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TheHealthyBrainInitiative:

A National Public Health Road Map to Maintaining Cognitive Health

TableofContents

Acknowledgements

Executive Summary 1

I Background 4 Whatiscognitivehealth? 5

WhyprepareaRoadMap? 7

Whyisitimportantandwhynow? 12

II State of Knowledge 16

Whatdoweknow? 17

Whatgapsexist? 18

Howcanpublichealthcontribute? 19

III Strategic Framework 22

Whatisourmodelforaction? 23

Whatprinciplesdoweembrace? 25

Whatdowehopetoaccomplish? 26

IV Development Process 28

Workgroupdeliberations 29

Conceptmappingprocess 34

V Actions by Cluster 36

Disseminatinginformation 38

Translatingknowledge 40

Implementingpolicy 41 Conductingsurveillance 43

Movingresearchintopractice 44

Conductinginterventionresearch 47

Measuringcognitiveimpairment

andburden 50

Developingcapacity 51

VI Next Steps 52

Prioritiesforaction 53

Implementation 57

Conclusion 57

Appendix A: Contributors 58

Appendix B: References 62

Suggested Citation: CentersforDiseaseControlandPreventionandtheAlzheimers

Association.TheHealthyBrainInitiative:ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth:Chicago,IL:AlzheimersAssociation;2007

Availableatwww.cdc.gov/agingandwww.alz.org

Centers for Disease Control and Prevention and the Alzheimers Association


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Acknowledgements

WethankthemembersoftheSteeringCommitteeforgivingcountlesshourstothink

aboutanddiscussthisNational Public Health Road Map to Maintaining Cognitive Health;

theircontributionshavebeeninvaluable.

LyndaAnderson,PhD(Cochair)

Centers for Disease Control and Prevention

StephenMcConnell,PhD(Cochair)

Alzheimers Association

FrankBailey,JD

AARP

WilliamF.Benson

Health Benefits ABCs

DebraCherry,PhD


GregCase

Administration on Aging

HughC.Hendrie,MB,ChB,DSc

Indiana University Center for Aging ResearchRegenstrief Institute, Inc.

JamesLaditka,DA,PhD,MPA

University of South Carolina

DebraLappin,JD

B&D Consulting LLC

MarcelleMorrisonBogorad,PhD

National Institute on Aging

PeterRabins,MD,MPH

Johns Hopkins University School of Medicine

RamonaL.Rusinak,RN,PhD

Arizona Department of Health Services

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ExecutiveSummary

InFall2005,theCentersforDiseaseControlandPreventionandtheAlzheimersAssociationformedanewpartnershiptoexaminehowbesttobringapublichealthperspectiveto

thepromotionofcognitivehealth.ToassistwiththisHealthy

BrainInitiative,thePartnersworkedcloselywiththeNational

InstituteonAgingandtheAdministrationonAgingtoconvene

amultidisciplinarySteeringCommitteeandanevenwiderarrayofinvitedexpertsfromconcernedpublicandprivate

sectororganizations.Togetherweexaminedthecurrentstate

ofknowledgeregardingthepromotionandprotectionof

cognitivehealth,identifiedimportantknowledgegaps,and

definedtheuniqueroleandcontributionsofpublichealth.

Wefocusedonvascularriskfactorsandphysicalactivity

becauseoftheirassociationwithcognitiveoutcomes,adopted

astrategicframework,andembarkedonanintensiveprocess

togeneratetheactionsofferedinthis National Public Health

Road Map to Maintaining Cognitive Health.

TheRoadMaprecognizescurrentsocialtrendsandother

factorsthataffectcognitivehealthfromapublichealth

standpoint:anagingpopulation,growingfearandconcern

expressedbymanypeopleastheyageabouttheirpotentiallossofcognitivefunction,increasingsocietalburdenfrom

cognitivedecline,greatercaregiverburden,andacontinued

lackofawarenessaboutcognitivehealthamongconsumers

andprovidersalike.

Withthisbackdrop,weofferaloftybutachievablelong-

termgoal:

To maintain or improve the cognitive performance of all adults.

Toaccomplishthisgoal,weproposeasetof44actionsthat

arefirmlygroundedinscience,emphasizeprimaryprevention,

assumeacommunityandpopulationapproach,andarecommittedtoeliminatingdisparitiesinpersonalhealthand

healthcareforracialorethnicgroups.Itiscriticaltonotethat

eachpriorityactionisbasedonadetailed,scientificrationale,

withimplementationtobebasedondemonstratedeffectiveness

ofspecificinterventions.Theseactionsshouldthereforebe

consideredinthecontextoftherationalespresentedin

SectionVoftheRoadMap.Withinthefullsetofactionsare10prioritiesworthyofimmediateattention:

Centers for Disease Control and Prevention and the Alzheimers Association|1


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ExecutiveSummary

Determinehowdiverseaudiencesthinkaboutcognitive

healthanditsassociationswithlifestylefactors.

Disseminatethelatestsciencetoincreasepublicunderstanding

ofcognitivehealthandtodispelcommonmisconceptions.

Helppeopleunderstandtheconnectionbetweenriskand

protectivefactorsandcognitivehealth.

Conductsystematicliteraturereviewsonproposedrisk

factors(vascularriskandphysicalinactivity)andrelated

interventionsforrelationshipswithcognitivehealth,harms,

gapsandeffectiveness.

Conductcontrolledclinicaltrialstodeterminetheeffect

ofreducingvascularriskfactorsonloweringtheriskof

cognitivedeclineandimprovingcognitivefunction.

Conductcontrolledclinicaltrialstodeterminetheeffectof

physicalactivityonreducingtheriskofcognitivedecline

andimprovingcognitivefunction.

Conductresearchonotherareaspotentiallyaffecting

cognitivehealthsuchasnutrition,mentalactivity,and

socialengagement.

Developapopulationbasedsurveillancesystemwith

longitudinalfollowupthatisdedicatedtomeasuringthe

publichealthburdenofcognitiveimpairmentinthe

UnitedStates.

Initiatepolicychangesatthefederal,state,andlocallevels

topromotecognitivehealthbyengagingpublicofficials.

Includecognitivehealthin Healthy People 2020,aset

ofhealthobjectivesforthenationthatwillserveasthe

foundationforstateandcommunitypublichealthplans.

Itisourhopethatthese10priorityactionswillservetofocus

thenationsresourcesonaddressingriskandprotectivefactors

forpromotingcognitivehealthoverthenext35years.Asa

livingandflexibledocument,theRoadMaprepresentsboth

acalltoactionandaguideforimplementinganeffective

coordinatedapproachtomovingcognitivehealthintopublic

healthpractice.Thekeytosuccessliesincontinuingand

expandingresearch;developingandchannelingresources;

workingtodeveloporstrengthenpartnershipswithlike-

mindedorganizations;designingcollaborativeoperational

plansofaction;andestablishingsystemstotrackprogress,facilitatecommunication,andexchangeinformation.

Continuedvigilanceonthisissue,andtimelytranslationof

researchfindingsintocommunityaction,willassurethat

wereapthepotentialrewardsthatpublichealthcanofferin

improvingqualityoflifeamongadultsandreducingsocietal

costsforhealthcareandotherservices.

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IVdevelopmentprocess

Vactions bycluster

VInext steps

IIIstrategicframework

IIstate ofknowledge

Ibackground

BackgroundWhat is cognitive health?

Thedistinctionbetweenthemindandbodywasaconcept

firstformallysetforthinthe17thcenturybyphilosopher

ReneDescartes.Overthenextseveralcenturies,thebody

wasseenastheconcernofphysicians,whilethemindwasthepurviewoforganizedreligion.1

Overtheyears,ourunderstandingofbodyandmind

hasevolvedsignificantly.Wenowrecognizethevitalrole

thatbothphysicalhealthandmentalhealthplayinshaping

ouroverallwell being,andweappreciatethevaluable

contributionsthatawidearrayofhealthprofessionscan

maketowardassuringthatwellbeing.


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Background

Mentalhealthencompassesemotionalfunctioningandthe

abilitytothink,reason,andremember(cognitivefunctioning).

Whilestandardized,widelyaccepteddefinitionsof cognitive

healthhaveyettobeadopted,mostexpertsagreethatthe

componentsofhealthycognitive functioning include:

language

thought

memory

executivefunction(theabilitytoplanandcarryouttasks)

judgment

attention

perception

rememberedskills(suchasdriving)

abilitytoliveapurposefullife2

Muchlikephysicalhealth,cognitivehealthcanbeviewed

alongacontinuumfromoptimalfunctioningtomild

cognitiveimpairmenttoseveredementia.Itisnotsimplythe

absenceofdiseasessuchasAlzheimersdisease;rather,itshould

berespectedforitsmultidimensionalnature,andthechanges

thattakeplaceoverthelifespanshouldbeaccepted,even

embraced,asanaturalpartoftheagingprocess.3

Cognitivedeclinecanrangefrommildcognitiveimpairment

todementia,butthesetwoconditionsarenotnecessarily

manifestationsofthesamedisease.Manypeoplenever

developanyseriousdeclineintheircognitiveperformance,

andthosewhodevelopmildcognitiveproblemsdonot

necessarilydevelopdementia.Althoughnotallpeoplewith

cognitivedeclinedevelopdementia,thosewithanamnesticformofmildcognitiveimpairmentdohaveamuchhigher

riskfordementiathanotheradults.

Thelackofcognitivehealthcanhaveprofoundimplications

forapersonsphysicalhealth.Olderadultsandothers

experiencingcognitiveimpairmentmaybeunabletocare

forthemselvesortoengageinnecessaryactivitiesofdaily

living,suchaspreparingmealsormanagingtheirfinances.Limitationsintheabilitytoeffectivelymanagemedications

andexistingmedicalconditionsareofparticularconcernwhen

apersonisexperiencingcognitiveimpairmentordementia.

