattern in a bus schedule. 2. Memory training focused on verbal episodic memory, which deals with acquisition and retrieval of information acquired in a particular place at a particular time. Participants were taught mnemonic strategies for remembering lists and sequences of items, text material, and main ideas and details of stories and other text-based information. Training exercises involved recalling laboratory-like episodic memory tasks as well as tasks related to everyday activities such as recalling a shopping list. 3. Speed training focused on visual search and the ability to identify and locate visual information quickly in a divided attention format, with and without distractors. Participants practiced speeded tasks on a computer, and were allowed to proceed to more complex tasks, and faster and faster presentation speeds at their own pace. 4. A control group received no training. In addition, booster training was provided to help participants maintain gains made from initial training and to further improve cognitive skills. Booster training was provided to a random sample of approximately 50% of training participants at 11 and 35-36 months after primary training. Participant involvement included assessments conducted at baseline, immediately post-intervention, and at 12, 24, 36 and 60 months. Assessments were conducted in individual and group sessions. For participants randomized to intervention groups, the interventions were conducted in small group settings in ten 60-75 minute sessions over a 5-6 week period. These were behavioral interventions with no pharmacologic component. Eleven months after the initial training was provided, booster training was offered, in all three intervention arms, to a randomly selected 60% of initially trained subjects. Booster training was delivered in four 75-minute sessions over a 2-3 week period. The primary study hypotheses were: * Each training group will perform better than the other training and control groups on their respective primary and proximal outcomes * Those groups that received booster training will perform better than those that did not receive booster training on their respective primary and proximal outcomes.
Interventions
BEHAVIORALCognitive Training
Memory, Reasoning, or Speed of Processing cognitive training interventions
Sponsors
National Institute on Aging (NIA)
National Institute of Nursing Research (NINR)
Carelon Research
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
PREVENTION
Masking
SINGLE (Subject)
Eligibility
Sex/Gender
ALL
Age
65 Years to No maximum
Healthy volunteers
Yes
Inclusion criteria
* Age 65 or older * Mini-Mental State Examination (MMSE) score 23 or greater * Vision scored greater than 20/50 * Minimal dependence in hygiene, bathing, and dressing
Exclusion criteria
* Significant decline in cognitive skills, physical abilities, or functional independence * Inability to complete study activities as evidenced by MMSE and vision scores lower than Inclusion Criteria requirement * Diagnosis of Alzheimer's disease * Stroke in previous 12 months * Cancer with limited life expectance * Current chemotherapy or radiation treatment * Communication problems * Planned move from study area * Scheduling conflicts that would preclude participation in study activities * Prior involvement in similar cognitive training studies
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Changes in Everyday Speed of Processing From Baseline to Year 10 | Up to 10 years | Everyday Speed of processing was computed as the summation of Complex Reaction Time (CRT) and Timed IADL (TIADL). For the analysis, the reversed score was used and the possible range of the reversed everyday speed of processing outcome is -3 to 100. Higher values for the reversed scores represent a better outcome. Changes in outcome were computed as 10 year minus baseline and the negative values indicate the decline from baseline. |
| Changes in Cognitive Abilities of Speed of Processing From Baseline to Year 10 | Up to 10 years | Speed of processing outcome was computed as the summation of three Useful Field of View tasks requiring identification and localization of information, with 75% accuracy, under varying levels of cognitive demand. For the analysis, the reversed score was used and the possible range of the reversed speed of processing outcome is 0 to 1500. Higher values for the reversed scores represent a better outcome. Changes in outcome were computed as 10 year minus baseline and the negative values indicate the decline from baseline. |
| Changes in Instrumental Activities of Daily Living (IADL) Difficulty From Baseline to Year 10 | Up to 10 years | The self-reported measure of everyday IADL function was the summation of the IADL difficulty sub-scores from the Minimum Dataset - Home Care (MDS-HC) which assesses performance in the past 7 days on 19 daily tasks spanning meal preparation, housework, finances, health care, telephone, shopping, travel, and need for assistance in dressing, personal hygiene, and bathing. For the analysis, the reversed score was used and the possible range of the reversed everyday IADL function outcome is 0 to 38. Higher values for the reversed scores represent a better outcome. Changes in outcome were computed as 10 year minus baseline and the negative values indicate the decline from baseline. |
| Changes in Everyday Problem Solving From Baseline to Year 10 | Up to 10 years | Everyday Problem Solving was computed as the summation of the Everyday Problems Test (EPT) and Observed Tasks of Daily Living (OTDL). The possible range of the everyday problem solving outcome is 0 to 56. Higher values represent a better outcome. Changes in outcome were computed as 10 year minus baseline and the negative values indicate the decline from baseline. |
