Engage Your Brain:

GCBH Recommendations on
Cognitively Stimulating Activities
 BACKGROUND: ABOUT GCBH AND ITS WORK

The Global Council on Brain Health (GCBH) is an independent collaborative of

scientists, health professionals, scholars and policy experts from around the world
working in areas of brain health related to human cognition. The GCBH focuses on
brain health relating to people’s ability to think and reason as they age, including
aspects of memory, perception and judgment. The GCBH is convened by AARP
with support from Age UK to offer the best possible advice about what older adults
can do to maintain and improve their brain health. GCBH members come together
to discuss specific lifestyle issue areas that may impact people’s brain health as
they age with the goal of providing evidence-based recommendations for people to
consider incorporating into their lives.

We know that many people across the globe are interested in learning, first, that
it is possible to influence their own brain health and, second, what can be done
to maintain their brain health as they age. We aim to be a trustworthy source of
information, basing recommendations on current evidence supplemented by a
consensus of experts from a broad array of disciplines and perspectives.

Engage Your Brain: GCBH Recommendations on Cognitively Stimulating Activities 1

COGNITIVELY STIMULATING
ACTIVITIES AND BRAIN HEALTH

Cognitively stimulating activities are mentally engaging the claims made by companies promoting the benefits of
activities or exercises that challenge a person’s ability to these games are exaggerated. With that in mind, we think
think. Many people wonder if you can maintain your thinking it is important to let people know the current state of the
abilities as you age by stimulating your brain through various scientific evidence, given that there are many activities that
intellectual activities. On March 19-21st, 2017, members of people do for work and/or leisure-time which evidence has,
the GCBH met in Washington, DC to examine the impact in fact, shown to be good for brain health.
of cognitively stimulating activities on brain health for
adults age 50 and older. Throughout the discussion, experts The GCBH provides recommendations based on its own
examined the evidence on whether engaging in cognitively experts’ research as well as the wider body of evidence across
stimulating activities has been shown to: (1) influence various fields of expertise in the areas of cognitive aging and
people’s brains in a positive way, (2) help maintain or improve neuroscience. The good news is that cognitively stimulating
people’s cognition, or (3) help people function better in activities that are mentally engaging and challenge your ability
everyday life. Participants are listed in Appendix 1. to think over your life can provide benefits for your brain
health. The phrase ‘use it or lose it’ captures the importance
The terms for cognitively stimulating activities run the that the GCBH experts give to the value of cognitively
gamut: mental challenges, mind teasers, games, education stimulating activities. While it’s never too late, the sooner you
and learning, using your brain, discovery, intellectual start the better because education and learning are known to
stimulation—the list goes on. Whatever terms we use, people enhance cognitive reserve1, making you less susceptible to the
believe that it is good for brain health to keep an active mind effects of age or disease-related brain changes.
as the aging process continues. But when you begin to look
for the scientific evidence about what works to maintain This paper summarizes the consensus reached by the experts
mental functioning as the brain changes over time, things get and describes the major points of discussion that led to
a little more complicated. their recommendations for adults age 50 and older. It also
identifies gaps in our knowledge about these activities and
The GCBH took up the challenge of trying to sort through cognition, provides a glossary defining terms used in the
the mountains of conflicting messages and scientific document, and lists resources for additional information.
information on the topic of cognitive stimulation because This paper is not intended to be a systematic, exhaustive
we know adults are looking for reliable ways to enhance review of all pertinent scientific literature on the topic.
their well-being and brain function as they age. AARP’s Rather the selected references provided at the end of the
2015 Survey on Brain Health showed that a large majority of document give helpful background material and present a
Americans age 50 and older (92%) think that challenging the sizeable sample of the current evidence base underpinning
mind with games and puzzles is important to maintaining the GCBH consensus in this area.
or improving brain health. A majority (66%) also think that
playing online games designed for brain health is important Acknowledgments: AARP Policy, Research, and International
for maintaining or improving brain health. Commercial Affairs; AARP Integrated Communications and Marketing;
claims of the benefit of online training commonly called and Age UK.
“brain games” are everywhere, so consumers naturally think
these products will be helpful. Suggested Citation: Global Council on Brain Health (2017).
“Engage Your Brain: GCBH Recommendations on Cognitively
Unfortunately, the evidence today regarding the benefits Stimulating Activities.” Available at:
of what most people consider “brain games” is weak to www.GlobalCouncilOnBrainHealth.org
non-existent. Games can be fun and engaging. But often,
DOI: doi.org/10.26419/pia.00001.001
1 “Cognitive reserve” is defined in the attached Glossary in Appendix 2.

2 Engage Your Brain: GCBH Recommendations on Cognitively Stimulating Activities

CONSENSUS STATEMENTS

These consensus statements and following recommendations are based on scientific evidence from
well-designed randomized controlled trials (RCTs) and epidemiological observational studies2 with
substantial sample sizes, the results of which were published in peer reviewed journals and replicated
by other scientists so that the experts have confidence in the results.

1) Throughout life, the brain is dynamic and constantly changing.

2) You can impact how your brain changes as you age. Across the lifespan, the brain
continues to develop new neurons and new neural connections. The connections between
your nerve cells can also change in many different parts of your brain.

a. Actions you take can affect how these nerve cells and the connections between them
develop and can impact how well your brain functions, including your memory,
attention, thinking, language and reasoning skills.
b. The physical and social environment in which you live can also influence the
development of your brain and cognitive functioning into old age.

3) Cognitively stimulating activities over the life course, such as engaging in formal or
self-initiated informal educational activities, continuing to engage in work experiences,
learning a new skill, or engaging in leisure activities that are mentally challenging, provide
benefits for adults’ brain health.

a. Cognitively stimulating activities are mentally-engaging activities or exercises that

challenge a person’s ability to think.
b. These activities can help you maintain your brain and cognitive abilities, such as your
memory, thinking, attention and reasoning skills as you age.
c. Observational studies suggest that cognitively stimulating activities may enhance a
person’s cognitive reserve.

i. Enhancing cognitive reserve may allow people to cope better with age-related brain
changes; and
ii. Enhancing cognitive reserve may reduce a person’s risk3 of developing dementia due
to Alzheimer’s disease and reduce the severity of symptoms if a person develops the
disease; and
iii. Enhancing cognitive reserve may reduce the severity of symptoms of other brain
diseases, such as Parkinson’s Disease, and lessen the damaging effect of stroke and
traumatic brain-injuries.

2 Randomized controlled trials and epidemiological observational studies are defined in the Glossary in Appendix 2. An overview of the
differences, strengths and limitations of two study types in humans is listed in Appendix 4.
3 “Risk” and “risk reduction” are defined in the attached Glossary in Appendix 2.

Engage Your Brain: GCBH Recommendations on Cognitively Stimulating Activities 3

 4) Cognitive training4 refers to a range of programs designed to teach strategies and provide
guided practice for improving a particular cognitive ability. (See Table 1 for a description
of different forms of cognitive training.)

5) Cognitive training on a specific cognitive ability (e.g., memory, speed of processing, etc.)
may improve that specific ability. (See Table 2 for a list of cognitive abilities and how those
skills are used in everyday activities.)

a. There is limited evidence that training focused on one cognitive ability (e.g. memory)
significantly improves another cognitive ability (e.g. speed of processing);
b. There is mixed evidence on whether training on one cognitive ability improves a
person’s ability to use that skill to maintain or improve function in everyday activities;
c. Nevertheless, the more similar the training is to the skills you use in everyday life, the
more likely that training will help you in everyday activities.