Dementiaaffectsapersonsabilitytocomprehendandacton

messages,andinvolvesproblemswithmemory,understanding

orusingwords,andidentifyingobjects.Thesignificantly

impairedcognitionassociatedwithdementialeadstoalossof

senseofselfandoflifelongmemories;adecreasingabilityto



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Mostimportanttoourabilitytoliveourliveswellisthecombinationofmentalprocesseswecallcognitionorknowing.Thiscombinationincludestheabilitytolearnnewthings,intuition,judgment,language,andremembering.Havingaclear,activemindatanyageisimportant,butas

wegetolderitcanmeanthedifferencebetweendependenceandindependentliving.4

copewiththenormaldemandsofliving;problemsaccessing

healthcaresystems;greatervulnerabilitytodisease,injury,

malnutrition,crime,andpossiblyabuse;andeventuallyaloss

ofindependence.Thatlossofindependencebecomesaburden

onfamiliesandsociety,astheindividualrequiresmoreintense

careandofteninstitutionalization.Inthelaterstages,the

cognitiveimpairmentassociatedwithdementiawillcreatetotal

dependency,andAlzheimersdiseaseisnowrankedasthe

8thleadingcauseofdeath.5

Why prepare a Road Map?

Bringingapublichealthperspectivetocognitivehealth

requiresaninclusiveandstrategicapproach.Muchimportant

workhasalreadybegun,initiatedandsponsoredbyavariety

oforganizationsandagenciesatnational,state,andlocallevels(seepages1011forasamplingofcurrentefforts).



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Background

Oneoftheselandmarkefforts,theNationalInstitutesofHealth

(NIH)CognitiveandEmotionalHealthProject(CEHP),

wasofficiallylaunchedin2001.Selectedexpertsfromseveral

universitiesandtheNIHcriticallyanalyzedthescientific

literaturetoidentifypossibleriskandprotectivefactorsfor

maintainingcognitiveandemotionalhealthinadults. 6In

recognitionoftheimportanceofthiseffort,andasfurthertestamenttotheincreasedvisibilitythatcognitivehealthis

receiving,Congressappropriatedfundsinfiscalyear2005to

theCentersforDiseaseControlandPrevention(CDC)to

addresscognitivehealthwithafocusonlifestyleissues.With

thissupport,CDCformedapartnershipwiththeAlzheimers

AssociationandisworkingcloselywiththeNationalInstitute

onAging,theAdministrationonAging,andotherpublicand

privatesectororganizationsonaHealthyBrainInitiative.

Thispartnership:

FormedaSteeringCommitteemadeupofnationalexperts

toprovideoverallguidanceandcoordinationfortheInitiative

(AppendixA).

ConvenedaPublicHealthResearchWorkingGroupMeetinginMay2006onThe Healthy Brain and Our Aging

Population:Translating Science to Public Health Practice.During

this2dayinvitationalmeeting,nationalexpertsreviewed

researchinpublichealthpreventionrelatedtobrainhealth,

anddiscussedspecificrecommendationsforaddressingrisk

andprotectivefactorsforpromotingcognitivehealth.They

focusedonvascularriskfactorsandphysicalactivitybecause

oftheirassociationwithcognitiveoutcomes.

Thefindingsfromthisresearchmeetingprovidedafoundation

andcommonframeofreferenceforthenextstepoftheHealthy

BrainInitiative:developingstrategicpublichealthrecommen-

dations.Forthistask,thePartnershipformedworkgroups

infourareasofpublichealthaction:PreventionResearch,

Communication,Surveillance,andPolicy.Eachworkgroup

waschargedwithdraftingrecommendationsformovingthe

nationforwardoverthenext35yearstowardthelongtermgoalofmaintainingandimprovingthecognitivefunctionof

adults.Keystakeholdersatthenational,state,andlocallevels

thenrefinedtherecommendationsandselectedthoseof

highestpriority(AppendixA).

TheNational Public Health Road Map to Maintaining Cognitive

Healthreflectstheculminationofthis18monthprocess.Asa

cornerstoneoftheInitiative,itoffersapathforhowwecan

learnmoreaboutcognitivehealthandthenultimately



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Wearebeginningtotakethenextsteps,buildingonthe

researchcomingoutofNIHandothers,andmovingwhatweknowoutintocommunitypractice.Thisiswherewecanmakeadifferenceinthe

everydaylivesofAmericans.LyndaA.Anderson,PhD

Healthy Aging Program,

Centers for Disease Control and Prevention

translatewhatwelearnintorealworldpracticetoimprove

thehealthofallAmericans.

TheauthorsoftheRoadMaprecognizethatinthecourse

ofdailylifethedomainsofemotionalandcognitivehealth

areinextricablylinkedandcannottrulybeseparated.For

thisRoadMap,however,weassumethisdistinctionandfocus

solelyoncognitivehealth.Onlyrecentlyhavepublichealth

expertiseandresourcesbeenrecognizedforaddressingcognitivehealth.TheRoadMapreflectsacommitmentto

bringtheareaofcognitivehealthuptoparwithemotional

healthastreatmentsandpreventivestrategiesbecomeavailable.

Itisthefirststepinasystematicprocessforbringingcognitive

andemotionalhealthtogetherinamorecomprehensiveand

coordinatedpublichealthapproach.



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Background

A Sampling of Current Efforts

Pursuing Research on Factors

Influencing Cognitive Health

TheNationalInstitutesofHealth(NIH)isfundingongoing

researchtoclarifytherelationshipamongminimizingvascular

riskfactors,exercise,otherlifestyleanddruginterventions,andcognitivehealthstatus.Epidemiologicstudiesare

identifyinglikelyriskandprotectivefactors;thesearebeing

testedinanimalstudies,whichalsocanhelpidentifythe

mechanismsbywhichriskandprotectivefactorsmightwork.

Inordertoconfirmthattheencouraginginterventions

identifiedinepidemiologyandanimalstudiescouldactually

maintaincognitivehealthifappliedtohumans,clinicaltrialsmustbecarriedout.Somearealreadyinprogressbutothers

arestillonlyintheplanningphase.NIHkeepsthepublicup-

todateonthecurrentstateofthesciencethroughoperation

ofaWebsiteandanationalclearinghouse.

Assessing

Public Perceptions

Formativeresearchwithdiversegroupsisrequiredtohelp

gainunderstandingonthepublicsperceptionsaboutcognitive

health.OnesucheffortiscurrentlyunderwaywiththesupportofCDC.TheHealthyAgingResearchNetwork,withinits

largerPreventionResearchCentersProgram(PRCHAN),

conductspreventionresearchonavarietyofhealthissues

involvingolderadults.WithinthePRCHAN,membersare

collaboratingonaseriesoffocusgroupsdesignedtoidentify

howdiversegroupsofolderadultsunderstandcognitive

healthandwhatapproachestohealthpromotionanddiseasepreventionrelatedtobrainhealththepublicmayfindmost

appealing.Thisprojecthasrecentlybeenexpandedtoexamine

theperceptionsofcaregiversandhealthcareproviders.Itwill

provideimportantdatathatcanbeaddedtowhatisalready

knownaboutcognitiveorbrainhealth,identifygapsin

knowledgeaboutcognitivehealthandrelatedriskfactors,

anddeterminewhethersuchbeliefsvaryacrossgeographical

distancesandbetweendiversepopulations.Finally,thisworkis

designedtoleadtothedevelopmentandtestingofashortset

ofquestionsthatcanbeusedtoassessthepublicsandpossibly

providersperceptionsaboutcognitivehealthforinclusionin

ongoingnationalattitudinalsurveys.

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Conducting Community

Education Programs

TheAlzheimersAssociationhasrecentlylauncheda5year

communitybaseddemonstrationprojecttopromoteabrain-

healthylifestyle.ThecommunityinterventionisdesignedtoaffectknowledgeandattitudesamongAfricanAmericanbaby

boomersrelatedtophysicalactivityandvascularriskfactors,

anditwillbeoverlaidwithothergeneralhealthbehaviors

suchasdiet,socialactivity,andmentalactivity.Duringthefirst

phaseofthisproject,theAlzheimersAssociationisleadinga

comprehensiveinterventionplanninganddevelopmenteffort,

includingformativeresearchtoassesscurrentneedsandobstaclesforthetargetpopulation,elicitingcommunityinput

andparticipation,andcreatingacomprehensive,multilevel

communityinterventionwithrobustevaluationmechanisms

tomeasuretheeffectivenessofthepublichealthprogramin

itsnextphase.

Developing Common Measures of Cognitive Decline

for Surveillance and Research

TheNationalInstitutesofHealthisleadinganinitiativeto

developunifiedandintegratedmethodsandmeasuresof

cognitive,emotional,motor,andsensoryhealthforuseinlargecohortstudiesandclinicaltrials.Researchershave

expressedtheneedforbriefassessmenttoolsthatcouldbe

usedasaformofcommoncurrencyacrossdiversestudy

designsandpopulations.Thisinitiativewilltakeadvantage

ofstateoftheartpsychometricresearchandnoveltesting

methodstodevelopaninnovativeapproachtoneurological

andbehavioralhealthmeasurement.Ultimately,itishopedthatthisapproachwillrespondtotheneedsofresearchersin

avarietyofsettings,withparticularemphasisonmeasuring

outcomesinlargelongitudinalandepidemiologicstudiesand

preventionorinterventiontrialsacrossthelifespan.With

anavailabletoolboxofmeasures,yieldsfromlargeandvery

expensivestudiescanbemaximizedbyallowingamuch

largernumberofimportantresearchquestionsregarding

neurologicalandbehavioralhealthtobestudied.Byensuring

thattheassessmentmethodsarecapableofcomparisonto

existingandcompletedstudiesandcanincorporatefuture

modifications,atrulyeconomicandvaluablenational

resourcefortheentireneurosciencecommunitywillresult.



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Background

Why is it importantand why now?

TheNational Public Health Road Map to Maintaining Cognitive

Healthcomesatacriticaltime,giventhedramaticagingof

theU.S.population,thegrowingscientificinterestinthe

roleoflifestylestrategiesinmaintainingcognitivefunction,

andincreasingawarenessofthesignificanthealth,social,

andeconomicburdensassociatedwithcognitivedecline.

