Neurofeedback For Executive Symptoms in Dementia
Thank you for considering participating in this ground breaking research. We are conducting this study because diminished cerebral blood flow and abnormal EEG activity have been identified as significant physical factors in people suffering from dementing illnesses. We are therefore actively recruiting subjects for a study designed to assess two approaches to improving brain blood flow activity using brainwave and cerebral oxygenation biofeedback training.
These methods are painless, do not involve
any medications and have no negative side effects. Biofeedback treatment has
been in use for over forty years and is widely accepted as being effective with
a variety of physical and neurological disorders. (click here for a
comprehensive bibliography of biofeedback research)
Subjects accepted into the study will
receive at no charge: an extensive
neuropsychological assessment and thirty sessions of individualized biofeedback
training either in Plymouth Meeting, PA, Los Angeles, CA, Litchfield, CT, Coral
Gables, FL, Manchester, NH, Boston, MA, St. Louis, MO or in your own
home.*
Contact Marvin Berman, Ph.D. at
610-940-0488 with your questions.
We suggest you print the following program description to review with your
doctor.
We welcome your physician’s questions.
Eligibility
is determined after reviewing two questionnaires that must be completed by both
the prospective subject and their caregiver or family member. We also require a
brief in-person interview that includes completion of a mental status
evaluation.
*home based training available in specific circumstances
where the caregivers can be trained to conduct biofeedback sessions. All
study-related services, equipment and training provided at no charge.
Study-related
documents:
Informed
Consent Form – this document is available for general information
purposes only. Actual completion of the informed consent will only take place
after someone has been determined to be eligible for the study.
IRB-Approved
Project Summary Form – this document explains in detail all aspects
of the study.
Flyer (Please Post
and Distribute)
A Brief Summary and Review
By Jon Frederick, Ph.D. and Marvin Berman,
Ph.D.
Abstract
(submitted to International Society for
Neurofeedback & Research 16th Annual Conference)
Previous studies have shown that dementia
is associated with reduced cerebral blood flow (CBF), and various quantitative
EEG (QEEG) abnormalities including a reduction in the dominant alpha frequency.
The purpose of this study is to test whether neurofeedback training to
normalize abnormal EEG activity and increase CBF can improve measures of memory
and executive function. Twelve participants are currently enrolled, where half
are randomly assigned to a waiting list control condition. All participants
receive a comprehensive assessment of memory and executive function, and a QEEG
assessment. Thirty sessions of QEEG-guided neurofeedback are administered,
where a random half of participants also receive frontal CBF biofeedback during
their sessions. Two treatment group participants and one control have presently
completed the study. Compared to the control case, the treated cases showed
improvements, ranging from modest to dramatic, in the Integrated Visual and
Auditory Continuous Performance Test (attention and response control), the Rey
Complex Figure (nonverbal recall), Memory Assessment System List Acquisition
(verbal working memory), the Behavior Rating Inventory of Executive
Function-Adult Version (executive symptom self-report), and the Delis-Kaplan
Executive Function System (DKEFS) Verbal and Design Fluency, and Letter-Number
Sequencing. These results should be interpretted cautiously because of low
subject number. For example, neurofeedback appeared to result in a poorer
performance on the Wisconsin Card Sort and DKEFS Word Context tests. Six
additional participants are expected to complete post-testing in time for this
presentation.
Introduction
This study measures whether executive and memory symptoms in dementia can be
effectively treated by neurofeedback training to increase frontal cerebral
blood flow (CBF) and normalize abnormal EEG rhythms. Neurofeedback
training has shown efficacy or possible efficacy for treating a variety of
central nervous system mediated disorders. However, this is the first
controlled study of neurofeedback to improve executive symptoms in persons with
dementia. Executive symptoms can include problems
with attention, impulsivity, planning, organizing, strategies of learning and
remembering, apathy, judgment, and insight.
In EEG biofeedback, an individual’s real-time
EEG is presented continuously as a visual or auditory signal, and desired variations
are rewarded. For example, a reduced peak alpha frequency (PAF) has been
commonly observed in dementia (Passant et al., 2005; Chan et al., 2004; Yenner
et al., 1996). A recent double-blind controlled study (Angelakis et al., 2007)
showed that neurofeedback rewarding increased peak alpha frequency (PAF)
improved cognitive processing speed and executive function in a small sample of
normal elderly adults.
However, not all dementia patients show a reduction in
PAF. Often, an abnormally high average amplitude in the slow (0-8 Hz) EEG
frequencies is present. EEG coherence, a measure of the number and strength of
connections between locations, may be reduced. While abnormalities in the
frontal leads are most commonly associated with executive symptoms,
abnormalities at other locations may be clinically significant. Often, multiple
abnormalities may be observed. For instance, excessive slow wave activity might
be associated with attentional difficulties, while increased high beta (22-30
Hz) activity can be associated with excessive emotional arousal, which
exacerbates the primary attentional problem.
A standard practice in neurofeedback therapy is to
analyze a baseline quantitative EEG (QEEG) during an initial assessment, and build
custom neurofeedback protocols designed to reward the normalization of each
client’s individual abnormalities (Lubar, 2004). Another standard
practice is to train multiple criteria during the same session. Thus, a participant may be rewarded for
increasing PAF, decreasing slow wave amplitude and high beta wave amplitude.
