Dec 17, 2009
By: Alvaro Fernandez
Dr. Michael Merzenich, Emeritus Professor at UCSF, is a leading pioneer in brain plasticity research. In the late 1980s, Dr. Merzenich was on the team that invented the cochlear implant. In 1996, he was the founding CEO of Scientific Learning Corporation (Nasdaq: SCIL), and in 2004 became co-founder and Chief Scientific Officer of Posit Science. He was elected to the National Academy of Sciences in 1999 and to the Institute of Medicine this year. He retired as Francis A. Sooy Professor and Co-Director of the Keck Center for Integrative Neuroscience at the University of California at San Francisco in 2007. You may have learned about his work in one of PBS TV specials, multiple media appearances, or neuroplasticity-related books.
(Alvaro Fernandez) Dear Michael, thank you very much for agreeing to participate in the inaugural SharpBrains Virtual Summit in January, and for your time today. In order to contextualize the Summit’s main themes, I would like to focus this interview on the likely big-picture implications during the next 5 years of your work and that of other neuroplasticity research and industry pioneers.
Thank you for inviting me. I believe the SharpBrains Summit will be very useful and stimulating, you are gathering an impressive group together. I am looking forward to January.
Neuroplasticity-based Tools: The New Health & Wellness Frontier
There are many different technology-free approaches to harnessing/ enabling/ driving neuroplasticity. What is the value that technology brings to the cognitive health table?
It’s all about efficiency, scalability, personalization, and assured effectiveness. Technology supports the implementation of near-optimally-efficient brain-training strategies. Through the Internet, it enables the low-cost distribution of these new tools, anywhere out in the world. Technology also enables the personalization of brain health training, by providing simple ways to measure and address individual needs in each person’s brain-health training experience. It enables assessments of your abilities that can affirm that your own brain health issues have been effectively addressed.
Of course substantial gains could also be achieved by organizing your everyday activities that grow your neurological abilities and sustain your brain health. Still, if the ordinary citizen is to have any real chance of maintaining their brain fitness, they’re going to have to spend considerable time at the brain gym!
One especially important contribution of technology is the scalability that it provides for delivering brain fitness help out into the world. Think about how efficient the drug delivery system is today. Doctors prescribe drugs, insurance covers them, and there is a drug store in every neighborhood in almost every city in the world so that every patient has access to them. Once neuroplasticity-based tools and outcomes and standardized, we can envision a similar scenario. And we don’t need all those drug stores, because we have the Internet!
Having said this, there are obvious obstacles. One main one, in my mind, is the lack of understanding of what these new tools can do. Cognitive training programs, for example, seem counter-intuitive to consumers and many professionals “ why would one try to improve speed-of-processing if all one cares about is memory? A second obvious problem is to get individuals to buy into the effort required to really change their brains for the better. That buy-in has been achieved for many individuals as it applies to their physical health, but we haven’t gotten that far yet in educating the average older person that brain fitness training is an equally effortful business!
Tools for Safer Driving: Teens and Adults
Safe driving seems to be one area where the benefits are more intuitive, which may explain the significant traction.
Yes, we see great potential and interest among insurers for improving driving safety, both for seniors and teens. Appropriate cognitive training can lower at-fault accident rates. You can measure clear benefits in relatively short time frames, so it won’t take long for insurers to see an economic rationale to not only offer programs at low cost or for free but to incentivize drivers to complete them. Allstate, AAA, State Farm and other insurers are beginning to realize this potential. It is important to note that typical accidents among teens and seniors are different, so that training methodologies will need to be different for different high-risk populations.
Yet, most driving safety initiatives today still focus on educating drivers, rather that training them neurologically. We measure vision, for example, but completely ignore attentional control abilities, or a driver’s useful field of view. I expect this to change significantly over the next few years.
Long-term care and health insurance companies will ultimately see similar benefits, and we believe that they will follow a similar course of action to reduce general medical and neurodegenerative disease- (Mild Cognitive Impairment and Alzheimer’s- and Parkinsons-) related costs. In fact, many senior living communities are among the pioneers in this field.
Boomers & Beyond: Maintaining Cognitive Vitality
Mainstream media is covering this emerging category with thousands of stories. But most coverage seems still focused on does it work? more than “how do we define It”, what does work mean? or work for whom, and for what? Can you summarize what recent research suggests?
We have seen clear patterns in the application of our training programs, some published (like IMPACT), some unpublished, some with healthy adults, and some with people with mild cognitive impairment or early Alzheimers Disease (AD). What we see in every case: 1) despite ones age, brain functioning can be improved, often with pretty impressive improvement in a short-time frame and limited time invested (10 or 20 or 30 or 40 hours over a period of a few weeks up to 2 or 3 months). 2) Basic neurological abilities in 60-90 year olds that are directly subject to training (for example, processing accuracy or processing speed) can be improved to the performance level of the average 20 or 30 or 40 year old through 3-10 hours of training at that specific ability. 3) Improvements generalize to broader cognitive measures, and to indices of quality of life. 4) Improvements are sustained over time (in different controlled studies, documented at all post-training benchmarks set between 3 to 72 months after training completion).
In normal older individuals, training effects endure “ but that does not mean that they could not benefit from booster or refresher training — or from ongoing training designed to improve other skills and abilities that limit their older lives. Importantly, a limited controlled study in mildly cognitively impaired individuals showed that in contrast to normal individuals, their abilities declined in the post-training epoch. These folks had improved substantially with training. Even while there abilities slowly deteriorated after training, they sustained their advantages over patients who were not trained. We believe that in these higher-risk individual, continued training will probably be absolutely necessary to sustain their brain health, and, if it can be achieved (and that is completely unproven), to protect them from a progression to AD. Moreover, for both these higher-risk and normal individuals, interventions should not be thought of as one-time cure-alls. Ongoing brain fitness training shall be the way to go.
