the healthy brain initiative healthy brain initiative: ... a strategic framework, and embarked on an...

The Healthy Brain Initiative A National Public Health Road Map to Maintaining Cognitive Health

TheHealthyBrainInitiative A National Public Health Road Map to Maintaining Cognitive Health

TableofContents

Acknowledgements

Executive Summary 1

I Background 4 Whatiscognitivehealth 5 WhyprepareaRoadMap 7 Whyisitimportantmdashandwhynow 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

Suggested Citation CentersforDiseaseControlandPreventionandtheAlzheimerrsquos AssociationTheHealthyBrainInitiativeANationalPublicHealthRoadMapto MaintainingCognitiveHealthChicagoILAlzheimerrsquosAssociation2007

Availableatwwwcdcgovagingandwwwalzorg

Centers for Disease Control and Prevention and the Alzheimerrsquos Association

Acknowledgements

WethankthemembersoftheSteeringCommitteeforgivingcountlesshourstothink aboutanddiscussthisNational Public Health Road Map to Maintaining Cognitive Health theircontributionshavebeeninvaluable

LyndaAndersonPhD(Cochair) Centers for Disease Control and Prevention

StephenMcConnellPhD(Cochair) Alzheimerrsquos Association

FrankBaileyJD AARP

WilliamFBenson Health Benefits ABCrsquos

DebraCherryPhD Alzheimerrsquos Association

GregCase Administration on Aging

HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc

JamesLaditkaDAPhDMPA University of South Carolina

DebraLappinJD BampD Consulting LLC

MarcelleMorrison-BogoradPhD National Institute on Aging

PeterRabinsMDMPH Johns Hopkins University School of Medicine

RamonaLRusinakRNPhD Arizona Department of Health Services

TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth

|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth

ExecutiveSummary

InFall2005theCentersforDiseaseControlandPrevention andtheAlzheimerrsquosAssociationformedanewpartnership

toexaminehowbesttobringapublichealthperspectiveto thepromotionofcognitivehealthToassistwiththisHealthy BrainInitiativethePartnersworkedcloselywiththeNational InstituteonAgingandtheAdministrationonAgingtoconvene amultidisciplinarySteeringCommitteeandanevenwider arrayofinvitedexpertsfromconcernedpublicandprivate sectororganizationsTogetherweexaminedthecurrentstate ofknowledgeregardingthepromotionandprotectionof cognitivehealthidentifiedimportantknowledgegapsand definedtheuniqueroleandcontributionsofpublichealth Wefocusedonvascularriskfactorsandphysicalactivity becauseoftheirassociationwithcognitiveoutcomesadopted astrategicframeworkandembarkedonanintensiveprocess togeneratetheactionsofferedinthis National Public Health Road Map to Maintaining Cognitive Health

TheRoadMaprecognizescurrentsocialtrendsandother factorsthataffectcognitivehealthfromapublichealth standpointanagingpopulationgrowingfearandconcern expressedbymanypeopleastheyageabouttheirpotential lossofcognitivefunctionincreasingsocietalburdenfrom cognitivedeclinegreatercaregiverburdenandacontinued lackofawarenessaboutcognitivehealthamongconsumers andprovidersalike

Withthisbackdropweofferaloftybutachievablelongshytermgoal

To maintain or improve the cognitive performance of all adults

Toaccomplishthisgoalweproposeasetof44actionsthat arefirmlygroundedinscienceemphasizeprimaryprevention assumeacommunityandpopulationapproachandare committedtoeliminatingdisparitiesinpersonalhealthand healthcareforracialorethnicgroupsItiscriticaltonotethat eachpriorityactionisbasedonadetailedscientificrationale withimplementationtobebasedondemonstratedeffectiveness ofspecificinterventionsTheseactionsshouldthereforebe consideredinthecontextoftherationalespresentedin SectionVoftheRoadMapWithinthefullsetofactionsare 10prioritiesworthyofimmediateattention

Centers for Disease Control and Prevention and the Alzheimerrsquos Association|

ExecutiveSummary

bull Determinehowdiverseaudiencesthinkaboutcognitive healthanditsassociationswithlifestylefactors

bull Disseminatethelatestsciencetoincreasepublicunderstanding ofcognitivehealthandtodispelcommonmisconceptions

bull Helppeopleunderstandtheconnectionbetweenriskand protectivefactorsandcognitivehealth

bull Conductsystematicliteraturereviewsonproposedrisk factors(vascularriskandphysicalinactivity)andrelated interventionsforrelationshipswithcognitivehealthharms gapsandeffectiveness

bull Conductcontrolledclinicaltrialstodeterminetheeffect ofreducingvascularriskfactorsonloweringtheriskof cognitivedeclineandimprovingcognitivefunction

bull Conductcontrolledclinicaltrialstodeterminetheeffectof physicalactivityonreducingtheriskofcognitivedecline andimprovingcognitivefunction

bull Conductresearchonotherareaspotentiallyaffecting cognitivehealthsuchasnutritionmentalactivityand socialengagement

bull Developapopulation-basedsurveillancesystemwith longitudinalfollow-upthatisdedicatedtomeasuringthe publichealthburdenofcognitiveimpairmentinthe UnitedStates

bull Initiatepolicychangesatthefederalstateandlocallevels topromotecognitivehealthbyengagingpublicofficials

bull IncludecognitivehealthinHealthy People 2020aset ofhealthobjectivesforthenationthatwillserveasthe foundationforstateandcommunitypublichealthplans

Itisourhopethatthese10priorityactionswillservetofocus thenationrsquosresourcesonaddressingriskandprotectivefactors forpromotingcognitivehealthoverthenext3-5yearsAsa livingandflexibledocumenttheRoadMaprepresentsboth acalltoactionandaguideforimplementinganeffective coordinatedapproachtomovingcognitivehealthintopublic healthpracticeThekeytosuccessliesincontinuingand expandingresearchdevelopingandchannelingresources workingtodeveloporstrengthenpartnershipswithlikeshymindedorganizationsdesigningcollaborativeoperational plansofactionandestablishingsystemstotrackprogress facilitatecommunicationandexchangeinformation

Continuedvigilanceonthisissueandtimelytranslationof researchfindingsintocommunityactionwillassurethat wereapthepotentialrewardsthatpublichealthcanofferin improvingqualityoflifeamongadultsandreducingsocietal costsforhealthcareandotherservices



IV development

process

V actions by

cluster

VI next steps

III strategic

framework

II state of

knowledge

I background

Background What is cognitive health

Thedistinctionbetweenthemindandbodywasaconcept firstformallysetforthinthe17thcenturybyphilosopher ReneDescartesOverthenextseveralcenturiesthebody wasseenastheconcernofphysicianswhilethemindwas thepurviewoforganizedreligion1

Overtheyearsourunderstandingofldquobodyandmindrdquo hasevolvedsignificantlyWenowrecognizethevitalrole thatbothphysicalhealthandmentalhealthplayinshaping ouroverallwell beingandweappreciatethevaluable contributionsthatawidearrayofhealthprofessionscan maketowardassuringthatwell-being

Background

Mentalhealthencompassesemotionalfunctioningandthe abilitytothinkreasonandremember(cognitivefunctioning) Whilestandardizedwidelyaccepteddefinitionsofcognitive healthhaveyettobeadoptedmostexpertsagreethatthe componentsofhealthycognitive functioning include

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

Muchlikephysicalhealthcognitivehealthcanbeviewed alongacontinuummdashfromoptimalfunctioningtomild cognitiveimpairmenttoseveredementiaItisnotsimplythe absenceofdiseasessuchasAlzheimerrsquosdiseaseratheritshould berespectedforitsmultidimensionalnatureandthechanges thattakeplaceoverthelifespanshouldbeacceptedeven embracedasanaturalpartoftheagingprocess3

Cognitivedeclinecanrangefrommildcognitiveimpairment todementiabutthesetwoconditionsarenotnecessarily manifestationsofthesamediseaseManypeoplenever developanyseriousdeclineintheircognitiveperformance andthosewhodevelopmildcognitiveproblemsdonot necessarilydevelopdementiaAlthoughnotallpeoplewith cognitivedeclinedevelopdementiathosewithanamnestic formofmildcognitiveimpairmentdohaveamuchhigher riskfordementiathanotheradults

Thelackofcognitivehealthcanhaveprofoundimplications forapersonrsquosphysicalhealthOlderadultsandothers experiencingcognitiveimpairmentmaybeunabletocare forthemselvesortoengageinnecessaryactivitiesofdaily livingsuchaspreparingmealsormanagingtheirfinances Limitationsintheabilitytoeffectivelymanagemedications andexistingmedicalconditionsareofparticularconcernwhen apersonisexperiencingcognitiveimpairmentordementia

Dementiaaffectsapersonrsquosabilitytocomprehendandacton messagesandinvolvesproblemswithmemoryunderstanding orusingwordsandidentifyingobjectsThesignificantly impairedcognitionassociatedwithdementialeadstoalossof senseofselfandoflifelongmemoriesadecreasingabilityto


ldquoMostimportanttoourabilitytoliveourliveswellisthe combinationofmentalprocesseswecalllsquocognitionrsquoor lsquoknowingrsquoThiscombinationincludestheabilitytolearn newthingsintuitionjudgmentlanguageandremembering Havingaclearactivemindatanyageisimportantbutas wegetolderitcanmeanthedifferencebetweendependence andindependentlivingrdquo4

copewiththenormaldemandsoflivingproblemsaccessing healthcaresystemsgreatervulnerabilitytodiseaseinjury malnutritioncrimeandpossiblyabuseandeventuallyaloss ofindependenceThatlossofindependencebecomesaburden onfamiliesandsocietyastheindividualrequiresmoreintense careandofteninstitutionalizationInthelaterstagesthe cognitiveimpairmentassociatedwithdementiawillcreatetotal dependencyandAlzheimerrsquosdiseaseisnowrankedasthe 8th-leadingcauseofdeath5

Why prepare a Road Map

Bringingapublichealthperspectivetocognitivehealth requiresaninclusiveandstrategicapproachMuchimportant workhasalreadybeguninitiatedandsponsoredbyavariety oforganizationsandagenciesatnationalstateandlocallevels (seepages10-11forasamplingofcurrentefforts)


Background

OneoftheselandmarkeffortstheNationalInstitutesofHealth (NIH)CognitiveandEmotionalHealthProject(CEHP) wasofficiallylaunchedin2001Selectedexpertsfromseveral universitiesandtheNIHcriticallyanalyzedthescientific literaturetoidentifypossibleriskandprotectivefactorsfor maintainingcognitiveandemotionalhealthinadults6In recognitionoftheimportanceofthiseffortandasfurther testamenttotheincreasedvisibilitythatcognitivehealthis receivingCongressappropriatedfundsinfiscalyear2005to theCentersforDiseaseControlandPrevention(CDC)to addresscognitivehealthwithafocusonlifestyleissuesWith thissupportCDCformedapartnershipwiththeAlzheimerrsquos AssociationandisworkingcloselywiththeNationalInstitute onAgingtheAdministrationonAgingandotherpublicand privatesectororganizationsonaHealthyBrainInitiative

Thispartnership

bull FormedaSteeringCommitteemadeupofnationalexperts toprovideoverallguidanceandcoordinationfortheInitiative (AppendixA)

bull ConvenedaPublicHealthResearchWorkingGroup MeetinginMay2006onThe Healthy Brain and Our Aging PopulationTranslating Science to Public Health PracticeDuring

this2-dayinvitationalmeetingnationalexpertsreviewed researchinpublichealthpreventionrelatedtobrainhealth anddiscussedspecificrecommendationsforaddressingrisk andprotectivefactorsforpromotingcognitivehealthThey focusedonvascularriskfactorsandphysicalactivitybecause oftheirassociationwithcognitiveoutcomes

Thefindingsfromthisresearchmeetingprovidedafoundation andcommonframeofreferenceforthenextstepoftheHealthy BrainInitiativedevelopingstrategicpublichealthrecommenshydationsForthistaskthePartnershipformedworkgroups infourareasofpublichealthactionPreventionResearch CommunicationSurveillanceandPolicyEachworkgroup waschargedwithdraftingrecommendationsformovingthe nationforwardoverthenext3-5yearstowardthelong-term goalofmaintainingandimprovingthecognitivefunctionof adultsKeystakeholdersatthenationalstateandlocallevels thenrefinedtherecommendationsandselectedthoseof highestpriority(AppendixA)

TheNational Public Health Road Map to Maintaining Cognitive Healthreflectstheculminationofthis18-monthprocessAsa cornerstoneoftheInitiativeitoffersapathforhowwecan learnmoreaboutcognitivehealthandthenultimately


ldquoWearebeginningtotakethe nextstepsbuildingonthe researchcomingoutofNIH andothersandmovingwhat weknowoutintocommunity practiceThisiswherewecan makeadifferenceinthe everydaylivesofAmericansrdquo LyndaAAndersonPhD Healthy Aging Program Centers for Disease Control and Prevention

translatewhatwelearnintoreal-worldpracticetoimprove thehealthofallAmericans

TheauthorsoftheRoadMaprecognizethatinthecourse ofdailylifethedomainsofemotionalandcognitivehealth areinextricablylinkedandcannottrulybeseparatedFor thisRoadMaphoweverweassumethisdistinctionandfocus solelyoncognitivehealthOnlyrecentlyhavepublichealth expertiseandresourcesbeenrecognizedforaddressing cognitivehealthTheRoadMapreflectsacommitmentto bringtheareaofcognitivehealthldquouptoparrdquowithemotional healthastreatmentsandpreventivestrategiesbecomeavailable Itisthefirststepinasystematicprocessforbringingcognitive andemotionalhealthtogetherinamorecomprehensiveand coordinatedpublichealthapproach


Background

A Sampling of Current Efforts

Pursuing Research on Factors Influencing Cognitive Health

TheNationalInstitutesofHealth(NIH)isfundingongoing researchtoclarifytherelationshipamongminimizingvascular riskfactorsexerciseotherlifestyleanddruginterventions andcognitivehealthstatusEpidemiologicstudiesare identifyinglikelyriskandprotectivefactorsthesearebeing testedinanimalstudieswhichalsocanhelpidentifythe mechanismsbywhichriskandprotectivefactorsmightwork Inordertoconfirmthattheencouraginginterventions identifiedinepidemiologyandanimalstudiescouldactually maintaincognitivehealthifappliedtohumansclinicaltrials mustbecarriedoutSomearealreadyinprogressbutothers arestillonlyintheplanningphaseNIHkeepsthepublicupshyto-dateonthecurrentstateofthesciencethroughoperation ofaWebsiteandanationalclearinghouse

