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TheHealthyBrainInitiative:
A National Public Health Road Map to Maintaining Cognitive Health
TableofContents
Acknowledgements
Executive Summary 1
I Background 4 Whatiscognitivehealth? 5
WhyprepareaRoadMap? 7
Whyisitimportantandwhynow? 12
II State of Knowledge 16
Whatdoweknow? 17
Whatgapsexist? 18
Howcanpublichealthcontribute? 19
III Strategic Framework 22
Whatisourmodelforaction? 23
Whatprinciplesdoweembrace? 25
Whatdowehopetoaccomplish? 26
IV Development Process 28
Workgroupdeliberations 29
Conceptmappingprocess 34
V Actions by Cluster 36
Disseminatinginformation 38
Translatingknowledge 40
Implementingpolicy 41 Conductingsurveillance 43
Movingresearchintopractice 44
Conductinginterventionresearch 47
Measuringcognitiveimpairment
andburden 50
Developingcapacity 51
VI Next Steps 52
Prioritiesforaction 53
Implementation 57
Conclusion 57
Appendix A: Contributors 58
Appendix B: References 62
Suggested Citation: CentersforDiseaseControlandPreventionandtheAlzheimers
Association.TheHealthyBrainInitiative:ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth:Chicago,IL:AlzheimersAssociation;2007
Availableatwww.cdc.gov/agingandwww.alz.org
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Acknowledgements
WethankthemembersoftheSteeringCommitteeforgivingcountlesshourstothink
aboutanddiscussthisNational Public Health Road Map to Maintaining Cognitive Health;
theircontributionshavebeeninvaluable.
LyndaAnderson,PhD(Cochair)
Centers for Disease Control and Prevention
StephenMcConnell,PhD(Cochair)
Alzheimers Association
FrankBailey,JD
AARP
WilliamF.Benson
Health Benefits ABCs
DebraCherry,PhD
Alzheimers Association
GregCase
Administration on Aging
HughC.Hendrie,MB,ChB,DSc
Indiana University Center for Aging ResearchRegenstrief Institute, Inc.
JamesLaditka,DA,PhD,MPA
University of South Carolina
DebraLappin,JD
B&D Consulting LLC
MarcelleMorrisonBogorad,PhD
National Institute on Aging
PeterRabins,MD,MPH
Johns Hopkins University School of Medicine
RamonaL.Rusinak,RN,PhD
Arizona Department of Health Services
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ExecutiveSummary
InFall2005,theCentersforDiseaseControlandPreventionandtheAlzheimersAssociationformedanewpartnershiptoexaminehowbesttobringapublichealthperspectiveto
thepromotionofcognitivehealth.ToassistwiththisHealthy
BrainInitiative,thePartnersworkedcloselywiththeNational
InstituteonAgingandtheAdministrationonAgingtoconvene
amultidisciplinarySteeringCommitteeandanevenwiderarrayofinvitedexpertsfromconcernedpublicandprivate
sectororganizations.Togetherweexaminedthecurrentstate
ofknowledgeregardingthepromotionandprotectionof
cognitivehealth,identifiedimportantknowledgegaps,and
definedtheuniqueroleandcontributionsofpublichealth.
Wefocusedonvascularriskfactorsandphysicalactivity
becauseoftheirassociationwithcognitiveoutcomes,adopted
astrategicframework,andembarkedonanintensiveprocess
togeneratetheactionsofferedinthis National Public Health
Road Map to Maintaining Cognitive Health.
TheRoadMaprecognizescurrentsocialtrendsandother
factorsthataffectcognitivehealthfromapublichealth
standpoint:anagingpopulation,growingfearandconcern
expressedbymanypeopleastheyageabouttheirpotentiallossofcognitivefunction,increasingsocietalburdenfrom
cognitivedecline,greatercaregiverburden,andacontinued
lackofawarenessaboutcognitivehealthamongconsumers
andprovidersalike.
Withthisbackdrop,weofferaloftybutachievablelong-
termgoal:
To maintain or improve the cognitive performance of all adults.
Toaccomplishthisgoal,weproposeasetof44actionsthat
arefirmlygroundedinscience,emphasizeprimaryprevention,
assumeacommunityandpopulationapproach,andarecommittedtoeliminatingdisparitiesinpersonalhealthand
healthcareforracialorethnicgroups.Itiscriticaltonotethat
eachpriorityactionisbasedonadetailed,scientificrationale,
withimplementationtobebasedondemonstratedeffectiveness
ofspecificinterventions.Theseactionsshouldthereforebe
consideredinthecontextoftherationalespresentedin
SectionVoftheRoadMap.Withinthefullsetofactionsare10prioritiesworthyofimmediateattention:
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ExecutiveSummary
Determinehowdiverseaudiencesthinkaboutcognitive
healthanditsassociationswithlifestylefactors.
Disseminatethelatestsciencetoincreasepublicunderstanding
ofcognitivehealthandtodispelcommonmisconceptions.
Helppeopleunderstandtheconnectionbetweenriskand
protectivefactorsandcognitivehealth.
Conductsystematicliteraturereviewsonproposedrisk
factors(vascularriskandphysicalinactivity)andrelated
interventionsforrelationshipswithcognitivehealth,harms,
gapsandeffectiveness.
Conductcontrolledclinicaltrialstodeterminetheeffect
ofreducingvascularriskfactorsonloweringtheriskof
cognitivedeclineandimprovingcognitivefunction.
Conductcontrolledclinicaltrialstodeterminetheeffectof
physicalactivityonreducingtheriskofcognitivedecline
andimprovingcognitivefunction.
Conductresearchonotherareaspotentiallyaffecting
cognitivehealthsuchasnutrition,mentalactivity,and
socialengagement.
Developapopulationbasedsurveillancesystemwith
longitudinalfollowupthatisdedicatedtomeasuringthe
publichealthburdenofcognitiveimpairmentinthe
UnitedStates.
Initiatepolicychangesatthefederal,state,andlocallevels
topromotecognitivehealthbyengagingpublicofficials.
Includecognitivehealthin Healthy People 2020,aset
ofhealthobjectivesforthenationthatwillserveasthe
foundationforstateandcommunitypublichealthplans.
Itisourhopethatthese10priorityactionswillservetofocus
thenationsresourcesonaddressingriskandprotectivefactors
forpromotingcognitivehealthoverthenext35years.Asa
livingandflexibledocument,theRoadMaprepresentsboth
acalltoactionandaguideforimplementinganeffective
coordinatedapproachtomovingcognitivehealthintopublic
healthpractice.Thekeytosuccessliesincontinuingand
expandingresearch;developingandchannelingresources;
workingtodeveloporstrengthenpartnershipswithlike-
mindedorganizations;designingcollaborativeoperational
plansofaction;andestablishingsystemstotrackprogress,facilitatecommunication,andexchangeinformation.
Continuedvigilanceonthisissue,andtimelytranslationof
researchfindingsintocommunityaction,willassurethat
wereapthepotentialrewardsthatpublichealthcanofferin
improvingqualityoflifeamongadultsandreducingsocietal
costsforhealthcareandotherservices.
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IVdevelopmentprocess
Vactions bycluster
VInext steps
IIIstrategicframework
IIstate ofknowledge
Ibackground
BackgroundWhat is cognitive health?
Thedistinctionbetweenthemindandbodywasaconcept
firstformallysetforthinthe17thcenturybyphilosopher
ReneDescartes.Overthenextseveralcenturies,thebody
wasseenastheconcernofphysicians,whilethemindwasthepurviewoforganizedreligion.1
Overtheyears,ourunderstandingofbodyandmind
hasevolvedsignificantly.Wenowrecognizethevitalrole
thatbothphysicalhealthandmentalhealthplayinshaping
ouroverallwell being,andweappreciatethevaluable
contributionsthatawidearrayofhealthprofessionscan
maketowardassuringthatwellbeing.
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Background
Mentalhealthencompassesemotionalfunctioningandthe
abilitytothink,reason,andremember(cognitivefunctioning).
Whilestandardized,widelyaccepteddefinitionsof cognitive
healthhaveyettobeadopted,mostexpertsagreethatthe
componentsofhealthycognitive functioning include:
language
thought
memory
executivefunction(theabilitytoplanandcarryouttasks)
judgment
attention
perception
rememberedskills(suchasdriving)
abilitytoliveapurposefullife2
Muchlikephysicalhealth,cognitivehealthcanbeviewed
alongacontinuumfromoptimalfunctioningtomild
cognitiveimpairmenttoseveredementia.Itisnotsimplythe
absenceofdiseasessuchasAlzheimersdisease;rather,itshould
berespectedforitsmultidimensionalnature,andthechanges
thattakeplaceoverthelifespanshouldbeaccepted,even
embraced,asanaturalpartoftheagingprocess.3
Cognitivedeclinecanrangefrommildcognitiveimpairment
todementia,butthesetwoconditionsarenotnecessarily
manifestationsofthesamedisease.Manypeoplenever
developanyseriousdeclineintheircognitiveperformance,
andthosewhodevelopmildcognitiveproblemsdonot
necessarilydevelopdementia.Althoughnotallpeoplewith
cognitivedeclinedevelopdementia,thosewithanamnesticformofmildcognitiveimpairmentdohaveamuchhigher
riskfordementiathanotheradults.
Thelackofcognitivehealthcanhaveprofoundimplications
forapersonsphysicalhealth.Olderadultsandothers
experiencingcognitiveimpairmentmaybeunabletocare
forthemselvesortoengageinnecessaryactivitiesofdaily
living,suchaspreparingmealsormanagingtheirfinances.Limitationsintheabilitytoeffectivelymanagemedications
andexistingmedicalconditionsareofparticularconcernwhen
apersonisexperiencingcognitiveimpairmentordementia.