A major obstacle is that there is not enough research funding for appropriate trials to address all of these issues, especially as they apply for the mildly cognitively impaired (pre-AD) or the AD populations. We’d welcome not only more research dollars but also more FDA involvement, to help clarify the claims being made.
Next Generation Assessments
A key element for the maturity of the field will be the widespread use of objective assessments. What do you see in that area?
Unfortunately, most researchers and policy initiatives are still wedded to relatively rudimentary assessments. For example, I recently participated in meetings designed to help define a very-well-supported EU initiative on how cognitive science can contribute to drug development, in which most applied assessments and most assessments development were still paper-based. This is a major missed opportunity, given the rapidly growing development and availability of automated assessments.
I believe we will see more independent assessments but also embedded assessments. For instance, in Scientific Learning we routinely use ongoing embedded assessments and cross-referenced state test achievement scores to develop models and profiles designed to determine the regimes of neuroplasticity-based training programs that must be applied so that individual students, school sites and school districts may achieve their academic performance goals.
Implications for Medicine and Mental Health
It seems clear that neuroplasticity-related assessment and training tools will impact medicine and mental health. Where and how do you think that may happen first?
This may surprise people who haven’t been following the area closely, but I believe cognitive training may well become a crucial part of the standard of care in schizophrenia over the next 3 or 4 years. With academic partners at UCSF, Yale and Konstanz University, and through the development of programs that effectively address cognitive deficits that limit this patient population, we have already designed a training program that is appropriate for evaluation in a medical-device-directed FDA trial. There is already agreement about the application of the MATRICS neurocognitive assessment battery for an FDA outcomes trial in this population, and NovaVision’s FDA approval of their stroke & TBI rehab strategies provide any important FDA precedent.
The NIH has been a key enabler of the NIH Toolbox, and the MATRICS process, both to standardize assessments. What impact may these have in schizophrenia and beyond?
The FDA’s adoption of MATRICS as a standard is a crucial step, because it provides a clear set of benchmarks that apply for any drug or non-drug approach to treatment. We would like to see the FDA establish similar benchmarks for all major clinical indications in neurological and psychiatric medicine. I haven’t followed the ToolBox so closely, and can’t really comment about its possible utility.
If we talk about wider clinical practice, we must recognize that many psychologists are attached to older forms of therapy that don’t incorporate contemporary cognitive neuroscience findings, and that neurologists and psychiatrists are strongly pharmaceutically oriented, and in any event are greatly pressed for time. Perhaps clinical practice will only change once we have developed the tools necessary to help professionals monitor the brain function and training (treatment) status of the very large number of patients that might typically be under their care.
Integrating Cognition with Home Health and Medical Home Models
That’s a very interesting point. How may remote monitoring and interventions happen? Is this similar to the model Cogmed uses today to deliver its working memory training via a network of clinicians?
We will probably see hybrid models emerge first. The clinician will, as usual, establish a diagnosis and initiate treatment in their office or clinic, probably with the assistance of a trained therapist. At some point, the therapy will continue at home. The therapist and the supervising clinician would be able to remotely monitor the patient’s performance by the use of our Internet tools. This model, originally developed and widely applied by Scientific Learning, has also been employed by Cogmed.
Only later may full telemedicine models emerge, where perhaps a neurologist monitors the brain function of several patients using appropriate tools, and identifies potential personalized preventive interventions with red flags that call for an office (or virtual) visit.
This has been a fascinating conversation, and a great context to the themes we will cover in depth in the summit. What else do you think will happen over the next few years?
First, I believe we’ll need to focus on public education, for people to understand the value of tools with limited face value. One important aspect of this is the need to find balance between what is fun and what has value as a cognitive enhancer “ which requires the activities to be very targeted, repetitive and slowly progressive. Not always the most fun “ people need to think fitness as much or more than games.
Second, I believe the role of providing supervision, coaching, support, will emerge to be a critical one. Think about the need for having a piano teacher, if you want to learn how to play the piano and improve over time. Technology may help fill this role, or empower and richly support real coaches who do so.
Which existing professional group is more likely to become the personal brain trainers of the future? or will we see a new profession emerge?
Frankly, I don’t know. To give you some context, at Scientific Learning we experimented with offering free access to therapists for a 2-month training. At Posit Science we first experimented with virtual coaches that many people seemed to hate, and later encouraged people who had completed the program to volunteer and coach new participants. Results were mixed. We’re now exploring other possibilities.
Let me mention a few other aspects. I believe we will also see a growing number of applications in languages other than English, which will be key given growing interest in South Korea, Japan and China on aging workforce issues (until now they have been mostly focused on childhood development, using English-based programs). We will also see the programs widely available to people who may not have computers at home. For example, Posit Science recently donated software equivalent in value to $1m to the Massachusetts public library system, as a model of how wider access (in this case, to help older drivers) might be provided.
My dream in all of this is to have standardized and credible tools to train the 5-6 main neurocognitive domains for cognitive health and performance through life, coupled with the right assessments to identify one’s individual needs and measure progress. For example, I’d like to know what the 10 things are that I need to fix, and where to start. Assessments could either measure the physical status of the brain, such as the degree of myelination, or measure functions over time via automated neuropsych assessments, which is probably going to be more efficient and scalable and potentially be self-administered in a home health model.
Mike, thank you very much once more for your time and insights.
My pleasure. I am looking forward to the very innovative Summit that SharpBrains is putting together to convene our little growing community.