Third in the Annual R13 AGS Conference Series, “From Bedside to Bench” “Does Mental and Physical Activity Promote Cognitive Vitality in Late Life?” Philadelphia, PA March 1-3, 2006 Third in the Annual R13 AGS Conference Series, “From Bedside to Bench”

“Does Mental and Physical Activity Promote 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?

Normal Cognitive Aging From: T. Salthouse, PhD

Normal Cognitive Aging: Considerable Variability At All Ages From: T. Salthouse, PhD

Normal Cognitive Aging: Conclusions 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? From: T. Salthouse, PhD

Lifestyle Interventions on Cognition Possible Effects of Lifestyle Interventions on Cognition Reverse Improved level of performance Slow rate No effect on rate Cognitive Performance Additional time above threshold Chronological Age From: T. Salthouse, PhD

Clinical Syndromes of Cognitive Decline Cognitive Vitality? Age-Associated Cognitive Impairment Cognitive Function Mild Cognitive Impairment Alzheimer’s Disease 50 60 70 80 Age

Clinical Syndromes of Cognitive Decline 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 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: Medical Co-morbidities Hypertension Diabetes Cholesterol, heart disease and stroke Hormones Inflammation

Preventing Cognitive Decline: Lifestyle Factors 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 Head trauma Smoking Alcohol Stress

Preventing Cognitive Decline: Lifestyle Factors Building “cognitive reserve” throughout life Education, social and occupational engagement Physical exercise Mental exercise

Risk Factors and Alzheimer’s Disease Neuronal injury Overproduction of beta-amyloid Amyloid plaque formation Neuronal injury and death Loss of cognitive function

Are There Proven Benefits of Physical and Mental 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…. 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

What is the Value of Cognitive Vitality with Aging What is the Value of Cognitive Vitality with Aging? It Depends on Your Perspective Society/Payers Population perspective Seeks cost-effectiveness Physician Clinical impact Individual QOL QOL=quality of life.

Complex Relationships: Cognition, Function, Quality of Life, Costs and 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 Cognitive 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 Secure Horizons (United Healthcare) Population-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

Health coaching, Memory Wellness, Fitness Training The Secure Horizons (United Healthcare) Population-Based Program For Cognitive Vitality Population Based Telephonic Screening Case Referral Telephonic Assessment Triage Normal (60%) At risk (35%) Dementia (< 5%) Prevention Monitoring Care Management Health coaching, Memory Wellness, Fitness Training

Using Technology to Advance Cognitive 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 Session To define normal cognitive aging To summarize current knowledge regarding the biological mechanisms underlying the effect of activity on cognitive health To summarize evidence in humans that mental and physical activity promotes cognitive health with aging To review clinical and population-based interventions that have been employed to disseminate this new knowledge 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

Summary 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