Neurobiology of Aging 61 (2018) 245e254

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Neurobiology of Aging
journal homepage: www.elsevier.com/locate/neuaging

Neuronal and behavioral effects of multi-day brain stimulation and

memory training
Daria Antonenko a, b, *,1, Nadine Külzow a,1, Angelica Sousa a, Kristin Prehn a,
Ulrike Grittner c, d, Agnes Flöel a, b, c, **
a
Charité e Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health,
Department of Neurology, NeuroCure Clinical Research Center, Berlin, Germany
b
Department of Neurology, Universitätsmedizin Greifswald, Greifswald, Germany
c
Center for Stroke Research, Charité e Universitätsmedizin, Berlin, Germany
d
Department of Biostatistics and Clinical Epidemiology, Charité e Universitätsmedizin, Berlin, Germany

a r t i c l e i n f o a b s t r a c t

Article history: Strategies for memory enhancement, especially for the older population, are of great scientific and public
Received 26 April 2017 interest. Here, we aimed at investigating neuronal and behavioral effects of transcranial direct current
Received in revised form 7 September 2017 stimulation (tDCS) paired with memory training. Young and older adults were trained on an object-
Accepted 18 September 2017
location-memory task on 3 consecutive days with either anodal or sham tDCS. Recall performance
Available online 28 September 2017
was assessed immediately after training, 1 day and 1 month later, as well as performance on trained
function and transfer task. Resting-state functional magnetic resonance imaging was conducted at
Keywords:
baseline and at 1-day follow-up to analyze functional coupling in the default mode network. Anodal tDCS
Aging
Cognitive training
led to superior recall performance after training, an associated increase in default mode network
Default mode network strength and enhanced trained function and transfer after 1 month. Our findings suggest that tDCS-
Resting-state fMRI accompanied multi-day training improves performance on trained material, is associated with benefi-
Transcranial direct current stimulation cial memory network alterations, and transfers to other memory tasks. Our study provides insight into
Transfer effects tDCS-induced behavioral and neuronal alterations and will help to develop interventions against age-
related cognitive decline.
Ó 2017 Elsevier Inc. All rights reserved.

1. Introduction improvements of trained and untrained functions (Au et al., 2017;

Research on the combination of cognitive training protocols
with noninvasive transcranial brain stimulation (NIBS) techniques
has gained attention as a means for cognitive enhancement in both
young and older adults (Elmasry et al., 2015; Passow et al., 2017;
Perceval et al., 2016). Given decline of cognitive function even in
healthy aging, combined NIBS-training protocols are of particular
relevance for older adults (Mameli et al., 2014; Perceval et al., 2016).
Especially, the modulation of brain plasticity with transcranial
direct current stimulation (tDCS) concurrent to intense task prac-
tice over multiple days holds promise to induce sustained
* Corresponding author at: Department of Neurology, NeuroCure Clinical
Research Center, Charité Universitätsmedizin, Charitéplatz 1, Berlin 10117, Germany.
Tel.: þ49 30 450 660 447; fax: þ49 3834 866875.
** Corresponding author at: Department of Neurology, Universitätsmedizin
Greifswald, Ferdinand-Sauerbruch-Straße, Greifswald 17475, Germany. Tel.: þ49
3834 86 6815; fax: þ49 3834 86 6875.
E-mail addresses: daria.antonenko@charite.de (D. Antonenko), agnes.floeel@
uni-greifswald.de (A. Flöel).
1
These authors shared first authorship.
0197-4580/$ e see front matter Ó 2017 Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.neurobiolaging.2017.09.017
Berryhill, 2017; Kuo and Nitsche, 2012; Mameli et al., 2014). The
benefits of cognitive training regimes alone, as well as the additive
effects of tDCS on trained and untrained functions, have been
challenged recently (Horvath et al., 2015; Melby-Lervag et al., 2016;
Nilsson et al., 2017). Those benefits have come into question
particularly in older populations, due to reduced neuroplasticity,
deficient neurotransmitter systems, and in general, higher inter-
individual variability in the course of aging (Dahlin et al., 2008;
Passow et al., 2017; von Bastian and Oberauer, 2014).
In young adults, the additive application of tDCS concurrent to
cognitive training over multiple days has been suggested to pro-
duce faster performance gains and more generalized cognitive
improvements (Elmasry et al., 2015; Ruf et al., 2017). However, the
robustness of these effects has been questioned (Horvath et al.,
2015; Mancuso et al., 2016). Beneficial effects on the trained task
have been observed in young adults for working memory (Au et al.,
2016; Martin et al., 2013; Richmond et al., 2014; Ruf et al., 2017) and
for associative learning (Meinzer et al., 2014). Anodal tDCS over
dorsolateral prefrontal cortices during a 3-day 3-back training
enhanced learning and resulted in maintenance and transfer of
246 D. Antonenko et al. / Neurobiology of Aging 61 (2018) 245e254

