Syncing your brain: electric currents to enhance cognition

DELirium treatment with Transcranial Electrical Stimulation (DELTES): study protocol for a multicentre, randomised, double-blind, sham-controlled trial

INTRODUCTION

Delirium, a clinical manifestation of acute encephalopathy, is associated with extended hospitalisation, long-term cognitive dysfunction, increased mortality and high healthcare costs. Despite intensive research, there is still no targeted treatment. Delirium is characterised by electroencephalography (EEG) slowing, increased relative delta power and decreased functional connectivity. Recent studies suggest that transcranial alternating current stimulation (tACS) can entrain EEG activity, strengthen connectivity and improve cognitive functioning. Hence, tACS offers a potential treatment for augmenting EEG activity and reducing the duration of delirium. This study aims to evaluate the feasibility and assess the efficacy of tACS in reducing relative delta power.

METHODS AND ANALYSIS

A randomised, double-blind, sham-controlled trial will be conducted across three medical centres in the Netherlands. The study comprises two phases: a pilot phase (n=30) and a main study phase (n=129). Participants are patients aged 50 years and older who are diagnosed with delirium using the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision criteria (DSM-5-TR), that persists despite treatment of underlying causes. During the pilot phase, participants will be randomised (1:1) to receive either standardised (10 Hz) tACS or sham tACS. In the main study phase, participants will be randomised to standardised tACS, sham tACS or personalised tACS, in which tACS settings are tailored to the participant. All participants will undergo daily 30 min of (sham) stimulation for up to 14 days or until delirium resolution or hospital discharge. Sixty-four-channel resting-state EEG will be recorded pre- and post the first tACS session, and following the final tACS session. Daily delirium assessments will be acquired using the Intensive Care Delirium Screening Checklist and Delirium Observation Screening Scale. The pilot phase will assess the percentage of completed tACS sessions and increased care requirements post-tACS. The primary outcome variable is change in relative delta EEG power. Secondary outcomes include (1) delirium duration and severity, (2) quantitative EEG measurements, (3) length of hospital stay, (4) cognitive functioning at 3 months post-tACS and (5) tACS treatment burden. Study recruitment started in April 2024 and is ongoing.

ETHICS AND DISSEMINATION

The study has been approved by the Medical Ethics Committee of the Utrecht University Medical Center and the Institutional Review Boards of all participating centres. Trial results will be disseminated via peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

NCT06285721.

A meta-analysis showing improved cognitive performance in healthy young adults with transcranial alternating current stimulation

Transcranial alternating current stimulation (tACS) is a non-invasive brain stimulation used for improving cognitive functions via delivering weak electrical stimulation with a certain frequency. This systematic review and meta-analysis investigated the effects of tACS protocols on cognitive functions in healthy young adults. We identified 56 qualified studies that compared cognitive functions between tACS and sham control groups, as indicated by cognitive performances and cognition-related reaction time. Moderator variable analyses specified effect size according to (a) timing of tACS, (b) frequency band of simulation, (c) targeted brain region, and (b) cognitive domain, respectively. Random-effects model meta-analysis revealed small positive effects of tACS protocols on cognitive performances. The moderator variable analyses found significant effects for online-tACS with theta frequency band, online-tACS with gamma frequency band, and offline-tACS with theta frequency band. Moreover, cognitive performances were improved in online- and offline-tACS with theta frequency band on either prefrontal and posterior parietal cortical regions, and further both online- and offline-tACS with theta frequency band enhanced executive function. Online-tACS with gamma frequency band on posterior parietal cortex was effective for improving cognitive performances, and the cognitive improvements appeared in executive function and perceptual-motor function. These findings suggested that tACS protocols with specific timing and frequency band may effectively improve cognitive performances.

Transcranial Current Stimulation as a Tool of Neuromodulation of Cognitive Functions in Parkinson’s Disease

Decrease in cognitive function is one of the most common causes of poor life quality and early disability in patients with Parkinson’s disease (PD). Existing methods of treatment are aimed at both correction of motor and non-motor symptoms. Methods of adjuvant therapy (or complementary therapy) for maintaining cognitive functions in patients with PD are of interest. A promising subject of research in this regard is the method of transcranial electric current stimulation (tES). Here we reviewed the current understanding of the pathogenesis of cognitive impairment in PD and of the effects of transcranial direct current stimulation and transcranial alternating current stimulation on the cognitive function of patients with PD-MCI (Parkinson’s Disease–Mild Cognitive Impairment).

