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Kua et al. 2019 - Can Computerized Cognitive Training Improve Cognition in Patients with Heart Failure - A Review

Journal of Cardiovascular Nursing
Vol. 34, No. 2, pp. E19–E27 x Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
Can Computerized Cognitive Training
Improve Cognition in Patients With
Heart Failure?
A Review
Zhong Jie Kua, MPsychClin; Michael Valenzuela, PhD; YanHong Dong, PhD
Background: Cognitive impairment is highly prevalent in patients with heart failure (HF), negatively impacting self-care
and consequently increasing mortality. Although computerized cognitive training (CCT) has been found to be
efficacious in improving cognition in older adults, little is known about the efficacy of CCT in patients with HF.
Purpose: This brief systematic review examined the feasibility and efficacy of CCT on cognitive functioning in patients
with HF. Methods: PubMed, Embase, and PsychINFO electronic databases were searched to identify randomized
controlled trials (RCTs) of CCT in patients with HF published from January 1, 2000, to December 31, 2017. A narrative
synthesis of intervention effectiveness on individual cognitive domains and functional outcomes was provided. Risk of
bias of the studies was also rated. Results: The search yielded 4 RCTs describing 3 cognitive training interventions
(n = 138). Preliminary evidence indicated that CCT may enhance the processing speed and working memory of patients
with HF. Intervention effects also seemed to confer transferrable benefits to functional outcomes of daily living.
The outcomes of the assembled studies were assessed using the Grades of Recommendation, Assessment,
Development and Evaluation system, and the quality of the evidence was found to be of moderate to low quality.
Conclusion: Computerized cognitive trainings show promise in enhancing the cognition of patients with HF. The
stability of the current findings would need to be tested in RCTs with larger sample sizes to validate the use of CCTs in
targeting cognitive impairment and self-care abilities for patients with HF.
KEY WORDS: heart
failure, cognition, cognitive training, computerized training
eart failure (HF) affects 1% to 2% of the adult population in developed countries.1 The incidence of
HF increases with age, with more than 80% of patients
being older than 65 years.2 Among these patients, HF is
Zhong Jie Kua, MPsychClin
Clinical Psychologist, Department of Psychology, Changi General
Hospital, Singapore.
Michael Valenzuela, PhD
Associate Professor, Brain & Mind Research Institute, Sydney Medical
School, The University of Sydney, Australia.
YanHong Dong, PhD
Research Assistant Professor, Alice Lee Centre for Nursing Studies and
Department of Medicine, Yong Loo Lin School of Medicine, National
University of Singapore, Singapore, and Centre for Healthy Brain Ageing
(CHeBA), School of Psychiatry, UNSW Medicine, The University of New
South Wales, Australia.
The authors have no conflicts of interest to disclose.
Y. Dong was a recipient of the National Medical Research Council
Transition Award during this review.
YanHong Dong, Alice Lee Centre for Nursing Studies, Yong Loo Lin
School of Medicine, National University of Singapore, Level 2, Clinical
Research Centre, Block MD11, 10 Medical Drive, Singapore 117597
(nurdy@nus.edu.sg; mdcdy@nus.edu.sg).
DOI: 10.1097/JCN.0000000000000558
a leading cause of hospitalization, early readmissions,
and mortality.3,4
Cognitive impairment is highly prevalent among the
HF population, where the risk of cognitive impairment
is twice as high among patients with HF than in agematched adults without HF.5,6 The cognitive domains
adversely affected in HF include working memory, learning memory and delay recall, attention, processing speed,
and executive function.7 Cognitive impairment has been
found to interfere with self-care abilities pivotal to HF
management.8,9 Cognitively impaired patients with
HF were less likely to seek help to cope with changes
in HF symptoms and adhere to medication regimen,10,11
leading to poor clinical outcomes. Cognitive impairment
has been reported to predict mortality, above and beyond HF alone.12
Despite its complications in the treatment of HF,
guidance on the management of cognitive impairment
remains sparse. A recent systematic review that investigated change in cognitive outcomes in HF yielded
studies of standard surgical and pharmacological HF
therapy, including heart transplantation, left ventricular
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
E20 The Journal of Cardiovascular Nursing x March/April 2019
assist device implantation, and medications.13 Several
of these interventions were hypothesized to be effective
based on postulated mechanisms responsible for the
pathogenesis of HF and cognitive decline: (1) via the
mediation of cerebral hypoperfusion and impaired
autoregulation of cerebral perfusion pressures, (2) cerebral emboli, leading to cardiac insufficiency, and
(3) shared myocardial and cerebral pathology with
Alzheimer's disease.6,14,15 Although improvements in
cognition were reported, none of the standard HF therapies found significant correlations between cardiac and
cognitive parameters, suggesting that cognition may not
be directly targeted via these interventions and the posited mechanistic links between HF and cognitive impairment remain unclear.