Assessing Public Perceptions

Formativeresearchwithdiversegroupsisrequiredtohelp gainunderstandingonthepublicrsquosperceptionsaboutcognitive healthOnesucheffortiscurrentlyunderwaywiththesupport ofCDCTheHealthyAgingResearchNetworkwithinits largerPreventionResearchCentersProgram(PRC-HAN) conductspreventionresearchonavarietyofhealthissues involvingolderadultsWithinthePRC-HANmembersare collaboratingonaseriesoffocusgroupsdesignedtoidentify howdiversegroupsofolderadultsunderstandcognitive healthandwhatapproachestohealthpromotionanddisease preventionrelatedtobrainhealththepublicmayfindmost appealingThisprojecthasrecentlybeenexpandedtoexamine theperceptionsofcaregiversandhealthcareprovidersItwill provideimportantdatathatcanbeaddedtowhatisalready knownaboutcognitiveorbrainhealthidentifygapsin knowledgeaboutcognitivehealthandrelatedriskfactors anddeterminewhethersuchbeliefsvaryacrossgeographical distancesandbetweendiversepopulationsFinallythisworkis designedtoleadtothedevelopmentandtestingofashortset ofquestionsthatcanbeusedtoassessthepublicrsquosandpossibly providersrsquoperceptionsaboutcognitivehealthforinclusionin ongoingnationalattitudinalsurveys

0 |TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth

Conducting Community Education Programs

TheAlzheimerrsquosAssociationhasrecentlylauncheda5-year community-baseddemonstrationprojecttopromoteabrainshyhealthylifestyleThecommunityinterventionisdesignedto affectknowledgeandattitudesamongAfricanAmericanbaby boomersrelatedtophysicalactivityandvascularriskfactors anditwillbeoverlaidwithothergeneralhealthbehaviors suchasdietsocialactivityandmentalactivityDuringthefirst phaseofthisprojecttheAlzheimerrsquosAssociationisleadinga comprehensiveinterventionplanninganddevelopmenteffort includingformativeresearchtoassesscurrentneedsand obstaclesforthetargetpopulationelicitingcommunityinput andparticipationandcreatingacomprehensivemultilevel communityinterventionwithrobustevaluationmechanisms tomeasuretheeffectivenessofthepublichealthprogramin itsnextphase

Developing Common Measures of Cognitive Decline for Surveillance and Research

TheNationalInstitutesofHealthisleadinganinitiativeto developunifiedandintegratedmethodsandmeasuresof cognitiveemotionalmotorandsensoryhealthforusein largecohortstudiesandclinicaltrialsResearchershave expressedtheneedforbriefassessmenttoolsthatcouldbe usedasaformofldquocommoncurrencyrdquoacrossdiversestudy designsandpopulationsThisinitiativewilltakeadvantage ofstate-of-the-artpsychometricresearchandnoveltesting methodstodevelopaninnovativeapproachtoneurological andbehavioralhealthmeasurementUltimatelyitishoped thatthisapproachwillrespondtotheneedsofresearchersin avarietyofsettingswithparticularemphasisonmeasuring outcomesinlargelongitudinalandepidemiologicstudiesand preventionorinterventiontrialsacrossthelifespanWith anavailabletoolboxofmeasuresyieldsfromlargeandvery expensivestudiescanbemaximizedbyallowingamuch largernumberofimportantresearchquestionsregarding neurologicalandbehavioralhealthtobestudiedByensuring thattheassessmentmethodsarecapableofcomparisonto existingandcompletedstudiesandcanincorporatefuture modificationsatrulyldquoeconomicrdquoandvaluablenational resourcefortheentireneurosciencecommunitywillresult


Background

Why is it importantmdashand why now

TheNational Public Health Road Map to Maintaining Cognitive Healthcomesatacriticaltimegiventhedramaticagingof theUSpopulationthegrowingscientificinterestinthe roleoflifestylestrategiesinmaintainingcognitivefunction andincreasingawarenessofthesignificanthealthsocial andeconomicburdensassociatedwithcognitivedecline

An aging population AgeisariskfactorforcognitivedeclineIn2004onein everyeightAmericansmdash363millionmdashwereaged65years orolderBy2030thisnumberisexpectedtonearlydouble to715millionAtthattime20ofthepopulationwillbe inthisagegroup7

Growing fear and concern about memory loss ThereisconsiderableconcernamongAmericansaboutthe lossofcognitivehealthtodiseaseordisability8aconcernthat seemstoincreasewithageMostolderadultslookforwardto havingalonglifeandyettheirgreatestworriesaboutliving toage75revolvearoundmemoryloss9Accordingtoarecent surveyadultsaremorethantwiceaslikelytofearlosingtheir mentalcapacity(62)astheirphysicalability(29)10

Increasing burden from cognitive decline IntheUnitedStatesthesocietalburdenofcognitive impairmenthasbeenexpressedmainlyintermsofprevalence incidenceandmortalityfordementiagenerallyorfor AlzheimerrsquosdiseaseinparticularMorerecentlyprevalence statisticsforldquomildcognitiveimpairmentrdquoorldquocognitive impairmentnodementiardquohavealsoappearedCognitive impairmentnodementiareferstoalevelofcognitive impairmentthatismoreseriousthanage-relatedcognitive impairmentbutitisnotassevereasAlzheimerrsquosdiseaseor otherformsofdementia

bull Alzheimerrsquosdiseasehasbeeninthetoptenleadingcauses ofdeathsincethe20thcentury11Notablythemortalityrates forAlzheimerrsquosdiseaseareontherisemdashincontrasttothe ratesforheartdiseaseandcancerwhicharecontinuing todecline12

bull Anestimated45millionAmericanshaveAlzheimerrsquos diseaseThatnumberhasdoubledsince1980andis expectedtobeashighas16millionby205013


ldquoThenewsciencehasshiftedthe focustotheideathatthereis valueinapublichealthstrategy ofgettingpeopletothinkabout theirbrainandhowtheymight altertheirbehaviortokeep theirbrainhealthyrdquo StephenMcConnellPhD Alzheimerrsquos Association

bull StudiesfromtheUnitedStatesandCanadahavesuggested thatmildcognitiveimpairmentorcognitiveimpairment nodementiamaybeaproblemfor16-25oftheelderly population(65andolder)141516

bull In2005MedicareandMedicaidspent$91billionand $21billionrespectivelyforpersonswithAlzheimerrsquosdisease17 Accordingtoa2004reportthatanalyzedMedicareclaims dataolderbeneficiarieswithdementiacostMedicarethree timesmorethanotherolderbeneficiaries18Basedoncurrent estimatesthesecostswilldoubleevery10years19

Caregiver burden Maintainingcognitivehealthcanmeanthedifference betweenlivingindependentlyorfacingtheneedforfamily orinstitutionalcareTheburdenofcognitivedeclineon caregiversisenormousThenumberofcaregiversinthe UnitedStatesin2003wasestimatedtobe444million20and thisnumberisexpectedtorisedramaticallywiththeagingof


Background

thepopulationThecostsofunpaidinformalcareprovidedby familieshavebeenshowntoaccountforalargeproportionof thecostsoftreatingdementiaandtheyincreasesharplyasthe patientrsquoscognitiveimpairmentworsens21Therearealso physicalandmentalcostsassociatedwithcaregivinginone studynearly43ofthefamilymembersprovidingcareto relativeswithdementiahadclinicallysignificantlevelsof depressionduringthelastfewmonthsofthepatientrsquoslife22 Numerousfactorsmakeprovidingcareforpersonswith severedementiaemotionallyandphysicallychallenginga betterunderstandingofthesefactorswillaidinthedesignof strategiesthatsupportthehealthandwell-beingofcaregivers

Underlying lack of information about what is known about brain health Manyadultsappeartobelievethatagingisatimeof irreversiblementaldeclineandthatdementiaisuniversal andinevitableThesemythspersistseventhoughrecent researchhasshownthatinthehealthyagingbrainnew synapsescontinuetoformandnervecellscanregenerate23

YetthereareemergingsignsthatAmericanslooktothe futurewithhopeBasedonseveralsurveysmenandwomen inthiscountryarewillingtotakeimportantstepstoimprove theircognitivehealth

bull Nearly9of10peoplereportedthattheythoughtitis possibletoimprovecognitivefitness24

bull Sixof10statedthattheyfelttheyshouldhavetheir cognitivehealthcheckedroutinelymuchlikearegular physicalcheckup25

bull Morethan8of10(84)reportedthattheytooksome timenearlyeverydaytoengageinactivitiesthatmaybe associatedwithimprovedcognitivehealthengagingin artorcreativeprojectsreadingkeepingphysicallyactive playinggamesordoingpuzzlesworkingorspending timewithfamilyandfriends26

bull Overhalfanticipatedamajormedicalbreakthroughin discoveringacureforAlzheimerrsquosdiseasewithinthenext 20years27


Giventhetremendousburdensdescribedtheirimpactand thedevelopingsciencepublichealthshouldstepforwardto addresscognitivehealthThepotentialcontributiontoquality oflifethepositiveimpactoncaregiversandtheanticipated savingsinthecostsofhealthcareandotherserviceswould beconsiderable28293031



I background

IV development

process

V actions by

cluster

VI next steps

III strategic

framework

II state of

knowledge

State of Knowledge What do we know

InMay2006CDCandtheAlzheimerrsquosAssociationinvited nationalexpertstoreviewresearchonpublichealth preventionrelatedtocognitivehealthandtoidentifyspecific recommendationsforaddressingriskfactorsthatpromoteand protectcognitivehealthDuringthismeetingparticipants examinedthecurrentstateofscienceconcerningmajorrisk

factorsincludinga)riskfactorsforvasculardiseaseand b)physicalinactivityandtheylookedatcurrentmodels formovingscienceintopublichealthpracticeParticipants focusedonthesefactorsbecauseoftheirassociationwith cognitiveoutcomes32Theyconcludedthatresearchsuggests thefollowingfactorsmaybeassociatedwiththemaintenance ofcognitivehealth1)preventingorcontrollinghighblood

StateofKnowledge

pressurecholesteroldiabetesoverweightandobesity 2)preventingorstoppingsmokingand3)being physicallyactive33

Severalspecificobservationswerenotedbymeeting participantsregardingtheassociationsbetweenvascular riskfactorsandphysicalinactivityandcognition

bull Evidenceexiststoindicatethatcumulativerisks forvasculardiseaseincreasetheriskforstrokeand cognitivedecline

bull Sufficientevidencealsoexiststosupporttheassociation betweenvascularhealthandcognitivehealthalthough clinicaltrialsarenecessarytoestablishtheeffectivenessof interventionstargetedtovascularriskfactors

bull Itisimportanttoemphasizethatcontrollingvascularrisk factorsisassociatedwithreductioninanindividualrsquosriskof cognitiveproblemsbutcurrentsciencedoesnotsupportthe relationshipbetweencontrollingvascularriskfactorsand improvedcognitivefunction

bull Growingevidenceexiststhatphysicalactivitymaymaintain orimprovesomeaspectsofcognitivefunctionintheshort termbutfurtherresearchisneededbothtodeterminelong

termoutcomesandthenatureofrecommendations(eg theamountofphysicalactivity)

bull Strongevidenceexiststosupporttherelationshipbetween physicalactivityandemotionalwell-being

WhilenotaspecificfocusoftheMayresearchmeeting additionalfactorsthatmaybeassociatedwithmaintaining cognitivefunctionincludesocialengagementaldquoheart-healthyrdquo dietandemotionalsupportsInadditionhigherhouseholdand communitysocioeconomiclevelsinearlylifeareassociated withhigherlevelsofcognitioninlatelifebutnotwiththerisk ofAlzheimerrsquosdiseaseorrateofcognitivedecline34

What gaps exist

Eachnewdiscoveryinmaintainingcognitivehealthraisesa hostofimportantquestionsSomeofthemorepressingissues arethefollowing

bull Howdowepromotetheimportanceofcognitivehealth issuestokeyconstituenciesandstakeholders

bull Whatarethepublicrsquosperspectivesonlifestylebehaviors choicesandattitudesconcerningcognitivehealthandthe burdenofcognitivedeclineWhatdoweviewasthebenefits


ldquoAllthethingsthatweknow arebadforyourheartturn outtobebadforyourbrainrdquo MarilynSAlbertPhD Johns Hopkins Medical Institutions

andbarriersofmodifyingpersonallifestyletoreducetherisks associatedwithcognitivedecline

bull Whatistheroleofpopulation-basedsurveillanceandthe appropriatesurveillancesystemstoassesscognitivedecline

bull Whatclinicaltrialsandotherresearchareneededto determinethelong-termoutcomesoflifestyleinterventions onparticularcognitivefunctions

bull Howdowelinkscientificallyvalidmessagesaboutriskof cognitivedeclinetocurrentpublichealthmessagesfor effortsinprimaryprevention

bull Whataretheeffectsofmodifyingmultipleriskfactors onminimizingcognitivedeclineorimproving cognitivefunction

How can public health contribute

Publichealthwasfirstdefinedin1926asldquothescienceandartof preventingdiseaseprolonginglifeandpromotinghealthand efficiencythroughorganizedcommunityeffortrdquo35That definitionhasremainedintactforover80yearswitharecent reiterationofpublichealthrsquosmissionasldquoassuringconditionsin whichpeoplecanbehealthyrdquo36

Organizedpublichealtheffortsoverthepast100yearshave yieldedremarkableachievementsTenconsideredtobeamong thegreatest37areintheareasof

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


StateofKnowledge

bull Saferandhealthierfoods bull Healthiermothersandbabies bull Familyplanning bull Fluoridationofdrinkingwater bull Recognitionoftobaccouseasahealthhazard

Theseachievementswerepossiblebecauseofcombined coordinatedeffortstoapplythreecorepublichealth functionsassessmentpolicydevelopmentandassurance

Assessmentcallsforregularlyandsystematicallycollecting analyzingandsharinginformationonthehealthofa communitySuchinformationhelpstodescribeand understandacommunityrsquoshealthstatusandneedsAssessment activitiesmightinvolveinvestigatingadversehealtheffects andhealthhazardstoidentifythemagnitudeofahealth problemitslocationtrendsovertimeandpopulationsat riskTheymayalsoldquodigdeeperrdquotoanalyzedeterminantsof identifiedhealthproblemssoastoilluminateetiologicand contributingfactorsthatplacecertainpopulationgroupsat riskforadversehealthoutcomes

Policy developmententailspromotionofpublichealth policiesthataregroundedinscience-baseddecisionmaking Bytakingtheleadinpolicydevelopmentpublichealthserves

asanadvocatebuildsconstituenciesandidentifiesresources inacommunityasitgeneratessupportiveandcollaborative relationshipswithpublicandprivateagenciesAnothercritical policyactivityinvolveshelpingcommunitiessetpriorities amonghealthneedsbasedonthesizeandseriousnessofthe healthproblemsandtheacceptabilityeconomicfeasibilityand effectivenessofinterventionsthecommunitycanthendevelop plansandpoliciestoaddressthosepriorities