An aging population

Ageisariskfactorforcognitivedecline.In2004,onein

everyeightAmericans36.3millionwereaged65years

orolder.By2030,thisnumberisexpectedtonearlydouble

to71.5million.Atthattime,20%ofthepopulationwillbe

inthisagegroup. 7

Growing fear and concern about memory loss

ThereisconsiderableconcernamongAmericansaboutthe

lossofcognitivehealthtodiseaseordisability, 8aconcernthat

seemstoincreasewithage.Mostolderadultslookforwardto

havingalonglife,andyettheirgreatestworriesaboutliving

toage75revolvearoundmemoryloss. 9Accordingtoarecent

survey,adultsaremorethantwiceaslikelytofearlosingtheir

mentalcapacity(62%)astheirphysicalability(29%).10

Increasing burden from cognitive decline

IntheUnitedStates,thesocietalburdenofcognitive

impairmenthasbeenexpressedmainlyintermsofprevalence,

incidence,andmortalityfordementiagenerallyorfor

Alzheimersdiseaseinparticular.Morerecently,prevalence

statisticsformildcognitiveimpairmentorcognitive

impairmentnodementiahavealsoappeared.Cognitive

impairmentnodementiareferstoalevelofcognitive

impairmentthatismoreseriousthanagerelatedcognitive

impairment,butitisnotassevereasAlzheimersdiseaseor

otherformsofdementia.

Alzheimersdiseasehasbeeninthetoptenleadingcauses

ofdeathsincethe20thcentury.11Notably,themortalityrates

forAlzheimersdiseaseareontheriseincontrasttotheratesforheartdiseaseandcancer,whicharecontinuing

todecline.12

Anestimated4.5millionAmericanshaveAlzheimers

disease.Thatnumberhasdoubledsince1980,andis

expectedtobeashighas16millionby2050.13



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Thenewsciencehasshiftedthefocustotheideathatthereisvalueinapublichealthstrategyofgettingpeopletothinkabouttheirbrainandhowtheymightaltertheirbehaviortokeeptheirbrainhealthy.StephenMcConnell,PhD


StudiesfromtheUnitedStatesandCanadahavesuggested

thatmildcognitiveimpairmentorcognitiveimpairment

nodementiamaybeaproblemfor1625%oftheelderly

population(65andolder).14,15,16

In2005,MedicareandMedicaidspent$91billionand

$21billion,respectively,forpersonswithAlzheimersdisease.17

Accordingtoa2004reportthatanalyzedMedicareclaims

data,olderbeneficiarieswithdementiacostMedicarethree

timesmorethanotherolderbeneficiaries.18Basedoncurrent

estimates,thesecostswilldoubleevery10years. 19

Caregiver burden

Maintainingcognitivehealthcanmeanthedifference

betweenlivingindependentlyorfacingtheneedforfamily

orinstitutionalcare.Theburdenofcognitivedeclineon

caregiversisenormous.ThenumberofcaregiversintheUnitedStatesin2003wasestimatedtobe44.4million20and

thisnumberisexpectedtorisedramaticallywiththeagingof



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Background

thepopulation.Thecostsofunpaid,informal careprovidedby

familieshavebeenshowntoaccountforalargeproportionof

thecostsoftreatingdementiaandtheyincreasesharplyasthe

patientscognitiveimpairmentworsens.21Therearealso

physicalandmentalcostsassociatedwithcaregiving;inone

study,nearly43%ofthefamilymembersproviding careto

relativeswithdementiahadclinically significantlevelsof

depressionduringthelastfewmonthsofthepatientslife.22

Numerousfactorsmakeprovidingcareforpersonswith

severedementiaemotionallyandphysicallychallenging;a

betterunderstandingofthesefactorswillaidinthedesignof

strategiesthatsupportthehealthandwellbeingofcaregivers.

Underlying lack of information about what is known about

brain healthManyadultsappeartobelievethatagingisatimeof

irreversiblementaldecline,andthatdementiaisuniversal

andinevitable.Thesemythspersistseventhoughrecent

researchhasshownthatinthehealthyagingbrain,new

synapsescontinuetoformandnervecellscanregenerate. 23

Yet,thereareemergingsignsthatAmericanslooktothe

futurewithhope.Basedonseveralsurveys,menandwomen

inthiscountryarewillingtotakeimportantstepstoimprove

theircognitivehealth.

Nearly9of10peoplereportedthattheythoughtitis

possibletoimprovecognitivefitness.24

Sixof10statedthattheyfelttheyshouldhavetheir

cognitivehealthcheckedroutinely,muchlikearegular

physicalcheckup.25

Morethan8of10(84%)reportedthattheytooksome

timenearlyeverydaytoengageinactivitiesthatmaybe

associatedwithimprovedcognitivehealth:engagingin

artorcreativeprojects,reading,keepingphysicallyactive,playinggamesordoingpuzzles,working,orspending

timewithfamilyandfriends.26

Overhalfanticipatedamajormedicalbreakthroughin

discoveringacureforAlzheimersdiseasewithinthenext

20years.27



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Giventhetremendousburdensdescribed,theirimpact,and

thedevelopingscience,publichealthshouldstepforwardto

addresscognitivehealth.Thepotentialcontributiontoquality

oflife,thepositiveimpactoncaregivers,andtheanticipated

savingsinthecostsofhealthcareandotherserviceswould

beconsiderable.28,29,30,31



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Ibackground

IVdevelopment

process

Vactions by

cluster

VInext steps

IIIstrategic

framework

IIstate of

knowledge

State ofKnowledgeWhat do we know?

InMay2006,CDCandtheAlzheimersAssociationinvited

nationalexpertstoreviewresearchonpublichealth

preventionrelatedtocognitivehealth,andtoidentifyspecific

recommendationsforaddressingriskfactorsthatpromoteandprotectcognitivehealth.Duringthismeeting,participants

examinedthecurrentstateofscienceconcerningmajorrisk

factors,including:a)riskfactorsforvasculardiseaseand

b)physicalinactivity,andtheylookedatcurrentmodels

formovingscienceintopublichealthpractice.Participants

focusedonthesefactorsbecauseoftheirassociationwith

cognitiveoutcomes.32Theyconcludedthatresearchsuggests

thefollowingfactorsmaybeassociatedwiththemaintenance

ofcognitivehealth:1)preventingorcontrollinghighblood


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StateofKnowledge

pressure,cholesterol,diabetes,overweight,andobesity;

2)preventingorstoppingsmoking;and3)being

physicallyactive.33

Severalspecificobservationswerenotedbymeeting

participantsregardingtheassociationsbetweenvascular

riskfactorsandphysicalinactivityandcognition.

Evidenceexiststoindicatethatcumulativerisks

forvasculardiseaseincreasetheriskforstrokeand

cognitivedecline.

Sufficientevidencealsoexiststosupporttheassociation

betweenvascularhealthandcognitivehealth,although

clinicaltrialsarenecessarytoestablishtheeffectivenessof

interventionstargetedtovascularriskfactors.

Itisimportanttoemphasizethatcontrollingvascularrisk

factorsisassociatedwithreductioninanindividualsriskof

cognitiveproblems,butcurrentsciencedoesnotsupportthe

relationshipbetweencontrollingvascularriskfactorsand

improvedcognitivefunction.

Growingevidenceexiststhatphysicalactivitymaymaintain

orimprovesomeaspectsofcognitivefunctionintheshort

term,butfurtherresearchisneededbothtodeterminelong

termoutcomesandthenatureofrecommendations(e.g.,

theamountofphysicalactivity).

Strongevidenceexiststosupporttherelationshipbetween

physicalactivityandemotionalwellbeing.

WhilenotaspecificfocusoftheMayresearchmeeting,

additionalfactorsthatmaybeassociatedwithmaintaining

cognitivefunctionincludesocialengagement,ahearthealthy

diet,andemotionalsupports.Inaddition,higherhouseholdand

communitysocioeconomiclevelsinearlylifeareassociated

withhigherlevelsofcognitioninlatelifebutnotwiththerisk

ofAlzheimersdiseaseorrateofcognitivedecline. 34

What gaps exist?

Eachnewdiscoveryinmaintainingcognitivehealthraisesa

hostofimportantquestions.Someofthemorepressingissues

arethefollowing:

Howdowepromotetheimportanceofcognitivehealth

issuestokeyconstituenciesandstakeholders?

Whatarethepublicsperspectivesonlifestylebehaviors,choices,andattitudesconcerningcognitivehealthandthe

burdenofcognitivedecline?Whatdoweviewasthebenefits



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Allthethingsthatweknowarebadforyourheartturnouttobebadforyourbrain.MarilynS.Albert,PhD

Johns Hopkins Medical Institutions

andbarriersofmodifyingpersonallifestyletoreducetherisks

associatedwithcognitivedecline?

Whatistheroleofpopulationbasedsurveillanceandthe

appropriatesurveillancesystemstoassesscognitivedecline?

Whatclinicaltrialsandotherresearchareneededto

determinethelongtermoutcomesoflifestyleinterventions

onparticularcognitivefunctions?

Howdowelinkscientificallyvalidmessagesaboutriskof

cognitivedeclinetocurrentpublichealthmessagesfor

effortsinprimaryprevention?

Whataretheeffectsofmodifyingmultipleriskfactors

onminimizingcognitivedeclineorimproving

cognitivefunction?

How can public health contribute?

Publichealthwasfirstdefinedin1926,asthescienceandartof

preventingdisease,prolonginglifeandpromotinghealthand

efficiencythroughorganizedcommunityeffort. 35That

definitionhasremainedintactforover80years,witharecent

reiterationofpublichealthsmissionasassuringconditionsin

whichpeoplecanbehealthy. 36

Organizedpublichealtheffortsoverthepast100yearshaveyieldedremarkableachievements.Tenconsideredtobeamong

thegreatest37areintheareasof:

Vaccination

Motorvehiclesafety

Saferworkplaces

Controlofinfectiousdiseases

Declineindeathsfromcoronaryheartdisease

andstroke



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StateofKnowledge

Saferandhealthierfoods

Healthiermothersandbabies

Familyplanning

Fluoridationofdrinkingwater

Recognitionoftobaccouseasahealthhazard

Theseachievementswerepossiblebecauseofcombined,

coordinatedeffortstoapplythreecorepublichealthfunctions:assessment,policydevelopment,andassurance.