training gains after 9 months (Ruf et al., 2017). Anodal tDCS over the associated increase in network strength after anodal tDCS. As brain-
left posterior temporoparietal junction during a 5-day learning of behavior associations have shown to be age dependent, with
new object-name associations led to faster and more pronounced stronger relationships in later life for most cognitive domains
learning success compared to the sham stimulation group, resulting (Antonenko and Floel, 2014; Grady et al., 2003; Madden et al., 2004;
in persistent gains after 1 week (Meinzer et al., 2014). Nyberg et al., 2012), we expected this association to be more pro-
In older adults, tDCS may constitute a promising approach to nounced in older adults.
restore functions and counteract age-related cognitive decline
(Mameli et al., 2014; Perceval et al., 2016). Effects of tDCS- 2. Materials and methods
accompanied multi-day training have been investigated only for
working memory processes (Jones et al., 2015; Nilsson et al., 2017; 2.1. Participants
Park et al., 2014; Stephens and Berryhill, 2016). The combination of
working memory practice with concurrent anodal tDCS over the Forty healthy adults participated in the study. The study sample
right prefrontal cortex led to maintained gains on trained and un- comprised 20 younger (12 women; mean age [standard deviation
trained visuospatial working memory functions (Jones et al., 2015) {SD}]/range: 25 years [4]/19e34) and 20 older adults (14 women;
and, beyond that, exerted beneficial effects on ecologically valid far mean age [SD]/range: 70 years [6]/60e78). All were native German
transfer tasks (Stephens and Berryhill, 2016). However, evidence speakers and had no history of neurological or psychiatric disor-
that tDCS-accompanied training causes longer-lasting and more ders. To assure cognitive functioning within age-related norms,
transferable cognitive enhancement than training alone is scarce healthy older participants underwent neuropsychological
and still debated. This may be due to heterogeneous methodolog- screening before study inclusion (Consortium to Establish a Regis-
ical approaches and the presence of null findings as well (Elmasry try for Alzheimer’s Disease, CERAD-Plus Test Battery, https://www.
et al., 2015; Talsma et al., 2016). In a recent study with a large memoryclinic.ch). Baseline characteristics for all participants are
group of older adults, anodal prefrontal tDCS over 20 sessions presented in Table 1. There were no significant differences in
during a complex working memory training failed to modulate baseline characteristics between anodal and sham groups. The
either training gains or immediate transfer (Nilsson et al., 2017). study was approved by the ethics committee of the Char-
The effects of tDCS on brain connectivity have been studied in itéeUniversitätsmedizin Berlin and conducted in accordance with
single-session investigations, but the neuronal correlates of tDCS- the Helsinki Declaration. Written informed consent was obtained
accompanied multi-day cognitive training in neural networks that from all participants before participation.
subserve the complex memory processes are largely unknown
(Elmasry et al., 2015; Wang and Voss, 2015). Changes in local
2.2. Experimental procedure
spontaneous brain activity and functional network connectivity
have been suggested as potential underlying mechanisms of tDCS-
All participants were administered a 3-day visuospatial memory
induced performance enhancement (Elmasry et al., 2015; Hunter
training using an object-location-memory (OLM) paradigm (Floel
et al., 2013; Meinzer et al., 2012). Recent research, focusing on
et al., 2012; Kulzow et al., 2014). During the beginning of the
interindividual variability of tDCS effects, has recognized age as one
training sessions, participants received either anodal or sham tDCS.
of the factors affecting responsiveness to tDCS (Antonenko et al.,
Recall performance was tested in a 3-alternative-forced-choice
2017; Meinzer et al., 2013; Summers et al., 2016). Studies using
(AFC) recall task after each training day as well as 1 day and 1 month
resting-state functional magnetic resonance imaging (rs-fMRI) for
after training. In addition, performance in a similar object-location-
the assessment of functional network connectivity during the
learning (OLL) paradigm and that in the auditory verbal learning
absence of a task revealed that the default mode network (DMN)
test (AVLT) were tested at all time points. One older participant of
represents the most prominent large-scale brain net-
workemediating episodic memory processes (for recent reviews,
see Jeong et al., 2015; Kim, 2016). Declines in DMN connectivity are Table 1
evident in healthy and pathological aging (Jones et al., 2011), pre- Baseline characteristics
dict age-related decrease in episodic memory performance (Fjell YA OA
et al., 2015; Wang et al., 2010; Ward et al., 2015), and may thus
Anodal Sham Anodal Sham
represent a sensitive biomarker for memory deficits (Salami et al.,
N (females) 10 (6) 10 (6) 10 (7) 10 (7)
2014). In fact, recent studies have observed increased DMN func- Age 24 (4) 26 (4) 71 (5) 70 (6)a
tional connectivity following anodal tDCS over the dorsolateral Education 16 (2) 18 (2) 16 (3) 15 (3)
prefrontal cortex (Keeser et al., 2011) and as a result of training- LQ 83 (27) 96 (6) 100 (0) 95 (11)
induced cognitive improvement (Cao et al., 2016; Chapman et al., MMSE 30 (1) 29 (1) 29 (1) 29 (1)
Digit span
2015).
Forward 9 (2) 9 (1) 8 (2) 9 (2)
This is the first study examining the effects of a combined tDCS- Backward 9 (2) 8 (3) 7 (2) 6 (1)a
plus-training approach with the focus on episodic memory func- Phonemic word fluency
tions on the behavioral level, and in parallel, its impact on DMN S 15 (4) 14 (6) 18 (3) 17 (6)
functional connectivity. We administered a visuospatial memory Animals 24 (6) 25 (4) 26 (7) 24 (6)
Semantic word fluency
training over multiple days with concurrent anodal tDCS in young G-R 12 (3) 14 (5) 16 (5) 15 (6)
and older adults. Our aim was to investigate the impact of tDCS and Sports-fruits 16 (2) 16 (1) 15 (2) 14 (3)
training, versus training alone (sham control), on functional BDI 2 (4) 3 (3) 4 (3) 5 (3)
network coupling of the DMN and associated recall performance, as Mean (standard deviation) values are shown. There were no differences in baseline
well as transfer on trained and untrained functions. We hypothe- characteristics between anodal and sham groups. Digit span (Härting and Wechsler,
sized that tDCS-accompanied episodic memory training would 2000) and Phonemic and semantic word fluency test (Aschenbrenner et al., 2000).
improve performance on trained and untrained tasks compared to Key: ANOVA, analysis of variance; BDI, Beck’s Depression Inventory (Hautzinger
et al., 1994); LQ, laterality quotient (Oldfield, 1971); MMSE, MinieMental State
sham stimulation in both young and older adults. Furthermore, as Examination (Folstein et al., 1975); OA, older adults; YA, young adults.
higher connectivity strength in the DMN most likely reflects a
p < 0.05 for comparison of YA versus OA (YA > OA, based on effect for age group
augmented network efficiency, we expected to observe an in univariate ANOVA).