Recently, research on a nonpharmacological
intervention—computerized cognitive training (CCT)—
has generated a strong evidence base to support its effectiveness in enhancing cognition or ameliorating the risk
of cognitive decline. Computerized cognitive training involves guided repetitive practice of standardized tasks
designed to target specific cognitive skills or processes,
with the aim of improving cognition via reinforcement
of neural pathways. Accessibility to cognitive training
is enhanced with the use of technology, particularly
for older adults whose mobility may be limited because
of their HF conditions. The computerized features also
enable a more individualized approach, as opposed to
their traditional counterparts, where activities may be
tailored to the users' ability levels, thereby improving
user engagement. The efficacy of CCT has been rigorously reviewed in a recent meta-analysis, which reported cognitive benefits in both cognitively healthy
older adults and patients with mild cognitive impairment.16,17 Although CCT has been found to be viable in
enhancing the cognitive function in other populations,
its effectiveness in HF remains unclear. This review thus
seeks to examine the feasibility and efficacy of CCT on
the cognition of patients with HF.
This review is reported in accordance with the Preferred
Reporting Items for Systematic Reviews and MetaAnalyses statement.18
Eligibility Criteria
Types of Studies
Randomized controlled trials (RCTs) published in the
English language from January 1, 2000, to December
31, 2017, were included.
Types of Participants
Studies included adults (18 years old) with a current
clinical diagnosis of HF with preserved ejection fraction
or HF with reduced ejection fraction. Participants with
any major neurological and/or psychiatric conditions
were excluded.
Types of intervention
Eligible studies compared the effects of 4 hours or more
of practice on standardized CCT tasks against an active
or passive control condition.
Types of Outcome Measures
Primary outcome measures included (1) feasibility of
intervention, measured through adherence rates and
patient satisfaction, and (2) cognitive function (memory,
working memory, attention, processing speed, and executive function), measured using standardized tests.
The secondary outcome measure was adaptive functioning, including instrumental activities of daily living.
Information Sources and Search Strategy
Searches were conducted in PubMed, Embase, and
PsycINFO using the search terms “heart failure or congestive heart failure,” “cognition or neuropsychological tests,” and “cognitive training or brain training or
memory training or computerized training” to identify
relevant studies. The reference lists of retrieved articles
were reviewed to identify studies that were overlooked
in the electronic search.
Study Selection
Eligibility assessment was performed independently in a
standardized manner via screening of titles and abstracts
by 2 authors (Z.K. and Y.D.). Disagreements in retrieved
full-text records were resolved by consensus.
Risk of Bias in Individual Studies
After the final selection of studies, risk of bias of individual studies was assessed using items recommended
in the Cochrane Collaboration's risk of bias tool.19 The
following aspects were assessed in the included studies
to account for any heterogeneity of results: sequence
generation, allocation concealment, blinding of outcome
assessors, extent of loss to follow-up, and selective outcome. Trials that failed to include assessor blinding or
were not compliant to intention-to-treat analyses were
considered high or unclear risk of bias.
Quality of Evidence
The Grades of Recommendation, Assessment, Development and Evaluation system20 was used to assess the
overall quality of evidence for the primary outcome of
cognitive functioning and secondary outcome of adaptive functioning.
