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Archives of Gerontology and Geriatrics 43 (2006) 327–335
www.elsevier.com/locate/archger
Abstract
The aim of the present study is to evaluate the outcomes of a computer-based cognitive training on
patients affected by Alzheimer’s disease (AD) compared with the outcomes on patients affected by
mild cognitive impairment (MCI), multiple system atrophy (MSA). Ten AD patients aged 74.1 5.6
years, with mini-mental state examination (MMSE) score at baseline of 23.9 2.4, and 10 MCI
patients aged 70.6 6.0 years, with MMSE score of 28.0 1.4, attending our day-hospital of
neurorehabilitation were selected for the study. Three MSA patients aged 69.0 9.5 years, MMSE
scores 26.7 2.3 were selected from the same setting in order to have a different control group. Each
patient attended two training programs and was evaluated according to cognitive and non-cognitive
functions at baseline at the end of the second training program. The AD group showed a significant
MMSE score improvement ( p = 0.010). On the contrary, MMSE scores at baseline and at follow-up
remained quite stable in the other two groups. AD patients also showed significant improvement in
the areas of verbal production ( p = 0.036) and executive functions ( p = 0.050). MCI patients
significantly improved in behavioral memory ( p = 0.017; p = 0.011). No significant improvement
was observed in MSA group. Our data seem to indicate that the same individualized rehabilitative
intervention could have different effects according to patient’s diagnosis. MCI and AD patients had
significant improvements in global cognitive status and/or in specific cognitive areas. On the contrary,
MSA patients did not benefit at all.
# 2006 Elsevier Ireland Ltd. All rights reserved.
Keywords: Computer-based neuropsychological training (NPT); NPT software; Mini-mental state examination
(MMSE); Alzheimer’s disease (AD); Mild cognitive impairment (MCI)
* Corresponding author. Tel.: +39 030 3197409; fax: +39 030 48508.
E-mail address: giovannacipriani@libero.it (G. Cipriani).
0167-4943/$ – see front matter # 2006 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.archger.2005.12.003
328 G. Cipriani et al. / Archives of Gerontology and Geriatrics 43 (2006) 327–335
1. Introduction
The NPT software (Tonetta, 1998), originally targeted to patients affected by aphasia,
has gradually been modified in order to broaden its application range. The present
version can be used in focal or global brain damage rehabilitation, as well as in children
education. It includes different exercises aimed to stimulate any of the following cognitive
functions: attention, memory, perception, visuospatial cognition, language, and non-verbal
intelligence.
Each cognitive function is stimulated by a specific group of exercises. Attention is
stimulated by exercises of: spread attention, divided attention through both acoustic and
visual inputs, divided attention through only visual input, semantic concentration, and
bidimensional object identification. Memory is stimulated by exercises of: short-term
visual memory, sequential visual memory, long-term visual memory, multiple information
learning, working memory, spatial memory, combined verbal and spatial memory, and
G. Cipriani et al. / Archives of Gerontology and Geriatrics 43 (2006) 327–335 329
2.2. Patients
2.3. Procedure
Each patient attended two training programs. A single training program (13–45 min
sessions held on 4 days per week) covered a 4-week-period. The break between the first and
the second training program lasted 6 2 weeks. Functional status, psychological
symptoms and neuropsychological performance were assessed for each patient at baseline
and after 3 months, i.e., at the end of the second training program. The neuropsychological
battery included MMSE and the following tests: phonemic (Novelli et al., 1986) and
semantic (Spinnler and Tognoni, 1987) verbal fluency (cued verbal production), visual
search (Spinnler and Tognoni, 1987) (sustained attention), trail making test part A and B
(Giovagnoli et al., 1996) (visual search, attention and executive functions), digit symbol
test (Wechsler, 1981) (psychomotor learning), and Rivermead behavioral memory test
(RBMT) (Wilson et al., 1985) (behavioral memory). Information about affective status,
functional autonomy, and quality of life were collected through geriatric depression scale
330 G. Cipriani et al. / Archives of Gerontology and Geriatrics 43 (2006) 327–335
(GDS) (Yesavage et al., 1983), advanced activity of daily living (AADL) (Reuben et al.,
1990), STAI-X1 (state anxiety) and STAI-X2 (trait anxiety) (Spielberger et al., 1983), and
short form health survey (SF-12) (Ware et al., 1996).
