the healthy brain initiative - alzheimer's association · pdf file| the healthy brain...

The Healthy Brain InitiativeA National Public Health Road Map to Maintaining Cognitive Health

Acknowledgements

Executive Summary 1

I Background 4 Whatiscognitivehealth? 5 WhyprepareaRoadMap? 7 Whyisitimportant—andwhynow? 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 Concept-mappingprocess 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

TheHealthyBrainInitiative:A National Public Health Road Map to Maintaining Cognitive Health

TableofContents

Suggested Citation: CentersforDiseaseControlandPreventionandtheAlzheimer’sAssociation.TheHealthyBrainInitiative:ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth:Chicago,IL:Alzheimer’sAssociation;2007

Availableatwww.cdc.gov/agingandwww.alz.org

Centers for Disease Control and Prevention and the Alzheimer’s Association

�|TheHealthyBrainInitiative: ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth

Acknowledgements

WethankthemembersoftheSteeringCommitteeforgivingcountlesshourstothinkaboutanddiscussthisNational Public Health Road Map to Maintaining Cognitive Health;theircontributionshavebeeninvaluable.

LyndaAnderson,PhD(Cochair)Centers for Disease Control and Prevention

StephenMcConnell,PhD(Cochair)Alzheimer’s Association

FrankBailey,JDAARP

WilliamF.BensonHealth Benefits ABC’s

DebraCherry,PhDAlzheimer’s Association

GregCaseAdministration on Aging

HughC.Hendrie,MB,ChB,DScIndiana University Center for Aging Research Regenstrief Institute, Inc.

JamesLaditka,DA,PhD,MPAUniversity of South Carolina

DebraLappin,JDB&D Consulting LLC

MarcelleMorrison-Bogorad,PhDNational Institute on Aging

PeterRabins,MD,MPHJohns Hopkins University School of Medicine

RamonaL.Rusinak,RN,PhDArizona Department of Health Services

TheHealthyBrainInitiative: ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth

�|TheHealthyBrainInitiative: ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth Centers for Disease Control and Prevention and the Alzheimer’s Association|�

ExecutiveSummary

InFall2005,theCentersforDiseaseControlandPreventionandtheAlzheimer’sAssociationformedanewpartnership

toexaminehowbesttobringapublichealthperspectivetothepromotionofcognitivehealth.ToassistwiththisHealthyBrainInitiative,thePartnersworkedcloselywiththeNationalInstituteonAgingandtheAdministrationonAgingtoconveneamultidisciplinarySteeringCommitteeandanevenwiderarrayofinvitedexpertsfromconcernedpublicandprivatesectororganizations.Togetherweexaminedthecurrentstateofknowledgeregardingthepromotionandprotectionofcognitivehealth,identifiedimportantknowledgegaps,anddefinedtheuniqueroleandcontributionsofpublichealth.Wefocusedonvascularriskfactorsandphysicalactivitybecauseoftheirassociationwithcognitiveoutcomes,adoptedastrategicframework,andembarkedonanintensiveprocesstogeneratetheactionsofferedinthis National Public Health Road Map to Maintaining Cognitive Health.

TheRoadMaprecognizescurrentsocialtrendsandotherfactorsthataffectcognitivehealthfromapublichealthstandpoint:anagingpopulation,growingfearandconcernexpressedbymanypeopleastheyageabouttheirpotentiallossofcognitivefunction,increasingsocietalburdenfromcognitivedecline,greatercaregiverburden,andacontinuedlackofawarenessaboutcognitivehealthamongconsumersandprovidersalike.

Withthisbackdrop,weofferaloftybutachievablelong-termgoal:

To maintain or improve the cognitive performance of all adults.

Toaccomplishthisgoal,weproposeasetof44actionsthatarefirmlygroundedinscience,emphasizeprimaryprevention,assumeacommunityandpopulationapproach,andarecommittedtoeliminatingdisparitiesinpersonalhealthandhealthcareforracialorethnicgroups.Itiscriticaltonotethateachpriorityactionisbasedonadetailed,scientificrationale,withimplementationtobebasedondemonstratedeffectivenessofspecificinterventions.TheseactionsshouldthereforebeconsideredinthecontextoftherationalespresentedinSectionVoftheRoadMap.Withinthefullsetofactionsare10prioritiesworthyofimmediateattention:

ExecutiveSummary

• Determinehowdiverseaudiencesthinkaboutcognitivehealthanditsassociationswithlifestylefactors.

• Disseminatethelatestsciencetoincreasepublicunderstandingofcognitivehealthandtodispelcommonmisconceptions.

• Helppeopleunderstandtheconnectionbetweenriskandprotectivefactorsandcognitivehealth.

• Conductsystematicliteraturereviewsonproposedriskfactors(vascularriskandphysicalinactivity)andrelatedinterventionsforrelationshipswithcognitivehealth,harms,gapsandeffectiveness.

• Conductcontrolledclinicaltrialstodeterminetheeffectofreducingvascularriskfactorsonloweringtheriskofcognitivedeclineandimprovingcognitivefunction.

• Conductcontrolledclinicaltrialstodeterminetheeffectofphysicalactivityonreducingtheriskofcognitivedeclineandimprovingcognitivefunction.

• Conductresearchonotherareaspotentiallyaffectingcognitivehealthsuchasnutrition,mentalactivity,andsocialengagement.

• Developapopulation-basedsurveillancesystemwithlongitudinalfollow-upthatisdedicatedtomeasuringthepublichealthburdenofcognitiveimpairmentintheUnitedStates.

• Initiatepolicychangesatthefederal,state,andlocallevelstopromotecognitivehealthbyengagingpublicofficials.

• IncludecognitivehealthinHealthy People 2020,asetofhealthobjectivesforthenationthatwillserveasthefoundationforstateandcommunitypublichealthplans.

Itisourhopethatthese10priorityactionswillservetofocusthenation’sresourcesonaddressingriskandprotectivefactorsforpromotingcognitivehealthoverthenext3-5years.Asalivingandflexibledocument,theRoadMaprepresentsbothacalltoactionandaguideforimplementinganeffectivecoordinatedapproachtomovingcognitivehealthintopublichealthpractice.Thekeytosuccessliesincontinuingandexpandingresearch;developingandchannelingresources;workingtodeveloporstrengthenpartnershipswithlike-mindedorganizations;designingcollaborativeoperationalplansofaction;andestablishingsystemstotrackprogress,facilitatecommunication,andexchangeinformation.

Continuedvigilanceonthisissue,andtimelytranslationofresearchfindingsintocommunityaction,willassurethatwereapthepotentialrewardsthatpublichealthcanofferinimprovingqualityoflifeamongadultsandreducingsocietalcostsforhealthcareandotherservices.


Centers for Disease Control and Prevention and the Alzheimer’s Association|�


What is cognitive health?

Thedistinctionbetweenthemindandbodywasaconceptfirstformallysetforthinthe17thcenturybyphilosopherReneDescartes.Overthenextseveralcenturies,thebodywasseenastheconcernofphysicians,whilethemindwasthepurviewoforganizedreligion.1

Overtheyears,ourunderstandingof“bodyandmind”hasevolvedsignificantly.Wenowrecognizethevitalrolethatbothphysicalhealthandmentalhealthplayinshapingouroverallwell-being,andweappreciatethevaluablecontributionsthatawidearrayofhealthprofessionscanmaketowardassuringthatwell-being.

Background

IVdevelopment

process

Vactions by

cluster

VInext steps

IIIstrategic

framework

IIstate of

knowledge

Ibackground


Mentalhealthencompassesemotionalfunctioningandtheabilitytothink,reason,andremember(cognitivefunctioning).Whilestandardized,widelyaccepteddefinitionsofcognitive healthhaveyettobeadopted,mostexpertsagreethatthecomponentsofhealthycognitive functioning include:

• language• thought• memory• executivefunction(theabilitytoplanandcarryouttasks)• judgment• attention• perception• rememberedskills(suchasdriving)• abilitytoliveapurposefullife2

Muchlikephysicalhealth,cognitivehealthcanbeviewedalongacontinuum—fromoptimalfunctioningtomildcognitiveimpairmenttoseveredementia.ItisnotsimplytheabsenceofdiseasessuchasAlzheimer’sdisease;rather,itshouldberespectedforitsmultidimensionalnature,andthechangesthattakeplaceoverthelifespanshouldbeaccepted,evenembraced,asanaturalpartoftheagingprocess.3

Cognitivedeclinecanrangefrommildcognitiveimpairmenttodementia,butthesetwoconditionsarenotnecessarilymanifestationsofthesamedisease.Manypeopleneverdevelopanyseriousdeclineintheircognitiveperformance,andthosewhodevelopmildcognitiveproblemsdonotnecessarilydevelopdementia.Althoughnotallpeoplewithcognitivedeclinedevelopdementia,thosewithanamnesticformofmildcognitiveimpairmentdohaveamuchhigherriskfordementiathanotheradults.

Thelackofcognitivehealthcanhaveprofoundimplicationsforaperson’sphysicalhealth.Olderadultsandothersexperiencingcognitiveimpairmentmaybeunabletocareforthemselvesortoengageinnecessaryactivitiesofdailyliving,suchaspreparingmealsormanagingtheirfinances.Limitationsintheabilitytoeffectivelymanagemedicationsandexistingmedicalconditionsareofparticularconcernwhenapersonisexperiencingcognitiveimpairmentordementia.

Dementiaaffectsaperson’sabilitytocomprehendandactonmessages,andinvolvesproblemswithmemory,understandingorusingwords,andidentifyingobjects.Thesignificantlyimpairedcognitionassociatedwithdementialeadstoalossofsenseofselfandoflifelongmemories;adecreasingabilityto

Background


copewiththenormaldemandsofliving;problemsaccessinghealthcaresystems;greatervulnerabilitytodisease,injury,malnutrition,crime,andpossiblyabuse;andeventuallyalossofindependence.Thatlossofindependencebecomesaburdenonfamiliesandsociety,astheindividualrequiresmoreintensecareandofteninstitutionalization.Inthelaterstages,thecognitiveimpairmentassociatedwithdementiawillcreatetotaldependency,andAlzheimer’sdiseaseisnowrankedasthe8th-leadingcauseofdeath.5

Why prepare a Road Map?

Bringingapublichealthperspectivetocognitivehealthrequiresaninclusiveandstrategicapproach.Muchimportantworkhasalreadybegun,initiatedandsponsoredbyavarietyoforganizationsandagenciesatnational,state,andlocallevels(seepages10-11forasamplingofcurrentefforts).

“Mostimportanttoourabilitytoliveourliveswellisthecombinationofmentalprocesseswecall‘cognition’or‘knowing.’Thiscombinationincludestheabilitytolearnnewthings,intuition,judgment,language,andremembering.Havingaclear,activemindatanyageisimportant,butaswegetolderitcanmeanthedifferencebetweendependenceandindependentliving.”4



Oneoftheselandmarkefforts,theNationalInstitutesofHealth(NIH)CognitiveandEmotionalHealthProject(CEHP),wasofficiallylaunchedin2001.SelectedexpertsfromseveraluniversitiesandtheNIHcriticallyanalyzedthescientificliteraturetoidentifypossibleriskandprotectivefactorsformaintainingcognitiveandemotionalhealthinadults.6Inrecognitionoftheimportanceofthiseffort,andasfurthertestamenttotheincreasedvisibilitythatcognitivehealthisreceiving,Congressappropriatedfundsinfiscalyear2005totheCentersforDiseaseControlandPrevention(CDC)toaddresscognitivehealthwithafocusonlifestyleissues.Withthissupport,CDCformedapartnershipwiththeAlzheimer’sAssociationandisworkingcloselywiththeNationalInstituteonAging,theAdministrationonAging,andotherpublicandprivatesectororganizationsonaHealthyBrainInitiative.

Thispartnership:

• FormedaSteeringCommitteemadeupofnationalexpertstoprovideoverallguidanceandcoordinationfortheInitiative(AppendixA).

