cognitive aging: what every older adult should...
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CognitiveAging:WhatEveryOlderAdultShould
KnowDanBlazerMD,MPH,PhD
JPGibbonsProfessorEmeritusPsychiatryandBehavioralSciencesDukeUniversitySchoolofMedicine
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Disclosures
• IchairedtheInstituteofMedicineConsensusCommitteefromwhichlargeportionsofthistalkderive.
• Ihaveupdatedareaswherenewandrelevantdatahaveemergedinformingourunderstandingofcognitiveaging.
• Nootherdisclosures
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InstituteofMedicine2015
FreePDFofthereport:www.iom.edu/cognitiveaging
Sponsors:
• McKnightBrainResearchFoundation
• NationalInstituteonAging• NationalInstituteofNeurologicalDisordersandStroke
• CentersforDiseaseControlandPrevention
• RetirementResearchFoundation
• AARP
CognitiveAging:ProgressinUnderstandingand
OpportunitiesforAction
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ThanksforSlidesandCollaboration
• SharonInouye,MD–Harvard
• BobWallaceMD–UniversityofIowa
• KristineYaffe,MD–UniversityofCalifornia,SanFrancisco
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WhatisCognitiveAging?
• Cognitionreferstothementalfunctionsinvolvedinattention,thinking,understanding,learning,remembering,solvingproblems,andmakingdecisions.
• Cognitiveagingisaprocessofgradual,ongoing,yethighlyvariablechangesincognitivefunctionsthatoccuraspeoplegetolder.
• Cognitiveagingisalifelongprocess.Itisnotadiseaseoraquantifiableleveloffunction.
• Inthecontextofaging,cognitivehealthisexemplifiedbyanindividualwhomaintainshisorheroptimalcognitivefunctionwithage.
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KeyFeaturesofCognitiveAging• Inherentinhumansandanimalsastheyage• Occursacrossthespectrumofindividualsastheyageregardlessofinitialcognitivefunction
• Highlydynamicprocesswithvariabilitywithinandbetweenindividuals
• Includescognitivedomainsthatmaynotchange,maydecline,ormayactuallyimprovewithaging,andthereisthepotentialforolderadultstostrengthensomecognitiveabilities
• Onlynowbeginningtobeunderstoodbiologicallyyetclearlyinvolvesstructuralandfunctionalbrainchanges
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ALifeCourseApproachtoAgingandCognitivePerformance
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Proportionsofpeopleages65andolderwithmoderateorseverememoryimpairmentversusnoormildmemoryimpairment
Health and Retirement Study, United States, 2002. SOURCE: FIFARS (Federal Interagency Forum on Aging-Related Statistics). 2004. Indicator 17: Memory impairment.
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DifferenceinSomeDomainsofCognitiveFunctionbyAge(MIDUSII,N=4,268,UnitedStates,2004-2006)
SOURCE: Lachman, M. E. 2014. Monitoring Cognitive Functioning: National Survey of Midlife in the United States (MIDUS). Presentation given to the IOM Committee at the April 2014 workshop.
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DifferencesinCognitiveFunctionbyAgeBasedonDifferentCognitiveTests,MIDUSII,
N=4,268
SOURCES: Lachman, M. E., and P. A. Tun. 2008. Cognitive testing in large-scale surveys: Assessment by telephone. In Handbook of Cognitive Aging: Interdisciplinary Perspectives, edited by S. Hofer and D. Alwin. Thousand Oaks, CA: Sage Publishers. Lachman, M. E. 2014. Monitoring Cognitive Functioning: National Survey of Midlife in the United States (MIDUS). Presentation given to the IOM Committee at the April 2014 workshop.
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Intra-individualchangesincognitionscoresovertime(randomsampleof500adults,ages50andolder)
SOURCES: McArdle, J. 2011. Longitudinal dynamic analyses of cognition in the health and retirement study panel. Advances in Statistical Analysis 95(4):453-480. McArdle, J. 2014. Cognitive measurements in the HRS/ADAMS surveys. Presentation given to the IOM Committee at the April 2014 workshop.