 D. Antonenko et al. / Neurobiology of Aging 61 (2018) 245e254
the sham group did not complete the 1-month follow-up (FU)
assessment. To assess functional network alterations, rs-fMRI was
conducted at baseline and 1 day after training (Fig. 1).
2.3. OLM training
Visuospatial memory training was administered using the OLM
paradigm (Antonenko et al., 2016; Floel et al., 2012; Kulzow et al.,
2014, 2016; Prehn et al., 2017). The task comprised a learning ses-
sion divided into multiple learning blocks, followed by a cued recall
of trained material. In brief, participants had to learn correct posi-
tions of buildings on a schematic street map. Buildings occurred on
their “correct” and “incorrect” locations, the “correct” pairings of
stimulus and location (total of different 30 building-location pairs)
were presented more frequently over the course of multiple
learning blocks (5 learning blocks for older adults with correct
pairings occurring 10 times more frequently; 3 learning blocks for
young adults to avoid ceiling performance with correct pairing
occurring 6 times more frequently than incorrect pairings, Prehn
et al., 2017). Incorrect trials consisted of the presentation of a
building on a position other than its “correct” position. Participants
responded to 120 stimulus-location pairings in each block (60
“correct”; 60 “incorrect”) by button press. Interstimulus interval
was 1 second, response interval was restricted to stimulus pre-
sentation (i.e., 3 seconds), and maximum duration of 1 learning
block being 8 minutes. Participants were not informed about the
underlying statistical principle of stimulus presentation, and
Young Adults (YA) Older Adults (OA)
N=20 N=20
anodal sham anodal sham
Cogni e screening; performance on
Baseline tr on (OLL) and transfer (AVLT);
re ng-state fMRI
+ 1 day
tDCS-accompanied visuospa l training
Training (OLM) on thr ve days;
recall assessed by 3-AFC test on each day
+ 1 day
Recall of trained material (3-AFC);
1-d FU tr on and transfer (OLL, AVLT);
re ng-state fMRI
+ 1 month
Recall of trained material (3-AFC);
1-m FU
tr on and transfer (OLL, AVLT)
Fig. 1. Experimental procedure. Twenty YA and 20 OA were administered the multi-
day tDCS-accompanied OLM training, half of each group with anodal, and the other half
with sham stimulation over the right temporoparietal cortex (with contralateral su-
praorbital reference electrode). Stimulation was administered on each training day
during the first 20 minutes of training. OLM training consisted of multiple learning
blocks (i.e., 3 in YA and 5 in OA) and a subsequent 3-AFC recall task. Recall performance
was tested again 1 day and 1 month later. In addition, performance on the trained
function (OLL) and a transfer task (AVLT) was tested before training as well as at both
FU assessments. Abbreviations: 3-AFC, 3-alternative-forced-choice; AVLT, auditory
verbal learning test; FU, follow-up; OA, older adults; OLL, object-location-learning;
OLM, object-location-memory; tDCS, transcranial direct current stimulation; YA,
younger adults.
247
feedback was not provided. Immediately after the learning blocks
on each of the training days, learning success was tested in a 3-AFC
recall task. Here, each building was presented once, and partici-
pants had to indicate (by button press) its “correct” position, which
was presented above the street map together with 3 possible po-
sitions (1 correct, 2 incorrect) marked by numbers. Recall perfor-
mance was again tested 1 day after training (recall of trained
material using a 3-AFC task) and in a 1-month FU assessment.
Performance was measured by the percentage of correct responses.
Recall performance at 1-day FU was used as main outcome variable
(Antonenko et al., 2016). The task was administered using the
software “Presentation” (https://www.neurobs.com).
2.4. Testing of trained function and transfer task
To examine maintenance of the trained function, a short version
of visuospatial OLL was implemented, which comprised 3 learning
blocks for the acquisition of 15 stimulus-location associations on a
less complex street map following the same learning principle as
mentioned previously (Kulzow et al., 2014). Learning performance
was defined as mean performance over all 3 learning blocks. During
recall, the acquired “correct” position of all 15 buildings had to be
indicated using a 3-AFC test. Recall data of 2 young participants at
baseline testing were missing due to technical issues. Duration of
the entire task was 15 minutes. The order of 3 parallel versions of
the task (different sets of buildings, different street maps) was
counterbalanced across participants and time points. To evaluate
transfer on another episodic memory task, performance on the
German version of the AVLT (Helmstaedter et al., 2001) was
assessed (at baseline, post-assessment, and FU assessment) again
with counterbalanced order of 3 parallel versions. Participants had
to remember and recall a list of 15 concrete nouns that were read
aloud by the investigator in 5 trials that required immediate recall
(learning score created as total sum of retrieved nouns in percent),
followed by a delayed free recall after a 30-minute interval as index
for consolidation.
2.5. Transcranial direct current stimulation
Direct current stimulation was delivered on each of the 3
training days during the beginning of OLM training (neuroConn DC-
Stimulator Plus; neuroCare Group GmbH, Munich, Germany).
Electrodes were inserted in saline-soaked sponges and centered
over the right temporoparietal cortex (anodal electrode, T6, 10e20
EEG system, size: 7  5 cm2) and the contralateral supraorbital
cortex (reference electrode, Fp2, size: 10  10 cm2; note, that the
larger size of this electrode renders the stimulation density over the
supraorbital cortex functionally ineffective, Nitsche et al., 2007).
The right temporoparietal region was selected as stimulation target
due to its involvement in the acquisition of associations between
objects and locations (Postma et al., 2008; Sommer et al., 2005;
Takahashi et al., 2008). In addition, anodal tDCS over this area has
been shown to improve performance on a similar version of the task
employed in our study (Floel et al., 2012; Prehn et al., 2017). Anodal
stimulation groups were administered to 20 minutes stimulation,
whereas in sham stimulation groups, the current was turned off
after 30 seconds (intensity: 1 mA, 10 seconds fade in/out).
Perception of stimulation was prompted at the end of each
training day and answers were merged intra-individually. Before
and after the 3-day OLM training, mood ratings were assessed using
the Positive and Negative Affect Schedule (Watson et al., 1988).
Participants rated their positive and negative affects (10 items each)
on a scale ranging from 1 to 5, where higher values describe more
positive or negative feelings, respectively.
248 D. Antonenko et al. / Neurobiology of Aging 61 (2018) 245e254
2.6. MRI data acquisition
MRI was conducted 1 day before and 1 day after the multi-day
training with a 3T Siemens Trio MRI system using a 12-channel head
coil at the Berlin Center for Advanced Neuroimaging. In each ses-
sion, a three-dimensional structural scanning protocol was applied