3. Results
The NPT mean scores and neuropsychological test mean scores at baseline were
compared with those collected at the 3-month follow-up (statistical significance of the
differences was performed through the non-parametric Wilcoxon test, using SPSS 10.0
software) in each of the three groups of patients. Both AD and MCI group showed better
performances at NPT at follow-up than at baseline. Cognitive areas showing the most
significant improvements in the AD group were memory (short-term, long-term, verbal,
and visual one), perception (perceptual recognition and identification) and attention (both
spread and divided one) (Table 1). Differently from the AD group, MCI patients
significantly improved also in working memory and psychomotor learning, but did not
reach great improvement in the area of perception (Table 2). The MSA group had no
significant improvement at NPT.
Comparison between baseline and follow-up performances of the 10 AD patients at
neuropsychological tests revealed a significant improvement in MMSE score ( p = 0.010),
verbal fluency (phonemic fluency) ( p = 0.041), and executive functions (trail making test
Table 1
Performances in NPT at baseline and at follow-up in the AD group (n = 10)
NPT tests Mean S.D. p
Pre Post
Visual exploration (total score) 1.2 1.2 5.7 2.3 0.003
Visuoverbal association (reaction time) 10.6 4.8 7.3 2.7 0.013
Face recognition (total score) 1.5 1.7 3.3 1.6 0.008
Visual discrimination (total score) 2.2 1.97 4.2 2.7 0.013
Auditory identification (total score) 1.4 0.9 3.3 1.2 0.003
Sequential visual memory (total score) 2.5 1.0 4.0 0.6 0.004
Information learning (total score) 2.8 2.5 7.1 2.5 0.003
Short-term visual memory (total score) 2.1 1.7 5.1 1.2 0.003
Long-term visual memory (total score) 2.1 0.8 3.2 0.6 0.005
Working memory (total score) 1.3 1.2 2.0 1.4 ns
Spread attention (reaction time) 0.8 0.2 0.5 0.2 0.016
Object identification (total score) 0.4 1.1 1.2 1.6 0.012
Divided attention (reaction time) 8.9 4.9 6.0 3.5 0.018
Semantic concentration (reaction time) 8.1 6.5 3.1 1.2 0.007
Phonological discrimination (total score) 1.4 0.9 3.5 1.7 0.003
Verbal comprehension (total score) 2.1 1.5 4.6 1.5 0.008
Semantic categorization (total score) 1.0 0.8 5.2 3.8 0.012
Logical-inductive reasoning (total score) 0.4 0.4 1.4 1.0 0.012
Psychomotor learning (total time) 528.6 19.3 376.2 127.3 ns
Pattern reproduction (total time) 93.7 40.6 39.6 14.2 0.003
Picture reproduction (total time) 489 152 240 175 0.028
G. Cipriani et al. / Archives of Gerontology and Geriatrics 43 (2006) 327–335 331
Table 2
Performances in NPT at baseline and at follow-up in the MCI group (n = 10)
NPT tests Mean S.D. p
Pre Post
Visual exploration (total score) 2.3 2.2 5.6 1.9 0.025
Visuoverbal association (reaction time) 7.97 5.4 5.8 3.8 ns
Face recognition (total score) 3.5 2.2 4.8 2.4 ns
Visual discrimination (total score) 2.5 1.9 5.1 2.2 0.012
Auditory identification (total score) 2.95 2.5 4.1 2.1 ns
Sequential visual memory (total score) 3.6 1.1 4.8 0.7 0.041
Information learning (total score) 3.2 2.0 8.5 2.8 0.012
Short-term visual memory (total score) 3.2 1.6 4.99 1.7 0.017
Long-term visual memory (total score) 2.9 0.6 3.9 0.6 0.023
Working memory (total score) 1.6 1.4 3.7 0.8 0.043
Spread attention (reaction time) 0.7 0.2 0.5 0.2 0.044
Object identification (total score) 1.8 1.2 2.9 1.3 0.036