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AssessmentofCognitiveAging
– Bestassessedwithinanindividualovertimesothatheorsheservesashisownnorm,thoughthisapproachincorporatespracticeeffects
– Needtoregularlyrevisitthenormsthatweusetostatisticallynormcognition
– CognitiveAgingisnotnormalagingorsuccessfulaging
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ImplicationsOfTheDefinition
• Asconceptsofdiseaseandsyndromeschange,cognitiveagingchanges– MCIwasoncenotMCI,notadiagnosis,sopriorcohortsthatdefinedcognitiveaginglikelyincludedpeoplewhohadMCIwhowouldnotbeincontemporarycohorts
• Overtime,thenormschange;theyshouldchange• Yetweoperationalizedefinitionsandreifywhatisadynamicprocess.
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Howlongisafoot?Thenatureofoperationaldefinitions
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BrainChangeswithCognitiveAging
• Humanandanimalstudies• Mechanismsofcognitiveaging:• -Geneticsundoubtedlyplayarolebutspecificgenetic
associationshavenotasyetbeenidentified.– Decreasesinneuronalfunction,notnumber
• Declinesinsynapticnumber• Declinesinsynapticfunction• Decreasedfunctionofmyelinsheaths
– Neurotransmitterchanges• DeclineinAMPAreceptorassociatedwithmemoryandsynapticplasticity 16
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DeclinesinSynapticIntegrity
• Studiesonnon-humanprimates
• Specificclassesofdendriticspineslostindorsolateralprefrontalcortex
• Thesespinesareveryimportantforsynapticplasticity
• Losscorrelateswithdeclinesinworkingmemory
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WhataresomeFunctionalMeasuresReflectingCognitiveAging?(IADLs)
• Fillingoutyourtaxform• Downloadingandusinganapp• Renewingyourdrivers’licenseandtagsonline• Preparingamealfromarecipe• GoingfromTerminal1toTerminal2atO’Hare• Servingonacommitteeforavolunteersocialgoal• Fixingaminorapplianceproblem• Adaptingtochallengingpersonal,socialsituations• PreparingPowerPointslides
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PersonalAdaptationstoCognitiveAging(Examples)PsycholAssessment17:168
• “External”Behaviors– Shoppinglists– Bookmarks– Notebirthdays– Telephonenumbers
• “InternalBehaviors– Memorytricks– Thinkaboutaplan– Linkoldandnew– Mentalimages
• “Reliance”– Askforhelptoremember________
• “Time”– Slowdownspeech– Readmoreslowly
• “Effort”– Inconversation– Concentration– Tryinghardtoremember
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RiskFactorsforCognitiveAging
• Factorswhichmayacceleratethedecline• Factorswhichmaybeopentointervention.
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Earlier“LifeCourse”RiskFactorsandConditions
• Educationaldevelopment(thoughaugmentedbypersonalactivitiessuchastripstothelibrary[inthepast])
• Adversechildandadolescentexposures
• Childandearlyadultmental/psychologicalconditions(e.g.,anxiety)
• Potentialoccupationalandotherenvironmentalexposures(e.g.,workingincognitivelynon-challengingoccupations)
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ImportanceofBehavioralConditionsasaWindowintoSubsequentCognitiveProblems
Behavioralconditions:-AttentionDeficitHyperactivityDisorder-Languagedisorders/Dyslexia-AutismSpectrumDisorder -Conductdisorders-SubstanceAbuse
Otherchildhoodandadultpsychiatricdisorders:-Depression -Eatingdisorders-Gambling-anxiety,negativeaffect,hostility,pessimism,hopelessness,andperceivedconstraints 22
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ExternalContributorstoCognitiveAging
• Inprocessofnormalaging,olderadultsareexposedtomanyfactorswhichmayacceleratecognitiveaging:
• Thesefactorsareknowntocontributetocognitivedysfunction.
