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1 Best Practices for Maintaining Cognitive Health in Older Age George W. Rebok, Ph.D., MA Professor, Department of Mental Health Johns Hopkins Bloomberg School of Public Health Elizabeth K. Tanner, Ph.D., RN, FNGNA Associate Professor, Johns Hopkins School of Nursing Odyssey Mini-Med School Johns Hopkins University December 1, 2011 Presentation Objectives 1. Describe the nature and scope of cognitive changes with age. 2. Identify the types of best practice interventions that are most effective with older adults in a variety of clinical i l and community settings e.g., ACTIVE, Baltimore Experience Corps. 3. Discuss specific strategies for improving memory, concentration, and everyday function in older adults. Outside of their own business, the ideas gained by men before they are twenty-five are practically the only ideas they shall have in their lives. They cannot get anything new. Disinterested curiosity is past, the mental grooves and channels set, the power of assimilation gone. William James (1893) Principles of Psychology I have two fixed ideas well known to my friends The first is the comparative uselessness of men above forty years of age. My second fixed idea is the uselessness of men above sixty years of age, and the incalculable benefit it would be in commercial, political and in professional life if, as a matter of course, men stopped work at this age. Dr. William Osler (Feb. 22, 1905) Marcus Tullius Cicero BC Dementia is not an inevitable consequence of old age An active mental life can prevent mental decline Intellectual activity gives buoyancy to the mind Old men retain their mental faculties provided their interest and application continue Mental gymnastics as anti-dementia strategy 1

2 The Alzheimer s Association Website Keep your brain active every day: Stay curious and involved commit to lifelong learning Read, write, work crossword or other puzzles Attend lectures and plays Enroll in courses at your local adult education center, community college or other community group Play games Garden Try memory exercises 2008, Johns Hopkins University. All rights reserved. Use It or Lose It? It s a fortunate person whose brain Is trained early, again and again, And who continues to use it To be sure not to lose it, So the brain, in old age, may not wane. (Rosenzweig MR, Bennett EL. Behavioral Brain Research 1996;78:57-65) Despite the frequent assertions of the mental exercise hypothesis, its intuitive plausibility, and an understandably strong desire to believe that it is true.., there is currently little scientific evidence that differential engagement in mentally stimulating activities alters the rate of mental aging. (Salthouse TA. Mental exercise and mental aging: Evaluating the validity of the Use it or lose it hypothesis. Perspectives on Psychological Science 2006; 1:68-87.) Use it or Lose it Hypothesis Has great popular appeal but has seldom been empirically tested Effortful cognitive activities appear to be protective against dementia in some studies Results of cognitive training studies show evidence for considerable cognitive plasticity Controlled trials are needed to assess effects of cognitive leisure activities on risk of dementia Brain Aging and Public Health Cognitive decline and dementia now recognized as important global public health problems Cognitive functioning in older adults predicts: Performance of everyday tasks Loss of independence Institutionalization Mortality Neuropsychological Performance Physical function Cognitive Reserve Everyday Function Cognitive Health Cognitive Health Brain Morphology Socio-behavioral Resources Health Status Biological Psychological Social Systems affected 2

3 How is YOUR Cognitive Health? DOG FOCUS TABLE PROMOTE FENCE VIEW PEN DISCUSS ROAD EXPECT To live is to remember and to remember is to live. - Samuel Butler Memory Aging Memory and memory decline is a major concern of older adults Memory ability is something everyone can understand and identify with Memory differences occur between younger vs. older adults Memory complaints are not a new phenomena Mnemosyne: goddess of memory Aristotle: wrote a volume on memory Mind as a wax tablet that memories made an impression on These impressions faded with time Prevalence of Memory Complaint and Poor Memory Performance Age N Memory Complaint % Poor Recall % Bassett & Folstein, Normal Cognitive Aging Not just memory Not just late in life Not just small effects 3