Assessmentcallsforregularlyandsystematicallycollecting,

analyzing,andsharinginformationonthehealthofa

community.Suchinformationhelpstodescribeand

understandacommunityshealthstatusandneeds.Assessment

activitiesmightinvolveinvestigatingadversehealtheffects

andhealthhazardstoidentifythemagnitudeofahealth

problem,itslocation,trendsovertime,andpopulationsat

risk.Theymayalsodigdeepertoanalyzedeterminantsof

identifiedhealthproblemssoastoilluminateetiologicand

contributingfactorsthatplacecertainpopulationgroupsat

riskforadversehealthoutcomes.

Policy developmententailspromotionofpublichealth

policiesthataregroundedinsciencebaseddecisionmaking.

Bytakingtheleadinpolicydevelopment,publichealthserves

asanadvocate,buildsconstituencies,andidentifiesresources

inacommunityasitgeneratessupportiveandcollaborative

relationshipswithpublicandprivateagencies.Anothercritical

policyactivityinvolveshelpingcommunitiessetpriorities

amonghealthneedsbasedonthesizeandseriousnessofthe

healthproblemsandtheacceptability,economicfeasibility,and

effectivenessofinterventions;thecommunitycanthendevelop

plansandpoliciestoaddressthosepriorities.

Assuranceistheguaranteethatservicesneededtoachieve

agreedupongoalsareactuallyprovided.Itispursuedby

encouragingtheactionsofothers(publicorprivate),requiring

actionthroughregulation,orbyprovidingservicesdirectly.

Thisthirdcorepublichealthfunctionencompassesmanaging

resourcesanddevelopingorganizationalstructures;implementingprogramsforpriorityhealthneeds;andevaluatingandproviding

qualityassurancetoensurethatprogramsareconsistentwith

plansandpoliciesorthatneededcorrectiveactionsare

takenpromptly.Inaddition,assuranceactivitieshelptoinform

andeducatethepubliconhealthissuesofconcern;promote

awarenessofpublichealthservices;andpromotehealth

educationinitiativesthatcontributetoindividualorcollective

changesinhealthknowledge,attitudes,andpracticesthat

makeforahealthiercommunity.



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Ifyoucouldgivepeopleinformationandtoolsthat

woulddelaytheonsetofcognitiveimpairmentbyafewyears,youwouldbedoingmuchtoimproveindividualsqualityoflifeas

wellasimprovingsociety.DebraCherry,PhD


Theapplicationofthesepublichealthfunctionstocognitive

healthoffershopeofsimilarachievementsasscientific

knowledgeadvances.Theareaofcognitivehealthisgaining

increasingattentionfrommultipleperspectivesandrepresents

ablossomingarenaforresearchandaction.Byembracing

cognitivehealthasapriorityissue,thepublichealthcommunity

wouldbemobilizedtostudy,identifyandimplementeffective

interventionsthatpreservethiskeycomponentofhealth.

Ourchallengeistoofferasystematicapproachthatwillassureacoordinatedandunifiednationaleffort.TheRoad

Mapmeetsthatchallengebylayingoutasharedvisionfora

workinprogress,onethatbuildsonthefoundationofthe

workdonetodate,establishesaframeworkwithinwhichto

viewthefindingsofthatwork,linksrelatedandcomplementary

activities,andshapestheworkofthefuture.



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Ibackground

IIstate of

knowledge

IVdevelopment

process

Vactions by

cluster

VInext steps

IIIstrategic

framework

StrategicFrameworkWhat is our model for action?

TodeveloptheRoadMap,weusedasynergisticmodel

(Figure1)formovingscienceintopublichealthpractice. 38

Themodelstartswiththeassumptionthatwemustfirst

understandtheexisting science and knowledge baseforpreservingandprotectingcognitivehealth,determinefindingsreadyto

bemovedintothepublichealtharena,andthenconduct

researchtofillimportantgapsinknowledge.

Atthesametime,wemustanalyzesocial and environmental

forcesthatcreatedemandandinfluencetheacceptanceofnew

knowledge.Thepushofscienceandthepullofthemarketcombinetoshapethecapacitythecomplementofhuman

andfinancialresourceswemusthaveinplacetoimprove


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StrategicFramework

Figure 139The Model: Moving Science into Public Health Practice

Intermediate Outcomes

Long Range Outcomes

Build and

strengthen capacity

(competencies,

resources,

partnerships, etc.)

Create/expand the science and

knowledge base

Create/sustain social/

environmental demand



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publichealthpractice.Strengtheningandbuildingcapacity

focusesonidentifyingkeypublichealthentities,determining

thenecessarycompetenciesandresources,andexpanding

partnershipstomountandsustainnecessaryactions.

Deployingthiscapacityeffectivelywillleadtodesired

intermediate and longrange outcomes.

What principles do we embrace?

Severalkeyprinciplesunderlieourapproachtomaintaining

cognitivehealth.

A firm grounding in science. Epidemiologicstudies

followedbythetestingofinterventionsinclinicaltrialswith

componentsthatincludecognitiveassessmentwillshow

whichlifestylefactorsbestmaintaincognitivehealthfor

thepopulation.Throughpopulationbasedsurveillance,

epidemiologyandpreventionresearch,publichealthcan

contributetoourunderstandingofcognitivehealthandcan

identifypromisinginterventionsthatmaybeeffectivein

promotingorprotectingit.TheRoadMaprecognizesthat

thisprocessisevolutionary,anditseekstobuilduponwhat

wecurrentlyknowbyincorporatingnewdiscoveriesastheyemerge.

Thepossibilityofpreventioninthisareaissonewandsoexcitingforfamilies,individuals,andgovernment.

JamesLaditka,DA,PhD,MPA

University of South Carolina

An emphasis on primary prevention.Publichealth

focusesonreducingthefactorsthatputpeopleatriskof

cognitivedecline,whileincreasingthefactorsthatpromote

andprotectcognitivehealth.Thus,theRoadMapfocuses

oninterventionsinhealthpromotionandriskreductionthat

preservecognitiveperformanceratherthanpreventdementia.

Itrecognizesthepotentialsynergisticapproachbyintegrating

theseinterventionswithotherlifestylemessagesandshowing

howtheymightfitwithpharmacologicinterventions.

A community and population approach. Publichealth

takesabroadviewandseekstoachievelastingchangein

thehealthofentirepopulations,extendingfarbeyondthe

medicaltreatmentofindividualpeople.Thus,theRoadMaps

recommendationsareexpansiveinscope,anddonotsingle

outanyparticularpeopleorgroupsforspecialattention.



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StrategicFramework

A commitment to eliminating disparities. Racial

andethnicdisparitiesinhealthandhealthcarearewell

documented.Theeliminationofsuchdisparitiesisacritical

componentofthenationalpublichealthagendaandakey

principleofthisRoadMapaswell. 40Thenumbersand

proportionofolderadultsfromdiverseracialandethnic

originsintheUnitedStatesareincreasing.In2003,nonwhite

ethnicandracialgroupsrepresented17%ofthepopulation

age65andolder,withthatproportionprojectedtoincrease

to28%by2030and39%by2050.41Weembracethis

diversityandrecognizeitsvalueinshapingpolicyinitiatives,

communicationstrategiesandlifestyleinterventions,and

populationbasedsurveillancerelatedtocognitivehealth.

What do we hope to accomplish?

Weenvisionanationinwhichthepublicembracescognitive

healthasapriorityandinvestsinrelatedhealthpromotion

andresearch.Toachievethisvision,wehaveadoptedalong-

termgoalandavarietyofoutcomesasmoreimmediategoals.

Our longterm goal is to maintain or improve the cognitive

performance of all adults.

Fourteenintermediateoutcomesencompasstheareasof

communication,surveillance,research,policyandpublic

healthcapacity.Theseareto:

Increaseawarenessabouttheimportanceofpromotingand

protectingcognitionamongthegeneralpublic,publichealth

andagingprofessionals,andpolicymakers.

Increaseknowledgeabouttheriskandprotectivefactors

associatedwithcognitionamongthegeneralpublicand

publichealthandagingprofessionals.

Decreasemisconceptionsandmythsaboutcognitivehealth

amongthegeneralpublic.

Determinecriticalpublichealthmeasuresformonitoring

cognitivefunctionatthepopulationlevel.

Incorporateappropriatecognitivemeasuresintopublic

healthsurveillancesystems.

Identifytheresearchgapsonmodifiableriskfactors

andcognition.

Securesustainedsupportforpublichealthresearch

topromoteandprotectcognitivehealth.



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Ifwemaintaincognitivefunctionovertime,thenwearemorelikelytobefunctionallyindependent.

MarilynAlbert,PhD

Johns Hopkins Medical Institutions

Disseminatetheresultsofcriticalpublichealthresearch

findingsaboutcognitivehealth.

Identifykeypublicandprivatepoliciestoaddress

cognitivehealth.

Modifykeypublicandprivatepoliciestoaddress

cognitivehealth.

Identifysuccessfulpublichealthbestpracticesonvascular

healthanddiabetes.

Increasecognitivehealthinterventionsthatare

complementarytovascularhealthanddiabetespublichealthstrategies.

Securesustainedsupportforpublichealthstrategiesto

promoteandprotectcognitivehealth.

Enhancethecapacityofagingandpublichealthservice

networkstoimplementeffectiveinterventionstopromote

andprotectcognitivehealth.



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IVdevelopment

process

IIIstrategic

framework

IIstate of

knowledge

Ibackground

Vactions by

cluster

VInext steps

DevelopmentProcessPhase I Workgroup deliberations

Fourworkgroupsofinvitedexpertsworkeddiligentlyand

collaborativelyovera7monthperiodtoidentifyrecommen

dationsinfourareasofpublichealthaction:Prevention

Research,Surveillance,PolicyandCommunication.The

chargetoeachworkgroupwastodefineitsareaoffocus,

identifyimportantprinciples,andrecommendactionsfor

movingthenationforwardoverthenext35yearstoward

thelong termgoalofmaintainingandimprovingthe

cognitivefunctionofadults.Thedefinitionsandprinciples

thatemergedarepresentedbelow.