Divided attention (reaction time) 5.5 2.9 4.1 2.8 ns
Semantic concentration (reaction time) 5.4 5.5 2.2 1.0 0.017
Phonological discrimination (total score) 2.8 1.7 4.7 3.0 ns
Verbal comprehension (total score) 4.0 2.8 5.2 2.9 0.025
Semantic categorization (total score) 3.6 3.1 6.3 3.4 0.025
Logical-inductive reasoning (total score) 1.2 0.9 2.8 1.5 0.012
Psychomotor learning (total time) 447.3 176.8 244.7 67.7 0.018
Pattern reproduction (total time) 63.6 28.0 34.9 16.8 0.012
Picture reproduction (total time) 349.3 106.4 210.3 71.5 0.018
4. Discussion
Table 3
Cognitive and non-cognitive test scores at baseline and follow-up in the AD group
Tests Mean S.D. p
Pre Post
MMSE (total score) 23.9 2.4 26.0 1.7 0.010
Phonemic fluency (total number of words) 19.3 3.4 21.8 4.1 ns
Phonemic fluency (z score) 0.8 0.3 0.5 0.5 0.041
Semantic fluency (total number of words) 53.4 10.3 53.1 10.6 ns
Semantic fluency (z score) 0.5 0.7 0.5 0.6 ns
Visual search (total score) 38.6 10.1 39.7 10.8 ns
Visual search (z score) 0.8 1.1 0.5 1.2 ns
Trail making test A (total time) 102.4 34.8 94.4 42.4 ns
Trail making test A (number of errors) 0.0 0.0 0.9 3.0 ns
Trail making test B (total time) 268.4 130.4 258.9 92.2 ns
Trail making test B (number of errors) 11.8 5.4 7.3 6.2 0.050
Digit symbol test (total score) 15.8 5.7 16.9 4.9 ns
RBMT (total score) 8.6 4.7 9.6 3.4 ns
RBMT(z score) 2.3 1.5 2.1 1.2 ns
GDS (total score) 6.8 4.3 4.9 3.3 ns
AADL (number of lost functions) 6.3 2.6 6.5 2.2 ns
STAI-X1 (total score) 37.6 9.9 32.7 12.8 ns
STAI-X2 (total score) 42.0 13.4 37.7 11.9 ns
SF-12 (physical C score) 52.9 10.1 54.5 9.8 ns
SF-12 (mental C score) 40.6 12.8 40.9 13.3 ns
Table 4
Cognitive and non-cognitive test scores at baseline and follow-up in the MCI group
Tests Mean S.D. p
Pre Post
MMSE (total score) 28.0 1.4 28.7 1.3 ns
Phonemic fluency (total number of words) 25.9 12.9 25.1 11.7 ns
Phonemic fluency (z score) 0.2 1.3 0.2 1.1 ns
Semantic fluency (total number of words) 67.9 21.3 73.4 17.3 ns
Semantic fluency (z score) 0.2 1.0 0.6 0.9 ns
Visual search (total score) 44.4 8.6 48.5 8.5 ns
Visual search (z score) 0.3 1.0 0.2 1.2 ns
Trail making test A (total time) 71.4 19.6 64.5 22.9 ns
Trail making test A (number of errors) 0.0 0.0 0.0 0.0 ns
Trail making test B (total time) 145.1 49.5 168.3 69.5 ns
Trail making test B (number of errors) 4.5 5.5 1.6 2.6 ns
Digit symbol test (total score) 27.0 6.1 28.5 7.1 ns
RBMT (total score) 16.7 4.0 19.1 4.5 0.017
RBMT (z score) 0.4 1.1 0.6 1.0 0.011
GDS (total score) 6.2 4.9 4.7 3.8 ns
AADL (number of lost functions) 7.0 1.1 7.0 2.3 ns
STAI-X1 (total score) 35.4 8.8 32.0 5.8 ns
STAI-X2 (total score) 45.1 12.6 38.6 9.7 ns
SF-12 (physical C score) 38.7 11.5 35.4 13.4 ns
SF-12 (mental C score) 42.4 10.0 49.3 10.5 ns
G. Cipriani et al. / Archives of Gerontology and Geriatrics 43 (2006) 327–335 333
on general cognitive performance. On the contrary, our data on AD and MCI patients
indicate that a daily training aimed to stimulate specific cognitive areas could improve
performances not only at computer-based trained exercises, but also at traditional
neuropsychological tests. However, our sample did not achieve significant improvement in
affective and functional areas, probably due to the low number of patients. Concerning the
functional status we should also underline that our patients were in a mild stage of disease
with a baseline low impairment.