6) Most commercial products marketed as “brain games” are not what the GCBH means
when discussing the benefits of cognitive training. If people play a “brain game,” they
may get better at that game, but improvements in game performance have not yet been
shown to convincingly result in improvements in people’s daily cognitive abilities. There
is insufficient evidence that improvements in game performance will improve people’s
overall functioning in everyday life. For example, we do not have evidence establishing
that getting better at playing Sudoku will help you manage your finances any better.

7) Training on a specific cognitive ability may improve that ability even when a person has mild
cognitive impairment (MCI). However, it has not been established that training can improve
cognitive ability in patients with clinical diagnosis of dementia (e.g. due to Alzheimer’s
disease) or alter the underlying course of the disease that may be causing it.

8) Many cognitive training studies have shown that a person can improve the ability for which
they are being trained. A few studies examining the long-term effects of cognitive training
have shown continued benefit even after training stops. However, the weight of evidence
suggests that you need to continue to apply the strategies learned during the training in order
to maintain or improve the ability over time.

9) Simply engaging in more cognitively stimulating activities is not necessarily better.

The quality of the activities (including novelty, variety, level of engagement, cognitive
challenge imposed and degree of enjoyment) is important. Moreover, the duration of time
in which you spend doing the activity plays an important role in the extent to which
those activities will maintain or improve your brain function.

10) More research is needed on the impacts that cognitively stimulating activities have on the
brain, but we have sufficient evidence to conclude that it is beneficial to remain mentally
active and to continue learning over the course of your lifespan.

4 The ACTIVE Cognitive Training Trial, a multi-site randomized, controlled trial training for memory, reasoning, or speed-of-processing formed the
basis for much of our discussion surrounding cognitive training. ACTIVE outcome assessments spanned ten years.

4 Engage Your Brain: GCBH Recommendations on Cognitively Stimulating Activities

 Table 2 is intended to show how the cognitive abilities people try to improve through
different types of cognitive training described in Table 1 relate to everyday activities in
peoples’ lives.

TABLE 1. TYPES OF COGNITIVE TRAINING

SETTING COGNITIVE ABILITIES TARGETED FOR TRAINING

• Individual • Attention
• Group • Declarative Memory
• Computerized • Episodic Memory
• Executive Function (working memory, ability to switch from task to task)
• Language
• Speed of Processing
• Visuospatial Skills
• Working Memory

TABLE 2. COGNITIVE ABILITIES AND HOW THEY RELATE TO EVERYDAY ACTIVITIES

EXAMPLES OF COGNITIVE
ABILITY PRIMARILY USED IN EXAMPLES OF EVERYDAY ACTIVITIES
EVERYDAY ACTIVITIES

Attention Driving, concentration on tasks

Declarative Memory Recalling grocery lists, names of people or places

Episodic Memory Remembering where you parked your car; Remembering an event that
happened at a particular place and time such as your wedding

Executive Function Planning out a future activity; working out the best solution to a problem

Language Finding the right word that was on the tip of your tongue

Speed Of Processing Reacting quickly when driving if a car suddenly stops in front of you,
catching a dropping object, or quickly verifying you have received the
correct change

Visuospatial Skills Map reading, furniture layout

Working Memory Memorizing a phone number long enough to write it down; doing mental
calculations in a store to calculate check out total

Engage Your Brain: GCBH Recommendations on Cognitively Stimulating Activities 5

RECOMMENDATIONS

1) Incorporate enjoyable cognitively stimulating activities as part of a healthy lifestyle to help

maintain your brain health and reduce the risk of cognitive decline as you get older.

2) Don’t wait until later life to try to maintain your brain health. Start today; the younger
you start challenging yourself with cognitively stimulating activities, the better your brain
function will be as you age.

3) Be flexible in choosing activities because there are many types of activities which may be
helpful. We don’t have good evidence that one particular cognitively stimulating activity is
more effective than another for maintaining your brain health.

a. If you are not currently engaging in cognitively stimulating activities, seek out a new
activity that challenges the way you think.
b. If you already engage in some cognitively stimulating activities, continue those you
enjoy and try to add one or two new activities into your life.
c. If you are already very active, consider new ways to challenge yourself such as volunteering
to serve as a companion or mentor to others in your community. Mentally stimulating
activities that incorporate social engagement and a purpose in life combine many different
elements that have been shown to be beneficial for brain health.
d. There are many different examples of cognitively stimulating activities that may help
adults maintain or improve their cognition or well-being. Consider practicing tai-chi,
taking photography classes, designing a quilt, investigating your genealogy, juggling,
cooking, gardening and learning how to play a musical instrument. Other examples
include learning new technologies, communicating in a different language or learning a
new one, creative writing, making art, and community volunteering.

4) Find ways to re-engage in old activities that you once found to be cognitively stimulating
which you may have given up. These may help to promote sustained interest and resurface
enjoyable memories.

5) Don’t let age limit the scope of your cognitively stimulating activities or intellectual
life. Your attitude plays an important role and can shape outcomes even when there are
physical limitations to overcome.

6) Seek out new activities that are challenging and will lead to the development of new
skills and encourage social engagement. It is the activity itself–and not how well you may
perform it—that should be the main goal.

7) Be realistic, there is no miracle to guarantee brain health.

6 Engage Your Brain: GCBH Recommendations on Cognitively Stimulating Activities

PRACTICAL TIPS

1) Find new ways to stimulate your brain. Novelty is important to continually

challenge the brain and is an element in what makes even routine cognitive activities
interesting and challenging.

2) Engage your brain along with someone else. Pick a skill or hobby that you want to
learn and find a mentor, friend, or companion to help you do it. Social aspects of activities
that challenge your brain can help inspire you to continue your efforts. If being with other
people motivates you as it does for many people, join a group activity.

3) Choose an activity that you enjoy. This will make it easier to stay motivated and
committed over time.

4) Make it easy on yourself. Select activities which fit in well with your schedule and are
easily accessible so you can stay engaged in the activity.

5) Aim for purposeful (deliberate) practice. This will help you to improve performance
over time. If you are taking up a new challenging hobby such as learning a new musical
instrument or learning a new language, feedback from an instructor, coach or mentor can
give you encouragement and keep you learning.

6) Find an activity where someone will notice whether you are present. Someone
who checks up on you if you miss a session can be an additional motivating factor to
keep you going.

7) Use life stages and transitions to change things up. Think about the changes in
your life as you age, such as moving, changing careers, or retiring as opportunities to try
new forms of cognitive stimulation. Maybe the new neighborhood has glass-blowing
classes, hiking trails, or a different music group to try out.

8) Study something you are interested in. Enroll in continuing education classes at a
local community college or university. Set achievable goals, enjoy the process, and reward
yourself along the way with something you find relaxing in order to gradually increase
your involvement in the activity.

9) Choose activities involving both mental and physical engagement. Physical activity
has been shown to improve cognition in adults, so choosing activities such as dancing or
tennis that involve both mental engagement and physical exercise is a wise use of your
time. (See The Brain-Body Connection: GCBH Recommendations on Physical Activity and
Brain Health for more information on how physical activity helps brain health.)

