“Checkmate the Onset of Dementia”: Prescribing Chess to Elderly People as a Primary Prevention of Dementia

by Ivan Fernández Vega, MD PhD on 25 January 2019

It is estimated that around 45 million people in the world suffer from dementia, most of them over 60 years old. With increases in life expectancy, this incidence is projected to double every 20 years [1]. In fact, dementia affects 13.9% of persons aged 71 years and older and 37.4% of those over 90 [2]. Alzheimer’s disease (AD) is the most common neurodegenerative disease and it is one of the greatest health-care challenges of the 21st century. AD inevitably leads to death, although patients frequently die of the complications of other chronic illnesses such as cardiovascular disease, cancer, respiratory disease, and diabetes [1, 3]. Interestingly, the prevalence of dementia in the United States among those aged 65 or older decreased significantly between 2000 and 2012. Increased levels of educational attainment have been linked to this decline in dementia prevalence, but the full set of social, behavioral, and medical factors that contributed to the decline remains unclear [4]. These days we are aware that the greatest risk factor for the development of AD is old age, but this in itself is not enough to cause the disease. Other major risk factors include the presence of one or more apolipoprotein gene E4 alleles, low educational and occupational attainment, family history of AD, moderate or severe traumatic brain injuries, and cardiovascular risk factors [5, 6]. Despite decades of study, there is to date no disease-modifying therapy against AD in particular or dementia in general. However, around a third of AD cases worldwide could be attributable to potentially modifiable risk factors [7, 8]. Interventions that postpone dementia onset by even two years would cut projected dementia prevalence in 2047 by 22% [9].

Normal cognitive aging (NCA) may be influenced not only by our genes but also by our lifestyle. Healthy aging, which incorporates stimulation of the mind, means revitalizing the brain and replacing unhealthy habits with healthy habits. Patients with AD have reduced activity levels (physical and mental) in mid-life compared with healthy control-group subjects [10]. Educational and occupational attainment have been found to protect against the development of the disease in a ‘‘use it or lose it’’ scenario, but participation in activities has received little attention [11]. According to various scientific indications, playing chess frequently delays NCA [12]. Neuroplasticity tells us about the importance of practice (repetitive engagement in activities that enhance brain health) if one wants to markedly improve brain function. Animal studies have found that a little daily stress may enhance neuronal and synaptic function, promote neurogenesis in the hippocampus, and improve cognitive performance in certain tasks [13].

Here there are twelve reasons to support the use of chess in the primary prevention of dementia:

  1. Chess is universal.
  2. Chess is cheap.
  3. Chess is a very complete activity: game, sport, art, and science. It provides very interesting connections between art and science [14].
  4. Chess has been documented for more than 15 centuries.
  5. Chess develops intelligence at any age, and particularly with children [15].
  6. Chess delays NCA [12, 16]. It also produces small amounts of stress which improves neuroplasticity.
  7. Chess has been shown to be very useful in various problem social contexts: in prisons, with drug addicts, the unprivileged, people who have panic attacks, and with hyperactive or autistic children [17, 18].
  8. Chess produces fascinating personalities. For instance, the world chess champion and genius Bobby Fisher.
  9. Chess is the only sport that can be played on the Internet. You can also meet people across the world because of chess and put into practice your social skills. There are many consolidated platforms such as Chess24, Chessbase, Lichess, iChess, etc.
  10. Chess has many variants that can be a great way to mix things up and apply your chess skills in different and exciting ways. The Encyclopedia of Chess Variants estimates that there are well over 2,000 different variants.
  11. Chess can be played on some platforms that are universally accessible. Chess can be concurrently played by people with different abilities and preferences, including people with disabilities (e.g., people with hand-motor or visual impairment or who are blind).
  12. Chess bestows a good image on those who play and sponsor it.

Finally, work has recently been published indicating that “speed of processing training” resulted in an almost 30% reduction in the risk of developing dementia [10]. This is the first study to show that any intervention (behavioral or pharmacological) can lower the risk of dementia, supporting the notion that playing chess should be part of this brain booster training.