Dementiaaffectsapersonsabilitytocomprehendandacton
messages,andinvolvesproblemswithmemory,understanding
orusingwords,andidentifyingobjects.Thesignificantly
impairedcognitionassociatedwithdementialeadstoalossof
senseofselfandoflifelongmemories;adecreasingabilityto
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Mostimportanttoourabilitytoliveourliveswellisthecombinationofmentalprocesseswecallcognitionorknowing.Thiscombinationincludestheabilitytolearnnewthings,intuition,judgment,language,andremembering.Havingaclear,activemindatanyageisimportant,butas
wegetolderitcanmeanthedifferencebetweendependenceandindependentliving.4
copewiththenormaldemandsofliving;problemsaccessing
healthcaresystems;greatervulnerabilitytodisease,injury,
malnutrition,crime,andpossiblyabuse;andeventuallyaloss
ofindependence.Thatlossofindependencebecomesaburden
onfamiliesandsociety,astheindividualrequiresmoreintense
careandofteninstitutionalization.Inthelaterstages,the
cognitiveimpairmentassociatedwithdementiawillcreatetotal
dependency,andAlzheimersdiseaseisnowrankedasthe
8thleadingcauseofdeath.5
Why prepare a Road Map?
Bringingapublichealthperspectivetocognitivehealth
requiresaninclusiveandstrategicapproach.Muchimportant
workhasalreadybegun,initiatedandsponsoredbyavariety
oforganizationsandagenciesatnational,state,andlocallevels(seepages1011forasamplingofcurrentefforts).
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Background
Oneoftheselandmarkefforts,theNationalInstitutesofHealth
(NIH)CognitiveandEmotionalHealthProject(CEHP),
wasofficiallylaunchedin2001.Selectedexpertsfromseveral
universitiesandtheNIHcriticallyanalyzedthescientific
literaturetoidentifypossibleriskandprotectivefactorsfor
maintainingcognitiveandemotionalhealthinadults. 6In
recognitionoftheimportanceofthiseffort,andasfurthertestamenttotheincreasedvisibilitythatcognitivehealthis
receiving,Congressappropriatedfundsinfiscalyear2005to
theCentersforDiseaseControlandPrevention(CDC)to
addresscognitivehealthwithafocusonlifestyleissues.With
thissupport,CDCformedapartnershipwiththeAlzheimers
AssociationandisworkingcloselywiththeNationalInstitute
onAging,theAdministrationonAging,andotherpublicand
privatesectororganizationsonaHealthyBrainInitiative.
Thispartnership:
FormedaSteeringCommitteemadeupofnationalexperts
toprovideoverallguidanceandcoordinationfortheInitiative
(AppendixA).
ConvenedaPublicHealthResearchWorkingGroupMeetinginMay2006onThe Healthy Brain and Our Aging
Population:Translating Science to Public Health Practice.During
this2dayinvitationalmeeting,nationalexpertsreviewed
researchinpublichealthpreventionrelatedtobrainhealth,
anddiscussedspecificrecommendationsforaddressingrisk
andprotectivefactorsforpromotingcognitivehealth.They
focusedonvascularriskfactorsandphysicalactivitybecause
oftheirassociationwithcognitiveoutcomes.
Thefindingsfromthisresearchmeetingprovidedafoundation
andcommonframeofreferenceforthenextstepoftheHealthy
BrainInitiative:developingstrategicpublichealthrecommen-
dations.Forthistask,thePartnershipformedworkgroups
infourareasofpublichealthaction:PreventionResearch,
Communication,Surveillance,andPolicy.Eachworkgroup
waschargedwithdraftingrecommendationsformovingthe
nationforwardoverthenext35yearstowardthelongtermgoalofmaintainingandimprovingthecognitivefunctionof
adults.Keystakeholdersatthenational,state,andlocallevels
thenrefinedtherecommendationsandselectedthoseof
highestpriority(AppendixA).
TheNational Public Health Road Map to Maintaining Cognitive
Healthreflectstheculminationofthis18monthprocess.Asa
cornerstoneoftheInitiative,itoffersapathforhowwecan
learnmoreaboutcognitivehealthandthenultimately
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Wearebeginningtotakethenextsteps,buildingonthe
researchcomingoutofNIHandothers,andmovingwhatweknowoutintocommunitypractice.Thisiswherewecanmakeadifferenceinthe
everydaylivesofAmericans.LyndaA.Anderson,PhD
Healthy Aging Program,
Centers for Disease Control and Prevention
translatewhatwelearnintorealworldpracticetoimprove
thehealthofallAmericans.
TheauthorsoftheRoadMaprecognizethatinthecourse
ofdailylifethedomainsofemotionalandcognitivehealth
areinextricablylinkedandcannottrulybeseparated.For
thisRoadMap,however,weassumethisdistinctionandfocus
solelyoncognitivehealth.Onlyrecentlyhavepublichealth
expertiseandresourcesbeenrecognizedforaddressingcognitivehealth.TheRoadMapreflectsacommitmentto
bringtheareaofcognitivehealthuptoparwithemotional
healthastreatmentsandpreventivestrategiesbecomeavailable.
Itisthefirststepinasystematicprocessforbringingcognitive
andemotionalhealthtogetherinamorecomprehensiveand
coordinatedpublichealthapproach.
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Background
A Sampling of Current Efforts
Pursuing Research on Factors
Influencing Cognitive Health
TheNationalInstitutesofHealth(NIH)isfundingongoing
researchtoclarifytherelationshipamongminimizingvascular
riskfactors,exercise,otherlifestyleanddruginterventions,andcognitivehealthstatus.Epidemiologicstudiesare
identifyinglikelyriskandprotectivefactors;thesearebeing
testedinanimalstudies,whichalsocanhelpidentifythe
mechanismsbywhichriskandprotectivefactorsmightwork.
Inordertoconfirmthattheencouraginginterventions
identifiedinepidemiologyandanimalstudiescouldactually
maintaincognitivehealthifappliedtohumans,clinicaltrialsmustbecarriedout.Somearealreadyinprogressbutothers
arestillonlyintheplanningphase.NIHkeepsthepublicup-
todateonthecurrentstateofthesciencethroughoperation
ofaWebsiteandanationalclearinghouse.
Assessing
Public Perceptions
Formativeresearchwithdiversegroupsisrequiredtohelp
gainunderstandingonthepublicsperceptionsaboutcognitive
health.OnesucheffortiscurrentlyunderwaywiththesupportofCDC.TheHealthyAgingResearchNetwork,withinits
largerPreventionResearchCentersProgram(PRCHAN),
conductspreventionresearchonavarietyofhealthissues
involvingolderadults.WithinthePRCHAN,membersare
collaboratingonaseriesoffocusgroupsdesignedtoidentify
howdiversegroupsofolderadultsunderstandcognitive
healthandwhatapproachestohealthpromotionanddiseasepreventionrelatedtobrainhealththepublicmayfindmost
appealing.Thisprojecthasrecentlybeenexpandedtoexamine
theperceptionsofcaregiversandhealthcareproviders.Itwill
provideimportantdatathatcanbeaddedtowhatisalready
knownaboutcognitiveorbrainhealth,identifygapsin
knowledgeaboutcognitivehealthandrelatedriskfactors,
anddeterminewhethersuchbeliefsvaryacrossgeographical
distancesandbetweendiversepopulations.Finally,thisworkis
designedtoleadtothedevelopmentandtestingofashortset
ofquestionsthatcanbeusedtoassessthepublicsandpossibly
providersperceptionsaboutcognitivehealthforinclusionin
ongoingnationalattitudinalsurveys.
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Conducting Community
Education Programs
TheAlzheimersAssociationhasrecentlylauncheda5year
communitybaseddemonstrationprojecttopromoteabrain-
healthylifestyle.ThecommunityinterventionisdesignedtoaffectknowledgeandattitudesamongAfricanAmericanbaby
boomersrelatedtophysicalactivityandvascularriskfactors,
anditwillbeoverlaidwithothergeneralhealthbehaviors
suchasdiet,socialactivity,andmentalactivity.Duringthefirst
phaseofthisproject,theAlzheimersAssociationisleadinga
comprehensiveinterventionplanninganddevelopmenteffort,
includingformativeresearchtoassesscurrentneedsandobstaclesforthetargetpopulation,elicitingcommunityinput
andparticipation,andcreatingacomprehensive,multilevel
communityinterventionwithrobustevaluationmechanisms
tomeasuretheeffectivenessofthepublichealthprogramin
itsnextphase.
Developing Common Measures of Cognitive Decline
for Surveillance and Research
TheNationalInstitutesofHealthisleadinganinitiativeto
developunifiedandintegratedmethodsandmeasuresof
cognitive,emotional,motor,andsensoryhealthforuseinlargecohortstudiesandclinicaltrials.Researchershave
expressedtheneedforbriefassessmenttoolsthatcouldbe
usedasaformofcommoncurrencyacrossdiversestudy
designsandpopulations.Thisinitiativewilltakeadvantage
ofstateoftheartpsychometricresearchandnoveltesting
methodstodevelopaninnovativeapproachtoneurological
andbehavioralhealthmeasurement.Ultimately,itishopedthatthisapproachwillrespondtotheneedsofresearchersin
avarietyofsettings,withparticularemphasisonmeasuring
outcomesinlargelongitudinalandepidemiologicstudiesand
preventionorinterventiontrialsacrossthelifespan.With
anavailabletoolboxofmeasures,yieldsfromlargeandvery
expensivestudiescanbemaximizedbyallowingamuch
largernumberofimportantresearchquestionsregarding
neurologicalandbehavioralhealthtobestudied.Byensuring
thattheassessmentmethodsarecapableofcomparisonto
existingandcompletedstudiesandcanincorporatefuture
modifications,atrulyeconomicandvaluablenational
resourcefortheentireneurosciencecommunitywillresult.
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Background
Why is it importantand why now?
TheNational Public Health Road Map to Maintaining Cognitive
Healthcomesatacriticaltime,giventhedramaticagingof
theU.S.population,thegrowingscientificinterestinthe
roleoflifestylestrategiesinmaintainingcognitivefunction,
andincreasingawarenessofthesignificanthealth,social,
andeconomicburdensassociatedwithcognitivedecline.
