People living with HIV (PLWH) are at greater risk of cognitive impairment than their HIV-negative counterparts. In fact, 30–50% of PLWH meet the neuropsychological criteria for HIV-Associated Neurocognitive Disorder (HAND; Bonnet et al., 2013; Wei et al., 2020). Cognitive impairment in PLWH is associated with more difficulty with everyday functioning and poorer quality of life (QoL; Vance et al., 2017). Cognitive impairment may be exacerbated by age-related cognitive declines (Waldrop et al., 2021). In the United States, this represents a public health concern as nearly half of PLWH are 50 years and older, and the percentage of older PLWH is expected to be 70% by 2030 (Brooks et al., 2012). Therefore, it is important to prevent cognitive impairment to maintain optimal cognitive function in PLWH as they age. Emerging research supports cognitive training as a viable option for protecting cognitive health in PLWH.
In a systematic review of 13 articles regarding cognitive training for PLWH, Vance, Fazeli, et al. (2019) found that cognitive training is beneficial for improving cognitive function in the targeted cognitive domain (e.g., executive functioning, attention, speed of processing). For example, in an experimental study of 46 PLWH, Vance et al. (2012) randomized participants to either an intervention group (n = 22) or a no-contact control group (n = 24). Ten hours of computerized cognitive exercises targeting training in speed of processing (SOP) were applied to the intervention group. The results demonstrated that SOP-targeted training significantly improved cognitive function in this domain (p = .04, power = 0.53), as measured by a neuropsychological test of visual SOP and visual attention. Improvements also translated to a speed-based laboratory performance measure of instrumental activities of daily living (e.g., counting change, finding items on a food shelf).
In the Training on Purpose Study (TOPS), Vance et al. (2021) conducted a two-group preexperimental/postexperimental design study using individualized-targeted computerized cognitive training with PLWH experiencing HAND, as measured by the Frascati criteria (Vance, Fazeli, Azuero, Wadley et al., 2021). More specifically, using norm-based (i.e., controlling for age/education) cognitive performance measures, HAND at baseline was defined if participants scored 1 or more SDs below their expected norm-based performance in at least two cognitive domains (i.e., SOP, attention, executive function, spatial learning and memory, delayed spatial learning and memory, spatial visualization, verbal learning and memory, and delayed verbal learning and memory). This algorithm for defining HAND is referred to as the Frascati criteria and is used extensively in neuroHIV research (Antinori et al., 2007). These participants were randomized to either the individualized-targeted computerized cognitive training group (n = 48) or the no-contact control group (n = 40). Those in the individualized-targeted computerized cognitive training group were assigned specific domain-specific cognitive training exercises. The cognitive training protocols were based on a three-step framework developed by the research team: (a) participants with cognitive impairments in SOP and/or attention were assigned targeted domain-specific cognitive training to improve these cognitive domains; (b) if there were no impairments in SOP and/or attention, participants were assigned to the least compromised among the impaired cognitive domains(e.g., if impairment was detected in domains with 1.5,1.8,or 2.0 SD below their expected norm-based performance, the cognitive domains with 1.5 and 1.8 were selected for training);and (c) the two targeted domains were selected from the steps 1 and 2 and participants engaged in the individualized-targeted computerized cognitive training of the selected domain (10 hours of each per domain).
The first aim of the TOPS was to reverse the diagnoses of HAND with individualized-targeted computerized cognitive training (Vance, Fazeli, Azuero, Wadley et al., 2021). Unexpectedly, domain-specific cognitive training was not effective in reversing HAND diagnoses in this study, but domain-specific cognitive training improved the domains that were targeted. The second aim of the TOPS was to examine whether individualized-targeted computerized cognitive training improved everyday functioning (Vance, Fazeli, Azuero, Frank et al., 2021). The everyday functioning of participants in the SOP training protocol group improved, specifically improvements were observed in medication adherence and instrumental activities of daily living. The third aim of the TOPS was to examine the effect of individualized-targeted computerized cognitive training on improvements in QoL indicators (e.g., cognitive complaints, depression, sleep quality, self-rated health, health-related QoL) of PLWH (Vance, Pope et al., 2021). The results showed improvements in cognitive complaints, depressive symptoms, and mental health in some of the eight domain-specific cognitive training protocols.