4 Memory Study the following words and then write as many as you can remember Goat Door Fish Desk Rope Lake Boot Frog Soup Mule Reasoning Select the best completion of the missing cell in the matrix Z-Score Salthouse Studies Percentile Spatial Visualization Select the object on the right that corresponds to the pattern on the left Perceptual Speed Classify the pairs as same (S) or different (D) as quickly as possible Word Recall (N = 2,230) Matrix Reasoning (N = 2,440) Spatial Relations (N = 1,618) Pattern Comparison (N = 6,547) Chronological Age Considerable variability at all ages Normal Cognitive Aging Not just memory Not just late in life Not just small effects Not well understood Number of Words Recalled Chronological Age Cognitive Aging Aging, Cognitive Health, and Cognitive Decline Cognitive Fu unction Age-Associated Associated Cognitive Impairment Cognitive Health? Mild Cognitive Impairment Alzheimer s Disease Age 4

5 Preventing Cognitive Decline With Aging: Medical Co-morbidities Hypertension Diabetes Cholesterol Heart disease and stroke Hormonal loss Inflammation Cognitive Training Intervention Programs Cognitive training studies improve older adults memory and cognitive performance (Ball, Berch, Helmers, et al., 2002; Rasmusson, Rebok, Bylsma, & Brandt, 1999) Cognitive training programs demonstrate that diverse socioeconomic, ability level, and racial populations benefit from traditional training (Ball et al., 2002; Baltes & Kliegl, 1992; Rebok & Balcerak, 1989; Willis & Schaie, 1986) Training effects demonstrated for wide age ranges, including oldest-old (Baltes, Smith, & Kliegl, 1990), normal elderly, and those with cognitive impairment (Cahn- Weiner, Malloy, Rebok, & Ott, 2003) ACTIVE Advanced Cognitive Training Intervention for Vital and Independent Elders ACTIVE Steering Committee Funded by the National Institute on Aging and the National Institute of Nursing Research ACTIVE Steering Committee University of Alabama- Birmingham Karlene Ball, Ph.D. Hebrew Rehabilitation Center for Aged, Boston University of Florida / Wayne State University Michael Marsiske, Ph.D. New England Research Institutes, t Coordinating Center John Morris, Ph.D. Sharon Tennstedt, Ph.D. Rich Jones, Sc.D. National Institute on Aging Indiana University Jonathan King, Ph.D. Frederick Unverzagt, Ph.D. National Institute of Nursing Johns Hopkins University Research George Rebok, Ph.D. Susan Marden, Ph.D. Pennsylvania State University Sherry Willis, Ph.D. ACTIVE: Primary Aim To test the efficacy of three cognitive interventions, to improve or maintain the cognitively demanding activities of daily living. Baseline Characteristics (N=2,802) Mean Age: years 73.6 (5.9) Range Gender: Female 75.9% Race: African American 26.0% Education: H.S. diploma 88.6% Marital Status: Married 35.9% Cognitive Status: MMSE score 27.3 (2.0) 5

6 Age < 65 years Excluded Substantial cognitive decline MMSE < 23 Self-reported Alzheimer's disease Substantial functional decline Assistance with dressing, personal hygiene, bathing Specified predisposing medical conditions (e.g., CVA) Severe sensory losses Communication difficulties Similar cognitive training Unlikely availability for study activities Non-English speaking Participant Characteristics ti Conceptual Model Training Cognitive Abilities Proximal Outcomes Daily Function Primary Outcomes Study Design Common Structural Features Small-groups (3-5 participants per group) Led by a certified trainer with a scripted manual 10 sessions over a 6-week period minutes per session Pre-specified order of sessions and rules for make-ups 80% compliance for successful completion ACTIVE: Memory Training Techniques Begin with use of simple memory strategies (such as grouping) and move to more complex techniques (such as method of loci), progressively fading out external/retrieval t lcues Subjects get at least 3 individual and group practice exercises per session, involving both lab-type tasks (word lists) and real-world tasks (shopping lists) Work with certified trainers in small groups of 3-5 with a manual, posters, and handouts. Principles of Memory Meaningfulness Organization Visualization Association Remembering to Pay Attention 6