An aging population
Ageisariskfactorforcognitivedecline.In2004,onein
everyeightAmericans36.3millionwereaged65years
orolder.By2030,thisnumberisexpectedtonearlydouble
to71.5million.Atthattime,20%ofthepopulationwillbe
inthisagegroup. 7
Growing fear and concern about memory loss
ThereisconsiderableconcernamongAmericansaboutthe
lossofcognitivehealthtodiseaseordisability, 8aconcernthat
seemstoincreasewithage.Mostolderadultslookforwardto
havingalonglife,andyettheirgreatestworriesaboutliving
toage75revolvearoundmemoryloss. 9Accordingtoarecent
survey,adultsaremorethantwiceaslikelytofearlosingtheir
mentalcapacity(62%)astheirphysicalability(29%).10
Increasing burden from cognitive decline
IntheUnitedStates,thesocietalburdenofcognitive
impairmenthasbeenexpressedmainlyintermsofprevalence,
incidence,andmortalityfordementiagenerallyorfor
Alzheimersdiseaseinparticular.Morerecently,prevalence
statisticsformildcognitiveimpairmentorcognitive
impairmentnodementiahavealsoappeared.Cognitive
impairmentnodementiareferstoalevelofcognitive
impairmentthatismoreseriousthanagerelatedcognitive
impairment,butitisnotassevereasAlzheimersdiseaseor
otherformsofdementia.
Alzheimersdiseasehasbeeninthetoptenleadingcauses
ofdeathsincethe20thcentury.11Notably,themortalityrates
forAlzheimersdiseaseareontheriseincontrasttotheratesforheartdiseaseandcancer,whicharecontinuing
todecline.12
Anestimated4.5millionAmericanshaveAlzheimers
disease.Thatnumberhasdoubledsince1980,andis
expectedtobeashighas16millionby2050.13
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Thenewsciencehasshiftedthefocustotheideathatthereisvalueinapublichealthstrategyofgettingpeopletothinkabouttheirbrainandhowtheymightaltertheirbehaviortokeeptheirbrainhealthy.StephenMcConnell,PhD
Alzheimers Association
StudiesfromtheUnitedStatesandCanadahavesuggested
thatmildcognitiveimpairmentorcognitiveimpairment
nodementiamaybeaproblemfor1625%oftheelderly
population(65andolder).14,15,16
In2005,MedicareandMedicaidspent$91billionand
$21billion,respectively,forpersonswithAlzheimersdisease.17
Accordingtoa2004reportthatanalyzedMedicareclaims
data,olderbeneficiarieswithdementiacostMedicarethree
timesmorethanotherolderbeneficiaries.18Basedoncurrent
estimates,thesecostswilldoubleevery10years. 19
Caregiver burden
Maintainingcognitivehealthcanmeanthedifference
betweenlivingindependentlyorfacingtheneedforfamily
orinstitutionalcare.Theburdenofcognitivedeclineon
caregiversisenormous.ThenumberofcaregiversintheUnitedStatesin2003wasestimatedtobe44.4million20and
thisnumberisexpectedtorisedramaticallywiththeagingof
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Background
thepopulation.Thecostsofunpaid,informal careprovidedby
familieshavebeenshowntoaccountforalargeproportionof
thecostsoftreatingdementiaandtheyincreasesharplyasthe
patientscognitiveimpairmentworsens.21Therearealso
physicalandmentalcostsassociatedwithcaregiving;inone
study,nearly43%ofthefamilymembersproviding careto
relativeswithdementiahadclinically significantlevelsof
depressionduringthelastfewmonthsofthepatientslife.22
Numerousfactorsmakeprovidingcareforpersonswith
severedementiaemotionallyandphysicallychallenging;a
betterunderstandingofthesefactorswillaidinthedesignof
strategiesthatsupportthehealthandwellbeingofcaregivers.
Underlying lack of information about what is known about
brain healthManyadultsappeartobelievethatagingisatimeof
irreversiblementaldecline,andthatdementiaisuniversal
andinevitable.Thesemythspersistseventhoughrecent
researchhasshownthatinthehealthyagingbrain,new
synapsescontinuetoformandnervecellscanregenerate. 23
Yet,thereareemergingsignsthatAmericanslooktothe
futurewithhope.Basedonseveralsurveys,menandwomen
inthiscountryarewillingtotakeimportantstepstoimprove
theircognitivehealth.
Nearly9of10peoplereportedthattheythoughtitis
possibletoimprovecognitivefitness.24
Sixof10statedthattheyfelttheyshouldhavetheir
cognitivehealthcheckedroutinely,muchlikearegular
physicalcheckup.25
Morethan8of10(84%)reportedthattheytooksome
timenearlyeverydaytoengageinactivitiesthatmaybe
associatedwithimprovedcognitivehealth:engagingin
artorcreativeprojects,reading,keepingphysicallyactive,playinggamesordoingpuzzles,working,orspending
timewithfamilyandfriends.26
Overhalfanticipatedamajormedicalbreakthroughin
discoveringacureforAlzheimersdiseasewithinthenext
20years.27
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Giventhetremendousburdensdescribed,theirimpact,and
thedevelopingscience,publichealthshouldstepforwardto
addresscognitivehealth.Thepotentialcontributiontoquality
oflife,thepositiveimpactoncaregivers,andtheanticipated
savingsinthecostsofhealthcareandotherserviceswould
beconsiderable.28,29,30,31
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Ibackground
IVdevelopment
process
Vactions by
cluster
VInext steps
IIIstrategic
framework
IIstate of
knowledge
State ofKnowledgeWhat do we know?
InMay2006,CDCandtheAlzheimersAssociationinvited
nationalexpertstoreviewresearchonpublichealth
preventionrelatedtocognitivehealth,andtoidentifyspecific
recommendationsforaddressingriskfactorsthatpromoteandprotectcognitivehealth.Duringthismeeting,participants
examinedthecurrentstateofscienceconcerningmajorrisk
factors,including:a)riskfactorsforvasculardiseaseand
b)physicalinactivity,andtheylookedatcurrentmodels
formovingscienceintopublichealthpractice.Participants
focusedonthesefactorsbecauseoftheirassociationwith
cognitiveoutcomes.32Theyconcludedthatresearchsuggests
thefollowingfactorsmaybeassociatedwiththemaintenance
ofcognitivehealth:1)preventingorcontrollinghighblood
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StateofKnowledge
pressure,cholesterol,diabetes,overweight,andobesity;
2)preventingorstoppingsmoking;and3)being
physicallyactive.33
Severalspecificobservationswerenotedbymeeting
participantsregardingtheassociationsbetweenvascular
riskfactorsandphysicalinactivityandcognition.
Evidenceexiststoindicatethatcumulativerisks
forvasculardiseaseincreasetheriskforstrokeand
cognitivedecline.
Sufficientevidencealsoexiststosupporttheassociation
betweenvascularhealthandcognitivehealth,although
clinicaltrialsarenecessarytoestablishtheeffectivenessof
interventionstargetedtovascularriskfactors.
Itisimportanttoemphasizethatcontrollingvascularrisk
factorsisassociatedwithreductioninanindividualsriskof
cognitiveproblems,butcurrentsciencedoesnotsupportthe
relationshipbetweencontrollingvascularriskfactorsand
improvedcognitivefunction.
Growingevidenceexiststhatphysicalactivitymaymaintain
orimprovesomeaspectsofcognitivefunctionintheshort
term,butfurtherresearchisneededbothtodeterminelong
termoutcomesandthenatureofrecommendations(e.g.,
theamountofphysicalactivity).
Strongevidenceexiststosupporttherelationshipbetween
physicalactivityandemotionalwellbeing.
WhilenotaspecificfocusoftheMayresearchmeeting,
additionalfactorsthatmaybeassociatedwithmaintaining
cognitivefunctionincludesocialengagement,ahearthealthy
diet,andemotionalsupports.Inaddition,higherhouseholdand
communitysocioeconomiclevelsinearlylifeareassociated
withhigherlevelsofcognitioninlatelifebutnotwiththerisk
ofAlzheimersdiseaseorrateofcognitivedecline. 34
What gaps exist?
Eachnewdiscoveryinmaintainingcognitivehealthraisesa
hostofimportantquestions.Someofthemorepressingissues
arethefollowing:
Howdowepromotetheimportanceofcognitivehealth
issuestokeyconstituenciesandstakeholders?
Whatarethepublicsperspectivesonlifestylebehaviors,choices,andattitudesconcerningcognitivehealthandthe
burdenofcognitivedecline?Whatdoweviewasthebenefits
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Allthethingsthatweknowarebadforyourheartturnouttobebadforyourbrain.MarilynS.Albert,PhD
Johns Hopkins Medical Institutions
andbarriersofmodifyingpersonallifestyletoreducetherisks
associatedwithcognitivedecline?
Whatistheroleofpopulationbasedsurveillanceandthe
appropriatesurveillancesystemstoassesscognitivedecline?
Whatclinicaltrialsandotherresearchareneededto
determinethelongtermoutcomesoflifestyleinterventions
onparticularcognitivefunctions?
Howdowelinkscientificallyvalidmessagesaboutriskof
cognitivedeclinetocurrentpublichealthmessagesfor
effortsinprimaryprevention?
Whataretheeffectsofmodifyingmultipleriskfactors
onminimizingcognitivedeclineorimproving
cognitivefunction?
How can public health contribute?
Publichealthwasfirstdefinedin1926,asthescienceandartof
preventingdisease,prolonginglifeandpromotinghealthand
efficiencythroughorganizedcommunityeffort. 35That
definitionhasremainedintactforover80years,witharecent
reiterationofpublichealthsmissionasassuringconditionsin
whichpeoplecanbehealthy. 36
Organizedpublichealtheffortsoverthepast100yearshaveyieldedremarkableachievements.Tenconsideredtobeamong
thegreatest37areintheareasof:
Vaccination
Motorvehiclesafety
Saferworkplaces
Controlofinfectiousdiseases
Declineindeathsfromcoronaryheartdisease
andstroke
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StateofKnowledge
Saferandhealthierfoods
Healthiermothersandbabies
Familyplanning
Fluoridationofdrinkingwater
Recognitionoftobaccouseasahealthhazard
Theseachievementswerepossiblebecauseofcombined,
coordinatedeffortstoapplythreecorepublichealthfunctions:assessment,policydevelopment,andassurance.
