DOI: 10.7860/JCDR/2015/13392.

6186
Review Article

Non Pharmacological Cognitive

Psychiatry Section

Enhancers – Current Perspectives

Ankur Sachdeva1, Kuldip Kumar2, Kuljeet Singh Anand3

ABSTRACT
Cognition refers to the mental processes involved in thinking, knowing, remembering, judging, and problem solving. Cognitive dysfunctions
are an integral part of neuropsychiatric disorders as well as in healthy ageing. Cognitive Enhancers are molecules that help improve
aspects of cognition like memory, intelligence, motivation, attention and concentration. Recently, Non Pharma­cological Cognitive
Enhancers have gained popularity as effective and safe alternative to various established drugs. Many of these Non Pharmacological
Cognitive Enhancers seem to be more efficacious compared to currently available Pharmacological Cognitive Enhancers. This review
describes and summarizes evidence on various Non Pharmacological Cognitive Enhancers such as physical exercise, sleep, meditation
and yoga, spirituality, nutrients, computer training, brain stimulation, and music. We also discuss their role in ageing and different
neuro-psychiatric disorders, and current status of Cochrane database recommendations. We searched the Pubmed database for the
articles and reviews having the terms ‘non pharmacological and cognitive’ in the title, published from 2000 till 2014. A total of 11 results
displayed, out of which 10 were relevant to the review. These were selected and reviewed. Appropriate cross-references within the
articles along with Cochrane reviews were also considered and studied.

Keywords: Ageing, Cognitive impairment, Dementia,Neuro-psychiatric disorders

Introduction which 10 were relevant to the review. Appropriate cross-references

Cognition refers to the higher mental functions of the brain and within the articles were also considered and studied. Cochrane
includes thinking, language, memory, attention, perception, review database was searched for the terms ‘exercise’, ‘sleep’,
planning, intelligence and problem solving [1]. They are subjective in ‘yoga’, ‘computer training’, and ‘music therapy’. Appropriate results
nature and may be affected by number of factors including ageing, pertinent to review were selected.
stress, various medical conditions such as hypertension, dementias, A range of strategies from environmental stimulation to exercise
Parkinson’s disease (PD) and psychiatric illnesses like schizophrenia, have been tested and developed to enhance cognition. Most
bipolar disorders [2,3]. All these disorders have some components interventions target either underlying disease pathologies or the
of or predispose to cognitive decline or dysfunction. processes underlying normal cognition.
Cognitive dysfunction  is the decline in intellectual functions such
as thinking, reasoning and remembering, which interferes with daily Physical Exercise
functioning. Considering the ever increasing population of the elderly Physical exercises, especially aerobic exercises, are documented
and stress related problems, cognitive decline is an epidemic in the to enhance and preserve cognitive functions. Hillman suggested
making [4]. Thus, memory enhancers are predicted to play a great that regular aerobic exercises improve cognition and have beneficial
role in the near future. Cognitive Enhancers (CE) are molecules (drugs, effects on brain functions [6]. Exercise is thought to enhance
supplements, nutraceuticals, and functional foods) or various brain production and release of neurotrophins specially, brain-derived
stimulation methods that improve some aspect of brain function or neurotrophic factor (BDNF) and also induces a cascade of molecular
cognition [5]. They may be Pharmacological Cognitive Enhancers and cellular processes that favor angiogenesis, neurogenesis and
(PCE) or Non-Pharmacological Cognitive Enhancers (NPCE). PCE synaptogenesis [7]. Physical activity is also hypothesized to improve
include herbal medicines (asparagus, gingko biloba, and ginseng) mood and cognition by increasing the synaptic transmission of
and pharmaceutical drugs. Only a few PCE are approved for monoamines as well as enhancing the release of endorphins.
enhancing cognition, most do not have established efficacy, have The effect of exercise has been studied across different age groups.
out of label use or are under research. Also, the ethical issues of Physical exercise was demonstrated to benefit intelligence and
using PCE in healthy ageing subjects are of great concern. These academic functions in school age children [8] as well as improve
concerns have promoted the use and research for NPCE. different aspects of cognition in older adults with and without
NPCE include physical exercise, sleep, meditation, computer pathological cognitive decline [9]. A recent meta-analysis [10]
training, brain stimulation, yoga and music. These are largely demonstrated that aerobic exercise improves cognitive functions
ignored and neglected, despite being relatively safe and culturally such as memory, processing speed, attention, and executive
accepted. Cochrane Reviews on non-pharmacological interventions functions. It may be concluded that physical activity helps to preserve
have found relative paucity of evidence regarding the effects of mental abilities throughout aging and across all age groups.
these interventions. This review describes various NPCE, the role Exercise also benefits subjects suffering from Mild Cognitive
of NPCE in ageing and various neuro-psychiatric disorders, and Impairment (MCI) or early-stage dementia [10]. Evidence suggests
the current status of Cochrane database recommendations. We that exercising in young leads to better cognitive output in elderly
searched the Pubmed database for all articles and reviews having and it follows dose-response effect [11]. The prefrontal and medial
the terms ‘non pharmacological and cognitive’ in the title, published temporal cortices, particularly hippocampus, are sensitive to
till 2014 since the year 2000. A total of 11 results displayed, out of exercise with trophic responses leading to increased volume and

