Journal of Alzheimer’s Disease 65 (2018) 931–949 931

DOI 10.3233/JAD-180455
IOS Press

Is Computerized Working Memory

Training Effective in Healthy Older
Adults? Evidence from a Multi-Site,
Randomized Controlled Trial
Sharon S. Simona , Erich S. Tuscha , Nicole C. Fenga , Krister Håkanssonb,c ,
Abdul H. Mohammedc,d and Kirk R. Daffnera,∗
a Department of Neurology, Center for Brain/Mind Medicine, Division of Cognitive and Behavioral
Neurology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
b Division of Clinical Geriatrics, Department of NVS, Karolinska Insitutet, Stockholm, Sweden
c Department of Psychology, Linnaeus University, Växjö, Sweden
d Center of Alzheimer Research, Department of Neurobiology, Karolinska Insitutet, Stockholm, Sweden

Handling Associate Editor: Sharon Naismith

Accepted 10 July 2018

Abstract.
Background: Developing effective interventions to attenuate age-related cognitive decline and prevent or delay the onset
of dementia are major public health goals. Computerized cognitive training (CCT) has been marketed increasingly to older
adults, but its efficacy remains unclear. Working memory (WM), a key determinant of higher order cognitive abilities, is
susceptible to age-related decline and a relevant target for CCT in elders.
Objective: To evaluate the efficacy of CCT focused on WM compared to an active control condition in healthy older adults.
Methods: Eighty-two cognitively normal adults from two sites (USA and Sweden) were randomly assigned to Cogmed
Adaptive or Non-Adaptive (active control) CCT groups. Training was performed in participants’ homes, five days per week
over five weeks. Changes in the performance of the Cogmed trained tasks, and in five neuropsychological tests (Trail Making
Test Part A and Part B, Digit Symbol, Controlled Oral Word Association Test and Semantic Fluency) were used as outcome
measures.
Results: The groups were comparable at baseline. The Adaptive group showed robust gains in the trained tasks, and there was
a time-by-group interaction for the Digit Symbol test, with significant improvement only after Adaptive training. In addition,
the magnitude of the intervention effect was similar at both sites.
Conclusion: Home-based CCT Adaptive WM training appears more effective than Non-Adaptive training in older adults
from different cultural backgrounds. We present evidence of improvement in trained tasks and on a demanding untrained
task dependent upon WM and processing speed. The benefits over the active control group suggest that the Adaptive CCT
gains were linked to providing a continuously challenging level of WM difficulty.

Keywords: Aging, computerized cognitive training, randomized controlled trial, working memory

∗ Correspondence to: Kirk R. Daffner, MD, FAAN, Center for

Brain/Mind Medicine, Division of Cognitive and Behavioral Neu- 60 Fenwood Road, Boston, MA 02115, USA. Tel.: +1 617 732
rology, Brigham and Women’s Hospital, Harvard Medical School, 8060; Fax: +1 617 738 9122; E-mail: kdaffner@bwh.harvard.edu.