Assessmentcallsforregularlyandsystematicallycollecting,
analyzing,andsharinginformationonthehealthofa
community.Suchinformationhelpstodescribeand
understandacommunityshealthstatusandneeds.Assessment
activitiesmightinvolveinvestigatingadversehealtheffects
andhealthhazardstoidentifythemagnitudeofahealth
problem,itslocation,trendsovertime,andpopulationsat
risk.Theymayalsodigdeepertoanalyzedeterminantsof
identifiedhealthproblemssoastoilluminateetiologicand
contributingfactorsthatplacecertainpopulationgroupsat
riskforadversehealthoutcomes.
Policy developmententailspromotionofpublichealth
policiesthataregroundedinsciencebaseddecisionmaking.
Bytakingtheleadinpolicydevelopment,publichealthserves
asanadvocate,buildsconstituencies,andidentifiesresources
inacommunityasitgeneratessupportiveandcollaborative
relationshipswithpublicandprivateagencies.Anothercritical
policyactivityinvolveshelpingcommunitiessetpriorities
amonghealthneedsbasedonthesizeandseriousnessofthe
healthproblemsandtheacceptability,economicfeasibility,and
effectivenessofinterventions;thecommunitycanthendevelop
plansandpoliciestoaddressthosepriorities.
Assuranceistheguaranteethatservicesneededtoachieve
agreedupongoalsareactuallyprovided.Itispursuedby
encouragingtheactionsofothers(publicorprivate),requiring
actionthroughregulation,orbyprovidingservicesdirectly.
Thisthirdcorepublichealthfunctionencompassesmanaging
resourcesanddevelopingorganizationalstructures;implementingprogramsforpriorityhealthneeds;andevaluatingandproviding
qualityassurancetoensurethatprogramsareconsistentwith
plansandpoliciesorthatneededcorrectiveactionsare
takenpromptly.Inaddition,assuranceactivitieshelptoinform
andeducatethepubliconhealthissuesofconcern;promote
awarenessofpublichealthservices;andpromotehealth
educationinitiativesthatcontributetoindividualorcollective
changesinhealthknowledge,attitudes,andpracticesthat
makeforahealthiercommunity.
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Ifyoucouldgivepeopleinformationandtoolsthat
woulddelaytheonsetofcognitiveimpairmentbyafewyears,youwouldbedoingmuchtoimproveindividualsqualityoflifeas
wellasimprovingsociety.DebraCherry,PhD
Alzheimers Association
Theapplicationofthesepublichealthfunctionstocognitive
healthoffershopeofsimilarachievementsasscientific
knowledgeadvances.Theareaofcognitivehealthisgaining
increasingattentionfrommultipleperspectivesandrepresents
ablossomingarenaforresearchandaction.Byembracing
cognitivehealthasapriorityissue,thepublichealthcommunity
wouldbemobilizedtostudy,identifyandimplementeffective
interventionsthatpreservethiskeycomponentofhealth.
Ourchallengeistoofferasystematicapproachthatwillassureacoordinatedandunifiednationaleffort.TheRoad
Mapmeetsthatchallengebylayingoutasharedvisionfora
workinprogress,onethatbuildsonthefoundationofthe
workdonetodate,establishesaframeworkwithinwhichto
viewthefindingsofthatwork,linksrelatedandcomplementary
activities,andshapestheworkofthefuture.
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Ibackground
IIstate of
knowledge
IVdevelopment
process
Vactions by
cluster
VInext steps
IIIstrategic
framework
StrategicFrameworkWhat is our model for action?
TodeveloptheRoadMap,weusedasynergisticmodel
(Figure1)formovingscienceintopublichealthpractice. 38
Themodelstartswiththeassumptionthatwemustfirst
understandtheexisting science and knowledge baseforpreservingandprotectingcognitivehealth,determinefindingsreadyto
bemovedintothepublichealtharena,andthenconduct
researchtofillimportantgapsinknowledge.
Atthesametime,wemustanalyzesocial and environmental
forcesthatcreatedemandandinfluencetheacceptanceofnew
knowledge.Thepushofscienceandthepullofthemarketcombinetoshapethecapacitythecomplementofhuman
andfinancialresourceswemusthaveinplacetoimprove
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StrategicFramework
Figure 139The Model: Moving Science into Public Health Practice
Intermediate Outcomes
Long Range Outcomes
Build and
strengthen capacity
(competencies,
resources,
partnerships, etc.)
Create/expand the science and
knowledge base
Create/sustain social/
environmental demand
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publichealthpractice.Strengtheningandbuildingcapacity
focusesonidentifyingkeypublichealthentities,determining
thenecessarycompetenciesandresources,andexpanding
partnershipstomountandsustainnecessaryactions.
Deployingthiscapacityeffectivelywillleadtodesired
intermediate and longrange outcomes.
What principles do we embrace?
Severalkeyprinciplesunderlieourapproachtomaintaining
cognitivehealth.
A firm grounding in science. Epidemiologicstudies
followedbythetestingofinterventionsinclinicaltrialswith
componentsthatincludecognitiveassessmentwillshow
whichlifestylefactorsbestmaintaincognitivehealthfor
thepopulation.Throughpopulationbasedsurveillance,
epidemiologyandpreventionresearch,publichealthcan
contributetoourunderstandingofcognitivehealthandcan
identifypromisinginterventionsthatmaybeeffectivein
promotingorprotectingit.TheRoadMaprecognizesthat
thisprocessisevolutionary,anditseekstobuilduponwhat
wecurrentlyknowbyincorporatingnewdiscoveriesastheyemerge.
Thepossibilityofpreventioninthisareaissonewandsoexcitingforfamilies,individuals,andgovernment.
JamesLaditka,DA,PhD,MPA
University of South Carolina
An emphasis on primary prevention.Publichealth
focusesonreducingthefactorsthatputpeopleatriskof
cognitivedecline,whileincreasingthefactorsthatpromote
andprotectcognitivehealth.Thus,theRoadMapfocuses
oninterventionsinhealthpromotionandriskreductionthat
preservecognitiveperformanceratherthanpreventdementia.
Itrecognizesthepotentialsynergisticapproachbyintegrating
theseinterventionswithotherlifestylemessagesandshowing
howtheymightfitwithpharmacologicinterventions.
A community and population approach. Publichealth
takesabroadviewandseekstoachievelastingchangein
thehealthofentirepopulations,extendingfarbeyondthe
medicaltreatmentofindividualpeople.Thus,theRoadMaps
recommendationsareexpansiveinscope,anddonotsingle
outanyparticularpeopleorgroupsforspecialattention.
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StrategicFramework
A commitment to eliminating disparities. Racial
andethnicdisparitiesinhealthandhealthcarearewell
documented.Theeliminationofsuchdisparitiesisacritical
componentofthenationalpublichealthagendaandakey
principleofthisRoadMapaswell. 40Thenumbersand
proportionofolderadultsfromdiverseracialandethnic
originsintheUnitedStatesareincreasing.In2003,nonwhite
ethnicandracialgroupsrepresented17%ofthepopulation
age65andolder,withthatproportionprojectedtoincrease
to28%by2030and39%by2050.41Weembracethis
diversityandrecognizeitsvalueinshapingpolicyinitiatives,
communicationstrategiesandlifestyleinterventions,and
populationbasedsurveillancerelatedtocognitivehealth.
What do we hope to accomplish?
Weenvisionanationinwhichthepublicembracescognitive
healthasapriorityandinvestsinrelatedhealthpromotion
andresearch.Toachievethisvision,wehaveadoptedalong-
termgoalandavarietyofoutcomesasmoreimmediategoals.
Our longterm goal is to maintain or improve the cognitive
performance of all adults.
Fourteenintermediateoutcomesencompasstheareasof
communication,surveillance,research,policyandpublic
healthcapacity.Theseareto:
Increaseawarenessabouttheimportanceofpromotingand
protectingcognitionamongthegeneralpublic,publichealth
andagingprofessionals,andpolicymakers.
Increaseknowledgeabouttheriskandprotectivefactors
associatedwithcognitionamongthegeneralpublicand
publichealthandagingprofessionals.
Decreasemisconceptionsandmythsaboutcognitivehealth
amongthegeneralpublic.
Determinecriticalpublichealthmeasuresformonitoring
cognitivefunctionatthepopulationlevel.
Incorporateappropriatecognitivemeasuresintopublic
healthsurveillancesystems.
Identifytheresearchgapsonmodifiableriskfactors
andcognition.
Securesustainedsupportforpublichealthresearch
topromoteandprotectcognitivehealth.
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Ifwemaintaincognitivefunctionovertime,thenwearemorelikelytobefunctionallyindependent.
MarilynAlbert,PhD
Johns Hopkins Medical Institutions
Disseminatetheresultsofcriticalpublichealthresearch
findingsaboutcognitivehealth.
Identifykeypublicandprivatepoliciestoaddress
cognitivehealth.
Modifykeypublicandprivatepoliciestoaddress
cognitivehealth.
Identifysuccessfulpublichealthbestpracticesonvascular
healthanddiabetes.
Increasecognitivehealthinterventionsthatare
complementarytovascularhealthanddiabetespublichealthstrategies.
Securesustainedsupportforpublichealthstrategiesto
promoteandprotectcognitivehealth.
Enhancethecapacityofagingandpublichealthservice
networkstoimplementeffectiveinterventionstopromote
andprotectcognitivehealth.
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IVdevelopment
process
IIIstrategic
framework
IIstate of
knowledge
Ibackground
Vactions by
cluster
VInext steps
DevelopmentProcessPhase I Workgroup deliberations
Fourworkgroupsofinvitedexpertsworkeddiligentlyand
collaborativelyovera7monthperiodtoidentifyrecommen
dationsinfourareasofpublichealthaction:Prevention
Research,Surveillance,PolicyandCommunication.The
chargetoeachworkgroupwastodefineitsareaoffocus,
identifyimportantprinciples,andrecommendactionsfor
movingthenationforwardoverthenext35yearstoward
thelong termgoalofmaintainingandimprovingthe
cognitivefunctionofadults.Thedefinitionsandprinciples
thatemergedarepresentedbelow.
