USE%20IT%20OR%20LOSE%20IT:%20%20Preventing%20Cognitive%20Decline%20in%20Aging

1
USE IT OR LOSE IT Preventing Cognitive Decline
in Aging

• Michael Pramuka, Ph.D.
• Western Psychiatric Institute and Clinic
• University of Pittsburgh Center for Healthy Aging

2
Other Potential Means of preventing cognitive
decline

• Management of Depression
• Diet
• Food Supplements (anti-oxidants)
• Exercise
• Adequate Sleep
• Stress Reduction
• Cholinesterase Inhibitors
• Reduce health risks for vascular dementia

3
Past Models of Cognitive Intervention

• Functional Approach
• Choose best environment
• Develop compensations
• Focus on everyday tasks
• Cognitive Approach
• Rehearse attention, memory, planning skills
• Apply to real-life situations

4
Past Models of Cognitive Intervention

• Both approaches resulted in
• Increased awareness of cognitive abilities and
  limitations
• Poor generalization
• Recruitment of intact functions/ preserved brain
  function
• Recent increasing evidence of functional
  treatment efficacy

5
Popular Model of Preserving Cognition in Aging

• Increased Cognitive Activity
• Improved Everyday Function
• Slowed cognitive decline
• VIA changes in cerebral organization or function

6
Popular Books

• Mind Games The Aging Brain and How to Keep It
  Healthy
• Wetzel, Kathryn, Harmeyer, Kathleen
•  The Memory Bible
• Small, Gary
• Keep Your Brain Young
• McKhann, Guy Albert, Marilyn
• Brain Fitness
• Goldman, Robert, Klatz, Ronald, Berger, Lisa

7
More Popular Books

• Use It or Lose It How to Keep Your Brain Fit as
  It Ages
• Bragdon, Allen. D., Gamon, David
• Keep Your Brain Alive 83 Neurobic Exercises to
  Help Prevent Memory Loss and Increase Mental
  Fitness
• Katz, Lawrence C., Rubin, Manning
• Reversing Memory Loss Proven Methods for
  Regaining, Strengthening, and Preserving Your
  Memory
• Mark, Vernon H., Mark, Jeffrey P.

8
 More Popular Books

• Exercises for the Whole Brain
• Bradgon, Allen D.
•  Exercise Your Mind
• Castorri, B. Alexis
• All popular books have one thing in common they
  cite one or several studies that implicate
  cognitive activity as a means of staving off
  Alzheimers or improving performance, and then go
  on to cite many activities, compensations, or
  strategies for improving cognition

9
Professional Literature More Active Lifestyles
Predict Preserved Cognitive Function

• Comes from both cross-sectional and longitudinal
  data
• Few studies provide a comprehensive or parallel
  literature review

10
Professional Literature Measuring WHAT

• Increased daily function
• Improved test performance
• Reduced risk of dementia
• Decreased rate of cognitive decline (preventing
  dementia?)
• Changes in the brain
• Cerebral changes (regions used)
• Increased dendritic networks and
• Nerve growth
• Neurochemical changes

11
Professional Literature Measuring WHO

• Normal community-dwelling elderly
• Normal but limited or at-risk elderly
• MCI elderly
• Demented elderly

12
Professional Literature Measuring HOW

• Level, type or frequency of cognitive activity by
  self-report or observation
• Type and frequency of physical activity by
  self-report
• Train improved memory and organizational skills
• Train increased mental flexibility
• Educate about memory, aging, and coping
• Measure or facilitate level of social activity

13
Positive emotional expression predicts longevity

• Danner, Deborah D., Snowdon, David Friesen,
  Wallace (2001)The Nun Study
• 180 nuns, age/educationcorrected
• ages 75-95
• measured expressed emotion in autobiographies
  written just prior to taking final vows

14
Lower linguistic ability in early life predicts
dementia and earlier deathSnowdon, Greiner,
Markesberry, 2000 The Nun Study

• 74 nuns
• ages 74- 97
• measured idea density in autobiographies
• looked at ratio of idea density to
  neurofibrillary tange counts
• idea density unrelated to vascular changes in
  brain

15
Engaged Lifestyle Participation in mentally
challenging activities predicts higher cognitive
scores (Lahar, 2000)

• Used WAIS-R Vocabulary, Digit Span, Boston Naming
  Test
• Compared cognition to self-report of everyday
  activities
• TV Viewing related to lower verbal skills in all
  age group
• Demonstrated relationship between activity and
  cognition in younger (under 49) but not older
  (over 50)