ISSN 1387-2877/18/$35.00 © 2018 – IOS Press and the authors. All rights reserved
932 S.S. Simon et al. / Working Memory Training in Older Adults: An RCT
INTRODUCTION
Age is the most important risk factor for devel-
oping dementia, a major source of dependence and
disability [1–3]. With people living to increasingly
advanced ages, the prevalence of dementia is expand-
ing [4]. The risk of developing dementia is one of the
most feared aspects of growing old [5], with more
than half the people over 65 years old having con-
cerns about their cognitive abilities [6–8]. Models
developed by Brookmeyer and colleagues [9] suggest
that even small delays in dementia onset could sig-
nificantly reduce the global burden of dementia. For
instance, postponing the onset of Alzheimer’s disease
(AD) by one year could result in a decrease of >9 mil-
lion in the worldwide prevalence of AD [9]. Given
the profound personal, social, and economic costs of
dementia, there is a need for evidence-based interven-
tions capable of delaying, attenuating or preventing
cognitive decline and dementia.
Healthy cognitive functioning is a critical compo-
nent of well-being, autonomy, and successful aging
[10, 11]. Converging lines of evidence indicate
that engagement in cognitively stimulating activi-
ties throughout the lifespan may reduce the risk of
cognitive deterioration and dementia [12–15]. This
research supports the cognitive reserve hypothesis,
which suggests that certain kinds of life experi-
ence, including education, occupational attainment,
and cognitively stimulating leisure activities, con-
tribute to the ability to cope with or compensate for
age-related cerebral decline, allowing adults to main-
tain cognitive task performance and daily activities
[16]. Interventions that engage individuals in cogni-
tively stimulating activities may help build cognitive
reserve enabling them to tolerate greater age- and
disease-related brain changes.
Brain plasticity has been shown to persist into old
age and may be stimulated by cognitive activities [17,
18]. Some investigators have argued that formal cog-
nitive training is a potential tool for improving mental
functioning [19–26]. In fact, recent reports suggest
that some forms of cognitive intervention (e.g., speed
of processing training) in healthy elders may have
long-term effects on everyday functioning [27, 28],
and even reduce the risk of developing dementia 10
years after the completion of a training program [29].
In the last decade, there has been a growing interest
in investigating the effect of working memory (WM)
training on healthy older adults. WM reflects the abil-
ity to maintain and manipulate information [30]. It is a
central mechanism supporting higher-order cognitive
abilities, such as fluid intelligence, language com-
prehension, problem solving and reasoning [31–35].
WM operations are dependent on a widespread
network, including fronto-striatal, parietal, and tem-
poral brain regions [36–40]. There is evidence that
WM declines with age [41–45], which can under-
mine performance of instrumental activities of daily
living [46].
The literature on the efficacy of WM training
in older adults has been controversial. On the one
hand, studies suggest that WM training can improve
information processing in older adults [26, 47, 48]
allowing them to sustain cognitive functioning and
remain active and engaged [47]. For example, there
is evidence of cognitive improvements on trained
tasks, and near-transfer to tasks not explicitly trained
(i.e., that test operations within the same cognitive
domain) [38, 48–54]. On the other hand, far-transfer
effects (i.e., that reflect operations in other cognitive
domains) have been challenging to demonstrate, and
results have not been uniform across studies [48, 51,
52, 55–59]. Moreover, there is limited evidence of
transfer to meaningful everyday life activities [28,
29, 60]. Inconsistencies in the literature may be due
to large differences in type, intensity, and duration
of the training programs, as well as variation in the
methodology, outcome measures used, and the char-
acteristics of the control groups (e.g., active versus
passive versus no-contact) [52].
In recent years, there has been an expanding
interest specifically in investigating computerized
cognitive training (CCT). CCT involves structured
practice on standardized and cognitively challenging
tasks and has advantages over traditional methods,
including visually appealing interfaces, efficient and
scalable delivery, and the potential to constantly
adapt training content and difficulty to individual
performance [50, 57, 59]. In this context, the
CCT industry has grown enormously, with sales
approaching $1.3 billion in 2013, and projections of
$3.38 billion by 2020 [61, 62]. These programs have
been increasingly marketed to older adults, often
with broad claims about cognitive and functional
improvement allegedly based on strong evidence
that frequently does not exist [51, 59, 63]. In 2014,
two groups of scientists published open letters on
the efficacy of brain-training interventions, with
conflicting perspectives. The first letter claimed that
brain training games do not provide a scientifically
grounded way to improve cognitive functioning
or reverse cognitive decline, and highlighted the
need for more research by investigators with no
 S.S. Simon et al. / Working Memory Training in Older Adults: An RCT
conflicting financial interests who will conduct
rigorously designed studies that include a control
group treated exactly the same as the trained group,
except for the specific training [64] (available on
http://longevity3.stanford.edu/blog/2014/10/15/the-
consensus-on-the-brain-training-industry-from-
the-scientific-community-2/). The second letter,
published months later [65] (available on www.
cognitivetrainingdata.org/the-controversy-does-
brain-training-work/response-letter/), argued that a
substantial and growing body of evidence shows that
certain cognitive-training regimens can significantly
improve cognitive function, and generalize to
everyday activities.
In their review article from the same year, Lampit
and colleagues [59] suggest that, in general, CCT for
older adults is ineffective under the following con-
ditions: unsupervised, at-home training, frequency
of more than three times per week, or sessions of
less than 30 minutes. However, what constitutes
the core components of an effective intervention
remains an unsettled issue since other studies have
reported training-gains for both healthy older adults
[50, 66] and MCI patients [67] after home-based,
unsupervised CCT with frequency of five days a
week. Further investigation is necessary to yield more
definitive conclusions about the efficacy of brain-
training interventions in older adults [50].
Interestingly, little is known about whether dif-
ferences in cultural background modulate training
effects, which is an important issue for determining if
such interventions can be successful in diverse popu-
lations. Culture has been shown to influence cognitive
skills and information processing. For example, stud-
ies using standard neuropsychological tests often
suggest robust differences in performance between
adults in the US and other nations [68–70]. Further-
more, there is evidence that cognitive skills such as
perception, attention and memory can vary across
cultures [71, 72]. Gutchess and collaborators empha-
size that cultural differences can be associated with
the engagement of distinct cognitive processes and
strategies, or the processing of different aspects of the
information [73]. On the other hand, theoretically, the
cognitive operations underlying WM are not specific
to particular groups of individuals, but apply more
generally [31] and previous work suggests no cross-
cultural differences in WM in teenagers [74]. In the
current study, we explored the potential impact of
culture and background on CCT in older adults by
recruiting two different samples of subjects, one from
an urban setting in the United States, and the other
933
from a rural setting in Sweden. We anticipated that
although the two samples may differ cognitively at
baseline, the magnitude of any training effects would
not be modulated by site.
Moreover, the influence of age on the training
response in older adults continues to be unclear.
Results of studies have varied regarding whether
the beneficial effect of cognitive training is greater
for young-old adults than old-old adults [75–78].
Although a recent meta-analysis on cognitive inter-
ventions for older adults reported no significant
differences in effect sizes based on age of study
participants [79], it is uncertain whether the oldest-
old population (∼80 years or older) demonstrates
a different training response than young-old adults
(∼60 to 80 years). For instance, a study found that
oldest-old adults without dementia (age range 75–101
years) were unable to enhance their memory perfor-
mance after training based on the method of loci
[80], a mnemonic technique that had yielded sub-
stantial learning benefits in young-old adults [81].
Nevertheless, there is evidence that the oldest-old
exhibit cognitive plasticity [82] and can improve WM
after cognitive training [19], suggesting that advanc-
ing age does not significantly alter the ability of older
adults to benefit from cognitive interventions, so long
as they have sufficient cognitive capacity to carry
out the training program [79]. The impact of cogni-
tive training on the oldest-old adults is an important
area of research, requiring additional investigation,
especially because this group is the fastest grow-
ing segment of the population in developed countries
[83]. To help address this issue, our sample comprised
a wide age range of older subjects (65–89 years) that
included young-old and old-old individuals, whose
average age was 10 years older than participants in
a similar, previous study on WM training in older
adults [50]. We expected that old-old adults would
also benefit from training, although we were uncer-
tain about whether the impact would be smaller than
that observed in their younger counterparts.
Sensitive to the methodological issues associated
with the investigation of cognitive training in older