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
Computerized Cognitive Training in Patients With HF E21
The initial search provided a total of 443 records. After
adjusting for duplicates and reviewing of titles and
abstracts, the authors discarded 434 studies. The full
text of the remaining 9 citations was examined and
5 articles were excluded because (1) no intervention was
documented or the intervention was not a form of cognitive training or (2) no cognitive outcomes were measured
(see Figure 1). A total of 4 articles were retained for the
final review.21–24
regardless of LVEF.24 Another study assessed the presence of HF through self-report.22
Two studies included an active control group where
controls were asked to read cardiovascular health
magazines.23,24 One study had a wait-listed control
group that received standard HF care during the study
and were offered the cognitive intervention when the
study period ended.21 Another study had a no-contact
control group.22 Two of the included studies were pilot
Intervention Features
Characteristics of Included Studies
The included studies encompassed 138 participants
(intervention group, n = 66; control group, n = 72)
(Table 1). Mean age ranged between 55.6 and 75.1 years.
Heart failure inclusion criteria consisted of (1) New York
Heart Association classification I to IV21,23,24 and (2) left
ventricular ejection fraction (LVEF) lower than 40%.21,23
One study included patients with documented HF
Three cognitive interventions were described in the
4 included RCTs (Table 1).
Athilingam et al (2015) assessed the feasibility and
efficacy of auditory cognitive training (ACT) on auditory
processing speed and working memory. The ACT program used in the study was the Brain Fitness Program
software developed by Posit Science Corporation.21 The
use of ACT was supported by the information degradation
FIGURE 1. Study flow diagram for cognitive interventions in HF.
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
66.8 (5.7) NYHA: II–IV
55.6 (13.7)
T = 13
C = 14
Pressler et al
Cognitive Training Outcomes
● 16-wk auditory cognitive training
● Moderate to large effect sizes for
● Advised to use program 30–60 min/d
improved auditory speed of processing
for 5 d/wk with goal of completing 40 h
(d = 0.78), speech processing (d = 0.88),
● Computerized auditory exercises aimed
and working memory (d = 0.50) compared
at enhancing speed and accuracy of
with wait-listed controls
auditory processing
● Everyday speed of processing composite— ● 6-wk speed of processing training
● Training group improved significantly in
average of
● Ten small group sessions lasting 60–75 min everyday speed of processing from pre to
(1) Timed Instrumental Activities of Daily
● Process-based practice of visual exercises
post training compared with no-contact
aimed at differentiating complex
control group
(2) Complex Reaction Time
information in short periods
(3) Useful Field of View
● The Hopkins Verbal Learning Test
● 8-wk Brain Fitness
● Training group improved significantly on
● The Digit Symbol Subtest
● Forty 1-h sessions
delayed recall over time as compared
● The Controlled Oral Word Association Test ● Computerized training program designed with active control group
● The Florida Cognitive Activities Scale
to enhance sensory integration of
● Both groups demonstrated improvement
● CogState Health battery
over time in memory, working memory,
● The Everyday Problems Test for Cognitive
psychomotor speed, executive function;
Challenged Elderly
no significant differences between
● Patient Satisfaction Questionnaire
training and control group
● The Hopkins Verbal Learning Test
● Brain Fitness program as above
● Training group had significant improvements
● The Digit Symbol Subtest
in working memory and less decline in
● The Controlled Oral Word Association Test
processing speed compared with active
● CogState Health battery
control group
● The Everyday Problems Test for Cognitive
Challenged Elderly
● Time Compressed Speech test
● Speech Perception in Noise Test
● Auditory N-Back Task
Abbreviations: NYHA, New York Heart Association; LVEF, left ventricular ejection fraction; C, control group; T, training group; HF, heart failure.