One aspect of training effects that has not previously been investigated (Vance, Fazeli, Azuero, Wadley et al., 2021) was self-perceived improvement in cognition after receiving individualized-targeted computerized cognitive training. These findings are important indicators of acceptability and perception of the utility of the intervention that was also a study aim of this NIH-funded R21 study. Perception of cognition is also important because if people perceive their cognition is poor or at risk, it can create anxiety and poor quality of life (Vance et al., 2020). Thus, the purpose of this analysis was to evaluate if participants perceived that cognitive training had directly affected their cognitive abilities and everyday functioning.
Methods
Design Overview
The TOPS examined the effects of individualized-targeted computerized cognitive training on cognition (e.g., reversing HAND), everyday functioning, and QoL. The treatment protocol consists of 20 hours of training focused on two domains of objective cognitive impairments. The University of Alabama at Birmingham’s Institutional Review Board approved the study (IRB Approval Number: F161122002). Complete details about the parent protocol are reported in the protocol article (Vance et al., 2018).
Participants
Participants were recruited from an HIV clinic, AIDS service organizations, and community venues through flyers. Eligible participants were individuals diagnosed with HIV for at least 1 year, 40+ years of age, proficient in English, no vision or hearing problems, and no self-reported neurological or severe neuropsychiatric conditions (e.g., schizophrenia). For specific information about eligibility criteria, refer to the main study outcome article (Vance, Fazeli, Azuero, Wadley et al., 2021).
Participants who completed the intervention arm (n = 41) were on average 54.6 (SD = 6.6) years old, and the majority were male (n = 29, 70.3%) and African American (n = 36, 90.0%). Participants had an average of 12.4 (SD = 2.5) years of education. The average years of being diagnosed with HIV was 17.6years (SD = 7.7). Participants had current CD4+ T lymphocyte count/mm3 of 684.4 (SD = 424.5) and nadir CD4+ T lymphocyte count/mm3 of 344.9 (SD = 348.3).
Measures
Two sets of questions were administered after cognitive training to the intervention group.
Perceived improvement questionnaire.
This experimenter-generated measure was used to evaluate the participants’ perceptions about whether the intervention improved their cognition and everyday functioning. These questions are face valid and we originally developed and effectively used most of these questions in a prior HIV cognitive training study (Kaur et al., 2014). The participants were asked, “Do you feel playing these games improved your: (a) mental abilities; (b) memory; (c) SOP; (d) attention; and (e) ability to do everyday activities such as driving or cooking?” Responses ranged from 1 (not at all) to 5 (extremely).
Training satisfaction question.
This experimenter-generated measure was used to evaluate the participants’ satisfaction (e.g., enjoyment) with the training protocol. This question is face valid and has been used effectively in a prior HIV cognitive training study (Kaur et al., 2014). Participants were asked, “How much did you enjoy these games?” Responses ranged from 1 (not at all) to 3 (moderately) to 5 (extremely).
Data Analysis
Average scores for perceptions of cognitive improvement and training satisfaction were tabulated for participants in the training group by cognitive domain training. Analyses were conducted using R software version 3.6.
Results
Overall, across cognitive training conditions, most participants reported that they felt the training had improved their cognition moderately or better on memory (87.2%), SOP (84.6%), attention (89.7%), and mental abilities (89.7%). When examined individually, Table 1 shows that these ratings were stable across types of cognitive training. Across cognitive training conditions, most participants (76.9%) reported that they felt the training had moderately or better improved their everyday functioning (M = 3.3, SD = 1.3). As seen in Table 1, analyses revealed perceived improvement was similar across the different types of cognitive domain training protocols (M range = 3.14–4.08). For the training satisfaction, most participants (94.9%) responded that they enjoyed the training at the level of moderately or better.
Table 1.