16
Engaged Lifestyle The Victoria Longitudinal
StudyHultsch, Hertzog, Small Dixon, 1999

• 250 adults followed over six years
• Generally high functioning/well educated
• Measured
• Cognitive status on standardized tests
• Activity level (both cognitive and physical)
• Self-reported health
• Personality (NEO)

17
Victoria Longitudinal Study Results

• No relationship between
• Self-reported health and cognition
• Personality and cognitive status
• active lifestyle and cognition
• Supports relationship between novel tasks and
  cognition (working memory)
• Alternative interpretation High-ability adults
  lead intellectually active lives

18
WW II Veterans Gold et al, 1995

• WWII Veterans tested twice over a 40 year period
• Higher intellect, better education, and higher
  SES lead to a more engaged lifestyle
• Concluded that engaged lifestyle then contributes
  to maintenance of verbal intellect

19
Seattle Longitudinal StudySchaie et al

• Begun in 1956 by K. Warner Schaie since 1981 at
  Penn State with wife Sherry Willis
• Now over 5000 adults followed every seven years
• Both longitudinal data on intellectual change
  over time and cross-sectional work on
  intellectual training
• Adult Intellectual Development the Seattle
  Longitudinal Study

20
Seattle Longitudinal Study

• Cognitive training on spatial orientation and
  inductive reasoning tasks
• 5 hour individual training
• Found improvement on both domains and less than
  average decline in inductive reasoning at seven
  year follow-up

21
Seattle Longitudinal Study

• Observations on better cognitive outcome in old
  age
• Absence of chronic disease
• Complex and intellectual stimulating environment
  throughout life
• Flexible personality style
• High intellectual status of spouse
• Persisting high perceptual processing speed

22
MacArthur Foundation Study

• 1200 participants
• Ages 70 80
• Followed for 10 years
• Better cognitive status predicted by
• Mental activity
• Physical activity
• Ongoing sense of meaning and contribution to
  community

23
Complex Work Improves Intellectual Function

• Schooler, Mulatu, Oates (1999)
• Extended a longitudinal study by Kohn Schooler
  of 1983
• Original sample of 3101 men
• 687 re-interviewed in 1974
• 334 again interviewed in 1994/1995
• Showed a positive effect of more challenging work
  on intellect, especially for older workers

24
Cognitively Stimulating Activities Reduce Risk of
Alzheimers Disease

• Wilson, Mendes de Leon, Barnes, Schneider,
  Bienias, Evans, and Bennett (2002)
• 801 Catholic nuns, priests, and brothers
• Followed from 1994 to 2001
• Ratings of frequency on 7 common activities
• Ratings of physical activity
• Neuropsychological testing

25
Results

• Higher cognitive activity associated with higher
  baseline cognitive function
• Ongoing cognitive activity associated with less
  decline in working memory and less decline in
  perceptual speed
• Controlling for age, education, and gender
• Lower level of cognitive activity predicted
  faster cognitive decline
• Risk of developing Alzheimers disease decreased
  by 33 for each additional point of reported
  cognitive activity

26
Professional Literature Training Programs for
Improved Cognition
27
Learning Mnemonic Strategies

• Yesavage, Sheikh, Friedman, Tanke, 1990
• 218 community dwelling elderly
• Mean age of 67, range 55 87
• Four 2 hour sessions of face-name association and
  list-learning strategies
• Variety of one-week pretraining (imagery,
  relaxation, or imagery plus judgment)

28
Learning Mnemonic Strategies Results of Yesavage
et al

• Both age and MMSE scores related to post-test
  performance
• No difference in type of pre-training on
  post-test performance
• Over age 75 had difficulty learning the
  list-learning mnemonic and performed poorer on
  both tasks
• Post test at the end of two week training no
  follow-up

29
Face-Name Recall Training in Dementia

• Lars, Staffan, Herlitz, Stigsdotter, Tiitanen,
  1991
• 8 patients with dementia (7 AD, 1 MID)
• Eight training sessions over two weeks
• Immediate and one month follow-up
• No improvement from baseline to immediate f/u on
  7 patients one did improve

30
Meta-analysis of Memory Training in Normal Elderly

• Verhaeghen, Marcoen, Goossens, 1992
• 31 research studies reviewed
• Retesting alone enhances memory performance on
  standardized tests
• Memory training improves performance
• Training gains are specific to training (poor
  generalizability)