Assuranceistheguaranteethatservicesneededtoachieve agreed-upongoalsareactuallyprovidedItispursuedby encouragingtheactionsofothers(publicorprivate)requiring actionthroughregulationorbyprovidingservicesdirectly Thisthirdcorepublichealthfunctionencompassesmanaging resourcesanddevelopingorganizationalstructuresimplementing programsforpriorityhealthneedsandevaluatingandproviding qualityassurancetoensurethatprogramsareconsistentwith plansandpoliciesmdashorthatneededcorrectiveactionsare takenpromptlyInadditionassuranceactivitieshelptoinform andeducatethepubliconhealthissuesofconcernpromote awarenessofpublichealthservicesandpromotehealth educationinitiativesthatcontributetoindividualorcollective changesinhealthknowledgeattitudesandpracticesthat makeforahealthiercommunity

0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth

ldquoIfyoucouldgivepeople informationandtoolsthat woulddelaytheonsetof cognitiveimpairmentby afewyearsyouwouldbe doingmuchtoimprove individualsrsquoqualityoflifeas wellasimprovingsocietyrdquo DebraCherryPhD Alzheimerrsquos Association

Theapplicationofthesepublichealthfunctionstocognitive healthoffershopeofsimilarachievementsasscientific knowledgeadvancesTheareaofcognitivehealthisgaining increasingattentionfrommultipleperspectivesandrepresents ablossomingarenaforresearchandactionByembracing cognitivehealthasapriorityissuethepublichealthcommunity wouldbemobilizedtostudyidentifyandimplementeffective interventionsthatpreservethiskeycomponentofhealth Ourchallengeistoofferasystematicapproachthatwill assureacoordinatedandunifiednationaleffortTheRoad Mapmeetsthatchallengebylayingoutasharedvisionfora ldquoworkinprogressrdquoonethatbuildsonthefoundationofthe workdonetodateestablishesaframeworkwithinwhichto viewthefindingsofthatworklinksrelatedandcomplementary activitiesandshapestheworkofthefuture



I background

II state of

knowledge

IV development

process

V actions by

cluster

VI next steps

III strategic

framework

Strategic Framework What is our model for action

TodeveloptheRoadMapweusedaldquosynergisticrdquomodel (Figure1)formovingscienceintopublichealthpractice38 Themodelstartswiththeassumptionthatwemustfirst understandtheexisting science and knowledge baseforpreserving andprotectingcognitivehealthdeterminefindingsreadyto

bemovedintothepublichealtharenaandthenconduct researchtofillimportantgapsinknowledge

Atthesametimewemustanalyzesocial and environmental forcesthatcreatedemandandinfluencetheacceptanceofnew knowledgeThepushofscienceandthepullofthemarket combinetoshapethecapacitymdashthecomplementofhuman andfinancialresourcesmdashwemusthaveinplacetoimprove

StrategicFramework

Figure 139 The Model Moving Science into Public Health Practice

Intermediate Outcomes

Long Range Outcomes

Build and strengthen capacity

(competencies resources

partnerships etc)

Createexpand the science and knowledge base

Createsustain social environmental demand


publichealthpracticeStrengtheningandbuildingcapacity focusesonidentifyingkeypublichealthentitiesdetermining thenecessarycompetenciesandresourcesandexpanding partnershipstomountandsustainnecessaryactions Deployingthiscapacityeffectivelywillleadtodesired intermediate and long-range outcomes

What principles do we embrace

Severalkeyprinciplesunderlieourapproachtomaintaining cognitivehealth

A firm grounding in science Epidemiologicstudies followedbythetestingofinterventionsinclinicaltrialswith componentsthatincludecognitiveassessmentwillshow whichlifestylefactorsbestmaintaincognitivehealthfor thepopulationThroughpopulation-basedsurveillance epidemiologyandpreventionresearchpublichealthcan contributetoourunderstandingofcognitivehealthandcan identifypromisinginterventionsthatmaybeeffectivein promotingorprotectingitTheRoadMaprecognizesthat thisprocessisevolutionaryanditseekstobuilduponwhat wecurrentlyknowbyincorporatingnewdiscoveriesas theyemerge

ldquoThepossibilityofprevention inthisareaissonewand soexcitingforfamilies individualsandgovernmentrdquo JamesLaditkaDAPhDMPA University of South Carolina

An emphasis on primary preventionPublichealth focusesonreducingthefactorsthatputpeopleatriskof cognitivedeclinewhileincreasingthefactorsthatpromote andprotectcognitivehealthThustheRoadMapfocuses oninterventionsinhealthpromotionandriskreductionthat preservecognitiveperformancemdashratherthanpreventdementia Itrecognizesthepotentialldquosynergisticrdquoapproachbyintegrating theseinterventionswithotherlifestylemessagesandshowing howtheymightfitwithpharmacologicinterventions

A community and population approach Publichealth takesabroadviewandseekstoachievelastingchangein thehealthofentirepopulationsextendingfarbeyondthe medicaltreatmentofindividualpeopleThustheRoadMaprsquos recommendationsareexpansiveinscopeanddonotsingle outanyparticularpeopleorgroupsforspecialattention


StrategicFramework

A commitment to eliminating disparities Racial andethnicdisparitiesinhealthandhealthcarearewell documentedTheeliminationofsuchdisparitiesisacritical componentofthenationalpublichealthagendaandakey principleofthisRoadMapaswell40Thenumbersand proportionofolderadultsfromdiverseracialandethnic originsintheUnitedStatesareincreasingIn2003nonwhite ethnicandracialgroupsrepresented17ofthepopulation age65andolderwiththatproportionprojectedtoincrease to28by2030and39by205041Weembracethis diversityandrecognizeitsvalueinshapingpolicyinitiatives communicationstrategiesandlifestyleinterventionsand population-basedsurveillancerelatedtocognitivehealth

What do we hope to accomplish

Weenvisionanationinwhichthepublicembracescognitive healthasapriorityandinvestsinrelatedhealthpromotion andresearchToachievethisvisionwehaveadoptedalongshytermgoalandavarietyofoutcomesasmoreimmediategoals

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

Fourteenintermediateoutcomesencompasstheareasof communicationsurveillanceresearchpolicyandpublic healthcapacityTheseareto

bull Increaseawarenessabouttheimportanceofpromotingand protectingcognitionamongthegeneralpublicpublichealth andagingprofessionalsandpolicymakers

bull Increaseknowledgeabouttheriskandprotectivefactors associatedwithcognitionamongthegeneralpublicand publichealthandagingprofessionals

bull Decreasemisconceptionsandmythsaboutcognitivehealth amongthegeneralpublic

bull Determinecriticalpublichealthmeasuresformonitoring cognitivefunctionatthepopulationlevel

bull Incorporateappropriatecognitivemeasuresintopublic healthsurveillancesystems

bull Identifytheresearchgapsonmodifiableriskfactors andcognition

bull Securesustainedsupportforpublichealthresearch topromoteandprotectcognitivehealth


ldquoIfwemaintaincognitive functionovertimethen wearemorelikelytobe functionallyindependentrdquo MarilynAlbertPhD Johns Hopkins Medical Institutions

bull Disseminatetheresultsofcriticalpublichealthresearch findingsaboutcognitivehealth

bull Identifykeypublicandprivatepoliciestoaddress cognitivehealth

bull Modifykeypublicandprivatepoliciestoaddress cognitivehealth

bull Identifysuccessfulpublichealthbestpracticesonvascular healthanddiabetes

bull Increasecognitivehealthinterventionsthatare complementarytovascularhealthanddiabetespublic healthstrategies

bull Securesustainedsupportforpublichealthstrategiesto promoteandprotectcognitivehealth

bull Enhancethecapacityofagingandpublichealthservice networkstoimplementeffectiveinterventionstopromote andprotectcognitivehealth



IV development

process

III strategic

framework

II state of

knowledge

I background

V actions by

cluster

VI next steps

Development Process Phase I Workgroup deliberations

Fourworkgroupsofinvitedexpertsworkeddiligentlyand collaborativelyovera7-monthperiodtoidentifyrecommen dationsinfourareasofpublichealthactionPrevention ResearchSurveillancePolicyandCommunicationThe chargetoeachworkgroupwastodefineitsareaoffocus identifyimportantprinciplesandrecommendactionsfor

movingthenationforwardoverthenext3-5yearstoward thelong termgoalofmaintainingandimprovingthe cognitivefunctionofadultsThedefinitionsandprinciples thatemergedarepresentedbelow

Prevention Research Research in public health prevention isdefinedhereasresearch thatappliesandtestspopulation-basedinterventionsthathave

DevelopmentProcess

thepotentialtomaintaincognitivehealthRecommendashytionsforcognitivehealthfocusprimarilyontwoareasmdash vascularriskfactorsandphysicalactivitymdashwithemphasis ontheneedforpracticalclinicaltrialstoshowthebenefits ofvascularhealthinterventionsandphysicalactivityon maintenanceoflong-termcognitivehealthTheseareas werechosenbecausetheyarethefirsttoemergefrom population-basedstudiesandanimalresearchaspromising areasforinterventionWhiletheepidemiologicevidence supportingthebenefitsofvascularhealthforcognitive functionismoredefinitivethanthelinkregardingphysical activitybothareasareworthyofattentionInadditionrecent findingsfromclinicaltrialshaveheightenedinterestinthe valueofmentalactivitiesbyshowingapositiveeffectfrom cognitivetrainingoncertaincognitivedomains

Researchonpreventionshouldnotbelimitedtotheseareas howeverOtherareas(suchasnutritionandsocialengagement) shouldalsoberecognizedasimportanttoaddressinthefuture Totheextentpossibleresearchshouldbemultidisciplinary andbuildonafirmunderstandingofhowthepublichealth careprofessionalsandavarietyofotherpartnersdefine perceiveandvaluecognitivehealthInadditionresearch methodologiesshouldconsiderhowtoconvertresultsfrom

randomizedcontroltrialstocommunitysettingshowto makeclinicalorevidence-basedworkpracticalandhow totranslateresearchintopublichealthpractice

Surveillance Surveillanceisdefinedasldquotheongoingsystematiccollection analysisinterpretationanddisseminationofhealth-related datardquo424344Theongoingnatureofpublichealthsurveillance itsapplicationtobroadpopulationsandlimitationsinresources oftenrestrictthenatureanddepthofinformationthatcan begatheredthroughtraditionalsurveillancemethodsused inresearchThesemethodsrangefromcreatingnew surveillancesystemstousingorenhancingexistingsystemsmdash andsurveillanceofcognitivefunctionisnoexceptionSelecting appropriatesurveillancemethodsforcognitivedeclinepresents someuniquechallengeshoweversuchasdefiningcriteriafor acognitivemoduleandmeasuringavarietyofdimensions (egriskfactorsattitudesandburdenofcaregivers)Inaddition becausemeasurementsmayvaryaccordingtoeducation languagecultureandraceorethnicityspecialcaremustbe takentoensurethatdataarenotmisinterpretedormisused


Methodsavailableforthesurveillanceofcognitivedecline inolderpopulationsthatdonotrelyonself-reportingface particularconstraints

Cognitivedeclineinindividualpeopleisdirectlyidentified throughrepeatedmeasurementsconductedoveraperiod oftimeToimplementthismethodofcaseascertainment inasurveillancesystemrequireslong-termfollow-upof population-basedcohortswithopen(continuousorsuccessive) enrollmentsSuchsystemsarenotoftenusedforchronic diseasesurveillanceastheyareexpensiveandrequirean extensivetimecommitmentfromparticipants

Repeatedcross-sectionalpopulationsurveysaremore commonlyemployedinsurveillanceparticularlyforsome chronicdiseasesandforsomeriskfactorsfordisease Unfortunatelytherearenocurrentlyestablishedmethods thatdefinitivelyascertaincasesofcognitivedeclinethrough cross-sectionalinterviewsaloneSelf-reporteddataare inaccurateinthisareaandtheusefulnessavailabilityand validityofproxy-reporteddataareuncertainDespitethese limitationssuchsurveyshavevalueinmeasuringthe prevalenceofriskfactorsforcognitivedeclineTheymay alsohavepotentialtomeasuresomeparametersofcognitive


DevelopmentProcess

functionsItispossiblethatchangesovertimeinthe populationdistributionofsuchparametersmaysuggest changesintheprevalenceofcognitivedeclinealthough suchinferencescanonlybemadewithcautionevenafter controllingforconfounderssuchaseducationcultureand socioeconomicstatus

Othermethodsofscreeningoridentifyingconditions associatedwithcognitivedecline(eggeneticscreening biomarkersandneuroimagingtests)donotyetappear practicalalthoughsomemayeventuallyproveusefulifthe costsarereasonable

Recommendationsforsurveillancemustbeofferedwiththese methodologicalconstraintsinmindrecognizingthetension betweenidealmethodsforwhichresourcesmaybedifficult toobtainandmorelimitedmethodsforwhichresourcesare morelikelyavailable

Policy RealizationoftheRoadMaprsquosvisionrequiresapolicybase inboththepublicandprivatesectorsthatsupportsand promotescognitivehealthThepublic sectorencompasses policymakersatfederalstateandlocallevelsTheprivate sector includesbothnot-for-profitandcommercialorganization

policiessuchascoverageofpreventionbyinsurershuman resourcedepartmentpoliciesemployeeassistanceprograms andotherworkplacepoliciesandpracticesPolicychanges inthepublicsectorcaninfluencepoliciesandbehaviorsinthe privatesectorconverselyprivatesectorpolicychangecan influencepublicpolicy

Toeffectpolicychangethepublichealthcaseforaddressing cognitivehealthmdashthefactthatobservationalevidenceand limitedshort-termclinicaltrialsnowexisttosupportsome preventionopportunitiesinthisareamdashmustbemadeinan easilyunderstandableandconsistentmannerNationalstate andlocalorganizationsagenciesandpolicymakersmustbe educatedaboutcognitivehealthandsubsequentlyengaged tohelppromotepositivepolicydevelopmentandchangethat willincreaseknowledgeandleadtobettercognitivehealth