• ConvenedaPublicHealthResearchWorkingGroupMeetinginMay2006onThe Healthy Brain and Our Aging Population: Translating Science to Public Health Practice.During

this2-dayinvitationalmeeting,nationalexpertsreviewedresearchinpublichealthpreventionrelatedtobrainhealth,anddiscussedspecificrecommendationsforaddressingriskandprotectivefactorsforpromotingcognitivehealth.Theyfocusedonvascularriskfactorsandphysicalactivitybecauseoftheirassociationwithcognitiveoutcomes.

ThefindingsfromthisresearchmeetingprovidedafoundationandcommonframeofreferenceforthenextstepoftheHealthyBrainInitiative:developingstrategicpublichealthrecommen-dations.Forthistask,thePartnershipformedworkgroupsinfourareasofpublichealthaction:PreventionResearch,Communication,Surveillance,andPolicy.Eachworkgroupwaschargedwithdraftingrecommendationsformovingthenationforwardoverthenext3-5yearstowardthelong-termgoalofmaintainingandimprovingthecognitivefunctionofadults.Keystakeholdersatthenational,state,andlocallevelsthenrefinedtherecommendationsandselectedthoseofhighestpriority(AppendixA).

TheNational Public Health Road Map to Maintaining Cognitive Healthreflectstheculminationofthis18-monthprocess.AsacornerstoneoftheInitiative,itoffersapathforhowwecanlearnmoreaboutcognitivehealthandthenultimately

Background


translatewhatwelearnintoreal-worldpracticetoimprovethehealthofallAmericans.

TheauthorsoftheRoadMaprecognizethatinthecourseofdailylifethedomainsofemotionalandcognitivehealthareinextricablylinkedandcannottrulybeseparated.ForthisRoadMap,however,weassumethisdistinctionandfocussolelyoncognitivehealth.Onlyrecentlyhavepublichealthexpertiseandresourcesbeenrecognizedforaddressingcognitivehealth.TheRoadMapreflectsacommitmenttobringtheareaofcognitivehealth“uptopar”withemotionalhealthastreatmentsandpreventivestrategiesbecomeavailable.Itisthefirststepinasystematicprocessforbringingcognitiveandemotionalhealthtogetherinamorecomprehensiveandcoordinatedpublichealthapproach.

“Wearebeginningtotakethenextsteps,buildingontheresearchcomingoutofNIHandothers,andmovingwhatweknowoutintocommunitypractice.ThisiswherewecanmakeadifferenceintheeverydaylivesofAmericans.”LyndaA.Anderson,PhDHealthy Aging Program, Centers for Disease Control and Prevention


�0 |TheHealthyBrainInitiative: ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth

Background

A Sampling of Current Efforts

Pursuing Research on Factors Influencing Cognitive Health

TheNationalInstitutesofHealth(NIH)isfundingongoingresearchtoclarifytherelationshipamongminimizingvascularriskfactors,exercise,otherlifestyleanddruginterventions,andcognitivehealthstatus.Epidemiologicstudiesareidentifyinglikelyriskandprotectivefactors;thesearebeingtestedinanimalstudies,whichalsocanhelpidentifythemechanismsbywhichriskandprotectivefactorsmightwork.Inordertoconfirmthattheencouraginginterventionsidentifiedinepidemiologyandanimalstudiescouldactuallymaintaincognitivehealthifappliedtohumans,clinicaltrialsmustbecarriedout.Somearealreadyinprogressbutothersarestillonlyintheplanningphase.NIHkeepsthepublicup-to-dateonthecurrentstateofthesciencethroughoperationofaWebsiteandanationalclearinghouse.

Assessing Public Perceptions

Formativeresearchwithdiversegroupsisrequiredtohelpgainunderstandingonthepublic’sperceptionsaboutcognitivehealth.OnesucheffortiscurrentlyunderwaywiththesupportofCDC.TheHealthyAgingResearchNetwork,withinitslargerPreventionResearchCentersProgram(PRC-HAN),conductspreventionresearchonavarietyofhealthissuesinvolvingolderadults.WithinthePRC-HAN,membersarecollaboratingonaseriesoffocusgroupsdesignedtoidentifyhowdiversegroupsofolderadultsunderstandcognitivehealthandwhatapproachestohealthpromotionanddiseasepreventionrelatedtobrainhealththepublicmayfindmostappealing.Thisprojecthasrecentlybeenexpandedtoexaminetheperceptionsofcaregiversandhealthcareproviders.Itwillprovideimportantdatathatcanbeaddedtowhatisalreadyknownaboutcognitiveorbrainhealth,identifygapsinknowledgeaboutcognitivehealthandrelatedriskfactors,anddeterminewhethersuchbeliefsvaryacrossgeographicaldistancesandbetweendiversepopulations.Finally,thisworkisdesignedtoleadtothedevelopmentandtestingofashortsetofquestionsthatcanbeusedtoassessthepublic’sandpossiblyproviders’perceptionsaboutcognitivehealthforinclusioninongoingnationalattitudinalsurveys.

Centers for Disease Control and Prevention and the Alzheimer’s Association|��

Conducting Community Education Programs

TheAlzheimer’sAssociationhasrecentlylauncheda5-yearcommunity-baseddemonstrationprojecttopromoteabrain-healthylifestyle.ThecommunityinterventionisdesignedtoaffectknowledgeandattitudesamongAfricanAmericanbabyboomersrelatedtophysicalactivityandvascularriskfactors,anditwillbeoverlaidwithothergeneralhealthbehaviorssuchasdiet,socialactivity,andmentalactivity.Duringthefirstphaseofthisproject,theAlzheimer’sAssociationisleadingacomprehensiveinterventionplanninganddevelopmenteffort,includingformativeresearchtoassesscurrentneedsandobstaclesforthetargetpopulation,elicitingcommunityinputandparticipation,andcreatingacomprehensive,multilevelcommunityinterventionwithrobustevaluationmechanismstomeasuretheeffectivenessofthepublichealthprograminitsnextphase.

Developing Common Measures of Cognitive Decline for Surveillance and Research

TheNationalInstitutesofHealthisleadinganinitiativetodevelopunifiedandintegratedmethodsandmeasuresofcognitive,emotional,motor,andsensoryhealthforuseinlargecohortstudiesandclinicaltrials.Researchershaveexpressedtheneedforbriefassessmenttoolsthatcouldbeusedasaformof“commoncurrency”acrossdiversestudydesignsandpopulations.Thisinitiativewilltakeadvantageofstate-of-the-artpsychometricresearchandnoveltestingmethodstodevelopaninnovativeapproachtoneurologicalandbehavioralhealthmeasurement.Ultimately,itishopedthatthisapproachwillrespondtotheneedsofresearchersinavarietyofsettings,withparticularemphasisonmeasuringoutcomesinlargelongitudinalandepidemiologicstudiesandpreventionorinterventiontrialsacrossthelifespan.Withanavailabletoolboxofmeasures,yieldsfromlargeandveryexpensivestudiescanbemaximizedbyallowingamuchlargernumberofimportantresearchquestionsregardingneurologicalandbehavioralhealthtobestudied.Byensuringthattheassessmentmethodsarecapableofcomparisontoexistingandcompletedstudiesandcanincorporatefuturemodifications,atruly“economic”andvaluablenationalresourcefortheentireneurosciencecommunitywillresult.

��|TheHealthyBrainInitiative: ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth

Why is it important—and why now?

TheNational Public Health Road Map to Maintaining Cognitive Healthcomesatacriticaltime,giventhedramaticagingoftheU.S.population,thegrowingscientificinterestintheroleoflifestylestrategiesinmaintainingcognitivefunction,andincreasingawarenessofthesignificanthealth,social,andeconomicburdensassociatedwithcognitivedecline.

An aging population Ageisariskfactorforcognitivedecline.In2004,oneineveryeightAmericans—36.3million—wereaged65yearsorolder.By2030,thisnumberisexpectedtonearlydoubleto71.5million.Atthattime,20%ofthepopulationwillbeinthisagegroup.7

Growing fear and concern about memory loss ThereisconsiderableconcernamongAmericansaboutthelossofcognitivehealthtodiseaseordisability,8aconcernthatseemstoincreasewithage.Mostolderadultslookforwardtohavingalonglife,andyettheirgreatestworriesaboutlivingtoage75revolvearoundmemoryloss.9Accordingtoarecentsurvey,adultsaremorethantwiceaslikelytofearlosingtheirmentalcapacity(62%)astheirphysicalability(29%).10

Increasing burden from cognitive decline IntheUnitedStates,thesocietalburdenofcognitiveimpairmenthasbeenexpressedmainlyintermsofprevalence,incidence,andmortalityfordementiagenerallyorforAlzheimer’sdiseaseinparticular.Morerecently,prevalencestatisticsfor“mildcognitiveimpairment”or“cognitiveimpairmentnodementia”havealsoappeared.Cognitiveimpairmentnodementiareferstoalevelofcognitiveimpairmentthatismoreseriousthanage-relatedcognitiveimpairment,butitisnotassevereasAlzheimer’sdiseaseorotherformsofdementia.

• Alzheimer’sdiseasehasbeeninthetoptenleadingcausesofdeathsincethe20thcentury.11Notably,themortalityratesforAlzheimer’sdiseaseareontherise—incontrasttotheratesforheartdiseaseandcancer,whicharecontinuingtodecline.12

• Anestimated4.5millionAmericanshaveAlzheimer’sdisease.Thatnumberhasdoubledsince1980,andisexpectedtobeashighas16millionby2050.13

Background


• StudiesfromtheUnitedStatesandCanadahavesuggestedthatmildcognitiveimpairmentorcognitiveimpairmentnodementiamaybeaproblemfor16-25%oftheelderlypopulation(65andolder).14,15,16

• In2005,MedicareandMedicaidspent$91billionand$21billion,respectively,forpersonswithAlzheimer’sdisease.17Accordingtoa2004reportthatanalyzedMedicareclaimsdata,olderbeneficiarieswithdementiacostMedicarethreetimesmorethanotherolderbeneficiaries.18Basedoncurrentestimates,thesecostswilldoubleevery10years.19

Caregiver burden Maintainingcognitivehealthcanmeanthedifferencebetweenlivingindependentlyorfacingtheneedforfamilyorinstitutionalcare.Theburdenofcognitivedeclineoncaregiversisenormous.ThenumberofcaregiversintheUnitedStatesin2003wasestimatedtobe44.4million20andthisnumberisexpectedtorisedramaticallywiththeagingof

“Thenewsciencehasshiftedthefocustotheideathatthereisvalueinapublichealthstrategyofgettingpeopletothinkabouttheirbrainandhowtheymightaltertheirbehaviortokeeptheirbrainhealthy.”StephenMcConnell,PhDAlzheimer’s Association


thepopulation.Thecostsofunpaid,informalcareprovidedbyfamilieshavebeenshowntoaccountforalargeproportionofthecostsoftreatingdementiaandtheyincreasesharplyasthepatient’scognitiveimpairmentworsens.21Therearealsophysicalandmentalcostsassociatedwithcaregiving;inonestudy,nearly43%ofthefamilymembersprovidingcaretorelativeswithdementiahadclinicallysignificantlevelsofdepressionduringthelastfewmonthsofthepatient’slife.22Numerousfactorsmakeprovidingcareforpersonswithseveredementiaemotionallyandphysicallychallenging;abetterunderstandingofthesefactorswillaidinthedesignofstrategiesthatsupportthehealthandwell-beingofcaregivers.

Underlying lack of information about what is known about brain health Manyadultsappeartobelievethatagingisatimeofirreversiblementaldecline,andthatdementiaisuniversalandinevitable.Thesemythspersistseventhoughrecentresearchhasshownthatinthehealthyagingbrain,newsynapsescontinuetoformandnervecellscanregenerate.23

Yet,thereareemergingsignsthatAmericanslooktothefuturewithhope.Basedonseveralsurveys,menandwomeninthiscountryarewillingtotakeimportantstepstoimprovetheircognitivehealth.

