Arnold School of Public Health Office for the Study of Aging North Carolina Conference on Aging...

Arnold School of Public HealthOffice for the Study of Aging

North Carolina Conference on Aging

Session 2C: Healthy Aging Plenary

Emerging Opportunities to Promote Cognitive Health

Jim LaditkaJim Laditka

North Carolina AD Prevalence

North Carolina Division of Aging and Adult Services Estimates 31,171 Moderate & Severe in 1998, 54,168 in 2020 . (Rates from U.S. GAO, Jan. 1998.)

0

10

20

30

40

50

60

65-69 70-74 75-79 80-84 85-89 90-94 95+

Age

Ra

te

Moderate, & Severe

Mild, Moderate, & Severe


Data Sources

Long-term CareEvaluations S.C. Inpatient

HospitalizationsS.C. Emergency

Departments

MedicaidMental HealthRecords

MemoryClinics

Vital Records

ChartAbstracts

SouthCarolinaUnique

Identifier

AlgorithmTo RemoveDuplicates*

South CarolinaAlzheimer’s Disease

RegistryN.C. & G.A.Hospitals

P.A.C.E.

Other

Long-term CareEvaluations S.C. Inpatient

HospitalizationsS.C. Emergency

Departments

MedicaidMental HealthRecords

MemoryClinics

Vital Records

ChartAbstracts

SouthCarolinaUnique

Identifier

AlgorithmTo RemoveDuplicates*

South CarolinaAlzheimer’s Disease

RegistryN.C. & G.A.Hospitals

P.A.C.E.

Other

*Duplicates *Duplicates occur because individuals often use more than one name, social security number, or other identifying occur because individuals often use more than one name, social security number, or other identifying information when using health or social services.information when using health or social services.

South Carolina AD PrevalenceAlzheimer's Disease and Related Disorders

Prevalence South Carolina, 2002

0

10

20

30

40

50

60

70

65-6

9

70-7

4

75-7

9

80-8

4

85-8

9

90-9

4Age

%

SC Alzheimer's Disease Registry

SC State Health Plan

East Boston Study (includes Mild AD)

Southern Calif Study (includes Questionable AD)


South Carolina AD Prevalence

AD Prevalence in SC

Prevalence of Alzheimer’s Disease, 2002,Prevalence of Alzheimer’s Disease, 2002,Comparing African Americans and European Americans, by SexComparing African Americans and European Americans, by Sex

AGE

55-64 65-74 75-84 85+

African Americans

Women (n=7,070)a 0.28 1.76 7.37 25.43

Men (=3,521)a 0.45 1.98 6.05 26.77

Non-Hispanic Whites

Women (n=12,914)a 0.14 0.81 4.18 16.47

Men (n=5,116)a 0.12 0.63 2.74 14.60

Prevalence Ratios and p-values:

African American Women Compared to non-Hispanic white Women

2.0p<0.0001

2.2p<0.0001

1.8p<0.0001

1.5p<0.0001

African American Men Compared to non-Hispanic white Men

3.8p<0.0001

3.1p<0.0001

2.2p<0.0001

1.8p<0.0001

aNumbers are Registry n’s, the number with an Alzheimer’s Diagnosis.


All Persons Age 65+, ADRD, South Carolina, All Persons Age 65+, ADRD, South Carolina, 2002 Observed to Expected Ratio2002 Observed to Expected Ratio

O/E Ratio

0.47 - 0.58

0.59 - 0.86

0.87 - 0.95

0.96 - 1.00

1.10 - 1.20

1.20 - 1.30

1.30 - 1.50

1.60 - 1.70

Horry

Aiken

York

Berkeley

Colleton

Lee

Jasper

Sumter

Orangeburg

Florence

LaurensFairfield

Richland

UnionOconee

Kershaw

Greenville

Anderson

Lexington

Chester

Williamsburg

Dillon

Marion

Newberry

Chesterfield

Clarendon

Spartanburg

Saluda

Pickens

Barnwell

Hampton

Lancaster

Abbeville

Darlington

Marlboro

Edgefield

Georgetown

Dorchester

Calhoun

Allendale

Cherokee

McCormick

Charleston

Beaufort


“Somehow, in all the confusion, I aged.”


If you turn 65 today, your life expectancy is:

Women: 84.4

Men: 81.4SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System, 2003

Arnold School of Public HealthOffice for the Study of Aging / CHSPR

One typical study…

Kivipelto et al., Archives of Neurology, Oct. 2005

• 21 year follow-up beginning at mid-life.

• Obesity doubled the odds of developing AD.

• High blood pressure doubled the odds of developing AD.

• High total cholesterol doubled the odds of developing

AD.

• With all three factors, the odds of developing AD were

more than 6 times greater.

Adjusted rate of dementia, those who exercise the most,compared with those who exercise the least, followed 5 years

0.1 1 10Relative Risk of Dementia

Laurin et al. 2001

Larson et al. 2006

Ruvio et al. 2005

Scarmeas et al. 2001

Abbott et al. 2004

Broe et al. 1998

Arnold School of Public HealthOffice for the Study of Aging / CHSPR

Adjusted relative risk of developing cognitive impairment in those who exercise the most, compared with those who exercise the least, followed 5 years

0.1 1 10Relative Risk of Cognitive Impairment

Flicker et al. 2005

Laurin et al. 2001

Stewart et al. 2001

Weuve et al. 2004


Adjusted relative risk of cognitive decline in those who exercise the most, compared with those who exercise the least, followed 5 years