31
Verhaeghen, et al Meta-analysis

• Treatment gains in Memory training were largest
• In group training rather than individual
• With younger participants
• In shorter training sessions (less than 1.5
  hours)
• When pre-training was provided

32
Longer-term Memory Training

• Oswald, Rupprecht, Gunzelmann, Tritt, 1995
• 375 people aged 75 89
• 272 treatment group, 103 controls
• Baseline, end-treatment, and one yr f/u
• Weekly intervention group over 30 weeks
• Training on
• Coping strategies
• Memory Training
• Psychomotor Training

33
Results 30 week Memory Training

• Memory groups improved memory test performance
• Coping strategy group improved everyday
  competence
• Best outcome was for combined psychomotor and
  memory training
• One yr f/u showed persisting effects of initial
  changes but overall performance decrements

34
Longer-term vs. Shorter Memory Training

• Woolverton, Scogin, Shackelford, Black, Duke,
  2001
• 77 participants community dwelling elderly
• Aged 60 88
• Self-paced instructional manuals
• 24 day one-hour study sessions
• 13 day shorter training geared to 3 targeted
  memory areas names, locations of objects, dates
  and appointments

35
Longer-term vs. Shorter Memory Training Results

• Group overall demonstrated improved performance
  in memory strategy use
• The 24 session group proved much more effective
  at memory strategy use and in improving
  performance on objective memory measures
• Shorter group had no demonstrable changes in
  targeted memory areas

36
Knowledge of Memory and Everyday Function
Improves with Education

• Troyer (2001)
• 36 participants and 24 controls
• Five weekly 2-hour sessions on
• Normal aging
• Memory processes
• Reducing risk of dementia
• Healthy lifestyle issues
• Everyday memory strategies
• Practice assignments between meetings

37
Troyer Results

• Greater pretest to post-test change scores on
  reports of everyday memory function
• Increased knowledge of how memory works
• Better performance on a prospective memory task
• No change in list learning or name recall tasks

38
ACTIVE (Advanced Cognitive Training for
Independent and Vital Elderly)

• Began enrollment in 1998
• Multi-center study (UAB, Boston, Indiana
  University, Johns Hopkins, Penn State)
• 2832 participants over the age of 65
• No evidence of cognitive, physical or functional
  decline
• 10 training sessions plus four booster session
  11 months later

39
ACTIVE

• Randomized to four groups
• Memory Training
• Reasoning Training
• Speed Training
• Control Group
• Measures of cognition, everyday function by
  self-report, paper and pencil, and observation
• Quality of Life, health service utilization,
  everyday mobility

40
Memory Training Caveats

• Memory training seems to have minimal effect on
  subjective measures of memory dysfunction (Floyd
  Scogin, 1997)
• Memory training does not typically address memory
  problems most elders complain about (Leirer,
  Morrow, Sheikh, Pariante, 1990 Yesavage, Lapp,
  Sheikh, 1989)
• Memory strategies require lots of effort and are
  seldom used outside of clinical training sessions
  (Park, Smith, Cavanaugh, 1990)

41
Increasing Complex Cognitive Activity Later in
Life might

• Increase sense of purpose, motivation, and hope
• Decrease depression
• Improve level of socialization
• Offer additional outlets for emotional expression
• Decrease stress and improve coping
• Improve use of compensatory strategies
• Increase depth of processing
• Increase level of physical activity
• Increase engagement with good role models

42
Research Outcomes

• Normal elderly can improve on cognitive tests
  with training
• Memory training shows minimal to no impact on
  subjective memory complaints or everyday function
• Lifelong cognitive activity may minimize risk of
  cognitive impairment
• No documentation that training activity leads to
  changes in brain

43
Research Outcomes

• Education on memory, healthy lifestyle, and
  compensatory strategies can improve subjective
  memory and prospective memory
• Unclear if increased mental activity late in life
  can affect cognitive status or stave off dementia
• No documented association between
• mind games and improved everyday function
• mind games and decreased risk of dementia

44
Final Observations

• Keep what youve got rather than try to get back
  what youve lost
• Be social activeenhances both emotions and
  cognitions
• Engage in novel real-life mental activity
  throughout life
• Our emphasis should be on activity/behavior that
  reduces disability and improves everyday function