adults, the current study sought to address some of
the concerns that have been raised. We conducted a
randomized controlled trial (RCT) that used an active
control group, recruited participants from two dif-
ferent countries with diverse cultural backgrounds,
included a broader age range of older adults, and was
funded by an impartial source. The investigation used
the commercially available Cogmed® QM platform
(Pearson Education, Inc.) to compare an Adaptive
934 S.S. Simon et al. / Working Memory Training in Older Adults: An RCT
WM training condition, wherein task difficulty was
continuously modulated based on performance, with
an active control condition (Non-Adaptive), wherein
the task difficulty remained the same [25]. By con-
tinually updating the degree of demand based on
real time performance, adaptive training provides an
ongoing intellectual challenge throughout the inter-
vention period and ensures that training is neither
boring nor overtaxing [57, 84]. A Non-Adaptive
group seems to be an excellent active control, since
this approach seeks to match all aspects of the actual
intervention, except for the increasingly challenging
training component [51]. Previous literature indi-
cates that Adaptive CCT can lead to greater cognitive
improvement than Non-Adaptive, accompanied by
changes in brain function, as indexed by fMRI and
event-related potentials [25, 36, 85].
Outcome measures for the current study, as
described in the Methods section below, reflected
performance on trained Cogmed tasks, and on five
neuropsychological tests that evaluated both near-
and far-transfer effects. Our primary outcomes reflect
the near-transfer effects, and the secondary outcomes
reflect the far-transfer effects. We chose outcome
measures that relied, in part, on WM, but differed
in terms of the content of the material being held
in WM and the extent to which WM was the central
cognitive process. We hypothesized that near-transfer
effects related to Cogmed training would include
tasks that require holding, updating and manipu-
lating information that has been visually presented
to the participant. Digit Symbol [86] and Trail
Making Test, Part B (TMT-B) [87] were chosen
as strong candidates for this kind of near-transfer
effects.
Other investigators have reported improvements in
Digit Symbol after cognitive training [27]. Although
Digit Symbol is classically considered a test of pro-
cessing speed, it requires various activities, such as
scanning, matching, switching and writing that are
reflective of several cognitive functions like percep-
tion, encoding and retrieval processes, transformation
of information stored in active memory, and decision-
making [88]. Many of these processes are related to
WM, and evidence suggests that speed of processing
has been tightly linked to WM capacity [89]. When
performing the Digit Symbol task, the better a per-
son can hold relevant information in mind, the faster
(and better) performance will be. Regarding TMT-B,
Sánchez-Cubillo and colleagues [90] have argued its
execution is contingent upon WM and task-switching
ability. Consistent with this thesis, other research has
shown that TMT-B performance is associated with
performance on WM tasks [91–93].
Trail Making Test, Part A (TMT-A) is a test of
visual attention that requires visual search and psy-
chomotor speed, but places low demands on WM
and executive control [90, 91, 94]. There is evi-
dence that adaptive CCT in older adults is associated
with improvement in tasks that require attention and
maintenance aspects of WM [50, 67, 95]. TMT-A
was included to help determine whether Adap-
tive Cogmed training would have a greater impact
than Non-Adaptive Cogmed training on more basic
aspects of attention. Although we hypothesize that
WM training can lead to gains on untrained tests of
attention (consistent with near-transfer effects), given
the limited WM load associated with TMT-A, there
was no compelling reason to predict that Adaptive
WM training would have a greater impact on TMT-A
performance than the control condition.
In terms of the far-transfer measures, although
phonemic and semantic word list generation requires
WM functions, these tasks rely most heavily on lex-
ical and semantic processing [96]. Based on the
literature, we hypothesized that we would find robust
near-transfer effects, especially in the outcomes that
demand more WM resources, but had low expec-
tations for observing far-transfer effects. As noted,
we also anticipated that the magnitude of the effects
would be similar across sites from the two different
countries.
METHODS
Study design, randomization, and sample size
calculation
The Successful Aging and Enrichment (SAGE)
study was a randomized controlled, two-site, single-
blind trial, using a four-group design, including three
treatment groups and a control group. The treat-
ment groups consisted of adaptive cognitive training,
physical exercise, and mindfulness meditation. The
active control group participated in a non-adaptive
cognitive training program. In the current report we
focus only on the results of the two cognitive training
conditions (Adaptive versus Non-Adaptive control).
Recruitment occurred between January 2014 and
October 2015. At each site, participants were ran-
domly assigned to one of the four intervention groups.
The data coordinating center of each site random-
ized participants to one of the intervention groups
using a computer block randomization system based
 S.S. Simon et al. / Working Memory Training in Older Adults: An RCT
on a Latin square design. We used the Latin square
design to counterbalance our four groups, since it is
an efficient approach for small RCTs involving more
than two treatment conditions [97]. Of note, the ran-
domization was done before the baseline assessment.
Neuropsychological assessment was conducted at
baseline and following the intervention. Research
staff were not blinded to treatment assignment of sub-
jects. However, subjects were blinded to the cognitive
training condition (adaptive versus non-adaptive) in
which they participated and were unaware of any
hypotheses associated with the two cognitive training
conditions.
Sample size was calculated using G-Power soft-
ware (G-Power, V.3.1). We determined that a sample
size of at least 30 subjects for each experimental
group would be sufficient to detect a medium-sized
effect of CCT on working memory ability in healthy
older adults with 0.90 power at an alpha level of 0.05.
Our estimation was based on the medium-sized effect
(d = 0.50) observed using the same CCT intervention
on a WM outcome (Digit Span Backward) found by
Vermeij and colleagues [67] in a pilot study involving
23 healthy older adults.
Participants and assessment
The initial sample consisted of 82 older adults
(age range 65 to 89, mean age 73.1 ± 6.1) living
independently with preserved functional and cogni-
tive status, who were recruited through community
announcements in the Boston metropolitan area,
USA (population of ∼4,800,000) [98] and Växjö
municipality, a rural region in Sweden (population
of ∼90,000) [99]. The study was approved by the
appropriate ethical review boards at the participating
sites (Boston, Partners Human Research Commit-
tee, protocol 2013P002266; and Linnaeus University,
Regional Ethical Committee, Linköping, protocol
dnr 2013/154-31). All participants completed writ-
ten informed consent. During a pre-training visit, the
participants completed a detailed screening evalua-
tion that included a structured interview to obtain a
medical, neurological, and psychiatric history; a for-
mal neurological evaluation, screening for vision and
hearing, and a neuropsychological assessment.
To be included in the study, participants had to be
65 years or older, English- or Swedish-speaking, have
an estimated intelligence quotient (IQ) ≥ 90 based
on the American or Sweden National Adult Reading
Test (AMNART, NART-SWE) [100, 101]; score ≥
26 on the Mini-Mental State Examination (MMSE)
935
[102]; and perform within one standard deviation
(SD) of mean for published age-based norms on
Logical Memory delayed recall test, from Wechsler
Memory Scale – Third Edition (WMS-III) [103], and
naming to confrontation, as assessed by the Boston
Naming Test (BNT) [104]. Subjects were excluded
if they had a history of central nervous system dis-
ease or major ongoing psychiatric disorders based
on DSM-IV criteria [105], exhibited clinically sig-
nificant depressive symptoms (scored ≥ 15 on the
Geriatric Depression Scale - GDS) [106, 107], had
focal abnormalities consistent with a brain lesion
as determined by a neurological examination, or
a history of clinically significant medical diseases.
Clinical history and baseline performance on neu-
ropsychological tests within one SD of the mean for
age allowed us to exclude subjects with mild cogni-
tive impairment [108] or early dementia [109].
Procedure
Participants in both cognitive training groups
received identical instructions about the training pro-
gram according to a standardized protocol. After the
baseline assessment, a research assistant (RA) visited
participants in their homes and provided a Hewlett-
Packard, 15.4” laptop computer and an orientation to
the Cogmed software program. Since the training was
delivered online, our staff verified technical require-
ments such as access to an internet browser. Also, to
ensure that the instructions were clear and the partic-
ipant had sufficient computer skills, the RA assisted
the participants in accessing the training system for
the first time and supervised the practice of the demo
version of the training. No training strategies were
offered by study personnel. The first training session
occurred approximately 7–10 days after the baseline
cognitive assessment.
During the intervention period, the participant’s
progress was monitored every week by an RA, who
contacted the participants by telephone to provide
support, as suggested by the software training
guidelines (available at: https://cogmed.com/wp-
content/uploads/2010/07/Coaching-manual-US-1.0.
9.pdf). The conversation focused on three general
areas: 1) the subject’s participation during the
prior week (e.g., any missed or abbreviated CCT
sessions); 2) any technical difficulties; and 3) any