Prevention ResearchResearch in public health prevention isdefinedhereasresearch

thatappliesandtestspopulationbasedinterventionsthathave

D l P


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DevelopmentProcess

thepotentialtomaintaincognitivehealth.Recommenda-

tionsforcognitivehealthfocusprimarilyontwoareas

vascularriskfactorsandphysicalactivitywithemphasis

ontheneedforpracticalclinicaltrialstoshowthebenefits

ofvascularhealthinterventionsandphysicalactivityon

maintenanceoflongtermcognitivehealth.Theseareas

werechosenbecausetheyarethefirsttoemergefrom

populationbasedstudiesandanimalresearchaspromising

areasforintervention.Whiletheepidemiologicevidence

supportingthebenefitsofvascularhealthforcognitive

functionismoredefinitivethanthelinkregardingphysical

activity,bothareasareworthyofattention.Inaddition,recent

findingsfromclinicaltrialshaveheightenedinterestinthe

valueofmentalactivitiesbyshowingapositiveeffectfrom

cognitivetrainingoncertaincognitivedomains.

Researchonpreventionshouldnotbelimitedtotheseareas,

however.Otherareas(suchasnutritionandsocialengagement)

shouldalsoberecognizedasimportanttoaddressinthefuture.

Totheextentpossible,researchshouldbemultidisciplinary

andbuildonafirmunderstandingofhowthepublic,health

careprofessionals,andavarietyofotherpartnersdefine,

perceive,andvaluecognitivehealth.Inaddition,research

methodologiesshouldconsiderhowtoconvertresultsfrom

randomizedcontroltrialstocommunitysettings;howto

makeclinicalorevidencebasedworkpractical;andhow

totranslateresearchintopublichealthpractice.

Surveillance

Surveillanceisdefinedastheongoing,systematiccollection,

analysis,interpretation,anddisseminationofhealthrelated

data.42,43,44

Theongoingnatureofpublichealthsurveillance,itsapplicationtobroadpopulations,andlimitationsinresources

oftenrestrictthenatureanddepthofinformationthatcan

begatheredthroughtraditionalsurveillancemethodsused

inresearch.Thesemethodsrangefromcreatingnew

surveillancesystemstousingorenhancingexistingsystems

andsurveillanceofcognitivefunctionisnoexception.Selecting

appropriatesurveillancemethodsforcognitivedeclinepresents

someuniquechallenges,however,suchasdefiningcriteriafor

acognitivemoduleandmeasuringavarietyofdimensions

(e.g.,riskfactors,attitudes,andburdenofcaregivers).Inaddition,

becausemeasurementsmayvaryaccordingtoeducation,

language,culture,andraceorethnicity,specialcaremustbe

takentoensurethatdataarenotmisinterpretedormisused.



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Methodsavailableforthesurveillanceofcognitivedecline

inolderpopulationsthatdonotrelyonselfreportingface

particularconstraints.

Cognitivedeclineinindividualpeopleisdirectlyidentified

throughrepeatedmeasurementsconductedoveraperiod

oftime.Toimplementthismethodofcaseascertainment

inasurveillancesystemrequireslongtermfollowupofpopulationbasedcohortswithopen(continuousorsuccessive)

enrollments.Suchsystemsarenotoftenusedforchronic

diseasesurveillance,astheyareexpensiveandrequirean

extensivetimecommitmentfromparticipants.

Repeatedcrosssectionalpopulationsurveysaremore

commonlyemployedinsurveillance,particularlyforsome

chronicdiseasesandforsomeriskfactorsfordisease.Unfortunately,therearenocurrentlyestablishedmethods

thatdefinitivelyascertaincasesofcognitivedeclinethrough

crosssectionalinterviewsalone.Selfreporteddataare

inaccurateinthisarea,andtheusefulness,availability,and

validityofproxyreporteddataareuncertain.Despitethese

limitations,suchsurveyshavevalueinmeasuringthe

prevalenceofriskfactorsforcognitivedecline.Theymayalsohavepotentialtomeasuresomeparametersofcognitive


Development Process


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DevelopmentProcess

functions.Itispossiblethatchangesovertimeinthe

populationdistributionofsuchparametersmaysuggest

changesintheprevalenceofcognitivedecline,although

suchinferencescanonlybemadewithcautionevenafter

controllingforconfounderssuchaseducation,culture,and

socioeconomicstatus.

Othermethodsofscreeningoridentifyingconditionsassociatedwithcognitivedecline(e.g.,geneticscreening,

biomarkers,andneuroimagingtests)donotyetappear

practical,althoughsomemayeventuallyproveusefulifthe

costsarereasonable.

Recommendationsforsurveillancemustbeofferedwiththese

methodologicalconstraintsinmind,recognizingthetension

betweenidealmethods,forwhichresourcesmaybedifficulttoobtain,andmorelimitedmethods,forwhichresourcesare

morelikelyavailable.

Policy

RealizationoftheRoadMapsvisionrequiresapolicybase

inboththepublicandprivatesectorsthatsupportsand

promotescognitivehealth.Thepublic sectorencompasses

policymakersatfederal,stateandlocallevels.Theprivate sector

includesbothnotforprofitandcommercialorganization

policies,suchascoverageofpreventionbyinsurers,human

resourcedepartmentpolicies,employeeassistanceprograms,

andotherworkplacepoliciesandpractices.Policychanges

inthepublicsectorcaninfluencepoliciesandbehaviorsinthe

privatesector;conversely,privatesectorpolicychangecan

influencepublicpolicy.

Toeffectpolicychange,thepublichealthcaseforaddressingcognitivehealththefactthatobservationalevidenceand

limitedshorttermclinicaltrialsnowexisttosupportsome

preventionopportunitiesinthisareamustbemadeinan

easilyunderstandableandconsistentmanner.National,state

andlocalorganizations,agenciesandpolicymakersmustbe

educatedaboutcognitivehealthandsubsequentlyengaged

tohelppromotepositivepolicydevelopmentandchangethat

willincreaseknowledgeandleadtobettercognitivehealth.

Moreover,policyrelatedtomaintainingcognitivehealthdoes

notjustaddresscare,behaviors,orriskfactorsbutalso

promotesresourcesforbuildingandmaintainingcommunity

infrastructurethatreinforcesindividualbehavior.Thiscould

includebikeorwalkingtrailstoencouragephysicalactivity,

communitywideorganizationsandstructuresthatsupporthealthybehavior,andotherchangestothebuiltandcultural



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Developingaroadmapforcognitivehealthprovidesuswithanopportunitytoreducehealthdisparities.Some

populationsareathighriskforcognitiveimpairmentduetohighratesofhypertensionordiabetes.TheRoadMapgivesusachancetoprovidebetterhealthinformationforallAmericans,includingthoseathighestrisk,sothatpeoplemayimprovetheirmotivationtochangetheirlifestyleforbetter

healthoutcomes.DebraCherry,PhD


environmentsthatadvancethepublichealthgoalofcognitive

health.Policyinitiativesmustbuildupon,relateto,andbecompatiblewithcommunicationsandresearcheffortsasthey

takeshapeandyieldnewinformation.

Communication

Thetermcommunication strategyimpliesamultidisciplinary

healthmarketingapproachthatincludescommunicatingand

disseminatingscientificallyvalidinformationandstrategic

interventionsthroughcustomercenteredandculturally

appropriatemeans.Acommunicationsstrategyforcognitive

healthaimstoeducate,motivate,andeffectpositivebehavior

changerelatedtocognitivehealthintargetedandatrisk

audienceswithin3years.

Toeffectivelyreachthisgoal,communicationmessagesand

methodsshould:

Besciencebased.

Begearedtopopulationsexperiencingthegreatest

disparitiesandrisksincognitivehealth.

Reachtheintendedaudienceandpromoteaction.

Assisttheconsumerinmakingmoreinformeddecisions.

Theaudienceofadultsaged4260years,alsoknownas

babyboomers,belongstothebiggestgenerationinAmerican

history.Cognitivehealthissuesprofoundlyaffecttheirparents

now,andtheywilltouchtheboomersinhugenumbersas

theygrowolder.Itisimportanttogetappropriatevalid,

evidencebasedmessagestothem,sotheymaytakeaction

forthemselvesaswellaspotentiallyinfluencetheirfamilies.

Specialfocusshouldbegiventohighriskpopulations,

vulnerablepopulationsandhealthcareproviders.Specific

racialorethnicgroups(e.g.,AfricanAmericans,Latinos)may

needtohavetargetedandculturallyappropriatematerialsandtoolsdevelopedbecausetheymaybeatgreaterriskfor


Development Process


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DevelopmentProcess

experiencingcognitivedeclineduetohigherrisksofvascular

disease,hypertensionanddiabetes.Healthcareprovidersmay

haveneedsandgapsinknowledgethatdifferfromthegeneral

publicbecausetheyareprovidinginformationaboutcognitive

healthtoothers.Aninitialfocusonthesegroupswouldnarrow

thescopeofeffort,affordingmoreachievableoutcomes.

Inaddition,beforereachingouttoconsumers,accurateinformationandoptionsshouldbeinplacethroughoutthe

broadermedicalandsocialserviceenvironment.Healthcare

professionalsarethemainsourceofinformationformany

consumers,andpastexperiencehasproventhebenefitsof

targetingprofessionalorganizationsfirstaspeerinfluencers

andtrainersofthesefrontlineproviders.

Phase 2 Concept-mapping process

Theworkgroupscollectivelyproposed42recommendations:

18inpreventionresearch,8incommunications,9inpolicy,

and7insurveillance.Aconceptmappingprocesswasthenused

toorganizeandvisuallyrepresentthem.Conceptmapping

combinesqualitativeandquantitativemethodstogenerate

mapsthatprovideavisualrepresentationofthecomplexrelationshipsamongideasandresults.45Itcanelicitideasfrom

large,diverse,andgeographicallydispersedgroupsabout

aparticulartopicwithinashorttimeframe.Unlikeother

qualitativemethods,conceptmappingalsoprovidesastructured

approachthatallowskeydecisionmakerstoparticipateinthe

finalinterpretationofalargergroupsperceptions.