Moreoverpolicyrelatedtomaintainingcognitivehealthdoes notjustaddresscarebehaviorsorriskfactorsbutalso promotesresourcesforbuildingandmaintainingcommunity infrastructurethatreinforcesindividualbehaviorThiscould includebikeorwalkingtrailstoencouragephysicalactivity community-wideorganizationsandstructuresthatsupport healthybehaviorandotherchangestothebuiltandcultural


ldquoDevelopingaroadmapforcognitivehealthprovidesus withanopportunitytoreducehealthdisparitiesSome populationsareathighriskforcognitiveimpairmentdue tohighratesofhypertensionordiabetesTheRoadMap givesusachancetoprovidebetterhealthinformationforall Americansincludingthoseathighestrisksothatpeoplemay improvetheirmotivationtochangetheirlifestyleforbetter healthoutcomesrdquo DebraCherryPhD Alzheimerrsquos Association

environmentsthatadvancethepublichealthgoalofcognitive healthPolicyinitiativesmustbuilduponrelatetoandbe compatiblewithcommunicationsandresearcheffortsasthey takeshapeandyieldnewinformation

Communication Thetermcommunication strategyimpliesamultidisciplinary healthmarketingapproachthatincludescommunicatingand disseminatingscientificallyvalidinformationandstrategic interventionsthroughcustomer-centeredandculturally appropriatemeansAcommunicationsstrategyforcognitive healthaimstoeducatemotivateandeffectpositivebehavior changerelatedtocognitivehealthintargetedandat-risk audienceswithin3years

Toeffectivelyreachthisgoalcommunicationmessagesand methodsshould

bull Besciencebased

bull Begearedtopopulationsexperiencingthegreatest disparitiesandrisksincognitivehealth

bull Reachtheintendedaudienceandpromoteaction

bull Assisttheconsumerinmakingmoreinformeddecisions

Theaudienceofadultsaged42-60yearsalsoknownas babyboomersbelongstothebiggestgenerationinAmerican historyCognitivehealthissuesprofoundlyaffecttheirparents nowandtheywilltouchtheboomersinhugenumbersas theygrowolderItisimportanttogetappropriatevalid evidence-basedmessagestothemsotheymaytakeaction forthemselvesaswellaspotentiallyinfluencetheirfamilies Specialfocusshouldbegiventohighriskpopulations vulnerablepopulationsandhealthcareprovidersSpecific racialorethnicgroups(egAfricanAmericansLatinos)may needtohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheymaybeatgreaterriskfor


DevelopmentProcess

experiencingcognitivedeclineduetohigherrisksofvascular diseasehypertensionanddiabetesHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthegeneral publicbecausetheyareprovidinginformationaboutcognitive healthtoothersAninitialfocusonthesegroupswouldnarrow thescopeofeffortaffordingmoreachievableoutcomes

Inadditionbeforereachingouttoconsumersaccurate informationandoptionsshouldbeinplacethroughoutthe broadermedicalandsocialserviceenvironmentHealthcare professionalsarethemainsourceofinformationformany consumersandpastexperiencehasproventhebenefitsof targetingprofessionalorganizationsfirstaspeerinfluencers andtrainersofthesefrontlineproviders

Phase 2 mdash Concept-mapping process

Theworkgroupscollectivelyproposed42recommendations 18inpreventionresearch8incommunications9inpolicy and7insurveillanceAconcept-mappingprocesswasthenused toorganizeandvisuallyrepresentthemConcept-mapping combinesqualitativeandquantitativemethodstogenerate mapsthatprovideavisualrepresentationofthecomplex relationshipsamongideasandresults45Itcanelicitideasfrom

largediverseandgeographicallydispersedgroupsabout aparticulartopicwithinashorttimeframeUnlikeother qualitativemethodsconceptmappingalsoprovidesastructured approachthatallowskeydecisionmakerstoparticipateinthe finalinterpretationofalargergrouprsquosperceptions

Forthisprojectconcept-mappingwasorganizedinto threesteps

Step 1involvedreviewingandrestructuringrecommendations fromtheworkgroupstoensurethateachrecommendation representedadistinctideaandidentifyingthelistof stakeholderswhowouldbeinvitedtoparticipateThislist includedmorethan150personsfromabroadarrayof institutionsincludingstateandfederalagenciesuniversities andfoundations

Step 2consistedofonlineratingandsortingbyinvited participantsandsubsequentanalysesoftheresults46Forthe ratingprocess140(ofthe150)participantswereaskedto rateboththerelativeimportanceofeachrecommendation anditscurrentactionpotentialForthesortingtask20of these140participantswerealsoaskedtocategorizethe recommendationsaccordingtotheirviewofsimilarmeanings orthemesTen(ofthe150)participantswereinvitedto


ldquoIamveryimpressedwiththeprocessbecausethisisafieldin whichpeoplehavestrongopinionsonmanydifferentissues Whatimpressedmewasthattheparticipantsinthereview processwereopentohearingabroadrangeofopinionsbut intheendoptedforscientificrigorastheguidingfeatureon whichrecommendationswerebasedrdquo PeterRabinsMDMPH CoauthorThe 36 Hour Day

participateinthesortingtaskonlyBecausetheratingand sortingprocesswasanonymousexactfiguresonparticipation arenotavailablehoweverbasedonthenumberoftotal responses69persons(outof140or493)providedinput intoratingtheimportanceandactionpotentialofeach recommendationAdditionally23persons(outof30or 767)organizedtherecommendationsintocategoriesto identifythemesorpatternsMultivariatestatisticaltechniques wereusedtoorganizeandvisuallypresentresultsofthe onlineprocessinaseriesofconceptmapsthatreflected relationshipsbetweenrecommendationsandtheclustering ofrecommendationsintocategories

Step 3 encompassedthereviewandinterpretationofthe resultsofPhase2andselectionofpriorityrecommendashytionsMembersoftheSteeringCommitteereviewedthe mapstoensurethattherecommendationsineachoftheeight clusterswereconsistentwiththeoverallthemeofthatcluster

TheCommitteereconstructedafewrecommendations creatingtwoadditionalrecommendations(foratotalof 44recommendations)andintwoinstancesmovedrecomshymendationstoadifferentclusterThefinalclusterlabelsare

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

AsafinalsteptheSteeringCommitteechoseasetof priorityrecommendationsoractions



I background

II state of

knowledge

III strategic

framework

IV development

process

V actions by

cluster

VI next steps

Actions by Cluster TheRoadMapisaldquolivingrdquodocumentexpectedtoevolve overtimeSomeactionsareachievablewithin1to3years whileotherswillrequiremoretimetocometofruition Somearelinkedandneedtooccurinacertainsequence withtheoutcomesofthefirstsettingthestageforinitiating thenextAndwhilenoparticularagegroupissingledoutfor specialattentiontheRoadMapconcentratesprimarilyon

interventionsformiddle-agedandolderadultsThisfocus recognizesthatinterventionstoreducerisksarebestbegun earlyinlifeyetadultsparticularlyolderadultsaremore likelytobeconcernedandmotivatedtotakeaction

ThefullsetofRoadMapactionsfallintoeightclusters Withineachclustertheactionsarelistedinnospecialorder ofpriorityTheletterinparenthesesaftereachactionrefers

ActionsbyCluster

tothegroup(eitherworkgrouporSteeringCommittee) thatoriginallyproposedit(P=PreventionResearch C=CommunicationP=PolicyS=SurveillanceSC=Steering Committee)Alloftheactionsgeneratedbythegroups areincluded

Inofferingtheseactionswecannotunderestimatethe complexitiesoftranslatingthemintoactionMostessentialis acommitmenttobasethisRoadMaponscientificevidence movingforwardcollaborativelytoleverageexistingresources andactivitiesaspromotionactivitiesbecomedefinedKey partnershipsmustbeformedamongadiversearrayof organizationsandagenciestobuildoncollectivestrengths delivercompatiblemessagesandinterventionsandassure efficientuseofresourcesExistinghealthpromotion communitiesassociatedwithheartdiseasestrokediabetes andphysicalactivityareinvaluableresourcesforpromoting cognitivehealth

Disseminating information

1 Disseminate the latest science to increase public

understanding of cognitive health and to dispel

common misconceptions (SC) Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelping thepublictounderstandthevaryinglevelsofevidence behindproposedinterventionsregardingcognitivehealth Unlesscredibleandbroadreachinginformationabout validinterventionsincognitivehealthisdisseminated consumerswillfillthegapwithuntestedprogramsand productsNotonlycantheseprogramsandproducts presentaneconomicburdenbutsomemayalsodistract theagingpopulationfrommeaningfullifestylechanges Communicationsstrategies(includingtheappropriate communicationchannels)shouldbuilduponcurrent effortsbyvariousorganizationsandagenciestoshare existinginformationandmaterialsoncognitivehealth researchandpossibleinterventionsthatareconsistent withcurrentscience


2

3

Develop communications strategies and tools

to increase awareness among health care providers

public health professionals and aging service

providers at the national state and local levels about

the current state of science of cognitive health (C) Indisseminatinginformationtothepublicinformation mustbefilteredthroughtrustedhealthandcommunity resourcesProvidingprofessionalswithaccurateevidenceshybasedinformationandtoolswillrespondtothegrowing interestamongconsumersregardingquestionson preservingcognitivehealth

Develop and implement a training curricula

related to cognitive health for continuing

professional education of health and human

services professionals (P) Toincreasetheawarenessandknowledgeofprofessionals inhealthandhumanservicesstrategiesshouldbedeveloped inbothpreserviceandin-servicemodalitiesBringingnew professionalsintothefieldwithappropriateknowledge isnotenoughthelevelofunderstandingofpracticing professionalsmustalsoberaisedsothattheycanhelpthe publicsortoutevidence-basedapproachestocognitive healthfromlessprovenorundemonstratedoutcomes

4

5

Develop creative and replicable means for raising

the publicrsquos awareness of cognitive health and

engaging the public in promoting the importance

of cognitive health through policy (P) Thepublicplaysanimportantroleinstimulatingboth publicsectorandmarketplaceactiononissuesitfinds importantItisessentialthatthepublicbeeducated basedoncurrentscienceandknowledgeofbest practicesThiswillcontributetothedevelopmentof anewconventionalwisdomregardingcognitivehealth

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-shopgo-toplaceforvalidandtested informationwillprovideconsumersandprofessionals whoserveolderadultsandtheirfamilieswiththetools tomakeinformeddecisionsabouttheirhealthandeffect positivebehaviorchangeThesitewouldprovideguiding principlestohelpconsumersandhealthinformation providersandprofessionalstoevaluatelocalservices thataddresstheseconcernsandtomaintaincurrent


ActionsbyCluster

understandingaboutcognitivehealthandthese interventionsasthesciencebecomesmoresophisticated

Translating knowledge

1 Determine how diverse audiences think about

cognitive health and its associations with

lifestyle factors (R) Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelop usefulprogramsitwillbeimperativetobetterunderstand thediversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththe generalpublicandpractitionersincludehowcognition isdefinedandtranslatedwhataspectsofcognitivehealth areimportant(includingthelevelofknowledgeabout vascularfactors)andhowconcernedthegeneralpublic isaboutcognitivehealth

2 Help people understand the connection between risk

and protective factors and cognitive health(CSC) Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire

clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinother studiesOfprimaryinterestareaspectsofpersonaland environmentalexperiencesthatmakeitmorelikely(risk factors)orlesslikely(protectivefactors)thatpeoplewill experiencecognitivedeclineConsiderationshouldbe giventotheseconnectionsandtopromotingabetter understandingofitincludinganunderstandingofareas inwhichclinicaltrialshave(orhavenotyet)established acauseandeffectbetweenriskandprotectivefactorsand cognitivehealth

3 Develop a mechanism to review cognitive health

messages and programs to determine their

scientific accuracy and public credibility (C) Currentlythepublichasnosinglesourceofinformed andvalidrecommendationsforprogramsservicesand lifestylerelatedinterventionstoaddresspositivemeasures incognitivehealthCreatingasystemforreviewingthe growingnumberofprogramsandprovidingpublicaccess tothereviewsgeneratedwillmoveconsumerscloserto informeddecisionsandmorepositiveinvestmentsinhealth


Implementing policy

1 Initiate policy changes at the federal state and local

levels to promote cognitive health by engaging

public officials(P) Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesector alonewillbeinsufficienttoreachdesiredresultsBecause programandfundingdecisionsaremadebypolicymakers atthenationalstateandlocallevelsitisimportantto engageandeducatethisaudiencePublicofficialshave significantcompetinginterestsitisessentialthatthey becomeeducatedandengagedinthisarenatocontribute topositivepolicychangeincognitivehealthinterventions andtosupporttheneedforfurtherresearch

2 Include cognitive health in Healthy People 2020

a set of health objectives for the nation that will

serve as the foundation for state and community

public health plans (P) ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe


ActionsbyCluster

maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-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) Includingcognitivehealthinsuchdocumentsasthe State of Aging and Health in America Reportwouldelevate itsstatusasarecognizedpublichealthissueandmakedata readilyavailableforactionArmedwithimportantdata fromthisandothermonitoringsystemspublichealth professionalswillbepreparedtomovepolicyforwardto testinterventions

4 Promote appropriate strategic partnerships among

associations government agencies insurers and

payers private industry public organizations and

elected officials to support and advance research

and policy related to cognitive health (P) Partnershipscanhelptomaximizelimitedresources (fiscalandpersonnel)andcompetingpriorities

Theyshouldbebaseduponsuchcriteriaastheability toexamineevidence-basedresearchestablishon-going formsofdialoguebuildleadershipandcapacityrelated topolicyandpublicandprofessionaleducationaddress diverseculturalandethnicpopulationsprovidefunding andexplorethelinksbetweenthevascularfactors physicalactivityandcognitivehealth

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) Toachievebroadeffectivecollaborationsforcognitive healthandemotionalwell-beingnationalorganizations andagenciesmustidentifyandagreetocommon groundNationalorganizationsandagenciesareessential tobothreachinglargenumbersofindividualmenand womenandtousingtheirinfluencetoeducatepolicy makersandopinionleadersEducationofthepublicand leadersofkeyorganizationsisaprecursortopolicy changerelatedtocognitivehealth


6 Convene policy experts to identify and examine

current policies (eg national policy state

policy private sector policy) that could be

modified modernized or broadened to include

cognitive health(P) Policiesshouldbeamendedtoreflectcurrentscience andknowledgeandbeinclusiveofcognitivehealth Adjustingandamplifyingcurrentpoliciesareefficient andeconomicalroutestosystemschange

7 Promote the modification of existing national

and state public health plans to include cognitive

health in their strategies or recommendations

where appropriate(P) Nationalandstatepublichealthplanssignificantly influenceeffortsinpublichealthandserveasa barometerofimprovementAsinterventionsare demonstratedthatcanhaveaneffectoncognitive healthincludingitintheseplanswouldelevateits statusasarecognizedpublichealthissueandprovide avenuefortheevaluationofprogress

