Use it or lose it preventing cognitive decline in aging
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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. Other Potential Means of preventing cognitive decline:. Management of Depression Diet

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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


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


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


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


Popular Model of Preserving Cognition in Aging

  • Increased Cognitive Activity

    • Improved Everyday Function

    • Slowed cognitive decline

  • VIA changes in cerebral organization or function


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


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.


 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


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


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


Professional Literature: Measuring WHO

  • Normal community-dwelling elderly

  • Normal but “limited” or “at-risk” elderly

  • MCI elderly

  • Demented elderly


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


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


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


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)


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)


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


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


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


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


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


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


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


Cognitively Stimulating Activities Reduce Risk of Alzheimer’s 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


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 Alzheimer’s disease decreased by 33% for each additional point of reported cognitive activity


Professional Literature: Training Programs for Improved Cognition


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)


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


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


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)


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


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


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


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


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


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


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


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


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


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)


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”


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


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


Final Observations

  • Keep what you’ve got rather than try to get back what you’ve lost

  • Be social active—enhances 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


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