GE NERATIONS Journal of the American Society on Aging

By Robert S. Wilson

Mental Stimulation and Brain Health:

Complex, Challenging Activities
Can Support Cognitive Health
in Older Adults
Observational and interventional studies are
investigating the effects of mental stimulation on
cognitive function, and the results are promising.

T here are wide individual differences in

late-life trajectories of change in cognitive
function. Cognition declines precipitously in
A discussion will follow about recent research on
interventions designed to enhance cognitive and
brain health in elders.
some individuals but gradually or not at all in
others. Longitudinal studies have linked more Mental Stimulation and Cognitive Function:
rapid cognitive decline in old age with increased Observational Studies
risk of disability, dementia, and death. With the
A basic challenge in research on cognitively
aging of the United States population, the scopestimulating activity is how best to define and
of the public health problem associated with assess it in people of varying socioeconomic,
late-life cognitive decline is projected to substan-
cultural, and ethnic backgrounds. The most
tially increase in the coming decades. As a result,
widely used approach has been to collect self-
there is an urgent need for strategies to delay the
reported data about frequency of participation in
development of cognitive impairment in old age. various activities judged to be mentally stimulat-
ing. These include activi-
ties such as reading,
How might mental stimulation enhance brain reserve? visiting a museum, or
Longitudinal neuroimaging studies provide some clues. playing card games. People
indicate whether or how
This article examines participation in often they participate in these types of activities,
mentally stimulating activity as a means of then results are combined to yield one or more
enhancing brain health in old age. The article summary indicators of overall level of participa-
will first review observational studies of the tion in mentally stimulating activities.
association between mentally stimulating In the past two decades, a number of longitu-
activity and cognitive health, and consider dinal studies have used self-report scales to
hypotheses about the basis of that association. measure frequency of mentally stimulating

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58 | Summer 2011 Vol. 35. No. 2
Pages 5862 Neuroscience of the Aging Brain: Perspectives on Brain Health and Lifestyle

activity at study baseline. With remarkably few addition, the level of mental activity participa-
exceptions, these studies have found better tion predicts loss of cognitive function after
cognitive outcomes in older people reporting controlling for education. The level of occupa-
higher baseline levels of mental activity com- tion, another indicator of socioeconomic status,
pared to lower levels in the form of slower has also been associated with the level of cog-
cognitive decline and reduced incidence of mild nition and risk of dementia in old age, but its
cognitive impairment and dementia (Wilson et relation to late-life cognitive decline has not
al., 2002; Verghese et al., 2006). been extensively studied. Some evidence links
mental stimulation in the workplace with better
Three hypotheses late-life cognition (Karp et al., 2009), but further
Despite the consistency of the association research in this area is needed. The association
between mentally stimulating activity and of mentally stimulating activity and preserved
late-life cognitive health, interpretation of the cognitive function in late life persists, after
association has been controversial. One view, controlling for late-life levels of social and
sometimes termed the reverse causality hypoth- physical activity and level of mentally stimulat-
esis, is that the level of mental
activity participation is an early
consequence of underlying Regional increases in brain volume have been
disease rather than a true risk observed in conjunction with training in juggling.
factor. Current support for this
hypothesis is limited, however. First, the level of ing activity prior to old age (Wilson et al., 2007).
mental activity predicts the risk of developing This suggests that the mentally stimulating
dementia after very long periods (e.g., two nature of the activity and its occurrence in old
decades in one study) (Crowe et al., 2003). age are critical to the association.
Second, higher-level mental activity predicts a A third explanation for the association
slower rate of cognitive decline among people between mentally stimulating activity and
without cognitive impairment, but not among late-life cognitive decline is that mental stimula-
those already exhibiting cognitive impairment tion somehow alters the function and structure
(Wilson et al., 2010). Finally, in clinical-patho- of neural systems that support memory and
logic research, the late-life level of mental cognition, allowing these systems to adapt to
activity participation does not appear to be age-related neurodegenerative changes. It has
associated with neuropathologic changes long been recognized that the correlation
thought to underlie late-life loss of cognition between the neuropathologic lesions tradition-
(Wilson et al., 2007) in contrast to other early ally associated with dementia and level of
signs of late-life neurodegeneration such as cognitive function proximate to death is far from
olfactory impairment (Wilson et al., 2011), gait perfect. For example, many older people who
disturbance (Schneider et al., 2006), and loss of die with no or mild cognitive impairment meet
body mass (Buchman et al., 2006). pathologic criteria for Alzheimers Disease
Another possibility is that the relationship (Bennett et al., 2006). Some of the lack of
between cognitive activity and cognitive function concordance between clinical and pathologic
reflects some other variable that is related to disease markers is undoubtedly due to measure-
each. Education is related to levels of cognitive ment error (e.g., unassessed pathology), but it
function and mental activity in old age, but it also suggests that individuals differ in their
does not appear to be related to the rate of ability to tolerate age-related neuropathologic
cognitive decline (Wilson et al., 2009). In lesions. This hypothetical ability to adapt to