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increases in hippocampal cerebral blood flow [12]. Exercise is exposure therapy was followed by sleep [29]. A study found sleep
considered protective for Alzheimer’s Disease. Several studies have problems to be associated with cognitive errors seen in anxiety and
reported reduced incidence of dementia or cognitive deterioration depression [30]. Depressed patients treated with olanzapine showed
with physical activity [13]. Daily physical training of 30 minutes improvement in sleep quality and it correlated with improvement in
reduces the number of hospitalizations in AD patients [14]. Exercise cognition and illness severity [31].
is considered as an adjunctive treatment and a preventive measure Sleep disturbances appear even before cognitive symptoms in
in Parkinson’s Disease (PD). Specific core areas for physical exercise the preclinical phase of AD. Poor quality sleep has been linked
therapy in PD includes cueing strategies to improve gait, cognitive with greater cognitive decline and increased risk of mild cognitive
movement strategies to improve transfers, special exercises to impairment and dementia. Cognition declines faster in older adults
improve balance and training of joint mobility and muscle power in who have disturbed sleep than those who sleep well [32].  Lee et
order to improve physical capacity [15]. al., concluded that patients with ADHD have more sleep problems
Patients with serious mental illnesses may also benefit with exercise. compared with controls, which positively correlated with the
Exercise has been shown to effectively treat depression and anxiety cognitive functions [33]. In conclusion, sleep enhances some
disorders along with enhancing cognition [16,17]. Physical exercise aspects of cognition but future research is needed to establish its
is an important component of stress reduction programs and has role as a cognitive enhancer and to evaluate the timeframe for which
shown on psychological well-being [18]. Exercise also improves the benefits persist.
symptoms such as reduced self esteem and social withdrawal. A
cochrane systematic review found exercise to significantly improve Meditation and Yoga
negative symptoms of mental state  along with quality of life [19]. Meditation has been emphasized to promote mental well-being,
No effect on positive symptoms was noted. However, one recent enhance attention and other cognitive capacities. Traditional
review found that exercise programs had no significant effect on approaches like Buddhist mindfulness meditations and Zen
symptoms of mental health [20]. We can conclude that there is meditations have resurged along with several modern group-based
converging evidence on several levels that physical exercise benefits standardized meditations. Meditation practice has been associated
and preserves cognition throughout the lifespan and across various with increased attention performance and cognitive flexibility in
neuropsychiatric disorders. experienced meditators as compared to control subjects [34].
A systematic review found preliminary positive effects of meditation
Sleep on attention, memory, executive function, processing speed, and
Sleep is considered important for effective functioning of brain general cognition in age related cognitive decline and degenerative
and cognition. Researchers have suggested that wide variety of disorders [35]. Cochrane database review found no significant
cognitive functions ranging from attention and memory, to language benefits of meditation therapy in children or adults diagnosed
and reasoning, are affected due to lack of adequate sleep [21]. with ADHD [36]. Another cochrane database review found that
Sleep-specific manipulations have been found to effectively enhance transcendental meditation is comparable and as effective in
cognitive functions [22]. reducing anxiety as other relaxation therapies [37]. Mind fulness
Sleep facilitates several cognitive functions such as working interventions have been found moderately effective in treating
memory, language processing, creativity and decision making [23]. negative symptoms in Schizophrenia and can be useful adjunct to
Short periods of day time naps benefit memory performance and pharmacotherapy [38].
concentration, even in subjects who are not sleep deprived. Sleep Yoga has its origins in Indian culture and is the oldest known form of
facilitates memory consolidation as well as subsequent acquisition meditation. Yoga based interventions appear to significantly improve
of new learning material [23]. Sleep also promotes the integration several cognitive domains in elderly such as immediate and delayed
and reprocessing of fresh memories into the existing reservoir of recall, verbal and visual memory, attention, working memory, verbal
long-term memories [24]. fluency, executive function and processing speed [39]. Yoga has
Surprisingly, inspite of so much research on sleep and its role emerged as an effective and feasible add on therapy in schizophrenia,
in memory enhancement, it is usually neglected in therapeutic with special benefits in improving social cognition and negative
aspects. The sleep state might be particularly well suited as a target symptoms [40]. However, a review comparing yoga to exercise found
for the enhancement of memory capacities. First, sleep can be no short term evidence of effects on positive symptoms, negative
timed in relation to learning so that it optimally supports encoding symptoms, quality of life and social function [41]. Yoga was found to
and memory consolidation. This may be possible by introducing benefit individuals with depressive symptoms, including quality of life
short naps before learning of new information [25]. The second way and cognition [42]. Some of the consistent effects of yoga practice
to augment memory during sleep is to manipulate memory and/or include stress reduction, emotion regulation, improved mood and
sleep directly in such a selective way that it targets the processing well being. It can be concluded that yoga and meditation are safe
of specific memory functions during sleep [22]. Pharmacological and effective traditional methods for enhancing cognition and their
agents can also be used to modulate the processing of memories use should be encouraged. Considering the multiple benefits of
during sleep. However, new learning of declarative and procedural Yoga, the World Health Organization has declared 21st June as the
memories during sleep is still out of question [22]. ‘International Yoga Day’ [43].
One of the clinical applications of sleep may be in restoring normal
cognitive functioning. Many neuro psychiatric and degenerative Spirituality
disorders are accompanied by changes in sleep patterns and Spirituality is considered as an important component of overall well-
dysfunctions of memory. Memory for words improved in patients being. Spirituality helps an individual cope with stressors in the world
with schizophrenia following stimulation of slow oscillations with and strives towards his potential. Inspite of growing recognition of
transcranial direct stimulation during sleep [26]. However, it was religion and spirituality as part of the treatment/rehabilitation plan for
observed that administration of olanzapine (which increases slow cognitively impaired patients, there are limited studies that focus on
wave sleep), and GABA agonist eszopiclone, failed to normalize its role for enhancing cognition.
memory consolidation in schizophrenia patients [27,28]. This Studies suggest that a few aspects of spirituality may assist in
calls for further research to clarify and establish the role of sleep decreasing depressive symptoms, including cognitive errors [44].
for enhancing cognition in these patients. In the treatment of Evidence shows that religious beliefs and spirituality may lead to
spider phobia, increase therapeutic effectiveness was found if enhanced levels of psychological well being, coping capacities,