questions or issues in need of clarification. Partic-
ipants were reminded that they could contact the
staff with any additional questions. Finally, words
of encouragement were provided. The post-training
936 S.S. Simon et al. / Working Memory Training in Older Adults: An RCT
visit was scheduled as close as possible to the end
of each participant’s training period (mean days
4.7 ± 5.9). Of note, there was no difference between
intervention groups in the number of days between
the last training session and the date of cognitive
testing (p > 0.5).
Interventions (WM training program)
A commercially available WM CCT program
(Cogmed® QM, Pearson Education, Inc.) was uti-
lized in the current study. Time commitments
were equivalent for both training conditions, which
consisted of 25 individual training sessions of approx-
imately 40 minutes. Participants were instructed to
train five days per week for five weeks. Training
sessions in both conditions were based on twelve dif-
ferent verbal and visuospatial tasks, which included
remembering a sequence of numbers, letters, shapes,
or spatial locations for immediate recall. Some exer-
cises involved active manipulation of information,
such as entering numbers in reverse to the order that
they had appeared or tracking the location and order
of pertinent moving circles that are highlighted (see
the Supplementary Material for more details about
the Cogmed tasks). Participants worked on eight of
the possible twelve tasks on each day of training;
the tasks that each participant had to complete on a
given day were pre-determined by the online train-
ing program and were consistent across subjects.
The specific tasks varied across the 25 days such
that each of the 12 tasks was practiced approxi-
mately the same number of times. Allocation of tasks
was exactly the same for both conditions. Partic-
ipants were instructed to perform all tasks within
one block of time with minimal breaks between
tasks.
Under Adaptive CCT, task difficulty was revised on
a trial-by-trial basis with the goal of establishing 60%
accuracy, thereby creating a consistently challenging
level of subjective difficulty for each individual. Task
difficulty was modulated by increasing or decreas-
ing the WM load for each trial, e.g., the number of
letters required to be kept in mind. Under the active
control training condition, task difficulty remained
at a constant, relatively low-load across all training
days, which involved two items. The Cogmed training
system automatically logs and saves data from each
training session, including times and performance
levels.
Outcomes measures
Changes in performance on the Cogmed training
tasks were measured using standard data provided by
Cogmed software. A Cogmed “Training Index” score
was computed for each training day based on aver-
aging the difficulty level of items held in WM with
60% accuracy for one spatial WM task and one of
two verbal WM tasks (whichever performance was
higher). The spatial WM task involved remember-
ing/reproducing the sequence of circles that were
lit up on a two-dimensional grid (called the “Grid”
task), and the verbal WM tasks involved remember-
ing the order of digits read aloud, and at test, entering
the numbers in reverse order on a number grid that
remained visible the whole time (“Numbers” task) or
that only became visible after all the numbers were
provided (“Hidden” task).
Several well-established neuropsychological tests
were used to assess the effect of the computer-
ized WM training. All participants were tested both
pre- and post-intervention. The outcome measures
included: 1) Trail Making Test, Part A (TMT-A) [87],
which measures visual attention and speed of pro-
cessing; 2) Trail Making Test, Part B (TMT-B) [87],
which measures WM, set shifting, processing speed,
and planning/sequencing; 3) Digit-Symbol from
Weschler Adult Intelligence Scale – Fourth Edition
(WAIS-IV) [86], which evaluates processing speed,
and the WM operations of maintaining information
online, monitoring, and manipulation; 4) Controlled
Oral Word Association Test (COWAT), also labelled
Phonemic Fluency [110]; and 5) Semantic Fluency
[111], both of which assess initiation, self-generation,
and monitoring. The COWAT included the letters
FAS, and the semantic fluency included the cate-
gories of vegetables, fruits and animals. Both fluency
tasks involve executive control, lexical knowledge
and retrieval [96]. Although the tasks place demands
on strategic search from semantic memory, phonemic
fluency requires a constrained search from a broad
set of lexical exemplars, whereas semantic fluency
may be accomplished with a relatively more con-
strained search of exemplars from an superordinate
category and relies on semantic associations within
the category [112].
As noted in the Introduction, performance on the
five administered neuropsychological tests varied in
the degree in the degree of reliance on WM oper-
ations, as well as the content of the material being
held in WM. Our primary outcomes are the tests that
involved WM, and were used to assess near-transfer
 S.S. Simon et al. / Working Memory Training in Older Adults: An RCT
effects. One test, TMT-A, was a relatively easy atten-
tional task that placed limited demands on WM. Two
tests, Digit Symbol and TMT-B were excellent can-
didates for determining near-transfer effects. They
depended heavily on WM involving visual material
and shared reliance on many of the cognitive pro-
cesses practiced in the WM training tasks. Finally,
our secondary outcomes (COWAT and semantic flu-
ency), were tests whose strong dependence on lexical
and semantic processing provided the opportunity to
assess far-transfer effects. We elected not to use a long
list of outcome measures because of concerns that if
positive results were observed on a limited number
of specified tests, as predicted, the findings could be
challenged as reflecting chance alone due to multiple
comparisons.
Statistical analysis
An intention-to-treat (ITT) analysis was carried out
in which all randomized participants were included in
the statistical analysis [113]. No imputations for the
missing data were made. Demographic and neuropsy-
chological baseline characteristics were assessed
using raw scores and differences across treatment
conditions and across sites were assessed using Pear-
son’s chi-square test (χ2 ) for dichotomous variables,
and independent sample t-test for continuous vari-
ables. We used Linear Mixed Models (LMM) to
model the association between predictors and each of
the outcome measures. We compared the fit statistics
of three models. The basic model included the fixed
main effects of the intervention condition, (adaptive
versus non-adaptive), assessment time (pre versus
post), and site (USA versus Sweden). The second
model included the terms described above, as well as
all the possible two-way interactions. Lastly, the third
model included all the above and the three-way inter-
action between intervention condition, time and site.
The models included participants as random inter-
cepts to adjust for within-participant correlations of
repeated measures. The parameters were estimated
using the Restricted Maxium Likehood Method, and
unstructured covariance was specified to model the
covariance structure of both the residuals and the ran-
dom factors. To reduce false discovery rate (FDR),
p-values for the interactions were adjusted employ-
ing the Benjamini-Hochberg (BH) procedure [114].
The BH procedure is defined as P ≤ (i/m)Q, where
P represents the individual P-value, i = the individual
p-value’s rank, m = total number of tests, and Q = the
FDR (which was set at 0.1).
937
Utilizing available Cogmed software, performance
gains during the course of training were computed
using the method described above to derive a
Cogmed Training Index score. This analysis focused
only the Adaptive condition, since the performance
of the control group was fixed at a constant low level
across the five weeks of intervention, and hence,
no performance changes were observed for subjects
under the control condition. Similar to a previous
study [50], performance on the first two sessions was
excluded from analyses due to lack of variability, as
the starting point was identical for all individuals. For
the remaining 23 sessions, mean daily performance
was generated by Cogmed software. A repeated
measures ANOVA was conducted with time (weeks
1–5) as the within-subject factor to investigate the
pattern of performance during training. Lastly, we
investigated the correlation between training gains
on Cogmed tasks and on the neuropsychological
tests. This correlation was based on calculating the
percentage change [((Time2-Time1)/Time1)*100] in
the Cogmed Training Index score (based on the per-
formance in the last session vs. the third session), and
percentage change on the neuropsychological tests.
Regarding the adherence analysis, we included all
subjects for whom we had pre- and post-intervention
data, regardless of their compliance level. However,
we also re-analyzed the data excluding subjects who
completed <75% of the training sessions. In addi-
tion, effect sizes [115] (Cohen’s d) were calculated
for outcome variables that demonstrated a significant
time-by-intervention group interaction. All analyses
were performed using IBM SPSS version 23, and
results were considered significant at p < 0.05.
RESULTS
Participant enrollment is shown in Fig. 1 according
to the CONSORT diagram [76]. A total of 95 per-
sons were screened for eligibility. One was excluded
due to depression. Twelve elected not to participate
(e.g., due to having insufficient time to commit to
the training program). The remaining 82 adults were
randomized to one of the two intervention programs.
Five subjects withdrew from the study (four from the
Adaptive group, and one from the control group) due
to family illness, complaints of wrist pain, and unex-
pected time constraints or need to travel. Differences
between the individuals who dropped out (n = 5)
and the rest of the sample (n = 77) were evaluated
using independent sample t-test for continuous vari-
ables and Pearson’s chi-square test for dichotomous
938 S.S. Simon et al. / Working Memory Training in Older Adults: An RCT