Does non-invasive brain stimulation modulate emotional stress reactivity?

Excessive emotional responses to stressful events can detrimentally affect psychological functioning and mental health. Recent studies have provided evidence that non-invasive brain stimulation (NBS) targeting the prefrontal cortex (PFC) can affect the regulation of stress-related emotional responses. However, the reliability and effect sizes have not been systematically analyzed. In the present study, we reviewed and meta-analyzed the effects of repetitive transcranial magnetic (rTMS) and transcranial direct current stimulation (tDCS) over the PFC on acute emotional stress reactivity in healthy individuals. Forty sham-controlled single-session rTMS and tDCS studies were included. Separate random effects models were performed to estimate the mean effect sizes of emotional reactivity. Twelve rTMS studies together showed no evidence that rTMS over the PFC influenced emotional reactivity. Twenty-six anodal tDCS studies yielded a weak beneficial effect on stress-related emotional reactivity (Hedges’ g = −0.16, CI_95% = [−0.33, 0.00]). These findings suggest that a single session of NBS is insufficient to induce reliable, clinically significant effects but also provide preliminary evidence that specific NBS methods can affect emotional reactivity. This may motivate further research into augmenting the efficacy of NBS protocols on stress-related processes.

Synchronizing Brain Rhythms to Improve Cognition

Impaired cognition is common in many neuropsychiatric disorders and severely compromises quality of life. Synchronous electrophysiological rhythms represent a core mechanism for sculpting communication dynamics among large-scale brain networks that underpin cognition and its breakdown in neuropsychiatric disorders. Here, we review an emerging neuromodulation technology called transcranial alternating current stimulation that has shown remarkable early results in rapidly improving various domains of human cognition by modulating properties of rhythmic network synchronization. Future noninvasive neuromodulation research holds promise for potentially rescuing network activity patterns and improving cognition, setting groundwork for the development of drug-free, circuit-based therapeutics for people with cognitive brain disorders.

NMDA Receptor-Mediated Motor Cortex Plasticity After 20 Hz Transcranial Alternating Current Stimulation

Transcranial alternating current stimulation (tACS) has been shown to modulate neural oscillations and excitability levels in the primary motor cortex (M1). These effects can last for more than an hour and an involvement of N-methyl-d-aspartate receptor (NMDAR) mediated synaptic plasticity has been suggested. However, to date the cortical mechanisms underlying tACS after-effects have not been explored. Here, we applied 20 Hz beta tACS to M1 while participants received either the NMDAR antagonist dextromethorphan or a placebo and the effects on cortical beta oscillations and excitability were explored. When a placebo medication was administered, beta tACS was found to increase cortical excitability and beta oscillations for at least 60 min, whereas when dextromethorphan was administered, these effects were completely abolished. These results provide the first direct evidence that tACS can induce NMDAR-mediated plasticity in the motor cortex, which contributes to our understanding of tACS-induced influences on human motor cortex physiology.

Frontal Beta Transcranial Alternating Current Stimulation Improves Reversal Learning

Electroencephalogram (EEG) studies suggest an association between beta (13-30 Hz) power and reversal learning performance. In search for direct evidence concerning the involvement of beta oscillations in reversal learning, transcranial alternating current stimulation (tACS) was applied in a double-blind, sham-controlled and between-subjects design. Exogenous oscillatory currents were administered bilaterally to the frontal cortex at 20 Hz with an intensity of 1 mA peak-to-peak and the effects on reward-punishment based reversal learning were evaluated in hundred-and-eight healthy volunteers. Pre- and post-tACS resting state EEG recordings were analyzed. Results showed that beta-tACS improved rule implementation during reversal learning and decreases left and right resting-state frontal theta/beta EEG ratios following tACS. Our findings provide the first behavioral and electrophysiological evidence for exogenous 20 Hz oscillatory electric field potentials administered over to the frontal cortex to improve reversal learning.