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fewer symptoms of distress, depression, anxiety and more positive depression and acts as a protective factor in clients with suicidal
affect [45]. Individuals with strong religious convictions often utilize ideation [57]. We can conclude that initial results of including music
positive religious coping behaviours to assist with stress reduction in cognitive training are encouraging. However, quantitative research
and emotion regulation. Kaufman et al., [46] found that spirituality based evidence is lacking in this field.
and religious practices, such as prayer, Bible reading, and
devotions, may decrease the rate of cognitive decline of Alzheimer’s Cognitive Training
patients. Religion and spirituality benefit participants in psychosocial Techniques of stimulating brain and cognition are widely practiced
rehabilitation programs. in areas of sports and rehabilitation. There have been studies and
In general, spirituality strengthens a sense of self and self-esteem and debates about different types of techniques involved in cognitive
helps in countering stigma and shame with positive self-attributions enhancement in ageing population, dementia and neuropsychiatric
[47]. Higher spiritual inclination are found to have positive effects for disorders.
persons diagnosed with Schizophrenia [48] and are associated with Visualization techniques require users to vividly imagine themselves
optimism and resiliency against stress among individuals recovering performing a task (running a race, going to a store), repeatedly
from substance abuse [49]. Spirituality empowers confidence, imagining every movement and the associated feelings [58]. These
presents a sense of purpose and opportunities for growth and exercises are hypothesized to work by activating the neural networks
positive change. which are involved in skill execution simultaneously as the task is
However, spirituality in itself is not free of negative consequences. held, optimizing neural reorganization.
Negative religious coping activities such as expressing anger at God, The concept of enhancing working memory (WM) through targeted
attributing negative events to God‘s punishment has been linked training has mounting evidence. Training related increase in WM
to greater affective distress, including greater anxiety, depression, capacity can improve a range of important cognitive skills. The
suicidality and lower self-esteem. Furthermore, emotional struggles training paradigms usually teach effective approaches to encode,
and feelings of rejection can be reinforced by religious communities register, and retrieve from WM [59]. Such methods of ‘strategy
who see mental disorders as signs of moral or spiritual failure. Hence, training’ have been successfully used in children with Down
caution needs to be taken while using spirituality in neuropsychiatric syndrome [60] to supplement specific WM deficits. Strategy
disorders and enhancing cognition. training was reported to slow the decline of, and perhaps improve,
WM in older adult populations [61]. Self-report measures indicating
Music improved everyday memory in trained older adults suggest utility
Music has been recently emphasized as an alternative way of of this training module. ‘Core training methods’ are designed to
enhancing cognition. Music therapy and other musical activities target ‘domain-general WM mechanisms’. These involve repetition
like listening to music, singing and playing a musical instrument of cognitively stimulating high intensity WM tasks, which improves
have shown promise in neuropsychiatric disorders, especially in WM [59]. Core training programme found benefits in cognition and
dementia. intelligence in young healthy adults, in cohort of children diagnosed
Two main types of music therapy are described: receptive and active with ADHD [62], quality of life improvements in patients with
music therapy. “Receptive music therapy consists of listening to multiple sclerosis [63], and patients with stroke and Schizophrenia
music by the therapist who sings or selects recorded music for the patients [64].
recipients. In active music therapy, recipients are actively involved Memory therapy in the mild to moderate stages of AD can be
in the music-making and playing instruments. The participants are successful, provided it is individualized based on patient’s daily
encouraged to participate and improvise with instruments or voice, problems and their residual cognitive capacities. Cognitive training
and with dance, music or singing” [50]. is an efficient method to delay cognitive decline in persons with MCI.
In Alzheimer’s patients, music part of memory seems interestingly Some techniques of cognitive stimulation make use of ecological or
spared by the disease [51]. Elderly adults who frequently play a virtual environments to compensate age related cognitive decline.
musical instrument are less likely to develop dementia. Positive Several types of cognitive trainings are available aimed at improving
effects on scores on working memory, perceptual speed, and memory, learning, attention, executive functions, mnemonic
motor skills were noted in elderly population after piano lessons techniques, or global cognition [65].
[52]. Music, amongst other cognitive exercises like puzzles and Mnemonic strategies can be seen as strong and reliable enhancers
crosswords, was proposed to have the strongest neuro-protective of learning and memory capacity. The ability to cope with verbal
effect [52]. A study showed the effectiveness of group music therapy or numerical information becomes increasingly important and
on depression and cognitive functions, particularly short term recall complex as age progresses. Mnemonics have been shown to be
function among elderly persons with mild and moderate dementia effective for retaining easy-to-learn material with small effect sizes.
[53]. Choir music was found to reduce depression, increase levels For difficult tasks, effect sizes may be as high as Cohen’s d of 3 or
of motivation, purpose, wellbeing and quality of life in people with 4. But mnemonics have not proved effective in age-related cognitive
dementia [54]. decline [66].
Music therapy may have a role in psychosocial rehabilitation Cognitive Remediation therapy (CRT) aims to improve cognitive
in enduring mental illnesses. It helps improve an individual’s processes in dementias and neuropsychiatric disorders. CRT
psychological and physiological well-being, social cohesiveness and expects that changes will maintain over follow up period and
emotional expressions [55]. It helps in reducing social isolation, and will translate into real world benefit. A meta analysis of cognitive
improves participation in external events. Music therapy significantly remedia­tion in Schizophrenia by McGurk et al., found that CRT
improved aggression/hostility in pre adolescents with emotional, resulted in significant improvements in most domains of cognition
learning, and behavioural problems. A randomized trial of music [67]. Cognitive adaptation training is a structured program that
therapy for in patients with Schizophrenia found benefits in negative utilizes measures such as mobile phone reminders and medication
and cognitive domains but not so in positive symptoms [55]. Gold administration aids that help with daily functioning [68]. Similarly,
et al., concluded that music therapy sessions help improve mental social cognition remediation programs have been developed
state and global functioning in Schizophrenia. Therefore, it adds to especially in regard to improving emotional perception, and facial
the standard care of treatment [56]. A Cochrane review suggested affect recognition.
that music therapy improves mood, is accepted by people with