Prevention ResearchResearch in public health prevention isdefinedhereasresearch
thatappliesandtestspopulationbasedinterventionsthathave
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DevelopmentProcess
thepotentialtomaintaincognitivehealth.Recommenda-
tionsforcognitivehealthfocusprimarilyontwoareas
vascularriskfactorsandphysicalactivitywithemphasis
ontheneedforpracticalclinicaltrialstoshowthebenefits
ofvascularhealthinterventionsandphysicalactivityon
maintenanceoflongtermcognitivehealth.Theseareas
werechosenbecausetheyarethefirsttoemergefrom
populationbasedstudiesandanimalresearchaspromising
areasforintervention.Whiletheepidemiologicevidence
supportingthebenefitsofvascularhealthforcognitive
functionismoredefinitivethanthelinkregardingphysical
activity,bothareasareworthyofattention.Inaddition,recent
findingsfromclinicaltrialshaveheightenedinterestinthe
valueofmentalactivitiesbyshowingapositiveeffectfrom
cognitivetrainingoncertaincognitivedomains.
Researchonpreventionshouldnotbelimitedtotheseareas,
however.Otherareas(suchasnutritionandsocialengagement)
shouldalsoberecognizedasimportanttoaddressinthefuture.
Totheextentpossible,researchshouldbemultidisciplinary
andbuildonafirmunderstandingofhowthepublic,health
careprofessionals,andavarietyofotherpartnersdefine,
perceive,andvaluecognitivehealth.Inaddition,research
methodologiesshouldconsiderhowtoconvertresultsfrom
randomizedcontroltrialstocommunitysettings;howto
makeclinicalorevidencebasedworkpractical;andhow
totranslateresearchintopublichealthpractice.
Surveillance
Surveillanceisdefinedastheongoing,systematiccollection,
analysis,interpretation,anddisseminationofhealthrelated
data.42,43,44
Theongoingnatureofpublichealthsurveillance,itsapplicationtobroadpopulations,andlimitationsinresources
oftenrestrictthenatureanddepthofinformationthatcan
begatheredthroughtraditionalsurveillancemethodsused
inresearch.Thesemethodsrangefromcreatingnew
surveillancesystemstousingorenhancingexistingsystems
andsurveillanceofcognitivefunctionisnoexception.Selecting
appropriatesurveillancemethodsforcognitivedeclinepresents
someuniquechallenges,however,suchasdefiningcriteriafor
acognitivemoduleandmeasuringavarietyofdimensions
(e.g.,riskfactors,attitudes,andburdenofcaregivers).Inaddition,
becausemeasurementsmayvaryaccordingtoeducation,
language,culture,andraceorethnicity,specialcaremustbe
takentoensurethatdataarenotmisinterpretedormisused.
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Methodsavailableforthesurveillanceofcognitivedecline
inolderpopulationsthatdonotrelyonselfreportingface
particularconstraints.
Cognitivedeclineinindividualpeopleisdirectlyidentified
throughrepeatedmeasurementsconductedoveraperiod
oftime.Toimplementthismethodofcaseascertainment
inasurveillancesystemrequireslongtermfollowupofpopulationbasedcohortswithopen(continuousorsuccessive)
enrollments.Suchsystemsarenotoftenusedforchronic
diseasesurveillance,astheyareexpensiveandrequirean
extensivetimecommitmentfromparticipants.
Repeatedcrosssectionalpopulationsurveysaremore
commonlyemployedinsurveillance,particularlyforsome
chronicdiseasesandforsomeriskfactorsfordisease.Unfortunately,therearenocurrentlyestablishedmethods
thatdefinitivelyascertaincasesofcognitivedeclinethrough
crosssectionalinterviewsalone.Selfreporteddataare
inaccurateinthisarea,andtheusefulness,availability,and
validityofproxyreporteddataareuncertain.Despitethese
limitations,suchsurveyshavevalueinmeasuringthe
prevalenceofriskfactorsforcognitivedecline.Theymayalsohavepotentialtomeasuresomeparametersofcognitive
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DevelopmentProcess
functions.Itispossiblethatchangesovertimeinthe
populationdistributionofsuchparametersmaysuggest
changesintheprevalenceofcognitivedecline,although
suchinferencescanonlybemadewithcautionevenafter
controllingforconfounderssuchaseducation,culture,and
socioeconomicstatus.
Othermethodsofscreeningoridentifyingconditionsassociatedwithcognitivedecline(e.g.,geneticscreening,
biomarkers,andneuroimagingtests)donotyetappear
practical,althoughsomemayeventuallyproveusefulifthe
costsarereasonable.
Recommendationsforsurveillancemustbeofferedwiththese
methodologicalconstraintsinmind,recognizingthetension
betweenidealmethods,forwhichresourcesmaybedifficulttoobtain,andmorelimitedmethods,forwhichresourcesare
morelikelyavailable.
Policy
RealizationoftheRoadMapsvisionrequiresapolicybase
inboththepublicandprivatesectorsthatsupportsand
promotescognitivehealth.Thepublic sectorencompasses
policymakersatfederal,stateandlocallevels.Theprivate sector
includesbothnotforprofitandcommercialorganization
policies,suchascoverageofpreventionbyinsurers,human
resourcedepartmentpolicies,employeeassistanceprograms,
andotherworkplacepoliciesandpractices.Policychanges
inthepublicsectorcaninfluencepoliciesandbehaviorsinthe
privatesector;conversely,privatesectorpolicychangecan
influencepublicpolicy.
Toeffectpolicychange,thepublichealthcaseforaddressingcognitivehealththefactthatobservationalevidenceand
limitedshorttermclinicaltrialsnowexisttosupportsome
preventionopportunitiesinthisareamustbemadeinan
easilyunderstandableandconsistentmanner.National,state
andlocalorganizations,agenciesandpolicymakersmustbe
educatedaboutcognitivehealthandsubsequentlyengaged
tohelppromotepositivepolicydevelopmentandchangethat
willincreaseknowledgeandleadtobettercognitivehealth.
Moreover,policyrelatedtomaintainingcognitivehealthdoes
notjustaddresscare,behaviors,orriskfactorsbutalso
promotesresourcesforbuildingandmaintainingcommunity
infrastructurethatreinforcesindividualbehavior.Thiscould
includebikeorwalkingtrailstoencouragephysicalactivity,
communitywideorganizationsandstructuresthatsupporthealthybehavior,andotherchangestothebuiltandcultural
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Developingaroadmapforcognitivehealthprovidesuswithanopportunitytoreducehealthdisparities.Some
populationsareathighriskforcognitiveimpairmentduetohighratesofhypertensionordiabetes.TheRoadMapgivesusachancetoprovidebetterhealthinformationforallAmericans,includingthoseathighestrisk,sothatpeoplemayimprovetheirmotivationtochangetheirlifestyleforbetter
healthoutcomes.DebraCherry,PhD
Alzheimers Association
environmentsthatadvancethepublichealthgoalofcognitive
health.Policyinitiativesmustbuildupon,relateto,andbecompatiblewithcommunicationsandresearcheffortsasthey
takeshapeandyieldnewinformation.
Communication
Thetermcommunication strategyimpliesamultidisciplinary
healthmarketingapproachthatincludescommunicatingand
disseminatingscientificallyvalidinformationandstrategic
interventionsthroughcustomercenteredandculturally
appropriatemeans.Acommunicationsstrategyforcognitive
healthaimstoeducate,motivate,andeffectpositivebehavior
changerelatedtocognitivehealthintargetedandatrisk
audienceswithin3years.
Toeffectivelyreachthisgoal,communicationmessagesand
methodsshould:
Besciencebased.
Begearedtopopulationsexperiencingthegreatest
disparitiesandrisksincognitivehealth.
Reachtheintendedaudienceandpromoteaction.
Assisttheconsumerinmakingmoreinformeddecisions.
Theaudienceofadultsaged4260years,alsoknownas
babyboomers,belongstothebiggestgenerationinAmerican
history.Cognitivehealthissuesprofoundlyaffecttheirparents
now,andtheywilltouchtheboomersinhugenumbersas
theygrowolder.Itisimportanttogetappropriatevalid,
evidencebasedmessagestothem,sotheymaytakeaction
forthemselvesaswellaspotentiallyinfluencetheirfamilies.
Specialfocusshouldbegiventohighriskpopulations,
vulnerablepopulationsandhealthcareproviders.Specific
racialorethnicgroups(e.g.,AfricanAmericans,Latinos)may
needtohavetargetedandculturallyappropriatematerialsandtoolsdevelopedbecausetheymaybeatgreaterriskfor
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DevelopmentProcess
experiencingcognitivedeclineduetohigherrisksofvascular
disease,hypertensionanddiabetes.Healthcareprovidersmay
haveneedsandgapsinknowledgethatdifferfromthegeneral
publicbecausetheyareprovidinginformationaboutcognitive
healthtoothers.Aninitialfocusonthesegroupswouldnarrow
thescopeofeffort,affordingmoreachievableoutcomes.
Inaddition,beforereachingouttoconsumers,accurateinformationandoptionsshouldbeinplacethroughoutthe
broadermedicalandsocialserviceenvironment.Healthcare
professionalsarethemainsourceofinformationformany
consumers,andpastexperiencehasproventhebenefitsof
targetingprofessionalorganizationsfirstaspeerinfluencers
andtrainersofthesefrontlineproviders.
Phase 2 Concept-mapping process
Theworkgroupscollectivelyproposed42recommendations:
18inpreventionresearch,8incommunications,9inpolicy,
and7insurveillance.Aconceptmappingprocesswasthenused
toorganizeandvisuallyrepresentthem.Conceptmapping
combinesqualitativeandquantitativemethodstogenerate
mapsthatprovideavisualrepresentationofthecomplexrelationshipsamongideasandresults.45Itcanelicitideasfrom
large,diverse,andgeographicallydispersedgroupsabout
aparticulartopicwithinashorttimeframe.Unlikeother
qualitativemethods,conceptmappingalsoprovidesastructured
approachthatallowskeydecisionmakerstoparticipateinthe
finalinterpretationofalargergroupsperceptions.