Engage Your Brain: GCBH Recommendations on Cognitively Stimulating Activities 7

PROCESS USED TO PRODUCE THE
CONSENSUS AND RECOMMENDATIONS

Issue specialists from around the world were selected to Nine Governance Committee members participated during
participate with the GCBH because they are considered the in-person meeting. The entire Governance Committee
leaders in their fields. These experts have conducted research reviewed and finalized the document during subsequent
that has significantly contributed to the body of evidence conference calls and emails from March to June 2017.
linking different stimulating activities with brain health The Governance Committee issuing the recommendations
amongst older adults. The diverse areas of their expertise are independent health professionals representing
represent different perspectives and disciplines including diverse expertise across three continents in epidemiology,
gerontology, neuropsychology, neurology, neuroscience, psychology, public health, neurology, psychiatry, geriatrics,
psychology, public health and speech-language pathology. cognitive neuroscience, neuropsychology, pharmacology,
medical ethics and health policy and neurodegeneration.
Thirteen issue specialists from four continents were asked
to critically examine the state of the science as of March The Governance Committee applied their expertise to
2017. They discussed findings from both observational and determine whether they concurred with the statements and
epidemiological studies to randomized controlled trials. to evaluate the objectivity and feasibility of the proposed
The experts considered the cumulative body of evidence to recommendations. The GCBH Governance Committee
determine whether it is sufficient to issue recommendations reviewed this summary document to decide whether it
for individuals to maintain and improve brain health. accurately reflected the expert opinions expressed and
the current state of science in the field. The Governance
The issue specialists considered 11 different questions as a Committee approved the document on June 30, 2017.
framework to guide their deliberations. The complete list
is available in Appendix 3, but the major questions they
addressed were: Does engaging in cognitively stimulating
activities as an adult age 50 and older 1) impact cognition, 2)
impact the brain, and 3) have the ability to positively impact
an adult’s everyday life?

After an in-depth moderated discussion, several follow-up

conference calls and an exchange and refinement of drafts,
the issue specialists arrived at 10 consensus statements to
summarize the impact of cognitively stimulating activities
on brain health. Based on their consensus, they made
seven recommendations related to stimulating activities
in the context of brain health and reducing the risk for
cognitive decline. They further agreed on practical tips to
help people around the world adopt behaviors to promote
their brain health.

Liaisons from civic and non-profit organizations with relevant

expertise in brain health were invited to provide input and
technical feedback during the Issue Experts and Governance
Committee’s refinement of the draft recommendations.

8 Engage Your Brain: GCBH Recommendations on Cognitively Stimulating Activities

DISCUSSION
There are differences in the way people’s brains age, with 11
some older people having fewer changes in their brain
10
structure and functioning than others. We all know people
9

Hippocampusvolym (ml)
who seem to thrive as they age and keep their mental
functioning sharp. Figure 1 shows individual variability in 8

different people, with some people in their 80s having the 7 Hippocampus

same hippocampal volume as people in their 30s. Given that 6

hippocampal volume is correlated with cognitive decline,
5
this figure helps illustrate both that cognitive decline is not
4
inevitable as we age, and that the rate of decline is not the 30 40 50 60 70 80
same for all individuals. Ålder

Figure 1 – (Det Åldrande Minnet/The Aging Memory, by Nyberg,

The GCBH agrees that there are many things people can do Nilsson, Letmark, published by Natur & Kultur, 2016, in Swedish.)
Note: Ålder is Age in Swedish
to promote their brain health as they age. Healthy aging is
a highly active process. Engaging in cognitively stimulating
activities can help you avoid cognitive decline, delay it, and
deal better with it should you eventually experience it. For to positively influence his or her brain health. So what are
example, continuing to work in a job you enjoy and that the expected benefits of engaging in cognitively stimulating
stimulates your thinking has been demonstrated to result activities? As one ages, there are expected changes in
in healthier brain aging. Scientific studies have established cognitive functions in several areas such as memory,
a link between participation in self-initiated, cognitively speed of processing and attention, so activities that help to
stimulating activities and better brain health in aging maintain these and other cognitive functions over time can
adults. Life experiences including education, occupation be beneficial. There is increasing evidence that participation
and engaging in leisure activities and learning are known to in cognitively stimulating activities may contribute to
enhance cognitive reserve, and better cognitive function is lowering the risk of dementia and cognitive impairment
associated with greater well-being. as one ages. And, to this end, research has also shown that
cognitive decline may accelerate when people stop engaging
It is never too late to benefit from cognitively stimulating in cognitively stimulating activities. Therefore, it is especially
activities, and you can learn new things at any age. In the important to keep up cognitively stimulating activities in the
same way that you need to maintain exercise for physical transition from work to retirement.
strength, you need to participate in mental activities to
support the health of your brain. There are many ways to
incorporate such activities into your daily life. For example,
deliberately engaging and challenging your brain over time
long after your formal schooling is over results in better
cognitive aging for adults. Education is key, not only formal
education as a youth, but life-long learning.

The dynamic or “plastic” nature of your brain refers to the

remarkable ability of your brain to respond to changes
within the body or the external environment over the
course of a lifespan. Brain plasticity therefore describes a
process through which the brain can modify its structure
and function. Seeking out cognitively stimulating activities
is a powerful example of an action that a person can take

Engage Your Brain: GCBH Recommendations on Cognitively Stimulating Activities 9

RANGE OF ACTIVITIES TO SEEK OUT engage in cognitively stimulating activities. But as noted
above, not all commercially-developed brain training games
Cognitively stimulating activities may be characterized have a sufficient evidence base to support the claims that
by novelty, requiring attention and focus, and a depth of companies and entities have promoted. Therefore, the GCBH
engagement. Given this definition, activities that you do urges people to look carefully at what such games offer and
regularly in your life can be cognitively stimulating if they examine the evidence base when considering choosing a
involve the characteristics above. Playing with grandchildren, computer based training. It is also important to consider
gardening, playing cards and playing chess are all activities other cognitively stimulating choices such as participating in
that can include elements of novelty and concentrated a book club or learning a new language.
attention. Calligraphy, or “Shufa” the art of brush writing, is
an example of an activity common amongst Asian cultures.
MEASURING EFFECTIVENESS
It stimulates the brain through intensive attention and
AND OUTCOMES OF COGNITIVE
planning, and in addition, it involves immediate sensory
feedback as one makes the brush strokes. There are many TRAINING PROGRAMS
examples of cognitively stimulating activities that people
from a range of cultures engage in. When trying to measure how well a cognitive training
program serves to promote brain health and whether it
could help you maintain cognitive function as you age, it
IMPORTANCE OF POSITIVE
is important to consider whether the activities that you are
FEEDBACK FROM OTHERS engaging in will improve your everyday functioning. There
is good evidence that brain training targeting a specific
Receiving feedback from friends and family appears to cognitive ability such as memory, reasoning, vocabulary and
motivate people to continue with activities that stimulate the speed of processing can improve that particular ability, but
brain. Negative results can discourage people from engaging in relatively little evidence exists that such improvements result
or maintaining cognitively stimulating activities. Training in in maintaining independence or quality of life.
groups where a person receives encouraging coaching from a
formal coach or friend seems to improve results. Simply doing Researchers have observed that better performance can be
the cognitively stimulating activity in the presence of others generated by merely telling people they are participating
may help to encourage one to continue participating. in training to enhance cognition. This suggests a placebo
effect or an effect due to the expectation that we have about
the effectiveness of the training in which we are engaged.
COMPUTER-BASED COGNITIVE
One recent study, for example, reported that participants
TRAINING PROGRAMS who were recruited for a study using flyers that included
terms such as “Brain Training and Cognitive Enhancement”
It is widely understood that healthy older adults seek showed a 5 to10 point increase in performance after a
out a range of strategies to maintain their brain function one hour session of cognitive training as compared to
in the face of normal cognitive aging and the associated participants who participated in the study but who had not
expected decline. The computer interface offers participants seen the flyer containing the words “Brain Training and
progressively challenging and adaptive interventions as Cognitive Enhancement.”
opposed to other types of cognitive interventions which
are more static and are not personalized. Computer-based
COGNITIVE TRAINING FOR
cognitive training programs offer adaptive training as a
key feature. Adaptive training can be personalized and INDIVIDUALS WITH DEMENTIA
introduces elements of novelty and difficulty. Improved
adherence and motivation to advance to the next level has For people with a diagnosis of dementia, there may
been reported in individuals participating in computer-based be specific treatments that could help maintain their
cognitive training activities. Evidenced-based, cognitive functioning over time. General forms of cognitively
training that has been made into a game on the computer stimulating activities can be beneficial for keeping people
to progressively challenge the mind can be a good way to living with dementia engaged and alert. For instance, it