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Brain Stimulation the idea that age-related decline cannot be only halted, but actually
Brain stimulation techniques were developed for therapeutic reversed. However, Whitlock et al., reported no effects of game-
purposes in psychiatry or neurology. They act by influencing regions based cognitive training on visuo spatial navigational abilities and
of the brain non-specifically rather than by some physiological memory [85]. Moreover, increased aggression and reduction of
alterations. Some of these methods are non invasive, while other empathy have been reported for violent computer games [86].
achieves greater selectivity by placing electrodes inside or on the Intensive, computer based cognitive training has showed improve-
brain. Non invasive techniques include Transcranial Direct Current ment in verbal learning and memory in MCI subjects [87]. A
Stimulation (tDCS) and Transcranial Magnetic Stimulation (TMS). cognition-specific computer based cognitive training program in PD
Invasive methods include Deep Brain Stimulation (DBS) and direct patients found improvement in attention and memory [88]. Cognitive
vagus nerve stimulation (dVNS). Some of these techniques exhibited remediation therapy, delivered via computerized programs, of
cognition enhancing effects on healthy individuals [69]. varying length and complexity has been found effective in people
While most of these methods help in encoding of memory and with severe, chronic mental illnesses such as Schizophrenia, bipolar
learning, a few like DBS may directly modulate and affect memory disorders and depression. Still, better study designs are needed
systems [70]. tDCS and TMS are the most researched. Anterior to develop and individualize computer based therapies for different
temporal lobe tDCS and paired pulse TMS stimulation during neuropsychiatric disorders.
encoding help enhance speed of recall [71,72]. Studies have found
tDCS to enhance performance on working memory tasks, learning Conclusion and Future Research
and recall of words on stimulation of left dorso-lateral prefrontal We summarized the effects of non pharmacological interventions
cortex (DLPFC) during encoding [73]. TMS and tDCS have been on cognition in healthy individuals, ageing population as well as in
found to enhance procedural skills by influencing brain plasticity neuropsychiatric disorders. All the non pharmacological interventions
and learning motor tasks by stimulation of the motor areas useful can be envisioned to be somewhat effective in maintaining and
in rehabilitation and therapy. fMRI guided studies have shown perhaps improving optimal levels of cognitive capabilities. Some of
stimulation of the right cortical region to be most successful. The the NPCE such as sleep, meditation, exercise, music, spirituality,
most common side effects reported are headaches, local pain and are based on widely accepted traditional habits. Others like, brain
confusion. The most serious risk is the occurrence of seizure. stimulation, cognitive training and computer based interventions are
There is limited data on cognitive restoration or enhancement in modern and complex.
neuropsychiatric disorders. Efficacy of rTMS on cognitive perfor- Most of these are cost effective and relatively free of adverse
mance in depressed individuals has yielded mixed results. Among 13 effects. Still, many issues are unresolved and need clarification. The
trials comparing active and sham rTMS, 8 did not report significant most important is of ethical concerns. Voices have been raised on
differences in regards to cognitive functions [74]. However, some possible issues of doctors “playing Gods” by trying to enhance what
studies did report improvement in cognitive functions after rTMS over is inherited, interference in nature, autonomy of patients, selective
the left DLPFC. Many studies found benefits in psychomotor speed improvements in cognitive domains, and improper use of NPCE for
and concentration, mood, executive functions and visuospatial competition in today’s world.
ability, procedural learning, verbal learning, working memory and These methods are still evolving and need strong research based
language in depressive disorders, post stroke depression and evidence before being conclusively used in clinical setting. They
depression with PD [75,76]. tDCS in depression has also shown may well be used as adjuvant therapeutic tools in the early stage
cognitive improvements in different domains [77]. Significant effect of neurodegenerative conditions. Comparative research on the
of rTMS in cognitive functions in schizophrenia has been observed variety of currently existing NPCE is strongly needed to evaluate the
[78]. However, one study did not find any cognitive improvement similarities and differences amongst them, so as to individualize the
[79]. Ahmed et al., found significant improvement in global cognitive therapy based on specific cognitive profile of the patient.
functioning by rTMS applied over the bilateral DLPFCs in Alzheimer
dementia [80] which was replicated in other RCTs [74]. In ADHD, References
a recent cross over study found beneficial effects of right DLPFC   [1] Kendra Cherry. What is cognition? [internet]. [cited 2014 Apr 14]. Available from:
rTMS in attention [81]. rTMS has been proposed as a potential tool http://psychology.about.com/od/cindex/g/def_cognition.htm.
  [2] Ringman JM, Cummings JL. Current and emerging pharmacological treatment
that may improve the symptoms of autism spectrum disorders, options for dementia. Behav Neurol. 2006;17:5-16.
specially error monitoring and post-error response correction [82].   [3] Lanni C, Lenzken SC, Pascale A, Vecchio ID, Racchi M, Pistoia F, et al.
We can conclude that these methods have beneficial effects on Cognition enhancers between treating and doping the mind. Pharmacol Res.
2008;57(3):196–213.
cognitive enhancement, although extensive research is needed to
  [4] Kumar K, Sachdeva A. Pharmacological cognitive enhancers in neuro-psychiatry
evaluate long term benefits. – a critical appraisal. Asian Journal of cognitive neurology. Forthcoming July
2015.
Computer Based Interventions   [5] Ingole SR, Rajput SK, Sharma SS. Cognition Enhancers: Current strategies and
future perspectives. CRIPS. 2008;9(3):42-48.
The rapid popularity and the concept of internet gaming addiction   [6] Hillman CH, Erickson KI, Kramer AF. Be smart, exercise your heart: exercise
in adolescents have generated concern among practitioners and effects on brain and cognition. Nat Rev Neurosci. 2008;9:58-65.
policy makers. However, Computer based repetitive stimulation   [7] Coelho FG, Gobbi S, Andreatto CA, Corazza DI, Pedroso RV, Santos-Galduroz
RF. Physical exercise modulates peripheral levels of brain derived neurotrophic
allows training of various cognitive tasks, which promotes
factor (BDNF): a systematic review of experimental studies in the elderly. Arch
cognitive well being. Computer based training programs have Gerontol Geriatr. 2013;56:10-5.
shown improvements of memory, attention, executive function   [8] Sibley BA, Etnier JL. The relationship between physical activity and cognition in
and processing speed along with working memory and episodic children: a meta-analysis. Pediatr Exerc Sci. 2003;15:243-56.
  [9] van Uffelen JG, Chin A, Paw MJ, Hopman-Rock M, van Mechelen W. The effects
memory in young and older adults [83]. There has been focus on of exercise on cognition in older adults with and without cognitive decline: a
enhancing long term memory or brain plasticity to prevent dementia systematic review. Clin J Sport Med. 2008;18(6):486-500.
and age related cognitive decline [84]. There have been variable [10] Smith PJ, Blumenthal JA, Hoffman BM, Cooper H, Strauman TA, Welsh- Bohmer
K, et al. A aerobic exercise and neurocognitive performance: a meta-analytic
effect sizes of computerized training on the cognitive domains.
review of randomized controlled trials. Psychosom Med. 2010;72 (3):239-52.
Processing speed and perceptual measures show medium to large [11] Middleton LE, Barnes DE, Lui LY, Yaffe K. Physical activity over the life course
effect sizes, while memory domains are only in the small or medium and its association with cognitive performance and impairment in old age. J Am
range [83]. It has been shown that improved cognitive performances Geriatr Soc. 2010;58:1322–26.
[12] Berchicci M, Lucci G, DiRusso F. Benefits of physical exercise on the aging brain:
maintained for 6 months after suspension of training, supporting the role of the prefrontal cortex. J Gerontol A Biol Sci Med Sci. 2013;68:1337-41.