Forthisproject,conceptmappingwasorganizedinto
threesteps.
Step 1involvedreviewingandrestructuringrecommendations
fromtheworkgroupstoensurethateachrecommendation
representedadistinctidea,andidentifyingthelistof
stakeholderswhowouldbeinvitedtoparticipate.Thislist
includedmorethan150personsfromabroadarrayof
institutions,includingstateandfederalagencies,universities,
andfoundations.
Step 2consistedofonlineratingandsortingbyinvited
participantsandsubsequentanalysesoftheresults.46Forthe
ratingprocess,140(ofthe150)participantswereaskedto
rateboththerelativeimportanceofeachrecommendation
anditscurrentactionpotential.Forthesortingtask,20of
these140participantswerealsoaskedtocategorizethe
recommendationsaccordingtotheirviewofsimilarmeanings
orthemes.Ten(ofthe150)participantswereinvitedto
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Iamveryimpressedwiththeprocessbecausethisisafieldin
whichpeoplehavestrongopinionsonmanydifferentissues.Whatimpressedmewasthattheparticipantsinthereviewprocesswereopentohearingabroadrangeofopinionsbutintheendoptedforscientificrigorastheguidingfeatureonwhichrecommendationswerebased.
PeterRabins,MD,MPH
Coauthor,The 36 Hour Day
participateinthesortingtaskonly.Becausetheratingand
sortingprocesswasanonymous,exactfiguresonparticipationarenotavailable;however,basedonthenumberoftotal
responses,69persons(outof140,or49.3%)providedinput
intoratingtheimportanceandactionpotentialofeach
recommendation.Additionally,23persons(outof30,or
76.7%)organizedtherecommendationsintocategoriesto
identifythemesorpatterns.Multivariatestatisticaltechniques
wereusedtoorganizeandvisuallypresentresultsoftheonlineprocessinaseriesofconceptmapsthatreflected
relationshipsbetweenrecommendationsandtheclustering
ofrecommendationsintocategories.
Step 3 encompassedthereviewandinterpretationofthe
resultsofPhase2,andselectionofpriorityrecommenda-
tions.MembersoftheSteeringCommitteereviewedthe
mapstoensurethattherecommendationsineachoftheeightclusterswereconsistentwiththeoverallthemeofthatcluster.
TheCommitteereconstructedafewrecommendations
creatingtwoadditionalrecommendations(foratotalof44recommendations)andintwoinstancesmovedrecom-
mendationstoadifferentcluster.Thefinalclusterlabelsare:
Disseminatinginformation
Translatingknowledge
Conductingsurveillance
Implementingpolicy
Measuringcognitiveimpairmentandburden
Movingresearchintopractice
Conductinginterventionresearch
Developingcapacity
Asafinalstep,theSteeringCommitteechoseasetof
priorityrecommendationsoractions.
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Ibackground
IIstate of
knowledge
IIIstrategic
framework
IVdevelopment
process
Vactions by
cluster
VInext steps
Actions byClusterTheRoadMapisalivingdocumentexpectedtoevolve
overtime.Someactionsareachievablewithin1to3years,
whileotherswillrequiremoretimetocometofruition.
Somearelinkedandneedtooccurinacertainsequence,
withtheoutcomesofthefirstsettingthestageforinitiating
thenext.And,whilenoparticularagegroupissingledoutforspecialattention,theRoadMapconcentratesprimarilyon
interventionsformiddleagedandolderadults.Thisfocus
recognizesthatinterventionstoreducerisksarebestbegun
earlyinlife;yet,adults,particularlyolderadults,aremore
likelytobeconcernedandmotivatedtotakeaction.
ThefullsetofRoadMapactionsfallintoeightclusters.
Withineachcluster,theactionsarelistedinnospecialorder
ofpriority.Theletterinparenthesesaftereachactionrefers
ActionsbyCluster
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tothegroup(eitherworkgrouporSteeringCommittee)
thatoriginallyproposedit(P=PreventionResearch,
C=Communication,P=Policy,S=Surveillance,SC=Steering
Committee).Alloftheactionsgeneratedbythegroups
areincluded.
Inofferingtheseactions,wecannotunderestimatethe
complexitiesoftranslatingthemintoaction.Mostessentialis
acommitmenttobasethisRoadMaponscientificevidence,
movingforwardcollaborativelytoleverageexistingresources
andactivitiesaspromotionactivitiesbecomedefined.Key
partnershipsmustbeformedamongadiversearrayof
organizationsandagenciestobuildoncollectivestrengths,
delivercompatiblemessagesandinterventions,andassure
efficientuseofresources.Existinghealthpromotion
communitiesassociatedwithheartdisease,stroke,diabetes,
andphysicalactivityareinvaluableresourcesforpromoting
cognitivehealth.
Disseminating information
1. Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions. (SC)
Evidenceexiststhatthecurrentboomergenerationis
concernedaboutcognitivehealthandfearsAlzheimers
disease.Onecriticalareaoffocusshouldbeonhelping
thepublictounderstandthevaryinglevelsofevidence
behindproposedinterventionsregardingcognitivehealth.
Unlesscredibleandbroadreachinginformationabout
validinterventionsincognitivehealthisdisseminated,
consumerswillfillthegapwithuntestedprogramsand
products.Notonlycantheseprogramsandproducts
presentaneconomicburden,butsomemayalsodistract
theagingpopulationfrommeaningfullifestylechanges.
Communicationsstrategies(includingtheappropriate
communicationchannels)shouldbuilduponcurrent
effortsbyvariousorganizationsandagenciestoshare
existinginformationandmaterialsoncognitivehealth
researchandpossibleinterventionsthatareconsistent
withcurrentscience.
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2.
3.
Develop communications strategies and tools
to increase awareness among health care providers,
public health professionals, and aging service
providers at the national, state, and local levels about
the current state of science of cognitive health. (C)
Indisseminatinginformationtothepublic,information
mustbefilteredthroughtrustedhealthandcommunity
resources.Providingprofessionalswithaccurate,evidence-basedinformationandtoolswillrespondtothegrowing
interestamongconsumersregardingquestionson
preservingcognitivehealth.
Develop and implement a training curricula
related to cognitive health for continuing
professional education of health and human
services professionals. (P)
Toincreasetheawarenessandknowledgeofprofessionals
inhealthandhumanservices,strategiesshouldbedeveloped
inbothpreserviceandinservicemodalities.Bringingnew
professionalsintothefieldwithappropriateknowledge
isnotenough;thelevelofunderstandingofpracticing
professionalsmustalsoberaisedsothattheycanhelpthe
publicsortoutevidencebasedapproachestocognitive
healthfromlessprovenorundemonstratedoutcomes.
4.
5.
Develop creative and replicable means for raising
the publics awareness of cognitive health and
engaging the public in promoting the importance
of cognitive health through policy. (P)
Thepublicplaysanimportantroleinstimulatingboth
publicsectorandmarketplaceactiononissuesitfinds
important.Itisessentialthatthepublicbeeducated
basedoncurrentscienceandknowledgeofbestpractices.Thiswillcontributetothedevelopmentof
anewconventionalwisdomregardingcognitivehealth.
Establish and maintain a Webbased cognitive
health clearinghouse, in partnership with
stakeholder organizations, that would be
recognized as a centralized site for scientifically
validated and recognized information. (C)
Aonestopshop,gotoplaceforvalidandtested
informationwillprovideconsumersandprofessionals
whoserveolderadultsandtheirfamilieswiththetools
tomakeinformeddecisionsabouttheirhealthandeffect
positivebehaviorchange.Thesitewouldprovideguiding
principlestohelpconsumersandhealthinformation
providersandprofessionalstoevaluatelocalservices
thataddresstheseconcernsandtomaintaincurrent
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understandingaboutcognitivehealthandthese
interventionsasthesciencebecomesmoresophisticated.
Translating knowledge
1. Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors. (R)Itisnotclearhowthegeneralpublicorpractitioners
perceiveandunderstandcognitivehealth.Todevelop
usefulprograms,itwillbeimperativetobetterunderstand
thediversetargetaudiences.Someissuesthatwouldbe
importanttounderstandfortranslationtoboththe
generalpublicandpractitionersinclude:howcognition
isdefinedandtranslated;whataspectsofcognitivehealth
areimportant(includingthelevelofknowledgeabout
vascularfactors);andhowconcernedthegeneralpublic
isaboutcognitivehealth.
2. Help people understand the connection between risk
and protective factors and cognitive health.(C,SC)
Riskandprotectivefactorsarekeystofiguringouthow
toaddressindividualandcommunityhealthandrequire
clarifyingforthepublicwhatisdemonstratedaseffective
inclinicaltrialsversusassociationsobservedinother
studies.Ofprimaryinterestareaspectsofpersonaland
environmentalexperiencesthatmakeitmorelikely(risk
factors)orlesslikely(protectivefactors)thatpeoplewill
experiencecognitivedecline.Considerationshouldbe
giventotheseconnectionsandtopromotingabetter
understandingofit,includinganunderstandingofareasinwhichclinicaltrialshave(orhavenotyet)established
acauseandeffectbetweenriskandprotectivefactorsand
cognitivehealth.
3. Develop a mechanism to review cognitive health
messages and programs to determine their
scientific accuracy and public credibility. (C)
Currently,thepublichasnosinglesourceofinformed
andvalidrecommendationsforprograms,services,and
lifestylerelatedinterventionstoaddresspositivemeasures
incognitivehealth.Creatingasystemforreviewingthe
growingnumberofprogramsandprovidingpublicaccess
tothereviewsgeneratedwillmoveconsumerscloserto
informeddecisionsandmorepositiveinvestmentsinhealth.