10 Engage Your Brain: GCBH Recommendations on Cognitively Stimulating Activities

is very helpful to have people engaged in music or craft conversation; this choice strengthens the decision-making
activities. In addition, engaging in routine activities related capability of the brain. Such reinforcement is particularly
to daily living can help support the person’s ability to engage apparent when multiple languages are used frequently
in and manage these activities. ‘Cognitive rehabilitation’ or by the individual. There is also research that suggests that
‘reablement’ are terms used to describe efforts focused on bilingualism may help people cope with brain changes.
addressing the impact of cognitive impairments on everyday
life. For people with mild to moderate dementia, cognitive As noted above, however, despite a large number of studies
rehabilitation aimed at helping people carry out specific showing the benefits of bilingualism, the evidence base is
every day, self-care activities can improve their ability to mixed. There are some studies which did not find any brain
complete those tasks. Group sessions that involve discussion health advantages from speaking more than one language.
among small groups of people can provide a different form Some researchers believe that studies failing to establish
of cognitive stimulation for individuals with dementia. a bilingual advantage are also less likely to be published
Psychological and pharmacological interventions may also as is often a concern in research not finding significant
be implemented to address specific difficulties. However, differences in outcomes between groups tested. Moreover,
for individuals with Alzheimer’s disease or other dementias, it has been argued that it is not bilingualism itself, but other
there is evidence that cognitive training programs aimed at factors associated with speaking more than one language
providing strategies or practicing focused cognitive abilities that may help protect against brain and cognitive decline.
like episodic memory or speed of processing are unlikely to Some researchers argue that bilingualism is associated with
be helpful. It is advisable to discuss treatment options with higher socio-economic status and education, which are both
your health care professional. associated with healthier lifestyles; it may be that such a
lifestyle correlates with better cognitive and brain health
Family members and friends of loved ones with dementia rather than bilingualism alone. However, recent work has
often want to know what they themselves can do to help. It is shown that the advantages of bilingualism can extend to
very important for people with dementia to maintain positive some individuals in low-educated and low socio-economic
relationships with family and friends. Friends and family can level populations. Therefore it appears that bilingualism
help their loved one to remain as socially engaged as possible might represent a protective shield against cognitive decline,
and can encourage opportunities to engage in activities that independent of literacy and education.
the person with dementia finds interesting and enjoyable.
This can improve mood and support psychological health. It
THE IMPACT OF COGNITIVELY
is also important for caregivers themselves to keep engaged
in cognitively stimulating activities. STIMULATING ACTIVITIES ON THE BRAIN

There have been brain-imaging studies investigating the

COGNITION AND SPEAKING effect of cognitive training on the size, shape, structure and
MORE THAN ONE LANGUAGE function of the brain and nerve cells. A few brain imaging
studies found that cognitive training can increase cortical
A great deal of research has been conducted in the area thickness and the integrity of the white matter. Cognitive
of cognition and bilingualism. While there is research training also changes functional brain measures; that is,
showing that learning and using more than one language cognitive training modifies which brain regions will be active
has a beneficial impact on the brain and on cognition, the when performing a task. Finally, there is some evidence
evidence from studies in this field is mixed. Some research of changes in the chemistry of the brain. While these are
has demonstrated that adult foreign language learning is interesting findings, much remains to be known regarding
accompanied by increases in gray matter in the regions of the the pattern and any short and long term impact of those
brain related to language. Some research has also shown that brain changes attributed to cognitive training.
older people who speak more than one language are better at
making decisions when faced with competing information
as compared to other similar individuals who only speak one
language. When a person can speak more than one language,
she or he must choose which language to speak in a particular

Engage Your Brain: GCBH Recommendations on Cognitively Stimulating Activities 11

MYTHS ABOUT THE AGING BRAIN
During the discussion, the GCBH issue experts set forth some of the common myths about aging brains
and then described why they were false.

MYTH #1: YOU ARE BORN WITH ALL THE

NEURONS YOUR BRAIN WILL EVER HAVE.

While most of the neurons in the brain are created before birth, some areas of the
brain do create new neurons throughout life in a process called neurogenesis. For
example, studies have shown that new neurons can be created in the region of the
brain involved in learning and memory in the adult brain. Moreover, it is thought that
the addition of new neurons later in life may actually enhance the formation of new
memories as those new neurons are more ‘plastic’ in nature and thus can more easily
modify their connections and store memories. There is hope that understanding the
biological basis of how new neurons are created will inform research aimed at helping
individuals with neurodegenerative diseases or brain injuries.

MYTH #2: YOU CANNOT LEARN NEW THINGS WHEN YOU

ARE OLD. (“YOU CAN’T TEACH AN OLD DOG NEW TRICKS.”)

Actually, there are many ways in which you may be able to positively influence
your brain health at any age through engagement in cognitively stimulating
activities (refer to the “Practical Tips” section of this report). Seeking out new social
connections, for example, involves learning new names and information about the
new people you encounter. Getting involved in new activities often involves learning
procedural details; such novel learning can be beneficial for brain health at any age.
Education and many life experiences including those on the job and during leisure
activities are known to enhance cognitive reserve (see Glossary, Appendix 2), and
better cognitive function is associated with better well-being.

MYTH #3: WE DON’T REALLY KNOW HOW THE BRAIN WORKS.

Great strides have been made in recent decades in understanding the structure
and function of the brain. Although the brain is very complex and there is still a
great deal to learn, new therapeutic treatments are underway to treat a range of
neurological conditions. Researchers are optimistic that the field of neuroscience is
at the cusp of many new and exciting breakthrough discoveries in brain health and
underlying links to behavior.

12 Engage Your Brain: GCBH Recommendations on Cognitively Stimulating Activities

 MYTH #4: DEMENTIA IS AN INEVITABLE
CONSEQUENCE OF OLD AGE.

Dementia is not inevitable and it is not a normal part of aging, although it is an

age-related condition. Dementia can be caused by Alzheimer’s disease or other age-
related disorders, such as stroke. Cognitive decline is associated with aging, but it is
important to draw a distinction between typical age-related changes in the brain and
those that are abnormal, which in some cases can progress to dementia.

MYTH #5: ONLY YOUNG PEOPLE CAN LEARN A NEW LANGUAGE.