54.7 (13.9) NYHA: I–III
LVEF: <40%
61.1 (11.5)
T = 21
C = 19
Pressler et al
HF was selfreported
75.4 (6.4)
75.1 (6.3)
T = 23
C = 31
Ellis et al
60.6 (8.1) NYHA: II – IV
LVEF: <40%
56.9 (13.1)
Age, Mean
(SD), y
Characteristics of the Reviewed Studies
Athilingam et al T = 9
E22 The Journal of Cardiovascular Nursing x March/April 2019
Computerized Cognitive Training in Patients With HF E23
theory, which postulates that processing errors in basic
perceptual systems led to higher-order cognitive difficulties.25 Thus, ACT aimed to improve the cognitive efficiency of the auditory processing system to enhance
higher-order cognitive function. Consisting of 6 listening
exercises, the ACT required participants to identify, discriminate, and remember speech tones, words, and instructions. These exercises are continually adapted in
speed and task complexity to participants' ongoing performance. Participants were instructed to use the program
daily for 30 to 60 minutes, with the goal of completing up
to 40 hours of ACT in 16 weeks. Computers were loaned
to participants who do not have a home computer or
Internet access.
Pressler et al (2011) also tested the Brain Fitness
Program on the memory, working memory, processing speed, and executive function of patients with HF.
Guided by the theories of neuroplasticity, this CCT
sought to enhance sensory integration of auditory
and visual information to strengthen neural networks
necessary for memory encoding and recall.23 The
program incorporated novel visual and auditory exercises to engage the user's learning and recall of information. Participants were asked to practice 40 hourly
sessions of the program over 8 weeks. Computers were
placed in the homes of all participants throughout the
intervention. A unique feature of this CCT was the inclusion of a nurse-enhanced component. Advanced
practice nurses visited and demonstrated use of the
program to participants weekly at their homes to assess HF-related symptoms and intervention adherence.
The same intervention and experimental design was examined again in Pressler et al (2015), but the nurses
made only weekly contact with participants through
telephone calls.
Ellis et al (2014) examined the effects of the speed of
processing training on HF participants who were part
of a longitudinal multisite RCT known as the Advanced
Cognitive Training for Independent and Vital Elderly.26
This training targeted the improvement of processing
speed in visual attention tasks. Computerized visual targets were presented via systematic reductions in display
speeds. Task complexity was modified by changing stimulus detection, identification, or by adjusting the locations of peripheral targets. The training was delivered in
ten 60–75-minute sessions by certified trainers in a group
setting over 6 weeks.
Risk of Bias in Included Studies
Two studies were rated as having a low risk of bias across
all criteria23,24 (Table 2). One study used cognitive measures that were novel to the study of CCT.21 Although
these outcome measures lacked validity, the context of
his RCT being a pilot study, in addition to the clear reporting of selection bias, performance bias and detection
bias warrant the study to be classified as low risk of bias.
Another study was considered high risk of bias owing
to reporting bias and failure to comply with the intentionto-treat analysis.22
Effects of Intervention
Feasibility Outcomes
Feasibility was measured in the pilot studies by the percentage of participants who completed the intervention
and the number of training hours completed.21,23 Of
the total participants assigned to the nurse-enhanced
Brain Fitness intervention group, 85% completed the
training. Seventy-seven percent were considered adherent to the intervention for meeting at least 90% of the
required training hours. Intervention adherence was also
met in the ACT study, with 78% of participants (completion criterion of 75%) completing at least 90% of the
training hours.21 Although other studies did not measure
feasibility, the reported completion rates were high (>80%).
Common reasons cited for withdrawal included being
ill or busy.
Cognitive Outcomes
Because of the variability of intervention features, the following results are presented as a narrative synthesis of
significant intervention effects across cognitive domains.
Processing Speed
The most commonly measured cognitive domain was
processing speed. Improvements in auditory processing
speed were observed for participants who completed
the ACT intervention at 16 weeks compared with waitlisted controls who demonstrated worsening performance
over time.21 Large effect sizes were observed for this
improvement (d = 0.78). Ellis et al (2014) found significant improvements in everyday speed of processing
compared with the no-contact control group post training. Pressler et al (2015) reported that after controlling
for age and LVEF, participants in the Brain Fitness group
showed significantly less decline in their processing speed
post intervention than active controls did. The above
evidence suggests that processing speed may be enhanced
by CCT.