| Changes in Cognitive Abilities of Memory From Baseline to Year 10 | Up to 10 years | Memory outcome was computed as the summation of Rey Auditory-Verbal Learning Test (AVLT), the Hopkins Verbal Learning Test (HVLT), and the Rivermead Behavioral Paragraph Recall test immediate recall. The possible range of the memory outcome is 0 to 132. Higher values represent a better outcome. Changes in outcome were computed as 10 year minus baseline and the negative values indicate the decline from baseline. |
| Changes in Cognitive Abilities of Reasoning From Baseline to Year 10 | Up to 10 years | Reasoning outcome was computed as the summation of total correct for Letter Series, Letter Sets, and Word Series. The possible range of the reasoning outcome is 0 to 75. Higher values represent a better outcome. Changes in outcome were computed as 10 year minus baseline and the negative values indicate the decline from baseline. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Examine Health, Genetic and Cognitive Moderators | 10th Year | To examine heath, genetic, and cognitive moderators (including cardiovascular disease,diabetes, depression, Apolipoprotein E (APOE) genotype, and low cognition and engagement) in individual response to training. |
| Estimate the Effects of ACTIVE Training to General Population | 10th Year | To estimate and project the effects of ACTIVE training to the general population of older adults by linking the measures and outcomes of ACTIVE to the Health and Retirement Study(and its subsidiary studies), a population-based, nationally-representative cohort. |
| Changes in Health-related Quality of Life (HRQol), Driving Function, Health Service Use | 10th Year | To determine if the cognitive interventions have beneficial effects on the distal outcomes of driving safety, personal care activities of daily living, health service utilization, and mortality. |
Countries
United States
Participant flow
Recruitment details
Recruitment occurred from March 1998 through October 1999 at six metropolitan field centers: University of Alabama at Birmingham, Boston Hebrew Rehabilitation Center for Aged (now Hebrew Senior Life), Indiana University School of Medicine, Johns Hopkins University, Pennsylvania State University, and Wayne State University.
Pre-assignment details
Eligibility and demographics were gathered at telephone screening.Health history, physical status, functional status, mental status, cognitive and function measures were gathered via in-person exams in individual and small-group formats at baseline.Eligible subjects were randomly assigned to one of three interventions or no-contact control group.
Participants by arm
| Arm | Count |
|---|---|
| Memory Training Memory training focused on verbal episodic memory. Participants were taught mnemonic strategies for remembering lists and sequences of items, text material, and main ideas and details of stories and other text-based information. | 703 |
| Reasoning Training Reasoning training focused on the ability to solve problems that follow a serial pattern. Participants were taught strategies to identify the pattern or sequence required to solve a problem. | 699 |
| Speed of Processing Training Speed of processing training focused on visual search and the ability to identify and locate visual information quickly in a divided attention format. Participants practiced increasingly complex speeded tasks on a computer. | 702 |
| Control This group did not complete any cognitive training interventions | 698 |
| Total | 2,802 |
Baseline characteristics
| Characteristic | Reasoning Training | Speed of Processing Training | Memory Training | Control | Total |
|---|---|---|---|---|---|
| Age, Categorical <=18 years | 0 Participants | 0 Participants | 0 Participants | 0 Participants | 0 Participants |
| Age, Categorical >=65 years | 699 Participants | 702 Participants | 703 Participants | 698 Participants | 2802 Participants |
| Age, Categorical Between 18 and 65 years | 0 Participants | 0 Participants | 0 Participants | 0 Participants | 0 Participants |
| Age, Continuous | 73.5 years STANDARD_DEVIATION 5.76 | 73.4 years STANDARD_DEVIATION 5.78 | 73.5 years STANDARD_DEVIATION 6.02 | 74.0 years STANDARD_DEVIATION 6.05 | 73.6 years STANDARD_DEVIATION 5.91 |
| Region of Enrollment United States | 699 participants | 702 participants | 703 participants | 698 participants | 2802 participants |
| Sex: Female, Male Female | 537 Participants | 538 Participants | 537 Participants | 514 Participants | 2126 Participants |
| Sex: Female, Male Male | 162 Participants | 164 Participants | 166 Participants | 184 Participants | 676 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk | EG002 affected / at risk | EG003 affected / at risk |
|---|---|---|---|---|
| deaths Total, all-cause mortality | — / — | — / — | — / — | — / — |
| other Total, other adverse events | 0 / 711 | 0 / 705 | 0 / 712 | 0 / 704 |
| serious Total, serious adverse events | 0 / 711 | 0 / 705 | 0 / 712 | 0 / 704 |
Outcome results
Primary
Changes in Cognitive Abilities of Memory From Baseline to Year 10
Memory outcome was computed as the summation of Rey Auditory-Verbal Learning Test (AVLT), the Hopkins Verbal Learning Test (HVLT), and the Rivermead Behavioral Paragraph Recall test immediate recall. The possible range of the memory outcome is 0 to 132. Higher values represent a better outcome. Changes in outcome were computed as 10 year minus baseline and the negative values indicate the decline from baseline.
