use it or lose it: can we prevent cognitive decline via activity
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USE IT OR LOSE IT: Preventing
Cognitive Decline in Aging
Michael Pramuka, Ph.D.Western Psychiatric Institute and Clinic
University of Pittsburgh Center for Healthy Aging
Other Potential Means of preventing cognitive decline: Management of Depression Diet Food Supplements (anti-oxidants) Exercise Adequate Sleep Stress Reduction Cholinesterase Inhibitors Reduce health risks for vascular
dementia
Past Models of Cognitive Intervention Functional Approach:
– Choose best environment– Develop compensations– Focus on everyday tasks
Cognitive Approach– Rehearse attention, memory,
planning skills– Apply to real-life situations
Past Models of Cognitive Intervention Both approaches resulted in
– Increased awareness of cognitive abilities and limitations
– Poor generalization– Recruitment of intact functions/
preserved brain function Recent increasing evidence of
functional treatment efficacy
Popular Model of Preserving Cognition in Aging
Increased Cognitive Activity– Improved Everyday Function– Slowed cognitive decline
VIA changes in cerebral organization or function
Popular Books Mind Games: The Aging Brain and How
to Keep It HealthyWetzel, Kathryn, & Harmeyer, Kathleen
The Memory BibleSmall, GaryKeep Your Brain Young
McKhann, Guy & Albert, Marilyn Brain Fitness
Goldman, Robert, Klatz, Ronald, & Berger, Lisa
More Popular Books: Use It or Lose It: How to Keep Your Brain
Fit as It AgesBragdon, Allen. D., & Gamon, David
Keep Your Brain Alive: 83 Neurobic Exercises to Help Prevent Memory Loss and Increase Mental Fitness
Katz, Lawrence C., & Rubin, Manning Reversing Memory Loss: Proven Methods
for Regaining, Strengthening, and Preserving Your Memory
Mark, Vernon H., & Mark, Jeffrey P.
More Popular Books Exercises for the Whole Brain
Bradgon, Allen D. Exercise Your Mind
Castorri, B. Alexis
All popular books have one thing in common: they cite one or several studies that implicate cognitive activity as a means of staving off Alzheimers or improving performance, and then go on to cite many activities, compensations, or strategies for improving cognition
Professional Literature: More Active Lifestyles Predict Preserved Cognitive Function Comes from both cross-
sectional and longitudinal data
Few studies provide a comprehensive or parallel literature review
Professional Literature: Measuring WHAT
Increased daily function Improved test performance Reduced risk of dementia Decreased rate of cognitive decline
(preventing dementia?) Changes in the brain
– Cerebral changes (regions used)– Increased dendritic networks and– Nerve growth– Neurochemical changes
Professional Literature: Measuring WHO
Normal community-dwelling elderly
Normal but “limited” or “at-risk” elderly
MCI elderly Demented elderly
Professional Literature: Measuring HOW
Level, type or frequency of cognitive activity by self-report or observation
Type and frequency of physical activity by self-report
Train improved memory and organizational skills
Train increased mental flexibility Educate about memory, aging, and
coping Measure or facilitate level of social
activity
Positive emotional expression predicts longevity Danner, Deborah D., Snowdon,
David & Friesen, Wallace (2001)The Nun Study
180 nuns, age/educationcorrected ages 75-95 measured expressed emotion in
autobiographies written just prior to taking final vows
Lower linguistic ability in early life predicts dementia and earlier deathSnowdon, Greiner, & Markesberry, 2000: The Nun Study 74 nuns ages 74- 97 measured idea density in
autobiographies looked at ratio of idea density
to neurofibrillary tange counts idea density unrelated to
vascular changes in brain
Engaged Lifestyle: Participation in mentally challenging activities predicts higher cognitive scores (Lahar, 2000)
Used WAIS-R Vocabulary, Digit Span, Boston Naming Test
Compared cognition to self-report of everyday activities
TV Viewing related to lower verbal skills in all age group
Demonstrated relationship between activity and cognition in younger (under 49) but not older (over 50)
Engaged Lifestyle: The Victoria Longitudinal StudyHultsch, Hertzog, Small & Dixon, 1999 250 adults followed over six years Generally high functioning/well
educated Measured:
– Cognitive status on standardized tests– Activity level (both cognitive and
physical)– Self-reported health– Personality (NEO)
Victoria Longitudinal Study: Results
No relationship between:– Self-reported health and cognition– Personality and cognitive status– “active lifestyle” and cognition
Supports relationship between novel tasks and cognition (working memory)
Alternative interpretation: High-ability adults lead intellectually active lives
WW II Veterans: Gold et al, 1995 WWII Veterans tested twice
over a 40 year period Higher intellect, better
education, and higher SES lead to a more engaged lifestyle
Concluded that engaged lifestyle then contributes to maintenance of verbal intellect
Seattle Longitudinal StudySchaie et al
Begun in 1956 by K. Warner Schaie; since 1981 at Penn State with wife Sherry Willis
Now over 5000 adults followed every seven years
Both longitudinal data on intellectual change over time and cross-sectional work on intellectual training
Adult Intellectual Development: the Seattle Longitudinal Study
Seattle Longitudinal Study
Cognitive training on spatial orientation and inductive reasoning tasks
5 hour individual training Found improvement on both
domains and less than average decline in inductive reasoning at seven year follow-up
Seattle Longitudinal Study
Observations on better cognitive outcome in old age– Absence of chronic disease– Complex and intellectual stimulating
environment throughout life– Flexible personality style– High intellectual status of spouse– Persisting high perceptual
processing speed
MacArthur Foundation Study
1200 participants Ages 70 – 80 Followed for 10 years Better cognitive status predicted
by:– Mental activity– Physical activity– Ongoing sense of meaning and
contribution to community
Complex Work Improves Intellectual Function
Schooler, Mulatu, & Oates (1999) Extended a longitudinal study by