Conducting surveillance

1 Define the goals of a surveillance system to

promote the development of an appropriate system

and the collection of data on cognitive health (S) Clearlydefinedgoalsofpublichealthsurveillancewill promotethedevelopmentofappropriatesurveillance systemsandthecollectionofconsistentdatathatprovide usefulinformationtoinformpublichealthpolicyGoals ofthesurveillancesystemmayincludedefiningtheburden ofcognitivedeclineinthepopulationmonitoringthe trendsinburden(egprevalenceincidence)monitoring trendsinriskfactorsdefiningthepopulationatincreased riskanddeterminingwhetheradditionalanalysesshould beperformedforthepurposeofpublichealthsurveillance

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(eg BehavioralRiskFactorSurveillanceSystemHealthand RetirementStudyNationalHealthInterviewSurvey)to


ActionsbyCluster

addressissuesrelatedtocognitivedeclineislesscostlyand maybemoreefficientthandevelopingnewsurveillance systemsHoweverthereareimportantlimitationsofexisting systemsandthedatatheycollectinparticularmostarecross sectionalratherthanlongitudinalManyarealreadyquite lengthywithmajorconstraintsonaddingnewitems Closeexaminationofthesesystemswillensurethatthey areamendedappropriatelyandcost-effectively

3 Identify existing studies that measure longitudinal

trends in cognitive function(S) Existinglargecohortorotherlongitudinalstudiesof cognitivedeclinemayprovideitemsthatcouldbe incorporatedintosurveillancesystemsformeasuringsuch declineSomeofthesestudiesmayhavevalidateditems usedpreviouslyinbothmajorityandminoritypopulations thatestimatevariabilityandtruechangeovertime

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-basedsurveillancesystemwouldassistin thecollectionofconsistentdatatomonitorassessand

informpublichealthprogramsandpolicyaboutthe publichealthburdenofcognitiveimpairment

Moving research into practice

1 Conduct systematic literature reviews on proposed

risk factors (vascular risk and physical inactivity)

and related interventions for relationships with

cognitive health harms gaps and effectiveness (R) Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice


risk factors (social engagement nutrition

and mental activity) and related interventions

relationships with cognitive health harms gaps

and effectiveness(RSC)


Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice

3 Conduct a systematic literature review on the

relationship between treatment of diabetes and

cognitive health (R) Someevidencesuggeststhatdiabetesisariskfactorfor cognitivedeclineRecommendationsfortypesofdiabetes management(egmedicationslifestylemodification)that mightalsobebeneficialforcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatingdiabetes interventionstocognitivechange(andmostlikely undertakingadditionalclinicaltrials)andidentificationof areasthatneedtobeclarifiedbeforespecificinterventions canbeproposed


relationship between treatment of hypertension

and cognitive health(R) Hypertensionisaknownriskfactorforstrokeand thereforeforvasculardementiaandcognitivedecline Recommendationsfortypesofantihypertensivetherapy andtherangesofbloodpressurefordifferentagegroups recommendedformaintainingcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatinghypertensive interventionstocognitivechangeandprobablynot withoutpursuingadditionalclinicaltrialsThesystematic literaturereviewwouldidentifyareasthatneedtobe clarifiedbeforespecificinterventionscanberecommended

5 Identify gaps in knowledge about cognitive health

and related lifestyle changes and determine


ActionsbyCluster

whether these vary by specific groups (C) Todevelopappropriatematerialsandtoolsthegapsin

knowledgeneedtobeunderstoodespeciallyamong high-riskpopulationsvulnerablepopulationsandhealth careproviders Specificracialorethnicgroupsmayneed tohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheyareatgreaterriskfor experiencingcognitivedeclineHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthe generalpublicbecausetheyarealsoprovidinginformation toothersaboutcognitivehealth

6 Conduct a systematic review of lifestyle interventions

and contextual factors to examine the benefits and

barriers to their adoption and maintenance (R) Understandingthebenefitsofandbarrierstoadopting andmaintaininganinterventionisoneofthecriticalsteps fortranslatinginterventionseffectivelyandefficaciouslyin acommunity-basedsetting

7 Conduct reviews of the literature to determine

the prescriptions for physical activity (eg type

frequency duration and intensity of activity) that

are effective in enhancing cognitive function(R) Itisimportanttoknowwhatkindsofphysicalactivity stimuliarenecessarytopromotecognitivehealthAn examinationofthescientificliteraturewillidentifygaps inknowledgeandfocusresearchWithoutsuchinformation andresearchdevelopmentaccurateadvicecannotbe conveyedtothepubliconhowactivetheyshouldbeto maintaintheircognitivehealth

8 Develop cognitive health interventions that

reflect the most current scientific research and

that are consistent with effective community-

based interventions (CSC) Clinicaltrialsassessingtheefficacyofinterventionsto effectcognitivefunctionandpublichealthstudies examiningtheeffectivenessandfeasibilityofcommunity-basedinterventionsareoftenreportedseparatelyMore comprehensiveapproachesinvolvingcollaborations betweenclinicalresearchersandcommunityparticipatory researchersarecriticaltoensurethattheeffectivenessand feasibilityofcognitivehealthinterventionsaredeveloped andtestedwithvariouscommunities


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) Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy


effect of physical activity on reducing the risk of cogshy

nitive decline and improving cognitive function (R) Todatefewifanyphysicalactivitystudies(including large-scalecontrolledclinicaltrialsofolderadultcohorts) havecombinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy

3 Conduct physical activity studies to determine the

long-term benefit of physical activity as it relates

to cognitive function (R) Todatestudiesofphysicalactivityinterventionsthathave assessedcognitiveoutcomestypicallyhavenofollow-upat alloronlyashortfollow-upStudiesofphysicalactivity

areneededtodeterminetowhatextentanycognitive benefitsassociatedwithphysicalactivitypersistacrosslongshytermfollow-upat6month1yearorlongertimeperiods Long-termfollow-upstudiesofphysicalactivityarealso neededtodeterminethedurationofcognitiveeffectsin thosewhostoptheprogram

4 Conduct studies to determine the physical activity

prescription (eg type of activity frequency

duration and intensity) needed to maintain or

promote cognitive functioning (R) Smallclinicaltrialshaveshownthataerobicactivity (egwalkingseveraltimesaweekfor6monthsduration) wascapableofproducingcognitiveimprovementin olderadultsatleastintheshorttermThesefewstudies howeverhaveyettoyieldaldquoprescriptionrdquothatcould begiventoolderadultsthusmanyquestionsremain tobeansweredaboutthetypesofactivity(egaerobic oranaerobicindividualorgroup)andtheirduration intensityandfrequencythatareneededtomaintainor evengaingoodcognitivefunction

5 Conduct studies to determine the effect of physical

activity and physical activity relapse on persons of


ActionsbyCluster

different backgrounds in relation to cognition (R) Similartothepharmacogeneticsapproachthathasbeen usedtodeterminetheefficacyofspecificdrugsforpersons withcertaingenotypesitseemspossiblethatrecomshymendationsforbehavioralinterventionssuchasphysical activitymightbecraftedtoanindividualpersonrsquos background(eggeneticendowmentculturalcontext lifehistoriesfitnesslevelsandage)

6 Identify how physical activity relates to those

aspects of cognitive functioning that are important

to the successful performance of activities of daily

living and instrumental activities of daily living(R) Itisimportanttounderstandhowanycognitivebenefit measuredinthelaboratorytranslatestobetterfunctioning inrealworldtasksAlthoughwell-controlledlaboratory studiesareessentialtoadvancingknowledgeinthisarea itiscurrentlynotclearhowmuchthecognitivetasks assessedinthesestudieswillgeneralizetothecognitive functioningrequiredinroutinedailyactivitiesimportantto olderadultssuchasbalancingacheckbooksafelydriving acarandcompliancewithprescriptionsformedications (ieknowinghowmanyorwhatpillstotakewhen)

7 Determine the feasibility of conducting secondary

analyses of existing studies to examine the

relationship between physical activity and the

maintenance of cognition (R) Itisrecognizedthatsecondaryanalysesofexistingdata setsoftenpossessmethodologicalproblems(including crosssectionaldata)Neverthelessdatasets(perhapseven somerepresentativeoftheUSpopulation)mayexistthat containvariablesrelatedtocognitivefunctioninghealth andphysicalactivityEffortstolocatesuchdataandto evaluateresearchquestionsandassociationsamongthe variablesmayprovideadditionalinsightsintothisarea

8 Identify the mechanisms that may mediate

the relationship between physical activity and

cognitive functioning(R) Physicalactivitymaynotaffectcognitivefunctiondirectly butitmaystillaffectitthroughintermediatemechanisms Itisimportanttoknowwhethertheassociationbetween physicalactivityandcognitivefunctioningismediated bychangesindiabetesoutcomesinvascularfitness outcomesorinriskfactorssuchashypertension orhyperlipidemia


9 Encourage cardiovascular disease and diabetes

researchers to use appropriate measures addressing

cognitive domains as outcomes in their studies(R) Thebestwaytounderstandwhichinterventionsin cardiovasculardisease anddiabeteswillaffectcognitive healthisforappropriateaspectsofcognitivemeasurestobe routinelyincludedinappropriatestudiesinthesetwoareas

10 Encourage research to determine the impact of

multiple vascular risks on cognition (R) Specificfocusisneededtobothunderstandthebiology ofhowvascularriskfactorsaffectcognitionandto determinewhethertheeffectsofhavingmultiplefactors areadditiveormultiplicative Someobservationalstudies havesuggestedthatthegreaterthenumberofvascular riskfactorsthegreaterthecognitivedeficitWeknow howeverthatclinicaltrialswithpharmacologicalagents thatcontrolindividualriskfactorshaveeffectivelyreduced vascularriskbuthavenotconsistentlyproducedcognitive benefitAbetterunderstandingofthemechanismsby whichmultiplevascularriskfactorsmaycontributeto cognitivedeficitscouldidentifytargetsforinterventionsto

reverseorreducethedeficitThebiologicalmechanisms oftheinteractionamongriskfactorsaswellasmodelsof thesizeoftheinteractioneffectoncognitionwouldassist indesigningtrialsofpotentiallyeffectiveinterventions

11 Conduct research on other areas potentially

affecting cognitive health such as nutrition mental

activity and social engagement (R) Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges


ActionsbyCluster

Measuring cognitive impairment and burden Usefulmeasurablecomponentsareexpectedtodiffer

1 Identify thresholds for cognitive decline that have

functional importance for population-based

surveillance systems (S) Itisimportanttorecognizepointsonthecontinuum ofcognitivedeclinethatarefunctionallymeaningful Itshouldalsoberecognizedthatmeasurementsbeyond somepointsonthiscontinuummayrequireinformation fromproxyrespondentsUsefulcomparisonsoffindings fromdifferentsurveillancesystemsandresearchstudiesare improvedifthereisconsistencyamongthethresholds beingusedFunctionallyimportantthresholdsshouldbe ofpracticalsignificancetohelpinformpublichealth policyregardingneedsforcaregiversupportandother specialhealthcareorsocialservices

2 Identify critical dimensions of cognition and the

most appropriate corresponding measures that

may be useful in surveillance systems (S) Itisimportanttoknowthekeycomponentsofcognition (egmemoryintelligenceproblemsolvingandreasoning) thataremostsensitiveandspecifictocognitivedecline andpracticallymeasurableinsurveillancesystems

accordingtothenatureofthesurveillancesystem particularlywhetherdatacollectionislongitudinal orcross-sectionalWithcrosssectionaldataalone fewerinferencesarepossibleregardingage-related cognitivedecline

3 Identify measures of the public health burden

of cognitive impairment on individual people

families and communities(SC) Thepublichealthburdenofcognitiveimpairment encompassesitseffectsonindividualmenandwomen caregiversfamiliesemployersandothersinthe communityTheseeffectsmayhavephysicalmental socialandeconomicdimensionsItisimportantto identifykeymeasurablecomponentsoftheseeffectsto enablethepublichealthburdentobefullyassessed monitoredanddescribed

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)


Thesequestionsmightexistwithinanongoing population-basedsurveillancesystemortheycould beaddedtosuchasystemTotheextentpossible education-andculture-independentmeasuresshould besoughtBecausetheeffectsofeducationandculture arepotentialconfoundersmeasuresandanalytic techniquesareneededthatwouldenablereduced cognitivefunctiontobedistinguishedfromlow performanceduetovariationsineducationalorcultural exposuresItiscriticaltorecognizeandcorrectthese confoundingeffectssoastoavoidmisinterpretingor misusingsurveillancedata

Developing capacity

1 Engage the private sector and other entities in

planning and funding research to address ways to

maintain and improve cognitive health including

clinical trials (R) Supportofresearchoncognitivehealthisexpensivein scopeeffortandcostPartnershipswithfederalagencies foundationsandotherentitieswilllikelybenecessaryto securesuchsupportandconductthisresearch

2 Convene researchers and community interventionshy

ists conducting interventions on risk and protective

factors to identify potential mechanisms to advance

the work in the field of cognitive health(R) Thefieldsofcardiovasculardiseasedepressiondiabetes andcognitionarebeginningtointersectAfterconducting literaturereviewsonwhatiscurrentlyknownaboutthe effectsofinterventionstargetingvascular factorsdepression anddiabetesoncognitivehealthresearchersand communityinterventionistsineachofthesefieldsshould beconvenedtodeterminestrategiesformovingthefield ofcognitivehealthforward



IV development

process

V actions by

cluster

VI next steps

III strategic

framework

II state of

knowledge

I background

NextSteps Priorities for action

Whilewebelievethatalloftheactionspresentedinthis RoadMapareimportantwearemindfulofthelimitedpool ofresourceswithwhichtoimplementthemBecauseof thisrealityweselected10actionsofhighestpriorityfor immediateattention