Effects of parietal exogenous oscillatory field potentials on subjectively perceived memory confidence

Previous research suggests involvement of parietal theta (3-7 Hz) power in subjectively perceived memory confidence during retrieval. To obtain further insights into the role of parietal theta activity during retrieval in processes associated with performance and confidence, fifty-four healthy volunteers performed a recognition memory task in a within-subject sham controlled transcranial alternating current stimulation (tACS) study. Participants encoded a subset of words at specific on-screen locations. During the retrieval phase accuracy and subjectively perceived confidence on item and source memory were evaluated while administering exogenous alternating field potentials. Results showed that 3.5 Hz tACS decreased subjectively perceived memory confidence as compared to sham and 8 Hz tACS. No tACS effects were found on accuracy regarding item and source memory. Our findings suggest that theta activity in the parietal cortex is implicated in subjectively perceived confidence in word recognition.

The Role of Left Dorsolateral Prefrontal Cortex in Language Processing

In addition to the role of left frontotemporal areas in language processing, there is increasing evidence that language comprehension and production require cognitive control and working memory resources involving the left dorsolateral prefrontal cortex (DLPFC). The aim of this study was to investigate the role of the left DLPFC in both language comprehension and production. In a double-blind, sham-controlled crossover experiment, thirty-two participants received cathodal or sham transcranial direct current stimulation (tDCS) to the left DLPFC while performing a language comprehension and a language production task. Results showed that cathodal tDCS increases reaction times in the language comprehension task, but decreases naming latencies in the language production task. However, additional analyses revealed that the polarity of tDCS effects was highly correlated across tasks, implying differential individual susceptibility to the effect of tDCS within participants. Overall, our findings demonstrate that left DLPFC is part of the complex cortical network associated with language processing.

Theta band transcranial alternating current stimulations modulates network behavior of dorsal anterior cingulate cortex

Dorsal anterior cingulate cortex (dACC) is an important region in the processing of both cognition and affect. Recently, transcranial brain stimulation has been used to modulate cortical activity, but it is unclear whether this stimulation has a specific effect on dACC. Based on EEG evidence that frontal midline theta activity is generated in dACC, we hypothesized that transcranial alternating current stimulation (tACS) with theta band frequency would modulate neural networks including dACC. In this study, we examined the effects of theta band tACS on functional networks and emotional state. Graph theory analysis for resting-state functional MRI data revealed that theta band tACS decreased functional integration and hub capacity in dACC, and the attenuation of dACC network function was associated with emotional state change. Overall, these results demonstrate that theta band stimulation can modulate dACC.

tDCS for Memory Enhancement: Analysis of the Speculative Aspects of Ethical Issues

Transcranial direct current stimulation (tDCS) is a promising technology to enhance cognitive and physical performance. One of the major areas of interest is the enhancement of memory function in healthy individuals. The early arrival of tDCS on the market for lifestyle uses and cognitive enhancement purposes lead to the voicing of some important ethical concerns, especially because, to date, there are no official guidelines or evaluation procedures to tackle these issues. The aim of this article is to review ethical issues related to uses of tDCS for memory enhancement found in the ethics and neuroscience literature and to evaluate how realistic and scientifically well-founded these concerns are? In order to evaluate how plausible or speculative each issue is, we applied the methodological framework described by Racine et al. (2014) for “informed and reflective” speculation in bioethics. This framework could be succinctly presented as requiring: (1) the explicit acknowledgment of factual assumptions and identification of the value attributed to them; (2) the validation of these assumptions with interdisciplinary literature; and (3) the adoption of a broad perspective to support more comprehensive reflection on normative issues. We identified four major considerations associated with the development of tDCS for memory enhancement: safety, autonomy, justice and authenticity. In order to assess the seriousness and likelihood of harm related to each of these concerns, we analyzed the assumptions underlying the ethical issues, and the level of evidence for each of them. We identified seven distinct assumptions: prevalence, social acceptance, efficacy, ideological stance (bioconservative vs. libertarian), potential for misuse, long term side effects, and the delivery of complete and clear information. We conclude that ethical discussion about memory enhancement via tDCS sometimes involves undue speculation, and closer attention to scientific and social facts would bring a more nuanced analysis. At this time, the most realistic concerns are related to safety and violation of users’ autonomy by a breach of informed consent, as potential immediate and long-term health risks to private users remain unknown or not well defined. Clear and complete information about these risks must be provided to research participants and consumers of tDCS products or related services. Broader public education initiatives and warnings would also be worthwhile to reach those who are constructing their own tDCS devices.