Memory was assessed as a primary outcome in the nurseenhanced CCT studies. Pressler et al (2011) found a statistically significant improvement in delayed recall memory
compared with age-matched controls immediately post
intervention and at follow-up at 4 weeks. Pressler et al
(2015), however, did not report similar intervention effects
on delayed memory. Inability to replicate findings was
attributed to (1) the study's small sample size and (2) participants' higher baseline memory performance, that is,
the Hopkins Verbal Learning Test-Revised scores,
relative to the first study.24 The effects of cognitive
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
E24 The Journal of Cardiovascular Nursing x March/April 2019
Risk of Bias for Measurement of Cognitive Outcomes in Studies of CCT on Patients With HF
training on memory function in patients with HF remain
unclear given the limited evidence.
Working Memory
Working memory was assessed in 3 studies. A moderate effect size was found for improvements in working
memory for participants in the ACT intervention
(d = 0.44) compared with the control group, who had
worsening scores over time.21 Pressler et al (2015) also
found significant intervention effects in the improvement
of working memory from baseline to 12 weeks post intervention for participants in the CCT group compared
with active controls, whose scores declined over time.
Even though a group-by-time interaction was not observed by Pressler et al (2011), a trend toward improvement in working memory was reported for the
intervention and control groups over time. This suggests that cognitive training programs may benefit
working memory in patients with HF; however, further
studies are required.
Executive Function
Executive function was assessed in the nurse-enhanced
CCT studies, but no significant intervention effects were
Attention was not assessed in any of the studies.
Quality of Evidence
A judgement was made to include all trials in the analysis
as most of the evidence for the primary outcome of cognitive function came from RCTs with few limitations.
Given considerable clinical heterogeneity in terms of
CCT features and cognitive outcome measures, the evidence was rated down from high to moderate quality
for inconsistency (Table 3). In addition, the total sample
size of the review was less than the optimal information
size (based on the control event rate of 0.2 and relative
risk reduction of 25%). The evidence was therefore further downgraded by another level based on imprecision.
Adaptive Functional Outcomes
Instrumental Activities of Daily Living (IADLs): HF
functional outcomes were measured in 3 of the studies.
Athilingam et al (2015) found that participants who
underwent ACT training had lesser decline in their HF
self-care scores (d = 0.34) compared with wait-listed
controls. Moreover, the ACT group tended to be more
accurate and faster in their performance of Timed Instrumental Activities of Daily Living post intervention,
whereas controls showed worsening speed and accuracy
over time.21 Although no significant intervention effects
on IADLs were reported in either of the nurse-enhanced
CCTs, there was a trend for improved performance
from baseline to 12 weeks post training in tasks of medications and telephone use for both training and active
control groups.23,24 Overall, CCT seemed to enhance
the adaptive functions of patients with HF.
The quality of evidence for adaptive functional
outcomes was mainly downgraded for imprecision
because of the small sample size of the current review,
which limited the ability to detect a precise estimate of
Despite growing interest in cognitive impairment and its
impacts on self-care in HF, intervention research that targets and manages these cognitive problems is limited. In
this review, we have reported preliminary evidence for
the feasibility and efficacy of cognitive training on patients with HF. Four studies describing 3 CCTs—the
ACT, the nurse-enhanced CCT, and the speed of processing training—were reviewed. Improvements in processing speed and working memory were found for
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
Computerized Cognitive Training in Patients With HF E25
Quality Assessment for Primary Cognitive Outcomes and Secondary Adaptive
Functional Outcomes
Quality Assessment
No. of patients
Primary outcome: cognitive functioning
138 (4)
No serious
Secondary outcome: adaptive functioning
84 (3)
No serious
Serious inconsistencya
No serious
No serious
No serious
Abbreviation: RCT, randomized controlled trial.
Clinical heterogeneity in terms of intervention features, measures used, and outcomes.