REFERENCES
[1] Scheltens P, Blennow K, Breteler MM, de Strooper B, Frisoni GB, Salloway S, Van der Flier WM (2016) Alzheimer's disease. Lancet 388, 505-517.
[2] Plassman BL, Langa KM, Fisher GG, Heeringa SG, Weir DR, Ofstedal MB, Burke JR, Hurd MD, Potter GG, Rodgers WL, Steffens DC, Willis RJ, Wallace RB (2007) Prevalence of dementia in the United States: the aging, demographics, and memory study. Neuroepidemiology 29, 125-132.
[3] Sarkar A, Irwin M, Singh A, Riccetti M, Singh A (2016) Alzheimer's disease: the silver tsunami of the 21(st) century. Neural Regen Res 11, 693-697.
[4] Langa KM, Larson EB, Crimmins EM, Faul JD, Levine DA, Kabeto MU, Weir DR (2017) A comparison of the prevalence of dementia in the United States in 2000 and 2012. JAMA Intern Med 177, 51-58.
[5] Apostolova LG, Risacher SL, Duran T, Stage EC, Goukasian N, West JD, Do TM, Grotts J, Wilhalme H, Nho K, Phillips M, Elashoff D, Saykin AJ, Alzheimer's Disease Neuroimaging Initiative (2018) Associations of the top 20 Alzheimer disease risk variants with brain amyloidosis. JAMA Neurol 75, 328-341.
[6] Apostolova LG (2016) Alzheimer disease. Continuum (Minneap Minn) 22, 419-434.
[7] Norton S, Matthews FE, Barnes DE, Yaffe K, Brayne C (2014) Potential for primary prevention of Alzheimer's disease: an analysis of population-based data. Lancet Neurol 13, 788-794.
[8] Sanchez-Mut JV, Graff J (2015) Epigenetic alterations in Alzheimer's disease. Front Behav Neurosci 9, 347.
[9] Brookmeyer R, Johnson E, Ziegler-Graham K, Arrighi HM (2007) Forecasting the global burden of Alzheimer's disease. Alzheimers Dement 3, 186-191.
[10] Edwards JD, Xu H, Clark DO, Guey LT, Ross LA, Unverzagt FW (2017) Speed of processing training results in lower risk of dementia. Alzheimers Dement (N Y) 3, 603-611.
[11] Friedland RP, Fritsch T, Smyth KA, Koss E, Lerner AJ, Chen CH, Petot GJ, Debanne SM (2001) Patients with Alzheimer's disease have reduced activities in midlife compared with healthy control-group members. Proc Natl Acad Sci U S A 98, 3440-3445.
[12] Desai AK (2011) Revitalizing the aged brain. Med Clin North Am 95, 463-475, ix.
[13] Lyons DM, Buckmaster PS, Lee AG, Wu C, Mitra R, Duffey LM, Buckmaster CL, Her S, Patel PD, Schatzberg AF (2010) Stress coping stimulates hippocampal neurogenesis in adult monkeys. Proc Natl Acad Sci U S A 107, 14823-14827.
[14] Sala G, Foley JP, Gobet F (2017) The effects of chess instruction on pupils' cognitive and academic skills: state of the art and theoretical challenges. Front Psychol 8, 238.
[15] Aciego R, Garcia L, Betancort M (2012) The benefits of chess for the intellectual and social-emotional enrichment in schoolchildren. Span J Psychol 15, 551-559.
[16] Dowd SB, Davidhizar R (2003) Can mental and physical activities such as chess and gardening help in the prevention and treatment of Alzheimer's? Healthy aging through stimulation of the mind. J Pract Nurs 53, 11-13.
[17] Barzegar K, Barzegar S (2017) Chess therapy: A new approach to curing panic attack. Asian J Psychiatr 30, 118-119.
[18] Pakenham-Walsh R (1949) Chess as a form of recreational therapy. J Ment Sci 95, 203.