Forthisproject,conceptmappingwasorganizedinto

threesteps.

Step 1involvedreviewingandrestructuringrecommendations

fromtheworkgroupstoensurethateachrecommendation

representedadistinctidea,andidentifyingthelistof

stakeholderswhowouldbeinvitedtoparticipate.Thislist

includedmorethan150personsfromabroadarrayof

institutions,includingstateandfederalagencies,universities,

andfoundations.

Step 2consistedofonlineratingandsortingbyinvited

participantsandsubsequentanalysesoftheresults.46Forthe

ratingprocess,140(ofthe150)participantswereaskedto

rateboththerelativeimportanceofeachrecommendation

anditscurrentactionpotential.Forthesortingtask,20of

these140participantswerealsoaskedtocategorizethe

recommendationsaccordingtotheirviewofsimilarmeanings

orthemes.Ten(ofthe150)participantswereinvitedto



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Iamveryimpressedwiththeprocessbecausethisisafieldin

whichpeoplehavestrongopinionsonmanydifferentissues.Whatimpressedmewasthattheparticipantsinthereviewprocesswereopentohearingabroadrangeofopinionsbutintheendoptedforscientificrigorastheguidingfeatureonwhichrecommendationswerebased.

PeterRabins,MD,MPH

Coauthor,The 36 Hour Day

participateinthesortingtaskonly.Becausetheratingand

sortingprocesswasanonymous,exactfiguresonparticipationarenotavailable;however,basedonthenumberoftotal

responses,69persons(outof140,or49.3%)providedinput

intoratingtheimportanceandactionpotentialofeach

recommendation.Additionally,23persons(outof30,or

76.7%)organizedtherecommendationsintocategoriesto

identifythemesorpatterns.Multivariatestatisticaltechniques

wereusedtoorganizeandvisuallypresentresultsoftheonlineprocessinaseriesofconceptmapsthatreflected

relationshipsbetweenrecommendationsandtheclustering

ofrecommendationsintocategories.

Step 3 encompassedthereviewandinterpretationofthe

resultsofPhase2,andselectionofpriorityrecommenda-

tions.MembersoftheSteeringCommitteereviewedthe

mapstoensurethattherecommendationsineachoftheeightclusterswereconsistentwiththeoverallthemeofthatcluster.

TheCommitteereconstructedafewrecommendations

creatingtwoadditionalrecommendations(foratotalof44recommendations)andintwoinstancesmovedrecom-

mendationstoadifferentcluster.Thefinalclusterlabelsare:

Disseminatinginformation

Translatingknowledge

Conductingsurveillance

Implementingpolicy

Measuringcognitiveimpairmentandburden

Movingresearchintopractice

Conductinginterventionresearch

Developingcapacity

Asafinalstep,theSteeringCommitteechoseasetof

priorityrecommendationsoractions.



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Ibackground

IIstate of

knowledge

IIIstrategic

framework

IVdevelopment

process

Vactions by

cluster

VInext steps

Actions byClusterTheRoadMapisalivingdocumentexpectedtoevolve

overtime.Someactionsareachievablewithin1to3years,

whileotherswillrequiremoretimetocometofruition.

Somearelinkedandneedtooccurinacertainsequence,

withtheoutcomesofthefirstsettingthestageforinitiating

thenext.And,whilenoparticularagegroupissingledoutforspecialattention,theRoadMapconcentratesprimarilyon

interventionsformiddleagedandolderadults.Thisfocus

recognizesthatinterventionstoreducerisksarebestbegun

earlyinlife;yet,adults,particularlyolderadults,aremore

likelytobeconcernedandmotivatedtotakeaction.

ThefullsetofRoadMapactionsfallintoeightclusters.

Withineachcluster,theactionsarelistedinnospecialorder

ofpriority.Theletterinparenthesesaftereachactionrefers

ActionsbyCluster


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tothegroup(eitherworkgrouporSteeringCommittee)

thatoriginallyproposedit(P=PreventionResearch,

C=Communication,P=Policy,S=Surveillance,SC=Steering

Committee).Alloftheactionsgeneratedbythegroups

areincluded.

Inofferingtheseactions,wecannotunderestimatethe

complexitiesoftranslatingthemintoaction.Mostessentialis

acommitmenttobasethisRoadMaponscientificevidence,

movingforwardcollaborativelytoleverageexistingresources

andactivitiesaspromotionactivitiesbecomedefined.Key

partnershipsmustbeformedamongadiversearrayof

organizationsandagenciestobuildoncollectivestrengths,

delivercompatiblemessagesandinterventions,andassure

efficientuseofresources.Existinghealthpromotion

communitiesassociatedwithheartdisease,stroke,diabetes,

andphysicalactivityareinvaluableresourcesforpromoting

cognitivehealth.

Disseminating information

1. Disseminate the latest science to increase public

understanding of cognitive health and to dispel

common misconceptions. (SC)

Evidenceexiststhatthecurrentboomergenerationis

concernedaboutcognitivehealthandfearsAlzheimers

disease.Onecriticalareaoffocusshouldbeonhelping

thepublictounderstandthevaryinglevelsofevidence

behindproposedinterventionsregardingcognitivehealth.

Unlesscredibleandbroadreachinginformationabout

validinterventionsincognitivehealthisdisseminated,

consumerswillfillthegapwithuntestedprogramsand

products.Notonlycantheseprogramsandproducts

presentaneconomicburden,butsomemayalsodistract

theagingpopulationfrommeaningfullifestylechanges.

Communicationsstrategies(includingtheappropriate

communicationchannels)shouldbuilduponcurrent

effortsbyvariousorganizationsandagenciestoshare

existinginformationandmaterialsoncognitivehealth

researchandpossibleinterventionsthatareconsistent

withcurrentscience.



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2.

3.

Develop communications strategies and tools

to increase awareness among health care providers,

public health professionals, and aging service

providers at the national, state, and local levels about

the current state of science of cognitive health. (C)

Indisseminatinginformationtothepublic,information

mustbefilteredthroughtrustedhealthandcommunity

resources.Providingprofessionalswithaccurate,evidence-basedinformationandtoolswillrespondtothegrowing

interestamongconsumersregardingquestionson

preservingcognitivehealth.

Develop and implement a training curricula

related to cognitive health for continuing

professional education of health and human

services professionals. (P)

Toincreasetheawarenessandknowledgeofprofessionals

inhealthandhumanservices,strategiesshouldbedeveloped

inbothpreserviceandinservicemodalities.Bringingnew

professionalsintothefieldwithappropriateknowledge

isnotenough;thelevelofunderstandingofpracticing

professionalsmustalsoberaisedsothattheycanhelpthe

publicsortoutevidencebasedapproachestocognitive

healthfromlessprovenorundemonstratedoutcomes.

4.

5.

Develop creative and replicable means for raising

the publics awareness of cognitive health and

engaging the public in promoting the importance

of cognitive health through policy. (P)

Thepublicplaysanimportantroleinstimulatingboth

publicsectorandmarketplaceactiononissuesitfinds

important.Itisessentialthatthepublicbeeducated

basedoncurrentscienceandknowledgeofbestpractices.Thiswillcontributetothedevelopmentof

anewconventionalwisdomregardingcognitivehealth.

Establish and maintain a Webbased cognitive

health clearinghouse, in partnership with

stakeholder organizations, that would be

recognized as a centralized site for scientifically

validated and recognized information. (C)

Aonestopshop,gotoplaceforvalidandtested

informationwillprovideconsumersandprofessionals

whoserveolderadultsandtheirfamilieswiththetools

tomakeinformeddecisionsabouttheirhealthandeffect

positivebehaviorchange.Thesitewouldprovideguiding

principlestohelpconsumersandhealthinformation

providersandprofessionalstoevaluatelocalservices

thataddresstheseconcernsandtomaintaincurrent


ActionsbyCluster


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understandingaboutcognitivehealthandthese

interventionsasthesciencebecomesmoresophisticated.

Translating knowledge

1. Determine how diverse audiences think about

cognitive health and its associations with

lifestyle factors. (R)Itisnotclearhowthegeneralpublicorpractitioners

perceiveandunderstandcognitivehealth.Todevelop

usefulprograms,itwillbeimperativetobetterunderstand

thediversetargetaudiences.Someissuesthatwouldbe

importanttounderstandfortranslationtoboththe

generalpublicandpractitionersinclude:howcognition

isdefinedandtranslated;whataspectsofcognitivehealth

areimportant(includingthelevelofknowledgeabout

vascularfactors);andhowconcernedthegeneralpublic

isaboutcognitivehealth.

2. Help people understand the connection between risk

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

Riskandprotectivefactorsarekeystofiguringouthow

toaddressindividualandcommunityhealthandrequire

clarifyingforthepublicwhatisdemonstratedaseffective

inclinicaltrialsversusassociationsobservedinother

studies.Ofprimaryinterestareaspectsofpersonaland

environmentalexperiencesthatmakeitmorelikely(risk

factors)orlesslikely(protectivefactors)thatpeoplewill

experiencecognitivedecline.Considerationshouldbe

giventotheseconnectionsandtopromotingabetter

understandingofit,includinganunderstandingofareasinwhichclinicaltrialshave(orhavenotyet)established

acauseandeffectbetweenriskandprotectivefactorsand

cognitivehealth.

3. Develop a mechanism to review cognitive health

messages and programs to determine their

scientific accuracy and public credibility. (C)

Currently,thepublichasnosinglesourceofinformed

andvalidrecommendationsforprograms,services,and

lifestylerelatedinterventionstoaddresspositivemeasures

incognitivehealth.Creatingasystemforreviewingthe

growingnumberofprogramsandprovidingpublicaccess

tothereviewsgeneratedwillmoveconsumerscloserto

informeddecisionsandmorepositiveinvestmentsinhealth.