• Nearly9of10peoplereportedthattheythoughtitispossibletoimprovecognitivefitness.24

• Sixof10statedthattheyfelttheyshouldhavetheircognitivehealthcheckedroutinely,muchlikearegularphysicalcheckup.25

• Morethan8of10(84%)reportedthattheytooksometimenearlyeverydaytoengageinactivitiesthatmaybeassociatedwithimprovedcognitivehealth:engaginginartorcreativeprojects,reading,keepingphysicallyactive,playinggamesordoingpuzzles,working,orspendingtimewithfamilyandfriends.26

• OverhalfanticipatedamajormedicalbreakthroughindiscoveringacureforAlzheimer’sdiseasewithinthenext20years.27

Background



Giventhetremendousburdensdescribed,theirimpact,andthedevelopingscience,publichealthshouldstepforwardtoaddresscognitivehealth.Thepotentialcontributiontoqualityoflife,thepositiveimpactoncaregivers,andtheanticipatedsavingsinthecostsofhealthcareandotherserviceswouldbeconsiderable.28,29,30,31



State of KnowledgeWhat do we know?

InMay2006,CDCandtheAlzheimer’sAssociationinvitednationalexpertstoreviewresearchonpublichealthpreventionrelatedtocognitivehealth,andtoidentifyspecificrecommendationsforaddressingriskfactorsthatpromoteandprotectcognitivehealth.Duringthismeeting,participantsexaminedthecurrentstateofscienceconcerningmajorrisk

factors,including:a)riskfactorsforvasculardiseaseandb)physicalinactivity,andtheylookedatcurrentmodelsformovingscienceintopublichealthpractice.Participantsfocusedonthesefactorsbecauseoftheirassociationwithcognitiveoutcomes.32Theyconcludedthatresearchsuggeststhefollowingfactorsmaybeassociatedwiththemaintenanceofcognitivehealth:1)preventingorcontrollinghighblood

IVdevelopment

process

Vactions by

cluster

VInext steps

IIIstrategic

framework

IIstate of

knowledge

Ibackground


pressure,cholesterol,diabetes,overweight,andobesity;2)preventingorstoppingsmoking;and3)beingphysicallyactive.33

Severalspecificobservationswerenotedbymeetingparticipantsregardingtheassociationsbetweenvascularriskfactorsandphysicalinactivityandcognition.

• Evidenceexiststoindicatethatcumulativerisksforvasculardiseaseincreasetheriskforstrokeandcognitivedecline.

• Sufficientevidencealsoexiststosupporttheassociationbetweenvascularhealthandcognitivehealth,althoughclinicaltrialsarenecessarytoestablishtheeffectivenessofinterventionstargetedtovascularriskfactors.

• Itisimportanttoemphasizethatcontrollingvascularriskfactorsisassociatedwithreductioninanindividual’sriskofcognitiveproblems,butcurrentsciencedoesnotsupporttherelationshipbetweencontrollingvascularriskfactorsandimprovedcognitivefunction.

• Growingevidenceexiststhatphysicalactivitymaymaintainorimprovesomeaspectsofcognitivefunctionintheshortterm,butfurtherresearchisneededbothtodeterminelong

termoutcomesandthenatureofrecommendations(e.g.,theamountofphysicalactivity).

• Strongevidenceexiststosupporttherelationshipbetweenphysicalactivityandemotionalwell-being.

WhilenotaspecificfocusoftheMayresearchmeeting,additionalfactorsthatmaybeassociatedwithmaintainingcognitivefunctionincludesocialengagement,a“heart-healthy”diet,andemotionalsupports.Inaddition,higherhouseholdandcommunitysocioeconomiclevelsinearlylifeareassociatedwithhigherlevelsofcognitioninlatelifebutnotwiththeriskofAlzheimer’sdiseaseorrateofcognitivedecline.34

What gaps exist?

Eachnewdiscoveryinmaintainingcognitivehealthraisesahostofimportantquestions.Someofthemorepressingissuesarethefollowing:

• Howdowepromotetheimportanceofcognitivehealthissuestokeyconstituenciesandstakeholders?

• Whatarethepublic’sperspectivesonlifestylebehaviors,choices,andattitudesconcerningcognitivehealthandtheburdenofcognitivedecline?Whatdoweviewasthebenefits

StateofKnowledge


andbarriersofmodifyingpersonallifestyletoreducetherisksassociatedwithcognitivedecline?

• Whatistheroleofpopulation-basedsurveillanceandtheappropriatesurveillancesystemstoassesscognitivedecline?

• Whatclinicaltrialsandotherresearchareneededtodeterminethelong-termoutcomesoflifestyleinterventionsonparticularcognitivefunctions?

• Howdowelinkscientificallyvalidmessagesaboutriskofcognitivedeclinetocurrentpublichealthmessagesforeffortsinprimaryprevention?

• Whataretheeffectsofmodifyingmultipleriskfactorsonminimizingcognitivedeclineorimprovingcognitivefunction?

How can public health contribute?

Publichealthwasfirstdefinedin1926,as“thescienceandartofpreventingdisease,prolonginglifeandpromotinghealthandefficiencythroughorganizedcommunityeffort.”35Thatdefinitionhasremainedintactforover80years,witharecentreiterationofpublichealth’smissionas“assuringconditionsinwhichpeoplecanbehealthy.”36

Organizedpublichealtheffortsoverthepast100yearshaveyieldedremarkableachievements.Tenconsideredtobeamongthegreatest37areintheareasof:

• Vaccination• Motor-vehiclesafety• Saferworkplaces• Controlofinfectiousdiseases• Declineindeathsfromcoronaryheartdisease andstroke

“Allthethingsthatweknowarebadforyourheartturnouttobebadforyourbrain.”MarilynS.Albert,PhDJohns Hopkins Medical Institutions


�0|TheHealthyBrainInitiative: ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth

• Saferandhealthierfoods• Healthiermothersandbabies• Familyplanning• Fluoridationofdrinkingwater• Recognitionoftobaccouseasahealthhazard

Theseachievementswerepossiblebecauseofcombined,coordinatedeffortstoapplythreecorepublichealthfunctions:assessment,policydevelopment,andassurance.

Assessmentcallsforregularlyandsystematicallycollecting,analyzing,andsharinginformationonthehealthofacommunity.Suchinformationhelpstodescribeandunderstandacommunity’shealthstatusandneeds.Assessmentactivitiesmightinvolveinvestigatingadversehealtheffectsandhealthhazardstoidentifythemagnitudeofahealthproblem,itslocation,trendsovertime,andpopulationsatrisk.Theymayalso“digdeeper”toanalyzedeterminantsofidentifiedhealthproblemssoastoilluminateetiologicandcontributingfactorsthatplacecertainpopulationgroupsatriskforadversehealthoutcomes.

Policy developmententailspromotionofpublichealthpoliciesthataregroundedinscience-baseddecisionmaking.Bytakingtheleadinpolicydevelopment,publichealthserves

asanadvocate,buildsconstituencies,andidentifiesresourcesinacommunityasitgeneratessupportiveandcollaborativerelationshipswithpublicandprivateagencies.Anothercriticalpolicyactivityinvolveshelpingcommunitiessetprioritiesamonghealthneedsbasedonthesizeandseriousnessofthehealthproblemsandtheacceptability,economicfeasibility,andeffectivenessofinterventions;thecommunitycanthendevelopplansandpoliciestoaddressthosepriorities.

Assuranceistheguaranteethatservicesneededtoachieveagreed-upongoalsareactuallyprovided.Itispursuedbyencouragingtheactionsofothers(publicorprivate),requiringactionthroughregulation,orbyprovidingservicesdirectly.Thisthirdcorepublichealthfunctionencompassesmanagingresourcesanddevelopingorganizationalstructures;implementingprogramsforpriorityhealthneeds;andevaluatingandprovidingqualityassurancetoensurethatprogramsareconsistentwithplansandpolicies—orthatneededcorrectiveactionsaretakenpromptly.Inaddition,assuranceactivitieshelptoinformandeducatethepubliconhealthissuesofconcern;promoteawarenessofpublichealthservices;andpromotehealtheducationinitiativesthatcontributetoindividualorcollectivechangesinhealthknowledge,attitudes,andpracticesthatmakeforahealthiercommunity.

StateofKnowledge


Theapplicationofthesepublichealthfunctionstocognitivehealthoffershopeofsimilarachievementsasscientificknowledgeadvances.Theareaofcognitivehealthisgainingincreasingattentionfrommultipleperspectivesandrepresentsablossomingarenaforresearchandaction.Byembracingcognitivehealthasapriorityissue,thepublichealthcommunitywouldbemobilizedtostudy,identifyandimplementeffectiveinterventionsthatpreservethiskeycomponentofhealth.Ourchallengeistoofferasystematicapproachthatwillassureacoordinatedandunifiednationaleffort.TheRoadMapmeetsthatchallengebylayingoutasharedvisionfora“workinprogress,”onethatbuildsonthefoundationoftheworkdonetodate,establishesaframeworkwithinwhichtoviewthefindingsofthatwork,linksrelatedandcomplementaryactivities,andshapestheworkofthefuture.

“Ifyoucouldgivepeopleinformationandtoolsthatwoulddelaytheonsetofcognitiveimpairmentbyafewyears,youwouldbedoingmuchtoimproveindividuals’qualityoflifeaswellasimprovingsociety.”DebraCherry,PhDAlzheimer’s Association



Strategic FrameworkWhat is our model for action?

TodeveloptheRoadMap,weuseda“synergistic”model(Figure1)formovingscienceintopublichealthpractice.38Themodelstartswiththeassumptionthatwemustfirstunderstandtheexisting science and knowledge baseforpreservingandprotectingcognitivehealth,determinefindingsreadyto

bemovedintothepublichealtharena,andthenconductresearchtofillimportantgapsinknowledge.

Atthesametime,wemustanalyzesocial and environmental forcesthatcreatedemandandinfluencetheacceptanceofnewknowledge.Thepushofscienceandthepullofthemarketcombinetoshapethecapacity—thecomplementofhumanandfinancialresources—wemusthaveinplacetoimprove

IVdevelopment

process

Vactions by

cluster

VInext steps

IIIstrategic

framework

IIstate of

knowledge

Ibackground


Figure 139 The Model: Moving Science into Public Health Practice

StrategicFramework

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


“Thepossibilityofpreventioninthisareaissonewandsoexcitingforfamilies,individuals,andgovernment.”JamesLaditka,DA,PhD,MPAUniversity of South Carolina publichealthpractice.Strengtheningandbuildingcapacity

focusesonidentifyingkeypublichealthentities,determiningthenecessarycompetenciesandresources,andexpandingpartnershipstomountandsustainnecessaryactions.Deployingthiscapacityeffectivelywillleadtodesiredintermediate and long-range outcomes.

What principles do we embrace?

Severalkeyprinciplesunderlieourapproachtomaintainingcognitivehealth.

A firm grounding in science. Epidemiologicstudiesfollowedbythetestingofinterventionsinclinicaltrialswithcomponentsthatincludecognitiveassessmentwillshowwhichlifestylefactorsbestmaintaincognitivehealthforthepopulation.Throughpopulation-basedsurveillance,epidemiologyandpreventionresearch,publichealthcancontributetoourunderstandingofcognitivehealthandcanidentifypromisinginterventionsthatmaybeeffectiveinpromotingorprotectingit.TheRoadMaprecognizesthatthisprocessisevolutionary,anditseekstobuilduponwhatwecurrentlyknowbyincorporatingnewdiscoveriesastheyemerge.

An emphasis on primary prevention.Publichealthfocusesonreducingthefactorsthatputpeopleatriskofcognitivedecline,whileincreasingthefactorsthatpromoteandprotectcognitivehealth.Thus,theRoadMapfocusesoninterventionsinhealthpromotionandriskreductionthatpreservecognitiveperformance—ratherthanpreventdementia.Itrecognizesthepotential“synergistic”approachbyintegratingtheseinterventionswithotherlifestylemessagesandshowinghowtheymightfitwithpharmacologicinterventions.

A community and population approach. Publichealthtakesabroadviewandseekstoachievelastingchangeinthehealthofentirepopulations,extendingfarbeyondthemedicaltreatmentofindividualpeople.Thus,theRoadMap’srecommendationsareexpansiveinscope,anddonotsingleoutanyparticularpeopleorgroupsforspecialattention.