Last comment on 31 January 2019 by Soraya Valles, PhD

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I enjoyed reading this interesting and timely blog on prescribing chess. With the increased awareness of, and also the practice of social prescribing, it seems more physicians and healthcare workers are appreciating the benefits of adding social prescriptions to the care plans of their patients. As we are well aware, many persons with dementia and AD also have other health care issues, in addition to declining cognitive abilities. These are wide ranging, and can include issues such as depression, anxiety, diabetes, osteoporosis amongst others. Complementary therapies such as music therapy or art therapy; and social programs could potentially help in managing and/or contribute to treating underlying factors to some health issues (such as loneliness and anxiety); while working in combination with physician directives and medications to ensure a more comprehensive symptom and treatment management strategy.

On November 1, 2018 a new initiative was launched in Montreal, Quebec, where physicians belonging to the Montreal-based medical association (Médecins francophones du Canada) acquired the capacity to prescribe a tour of Quebec’s Montreal Museum of Fine Arts for free to 50 of their patients and/or family members. The choice of museums was selected as visits to such cultural institutions may help boost a person’s mood and elevate serotonin [1].

With respect to chess, I see it potentially having not only benefits for cognition but also for reducing feelings of social isolation, loneliness and fostering a sense of connection to others. Chess may be a challenging game for persons who have never played the game and who are in the early stages of dementia, but I also think supports could be built into the game to help those new to it. Here is a link to a recent 2018 news article on social prescribing if you are interested in learning more on the subject. https://www.thestar.com/life/health_wellness/opinion/2018/03/18/doctors-....

Reference

[1] Solly M (2018) British Doctors may soon prescribe art, music, dance, singing lessons. Smithsonian. Retrieved from: https://www.smithsonianmag.com/smart-news/british-doctors-may-soon-presc...

The basic idea of engaging in activities that are mentally stimulating during advanced aging have been reported to reduce cognitive decline and dementia in a number of studies. For example, Wilson and colleagues [1] in a 5 year study showed that such mentally challenging activities in a diversified elderly group, including playing chess on a regular basis, led to better cognitive function when participants were compared to cognitively inactive persons. 

Dr. Fernandez-Vega takes these findings a step further by suggesting that
‘prescribing’ chess to elderly people could reduce cognitive decline.  Although this is an interesting suggestion, he does not provide us with a plan on how to get the rising population of elderly people to play chess.

Perhaps teaching and encouraging chess playing could be tried at senior centers or senior living communities. Chess playing could be recommended by medical practitioners, memory clinics, and relatives of the elderly living with them.

However, the reality is that implementing such a strategy as a preventive tactic to lower dementia risk is no picnic and would require acceptance as “medical standard of care practice” by physicians and health care professionals as well as general compliance by patients. There are those who would argue that no clear evidence-based medicine exists to support a clinical practice guideline that health care workers should follow. A counter argument, on the other hand, could point out that playing chess is not invasive technology, is non-harmful to patients and is possibly therapeutic, although in my judgment, chess can be highly addictive.

My own experience, I confess, is that I have a soft spot for chess that still lingers to this day having been an avid tournament player while in high school and captain of my college chess team. Aside from the keen analytic process good chess playing demands, the game taught me to refine my thinking when making important decisions, to judge the consequences of an action or inaction, and to consider the big picture of a stratagem, not a snippet of it. 

An important aspect of engaging in mentally stimulating activities with respect to extending cognitive ability brings up the so called “cognitive reserve” hypothesis, an unproven concept adapted to the notion that educational elitism ostensibly confers a delay in time to cognitive decline and dementia. Cognitive reserve in geriatrics is nevertheless an unseen and presently non-measurable construct although it has gained a wide audience among many investigators.

