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USE IT OR LOSE IT: Preventing Cognitive Decline in Aging

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

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  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 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

  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 Alzheimer’s 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 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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