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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

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
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
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 intervention1
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
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
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
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 books1
 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
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
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
Professional Literature: Measuring WHO
  • Normal community-dwelling elderly
  • Normal but “limited” or “at-risk” elderly
  • MCI elderly
  • Demented elderly
professional literature measuring how
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
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 study hultsch hertzog small dixon 1999
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
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
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 study schaie et al
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
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 study1
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
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
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
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
  • 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
learning mnemonic strategies
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
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
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
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
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
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
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
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
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
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
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
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
  • 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 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
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
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 outcomes1
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
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