Time frame: Up to 10 years
Population: Of the randomized subjects, 943 subjects who had the memory outcome at year 10 were used.
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Memory Training | Changes in Cognitive Abilities of Memory From Baseline to Year 10 | -10.6 units on a scale | Standard Deviation 28.3 |
| Reasoning Training | Changes in Cognitive Abilities of Memory From Baseline to Year 10 | -11.2 units on a scale | Standard Deviation 26.3 |
| Speed of Processing Training | Changes in Cognitive Abilities of Memory From Baseline to Year 10 | -12.7 units on a scale | Standard Deviation 25.5 |
| Control | Changes in Cognitive Abilities of Memory From Baseline to Year 10 | -9.4 units on a scale | Standard Deviation 29.6 |
Comparison: Effect size was defined as training improvement from baseline to year 10 minus control improvement from baseline to year 10 divided by the intrasubject standard deviation (SD) of the composite score. Positive effect sizes indicate improvement.p-value: 0.4399% CI: [-0.14, 0.27]Mixed Models Analysis
Comparison: Effect size was defined as training improvement from baseline to year 10 minus control improvement from baseline to year 10 divided by the intrasubject standard deviation (SD) of the composite score. Positive effect sizes indicate improvement.p-value: 0.1799% CI: [-0.31, 0.1]Mixed Models Analysis
Comparison: Effect size was defined as training improvement from baseline to year 10 minus control improvement from baseline to year 10 divided by the intrasubject standard deviation (SD) of the composite score. Positive effect sizes indicate improvement.p-value: 0.5299% CI: [-0.25, 0.15]Mixed Models Analysis
Primary
Changes in Cognitive Abilities of Reasoning From Baseline to Year 10
Reasoning outcome was computed as the summation of total correct for Letter Series, Letter Sets, and Word Series. The possible range of the reasoning outcome is 0 to 75. Higher values represent a better outcome. Changes in outcome were computed as 10 year minus baseline and the negative values indicate the decline from baseline.
Time frame: Up to 10 years
Population: Of the randomized subjects, 938 subjects who had the reasoning outcome at year 10 were used.
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Memory Training | Changes in Cognitive Abilities of Reasoning From Baseline to Year 10 | -3.23 units on a scale | Standard Deviation 8.61 |
| Reasoning Training | Changes in Cognitive Abilities of Reasoning From Baseline to Year 10 | -0.049 units on a scale | Standard Deviation 7.91 |
| Speed of Processing Training | Changes in Cognitive Abilities of Reasoning From Baseline to Year 10 | -3.94 units on a scale | Standard Deviation 8.34 |
| Control | Changes in Cognitive Abilities of Reasoning From Baseline to Year 10 | -3.04 units on a scale | Standard Deviation 8.02 |
Comparison: Effect size was defined as training improvement from baseline to year 10 minus control improvement from baseline to year 10 divided by the intrasubject standard deviation (SD) of the composite score. Positive effect sizes indicate improvement.p-value: 0.6999% CI: [-0.17, 0.12]Mixed Models Analysis
Comparison: Effect size was defined as training improvement from baseline to year 10 minus control improvement from baseline to year 10 divided by the intrasubject standard deviation (SD) of the composite score. Positive effect sizes indicate improvement.p-value: <0.0199% CI: [0.09, 0.38]Mixed Models Analysis
Comparison: Effect size was defined as training improvement from baseline to year 10 minus control improvement from baseline to year 10 divided by the intrasubject standard deviation (SD) of the composite score. Positive effect sizes indicate improvement.p-value: 0.2799% CI: [-0.2, 0.08]Mixed Models Analysis
Primary
Changes in Cognitive Abilities of Speed of Processing From Baseline to Year 10
Speed of processing outcome was computed as the summation of three Useful Field of View tasks requiring identification and localization of information, with 75% accuracy, under varying levels of cognitive demand. For the analysis, the reversed score was used and the possible range of the reversed speed of processing outcome is 0 to 1500. Higher values for the reversed scores represent a better outcome. Changes in outcome were computed as 10 year minus baseline and the negative values indicate the decline from baseline.