NextSteps

bull Determine how diverse audiences think about


lifestyle factors

Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelopuseful programsitwillbeimperativetobetterunderstandthe diversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththegeneral publicandpractitionersincludehowcognitionisdefined andtranslatedwhataspectsofcognitivehealthareimportant (includingthelevelofknowledgeaboutvascularfactors)and howconcernedthegeneralpublicisaboutcognitivehealth

bull Disseminate the latest science to increase public


common misconceptions

Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelpingthe publictounderstandthevaryinglevelsofevidencebehind proposedinterventionsregardingcognitivehealthUnless credibleandbroadreachinginformationaboutvalid

interventionsincognitivehealthisdisseminatedconsumers willfillthegapwithuntestedprogramsandproductsNot onlycantheseprogramsandproductspresentaneconomic burdenbutsomemayalsodistracttheagingpopulation frommeaningfullifestylechangesCommunications strategies(includingtheappropriatecommunication channels)shouldbuilduponcurrenteffortsbyvarious organizationsandagenciestoshareexistinginformation andmaterialsoncognitivehealthresearchandpossible interventionsthatareconsistentwithcurrentscience

bull Help people understand the connection between

risk and protective factors and cognitive health

Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinotherstudies Ofprimaryinterestareaspectsofpersonalandenvironmental experiencesthatmakeitmorelikely(riskfactors)orless likely(protectivefactors)thatpeoplewillexperience cognitivedeclineConsiderationshouldbegiventothese connectionsandtopromotingabetterunderstandingofit includinganunderstandingofareasinwhichclinicaltrials


have(orhavenotyet)establishedacauseandeffectbetween riskandprotectivefactorsandcognitivehealth

bull 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

Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbedocumented andremaininggapsinthefieldshouldbeidentifiedin ordertomovestrategiesintopublichealthpractice

bull Conduct controlled clinical trials to determine the



cognitive function

Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy


effect of physical activity on reducing the risk of

cognitive decline and improving cognitive function

Todatefewifanyphysicalactivitystudies(includinglargeshyscalecontrolledclinicaltrialsofolderadultcohorts)have combinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy

bull Conduct research on other areas potentially affecting

cognitive health such as nutrition mental activity

and social engagement

Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges

bull 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-basedsurveillancesystemwouldassistinthe collectionofconsistentdatatomonitorassessandinform


NextSteps

publichealthprogramsandpolicyaboutthepublichealth burdenofcognitiveimpairment

bull Initiate policy changes at the federal state and local


public officials

Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesectoralone willbeinsufficienttoreachdesiredresultsBecauseprogram andfundingdecisionsaremadebypolicymakersatthe nationalstateandlocallevelsitisimportanttoengage andeducatethisaudiencePublicofficialshavesignificant competinginterestsitisessentialthattheybecomeeducated andengagedinthisarenatocontributetopositivepolicy changeincognitivehealthinterventionsandtosupport theneedforfurtherresearch

bull 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 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020

Theseprioritiescutacrosstheclustersandasapackage wouldputourldquobestfootforwardrdquoinmeetingthepublic healthchallengesofcognitivehealthThepriorityactionsput forthrepresentthebestthinkingofleadingexpertsacross diversefieldsofinfluenceTheyhavebeenidentifiedasones thatarenecessarytomovingtheissueofcognitivehealth intopublichealthpracticeWeurgethenationtoadoptthese 10actionsandtojoinforcesinimplementingthemover thenext3-5yearsDoingsowouldbemakingtremendous stridestowardsachievingourlong-termvisionmaintaining orimprovingthecognitiveperformanceofalladults


Implementation

Effectiveimplementationoftheactionsoutlinedinthis RoadMaphingesonseveralfactors

bull Organizationswillneedtoidentifyclearlywhichactions theywishtoaddressandcollaboratewithothergroupsthat shareaninterestinthoseactions

bull Organizationsshoulddevelopandstrengthenpartnerships withotherlike-mindedorganizations

bull Organizationsshoulddeveloptheirownplanstoachieve theirselectedactions

bull Organizationsshouldestablishsystemstotracktheir progresstowardscompletingtheirplansofactionandto facilitatecommunicationandexchangeofinformation

Asthescienceofcognitivehealthiscontinuallyevolvingthe RoadMapshouldbeviewedasalivingdocumentthatcontains awiderangeofactionsonhowtoproceedAsweachievesome oftheactionswecanusetheRoadMaptomoveforwardand addressotheractionsthatbecomerelevantandfeasible

Conclusion

ThisRoadMapcomesatacriticaltimewhenscientificinterest incognitivehealthisbeginningtomeettheburgeoningdemand ofthepublicforwaystomaintaincognitivefunctionItsetsin motionacourseofactionforestablishingpartnershipsmaking cognitivehealthaprominentpublichealthissueandpreparing societyforconcertedeffortstomaintainingthecognitive healthofolderAmericans

TheRoadMapisbothacalltoactionandaguideforimpleshymentinganeffectivecoordinatedapproachtomovingcognitive healthintopublichealthpracticeThekeytosuccessliesin continuingandexpandingresearchdevelopingandchanneling resourcesandworkingcollaborativelytomovetheevidence aboutmaintainingcognitivehealthintonationalaction



AppendixAContributors

Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine

FrankBaileyJD AARP

DianeBazelides Alzheimerrsquos Association National Board

VickyCahan National Institutes of Health

NancyCeridwyn American Society on Aging

MarthaDiSario Pacific Communications Enterprises

BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives

JeffMcKenna Centers for Disease Control and Prevention

MichaelCPatterson AARP

DeloresPlutoPhD University of South Carolina

MarySchwartzMS Alzheimerrsquos Association

BobRosenblatt National Academy of Social Insurance

Policy Workgroup WilliamFBenson Health Benefits ABCrsquos

JoyCameron National Governors Association

IrisFreeman Advocacy Strategy

KathrynGallagher Centers for Disease Control and Prevention

RobynGoldenLCSW Rush University Medical Center

CatherineGordonRNMBA Centers for Disease Control and Prevention

MaryGuthrie Administration on Aging

DavidHoffmanMEd New York State Department of Health

JimHoward California Department of Health Services


StephenMcConnellPhD Alzheimerrsquos Association

SandyMarkwood National Association for Area Agencies on Aging

MarkSchoeberl American Heart Association

PaulTibbitsJr American Diabetes Association

Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions

MargaretGatzPhD University of Southern California

JNeilHendersonPhD University of Oklahoma Health Sciences Center

KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania

RhondaMontgomeryPhD University of Wisconsin - Milwaukee



MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine

JesusSoaresMScScD Emory University Centers for Disease Control and Prevention

WilliamThiesPhD Alzheimerrsquos Association

BarbaraVickreyMDMPH University of California at Los Angeles

MollyWagsterPhD National Institute on Aging

NancyWhitelawPhD National Council On Aging

ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention

KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center

Surveillance Workgroup DallasAndersonPhD National Institute of Aging


WalterldquoBudrdquoKukullPhD University of Washington

JamesNLaditkaDAPhDMPA University of South Carolina

KennethMLangaMDPhD University of Michigan

EricBLarsonMDMPH Group Health Center for Health Studies

LenoreLaunerPhD National Institute on Aging

LisaCMcGuirePhD Centers for Disease Control and Prevention

DanMungasPhD University of California Davis

NathaliedeRekeneireMDMS Centers for Disease Control and Prevention

PaulScherrPhDDSc Centers for Disease Control and Prevention

DavidThurmanMD Centers for Disease Control and Prevention

Centers for Disease Control and Prevention and the Alzheimerrsquos Association |


Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations

RobertBlancatoMPA Matz Blancato amp Associates Inc

AmyRBorensteinPhD University of South Florida

JohnCSBreitnerMDMPH University of Washington

CarolBryantPhD University of South Florida

CarlCaspersenPhD Centers for Disease Control and Prevention

WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign

JamesCooperMD George Washington University School of Medicine

CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine

RodDishmanPhD University of Georgia

CharlesFEmeryPhD Ohio State University

PaulEstabrooksPhD Kaiser Permanente-Colorado

JenniferLEtnierPhD University of North Carolina at Greensboro

DenisAEvansMD Rush Institute for Healthy Aging Rush University

JeffFinn American Society on Aging

PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco

MaryGanguliMDMPH University of Pittsburgh School of Medicine

FrancineGrodsteinScD Harvard Medical School

BradleyDHatfieldPhD University of Maryland

MichaelJohnson OBC Group LLC

ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign

DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention

MichaelWLinkPhD Centers for Disease Control and Prevention

NancyBEmersonLombardoPhD Boston University School of Medicine

EdwardMcAuleyPhD University of Illinois at Urbana-Champaign

GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University

ToniPMilesMDPhD University of Louisville

MarkMossPhD Boston University School of Medicine

MarciaOryPhDMPH The Texas AampM University System Health Science Center

RonaldCPetersenPhDMD Mayo Clinic College of Medicine

ScottLParkin National Council on Aging

TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago

StephanieRamsey Centers for Disease Control and Prevention

GeorgeWRebokPhD Johns Hopkins University

WalterARoccaMDMPH Mayo Clinic College of Medicine

KenRockwoodMDFRCPC Dalhousie University

GailShearer Consumers Union

PhillipDTomporowskiPhD University of Georgia

TerrieFoxWetlePhD Brown University

PeterZandiPhDMPHMHS Johns Hopkins University

Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention

MarkConner Northrop Grumman Centers for Disease Control and Prevention

KristineLDayMPH Centers for Disease Control and Prevention

SheilaJackMUPMSJ Alzheimerrsquos Association

BrendaPepe Concept Systems Inc

PeterReedPhDMPH Alzheimerrsquos Association

WalkerTisdaleMPH Alzheimerrsquos Association

SusanToalMPH Public Health WriterEditor

CatherineVanBrunschot Concept Systems Inc



AppendixBReferences

1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9

2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000

3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32

4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004

5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007

6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32

7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp

8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm

9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st

centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)

ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf

11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4

12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92

13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22

14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6

15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12

16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62

17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003

18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94

19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4

20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf

21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2

22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43

23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051


25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm


27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf

28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2


30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94


AppendixBReferences

31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002


33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5

34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14

35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8

36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998

37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243

38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9

39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11

40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov

41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj

42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000

43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998

44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6

45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007

46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy


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 peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability

Alzheimerrsquos Association

The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos 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 Alzheimerrsquos

Table of Contents

Acknowledgements

p01 | Executive Summary

p04 | I Background

p05 | What is cognitive health

p07 | Why prepare a Road Map

p12 | Why is it importantmdashand why now

p16 | II State of Knowledge

p17 | What do we know

p18 | What gaps exist

p19 | How can public health contribute

p22 | III Strategic Framework

p23 | What is our model for action

p25 | What principles do we embrace

p26 | What do we hope to accomplish

p28 | IV Development Process

p29 | Workgroup deliberations

p34 | Concept-mapping process

p36 | V Actions by Cluster

p38 | Disseminating information

p40 | Translating knowledge

p41 | Implementing policy

p43 | Conducting surveillance

p44 | Moving research into practice

p47 | Conducting intervention research

p50 | Measuring cognitive impairment and burden

p51 | Developing capacity

p52 | VI Next Steps

p53 | Priorities for action

p57 | Implementation

p57 | Conclusion

p58 | Appendix A Contributors

p62 | Appendix B References

TheHealthyBrainInitiative A National Public Health Road Map to Maintaining Cognitive Health

TableofContents

Acknowledgements

Executive Summary 1

I Background 4 Whatiscognitivehealth 5 WhyprepareaRoadMap 7 Whyisitimportantmdashandwhynow 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

Suggested Citation CentersforDiseaseControlandPreventionandtheAlzheimerrsquos AssociationTheHealthyBrainInitiativeANationalPublicHealthRoadMapto MaintainingCognitiveHealthChicagoILAlzheimerrsquosAssociation2007

Availableatwwwcdcgovagingandwwwalzorg

Centers for Disease Control and Prevention and the Alzheimerrsquos Association

Acknowledgements




FrankBaileyJD AARP












ExecutiveSummary








ExecutiveSummary















IV development

process

V actions by

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VI next steps

III strategic

framework

II state of

knowledge

I background




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I background

IV development

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VI next steps

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What gaps exist
















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IV development

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bull Besciencebased






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IV development

process

V actions by

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VI next steps




ActionsbyCluster








2

3










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5











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Implementing policy









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Developing capacity











IV development

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V actions by

cluster

VI next steps

III strategic

framework

II state of

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I background



NextSteps



lifestyle factors




















cognitive function













the United States



NextSteps




public officials





health plans




Implementation







Conclusion







FrankBaileyJD AARP









































































































AppendixBReferences

































AppendixBReferences






















Table of Contents

Acknowledgements


p04 | I Background
























p52 | VI Next Steps



p57 | Conclusion



Acknowledgements




FrankBaileyJD AARP












ExecutiveSummary








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IV development

process

V actions by

cluster

VI next steps

III strategic

framework

II state of

knowledge

I background




Background













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Thispartnership











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I background

IV development

process

V actions by

cluster

VI next steps

III strategic

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II state of

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What gaps exist
















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I background

II state of

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IV development

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V actions by

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VI next steps

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Long Range Outcomes



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IV development

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III strategic

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II state of

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I background

V actions by

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VI next steps





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bull Besciencebased






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I background

II state of

knowledge

III strategic

framework

IV development

process

V actions by

cluster

VI next steps




ActionsbyCluster








2

3










4

5











ActionsbyCluster













Implementing policy









ActionsbyCluster



































ActionsbyCluster






























ActionsbyCluster


































ActionsbyCluster
























ActionsbyCluster



















Developing capacity











IV development

process

V actions by

cluster

VI next steps

III strategic

framework

II state of

knowledge

I background



NextSteps



lifestyle factors




















cognitive function













the United States



NextSteps




public officials





health plans




Implementation







Conclusion







FrankBaileyJD AARP









































































































AppendixBReferences

































AppendixBReferences






















Table of Contents

Acknowledgements


p04 | I Background
























p52 | VI Next Steps



p57 | Conclusion




ExecutiveSummary








ExecutiveSummary















IV development

process

V actions by

cluster

VI next steps

III strategic

framework

II state of

knowledge

I background




Background













Background


Thispartnership











Background












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Background












I background

IV development

process

V actions by

cluster

VI next steps

III strategic

framework

II state of

knowledge




StateofKnowledge










What gaps exist
















StateofKnowledge












I background

II state of

knowledge

IV development

process

V actions by

cluster

VI next steps

III strategic

framework





StrategicFramework



Long Range Outcomes



partnerships etc)












StrategicFramework
























IV development

process

III strategic

framework

II state of

knowledge

I background

V actions by

cluster

VI next steps





DevelopmentProcess










DevelopmentProcess













bull Besciencebased






DevelopmentProcess


















I background

II state of

knowledge

III strategic

framework

IV development

process

V actions by

cluster

VI next steps




ActionsbyCluster








2

3










4

5











ActionsbyCluster













Implementing policy









ActionsbyCluster



































ActionsbyCluster






























ActionsbyCluster


































ActionsbyCluster
























ActionsbyCluster



















Developing capacity











IV development

process

V actions by

cluster

VI next steps

III strategic

framework

II state of

knowledge

I background



NextSteps



lifestyle factors




















cognitive function













the United States



NextSteps




public officials





health plans




Implementation







Conclusion







FrankBaileyJD AARP









































































































AppendixBReferences

































AppendixBReferences






















Table of Contents

Acknowledgements


p04 | I Background
























p52 | VI Next Steps



p57 | Conclusion



ExecutiveSummary















IV development

process

V actions by

cluster

VI next steps

III strategic

framework

II state of

knowledge

I background




Background













Background


Thispartnership











Background












Background














Background












I background

IV development

process

V actions by

cluster

VI next steps

III strategic

framework

II state of

knowledge




StateofKnowledge










What gaps exist
















StateofKnowledge












I background

II state of

knowledge

IV development

process

V actions by

cluster

VI next steps

III strategic

framework





StrategicFramework



Long Range Outcomes



partnerships etc)