Research also suggests that impaired cerebral blood
flow (CBF) plays an important role in dementia. While a number of studies show
that regulation of CBF can trained with biofeedback, very little clinical
efficacy research has been published about CBF biofeedback. The present study
would be the first controlled clinical efficacy study of hemoencephalography
biofeedback.
Spilt et al. (2005) hypothesized that
neurodegeneration and dementia are largely secondary to pathologies of CBF. For
example, Alzheimer’s patients with brain damage (regions of MRI signal
hyperintensity) have increased oxygen extraction per mL/min. That is, blood
supply rather than demand seems to be the problem. Oxygen extraction would be
expected to be the same if reduced blood flow were secondary to tissue damage
(Spilt et al., 2005; Yamaji et al, 1997).
When compared to elderly controls with
optimal cognitive function, patients with dementia did not differ significantly
from elderly controls with respect to the number of cerebral infarctions.
Demented patients showed significantly more white matter lesions and
cerebrospinal fluid, but a reduction in cerebral blood flow had the largest
effect. After the effect of reduced blood flow was included, the effects of
white matter lesions and CSF were insignificant.
Single photon emission computed tomography
(SPECT) studies have shown cerebral blood flow to be significantly reduced in
the frontal and temporal regions in frontotemporal dementia (FTD) patients
(Miller et al., 1997; Read et al., 1995). The anatomical distribution of
reduced CBF corresponds to the pattern of neuropsychological deficits
(McMurtray et al., 2006).
Recent
studies have suggested that individuals can learn to increase CBF through
biofeedback. Yoo et al. (2006) showed that participants given feedback of fMRI
activity while listening to music were able to significantly increase the mean
blood oxygenation in the auditory cortex. Another study (deCharms et al., 2005)
trained participants to change fMRI activity in the rostral anterior cingulate
gyrus (RACG), a region implicated in pain perception. Control conditions
included sham feedback or feedback from a different brain region. When a
noxious thermal stimulus was applied, participants had decreased pain sensation
when trained to decrease RACG activity and increased pain sensation when
trained to increase RACG activity. In another phase of the study, eight chronic
pain patients reported decreased pain after down-training fMRI in the same
region.
FMRI costs
more than $1000 per session, which places this form of therapy beyond the reach
of most patients. However, it is possible to provide CBF neurofeedback for the
outermost 1.5 cm of cerebral cortex with a relatively inexpensive device that
uses the refractive properties of oxygenated hemogoblin to red and infrared
light (Toomim et al., 2004). A light source is attached to the scalp (typically
on the forehead) with a headband, 3 cm away from an infrared sensor, which
detects the relative absorption by oxygenated blood. This procedure is known as
hemoencephalography or HEG. Toomim et al. (2004) showed that ten sessions
improved impulsivity scores on the Test Of Variables of Attention (TOVA) in 28
patients of diverse psychopathology. Carmen (2004) provided frontal HEG to 100
migraine patients, and found that 90% of those who completed at least six
sessions reported significant improvement in migraine symptoms. In a single
case study, Mize (2004) reported that a child with ADHD showed significant
improvement on the IVA, which improvement persisting into the 18-month
follow-up.
While HEG
is widely used by clinicians, the few studies of HEG have significant
limitations, including the lack of a control group. More peer-reviewed,
clinical research on HEG biofeedback training is greatly needed.
Dependent
Measures
Participants will be assessed before and
after 30 sessions of neurofeedback with the following.
(1) Memory Assessment
Scale (PAR Inc). Assesses short-term and delayed memory for lists, details of a
story, figures, names and faces.
(2) Rey-Osterreith
Complex Figure Task. Measures visual spatial constructional ability and
visuospatial memory.
(3)
(4) Integrated Visual and Auditory Continuous
Performance Test (IVA). Measures attention and impulse control.
(5) Delis-Kaplan Executive Function
battery. Assesses flexibility of thinking, concept formation, problem solving,
planning, creativity, impulse control and inhibition.
(6) Behavior
Rating Inventory of Executive Function-Adult Version (BRIEF-A; self-report and
also an informant report by the primary caregiver and/or significant other).
This instrument includes a Behavioral Regulation Index assessing symptoms
inhibition, shifting, emotional control, and self-monitoring; and a
Metacognition Index assessing Working Memory, Initiate, Plan/Organize, Task
Monitor, and Organization of Materials.
(7) Symptom Checklist
90-R. This is a comprehensive checklist for co-morbid psychiatric symptoms
including Somatization, Obsessive-Compulsive, Interpersonal Sensitivity,
Depression, Anxiety, Hostility, Phobic Anxiety, Paranoid Ideation, and
Psychoticism. We hypothesize an improvement the Global Severity Index will be
associated with improvements in cognitive function.
A quantitative EEG will also be analyzed
to assess abnormalities in brain function.
Treatment
Protocol
Participants will be randomly assigned
into one of three groups: (a) EEG neurofeedback; (b) EEG+HEG neurofeedback
combined; (c) a waiting list control group. The waiting list control group is
eventually provided treatment and randomly assigned to strengthen comparisons
among (a) and (b).
Treatment
Available Nationwide
Most testing and treatment sessions will be conducted
at our clinic at