4 Journal of Clinical and Diagnostic Research. 2015 Jul, Vol-9(7): VE01-VE06

www.jcdr.net Ankur Sachdeva et al., Non Pharmacological Cognitive Enhancers – Current Perspectives

[13] Kaur J, Garnawat D, Bhatia MS, Sachdev M. Rehabilitation in Alzheimer’s [46] Kaufman Y, Anaki D, Binns M, Freedman M. Cognitive decline in alzheimer disease:
disease. Delhi Psychiatry J. 2013;16:166-70. Impact of spirituality, religiosity, and QOL. Neurology. 2007;68(18):1509-14.
[14] Teri L, Gibbons LE, McCurry SM, Logsdon RG, et al. Exercise plus behavioural [47] Anthony WA. The principle of personhood: The field‘s transcendent principle.
management in patients with alzheimer’s disease: a randomized trail.  JAMA. psychiatr. Rehabil J. 2004;27:205.
2003;290(15):2015-22. [48] Walsh J. The impact of schizophrenia on clients religious beliefs: Implications for
[15] Kaur J, Sharma S. Sachdev M, Mittal J. Rehabilitation of patients with Parkinson families. Fam Soc. 1995;76:551–58.
disease. Delhi Psychiatry J. 2012;15:398-401. [49] Pardini D, Plante TG, Sherman A. Strength of religious faith and its association
[16] Rimer J, Dwan K, Lawlor DA, Greig CA, McMurdo M, Morley W, et al. Exercise with mental health outcomes among recovering alcoholics and addicts. J Subst
for depression. Cochrane Database of Systematic Reviews. 2012;7:CD004366. Abuse Treat. 2001;19:347–54.
doi:10.1002/14651858.CD004366.pub5. [50] Vink AC, Bruinsma MS, Scholten RJPM. Music therapy for people with
[17] Jayakody K, Gunadasa S, Hosker C. Exercise for anxiety disorders: systematic dementia. Cochrane Database of Systematic Reviews. 2004;3:CD003477. DOI:
review. Br J Sports Med. 2014;48:187–96. 10.1002/14651858.CD003477.pub2.
[18] Eime RM, Young JA, Harvey JT, Charity MC, Payne WR. A systematic review of [51] Spiro N. Music and dementia: Observing effects and searching for underlying
the psychological and social benefits of participation in sport for adults: informing theories. Aging Ment Health. 2010;14(8):891-99.
development of a conceptual model of health through sport. Int J Behav Nutr [52] Wan C Y, Schlaug G. Music making as a tool for promoting brain plasticity across
Phys Act. 2013; 10:135. the life span. The Neuroscientist: A Review Journal Bringing Neurobiology,
[19] Gorczynski P, Faulkner G. Exercise therapy for schizophrenia. Cochrane Neurology and Psychiatry. 2010;16(5):566-77.
Database of Systematic Reviews. 2010;5:CD004412. DOI: 10.1002/14651858. [53] Chu H, Yang CY, Lin Y, Ou KL, Lee TY, O’Brien AP, et al. The impact of group
CD004412.pub2 music therapy on depression and cognition in elderly persons with dementia: a
[20] Pearsall R, Smith DJ, Pelosi A, Geddes J. Exercise therapy in adults with randomized controlled study. Biol Res Nurs. 2014;16:209-17.
serious mental illness: a systematic review and meta-analysis. BMC Psychiatry. [54] Robertson-Gillam K. Hearing the voice of the elderly: The potential for choir
2014;14:117. work to reduce depression and meet spiritual needs, in E Mackinlay (ed) Ageing,
[21] Jackson ML, Gunzelmann G, Whitney P, Hinson JM, Belenky G, Rabat A, et al. Disability and Spirituality: addressing the challenge of disability in later life,
Deconstructing and reconstructing cognitive performance in sleep deprivation. London: Jessica Kingsley; 2008.
Sleep Med Rev. 2013;17:215–25. [55] Talwar N, Crawford MJ, Maratos A, Nur U, McDermott O, Procter S. Music
[22] Diekelmann S. Sleep for cognitive enhancement. Front Syst Neurosci. 2014;8:46. therapy for in-patients with schizophrenia: exploratory randomised controlled
[23] Rasch B, Born J. About sleep’s role in memory. Physiol Rev. 2013;93:681– 766. trial. Br J Psychiatry.  2006;189:405–09.
[24] Stickgold R, Walker MP. Sleep-dependent memory triage: evolving generalization [56] Gold C, Heldal TO, Dahle T, Wigram T. Music therapy for schizophrenia or