StrategicFramework
























IV development

process

III strategic

framework

II state of

knowledge

I background

V actions by

cluster

VI next steps





DevelopmentProcess










DevelopmentProcess













bull Besciencebased






DevelopmentProcess


















I background

II state of

knowledge

III strategic

framework

IV development

process

V actions by

cluster

VI next steps




ActionsbyCluster








2

3










4

5











ActionsbyCluster













Implementing policy









ActionsbyCluster



































ActionsbyCluster






























ActionsbyCluster


































ActionsbyCluster
























ActionsbyCluster



















Developing capacity











IV development

process

V actions by

cluster

VI next steps

III strategic

framework

II state of

knowledge

I background



NextSteps



lifestyle factors




















cognitive function













the United States



NextSteps




public officials





health plans




Implementation







Conclusion







FrankBaileyJD AARP









































































































AppendixBReferences

































AppendixBReferences






















Table of Contents

Acknowledgements


p04 | I Background
























p52 | VI Next Steps



p57 | Conclusion




IV development

process

V actions by

cluster

VI next steps

III strategic

framework

II state of

knowledge

I background




Background













Background


Thispartnership











Background












Background














Background












I background

IV development

process

V actions by

cluster

VI next steps

III strategic

framework

II state of

knowledge




StateofKnowledge










What gaps exist
















StateofKnowledge












I background

II state of

knowledge

IV development

process

V actions by

cluster

VI next steps

III strategic

framework





StrategicFramework



Long Range Outcomes



partnerships etc)












StrategicFramework
























IV development

process

III strategic

framework

II state of

knowledge

I background

V actions by

cluster

VI next steps





DevelopmentProcess










DevelopmentProcess













bull Besciencebased






DevelopmentProcess


















I background

II state of

knowledge

III strategic

framework

IV development

process

V actions by

cluster

VI next steps




ActionsbyCluster








2

3










4

5











ActionsbyCluster













Implementing policy









ActionsbyCluster



































ActionsbyCluster






























ActionsbyCluster


































ActionsbyCluster
























ActionsbyCluster



















Developing capacity











IV development

process

V actions by

cluster

VI next steps

III strategic

framework

II state of

knowledge

I background



NextSteps



lifestyle factors




















cognitive function













the United States



NextSteps




public officials





health plans




Implementation







Conclusion







FrankBaileyJD AARP









































































































AppendixBReferences

































AppendixBReferences






















Table of Contents

Acknowledgements


p04 | I Background
























p52 | VI Next Steps



p57 | Conclusion



Background













Background


Thispartnership











Background












Background














Background












I background

IV development

process

V actions by

cluster

VI next steps

III strategic

framework

II state of

knowledge




StateofKnowledge










What gaps exist
















StateofKnowledge












I background

II state of

knowledge

IV development

process

V actions by

cluster

VI next steps

III strategic

framework





StrategicFramework



Long Range Outcomes



partnerships etc)












StrategicFramework
























IV development

process

III strategic

framework

II state of

knowledge

I background

V actions by

cluster

VI next steps





DevelopmentProcess










DevelopmentProcess













bull Besciencebased






DevelopmentProcess


















I background

II state of

knowledge

III strategic

framework

IV development

process

V actions by

cluster

VI next steps




ActionsbyCluster








2

3










4

5











ActionsbyCluster













Implementing policy









ActionsbyCluster



































ActionsbyCluster






























ActionsbyCluster


































ActionsbyCluster
























ActionsbyCluster



















Developing capacity











IV development

process

V actions by

cluster

VI next steps

III strategic

framework

II state of

knowledge

I background



NextSteps



lifestyle factors




















cognitive function













the United States



NextSteps




public officials





health plans




Implementation







Conclusion







FrankBaileyJD AARP









































































































AppendixBReferences

































AppendixBReferences






















Table of Contents

Acknowledgements


p04 | I Background
























p52 | VI Next Steps



p57 | Conclusion








Background


Thispartnership











Background












Background














Background












I background

IV development

process

V actions by

cluster

VI next steps

III strategic

framework

II state of

knowledge




StateofKnowledge










What gaps exist
















StateofKnowledge












I background

II state of

knowledge

IV development

process

V actions by

cluster

VI next steps

III strategic

framework





StrategicFramework



Long Range Outcomes



partnerships etc)












StrategicFramework
























IV development

process

III strategic

framework

II state of

knowledge

I background

V actions by

cluster

VI next steps





DevelopmentProcess










DevelopmentProcess













bull Besciencebased






DevelopmentProcess


















I background

II state of

knowledge

III strategic

framework

IV development

process

V actions by

cluster

VI next steps




ActionsbyCluster








2

3










4

5











ActionsbyCluster













Implementing policy









ActionsbyCluster



































ActionsbyCluster






























ActionsbyCluster


































ActionsbyCluster
























ActionsbyCluster



















Developing capacity











IV development

process

V actions by

cluster

VI next steps

III strategic

framework

II state of

knowledge

I background



NextSteps



lifestyle factors




















cognitive function













the United States



NextSteps




public officials





health plans




Implementation







Conclusion







FrankBaileyJD AARP









































































































AppendixBReferences

































AppendixBReferences






















Table of Contents

Acknowledgements


p04 | I Background
























p52 | VI Next Steps



p57 | Conclusion







Background












Background














Background












I background

IV development

process

V actions by

cluster

VI next steps

III strategic

framework

II state of

knowledge




StateofKnowledge










What gaps exist
















StateofKnowledge












I background

II state of

knowledge

IV development

process

V actions by

cluster

VI next steps

III strategic

framework





StrategicFramework



Long Range Outcomes



partnerships etc)












StrategicFramework
























IV development

process

III strategic

framework

II state of

knowledge

I background

V actions by

cluster

VI next steps





DevelopmentProcess










DevelopmentProcess













bull Besciencebased






DevelopmentProcess


















I background

II state of

knowledge

III strategic

framework

IV development

process

V actions by

cluster

VI next steps




ActionsbyCluster








2

3










4

5











ActionsbyCluster













Implementing policy









ActionsbyCluster



































ActionsbyCluster






























ActionsbyCluster


































ActionsbyCluster
























ActionsbyCluster



















Developing capacity











IV development

process

V actions by

cluster

VI next steps

III strategic

framework

II state of

knowledge

I background



NextSteps



lifestyle factors




















cognitive function













the United States



NextSteps




public officials





health plans




Implementation







Conclusion







FrankBaileyJD AARP









































































































AppendixBReferences

































AppendixBReferences






















Table of Contents

Acknowledgements


p04 | I Background
























p52 | VI Next Steps



p57 | Conclusion








Background














Background












I background

IV development

process

V actions by

cluster

VI next steps

III strategic

framework

II state of

knowledge




StateofKnowledge










What gaps exist
















StateofKnowledge












I background

II state of

knowledge

IV development

process

V actions by

cluster

VI next steps

III strategic

framework





StrategicFramework



Long Range Outcomes



partnerships etc)












StrategicFramework
























IV development

process

III strategic

framework

II state of

knowledge

I background

V actions by

cluster

VI next steps





DevelopmentProcess










DevelopmentProcess













bull Besciencebased






DevelopmentProcess


















I background

II state of

knowledge

III strategic

framework

IV development

process

V actions by

cluster

VI next steps




ActionsbyCluster








2

3










4

5











ActionsbyCluster













Implementing policy









ActionsbyCluster



































ActionsbyCluster






























ActionsbyCluster


































ActionsbyCluster
























ActionsbyCluster



















Developing capacity











IV development

process

V actions by

cluster

VI next steps

III strategic

framework

II state of

knowledge

I background



NextSteps



lifestyle factors




















cognitive function













the United States



NextSteps




public officials





health plans




Implementation







Conclusion







FrankBaileyJD AARP









































































































AppendixBReferences

































AppendixBReferences






















Table of Contents

Acknowledgements


p04 | I Background
























p52 | VI Next Steps



p57 | Conclusion








Background












I background

IV development

process

V actions by

cluster

VI next steps

III strategic

framework

II state of

knowledge




StateofKnowledge










What gaps exist
















StateofKnowledge












I background

II state of

knowledge

IV development

process

V actions by

cluster

VI next steps

III strategic

framework





StrategicFramework



Long Range Outcomes



partnerships etc)












StrategicFramework
























IV development

process

III strategic

framework

II state of

knowledge

I background

V actions by

cluster

VI next steps





DevelopmentProcess










DevelopmentProcess













bull Besciencebased






DevelopmentProcess


















I background

II state of

knowledge

III strategic

framework

IV development

process

V actions by

cluster

VI next steps




ActionsbyCluster








2

3










4

5











ActionsbyCluster













Implementing policy









ActionsbyCluster



































ActionsbyCluster






























ActionsbyCluster


































ActionsbyCluster
























ActionsbyCluster



















Developing capacity











IV development

process

V actions by

cluster

VI next steps

III strategic

framework

II state of

knowledge

I background



NextSteps



lifestyle factors




















cognitive function













the United States



NextSteps




public officials





health plans




Implementation







Conclusion







FrankBaileyJD AARP









































































































AppendixBReferences

































AppendixBReferences






















Table of Contents

Acknowledgements


p04 | I Background
























p52 | VI Next Steps



p57 | Conclusion






I background

IV development

process

V actions by

cluster

VI next steps

III strategic

framework

II state of

knowledge




StateofKnowledge










What gaps exist
















StateofKnowledge












I background

II state of

knowledge

IV development

process

V actions by

cluster

VI next steps

III strategic

framework





StrategicFramework



Long Range Outcomes



partnerships etc)












StrategicFramework
























IV development

process

III strategic

framework

II state of

knowledge

I background

V actions by

cluster

VI next steps





DevelopmentProcess










DevelopmentProcess













bull Besciencebased






DevelopmentProcess


















I background

II state of

knowledge

III strategic

framework

IV development

process

V actions by

cluster

VI next steps




ActionsbyCluster








2

3










4

5











ActionsbyCluster













Implementing policy









ActionsbyCluster



































ActionsbyCluster






























ActionsbyCluster


































ActionsbyCluster
























ActionsbyCluster



















Developing capacity











IV development

process

V actions by

cluster

VI next steps

III strategic

framework

II state of

knowledge

I background



NextSteps



lifestyle factors




















cognitive function













the United States



NextSteps




public officials





health plans




Implementation







Conclusion







FrankBaileyJD AARP









































































































AppendixBReferences

































AppendixBReferences






















Table of Contents

Acknowledgements


p04 | I Background
























p52 | VI Next Steps



p57 | Conclusion



StateofKnowledge










What gaps exist
















StateofKnowledge












I background

II state of

knowledge

IV development

process

V actions by

cluster

VI next steps

III strategic

framework





StrategicFramework



Long Range Outcomes



partnerships etc)












StrategicFramework
























IV development

process

III strategic

framework

II state of

knowledge

I background

V actions by

cluster

VI next steps





DevelopmentProcess










DevelopmentProcess













bull Besciencebased






DevelopmentProcess


















I background

II state of

knowledge

III strategic

framework

IV development

process

V actions by

cluster

VI next steps




ActionsbyCluster








2

3










4

5











ActionsbyCluster













Implementing policy









ActionsbyCluster



































ActionsbyCluster






























ActionsbyCluster


































ActionsbyCluster
























ActionsbyCluster



















Developing capacity











IV development

process

V actions by

cluster

VI next steps

III strategic

framework

II state of

knowledge

I background



NextSteps



lifestyle factors




















cognitive function













the United States



NextSteps




public officials





health plans




Implementation







Conclusion







FrankBaileyJD AARP









































































































AppendixBReferences

































AppendixBReferences






















Table of Contents

Acknowledgements


p04 | I Background
























p52 | VI Next Steps



p57 | Conclusion














StateofKnowledge












I background

II state of

knowledge

IV development

process

V actions by

cluster

VI next steps

III strategic

framework





StrategicFramework



Long Range Outcomes



partnerships etc)












StrategicFramework
























IV development

process

III strategic

framework

II state of

knowledge

I background

V actions by

cluster

VI next steps





DevelopmentProcess










DevelopmentProcess













bull Besciencebased






DevelopmentProcess


















I background

II state of

knowledge

III strategic

framework

IV development

process

V actions by

cluster

VI next steps




ActionsbyCluster








2

3










4

5











ActionsbyCluster













Implementing policy









ActionsbyCluster



































ActionsbyCluster






























ActionsbyCluster


































ActionsbyCluster
























ActionsbyCluster



















Developing capacity











IV development

process

V actions by

cluster

VI next steps

III strategic

framework

II state of

knowledge

I background



NextSteps



lifestyle factors




















cognitive function













the United States



NextSteps




public officials





health plans




Implementation







Conclusion







FrankBaileyJD AARP









































































































AppendixBReferences

































AppendixBReferences






















Table of Contents

Acknowledgements


p04 | I Background
























p52 | VI Next Steps



p57 | Conclusion







I background

II state of

knowledge

IV development

process

V actions by

cluster

VI next steps

III strategic

framework





StrategicFramework



Long Range Outcomes



partnerships etc)












StrategicFramework
























IV development

process

III strategic

framework

II state of

knowledge

I background

V actions by

cluster

VI next steps





DevelopmentProcess










DevelopmentProcess













bull Besciencebased






DevelopmentProcess


















I background

II state of

knowledge

III strategic

framework

IV development

process

V actions by

cluster

VI next steps




ActionsbyCluster








2

3










4

5











ActionsbyCluster













Implementing policy









ActionsbyCluster



































ActionsbyCluster






























ActionsbyCluster


































ActionsbyCluster
























ActionsbyCluster



















Developing capacity











IV development

process

V actions by

cluster

VI next steps

III strategic

framework

II state of

knowledge

I background



NextSteps



lifestyle factors




















cognitive function













the United States



NextSteps




public officials





health plans




Implementation







Conclusion







FrankBaileyJD AARP









































































































AppendixBReferences

































AppendixBReferences






















Table of Contents

Acknowledgements


p04 | I Background
























p52 | VI Next Steps



p57 | Conclusion



StrategicFramework



Long Range Outcomes



partnerships etc)












