The ACTIVE Study

In response to data indicating that persons over age 65 account for almost half of all days of care in short stay hospitals (Graves & Kozak, 1999), constitute the majority of residents of nursing homes (Strahan, 1997), and account for over 75% of required formal home-based care supports (Levit et al., 1997; Office, 1996), the National Institute on Aging and the National Institute for Nursing Research funded an initiative to test the effectiveness of cognitive interventions in maintaining cognitive health and functional independence in older adults. This initiative was based on evidence that the cognitive performance of older adults can be improved through systematic training focused on cognitive skills (Baltes, Kuhl, Gutzmann, & Sowarka, 1995; Caprio-Prevette & Fry, 1996; Hayslip, Maloy, & Kohl, 1995; Kramer, Larish, & Strayer, 2002; Mohs et al., 1998; Neely & Backman, 1995; Noice, Noice, & Staines, 2004; Oswald, Rupprecht, Gunzelmann, & Tritt, 1996) paired with evidence of the importance of cognitive functioning for performing activities of daily living (Allaire & Marsiske, 1999; Backman & Hill, 1996; Burdick et al., 2005; Cahn-Weiner, Malloy, Boyle, Marran, & Salloway, 2000; Owsley, Sloane, McGwin, & Ball, 2002) and maintaining health related quality of life among older adults (Hultsch, Hammer, & Small, 1993; Swan, Carmelli, & LaRue, 1995; Wolinsky & Johnson, 1991). At that time, essentially no research had been conducted demonstrating training transfer to real-world functional outcomes in later adulthood. The Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) trial addressed this gap. The goal of ACTIVE was to test the effectiveness of three cognitive interventions (memory, reasoning, and visual speed of processing) in maintaining cognitive health and functional independence in older adults. The targeted abilities-- memory, reasoning, and speed of processing—were selected based on evidence that they exhibit relatively early age-related decline, beginning on average in the mid-sixties (Schaie, 1996), that interventions have been shown to be effective in training these abilities (K Ball, 1997; K. Ball & Owsley, 2000; Kliegl, Smith, & Baltes, 1990; Lachman, Weaver, Bandura, Elliott, & Lewkowicz, 1992; McDougal, 1999; Mohs et al., 1998; Oswald et al., 1996; Rasmusson, Rebok, Bylsma, & Brandt, 1999; Rebok & Balcerak, 1989; S. Willis, 1990; S. Willis, Cornelius, Blow, & Baltes, 1983; S. Willis & Nesselroade, 1990; S. Willis & Schaie, 1986, 1994), and that performance on these abilities is associated with performance of cognitively demanding instrumental activities of daily living, critical for independent living (K. Ball & Owsley, 2000; K. Ball, Owsley, Sloane, Roenker, & Bruni, 1993; Diehl, Willis, & Schaie, 1995; S. L. Willis, 1996; S. L. Willis, Jay, Diehl, & Marsiske, 1992). ACTIVE began in September, 1996 at six field centers: the University of Alabama at Birmingham, the Boston Hebrew Rehabilitation Center for Aged (now Hebrew Senior Life), the Indiana University School of Medicine, the Johns Hopkins University, the Pennsylvania State University, and Wayne State University, with a data coordinating center at the New England Research Institutes. The conceptual model that informed the design of ACTIVE (Figure 1) was based on prior evidence showing that cognitive training would be domain specific. That is, each intervention was expected to result in specific improvement on measures of the trained ability relative to the other interventions and control group. For example, training in memory was expected to improve memory function (the proximal outcome) but was not expected to improve reasoning or speed of processing skills. On the other hand, intervention effects were expected to show some level of general transfer to daily function (the primary outcome) based on the critical assumption that declines in cognitive function lead to declines in activities in daily living. In other words, improvement in cognitive ability should result in maintenance of functional independence. In turn, maintained functional independence could result in a positive cascade of effects including improvements in quality of life, mobility, and health service utilization. Figure 1 Hypothesized mode of effects in ACTIVE trial. Influence of intervention on primary and secondary outcomes is mediated through trained abilities. Bold lines represent specific effects of training. Dashed lines represent non-specific effects of training .