Professional Documents
Culture Documents
Abstract
Background: Vascular cognitive impairment, no dementia (VCIND) refers to cognitive deficits associated with
underlying vascular causes that fall short of a dementia diagnosis. There is currently no treatment for VCIND.
Computerized cognitive training, which has significantly improved cognitive function in healthy older adults
and patients with cognitive impairment has not yet been applied to VCIND.
Methods/Design: The proposed study is a three-center, double-blinded, randomized controlled trial that will
include 60 patients with VCIND. The patients will be randomized to either a training or a control group. The
intervention is internet-based cognitive training performed for 30 min over 35 sessions. Neuropsychological
assessment and functional and structural MRI will be performed before and after 7 weeks training. Primary
outcomes are global cognitive function and executive function. Secondary outcome measures are neuroplasticity
changes measured by functional and structural MRI.
Discussion: Applying an internet-based, multi-domain, adaptive program, this study aims to assess whether
cognitive training improves cognitive abilities and neural plasticity in patients with subcortical VCIND. In addition
to the comprehensive assessment of the participants by neuropsychological tests, cerebrovascular risk factors
and apolipoprotein E genotyping, neuroplasticity will be used as an evaluation outcome in this study for, to our
knowledge, the first time. The combination of functional and structural MRI and neuropsychological tests will
have strong sensitivity in evaluating the effects of cognitive training and will also reveal the underlying mechanisms
at work.
Trial registration: ClinicalTrials.gov NCT02640716. Retrospectively registered on 21 December 2015.
Keywords: Cognitive training, Magnetic resonance imaging, Neuroplasticity, No dementia, Protocol, Randomized
controlled clinical trial, Vascular cognitive impairment
© 2016 Tang et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Tang et al. Trials (2016) 17:392 Page 2 of 7
Patient or informant report of cognitive impairment using simple randomization of random number table
involving memory or other cognitive domains method in SAS software (SAS Institute, Inc., Cary, NC,
lasting for at least 3 months USA). Afterwards, the sealed randomization codes and
Neither normal nor demented according to the intervention number are sent out to each center. Blind-
criteria of the Diagnostic and Statistical Manual ing will be broken only if a participant needs emergency
of Mental Disorders, Fourth Edition [30, 31], with treatment. Once the blinding is broken, the participant
a Clinical Dementia Rating ≥0.5 on at least one will be managed as off-trial.
domain [32] and a global score ≤0.5; a Mini-Mental
State Examination score ≥20 (primary school), Blinding
or ≥24 (junior school or above) [33, 34] Patients, caregivers, radiologists, statisticians, and neuro-
Normal or slightly impaired activities of daily psychologists who measure the outcomes will be blinded
living as defined by a total score of ≤1.5 on the to the randomization status. Blinding will also be main-
three functional Clinical Dementia Rating domains tained for data management, outcome assessment, and
(home and hobbies, community affairs, and data analysis.
personal care) [34]
MRI entry criteria: Intervention
o At least three supratentorial subcortical small Previous studies showed that training approaches with
infarcts (3–20 mm in diameter), with or without multi-domain, personalized, and adaptive training
white matter lesions of any degree; or moderate features are more effective [19, 37, 38]. Therefore, cogni-
to severe white matter lesions (score ≥2 tive training will be a computerized multi-domain adap-
according to the Fazekas rating scale) [35] with tive training program in this trial. Training paradigms
or without small infarcts that were successfully used in previous studies will be
o Absence of cortical and watershed infarcts, adopted [19, 37], including processing speed, attention,
hemorrhages, hydrocephalus, and white matter long-term memory, working memory, flexibility, calcula-
lesions with specific causes (e.g., multiple tion, and problem solving. Specific training paradigms
sclerosis) include a time perception task, visual search task, rapid
o No hippocampal or entorhinal cortex atrophy serial presentation task, delayed match to sample task,
(score 0 according to the medial temporal lobe paired-associate recall task, attention span task, digit
atrophy scale of Scheltens) [36] span task, go–no go task, Stroop task, task switching,
and n-back working memory task. To enable adaptive
Exclusion criteria training, each task was designed with several difficulty
levels. Based on previous tests with a large size sample,
Severe aphasia, physical disabilities, or any other the tasks will be further grouped in each domain with
factor that might preclude completion of varied task difficulty. At the beginning, assignment tasks
neuropsychological testing from these domains will be similar across participants.
Clinically significant gastrointestinal, renal, hepatic, On each training day, five tasks (2 min per task, each
respiratory, infectious, endocrine, or cardiovascular three times, in total 30 min per day) will be assigned.
system disease; cancer; alcoholism; drug addiction Within each task, high accuracy (>80 %) is required to
Disorders other than subcortical VCIND that upgrade. To manipulate the adaptive change, the num-
might affect cognition; a Hamilton Depression Scale ber of types of stimuli, the presentation probability of
score >17 or schizophrenia; new strokes within 3 each type of stimuli, and the size and duration of a
months before baseline; inherited or inflammatory stimulus were systematically set. To keep a systematical
small vessel disease setting, only one parameter will be changed, while the
Use of medications that may affect cognitive other parameters will be kept as constant in one level
functioning, including tranquilizers, anti-anxiolytics, upgraded. Once the task performance is higher than
hypnotics, nootropics, and cholinomimetic agents; 80 % of the norm performance of a normal aging
and inability to undergo brain MRI population, the task will be replaced by a harder task
from the same domain. The training is thus also
Randomization adaptive at participant level, with a similar setup but
Participants will be randomly allocated to either the personalized progress across participants.