Time frame: Up to 10 years
Population: Of the randomized subjects, 879 subjects who had the speed outcome at year 10 were used.
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Memory Training | Changes in Cognitive Abilities of Speed of Processing From Baseline to Year 10 | -144.4 units on a scale | Standard Deviation 228.6 |
| Reasoning Training | Changes in Cognitive Abilities of Speed of Processing From Baseline to Year 10 | -126.2 units on a scale | Standard Deviation 253.6 |
| Speed of Processing Training | Changes in Cognitive Abilities of Speed of Processing From Baseline to Year 10 | 24.3 units on a scale | Standard Deviation 252.1 |
| Control | Changes in Cognitive Abilities of Speed of Processing From Baseline to Year 10 | -123.3 units on a scale | Standard Deviation 277.7 |
Comparison: Effect size was defined as training improvement from baseline to year 10 minus control improvement from baseline to year 10 divided by the intrasubject standard deviation (SD) of the composite score. Positive effect sizes indicate improvement.p-value: 0.4599% CI: [-0.29, 0.16]Mixed Models Analysis
Comparison: Effect size was defined as training improvement from baseline to year 10 minus control improvement from baseline to year 10 divided by the intrasubject standard deviation (SD) of the composite score. Positive effect sizes indicate improvement.p-value: 0.9599% CI: [-0.22, 0.23]Mixed Models Analysis
Comparison: Effect size was defined as training improvement from baseline to year 10 minus control improvement from baseline to year 10 divided by the intrasubject standard deviation (SD) of the composite score. Positive effect sizes indicate improvement.p-value: <0.0199% CI: [0.43, 0.88]Mixed Models Analysis
Primary
Changes in Everyday Problem Solving From Baseline to Year 10
Everyday Problem Solving was computed as the summation of the Everyday Problems Test (EPT) and Observed Tasks of Daily Living (OTDL). The possible range of the everyday problem solving outcome is 0 to 56. Higher values represent a better outcome. Changes in outcome were computed as 10 year minus baseline and the negative values indicate the decline from baseline.
Time frame: Up to 10 years
Population: Of the randomized subjects, 1104 subjects who had the everyday problem solving outcome at year 10 were used.
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Memory Training | Changes in Everyday Problem Solving From Baseline to Year 10 | -6.10 units on a scale | Standard Deviation 9.75 |
| Reasoning Training | Changes in Everyday Problem Solving From Baseline to Year 10 | -5.58 units on a scale | Standard Deviation 9.56 |
| Speed of Processing Training | Changes in Everyday Problem Solving From Baseline to Year 10 | -5.98 units on a scale | Standard Deviation 9.32 |
| Control | Changes in Everyday Problem Solving From Baseline to Year 10 | -5.67 units on a scale | Standard Deviation 9.85 |
Comparison: Effect size was defined as training improvement from baseline to year 10 minus control improvement from baseline to year 10 divided by the intrasubject standard deviation (SD) of the composite score. Positive effect sizes indicate improvement.p-value: 0.9799% CI: [-0.23, 0.24]Mixed Models Analysis
Comparison: Effect size was defined as training improvement from baseline to year 10 minus control improvement from baseline to year 10 divided by the intrasubject standard deviation (SD) of the composite score. Positive effect sizes indicate improvement.p-value: 0.8699% CI: [-0.25, 0.22]Mixed Models Analysis
Comparison: Effect size was defined as training improvement from baseline to year 10 minus control improvement from baseline to year 10 divided by the intrasubject standard deviation (SD) of the composite score. Positive effect sizes indicate improvement.p-value: 0.9399% CI: [-0.23, 0.24]Mixed Models Analysis
Primary
Changes in Everyday Speed of Processing From Baseline to Year 10
Everyday Speed of processing was computed as the summation of Complex Reaction Time (CRT) and Timed IADL (TIADL). For the analysis, the reversed score was used and the possible range of the reversed everyday speed of processing outcome is -3 to 100. Higher values for the reversed scores represent a better outcome. Changes in outcome were computed as 10 year minus baseline and the negative values indicate the decline from baseline.
Time frame: Up to 10 years
Population: Of the randomized subjects, 938 subjects who had the everyday speed of processing outcome at year 10 were used.