using high-resolution T1-weighted magnetization prepared rapid
gradient echo imaging (repetition time ¼ 1900 ms; echo time ¼
2.52 ms; 192 sagittal slices; voxel size: 1  1  1 mm3; flip angle ¼
9 ). Acquisition of rs-fMRI was performed using an echo-planar
imaging sequence (3  3  4 mm3; repetition time ¼ 2300 ms;
echo time ¼ 30 ms; flip angle 90 ; 35 slices; no gap; interleaved
acquisition; field of view 192  192 mm2; matrix ¼ 64  64; 150
volumes). Participants were instructed to keep their eyes closed, not
to fall asleep or think of anything in particular. None of the partic-
ipants fell asleep during the scanning interval as per self-report. An
additional fluid attenuated inversion recovery sequence was ac-
quired for neuroradiological assessment and to exclude structural
abnormalities. Two young individuals (n ¼ 1 in sham group, n ¼ 1 in
anodal group) had missing data due to MRI contraindications.
2.7. MRI data analysis
Image analysis was performed using tools from the FMRIB
Software Library (http://fsl.fmrib.ox.ac.uk/fsl/fslwiki/, Jenkinson
et al., 2012). To quantify individual brain atrophy, we used the T1-
weighted images at baseline and estimated individual brain tissue
volume, normalized for head size using SIENAX (Smith et al., 2002).
Mean (SD) values were 1487.43 (84.92) cm3 for old anodal partic-
ipants, 1475.04 (108.76) cm3 for old sham participants, 1648.05
(76.42) cm3 for young anodal participants, and 1628.77 (79.86) cm3
for young sham participants. Normalized brain volumes were lower
in older compared to young adults (main effect for “age group”:
F(1,36) ¼ 29.57, p < 0.001) but did not differ between anodal and
sham groups (main effect for “condition”: F(1,36) ¼ 0.30, p ¼ 0.587;
“age group”  “condition” interaction: F(1,36) ¼ 0.14, p ¼ 0.906).
Preprocessing of individual 4D data sets included motion
(using MCFLIRT) and slice time correction, brain extraction,
spatial smoothing using a gaussian kernel of full-width half-
maximum of 5 mm, and high-pass temporal filtering of 100 sec-
onds (0.01 Hz). Functional images were aligned to individual
structural T1-weighted images using boundary-based registration
(Greve and Fischl, 2009) and then to standard space (Montreal
Neurological Institute 2 mm) using the nonlinear registration tool
(12 degrees of freedom; warp resolution: 10 mm; resampling
resolution: 2 mm). All 4D data sets were visually inspected for
severe artifacts, and all images were examined after each pro-
cessing step. To quantify the amount of head movement, mean
head motion parameters were extracted from preprocessing
representing the mean relative displacement in millimeters of
each brain volume as compared to the previous volume (Van Dijk
et al., 2012).
Independent component analyses were carried out using FMRIB
Software Library’s MELODIC tool 3.14 (Beckmann et al., 2005). In-
dividual data were temporally concatenated across participants and
time points to create a single 4D data set. This data set was then
decomposed into 20 independent components. Components of in-
terest (i.e., the DMN and the sensorimotor network used as control
network) were selected by visual inspection based on previous
literature (Beckmann et al., 2005). Next, the dual-regression
approach was used to identify separate maps for each participant
and time point. This involved a spatial regression of these compo-
nents against each individual 4D data set and, subsequently, a
temporal regression of the resulting time series to generate
participant-specific and time pointespecific spatial maps. Those
maps reflect the participant-specific and time pointespecific
strength of functional connectivity within the respective network
(Bachtiar et al., 2015; Binnewijzend et al., 2012). The resulting
network maps were then masked by the group mean map of the
respective component, and the mean values extracted for each
participant and time point were used to quantify the strength of
functional connectivity within the network (Amadi et al., 2014;
Antonenko et al., 2017; Bachtiar et al., 2015; Stagg et al., 2014).
For seed-based analysis, we used a probabilistic mask from the
Harvard-Oxford cortical atlas (right middle temporal gyrus,
temporo-occipital part, thresholded at 50%, Desikan et al., 2006) to
obtain a region-of-interest for the brain area under the active tDCS
electrode, which corresponded to the stimulation target (Koessler
et al., 2009; Okamoto et al., 2004). The time course of the blood
oxygenation level dependent signal in this region-of-interest was
extracted from each participant’s preprocessed resting-state 4D
data set. The resulting time courses were then correlated with the
time course extracted from the DMN (derived from Independent
component analyses) to obtain individual functional correlations
between the stimulation target and the DMN for each time point. As
Pearson’s r is not normally distributed, the resulting r values were
transformed into z scores using Fisher r-to-z transformation.
2.8. Statistical analysis
IBM SPSS Statistics 24 (http://www-01.ibm.com/software/uk/
analytics/spss/) and R software (version 3.3.2; https://www.r-
project.org) were used for statistical analyses. Repeated-
measurements analyses of variance (ANOVAs) were conducted to
test for time (baseline,1-day FU), condition (anodal, sham), and group
(young adults [YA], older adults [OA]) differences in resting-state
functional connectivity as well as their interactions. To account for
interindividual differences in brain volume or head movement,
baseline normalized brain volume and mean displacement were
included as additional covariates, where appropriate. Two-factorial
univariate ANOVAs were conducted for comparison of behavioral
performance between conditions (anodal, sham) and groups (YA, OA)
as well as their interaction. Nonsignificant interactions of univariate
ANOVAs were not reported. In models comparing OLM/OLL perfor-
mance, baseline mean learning performance was included as addi-
tional covariate. Levene test of variance homogeneity was conducted
to test if assumptions for ANOVAs were met. In case of significant
heteroscedasticity, the nonparametric alternative, that is, the
Brunner-Dette-Munk test, which is a 2-way heteroscedastic rank-
based permutation test, was conducted (Brunner et al., 1997). Pear-
son’s correlation coefficients were computed for linear associations
between variables. A 2-sided significance level of a ¼ 0.05 was used.
No adjustments for multiple comparisons were applied.
3. Results
3.1. Transcranial DCSeaccompanied OLM training improved recall
performance
Performance on each learning block and recall of each day of the
visuospatial memory training as well as recall of the trained ma-
terial 1 day and 1 month after training is shown in Fig. 2.
3.1.1. Performance during training
Mean learning performance during training did not differ
significantly between conditions (F(1,35) ¼ 2.42, p ¼ 0.138), but be-
tween age groups, representing superior performance in young
compared to older adults (F(1,35) ¼ 6.12, p ¼ 0.018). For mean recall
performance after training on each day, we observed significant
differences between conditions (F(1,36) ¼ 4.72, p ¼ 0.037) and age
 D. Antonenko et al. / Neurobiology of Aging 61 (2018) 245e254 249