I have argued in previous publications (see [2]), that possible extension of cognitive ability from cognitive meltdown is not dependent on accumulating a lofty crystallized intelligence but the practice that uses mentally stimulating activities during the aging process, regardless of educational attainment. Possessing a higher level of education than lesser educated people provides an obvious statistical advantage during advanced aging compared to individuals not as much exposed to reading a newspaper or book, joining a book club, doing puzzles, participating in a creative project, learning a craft, taking a class at the local community college, and engaging in many other mentally challenging endeavors.

However, if lesser educated people regularly participate in some of these mental tasks, they are as likely as the better educated to diminish their risk of cognitive decline. This has been shown in multiple studies when groups with different educational backgrounds are cognitively tested for factors unrelated to schooling levels [1].

The reason is that engaging in mental activities, in this case, during advanced aging, results in a neuronal response that dynamizes cerebral perfusion. This process has been variously described using functional magnetic resonance imaging (fMRI), blood oxygen dependent level (BOLD) response and cerebral perfusion measurements following sustained neuronal stimuli [3].

Cognitive reserve is not, in my opinion, at play here (if it even exists). A more cogent explanation would involve consistent neuronal activation that ‘keeps local neurons on their toes and astrocytes on their endfeet’ (a system called neurovascular coupling) and which elicits hemodynamic responses associated with increased blood flow to the brain, thus assuring an appropriate energy supply needed by active brain cells.

It is clear this problem needs to be intensely examined with state-of-the-art tools that can determine the effects of neurovascular coupling on cognitive aging and, especially, on vascular risk factors to Alzheimer’s dementia.

References
[1] Wilson RS, Segawa E, Boyle PA, Bennett DA (2012) Influence of late-life cognitive activity on cognitive health. Neurology 78, 1123–1129.
[2] de la Torre JC (2016) Alzheimer’s Turning Point: A Vascular Approach To Clinical Prevention. Springer International Publishing AG, Switzerland, pp. 155-157.
[3] Buxton RB, Uludağ K, Dubowitz DJ, Liu TT (2004) Modeling the hemodynamic response to brain activation. Neuroimage 23 Suppl 1, S220-233.

The game of chess has often been seen as a relatively difficult endeavor suitable for particularly intelligent people because of the need for concentration and anticipation of moves that require good support from imagination and abstract thinking. Without doubt, chess playing is currently classified as an intellectually complete activity. In this line, chess playing seems to be useful to train cerebral plasticity, promote learning and concentration, and derive pleasure. It has also been useful to reduce stress and panic attacks.  

The fame of chess has also often been obscured by the apparent high incidence of mental disorders in great players, such as Paul Morphy, Wilhelm Steinitz, Emmanuel Lasker, Alexander Alekhine, Mikhail Botvinik, Mikhail Tal, Bobby Fischer, and Garry Kasparov, among others. However, it is difficult to know if these rare cases in chess do not also occur in other disciplines in which the individual pushes himself to the limit of his physical or mental force; or conversely, if it is a previous mental state that induces the genius to spend hours analyzing possible moves of some pieces that have an unparalleled strategic and symbolic value.

Recent studies have shown that chess playing may be an activity that delays the appearance of cognitive impairment. It is not surprising since mental activity exercises neural plasticity and enhances the use of alternative neuronal pathways to solve different tasks. Chess is then one of the activities that can be used to delay cognitive impairment in middle-age.

However, when we are living or working with individuals suffering from cognitive impairment, the rules of chess appear to be too complicated and often frustrating for the patient. Other less abstract activities geared to obtaining more detectable positive material, sensory, or physical results are more effective and rewarding.

Can we recommend backgammon, which is 50% skill and 50% chance, the perfect board game for friends to play day after day, year after year?

The suggestion made by Dr. Fernandez-Vega of implementing chess as a strategy to delay the onset of dementia is interesting. However, I share some of the concerns raised by Dr. de La Torre. Playing chess may result too difficult for some patients. I believe that to maximize results a tailored/personalized set of cognitively stimulating activities (including chess) should be put in place in combination with innovative pharmacological approaches (see for instance the use of cognitive enhancers) (1).