Sample size insufficient to detect precise estimate of effect.
participants with HF who had undergone the CCTs as
compared with controls. No effects on executive function were found. Computerized cognitive trainings also
improved adaptive functioning, including IADLs. Overall, adherence to interventions was high and participants
were highly satisfied with the interventions, indicating
the willingness of older patients with HF to receive cognitive training. This brief review is the first, to our knowledge, that synthesizes evidence showing that cognitive
domains typically adversely affected in HF may be
amenable to change via these targeted cognitive
The findings of improvements in processing speed
and working memory are encouraging, given that these
2 cognitive domains were commonly identified to be
adversely affected in patients with HF.6 Previous metaanalyses on CCTs in other populations have also found
these domains to be highly responsive to training, demonstrating moderate to large effect sizes.16,17,27 Whereas
improvements in these lower-order cognitive processes
have been found, there seemed to be a lack of intervention effects on higher-order cognition, including delayed
memory and executive functioning. As these domains
were assessed in only 2 studies with small sample sizes,
it is premature to draw conclusions about the efficacy
of CCT on the memory and executive functions of patients with HF. However, the lack of translational benefits from lower-order to higher-order cognitive function
raises doubts about the hypothesized mechanisms of
the information degradation and neuroplasticity theories that underlie the Brain Fitness programs. Only 1 of
the reviewed studies sought to examine the pathways
through which CCT may improve cognition. An exploratory analysis conducted by Pressler et al (2015) found
that their 8-wk CCT was significantly associated with
increased levels of a brain-derived neurotropic factor involved in long-term memory formation and neuronal
growth.24 This provides preliminary mechanistic insight
to the effects of CCT and supports future studies in
using biomarkers and neuroimaging to ascertain the
mechanisms through which cognitive interventions
may benefit cognition in HF.
The lack of intervention effects in memory and executive function could be explained by the training content
of the CCTs. Gains in cognitive training have been found
to be reflective of training domains.28 The reviewed
CCTs consisted primarily of processing speed and working memory tasks instead of delayed recall, attention,
and executive processes, thereby possibly accounting
for a paucity of benefits in these domains. Future studies
could thus consider developing CCTs that directly target
higher-order processes given their impacts on ability to
manage HF self-care. Aside from training modalities,
intervention designs have shown to influence cognitive
outcomes.17 Delivering CCT in a group-based setting was
superior to home-based training owing to direct supervision to ensure treatment adherence, support technological issues, and motivate patients through increased
social interaction.17 This could have contributed to the
success of group-based speed of processing training.22
While the Brain Fitness interventions were administered
within the homes of participants, they were visited or
contacted weekly by nurses, who offer training support
and motivation, thereby potentially contributing to higher
treatment adherence and effects.23,24 Interventions involving advanced practice nurses have shown consistent
efficacy in improving functional outcomes such as
HF-related hospitalizations and quality of life.29,30 The
unique contribution of supervision for home-based CCT
can be considered for future studies.
The current review has also demonstrated preliminary benefits of CCTs on daily functional outcomes in
patients with HF. However, improvement in self-care
abilities remains unclear. In research of cognitive training, transfer effects have been observed in the training of
executive control processes, where improvements were
extended beyond a specific task to structurally similar
new task settings.31–34 Transfer of training effects was
also observed across different modalities, from cognition
to improved physical benefits, including improved balance
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
E26 The Journal of Cardiovascular Nursing x March/April 2019
What's New and Important
Cognitive domains adversely affected in HF may be
amenable to change by
nonpharmacological interventions.
Preliminary evidence was found for the efficacy of CCT
on improving the processing speed and working
memory in patients with HF. Computerized cognitive
training also appeared to improve the adaptive
functioning of patients with HF.
Quality of the evidence was rated to be of moderate to
low quality and hence should be treated with caution.
The stability of current findings would need to be
evaluated in future RCTs involving larger sample sizes.
and postural control in healthy older adults.33,35 Such findings are encouraging when considered in the context of
self-care in HF. Future studies could thus explore the efficacy of targeted cognitive training on the uptake of selfcare skills.