Table 1
Demographic variables and neuropsychological raw scores in each
intervention group
Variables Adaptive Control p
(n = 41) (n = 41)
M (SD) M (SD)
Age (y) 72.4 (5.6) 73.7 (6.5) 0.33
Gender (Male/Female) 12/29 15/26 0.31
Education (y) 15.7 (3.7) 15.3 (3.2) 0.60
GDS 6.2 (3.9 5.5 (4.0) 0.47
MMSE 29.2 (1.1) 29.0 (1.3) 0.48
AMNART (Estimated IQ) 122.6 (5.9) 120.6 (6.0) 0.13
Logical Memory (WMS-III) 26.1 (9.0) 26.7 (7.1) 0.76
BNT 14.1 (3.0) 13.6 (1.4) 0.34
TMT, Part A (s) 37.5 (11.4) 42.6 (17.0) 0.12
TMT, Part B (s) 84.1 (25.3) 97.1 (55.7) 0.17
Digit Symbol (WAIS-IV) 54.7 (15.0) 53.0 (11.5) 0.57
COWAT (Letters FAS) 42.4 (11.3) 42.1 (9.7) 0.90
Semantic Fluency (3 Categories) 44.5 (11.5) 43.7 (11.6) 0.74
Fig. 1. CONSORT flow chart for selection of study participants. Semantic Fluency (Animals) 18.7 (5.5) 18.1 (5.3) 0.64
AMNART, American version of the National Adult Reading Test;
variables. There were no group differences in baseline
BNT, Boston Naming Test; COWAT, Controlled Oral Word Asso-
cognitive performance or on any demographic vari- ciation Test; GDS, Geriatric Depression Scale; IQ, Intelligence
able (i.e., age, education, gender). However, there was Quotient; M, mean; MMSE, Mini-Mental State Examination; SD,
a difference between sites (p = 0.03), as four of the standard deviation; TMT, Trail Making Test; WAIS-IV, Wechsler
five subjects that dropped out were from the Swedish Adult Intelligence Scale 4th-Edition; WMS-III, Wechsler Memory
Scale 3rd-Edition.
sample and one from the US sample.
Table 2
Demographics and baseline neuropsychological Demographic variables and neuropsychological raw scores in each
site group
performance by intervention group
Variables USA Sweden p
Demographics and baseline neuropsychological (n = 39) (n = 43)
M (SD) M (SD)
characteristics from the included participants are
Age (y) 75.7 (6.3) 70.7 (4.8) <0.001*
shown in Table 1. There were no differences between Gender (Male/Female) 10/29 17/26 0.18
intervention groups in terms of age, years of formal Education (y) 17.5 (2.7) 13.8 (3.2) <0.001*
education, sex, global cognition (MMSE), or any of GDS 2.5 (1.9) 9.5 (1.8) <0.001*
the neuropsychological test scores. MMSE 29.1 (1.2) 29.2 (1.2) 0.64
AMNART (Estimated IQ) 121.1 (5.3) 122.0 (6.6) 0.54
Logical Memory (WMS-III) 28.1 (6.9) 24.9 (8.8) 0.07
Demographics and baseline neuropsychological BNT 14.2 (1.1) 13.6 (3.1) 0.22
performance by site TMT, Part A (s) 40.3 (14.9) 39.8 (14.4) 0.86
TMT, Part B (s) 91.9 (55.6) 89.4 (29.1) 0.79
Digit Symbol (WAIS-IV) 59.4 (14.5) 48.8 (10.0) <0.001*
Table 2 compares the baseline demographic and COWAT (Letters FAS) 42.9 (9.7) 41.7 (11.1) 0.60
neuropsychological characteristics of the participants Semantic Fluency (3 Categories) 42.9 (10.3) 45.2 (12.5) 0.38
from the two countries (USA and Sweden). Partici- Semantic Fluency (Animals) 16.9 (4.6) 19.8 (5.6) 0.01*
pants from the two sites differed in age [t(80) = 3.95, AMNART, American version of the National Adult Reading Test;
p < 0.001] and education [t(80) = 5.53, p < 0.001], BNT, Boston Naming Test; COWAT, Controlled Oral Word Asso-
ciation Test; GDS, Geriatric Depression Scale; IQ, Intelligence
with participants from US being older and having Quotient; M, mean; MMSE, Mini-Mental State Examination; SD,
more years of education. The Swedish sample had standard deviation; TMT, Trail Making Test; WAIS-IV, Wechsler
higher scores on the GDS [t(72) = –15.59, p < 0.001]. Adult Intelligence Scale 4th-Edition; WMS-III, Wechsler Memory
Although the scores on all cognitive tests were within Scale 3rd-Edition. * Represents significant p-values, < 0.05.
the normal range, the Swedish subjects showed a
worse performance on the Digit Symbol (WAIS-IV) Adherence rates
[t(80) = 3.89, p < 0.001], and a better performance on
semantic fluency for animals [t(75) = –2.48, p = 0.01], The Cogmed software tracked the number of ses-
which did not impact the overall, three-category sions completed by each subject, and adherence
semantic fluency performance (p = 0.38). rate was then calculated as number of sessions
 S.S. Simon et al. / Working Memory Training in Older Adults: An RCT 939