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Memory Training | Changes in Everyday Speed of Processing From Baseline to Year 10 | -1.53 units on a scale | Standard Deviation 2.17 |
| Reasoning Training | Changes in Everyday Speed of Processing From Baseline to Year 10 | -1.39 units on a scale | Standard Deviation 1.88 |
| Speed of Processing Training | Changes in Everyday Speed of Processing From Baseline to Year 10 | -1.47 units on a scale | Standard Deviation 1.98 |
| Control | Changes in Everyday Speed of Processing From Baseline to Year 10 | -1.42 units on a scale | Standard Deviation 1.78 |
Comparison: Effect size was defined as training improvement from baseline to year 10 minus control improvement from baseline to year 10 divided by the intrasubject standard deviation (SD) of the composite score. Positive effect sizes indicate improvement.p-value: 0.7899% CI: [-0.19, 0.23]Mixed Models Analysis
Comparison: Effect size was defined as training improvement from baseline to year 10 minus control improvement from baseline to year 10 divided by the intrasubject standard deviation (SD) of the composite score. Positive effect sizes indicate improvement.p-value: 0.9699% CI: [-0.21, 0.21]Mixed Models Analysis
Comparison: Effect size was defined as training improvement from baseline to year 10 minus control improvement from baseline to year 10 divided by the intrasubject standard deviation (SD) of the composite score. Positive effect sizes indicate improvement.p-value: 0.5699% CI: [-0.26, 0.16]Mixed Models Analysis
Primary
Changes in Instrumental Activities of Daily Living (IADL) Difficulty From Baseline to Year 10
The self-reported measure of everyday IADL function was the summation of the IADL difficulty sub-scores from the Minimum Dataset - Home Care (MDS-HC) which assesses performance in the past 7 days on 19 daily tasks spanning meal preparation, housework, finances, health care, telephone, shopping, travel, and need for assistance in dressing, personal hygiene, and bathing. For the analysis, the reversed score was used and the possible range of the reversed everyday IADL function outcome is 0 to 38. Higher values for the reversed scores represent a better outcome. Changes in outcome were computed as 10 year minus baseline and the negative values indicate the decline from baseline.
Time frame: Up to 10 years
Population: Of the randomized subjects, 1211 subjects who had the IADL outcome at year 10 were used.
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Memory Training | Changes in Instrumental Activities of Daily Living (IADL) Difficulty From Baseline to Year 10 | -3.05 units on a scale | Standard Deviation 7.38 |
| Reasoning Training | Changes in Instrumental Activities of Daily Living (IADL) Difficulty From Baseline to Year 10 | -2.66 units on a scale | Standard Deviation 6.31 |
| Speed of Processing Training | Changes in Instrumental Activities of Daily Living (IADL) Difficulty From Baseline to Year 10 | -2.34 units on a scale | Standard Deviation 5.62 |
| Control | Changes in Instrumental Activities of Daily Living (IADL) Difficulty From Baseline to Year 10 | -3.61 units on a scale | Standard Deviation 7.67 |
Comparison: Effect size was defined as training improvement from baseline to year 10 minus control improvement from baseline to year 10 divided by the intrasubject standard deviation (SD) of the composite score. Positive effect sizes indicate improvement.p-value: <0.0199% CI: [0.12, 0.84]Mixed Models Analysis
Comparison: Effect size was defined as training improvement from baseline to year 10 minus control improvement from baseline to year 10 divided by the intrasubject standard deviation (SD) of the composite score. Positive effect sizes indicate improvement.p-value: <0.0199% CI: [0.02, 0.74]Mixed Models Analysis
Comparison: Effect size was defined as training improvement from baseline to year 10 minus control improvement from baseline to year 10 divided by the intrasubject standard deviation (SD) of the composite score. Positive effect sizes indicate improvement.p-value: <0.0199% CI: [0.01, 0.72]Mixed Models Analysis
Secondary
Changes in Health-related Quality of Life (HRQol), Driving Function, Health Service Use
To determine if the cognitive interventions have beneficial effects on the distal outcomes of driving safety, personal care activities of daily living, health service utilization, and mortality.
Time frame: 10th Year
Secondary
Estimate the Effects of ACTIVE Training to General Population
To estimate and project the effects of ACTIVE training to the general population of older adults by linking the measures and outcomes of ACTIVE to the Health and Retirement Study(and its subsidiary studies), a population-based, nationally-representative cohort.
Time frame: 10th Year
Secondary
Examine Health, Genetic and Cognitive Moderators
To examine heath, genetic, and cognitive moderators (including cardiovascular disease,diabetes, depression, Apolipoprotein E (APOE) genotype, and low cognition and engagement) in individual response to training.
Time frame: 10th Year