A commitment to eliminating disparities. Racialandethnicdisparitiesinhealthandhealthcarearewelldocumented.TheeliminationofsuchdisparitiesisacriticalcomponentofthenationalpublichealthagendaandakeyprincipleofthisRoadMapaswell.40ThenumbersandproportionofolderadultsfromdiverseracialandethnicoriginsintheUnitedStatesareincreasing.In2003,nonwhiteethnicandracialgroupsrepresented17%ofthepopulationage65andolder,withthatproportionprojectedtoincreaseto28%by2030and39%by2050.41Weembracethisdiversityandrecognizeitsvalueinshapingpolicyinitiatives,communicationstrategiesandlifestyleinterventions,andpopulation-basedsurveillancerelatedtocognitivehealth.

What do we hope to accomplish?

Weenvisionanationinwhichthepublicembracescognitivehealthasapriorityandinvestsinrelatedhealthpromotionandresearch.Toachievethisvision,wehaveadoptedalong-termgoalandavarietyofoutcomesasmoreimmediategoals.

Our long-term goal is to maintain or improve the cognitive performance of all adults.

Fourteenintermediateoutcomesencompasstheareasofcommunication,surveillance,research,policyandpublichealthcapacity.Theseareto:

• Increaseawarenessabouttheimportanceofpromotingandprotectingcognitionamongthegeneralpublic,publichealthandagingprofessionals,andpolicymakers.

• Increaseknowledgeabouttheriskandprotectivefactorsassociatedwithcognitionamongthegeneralpublicandpublichealthandagingprofessionals.

• Decreasemisconceptionsandmythsaboutcognitivehealthamongthegeneralpublic.

• Determinecriticalpublichealthmeasuresformonitoringcognitivefunctionatthepopulationlevel.

• Incorporateappropriatecognitivemeasuresintopublichealthsurveillancesystems.

• Identifytheresearchgapsonmodifiableriskfactorsandcognition.

• Securesustainedsupportforpublichealthresearchtopromoteandprotectcognitivehealth.

StrategicFramework


“Ifwemaintaincognitivefunctionovertime,thenwearemorelikelytobefunctionallyindependent.”MarilynAlbert,PhDJohns Hopkins Medical Institutions

• Disseminatetheresultsofcriticalpublichealthresearchfindingsaboutcognitivehealth.

• Identifykeypublicandprivatepoliciestoaddresscognitivehealth.

• Modifykeypublicandprivatepoliciestoaddresscognitivehealth.

• Identifysuccessfulpublichealthbestpracticesonvascularhealthanddiabetes.

• Increasecognitivehealthinterventionsthatarecomplementarytovascularhealthanddiabetespublichealthstrategies.

• Securesustainedsupportforpublichealthstrategiestopromoteandprotectcognitivehealth.

• Enhancethecapacityofagingandpublichealthservicenetworkstoimplementeffectiveinterventionstopromoteandprotectcognitivehealth.



Development ProcessPhase I — Workgroup deliberations

Fourworkgroupsofinvitedexpertsworkeddiligentlyandcollaborativelyovera7-monthperiodtoidentifyrecommen-dationsinfourareasofpublichealthaction:PreventionResearch,Surveillance,PolicyandCommunication.Thechargetoeachworkgroupwastodefineitsareaoffocus,identifyimportantprinciples,andrecommendactionsfor

movingthenationforwardoverthenext3-5yearstowardthelong-termgoalofmaintainingandimprovingthecognitivefunctionofadults.Thedefinitionsandprinciplesthatemergedarepresentedbelow.

Prevention Research Research in public health prevention isdefinedhereasresearchthatappliesandtestspopulation-basedinterventionsthathave

IVdevelopment

process

Vactions by

cluster

VInext steps

IIIstrategic

framework

IIstate of

knowledge

Ibackground


thepotentialtomaintaincognitivehealth.Recommenda-tionsforcognitivehealthfocusprimarilyontwoareas—vascularriskfactorsandphysicalactivity—withemphasisontheneedforpracticalclinicaltrialstoshowthebenefitsofvascularhealthinterventionsandphysicalactivityonmaintenanceoflong-termcognitivehealth.Theseareaswerechosenbecausetheyarethefirsttoemergefrompopulation-basedstudiesandanimalresearchaspromisingareasforintervention.Whiletheepidemiologicevidencesupportingthebenefitsofvascularhealthforcognitivefunctionismoredefinitivethanthelinkregardingphysicalactivity,bothareasareworthyofattention.Inaddition,recentfindingsfromclinicaltrialshaveheightenedinterestinthevalueofmentalactivitiesbyshowingapositiveeffectfromcognitivetrainingoncertaincognitivedomains.

Researchonpreventionshouldnotbelimitedtotheseareas,however.Otherareas(suchasnutritionandsocialengagement)shouldalsoberecognizedasimportanttoaddressinthefuture.Totheextentpossible,researchshouldbemultidisciplinaryandbuildonafirmunderstandingofhowthepublic,healthcareprofessionals,andavarietyofotherpartnersdefine,perceive,andvaluecognitivehealth.Inaddition,researchmethodologiesshouldconsiderhowtoconvertresultsfrom

randomizedcontroltrialstocommunitysettings;howtomakeclinicalorevidence-basedworkpractical;andhowtotranslateresearchintopublichealthpractice.

SurveillanceSurveillanceisdefinedas“theongoing,systematiccollection,analysis,interpretation,anddisseminationofhealth-relateddata.”42,43,44Theongoingnatureofpublichealthsurveillance,itsapplicationtobroadpopulations,andlimitationsinresourcesoftenrestrictthenatureanddepthofinformationthatcanbegatheredthroughtraditionalsurveillancemethodsusedinresearch.Thesemethodsrangefromcreatingnewsurveillancesystemstousingorenhancingexistingsystems—andsurveillanceofcognitivefunctionisnoexception.Selectingappropriatesurveillancemethodsforcognitivedeclinepresentssomeuniquechallenges,however,suchasdefiningcriteriaforacognitivemoduleandmeasuringavarietyofdimensions(e.g.,riskfactors,attitudes,andburdenofcaregivers).Inaddition,becausemeasurementsmayvaryaccordingtoeducation,language,culture,andraceorethnicity,specialcaremustbetakentoensurethatdataarenotmisinterpretedormisused.

DevelopmentProcess


Methodsavailableforthesurveillanceofcognitivedeclineinolderpopulationsthatdonotrelyonself-reportingfaceparticularconstraints.

Cognitivedeclineinindividualpeopleisdirectlyidentifiedthroughrepeatedmeasurementsconductedoveraperiodoftime.Toimplementthismethodofcaseascertainmentinasurveillancesystemrequireslong-termfollow-upofpopulation-basedcohortswithopen(continuousorsuccessive)enrollments.Suchsystemsarenotoftenusedforchronicdiseasesurveillance,astheyareexpensiveandrequireanextensivetimecommitmentfromparticipants.

Repeatedcross-sectionalpopulationsurveysaremorecommonlyemployedinsurveillance,particularlyforsomechronicdiseasesandforsomeriskfactorsfordisease.Unfortunately,therearenocurrentlyestablishedmethodsthatdefinitivelyascertaincasesofcognitivedeclinethroughcross-sectionalinterviewsalone.Self-reporteddataareinaccurateinthisarea,andtheusefulness,availability,andvalidityofproxy-reporteddataareuncertain.Despitetheselimitations,suchsurveyshavevalueinmeasuringtheprevalenceofriskfactorsforcognitivedecline.Theymayalsohavepotentialtomeasuresomeparametersofcognitive



functions.Itispossiblethatchangesovertimeinthepopulationdistributionofsuchparametersmaysuggestchangesintheprevalenceofcognitivedecline,althoughsuchinferencescanonlybemadewithcautionevenaftercontrollingforconfounderssuchaseducation,culture,andsocioeconomicstatus.

Othermethodsofscreeningoridentifyingconditionsassociatedwithcognitivedecline(e.g.,geneticscreening,biomarkers,andneuroimagingtests)donotyetappearpractical,althoughsomemayeventuallyproveusefulifthecostsarereasonable.

Recommendationsforsurveillancemustbeofferedwiththesemethodologicalconstraintsinmind,recognizingthetensionbetweenidealmethods,forwhichresourcesmaybedifficulttoobtain,andmorelimitedmethods,forwhichresourcesaremorelikelyavailable.

Policy RealizationoftheRoadMap’svisionrequiresapolicybaseinboththepublicandprivatesectorsthatsupportsandpromotescognitivehealth.Thepublic sectorencompassespolicymakersatfederal,stateandlocallevels.Theprivate sectorincludesbothnot-for-profitandcommercialorganization

policies,suchascoverageofpreventionbyinsurers,humanresourcedepartmentpolicies,employeeassistanceprograms,andotherworkplacepoliciesandpractices.Policychangesinthepublicsectorcaninfluencepoliciesandbehaviorsintheprivatesector;conversely,privatesectorpolicychangecaninfluencepublicpolicy.

Toeffectpolicychange,thepublichealthcaseforaddressingcognitivehealth—thefactthatobservationalevidenceandlimitedshort-termclinicaltrialsnowexisttosupportsomepreventionopportunitiesinthisarea—mustbemadeinaneasilyunderstandableandconsistentmanner.National,stateandlocalorganizations,agenciesandpolicymakersmustbeeducatedaboutcognitivehealthandsubsequentlyengagedtohelppromotepositivepolicydevelopmentandchangethatwillincreaseknowledgeandleadtobettercognitivehealth.

Moreover,policyrelatedtomaintainingcognitivehealthdoesnotjustaddresscare,behaviors,orriskfactorsbutalsopromotesresourcesforbuildingandmaintainingcommunityinfrastructurethatreinforcesindividualbehavior.Thiscouldincludebikeorwalkingtrailstoencouragephysicalactivity,community-wideorganizationsandstructuresthatsupporthealthybehavior,andotherchangestothebuiltandcultural

DevelopmentProcess


environmentsthatadvancethepublichealthgoalofcognitivehealth.Policyinitiativesmustbuildupon,relateto,andbecompatiblewithcommunicationsandresearcheffortsastheytakeshapeandyieldnewinformation.

Communication Thetermcommunication strategyimpliesamultidisciplinaryhealthmarketingapproachthatincludescommunicatinganddisseminatingscientificallyvalidinformationandstrategicinterventionsthroughcustomer-centeredandculturallyappropriatemeans.Acommunicationsstrategyforcognitivehealthaimstoeducate,motivate,andeffectpositivebehaviorchangerelatedtocognitivehealthintargetedandat-riskaudienceswithin3years.

Toeffectivelyreachthisgoal,communicationmessagesandmethodsshould:

• Besciencebased.

• Begearedtopopulationsexperiencingthegreatestdisparitiesandrisksincognitivehealth.

• Reachtheintendedaudienceandpromoteaction.

• Assisttheconsumerinmakingmoreinformeddecisions.

Theaudienceofadultsaged42-60years,alsoknownasbabyboomers,belongstothebiggestgenerationinAmericanhistory.Cognitivehealthissuesprofoundlyaffecttheirparentsnow,andtheywilltouchtheboomersinhugenumbersastheygrowolder.Itisimportanttogetappropriatevalid,evidence-basedmessagestothem,sotheymaytakeactionforthemselvesaswellaspotentiallyinfluencetheirfamilies.Specialfocusshouldbegiventohighriskpopulations,vulnerablepopulationsandhealthcareproviders.Specificracialorethnicgroups(e.g.,AfricanAmericans,Latinos)mayneedtohavetargetedandculturallyappropriatematerialsandtoolsdevelopedbecausetheymaybeatgreaterriskfor

“Developingaroadmapforcognitivehealthprovidesuswithanopportunitytoreducehealthdisparities.Somepopulationsareathighriskforcognitiveimpairmentduetohighratesofhypertensionordiabetes.TheRoadMapgivesusachancetoprovidebetterhealthinformationforallAmericans,includingthoseathighestrisk,sothatpeoplemayimprovetheirmotivationtochangetheirlifestyleforbetterhealthoutcomes.”DebraCherry,PhDAlzheimer’s Association



experiencingcognitivedeclineduetohigherrisksofvasculardisease,hypertensionanddiabetes.Healthcareprovidersmayhaveneedsandgapsinknowledgethatdifferfromthegeneralpublicbecausetheyareprovidinginformationaboutcognitivehealthtoothers.Aninitialfocusonthesegroupswouldnarrowthescopeofeffort,affordingmoreachievableoutcomes.

