1. Arnold School of Public Health Office for the Study of Aging North Carolina Conference on Aging Session 2C: Healthy Aging Plenary Emerging Opportunities to Promote Cognitive Health Jim Laditka

2. 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.) Moderate, & Severe Mild, Moderate, & Severe

3. Arnold School of Public Health Office for the Study of Aging Data Sources *Duplicates occur because individuals often use more than one name, social security number, or other identifying information when using health or social services.

4. South Carolina AD Prevalence

5. Arnold School of Public Health Office for the Study of Aging South Carolina AD Prevalence

6. AD Prevalence in SC Prevalence of Alzheimer’s Disease, 2002, Comparing African Americans and European Americans, by Sex AGE 55-6465-7475-8485+ African Americans Women (n=7,070) a 0.281.767.3725.43 Men (=3,521) a 0.451.986.0526.77 Non-Hispanic Whites Women (n=12,914) a 0.140.814.1816.47 Men (n=5,116) a 0.120.632.7414.60 Prevalence Ratios and p-values: African American Women Compared to non-Hispanic white Women 2.0 p<0.0001 2.2 p<0.0001 1.8 p<0.0001 1.5 p<0.0001 African American Men Compared to non-Hispanic white Men 3.8 p<0.0001 3.1 p<0.0001 2.2 p<0.0001 1.8 p<0.0001 a Numbers are Registry n’s, the number with an Alzheimer’s Diagnosis.

7. Arnold School of Public Health Office for the Study of Aging All Persons Age 65+, ADRD, South Carolina, 2002 Observed to Expected Ratio

8. Arnold School of Public Health Office for the Study of Aging “Somehow, in all the confusion, I aged.”

9. Arnold School of Public Health Office for the Study of Aging If you turn 65 today, your life expectancy is: Women: 84.4 Men: 81.4 SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System, 2003

10. Arnold School of Public Health Office 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.

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

12. Arnold School of Public Health Office 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

13. Arnold School of Public Health Office for the Study of Aging Adjusted relative risk of cognitive decline in those who exercise the most, compared with those who exercise the least, followed 5 years Rockwood et al., Mech Ageing Dev, 2004; 125(7): 517-19

14. Arnold School of Public Health Office for the Study of Aging Adjusted rates of developing Alzheimer’s Disease in those who exercise the most, versus those who exercise the least, over 5 years of follow-up

15. Arnold School of Public Health Office for the Study of Aging The association between mid-life physical activity and late-life dementia & Alzheimer’s Disease has been reported as enhanced in ApoE4 carriers Rovio et al. Lancet Neurology 2005; 4: 705-11. e

16. Arnold School of Public Health Office for the Study of Aging What kind of exercise? How much?

17. Arnold School of Public Health Office for the Study of Aging 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)

18. 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.

19. Metabolic Equivalents (METs) Activity METs Inactive (lying quietly) 1.0 Walking, household 2.0 Walking, 3.0 MPH* 3.3 Walking, 3.5 MPH* 3.8 Walking, 4.0 MPH* 5.0 Walk or Run, 5.0 MPH* 8.0 Running, 6.0 MPH* 10.0 *Level, firm surface (See Ainsworth et al., Med & Sci in Sports & Exercise, 2000)

20. Adjusted HRs of total dementia mortality per 1-MET increase, by sex Adjusted for: age, exam year, BMI, smoking, alcohol intake, abnormal exercise ECG responses, HTN, DM, hypercholesterolemia, and health status. P =0.04 P=0.009 1.0 0.8

21. ACLS Maximal MET Tertiles Women Men Low 7.6 > 9.5

22. Sex and Examination Year-adjusted Total Dementia Mortality Rates by CRF Tertiles & Age at Baseline P = 0.07P < 0.0001

23. Arnold School of Public Health Office for the Study of Aging 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

24. 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 NEventsOR95% CI Low363551Referent Moderate1,1311050.560.40-0.80 High1,5911220.460.32-0.65 P-linear trend <0.0001

25. Factors Related to Maintenance of Cognitive Health Avoid Vascular Damage “Heart Healthy” is “Brain Healthy”  Blood pressure  Cholesterol  Diabetes  Weight  Smoking  Physical activity

26. Arnold School of Public Health Office for the Study of Aging “The Healthy Brain Initiative: A Roadmap to Maintaining Cognitive Health” CDC Alzheimer’s Association NIH AARP The Healthy Aging Research Network Other partners

27. Physical Activity Diet Cognitive stimulation Environmental enrichment Arnold School of Public Health Office for the Study of Aging Invitational Expert Consensus Summit on Wellness for Persons with Dementia Oct 20-21, 2005

28. Arnold School of Public Health Office for the Study of Aging Physician Focus Groups, 2007 “What do you say to your patients about maintaining brain health?”

29. Arnold School of Public Health Office for the Study of Aging Physician Focus Groups, 2007 Preliminary result: “Nothing”

30. Arnold School of Public Health Office for the Study of Aging Physician Focus Groups, 2007 “Why is it that you do not discuss brain health with your patients?”

31. Arnold School of Public Health Office for the Study of Aging Physician Focus Groups, 2007 Preliminary result: “There isn’t any evidence that there is anything they can do about it. It would be a waste of time.”

32. Sex and Examination Year-adjusted Total Dementia Mortality Rates by CRF Tertiles & Age at Baseline P = 0.07P < 0.0001

33. “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

34. Arnold School of Public Health Office for the Study of Aging North Carolina Conference on Aging Session 2C: Healthy Aging Plenary Emerging Opportunities to Promote Cognitive Health Jim Laditka