through selective processing. Nat Neurosci. 2013;16:139–45. schizophrenia-like illnesses. Cochrane Database of Systematic Reviews
[25] Payne JD, Chambers AM, Kensinger EA. Sleep promotes lasting changes in 2005;2:CD004025. DOI: 10.1002/14651858.CD004025.pub2.
selective memory for emotional scenes. Front Integr Neurosci. 2012;6:108. [57] Maratos A, Gold C, Wang X, Crawford M. Music therapy for depression. Cochrane
[26] Goder R, Baier PC, Beith B, Baecker C, Seeck-Hirschner M, Junghanns K, Database of Systematic Reviews. 2008;1:CD004517. DOI: 10.1002/14651858.
et al. Effects of transcranial direct current stimulation during sleep on memory CD004517.pub2.
performance in patients with schizophrenia. Schizophr Res. 2013;144:153–54. [58] Jackson P L, Doyon J, Richards C L, Malouin F. The efficacy of combined
[27] Goder R, Fritzer G, Gottwald B, Lippmann B, Seeck-Hirschner M, Serafin I, et physical and mental practice in the learning of a foot-sequence task after stroke:
al. Effects of olanzapine on slow wave sleep, sleep spindles and sleep related A case report. Neurorehab Neural Re. 2004;18(2):106–11.
memory consolidation in schizophrenia. Pharmacopsychiatry. 2008;41:92–99. [59] Morrison AB, Chein JM. Does working memory training work? The promise and
[28] Wamsley EJ, Shinn AK, Tucker MA, Ono KE, McKinley SK, Ely AV, et al. The effects challenges of enhancing cognition by training working memory. Psychon B Rev.
of eszopiclone on sleep spindles and memory consolidation in schizophrenia: a 2011;18(1):46-60.
randomized placebo-controlled trial. Sleep. 2013;36:1369–76. [60] Conners FA, Rosenquist CJ, Arnett L, Moore MS, Hume LE. Improving memory
[29] Kleim B, Wilhelm FH, Temp L, Margraf J, Wiederhold BK, Rasch B. Sleep span in children with Down syndrome. J Intell Disabil Res. 2008;52:244–55.
enhances exposure therapy. Psychol Med. 2014;44(7):1511-19. [61] Carretti B, Borella E, De Beni R. Does strategic memory training improve the
[30] Alfano CA, Zakem AH, Costa NM, Taylor LK, Weems CF. Sleep problems and working memory performance of younger and older adults? Exp Psychol.
their relation to cognitive factors, anxiety, and depressive symptoms in children 2007;54:311–20.
and adolescents. Depress Anxiety. 2009;26:503–12. [62] Holmes J, Gathercole SE, Place M, Dunning DL, Hilton K, Elliot JG. Working
[31] Lazowski LK, Townsend B, Hawken ER, Jokic R, du Toit R, Milev R. Sleep memory deficits can be overcome: Impacts of training and medication on working
architecture and cognitive changes in olanzapine-treated patients with memory in children with ADHD. Appl Cognitive Psych. 2010;24(6):827–36.
depression: A double blind randomized placebo controlled trial.  BMC [63] Vogt A, Kappos L, Calabrese P, Stocklin M, Gschwind L, Opwis K, et al. Working
Psychiatry. 2014;14:202. memory training in patients with multiple sclerosis - comparison of two different
[32] Lim AS, Kowgier M, Yu L, Buchman AS, Bennett DA. Sleep fragmentation and training schedules. Restor Neurol Neuros. 2009;27(3): 225–35.
the risk of incident alzheimer’s disease and cognitive decline in older persons.  [64] Wykes T, Reeder C, Corner J, Williams C, Everitt B. The effects of neurocognitive
Sleep. 2013;36(7):1027-32. remediation on executive processing in patients with schizophrenia. Schizophrenia
[33] Lee HK, Jeong JH, Kim NY, Park M, Kim TW, Seo HJ, et al. Sleep and cognitive Bull. 1999;25(2):291–307.
problems in patients with attention-deficit hyperactivity disorder. Neuropsychiatr [65] Klusmann V, Evers A, Schwarzer R, Schlattmann P, Reischies FM, Heuser I,
Dis Treat. 2014;10:1799-805. et al. Complex mental and physical activity in older women and cognitive
[34] Hodgins HS, Adair KC. Attentional processes and meditation. Conscious Cogn. performance: a6-month randomized controlled trial. J Gerontol A Biol Sci Med