Overall, the quality of evidence was assessed to be low for
cognitive outcomes and moderate for adaptive functional
outcomes. This is primarily because of the inconsistency
and imprecision of results across the small number of reviewed studies. With only 4 studies included, there may
be large potential impact if the average effect of a study
differs in size or direction. The generalizability of the current findings was also limited because of the small sample sizes. Future RCTs involving larger sample sizes are
required to ascertain the stability of intervention effects
on the cognition of patients with HF. One of the studies
relied only on self-report instead of clinical measures to
determine the presence of HF. Hence, participants were
not stratified by HF severity when allocated to treatment
conditions and it is unclear whether HF status might
have an impact on treatment effects. Furthermore, a recent meta-analysis has found that the cognitive function
in patients with HF declined significantly within 1 year.13
Hence, it is questionable as to whether the effects of shortterm interventions may be retained over a longer duration. Caution should therefore be taken when interpreting
these results; they are considered indicative rather than
This review highlights potentially promising results when
using cognitive training programs to improve the cognitive functions of patients with HF. Further RCTs with
larger sample sizes are required to confirm intervention
effects. Nonetheless, this finding is encouraging considering the association between cognitive impairment and
suboptimal self-care among patients with HF. It will be
important to examine whether any putative cognitive
benefits translate into improved self-care management.
1. Ponikowski P, Anker SD, AlHabib KF, et al. Heart failure:
preventing disease and death worldwide. ESC Heart Fail.
2. Bui AL, Horwich TB, Fonarow GC. Epidemiology and risk
profile of heart failure. Nat Rev Cardiol. 2011;8(1):30–41.
3. Roger VL, Go AS, Lloyd-Jones DM, et al. Heart disease and
stroke statistics—2011 update: a report from the American
Heart Association. Circulation. 2011;123(4):e18–e209.
4. Ross JS, Chen J, Lin Z, et al. Recent national trends in readmission rates after heart failure hospitalization. Circ Heart
Fail. 2010;3(1):97–103.
5. Gure TR, Blaum CS, Giordani B, et al. Prevalence of cognitive
impairment in older adults with heart failure. J Am Geriatr
Soc. 2012;60(9):1724–1729.
6. Leto L, Feola M. Cognitive impairment in heart failure patients.
J Geriatr Cardiol. 2014;11(4):316–328.
7. Vogels RL, Scheltens P, Schroeder-Tanka JM, Weinstein HC.
Cognitive impairment in heart failure: a systematic review of
the literature. Eur J Heart Fail. 2007;9(5):440–449.
8. Dickson VV, Tkacs N, Riegel B. Cognitive influences on selfcare decision making in persons with heart failure. Am Heart
J. 2007;154(3):424–431.
9. Ponikowski P, Voors AA, Anker SD, et al. 2016 ESC guidelines for the diagnosis and treatment of acute and chronic
heart failure: the Task Force for the Diagnosis and Treatment
of Acute and Chronic Heart Failure of the European Society of
Cardiology (ESC)Developed with the special contribution of
the Heart Failure Association (HFA) of the ESC. Eur Heart J.
10. Currie K, Rideout A, Lindsay G, Harkness K. The association
between mild cognitive impairment and self-care in adults with
chronic heart failure: a systematic review and narrative synthesis.
J Cardiovasc Nurs. 2015;30(5):382–393.
11. Harkness K, Heckman GA, Akhtar-Danesh N, Demers C,
Gunn E, McKelvie RS. Cognitive function and self-care management in older patients with heart failure. Eur J Cardiovasc
Nurs. 2014;13(3):277–284.
12. Zuccalà G, Pedone C, Cesari M, et al. The effects of cognitive
impairment on mortality among hospitalized patients with
heart failure. Am J Med. 2003;115(2):97–103.
13. Hajduk AM, Kiefe CI, Person SD, Gore JG, Saczynski JS.
Cognitive change in heart failure: a systematic review. Circ
Cardiovasc Qual Outcomes. 2013;6(4):451–460.
14. Alagiakrishnan K, Mah D, Ahmed A, Ezekowitz J. Cognitive
decline in heart failure. Heart Fail Rev. 2016;21(6):661–673.
15. Cannon JA, McMurray JJ, Quinn TJ. 'Hearts and minds': association, causation and implication of cognitive impairment
in heart failure. Alzheimers Res Ther. 2015;7(1):22.
16. Hill NT, Mowszowski L, Naismith SL, Chadwick VL, Valenzuela M,
Lampit A. Computerized cognitive training in older adults with
mild cognitive impairment or dementia: a systematic review
and meta-analysis. Am J Psychiatry. 2017;174(4):329–340.