Inaddition,beforereachingouttoconsumers,accurateinformationandoptionsshouldbeinplacethroughoutthebroadermedicalandsocialserviceenvironment.Healthcareprofessionalsarethemainsourceofinformationformanyconsumers,andpastexperiencehasproventhebenefitsoftargetingprofessionalorganizationsfirstaspeerinfluencersandtrainersofthesefrontlineproviders.

Phase 2 — Concept-mapping process

Theworkgroupscollectivelyproposed42recommendations:18inpreventionresearch,8incommunications,9inpolicy,and7insurveillance.Aconcept-mappingprocesswasthenusedtoorganizeandvisuallyrepresentthem.Concept-mappingcombinesqualitativeandquantitativemethodstogeneratemapsthatprovideavisualrepresentationofthecomplexrelationshipsamongideasandresults.45Itcanelicitideasfrom

large,diverse,andgeographicallydispersedgroupsaboutaparticulartopicwithinashorttimeframe.Unlikeotherqualitativemethods,conceptmappingalsoprovidesastructuredapproachthatallowskeydecisionmakerstoparticipateinthefinalinterpretationofalargergroup’sperceptions.

Forthisproject,concept-mappingwasorganizedintothreesteps.

Step 1involvedreviewingandrestructuringrecommendationsfromtheworkgroupstoensurethateachrecommendationrepresentedadistinctidea,andidentifyingthelistofstakeholderswhowouldbeinvitedtoparticipate.Thislistincludedmorethan150personsfromabroadarrayofinstitutions,includingstateandfederalagencies,universities,andfoundations.

Step 2consistedofonlineratingandsortingbyinvitedparticipantsandsubsequentanalysesoftheresults.46Fortheratingprocess,140(ofthe150)participantswereaskedtorateboththerelativeimportanceofeachrecommendationanditscurrentactionpotential.Forthesortingtask,20ofthese140participantswerealsoaskedtocategorizetherecommendationsaccordingtotheirviewofsimilarmeaningsorthemes.Ten(ofthe150)participantswereinvitedto

DevelopmentProcess


participateinthesortingtaskonly.Becausetheratingandsortingprocesswasanonymous,exactfiguresonparticipationarenotavailable;however,basedonthenumberoftotalresponses,69persons(outof140,or49.3%)providedinputintoratingtheimportanceandactionpotentialofeachrecommendation.Additionally,23persons(outof30,or76.7%)organizedtherecommendationsintocategoriestoidentifythemesorpatterns.Multivariatestatisticaltechniqueswereusedtoorganizeandvisuallypresentresultsoftheonlineprocessinaseriesofconceptmapsthatreflectedrelationshipsbetweenrecommendationsandtheclusteringofrecommendationsintocategories.

Step 3 encompassedthereviewandinterpretationoftheresultsofPhase2,andselectionofpriorityrecommenda-tions.MembersoftheSteeringCommitteereviewedthemapstoensurethattherecommendationsineachoftheeightclusterswereconsistentwiththeoverallthemeofthatcluster.

TheCommitteereconstructedafewrecommendationscreatingtwoadditionalrecommendations(foratotalof44recommendations)andintwoinstancesmovedrecom-mendationstoadifferentcluster.Thefinalclusterlabelsare:

• Disseminatinginformation• Translatingknowledge• Conductingsurveillance• Implementingpolicy• Measuringcognitiveimpairmentandburden• Movingresearchintopractice• Conductinginterventionresearch• Developingcapacity

Asafinalstep,theSteeringCommitteechoseasetofpriorityrecommendationsoractions.

“Iamveryimpressedwiththeprocessbecausethisisafieldinwhichpeoplehavestrongopinionsonmanydifferentissues.Whatimpressedmewasthattheparticipantsinthereviewprocesswereopentohearingabroadrangeofopinionsbutintheendoptedforscientificrigorastheguidingfeatureonwhichrecommendationswerebased.”PeterRabins,MD,MPHCoauthor, The 36 Hour Day



Actions by ClusterTheRoadMapisa“living”documentexpectedtoevolveovertime.Someactionsareachievablewithin1to3years,whileotherswillrequiremoretimetocometofruition.Somearelinkedandneedtooccurinacertainsequence,withtheoutcomesofthefirstsettingthestageforinitiatingthenext.And,whilenoparticularagegroupissingledoutforspecialattention,theRoadMapconcentratesprimarilyon

interventionsformiddle-agedandolderadults.Thisfocusrecognizesthatinterventionstoreducerisksarebestbegunearlyinlife;yet,adults,particularlyolderadults,aremorelikelytobeconcernedandmotivatedtotakeaction.

ThefullsetofRoadMapactionsfallintoeightclusters.Withineachcluster,theactionsarelistedinnospecialorderofpriority.Theletterinparenthesesaftereachactionrefers

IVdevelopment

process

Vactions by

cluster

VInext steps

IIIstrategic

framework

IIstate of

knowledge

Ibackground


tothegroup(eitherworkgrouporSteeringCommittee)thatoriginallyproposedit(P=PreventionResearch,C=Communication,P=Policy,S=Surveillance,SC=SteeringCommittee).Alloftheactionsgeneratedbythegroupsareincluded.

Inofferingtheseactions,wecannotunderestimatethecomplexitiesoftranslatingthemintoaction.MostessentialisacommitmenttobasethisRoadMaponscientificevidence,movingforwardcollaborativelytoleverageexistingresourcesandactivitiesaspromotionactivitiesbecomedefined.Keypartnershipsmustbeformedamongadiversearrayoforganizationsandagenciestobuildoncollectivestrengths,delivercompatiblemessagesandinterventions,andassureefficientuseofresources.Existinghealthpromotioncommunitiesassociatedwithheartdisease,stroke,diabetes,andphysicalactivityareinvaluableresourcesforpromotingcognitivehealth.

Disseminating information

1. Disseminate the latest science to increase public

understanding of cognitive health and to dispel

common misconceptions. (SC)EvidenceexiststhatthecurrentboomergenerationisconcernedaboutcognitivehealthandfearsAlzheimer’sdisease.Onecriticalareaoffocusshouldbeonhelpingthepublictounderstandthevaryinglevelsofevidencebehindproposedinterventionsregardingcognitivehealth.Unlesscredibleandbroadreachinginformationaboutvalidinterventionsincognitivehealthisdisseminated,consumerswillfillthegapwithuntestedprogramsandproducts.Notonlycantheseprogramsandproductspresentaneconomicburden,butsomemayalsodistracttheagingpopulationfrommeaningfullifestylechanges.Communicationsstrategies(includingtheappropriatecommunicationchannels)shouldbuilduponcurrenteffortsbyvariousorganizationsandagenciestoshareexistinginformationandmaterialsoncognitivehealthresearchandpossibleinterventionsthatareconsistentwithcurrentscience.

ActionsbyCluster


2. 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,informationmustbefilteredthroughtrustedhealthandcommunityresources.Providingprofessionalswithaccurate,evidence-basedinformationandtoolswillrespondtothegrowinginterestamongconsumersregardingquestionsonpreservingcognitivehealth.

3. Develop and implement a training curricula

related to cognitive health for continuing

professional education of health and human

services professionals. (P)Toincreasetheawarenessandknowledgeofprofessionalsinhealthandhumanservices,strategiesshouldbedevelopedinbothpreserviceandin-servicemodalities.Bringingnewprofessionalsintothefieldwithappropriateknowledgeisnotenough;thelevelofunderstandingofpracticingprofessionalsmustalsoberaisedsothattheycanhelpthepublicsortoutevidence-basedapproachestocognitivehealthfromlessprovenorundemonstratedoutcomes.

4. Develop creative and replicable means for raising

the public’s awareness of cognitive health and

engaging the public in promoting the importance

of cognitive health through policy. (P)Thepublicplaysanimportantroleinstimulatingbothpublicsectorandmarketplaceactiononissuesitfindsimportant.Itisessentialthatthepublicbeeducatedbasedoncurrentscienceandknowledgeofbestpractices.Thiswillcontributetothedevelopmentofanewconventionalwisdomregardingcognitivehealth.

5. Establish and maintain a Web-based cognitive

health clearinghouse, in partnership with

stakeholder organizations, that would be

recognized as a centralized site for scientifically

validated and recognized information. (C)Aone-stop-shop,go-toplaceforvalidandtestedinformationwillprovideconsumersandprofessionalswhoserveolderadultsandtheirfamilieswiththetoolstomakeinformeddecisionsabouttheirhealthandeffectpositivebehaviorchange.Thesitewouldprovideguidingprinciplestohelpconsumersandhealthinformationprovidersandprofessionalstoevaluatelocalservicesthataddresstheseconcernsandtomaintaincurrent



understandingaboutcognitivehealthandtheseinterventionsasthesciencebecomesmoresophisticated.

Translating knowledge

1. Determine how diverse audiences think about

cognitive health and its associations with

lifestyle factors. (R)Itisnotclearhowthegeneralpublicorpractitionersperceiveandunderstandcognitivehealth.Todevelopusefulprograms,itwillbeimperativetobetterunderstandthediversetargetaudiences.Someissuesthatwouldbeimportanttounderstandfortranslationtoboththegeneralpublicandpractitionersinclude:howcognitionisdefinedandtranslated;whataspectsofcognitivehealthareimportant(includingthelevelofknowledgeaboutvascularfactors);andhowconcernedthegeneralpublicisaboutcognitivehealth.

2. Help people understand the connection between risk

and protective factors and cognitive health.(C,SC)Riskandprotectivefactorsarekeystofiguringouthowtoaddressindividualandcommunityhealthandrequire

clarifyingforthepublicwhatisdemonstratedaseffectiveinclinicaltrialsversusassociationsobservedinotherstudies.Ofprimaryinterestareaspectsofpersonalandenvironmentalexperiencesthatmakeitmorelikely(riskfactors)orlesslikely(protectivefactors)thatpeoplewillexperiencecognitivedecline.Considerationshouldbegiventotheseconnectionsandtopromotingabetterunderstandingofit,includinganunderstandingofareasinwhichclinicaltrialshave(orhavenotyet)establishedacauseandeffectbetweenriskandprotectivefactorsandcognitivehealth.

3. Develop a mechanism to review cognitive health

messages and programs to determine their

scientific accuracy and public credibility. (C)Currently,thepublichasnosinglesourceofinformedandvalidrecommendationsforprograms,services,andlifestylerelatedinterventionstoaddresspositivemeasuresincognitivehealth.Creatingasystemforreviewingthegrowingnumberofprogramsandprovidingpublicaccesstothereviewsgeneratedwillmoveconsumersclosertoinformeddecisionsandmorepositiveinvestmentsinhealth.

ActionsbyCluster


Implementing policy

1. Initiate policy changes at the federal, state, and local

levels to promote cognitive health by engaging

public officials.(P)Far-reachingpublichealthissuesdemandinformedactionbypublicofficials,becauseactionbytheprivatesectoralonewillbeinsufficienttoreachdesiredresults.Becauseprogramandfundingdecisionsaremadebypolicymakersatthenational,stateandlocallevels,itisimportanttoengageandeducatethisaudience.Publicofficialshavesignificantcompetinginterests;itisessentialthattheybecomeeducatedandengagedinthisarenatocontributetopositivepolicychangeincognitivehealthinterventionsandtosupporttheneedforfurtherresearch.

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)ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidelyrecognizedapproachtoimprovinghealth.Asresearchdemonstrateswaysinwhichcognitivehealthcanbe



maintained,theareaofcognitivehealthcanbeelevatedtoamajorhealthprioritybybeingincorporatedintotheoutcome-orientedapproachusedbyHealthy People 2020.