(1) Brem AK, Sensi SL. Towards Combinatorial Approaches for Preserving Cognitive Fitness in Aging. Trends Neurosci. 2018 Dec;41(12):885-897. doi: 10.1016/j.tins.2018.09.009. Epub 2018 Oct 18.

 

 

 

 

Alzheimer's disease (AD) is a neurodegenerative disease, where there is a clear cognitive loss that advance progressively until patient death. The causes that lead to the AD to delay cognitive decline and death are still currently unknown and therefore the use of appropriate games to prevent the cognitive decline, could be an option. The article written by Ivan Fernández Vega indicating that prescribing chess to the elderly population can help to decrease dementia including Alzheimer’s disease, presents an interesting idea. The study of Wilson has been the most convincing about chess and mental activity [1,2] but why only chess, perhaps there are no other games that favor attention and cognitive ability? For example Mahjong, on which many articles indicate their benefits [3], the crosswords or Sudoku, etc. All of them develop the concentration and memory, so no difference should be found between them. These games have not shown as many benefits as announced by the industry, but cognitive training helps increases brain neuroplasticity and communication between different cells in our brain.

The use of games that affect cognition and exercise the brain can act through various physiological mechanisms. In the brain there must be at all times a balance between neurons and astrocytes at functional level [4]. Many researchers have focused on the neurons and the improvements they could suffer with the use of these games. Changes in their number or in the number of connections, etc. But one might ask what happens with the astrocytes or with the oligodendroglia. In the first case, astrocytes are responsible for a multitude of functions and the scientific community are discovering more and more, therefore, research should not be circumscribed exclusively to neurons. Furthermore, respect to oligodendroglia, changes in neuronal myelination must also be taken into account, because, if the neurons lose myelin, the rapid response of the neurons, will not produce. Accordingly, I think that we need to study more about the involvement of astrocytes, oligodendroglia and microglia in the increment of cognition and the role that have chess and other games. Furthermore, brain cells would need much more energy during chess use, with greater oxygen and energy supply and therefore with the need for more cerebral blood flow. The greater cerebral irrigation can contribute to increase the elimination of cerebral toxins, such as astrocytes do [5], and also decrease inflammation and oxidative stress.

Just as exercising achieves delaying the aging of the body, exercising the mind allows brain aging to be delayed. As the aging of the population is increasing in the first world, and spending on human and medical resources are increasing, achieving better physical and mental health can be considered essential today. At the scientific level, one of the important steps to verify if this hypothesis is true would be to carry out a study with a high number of participants (about 3000 persons) and over a long period of time (minimum 3 years). Obviously the experiment would be very expensive and many of the participants could leave the study.

References
[1] Wilson RS, Segawa E, Boyle PA, Bennett DA (2012) Influence of late-life cognitive activity on cognitive health. Neurology 78, 1123–1129.
[2] Lin Q, Cao Y, Gao J (2015) The impacts of a GO-game (Chinese chess) intervention on Alzheimer disease in a Northeast Chinese population. Front Aging Neurosci 7, 163.
[3] Cheng ST, Chan AC, Yu EC (2006) An exploratory study of the effect of mahjong on the cognitive functioning of persons with dementia. Int J Geriatr Psychiatry 21, 611-617.
[4] Aguirre-Rueda D, Guerra-Ojeda S, Aldasoro M, Iradi A, Obrador E, Ortega A, Mauricio MD, Vila JM, Valles SL (2015) Astrocytes protect neurons from Aβ1-42 peptide-induced neurotoxicity increasing TFAM and PGC-1 and decreasing PPAR-γ and SIRT-1. Int J Med Sci 12, 48-56.
[5] Aguirre-Rueda D, Guerra-Ojeda S, Aldasoro M, Iradi A, Obrador E, Mauricio MD, Vila JM, Marchio P, Valles SL (2015) WIN 55,212-2, agonist of cannabinoid receptors, prevents amyloid β1-42 effects on astrocytes in primary culture. PLoS One 10, e0122843.