2010;19:872-78. Sci. 2010;65:680–88.
[35] Gard T, Hölzel BK, Lazar SW. The potential effects of meditation on age-related [66] Karpicke JD, Roediger HL. The critical importance of retrieval for learning.
cognitive decline: a systematic review. Ann Ny Acad Sci. 2014;1307:89-103. Science. 2008;319: 966-68.
[36] Krisanaprakornkit T, Ngamjarus C, Witoonchart C, Piyavhatkul N. Meditation [67] McGurk SR, Twamley EW, Sitzer DI, McHugo GJ, Mueser KT. A meta-analysis
therapies for attention-deficit/hyperactivity disorder (ADHD). Cochrane Database of cognitive remediation in schizophrenia. Am J Psychiatry. 2007;164(12):
of Systematic Reviews. 2010;6:CD006507. DOI: 10.1002/14651858.CD006507. 1791–802.
pub2 [68] Statucka M, Walder DJ. Efficacy of social cognition remediation programs targeting
[37] Krisanaprakornkit T, Sriraj W, Piyavhatkul N, Laopaiboon M. Meditation facial affect recognition deficits in schizophrenia: a review and consideration of
therapy for anxiety disorders. Cochrane Database of Systematic Reviews. high-risk samples and sex differences. Psychiatry Res. 2013;206:125–39.
2006;1:CD004998. DOI: 10.1002/14651858.CD004998.pub2. [69] McKinley RA, Bridges N, Walters CM, Nelson J. Modulating the brain at work
[38] Khoury B,  Lecomte T,  Gaudiano BA,  Paquin K.  Mindfulness interventions for using noninvasive transcranial stimulation. NeuroImage. 2012;59(1):129-37.
psychosis: A meta-analysis. Schizophr Res. 2013;150:176-84. [70] Suthana N, Haneef Z, Stern J, Mukamel R, Behnke E, Knowlton B, et al. Memory
[39] Hariprasad VR, Koparde V, Sivakumar PT, Varambally S, Thirthalli J, Varghese enhancement and deep-brain stimulation of the entorhinal area. New Eng J Med.
M, et al. Randomized clinical trial of yoga-based intervention in residents from 2012;366(6):502-10.
elderly homes: Effects on cognitive function.  Indian J Psychiatry.  2013;55(3): [71] Ross LA, McCoy D, Wolk DA, Coslett HB, Olson IR. Improved proper name
S357–S63. recall by electrical stimulation of the anterior temporal lobes. Neuropsychologia.
[40] Bangalore NG, Varambally S. Yoga therapy for Schizophrenia. Int J Yoga. 2012; 2010;48(12):3671-74.
5:85–91. [72] Gagnon G, Schneider C, Grondin S, Blanchet S. Enhancement of episodic
[41] Cramer H, Lauche R, Klose P, Langhorst J, Dobos G. Yoga for schizophrenia: a memory in young and healthy adults: a paired-pulse TMS study on encoding
systematic review and meta-analysis. BMC Psychiatry. 2013;13:32. and retrieval performance. Neurosci Lett. 2010;488 (2):138-42.
[42] Cramer H, Lauche R, Langhorst J, Dobos G. Yoga for depression: a systematic [73] Teo F, Hoy KE, Daskalakis ZJ, Fitzgerald PB. Investigating the role of current
review and meta-analysis. Depress Anxiety. 2013;20:1068–83. strength in tDCS modulation of working memory performance in healthy controls.
[43] FROM THE UN GENERAL ASSEMBALY. United Nations declares 21 June as Front Psychiatry. 2011;2:45.
International Day of Yoga [internet]. 12 Dec. 2014 [cited 2015 Feb 01]. Available [74] Demirtas-Tatlidede A, Vahabzadeh-Hagh AM, Pascual-Leone A. Can
from: http://www.unic.org.in/display.php?E=13712&K=Yoga. noninvasive brain stimulation enhance cognition in neuropsychiatric disorders?
[44] Blazer DG. Section introduction: Spirituality, depression and suicide. South Med Neuropharmacology. 2013;64:566-78.
J. 2007;100(7):733-34. [75] Boggio PS, Fregni F, Bermpohl F, Mansur CG, Rosa M, Rumi DO, et al. Effect of
[45] Grabovac A, Clark N, McKenna M. Pilot study and evaluation of postgraduate repetitive TMS and fluoxetine on cognitive function in patients with Parkinson’s
course on “The interface between spirituality, religion and psychiatry.” Acad disease and concurrent depression. Mov Disord. 2005;20:1178-84.
Psychiatr. 2008;32(4):332-37.