Perceived Improvement and Enjoyment Across Cognitive Training Domains (N = 41)
| Perceived Improvement and Enjoyment | Overall Improvement Score |
Cognitive Training |
|||||||
|---|---|---|---|---|---|---|---|---|---|
| Moderate or Better |
Speed of Processing |
Attention |
Verbal Learning and Memory |
Delayed Verbal Memory |
Executive Functioning |
Spatial Learning and Memory |
Delayed Spatial Memory |
Spatial Visualization |
|
| (n = 39) |
(n = 19) |
(n = 13) |
(n = 13) |
(n = 10) |
(n = 4) |
(n = 6) |
(n = 7) |
(n = 10) |
|
| N (%) | M (SD) | M (SD) | M (SD) | M (SD) | M (SD) | M (SD) | M (SD) | M (SD) | |
|
| |||||||||
| Do you feel playing these games improved your memory? | 34 (87.2) | 3.74 (0.99) | 3.77 (0.83) | 3.73 (0.9) | 3.89 (1.27) | 4 (1.15) | 3.67 (1.51) | 3 (0.82) | 3.89 (1.05) |
|
| |||||||||
| Do you feel playing these games i mproved you r speed of processing? | 33 (84.6) | 3.79 (1.13) | 4.08 (0.86) | 3.64 (0.67) | 3.22 (1.09) | 4 (1.15) | 3.83 (1.17) | 3.57 (0.79) | 4 (1) |
|
| |||||||||
| Do you feel playing these games improved your attention? | 35 (89.7) | 3.68 (1.16) | 3.69 (1.11) | 3.91 (0.54) | 4 (1) | 4 (1.15) | 3.83 (1.17) | 4.14 (0.69) | 4.11 (0.6) |
|
| |||||||||
| Do you feel playing these games improved your mental abilities? | 35 (89.7) | 3.74 (0.93) | 3.92 (0.64) | 3.55 (0.82) | 3.56 (1.13) | 4 (1.15) | 3.67 (1.51) | 3.71 (0.49) | 4.11 (0.78) |
|
| |||||||||
| Do you feel playing these games improved your ability to do everyday activities such as driving or cooking? | 30 (76.9) | 3.47 (1.35) | 3.69 (1.32) | 3.36 (1.03) | 3 (1.22) | 3.75 (1.89) | 2.83 (1.6) | 3 (1.15) | 3.22 (1.2) |
|
| |||||||||
| How much did you enjoy these games? | 37 (94.9) | 3.89 (0.94) | 4.08 (0.76) | 3.64 (0.81) | 4 (1) | 4 (1.15) | 3.67 (1.21) | 3.14 (0.38) | 3.67 (0.87) |
Notes. Scores range from 1 (not at all), 2 (a little), 3 (moderately), 4 (very much), to 5 (extremely).
Discussion
The TOPS was designed to reverse the diagnosis of HAND and improve the everyday functioning and QoL based on the Individualized-Targeted Cognitive Training Framework. For this training perception article, we observed that most participants in the different cognitive domain training protocols reported that they perceived such cognitive training improved their cognitive abilities, which represents a way that cognitive training can improve their QoL and perhaps perception of well-being. In our prior TOPS article focused on everyday functioning measures (i.e., Timed Instrumental Activities of Daily Living, Lawton & Brody IADL scale, medication adherence), cognitive training did not result in a consistent effect on everyday functioning (Vance, Fazeli, Azuero, Frank et al., 2021). But, when we asked specifically if cognitive training affected everyday functioning, as presented in this current article, we observed that across each type of cognitive domain training, participants indicated that such engagement in the training protocol helped improve their everyday functioning. Although we do not know the extent to whether the cognitive training did or did not produce such an effect, this perception alone may have QoL benefits.
Implications for Practice
In the TOPS, we asked participants with HAND what were their reactions or concerns about receiving the study diagnosis of HAND (Vance, Fazeli, et al., 2019). Although most themes that emerged were positive or neutral (e.g., desire to improve, confirmation, not concerned/no reaction, unexpected, knowledge seeking), negative themes such as concern, anxiety, and sadness emerged as well. For PLWH who were concerned about their cognition, cognitive training represents a potential strategy to assuage their concerns and fears and may also empower them by providing an activity that might actively benefit their cognitive ability, consistent with recent research in HIV (Waldrop et al., 2021). In fact, perhaps engaging in cognitive training may be a catalyst for engaging in other activities that promote brain health.