100 was not significant (F(1,35) ¼ 2.89, p ¼ 0.098), but a significant main
YA, anodal * * * *
YA, sham effect of age group again indicated superior performance in young
90 OA, anodal compared to older adults (F(1,35) ¼ 9.89, p ¼ 0.003).
OA, sham
In sum, tDCS-accompanied training significantly ameliorated
80 recall performance (assessed by 3-AFC) on the training days and
% correct

1 day after training, compared to training alone (sham stimulation),

70 but had no significant effect after 1 month. Young adults out-
performed older adults at all time points.
60

3.2. Transcranial DCSeaccompanied OLM training augmented

50
40
L1 L2 L3 L4 L5 R R L1 L2 L3 L4 L5 R R L1 L2 L3 L4 L5 R
Day 1 Day 2 Day 3
Fig. 2. Performance during and after OLM training. Response accuracy (% correct)
during each learning (L) block and recall (R) on each training day as well as recall at 1-
day and 1-month FU is depicted. Squares represent YA and circles OA. Dark fillings are
for anodal groups, whereas light fillings are for sham groups. Note that YA were
administered 3 learning blocks per day, whereas OA had 5 (see Materials and Methods
section). Means and standard errors are shown. *p  0.05. Abbreviations: FU, follow-
up; OA, older adults; OLM, object-location-memory; YA, young adults.
groups (F(1,36) ¼ 30.42, p < 0.001), indicating superior performance
under anodal compared to sham stimulation and in young
compared to older adults.
3.1.2. Delayed recall performance after training
Recall of trained material after 1 day revealed a significant main
effect of condition, indicating increased memory performance after
the 3-day training under anodal compared to sham stimulation
(F(1,26) ¼ 6.62, p ¼ 0.016). Further, a significant main effect of group
indicated superior performance in young compared to older adults
(F(1,26) ¼ 21.88, p < 0.001). After 1 month, main effect of condition
functional connectivity in the DMN
R R A repeated-measurements ANOVA revealed that the change of
1-d 1-m DMN strength significantly differed between stimulation condi-
FU FU tions (time  condition interaction: F(1,34) ¼ 4.86, p ¼ 0.034),
reflecting increased DMN strength from baseline to 1-day FU as-
sessments under anodal compared to sham stimulation (Fig. 3). All
other main and interaction effects were nonsignificant (F’s  3.0, p’s
 0.09). No significant effect was observed in the sensorimotor
network (F’s  1.75, p’s  0.194).
Seed-based analysis confirmed an increased functional connec-
tivity between the stimulation target and the DMN after anodal tDCS
(time  condition interaction: F(1,34) ¼ 5.38, p ¼ 0.026). All other main
and interaction effects were nonsignificant (F’s  2.1, p’s  0.16).
3.3. Transcranial DCSeinduced changes in functional connectivity
are associated with memory improvement
Changes in DMN strength were significantly correlated with
recall performance (at 1-day FU), in the direction that increased
strength was associated with superior performance (partial corre-
lation coefficient: r (corrected for age) ¼ 0.36, p ¼ 0.031; Fig. 4).
Explorative separate correlational analyses unveiled that the posi-
tive association between DMN and recall performance was mainly

A 18

C
3 YA
B x=2 y=-33 z=24
4 OA
*
12 2
YA, anodal YA, sham OA, anodal OA, sham
Change in DMN strength

10 1
DMN strength

8 0

-1
6

-2
4

-3
2
Baseline 1-d Baseline 1-d Baseline 1-d Baseline 1-d
FU FU FU FU anodal sham
Fig. 3. Change in DMN strength from before to after training. (A) DMN as derived from ICA (MELODIC, FSL). (B) DMN strength (arbitrary units) at baseline and 1-day FU for each
participant. (C) Change of DMN strength (difference between 1-day FU and baseline) for anodal and sham groups. Means and standard errors are shown. *p  0.05. Abbreviations:
DMN, default mode network; FSL, FMRIB Software Library; FU, follow-up; ICA, independent component analysis; MELODIC, Multivariate Exploratory Linear Optimized Decom-
position into Independent Components; OA, older adults; YA, young adults.
250 D. Antonenko et al. / Neurobiology of Aging 61 (2018) 245e254

driven by the older group that received anodal stimulation (Pear- Table 2
son’s r ¼ 0.73, p ¼ 0.02). Performance on trained function and transfer task

YA OA
3.4. Effects of tDCS-accompanied training on trained function and Anodal Sham Anodal Sham
transfer task Baseline
OLL
Performance on OLL and AVLT tasks assessed at baseline before Learning 68.8 (6.1) 62.7 (6.8) 58.3 (7.7) 60.6 (7.5)a
Recall 74.2 (8.3) 63.3 (13.4) 47.3 (16.8) 56.0 (15.8)a
the training days and 1 day and 1 month after training is shown in
AVLT
Table 2. Learning 83.2 (12.1) 85.7 (5.8) 70.5 (12.8) 73.1 (10.9)a
Recall 92.7 (8.6) 90.7 (9.0) 63.3 (15.8) 71.3 (19.6)a
3.4.1. Performance at baseline 1-day FU
For both trained function (OLL) and transfer task (AVLT), no OLL
Learning 76.2 (7.3) 67.0 (9.4) 62.9 (3.7) 61.4 (9.2)a
significant difference was observed between anodal and sham Recall 90.0 (10.5) 77.3 (21.6) 62.0 (15.7) 64.0 (12.3)a
stimulation groups before the intervention for learning and recall AVLT
(all F’s < 1). Significant main effect of age group showed better Learning 90.5 (8.0) 88.1 (7.0) 68.8 (13.7) 72.7 (18.0)a
performance in young compared with older adults in learning and Recall 98.7 (2.8) 94.0 (7.3) 60.7 (17.1) 70.0 (27.1)a
1-month FU
recall of OLL (F(1,37) ¼ 7.36, p ¼ 0.010 and F(1,35) ¼ 11.60, p ¼ 0.002) as
OLL
well as in learning and recall of AVLT (F(1,37) ¼ 14.22, p ¼ 0.001 and Learning 77.0 (9.2) 63.9 (8.4) 65.2 (5.5) 63.8 (5.9)a,b
F(1,32) ¼ 25.74, p < 0.001). Recall 91.3 (10.4) 66.0 (18.2) 64.7 (11.8) 57.8 (16.7)a,b
AVLT
3.4.2. Performance 1 day after training Learning 90.7 (6.5) 93.1 (5.4) 74.4 (16.3) 74.3 (13.8)a
Recall 98.0 (3.2) 94.0 (5.8) 75.6 (16.7) 61.3 (26.8)a,b
For both OLL and AVLT performance, no differences between
stimulation conditions were observed (all F’s  1). Significant main Mean (standard deviation) values for percentage of correct responses are shown.
Key: AVLT, auditory verbal learning test; FU, follow-up; OA, older adults; OLL,
effect of age group revealed better performance in young compared
object-location-learning; OLM, object-location-memory; tDCS, transcranial direct
with older adults in learning and recall of OLL (F(1,34) ¼ 7.75, p ¼ current stimulation; YA, young adults.
0.009 and F(1,36) ¼ 17.53, p < 0.001) and learning and recall of AVLT a
p < 0.05 for age group comparison (YA > OA).
(F(1,30) ¼ 19.01, p < 0.001 and F(1,22) ¼ 52.27, p < 0.001). b
p < 0.05 for stimulation condition comparison (anodal tDCS > sham tDCS;
printed in bold for visualization purposes).

