ISOA () Does Mental and Physical Activity Promote Cognitive Vitality in Late Life? Philadelphia, PA...

ISOA (www.aging-institute.org)

““Does Mental and Physical Activity Does Mental and Physical Activity Promote Cognitive Vitality in Late Life?”Promote Cognitive Vitality in Late Life?”

Philadelphia, PAPhiladelphia, PAMarch 1-3, 2006March 1-3, 2006

Third in the Annual R13 AGS Conference Series,

“From Bedside to Bench”


““Does Mental and Physical Activity Promote Does Mental and Physical Activity Promote Cognitive Vitality in Late Life?”Cognitive Vitality in Late Life?”

• Sponsor: American Geriatrics Society – Julie Zaharatos, MPH, Manager, Governance & Public Policy

• Support: National Institute of Aging– Judith Salerno, MD, MS, Deputy Director

• Chairperson and Organizer: Howard Fillit, MD • Committee Members:

– Michelle C. Carlson, PhD– William T. Greenough, PhD– Arthur Kramer, PhD– George Rebok, PhD– Robert Wilson, PhD– Stephanie Studenski, MD, MPH, AGS Research Committee Chair


Defining Current Issues in Cognitive Vitality with Aging

• What is cognitive vitality with aging?

• What causes age-related cognitive decline?

• What is the clinical and societal significance of age-related cognitive decline?

• Can age-related cognitive decline be prevented or treated?

ISOA (www.aging-institute.org)Chronological Age

20 30 40 50 60 70 80 90

Z-S

core

-2.0

-1.5

-1.0

-0.5

0.0

0.5

1.0

1.5

Word Recall (N = 2,230)Matrix Reasoning (N = 2,440)Spatial Relations (N = 1,618)Pattern Comparison (N = 6,547)

84

69

50

31

16

7

Per

cent

ile

Normal Cognitive Aging

From: T. Salthouse, PhD


Normal Cognitive Aging: Considerable Variability At All Ages



• Decline is ubiquitous but not universal

• Changes in cognitive function are pervasive, but possibly preventable

• Do lifestyle interventions

• Alter rate of aging?

• Delay time to a functional threshold?

Normal Cognitive Aging:Conclusions


ISOA (www.aging-institute.org)Chronological Age

Co

gni

tive

Pe

rfor

ma

nce

Reverse

Slow rate

No effecton rate

Possible Effects of Lifestyle Interventions on Cognition


Additional timeabove threshold

Improved level of performance


Clinical Syndromes of Clinical Syndromes of Cognitive Decline Cognitive Decline

Mild Mild Cognitive Cognitive

ImpairmentImpairment

Alzheimer’s Alzheimer’s DiseaseDisease

Age-Associated Age-Associated Cognitive Cognitive

ImpairmentImpairment

Age Age

Cog

nit

ive F

un

cti

on

Cog

nit

ive F

un

cti

on

80706050

Cognitive Cognitive Vitality?Vitality?


Clinical Syndromes of Cognitive Decline Clinical Syndromes of Cognitive Decline With Aging With Aging

• Age-Associated Memory Impairment (AAMI)– 1 memory test > 1 SD below mean– 1% estimated annual dementia incidence– 40% of 65+ population or 16 million

• Mild Cognitive Impairment (MCI)– Delayed recall impairment, other syndromes– 15% estimated annual dementia incidence – 10% of 65+ population or 4 million

• Dementia– Global cognitive impairment

– 5% of people over 65, 25% over 75


Prevention and Cognitive HealthPrevention and Cognitive Health

• Primary prevention: maintain cognitive vitality, prevent cognitive decline with aging

• Secondary prevention: prevent dementia

• Tertiary prevention: prevent the progression of dementia


Preventing Cognitive Decline With Aging: Preventing Cognitive Decline With Aging: Medical Co-morbiditiesMedical Co-morbidities

• Hypertension

• Diabetes

• Cholesterol, heart disease and stroke

• Hormones

• Inflammation


Nutritional

• Folate, B6 and B12 and homocysteine

• Anti-oxidants– vitamin C and E, and other

anti-oxidants (red wine, dark vegetables and fruits)?