Kohn & Schooler of 1983 Original sample of 3101 men 687 re-interviewed in 1974 334 again interviewed in 1994/1995 Showed a positive effect of more
challenging work on intellect, especially for older workers
Cognitively Stimulating Activities Reduce Risk of Alzheimer’s Disease
Wilson, Mendes de Leon, Barnes, Schneider, Bienias, Evans, and Bennett (2002)
801 Catholic nuns, priests, and brothers
Followed from 1994 to 2001 Ratings of frequency on 7 common
activities Ratings of physical activity Neuropsychological testing
Results: Higher cognitive activity associated with
higher baseline cognitive function Ongoing cognitive activity associated with
less decline in working memory and less decline in perceptual speed
Controlling for age, education, and gender:– Lower level of cognitive activity predicted
faster cognitive decline– Risk of developing Alzheimer’s disease
decreased by 33% for each additional point of reported cognitive activity
Learning Mnemonic Strategies Yesavage, Sheikh, Friedman, & Tanke,
1990 218 community dwelling elderly Mean age of 67, range 55 – 87 Four 2 hour sessions of face-name
association and list-learning strategies Variety of one-week pretraining
(imagery, relaxation, or imagery plus judgment)
Learning Mnemonic Strategies: Results of Yesavage et al Both age and MMSE scores
related to post-test performance No difference in type of pre-
training on post-test performance Over age 75 had difficulty learning
the list-learning mnemonic and performed poorer on both tasks
Post test at the end of two week training; no follow-up
Face-Name Recall Training in Dementia
Lars, Staffan, Herlitz, Stigsdotter, & Tiitanen, 1991
8 patients with dementia (7 AD, 1 MID)
Eight training sessions over two weeks
Immediate and one month follow-up No improvement from baseline to
immediate f/u on 7 patients; one did improve
Meta-analysis of Memory Training in Normal Elderly
Verhaeghen, Marcoen, & Goossens, 1992
31 research studies reviewed Retesting alone enhances memory
performance on standardized tests
Memory training improves performance
Training gains are specific to training (poor generalizability)
Verhaeghen, et al Meta-analysis
Treatment gains in Memory training were largest:– In group training rather than
individual–With younger participants– In shorter training sessions
(less than 1.5 hours)–When pre-training was provided
Longer-term Memory Training Oswald, Rupprecht, Gunzelmann, &
Tritt, 1995 375 people aged 75 – 89 272 treatment group, 103 controls Baseline, end-treatment, and one yr f/u Weekly intervention group over 30
weeks Training on:
– Coping strategies– Memory Training– Psychomotor Training
Results: 30 week Memory Training
Memory groups improved memory test performance
Coping strategy group improved everyday competence
Best outcome was for combined psychomotor and memory training
One yr f/u showed persisting effects of initial changes but overall performance decrements
Longer-term vs. Shorter Memory Training Woolverton, Scogin, Shackelford,
Black, & Duke, 2001 77 participants –community
dwelling elderly Aged 60 – 88 Self-paced instructional manuals 24 day one-hour study sessions 13 day shorter training geared to 3
targeted memory areas: names, locations of objects, dates and appointments
Longer-term vs. Shorter Memory Training: Results
Group overall demonstrated improved performance in memory strategy use
The 24 session group proved much more effective at memory strategy use and in improving performance on objective memory measures
Shorter group had no demonstrable changes in targeted memory areas
Knowledge of Memory and Everyday Function Improves with Education
Troyer (2001) 36 participants and 24 controls Five weekly 2-hour sessions on
– Normal aging– Memory processes– Reducing risk of dementia– Healthy lifestyle issues– Everyday memory strategies– Practice assignments between meetings
Troyer Results: Greater pretest to post-test
change scores on reports of everyday memory function
Increased knowledge of how memory works
Better performance on a prospective memory task
No change in list learning or name recall tasks
ACTIVE (Advanced Cognitive Training for Independent and Vital Elderly)
Began enrollment in 1998 Multi-center study (UAB, Boston,
Indiana University, Johns Hopkins, Penn State)
2832 participants over the age of 65
No evidence of cognitive, physical or functional decline
10 training sessions plus four “booster session 11 months later
ACTIVE Randomized to four groups:
– Memory Training– Reasoning Training– Speed Training– Control Group
Measures of cognition, everyday function by self-report, paper and pencil, and observation
Quality of Life, health service utilization, everyday mobility
Memory Training Caveats Memory training seems to have
minimal effect on subjective measures of memory dysfunction (Floyd & Scogin, 1997)
Memory training does not typically address memory problems most elders complain about (Leirer, Morrow, Sheikh, Pariante, 1990; Yesavage, Lapp, & Sheikh, 1989)
Memory strategies require lots of effort and are seldom used outside of clinical training sessions (Park, Smith, & Cavanaugh, 1990)
Increasing Complex Cognitive Activity Later in Life might: Increase sense of purpose, motivation, and
hope Decrease depression Improve level of socialization Offer additional outlets for emotional
expression Decrease stress and improve coping Improve use of compensatory strategies Increase depth of processing Increase level of physical activity Increase engagement with good “role
models”
Research Outcomes Normal elderly can improve on
cognitive tests with training Memory training shows minimal to
no impact on subjective memory complaints or everyday function
Lifelong cognitive activity may minimize risk of cognitive impairment
No documentation that training activity leads to changes in brain
Research Outcomes Education on memory, healthy lifestyle,
and compensatory strategies can improve subjective memory and prospective memory
Unclear if increased mental activity late in life can affect cognitive status or stave off dementia
No documented association between– “mind games” and improved everyday
function– “mind games” and decreased risk of dementia
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