American Society on Aging Summer 2011 Volume 35. Number 2 | 59

GE NER ATIO NS Journal of the American Society on Aging Pages 5862

neuropathologic damage is generally referred to Data on this foregoing point support the
as brain reserve. According to the brain reserve brain reserve hypothesis. In one population-
hypothesis, a high level of reserve allows an based study, older persons without dementia
individual to maintain relatively intact cognitive rated their level of cognitive activity. A mean of
function despite the accumulation of neuro- six years later, subjects had a dementia evalua-
pathologic changes. Thus, a mentally stimulat- tion and then were followed with cognitive
ing lifestyle might enhance brain reserve and function tests for an additional six years. In
thereby protect against the development of those without cognitive impairment at the
cognitive impairment. diagnostic evaluation, a prior history of being
mentally active was associated with less cogni-
How can mental stimulation enhance brain reserve? tive decline. By contrast, the opposite result was
Longitudinal neuroimaging studies provide obtained in the dementia group, with more rapid
some clues as to how mental stimulation might cognitive decline in those with a pre-morbid
enhance brain reserve. A study of medical history of mental activity (Wilson et al., 2010). In
students preparing for a critical series of qualify- line with brain reserve theory, these data suggest
ing examinations found increased volume in that a mentally stimulating lifestyle compresses
portions of the hippocampus and neocortex the cognitive morbidity of late-life dementia by
(Draganski et al., 2006). Regional increases in delaying its onset and by its association with
brain volume have also been observed in con- more rapid decline after dementia onset.
junction with training in juggling (Draganski et
al., 2004). These observations and an extensive Mental Stimulation and Cognitive Function:
body of animal research support the idea that Intervention Studies
the functional and structural characteristics of The observational research reviewed to this
the neural systems underlying cognition are point supports the idea that mentally stimulating
partially activity dependent. A mentally stimu- activity protects against the initial development
lating lifestyle may enhance brain reserve by of cognitive impairment in old age. These
contributing to the efficiency and adaptability of findings suggest that interventions that enhance
neural systems underlying cognition. mental stimulation may help maximize late-life
In cognitively healthy old people, the brain cognitive health.
reserve and reverse causality hypotheses each There is a long history of research on inter-
predict that higher mental activity will be ventions designed to improve cognitive skill (for
associated with less cognitive decline. An a detailed review, see Hertzog et al., 2009).
important corollary of the brain reserve hy- Overall, these studies have demonstrated that
pothesis, however, is that beyond some thresh- training can substantially improve cognitive
old of pathology, brain reserve is no longer skills in older people. The problem has been that
protective. It follows that when cognitive these training gains are mainly task-specific and
impairment initially becomes apparent, elders do not transfer to tasks that draw upon similar
who had a high level of brain reserve have more cognitive skills, but were not practiced.
neuropathology than persons who had low
levels of brain reserve. Therefore, brain reserve Recent approaches designed to improve
theory, unlike the reverse causality hypothesis, cognitive skill
predicts that a pre-morbid history of mental Two recent approaches appear to have overcome
stimulation should be associated with more this transference problem. A number of narrow
rapid cognitive decline at some point after interventions that target executive control
cognitive symptoms appear. processes have been shown to enhance a broad

60 | Summer 2011 Volume 35. Number 2 American Society on Aging

Pages 5862 Neuroscience of the Aging Brain: Perspectives on Brain Health and Lifestyle

spectrum of cognitive skills, with improvement such as the most efficient training methods,
occurring at the ability level rather than the task
optimal dose and timing of training, and the
level (Basak et al., 2008; Jaeggi et al., 2008). long-term effects of training on late-life cognitive
Moreover, these training gains are accompanied and brain health. Eventually, one may be able to
select from a range of cognitive training
programs and real-world experiences
Eventually, people may be able to select known to enhance cognitive function
from a range of cognitive training programs and brain reserve. Because such inter-
and real-world experiences known to enhance ventions are not thought to affect
underlying neurodegenerative processes
cognitive function and brain reserve. that strongly contribute to late-life
cognitive decline, the goal of mental
by neuroplastic changes in white matter in brain stimulation interventions is to delay the onset of
regions that support executive control processes decline and thereby maximize the portion of the
such as working memory, suggesting a training- lifespan spent in a cognitively healthy state.
induced increase in myelination (Lovden et al.,
2010; Takeuchi et al., 2010). Conclusion
A second approach has been to use broad As we await further advances in basic and
interventions that engage older persons along translational research on late-life cognitive
multiple dimensions, such as taking acting interventions, the present results suggest that a
classes (Noice and Noice, 2009) or working in an mentally stimulating and growth-oriented
urban elementary school (Fried et al., 2004), lifestyle is an important part of maintaining
complex activities that are likely to challenge cognitive health in old age. Current research
executive control skills. suggests that the activities should be complex
The new intervention studies are important. and challenging, and because they need to be
They support the idea that the link in observa- sustained over a period of time, these endeavors
tional research between mentally stimulating should be engaging and enjoyable.
activity and cognitive outcomes is causal. These
studies also suggest that complex attentional Robert S. Wilson, Ph.D., is the senior neuropsycholo-
skills are a key component of both narrow and gist of the Rush Alzheimers Disease Center and a
broad interventions. Importantly, these training professor in the Departments of Neurological
experiences are accompanied by neuroplastic Sciences and Psychology at Rush University Medical
changes in brain structure. Much remains to be Center in Chicago, Ill.
learned, however. These include basic issues

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