(Editor’s Note: In order to help readers familiarize themselves with the work and thinking of Dr. Michael Merzenich, one of the winners of the 2016 Kavli Prize in Neuroscience for groundbreaking work on neuroplasticity, we are condensing and republishing the comprehensive conversation that Dr. Merzenich and Alvaro Fernandez had in 2009, in preparation for the inaugural SharpBrains Virtual Summit.)
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, 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 in 2009.
(Alvaro Fernandez) 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!
Safe driving seems to be one area where the benefits are more clear to see.
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.
Can you summarize what your recent research around brain training 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 one’s age, brain functioning can be improved, often with pretty impressive improvement in a short-time frame and limited time invested, 2) Basic neurological abilities in 60–90 year olds that are directly subject to training can be improved to the performance level of the average 20 or 30 or 40 year old, 3) Improvements generalize to broader cognitive measures, and to indices of quality of life, 4) Improvements are sustained over time…but that does not mean that they could not benefit from booster or refresher training.
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.
A key missing ingredient is 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…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.
It seems clear that neuroplasticity-related 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.
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.
That’s a very interesting point. How may remote monitoring and interventions happen?
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.
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.
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. 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.
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.
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