7 Visualization Seeing something in your mind s eye How many windows are in the house you grew up in? Picture yourself walking through a familiar place and noticing items Describe the directions for completing a familiar task Recipe or cooking instructions DVD, remote control Computer: turning on and setting up Association Combining two objects in a meaningful way Choose two unconnected words and form a visualization between them Strange associations are more powerful Penny & Banana: penny balancing on the tip of the banana it falls off when you reach for it Motion in the association will make it easier to remember Sailboat & Tree: sailboat rocking in the breeze on a tree limb Memory for Lists How many of the words from the list at the beginning of the session can you remember? How did you study or remember the words? Word List Potential Strategies: List Memory DOG FOCUS TABLE PROMOTE FENCE VIEW PEN DISCUSS ROAD EXPECT Concentration Repetition Organization Categorization Visualize a familiar route and drop items along the route (loci) Picture items in logical places Alphabetize Create a story Make up a sentence with the first letter of each word Imagine yourself using the items Picture the items in illogical places 7

8 Memory Man Memory Man ACTIVE: Inductive Reasoning Training Trainer demonstrates strategies to identify rule/pattern Participants practice solving gproblems using rule/pattern Participants receive feedback on performance Individual and group exercises involving application of the rule/pattern Patterns in Medication Schedules Look at Mr. Jones medication schedule. Fill in the calendar for one week. Put an A, B, or C in the calendar when he should take each medication. If he should take two pills of a certain medication at one time, put AA or BB. Below is a sample calendar: Time Of Day Sun Mon Tues Wed Thurs Fri Sat Morning Noon AA B AA B AA B AA B AA B AA B AA B Evening AA AA AA AA AA AA AA Bedtime C C C C C C C Medication A: Medication B: Medication C: Time Of Day Sun Mon Tues Wed Thurs Fri Sat Morning Noon Evening Weekly Medication Schedule Mr. Jones Put an A in the schedule for when Medication A should be taken Put an B in the schedule for when Medication B should be taken Put an C in the schedule for when Medication C should be taken Useful Field of View The useful field of view refers to the area that one can see and cognitively process and interpret. With cognitive slowing, the area shrinks to only the area a person sees directly in front of the eyes without the side vision, called peripheral vision. Bedtime 8

9 Courtesy of Karlene Ball, UAlabama Birmingham Roybal Center for Research Applied Gerontology Initial Effect Sizes (JAMA 2002) ACTIVE Findings: Effects on Everyday Task & Functioning Expected Decline Baseline 7 Years 14 years Training Gains Baseline Immediate 2 Years Memory Reasoning Speed No Transfer from Basic Ability Training to Everyday Functioning for any of the 3 Treatment groups Decline in Functioning occurs later than decline in basic abilities Positive selected control group - delay in onset of functional decline Effect Sizes at 5 Years (JAMA 2006) Effect of Training on Function: Self-Reported IADLs Standardized Traini ing Effect Size (Control Group as Reference) Memory composite Reasoning composite Speed composite Mean IADL Difficulty Score Memory trained Reasoning trained Speed trained -0.8 Baseline Year 1 Year 2 Year 3 Year 4 Year 5 (N=2802) (N=2325) (N=2234) (N=2101) (N=1877) Time Training Group Memory trained Reasoning trained Speed trained Control 9

10 Other Intervention Studies Speed of Processing training has been shown to result in: Fewer dangerous maneuvers while driving Improved hazard detection in simulations Faster reaction times to road signs Increased mobility Improved Timed IADLs Some Caveats about Cognitive Training for Promoting Healthy Cognitive Aging Training gains may be of lower magnitude than many elderly, patients, and caregivers expect and progress may not be steady; problem of raising false hope and blaming the victim for cognitive declines Training effects tend to be highly task-specific and show limited generalizability; effects are reasonably durable but maintenance doesn t automatically ti occur. Severely cognitively impaired and demented patients may show little benefit from cognitive training Training may not prevent cognitive decline, BUT it can boost performance and may delay normative cognitive decline. A few sessions of cognitive training may not be sufficient to alter the life course with respect to decline, BUT it may compress the point of cognitive disability into a smaller window at the end of life. Next-Generation Training Platforms Experiential/engagement: global, nonability specific interventions (e.g., Baltimore Experience Corps ) Trainer-less Training: collaborative, interactive (e.g., Willis s work with older couples) Technology-based: video training, computerized training, internet-based (e.g., Memory University) Multimodal Training: combine different training modalities (e.g., Mind-Body training) Perceptions of Usefulness to Others & 7-yr Incident Disability or Mortality RB - Mobility Disability Never/rarely Katz ADL Disability Sometimes Gruenewald et al, MacArthur Study of Successful Aging Mortality Ref. Group=Frequently useful Social Integration & 12-yr Risk of Cognitive Decline % Cog. 30 Decline Bassuk et al, Ann Intern Med, 131: , Ties 1-2 Ties 3-4 Ties 5-6 Ties Social Engagement Ties = married, 3+ monthly visual contacts; 10+ nonvisual contacts, group membership, reg. church attendance, reg. social activities Social Integration & 3-year incidence of Dementia 160 RR= per 1,000 RR= RR=2.6 person-years Poor Limited Moderate Extensive Level of Social Integration (married, live w/ others, reg. & satisfying ties w/ children & frd/rel) Fratiglioni et al, Lancet, 355: ,