3.4.3. Performance 1 month after training

The trained function (OLL) showed a significant stimulation ef-
stimulation, indicating better performance in anodal groups
fect for both learning and recall (F(1,34) ¼ 8.10, p ¼ 0.007 and F(1,35) ¼
(F(1,29) ¼ 4.23, p ¼ 0.049). Again, young adults performed better
11.90, p ¼ 0.001), indicating improved performance after training
compared with older adults in OLL (learning: F(1,34) ¼ 2.99, p ¼
combined with anodal compared with sham stimulation. In the
0.093; recall: F(1,35) ¼ 13.95, p ¼ 0.001) and AVLT (learning: F(1,31) ¼
transfer task (AVLT), performance did not differ in learning (F < 1)
20.28, p < 0.001; recall: F(1,29) ¼ 28.78, p < 0.001).
but was significantly different in recall between anodal and sham
In sum, stimulation-induced effects were only evident 1 month
after training with better learning and recall performance on the
trained function (OLL) and better recall performance on transfer
YA, anodal r=.36, p=.03
task (AVLT) in anodal stimulation compared with sham stimulation.
7.5 YA, sham Young adults outperformed older adults in learning and recall
OA, anodal scores at all test sessions (baseline, 1-day FU, and 1-month FU).
OA, sham
Change in DMN strength

5.0 3.5. Stimulation perception and mood ratings

Postexperimental debriefing revealed minor differences in

2.5 stimulation perception in young adults (2/10 in sham and 6/10 in
anodal), which did not reach statistical significance (c2 ¼ 3.33, p ¼
0.068). Older adults did not differ in perception (2/10 in sham and
0.0 2/10 in anodal confirmed that they have perceived the stimulation).
Mood ratings that were given on the Positive and Negative Affect
Schedule are shown in Table 3. Positive and negative affects did not
-2.5 differ between stimulation conditions at all time points (all F’s < 1).
Age groups did differ in their positive affect, indicating that older
adults rated positive items higher compared with younger adults at
-5.0 all time points (baseline: F(1,36) ¼ 7.80, p ¼ 0.008; 1-day FU: F(1,36) ¼
5.39, p ¼ 0.026; 1-month FU: F(1,32) ¼ 5.54, p ¼ 0.025). At baseline
testing, young adults scored higher on negative items compared
40 50 60 70 80 90 100
with older adults (F(1,36) ¼ 4.40, p ¼ 0.043).
OLM performance
(1-d FU) 4. Discussion