3. Include the public health burden of cognitive

impairment in the State of Aging and Health

in America Report when population level data

are available. (P)IncludingcognitivehealthinsuchdocumentsastheState of Aging and Health in America Reportwouldelevateitsstatusasarecognizedpublichealthissueandmakedatareadilyavailableforaction.Armedwithimportantdatafromthisandothermonitoringsystems,publichealthprofessionalswillbepreparedtomovepolicyforwardtotestinterventions.

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.

Theyshouldbebaseduponsuchcriteriaastheabilityto:examineevidence-basedresearch;establishon-goingformsofdialogue;buildleadershipandcapacityrelatedtopolicyandpublicandprofessionaleducation;addressdiverseculturalandethnicpopulations;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,effectivecollaborationsforcognitivehealthandemotionalwell-being,nationalorganizationsandagenciesmustidentifyandagreetocommonground.Nationalorganizationsandagenciesareessentialtobothreachinglargenumbersofindividualmenandwomenandtousingtheirinfluencetoeducatepolicymakersandopinionleaders.Educationofthepublicandleadersofkeyorganizationsisaprecursortopolicychangerelatedtocognitivehealth.

ActionsbyCluster


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)Policiesshouldbeamendedtoreflectcurrentscienceandknowledgeandbeinclusiveofcognitivehealth.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)Nationalandstatepublichealthplanssignificantlyinfluenceeffortsinpublichealthandserveasabarometerofimprovement.Asinterventionsaredemonstratedthatcanhaveaneffectoncognitivehealth,includingitintheseplanswouldelevateitsstatusasarecognizedpublichealthissueandprovideavenuefortheevaluationofprogress.

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) Clearlydefinedgoalsofpublichealthsurveillancewillpromotethedevelopmentofappropriatesurveillancesystemsandthecollectionofconsistentdatathatprovideusefulinformationtoinformpublichealthpolicy.Goalsofthesurveillancesystemmayinclude:definingtheburdenofcognitivedeclineinthepopulation;monitoringthetrendsinburden(e.g.,prevalence,incidence);monitoringtrendsinriskfactors;definingthepopulationatincreasedrisk;anddeterminingwhetheradditionalanalysesshouldbeperformedforthepurposeofpublichealthsurveillance.

2. Determine which existing general population-based

surveillance systems include information useful for

the surveillance of cognitive health at national, state

and local levels. (S)Addingtoorchangingexistingsurveillancesystems(e.g.,BehavioralRiskFactorSurveillanceSystem,HealthandRetirementStudy,NationalHealthInterviewSurvey)to



addressissuesrelatedtocognitivedeclineislesscostlyandmaybemoreefficientthandevelopingnewsurveillancesystems.However,thereareimportantlimitationsofexistingsystemsandthedatatheycollect;inparticular,mostarecrosssectionalratherthanlongitudinal.Manyarealreadyquitelengthy,withmajorconstraintsonaddingnewitems.Closeexaminationofthesesystemswillensurethattheyareamendedappropriatelyandcost-effectively.

3. Identify existing studies that measure longitudinal

trends in cognitive function.(S)Existinglargecohortorotherlongitudinalstudiesofcognitivedeclinemayprovideitemsthatcouldbeincorporatedintosurveillancesystemsformeasuringsuchdecline.Someofthesestudiesmayhavevalidateditemsusedpreviouslyinbothmajorityandminoritypopulationsthatestimatevariabilityandtruechangeovertime.

4. Develop a population-based surveillance system

with longitudinal follow-up that is dedicated to

measuring the public health burden of cognitive

impairment in the United States. (S)Apopulation-basedsurveillancesystemwouldassistinthecollectionofconsistentdatatomonitor,assess,and

informpublichealthprogramsandpolicyaboutthepublichealthburdenofcognitiveimpairment.

Moving research into practice

1. Conduct systematic literature reviews on proposed

risk factors (vascular risk and physical inactivity)

and related interventions for relationships with

cognitive health, harms, gaps and effectiveness. (R) Itiscriticaltoexamineallstudiestodatetodocumentwhichinterventionshavebeenproveneffective.Suchreviewsshouldfocusondeterminingtherelationshipsbetweenriskfactors,protectivefactors,andcognitivefunctionacrossobservationalandclinicaltrials.Whereinterventionsexist,theireffectivenessshouldbedocumentedandremaininggapsinthefieldshouldbeidentifiedinordertomovestrategiesintopublichealthpractice.

2. Conduct systematic literature reviews on proposed

risk factors (social engagement, nutrition,

and mental activity) and related interventions

relationships with cognitive health, harms, gaps

and effectiveness.(R,SC)

ActionsbyCluster


Itiscriticaltoexamineallstudiestodatetodocumentwhichinterventionshavebeenproveneffective.Suchreviewsshouldfocusondeterminingtherelationshipsbetweenriskfactors,protectivefactors,andcognitivefunctionacrossobservationalandclinicaltrials.Whereinterventionsexist,theireffectivenessshouldbedocumentedandremaininggapsinthefieldshouldbeidentifiedinordertomovestrategiesintopublichealthpractice.

3. Conduct a systematic literature review on the

relationship between treatment of diabetes and

cognitive health. (R)Someevidencesuggeststhatdiabetesisariskfactorforcognitivedecline.Recommendationsfortypesofdiabetesmanagement(e.g.,medications,lifestylemodification)thatmightalsobebeneficialforcognitivehealthcannotbemadewithoutareviewoftheliteraturerelatingdiabetesinterventionstocognitivechange(andmostlikelyundertakingadditionalclinicaltrials),andidentificationofareasthatneedtobeclarifiedbeforespecificinterventionscanbeproposed.

4. Conduct a systematic literature review on the

relationship between treatment of hypertension

and cognitive health.(R)Hypertensionisaknownriskfactorforstroke,andthereforeforvasculardementiaandcognitivedecline.Recommendationsfortypesofantihypertensivetherapyandtherangesofbloodpressurefordifferentagegroupsrecommendedformaintainingcognitivehealthcannotbemadewithoutareviewoftheliteraturerelatinghypertensiveinterventionstocognitivechange,andprobablynotwithoutpursuingadditionalclinicaltrials.Thesystematicliteraturereviewwouldidentifyareasthatneedtobeclarifiedbeforespecificinterventionscanberecommended.

5. Identify gaps in knowledge about cognitive health

and related lifestyle changes, and determine



whether these vary by specific groups. (C) Todevelopappropriatematerialsandtools,thegapsin

knowledgeneedtobeunderstood,especiallyamonghigh-riskpopulations,vulnerablepopulations,andhealthcareproviders. Specificracialorethnicgroupsmayneedtohavetargetedandculturallyappropriatematerialsandtoolsdevelopedbecausetheyareatgreaterriskforexperiencingcognitivedecline.Healthcareprovidersmayhaveneedsandgapsinknowledgethatdifferfromthegeneralpublicbecausetheyarealsoprovidinginformationtoothersaboutcognitivehealth.

6. Conduct a systematic review of lifestyle interventions

and contextual factors to examine the benefits and

barriers to their adoption and maintenance. (R)Understandingthebenefitsofandbarrierstoadoptingandmaintaininganinterventionisoneofthecriticalstepsfortranslatinginterventionseffectivelyandefficaciouslyinacommunity-basedsetting.

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)Itisimportanttoknowwhatkindsofphysicalactivitystimuliarenecessarytopromotecognitivehealth.Anexaminationofthescientificliteraturewillidentifygapsinknowledgeandfocusresearch.Withoutsuchinformationandresearchdevelopment,accurateadvicecannotbeconveyedtothepubliconhowactivetheyshouldbetomaintaintheircognitivehealth.

8. Develop cognitive health interventions that

reflect the most current scientific research and

that are consistent with effective community-

based interventions. (C,SC)Clinicaltrialsassessingtheefficacyofinterventionstoeffectcognitivefunctionandpublichealthstudiesexaminingtheeffectivenessandfeasibilityofcommunity-basedinterventionsareoftenreportedseparately.Morecomprehensiveapproachesinvolvingcollaborationsbetweenclinicalresearchersandcommunityparticipatoryresearchersarecriticaltoensurethattheeffectivenessandfeasibilityofcognitivehealthinterventionsaredevelopedandtestedwithvariouscommunities.

ActionsbyCluster


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(includinglarge-scalecontrolledclinicaltrialsofolderadultcohorts)havecombinedcognitivehealthoutcomesandvascularoutcomesinasinglestudy.

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(includinglarge-scalecontrolledclinicaltrialsofolderadultcohorts)havecombinedoutcomesforcognitivehealthandphysicalactivityoutcomesinasinglestudy.

3. Conduct physical activity studies to determine the

long-term benefit of physical activity as it relates

to cognitive function. (R)Todate,studiesofphysicalactivityinterventionsthathaveassessedcognitiveoutcomestypicallyhavenofollow-upatalloronlyashortfollow-up.Studiesofphysicalactivity

areneededtodeterminetowhatextentanycognitivebenefitsassociatedwithphysicalactivitypersistacrosslong-termfollow-up:at6month,1year,orlongertimeperiods.Long-termfollow-upstudiesofphysicalactivityarealsoneededtodeterminethedurationofcognitiveeffectsinthosewhostoptheprogram.

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)wascapableofproducingcognitiveimprovementinolderadults,atleastintheshortterm.Thesefewstudies,however,haveyettoyielda“prescription”thatcouldbegiventoolderadults;thus,manyquestionsremaintobeansweredaboutthetypesofactivity(e.g.,aerobicoranaerobic,individualorgroup)andtheirduration,intensity,andfrequencythatareneededtomaintain,orevengain,goodcognitivefunction.

5. Conduct studies to determine the effect of physical

activity and physical activity relapse on persons of



different backgrounds in relation to cognition. (R)Similartothepharmacogeneticsapproachthathasbeenusedtodeterminetheefficacyofspecificdrugsforpersonswithcertaingenotypes,itseemspossiblethatrecom-mendationsforbehavioralinterventionssuchasphysicalactivitymightbecraftedtoanindividualperson’sbackground(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)Itisimportanttounderstandhowanycognitivebenefitmeasuredinthelaboratorytranslatestobetterfunctioninginrealworldtasks.Althoughwell-controlledlaboratorystudiesareessentialtoadvancingknowledgeinthisarea,itiscurrentlynotclearhowmuchthecognitivetasksassessedinthesestudieswillgeneralizetothecognitivefunctioningrequiredinroutinedailyactivitiesimportanttoolderadults,suchasbalancingacheckbook,safelydrivingacar,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)Itisrecognizedthatsecondaryanalysesofexistingdatasetsoftenpossessmethodologicalproblems(includingcrosssectionaldata).Nevertheless,datasets(perhapsevensomerepresentativeoftheU.S.population)mayexistthatcontainvariablesrelatedtocognitivefunctioning,health,andphysicalactivity.Effortstolocatesuchdataandtoevaluateresearchquestionsandassociationsamongthevariablesmayprovideadditionalinsightsintothisarea.

8. Identify the mechanisms that may mediate

the relationship between physical activity and

cognitive functioning.(R)Physicalactivitymaynotaffectcognitivefunctiondirectlybutitmaystillaffectitthroughintermediatemechanisms.Itisimportanttoknowwhethertheassociationbetweenphysicalactivityandcognitivefunctioningismediatedbychangesindiabetesoutcomes,invascularfitnessoutcomes,orinriskfactorssuchashypertensionorhyperlipidemia.

ActionsbyCluster


9. Encourage cardiovascular disease and diabetes

researchers to use appropriate measures addressing

cognitive domains as outcomes in their studies.(R)Thebestwaytounderstandwhichinterventionsincardiovasculardisease anddiabeteswillaffectcognitivehealthisforappropriateaspectsofcognitivemeasurestoberoutinelyincludedinappropriatestudiesinthesetwoareas.