While it is true that children exposed to a new language can usually become fluent
with greater ease than adults, people can learn a new language at any age. Part of
the barrier for language learning in adults may be cultural customs. For example,
in some countries such as Sweden, it is common for retired people to take language
classes for a new language, whereas it is not as common in the United States.
Children may find it easier as language and grammatical sentence structure for
children tend to be less complex, and kids are often less self-conscious while trying
new endeavors. That said, it is indeed possible to acquire a new language at any age.
It is particularly helpful to reinforce these language skills by seeking out individuals
in your community who speak that language to practice.

MYTH #6: OLDER PEOPLE ARE DOOMED TO FORGET THINGS.

Some people have an easier time remembering details than others; this is true of people
of all ages. No matter your age, many people find it helpful to use different strategies to
remember names, facts, etc. For example, making lists and writing down the names of
items you must remember can be effective ways to remember items to pick up at the
market. Visual cues are another way to tap into your memory. Take time to examine
visual characteristics of your surroundings and people around you. A lot of what people
attribute to poor memory is not paying close attention.

MYTH #7: A PERSON WHO HAS

MEMORY TRAINING NEVER FORGETS.

Maintaining your skills requires you to continue to practice those skills. While it
is important to recognize that there is no miracle cure to guarantee brain health,
continually challenging your brain can help to maintain it. “Use it or lose it” applies
to memory training as well as to maintaining your physical health.

Engage Your Brain: GCBH Recommendations on Cognitively Stimulating Activities 13

KNOWLEDGE GAPS
GCBH members identified areas where more research is needed to better understand the impact of
cognitive stimulating activity on brain health in adults.

WHICH ASPECT OF COGNITIVELY involved in cognitive stimulation. More theories are being
STIMULATING ACTIVITIES CONTRIBUTES developed and tools, including neuroimaging techniques and
animal models, will be critical in our pursuit to understand how
TO BRAIN HEALTH?
learning and transfer of skills work within the brain.
Many activities have different aspects or components to them
which could be contributing to a beneficial effect on the HOW DO INDIVIDUAL DIFFERENCES
brain. For example, most cognitively stimulating activities IMPACT THE WAY PEOPLE RESPOND TO
also incorporate social engagement and/or physical activity COGNITIVELY STIMULATING ACTIVITIES?
aspects into the activity which researchers call “multi-
modal.” We have yet to fully understand which aspect of the
We know very little about how certain factors such as gender,
chosen activity contributes on its own to brain health. The
disease status, education, age and genetics contribute to
component parts may moderate the effect of each activity,
differences in the effects of cognitively stimulating activities
and it may be the combination of factors taken together
on brain structure and function. Nor do we have a good
that generates the most benefit. Further research on the
understanding of why some people engage or adhere to a
independent contribution of all the elements involved in the
cognitive training program and others do not. While we
activities could shed more light on this issue.
know that cognitive functioning is influenced by a wide
range of factors that have socio-economic underpinnings,
more work on how to mitigate the harmful effects of low
DO LEISURE BASED INTERVENTIONS
socio-economic status needs to be accomplished.
HAVE SIMILAR EFFECTS AS COGNITIVE
TRAINING AND CAN THEY COMPLEMENT HOW WELL CAN COGNITIVE
EACH OTHER? TRAINING PROGRAMS TRANSLATE TO
IMPROVEMENTS IN EVERYDAY FUNCTION?
We do not know whether cognitively stimulating leisure-time
activities, for example, calligraphy or gardening, have the
Some methodological challenges exist in studies that have
same benefits for cognition as cognitive training programs
been conducted to assess the effects of cognitive training
specifically designed to teach strategies and provide
programs. One major problem is how to measure the benefit
guided practice for improving a particular ability. Further
of these programs on activities of daily living. As researchers
comparative research into what are the most effective forms
do not usually observe every moment in people’s everyday
of cognitively stimulating activities could help people choose
life, they rely on questionnaires which might fail to capture
among many options.
the true effect of the training in the context of people’s
complex daily life situations. It is difficult to assess cognitive
WHAT ARE THE UNDERLYING BIOLOGICAL training programs impact on everyday activities that tap
MECHANISMS THAT ARE IMPACTED BY into executive function abilities such as driving, planning
COGNITIVELY STIMULATING ACTIVITIES? an activity, changing a strategy when necessary, and dealing
with several sources of information. Therefore, developing
While we have some knowledge of the neural basis of benefits research methods that appropriately measure applicability
of cognitively stimulating activities such as impacting neural to peoples’ everyday life and conducting this research could
networks and activating neurotransmitters, more research help us answer this question.
is needed to better understand the underlying mechanisms

14 Engage Your Brain: GCBH Recommendations on Cognitively Stimulating Activities

WHAT IS THE OPTIMAL DURATION OF
COGNITIVELY STIMULATING ACTIVITIES?

Because this field of study is still in an early stage of

development, we do not have sufficient information
regarding how much (what dose of) cognitive stimulation
is the most effective for improving cognitive functioning.
Studies should explore how much training is needed to
generate benefit, such as total hours of exposure, as well
as how often, such as daily, weekly, or monthly. Further,
we know relatively little about how long the training’s
effects last after the training ceases. More developed theory
about how cognitive training affects the brain could guide
exploration of these dose factors. It may be that different
cognitive processes may require different amounts of
training to reach an optimal level of performance. However,
it is best to maintain a variety of cognitively stimulating
activities throughout your life.

IS NON-INVASIVE BRAIN STIMULATION

SAFE AND EFFECTIVE FOR MAINTAINING
COGNITIVE FUNCTION?

Non-invasive brain stimulation (NIBS) is rapidly growing

in acceptance as a tool in neuroscience research and clinical
applications. Transcranial magnetic stimulation or TMS, and
transcranial current stimulation or tCS, are the most common
forms of NIBS at present. NIBS applies electric or electro-
magnetic energy through the scalp to impact brain function.
NIBS may be useful as a therapeutic device for several
psychiatric and neurological diseases. The United States Food
and Drug Administration has cleared several TMS devices
for therapeutic use in major depression and migraines, and
these applications are covered by insurance companies for
these purposes. NIBS can impact cognitive processing in
the brain, may improve performance in cognitive tasks, and
may enhance the effects of cognitive training. There are
clinics in several countries offering expensive treatments
combining cognitive training and NIBS. However, there
is insufficient scientific evidence to conclude that NIBS
can lower the risk of cognitive decline, and there are open
questions about long-term safety, mechanisms of action,
and potential lasting impact on the brain. Therefore, NIBS
should only be used for cognitive enhancement in research
settings under supervision. Direct-to-consumer devices and
do-it-yourself approaches are gaining popularity, but people
should be cautious and should seek professional advice and
consultation before using NIBS.