Fig. 4. Brain-behavior correlation. Scatter plot of memory performance at 1-day FU
assessment (% correct) and change in DMN strength. Partial correlation coefficient
(corrected for age). Means and standard errors are shown. Abbreviations: DMN, default
mode network; FU, follow-up; OA, older adults; OLM, object-location-memory; YA,
young adults.
Here, we examined the neuronal and behavioral effects of a
tDCS-accompanied episodic memory training in young and healthy
older adults. Participants received either anodal or sham tDCS
during the first 20 minutes of training on each of the 3 training
 D. Antonenko et al. / Neurobiology of Aging 61 (2018) 245e254
Table 3
Participants’ mood ratings
YA OA
Anodal Sham Anodal
Baseline
Positive affect 2.6 (0.8) 3.0 (0.6) 3.5 (0.7)
Negative affect 1.1 (0.1) 1.2 (0.2) 1.0 (0.1)
1-d FU
Positive affect 2.7 (0.9) 2.9 (0.9) 3.5 (0.9)
Negative affect 1.1 (0.2) 1.1 (0.2) 1.1 (0.2)
1-mo FU
Positive affect 2.5 (0.8) 2.9 (1.0) 3.4 (0.8)
Negative affect 1.2 (0.3) 1.2 (0.3) 1.1 (0.1)
Mean (standard deviation) values are shown.
Key: FU, follow-up; OA, older adults; YA, younger adults.
a
p < 0.05 for age group comparison (OA > YA).
b
p < 0.05 for age group comparison (YA > OA).
days. We found that anodal tDCS led to a significantly larger recall
performance (as assessed by recall 1 day after training) compared
with sham stimulation. Furthermore, functional network coupling
of the DMN increased after training in participants who had
concurrently received anodal tDCS. Seed-based analyses confirmed
an augmented coupling between the stimulation target (i.e., right
temporoparietal cortex) and the DMN after anodal tDCS. The in-
crease in DMN strength was positively associated with enhanced
memory performance. Finally, trained function and transfer task
performance assessed 1 month after episodic memory training
revealed a benefit for participants who underwent the combined
tDCS-plus-training intervention.
4.1. Effect of the intervention on recall performance
We found that anodal tDCS significantly improved memory
performance (as assessed by recall 1 day after training) after tDCS-
accompanied training compared with sham. Recall assessed on
each training day also demonstrated ameliorated task performance
in the anodal stimulation groups. These findings are in line with
previous reports of multi-day combinations of cognitive training
with NIBS in the young (Au et al., 2016; Meinzer et al., 2014; Ruf
et al., 2017; Wang et al., 2014) and importantly, expand previous
findings of single-session brain stimulation studies on episodic
memory in older adults (Floel et al., 2012; Sandrini et al., 2016).
Evidence of additive effects of multisession tDCS in older adults
stems from prefrontal tDCS concurrent to working memory training
approaches only and is not unequivocal (Berryhill, 2017; Passow
et al., 2017). With regard to immediate training gains, no benefi-
cial effects have been observed in older adults after anodal pre-
frontal tDCS during visuospatial working memory training (Jones
et al., 2015; Stephens and Berryhill, 2016) or training of the work-
ing memory components “updating” and “switching” (Nilsson et al.,
2017). However, these studies differed to ours in several ways, such
as the cognitive domain that was trained, and methodological
factors including target area, electrode montage, electrode size, and
intensity, timing and duration of stimulation, all of which may
affect the cognitive outcome (Berryhill et al., 2014; Woods et al.,
2016). Our present results add to the literature on tDCS-induced
behavioral enhancement in the trained task by providing the first
evidence of beneficial effects of a multi-day OLM training accom-
panied by right temporoparietal anodal tDCS not only in young but
also in older adults.
4.2. Effect of the intervention on DMN strength
To probe the underlying mechanisms of tDCS-induced training
effects, we tested the effects of the combined tDCS-plus-training
251
intervention on resting-state functional coupling changes. This is
the first study exploring changes in rs-fMRI metrics in such a
combined approach. This is an issue of outstanding relevance for
Sham the field of translational neuroscience (see also Stephens and
Berryhill, 2016). Our focus on the DMN was motivated by (1) its
3.3 (0.8)a well-established association with age-related episodic memory
1.1 (0.1)b deficits (Jeong et al., 2015; Salami et al., 2014; Wang et al., 2010)
and (2) recent evidence for its plasticity induced by cognitive
3.4 (0.8)a
1.1 (0.2)
training interventions in young and older adults (Chapman et al.,
2015; Takeuchi et al., 2013). Furthermore, the consistent observa-
3.2 (0.6)a tion of decreased functional coupling in the DMN in age and Alz-
1.1 (0.1) heimer’s disease (Jones et al., 2011; Sala-Llonch et al., 2015)
suggests that rs-fMRI metrics assessing intrinsic functional brain
activity may constitute a sensitive biomarker and diagnostic tool
for healthy and for pathological aging (see also Ferreira and
Busatto, 2013; Salami et al., 2014) as well as for the investigation
of intervention-induced changes (Kobe et al., 2017). Our data
showed that anodal tDCS during a multiple-day associative mem-
ory training (visuospatial learning) resulted in an increase of DMN
strength from before to after the intervention. Seed-based analyses
on temporal coupling between the stimulation target and the DMN
confirmed responsiveness of this network to the intervention.
Please note that we did not observe baseline differences in DMN
connectivity between age groups in our sample, probably due to
high variability in the older group. Although age-related connec-
tivity reductions are the most consistent finding reported in the
literature (see however Jones et al., 2011; Westlye et al., 2011),
recent evidence suggests that age effects in the DMN are subtle and
not consistent for all brain areas implicated in the DMN. Moreover,
selection of the methodological approach influences the results (cf.
Ferreira and Busatto, 2013). Nevertheless, our findings support the
idea that tDCS effects stem from the induction of neuronal plas-
ticity on functional networks indirectly connected to the stimula-
tion target over the right temporoparietal cortex (Mameli et al.,
2014). Furthermore, the magnitude of DMN change was posi-
tively correlated with recall performance after 1 day in the direc-
tion that higher increase in the DMN after training was associated
with better performance. This association was driven by older
participants who received anodal stimulation, suggesting that
tDCS, with the parameters applied in the current protocol, enables
the modulation of interacting neural and behavioral processes in
older adults. Episodic memory is one of the most vulnerable
cognitive domains in aging and highly relevant for everyday ac-
tivities (Nyberg et al., 2012). Our results help to elucidate the
mechanisms underlying combined effects of tDCS and memory
training in older adults, suggesting that strengthening DMN
coupling by interventional approaches may lead to preserved
memory functions in old age (Cabral et al., 2017; Grady et al., 2003;
Nyberg et al., 2012).
Using multi-day transcranial magnetic stimulation (TMS)
treatment to a left parietal location, Wang et al. found a positive
impact on both associative memory performance (face-cued word
recall) and fMRI connectivity of the DMN and hippocampus in
young adults. Similar to our findings, larger TMS-induced connec-
tivity increases correlated with memory improvement (Wang et al.,
2014). Our findings lend further support for the potential of a
combined NIBS-plus-training approach to improve episodic mem-
ory performance in young and older adults and to produce correl-
ative fMRI connectivity alterations in a network involved in human
cognition (Raichle, 2015). Using transcranial random noise stimu-
lation over bilateral prefrontal regions together with near-infrared
spectroscopy, Snowball et al. observed stimulation-induced im-
provements on complex arithmetic tasks and more efficient neu-
rovascular coupling in the left prefrontal region (Snowball et al.,
2013). Behavioral and neuronal changes persisted 6 months after
252 D. Antonenko et al. / Neurobiology of Aging 61 (2018) 245e254
training in the stimulated compared to the sham group of young
adults. Together, these findings imply that NIBS concurrent to a
cognitive training protocol may exert associated beneficial effects
on the neuronal and behavioral levels and may even persist over a
long term. However, the magnitude of neuronal changes, their
temporal dynamics, their association with, and their predictive
quality of behavioral changes in different age groups are unknown
so far and await longitudinal FU studies.
4.3. Effects of the intervention after 1 month on trained and
untrained material
On the behavioral level, we did not find differences in recall
performance of trained material between stimulation conditions at
the 1-month FU assessment, suggesting that the beneficial effect of
tDCS may not persist. In a new analysis of their data, Wang and Voss
demonstrated that their TMS-induced beneficial effects on trained
memory performance and functional connectivity persisted in an
FU assessment (with an average interval of 15 days between
intervention and testing, Wang and Voss, 2015). However, instead