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Implementing policy

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

levels to promote cognitive health by engaging

public officials.(P)

Farreachingpublichealthissuesdemandinformedaction

bypublicofficials,becauseactionbytheprivatesector

alonewillbeinsufficienttoreachdesiredresults.Because

programandfundingdecisionsaremadebypolicymakers

atthenational,stateandlocallevels,itisimportantto

engageandeducatethisaudience.Publicofficialshave

significantcompetinginterests;itisessentialthatthey

becomeeducatedandengagedinthisarenatocontribute

topositivepolicychangeincognitivehealthinterventions

andtosupporttheneedforfurtherresearch.

2. Include cognitive health in Healthy People 2020,

a set of health objectives for the nation that will

serve as the foundation for state and community

public health plans. (P)

Thedevelopmentanduseofdocumentssuchas Healthy

People 2020willrepresentasystematicandwidely

recognizedapproachtoimprovinghealth.Asresearch

demonstrateswaysinwhichcognitivehealthcanbe


ActionsbyCluster


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maintained,theareaofcognitivehealthcanbeelevated

toamajorhealthprioritybybeingincorporatedintothe

outcomeorientedapproachusedbyHealthy People 2020.

3. Include the public health burden of cognitive

impairment in the State of Aging and Health

in America Reportwhen population level data

are available. (P)

Includingcognitivehealthinsuchdocumentsasthe

State of Aging and Health in America Reportwouldelevate

itsstatusasarecognizedpublichealthissueandmakedata

readilyavailableforaction.Armedwithimportantdata

fromthisandothermonitoringsystems,publichealth

professionalswillbepreparedtomovepolicyforwardto

testinterventions.

4. Promote appropriate strategic partnerships among

associations, government agencies, insurers and

payers, private industry, public organizations, and

elected officials to support and advance research

and policy related to cognitive health. (P)

Partnershipscanhelptomaximizelimitedresources

(fiscalandpersonnel)andcompetingpriorities.

Theyshouldbebaseduponsuchcriteriaastheability

to:examineevidencebasedresearch;establishongoing

formsofdialogue;buildleadershipandcapacityrelated

topolicyandpublicandprofessionaleducation;address

diverseculturalandethnicpopulations;providefunding;

andexplorethelinksbetweenthevascularfactors,

physicalactivity,andcognitivehealth.

5. Engage national organizations and agencies that

focus on the older population, and educate these

agencies about cognitive health and its connection

to their missions.(P)

Toachievebroad,effectivecollaborationsforcognitive

healthandemotionalwellbeing,nationalorganizations

andagenciesmustidentifyandagreetocommon

ground.Nationalorganizationsandagenciesareessential

tobothreachinglargenumbersofindividualmenand

womenandtousingtheirinfluencetoeducatepolicy

makersandopinionleaders.Educationofthepublicand

leadersofkeyorganizationsisaprecursortopolicy

changerelatedtocognitivehealth.



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6. Convene policy experts to identify and examine

current policies (e.g., national policy, state

policy, private sector policy) that could be

modified, modernized, or broadened to include

cognitive health.(P)

Policiesshouldbeamendedtoreflectcurrentscience

andknowledgeandbeinclusiveofcognitivehealth.

Adjustingandamplifyingcurrentpoliciesareefficientandeconomicalroutestosystemschange.

7. Promote the modification of existing national

and state public health plans to include cognitive

health in their strategies or recommendations

where appropriate.(P)

Nationalandstatepublichealthplanssignificantly

influenceeffortsinpublichealthandserveasa

barometerofimprovement.Asinterventionsare

demonstratedthatcanhaveaneffectoncognitive

health,includingitintheseplanswouldelevateits

statusasarecognizedpublichealthissueandprovide

avenuefortheevaluationofprogress.

Conducting surveillance

1. Define the goals of a surveillance system to

promote the development of an appropriate system

and the collection of data on cognitive health. (S)

Clearlydefinedgoalsofpublichealthsurveillancewill

promotethedevelopmentofappropriatesurveillance

systemsandthecollectionofconsistentdatathatprovide

usefulinformationtoinformpublichealthpolicy.Goals

ofthesurveillancesystemmayinclude:definingtheburden

ofcognitivedeclineinthepopulation;monitoringthe

trendsinburden(e.g.,prevalence,incidence);monitoring

trendsinriskfactors;definingthepopulationatincreased

risk;anddeterminingwhetheradditionalanalysesshould

beperformedforthepurposeofpublichealthsurveillance.

2. Determine which existing general populationbased

surveillance systems include information useful for

the surveillance of cognitive health at national, state

and local levels. (S)

Addingtoorchangingexistingsurveillancesystems(e.g.,

BehavioralRiskFactorSurveillanceSystem,Healthand

RetirementStudy,NationalHealthInterviewSurvey)to


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addressissuesrelatedtocognitivedeclineislesscostlyand

maybemoreefficientthandevelopingnewsurveillance

systems.However,thereareimportantlimitationsofexisting

systemsandthedatatheycollect;inparticular,mostarecross

sectionalratherthanlongitudinal.Manyarealreadyquite

lengthy,withmajorconstraintsonaddingnewitems.

Closeexaminationofthesesystemswillensurethatthey

areamendedappropriatelyandcosteffectively.

3. Identify existing studies that measure longitudinal

trends in cognitive function.(S)

Existinglargecohortorotherlongitudinalstudiesof

cognitivedeclinemayprovideitemsthatcouldbe

incorporatedintosurveillancesystemsformeasuringsuch

decline.Someofthesestudiesmayhavevalidateditems

usedpreviouslyinbothmajorityandminoritypopulations

thatestimatevariabilityandtruechangeovertime.

4. Develop a populationbased surveillance system

with longitudinal followup that is dedicated to

measuring the public health burden of cognitive

impairment in the United States. (S)

Apopulationbasedsurveillancesystemwouldassistin

thecollectionofconsistentdatatomonitor,assess,and

informpublichealthprogramsandpolicyaboutthe

publichealthburdenofcognitiveimpairment.

Moving research into practice

1. Conduct systematic literature reviews on proposed

risk factors (vascular risk and physical inactivity)

and related interventions for relationships withcognitive health, harms, gaps and effectiveness. (R)

Itiscriticaltoexamineallstudiestodatetodocument

whichinterventionshavebeenproveneffective.Such

reviewsshouldfocusondeterminingtherelationships

betweenriskfactors,protectivefactors,andcognitive

functionacrossobservationalandclinicaltrials.Where

interventionsexist,theireffectivenessshouldbe

documentedandremaininggapsinthefieldshould

beidentifiedinordertomovestrategiesintopublic

healthpractice.

2. Conduct systematic literature reviews on proposed

risk factors (social engagement, nutrition,

and mental activity) and related interventions

relationships with cognitive health, harms, gapsand effectiveness.(R,SC)



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Itiscriticaltoexamineallstudiestodatetodocument

whichinterventionshavebeenproveneffective.Such

reviewsshouldfocusondeterminingtherelationships

betweenriskfactors,protectivefactors,andcognitive

functionacrossobservationalandclinicaltrials.Where

interventionsexist,theireffectivenessshouldbe

documentedandremaininggapsinthefieldshould

beidentifiedinordertomovestrategiesintopublichealthpractice.

3. Conduct a systematic literature review on the

relationship between treatment of diabetes and

cognitive health. (R)

Someevidencesuggeststhatdiabetesisariskfactorfor

cognitivedecline.Recommendationsfortypesofdiabetes

management(e.g.,medications,lifestylemodification)that

mightalsobebeneficialforcognitivehealthcannotbe

madewithoutareviewoftheliteraturerelatingdiabetes

interventionstocognitivechange(andmostlikely

undertakingadditionalclinicaltrials),andidentificationof

areasthatneedtobeclarifiedbeforespecificinterventions

canbeproposed.

4. Conduct a systematic literature review on the

relationship between treatment of hypertensionand cognitive health.(R)

Hypertensionisaknownriskfactorforstroke,and

thereforeforvasculardementiaandcognitivedecline.

Recommendationsfortypesofantihypertensivetherapy

andtherangesofbloodpressurefordifferentagegroups

recommendedformaintainingcognitivehealthcannotbe

madewithoutareviewoftheliteraturerelatinghypertensive

interventionstocognitivechange,andprobablynot

withoutpursuingadditionalclinicaltrials.Thesystematic

literaturereviewwouldidentifyareasthatneedtobe

clarifiedbeforespecificinterventionscanberecommended.

5. Identify gaps in knowledge about cognitive health

and related lifestyle changes, and determine


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whether these vary by specific groups. (C)

Todevelopappropriatematerialsandtools,thegapsin

knowledgeneedtobeunderstood,especiallyamong

highriskpopulations,vulnerablepopulations,andhealth

careproviders. Specificracialorethnicgroupsmayneed

tohavetargetedandculturallyappropriatematerialsand

toolsdevelopedbecausetheyareatgreaterriskfor

experiencingcognitivedecline.Healthcareprovidersmayhaveneedsandgapsinknowledgethatdifferfromthe

generalpublicbecausetheyarealsoprovidinginformation

toothersaboutcognitivehealth.

6. Conduct a systematic review of lifestyle interventions

and contextual factors to examine the benefits and

barriers to their adoption and maintenance. (R)

Understandingthebenefitsofandbarrierstoadopting

andmaintaininganinterventionisoneofthecriticalsteps

fortranslatinginterventionseffectivelyandefficaciouslyin

acommunitybasedsetting.

7. Conduct reviews of the literature to determine

the prescriptions for physical activity (e.g., type,

frequency, duration, and intensity of activity) that

are effective in enhancing cognitive function.(R)

Itisimportanttoknowwhatkindsofphysicalactivity

stimuliarenecessarytopromotecognitivehealth.An

examinationofthescientificliteraturewillidentifygaps

inknowledgeandfocusresearch.Withoutsuchinformation

andresearchdevelopment,accurateadvicecannotbe

conveyedtothepubliconhowactivetheyshouldbeto

maintaintheircognitivehealth.

8. Develop cognitive health interventions that

reflect the most current scientific research and

that are consistent with effective community

based interventions. (C,SC)

Clinicaltrialsassessingtheefficacyofinterventionsto

effectcognitivefunctionandpublichealthstudies

examiningtheeffectivenessandfeasibilityofcommunity

basedinterventionsareoftenreportedseparately.More

comprehensiveapproachesinvolvingcollaborations

betweenclinicalresearchersandcommunityparticipatory

researchersarecriticaltoensurethattheeffectivenessand

feasibilityofcognitivehealthinterventionsaredeveloped

andtestedwithvariouscommunities.