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Implementing policy
1. Initiate policy changes at the federal, state, and local
levels to promote cognitive health by engaging
public officials.(P)
Farreachingpublichealthissuesdemandinformedaction
bypublicofficials,becauseactionbytheprivatesector
alonewillbeinsufficienttoreachdesiredresults.Because
programandfundingdecisionsaremadebypolicymakers
atthenational,stateandlocallevels,itisimportantto
engageandeducatethisaudience.Publicofficialshave
significantcompetinginterests;itisessentialthatthey
becomeeducatedandengagedinthisarenatocontribute
topositivepolicychangeincognitivehealthinterventions
andtosupporttheneedforfurtherresearch.
2. Include cognitive health in Healthy People 2020,
a set of health objectives for the nation that will
serve as the foundation for state and community
public health plans. (P)
Thedevelopmentanduseofdocumentssuchas Healthy
People 2020willrepresentasystematicandwidely
recognizedapproachtoimprovinghealth.Asresearch
demonstrateswaysinwhichcognitivehealthcanbe
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maintained,theareaofcognitivehealthcanbeelevated
toamajorhealthprioritybybeingincorporatedintothe
outcomeorientedapproachusedbyHealthy People 2020.
3. Include the public health burden of cognitive
impairment in the State of Aging and Health
in America Reportwhen population level data
are available. (P)
Includingcognitivehealthinsuchdocumentsasthe
State of Aging and Health in America Reportwouldelevate
itsstatusasarecognizedpublichealthissueandmakedata
readilyavailableforaction.Armedwithimportantdata
fromthisandothermonitoringsystems,publichealth
professionalswillbepreparedtomovepolicyforwardto
testinterventions.
4. Promote appropriate strategic partnerships among
associations, government agencies, insurers and
payers, private industry, public organizations, and
elected officials to support and advance research
and policy related to cognitive health. (P)
Partnershipscanhelptomaximizelimitedresources
(fiscalandpersonnel)andcompetingpriorities.
Theyshouldbebaseduponsuchcriteriaastheability
to:examineevidencebasedresearch;establishongoing
formsofdialogue;buildleadershipandcapacityrelated
topolicyandpublicandprofessionaleducation;address
diverseculturalandethnicpopulations;providefunding;
andexplorethelinksbetweenthevascularfactors,
physicalactivity,andcognitivehealth.
5. Engage national organizations and agencies that
focus on the older population, and educate these
agencies about cognitive health and its connection
to their missions.(P)
Toachievebroad,effectivecollaborationsforcognitive
healthandemotionalwellbeing,nationalorganizations
andagenciesmustidentifyandagreetocommon
ground.Nationalorganizationsandagenciesareessential
tobothreachinglargenumbersofindividualmenand
womenandtousingtheirinfluencetoeducatepolicy
makersandopinionleaders.Educationofthepublicand
leadersofkeyorganizationsisaprecursortopolicy
changerelatedtocognitivehealth.
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6. Convene policy experts to identify and examine
current policies (e.g., national policy, state
policy, private sector policy) that could be
modified, modernized, or broadened to include
cognitive health.(P)
Policiesshouldbeamendedtoreflectcurrentscience
andknowledgeandbeinclusiveofcognitivehealth.
Adjustingandamplifyingcurrentpoliciesareefficientandeconomicalroutestosystemschange.
7. Promote the modification of existing national
and state public health plans to include cognitive
health in their strategies or recommendations
where appropriate.(P)
Nationalandstatepublichealthplanssignificantly
influenceeffortsinpublichealthandserveasa
barometerofimprovement.Asinterventionsare
demonstratedthatcanhaveaneffectoncognitive
health,includingitintheseplanswouldelevateits
statusasarecognizedpublichealthissueandprovide
avenuefortheevaluationofprogress.
Conducting surveillance
1. Define the goals of a surveillance system to
promote the development of an appropriate system
and the collection of data on cognitive health. (S)
Clearlydefinedgoalsofpublichealthsurveillancewill
promotethedevelopmentofappropriatesurveillance
systemsandthecollectionofconsistentdatathatprovide
usefulinformationtoinformpublichealthpolicy.Goals
ofthesurveillancesystemmayinclude:definingtheburden
ofcognitivedeclineinthepopulation;monitoringthe
trendsinburden(e.g.,prevalence,incidence);monitoring
trendsinriskfactors;definingthepopulationatincreased
risk;anddeterminingwhetheradditionalanalysesshould
beperformedforthepurposeofpublichealthsurveillance.
2. Determine which existing general populationbased
surveillance systems include information useful for
the surveillance of cognitive health at national, state
and local levels. (S)
Addingtoorchangingexistingsurveillancesystems(e.g.,
BehavioralRiskFactorSurveillanceSystem,Healthand
RetirementStudy,NationalHealthInterviewSurvey)to
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addressissuesrelatedtocognitivedeclineislesscostlyand
maybemoreefficientthandevelopingnewsurveillance
systems.However,thereareimportantlimitationsofexisting
systemsandthedatatheycollect;inparticular,mostarecross
sectionalratherthanlongitudinal.Manyarealreadyquite
lengthy,withmajorconstraintsonaddingnewitems.
Closeexaminationofthesesystemswillensurethatthey
areamendedappropriatelyandcosteffectively.
3. Identify existing studies that measure longitudinal
trends in cognitive function.(S)
Existinglargecohortorotherlongitudinalstudiesof
cognitivedeclinemayprovideitemsthatcouldbe
incorporatedintosurveillancesystemsformeasuringsuch
decline.Someofthesestudiesmayhavevalidateditems
usedpreviouslyinbothmajorityandminoritypopulations
thatestimatevariabilityandtruechangeovertime.
4. Develop a populationbased surveillance system
with longitudinal followup that is dedicated to
measuring the public health burden of cognitive
impairment in the United States. (S)
Apopulationbasedsurveillancesystemwouldassistin
thecollectionofconsistentdatatomonitor,assess,and
informpublichealthprogramsandpolicyaboutthe
publichealthburdenofcognitiveimpairment.
Moving research into practice
1. Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity)
and related interventions for relationships withcognitive health, harms, gaps and effectiveness. (R)
Itiscriticaltoexamineallstudiestodatetodocument
whichinterventionshavebeenproveneffective.Such
reviewsshouldfocusondeterminingtherelationships
betweenriskfactors,protectivefactors,andcognitive
functionacrossobservationalandclinicaltrials.Where
interventionsexist,theireffectivenessshouldbe
documentedandremaininggapsinthefieldshould
beidentifiedinordertomovestrategiesintopublic
healthpractice.
2. Conduct systematic literature reviews on proposed
risk factors (social engagement, nutrition,
and mental activity) and related interventions
relationships with cognitive health, harms, gapsand effectiveness.(R,SC)
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Itiscriticaltoexamineallstudiestodatetodocument
whichinterventionshavebeenproveneffective.Such
reviewsshouldfocusondeterminingtherelationships
betweenriskfactors,protectivefactors,andcognitive
functionacrossobservationalandclinicaltrials.Where
interventionsexist,theireffectivenessshouldbe
documentedandremaininggapsinthefieldshould
beidentifiedinordertomovestrategiesintopublichealthpractice.
3. Conduct a systematic literature review on the
relationship between treatment of diabetes and
cognitive health. (R)
Someevidencesuggeststhatdiabetesisariskfactorfor
cognitivedecline.Recommendationsfortypesofdiabetes
management(e.g.,medications,lifestylemodification)that
mightalsobebeneficialforcognitivehealthcannotbe
madewithoutareviewoftheliteraturerelatingdiabetes
interventionstocognitivechange(andmostlikely
undertakingadditionalclinicaltrials),andidentificationof
areasthatneedtobeclarifiedbeforespecificinterventions
canbeproposed.
4. Conduct a systematic literature review on the
relationship between treatment of hypertensionand cognitive health.(R)
Hypertensionisaknownriskfactorforstroke,and
thereforeforvasculardementiaandcognitivedecline.
Recommendationsfortypesofantihypertensivetherapy
andtherangesofbloodpressurefordifferentagegroups
recommendedformaintainingcognitivehealthcannotbe
madewithoutareviewoftheliteraturerelatinghypertensive
interventionstocognitivechange,andprobablynot
withoutpursuingadditionalclinicaltrials.Thesystematic
literaturereviewwouldidentifyareasthatneedtobe
clarifiedbeforespecificinterventionscanberecommended.
5. Identify gaps in knowledge about cognitive health
and related lifestyle changes, and determine
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whether these vary by specific groups. (C)
Todevelopappropriatematerialsandtools,thegapsin
knowledgeneedtobeunderstood,especiallyamong
highriskpopulations,vulnerablepopulations,andhealth
careproviders. Specificracialorethnicgroupsmayneed
tohavetargetedandculturallyappropriatematerialsand
toolsdevelopedbecausetheyareatgreaterriskfor
experiencingcognitivedecline.Healthcareprovidersmayhaveneedsandgapsinknowledgethatdifferfromthe
generalpublicbecausetheyarealsoprovidinginformation
toothersaboutcognitivehealth.
6. Conduct a systematic review of lifestyle interventions
and contextual factors to examine the benefits and
barriers to their adoption and maintenance. (R)
Understandingthebenefitsofandbarrierstoadopting
andmaintaininganinterventionisoneofthecriticalsteps
fortranslatinginterventionseffectivelyandefficaciouslyin
acommunitybasedsetting.
7. Conduct reviews of the literature to determine
the prescriptions for physical activity (e.g., type,
frequency, duration, and intensity of activity) that
are effective in enhancing cognitive function.(R)
Itisimportanttoknowwhatkindsofphysicalactivity
stimuliarenecessarytopromotecognitivehealth.An
examinationofthescientificliteraturewillidentifygaps
inknowledgeandfocusresearch.Withoutsuchinformation
andresearchdevelopment,accurateadvicecannotbe
conveyedtothepubliconhowactivetheyshouldbeto
maintaintheircognitivehealth.