10. Encourage research to determine the impact of

multiple vascular risks on cognition. (R)Specificfocusisneededtobothunderstandthebiologyofhowvascularriskfactorsaffectcognitionandtodeterminewhethertheeffectsofhavingmultiplefactorsareadditiveormultiplicative. Someobservationalstudieshavesuggestedthatthegreaterthenumberofvascular riskfactors,thegreaterthecognitivedeficit.Weknow,however,thatclinicaltrialswithpharmacologicalagentsthatcontrolindividualriskfactorshaveeffectivelyreducedvascularriskbuthavenotconsistentlyproducedcognitivebenefit.Abetterunderstandingofthemechanismsbywhichmultiplevascularriskfactorsmaycontributetocognitivedeficitscouldidentifytargetsforinterventionsto

reverseorreducethedeficit.Thebiologicalmechanismsoftheinteractionamongriskfactors,aswellasmodelsofthesizeoftheinteractioneffectoncognition,wouldassistindesigningtrialsofpotentiallyeffectiveinterventions.

11. Conduct research on other areas potentially

affecting cognitive health such as nutrition, mental

activity, and social engagement. (R)Scienceisevolvingregardingriskandprotectivefactorsintheareasofcognitivetraining,nutrition,andsocialengagement.Itiscriticaltomonitorandincludetheseareasasthescienceemerges.



Measuring cognitive impairment and burden

1. Identify thresholds for cognitive decline that have

functional importance for population-based

surveillance systems. (S)Itisimportanttorecognizepointsonthecontinuumofcognitivedeclinethatarefunctionallymeaningful.Itshouldalsoberecognizedthatmeasurementsbeyondsomepointsonthiscontinuummayrequireinformationfromproxyrespondents.Usefulcomparisonsoffindingsfromdifferentsurveillancesystemsandresearchstudiesareimprovedifthereisconsistencyamongthethresholdsbeingused.Functionallyimportantthresholdsshouldbeofpracticalsignificancetohelpinformpublichealthpolicyregardingneedsforcaregiversupportandotherspecialhealthcareorsocialservices.

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)thataremostsensitiveandspecifictocognitivedeclineandpracticallymeasurableinsurveillancesystems.

Useful,measurablecomponentsareexpectedtodifferaccordingtothenatureofthesurveillancesystem,particularlywhetherdatacollectionislongitudinalorcross-sectional.Withcrosssectionaldataalone,fewerinferencesarepossibleregardingage-relatedcognitivedecline.

3. Identify measures of the public health burden

of cognitive impairment on individual people,

families, and communities.(SC)Thepublichealthburdenofcognitiveimpairmentencompassesitseffectsonindividualmenandwomen,caregivers,families,employers,andothersinthecommunity.Theseeffectsmayhavephysical,mental,social,andeconomicdimensions.Itisimportanttoidentifykeymeasurablecomponentsoftheseeffectstoenablethepublichealthburdentobefullyassessed,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)

ActionsbyCluster


Thesequestionsmightexistwithinanongoingpopulation-basedsurveillancesystem,ortheycouldbeaddedtosuchasystem.Totheextentpossible,education-andculture-independentmeasuresshouldbesought.Becausetheeffectsofeducationandculturearepotentialconfounders,measuresandanalytictechniquesareneededthatwouldenablereducedcognitivefunctiontobedistinguishedfromlowperformanceduetovariationsineducationalorculturalexposures.Itiscriticaltorecognizeandcorrecttheseconfoundingeffectssoastoavoidmisinterpretingormisusingsurveillancedata.

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)Supportofresearchoncognitivehealthisexpensiveinscope,effort,andcost.Partnershipswithfederalagencies,foundations,andotherentitieswilllikelybenecessarytosecuresuchsupportandconductthisresearch.

2. Convene researchers and community intervention-

ists conducting interventions on risk and protective

factors to identify potential mechanisms to advance

the work in the field of cognitive health.(R)Thefieldsofcardiovasculardisease,depression,diabetes,andcognitionarebeginningtointersect.Afterconductingliteraturereviewsonwhatiscurrentlyknownabouttheeffectsofinterventionstargetingvascular factors,depression,anddiabetesoncognitivehealth,researchersandcommunityinterventionistsineachofthesefieldsshouldbeconvenedtodeterminestrategiesformovingthefieldofcognitivehealthforward.



NextStepsPriorities for action

WhilewebelievethatalloftheactionspresentedinthisRoadMapareimportant,wearemindfulofthelimitedpoolofresourceswithwhichtoimplementthem.Becauseofthisreality,weselected10actionsofhighestpriorityforimmediateattention.

IVdevelopment

process

Vactions by

cluster

VInext steps

IIIstrategic

framework

IIstate of

knowledge

Ibackground


• Determine how diverse audiences think about

cognitive health and its associations with

lifestyle factors.

Itisnotclearhowthegeneralpublicorpractitionersperceiveandunderstandcognitivehealth.Todevelopusefulprograms,itwillbeimperativetobetterunderstandthediversetargetaudiences.Someissuesthatwouldbeimportanttounderstandfortranslationtoboththegeneralpublicandpractitionersinclude:howcognitionisdefinedandtranslated;whataspectsofcognitivehealthareimportant(includingthelevelofknowledgeaboutvascularfactors);andhowconcernedthegeneralpublicisaboutcognitivehealth.

• Disseminate the latest science to increase public

understanding of cognitive health and to dispel

common misconceptions.

EvidenceexiststhatthecurrentboomergenerationisconcernedaboutcognitivehealthandfearsAlzheimer’sdisease.Onecriticalareaoffocusshouldbeonhelpingthepublictounderstandthevaryinglevelsofevidencebehindproposedinterventionsregardingcognitivehealth.Unlesscredibleandbroadreachinginformationaboutvalid

interventionsincognitivehealthisdisseminated,consumerswillfillthegapwithuntestedprogramsandproducts.Notonlycantheseprogramsandproductspresentaneconomicburden,butsomemayalsodistracttheagingpopulationfrommeaningfullifestylechanges.Communicationsstrategies(includingtheappropriatecommunicationchannels)shouldbuilduponcurrenteffortsbyvariousorganizationsandagenciestoshareexistinginformationandmaterialsoncognitivehealthresearchandpossibleinterventionsthatareconsistentwithcurrentscience.

• Help people understand the connection between

risk and protective factors and cognitive health.

Riskandprotectivefactorsarekeystofiguringouthowtoaddressindividualandcommunityhealthandrequireclarifyingforthepublicwhatisdemonstratedaseffectiveinclinicaltrialsversusassociationsobservedinotherstudies.Ofprimaryinterestareaspectsofpersonalandenvironmentalexperiencesthatmakeitmorelikely(riskfactors)orlesslikely(protectivefactors)thatpeoplewillexperiencecognitivedecline.Considerationshouldbegiventotheseconnectionsandtopromotingabetterunderstandingofit,includinganunderstandingofareasinwhichclinicaltrials

NextSteps


have(orhavenotyet)establishedacauseandeffectbetweenriskandprotectivefactorsandcognitivehealth.

• Conduct systematic literature reviews on proposed

risk factors (vascular risk and physical inactivity) and

related interventions for relationships with cognitive

health, harms, gaps and effectiveness.

Itiscriticaltoexamineallstudiestodatetodocumentwhichinterventionshavebeenproveneffective.Suchreviewsshouldfocusondeterminingtherelationshipsbetweenriskfactors,protectivefactors,andcognitivefunctionacrossobservationalandclinicaltrials.Whereinterventionsexist,theireffectivenessshouldbedocumentedandremaininggapsinthefieldshouldbeidentifiedinordertomovestrategiesintopublichealthpractice.

• Conduct controlled clinical trials to determine the

effect of reducing vascular risk factors on lowering

the risk of cognitive decline and improving

cognitive function.

Todate,fewvascularstudies(includinglarge-scalecontrolledclinicaltrialsofolderadultcohorts)havecombinedcognitivehealthoutcomesandvascularoutcomesinasinglestudy.

• Conduct controlled clinical trials to determine the

effect of physical activity on reducing the risk of

cognitive decline and improving cognitive function.

Todate,few,ifany,physicalactivitystudies(includinglarge-scalecontrolledclinicaltrialsofolderadultcohorts)havecombinedoutcomesforcognitivehealthandphysicalactivityoutcomesinasinglestudy.

• Conduct research on other areas potentially affecting

cognitive health such as nutrition, mental activity,

and social engagement.

Scienceisevolvingregardingriskandprotectivefactorsintheareasofcognitivetraining,nutrition,andsocialengagement.Itiscriticaltomonitorandincludetheseareasasthescienceemerges.

• Develop a population-based surveillance system with

longitudinal follow-up that is dedicated to measuring

the public health burden of cognitive impairment in

the United States.

Apopulation-basedsurveillancesystemwouldassistinthecollectionofconsistentdatatomonitor,assess,andinform



publichealthprogramsandpolicyaboutthepublichealthburdenofcognitiveimpairment.

• Initiate policy changes at the federal, state, and local

levels to promote cognitive health by engaging

public officials.

Far-reachingpublichealthissuesdemandinformedactionbypublicofficials,becauseactionbytheprivatesectoralonewillbeinsufficienttoreachdesiredresults.Becauseprogramandfundingdecisionsaremadebypolicymakersatthenational,state,andlocallevels,itisimportanttoengageandeducatethisaudience.Publicofficialshavesignificantcompetinginterests;itisessentialthattheybecomeeducatedandengagedinthisarenatocontributetopositivepolicychangeincognitivehealthinterventionsandtosupporttheneedforfurtherresearch.

• 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.

ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidelyrecognizedapproachtoimprovinghealth.Asresearchdemonstrateswaysinwhichcognitivehealthcanbemaintained,theareaofcognitivehealthcanbeelevatedtoamajorhealthprioritybybeingincorporatedintotheoutcome-orientedapproachusedbyHealthy People 2020.

Theseprioritiescutacrosstheclustersand,asapackage,wouldputour“bestfootforward”inmeetingthepublichealthchallengesofcognitivehealth.Thepriorityactionsputforthrepresentthebestthinkingofleadingexpertsacrossdiversefieldsofinfluence.Theyhavebeenidentifiedasonesthatarenecessarytomovingtheissueofcognitivehealthintopublichealthpractice.Weurgethenationtoadoptthese10actionsandtojoinforcesinimplementingthemoverthenext3-5years.Doingsowouldbemakingtremendousstridestowardsachievingourlong-termvision:maintainingorimprovingthecognitiveperformanceofalladults.

NextSteps


Implementation

EffectiveimplementationoftheactionsoutlinedinthisRoadMaphingesonseveralfactors.

• Organizationswillneedtoidentifyclearlywhichactionstheywishtoaddress,andcollaboratewithothergroupsthatshareaninterestinthoseactions.

• Organizationsshoulddevelopandstrengthenpartnershipswithotherlike-mindedorganizations.

• Organizationsshoulddeveloptheirownplanstoachievetheirselectedactions.

• Organizationsshouldestablishsystemstotracktheirprogresstowardscompletingtheirplansofactionandtofacilitatecommunicationandexchangeofinformation.

Asthescienceofcognitivehealthiscontinuallyevolving,theRoadMapshouldbeviewedasalivingdocumentthatcontainsawiderangeofactionsonhowtoproceed.Asweachievesomeoftheactions,wecanusetheRoadMaptomoveforwardandaddressotheractionsthatbecomerelevantandfeasible.

Conclusion

ThisRoadMapcomesatacriticaltimewhenscientificinterestincognitivehealthisbeginningtomeettheburgeoningdemandofthepublicforwaystomaintaincognitivefunction.Itsetsinmotionacourseofactionforestablishingpartnerships,makingcognitivehealthaprominentpublichealthissue,andpreparingsocietyforconcertedeffortstomaintainingthecognitivehealthofolderAmericans.

TheRoadMapisbothacalltoactionandaguideforimple-mentinganeffectivecoordinatedapproachtomovingcognitivehealthintopublichealthpractice.Thekeytosuccessliesincontinuingandexpandingresearch,developingandchannelingresources,andworkingcollaborativelytomovetheevidenceaboutmaintainingcognitivehealthintonationalaction.