Fig. 2. Performance changes on Cogmed tasks across five weeks in the Adaptive group (based on Training Index Scores). The units on the
y-axis reflect an arbitrary number system developed by Cogmed. Graph A represents the performance of the entire sample, and graph B
shows the performance by each site. Error bars represent standard errors.

Table 3
Pre and Post means and standard deviation by intervention and sitea
PRE Adaptive Group PRE Control Group
All US Sweden All US Sweden
(N = 41) (n = 19) (n = 22) (N = 41) (n = 20) (n = 21)
TMT-Ab 37.5 (11.4) 36.4 (11.3) 38.5 (11.6) 42.6 (17.0) 44.0 (17.2) 41.1 (17.1)
TMT-Bb 84.1 (25.3) 82.4 (25.6) 85.5 (25.5) 97.1 (55.7) 101.0 (73.4) 93.4 (32.5)
Digit Symbol 54.7 (15.0) 63.3 (17.0) 46.1(13.1) 53.0 (11.5) 56.6 (13.2) 49.6 (8.6)
COWAT 42.4 (11.3) 44.7 (15.4) 46.2 (20.4) 42.1 (9.7) 43.4 (10.0) 40.9 (9.4)
Semantic Fluencyc 44.5 (11.5) 42.2 (8.6) 45.0 (15.5) 43.7 (11.6) 42.7 (11.5) 44.7 (11.9)
POST Adaptive Group POST Control Group
All US Sweden All US Sweden
(N = 37) (n = 18) (n = 19) (N = 40) (n = 20) (n = 20)
TMT-Ab 37.3 (12.13) 36.9 (10.5) 36.1 (8.7) 37.1 (13.0) 38.3 (16.1) 35.9 (9.2)
TMT-Bb 78.3 (29.8) 76.6 (34.6) 80.0 (25.1) 88.6 (38.8) 85.7 (46.2) 91.6 (30.6)
Digit Symbol 61.4 (12.7) 67.7 (11.7) 55.5 (10.8) 54.9 (13.9) 58.2 (14.6) 51.5 (12.6)
COWAT 45.9 (15.2) 43.5 (10.0) 48.1 (18.9) 44.8 (11.6) 42.5 (90.0) 47.2 (13.6)
Semantic Fluencyc 43.4 (11.3) 43.5 (9.3) 43.4 (12.8) 44.7 (12.2) 42.9 (11.1) 46.4 (13.4)
a Datarepresents raw scores; b The more negative values represents the better performance; c 3 categories. COWAT, Controlled Oral Word
Association Test; TMT, Trail Making Test.