An interesting debate is going in the literature about the differences between what
cognitive rehabilitation and cognitive training do mean. Cognition-focused interventions
for mild demented people have typically adopted a cognitive training model, rather than
cognitive rehabilitation. The cognitive training approach has a number of important
limitations: little range of possible modifications according to individual needs and coping
strategies, poor integration with emotional responses, no effect of generalization to
everyday life nor to clinical status. On the contrary, cognitive rehabilitation is a more
individualized approach, aimed to enable patients and their families ‘‘to live with, manage,
by-pass, reduce or come to terms’’ with cognitive deficits and related problems, in order to
reach a better quality of life (Wilson, 1997, 2002).
Our cognitive intervention could be placed at an intermediate point between cognitive
training and cognitive rehabilitation, because the standardized daily training may be
adapted to the individual’s characteristics. It implies a continuous stimulation of preserved
cognitive functions, aimed to produce, at the same time, a direct improvement on trained
NPT exercises and an effect on patient’s performance at neuropsychological tests.
Recent observational studies and placebo controlled trials evaluating the effect of AchE-
I on cognitive decline in mild to moderate AD patients demonstrate that, after the initial
improvement within the first 6 months, patients maintain baseline MMSE scores for about
a year, and then decline (Doody et al., 2001b; Tariot, 2001; Tariot et al., 2001; Wolfson
et al., 2002; Hager et al., 2003; Jones et al., 2004). Thus, it is particularly important to
evaluate the additive effect of non-pharmacological treatments in delaying the continuous
progression of the disease.
Our data seem to indicate that an individualized rehabilitative intervention targeted to
preserve neuropsychological functions may broaden the effect of AchE-I treatment.
Moreover, the outcomes of NPT training on our 10 MCI patients open new possibilities of
intervention.
On the contrary, the fact that MSA patients (even if they formed a very small group) did
not get any improvement seems to demonstrate that this kind of training is disease-specific.
However, further investigations are needed.
References
Backman, L., 1996. Utilizing compensatory task conditions for episodic memory in Alzheimer’s disease. Acta
Neurol. Scand. Suppl. 165, 109–113.
Clare, L., Woods, R., Moniz-Cook, E., Orrell, M., Spector, A., 2003. Cognitive rehabilitation and cognitive training
for early-stage Alzheimer’s disease and vascular dementia. Cochrane Database Syst. Rev. (4), CD003260.
Davis, R.N., Massman, P.J., Doody, R.S., 2001. Cognitive intervention in Alzheimer disease: a randomized
placebo-controlled study. Alzheimer Dis. Assoc. Disord. 15, 1–9.
334 G. Cipriani et al. / Archives of Gerontology and Geriatrics 43 (2006) 327–335
De Vreese, L.P., Neri, M., Fioravanti, M., Belloi, L., Zanetti, O., 2001. Memory rehabilitation in Alzheimer’s
disease: a review of progress. Int. J. Geriatr. Psychiatry 16, 794–809.
Doody, R.S., Stevens, J.C., Beck, C., Dubinsky, R.M., Kave, J.A., Gwyther, L., Mohs, R.C., Thal, L.J.,
Whitehouse, P.J., DeKosky, S.T., Cummings, J.L., 2001a. Practice parameter: management of dementia
(an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of
Neurology. Neurology 56, 1154–1166.