Posterior resting state EEG asymmetries are associated with hedonic valuation of food

Research on the hedonic value of food has been important in understanding the motivational and emotional correlates of normal and abnormal eating behaviour. The aim of the present study was to explore associations between hemispheric asymmetries recorded during resting state electroencephalogram (EEG) and hedonic valuation of food. Healthy adult volunteers were recruited and four minutes of resting state EEG were recorded from the scalp. Hedonic food valuation and reward sensitivity were assessed with the hedonic attitude to food and behavioural activation scale. Results showed that parieto-occipital resting state EEG asymmetries in the alpha (8-12Hz) and beta (13-30Hz) frequency range correlate with the hedonic valuation of food. Our findings suggest that self-reported sensory-related attitude towards food is associated with interhemispheric asymmetries in resting state oscillatory activity. Our findings contribute to understanding the electrophysiological correlates of hedonic valuation, and may provide an opportunity to modulate the cortical imbalance by using non-invasive brain stimulation methods to change food consumption.

A meta-analytic study of exogenous oscillatory electric potentials in neuroenhancement

The assumption that transcranial alternating current stimulation (tACS) enhances perceptual and cognitive ability in healthy volunteers by exposing the brain to exogenous oscillatory electric fields is increasingly finding its way into society and commercial parties. The aim of the present study is to quantify the effects of exogenous oscillatory electric field potentials on neuroenhancement in healthy volunteers. The meta-analysis included fifty-one sham controlled experiments that investigated the effects of tACS on perception and cognitive performance. Results from random effects modelling of the cumulative effect size showed small, but robust perceptual and cognitive enhancement in healthy participants to weak exogenous oscillatory electric field potentials. Analyses of tACS parameters indicate that simultaneous stimulation of the anterior and posterior locations of the scalp at >1mA intensity currently has the highest probability of increasing performance. However, technical and methodological issues currently limit the applicability of tACS in neuroenhancement. Additional research is needed to further evaluate the potential of tACS in perception and cognitive ability, and to establish the contexts and parameters under which tACS is effective.

Cutaneous retinal activation and neural entrainment in transcranial alternating current stimulation: A systematic review

Transcranial alternating current stimulation (tACS) applies exogenous oscillatory electric field potentials to entrain neural rhythms and is used to investigate brain-function relationships and its potential to enhance perceptual and cognitive performance. However, due to current spread tACS can cause cutaneous activation of the retina and phosphenes. Several lines of evidence suggest that retinal phosphenes are capable of inducing neural entrainment, making the contributions of central and peripheral stimulation to the effects in the brain difficult to disentangle. In this literature review, the importance of this issue is further illustrated by the fact that photic stimulation can have a direct impact on perceptual and cognitive performance. This leaves open the possibility that peripheral photic stimulation can at least in part explain the central effects that are attributed to tACS. The extent to which phosphene perception contributes to the effects of exogenous oscillatory electric fields in the brain and influence perception and cognitive performance needs to be examined to understand the working mechanisms of tACS in neurophysiology and behaviour.

Hypothesis-driven methods to augment human cognition by optimizing cortical oscillations

Cortical oscillations have been shown to represent fundamental functions of a working brain, e.g., communication, stimulus binding, error monitoring, and inhibition, and are directly linked to behavior. Recent studies intervening with these oscillations have demonstrated effective modulation of both the oscillations and behavior. In this review, we collect evidence in favor of how hypothesis-driven methods can be used to augment cognition by optimizing cortical oscillations. We elaborate their potential usefulness for three target groups: healthy elderly, patients with attention deficit/hyperactivity disorder, and healthy young adults. We discuss the relevance of neuronal oscillations in each group and show how each of them can benefit from the manipulation of functionally-related oscillations. Further, we describe methods for manipulation of neuronal oscillations including direct brain stimulation as well as indirect task alterations. We also discuss practical considerations about the proposed techniques. In conclusion, we propose that insights from neuroscience should guide techniques to augment human cognition, which in turn can provide a better understanding of how the human brain works.