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Ref:HHS,ProfileofOlderAmericans,2013
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HospitalizationasaRiskforCognitiveDecline
Nearlyeveryolderadultwillexperienceatleastoneacuteillness,surgery,orhospitalizationNearly1/4of65+agegroupwillbehospitalizedeachyear.Thatnumberincreaseddramaticallyforthe85+agegroup.Thefrequencyofdeliriumamongthosehospitalizedis25%(Inouyeetal,1993)
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ImpactofHospitalization
WilsonRSetal.Neurology2012;78:950-56 25
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ExternalContributorstoCognitiveDecline• Medications(psychoactive)
• Anticholinergics• Polypharmacy
• Vascularriskanddisease(cerebro-andcardio-vascular)
• Hospitalizations• Acutemedicalillness• Majorsurgery• Intensivecareunitstay
• SeriousInfections• Alcoholabuse
• Multimorbidity:• Hypertension• Diabetesmellitus• Chronicrenaldisease• Cancer• Thyroiddisease
Hearingloss • Depression• Visionloss • Headtrauma
• Sleepdisorders,sleepapnea • Geneticfactors26
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MedicationsandCognitiveDecline
• Olderadultsareprescribed14drugsperyearonaverage
• Highriskmedsincludeanticholinergicdrugs,benzodiazepines,andsedative/hypnotics.
• 20–50%onanticholinergicdrugs(associatedwithcognitiveimpairment)
• Potentanticholinergicsandover-the-counterantihistaminessuchasdiphenhydramine(Benadryl)especiallyarisk
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Whatarepeopledoingtointerveneincognitiveaging?
-Computerizedbraingames-Drugs(incl.caffeine)-Stimulants:(methylphenidate/amphetamines)-Transcranialelectricstimulation-Nootropics(SeeScience350:379)
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EvidencedBasedMessagesforCliniciansandthePublic
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Messaging
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RecommendationstoIndividualsandFamilies
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RecentStudiesofInterventionforCognitiveAging
• Sprint-Mind-IntensiveBPcontrolsignificantlyreducedtheriskofmildcognitiveimpairment(14.6vs18.3casesper1000person-years(JAMA,2019)
• PooledanalysesofMediterraneanDiet-Fifteencohortstudieswith41,492participantsand2RCTswith309and162participantsininterventionandcontrolgroups,respectively,wereincluded.Theprimaryoutcomeofinterestwascognitivefunction,dividedintodomainsofmemoryandexecutivefunction.Meta-analysisofcohortstudiesrevealedasignificantassociationbetweenMeDiandolderadults'episodicmemoryandglobalcognitionbutnotworkingmemoryorsemanticmemoryMeta-analysisofRCTsrevealedthatcomparedwithcontrols,theMeDietimproveddelayedrecallworkingmemory,andglobalcognition.(McEvoyetal,2017)
• Sleep–nappingtimemaybeassociatedwithincreasedcognitivedecline.(Lengetal,2019
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BrainStimulationActivities(BrainGames)• Noquestionthatifmostpersonspracticeusingbraingames,theywillimproveinfunctiononthegames.
• Brainstimulationgameshavenotasyetbeendemonstratedto– Transfertoeverydayactivitiesovertime– MaintaingainsovertimeoncethegamesarenolongerplayedBraingamesdocomewithacost
AsmallbutforsomesignificantfinancialcostAnxietyoverperformanceonthegameandcomparisonwithothers.
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TheACTIVEStudy(Reboketal,2014)
• Nearly3000subjectsfollowedforuptotenyears• Computerizedbraingamescoupledwithgroupinteractionandinstruction
• Associatedwithboostersessions
• CognitivetrainingresultedinlessdeclineinADLs.
• Reasoningandspeedtrainingimpactfounduptotenyears.