Engage Your Brain: GCBH Recommendations on Cognitively Stimulating Activities 15

CONCLUSION
Your brain has the remarkable ability to respond to changes enhancing reasoning…memory, and speed of processing. Such
within the body or the external environment over the course structured training exercise may or may not be computer
of your lifespan. The aging brain shows plasticity allowing it to based.” It also said that it “is appropriate for public health
modify its structure and function at all ages when faced with practitioners and health care providers to include mention
the challenges of mental activities. Seeking out cognitively of the potential cognitive benefits of these interventions
stimulating activities is a powerful way for a person to when promoting their adoption for the prevention or control
positively influence their brain health as they age. The GCBH of other diseases and conditions.” The committee identified
has identified many cognitively stimulating activities you the need for improvements in methodologies of future
may already be doing. If so, keep it up and challenge yourself research as well as the need for the NIH and others to support
to do more complex versions of the stimulating activities further research to strengthen the evidence base on these
you already love. Or try new and different ones. If you aren’t interventions as well as others. The GCBH endorses the need
currently engaging in any of the suggested activities, consider for and importance of such research.
branching out and challenging yourself.
The National Academies’ Report Highlights concluded that
The consensus statements and recommendations above “[c]linical trials and other studies have yielded encouraging
are based on the current state of science as of March data for some interventions, and the public should have
2017. Immediately before the GCBH approved these access to this information to inform choices on how to invest
recommendations, the National Academies of Science, time and resources to maintain brain health with aging.”
Engineering and Medicine (National Academies) issued The GCBH has provided such information. Based on their
their report, “Preventing Cognitive Decline and Dementia: A knowledge of the relevant observational epidemiological
Way Forward” on June 22, 2017. This report was sponsored evidence, clinical trial evidence from randomized controlled
by the National Institute on Aging (NIA) of the National trials, and their own experience and expertise in the field, the
Institutes of Health (NIH), U.S. Department of Health and GCBH concluded they could reliably recommend that people
Human Services. It was based in large part on a systematic incorporate enjoyable cognitively stimulating activities as
review of experimental evidence on the effectiveness or part of a healthy lifestyle to help maintain their brain health
harm of interventions for preventing, slowing, or delaying and reduce the risk of cognitive decline as people age. It
the onset of clinical Alzheimer’s-type dementia, mild is worth repeating the tenth and final GCBH consensus
cognitive impairment, and/or age related cognitive decline. statement. More research is needed on the impacts that
The evidence review was also supported by the NIA, and cognitively stimulating activities have on the brain, but we
conducted by the U.S. Agency for Healthcare Research and have sufficient evidence to conclude that it is beneficial to
Quality (AHRQ). remain mentally active and to continue learning over the
course of your lifespan.
The National Academies committee found that the “AHRQ
systemic review did not identify any specific interventions As further developments occur in the study of the impact
with enough evidence to justify mounting an assertive of stimulating activities on brain health, the GCBH will
public health campaign to encourage people to adopt them periodically revisit these recommendations and provide
for preventing cognitive decline and dementia.” Based on updates when appropriate.
findings from the systemic review and other supplemental
data sources, however, the National Academies committee
concluded that “beneficial effects of the following three classes
of interventions are supported by encouraging, although
inconclusive evidence: cognitive training, blood pressure
management in people with hypertension, and increased
physical activity.” Cognitive training was defined as including
“a broad set of interventions, including those aimed at

16 Engage Your Brain: GCBH Recommendations on Cognitively Stimulating Activities

APPENDICES
1) PARTICIPANTS, WITH PARTICIPANTS’ AND LIAISONS’ LIST OF ADDITIONAL RESOURCES

2) GLOSSARY

3) DISCUSSION QUESTIONS FRAMING THE DELIBERATIONS

4) DIFFERENCES, STRENGTHS AND LIMITATIONS OF TWO STUDY TYPES IN HUMANS

5) DISCLOSURE STATEMENT OF POTENTIAL CONFLICTS OF INTEREST

6) FUNDING

7) SELECTED REFERENCES

1. PARTICIPANTS
Members of the Global Council on Brain Health are independent health care professionals and experts
coming from a variety of disciplines. The cognitive activity issue specialists and Governance Committee
members formulated these recommendations, and the Governance Committee approved them.

ISSUE SPECIALISTS

ANA INÉS-ANSALDO, Ph.D. GEORGE REBOK, Ph.D.

University of Montréal, Canada Johns Hopkins University, USA
DAVID BARTRÉS-FAZ, Ph.D. BARBARA J. SAHAKIAN, DSC, FMedSci
University of Barcelona, Spain University of Cambridge, UK
SYLVIE BELLEVILLE, Ph.D. YAAKOV STERN, Ph.D.
University of Montréal, Canada Columbia University, USA
NEIL CHARNESS, Ph.D. SHERRY L. WILLIS, Ph.D.
Florida State University, USA University of Washington, USA
SHEUNG-TAK CHENG, Ph.D.
The Education University of Hong Kong GOVERNANCE COMMITTEE
ARTHUR F. KRAMER, Ph.D.
Northeastern University, USA MARILYN ALBERT, Ph.D.
Johns Hopkins University, USA (Chair)
FACUNDO MANES, Ph.D.
Facaloro University of Buenos Aires, Argentina LINDA CLARE, Ph.D. Sc.D.
University of Exeter, UK (Vice Chair)
LARS NYBERG, Ph.D.
Umeå University, Sweden KAARIN ANSTEY, Ph.D.
Australian National University, Australia
ALVARO PASCUAL-LEONE, M.D., Ph.D.
Harvard Medical School, MARTHA CLARE MORRIS, Sc.D.
Beth Israel Deaconess Medical Center, USA Rush University, USA

Engage Your Brain: GCBH Recommendations on Cognitively Stimulating Activities 17

PEGGYE DILWORTH-ANDERSON, Ph.D. LIAISONS
University of North Carolina–Chapel Hill, USA
Other experts from relevant public agencies and non-profit
S. DUKE HAN, PH.D., ABPP-CN
associations reviewed the paper and provided guidance and
University of Southern California, USA
feedback to help shape the document. Grateful
YVES JOANETTE, Ph.D. acknowledgment goes to:
University of Montreal, Canada
LIBBY ARCHER
JASON KARLAWISH, M.D. World Dementia Council
University of Pennsylvania, USA
MATTHEW BAUMGART
MIIA KIVIPELTO, M.D., Ph.D. Alzheimer’s Association
Karolinska Institutet, Sweden
DOUG BROWN, Ph.D.
JESSICA LANGBAUM, Ph.D. Alzheimer Society
Banner Alzheimer’s Institute, USA
MELINDA KELLEY, Ph.D.
JACOBO MINTZER, M.D., M.B.A. National Institute on Aging*
Roper St. Francis Clinical Biotechnology Research
LISA MCGUIRE, Ph.D.
Institute, USA
Centers for Disease Control and Prevention*
RONALD PETERSEN, M.D., Ph.D.
JANE TILLY, Dr.PH
Mayo Clinic, USA
Administration for Community Living*
KATE ZHONG, M.D.
MOLLY WAGSTER, Ph.D.
Global Alzheimer’s Platform Foundation, USA
National Institute on Aging*
MODERATOR JOAN WEISS, Ph.D., RN, CRNP
Health Resources and Services Administration*
*Participation in this activity by these individuals does not necessarily represent
JACKIE JUDD the official viewpoint of the U.S. Department of Health and Human Services, the
Health Media Journalist National Institutes of Health, or the National Institute on Aging.

STAFF
PARTICIPANT AND LIAISONS’ LIST
OF ADDITIONAL RESOURCES
NICHOLAS BARRACCA
AARP
THE DISCONNECTED MIND PROJECT – FUNDED BY
LINDSAY R. CHURA, Ph.D.
AGE UK
AARP
ageuk.org.uk/about-us/what-we-do/the-disconnected-mind/
JAMES GOODWIN, Ph.D.
PREVENTING COGNITIVE DECLINE AND DEMENTIA:
Age UK
A WAY FORWARD
CARL LEVESQUE doi.org/10.17226/24782
AARP
THE BRAIN HEALTH RESOURCE FROM THE
WILLIAM HU, M.D., Ph.D. ADMINISTRATION ON COMMUNITY LIVING (ACL)
Emory University, and Consultant to GCBH acl.gov/node/293
SARAH LENZ LOCK, J.D.
AARP
DEBRA WHITMAN, Ph.D.
AARP

18 Engage Your Brain: GCBH Recommendations on Cognitively Stimulating Activities

2. GLOSSARY
The glossary highlights how the GCBH used these terms within the context of their discussions and in
this document.