8. Develop cognitive health interventions that
reflect the most current scientific research and
that are consistent with effective community
based interventions. (C,SC)
Clinicaltrialsassessingtheefficacyofinterventionsto
effectcognitivefunctionandpublichealthstudies
examiningtheeffectivenessandfeasibilityofcommunity
basedinterventionsareoftenreportedseparately.More
comprehensiveapproachesinvolvingcollaborations
betweenclinicalresearchersandcommunityparticipatory
researchersarecriticaltoensurethattheeffectivenessand
feasibilityofcognitivehealthinterventionsaredeveloped
andtestedwithvariouscommunities.
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Conducting intervention research
1. Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function. (R)
Todate,fewvascularstudies(includinglargescalecontrolled
clinicaltrialsofolderadultcohorts)havecombinedcognitive
healthoutcomesandvascularoutcomesinasinglestudy.
2. Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of cog-
nitive decline and improving cognitive function. (R)
Todate,few,ifany,physicalactivitystudies(including
largescalecontrolledclinicaltrialsofolderadultcohorts)
havecombinedoutcomesforcognitivehealthandphysicalactivityoutcomesinasinglestudy.
3. Conduct physical activity studies to determine the
longterm benefit of physical activity as it relates
to cognitive function. (R)
Todate,studiesofphysicalactivityinterventionsthathave
assessedcognitiveoutcomestypicallyhavenofollowupat
alloronlyashortfollowup.Studiesofphysicalactivity
areneededtodeterminetowhatextentanycognitive
benefitsassociatedwithphysicalactivitypersistacrosslong-
termfollowup:at6month,1year,orlongertimeper iods.
Longtermfollowupstudiesofphysicalactivityarealso
neededtodeterminethedurationofcognitiveeffectsin
thosewhostoptheprogram.
4. Conduct studies to determine the physical activity
prescription (e.g., type of activity, frequency,
duration, and intensity) needed to maintain or
promote cognitive functioning. (R)
Smallclinicaltrialshaveshownthataerobicactivity
(e.g.,walkingseveraltimesaweekfor6monthsduration)
wascapableofproducingcognitiveimprovementin
olderadults,atleastintheshortterm.Thesefewstudies,
however,haveyettoyieldaprescriptionthatcould
begiventoolderadults;thus,manyquestionsremain
tobeansweredaboutthetypesofactivity(e.g.,aerobic
oranaerobic,individualorgroup)andtheirduration,
intensity,andfrequencythatareneededtomaintain,or
evengain,goodcognitivefunction.
5. Conduct studies to determine the effect of physical
activity and physical activity relapse on persons of
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different backgrounds in relation to cognition. (R)
Similartothepharmacogeneticsapproachthathasbeen
usedtodeterminetheefficacyofspecificdrugsforpersons
withcertaingenotypes,itseemspossiblethatrecom-
mendationsforbehavioralinterventionssuchasphysical
activitymightbecraftedtoanindividualpersons
background(e.g.,geneticendowment,culturalcontext,
lifehistories,fitnesslevels,andage).
6. Identify how physical activity relates to those
aspects of cognitive functioning that are important
to the successful performance of activities of daily
living and instrumental activities of daily living.(R)
Itisimportanttounderstandhowanycognitivebenefit
measuredinthelaboratorytranslatestobetterfunctioning
inrealworldtasks.Althoughwellcontrolledlaboratory
studiesareessentialtoadvancingknowledgeinthisarea,
itiscurrentlynotclearhowmuchthecognitivetasks
assessedinthesestudieswillgeneralizetothecognitive
functioningrequiredinroutinedailyactivitiesimportantto
olderadults,suchasbalancingacheckbook,safelydriving
acar,andcompliancewithprescriptionsformedications
(i.e.,knowinghowmanyorwhatpillstotakewhen).
7. Determine the feasibility of conducting secondary
analyses of existing studies to examine the
relationship between physical activity and the
maintenance of cognition. (R)
Itisrecognizedthatsecondaryanalysesofexistingdata
setsoftenpossessmethodologicalproblems(including
crosssectionaldata).Nevertheless,datasets(perhapseven
somerepresentativeoftheU.S.population)mayexistthatcontainvariablesrelatedtocognitivefunctioning,health,
andphysicalactivity.Effortstolocatesuchdataandto
evaluateresearchquestionsandassociationsamongthe
variablesmayprovideadditionalinsightsintothisarea.
8. Identify the mechanisms that may mediate
the relationship between physical activity and
cognitive functioning.(R)
Physicalactivitymaynotaffectcognitivefunctiondirectly
butitmaystillaffectitthroughintermediatemechanisms.
Itisimportanttoknowwhethertheassociationbetween
physicalactivityandcognitivefunctioningismediated
bychangesindiabetesoutcomes,invascularfitness
outcomes,orinriskfactorssuchashypertension
orhyperlipidemia.
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9. Encourage cardiovascular disease and diabetes
researchers to use appropriate measures addressing
cognitive domains as outcomes in their studies.(R)
Thebestwaytounderstandwhichinterventionsin
cardiovasculardisease anddiabeteswillaffectcognitive
healthisforappropriateaspectsofcognitivemeasurestobe
routinelyincludedinappropriatestudiesinthesetwoareas.
10. Encourage research to determine the impact of
multiple vascular risks on cognition. (R)
Specificfocusisneededtobothunderstandthebiology
ofhowvascularriskfactorsaffectcognitionandto
determinewhethertheeffectsofhavingmultiplefactors
areadditiveormultiplicative. Someobservationalstudies
havesuggestedthatthegreaterthenumberofvascular
riskfactors,thegreaterthecognitivedeficit.Weknow,
however,thatclinicaltrialswithpharmacologicalagents
thatcontrolindividualriskfactorshaveeffectivelyreduced
vascularriskbuthavenotconsistentlyproducedcognitive
benefit.Abetterunderstandingofthemechanismsby
whichmultiplevascularriskfactorsmaycontributeto
cognitivedeficitscouldidentifytargetsforinterventionsto
reverseorreducethedeficit.Thebiologicalmechanisms
oftheinteractionamongriskfactors,aswellasmodelsofthesizeoftheinteractioneffectoncognition,wouldassist
indesigningtrialsofpotentiallyeffectiveinterventions.
11. Conduct research on other areas potentially
affecting cognitive health such as nutrition, mental
activity, and social engagement. (R)
Scienceisevolvingregardingriskandprotectivefactors
intheareasofcognitivetraining,nutrition,andsocialengagement.Itiscriticaltomonitorandincludethese
areasasthescienceemerges.
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Measuring cognitive impairment and burden Useful,measurablecomponentsareexpectedtodiffer
1. Identify thresholds for cognitive decline that have
functional importance for populationbased
surveillance systems. (S)
Itisimportanttorecognizepointsonthecontinuum
ofcognitivedeclinethatarefunctionallymeaningful.
Itshouldalsoberecognizedthatmeasurementsbeyond
somepointsonthiscontinuummayrequireinformation
fromproxyrespondents.Usefulcomparisonsoffindings
fromdifferentsurveillancesystemsandresearchstudiesare
improvedifthereisconsistencyamongthethresholds
beingused.Functionallyimportantthresholdsshouldbe
ofpracticalsignificancetohelpinformpublichealth
policyregardingneedsforcaregiversupportandother
specialhealthcareorsocialservices.
2. Identify critical dimensions of cognition and the
most appropriate corresponding measures that
may be useful in surveillance systems. (S)
Itisimportanttoknowthekeycomponentsofcognition
(e.g.memory,intelligence,problemsolving,andreasoning)
thataremostsensitiveandspecifictocognitivedecline
andpracticallymeasurableinsurveillancesystems.
accordingtothenatureofthesurveillancesystem,
particularlywhetherdatacollectionislongitudinal
orcrosssectional.Withcrosssectionaldataalone,
fewerinferencesarepossibleregardingagerelated
cognitivedecline.
3. Identify measures of the public health burden
of cognitive impairment on individual people,
families, and communities.(SC)
Thepublichealthburdenofcognitiveimpairment
encompassesitseffectsonindividualmenandwomen,
caregivers,families,employers,andothersinthe
community.Theseeffectsmayhavephysical,mental,
social,andeconomicdimensions.Itisimportantto
identifykeymeasurablecomponentsoftheseeffectsto
enablethepublichealthburdentobefullyassessed,
monitored,anddescribed.
4. Identify a set of questions appropriate for use in
people of diverse educational attainment, culture,
and ethnicity that will measure cognitive function
with sufficient sensitivity, specificity, and
predictive values.(S)
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Thesequestionsmightexistwithinanongoing
populationbasedsurveillancesystem,ortheycould
beaddedtosuchasystem.Totheextentpossible,
educationandcultureindependentmeasuresshould
besought.Becausetheeffectsofeducationandculture
arepotentialconfounders,measuresandanalytic
techniquesareneededthatwouldenablereduced
cognitivefunctiontobedistinguishedfromlowperformanceduetovariationsineducationalorcultural
exposures.Itiscriticaltorecognizeandcorrectthese
confoundingeffectssoastoavoidmisinterpretingor
misusingsurveillancedata.
Developing capacity
1. Engage the private sector and other entities in
planning and funding research to address ways to
maintain and improve cognitive health, including
clinical trials. (R)
Supportofresearchoncognitivehealthisexpensivein
scope,effort,andcost.Partnershipswithfederalagencies,
foundations,andotherentitieswilllikelybenecessaryto
securesuchsupportandconductthisresearch.
2. Convene researchers and community intervention-
ists conducting interventions on risk and protectivefactors to identify potential mechanisms to advance
the work in the field of cognitive health.(R)
Thefieldsofcardiovasculardisease,depression,diabetes,
andcognitionarebeginningtointersect.Afterconducting
literaturereviewsonwhatiscurrentlyknownaboutthe
effectsofinterventionstargetingvascular factors,depression,
anddiabetesoncognitivehealth,researchersand
communityinterventionistsineachofthesefieldsshould
beconvenedtodeterminestrategiesformovingthefield
ofcognitivehealthforward.
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IVdevelopment
process
Vactions by
cluster
VInext steps
IIIstrategic
framework
IIstate of
knowledge
Ibackground
Next