StrategicFramework
























IV development

process

III strategic

framework

II state of

knowledge

I background

V actions by

cluster

VI next steps





DevelopmentProcess










DevelopmentProcess













bull Besciencebased






DevelopmentProcess


















I background

II state of

knowledge

III strategic

framework

IV development

process

V actions by

cluster

VI next steps




ActionsbyCluster








2

3










4

5











ActionsbyCluster













Implementing policy









ActionsbyCluster



































ActionsbyCluster






























ActionsbyCluster


































ActionsbyCluster
























ActionsbyCluster



















Developing capacity











IV development

process

V actions by

cluster

VI next steps

III strategic

framework

II state of

knowledge

I background



NextSteps



lifestyle factors




















cognitive function













the United States



NextSteps




public officials





health plans




Implementation







Conclusion







FrankBaileyJD AARP









































































































AppendixBReferences

































AppendixBReferences






















Table of Contents

Acknowledgements


p04 | I Background
























p52 | VI Next Steps



p57 | Conclusion











StrategicFramework
























IV development

process

III strategic

framework

II state of

knowledge

I background

V actions by

cluster

VI next steps





DevelopmentProcess










DevelopmentProcess













bull Besciencebased






DevelopmentProcess


















I background

II state of

knowledge

III strategic

framework

IV development

process

V actions by

cluster

VI next steps




ActionsbyCluster








2

3










4

5











ActionsbyCluster













Implementing policy









ActionsbyCluster



































ActionsbyCluster






























ActionsbyCluster


































ActionsbyCluster
























ActionsbyCluster



















Developing capacity











IV development

process

V actions by

cluster

VI next steps

III strategic

framework

II state of

knowledge

I background



NextSteps



lifestyle factors




















cognitive function













the United States



NextSteps




public officials





health plans




Implementation







Conclusion







FrankBaileyJD AARP









































































































AppendixBReferences

































AppendixBReferences






















Table of Contents

Acknowledgements


p04 | I Background
























p52 | VI Next Steps



p57 | Conclusion













IV development

process

III strategic

framework

II state of

knowledge

I background

V actions by

cluster

VI next steps





DevelopmentProcess










DevelopmentProcess













bull Besciencebased






DevelopmentProcess


















I background

II state of

knowledge

III strategic

framework

IV development

process

V actions by

cluster

VI next steps




ActionsbyCluster








2

3










4

5











ActionsbyCluster













Implementing policy









ActionsbyCluster



































ActionsbyCluster






























ActionsbyCluster


































ActionsbyCluster
























ActionsbyCluster



















Developing capacity











IV development

process

V actions by

cluster

VI next steps

III strategic

framework

II state of

knowledge

I background



NextSteps



lifestyle factors




















cognitive function













the United States



NextSteps




public officials





health plans




Implementation







Conclusion







FrankBaileyJD AARP









































































































AppendixBReferences

































AppendixBReferences






















Table of Contents

Acknowledgements


p04 | I Background
























p52 | VI Next Steps



p57 | Conclusion



DevelopmentProcess










DevelopmentProcess













bull Besciencebased






DevelopmentProcess


















I background

II state of

knowledge

III strategic

framework

IV development

process

V actions by

cluster

VI next steps




ActionsbyCluster








2

3










4

5











ActionsbyCluster













Implementing policy









ActionsbyCluster



































ActionsbyCluster






























ActionsbyCluster


































ActionsbyCluster
























ActionsbyCluster



















Developing capacity











IV development

process

V actions by

cluster

VI next steps

III strategic

framework

II state of

knowledge

I background



NextSteps



lifestyle factors




















cognitive function













the United States



NextSteps




public officials





health plans




Implementation







Conclusion







FrankBaileyJD AARP









































































































AppendixBReferences

































AppendixBReferences






















Table of Contents

Acknowledgements


p04 | I Background
























p52 | VI Next Steps



p57 | Conclusion







DevelopmentProcess













bull Besciencebased






DevelopmentProcess


















I background

II state of

knowledge

III strategic

framework

IV development

process

V actions by

cluster

VI next steps




ActionsbyCluster








2

3










4

5











ActionsbyCluster













Implementing policy









ActionsbyCluster



































ActionsbyCluster






























ActionsbyCluster


































ActionsbyCluster
























ActionsbyCluster



















Developing capacity











IV development

process

V actions by

cluster

VI next steps

III strategic

framework

II state of

knowledge

I background



NextSteps



lifestyle factors




















cognitive function













the United States



NextSteps




public officials





health plans




Implementation







Conclusion







FrankBaileyJD AARP









































































































AppendixBReferences

































AppendixBReferences






















Table of Contents

Acknowledgements


p04 | I Background
























p52 | VI Next Steps



p57 | Conclusion







bull Besciencebased






DevelopmentProcess


















I background

II state of

knowledge

III strategic

framework

IV development

process

V actions by

cluster

VI next steps




ActionsbyCluster








2

3










4

5











ActionsbyCluster













Implementing policy









ActionsbyCluster



































ActionsbyCluster






























ActionsbyCluster


































ActionsbyCluster
























ActionsbyCluster



















Developing capacity











IV development

process

V actions by

cluster

VI next steps

III strategic

framework

II state of

knowledge

I background



NextSteps



lifestyle factors




















cognitive function













the United States



NextSteps




public officials





health plans




Implementation







Conclusion







FrankBaileyJD AARP









































































































AppendixBReferences

































AppendixBReferences






















Table of Contents

Acknowledgements


p04 | I Background
























p52 | VI Next Steps



p57 | Conclusion



DevelopmentProcess


















I background

II state of

knowledge

III strategic

framework

IV development

process

V actions by

cluster

VI next steps




ActionsbyCluster








2

3










4

5











ActionsbyCluster













Implementing policy









ActionsbyCluster



































ActionsbyCluster






























ActionsbyCluster


































ActionsbyCluster
























ActionsbyCluster



















Developing capacity











IV development

process

V actions by

cluster

VI next steps

III strategic

framework

II state of

knowledge

I background



NextSteps



lifestyle factors




















cognitive function













the United States



NextSteps




public officials





health plans




Implementation







Conclusion







FrankBaileyJD AARP









































































































AppendixBReferences

































AppendixBReferences






















Table of Contents

Acknowledgements


p04 | I Background
























p52 | VI Next Steps



p57 | Conclusion











I background

II state of

knowledge

III strategic

framework

IV development

process

V actions by

cluster

VI next steps




ActionsbyCluster








2

3










4

5











ActionsbyCluster













Implementing policy









ActionsbyCluster



































ActionsbyCluster






























ActionsbyCluster


































ActionsbyCluster
























ActionsbyCluster



















Developing capacity











IV development

process

V actions by

cluster

VI next steps

III strategic

framework

II state of

knowledge

I background



NextSteps



lifestyle factors




















cognitive function













the United States



NextSteps




public officials





health plans




Implementation







Conclusion







FrankBaileyJD AARP









































































































AppendixBReferences

































AppendixBReferences






















Table of Contents

Acknowledgements


p04 | I Background
























p52 | VI Next Steps



p57 | Conclusion



ActionsbyCluster








2

3










4

5











ActionsbyCluster













Implementing policy









ActionsbyCluster



































ActionsbyCluster






























ActionsbyCluster


































ActionsbyCluster
























ActionsbyCluster



















Developing capacity











IV development

process

V actions by

cluster

VI next steps

III strategic

framework

II state of

knowledge

I background



NextSteps



lifestyle factors




















cognitive function













the United States



NextSteps




public officials





health plans




Implementation







Conclusion







FrankBaileyJD AARP









































































































AppendixBReferences

































AppendixBReferences






















Table of Contents

Acknowledgements


p04 | I Background
























p52 | VI Next Steps



p57 | Conclusion



2

3










4

5











ActionsbyCluster













Implementing policy









ActionsbyCluster



































ActionsbyCluster






























ActionsbyCluster


































ActionsbyCluster
























ActionsbyCluster



















Developing capacity











IV development

process

V actions by

cluster

VI next steps

III strategic

framework

II state of

knowledge

I background



NextSteps



lifestyle factors




















cognitive function













the United States



NextSteps




public officials





health plans




Implementation







Conclusion







FrankBaileyJD AARP









































































































AppendixBReferences

































AppendixBReferences






















Table of Contents

Acknowledgements


p04 | I Background
























p52 | VI Next Steps



p57 | Conclusion



ActionsbyCluster













Implementing policy









ActionsbyCluster



































ActionsbyCluster






























ActionsbyCluster


































ActionsbyCluster
























ActionsbyCluster



















Developing capacity











IV development

process

V actions by

cluster

VI next steps

III strategic

framework

II state of

knowledge

I background



NextSteps



lifestyle factors




















cognitive function













the United States



NextSteps




public officials





health plans




Implementation







Conclusion







FrankBaileyJD AARP









































































































AppendixBReferences

































AppendixBReferences






















Table of Contents

Acknowledgements


p04 | I Background
























p52 | VI Next Steps



p57 | Conclusion



Implementing policy









ActionsbyCluster



































ActionsbyCluster






























ActionsbyCluster


































ActionsbyCluster
























ActionsbyCluster



















Developing capacity











IV development

process

V actions by

cluster

VI next steps

III strategic

framework

II state of

knowledge

I background



NextSteps



lifestyle factors




















cognitive function













the United States



NextSteps




public officials





health plans




Implementation







Conclusion







FrankBaileyJD AARP









































































































AppendixBReferences

































AppendixBReferences






















Table of Contents

Acknowledgements


p04 | I Background
























p52 | VI Next Steps



p57 | Conclusion



ActionsbyCluster



































ActionsbyCluster






























ActionsbyCluster


































ActionsbyCluster
























ActionsbyCluster



















Developing capacity











IV development

process

V actions by

cluster

VI next steps

III strategic

framework

II state of

knowledge

I background



NextSteps



lifestyle factors




















cognitive function













the United States



NextSteps




public officials





health plans




Implementation







Conclusion







FrankBaileyJD AARP









































































































AppendixBReferences

































AppendixBReferences






















Table of Contents

Acknowledgements


p04 | I Background
























p52 | VI Next Steps



p57 | Conclusion





















ActionsbyCluster






























ActionsbyCluster


































ActionsbyCluster
























ActionsbyCluster



















Developing capacity











IV development

process

V actions by

cluster

VI next steps

III strategic

framework

II state of

knowledge

I background



NextSteps



lifestyle factors




















cognitive function













the United States



NextSteps




public officials





health plans




Implementation







Conclusion







FrankBaileyJD AARP









































































































AppendixBReferences

































AppendixBReferences






















Table of Contents

Acknowledgements


p04 | I Background
























p52 | VI Next Steps



p57 | Conclusion













ActionsbyCluster


































ActionsbyCluster
























ActionsbyCluster



















Developing capacity











IV development

process

V actions by

cluster

VI next steps

III strategic

framework

II state of

knowledge

I background



NextSteps



lifestyle factors




















cognitive function













the United States



NextSteps




public officials





health plans




Implementation







Conclusion







FrankBaileyJD AARP









































































































AppendixBReferences

































AppendixBReferences






















Table of Contents

Acknowledgements


p04 | I Background
























p52 | VI Next Steps



p57 | Conclusion






















ActionsbyCluster
























ActionsbyCluster



















Developing capacity











IV development

process

V actions by

cluster

VI next steps

III strategic

framework

II state of

knowledge

I background



NextSteps



lifestyle factors




















cognitive function













the United States



NextSteps




public officials





health plans




Implementation







Conclusion







FrankBaileyJD AARP









































































































AppendixBReferences

































AppendixBReferences






















Table of Contents

Acknowledgements


p04 | I Background
























p52 | VI Next Steps



p57 | Conclusion













ActionsbyCluster



















Developing capacity











IV development

process

V actions by

cluster

VI next steps

III strategic

framework

II state of

knowledge

I background



NextSteps



lifestyle factors




















cognitive function













the United States



NextSteps




public officials





health plans




Implementation







Conclusion







FrankBaileyJD AARP









































































































AppendixBReferences

































AppendixBReferences






















Table of Contents

Acknowledgements


p04 | I Background
























p52 | VI Next Steps



p57 | Conclusion




Developing capacity











IV development

process

V actions by

cluster

VI next steps

III strategic

framework

II state of

knowledge

I background



NextSteps



lifestyle factors




















cognitive function













the United States



NextSteps




public officials





health plans




Implementation







Conclusion







FrankBaileyJD AARP









































































































AppendixBReferences

































AppendixBReferences






















Table of Contents

Acknowledgements


p04 | I Background
























p52 | VI Next Steps



p57 | Conclusion




IV development

process

V actions by

cluster

VI next steps

III strategic

framework

II state of

knowledge

I background



NextSteps



lifestyle factors




















cognitive function













the United States



NextSteps




public officials





health plans




Implementation







Conclusion







FrankBaileyJD AARP









































































































AppendixBReferences

































AppendixBReferences






















Table of Contents

Acknowledgements


p04 | I Background
























p52 | VI Next Steps



p57 | Conclusion



NextSteps



lifestyle factors




















cognitive function













the United States



NextSteps




public officials





health plans




Implementation







Conclusion







FrankBaileyJD AARP









































































































AppendixBReferences

































AppendixBReferences






















Table of Contents

Acknowledgements


p04 | I Background
























p52 | VI Next Steps



p57 | Conclusion












cognitive function













the United States



NextSteps




public officials





health plans




Implementation







Conclusion







FrankBaileyJD AARP









































































































AppendixBReferences

































AppendixBReferences






















Table of Contents

Acknowledgements


p04 | I Background
























p52 | VI Next Steps



p57 | Conclusion



NextSteps




public officials





health plans




Implementation







Conclusion







FrankBaileyJD AARP









































































































AppendixBReferences

































AppendixBReferences






















Table of Contents

Acknowledgements


p04 | I Background
























p52 | VI Next Steps



p57 | Conclusion



Implementation







Conclusion







FrankBaileyJD AARP









































































































AppendixBReferences

































AppendixBReferences






















Table of Contents

Acknowledgements


p04 | I Background
























p52 | VI Next Steps



p57 | Conclusion






FrankBaileyJD AARP









































































































AppendixBReferences

































AppendixBReferences






















Table of Contents

Acknowledgements


p04 | I Background
























p52 | VI Next Steps



p57 | Conclusion























































AppendixBReferences

































AppendixBReferences






















Table of Contents

Acknowledgements


p04 | I Background
























p52 | VI Next Steps



p57 | Conclusion



AppendixBReferences






















Table of Contents

Acknowledgements


p04 | I Background
























p52 | VI Next Steps



p57 | Conclusion







Table of Contents

Acknowledgements


p04 | I Background
























p52 | VI Next Steps



p57 | Conclusion



the healthy brain initiative healthy brain initiative: ... a strategic framework, and embarked on an...

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