intervention group or the control group in a ratio of 1:1. For the control group, processing speed and attention
After participants have given their informed consent, tasks are included, with five tasks and 30 min training in
randomization will be performed by an independent each day. Importantly, a fixed, primary difficulty level for
statistician who is blinded to the patient interventions all participants in the control group is set. The training
Tang et al. Trials (2016) 17:392 Page 4 of 7
imaging and functional MRI data collected during the primary outcome measures of interest. An independent-
episodic memory task will be analyzed using the FSL sample t test will be used separately for the assessment
package (FMRIB Analysis Group, Oxford, UK). Brain criterion and the rating scales of function, to ensure that
activation and connectivity changes before and after baseline levels are comparable between the training and
training will be compared between experimental and control groups. A paired-samples t test will be conducted
control groups. By using tract-based spatial statistics to compare the changes in scores in the trained tasks to
implanted in FSL, fractional anisotropy and mean dif- investigate the training efficacy. The performance change
fusivity values in central white matter tracts will be of the trained tasks will be further correlated with the
measured and compared before and after training. neuropsychological change. To test whether the training
will improve neuropsychological performance in the con-
Apolipoprotein E genotyping trol group, correlation analysis will be conducted between
High-molecular-weight DNA will be isolated from per- the performance of trained tasks and the neuropsycho-
ipheral blood leukocytes using a QIAamp DNA Blood logical change. To determine the training transfer effect, a
Kit (QIAGEN, Valencia, CA, USA). Genomic DNA will series of 2 × 2 ANOVAs will be conducted with group and
be amplified by PCR using the primers ApoE-5′: 5′- time points as the two factors. For all analyses, signifi-
AGACGCGGGCACGGCTGTCCAAGGA-3′ and ApoE- cance levels will be set to 0.05, and effect sizes refer to
3′: 5′-CCCTCGCGGGCCCCGGCCTGGTACAC-3′ with partial η-square values. Statistical analysis will be con-
the following conditions: denaturation at 95 °C for 5 mi- ducted using SPSS20.0 software. Imaging data will be ana-
nutes, followed by 30 cycles at 95 °C for 30 s, annealing at lyzed using FSL to detect any changes in brain function
60 °C for 30 s, and extending at 72 °C for 30 s. The PCR and structure due to cognitive training.
products will be digested with HhaI (R0139S, New Eng-
land BioLabs, Beverly, MA, USA). The fragments will be
separated by electrophoresis on a 20 % polyacrylamide gel Discussion
and visualized using GelGreen™ nucleic acid gel stain To our knowledge, this trial is the first to evaluate the cogni-
(89139–144, Biotium, Hayward, CA, USA). tive training efficacy in VCIND patients. This study has
several strengths. First, the multi-domain cognitive training
Data monitoring applied in this study is highly adaptive and internet-based.
All participants from three centers will be evaluated by Such training is believed to be effective in enhancing cogni-
the same trained neuropsychologists and undergo brain tive function. Conducting training on the internet is conveni-
MRI using the same MRI scanner. Imaging data are ent, allowing patients to train at home and doctors to easily
checked for quality and protocol conformity after each manage the training protocol and monitor training progress.
scanning session. Second, functional and structural plasticity are used as
the evaluation outcome measures. Compared with the
Sample size estimates traditional efficacy evaluations, which use neuropsycho-
In preliminary tests, the observed mean difference in logical tests, the combination of neuroplasticity and
change from baseline in the DST, WHO-UCLA Auditory neuropsychological tests in this study will be more sensi-
Verbal Learning Test, and Boston Naming Test scores tive in testing cognitive training efficacy, because smaller
between training and control groups were 14.92, 3.35, training effects could be detected by MRI indices, such as
and 7.59, respectively, and the standard deviations were brain activity and connectivity [16]. In this trial, by includ-
18.41, 4.05, and 9.06, respectively. Based on these data, ing the functional and structural MRI measurements, a
sample sizes of 48, 46, and 46, respectively, were needed further purpose is to reveal the underlying mechanism at
to obtain a statistical power of 80 % with a significance work. For instance, fMRI measurement would provide evi-
level of 5 %. We used the largest sample size of 48, and dence to distinguish whether neural efficiency was im-
the inclusion number has been set to 60 patients, allow- proved or the brain function was reorganized to achieve
ing for a maximum dropout rate of 20 %. Power calcula- cognitive enhancement. The structural MRI measurement
tions are based on the primary outcome measures, would provide evidence on the structural constraint on
which are assessed by neuropsychological tests. The stat- functional change due to cognitive training.
istical power measures will be calculated using the Another strength of this trial is the comprehensive
POWER procedure in SAS® Version 9.3. assessment of the participants on multiple levels, includ-
ing neuropsychological tests, neuroplasticity analysis,
Statistical analysis cerebrovascular risk factors, and apolipoprotein E geno-
Performance changes in the assessment scores related to typing. This comprehensive assessment will be able to
global cognitive function (Montreal Cognitive Assessment) identify possible biomarkers involved in the effects of
and executive function (Trail Making Test B-A) are the cognitive training in VCIND.
Tang et al. Trials (2016) 17:392 Page 6 of 7