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Conducting intervention research

1. Conduct controlled clinical trials to determine the

effect of reducing vascular risk factors on lowering

the risk of cognitive decline and improving

cognitive function. (R)

Todate,fewvascularstudies(includinglargescalecontrolled

clinicaltrialsofolderadultcohorts)havecombinedcognitive

healthoutcomesandvascularoutcomesinasinglestudy.

2. Conduct controlled clinical trials to determine the

effect of physical activity on reducing the risk of cog-

nitive decline and improving cognitive function. (R)

Todate,few,ifany,physicalactivitystudies(including

largescalecontrolledclinicaltrialsofolderadultcohorts)

havecombinedoutcomesforcognitivehealthandphysicalactivityoutcomesinasinglestudy.

3. Conduct physical activity studies to determine the

longterm benefit of physical activity as it relates

to cognitive function. (R)

Todate,studiesofphysicalactivityinterventionsthathave

assessedcognitiveoutcomestypicallyhavenofollowupat

alloronlyashortfollowup.Studiesofphysicalactivity

areneededtodeterminetowhatextentanycognitive

benefitsassociatedwithphysicalactivitypersistacrosslong-

termfollowup:at6month,1year,orlongertimeper iods.

Longtermfollowupstudiesofphysicalactivityarealso

neededtodeterminethedurationofcognitiveeffectsin

thosewhostoptheprogram.

4. Conduct studies to determine the physical activity

prescription (e.g., type of activity, frequency,

duration, and intensity) needed to maintain or

promote cognitive functioning. (R)

Smallclinicaltrialshaveshownthataerobicactivity

(e.g.,walkingseveraltimesaweekfor6monthsduration)

wascapableofproducingcognitiveimprovementin

olderadults,atleastintheshortterm.Thesefewstudies,

however,haveyettoyieldaprescriptionthatcould

begiventoolderadults;thus,manyquestionsremain

tobeansweredaboutthetypesofactivity(e.g.,aerobic

oranaerobic,individualorgroup)andtheirduration,

intensity,andfrequencythatareneededtomaintain,or

evengain,goodcognitivefunction.

5. Conduct studies to determine the effect of physical

activity and physical activity relapse on persons of


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different backgrounds in relation to cognition. (R)

Similartothepharmacogeneticsapproachthathasbeen

usedtodeterminetheefficacyofspecificdrugsforpersons

withcertaingenotypes,itseemspossiblethatrecom-

mendationsforbehavioralinterventionssuchasphysical

activitymightbecraftedtoanindividualpersons

background(e.g.,geneticendowment,culturalcontext,

lifehistories,fitnesslevels,andage).

6. Identify how physical activity relates to those

aspects of cognitive functioning that are important

to the successful performance of activities of daily

living and instrumental activities of daily living.(R)

Itisimportanttounderstandhowanycognitivebenefit

measuredinthelaboratorytranslatestobetterfunctioning

inrealworldtasks.Althoughwellcontrolledlaboratory

studiesareessentialtoadvancingknowledgeinthisarea,

itiscurrentlynotclearhowmuchthecognitivetasks

assessedinthesestudieswillgeneralizetothecognitive

functioningrequiredinroutinedailyactivitiesimportantto

olderadults,suchasbalancingacheckbook,safelydriving

acar,andcompliancewithprescriptionsformedications

(i.e.,knowinghowmanyorwhatpillstotakewhen).

7. Determine the feasibility of conducting secondary

analyses of existing studies to examine the

relationship between physical activity and the

maintenance of cognition. (R)

Itisrecognizedthatsecondaryanalysesofexistingdata

setsoftenpossessmethodologicalproblems(including

crosssectionaldata).Nevertheless,datasets(perhapseven

somerepresentativeoftheU.S.population)mayexistthatcontainvariablesrelatedtocognitivefunctioning,health,

andphysicalactivity.Effortstolocatesuchdataandto

evaluateresearchquestionsandassociationsamongthe

variablesmayprovideadditionalinsightsintothisarea.

8. Identify the mechanisms that may mediate

the relationship between physical activity and

cognitive functioning.(R)

Physicalactivitymaynotaffectcognitivefunctiondirectly

butitmaystillaffectitthroughintermediatemechanisms.

Itisimportanttoknowwhethertheassociationbetween

physicalactivityandcognitivefunctioningismediated

bychangesindiabetesoutcomes,invascularfitness

outcomes,orinriskfactorssuchashypertension

orhyperlipidemia.



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9. Encourage cardiovascular disease and diabetes

researchers to use appropriate measures addressing

cognitive domains as outcomes in their studies.(R)

Thebestwaytounderstandwhichinterventionsin

cardiovasculardisease anddiabeteswillaffectcognitive

healthisforappropriateaspectsofcognitivemeasurestobe

routinelyincludedinappropriatestudiesinthesetwoareas.

10. Encourage research to determine the impact of

multiple vascular risks on cognition. (R)

Specificfocusisneededtobothunderstandthebiology

ofhowvascularriskfactorsaffectcognitionandto

determinewhethertheeffectsofhavingmultiplefactors

areadditiveormultiplicative. Someobservationalstudies

havesuggestedthatthegreaterthenumberofvascular

riskfactors,thegreaterthecognitivedeficit.Weknow,

however,thatclinicaltrialswithpharmacologicalagents

thatcontrolindividualriskfactorshaveeffectivelyreduced

vascularriskbuthavenotconsistentlyproducedcognitive

benefit.Abetterunderstandingofthemechanismsby

whichmultiplevascularriskfactorsmaycontributeto

cognitivedeficitscouldidentifytargetsforinterventionsto

reverseorreducethedeficit.Thebiologicalmechanisms

oftheinteractionamongriskfactors,aswellasmodelsofthesizeoftheinteractioneffectoncognition,wouldassist

indesigningtrialsofpotentiallyeffectiveinterventions.

11. Conduct research on other areas potentially

affecting cognitive health such as nutrition, mental

activity, and social engagement. (R)

Scienceisevolvingregardingriskandprotectivefactors

intheareasofcognitivetraining,nutrition,andsocialengagement.Itiscriticaltomonitorandincludethese

areasasthescienceemerges.


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Measuring cognitive impairment and burden Useful,measurablecomponentsareexpectedtodiffer

1. Identify thresholds for cognitive decline that have

functional importance for populationbased

surveillance systems. (S)

Itisimportanttorecognizepointsonthecontinuum

ofcognitivedeclinethatarefunctionallymeaningful.

Itshouldalsoberecognizedthatmeasurementsbeyond

somepointsonthiscontinuummayrequireinformation

fromproxyrespondents.Usefulcomparisonsoffindings

fromdifferentsurveillancesystemsandresearchstudiesare

improvedifthereisconsistencyamongthethresholds

beingused.Functionallyimportantthresholdsshouldbe

ofpracticalsignificancetohelpinformpublichealth

policyregardingneedsforcaregiversupportandother

specialhealthcareorsocialservices.

2. Identify critical dimensions of cognition and the

most appropriate corresponding measures that

may be useful in surveillance systems. (S)

Itisimportanttoknowthekeycomponentsofcognition

(e.g.memory,intelligence,problemsolving,andreasoning)

thataremostsensitiveandspecifictocognitivedecline

andpracticallymeasurableinsurveillancesystems.

accordingtothenatureofthesurveillancesystem,

particularlywhetherdatacollectionislongitudinal

orcrosssectional.Withcrosssectionaldataalone,

fewerinferencesarepossibleregardingagerelated

cognitivedecline.

3. Identify measures of the public health burden

of cognitive impairment on individual people,

families, and communities.(SC)

Thepublichealthburdenofcognitiveimpairment

encompassesitseffectsonindividualmenandwomen,

caregivers,families,employers,andothersinthe

community.Theseeffectsmayhavephysical,mental,

social,andeconomicdimensions.Itisimportantto

identifykeymeasurablecomponentsoftheseeffectsto

enablethepublichealthburdentobefullyassessed,

monitored,anddescribed.

4. Identify a set of questions appropriate for use in

people of diverse educational attainment, culture,

and ethnicity that will measure cognitive function

with sufficient sensitivity, specificity, and

predictive values.(S)



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Thesequestionsmightexistwithinanongoing

populationbasedsurveillancesystem,ortheycould

beaddedtosuchasystem.Totheextentpossible,

educationandcultureindependentmeasuresshould

besought.Becausetheeffectsofeducationandculture

arepotentialconfounders,measuresandanalytic

techniquesareneededthatwouldenablereduced

cognitivefunctiontobedistinguishedfromlowperformanceduetovariationsineducationalorcultural

exposures.Itiscriticaltorecognizeandcorrectthese

confoundingeffectssoastoavoidmisinterpretingor

misusingsurveillancedata.

Developing capacity

1. Engage the private sector and other entities in

planning and funding research to address ways to

maintain and improve cognitive health, including

clinical trials. (R)

Supportofresearchoncognitivehealthisexpensivein

scope,effort,andcost.Partnershipswithfederalagencies,

foundations,andotherentitieswilllikelybenecessaryto

securesuchsupportandconductthisresearch.

2. Convene researchers and community intervention-

ists conducting interventions on risk and protectivefactors to identify potential mechanisms to advance

the work in the field of cognitive health.(R)

Thefieldsofcardiovasculardisease,depression,diabetes,

andcognitionarebeginningtointersect.Afterconducting

literaturereviewsonwhatiscurrentlyknownaboutthe

effectsofinterventionstargetingvascular factors,depression,

anddiabetesoncognitivehealth,researchersand

communityinterventionistsineachofthesefieldsshould

beconvenedtodeterminestrategiesformovingthefield

ofcognitivehealthforward.



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IVdevelopment

process

Vactions by

cluster

VInext steps

IIIstrategic

framework

IIstate of

knowledge

Ibackground

Next

the healthy brain initiative

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