17. Lampit A, Hallock H, Valenzuela M. Computerized cognitive
training in cognitively healthy older adults: a systematic review
and meta-analysis of effect modifiers. PLoS Med. 2014;11(11):
18. Moher D, Shamseer L, Clarke M, et al. Preferred Reporting
Items for Systematic Review and Meta-analysis Protocols
(PRISMA-P) 2015 statement. Syst Rev. 2015;4(1):1.
19. Higgins JP, Altman DG, Gotzsche PC, et al. The Cochrane
Collaboration's tool for assessing risk of bias in randomised
trials. BMJ. 2011;d5928:343.
20. Guyatt GH, Oxman AD, Kunz R, Vist GE, Falck-Ytter Y,
Schünemann HJ. Rating quality of evidence and strength of
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
Computerized Cognitive Training in Patients With HF E27
recommendations: what is “quality of evidence” and why is
it important to clinicians? BMJ. 2008;336(7651):995–998.
Athilingam P, Edwards JD, Valdes EG, Ji M, Guglin M.
Computerized auditory cognitive training to improve cognition and functional outcomes in patients with heart failure:
results of a pilot study. Heart Lung. 2015;44(2):120–128.
Ellis ML, Edwards JD, Peterson L, Roker R, Athilingam P.
Effects of cognitive speed of processing training among older
adults with heart failure. J Aging Health. 2014;26(4):600–615.
Pressler SJ, Therrien B, Riley PL, et al. Nurse-enhanced memory intervention in heart failure: the MEMOIR study. J Card
Fail. 2011;17(10):832–843.
Pressler SJ, Titler M, Koelling TM, et al. Nurse-enhanced
computerized cognitive training increases serum brain-derived
neurotropic factor levels and improves working memory in
heart failure. J Card Fail. 2015;21(8):630–641.
Schneider BA, Pichora-Fuller MK. Implications of perceptual
deterioration for cognitive aging research. In: Craik FIM, Salthouse
TA, eds. The Handbook of Aging and Cognition. 2nd ed.
Mahwah, NJ, US: Lawrence Erlbaum Associates Publishers; 2000:155–219.
Jobe JB, Smith DM, Ball K, et al. ACTIVE: a cognitive intervention trial to promote independence in older adults. Control
Clin Trials. 2001;22(4):453–479.
Leung IH, Walton CC, Hallock H, Lewis SJ, Valenzuela M,
Lampit A. Cognitive training in Parkinson disease: a systematic
review and meta-analysis. Neurology. 2015;85(21):1843–1851.
Ball K, Berch DB, Helmers KF, et al. Effects of cognitive
training interventions with older adults: a randomized controlled trial. JAMA. 2002;288(18):2271–2281.
Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley
KM, Schwartz JS. Transitional care of older adults hospitalized
with heart failure: a randomized, controlled trial. J Am Geriatr
Soc. 2004;52(5):675–684.
Sochalski J, Jaarsma T, Krumholz HM, et al. What works in
chronic care management: the case of heart failure. Health
Aff. 2009;28(1):179–189.
Bherer L, Kramer AF, Peterson MS, Colcombe S, Erickson K,
Becic E. Transfer effects in task-set cost and dual-task cost
after dual-task training in older and younger adults: further
evidence for cognitive plasticity in attentional control in late
adulthood. Exp Aging Res. 2008;34(3):188–219.
Karbach J, Kray J. How useful is executive control training?
Age differences in near and far transfer of task-switching training. Dev Sci. 2009;12(6):978–990.
Li KZ, Roudaia E, Lussier M, Bherer L, Leroux A, McKinley
PA. Benefits of cognitive dual-task training on balance performance in healthy older adults. J Gerontol A Biol Sci Med Sci.
Bherer L. Cognitive plasticity in older adults: effects of cognitive training and physical exercise. Ann N Y Acad Sci. 2015;
Li H, Li J, Li N, Li B, Wang P, Zhou T. Cognitive intervention
for persons with mild cognitive impairment: a meta-analysis.
Ageing Res Rev. 2011;10(2):285–296.
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