11 Ho: generativity is key to successful psychological aging [Erikson] Leaving a legacy Leaving the world better for future generations Productive, meaningful engagement A win-win: target roles to societal unmet needs We are an aging society By 2030: 20% 65 and over, including 75 million baby boomers 25% 60 and over As many adults >65 as children <18 One Model for such a Win-Win: Experience Corps High intensity volunteering for older adults High impact roles in public elementary schools improving outcomes for children Cii Critical mass of older adults: Shift outcomes for schools Force for social benefit Social networks and friendships Health promotion program embedded» Fried et al, 2004 Older Adults as A Source of Social Capital for Urban Education Urban public schools: education to the majority of children in the US. Most under-resourced and lack the human capital to meet their educational mission. Older adults can offer: the stability, consistency, and caring which are essential to learning, their experience and presence as role models. the social capital needed to support the educational needs of children directly on a large scale. Experience Corps: Nationally Developed to promote the health of older adults and fulfill unmet social and academic needs in public elementary schools (Freedman & Fried, 1997) Two national demonstrations ( ; ), sponsored by Corporation for National Service Implementation and expansion in 20+ cities 11

12 Experience Corps: Baltimore Volunteers 60 and older Trained and placed in public elementary schools: K-3 Critical mass: teams of in each school High intensity: 15 hours per week Sustained dose: full school year Monthly stipend to reimburse for out-of-pocket of expenses Meaningful roles Literacy and Math activities Behavioral Management Freedman & Fried, 1997; Fried et al., 2004 Experience Corps Research Team Jeremy Barron Michelle Carlson Linda Fried Kevin Frick Katherine Giuriceo Tara Gruenewald Sylvia McGill Jeanine Parisi George Rebok Teresa Seeman Erwin Tan Elizabeth Tanner Vijay Varma Qian-Li Xue Funded by grants from the National Institute on Aging P01AG , Weinberg Foundation, Erickson Foundation, and AmeriCorps Causal Pathway: Experience Corps Performance-based measures Primary Primary/ Secondary outcomes and Intervention Pathways [Self Report] Mechanisms intermediate mechanisms Outcomes Falls Physical Activity Strength, balance Walking Speed or preserved function or delayed decline in: Frailty Experience Corps Participation - Generative Role Performance Cognitive Activity Cortical plasticity; Memory Executive function Complex task performance Mobility Function IADLs Social Activity, Engmnt. Social Integration & Support Generativit y Psycho-Social Well-being Baltimore Sun, 06/11/06 by Joe Polazzolo Sun Reporter Baltimore Sun, 06/11/06 by Joe Polazzolo Sun Reporter 12