Journal of Clinical and Diagnostic Research. 2015 Jul, Vol-9(7): VE01-VE06 5

 Ankur Sachdeva et al., Non Pharmacological Cognitive Enhancers – Current Perspectives www.jcdr.net

[76] Holtzheimer PE, McDonald WM, Mufti M, Kelley ME, Quinn S, Corso G, et al. [83] Smith GE, Housen P, Yaffe K, Ruff R, Kennison RF, Mahncke HW. A cognitive
Accelerated repetitive transcranial magnetic stimulation for treatment-resistant training program based on principles of brain plasticity: results from the
depression. Depress Anxiety. 2010;27:960-63. improvement in memory with plasticity-based adaptive cognitive training
[77] Loo CK, Sachdev P, Martin D, Pigot M, Alonzo A, Malhi GS, et al. A double-blind, (IMPACT) study. J Am Geriatr Soc. 2009;57(4):594-03.
sham-controlled trial of transcranial direct current stimulation for the treatment of [84] Miller KJ, Dye RV, Kim J, Jennings JL, O’Toole E, Wong J, et al. Effect of a
depression. Int. J Neuropsychopharmacol. 2010;13:61-69. computerized brain exercise program on cognitive performance in older adults.
[78] Barr MS, Farzan F, Arenovich T, Chen R, Fitzgerald PB, Daskalakis ZJ. The effect Am J Geriatr Psychiatry. 2013;21:655–63.
of repetitive transcranial magnetic stimulation on gamma oscillatory activity in [85] Whitlock LA, Collins AC, Allaire JC. Individual differences in response to cognitive
schizophrenia. PLoS One. 2011;6:e22627. training: using a multi-modal, attentionally demanding game-based intervention
[79] Sachdev P, Loo C, Mitchell P, Malhi G. Transcranial magnetic stimulation for the for older adults. Comput Human Behav.2012;28:1091–96.
deficit syndrome of schizophrenia: a pilot investigation. Psychiatry Clin Neurosci. [86] Anderson CA, Shibuya A, Ihori N, Swing EL, Bushman BJ, Sakamoto A, et al.
2005;59:354-57. Violent video game effects on aggression, empathy, and prosocial behaviour in
[80] Ahmed MA, Darwish ES, Khedr EM, El Serogy YM, Ali AM. Effects of low versus eastern and western countries: a meta analytic review. Psychol Bull. 2010;136
high frequencies of repetitive transcranial magnetic stimulation on cognitive function (2):151-73.
and cortical excitability in Alzheimer’s dementia. J Neurol. 2012;259:83-92. [87] Barnes DE, Yaffe K, Belfor N, Jagust WJ, DeCarli C, Reed BR, et al. Computer-
[81] Bloch Y, Harel EV, Aviram S, Govezensky J, Ratzoni G, Levkovitz Y. Positive effects based cognitive training for mild cognitive impairment: Results from a Pilot
of repetitive transcranial magnetic stimulation on attention in ADHD Subjects: a Randomized, Controlled Trial. Alz Dis Assoc Dis. 2009;23(3):205-10.
randomized controlled pilot study. World J Biol Psychiatry. 2010;11:755-58. [88] Zimmermann R, Gschwandtner U, Benz N, Hatz F, Schindler C, Taub E, et
[82] Sokhadze EM, Baruth JM, Sears L, Sokhadze GE, El-Baz AS, Casanova MF. al.  Cognitive training in Parkinson disease: cognition-specific vs nonspecific
Prefrontal neuromodulation using rTMS improves error monitoring and correction computer training. Neurology. 2014;82(14):1219-26.
function in autism. Appl Psychophysiol Biofeedback. 2012;37:91-102.

PARTICULARS OF CONTRIBUTORS:
1. Senior Resident, Department of Psychiatry and Drug De-addiction, Post Graduate Institute of Medical Education and Research,
Dr Ram Manohar Lohia Hospital, New Delhi, India.
2. Associate Professor, Department of Psychiatry, Vardhman Mahavir Medical College and Safdarjang Hospital, New Delhi, India.
3. Professor, Head of the Department, Department of Neurology, Post Graduate Institute of Medical Education and Research, Dr Ram Manohar Lohia Hospital,
New Delhi, India.

NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Ankur Sachdeva,
Senior Resident, Department of Psychiatry and Drug De-addiction, Post Graduate Institute of Medical Education and Research,
Dr Ram Manohar Lohia Hospital, Park Street, New Delhi-110001, India. Date of Submission: Feb 11, 2015
E-mail: [email protected] Date of Peer Review: Apr 28, 2015
Date of Acceptance: May 23, 2015
Financial OR OTHER COMPETING INTERESTS: None. Date of Publishing: Jul 01, 2015

6 Journal of Clinical and Diagnostic Research. 2015 Jul, Vol-9(7): VE01-VE06