• Omega-3-fatty acids, DHA

• Caloric restriction

Preventing Cognitive Decline: Preventing Cognitive Decline: Lifestyle FactorsLifestyle Factors

• Head trauma• Smoking • Alcohol • Stress


Building “cognitive reserve” throughout lifeBuilding “cognitive reserve” throughout life

• Education, social and occupational engagement

• Physical exercise

• Mental exercise

Preventing Cognitive Decline: Preventing Cognitive Decline: Lifestyle FactorsLifestyle Factors


Risk Factors and Alzheimer’s Disease Risk Factors and Alzheimer’s Disease

Neuronal injury

Overproduction of beta-amyloid

Amyloid plaque formation

Loss of cognitive function

Risk Factors

Neuronal injury and death


Are There Are There ProvenProven Benefits of Physical and Mental Benefits of Physical and Mental Activity on Cognitive Health in Aging?Activity on Cognitive Health in Aging?

• Epidemiologic and intervention trials support physical activity benefits on promoting cognitive health and preventing cognitive decline including dementia

• Benefits of mental activity less clear

– Epidemiologic studies generally support life long education, continuing social and occupational engagement, mental “exercise” in preventing cognitive decline and dementia

– However, more intervention studies needed

• Is the evidence good enough to make population recommendations at this time?


Is Cognitive Vitality in Aging Important?Is Cognitive Vitality in Aging Important?It Depends on Your Perspective….It Depends on Your Perspective….

• Achieving and maintaining cognitive vitality and preventing Alzheimer’s disease is a highly valued outcome among older persons, affecting primarily quality of life

• For physicians, society, and payers, the value of cognitive vitality is not as clear

• Cognitive vitality is important only if we can define it and achieve it and demonstrate value


Society/PayersSociety/Payers Population perspectivePopulation perspective

Seeks cost-effectivenessSeeks cost-effectiveness

PhysicianClinical impact

What is the Value of Cognitive Vitality with Aging? What is the Value of Cognitive Vitality with Aging?

It Depends on Your PerspectiveIt Depends on Your Perspective

QOL=quality of life.QOL=quality of life.

IndividualQOL


Complex Relationships: Complex Relationships: Cognition, Function, Quality of Life, Costs Cognition, Function, Quality of Life, Costs

and Activityand Activity

• Ability to function is a key objective measure of quality of life (QOL)—important to individuals

• Are there functional deficits associated with cognitive decline in aging?– important in medical care

• Are there excess costs associated with cognitive decline with aging? – important to society and payers

• If activity improves cognitive health, does it improve quality of life, function and reduce costs?


Possible Sources of Excess Costs Due to Possible Sources of Excess Costs Due to Cognitive DeclineCognitive Decline

• Functional impairment

• Accidents

• Medication noncompliance and poor control of medical comorbidities

• Loss of productivity

• Caregiver burden

Source: Hill JW, et al. Neurology. 2002;58:62-70.


The The Secure Horizons (United Healthcare) Secure Horizons (United Healthcare) Population-Based Program For Cognitive VitalityPopulation-Based Program For Cognitive Vitality

• A population-based program currently available to 180,000 Medicare Advantage managed care members in multiple regions of the US

– Approved by CMS as part of health plan Medicare benefit

– Part of an overall wellness program that also includes nutrition, financial and other health promotion components

– Includes telephonic health coaching and free access to a senior fitness program

– Free access to comprehensive “memory wellness” program that includes mental exercise


Population Based Telephonic ScreeningPopulation Based Telephonic Screening

Telephonic AssessmentTelephonic Assessment

TriageTriage

Care ManagementCare ManagementPreventionPrevention MonitoringMonitoring

Normal (60%)Normal (60%) At risk (35%)At risk (35%) Dementia (< 5%)Dementia (< 5%)

Case ReferralCase Referral

The The Secure Horizons (United Healthcare) Secure Horizons (United Healthcare) Population-Based Program For Cognitive VitalityPopulation-Based Program For Cognitive Vitality

Health coaching, Memory Wellness, Fitness Training


Using Technology to Advance Using Technology to Advance Cognitive Health in Primary CareCognitive Health in Primary Care

• Neuropsychometric testing is important, but time consuming, expensive and not readily available or practical in primary care

• Computerized methods for cognitive screening and assessment make neuropsych testing practical in primary care

• Computerized methods for cognitive training can also be implemented in primary care and in the community


Goals of SessionGoals of Session

1. To define normal cognitive aging

2. To summarize current knowledge regarding the biological mechanisms underlying the effect of activity on cognitive health

3. To summarize evidence in humans that mental and physical activity promotes cognitive health with aging

4. To review clinical and population-based interventions that have been employed to disseminate this new knowledge

5. To create a research agenda to define outstanding issues and develop strategies to further define the role of physical and mental activity in promoting cognitive health with aging


SummarySummary

• Achieving and maintaining cognitive vitality with aging is possible

• Cognitive vitality has value to individuals, in health care, and to society.

• Physical and mental activity contribute significantly to cognitive health in aging

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