13 EC Pilot Randomized Trial: volunteers >60 years Randomized to treatment (n=72) or control schools (n = 79) 98% retention rate in Year months follow-up Baseline Characteristics of Experience Corps Participants Age ( Range: 60-91) % % > 71 36% Gender Male 18% Race Black 92% White 8% Married 24% Education High school or less 82% Health Excellent/very good 29% Good 60% Fair 12% Short-term Change in Risk Factors for Disability: Pilot Randomized Controlled Trial, EC versus Controls, 4-8 month follow-up Physical Activity Cognitive Activity Social Activity Change in Blocks Walked Per Week % of Change from BL Lto FU 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% -5.0% -10.0% -15.0% Walking Distance(block) per Week 31.4% Intervention Group Control -9.0% Fried 2004 % of change fro om BL to FU Number of TV Hours per Day 20.0% 18.1% 15.0% 10.0% 5.0% 0.0% Intervention Control -5.0% -3.9% -10.0% Group Social Support: EC Preliminary pilot data (@ 12mos) Want more emotional support Feel I made a difference Feel others need me # people around to check on you # reported ties EC Percent Control 13

14 Preliminary evidence 12mos post-ec participation) EC Pilot Study: Boosts Cognition over 6 Months 20% Control Intervention 15% 15% 13% 11% 10% Still talk to friends from EC Talk at least 1/wk Visit w/ friends from EC Percent change (b baseline to followup) 5% 0% -5% -10% -15% 0% -10% -15% -8% Percent -20% -25% Verbal & Visual Memory -22% Psychomotor Speed Executive Function Carlson, Saczynski, Rebok, et al., 2008 EC Functional Brain MRI (fmri) Pilot Study: Demographics of Intervention (N=8) & Controls (N=9) EC participants > Controls on test of executive function following 6 month exposure Characteristic Participants Controls Age, mean years 68 (r: 62-78) 68 (r: 63-75) Female, n (%) 8 (100) 9 (100) African American, n (%) 8 (100) 9 (100) Education, mean years Widowed, n (%) 5 1 MMSE, mean PFC= prefrontal cortex; ACC= anterior cingulate cortex (Carlson, Erickson, Kramer, Colcombe, Bolea, Mielke, Rebok, and Fried, 2009) Can a high intensity, multimodal volunteer role contribute to improved health in aging Disability: mobility Frailty Falls Cognitive function: memory, executive function Large-scale RCT of EC: Baltimore Evaluation funded through a P01 from NIA Initiated in Fall 2006 and concluding in December 2011 Conducted in partnership with Greater Homewood Community Corporation and Baltimore Public School System Randomized 702 individuals id to EC or low-activity it control; 21 public elementary schools Administered multiple measures at baseline and at 4, 8, 12, 16, 20, and 24 months post-baseline Physical: Disability, mobility, frailty, fall risk Cognitive: Memory, processing speed, executive function Psychosocial: Generativity, social networks and support 14

15 Hypothesized Outcomes for Children and Schools Selective improvements in reading/ academic performance, classroom behavior, and readiness-to-learn among urban children participating in the EC program Help reduce student absenteeism School climate will improve Increased teacher retention Direct positive association between improved school performance and older EC volunteer retention and satisfaction Implications: Volunteering Designed as a Social Model for Health Promotion Cost-benefit: Investing in older adults to invest in children Opportunity to invest in health promotion for older adults, while not pitting generations against each other for resources Brings health promotion into community to groups not typically reached; health disparities Import and Implications: How do you engage and retain individuals in high intensity volunteering? Social model for health promotion Compression of morbidity Health disparities Benefits of an aging society How do you protect the public s cognitive health? Research on prevention of cognitive decline in later life is a fast-moving area, so it is important to stay current. Engaging in thought-stimulating activities (e.g., reading cross-word puzzles, playing chess, playing videogames) early in life may help maintain cognitive health across the life span. Don t expect one cognitive activity or exercise will be the gateway to cognitive improvement or that improvement will come without practice or effort. Try to stay cognitively, socially, and physically active as long as possible. World s Oldest Ph.D. Candidate Trent Lane years old -- pursuing Ph.D. in physics -- flies own singleengine plane -- maintains 25-acre farm in Louisiana -- holds five national Track and Field records and several world records 15

16 Contact Information Dr. George W. Rebok Professor Department of Mental Health Johns Hopkins University 624 North Broadway Baltimore, MD Phone: Fax: Contact Information Dr. Elizabeth K. Tanner Associate Professor Johns Hopkins School of Nursing and Center on Aging and Health 525 N. Wolfe Street Baltimore, MD Phone: Fax: