A recently published study provides evidence that crosswords may slow the progress of cognitive decline. Although the study is not conclusive, it does suggest that the “mental exercise” of these puzzles can help slow the progression of dementia.
When I was a grad student at Syracuse University, a bunch of grad students would meet over coffee and bagels to do the New York Times Sunday crossword puzzle. It was a team effort because it was so large and so difficult. I haven’t done a crossword puzzle since those days, but I know many of my contemporaries still do the Sunday New York Times version. The New York Times even has an app for their popular crosswords, so you don’t even have to get your fingers dirty by reading a newspaper.
As I always do, I will examine and critique the design and results of the paper to see if you start doing crosswords with your grandmother to help reduce her rate of cognitive decline. It might be a fun way to bond with your senior relatives.
What are dementia and Alzheimer’s disease?
Before I proceed, it’s important to describe what are dementia and Alzheimer’s disease (AD). Both are chronic neurodegenerative diseases that usually start slowly and worsen over time. AD accounts for 60-70% of dementia cases, even though the terms are sometimes conflated. To be clear, Alzheimer’s disease is a form of dementia.
Amyloid plaques, phosphorylated tau tangles, and neurofibrillary tangles are generally easily visible pathologies that can be observed by microscopic analysis of brain tissue from autopsies of those potentially afflicted by AD. These plaques and tangles seem to have an effect on nerve functioning. Despite these observations, the precise pathophysiology, or development, of the disease is not known.
Of course, dementia includes these pathologies, but because it is a broader term, it includes other types of neurological conditions that are not related to AD.
The causes of AD are unknown (notice how much we do not know about this disease). However, it is speculated that it is mostly genetically related, with a large number of genes that underlie this relationship. Despite the internet tropes, there is no rigorous evidence that aluminum causes AD – I really wish this belief went away fast.
And since we have no clear understanding of the etiology and pathophysiology of AD, there really are no treatments available today for the disease, though some drugs target the amyloid plaques but have not been shown to actually change the outcomes of AD.
There are a couple of medications that help manage some of the symptoms of the disease, but they are certainly not cures. Several drugs at the very earliest stages of development may hold out hope to actually treat the underlying disease.
One more thing that needs to be made clear. There are no biological tests for Alzheimer’s disease — usually, you can only find the amyloid plaques and other pathologies in post-mortem autopsies. Unfortunately. in the absence of an autopsy, clinical diagnoses of AD are “possible” or “probable”, based on other findings, such as memory tests and other methods.
Crosswords and cognitive decline paper
In a paper published on 27 October 2022 in NEJM Evidence, D.P. Devanand, MD, Department of Psychiatry, Columbia University Medical Center, New York, and colleagues developed a two-site, single-blinded, 78-week trial of participants with mild cognitive impairment (MCI). The study was stratified by age, severity (early/late MCI), and site, and participants were randomly assigned to 12 weeks of intensive, home-based, computerized training with Web-based cognitive games or Web-based crossword puzzles, followed by six booster sessions.
The researchers recruited 107 adults ages 55 to 95 with mild cognitive impairment. For 12 weeks, they were all asked to play one of two types of games, four times a week — 30 minutes on Lumosity, a popular cognitive training platform, or 30 minutes attempting a digital crossword.
After 12 weeks, the participants were reevaluated and given six “booster” doses of additional gameplay during the 78-week experiment.
At the end of the randomized clinical trial, the researchers gave standard assessments, such as the Alzheimer’s Disease Assessment Scale-Cognitive Subscale (ADAS-Cog) score, to measure cognitive decline and asked friends and family to report on their day-to-day functioning. MRI scans were given to participants to measure brain volume changes.
After that metric tonne of science, let’s get down to the key results:
- ADAS-Cog score worsened slightly for games and improved for crosswords at week 78
- From baseline to week 78, the mean ADAS-Cog score worsened for games (9.53 to 9.93) and improved for crosswords (9.59 to 8.61). The lower the score, the better.
- Decreases in hippocampal volume and cortical thickness (both measurements of brain volume) were greater for games than for crosswords.
The researchers concluded:
Home-based computerized training with crosswords demonstrated superior efficacy to games for the primary outcome of baseline-adjusted change in ADAS-Cog score over 78 weeks.
The first thing I want to do is caution the reader that this study does not show crosswords are a cure for cognitive decline. What it does show is that the rate of decline is decreased compared to those who use non-crossword games.
This study has some significant limitations:
- It does not provide any information on whether starting crosswords at a younger age has any effect on cognitive decline.
- It does not provide any data as to whether crosswords (or other types of games) actually decrease the risk of dementia or Alzheimer’s disease.
- It does not eliminate the possibility that games such as Lumosity may be as useful as crosswords because individuals may be more familiar with crosswords.
- The number of participants is quite small, so the statistics aren’t as solid as one would find with a larger trial, say 1000 participants.
- There is no information as to whether there are biologically plausible mechanisms in which crosswords affect cognitive decline. Crosswords may not stimulate the types of abilities that are lost with mild cognitive decline.
I am giving this study three out of five stars. It is very intriguing, but it needs to be repeated in a larger study. It also has to provide some plausible mechanisms so that we might infer causation from this correlation.
So, I guess I’m going to continue playing Wordle, that game wish is a target of obsession by many people.
- Devanand DP, Goldberg TE, Qian M, Rushia SN, Sneed JR, Andrews HF, Nino I, Phillips J, Pence ST, Linares AR, Hellegers CA, Michael AM, Kerner NA, Petrella JR, Doraiswamy PM (2022) Computerized games versus crosswords training in mild cognitive impairment. NEJM Evid, 27 October 2022. doi: 10.1056/EVIDoa2200121
- Hambrick DZ, Salthouse TA, Meinz EJ. Predictors of crossword puzzle proficiency and moderators of age-cognition relations. J Exp Psychol Gen. 1999 Jun;128(2):131-64. doi: 10.1037//0096-34184.108.40.206. PMID: 10406103.