ATTENTION COGNITIVE MAINTENANCE thinking and social abilities and

The concentration of awareness in a Individual differences in cognitive affecting them severely enough to
focal and perceptive way. abilities and health due to upkeep interfere with daily functioning.
or re-engagement that allow some Though dementia generally involves
BRAIN HEALTH people to show little or no age- memory loss, memory loss has
A state of having good underlying related cognitive decline. different causes. So memory loss
neural mechanisms to support high alone doesn’t mean you have
functioning mental processes of COGNITIVE RESERVE dementia. Alzheimer’s disease is the
cognition and that supports well-being. Individual differences in the resilience most common cause of a progressive
or adaptability of cognitive processes, dementia in older adults, but there
BRAIN MAINTENANCE such as memory, reasoning and are a number of causes of dementia.
Individual differences in the attention, that together help explain Depending on the cause, some
manifestation of age-related brain why some people are more susceptible dementia symptoms can be reversed.
changes and pathology that allow than others to age- or disease-related
some people to show little or no brain changes. EFFICACY
age-related cognitive decline. The degree to which an
COGNITIVE RESILIENCE intervention accomplishes the
BRAIN RESERVE The brain’s ability to respond more desired or projected outcomes.
Individual differences adaptively to stress.
in the brain size or neuronal EPIDEMIOLOGICAL STUDIES
count which allows resilience or CONFOUNDER (which can be cross-sectional or
adaptability of some people (and not A situation in which the effect or longitudinal). In these studies, which
others) to curb age- or disease-related association between an exposure are observational in nature, scientists
brain changes. and outcome is distorted by the try to establish a link between
presence of another variable. lifestyle activities over time (e.g.,
COGNITION education) and long-term outcomes
The ability to attend (pay attention CORTICAL THICKNESS (brain health with aging).
to something), think, learn, and A measure used to describe the
remember. It is the basis for how we thickness of the layers of the cerebral EXECUTIVE FUNCTION
reason, concentrate, plan, exercise cortex (outer layer of neural tissue) in The mental process needed when you
judgment, and organize. humans and other mammals. use working memory, or undertake
planning, problem-solving and
COGNITIVE DECLINE DAILY LIVING ACTIVITIES decision making.
The Institutes of Medicine (IOM) in (ACTIVITIES OF DAILY LIVING – ADL)
2015 defined a similar term, cognitive An umbrella term that refers to FLEXIBILITY
aging, as the lifelong process of activities or tasks that people The readiness with which a person’s
gradual and ongoing, yet highly undertake routinely in their everyday focus changes selectively in response
variable, change in cognitive functions life, including self-care. to the environment.
that occur as people get older.
Cognitive decline is a term used by the DEMENTIA GREY MATTER
experts to describe losing cognitive Dementia isn’t a specific disease. A description of the brain tissue
abilities over time as people age absent Instead, dementia describes a group that processes information. (See also,
a specific disease or condition. of symptoms related to memory, white matter definition.)

Engage Your Brain: GCBH Recommendations on Cognitively Stimulating Activities 19

INTERVENTION NETWORK Dementia (due to Alzheimer’s disease
Any measure whose purpose is to The series of neuron connections or another related disorder) is one
improve health or alter the course which control a person’s abilities condition, and cognitive decline (the
of disease. and responses. slowing of thinking and memory in
the absence of a major brain disease)
LANGUAGE PLASTICITY is another condition. When scientists
A formal system of communication The process in the brain that allows study risk reduction strategies for
which involves the combination learning to occur. cognitive decline, they are looking
of words and/or symbols, whether for factors that can reduce the risk of
written or spoken, as well as some RANDOMIZED CONTROLLED impairment to cognitive functions in
rules that govern them. TRIAL (RCT) the population in general. Therefore,
In a typical randomized controlled some activity or intervention that
LITERACY trial, people are randomly selected reduces risk for a particular condition
The ability to read and write. to receive either the intervention or disease means that a smaller
or a control condition. In a double- proportion of people who engage
LONGITUDINAL STUDIES blind trial, both the participants and in that activity are likely to have the
In longitudinal research, scientists the researchers are unaware of (or condition or disease. However, risk
observe changes over an extended “blinded” to) which person received reduction strategies are not the same
period of time to establish the time- the intervention until after the as preventing any one individual from
sequence in which things occur or results are analyzed. getting the condition or suffering
the effect of a factor over time. from disease. For example, research
REASONING has long shown that wearing a
MEMORY The thought process behind an seatbelt reduces – but does not
The mental faculty of retaining and action or judgment. eliminate – the chance of injuries
recalling past experience based on among people who are involved
the mental processes of learning, RISK in automobile accidents and we
retention, recall and recognition. Risk is the chance or probability of a nevertheless now recommend people
particular event happening in a group wear seatbelts while they are driving.
DECLARATIVE MEMORY of people with similar characteristics
The conscious remembering of or traits, compared with those not SPEED OF PROCESSING
factual information (semantic having that characteristic or trait. How quickly you carry out simple
memory) or previous experiences Making up an individual’s overall decision-making. For example, how
(episodic memory). risk of having a condition is the quickly you can take in a bit of new
cumulative effects of factors that information, reach some judgment
EPISODIC MEMORY increase the chance of developing on it and then formulate a response.
Memory of autobiographical the condition (risk factors) as well
events. The storage of unique as factors that decrease the chance TRAINING
events or experiences associated of developing the same condition A specific practice or intervention
with a specific time and place. (protective factors). of a cognitive ability, usually in the
academic or research setting, which
SEMANTIC MEMORY RISK REDUCTION improves a specific cognitive ability
A portion of long-term memory Reducing risks for cognitive decline and may transfer to improvement in
that holds the knowledge of facts. or impairment in the abilities to everyday outcomes.
think, reason, and remember means
WORKING MEMORY lowering your chances of experiencing VISUOSPATIAL SKILLS
The ability to hold information in loss in those abilities. A person’s The ability to mentally combine visual
mind long enough to integrate or overall risk may also be reduced and spatial information for successful
reorder information. by increasing factors that protect completion of a spatial task.
against cognitive decline or dementia.

20 Engage Your Brain: GCBH Recommendations on Cognitively Stimulating Activities

WHITE MATTER
A description of the brain tissue,
covered in a white fatty protein, used
to connect areas of the brain with are
farther apart. These are “highways”
transmitting information from one
area of grey matter to another.(See
also grey matter definititon.)

3. DISCUSSION QUESTIONS
FRAMING THE DELIBERATIONS
1) Can cognitively stimulating activities maintain or improve mental abilities such as memory
and reasoning skills in adults without cognitive impairment as they age?

a. What evidence do we have on specific types of cognitively stimulating activity that lead
to maintaining or improving cognition?
b. Is there evidence concerning the likely duration, intensity and frequency necessary for
cognitively stimulating activity to achieve the greatest cognitive benefit?
c. Is there evidence that there must be an increase in mental exertion, or novelty, or
deliberate, active participation for the activity to maintain or improve cognitive function?
d. Can cognitively stimulating activities impact age-associated cognitive decline?

2) Can cognitively stimulating activities affect the course of decline associated with age-
related neurological diseases, such as the dementias?