0.1 1 10Relative Risk of Cognitive Decline

Lyttle et al. 2004

Schuit et al. 2001

Yaffe et al. 2001

Rockwood et al., Mech Ageing Dev, 2004; 125(7): 517-19


Adjusted rates of developing Adjusted rates of developing Alzheimer’s DiseaseAlzheimer’s Diseasein those who exercise the most, versus those whoin those who exercise the most, versus those whoexercise the least, over 5 years of follow-upexercise the least, over 5 years of follow-up

0.01 0.1 1 10Relative Risk of Alzheimer's Disease

Larson et al. 2006

Laurin et al. 2001

Ruvio et al. 2005

Yoshitake et al. 1995

Abbott et al. 2004

Broe et al. 1998


The association between mid-life physical activityThe association between mid-life physical activityand late-life dementia & Alzheimer’s Diseaseand late-life dementia & Alzheimer’s Diseasehas been reported as enhanced in ApoE4 carriershas been reported as enhanced in ApoE4 carriers

0.01 0.1 1 10Relative Risk of Dementia/AD

Dementia: ApoE4+

Dementia: ApoE4-

AD: ApoE4+

AD: ApoE4-

Rovio et al. Lancet Neurology 2005; 4: 705-11.

ee


What kind of exercise? How much?


Exercise Type and Intensity

• Frequency: – 3x/wk is better than <3x/wk (Laurin et al. 2001)– 5x/wk may offer little additional benefit (Lytle et al. 2004)

• Intensity: – more intense activity is associated with less cognitive

decline (Flicker et al. 2005, van Gelder et al. 2004)

• Duration: – 30min appears to be adequate – >30min & >60 min may offer little additional protection

(Schuit et al. 2001)

Study Design & Population

• Prospective observational study, Aerobics Center Longitudinal Study (ACLS).

• Baseline: 45,140 men, 14,820 women.

• Ages 20-88.

• Examined 1970-2001.

• Average 17 years of follow up.

• 1,012,125 person-years of observation.

Metabolic Equivalents (METs)Activity METs

Inactive (lying quietly) 1.0Walking, household 2.0Walking, 3.0 MPH* 3.3Walking, 3.5 MPH* 3.8Walking, 4.0 MPH* 5.0Walk or Run, 5.0 MPH* 8.0Running, 6.0 MPH* 10.0

*Level, firm surface (See Ainsworth et al., Med & Sci in Sports & Exercise, 2000)

Adjusted HRs of total dementia mortality

per 1-MET increase, by sex

Female Male

Adjusted for: age, exam year, BMI, smoking, alcohol intake, abnormal exercise ECG responses, HTN, DM, hypercholesterolemia, and health status.

P =0.04 P=0.0091.0

0.8

ACLS Maximal MET Tertiles

Women Men

Low < 5.8 < 7.2

Medium 5.8 - 7.6 7.2 - 9.5

High > 7.6 > 9.5

Sex and Examination Year-adjustedTotal Dementia Mortality Rates by CRF Tertiles & Age at Baseline

P = 0.07P < 0.0001

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6

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12

Low Middle High

Age ≥ 55 years

CRF Tertile

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0.2

0.4

0.6

0.8

1

1.2

1.4

Low Middle High

Age < 55 years

Rat

e pe

r 10

,000

per

son-

year

s

CRF Tertile


4 Recent meta-analyses

• Colcombe & Kramer (2003)• Heyn, Abreu & Ottenbacher (2004)• Netz, Wu, Becker & Tenebaum (2005)• Hendrie et al (2006)

• All found positive effects of exercise on cognition

Adjusted Odds Ratios for Depression at follow-up

Adjusted for: age, baseline examination year and survey response year. stressful occupation (yes or no), current smoking (yes or no), alcohol consumption (≥ 5 drinks/week or not), body mass index, hypertension, diabetes (present or not for each), and abnormal exercise ECG responses (present or not).

CRF N Events OR 95% CI

Low 363 55 1 Referent

Moderate 1,131 105 0.56 0.40-0.80

High 1,591 122 0.46 0.32-0.65

P-linear trend

<0.0001

Factors Related to Maintenance of Cognitive Health

• Avoid Vascular Damage

• “Heart Healthy” is “Brain Healthy” Blood pressure Cholesterol Diabetes Weight Smoking Physical activity


“The Healthy Brain Initiative: A Roadmap to Maintaining Cognitive Health”

• CDC

• Alzheimer’s Association

• NIH

• AARP

• The Healthy Aging Research Network

• Other partners

• Physical Activity

• Diet

• Cognitive stimulation

• Environmental enrichment


Invitational Expert Consensus Summit on Wellness for Persons with Dementia

Oct 20-21, 2005


Physician Focus Groups, 2007

“What do you say to your patients

about maintaining brain health?”



Preliminary result:

“Nothing”



“Why is it that you do not discuss

brain health with your patients?”



Preliminary result:

“There isn’t any evidence that there

is anything they can do about it.

It would be a waste of time.”

Sex and Examination Year-adjustedTotal Dementia Mortality Rates by CRF Tertiles & Age at Baseline

P = 0.07P < 0.0001

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Low Middle High

Age ≥ 55 years

CRF Tertile

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0.8

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1.2

1.4

Low Middle High

Age < 55 years

Rat

e pe

r 10

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per

son-

year

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CRF Tertile

“Epidemiology Cannot Establish Causation”

• Causal inferences are usually uncertain

• Causal inference is strengthened by evidence from all branches of medical science--pathophysiology, epidemiology, and controlled experiments

• Established causal inferences not relying on experimental evidence in humans– Thalidomide and birth defects

– Radiation and cancer

– Cigarette smoking and lung cancer


North Carolina Conference on Aging

Session 2C: Healthy Aging Plenary

Emerging Opportunities to Promote Cognitive Health

Jim LaditkaJim Laditka

Arnold School of Public Health Office for the Study of Aging North Carolina Conference on Aging...

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