Communications WorkgroupMaryGuerriero Austrom,PhDIndiana Alzheimer’s Research Center Indiana University School of Medicine

FrankBailey,JDAARP

DianeBazelidesAlzheimer’s Association National Board

VickyCahanNational Institutes of Health

NancyCeridwynAmerican Society on Aging

MarthaDiSarioPacific Communications Enterprises

BarbaraE.Gill,MBAThe Dana Foundation The Dana Alliance for Brain Initiatives

JeffMcKennaCenters for Disease Control and Prevention

MichaelC.PattersonAARP

DeloresPluto,PhDUniversity of South Carolina

MarySchwartz,MSAlzheimer’s Association

BobRosenblattNational Academy of Social Insurance

Policy WorkgroupWilliamF.BensonHealth Benefits ABC’s

JoyCameronNational Governors Association

IrisFreemanAdvocacy Strategy

KathrynGallagherCenters for Disease Control and Prevention

RobynGolden,LCSWRush University Medical Center

CatherineGordon,RN,MBACenters for Disease Control and Prevention

MaryGuthrieAdministration on Aging

DavidHoffman,MEdNew York State Department of Health

JimHowardCalifornia Department of Health Services

DebraLappin,JDB&D Consulting LLC

StephenMcConnell,PhDAlzheimer’s Association

SandyMarkwoodNational Association for Area Agencies on Aging

MarkSchoeberlAmerican Heart Association

PaulTibbitsJr.American Diabetes Association

Prevention Research WorkgroupMarilynAlbert,PhDJohns Hopkins Medical Institutions

MargaretGatz,PhDUniversity of Southern California

J.NeilHenderson,PhD University of Oklahoma Health Sciences Center

KathrynJedrziewski,PhDInstitute on Aging University of Pennsylvania

RhondaMontgomery,PhDUniversity of Wisconsin - Milwaukee

MarcelleMorrison-Bogorad,PhDNational Institute on Aging

PeterRabins,MD,MPHJohns Hopkins University School of Medicine

MarySano,PhDAlzheimer’s Disease Research Center Mount Sinai School of Medicine

JesusSoares,MSc,ScDEmory University Centers for Disease Control and Prevention

WilliamThies,PhDAlzheimer’s Association

BarbaraVickrey,MD,MPHUniversity of California at Los Angeles

MollyWagster,PhDNational Institute on Aging

NancyWhitelaw,PhDNational Council On Aging

ShereeMarshallWilliams,PhD,MScCenters for Disease Control and Prevention

KristineYaffe,MDUniversity of California, San Francisco San Francisco Veteran’s Administration Medical Center

Surveillance WorkgroupDallasAnderson,PhDNational Institute of Aging

HughC.Hendrie,MB,ChB,DScIndiana University Center for Aging Research Regenstrief Institute, Inc.

Walter“Bud”Kukull,PhDUniversity of Washington

JamesN.Laditka,DA,PhD,MPAUniversity of South Carolina

KennethM.Langa,MD,PhDUniversity of Michigan

EricB.Larson,MD,MPHGroup Health Center for Health Studies

LenoreLauner,PhDNational Institute on Aging

LisaC.McGuire,PhDCenters for Disease Control and Prevention

DanMungas,PhDUniversity of California, Davis

NathaliedeRekeneire,MD,MSCenters for Disease Control and Prevention

PaulScherr,PhD,DScCenters for Disease Control and Prevention

DavidThurman,MDCenters for Disease Control and Prevention

AppendixA:Contributors

Centers for Disease Control and Prevention and the Alzheimer’s Association | ��

Additional ContributorsAveryspecialthankyoutoallofthemenandwomenwhoprovidedfeedbackontherecommendations.

RobertBlancato,MPAMatz, Blancato & Associates, Inc

AmyR.Borenstein,PhDUniversity of South Florida

JohnC.S.Breitner,MD,MPHUniversity of Washington

CarolBryant,PhDUniversity of South Florida

CarlCaspersen,PhDCenters for Disease Control and Prevention

WojtekChodzko-Zajko,PhDUniversity of Illinois at Urbana-Champaign

JamesCooper,MDGeorge Washington University School of Medicine

CarlCotman,PhDInstitute for Brain Aging and Dementia University of California at Irvine

RodDishman,PhDUniversity of Georgia

CharlesF.Emery,PhDOhio State University

PaulEstabrooks,PhDKaiser Permanente-Colorado

JenniferL.Etnier,PhDUniversity of North Carolina at Greensboro

DenisA.Evans,MDRush Institute for Healthy Aging Rush University

JeffFinnAmerican Society on Aging

PatrickFox,PhDInstitute for Health & Aging University of California at San Francisco

MaryGanguli,MD,MPHUniversity of Pittsburgh School of Medicine

FrancineGrodstein,ScDHarvard Medical School

BradleyD.Hatfield,PhDUniversity of Maryland

MichaelJohnsonOB*C Group, LLC

ArthurKramer,PhDBeckman Institute University of Illinois at Urbana-Champaign

DarwinLabarthe,MD,MPH,PhDCenters for Disease Control and Prevention

MichaelW.Link,PhDCenters for Disease Control and Prevention

NancyB.EmersonLombardo,PhDBoston University School of Medicine

EdwardMcAuley,PhDUniversity of Illinois at Urbana-Champaign

GuyMcKhann,MDThe Zanvyl Krieger Mind/Brain Institute Johns Hopkins University

ToniP.Miles,MD,PhDUniversity of Louisville

MarkMoss,PhDBoston University School of Medicine

MarciaOry,PhD,MPHThe Texas A&M University System Health Science Center

RonaldC.Petersen,PhD,MDMayo Clinic College of Medicine

ScottL.ParkinNational Council on Aging

TomProhaska,PhDThe Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago

StephanieRamseyCenters for Disease Control and Prevention

GeorgeW.Rebok,PhDJohns Hopkins University

WalterA.Rocca,MD,MPHMayo Clinic College of Medicine

KenRockwood,MD,FRCPCDalhousie University

GailShearerConsumers Union

PhillipD.Tomporowski,Ph.D.University of Georgia

TerrieFoxWetle,PhDBrown University

PeterZandi,PhD,MPH,MHSJohns Hopkins University

StaffLindsayAbraham,MPHNorthrop Grumman/ Centers for Disease Control and Prevention

MarkConnerNorthrop Grumman/ Centers for Disease Control and Prevention

KristineL.Day,MPHCenters for Disease Control and Prevention

SheilaJack,MUP,MSJAlzheimer’s Association

BrendaPepeConcept Systems, Inc.

PeterReed,PhD,MPHAlzheimer’s Association

WalkerTisdale,MPHAlzheimer’s Association

SusanToal,MPHPublic Health Writer/Editor

CatherineVanBrunschotConcept Systems, Inc.

AppendixA:Contributors


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6 HendrieHC,AlbertMS,ButtersMA,etal.TheNIHCognitiveandEmotionalHealthProject,ReportoftheCriticalEvaluationStudyCommittee.Alzheimers Dement2006;2:12-32.

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8 ASA-MetLifeFoundation.Attitudes and awareness of brain health poll. SanFrancisco:AmericanSocietyonAging,2006.Availableat:http://www.asaging.org/asav2/mindalert/brainhealthpoll.cfm.

9 CutlerNE,WhitelawNW,BeattieBL.American perceptions of aging in the 21st century.Washington(DC):NationalCouncilontheAging,2002.

10 Research!America.American speaks: poll data summary. Volume 7. Alexandria(VA);Research!America,2006.Availableat:http://www.researchamerica.org/publications/AmericaSpeaks/AmericaSpeaksV7.pdf.

11 KhachaturianZS,KhachaturianAS. Publichealthpremisefornationalresearchpriorities:mortalityversusdisability.Alzheimers Dement 2005;1:20-4.

12 HeronMP,SmithBL.Deaths:leadingcausesfor2003. Nat Vital Stat Rep 2007;55:1-92.

13 HebertLE,ScherrPA,BieniasJL,BennettDA,EvansDA.AlzheimerdiseaseintheU.S.population:prevalenceestimatesusingthe2000Census.Archives of NeurologyAugust2003;60:1119-22.

14 GrahamJE,RockwoodK,BeattieBL,etal.Prevalenceandseverityofcognitiveimpairmentwithandwithoutdementiainanelderlypopulation.Lancet 1997;349:1793-6.

15 LopezOL,KullerLH,FitzpatrickA,IvesD,BeckerJT,BeauchampN.Evaluationofdementiainthecardiovascularhealthcognitionstudy.Neuroepide-miology 2003;22:1-12.

16 UnverzagtFW,GaoS,BaiyewuO,etal.Prevalenceofcognitiveimpairment:datafromtheIndianapolisStudyofHealthandAging.Neurology2001;57:1655-62.

17 TheLewinGroupandAlzheimer’sAssociation.Saving lives, saving money: dividends for Americans investing in Alzheimer’s research.Washington(DC):Alzheimer’sAssociation,2003.

18 BynumJPW,RabinsPV,WellerWE,NiefeldM,AndersonGF,WuA.TheimpactofdementiaandchronicillnessonMedicareexpendituresandhospitaluse.JAm Geriatr Soc2004;52:187-94.

19 KhachaturianZS,KhachaturianAS.Publichealthpremisefornationalresearchpriorities:mortalityversusdisability.Alzheimers Dement2005;1:20-4.

20 NationalAllianceforCaregivingandAARP.Caregiving in the US. April2004.Availableat:http://www.caregiving.org/data/04finalreport.pdf.

21 Prigerson HG. Coststosocietyoffamilycaregivingforpatientswithend-stageAlzheimer’sdisease.N Engl JMed 2003;349:1891-2.

22 Schulz R,MendelsohnAB,HaleyWE,MahoneyD,AllenRS,ZhangS,ThompsonL,BelleSH.ResourcesforenhancingAlzheimer’scaregiverhealthinvestigators.End-of-lifecareandtheeffectsofbereavementonfamilycaregiversofpersonswithdementia.N Engl J Med 2003;349:1936-43.

23 Alzheimer’sAssociation:25yearsofsupportingscienceandshapingtheAlzheimerResearchAgenda.Alzheimers Dement2005;1.


25 ASA-MetLifeFoundation.Attitudes and awareness of brain health poll.,SanFrancisco:AmericanSocietyonAging,2006.Availableat:http://www.asaging.org/asav2/mindalert/brainhealthpoll.cfm.


27 Research!America.American speaks: poll data summary. Volume 7. Alexandria(VA);Research!America,2006.Availableat:http://www.researchamerica.org/publications/AmericaSpeaks/AmericaSpeaksV7.pdf.

28 Prigerson HG. Coststosocietyoffamilycaregivingforpatientswithend-stageAlzheimer’sdisease.N Engl J Med2003;349:1891-2.

29 TheLewinGroupandAlzheimer’sAssociation.Saving lives, saving money: dividends for Americans investing in Alzheimer’s research.Washington(DC):Alzheimer’sAssociation,2003.

30 BynumJPW,RabinsPV,WellerWE,NiefeldM,AndersonGF,WuA.TheimpactofdementiaandchronicillnessonMedicareexpendituresandhospitaluse.Am Geriatr Soc 2004;52:187-94.

Centers for Disease Control and Prevention and the Alzheimer’s Association| ��

AppendixB:References

AppendixB:References

31 KoppelR,theAlzheimer’sAssociation.Alzheimer’s disease: the costs to US business in 2002.Washington(DC):Alzheimer’sAssociation;2002.

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Centers for Disease Control and Prevention

The Centers for Disease Control and Prevention, as the sentinel for the health of people in the United States and throughout the world, strives to protect people’s health and safety, provide reliable health information, and improve health through strong partnerships. CDC’s mission is to promote health and quality of life by preventing and controlling disease, injury, and disability.

Alzheimer’s Association

The Alzheimer’s Association is the leading voluntary health organization in Alzheimer care, support and research. Our mission is to eliminate Alzheimer’s disease through the advancement of research; to provide and enhance care and support for all affected; and to reduce the risk of dementia through the promotion of brain health. Our vision is a world without Alzheimer’s.

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