3) Are there specific cognitive activities you would encourage or discourage for the purpose
of reducing the risk of or delaying age-related cognitive decline or age-related neurological
disorders (e.g., stimulating activities that people should engage in such as taking up new
or novel activities, promoting flexible thinking, or mixing physical activity with cognitive
activity such as tai chi)?

4) What are the limitations in our scientific knowledge about the ages/types/conditions
of people who can benefit from cognitive activity (e.g., only literate people have been
evaluated so we don’t know about those who can’t read, or if individuals reach a certain
age it is too late to benefit from cognitive training, or if an individual has had a stroke or is
already experiencing dementia, he or she will not benefit from cognitive training, etc.)?

5) Do certain aspects of cognitive training (e.g., repeated exposure through practice) have an
impact on how the brain responds?

a. Is there neuropsychological, structural (MRI), or functional (PET, fMRI) evidence of the

impact of short and long-term cognitive training?
b. What are the best standards and practices for evaluating such cognitive training
interventions?

Engage Your Brain: GCBH Recommendations on Cognitively Stimulating Activities 21

 c. What is the opportunity cost of engaging in cognitive-training games? That is, what is
the relative impact of improving performance on games one purchases versus engaging
in other life style activities thought to promote brain health?
d. What do we know about the duration and scope of training necessary to maintain
cognitive function over time?

6) What is the impact of education on cognitive health? There is speculation that declining
rates of dementia are linked to more educated populations in many regions of the world.
Is there research to support this? And what is the evidence for the benefit of formal
education for individuals when they are young vs. the impact of educational programs
across the lifespan?

7) What is known about social determinants of health and individual differences as well as
factors that can modulate responses to cognitive activities?

8) To what extent does cognitive training impact a person’s ability to maintain his or her
independence in their communities? (i.e., is there evidence that cognitive training that
improves performance on a specific task can support maintenance or improvement in
daily activities?)

9) What role does non-invasive brain stimulation play in brain [cognitive?] plasticity and the
potential for rehabilitation in individuals with cognitive decline?

10) What does research say about the advantages of bilingualism in cognitive aging?

a. What types of advantages have been documented, in regards to brain function and
cognitive skills?
b. Is it the fact of being bilingual that explains these advantages, or could they result from
other factors generally associated with bilingualism, such as education and socio-
economic status?
c. How does age of second language acquisition affect the bilingual advantage?
d. What is the impact of bilingualism on cognitive health in cases of dementia?
e. Would you recommend older people learn a new language?

11) If we have a sufficient basis for recommending cognitive activity to adults, what evidence
exists for how to motivate adults to engage and sustain these cognitive activities if they are
not already participating in these activities?

22 Engage Your Brain: GCBH Recommendations on Cognitively Stimulating Activities

4. DIFFERENCES, STRENGTHS AND LIMITATIONS
OF TWO STUDY TYPES IN HUMANS
EPIDEMIOLOGICAL
RANDOMIZED CONTROLLED TRIALS (RCTS)
(OBSERVATIONAL) STUDIES
PURPOSE To observe a group of people in To determine, in a controlled setting, whether implementing
their natural surroundings (often a change (in behavior, diet, medication, etc.) can definitively
over extended periods of time), and lead to a specific outcome. This compares those engaging
to identify personal characteristics, in an activity with those not engaging in the activity.
behaviors, and conditions which predict
someone’s chance of developing a
condition or a disease.

EXAMPLE Researchers who survey and follow Researchers at University Medical Center wish to recruit
women living in Metropolis show that 500 women in their 60s to determine whether having them
women who run weekly have fewer run weekly can reduce their chance of heart attack during
incidents of heart attack in their 60s. the one year study compared to those who don’t run.

STUDY Years to decades Weeks to months, sometimes years

DURATION

STRENGTHS • Usually larger number of people • Helps to prove causal link and to better understand mechanisms.
• Can take into account influences from many • Randomization can eliminate many competing hypotheses as why the
more factors and personal characteristics and change actually happened (because confounding factors have an equal
disease states probability of occurring in all groups).
• Can assess many dose levels and durations • Can test whether different dose of the intervention (e.g., exercise
of behavior. frequency, drug dose) can lead to different outcomes.
• Can detect slow or cumulative changes over time • Uses detailed and objective measurements and assessments.
• Where observational studies are representative
of the population, they have greater external
validity which means that the findings can be
applied to a wider range of people.

LIMITATIONS • Does not prove any specific causal link. • Usually smaller number of people.
• May not capture all characteristics which • While an RCT attempts to control for confounding factors, it may not
influence health. capture all characteristics which influence health.
• Any characteristic may reflect another more • The study may be too limited in size or duration to detect subtle effects.
important factor (e.g., people who take • Difficult to test conditions which scientists cannot change (e.g., gender,
expensive medications may have better access genetics, past exposure).
to health care).
• Difficult to generalize from one region to another due to differences in
• Selective drop-out of those less socially diet, environment, healthcare, etc.
advantaged and less healthy.
• In smaller RCTs, outcomes can be biased by accidental inclusion of people
• Difficult to generalize from one region to who are much more or much less likely to respond to the intervention.
another due to differences in diet, environment,
• Effects are restricted to defined dose and intervention type.
healthcare, etc.
• RCTs usually have very strict inclusion and exclusion criteria so the samples
• Often cannot collect detailed information due to
are often unrepresentative and results cannot be as widely generalized.
the large numbers of participants and measures.
• Attrition rate during the course of the RCT could bias the results.
• Expensive to set up and run, especially over
long periods. • Outcome reporting bias can influence results in which primary outcomes
are changed, introduced or omitted since the original protocol.
• Some studies rely on self-reported behavior
which may be inaccurate. • Short time frame limits capacity to examine long term interventions which is
particularly relevant for lifestyle changes that may lead to small, cumulative
• People who partake in a study to be followed for
effects over years and decades such as cognitively stimulating activity.
long periods of time might bias inclusion.

Engage Your Brain: GCBH Recommendations on Cognitively Stimulating Activities 23

5. DISCLOSURE STATEMENT OF POTENTIAL
FINANCIAL CONFLICTS OF INTEREST

All of the twenty-six GCBH experts participating in the formulation of this paper were asked
to disclose potential conflicts of interest. Twenty-three of the experts who participated in
the meeting and contributed to the formulation of the recommendations attested they had
no conflicts of interest. Three disclosed on-going relationships which have the potential to
raise perceived financial conflicts of interest involving consulting with for-profit companies.
Dr. Petersen declared part-time consultation with several pharmaceutical companies. Dr.
Sahakian declared consulting with a pharmaceutical company, as well as with a cognitive
assessment company, Cambridge Cognition, and a mobile brain training company, Peak. Dr.
Pascual-Leone declared participating on scientific advisory boards for several companies
developing transcranial stimulation methods, as well as a computer-based cognitive training
company, Constant Therapy. Dr. Pascual-Leone also holds numerous patents relating to
transcranial stimulation. These disclosures are available upon request by contacting staff of
the Global Council on Brain Health. The authors are unaware of any affiliation that affected
the objectivity of this paper and its recommendations.

6. FUNDING
AARP provided the funding and staffing for the convening of the consensus meeting,
conference calls and formulation of this consensus and recommendation paper. AARP
paid for the travel costs associated with attending the in-person meeting and provided
modest honoraria for the experts participating in the meeting March 19 – 21, 2017 and the
participation of the Governance Committee members in conference calls. Liaisons did not
receive reimbursement or honoraria.

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