completed divided by 25 sessions (i.e., maximum
number of sessions). When analyzing all subjects,
adherence rates were not different between interven-
tion groups [t(75) = –1.00, p = 0.32], with very high
adherence in both groups (Adaptive group: 96.7%
(range: 32–100%); Non-Adaptive group: 98.8%
(range: 76–100%). Moreover, adherence rates were
different between sites [t(75) = 2.18, p = 0.03], with
100% of adherence in the US sample, and 95.7%
in the Swedish sample. Note that only one subject
(from the Adaptive Group in the Swedish sample)
had a low adherence rate (32%). All other subjects
had adherence rates over 75%.
Performance gains during training (Cogmed
Training Index Score)
Across the five weeks of training, participants in
the adaptive condition significantly improved their
WM performance on the tasks that were trained
(F(4,128) = 43.15, p < 0.001), an effect that was
not modulated by site (F(4,128) = 1.12, p = 0.17)
(Fig. 2).
Effects of time, intervention, and site
Table 3 shows mean and standard deviations of
the raw scores for both intervention groups and
sites, and Table 4 presents estimates and standard
errors associated with fixed and random effects
(Model 2). According to Model 2, we observed
an effect of assessment time for TMT-A, and
Phonemic Fluency, with scores at post-intervention
being better than at pre-intervention (TMT-A:
[t(76) = 2.40, p = 0.01]; Phonemic Fluency (COWAT)
[t(76) = –2.81, p = 0.006]. There was no main effect of
intervention or site for any of the neuropsychological
outcome measures.
940 S.S. Simon et al. / Working Memory Training in Older Adults: An RCT

Table 4
Intent-to-Treat Linear Mixed-Effects Model 2 Resultsa
TMT-A TMT-B Digit Symbol COWAT SF
␤ (SE) ␤ (SE) ␤ (SE) ␤ (SE) ␤ (SE)
Fixed effects
Constant 3.57 (2.52)*** 9.16 (7.67)*** 5.17 (2.70)*** 4.70 (2.82)*** 4.54 (2.56)***
Time 6.04 (2.60)* 3.95 (7.23) –2.21 (1.88) –5.94 (1.99)** –0.19 (3.54)
Intervention 0.31 (3.53) –9.00 (1.07) 3.65 (3.71) 2.11 (3.75) –1.94 (1.54)
Site 2.81 (3.53) –5.11 (1.07) 6.39 (3.76) –3.92 (3.80) –1.86 (3.59)
Time * Intervention –4.09 (3.04) –3.06 (8.45) –4.99 (2.20)* –0.85 (2.33) 1.88 (1.80)
Time * Site –1.15 (3.04) 8.33 (8.45) 0.86 (2.20) 6.12 (2.32)* –1.23 (1.80)
Intervention * Site –2.52 (4.88) –1.90 (1.50) 6.87 (5.07) –1.97 (4.64) 1.76 (4.90)
Random effects
Intercept 1.24 (3.39)*** 1.11 (3.04)*** 7.50 (2.42)** 4.08 (1.81)*** 6.77 (2.18)**
a Data
based raw scores; SE, standard error; *p < 0.05; **p < 0.01; ***p < 0.001. COWAT, Controlled Oral Word Association Test; SF,
Semantic Fluency; TMT, Trail Making Test.

Table 5
Effect size (Cohen’s d), SE and 95% confidence interval associated
with each outcome measure at post-training
Adaptive versus Non Adaptive
EF (SE) 95% CI
TMT, Part A 0.02 (0.23) –0.43–0.46
TMT, Part B –0.30 (0.23) –0.74–0.16
Digit Symbol 0.49 (0.23) 0.03–0.94
COWAT 0.08 (0.23) –0.37–0.53
Semantic Fluency –0.11 (0.23) –0.56–0.34
Positive effect size favors adaptive training. COWAT, Controlled
Oral Word Association test; TMT, Trail Making Test.