of performance increases in the recall of specific stimulus-pairings,
the authors observed increases in participants’ ability to learn new
relational information at FU assessment. This key finding suggests
that a potential long-term effect of a combined approach may not
necessarily translate into improved performance on the trained
material but may exert a beneficial effect on learning of new as-
sociations. Our data lend additional support to this hypothesis by
demonstrating superior performance on a different version of the
task in the anodal compared with the sham condition after
1 month. Thus, although participants in the stimulation conditions
did not differ in their recall performance of the trained material,
those who previously received anodal stimulation during OLM
training were able to better acquire new visuospatial associations
after 1 month.
Furthermore, at 1-month FU, we observed superior perfor-
mance on a different episodic memory task (i.e., retention of a
word list) in those participants who had received anodal tDCS
during training. Such transfer effects have been demonstrated in
older adults after a tDCS-accompanied training schedule on far
transfer tasks (Jones et al., 2015; Stephens and Berryhill, 2016),
even in the absence of gains on performance in the trained task or
near-transfer tasks (Stephens and Berryhill, 2016). Likewise in
young adults, transfer effects have been observed for tDCS together
with multi-day working memory training in some studies (Au
et al., 2016; Ruf et al., 2017), but not others (see Elmasry et al.,
2015 for a review). In the present study, we provide first evi-
dence for transfer effects of tDCS-accompanied visuospatial
episodic memory training.
Notably, the effects of anodal tDCS on a different version of the
training task and on a transfer task were not evident on the day
after the intervention, but 1 month later. Here, we hypothesize that
a consolidation process has to take place before differential training
benefits between conditions emerge. In young adults, Au et al.
found stronger tDCS effects on the trained function on the fourth
training day when it was separated from the previous session by at
least a weekend (Au et al., 2016). Thus, it is reasonable that even in
the absence of immediate effects, differential effects on sustained
gains can emerge due to training plus anodal tDCS, compared to
training plus sham (Jones et al., 2015; Stephens and Berryhill, 2016).
These effects would go unnoticed in studies focusing on immediate
effects only (Berryhill, 2017; Nilsson et al., 2017). Whether these
differential effects are still evident after even longer time periods
(as suggested by Ruf et al. (2017) for tDCS-accompanied working
memory training in young adults) remains to be elucidated in
future studies.
4.4. Implications for the design of studies testing cognitive effects of
tDCS-plus-training
NIBS concurrently to cognitive and motor training is considered
an effective approach to ameliorate function and induce brain
plasticity (Au et al., 2017; Elmasry et al., 2015; Perceval et al., 2016).
Recently, however, evidence has cumulated concerning the het-
erogeneity of findings, including null results, leading to discussions
about the impact of methodological, but also interindividual factors
(e.g., Horvath et al., 2014; Katz et al., 2017), or even challenging the
efficiency of tDCS for cognitive enhancement altogether (Berryhill
et al., 2014; Horvath et al., 2015; Nilsson et al., 2017). One deci-
sive factor may be the single-session approach of tDCS experiments
that currently dominate the literature (cf. Au et al., 2017). Multiple
consecutive days of training accompanied by NIBS could exert
sustained effects that outlast stimulation intervals (Au et al., 2016;
Meinzer et al., 2014) and exert effects beyond the trained task (Au
et al., 2017; Stephens and Berryhill, 2016). One reason for the effi-
cacy of multisession studies, as compared to single sessions, may
relate to offline consolidation effects that emerge between training
days (Au et al., 2017; Reis et al., 2009). However, a recent study
failed to observe training gains or transfer to untrained tasks after
20 sessions of tDCS-accompanied working memory training in
older adults, challenging the efficiency of dorsolateral prefrontal
stimulation altogether (Nilsson et al., 2017). Second, sustained
transfer of training gains to untrained material (i.e., assessed after
an interval of at least 4 weeks)dparticularly important in the
context of translational neuroscience (Berryhill et al., 2014;
Stephens and Berryhill, 2016)dhas not unequivocally benefited
from the stimulation or was not investigated (as in Nilsson et al.
(2017); see also Stephens and Berryhill (2016) for a discussion on
this topic). The present study supports the notion that beneficial
long-term transfer due to tDCS-accompanied cognitive training
may even emerge in the absence of immediate effects on the
trained function (Stephens and Berryhill, 2016).
Several limitations should be considered when interpreting our
findings. First, given that our sample size was rather small, findings
reported here should be reproduced in larger cohorts before firm
conclusions can be drawn. Twenty participants per cell might
provide a useful point of reference (cf. Melby-Lervag et al., 2016;
Simmons et al., 2011). Of note, our main hypothesis with regard
to a positive tDCS effect on visuospatial performance was tested in
the group of 20 versus 20 participants in the present study. Second,
we are not able to disentangle the separate impact of cognitive
training and brain stimulation due to the absence of a “tDCS only”
condition (cf. Passow et al., 2017; Talsma et al., 2016). However, we
argue that tDCS most likely strengthens task-relevant functional
networks when applied during task execution (Berryhill, 2017;
Martin et al., 2014; Woods et al., 2016). Third, owing to unequal
number of learning blocks in young and older adults, young adults
received tDCS during a larger proportion of the learning task. Given
that performance gain and stimulation duration are not linearly
related, might even reverse with prolonged stimulation (Batsikadze
et al., 2013; Monte-Silva et al., 2013), and effects of stimulation
outlast the stimulation period itself (Nitsche and Paulus, 2001), we
do not expect a major impact on between-group differences in
response to tDCS. However, we concede that higher tDCS-plus-
training gains in older adults with a larger part of the training
covered by tDCS cannot be ruled out. Fourth, as we did not vary the
stimulation target, we cannot conclude specificity of right tem-
poroparietal tDCS for the observed effects. It is conceivable that
other targets involved or overlapping with the functional network
would have exerted similar effects (Jones et al., 2015).
Taken together, in the future, integrative approaches that use
multi-day training interventions combined with brain stimulation
 D. Antonenko et al. / Neurobiology of Aging 61 (2018) 245e254
in larger samples are needed. These studies should systematically
examine the effects on trained and untrained functions in multiple
cognitive domains, taking into account online and offline effects as
well as the neuronal underpinnings (Bergmann et al., 2016;
Berryhill et al., 2014). Careful design of such multi-day studies is
needed, with appropriate control conditions (Melby-Lervag et al.,
2016), consideration of carryover effects that may obscure statisti-
cal differences between stimulation conditions in within-subject
approaches (as discussed also by Wang and Voss, 2015), and
matching of groups for training task performance before inter-
vention to exclude chance baseline differences that hamper the
interpretation of tDCS effects (Martin et al., 2013). Studies should
assess delayed performance differences (i.e., at least after 1 month)
to not overlook potential long-term effects (Berryhill, 2017).
5. Conclusions
In translational neuroscience, an increased understanding of the
neuronal and transfer effects of memory-enhancing interventions
is pivotal. Importantly, investigation of mechanisms and long-term
behavioral effects of training is necessary to develop ecologically
valid interventions against age-related cognitive decline. Here, we
provide first evidence for the efficacy of a combined approach that
may exert beneficial effects on immediate episodic memory per-
formance, associated neuronal network integrity, and may even
convey long-term transfer effects. Systematic longitudinal studies
on multiple cognitive domains and modalities are now needed to
further enhance our understanding of additive effects of brain
stimulation on cognitive training interventions and to move these
interventions closer to clinical application.
Disclosure statement
The authors have no actual or potential conflicts of interest.
Acknowledgements
This work was supported by the Deutsche For-
schungsgemeinschaft (DFG, FL 379-10) and the Bundesministerium
für Bildung und Forschung (BMBF, 01GQ1424A). The authors thank
Magda E. Cesarz, Thorge Profitlich, and Almut Dünnebeil for helping
in data acquisition, Franziska Krobisch for statistical assistance, and
Gloria Benson for proofreading and language editing.
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