Doody, R.S., Dunn, J.K., Clark, C.M., Farlow, M., Foster, N.L., Liao, T., Gonzales, N., Lai, E., Massman, P.,
2001b. Chronic donepezil treatment is associated with slowed cognitive decline in Alzheimer’s disease.
Dement. Geriatr. Cogn. Disord. 12, 295–300.
Evans, J.E., Levine, B., 2002. Is cognitive rehabilitation effective? Neuropsychol. Rehabil. 12, 85–91.
Farina, E., Fioravanti, R., Chiavari, L., Imbornone, E., Alberoni, M., Pomati, S., Pinardi, G., Pignatti, R., Mariani,
C., 2002. Comparing two programs of cognitive training in Alzheimer’s disease: a pilot study. Acta Neurol.
Scand. 105, 365–371.
Folstein, M.F., Folstein, S.E., McHugh, P.R., 1975. ‘‘Mini Mental State’’: a practical method for grading the
cognitive state of patients for the clinician. J. Psychiatr. Res. 12, 189–198.
Giovagnoli, A.R., Del Pesce, M., Macheroni, S., Capitani, E., 1996. Trail Making Test: normative values from 287
normal adult controls. Ital. J. Neurol. Sci. 17, 305–309.
Hager, K., Calabrese, P., Frolich, L., Gobel, C., Berger, F.M., 2003. An observational clinical study of the efficacy
and tolerability of donepezil in the treatment of Alzheimer’s disease. Dement. Geriatr. Cogn. Disord. 15, 189–
198.
Hofmann, M., Hock, C., Muller-Spahn, F., 1996. Computer-based cognitive training in Alzheimer’s disease
patients. Ann. N. Y. Acad. Sci. 777, 249–354.
Hofmann, M., Rosler, A., Schwarz, W., Muller-Spahn, F., Krauchi, K., Hock, C., Seifritz, E., 2003. Interactive
computer-training as a therapeutic tool in Alzheimer’s disease. Compr. Psychiatry 44, 213–219.
Jones, R.W., Soininen, H., Hager, K., Aarsland, D., Passmore, P., Murthy, A., Zhang, R., Bahra, R., 2004. A
multinational, randomised, 12-week study comparing the effects of donepezil and galantamine in patients with
mild to moderate Alzheimer’s disease. Int. J. Geriatr. Psychiatry 19, 58–67.
McKhann, G., Drachman, D., Folstein, M., Katzman, R., Price, D., Stadlan, E.M., 1984. Clinical diagnosis of
Alzheimer’s disease: Report of the NINCDS-ADRDA work group under the auspices of Department of Health
and Human Services Task Force on Alzheimer’s disease. Neurology 34, 939–944.
Metitieri, T., Zanetti, O., Geroldi, C., Frisoni, G.B., De Leo, D., Dello Buono, M., Bianchetti, A., Trabucchi, M.,
2001. Reality orientation therapy to delay outcomes of progression in patients with dementia. A retrospective
study. Clin. Rehabil. 15, 471–478.
Novelli, G., Laiacona, M., Papagno, C., Vallar, G., Capitani, E., Cappa, S.F., 1986. Tre test clinici di ricerca e
produzione lessicale. Taratura su soggetti normali. Arch. Neurol. Psicol. Psichiatr. 47, 477–506 (in Italian).
Oriani, M., Moniz-Cook, E., Binetti, G., Zanieri, G., Frisoni, G.B., Geroldi, C., De Vreese, L.P., Zanetti, O., 2003.
An electronic memory aid to support prospective memory in patients in the early stages of Alzheimer’s
disease: a pilot study. Aging Ment. Health 7, 22–27.
Reuben, D.B., Laliberte, L., Hiris, J., 1990. A hierarchical exercise scale to measure function at the advanced
activities of daily living (AADL) level. J. Am. Geriatr. Soc. 38, 855–861.
Schreiber, M., Schweizer, A., Lutz, K., Kalveram, K.T., Jäncke, L., 1999. Potential of an interactive computer-
based training in the rehabilitation of dementia: an initial study. Neuropsychol. Rehabil. 9, 155–167.
Spector, A., Orrell, M., Davies, S., Woods, B., 2000. Reality orientation for dementia. Cochrane Database Syst.
Rev. (4), CD001119.
Spielberger, C.S., Gorsuch, R.L., Lushene, R.E., 1983. Manual for the State Trait Anxiety Inventory (STAI).
Consulting Psychologists Press, Palo Alto, CA.
Spinnler, H., Tognoni, G., 1987. Standardizzazione e taratura Italiana di test neuropsicologici. Ital. J. Neurol. Sci. 6
(Suppl. 8) (in Italian).
Tariot, P.N., 2001. Maintaining cognitive function in Alzheimer disease: how effective are current treatments?
Alzheimer Dis. Assoc. Disord. 15 (Suppl. 1), S26–S33.
Tariot, P.N., Cummings, J.L., Katz, I.R., Mintzer, J., Perdomo, C.A., Schwam, E.M., Whalen, E., 2001. A
randomized, double-blind, placebo-controlled study of the efficacy and safety of donepezil in patients with
Alzheimer’s disease in the nursing home setting. J. Am. Geriatr. Soc. 49, 1590–1599.
G. Cipriani et al. / Archives of Gerontology and Geriatrics 43 (2006) 327–335 335
Tonetta, M., 1998. Riabilitazione neuropsicologica e TNP (training neuropsicologico). Aspetti teorici e pragma-
tici. New Magazine Publisher, Trento (in Italian).
Ware, J.E., Kosinski, M., Keller, S.D., 1996. A 12-item Short Form Health Survey: construction of scales and
preliminary tests of reliability and validity. Med. Care 34, 220–223.
Wechsler, D., 1981. Wechsler Adult Intelligence Scale-Revised Manual. The Psychological Corporation, New
York.
Wilson, B.A., 1997. Cognitive rehabilitation: how it is and how it might be. J. Int. Neuropsychol. Soc. 3, 487–496.
Wilson, B.A., 2002. Towards a comprehensive model of cognitive rehabilitation. Neuropsychol. Rehabil. 12, 97–
110.
Wilson, B.A., Cockburn, J., Baddeley, A.D., 1985. The Rivermead Behavioural Memory Test Manual. Valley Test
Co., Reading Thames.
Wolfson, C., Oremus, M., Shukla, V., 2002. Donepezil and rivastigmine in the treat-ment of Alzheimer’s disease: a
best-evidence synthesis of the published data on their efficacy and cost-effectiveness. Clin. Ther. 24, 862–886.
Yesavage, J.A., Brink, T.L., Rose, T.L., Lum, O., Huang, V., Adey, M., Leirer, V.O., 1983. Development and
validation of a geriatric depression screening scale: a preliminary report. J. Psychiatr. Res. 17, 37–49.
Zanetti, O., Frisoni, G.B., De Leo, D., Dello Buono, M., Bianchetti, A., Trabucchi, M., 1995. Reality orientation
therapy in Alzheimer disease: useful or not? A controlled study. Alzheimer Dis. Assoc. Disord. 9, 132–138.
Zanetti, O., Binetti, G., Magni, E., Rozzini, L., Bianchetti, A., Trabucchi, M., 1997. Procedural memory
stimulation in Alzheimer’s disease: impact of a training programme. Acta Neurol. Scand. 95, 152–157.
Zanetti, O., Zanieri, G., Di Giovanni, G., De Vreese, L.P., Pezzini, A., Metitieri, T., Trabucchi, M., 2001.
Effectiveness of procedural memory stimulation in mild Alzheimer’s disease patients: A controlled study.
Neuropsychol. Rehabil. 11, 263–272.
Zanetti, O., Oriani, M., Geroldi, C., Binetti, G., Frisoni, G.B., Di Giovanni, G., De Vreese, L.P., 2002. Predictors of
cognitive improvement after reality orientation in Alzheimer’s disease. Age Ageing 31, 193–196.