Training effects

Our LMM analysis (Model 2) revealed a time-

by-group interaction for Digit-Symbol (p = 0.02),
with a medium effect size of treatment (d = 0.49)
(for more details see Table 5). The interaction
remained significant after controlling for FDR using
Benjamini-Hochberg procedure (P ≤ (i/m)Q) [114]
(Fig. 3), and was driven by a training-related improve-
ment for the Adaptive intervention group only
[t(36) = –4.61, p < 0.001], and not for the control
group [t(39) = –1.12, p = 0.26]. Additional analyses
revealed that the groups did not differ at baseline
(p = 0.57), but after the five-week intervention the
group that received Adaptive Cogmed training per-
formed significantly better on Digit-Symbol than
the control group (p = 0.03). In addition, the time-
by-group interaction for Digit-Symbol remained
significant (p = 0.01) after controlling for speed of
processing (TMT-A) performance.
Model 3 revealed no time-by-group-by-site inter-
action in the cognitive outcomes, indicating that the
magnitude of the training effect for Digit Symbol was
similar for both sites (see Supplementary Material). It
Fig. 3. Cognitive performance in Digit Symbol test. *Represents
p < 0.05, indicating a significant time-by-group interaction. Error
bars represent standard errors.
is relevant to highlight that after excluding the subject
with low adherence rate, the pattern and significance
of the results described in this section remained the
same. Also of note, we repeated the analysis using
ANOVA, which yielded the same statistical results
as was found using LMM.
Correlation between training gains and transfer
effect
There was a positive correlation between the
percentage change in performance on the Cogmed
tasks (i.e., training gain) and percentage change in
performance on Digit Symbol (r = 0.37; p = 0.02),
which remained significant after controlling for site
(r = 0.40; p = 0.02) (Fig. 4).
 S.S. Simon et al. / Working Memory Training in Older Adults: An RCT
Fig. 4. Scatterplot representing the correlation between % of change on Cogmed Adaptive training (i.e., training gain) and % of change on
Digit Symbol performance.
Exploratory analysis: Effect on age on training
response
In an exploratory analysis (LLM) including all
subjects, we examined whether the magnitude of
the intervention effect was different for young-old
versus old-old subjects. To do so, we performed
a median split by age for each of the inter-
vention groups. The mean age of the young-old
subjects was 68.1 ± 2.22 and of the old-old sub-
jects was 78.0 ± 4.57. The age of young-old and
old-old subjects did not differ between intervention
groups (young-old: [t(39) = –0.34, p = 0.72; old-old:
[t(39) = –1.34, p = 0.18]. For Digit Symbol, a three-
way interaction between intervention group, time,
and age-group was not observed [F(1,73) = 0.37,
p = 0.68], suggesting that the magnitude of the train-
ing effect was not different for young-old and old-old
adults. Also of note, we did not find interaction with
age-group for any of the other outcome measures.
DISCUSSION
The current study investigated the effects of five
weeks of intensive computerized WM training on
cognitively healthy older adults. The formal aspects
of the intervention (home-based, computer interface,
WM tasks, ∼40 min/day, five days/week over five
weeks) were shared by the experimental (Adaptive
training) and the control (Non-Adaptive training)
941
conditions, but the level of task difficulty was only
adjusted in the experimental condition. This study
design allowed us to isolate the role of continuously
challenging participants in a WM training program.
Training gain on practiced tasks and transfer effects
on specified neuropsychological tests were investi-
gated.
Similar to previous work [25, 50, 67], our study
employed Cogmed, a computerized WM training
paradigm. Execution of the Cogmed tasks requires
maintaining stored information, shifting between
encoding and retrieval demands, and exercising other
aspects of attentional control. The beneficial effects
of the Cogmed program have been reported in sev-
eral clinical populations, including patients with
attention-deficit/hyperactivity disorder [116–119];
brain injury [120, 121]; epilepsy [122], and older
adults with mild cognitive impairment [67, 123].
However, there is sparse literature regarding the cog-
nitive effects of this paradigm on healthy older adults
[67, 124].
The most salient finding of our study of older adults
is the intervention-associated improvement in perfor-
mance on the Digit Symbol task, one of the primary
outcomes. There are several reasons why we do not
believe that this result is simply a reflection of chance.
Importantly, we predicted this outcome based on an
analysis of the likely near-transfer effects associ-
ated with participation in Adaptive Cogmed training.
Transfer effects may occur if the trained and transfer
942 S.S. Simon et al. / Working Memory Training in Older Adults: An RCT
tasks engage overlapping cognitive processing com-
ponents and brain regions [67, 125]. Although all of
the tasks that served as outcome measures relied, in
part, on WM, they differed in terms of the content of
the material being held in WM and the extent to which
WM was the central cognitive process. Cogmed tasks
involve training in holding on-line and updating infor-
mation, operations that are critical to carrying out the
Digit Symbol task [88]. The link between Cogmed
training and changes in performance on the Digit
Symbol task is strengthened by the positive corre-
lation that was observed between performance gains
on Cogmed tasks (as measured by the Training Index)
and improvement on Digit Symbol. In addition, the
beneficial impact of Cogmed training on Digit Sym-
bol continued to be observed after using a procedure
to reduce FDR. Critically, the time-by-group interac-
tion observed on Digit Symbol remained significant
after controlling for speed processing performance
(TMT-A), suggesting that the gains on Digit-Symbol
task likely reflect improvement in WM, and not in
speed processing. Lastly, the effect size observed
(d = 0.49) was medium, in line with a previous study
[67], but in contrast to the small effect sizes reported
in several computerized cognitive training studies
[59].
Our prediction about training-related improvement
in TMT-B was not substantiated. We hypothesize that
the difference in training effects for Digit Symbol and
TMT-B may be due the fact that maintenance and
rapid retrieval of information held in WM, which are
extensively practiced in the Cogmed program, are
much more relevant to Digit Symbol than TMT-B.
For instance, once the symbol–digit relationships are
successfully held in WM, it is no longer necessary to
rely on visual scanning of the key at the top of the
administration sheet, to produce correct responses.
Reliance on WM can reduce the time to generate
an accurate response, resulting in an increased score
on the Digit-Symbol test. Cogmed tasks place much
less emphasis on shifting sets, which is one of the
cardinal features of TMT-B. In fact, prior studies
with Cogmed indicate that this program has a lim-
ited effect on interference control [50, 67, 126],
which contributes to set-shifting abilities. The dif-
ferential impact of the intervention on Digit Symbol
and TMT-B suggests that transfer effects associated
with training may be very sensitive to the specific
cognitive operations that are practiced during the
training period.
In our study both Adaptive and Non-Adaptive
Cogmed training were associated with a similar
degree of improvement in TMT-A performance (i.e.,
main effect of time; no time by intervention inter-
action). This result may reflect increased familiarity
with this test and the development of practice
effects. However, the Cogmed training protocols
(with or without ongoing adjustments to level of
task demand) require attention, visual tracking and
speeded responses, which could facilitate improve-
ment of performance on relatively simple tasks like
TMT-A. As predicted, there seems to be no advantage
to the adaptive training intervention when subjects
are asked to perform untrained tasks like TMT-A that
involve very low-level WM demands.
Although phonemic and categorical word list gen-
eration requires WM [96], these tasks rely heavily
on lexical and semantic processing. In contrast to
Digit Symbol, word list generation does not involve
manipulation of visually presented stimuli, but rather
depends on access to one’s mental lexicon. Training-
related improvement on word fluency tasks would
be consistent with far-transfer effects, but no such
effects were observed in this study. These findings
are in line with literature that has reported inconsis-
tent far-transfer effects after WM training [52, 56].
Previous studies of older adults who have partici-
pated in the Cogmed training program also have failed
to observe far-transfer effects on measures of rea-
soning, interference control, and episodic memory
[50, 67]. The transfer effects observed in the current
study were limited to the processing of external visual
stimuli (and not internal mental stimuli). However,
it is noteworthy that the kinds of cognitive opera-
tions needed to effectively carry out the Digit Symbol
task are vital to many complex, real world activities
(e.g., driving), which require the maintenance and
updating of visual stimuli. Consistent with this idea,
Digit Symbol is the only non-memory task in the
Preclinical Alzheimer Cognitive Composite (PACC)
score, which is an index that has been shown to pre-
dict decline in independent, cognitively normal older
adults at risk for AD [127–129].
Our intervention focused on the training of only
one cognitive domain (WM), which may have limited
transfer effects compared to multi-domain training
routines. Theoretically, the latter approach engages
many cognitive processes, which may yield broader
transfer effects [52]. However, the meta-analysis
by Mewborn and colleagues [79] challenges this
idea, suggesting that multi-domain training interven-
tions are not more successful than single-domain
interventions at improving cognition immediately
post-intervention. In fact, these authors found that
 S.S. Simon et al. / Working Memory Training in Older Adults: An RCT
WM training was more effective than all other
single-domain interventions and than multi-domain
interventions that did not include WM training.
Our study design provided an opportunity to exam-
ine whether the impact of computerized Adaptive
WM training was influenced by the demographic
make-up of participants. Subjects from Sweden and
the United States differed in terms of cultural back-
ground, age, education, and baseline performance
on neuropsychological tests. Växjö, Sweden is a
rural community, whereas Boston, Massachusetts is
a metropolitan one. On average, participants from
the US site were older, had more years of formal
education, and performed better on several baseline
neuropsychological tests. Despite these notewor-
thy differences between the two sites, there was
no time-by-intervention group-by-site interaction for
performance on Digit Symbol, indicating that the
magnitude of the training effect was similar across
the two sites. These results are consistent with a meta-
analysis suggesting that demographic variables such
as age and education do not reliably modify the over-
all effect of cognitive interventions in older adults
[79]. Additional research is needed to further clarify
the potential influence of cultural factors on cogni-
tive training effects. To the best of our knowledge,
our study is the first to compare the impact of CCT
on elders from different countries. Confirmation of
our results indicating similar training-related effects
for participants from diverse backgrounds would be
important since CCT has the advantage of being read-
ily accessible through the internet to individuals from
different countries and cultural backgrounds. Impor-
tantly, our findings suggest good external validity of
our computerized training protocol, which was appli-
cable in different cultural contexts.
Results from the current study are pertinent to
the question of whether old-old adults can benefit
from CCT WM training. Brehmer and colleagues [50]
studied normal young-old adults, 60 to 70 years old,
and found that participants in the Adaptive training
group outperformed those in the control group on
several untrained cognitive tasks involving WM and
sustained attention, such as Digit Span, Span Board
and Paced Auditory Serial Addition Test (PASAT).
The current investigation extends these findings to an
older sample, 65–89, whose average age was ∼10
years higher (mean age 73.1) than participants in
the Brehmer study (mean age 63.7). Our exploratory
analysis using a median split of participants by age
found that young-old and old-old adults benefit to a
similar degree from the training, as measured by the
943
Digit Symbol task. Our findings are in line with a
previous report that old-old adults (∼80 years) can
improve visual WM after WM training [19]. In addi-
tion, results of studies have varied regarding whether
the beneficial effect of cognitive training is greater for
young-old adults than old-old adults [75–78]. Rel-
evant to this question is a recent meta-analysis on
cognitive interventions in older adults that reported
no significant difference in effect size based on age
of study participants [79]. The authors suggest that
advancing age does not significantly alter the ability
of older adults to benefit from cognitive interven-
tions, if they have large enough cognitive capacity
to execute the training program.
Our results do not support the claims by Lampit
and collaborators [59] that training more than three
times per week lacks efficacy. Moreover, we would
question their suggestion that unlike group-based
training, home-based training is ineffective. Our
findings and those from other recent studies [50,
130, 131] demonstrate that CCT done in the homes
of older participants can improve cognitive per-
formance on untrained tasks. Further confirmation
of these results is critical, given the accessibility
and relatively low cost of in-home, computer-based
cognitive exercises. Participation in either the exper-
imental or control condition was demanding and
involved five ∼40 minutes sessions per week over
five weeks. Although the study did not include a
direct measure of motivation, excellent adherence
rates in both groups strongly suggest that partici-
pants were highly motivated and engaged. We believe
that actively communicating with participants on a
weekly basis in ways that provided both motiva-
tional and technical support contributed to our high
adherence rates. Additional research is necessary
to determine the extent to which an ongoing rela-
tionship with a member of the study or care team
and the implementation of structured supervision are
essential components to a successful home-based
cognitive intervention program, as some investiga-
tors have suggested [132]. Consistent with our study,
a previous Cogmed home-based CCT with older
adults [50] reported a high adherence rate (94%),
which is also similar to studies with children suf-
fering from epilepsy [133] who had adherence rates
of approximately 90%. Finally, we believe the indi-
viduals that agree to participate in an intense-dose
training protocol like ours (i.e., five days per week
over five weeks) were already highly motivated,
which probably contributed to the high adherence rate
observed.
944 S.S. Simon et al. / Working Memory Training in Older Adults: An RCT
In general, it is much more challenging to demon-
strate training effects when using an active control
group, as was done in the current study, than a
comparison group involving either no contact or par-
ticipation in a very different kind of intervention
protocol (e.g., viewing educational videos) [51, 52].
Our active control condition included all aspects
of the training intervention except for real-time
adjustments to level of task difficulty. The observed
benefits of Adaptive CCT over the active control sug-
gest that the gains were not due to practice effects
or non-specific intervention effects (e.g., involving
motivation, test familiarity, or changes in perfor-
mance anxiety) [57, 134, 135], but were linked to
providing a continuously challenging level of WM
difficulty. Additionally, blinding participants to group
assignment reduced the likelihood that subject expec-
tations or placebo effects can adequately account for
our findings.
Despite the originality and the careful experimen-
tal design of the present study, we acknowledge
several limitations that remain unaddressed. First,
although the study was approved by the Institutional
Review Boards at the two sites, it was not regis-
tered (e.g., clinicaltrials.gov), which could negatively
impact the quality rating of the trial. Second, although
the magnitude of improvement did not differ across
sites, suggesting that training effects were similar
for participants from different cultural backgrounds,
further research with greater statistical power is
necessary to reach more definitive conclusions. We
were not able to disentangle possible cultural differ-
ences between sites from demographic and cognitive
differences (presented in Table 2), or the environ-
mental context (rural versus urban). Therefore, the
present conclusions should be considered with cau-
tion. Third, due to the moderate sample size, our
study was not able to address mediating factors that
predict intervention response, which is critical for
identifying those participants who are most likely to
benefit from WM CCT. Fourth, although controlling
for false discovery rates reduces the likelihood that
our findings are due to chance, the transfer effect
observed in the current study relies on only one
cognitive task, and does not reflect converging evi-
dence from multiple tasks. Further investigation is
needed to replicate our findings using other cognitive
measures. Fifth, although we provide data on train-
ing gains on the Cogmed tasks, we did not include
a criterion task (i.e., WM task similar to the ones
in which participants were trained) to determine if
performance at baseline or after training differed
between experimental groups that might help account
for the near-transfer effect observed. Sixth, in con-
trast to several other studies, we did not use episodic
memory, reasoning or fluid intelligence as outcome
measures [50, 67], leaving open the question whether
the Cogmed WM training program would result in
these kinds of far-transfer effects. Finally, it will be
important for future studies to determine whether the
cognitive benefits observed are maintained over time
and to investigate possible transfer effects to real-
world activities.
In conclusion, this multi-site, randomized con-
trolled study demonstrated that healthy older adults
can benefit from an intense five-week WM CCT.
Compared to an active control condition, Adaptive
training effectively improved performance on a task
emphasizing WM and processing speed. The benefits
over the active control group suggest that our CCT
gains were not due to practice or non-specific inter-
vention effects, but were associated with providing
a continuously challenging level of WM difficulty.
Importantly, the magnitude of improvement was
similar in two subject samples with differing demo-
graphics and was not modulated by age, indicating
that computerized WM training can be effective for
older adults from divergent cultural backgrounds.
It remains to be determined whether this type of
intervention is more effective than other kinds of
readily available cognitively stimulating activities.
The results observed with this WM training pro-
gram, which took place in the participant’s own home
via the internet, suggest that the program is promis-
ing, potentially scalable, and worthy of additional
study.
ACKNOWLEDGMENTS
The authors would like to thank Mayada Guzmán
for her excellent administrative assistance. The
authors also thank Cogmed® & Pearson® for allow-
ing access to the training programs.
This study was funded by the Kamprad Family
Foundation, Växjö, Sweden. In addition, the Lab-
oratory of Healthy Cognitive Aging at Brigham
at Women’s Hospital has been sustained by NIA
GrantR01AG017935 and ongoing support from the
Wimberly family, the Muss family, and the Mor-
timer/Grubman family.
Authors’ disclosures available online (https://
www.j-alz.com/manuscript-disclosures/18-0455r1).
 S.S. Simon et al. / Working Memory Training in Older Adults: An RCT
SUPPLEMENTARY MATERIAL
The supplementary material is available in the
electronic version of this article: http://dx.doi.org/
10.3233/JAD-180455.
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