Implications for Research
Perceived improvement in cognitive function and everyday functioning was observed regardless of their improvement measured by standard objective measures. These results may be affected by factors not considered in this study, such as confidence in mental and everyday functioning or self-esteem. In other words, participating in such cognitive training can produce behavioral or emotional change in participants even if it is not intended. For further investigation, studies that include these additional factors (i.e., locus of control) are suggested.
The positive result on the training satisfaction indicates that the individualized-targeted computerized cognitive training is favorable for participants. Knowing training does not burden participants, and may be enjoyable to the participants, further research can be built on the protocol developed in this study.
Strengths and Limitations
Overall strengths and limitations are mentioned in previous studies (Vance, Fazeli, Azuero, Frank et al., 2021; Vance, Fazeli, Azuero, Wadley et al., 2021; Vance, Pope et al., 2021). For our current study, a particular strength is noted. That is, few cognitive training studies asked about perceived changes. This study provided information about participants’ perceived improvement in cognition and everyday functioning, which was different from improvements measured by objective measures. This highlights the necessity of measuring subjective effects of cognitive training to understand how participants perceive the usefulness of the intervention, which may lead to the adoption of the intervention. Study limitations are likewise noted. First, we did not assess perception changes in all cognitive domains assessed. One reason why we did not is because we were uncertain if participants would be cognizant or have the psychological health literacy to understand what we meant by each of the eight cognitive domains because these are highly conceptualized neuropsychological terms. In other words, it is face valid to ask about one’s memory or attention because these are commonly understood in our normal English conversation. Although, asking people to rate their delayed spatial memory ability, spatial visualization ability, delayed verbal memory ability, and so forth would be useless and not valid, given that our sample probably would not have the psychological training to understand fully what these concepts mean to rate their own ability level in these cognitive domains. Second, we did not gather the qualitative data needed to understand how their perceptions of training affected their cognition, everyday functioning, and QoL. Exploring the perceptions of cognitive training from a qualitative perspective would be a unique contribution to the literature.
Key Considerations.
Nearly 30–50% of people living with HIV (PLWH) have HIV-associated neurocognitive disorder.
Individualized-targeted computerized cognitive training may improve cognition and everyday functioning in select domains.
PLWH perceived improvement in overall cognitive domains and everyday functioning after individualized-targeted computerized cognitive training.
As older PLWH have concerns about cognitive decline, cognitive training may assuage their concerns and empower them by providing an activity that might benefit their cognitive ability.
Acknowledgments
This study was funded by an NIH/NINR R21-award (1R21NR016632–01;ClinicalTrials.gov(NCT03122288); D. E. Vance, Principal Investigator) titled “Individualized-Targeted Cognitive Training in Older Adults with HAND.” Special thanks to our research team, especially Brittany Bradley, Delaney Diehl, Shyla Hossain, Michael Jenson, Peggy McKie, Josiah Robinson, Frida Tende, and Tess Walker.
Footnotes
Disclosures
All other authors report no real or perceived vested interest that relate to this article that could be construed as a conflict of interest.
Contributor Information
Jun Y. Byun, School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, USA..
Andres Azuero, School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, USA..
Pariya L. Fazeli, School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, USA..
Wei Li, Department of Clinical and Diagnostic Sciences, School of Health Professions, University of Alabama at Birmingham, Birmingham, Alabama, USA..
Crystal Chapman Lambert, School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, USA..
Victor A. Del Bene, Department of Neurology, University of Alabama at Birmingham, Birmingham, Alabama, USA..
Kristen Triebel, Department of Neurology, University of Alabama at Birmingham, Birmingham, Alabama, USA..
Alexandra Jacob, Department of Psychology, University of Alabama at Birmingham, Birmingham, Alabama, USA..
David E. Vance, School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, USA..
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